Cancer. From cure to prevention.
Dr Nigel Marchbank
Consultant Radiologist, Brighton and Sussex Medical
School.
Medical Director
Sussex Cancer Network
1
Content of talk
• Changes in cancer care in England
• Examine recent global changes in public
health and science
• Look into future
Breast cancer pathway 1984
• Mrs Ogden
• Born 1936
• Right breast lump
• Mother died of breast
cancer aged 42
• Referred to
Hospital
2
Breast cancer pathway 1984
•
•
•
•
•
•
•
•
Saw Mr Spratt (Day 56)
M
Mammogram
(Day
(D 92)
Mastectomy (Day 126)
3/12 follow-up in surgical clinic
3/12 later metastatic pleural effusion
Oncologist
Chemo
Died 8/12 later in hospital
Why need for a Cancer Plan in
England?
• Worst mortality
i E
in
Europe
• Historic
underinvestment
• No National
Strategy
3
Burden of cancer in England 2008:
Incidence 230,000 cases p.a.
breast
lung
colorectal
prostate
other
Burden of cancer in England 2008:
Mortality 125,000 deaths
breast
lung
colorectal
prostate
other
4
Women
Men
Five year age standardised relative survival (%),
adults diagnosed 1996-1999,
England and Wales by sex and site
Testis
Melanoma
Prostate
Bladder
Larynx
Colon
Rectum
NHL
Kidney
Leukaemia
Multiple myeloma
Stomach
Brain
Oesophagus
Lung
Pancreas
Melanoma
Breast
Uterus
Cervix
Bladder
NHL
Rectum
Colon
Kidney
Ovary
Leukaemia
Multiple myeloma
Brain
Stomach
Oesophagus
Lung
Pancreas
96%
77%
More than 50% survival:
30% of cases diagnosed
65%
64%
62%
%
47%
47%
47%
45%
10-50% survival:
32% of cases diagnosed
36%
23%
13%
12%
7%
6%
less than 10% survival:
24% of cases diagnosed
2%
87%
77%
73%
61%
54%
52%
51%
48%
46%
36%
35%
More than 50% survival:
49% of cases diagnosed
10-50% survival:
22% of cases diagnosed
23%
15%
14%
8%
6%
less than 10% survival:
16% of cases diagnosed
2%
Five-year relative survival
NHS Cancer Plan 2000
5
NHS Cancer Plan 2000
It had four aims:
• to save more lives
• to ensure people with cancer get the right professional
support and care as well as the best treatments
• to tackle the inequalities in health that mean unskilled
workers are twice as likely to die from cancer as
professionals
• to build for the future through investment in the cancer
workforce, through strong research and through
preparation for the genetics revolution, so that the NHS
never falls behind in cancer care again
Commitments in Cancer Plan
• Reduce smoking
– 32% in 1998 to 26% b
by 2010
• Waiting times
• Investment
– £670 million per year
– £50 million for Palliative Care
• Improving Outcomes Guidance
• Cancer Networks
6
Waiting times targets
• 2 week wait
• 1 month wait
• 2 month wait
Urgent GP
referral
Any
referral
Urgent GP
referral
Initial
consultation
Initial
consultation
Initial
consultation
Diagnosis
Diagnosis
Diagnosis
Decision to
treat
First
treatment
Decision to
treat
First
treatment
Decision to
treat
First
treatment
1 and 2 month targets 2003/04
100%
Percentage meeting target
90%
80%
70%
60%
50%
40%
30%
B reas t
G y naec ology
Lower G I
Upper G I
Lung
Urology
(ex c luding
tes tic ular)
1 m onth target
91.8%
89.4%
90.6%
98.6%
95.0%
84.3%
2 m onth target
88.8%
81.8%
45.9%
75.0%
80.0%
71.3%
7
Improving Outcomes Guidance
•
•
•
•
•
•
•
•
•
•
•
•
•
Breast
Colorectal
Lung
Gynaecology
Upper Gastrointestinal
Urology
Haematology
Supportive and Palliative Care
Head and Neck
Children and young people
Skin
Sarcomas
Central Nervous System
1996 (2002)
1997 (2004)
1997 (2005)
1999
2001
2002
2003
2004
2004
2005
2006
2006
2006
Common themes in IOGs
•
•
•
•
•
Guidance to Commissioners
P
Prevention/Early
ti /E l di
diagnosis
i
Critical mass
Multidisciplinary Teams
Patient experience
– Key worker
– Information
– Choice
8
Cancer Networks
• To implement Cancer Plan at local level
• Organisations involving clinicians, health
professionals, commissioners, providers,
patients and carers and voluntary sector
• Boundaries to reflect patient flows into a
Cancer Centre
• 800 000 to 3 million population
Sussex Cancer Network
Sussex Cancer Network
PCT Coverage
Crawley
Crawley Hospital
H
Surrey West Sussex &
Hampshire Cancer Network
The Queen
Victoria H
Hospital
H
East
Grinstead
Royal
Tunbridge
A26 Wells
A22
Horsham
Horsham Hospital
Princess Royal Hospital
Midhurst
A272
A272
A26
H
A272
Uckfield
West
Sussex
A22
Conquest Hospital
Lewes
Southlands Hospital
A27
H
Worthing
Brighton
H
A259
Hastings
A27
Chichester
Central South Coast Cancer Network Worthing Hospital H
Rye
A259
A283
A280
Hastings
and Rother
A21
A24
Bognor
Regis
East Sussex
Downs
and Weald
A23
St Richards Hospital
H
Kent and
Sussex H
Hospital
A27
H Brighton General Hospital
H Royal Sussex County Hospital
A259
Eastbourne District
General Hospital H
Brighton
& Hove
Eastbourne
9
100%
2wk
1mth
2mth
95%
90%
85%
80%
75%
70%
65%
03/04
04/05
05/06
06/07
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
60%
Q1
Performance Against Target
Sussex Cancer Network - Performance Against Cancer
Waiting Times Targets (2003/4 - 2007/8)
07/08
Cancer mortality (persons under age 75) from
all cancers in England,
1993 to 2006
160
Target:
20%
minimum
reduction
from
1995-97
baseline rate
140
120
100
80
60
40
20
0
1993/4/5
1995/6/7
1997/8/9
1999/2000/1
2001/2/3
2003/4/5
2005/6/7
2007/8/9
2009/10/11
10
Cancer mortality in people under age 75 – Inequality gap
England 1993-2007 and target for the year ‘2010’
Age standardised mortality rate
Per 100,000 population
Progress since baseline:
180
A fall of 13.2% in the gap
Spearhead
Group
p
170
160
20.7
150
140
England
Target:
130
18.0
6%
120
minimum
reduction
in absolute
gap, from
1995-97
2009/10/11 baseline
19.5
110
1000
1993/4/5
1995/6/7
1997/8/9
1999/2000/1
2001/2/3
2003/4/5
3 year average
baseline
Projection of cancer mortality for England
(exponential projection based on data for the 10 years 1998-2007)
Target reduction for Spearhead Group i.e. to achieve target
reduction in gap given observed/projected England rate
Source: ONS (ICD9 140-209; ICD10 C00-C97)
2005/6/7
2007/8/9
Progress
Actual Data
Inequality Gap in rate*
target
Target
(deaths per 100,000 population)
* The absolute gap between rate for England and rate for Spearhead Group
(in deaths per 100,000 population)
Cancer Reform Strategy 2007
•
•
•
•
Builds on progress made
since the publication of the
NHS Cancer Plan
Recognises key challenges
and opportunities for
improving outcomes
Sets out a clear direction for
th nextt 5 years
the
Shows how we will deliver
cancer outcomes which are
amongst the best in the world
11
Cancer Reform Strategy
• 6 key areas for action
– Prevention
– Diagnosing cancer earlier
– Ensuring better treatment
– Living with and beyond cancer
– Reducing cancer inequalities
– Delivering care in the most appropriate setting
• 4 key drivers for delivery
– Using information to drive quality and choice
– Stronger commissioning
– Funding world class cancer care
– Planning for the future
Breast cancer pathway 2009
•
•
•
•
Patsy Ogden born 1970
Nurse
1 daughter age 6/12 (Lucy)
Mother/grandmother both
died breast cancer
• Aware of breast cancer
• Too busy to go to GP
12
Breast cancer pathway 2009
•
•
•
•
•
•
•
•
Noticed lump in right breast
GP referred under 2 week wait
Breast surgeon and CNS (Day 8)
Mammogram/US/Biopsy/MRI (Day 25)
Multi-disciplinary team (Day 28)
Lumpectomy and SNB (Day 42)
Adj
Adjuvant
t ttreatment
t
t
Follow-up programme
Breast Cancer Survival Trends
Cancer Research UK/ Office for National Statistics
13
Improvements in
breast cancer care
•
•
•
•
•
Awareness
Screening
Sub-specialisation
Adjuvant treatments
Faster access to
treatment
Requirements for breakthroughs in
medicine
• Public Health need
• Scientific breakthrough
14
Breakthrough in Medicine 1865
• Public health need
– Surgical wound infection
• Scientific breakthrough
– Microbial theory
– Advances in Chemistry
y
• Lister introduces antisepsis
2009 - What is the Public Health Need?
•
•
•
•
•
Shift from acute to chronic conditions
Aging population
Health Inequalities
Emerging infectious diseases
Obesity
15
2009 – Scientific Discoveries
Human Genome Project and Hap Map
• 1990-1999 DNA sequencing techniques
• 1998-2002 Mapping of genetic diversity
• 2001 - 2009 Mapping of disease genes
Mapping of disease genes
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18
16
14
12
10
8
6
4
2
0
Disease gene
discoveries
2000 2001 2002 2003 2004 2005 2006 2007
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Paradigm Shifts
• Cosmology: Ptolemy to Copernicus
• Evolution: Lemarck to Darwin
• Gravitation: Newton to Einstein
"a
a new scientific truth does not
triumph by convincing its
opponents and making them
see the light, but rather
because its opponents
eventually die, and a new
generation grows up that is
familiar with it.“ Max Planck
A paradigm shift in sport
• The straddle
• 1968 The Fosbury flop
• High jump world record
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Medicine…the Paradigm shift ?
• The Past
• Curative
C ti
• The Future
• Preventive
P
ti
– Loss of function
– Little understanding of
molecular events
– Expensive
• Cost
• Disability
– Intervene before
symptoms
– Identify molecular
events/predict those at
risk
– More effective
The P4 Paradigm
•
•
•
•
Predictive
Personalised
Pre-emptive
Participatory
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Breast Cancer Pathway 2034
• Lucy
• Born 6/12 ago
• Mother survived breast cancer
age 38
• G’mother and Great G’mother
died pre-menopausal
• Age 15…GP does genetic
mapping
• She has 4 of 20 known Breast
cancer genes
• Lifestyle change…diet
• Screening from 25
• Plans prophylactic mastectomies
with reconstructions at age 35
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