Cancer:
Meeting the challenges
Professor Mike Richards
October 2009
BOPA/UKONS
Brighton
Meeting the challenges: Overview
•
Brief review of progress on cancer over the past decade
•
Current and future challenges and priorities
•
Emphasis on chemotherapy and patient-centred care
Cancer: 10-15 years ago
• Long waiting times
• Lack of infrastructure (CT, MRI, Linacs, staff)
• Lack of specialisation
• Fragmented care within hospitals (surgeons, pathologists,
radiologists, oncologists etc. not working together)
• Poor communication between 1º, 2º and 3º care
• Poor survival rates
• Poor experience of care for patients
Cancer survival in the 1990s
Cancer: What have we done?
• Reduced smoking rates
• Improved screening
• Reduced waits:
14/31/62
• Invested in staff and equipment
• Established multidisciplinary team working
• Reconfigured services in line with NICE ‘IOGs’
• Established networks across 1º, 2º and 3º care
• Improved treatment (S, RT, CT)
• Improved supportive and palliative care
Progress on cancer
• Survival rates are improving
• Patient experience has improved (large surveys)
• Mortality has fallen - especially in people under 75
years
Chart 3.13: Male premature mortality from cancer
Aged under 65 years, England, EU-15 countries and selected averages
Standardised death rate (SDR) per 100,000 population
170
KEY
Best EU-15 country
Worst EU-15 country
England
EU average (all countries in the EU)
EU-15 (member countries before 2004)
EU-12new (member countries from 2004)
150
130
EU-12new
110
France
EU average
90
EU-15
70
England
Sweden
50
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
Source: England ONS Mortality data. Web link http://www.statistics.gov.uk/statbase/Product.asp?vlnk=6725 analysed by DH Analysts.
All other countries - WHO, Health For All Database-Jul 2008. Web link http://www.euro.who.int/hfadb
1999
2001
2003
2005
Chart 3.15: Female premature mortality from cancer
Aged under 65 years, England, EU-15 countries and selected averages
Standardised death rate (SDR) per 100,000 population
120
KEY
110
Best EU-15 country
Worst EU-15 country
England
EU average (all countries in the EU)
EU-15 (member countries before 2004)
EU-12new (member countries from 2004)
100
90
Denmark
80
EU-12new
70
England
EU average
EU-15
60
50
Greece
40
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
Source: England ONS Mortality data. Web link http://www.statistics.gov.uk/statbase/Product.asp?vlnk=6725 analysed by DH Analysts.
All other countries - WHO, Health For All Database-Jul 2008. Web link http://www.euro.who.int/hfadb
1999
2001
2003
2005
Cancer: Looking forwards
• The economic downturn will inevitably impact on the
NHS and on cancer
• We know that we still have a long way to go to deliver
our goal of world class outcomes
• Different approaches will be needed if we are to
continue driving up quality
• This is the QIPP agenda: Quality, Innovation,
Productivity and Prevention
Cancer: Challenges
• Increasing incidence (1.5% pa) and prevalence (3%pa)
• Survival rates are improving but are still poor cf. Europe
• Mortality is not falling as fast in older people as in younger
people
• Inequalities persist (race, age, gender, deprivation,
religion, sexual orientation)
• New technologies may improve outcomes, but some will
be expensive
Cancer: A huge agenda
• Prevention
• Awareness and early diagnosis
• Waiting times (e.g. for breast symptoms)
• Surgery
– achieving optimal quality
• Radiotherapy
– introducing new technologies
• Chemotherapy
– ensuring quality and safety
– improving access to new medicines
• Survivorship
• Reducing inequalities
• Transforming inpatient care
• Driving quality improvement through intelligence
• Stronger commissioning
National Awareness and Early Diagnosis Initiative
• Late diagnosis results in 5,000-10,000 avoidable deaths from
cancer each year
• A combination of factors is almost certainly responsible

Low public awareness

Difficulty accessing GP services

GPs missing diagnosis

GPs having poor access to diagnostics
• Actions needed:
Baseline assessments by PCTs
Community awareness raising
Primary care audits
Better diagnostic services
• Additional costs likely to be offset by reduction in late stage cancer
(with expensive drugs). Economic analysis in progress.
Chemotherapy
• Improving Access to Medicines for NHS Patients
(Richards Report, November 2008)
• NCEPOD Report (November 2008)
• National Chemotherapy Advisory Group report
(August 2009)

Elective chemotherapy – back to basics on assessment,
delivery, monitoring etc.

Acute oncology – more effective management of acute
complications of chemotherapy
Richards Report 2008: Background
• Some cancer drugs which were available in other
countries were not being funded by the NHS
• Variations in decision making within England (PCTs)
during interval between licensing and NICE decision
• Some patients who were choosing to buy unfunded
drugs were then being denied NHS care
• “Top-ups” became a major issue for patients,
clinicians, NHS managers and the public/media
Richards Report 2008: Key recommendations
1. NHS patients should have greater access to new
medicines:

PCT processes to be improved

Improved timeliness of NICE appraisals

Flexible pricing (PPRS)

Greater flexibility from NICE for ‘end of life’ drugs
2. Patients who choose to pay for unfunded drugs should
not be denied NHS care
3. NHS and private elements of care should be kept
separate
Richards Report 2008: Other recommendations
• The extent and causes of international variations in drug
usage should be investigated
• SHAs should ensure that … revised guidance is
implemented properly
• The use of unfunded drugs should be audited
• Patients should be given balanced information
• Clinicians should be given extra communication skills
training
International variations in drug usage (1)
• DH Advisory Group
Co-chairs: Mike Richards (DH) & John Melville (Roche)
+ ABPI, pharma, clinicians and patients
• Looking at around 12 countries
• IMS Health as primary data source – with validation by
individual companies
• Broad spectrum of conditions/drugs
International variations in drug usage (2)
• Cancer: ‘New’, intermediate and ‘old’
• CVD: Statins and thrombolytics
• Mental health: Anti-psychotics
• LTC: Arthritis, osteoporosis, MS
• Older people: Dementia
• Children: Drugs for RSV
• Ophthalmology: Wet AMD
• Infections: Drugs for hepatitis C
Audit of drug usage
• Scope

Drugs turned down or restricted by NICE

Drugs approved through the NICE ‘end of life’ scheme
• Q1: How widely are these drugs being used? (IMS Health)
• Q2: Are commissioners being asked to approve unfunded
drugs as exceptional cases? (PCTs)
• Q3: Who is paying for unfunded drugs? (Trusts)
e.g. NHS, insurance or individuals
• Q4: What information are patients being given?
[Contact: william.gray@sheffieldpct.nhs.uk]
NCEPOD report (November 2008)
• Review of case notes of 546 patients who died within 30
days of chemotherapy
• Overall standard of care
35% Good
49% Room for improvement (mostly clinical)
8% Less than satisfactory
8% Insufficient data
• In 27% chemotherapy was judged to have caused or
hastened death
• Problems identified at each step in the chemotherapy
process
Chemotherapy Services in England:
Ensuring Quality and Safety
• NCAG report published August 2009
• Recommendations related to:

Elective chemotherapy processes (chemotherapy care
pathway)

Acute oncology

Infrastructure: Leadership, governance, training etc.
“Acute Oncology” services
Problems
• Increasing emergency admissions of cancer patients
• Many have complications following chemotherapy
• Poor communication between general medicine and oncology services
• Long lengths of stay and poor care
Solution
• All acute hospitals to establish an ‘acute oncology’ service – bringing
together A&E, General Medicine, Oncologists and Oncology Nurse
Practitioners
• Improved quality and reduced costs (e.g. Whittington Hospital)
Living with and beyond cancer
(Chapter 5 of the CRS)
• Patient information
• Communication skills
• Implementation of NICE supportive and palliative care
guidance
• National Cancer Survivorship Initiative
• Patient Survey Programme
• Quality in nursing initiatives
• End of Life Care
National Cancer Survivorship Initiative
Five shifts
1. Attitudes
•
From medical model to partnership/empowerment
•
From focus on disease to focus on recovery and well
being
2. Better information
3. Individual care planning
4. Tailored support
5. Improved measurement
Reducing Inequalities (Chapter 6)
• Understanding inequalities in incidence, survival and mortality
by race, age, gender, disability, religion, sexual orientation,
deprivation, rurality etc.
• Important new reports from NCIN (e.g. on men and cancer;
ethnicity; age)
• Lifestyle factors are likely to account for most of the differences
in incidence
• Late diagnosis appears to be a significant contributor to poor
survival for ethnic minorities, older people and socially deprived
• Older people may be undertreated
Transforming inpatient care (Chapter 7)
• Ensure day case surgery is adopted whenever
appropriate (wide variations in practice)
• Elective inpatient surgery

Enhanced Recovery Programme
• Emergency admissions

Avoid where possible

Streamline care

‘Acute oncology’
Enhanced Recovery Programme
• A ‘new’ approach to elective surgery
• Applications to colorectal, orthopaedic, gynae and urological
surgery (and probably other areas)
• Different preoperative, perioperative and postoperative care
• Good evidence base
• Clinical champions
• Potential to improve quality and reduce bed days (e.g.
colorectal 13  6 days)
Challenge: To implement enhanced recovery across England
within 2 years
QIPP and cancer
• The economic downturn will inevitably impact on the
NHS
• Different approaches will be needed if we are to
continue driving up quality
 QIPP:
Quality
Innovation
Prevention
Productivity
QIPP and Cancer: A possible framework
QIPP Category
Quality, innovation
and/or prevention
Productivity
A

Cost saving
B

Cost neutral
C

Low cost per QALY
(e.g. <£5-10k per QALY)
D

Higher cost per QALY
(e.g. £10-30k per QALY)
Existing cancer developments and QIPP
Quality Innovation Productivity Prevention

Action on smoking
Screening improvements


Waiting times


MDT working


Clinical nurse specialists


Surgical training programmes


Radiotherapy upgrading

()
New drugs


Palliative care improvements



?
Cancer and QIPP: Looking forwards …
Qual.
Inn.
Prev.
Prod.
• Enhanced recovery


Cost-saving
• Acute oncology


Cost-saving
• Cervical screening redesign



Cost-saving
• Digital mammography



?Cost-saving
• Robotic surgery


• National Awareness and
Early Diagnosis Initiative


• Radiotherapy


?Low cost/QALY
• New drugs


High cost/QALY
?Cost-saving

?Low cost/QALY
Summary
• We have made good progress on quality of cancer
services – but there is still a lot to do
• There are major opportunities for improving quality and
productivity through innovation even during the financial
downturn