General elections come and go — and pub bores bray about it not mattering who you vote for because the government still gets in — but illness does not have a calendar, and in general practitioners’ offices medicine rolls on regardless. Giving bad news to patients can sometimes be rather like waiting for a bus: you don’t see any serious cases for a while and then three come along at once.
I’ve been feeling a bit like that this week, having had to give the worst kind of news to several patients including two cases of lung cancer — the most common form of cancer in the UK and one that kills about 40,000 people in the UK every year, killing more men than bowel and prostate cancer combined. It remains the most common cause of death from cancer in both men and women, although it affects slightly more men than women.
Somewhat depressingly, only some 6 per cent of patients with lung cancer can expect to be alive five years after diagnosis. The reasons for this grim statistic are varied but key ones include late presentation at diagnosis, social deprivation, a lack of advocacy and research, old-fashioned cancer stigma and variable access to staff, diagnostics and treatment.
As most people are aware, smoking remains the primary cause of lung cancer, and although non-smokers can get lung cancer, the risk is about ten times greater for smokers and this increases with the number of cigarettes smoked. Smoking more than 20 cigarettes a day increases the risk of developing lung cancer by some 30 to 40 times compared with non-smokers although the risk of lung cancer in an ex-smoker falls to the same level as a non-smoker about 15 years after stopping.
Unfortunately, a great many of the cases of lung cancer I see present too late for curative treatment and in more than half of them the disease has already spread to other parts of the body at the time of diagnosis. Early diagnosis is more difficult than you may think because many of the common symptoms of lung cancer (see box, p18) are similar to conditions such as chronic bronchitis and emphysema. The first investigation I always use is a chest X-ray — but if a lung tumour is present, it needs to be at least a centimetre in diameter to be detectable.
By the time a tumour has reached this size, the original cell which became cancerous has divided (or doubled) 36 times. As death usually results after 40 such cell divisions, it can be seen that lung cancer is a disease that is usually detected late in its natural course. Simple blood tests are also carried out and there is usually a bronchoscopy — a direct inspection of the inside of the lungs with a thin fibre-optic instrument. Depending on where the cancer is, a sample of the tumour may be obtained and a sample of spit will be examined for cancer cells. If the cancer has spread, then a CT scan can provide more information about how severe this is.
Only one in five patients are suitable for surgery — another grim statistic — and many cases are therefore treated with chemotherapy, given either by an oncologist or by a physician in chest diseases with special experience in chemotherapy. Chemotherapy is effective in that it both prolongs and improves the quality of survival in many lung cancer patients but it is a powerful treatment and so has side effects, particularly nausea, vomiting and hair loss. Radiotherapy (X-ray treatment) can also be used in certain lung tumours, either with localised cancers that are inoperable, or for relieving symptoms such as blood in the sputum and severe bone pain.
So far, so depressing, and politicians of all hues queue up to promise various panaceas. However, this is where the harsh realpolitik of the NHS begins to show its face and it all starts with clever science in a laboratory.
Scientists have found that lung cancer cells have molecules on their surface that can in turn stimulate more cancer growth. This is similar to the situation we have in breast cancer, and just as with that type of tumour, drugs have now been developed to block these lung cancer receptors and so limit its growth and spread. This depends on knowing the genetic profile of the tumour from a biopsy — an unpleasant experience for the patient but one which has now been made easier and simpler by a new technique called endobronchial ultrasound.
Here, a special probe takes tissue samples from the lungs.This is employed in around 100 specialist units in Britain but regional variations exist and not all patients have easy access to this test, or any access at all. Indeed, physicians have no standardised pathway: the three main challenges to conducting tests locally are reported as no biopsy samples being available, no clear testing pathway, and a lack of funding for ordering tests. In plain language, the NHS has no infrastructure in place to enable the cost-effective and quick processing of these samples.
It is shameful that rates of such molecular tests for lung cancers are less than one third in the UK. In France, over two thirds of all lung cancer tumours are tested in this way.
If a biopsy is obtained, the sample can then be subjected to molecular diagnostic testing in order to match the tumour to a specific drug — known as ‘personalised medicine’ treatment. Such drugs are available that are both innovative and effective, and if I had lung cancer, I would be standing outside the Houses of Parliament demanding my right to them with my last breath. Ultimately we come down to the two things that any argument involving the NHS is always about — money and joined-up thinking.
In 2010 the government started a Cancer Drugs Fund, ostensibly to give people access to cancer medications that had not yet been approved by the National Institute for Health and Care Excellence (Nice). At ground level for my patients this has always seemed like smoke and mirrors and so it should have come as no surprise when last autumn it was announced that up to half the cancer drugs it was making available were being removed from the list because they were viewed as too expensive. This gives patients the impression that the whole scheme is illogical, subject to political whim and more like a vanity project than a serious attempt to improve the lot of cancer patients.
The money spent on the fund since 2010 would have been better served by ensuring that all laboratories across the country had co-ordinated facilities for molecular testing, so allowing for earlier treatment and improved survival rates in lung cancer. Until this happens, any new government will continue to fiddle while the lungs of the country burn.
Lung cancer stats
Around 43,500 people were diagnosed with lung cancer in the UK in 2011 that’s around 120 people every day.
9 in 10
Almost 9 in 10 lung cancer cases occur in people aged 60 and over
4 to 10
For every four to ten cases in women there are around 12 in men
Since the late 1970s incidence rates in men have decreased by 48%
Smoking is linked to an estimated 86% of lung cancer cases in the UK
9 in 10
Almost 9 in 10 lung cancer cases occur in people aged 60 and over
Six countries in Europe have a higher incidence rate among women than the UK
In Europe, over 400,000 cases of lung cancer were diagnosed in 2012
Worldwide, 1.83 million new cases of lung cancer were diagnosed in 2012
Overall, 5% of people diagnosed with lung cancer survive the disease for at least ten years after diagnosis
An estimated 89% of lung cancers in the UK are linked to lifestyle factors
Insufficient fruit and veg intake is linked to 9% of lung cancer cases in the UK