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The New NICE Guidelines for Management of Breast Cancer—A Personal Commentary
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The nice face of rationing
Rationing, as we think we understand it, was imposed in World War II to harness the country’s economy to common effective endeavour, which as a by-product promulgated a sense of national unity, and undoubtedly improved the health of the populace. Arguably, much of the electorate’s distaste for food rationing stemmed from its extension 9 years into the peace, after the enemy was beat, but at a time when the nation was burdened by massive debts as well as the immense costs of reconstruction.
Doctors were closely involved with rationing from its inception. Much of the underlying nutritional science had a sound theoretical basis in pre-war work on food composition by Professor Robert McCance and Dr Elsie Widdowson. At the outbreak of the war, they were charged with investigating whether the supply of home-produced food might be stretched by rationing to meet the nutritional needs of the populace. They studied the effects of a diet that some considered intolerable by living on it themselves for 3 months, before finally undertaking a 12-hour, 36-mile hike across the Lake District, including a 7,000 ft climb to prove the diet’s effectiveness in sustaining hard, physical activity.3 The War in the Atlantic aside, from a medical perspective, nearly 7 decades on, wartime food rationing seems to have been an unqualified success: infant mortality declined, and the average age at which people died from natural causes increased. And certainly to me, as an undergraduate, the sight of a lean, fit, sparkly eyed 90-odd-year-old McCance wobbling about on his bike in plus fours was a great advert for a lifetime of black coffee for breakfast, an apple for lunch and plenty of potatoes and sprouts for dinner.
In this edition of Cancer Services Forum, Professor Chris Poole’s personal commentary on the new NICE guidelines for breast cancer provides a colourful account of what he describes as NICE rationing. He discusses some controversial issues around continuing inequalities, a perceived non-transparency of data analysis and the problems with clinical trial crossover when looking for meaningful endpoints on which to base funding decisions.
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Discussion.