Equality in access to cancer treatment: a crossroad in UK cancer services?

Dear Colleagues,

Welcome to the October 2011 issue of Cancer Services Forum.

This month’s issue features an update on key points of interest in cancer services written by Succinct Healthcare Communication’s own Carolyn Staines. The update looks at The Lancet Oncology Commission‘s report, Delivering affordable cancer care in high-income countries, which considers the major problems concerning all those involved with the planning, delivering, receiving and paying for cancer care in the UK.

I hope you enjoy this month’s issue. If you would like to have your say on any of the items discussed, please email me at csf@succinctcomms.com or post your comment online at www.canserforum.com

The Editor

Cancer Services Forum

Introduction

In September 2011, The Lancet Oncology Commission released the report Delivering affordable cancer care in high-income countries.¹ This report highlighted a major issue facing people involved with planning, delivering, receiving and paying for cancer services in the UK: how can we afford to deliver high-quality and equitable care? This issue affects all countries, and difficult decisions have to be made in determining policy, providing services and paying for the rapidly evolving cancer care pathways. We also need to assess the potential effect these decisions have on equality of access for patients.

Media misunderstandings

The overall message of the report is that we can afford to deliver outcome-driven high-quality cancer care, but only by making fundamental changes to how we think of, and measure, the concept of “value” applied across integrated care pathways. However, the media have focused mainly on one aspect of the report, with emotive articles stating that cancer specialists believe spending money on high-cost cancer drugs at the end of life is futile.^2,3 Few people who have read the report in its entirety agree with this interpretation. Although we may baulk at the use of the term futile, what the report actually highlights is that a substantial proportion of the total spend on cancer care is delivered in the last weeks or days of a patient’s life, and that much of this care, such as chemotherapy, is futile. Such treatment may potentially be in conflict with the patient’s wishes and can have a detrimental effect on quality of life. Providing futile disease-directed care can “distract from a focus on palliative care that can improve quality of life and even prolong survival”.¹ The media reports do not recognise that end-of-life care involves a range of active options other than chemotherapy, and that the focus should be on what delivers the best qualityof- life outcomes for patients and their families. In this context, the report refers to “cancer care” not cancer drugs specifically. It is also patient-centric and makes an important distinction between endof- life management and palliative care, a distinction that is missed in most media reports. We need to ensure that the key messages of this report are not misrepresented and that attention is not diverted away from the crucial question: how to ensure that cancer care in the UK is built around equality of access to treatment that provides the best outcomes within an affordable framework to maximise value both to society as a whole and individual patients.

In my discussions with clinicians and service managers, it is clear that their focus is on the issues of enabling equality of access to care that delivers the best possible outcomes (in its wider context) and delivering quality care pathways within an affordable budget. Our concept of what “value” and “outcomes” mean to patients, society and the NHS is fundamental to the direction we choose to take with cancer care in the UK.

Key issues

So what are the key messages of the Lancet report?

The report highlights that people involved in cancer care in the UK need to start thinking differently about how to define “value” and “outcomes”, and how these definitions might change at different parts of the care pathway. The authors note that society’s views are essential, although they must be derived through consulting with patients and an “informed” public. Our perspective of value must bear in mind that certain treatments may be ineffective or just marginally effective, but still incur a high cost and have unwanted effects on the patient. Furthermore, use of resources on such treatment can mean loss of opportunity to allocate the resources elsewhere in the care pathway.

Costs and resource use need to be considered within the framework of an integrated care pathway that includes the whole system of healthcare (disease-directed and supportive therapeutics, screening, disease prevention, and diagnostic and professional services). If we continue to develop and evaluate cancer care only within different fragments of the care pathway, we will be unable to identify the effect that investing or reorganising in one part has on outcomes and value. Efficiencies can be made by identifying care episodes that have little or no effect on health outcomes. Importantly, the emphasis is on health outcomes rather than just a single outcome criterion, such as survival.

An important issue is to ensure care pathways are based on a high-quality evidence base. The burden of proof of value should underlie all decisions at intervention points in the care pathway, including diagnosis and follow up. In this context, the report authors cite the current interest in identification of biomarkers for treatment efficacy—a major topic of discussion at the recent European Multidisciplinary Cancer Congress in Stockholm. We still have some way to go in order to realise the full potential of personalised cancer treatment based on individual tumour factors, and such an approach will require investment in genome testing. However, the value of personalised, biomarker-guided treatment will become evident in the ability to assign patients to treatments that they are likely to respond to, and sparing them from the side effects and complications of ineffective treatments. Underpinning the recommendations made in the Lancet report is the requirement for accurate data. Treatment strategies are generally based on data from quantitative clinical trials, which do not necessarily translate to the patient population seen in the clinic. To fully consider the true value of certain facets of cancer care, the NHS will need to incorporative more qualitative research into its evidence base.

Summary

The tension between national, regional and local health decision making in the UK is not new, and is underpinned by issues around equality (of access, provision, funding and outcomes). Cancer care provision and funding are complex, and the economics and affordability of introducing new technologies into care pathways has long been one of the factors affecting equality of access.

The acquisition cost of cancer drugs is only one small part of this equation, but has a high profile since it is an easily identified (but oversimplified) comparator for equality of access. It is also a parameter whereby efficiencies may also be cash releasing, unlike many efficiencies in the NHS.

Several factors need to be acknowledged before a discussion around equality of access, value and affordability can take place. Much has happened to address the UK-wide inequalities in cancer outcomes, first addressed by the Calman Hine report in 1995.⁴ There are several reasons for the variation in cancer outcomes, including local population factors, such as ethnic, cultural and socioeconomic differences and variation in exposure to causal factors. There is, therefore, a rationale to combine national policy standards and targets with local decision making on how the cancer budget is best spent to meet local demands. The challenge is that each locality may have a different baseline for each part of the care pathway, dependant on the population and its health needs. Equality of access to specific treatment options must be viewed in this context. Cancer networks have come some way to reconciling national directives and local decision making to the best service decisions regionally. Nevertheless, there is still national inequality of access across the UK, since comparisons between what interventions a patient may have access to are made within the context of comparing only fragments of an overall patient pathway.

The Lancet report will hopefully be considered in its entirety and not judged on the emotive headlines in the media. The route we decide to follow at this crossroad in oncology will determine if we can continue to develop affordable cancer care that delivers the outcomes and values that society deserves.

References

1. Sullivan R, Peppercorn J, Sikora K et al. Delivering affordable cancer care in highincome countries. Lancet Oncol 2011; 12: 933–980.
2. Sky News. Dying cancer patients given ‘futile’ drugs. Available at: http://news.sky.com/home/ uk-news/article/16077913 (accessed October 2011).
3. The Guardian. Call over ‘futile’ cancer treatment. Available at: http://www.guardian. co.uk/uk/feedarticle/9867172 (accessed October 2011).
4. Calman K, Hine D. A policy framework for commissioning cancer services: a report by the expert advisory group on cancer to the chief medical officers of England and Wales. London: DH, 1995.