With the general election upon us, we have a chance to put our natural British instinct to complain into full swing.
And whilst the politicians can't fix Britain's single most common complaint, the weather, we as a populous might be able to put our money where our mouth is and vote for those parties offering to fix the things we care about the most.
As a cancer doctor, one of the biggest draws of my vote is for improvements to the NHS. Right up there with climate change and a general feeling of goodwill to all, my vote will go to those attempting to tackle cancer waiting times.
This topic of conversation has bizarrely not featured heavily in anyone's list of priorities or promises. Cancer seems to have been consumed into the vacuous blob and catch-all statement of - "Fixing the NHS".
A statement so nonspecific and detached from what the NHS actually is, that I wouldn't trust whoever throws it around to carry out the job - not with a barge pole! (Not that I would trust anyone to fix anything with a barge pole, but I'm sure you get the sentiment.)
So today let's talk about cancer services, why it really does matter if you have to wait for cancer treatment, and why it should factor in on everyone's decision-making when they hit the ballot box today...
Potholes and Sky TV
Whilst brilliant for a meme, the main issues that have repeatedly grabbed my news and social media feeds are funding Rishi Sunaks satellite dish and fixing potholes...
Now don't get me wrong, I feel sorry for anyone who grew up without Nickelodeon and the Rugrats. I probably developed the majority of my moral compass from Rugrats, and I think I'm a pretty all-right guy on the morality scale. Rishi, that explains a lot - HAH!
In addition, having had 2 tyres blown to potholes this year - I can thoroughly sympathise.
It's way more likely to happen than a cancer diagnosis - probably.
However, with the incidence of cancer diagnosis' steadily increasing, it won't be long before half of us will be sitting across from a doctor getting what feels like, and may in fact be, the worst news of our life.
Despite the 'C' word being up there when it comes to the most feared things your doctor is going to tell you that you have, people don't seem to care about it too much when it comes to hitting the ballot boxes. Maybe that's because there is a sense of general unknown regarding the consequences of such delays.
I mean, why would a member of the public who hasn't had a family member affected by cancer know what a delay in treatment means for them?
Most people don't want to think about it, and that's perfectly reasonable because it's scary road to take your mind down.
Outside of the hospital and outside of those in the know, It's easy to assume that a delay means you just have to wait in line a bit longer. Everyone knows that the NHS is struggling... I'll be reasonable and wait my turn, after all being British queuing comes very naturally to me.
However, given that delays cost lives when it comes to cancer, the general public needs to know why NHS waiting times matter. And I mean, really really matters.
Come on, are the delays really that bad? Isn't this just a bit of NHS bashing?
After seeing the result of these delays first-hand, I've had to discuss the unfortunate question of "Could this have been avoided if I had the treatment earlier?" multiple times.
But bias is a powerful thing, and the first thing I asked when I started investigating this subject was, "Are the delays really that bad? Surely I've just seen a disproportionate number of cases, this is just a bit of NHS bashing - we've all done it."
But much to my horror, the more I learned, the worse the reality of the situation actually became. To add insult to injury, these delays are not just a one-off after a bad year, or secondary to COVID and a catch-up effect. The waiting times have been steadily increasing for the last 11 years. (So conservatives - we are looking at you for someone to blame given you've been in charge for the last 14).
Give me numbers to back this up
I'm going to throw some statistics at you now to try and illustrate the problem.
For a moment, if you can, I'd like you to imagine you were at the end of one of these statistics. After all, every number here is a person, and statistically, you've got a 1 in 3 chance of it being you one day. That's a sobering thought in itself.
But also for every parent, sibling and loved one out there, each one of these numbers is someone waiting for treatment. As a father and husband, that scares the hell out of me.
So to give a snapshot of cancer waiting times from Cancer Research UK, here are the latest results in England for April 2024:
The Faster Diagnosis Standard: Target Missed
73.5% of people were diagnosed or had cancer ruled out, within 28 days of an urgent referral in April 2024. The target is 75% and this target has only been met twice since its introduction in October 2021.
The 62-day referral to treatment standard: Target Missed
Only 66.6% of people in England received their diagnosis and started their first treatment within 2 months (or 62 days) of an urgent referral* in April 2024. The target is 85% and has not been met since December 2015.
The 31-day decision to treat standard: Target Missed
89.2% of people started treatment** within 31 days of doctors deciding a treatment plan in April 2024. The target is 96%.
Not looking good is it!
Holy potatoes. But surely cancer waiting times have been a government priority for a while?
Unfortunately, the track record suggests differently.
So what do delays to treatment mean?
Not to kick start your voting day with a bout of depression, but we are talking about the difference between living vs. dying due to delays in treatment.
To directly quote CRUK :
"The picture is different for different cancer types – some progress quicker than others – but we know the overall impact is likely to be negative. One study estimated that a 4-week delay to cancer surgery led to a 6-8% increased risk of dying."
Enough Sam, don't be a politician, back this up with the Science!!
I do not wish to come across as callous or unsympathetic, especially after asking people to put themselves into a mindset of being on the other side of the statistics I've been quoting.
But to understand the science behind the statistics and do something about it, it is important to be able to create a picture without being emotionally attached to the numbers. So forgive me for talking bluntly about life and death due to cancer in the following passages.
To start with, it's worth highlighting that this isn't new information.
We've known for a while now that the longer you wait for your treatment, the more likely you are to die of it. It's also not rocket science when you think about what cancer is. Uncontrolled cell proliferation. The longer it's in your body left unchecked - the longer it has to grow and try to move around.
This paper from the October 2020 British Medical Journal sums it up nicely:
With an accompanying visual abstract:
For those unfamiliar with the language used above, this paper has taken common cancers like lung, breast, and colon cancer, and performed analysis on the likelihood of death due to delays. Specifically, delays in surgery and adjuvant treatments.
(Adjuvant treatment means chemotherapy or other systemic anti-cancer therapy after having surgery). It uses the term 'Hazard Ratio' to describe the risk of death for every four-week delay in treatment. A Hazard ratio is used in survival analysis to compare the outcome of two groups.
The diagram above illustrates these hazard ratios with green lines with dots.
Despite the soothing green, this is showing us bad news.
To explain this a bit more clearly, I'll take the specific example of breast cancer from above:
Here you can see that the hazard ratio of a delay in surgery for breast cancer is 1.08 (4-week delay) vs 1.0 (no delay).
What does that mean?
That means for every 1,000 patients who have a delay of 4 weeks of treatment, 10 additional people will die.
Exactly.
Explaining the numbers
For those of you who are keen-eyed, the inforgraphic showing 10 extra deaths per 1,000 - you may say - well wait if it's a hazard ratio of 1.08 or an 8 % increase - how does that calculation work ?!
What is shown in this study is that sadly, 12% of breast cancer patients will die even if there is no delay in their surgery.
So if you have 1,000 patients - 12 people will die regardless of any delay.
Because of the delay, there will be additional deaths. The key word here is additional.
To work out how many additional deaths, we use the calculation below:
Additional deaths = Baseline mortality * Hazard ratio increase
12 * 8 % (0.08) = 0.96
So just under ~'1' (or 0.96 ) extra people per hundred people will die, or ~10 additional people will die per 1,000. That may not seem a huge amount. But given that we have around ~56,000 new breast cancer cases a year, that number quickly becomes very relevant.
What about the non-surgical side of things?
I'm no surgeon, but the delays in treatment affect us all as caregivers in the multi-disciplinary team. My realm of expertise falls in the giving and analysis of systemic anti-cancer therapy, including chemo, targeted, hormonal, immuno... and pretty much any other word you can add the 'therapy' postfix to.
One of the shocking results shown is the delay of adjuvant systemic therapy in colon cancer. A hazard ratio of 1.13 from a delay of 4 weeks. A shocking additional 13% of patients will die.
Further research in this area has shown that starting adjuvant chemotherapy (i.e. giving chemotherapy after surgery to mop up all the invisible cancer cells that might be there), if it's not started within eight weeks for colon cancer patients, significantly increases the likelihood of the cancer coming back, and you then being more likely to die.
Well - what are we waiting for !? Let's fix this - I don't want to wait for treatment and die because of it. If only it was that simple, what most people don't realise is the chain of events that has to happen from diagnosis to starting treatment. Let's have a look at the chain...
Cancer: Diagnosis to treatment
It takes teams of experienced people to get you from your first symptom to treatment.
(And this is assuming you have a symptom - some people are picked up on screening or present with an emergency where the cancer has already spread).
So to give you a flavour of what has to happen before you're even in front of someone like me who can talk to you about what treatments are available - something like the below has to happen:
GP Visit: You have to visit your GP with symptoms, and they have to diagnose you with a suspected cancer. GP's generally do a very good job of picking up the red flags of cancer despite what you might think. If you've got a an ache or pain, it's far more likely to be something that isn't cancer related, and that needs to be explored first. However, if there is a concern, an urgent referral needs to be made!
Referral to Specialist: GP refers patient to a specialist for further examination.
Imaging: Specialist orders a CT scan with detailed images of the suspected area elsewhere to see if the cancer has spread.
Biopsy: A biopsy is performed to collect tissue samples from a safe place to put a needle into.
Determine Cancer Type: A pathologists has to take this sample and analyze it under a microscope to determine the type of cancer and how aggressive it is. It also needs to be tested for genetic markers and biomarkers that will guide treatments.
MDT Discussion: Multi-disciplinary team (MDT) discusses the case to formulate a treatment plan. This includes surgeons, oncologists, radiologists and pathologists. You want all the experts there agreeing on what it is, where it is, and what the best way of treating it is.
Treatment Plan: The treatment plan is finalized based on MDT recommendations
See your specialist (Surgery / Oncology) : This is where you find out you've got cancer. Discuss what your cancer is, how we can treat it, and give you a chance to decide if you want treatment or not.
Start Treatment: Once you've given the green light, we get you into a slot ASAP.
As you can see from the above, there are lots of places these delays can be introduced. Diagnosing and treating cancer is a complex beast with lots of moving parts.
Voting Day: Problems problems problems, what's the solution then?
There is no magic pill for this. No quick fix.
So what can we do about it?
It's going to take thought, investment of time, money and someone who understands the system.
We can vote for a party that recognises this is a big problem and is going to do something about it. Not just privatise the hell to line their own pockets and so only those with cash can afford it. (Speaking of which we need a party that will stop the dodgy deals and backhanders going through parliament - PPE anyone?!)
To the politicians
At the end of the day, I don't want a politician promising to cut my taxes.
I'm not a rich man, I get by and that's okay. Of course, I want more money, who doesn't?
So tax the right people who can afford it. Tax the companies making billions from us and not paying tax. Invest that money in the country and the NHS. Stop promising nonsense, and inventing money out of nothing to make us all have a few less tax bucks to pay whilst the system falls apart.
Acknowledge there are problems, and that it will cost money to fix them. Spend it on the right things. Not your ever-increasing disproportionate public service salaries.
When you do that, we can start looking after everyone who needs it - properly.
Especially those with cancer, and not just those who can afford it.
Summary
People will die of cancer that didn't have to because of delays.
This is the long and short of my message.
So come this 4th of July, please vote to help our NHS.
Wealth is important. But health is more important. You can't buy health.
I'd give everything I have if it meant keeping my family healthy. Most would. Many do.
I've been apathetic in the past, feeling my choice didn't really matter - however, this year I'm going to show those supposedly running the country that I think we've all had enough.
I think it's safe to say that we have been misled, messed around, and generally we are all very pissed off about it. Today our act of civil disobedience should not be apathy, it should be our vote.
