Early diagnosis, NHS under pressure, skirt sizes, and progress in bowel cancer
Kat: This is the Cancer Research UK podcast for October 2014. This month, the challenges of late diagnosis in an NHS stretched to breaking point, chasing the evidence on skirt size and cancer risk, and a personal story of progress. Plus our heroes and zeros.
Hello and welcome, I’m Kat Arney. If you've been following the news over the past few years, it's been hard to miss the headlines about the changes that have been happening to the NHS. This month we released a report looking at the state of cancer services within the NHS, which reveals that cracks are starting show in an NHS stretched to breaking point. At the same time, a new analysis shows that investing in diagnosing cancer earlier could save the NHS significant amounts of money, as well as saving many lives. To shed some light on what these reports mean, our reporter Greg Jones spoke to senior policy manager Emlyn Samuel.
Emlyn: The NHS in England has been through a huge period of change. It's been tied down by financial constraints for a number of years, it's been through a huge NHS reform, and so we wanted to just assess how cancer services are working, how they're performing for cancer patients today.
Greg: So what has the report told us about how they're performing?
Emlyn: I think the high-level findings show that actually they've held up remarkably well, and that's really a credit to the NHS staff who've been working in cancer services. But there are really worrying signs as I said. It's been through a period of huge change, the financial constraints it's been under and the reforms that it's been through, coupled with a huge increase in demand for the services, means that they're really starting to struggle and we're starting to see signs of patient care starting to fall off a little bit. And so that's where it's starting to be worrying and we need to see investment in those services to make sure that we can keep the care that is needed.
Greg: So what needs to happen now? What are the next steps? How do we respond to the findings of this report?
Emlyn: I think the findings are quite clear. What Cancer Research UK's calling for is greater investment in NHS cancer services. What it shows us is that we need greater national leadership on cancer. We really need people in the Department of Health and NHS England to really drive forward improvements in cancer services. I also think there needs to be better clarification about how cancer services are commissioned in the NHS as well, so those are the major things that we would like to see happen.
Greg: We've also seen a report out recently that has identified that nearly half of cancers are diagnosed at a late stage. What's the significance of this?
Emlyn: This is really worrying because we know that if we diagnose cancer earlier then the chances of survival are much greater. This is because you have better treatment options, more effective treatment options, and you're more likely to survive. So it's really important that we get better at diagnosing cancer earlier. So these are quite worrying figures. And we also published a report that looks at the financial benefits as well as the patient benefits in the NHS, of diagnosing cancer earlier as well.
Greg: What has that found? Is that saying there's a difference in the cost of treating a patient if they diagnosed earlier as opposed if there diagnosed late?
Emlyn: So the report looked at four different types of cancer: colon, rectal, ovarian and lung cancer. And it found that if you diagnose at the earliest stage than the cost implications for the NHS are quite great. It found that about £44 million could be saved and that would benefit over 11,000 patients. So provides a compelling case to invest in better early diagnosis of cancer.
Greg: We know that we have a growing and an ageing population, the number of cancer cases is going to continue to rise. So what action do we need to be taking now in order to deal with future demands of cancer patients who are going to be going through the NHS?
Emlyn: I think the evidence that we've produced recently shows that we really do need investment in cancer services. We need to make sure that the NHS can cope with the increasing demand that is going to be seen, we need to diagnose cancers earlier, and we really need to make sure that there is enough resource and investment in cancer services to make sure that our cancer outcomes are comparable to the best in the world.
Kat: Emlyn Samuel talking to Greg Jones. Another story that hit the headlines this month was about the link between skirt size and cancer risk, based on results from a UK study of nearly 93,000 postmenopausal women that looked at whether increasing skirt size since their twenties was associated with increased breast cancer risk. It found that going up a skirt size every 10 years - say from a size eight at age 25 to a size 16 at 65 - was linked to a 33 per cent increased risk of developing breast cancer after the menopause. Although that may sound like a lot, overall just over 1 per cent of all the women in the study developed breast cancer, so it's actually an increase of a third from a relatively low starting point. Not only that, but there are a few other things to bear in mind about the study, as our health information officer Tom Stansfeld explains.
Tom: While this study was really interesting, there are a few fundamental issues that we had with it. So it was asking women who were 55 or 60 to remember their skirt size when they were in their 20s, which already can lead to a few issues with self reporting. Also we were slightly concerned that dress sizes have actually changed. So what was a size 10 or 12 then is a different size now, so being able to measure against what is essentially a moving scale is quite difficult. So while the study is interesting and it did show that an increase in skirt size over time increased the risk of postmenopausal breast cancer, the message that we want people to take home is that watching your weight and knowing if you are overweight is a much simpler and straightforward message to take home.
Kat: Tom Stansfeld. And finally in the news this month, our scientists at the University of Manchester, led by Dr Claudia Wellbrock, have made an important discovery about how melanoma skin cancer cells can twist the immune system to their own ends – a finding that could pave the way for more effective treatments in the future. Their work has been published this month in the journal Cancer Discovery, so I asked our senior science communications officer Dr Emma Smith to explain more.
Emma: The researchers were looking at the most serious type of skin cancer called melanoma, and what they found is that a type of white blood cell called a macrophage actually senses the tumour cells and they can kind of understand that the tumour is wrong, that the tumour cells aren't meant to be growing out of control like they are. And these white blood cells produce an SOS signal to get the rest of the immune system charged up and to try and attack the tumour. Actually the scientists found out that the cancer cells are hijacking this chemical signal and using it to help themselves survive and carry on growing. So by stopping these white blood cells, the macrophages, releasing this chemical call to action the team found that the tumours actually didn't grow so quickly and the melanoma then became easy to treat.
Kat: This sounds really exciting, but is it something that is going to be a treatment very soon? Where do we go forward from this?
Emma: So it isn't treatment at the moment, but this approach could lead to a new kind of treatment called immunotherapy, which is a really promising and exciting field at the moment. What it could lead to is a new treatment that actually makes the current standard of treatments for melanoma more effective by boosting an immune response and slowing down the growth of the cancer cells themselves. But unfortunately, as with most research, it is still early days and the treatment doesn't exist yet. It's been tested on cells grown in the lab and in mice, but it is a promising combination and we really look forward to seeing how it progresses in the future.
Kat: Emma Smith, on the latest discovery in skin cancer.
Back in 2012, Nicola Bourne was shocked to discover she had bowel cancer at the age of just 31, while coping with two small children. Not only that, she was the fourth generation of her family affected by the disease. Based on this experience, Nicola thought she knew what to expect, but she was surprised to see how far treatment had moved on in just a decade since her mum’s diagnosis. She told our reporter Alan Worsley how things have changed.
Nicola: I had a very strong family history of bowel cancer: my mother had passed away from bowel cancer four years earlier, my grandmother a few years before that, and 10 years earlier had been the first time my mum had bowel cancer. So I'd been through the process already with her having it, having the treatment. I was thinking she'd got better and then subsequently having a terminal diagnosis.
Alan: So when you started to see the symptoms, you thought "I know what this is". Was it difficult to convince the GP to diagnose it?
Nicola: Yes very. When I first started getting the symptom of rectal bleeding, which was about eight years before I was diagnosed, I went to see the GP then. He was completely dismissive and said I was far too young to have bowel cancer,. He said that if the bleeding stopped I didn't need to worry. The bleeding did stop, so I thought "Great, I'm just being paranoid". But I now know that would have been the early stages, and actually intermittent bleeding is [not] normal, so that was a false hope.
Alan: A false positive in a sense. You were showing one of the classic signs, and you knew it was a sign, and even though at the time you were quite young - so 30s quite young to get bowel cancer - but with these hereditary bowel cancer cases it can happen that early. Was it a fairly constant worry?
Nicola: In the years leading up to the diagnosis, I'd say it was on and off really. If the bleeding came back I would start to panic and I'd normally see a GP who would say it was nothing, but I guess in my heart looking back I wonder if I kind of did know. But it's easier to just think "No, they know what they're doing", and leave it there. During my second pregnancy with my daughter the bleeding became so severe that just going to the toilet at all became excruciatingly painful, and I knew there was something absolutely wrong.
I did go to the GP and I spoke to the midwife but in both instances they felt that some rectal bleeding was normal during pregnancy. I kept saying this is not normal, this is extreme, and I later found out that the tumour was actually growing into the back passage and that's what was making it so painful. That was really when I pushed to be seen, at six weeks after the baby – you have a check to make sure that you are the baby are okay – I went back and said it's worse, it's even more painful...
Alan: ...I'm not okay...
Nicola: ...it's not pregnancy related, that was when they finally... you know.
Alan: And then what happened after the diagnosis?
Nicola: After the diagnosis, further tests and I had a PET scan which showed that it was much more advanced than they had initially thought. It had spread from outside the tumour and through the bowel, so I knew it was going to be a big amount of treatment and a very large operation. In a way I just went into a very practical mode. I think that everybody else panicked, whereas I was just a lot more trying to figure it all out. I knew that especially with having the baby and a toddler, they said very early on that my treatment was going to be extreme, so I would have very little energy and I would need help. We hired a nanny, which thank God we were able to do, because that's just not an option for a lot of people and I honestly do not know how they manage to cope. But, having said that, I also didn't have the support from my mum obviously, because she passed away a few years earlier.
And it was for me like that the whole way through, okay let's deal with the chemo, let's deal with the radiotherapy, there's always the next push to get better. But I started waning quite heavily, especially after the surgery, I was very tired and I just felt I couldn't keep fighting any more. That last three months, going back on chemotherapy and stuff for that last time, I just felt I don't want to do this anymore, just leave me alone. I don't care if I'm not, get well, I just don't want to do this any more – but you know you do.
Alan: What was the difference you'd seen between the treatment that your mother went through when you went through?
Nicola: It was huge and I didn't expect it to be as big of a difference as it was. When my mum was ill she had an operation, followed by six months of chemotherapy, which was given to her intravenously once a week in hospital. She had heard that there was a chemotherapy tablet that you could take at home being developed, and she asked about it, but the oncologist said that it was still in the trial stages and wasn't available. But when we started talking about my treatment, that chemotherapy tablet have now become the standard. So for me I only had to go into hospital once every three weeks to have chemotherapy intravenously, and the rest of the time for two weeks then I would take the chemotherapy tablets at home.
Alan: Especially as a mother, being able to spend the time at home as opposed to being in hospital – and just in that 10 years things had advanced...
Nicola: Yes, a massive change. And it wasn't just with the drugs, it was also with the care that surrounded the whole cancer experience. Having dedicated nurses in the hospital who were supporting you, there was so much emphasis put on the patient's experience and how you are feeling, what they could do to help with the effects. I felt with my mum it was a lot more like, "It's chemotherapy of course you're going to feel sick, of course you're going to feel unwell and have no energy", but with me it was constantly "How are you feeling? What can we give to counteract that? We've got other anti-sickness drugs we can give you". It was the whole thing - it wasn't just the chemo, it was all the medication around it and the attitudes towards me.
Alan: The entire experience.
Nicola: Yeah, it was just completely different
Alan: What would you hope to see in the next 10 years?
Nicola: For my case specifically, with my mum, grandmother and my great-grandfather, we've all had it. It has been looked at by the genetics team, and they haven't been able to find a link. They're confident there is one, obviously, because there's four generations, but they can't find it yet. So they're going to review my case in five years and then be able to retest against the latest genetic findings. So for me that's one of the big areas, if we can try and find if there is this genetic link, for my children but also for my brother and sister – if we could find a way of just being able to know if it is something that they need to be concerned about or if they have skipped the gene, fingers crossed.
That would make a massive difference, knowing that should my kids be faced with this, this is the difference between my mums and my treatment, again, should they face it there would be that leap again where it would be even more comfortable, and even more patient focused and helping with the symptoms. And also for myself, I know what it is to lose a mum to cancer. I was 28 when my mum passed away, my brother was only 18, and obviously has a massive impact. And while I appreciate they will lose me one day, I want it to be as late as possible. I want to be here to experience as much of their lives as I can. My mum never got to meet her grandchildren, I want to meet my grandchildren and get to experience all those things. So for me as well I want the research to keep finding a way to make sure that I never have to go through anything like that again.
Kat: That was Nicola Bourne talking with Alan Worsley. And you can read more of Nicola’s story on our blog – just follow the link in the Soundcloud player.
Now it’s time for our heroes and zeros. Following on from our news story about the stresses on the NHS, our heroes this month are the NHS staff who are stretched to breaking point to provide cancer services across the UK, in the wake of NHS reforms that have fragmented the country’s cancer networks and a growing demand for services. We salute all the hardworking NHS staff who have done so much to help more people survive cancer, but without better funding, planning and leadership, the future for the nation’s cancer services is looking bleak.
And finally, our zero this month goes to overexcited media coverage of early lab results ranging from claims that berries should be added to chemotherapy, or that the cure for cancer is lurking in toads. A very early stage lab study found that combining wild chokeberry extract with chemotherapy was more effective at killing pancreatic cancer cells growing in a dish. But it’s far too soon to know whether the same effect will be seen in patients. Similarly, another lab study showed that the venom produced by cane toads can kill cancer cells in a laboratory dish – again, a long way from being an effective or safe treatment for actual people.
That’s all for this month. My thanks to Alan Worsley, Greg Jones and Stephanie McClellan for production and reporting, and we’ll see you again next month when we report back from the NCRI Cancer Conference – the UK’s biggest gathering of cancer researchers.
We’d also like to answer your questions in our podcast, so please email them to firstname.lastname@example.org, post on our Facebook page, or tweet us – that’s @CR_UK. And if you’re listening to this on Soundcloud, please leave us a comment with your feedback. Thanks very much and bye for now.