Guest post: Are older cancer patients missing out on surgery?

John Butler is a Consultant Gynaecologist at the Royal Marsden Hospital. Here, he gives us his thoughts on new data on surgery in the NHS

As a surgeon I see patients of all ages – from the young to very old.

All patients must be treated with the same level of diligence. The aim of cancer treatment is, after all, to provide the best chance of survival, the lowest chance of recurrence and the best quality of life for patients, no matter what age they are.

Surgery is often the most effective treatment for solid cancers – it is estimated to contribute to half of cases where cancer is cured. For some patients with early stage cancer, cure can be achieved with surgery alone.

But we know that survival in the UK lags behind other comparable countries, and the evidence suggests that treatment quality is likely to be a significant factor in this.

So, is it really the case that patients of all ages get access to the surgical treatment they need? This is what the analysis published today by Cancer Research UK and the National Cancer Intelligence Network (NCIN) has tried to determine.

The findings paint an interesting picture, with data showing that older patients are having significantly less surgery than younger patients for a range of cancers.

But while this analysis provides very useful information, the data don’t tell the whole story:  there are many things that influence why older patients may not have surgery.

So it’s still hard to tell whether the levels of surgery identified are too low – or perhaps even too high.

Why might patients not have surgery?

“What becomes more challenging is when the health system is stressed” – John Butler, Consultant Gynaecologist

A patient is much more likely to be eligible for surgery if their cancer is diagnosed at an earlier stage. This is why early diagnosis is so incredibly important.

Without looking at stage, and often the subtype of cancer, it is very hard to tell whether patients – old or young – would be appropriate for surgery in the first place.

So it may be that patients are receiving appropriate treatment for their condition because it is so advanced, rather than them missing out on surgery due to “ageism”.

Also, the older patients are, the more likely they are to have other health problems that may prevent them from being able to undergo safe surgery.

Another factor is patient choice. After the options have been discussed, patients rightly have the final say about what treatment they want to have. Some might simply not want to have surgery, but there isn’t really any way we can tell this from data.

The opinion patients have around surgery is important. And the publication of surgeon-specific mortality data last month shines a light on surgery outcomes and, I hope, will lead to further improvement.

But while I support the principle of transparency, I hope that publishing these data doesn’t make surgeons more risk averse when it comes to treating more challenging cases who could benefit from surgery – for example the elderly, or patients with other health problems.

But pressures on the NHS are an issue

In my own practice and experience, the NHS is generally good at treating young patients where the choices around treatment are straightforward.

What becomes more challenging is when the health system is stressed. This is clearly the case in cancer services at the moment, as we can see through the 62 day waiting time standard – the time taken between a patient being referred for diagnosis and receiving their first treatment – being missed for the third successive quarter.

For many older patients major surgery is possible and safe. But it requires close working between surgeons, anaesthetists, intensive care teams, nurses, physiotherapists and community services.

Another particular problem is the availability of intensive care beds for elderly cancer patients undergoing surgery.

In my specialism, ovarian cancer, surgeons are sometimes not able to operate for several weeks due to delays these issues create, and therefore many patients will receive chemotherapy rather than surgery.

This reflects both pressures on the NHS’s capacity and, in perhaps some cases, a misconception that little can be done for some older cancer patients.

Further investigation needed

Let’s not forget that we are getting better in the UK. For example, lung cancer is among the cancers with the lowest survival. But through greater involvement of surgeons who specialise in lung surgery within multidisciplinary teams and other mechanisms to understand rates of lung surgery, survival for all age groups in lung cancer has started to increase.

Today’s analysis provides a great platform to further understand issues around access to surgery. And while it doesn’t necessarily tell the whole story, it most certainly highlights the need for further investigation into the reasons for the lower surgery levels among the elderly.

I would be particularly interested to see research on how surgery varies against things like stage of diagnosis and where people live; comparisons with radiotherapy and chemotherapy access; and the impact of patient choice.

All in all, to improve our survival we must ensure cancer is diagnosed early, improve access to potentially curative treatments like surgery and support the NHS to deliver them in a timely fashion.

Making sure all patients – young or old – get the best treatment is vital. And understanding the reasons behind variation in access will give us the tools to do this.