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New data out today offers a first glimpse at one aspect of the effects of cancer treatments, such as chemotherapy, across the whole NHS in England. Here, our chief clinician, Professor Peter Johnson, outlines the role these data will play in improving care for cancer patients in the future.
It’s always an uncertain time for cancer patients and their families when treatment is about to start.
But it can also be true for doctors like me.
We want to be sure that the treatments we prescribe have the best chance of helping each individual patient. And this is particularly true when considering treatments that can affect the entire body – including chemotherapy, targeted drugs and the latest immunotherapies.
It’s vital that we know as much as possible about how these systemic anti-cancer therapies (SACT) affect the different patients who arrive in our clinics with different needs.
We also need to know whether our patients are getting the best possible care, so that we can find ways to improve.
We know that UK cancer survival has doubled in the last 40 years but, frustratingly, we’ve not been able to measure all the finer details that we need. In fact, there has been very limited data on what happens to patients receiving these treatments in the NHS, despite most of them being prescribed on computers.
Today, that is starting to change.
We’ve been given a first look at new data, held by Public Health England, which allows us to examine these issues for all patients receiving these treatments in the English NHS.
In the first study of its kind in the world – published in The Lancet Oncology – we’ve worked with Public Health England to examine one aspect of how we deliver these treatments. We’ve measured the proportion of lung and breast cancer patients throughout England who die within 30 days of being given a dose of SACT treatment.
All types of treatment come with risks as well as benefits. It’s only by understanding the risks that we can manage them effectively, and ensure that our patients have the information to balance them against the potential gains.
We can’t say from this data whether specific patients should or shouldn’t have had different treatments. But it’s obvious that dying so soon after treatment makes it very unlikely someone has had the benefits that might be expected for other patients.
Crucially, what this data does is put our treatments in context. It starts to help doctors like me understand why these deaths occur and helps us minimise the risks and improve care for patients.
A rare event
Reassuringly, the report shows that these short-term deaths are relatively rare – similar to the findings from smaller studies.
In total we examined data from 28,364 women with breast cancer and 15,045 men and women with lung cancer who had received these treatments in England in 2014.
We found that for patients given SACT treatments with the intent of curing their disease fewer than 1 in every 100 breast cancer patients and 3 in every 100 lung cancer patients died within 30 days of having treatment in England.
The data also showed that the risk of these deaths depended on the age of the patient, their general wellbeing, gender (for lung cancer patients), and whether the treatment was given for curative or palliative reasons.
There were more deaths within 30 days for patients receiving palliative treatments, but they were still relatively rare – 7 in every 100 breast cancer patients and 10 in every 100 lung cancer patients. These patients had advanced, incurable cancers and the aim of treatment was to improve their quality of life for as long as possible by controlling cancer growth and providing relief from their symptoms.
For these patients, who are often very unwell, the risks are unavoidably higher. It’s essential that doctors like me have frank discussions with patients in these situations so we can agree on a treatment that will give them the results they want.
These findings help us to do that, so we can decide together whether these more intense treatments are the best way to achieve those results.
Knowing the details lets you know the risks
It’s a complex picture and we know there are gaps in the data, but now we have this information for the first time we can begin understanding it to improve the outlook for our patients.
One important result was that short-term death was more likely for older patients with breast and non-small cell lung cancer (NSCLC) who were given these treatments with the aim of curing their disease.
For the oldest group of breast cancer patients, the risk of short-term death was also higher than some estimates from clinical trials.
It’s likely that this is because older patients tend to be frailer, with other health problems and less able to tolerate side-effects than their younger counterparts.
A new benchmark
Previously, the only estimates of these deaths have come from clinical trials, which tend to involve patients who are younger and with few other medical problems.
In the real-world environment of the NHS, the situation is far more complex.
That’s why these new data, which includes patients from across the nation, are so vital for understanding how the risk differs among patients who fall outside the carefully defined rules of a clinical trial.
The report also shows that the risk of short-term death varies between NHS hospital trusts. At the moment there are still important gaps in the data, which make it hard to say whether the variation reflects real differences in quality of care or simply how a trust manages its data.
For example some trusts have not yet been able to accurately record whether the SACT treatment was given with curative or palliative intent.
That’s why it’s vital that these data continue to be collected in full, and trusts continue to review and improve the quality of the data they are providing.
But of course, early death is only one measure of the care a patient receives; the only way to avoid all deaths after treatment is not to give any treatment, which is not a solution. If more patients at high risk of early death receive SACT treatments, it might actually lead to better survival overall, if more patients benefit from it.
It’s important to help trusts and doctors review how we can balance these risks and benefits, with reducing the number of short-term deaths just one aspect of the journey towards better outcomes from cancer treatment.
How can this data improve cancer care?
This is the first time this type of data has been collected and analysed so extensively for a whole country. The process was a huge undertaking, but it now means we have a way to measure whether the health service is getting better at giving the right drugs to the right patients. It’s vital that these data continue to be collected and analysed to ensure there’s an improvement year on year.
Huge improvements in the data being provided to Public Health England by the NHS trusts has made this work possible. But it’s disappointing that the NHS still struggles with quality and completeness of data; these things are still holding us back.
I would like to see all trusts adopting electronic prescribing systems that allow much better data collection, and doing all they can to fix the information gaps that might stop us from using the data to its full potential.
Those trusts that aren’t doing so well also need to urgently review their data management and patient care to ensure that any issues are rapidly addressed.
This has already begun, and I hope to see improvements very soon.
The next step will be to start including more types of cancer in these reports, and other factors affecting patient care. And I want to see major improvements in the data available on other cancer treatments, such as surgery and radiotherapy, for which similar issues exist.
With that in hand, I’m confident that I, my colleagues, and NHS hospital trusts – not just in England but across the UK – will be better placed to keep raising the bar for our patients.
Professor Peter Johnson, chief clinician at Cancer Research UK
Wallington, M., et al. (2016). 30-day mortality after systemic anticancer treatment for breast and lung cancer in England: a population-based, observational study. The Lancet Oncology. DOI: 10.1016/S1470-2045(16)30383-7