Surgery, radiotherapy and chemotherapy are the mainstays of cancer treatment.
So it’s surprising that, despite decades of use, it has been impossible to answer this seemingly simple question: which patients are getting which types of treatment?
New data, out today, starts to give us some answers.
In a world-first, the National Cancer Registration and Analysis Service (NCRAS), in partnership with Cancer Research UK, have used data from England to see which treatments are being used across all types of cancer, for the whole population.
And it shows that generally patients diagnosed an earlier stage are more likely to receive surgery, and avoid chemotherapy.
A Big Data first
“For some years we have been building the datasets to capture cancer treatments in England,” says Mr Andy Nordin, a specialist gynaecological oncologist and lead clinical advisor on the project.
Bringing these datasets together gives a nearly complete picture of cancer treatments in England for the first time, he adds.
The overall picture
The analysis covers all cancer cases diagnosed in England from 2013 to 2014. That’s more than half a million diagnoses.
Looking at all these cases combined, surgery to remove the tumour was the most commonly used primary treatment.
More than 4 in 10 (45%) patients were treated with surgery to remove their tumour. While almost 3 in 10 patients were treated with chemotherapy (28%) and radiotherapy (27%). Patients in each of these groups may have had the treatment on its own, or in combination with other the treatments.
But a different pattern emerged if the cancer was diagnosed at the earliest or latest stage.
Most patients diagnosed at stage 1 have surgery as part of their treatment (70%). This means they are more than five times as likely to be treated with surgery than patients diagnosed at stage 4 (13%).
While patients diagnosed at stage 4 are around three times as likely (39%) to have chemotherapy than those diagnosed at stage 1 (12%).
The importance of early diagnosis
This shows that patients diagnosed at the earliest stage are more likely to receive treatment that has a better chance of curing them and fewer long term side effects. The challenge is boosting the number of cases diagnosed at an earlier stage.
“Surgery remains the most important treatment for cancer,” says Nordin.
“As a general rule for most cancers, the earlier the cancer is diagnosed, the more likely that it can be effectively treated by surgery alone, without the need for additional types of treatment.”
“This often provides the best chance of disease cure whilst minimising the risk of long term side effects of treatment which can impact on patients’ quality of life.”
This pattern for cancers diagnosed at the earliest and latest stage looks the same across the majority featured in the report. But the scale of the differences highlight some big opportunities for progress.
More than half of patients diagnosed with stage 1 non-small cell lung cancer (NSCLC) were treated with surgery.
Because lung cancers are close to the heart and big blood vessels in the centre of the chest, it becomes very difficult to surgically remove them when the tumour has spread
– Professor Mick Peake, lung cancer specialist
This was around 35 times higher than for those diagnosed at stage 4, who were around 5 times as likely to be treated with chemotherapy.
Professor Mick Peake, a lung cancer specialist and clinical lead for NCRAS says that surgery is rarely of any value when the lung cancer has spread to other organs. And in many patients with later stage disease it’s simply not technically possible to remove the tumour by surgery.
“Because lung cancers are close to the heart and big blood vessels in the centre of the chest, it becomes very difficult to surgically remove them when the tumour has spread (at stages 3 and 4) without causing serious harm to adjacent organs,” he says.
But it’s not just that sugery becomes harder for late stage cases.
Peake says that chemotherapy can be used at an early stage alongside surgery to reduce the risk of the cancer coming back, and is therefore potentially curative in that context. But he says that most chemotherapy used for treating later stage lung cancer is “essentially given to extend and improve the quality of life by a modest period”.
Less than a fifth (16%) of non-small cell lung cancer patients included in the analysis were diagnosed at stage 1.
This must change, and it shows why we must do everything we can to ensure cancer is diagnosed earlier, from encouraging the public to get unusual or persistent changes checked out by a GP to funding research into the early detection of cancer.
Colon and rectal cancer
Colon and rectal cancer are the cancers collectively referred to as bowel cancer. And by looking at each type separately, some interesting differences appear.
“The data shows the earlier the stage the more likely you are to get surgery and the less likely you are to get chemotherapy for colon cancer, and chemotherapy and radiotherapy for rectal cancer,” says Dr Roland Valori, consultant gastroenterologist and NCRAS clinical lead.
But less than a fifth (15%) of patients with these two cancers were diagnosed at stage 1.
That isn’t good enough.
The UK’s bowel cancer screening programmes are proven to increase the proportion of bowel cancers diagnosed at an early stage. But with just over half (56%) of people in England taking part in bowel screening following an invitation, it’s clear where a boost in early diagnoses could come from.
A new bowel screening test called FIT (faecal immunochemical test) is due to replace the current bowel screening test in England in 2018.
And pilot studies (here and here) have shown that introducing FIT as the main screening test will increase the number of people who participate in bowel screening, especially in hard to reach groups.
Valori says the introduction of a FIT could have a big impact. And bowel screening doesn’t just help to diagnose cancer earlier.
“It’s important that people understand that colonoscopy following an abnormal screening result detects a lot of precancerous polyps which can be removed at the time of the procedure,” he adds.
And removing these polyps, Valori says, could prevent cancer from developing altogether.
Understanding other forms of care
The data out today cover the three main types of cancer treatment. This means that others, including palliative surgery, hormonal treatment, active monitoring, and some other, rarer approaches, were not included.
This may partly explain why the report shows a third of patients had no record of receiving surgery, chemotherapy or radiotherapy.
These patients may also have received treatment outside of the time frame assessed, or in a private setting, which isn’t covered by the data. And there may also be some treatment records missing from the datasets used.
More work is needed to understand the care these patients receive.
This is only the start
These data have the potential to help us understand whether patients are getting the most appropriate treatments for them.
“At the moment we are limited by the fact that we don’t know what the optimal treatment rates are, it is certainly not the case that one-size fits all patients,” says Peake.
And many factors, including a patient’s other health conditions, their age and treatment preferences will affect what treatment is right for them.
That’s why another round of data is due to be released in early 2018, which will look at how these factors might affect the likelihood a patient receives each type of treatment. These data can then be used for further studies, for example looking at how differences in treatment affect patients’ survival chances.
By combining this information, and seeing how different factors affect survival, doctors can start to make more personalised care plans for their patients. And it will help health services plan for what they’ll need if more cancers are diagnosed earlier.
This research also reinforces that the health service needs the right staff and equipment to diagnose more cancer patients earlier.
“During the coming years we will analyse the effectiveness of different treatments, and differences in treatments between different groups in the population and different regions of the country, in order to make changes to improve outcomes in the future,” says Nordin.
“Without the knowledge of what is happening now, it is impossible to monitor the impact of any changes in the quality of care, in terms of improvements in the outcomes for patients in the future.”
Sarah Testori is an early diagnosis manager at Cancer Research UK