Saturday, April 29, 2017

Cancer: The Problem Is Prevalence

Success is taking its toll.

By most measures, we do a magnificent job as a society with cancer. Over the past 30-plus years, the overwhelming majority of new cases of cancer - what we call incidence - has been a side effect of population growth and population aging. We could do better with lifestyle choices, smoking being the obvious habit we'd do well as a society to kick. Still, we should tip our hat to the fact that the incidence of breast, colon, and prostate cancers have been falling every year. Awareness and screening are doing their job.

Moreover, we're getting very good at treating it, not that cancer is a monolithic disease. Death from cancer, adjusted for age, has been falling on average for 20 years now. Death rates from prostate, colon, and breast cancers have been dropping by 2-3 percent a year for at least a decade. The majority of people with anything less than metastatic cancer (spread through the body) live at least three years, and the numbers have improved dramatically over the last few decades. So what's the problem?

The problem is that while resources, human and otherwise, have kept pace with the incidence of cancer, they haven't kept pace with its prevalence, the number of people living with the disease. In contrast to what we see with many other conditions like diabetes or heart disease, cancer patients can't be referred back to primary care (family doctor or nurse practitioner) with instructions for long-term management unless they've been cured. And if the patient's cancer is metastatic, only the cancer care system can provide appropriate management. 

Consider the following: chemotherapy requires hospital or quasi-hospital infrastructure; the treatment agents, and familiarity with their effects and toxicities, are not encountered in most medical training programs; the evidence base is in constant flux; and treating the patient often involves the entire family, in particular as end-of-life care approaches. Cancer care blends the long-term and intimate doctor-patient relationship seen in family practice with the highly specific knowledge base of a medical sub-specialty. There are few doctors that have the unique combination of intellectual and emotional skills needed to thrive in the field, and fewer still that have the passion to pursue it.

We're seeing an explosion in the prevalence of cancer i.e. the number of people surviving with the disease. In the past 20 years, the proportion of people alive with breast and colon cancer has risen by roughly 45%. For lung cancer that figure is 31%, and the number for prostate cancer is well over 100% - more than double the number of people alive with the disease.

What do all these numbers mean? It means the doctors providing care for cancer patients and their families have been pushed past the edge. The Cancer Centre in London, Ontario (now my home) has seen doctors suffer life-threatening health crises in the past few years. Some doctors urgently needed time away for mental health, one of whom did not return to work. The rest are reaching advanced stages of burnout. There is no reason to suspect the situation is different anywhere else in the country. 

Money won't solve anything. You could bump the pay of every oncologist in the country by $100,000 per annum, and it wouldn't change the emotional or time demands of the job. A sympathetic administration is always nice, and God knows the computer system doesn't help, but no amount of money and micromanagement will make the situation any better until a basic fact is acknowledged: if we want people to live longer and better lives with cancer, forget about the skyrocketing direct costs of treatment (though we need money for that too). No, we're going to need highly trained, skilled, dedicated professionals...and the ones providing that care now need all the help they can get. Yes, we train some family doctors to do the work, and could always train more. But that's a classic example of robbing Peter to pay Paul, stretching the pool of family doctors beyond where they are now, unless we decide to kill off family medicine as a profession...and for the record, I think that's a terrible idea.

There will always be debate about sustainability in health care, and there will always be trade-offs among public policy priorities. However, if we want our cancer patients to live longer, live better, and yes, die better, the people on the front lines working themselves to exhaustion towards that end need our help. And they need that help today.

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