Ireland’s ‘cancer boom’: what’s gone wrong?

We’ve got cancer licked. More and more people are getting cancer. Lifestyle plays a big role. Actually, it’s more down to luck.

You don’t have to look very far for advice about cancer, although much of it can be confusing and worrying. What will soon be the world’s most common disease gets a sometimes bewildering amount of attention.

For scientists, cancer may be one of the most exciting areas in which to work, and one in which huge strides have been made in the development of drugs and personalised treatments.

But most of us just want answers to simple questions: What are my chances of getting the big C? If survival rates are improving so much, why are more people getting the disease? And why do I know so many people who have cancer and who have died from it?

These apparent paradoxes were borne out in a review published this week of Ireland’s cancer strategy, which predicted that the incidence of the disease will double by 2040 despite improvements in services. Another report, also published this week, says that one in two people in the UK will contract cancer in their lifetime; the figures for the Republic are likely to be similar.

So why are we enduring a cancer "boom", as the report from the National Cancer Control Programme (NCCP) put it during the week?

"Rising cancer rates aren't caused by Sellafield or overhead power lines or any of the other reasons people blame. It's a disease of the middle-aged and old, and as the population ages there will be more cancer," says Prof John Crown, the country's best-known oncologist.

And with 20,000 people turning 65 every year, Ireland’s population is undoubtedly greying.

At the same time, Crown points out, many of the formerly competing causes of death, such as infectious diseases, have fallen away in importance, leaving cancer out there along with heart disease as the biggest killer. It’s also a disease of affluence, one that thrives on the smoking, drinking, high blood sugars and physical inactivity so common in our 21st-century society, he says.

Another reason that it has become more common, as highlighted in a recent report from the National Cancer Registry, in Cork, is that cases are being detected earlier and better. This means that although we have more cases of the disease, more people are surviving it, and for longer. Today 60 per cent of cancers are cured.

Survival rates

The five-year survival rates for all invasive cancers jumped from 45 per cent for patients diagnosed between 1994 and 1999 to 59 per cent for those diagnosed between 2006 and 2011. If you had breast cancer your chances of survival increased from 72 per cent to 81 per cent. The improvement for prostate cancer was even better, rising from 69 per cent to 91 per cent.

Even in the case of tumours affecting internal organs, which tend to be harder to treat, there were significant improvements from a low base. The five-year survival rate for cancers of the pancreas grew from 6 per cent to 9 per cent, and lung-cancer survival increased from 10 per cent to 15 per cent.

All of which means there are more people around than ever before who either have cancer or have survived it. More than 122,000 people who contracted cancer in the past 20 years are alive today, and 94,000 of these have survived at least 10 years with the disease. This explains why we know more people with cancer, or who have had the disease, and why it is increasingly part of the national conversation.

Although the increase in survival rates is welcome news, it has significant implications for the health service in the years to come. That’s because survivors have greater health needs, both physical and mental, than the rest of the population. Plus the simple fact that they’ve survived to grow old means they are likely to go on to suffer other ailments.

Cancer services in Ireland have come a long way since the 1980s, when the disease was still regarded as a life sentence. Then there were the repeated scandals over misdiagnosis and delayed diagnosis of serious cases, and long waiting lists for treatment.

Crown attributes the improvement in survival rates to an increase in the number of specialists working in the system.

“I was only the fourth oncologist in the country when I was appointed, in 1994; the previous appointment had been made a decade earlier. Today there are 35 of us,” he says.

Crediting the former health minister Michael Noonan with the ramping up of services, he says a key determinant in survival rates is the availability of high-quality surgery.

Ireland developed its first national cancer strategy in 1996, with the aim of reducing the death rate from the disease by 15 per cent over a decade. More than €400 million was ploughed into services, and scores of new appointments were made.

The results were largely positive, but one alarming trend turned up: your chances of getting treatment and surviving the disease varied hugely across regions. As a result, a consolidation of services was placed at the heart of the second national strategy, launched in 2006.

In a programme of change the likes of which has seldom been seen in the health service, the 36 locations where cancer patients were treated were bundled into eight regional centres offering better, more specialised services. The dedicated National Cancer Control Programme was established and put under the direction of strong-minded experts such as Prof Tom Keane and Dr Susan O'Reilly.

Cancer survival rates are improving everywhere, so the bad news is that Irish rates are still generally higher than the European average, as improvements in our services have failed to keep pace with progress elsewhere in the EU.

The incidence of the disease here is 10 per cent higher than the EU average for men and 16 per cent higher for women. Mortality is 14 per cent higher for women but 9 per cent lower for men.

Other black spots are increases in the incidence of and deaths from lung cancer and melanomas, high mortality from pancreatic cancer and low treatment rates among older patients.

Ireland has the worst survival rates in Europe for cancer of the ovaries and fallopian tubes and below-average rates for cervical, breast and stomach cancer. The incidence of lung cancer is falling among men but rising among women, reflecting changing smoking patterns from decades earlier.

The second national strategy has been independently reviewed, and that report is now with Minister for Health Leo Varadkar.

"Steady progress" is how the radiation oncologist Charles Gillham describes the improvements in the service. He points out that cancer is an umbrella term for dozens of types of tumours that behave abnormally in different parts of the body, so it is difficult to generalise.

Since the NCCP was set up, a range of other disease-specific clinical programmes have been established. Hospital groups are also being set up. This has led to speculation that the cancer programme may be folded into the broader set of programmes.

Challenge

“I don’t see us becoming just another clinical programme. Cancer is too complex and too common to be in a group with other conditions,” says Dr

Jerome Coffey

, interim director of the NCCP. Its future, he says, is assured.

He says the challenge now, moving into a third national strategy, is to build on past successes and perform “even better”. Priorities for the future include improvements in data systems and in training.

John Crown, who says the NCCP is “a bureaucracy that has made no difference”, agrees on the need for reforms in the way we train doctors. Of the country’s 35 oncologists, 25 were trained in one of the top five medical schools in the US, he says. Big changes are needed if we are to ensure that the most talented doctors stay in the system or return to Ireland after training abroad.

We have twice as many medical schools as we need, and the existing structure should be consolidated in order to improve the quality of training, he argues. The newly enlarged schools would then operate university-type hospitals, as happens in many large US cities.

CAUSE AND EFFECT

Cancer is not just a question of luck

“Most cancer cases ‘due to bad luck’,” ran the headlines on one of the most eyebrow-raising pieces of scientific research last month.

The media reports, based on a US study from Johns Hopkins University, claimed that two-thirds of cancers were simply due to bad luck and that only a third were due to environmental, lifestyle or genetic risk factors.

If this were true there would be little point in intervening to reduce someone’s risk by, for example, getting them to exercise, drink less alcohol or even stop smoking.

The sweeping headlines weren’t true, as commentators who looked at both the original study and the media coverage were quick to point out. Yet, confusingly to the layman, the reporting wasn’t entirely wrong, either, and it is true that an element of “bad luck” arises in cancer cases.

The problem arose when reporters went from comparing cancer rates in different tissues to making statements about cancer rates in the population. The fact the study didn’t cover the major cancers of the breast and prostate was also overlooked.

All the same, the study cut to the core of much of the public discourse about the disease. We all know of grannies who smoked and drank and lived into their 90s in good health.

“There are things we can do to lessen our risk, but there are no guarantees against cancer,” says Charles Gillham, radiation oncologist of St Luke’s Network in Dublin. “That’s why, understandably, we feel an inherent unfairness when a person who has lived a healthy life gets the disease.”

The fact is, he says, for lots of cancers we have no idea what causes them. Stopping smoking or drinking less will reduce the risks, but 5 per cent of cancers have a genetic predisposition, and there remains an element of bad luck or chance.