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The indisputable case for prevention and early detection

The cost of cancer to society as a whole, including costs for the loss of productivity, is an estimated £5 billion a year – and these figures are set to increase. Professor Sir Salvador Moncada from The University of Manchester outlines why he considers the prevention and early detection of cancer the only way forward.

It is possible that if we prioritise the prevention and early detection (PED) of cancer, over 60% of all cancers could be prevented or cured. This would reduce the number of people we need to treat as chronic patients down to a manageable figure and would be a huge success from a medical, societal and economic point of view.

In my opinion, the reduction of the long-term burden of disease has to be the main objective in the fight against cancer.

One in three people currently get cancer, but the latest research indicates that this figure will increase to one in two of us developing it at some point of our lives. These numbers are stark. There is, however, increasing evidence indicating that many cancers could be prevented, with most recent research suggesting a 42% reduction could be possible through lifestyle changes and other actions such as vaccinations, as in the case of cervical cancer.

Furthermore, if cancer is detected early it can be cured with interventions that cost a fraction of the price of later stage treatment.

Studies suggest that early stage treatment of cancers of the colon, rectum, lung and ovary costs the NHS between £3,000 and £5,000 per patient, while treatment of advanced disease will cost between £12,000 and £15,000. The difference in survival between the two groups is enormous; in the case of colon cancer for example, nine out of ten patients will be alive ten years after treatment if their disease is caught early, while less than one in ten will survive that time if diagnosed late.

“If cancer is detected early it can be cured with interventions that cost a fraction of the price of later stage treatment.”

The cost of cancer

Cancer is an important and costly health problem. Historically, we’ve diagnosed it late and then treated it with procedures or drugs that until recently produced dismal results from both a treatment and side effect perspective.

The treatment for many cancers has improved to the point that a diagnosis is no longer a death sentence. Increased survival in some cancers is very impressive. In 1971 half of patients lived for less than a year after diagnosis, while in 2010 the same proportion survived for 10 years or more. This increase is even more significant when you consider that for some cancers, such as pancreatic, survival remains low.

The problem with cancer is that the return to health is uncertain, especially when diagnosed late. This leads to expensive follow up, which relentlessly increases with the development of newer, more sophisticated treatment and monitoring methods, and with the development of medicines that do not cure, but only extend life.

The additional costs resulting from long-term follow up of cancer also need to be factored into the equation. For example, in 2012-2013 cancer treatment cost the NHS, depending on estimates, between £5 billion and £6 billion, but the cost to society as a whole - including costs for the loss of productivity - was £18.3 billion. The cost of dealing with cancer is set to increase by about 9% per year, meaning the cost to society therefore is likely to be over £40 billion by 2021.

Cancer, however, cannot be eliminated and some people will require long-term treatment and follow up. We should therefore do everything we can to reduce the number of incidences, since looking after half of the population as chronic cancer patients is not affordable.

Obviously, more basic research to better understand the more advanced stages disease is needed to improve treatment but here again, we should be investing more in research focused on the discovering the origins of cancer and its connection with genetics and different risk factors.

This research, as well as helping with our knowledge in prevention, will enable more accurate risk stratification and identify the best way of dealing with a cancer once detected early, therefore informing on the appropriate medical approach on a patient by patient basis.

Understanding risk factors

There are also some cancers, such as prostate, where historically, we’ve over-diagnosed or over-treated. Many patients have small, slow-growing tumours that don’t require treatment, just observational follow-up. Improved understanding of the genetics and the risk factors associated with these cancers will allow a more accurate, and personalised, therapeutic approach following early diagnosis. The same applies to a number of other situations.

For example, young people with colon cancer, in contrast to older patients, may be given chemotherapy following surgery without apparent benefit. The reasons for this difference are not yet clear but they will be clarified by genetic and risk factor studies. It’s also important to consider that in the absence of this background work, there is the danger that very powerful new tests and medicines may lead to over-treatment and over-diagnosis.

In Greater Manchester we’ve made great strides in our PED research portfolio. For example, our innovative lung cancer screening project which resulted in 46 diagnoses of lung cancer, of which 80% of were stage 1 or 2 and therefore highly curable. This contrasts with historical data from Manchester in which approximately 50% of lung cancers detected were at stage 4 with a survival close to zero 10 years after being diagnosed.

We have the ideal situation in Manchester now thanks to the devolved health and social care budget. If we do it right then we can tilt the balance of all our activity to early stage disease for all the population. In other words not just treating or managing the disease but either preventing or treating with the intention of curing it.

I believe that the PED strategy should also be applied to people who have been treated and are surviving cancer treatment. As with the healthy population, the objective in these patients is to either prevent recurrence or, if it happens, to detect it as early as possible. This suggests that many of the activities deployed for PED in the general population will be also applicable to those patients too. Looking to the future, a key research project will be monitoring the health of the long-term survivors and the impact of the side effects in the quality of their life.

Manchester researchers are focused on tipping the balance from treatment to the prevention and early detection of cancer.