House of Commons - Science and Technology

Select Committee on Science and Technology Sixth Report

SIXTH REPORT

The Science and Technology Committee has agreed to the following Report:—

CANCER RESEARCH—A FRESH LOOK

INTRODUCTION

Government Cancer Strategy and the National Cancer Director

1. In 1995, an Expert Advisory Group, established by Kenneth Calman and Deirdre Hine, then the Chief Medical Officers for England and Wales respectively, published its report on the organisation and delivery of cancer care services in England and Wales. The report has become known as the 'Calman-Hine' report. It recommended the creation of cancer networks based around cancer centres, with local cancer units in district general hospitals. It also recognised the importance of primary care (general practice) in the delivery of cancer care. The explicit objective of the Calman-Hine recommendations was to provide all patients with "access to a uniformly high quality of care in the community or hospital wherever they may live to ensure maximum possible cure rates and best quality of life".[7]

2. In July 1999 the Government published its White Paper on Saving Lives: Our Healthier Nation which, inter alia, set out plans to improve the health of the nation and identified cancer, along with coronary heart disease, mental health and accidents, as priority areas for action.[8] It set a target to reduce, from 1997 levels, cancer death rates in people under the age of 75 by 20 per cent by 2010. The Government subsequently, in October 1999, appointed a National Cancer Director, Professor Mike Richards, who has stated that his first priority is to develop the workforce necessary to deliver cancer care in line with Calman-Hine standards across the country.[9]

3. Reports indicating that outcomes for cancer patients in the UK were poor in comparison with those in other European countries and the USA led to our decision to conduct this inquiry. We also wanted to investigate perceptions that cancer research in the UK was under-funded and poorly co-ordinated. Changes in the way cancer services are delivered, the appointment of a National Cancer Director and a willingness on the part of the two largest cancer research charities to work together more closely added to the timeliness of taking a fresh look at the organisation of cancer research.

Conduct of the Inquiry

4. During this inquiry we have received evidence from a wide range of organisations and individuals. In 8 oral evidence sessions we have heard from 30 sets of witnesses. Their expertise and insights have been supplemented by 106 written submissions. We have visited several cancer research and treatment centres in the UK and also in the USA, Canada and Finland where we benefited from discussions with leading cancer specialists, patients, commentators and policy-makers. We are grateful to all those who have assisted us during our inquiry either through oral or written evidence or who contributed on a more informal basis.

5. In an innovative move, we decided to widen the scope of our consultations by taking oral evidence from a larger number of witnesses than is usual. Following a format close to that used by committees in the US Congress, we invited 20 witnesses, including a range of cancer patients, patients' groups, and health professionals to make short statements to the Committee over the course of an afternoon. We found that by seeking evidence from a broader cross-section of witnesses than those normally called, we were able to obtain first-hand views of end-users of cancer services and research — members of the public — and we believe our inquiry benefited from a broader range of experience and expertise than would otherwise have been possible. Some also gave their evidence at some emotional cost to themselves and we thank them for contributing despite these difficulties. We are grateful to all those who appeared during that session, many of whom were not only giving evidence to a select committee for the first time but also making their first visit to Parliament. We appreciated their tolerance in working to procedures which were not only new to them, but new to us too. The opinions and experiences which emerged during that session have both informed and influenced our findings. We hope all those who participated will agree that it was a useful process. It is certainly one which we shall use again should an appropriate occasion arise.

6. We also extend our thanks to our specialist advisers for this inquiry: Professor Derek Burke, former Vice-Chancellor of the University of East Anglia; Professor Michel Coleman, Professor of Epidemiology and Vital Statistics and Head of the Cancer and Public Health Unit at the London School of Hygiene and Tropical Medicine, and Deputy Chief Medical Statistician at the Office for National Statistics; Dr Helena Earl, Lecturer in Medical Oncology at the University of Cambridge and Consultant at Addenbrooke's Hospital ; and Professor Michael Elves, former Director of the Office of Scientific and Educational Affairs, Glaxo Wellcome plc. Their advice has been valuable and appreciated.

The Nature of Malignancies

7. Cancer has been a scourge of the human race from the earliest times. Until relatively recently a diagnosis of cancer was virtually a death sentence for the sufferer. For the medical profession it has been a source of considerable frustration, being amenable to very few therapeutic interventions, and then frequently only providing a stay of execution. Although generally thought of as a single disease, 'cancer' is in fact a term which covers a range of malignant conditions which can affect almost any organ or tissue in the body. Cancer occurs when tissue cells escape from the normal molecular regulatory processes and then divide in an uncontrolled and abnormal manner. In most cancers this uncontrolled growth results in the formation of a tumour.

8. In many cancers the malignant cells will leave their tissue of origin and migrate to, and infiltrate, other tissues creating secondary tumour growths or metastases. The tumour, both primary and secondary, exerts its lethal effects by virtue of its expansion into normal tissues and organs, compressing them and often killing healthy cells and thus compromising the normal function of major and vital organs. Leukaemias and lymphomas are a group of malignancies in which the cells undergoing malignant transformation originate in the normal blood-forming tissues - the bone marrow, spleen and lymphoid tissue. These cells invade other tissues and compromise their function, and will also displace the normal blood forming cells, resulting in anaemia, and reduction in numbers of infection-fighting white blood cells and platelets which are essential for the effective control of bleeding.

9. Under normal conditions, tissue cells will go through the processes of division, differentiation and then ultimately death under the influence of a variety of molecular control mechanisms. These are carefully regulated to ensure the orderly development and normal functioning of organs and tissues. It is when these cellular control mechanisms become deranged, often as a result of changes in the genes (mutations) involved in cellular regulation, that cells escape normal control. Thus the tumour cells divide inappropriately, often fail to differentiate and do not respond to the usual cell death signals. The malignant cells become, in effect, immortal.

10. Cancer is essentially a disorder of the cellular genetic material. Damage to deoxyribonucleic acid (DNA) can be caused by a number of environmental factors such as ionising radiation, chemical carcinogens and some viruses.[10] Serious damage to DNA normally leads to the death of the individual cell. More subtle damage, or mutation, of genes, particularly those which regulate cell division, growth, differentiation and death, may lead to uncontrolled cellular division and proliferation, and in turn, malignant transformation and cancer. Only a small proportion of individuals are known to inherit a genetic predisposition to certain cancers: in these individuals, the cells contain genes which make them particularly vulnerable to changes that cause cancer.

11. Cancers are classified on the basis of the organ or tissue from which they originate, that is the site of the primary tumour. Identification of the tissue of origin and the degree of differentiation of tumour cells is based upon microscopic examination of tumour tissue. In addition, an important piece of information required for decisions about the management of cancer patients is the stage reached by the tumour; this reflects the extent of invasion of surrounding normal tissue and metastatic spread to other tissues and organs. Although there are many different types of cancer, which can affect most tissues in the body, the great majority of cancer patients are affected by a few common cancer types such as lung cancer, bowel cancer, breast cancer or prostate cancer.

12. Cancers are not a homogeneous group of diseases and will have reached different stages in their development at the time of diagnosis. This means that the type of treatment offered and the response of the tumour to treatment will vary. In the case of discrete tumours which have not encroached too far into normal tissue, and have not spread to other sites, surgical removal of the primary tumour will be appropriate and may provide a tumour-free period for the patient, if not a cure. In other circumstances, particularly where surgery is inappropriate or does not dispose of the entire tumour, radiotherapy or the use of anti-cancer drugs (chemotherapy) will be more appropriate. Thus it is important to provide cancer patients with treatment which is aimed at their specific form of cancer and the stage of its progression.

The Need for Research

13. Chemotherapy and radiotherapy are generally targeted at the proliferation process of cells and do not act on the tumour cells alone. There is a significant risk that normal tissues, particularly those with high turnover of cells and so a dependance upon cellular proliferation — such as the bone marrow, skin or bowel — will be detrimentally affected by these types of treatment. Much current, non-surgical cancer treatment therefore has some serious side-effects which commonly limit the treatment and a challenge facing researchers therefore is to find medicines and radiotherapy techniques which will act selectively to destroy or control the tumour cell population and spare the normal tissues. The increasing knowledge and understanding of the molecular basis of regulation of cellular processes and their derangement in the cancer cell that is arising out of genomics and molecular biology, offer a potential route to achieving this goal.

14. Other approaches to tackling cancer include the use of the body's own immune system to attack the cancer cells. Immunotherapy has had more success against lymphomas and some leukaemias than solid tumours but new techniques are being developed which promise effectiveness in a wider group of cancers.

15. Research into the basic mechanisms of cellular control helps us to understand how cancers develop. Research into the causes of cancer has enabled preventive measures to be defined, notably avoidance of tobacco use. Research has also shown that screening programmes can lead to earlier detection and lower mortality, notably from breast and cervical cancers in women; screening shows promise for other cancers. Research over the last 40 years has delivered an increasing range of drugs and radiotherapy treatments that are effective against certain cancers. Research has led to improved quality of life for patients undergoing treatment with unpleasant side-effects and for patients whose cancers are not curable. Research shows that average survival remains low for most types of cancer, although this has improved significantly in recent years.[11] While improvements in treatment resulting from developments in surgery, chemotherapy, radiotherapy and immunotherapy are undisputed, cancer is still a difficult disease to manage or cure. Although some cancer-causing agents are known, preventive strategies remain under-developed. Research into all these aspects of cancer remains a pressing need.

16. The Government reported spending £112.3 million on cancer research in 1998/99.[12] This figure must be compared to the £160 million plus invested in cancer research by medical research charities and the some £500 million invested by industry in the pharmaceutical and other sectors.[13] It is clear from these figures that Government is an important, but not the dominant, funder of cancer research in the UK. The majority of its funding (£63 million of the £112 million total) is awarded to National Health Service (NHS) providers to cover the additional costs associated with research and development which is performed in the NHS but funded by research charities, the Medical Research Council (MRC) or industry.[14] The main route through which Government funds cancer research directly is the MRC, which provides annually some £28.5 million from its own budget.[15]

Cancer incidence, survival and mortality

17. Cancer represents a formidable challenge to the health of the UK population. Annual death rates (deaths per 100,000 persons) from all types of cancer combined have been falling steadily since the early 1970s. Death rates are higher for men than for women but have been falling more quickly. Cancer is still responsible for some 156,000 deaths each year, about one in four of all deaths.[16] About 250,000 people are diagnosed with cancer each year, and on current patterns of incidence, about four out of ten persons can expect to be diagnosed with cancer at some point in their life.[17] As the proportion of elderly persons in the population increases, so the number of persons diagnosed with cancer each year is likely to increase. At any one time, there are approximately one million cancer survivors in the UK. The most recently published data show that survival rates for all cancers combined have been improving steadily, but there was no improvement for cancers of the lung or prostate.[18]

18. Cancer data for the UK are compared with those for other countries in Europe and North America in tables 1 to 3, for all cancers combined and for the three most common cancers: those of the lung, breast and large bowel. The tables show the annual number of new cases (incidence) or deaths (mortality) per 100,000 population, together with the percentage of patients who survived five years from diagnosis. Overall recorded incidence rates in the UK are broadly similar to those elsewhere in Europe and in Canada, but lower than in the USA. Death rates in the UK are higher than, for example, in Finland and the USA. For most major cancers, including those presented in table 3, five-year survival rates are generally lower in England and Wales and in Scotland than the European average or in the countries of northern and western Europe.[19] Even allowing for the difficulties inherent in such comparisons, the Government has recognised that in cancer survival "England and Wales generally lag behind Europe".[20]

Cancer incidence, mortality and survival rates, selected countries and regions
Table 1: Incidence rates	All cancers		Lung		Breast	Large bowel²
Number of new cases per 100,000 persons per year, by sex¹
	M	F	M	F	F	M	F
UK, England and Wales (1988-1990)	261.1	225.5	62.4	22.8	68.8	33.9	23.7
UK, Scotland	306.2	256.8	79.8	33.8	72.7	38.0	27.7
Europe - North
Denmark	273.9	261.6	51.9	25.4	73.3	37.7	30.3
Finland (1987-1992)	251.0	204.1	54.3	8.2	65.0	23.3	18.2
Sweden	240.7	228.5	23.9	10.9	72.9	29.8	24.1
Europe - West and South
France, Doubs	323.1	202.6	50.9	6.5	67.3	36.6	23.5
Italy, Varese	354.6	226.5	77.6	8.5	73.5	43.5	26.9
Netherlands (1989-1992)	288.4	225.0	73.0	13.0	79.6	36.4	27.8
Spain, Murcia	250.5	153.8	47.2	3.6	43.9	25.8	18.5
Europe - East
Estonia	269.8	172.3	75.7	8.3	36.5	25.7	18.9
Slovakia	308.6	188.5	79.1	8.7	38.6	40.6	23.6
Slovenia	268.5	180.0	65.7	9.1	46.2	32.9	19.9
North America
Canada, Ontario	325.7	261.1	62.2	28.2	78.1	45.1	31.1
USA, SEER areas, Whites	370.9	280.9	61.3	33.8	90.7	42.4	29.5
USA, SEER areas, Blacks	454.6	271.7	99.1	38.5	79.4	46.4	35.3
¹ Incidence data are for the period 1988-92 except where shown. Rates are age-standardised to the world population.

Table 2: Mortality rates	All cancers		Lung		Breast	Large bowel²
Number of deaths per 100,000 persons per year, by sex³
	M	F	M	F	F	M	F
United Kingdom	185.2	134.7	61.4	21.8	30.4	21.2	15.9
Europe - North
Denmark	183.3	145.4	52.5	23.7	29.5	23.9	19.6
Finland	151.5	93.9	49.4	7.0	18.0	12.7	9.9
Sweden	138.0	106.2	24.4	10.5	19.2	15.8	12.7
Europe - West and South
France	199.2	92.5	47.7	5.4	21.2	18.6	12.6
Italy	188.5	103.5	57.8	7.7	21.6	16.3	11.4
Netherlands	193.3	115.9	70.3	11.0	28.7	18.7	15.0
Spain	165.5	82.0	46.6	3.7	17.8	15.0	10.2
Europe - East
Estonia	208.6	105.1	69.6	7.1	16.9	17.9	12.2
Slovakia	213.7	104.7	67.4	7.1	18.1	25.1	14.4
Slovenia	206.9	109.8	59.6	8.4	22.0	23.0	13.6
North America
Canada	166.8	113.0	56.1	21.1	24.0	17.6	12.6
USA	171.4	118.2	58.3	25.2	23.4	17.4	12.9
²Colon and rectum combined. ³Mortality data are for 1990. Rates are age-standardised to the world population.

Table 3: Five-year survival rates	All cancers		Lung		Breast	Colon
Percentage of patients surviving five years from diagnosis⁴
	M	F	M	F	F	M	F
UK, England	31.1	42.7	7.0	7.1	66.7	41.0	41.3
UK, Scotland	28.8	38.5	6.1	6.3	65.0	41.1	41.1
European average	35.0	47.5	8.9	9.9	72.5	46.8	46.7
Europe - North
Denmark	31.8	44.8	5.6	5.9	70.6	39.2	42.7
Finland	37.7	50.1	10.0	11.2	78.4	47.6	50.0
Sweden	47.6	56.7	8.8	9.6	80.6	51.8	55.2
Europe - West and South
France	37.7	55.7	11.5	15.9	80.3	51.8	54.0
Italy	33.9	49.2	8.6	10.1	76.7	46.9	47.0
Netherlands	34.7	50.7	11.7	10.8	74.4	58.7	55.7
Spain	39.4	49.2	11.9	-	70.4	49.5	49.4
Europe - East
Estonia	22.0	37.5	5.4	13.9	59.5	36.5	38.0
Slovakia	31.7	41.6	12.0	19.1	58.3	38.9	38.3
Slovenia	23.5	40.0	6.2	6.9	64.2	33.2	38.1
⁴Patients diagnosed 1985-89 and followed up to 1994. Relative survival rates, adjusted for national mortality and age-standardised to the EUROCARE population for each cancer. Sources: WHO and International Agency for Research on Cancer, Lyon, France.

7 A Policy Framework for Commissioning Cancer Services: A Report by the Expert Advisory Group to the Chief Medical Officers of England and Wales. Department of Health, April 1995. (Hereafter the Calman-Hine report). Back

8 Saving Lives: Our Healthier Nation, Department of Health, Cm 4386, July 1999, (Hereafter Saving Lives: Our Healthier Nation), p. 71. Back

9 Q. 2. Back

10 Deoxyribonucleic acid is the molecule which makes up genetic material. Back

11 Ev. pp. 110-111. Back

12 Ev. p. 25. Back

13 Ev. p. 291; Q. 160. Back

14 Ev. pp. 7, 11. Back

15 Ev. p. 26. Back

16 Challenging Cancer, Department of Health, 1999.(www.doh.gov.uk/cancer.htm). Hereafter: Challenging Cancer. Back

17 Office for National Statistics. Cancer statistics: registrations of cancer diagnosed in 1993, England and Wales. Series MB1 no. 26, The Stationery Office, 1999. Back

18 Office for National Statistics. Cancer Survival Trends for England and Wales 1971-1995, deprivation and NHS Region. Series SMPS No. 61, The Stationery Office, 1999, pp 1-695. Back

19 Office for National Statistics. Cancer Survival Trends in England and Wales 1971-1995: deprivation and NHS Region. Series SMPS No. 61, The Stationery Office, 1999, pp1-695; Scottish Cancer Intelligence Unit. Trends in cancer survival in Scotland 1971-1995, Information and Statistics Division, 2000; Berrino F et al., eds. Survival of cancer patients in Europe: the EUROCARE-2 study. (IARC Scientific Publications No. 151), International Agency for Research on Cancer, 1999. Back