Select Committee on Health Written Evidence


APPENDIX 34

Memorandum by AstraZeneca UK (PC 47)

  1.  AstraZeneca is a pharmaceutical business headquartered in London that is ranked in the top five global pharmaceutical companies by sales. AstraZeneca is the second largest UK investor in R&D in any sector.

  2.  We wish to work in partnership with the NHS to deliver high-quality care to the people of the United Kingdom. As such, AstraZeneca wholly supports the ambition of the NHS to raise the quality of healthcare, equity of access to treatments and improving patient experience.

  3.  We wish is to be viewed as a partner with the NHS in the treatment of cancer, enabling the goals of the NHS Cancer Plan to be achieved through the provision of effective medicines.

  4.  AstraZeneca's UK cancer heritage is well known. Five medicines for the four most common cancers, which are responsible for over half of all diagnosed cancers, were discovered in our UK laboratories and include tamoxifen (Nolvadex®) for breast cancer and goserelin (Zoladex®) for prostate cancer. We have an active discovery programme targeted at developing the next generation of cancer medicines. Our heritage in oncology is the reason for which submission uses cancer treatment to exemplify the points made.

SUMMARY

  5.  AstraZeneca believes that each individual with cancer should be at the heart of decisions about their management, which entails their active involvement and informed choice of options at every stage of their journey.

  6.  This submission is founded on a cancer care model that is outlined under point 15 and the attached diagram.

  7.  Definitions of palliation relate to meeting the needs of people whose lives will be shortened by illness. In broad terms, palliation encompasses all care that is not of curative intent. We believe that cancer care is a continuum with three steps that are defined by the intent of treatment. Most patients are treated to optimise their outcome; we have coined "optimise" to describe this intermediate step. "Optimise" is between "cure" and "palliate". The "optimise" step has historically been an indistinguishable part of the continuum since therapies are perceived (and may be intended) as curative when they might equally be considered (or effect an outcome that is) palliative.

  8.  Current Government policy contains both positive and negative drivers for the "optimise" patient. A greater understanding of the "optimise" patient would recognise that the term describes the majority of patients and their views, needs and beliefs should be recognised and responded to.

  9.  The patient-centeredness of end-of-life care needs to be applied equally to patients at all steps of their disease. On a pragmatic point, patients move along the continuum, sometimes imperceptibly, making it essential that palliative considerations (eg quality of life, symptomatic relief, independence) are applied at all steps.

CANCER TREATMENT AND PALLIATION

  10.  Cancer resulted in the death of over 155,000 British people in 2002, one quarter of the total.[18] Some 270,000 people were diagnosed with cancer in 2000, the most recent year for which figures are available.[19]

  11.  The majority of cancer patients are not in the early stages of cancer when first seen by a medical professional. For some, the only realistic treatment option is palliative care. It is understandable therefore that palliative services are increasingly well developed in the UK and that there is a vibrant hospice movement.

PALLIATION AND THE CONTINUUM OF CANCER CARE

  12.  The WHO has refined its definition of palliative to recognise that its principles should be applied earlier in the treatment continuum:

    The earlier WHO definition of palliative care stressed its relevance to patients not responsive to curative therapy. This statement might be interpreted as relegating palliative care to the last steps of care. Today, however, there is wide recognition that the principles of palliative care should be applied as early as possible in the course of any chronic, ultimately fatal illness.[20]

  13.  There is a crucial distinction between treatment of curative intent and treatment of palliative intent. Treatment of curative intent aims to prevent the patient from dying from their cancer or delaying its progress beyond the point of the patient's death from another cause. Patients who relapse after treatment of curative intent or who present with later stage disease are offered treatment intended to increase life quality and length.

  14.  The difference between curative and palliative care, specifically medical and surgical interventions, is not discrete for three main reasons:

  14.1  Many medical and surgical interventions are used with both curative and palliative intent. Surgery may be to undertaken to remove all traces of a localised tumour or to debulk a larger tumour to bring about a reduction in symptoms, for example. The only point at which a patient can definitively be described as cured, if that was the intent of the intervention, is to review a the cause of their eventual death.

  14.2  New cancer treatments are first used either in addition to existing therapies or in patients for whom there is no other active treatment available. Over time, effectiveness is studied alone or earlier in the disease.

  14.3  The physician/care team and patient share a primary goal of curing the cancer. The chance of cure is lower where the cancer is less contained and more aggressive. However, given this powerful psychological motivator, therapies may be presented and perceived as being curative when they might actually be palliative. Contrarily, palliative treatment that delays progression of the cancer may mean that the patient dies of another cause, such as heart disease, which is also a successful outcome.

  15.  Given the uncertainty of what is curative and what palliative, cancer care following diagnosis can usefully be understood as a continuum consisting of three main steps that are defined by their intent or outcome. A visual representation is attached.

  15.1  "Cure"—treatment success is where the patient's life is the same length as if the cancer had not existed because all traces of the cancer have been removed.

  15.2  "Optimise"—treatment success is where the patient's life is the same length as if the cancer had not existed OR the patient's life is longer than if the cancer has been untreated AND/OR the patient's quality of life is greater than if the cancer was untreated.

  15.3  "Palliate"—treatment success is where the patient and their family achieve the best end-of-life journey.

  16.  Patients move sometimes imperceptibly along the cancer care continuum. The antecedents of the pain and suffering of the terminal patient are the symptoms of the "optimise" patient. As the World Health Organisation notes, "People do not `get used to' pain; rather, chronic unrelieved pain changes the status of the neural transmission of the pain message within the nervous system, with reinforcement of pain transmission, and activation of previously silent pathways."21

  17.  The concept of the "optimise" step in cancer care is not a challenge to the rights of those at the end of their lives. It is intended to distinguish between care that aims to give the best end-of-life journey and care that aims to increase quality and length of life or even cure. Most patients can be classed as being at the "optimise" step but are not clearly identifiable using the cure/palliate model.

THE IMPACT AND EFFECTIVENESS OF GOVERNMENT POLICY

  18.  The NHS Cancer Plan[21] has delivered significant improvements in cancer services and outcomes. The Cancer Plan has as its primary objective a 20% reduction in deaths from cancer in those over 75 years of age by 2010. This is understandable given the death toll from cancer and the fact that the UK's cancer outcomes are historically inferior to comparable European countries.

  18.1  The impact of this top-level mortality target, along with other measures in the Cancer Plan such as extended screening services, is to prioritise patients who have a greater chance of cure. The Government has announced that it has already achieved more than half of that target, reducing deaths by 10.2%. At the current rate, the target might be expected to be achieved by 2006-07. This is great progress and would allow for a re-prioritisation of funds and resources in favour of quality of life for "optimise" and "palliate" patients.

  18.2  Such a re-prioritisation would be particularly relevant in lung cancer, a disease that has an average six-month prognosis from diagnosis and which is the biggest cause of cancer-related death. Cure is the primary goal if the disease is caught before the symptoms become debilitating. However, cure is unlikely in nearly all cases irrespective of stage at presentation. The patient's highest treatment goal then becomes symptom reduction—particularly reduction in breathlessness—or the hope of cure. Addressing these goals has immense value to the patient, but since cure is unlikely, it would not contribute to the Cancer Plan's dominant objective of reducing death from cancer.

  19.  Building on the Best, the command paper that summarises the Government's commitment to increase patient choice, notes: "But wherever possible the NHS will empower patients individually by giving them personal choices—about where, when, how, and by whom they are treated, and about the treatment they receive."

  19.1  It is clear that there is greater patient choice over where and when they are treated, such as a choice of hospitals at the point of GP referral by 2005. There is a commitment also to making high-quality resources available to patients to enable self-management and more informed decisions.

  19.2  In terms of giving the patients a wider choice in the care and treatment they receive, the document commits to greater choice in "end of life" care. However, if patients are to be at the heart of treatment decisions, it is equitable that "cure" and "optimise" patients should be given a greater role in the choice of their treatment and not just "palliate" patients.

  20.  The National Institute for Clinical Excellence (NICE)

  20.1  AstraZeneca believes that the approval by NICE of certain cancer medicines that are of greater benefit to the patient experience and patient choice than to patient's life length is a positive move that favours the needs of "optimise" patients.

  20.2  The uptake of cancer medicines for which NICE has published positive guidance was the subject of a review by the Civitas think tank, which showed that access to medicines is not universal or equitable. Results are awaited from separate ongoing reviews of the uptake of NICE medicines. Clearly, patients need to be given access to medicines that have been approved by NICE if the patient is to have a meaningful choice in their management.

February 2004



18   Cancer Research UK. http://www.cancerresearchuk.org/aboutcancer/statistics/mortality?version=1 Back

19   UK Association of Cancer Registries. Cancer. http://www.cancerresearchuk.org.uk/aboutcancer/statistics/incidence?version=1 Back

20   Sepu«lveda C, Marlin A, Yoshida T, et al. Palliative Care. The World Health Organization's Global Perspective. Journal of Pain and Symptom Management 2002; 24: 91-96. Back

21   The Cancer Plan. Department of Health 2000. Back


 
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Prepared 26 July 2004