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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