In defence of cancer doctors…..

Cancer is predominantly a disease of ageing.  This is because cancer is caused by DNA mutations that are collected over time.  For many reasons we are all living longer, and as a result cancer is becoming more prevalent.  This is not rocket science and it means that many “elderly” people will be diagnosed with cancer.

So how helpful is it for Ciaran Devane, CEO of Macmillan Cancer Support, (@ciarandevane) and perhaps one of the most influential people in the UK to have a voice about cancer to say that elderly people with cancer in the UK are being “written off” and to blame “age discrimination and inadequate assessment methods” amongst those of us treating cancer as the reason.

Yes, that’s right, if you are someone who treats people with cancer you are being labelled as discriminatory.

Quite frankly I find it a little insulting, somewhat patronising, frustrating, and just plain wrong.  But Macmillan have a job to do and fundamentally we are on the same side; we all want better outcomes for people with cancer.

The problem is that press releases and quotes such as this are picked up by the media and reported under headlines like: Too many needless deaths because elderly cancer sufferers ‘written off’.  We can blame sensationalist journalism, and Laura Donnelly at The Telegraph should know better, but responsibility rests with Macmillan because they know how these things play in the media.

So why did Mr Devane decide to take a swipe at the hard-working cancer doctors in the UK?  Well, in concert with the National Cancer Intelligence Network (NCIN), Macmillan has been looking at survival rates for cancers across age groups.  They point out that more than 130,000 people in the UK have survived for at least 10 years after being diagnosed with cancer at 65 or over, and that more than 8000 of these people were diagnosed when over the age of 80.

This is really excellent news.

Where we as a country apparently fail is when our survival rates are compared to the rest of Europe.  Using lung cancer as an example they state that for the under 45’s we (UK & Ireland) are only 9% worse that the European average, but the gap increases to 44% for the over 75’s.

Mr Devane’s conclusion is that the cause must be discrimination, but he offers no evidence.  We know that comparing the UK with the rest of Europe is fraught with difficulty, including problems relating to socio-economic class, migration and overall societal health (see the excellent commentary on the EUROCARE-5 study by Alastair J Munro).

But is it fair of me to criticize Macmillan and Mr Devane without offering some objective data of my own?  I think not, so here goes:

The Oesophago-gastric team at University Hospital Southampton (@UHSFT), where I work, looks after people with cancer of the oesophagus (gullet) and stomach.  I think we do an important job because rates of oesophageal cancer in men in the UK have risen by 50% over the last 40 years, and are still rising.  And we treat ‘elderly’ people.  Since April 2011 the median age of the patients that I have operated on is 69.  In fact, 60% of them were over 65 years old and 28% over 75.  This is for an operation that involves opening the chest and abdomen and is associated with very high risk (I explain in the video at the bottom of the link), even in the youngest and fittest.  These figures are backed up by the National Oesophago-Gastic Cancer Audit (NOGCA) 2013 that shows that the median age for treatment with pre-operative chemotherapy and surgery is 65 years.  Furthermore, 8% of operations were performed in the over 80’s age group.  Yes, patients who were treated with curative intent were younger, but importantly, they were also fitter.  This is reflected in the fact that only about half of patients who started palliative chemotherapy treatment finished the prescribed course.

Put plainly, in oesophageal and gastric cancer we understand the demands of an elderly population and we base our decisions not on age alone.  We are prepared to offer potentially dangerous procedures to elderly people if we as a team (including the patient) think it is the right thing for them as an individual.

So, Macmillan and Mr Devane, you are right, we should always be looking for ways to improve and in some case we could do better……..but so could you.

A patient’s view: Wendy shares her story

Wendy Mould – one of Tim’s patients – shares her thoughts about her treatment this year, and looks ahead to the future.

Wendy Mould

Christmas is a lovely time of year but this year its special because I realise I am actually here being able to enjoy it. I could so easily – without the skills and the care of the cancer marathon team and research – not be here this year.

All of us that have been able to be operated on and survived are very grateful to everyone involved. Christmas is very special to me this year. I have really learnt to appreciate my home, my family and my friends, who also have been with me through this marathon.

I’m still only 5 months post-op and still probably have some way to go – learning to eat with a small stomach is still very hard at the moment. But I’m learning, and I’m now looking forward to the New Year and a new future with a lot more care of life than previous years.

Cancer is not all bad. It teaches you to value your world and that costs nothing. Cancer is one of the worst experiences of my life but I am so grateful I am here to see my grandchildren grow and every day is priceless.

My special thanks go to Tim Underwood who with his team operated on me and also to Donna Sharland, leading nurse who has been with me, answered all my questions, even when she was not on duty, and has kept me positive even when I was down.

Please if you have anything left after Christmas shopping, donate to the Cancer Marathon Team and help to stamp out the cruellest disease on earth, cancer.

Thank you.

Sincerely,

Wendy Mould

7Seven working – is that what you really want?

So the world and his wife is demanding seven day working from the NHS.  NHS workers, doctors, nurses, journalists and patients alike are jumping on to Twitter to tell us that “it is the least we should expect” and they tell us about very real experiences of sub-standard care received at a weekend. 

Why shouldn’t we be using the expensive NHS infrastructure 7 days a week? After all that would be maximally productive… we could all be operating, doing clinics, and holding multidisciplinary team meetings. 

As it stands, dedicated nurses (who already work 7Seven shifts by the way) say they can’t find a doctor to review their patients; the doctors complain that they can’t get the x-rays and CT scans that they need; everyone moans that there aren’t enough physios and occupational therapists  (if any at all) – and that’s just in hospital.  Try getting to see a GP who actually knows something about you on a Sunday,. And as for social services, well at one stage last week over 100 patients were in a local hospital, medically fit for discharge with nowhere to go…

There are islands of hope within this sea of weekend confusion.  I was on-call last weekend for surgery in my own hospital and there were 3 other consultant surgeons in the hospital seeing patients and helping me out.  We are not alone, and many other trusts provide an equally good, if not better weekend service.

This is fine in a teaching hospital, with lots of senior staff divided into teams of specialists who can provide their own weekend rotas.  But what if you work in a small district general hospital with 4 surgeons?  I don’t think anybody in their right mind would expect them to be in the hospital every weekend… would they?

And surgery doesn’t get it bad.  My wife is an Emergency Medicine (A&E to you and I) consultant in one of the busiest departments in the country.  They are already asked to work more antisocial hours than anyone else in healthcare, and seem to get all the blame for the 4 hour target breaches, despite having no control over patient flow through the hospital.

This really is quite a simple concept – if the back door is shut and the front door stays open, there will very quickly be “no room at the inn”, the Emergency Department queue is just a manifestation of the systemic failure of the NHS and social care to provide a joined up service. At weekends… nothing moves.

I will venture onto dangerous ground now, but before reading on be assured that I am not asking for sympathy because I decided to do what I do because I love it.

Somewhere amongst our noble desire to demand and provide the best quality care the first time, every time, no matter what time of the day, or day of the week, we forget that it is human beings that do the caring.  We have families. Our children go to school (during the week) and sometimes like to see us at weekends.  Our friends do things at weekends and occasionally invite us along.  We might even have a sporting interest that helps keep us normal and healthy; most teams play at weekends.  Between us, my wife and I give 15 weekends a year to the NHS (21 if you count Friday night into Saturday morning), I think this is enough..?

So the care system is complex, but it should not be beyond the wit of man to work things out.

Perhaps the answer is to finally grasp the nettle of centralisation, and do it properly.  Not every town will have an A&E as we currently know it.  Doctors, nurses, managers, politicians and patients will have to get over their parochial attachments, and accept that – for the sake of their own health, and that of their patients – they will have to work with the hospital down the road and not against it.  It is inevitable that complex surgery and interventional medicine will centralise further – if I have a heart attack at 3am, I want my angiogram and stent straight away – and I don’t care if you a have to fly me there to get it.

Some hospitals will have to close… and probably more than you think.

Here is the rub: the population seems to want world-class 7Seven care on their doorstep, but fail to realise that this is impossible.  Whilst they might agree with the arguments in principle, they don’t think it is “their” local hospital that should close  (look what happened to the children’s cardiac surgery review). Politicians are perhaps the worst offenders, it is seen as career suicide to support the closure of a local facility (even if it makes sense) and, as the general election looms, they will all be out insisting that they will “never” let the local hospital shut.

And when smaller trusts try to do something sensible, the special interest groups (NIMBYs in my opinion)  get their knickers in a knot and make referrals to the competition commission… assuming they have any idea about the best way to run a complex health care service, that is a MONOPOLY provider by the way.

So are we ready for what 7Seven will really look like?

Fewer acute hospitals, further apart, using doctors and nurses from around the region to make their working life bearable.

Patients and relatives travelling that bit further for the best care, with the emotional, time and financial demands that this brings.

Small hospitals closing, merging or changing shape completely.  This is happening for trauma care right now and outcomes are better… much better.  It could be coming to the rest of medicine sooner than you think.

And what if we don’t change… well the scandal of Emergency Medicine recruitment gives us the answer.  Nobody wants to train to be an A&E doctor right now because it’s all antisocial high-pressure working.  The shifts are terrible, their leave is dictated to them, and they are blamed for the failings of the health service as a whole… I wouldn’t do it and I am proud and amazed that Mrs U does.

Tim

The other side of the knife

Tim in hospital

Before…

“The risks include: stroke, heart failure and death”… so I signed the consent form, and my colleague, Arthur Yue, got on and did the procedure.

I am sure that he told me some numbers to quantify the risk, something like “less than 1 in 1000 chance of dying”, but I can’t remember now, and I’m not sure I was really listening anyway.

I am 39, fit and healthy, and this was going to sort me out so I could get on with my life.  I had complete trust in both Arthur and my anaesthetist, and nothing was going to go wrong for me – why should it?

But despite being a surgeon, despite knowing what goes on in an operating theatre, and despite knowing the staff…. well I was still nervous.

I wasn’t worried that both my groins had been shaved and everyone in the room would get to see my “unmentionables”; I wasn’t worried about waking up and crying like a new-born baby, or saying the most inappropriate things to people that I work with (this happens for real all the time), because the recovery room staff are pros and they know how to handle the most difficult patients (even me).

No, I was worried because, without the procedure, I might not be able to train for the New York Marathon, and with it I was going to lose valuable training time while I recovered.

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