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.

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5 thoughts on “In defence of cancer doctors…..

  1. As a recent 70 year old patient at SGH my full gasterectomy, carried out by a dedicated team of specialists and nurses, I fully concur with the thoughts of ‘TimTheSurgeon’. My own medical history of a quadruple heart bypass, carried out 27 years ago, bladder cancer, diagnosed and successfully treated at the age of 65 years (7 years ago) and stomach cancer diagnosed and successfully treated 3 months ago was NOT influenced, in my opinion, by age or previous life threatening problems. I would like to think that the only influence was that I have a positive attitude and the desire to get up and about – living life!

  2. 8% of resections in patients over 80 sounds much less impressive when you realise that approx. quarter of people are diagnosed with OG cancer aged 80+.
    http://www.cancerresearchuk.org/cancer-info/cancerstats/types/oesophagus/incidence/#By2
    5-year relative survival (which takes account of the fact that older people are more likely to die of other causes) shows 5 year survival rates for people aged 80+ at less than a quarter of those for people aged 60-69
    http://www.cancerresearchuk.org/cancer-info/cancerstats/types/oesophagus/survival/#age

    • Thanks Nick for an insightful comment. This is a complex issue and not just about discrimination based on age as suggested in the original piece. A resection for oesophageal cancer is a massive undertaking for the patient and their family/friends. In my experience when faced with the reality of an oesophagectomy with the potential risks (1 in 50 death and 1 in 3 major complication) and 9-12 months recovery and a permanent change to quality of life, some patients of all ages decide that it is not right for them. I think this tends to happen more often in the over 80′s and people must be supported when they make such a brave decision.

      It is unrealistic to expect equivalent resection rates across all age groups and we must protect individual autonomy. I do agree that patients should be given the options and help to make these decisions for themselves.

      • I was diagnosed Barrett’s at age 46 low grade dysplasia. One year later it was high grade dysplasia with inconclusive at biopsy for suspicious lump. I was female never smoked or drank alcohol was healthy keep fit at gym but almost fourteen stones at heaviest but suffered Gerd since a baby,could not breast or formula feed and in those days my grandfather watered down carnation milk for me and dairy foods were given but I had weak stomach and was undernourished as a child of a family of six children of which I was child number three. Both parents were heavy smokers, I had endometriosis and iron deficient regularly and had endometrial ablation and polyps and ovarian cysts very large in my thirties.had two daughters1981 and1984 long labour and low cavity forceps delivery.until then I was a steady weight but huge weight gain after being on birth control pill ,due to young sisters death from breast cancer at age30 ( brac2) lots of aunts died from same all on my dad’s side. Walked six miles a day as children’s school had no bus and I had a very physical lifestyle but could not easily keep off the weight and stood steady around thirteen stone but joined slimming group and lost four stones but always gained again unless I kept down to 800 cals a day despite step aerobics swimming hillwalking etc, sleep problems since infancy because of regurgitation of food even many hours after eating……I thought this was normal until in my forties I found pain an issue and bronchial spasms causing me to have asthma type symptoms where I could not breathe because of the pain in gullet and throat. Despite years at doctors surgery I was told to not eat spicy foods and to lose weight….nothing helped until I started to read and then research once computers became available and self diagnosed likely problem as Barrett’s but doctor dismissed me when I asked for a referral and an endoscopy, things deteriorated until a few ambulance call outs because of the fear from the acid reflux and it getting inhaled and I could not breathe and was taken into hospital and given stuff into veins to relax me to enable breathing and to reduce the acid then sent home. GP still did nothing and I was scared now because I was certain something was eating my flesh away and I was often hoarse and had weird sticky mphlegm that gave me a cough and also was constantly bringing up frothy mucus that looked like partly whipped egg white and I could not lie down or even bend down because do the immediate rush up my throat of bile/ stomach acid or half digested food that had been my dinner days ago. I made another appointment to see the doctor and this time I threatened to sue him if I privately had the endoscopy and they found I had something wrong….he threw down his pen and said, I will send you but if I did that for every patient who had heartburn the NHS would go bankrupt. The results when they came back were put into my file and no one even called to tell me but as I had only the throat spray and the surgeon was shocked and sickened at the state of my eosophagus I was kept back till he was done with the other patients and he sat with my husband and myself and told me how this can progress and he wanted to know all about my eating and drinking habits but as I mentioned, I was a Christian in a Pentecostal church that was part of the temperance movement and was against alcohol and smoking but I did drink between two and four litres a day of diet coke or diet Pepsi because I didn’t drink coffee or tea and this surgeon said he was positive that the rise of adenocarcinomas were on the increase in the past thirty years and that was about as long as diet sodas had been on the market and he felt that the aspartame and saccharin in these had some effect and could be involved in causing the damage to the lining of the gullet. I wondered how far back have people been having adenocarcinoma and Barrett’s in non smokers and non drinkers and also wondered how the NICE guidelines can be in place and that the people who make the decision on when a doctor should refer a patient for endoscopy ONLY when they have difficulty swallowing and have pain and unexplained weight loss…….BY THEN IT IS ESTABLISHED: and already advanced making cure difficult…. And all because of cost….roll on the breath test to start the ball rolling but it terrifies me to think if I had not researched my symptoms and listened to my doctor( who when I confronted him after my nine hour surgery…shrugged his shoulders and said he had followed the guidelines and if I didn’t like it that I should take it up with the policy makers who wrote up the guidelines…..namely….the surgeons who do the scopes??? Shocking…..I would be dead now if I had not threatened to sue and now wonder how many people could have survived if the guidelines were changed and more sensible…..I was very ill for a long time because of complications and if I had known then what I now know….perhaps I would have taken legal advice….I now have central sleep aponeas and have both an oxygen machine and also a resmed auto set pace wave machine and face mask to regulate my breathing and to force air into me when I stop breathing….up to 54 times every hour….and I must sleep sitting upright….so I am alive….and I am told to be grateful……and I am….but if the doctors had more time and better training……compelled to keep learning……and if someone had looked at the pattern of my life health since childhood ….maybe they would have seen a pattern of digestive problems….and….maybe if I had been scoped years before……then I could look forward to an exciting time with my new grandson…….with my health intact and my abilities instead of my disabilities…..enabling me to look after him while my specialist nurse daughter returns to work in the max fac dept of the hospital where she loves the patients presenting with head neck and mouth cancers…..but my energy is so low because I am in constant pain…..nerve damage partly controlled with fentanyl(morphine) and my sleep is only for a few minutes at a time adding up to about three hours a day….so my concentration is poor……and as he learns to toddle…..I might fall asleep exhausted for days and nights denied a proper lie down and the machine alarm going off… Because I stopped breathing for too long…..and exhausted I slip down and acid slips up and I panick awake and draw air and vomit into my mouth and nose and the sting and the burn as it hits up my nose and down into my lungs brings such pain and tears start and tiredness makes the fixed smile dissolve from my face as I can feel the damage coursing through the already reduced stomach and eosophagus and wonder …what next……

  3. As someone in my late 30′s having had a resection in 2013 with Tim’s team I think that these journalists need to wind their necks in on this issue and get back to appreciation for what a fine job is being done under very difficult circumstances in many cases. I remain hopeful that my youth is on my side in terms of survival rates, for my two young daughters’ sake. I wish Tim and Jamie and Donna and all the team, the very best with their continued fantastic work and hope that the evolution of personalised medicine can progress to help me and others in future should we need it. Love to all affected by this disease, keep believing in the medicine and technology and we will beat it.

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