Breast removal for cancer is postcode lottery, study shows

Women with breast cancer are five times more likely to undergo a mastectomy rather than have less invasive surgery in some parts of the country compared with others, research has shown.

Sufferers living in some parts of the North are far more likely to undergo the major operation, rather than having the "breast conserving" surgery more common elsewhere, according to NHS figures revealing a "postcode lottery" in cancer care.

Statistics showing the ratio of mastectomies to less invasive procedures to treat breast cancer, show that Redcar and Cleveland, in the North East, is the place where patients were most likely to have at least one breast removed.

Those in the London borough of Richmond and Twickenham were the most likely to receive treatment which removed just part of their breast, with radiotherapy used to prevent the spread of tumours.

The statistics show that those living in Wolverhampton, West Midlands, the London borough of Kingston, South Staffordshire and Telford in Shropshire were also more likely to have mastectomies.

Research has found that for many women with breast cancer, either treatment has a similar survival rate, if the tumour is of a size where it can be removed without the whole breast being lost. The chance of drastic surgery was highest in the North. 

Women living in Redcar and Cleveland, in the North East, were five times as likely to have their whole breasts removed, rather than part of them, compared with those living in Richmond and Twickenham.

Those in Ashton, Leigh and Wigan, in the North West, Middlesbrough, in the North East and Bassetlaw in Nottinghamshire were also most likely to have mastectomies.

The new NHS figures, placed in the House of Commons library, show massive variations in practices across the country. Analysis found no relationship between the patterns and rates of survival in different parts of the country.

Experts said it was impossible to know from the data whether the massive discrepancies reflected the choices made by women from different areas, or pressure put on them by surgeons.

Cancer charities urged surgeons working in the areas most likely to carry out mastectomies, to carry out further investigations.

Women with breast cancer should be offered the option of mastectomy, or less invasive surgery backed by radiotherapy. Research has shown that for most women, the survival chances are similar, although those with larger tumours may have no choice but have the more drastic operation.

Meg McArthur, from Macmillan Cancer Support, said: "These variations are really substantial, and they really do require further investigation. In some cases – such as the way a tumour is positioned, women would have no choice but to have a full mastectomy, but that really wouldn't explain the scale of the difference shown here."

She said it was vital that women diagnosed with breast cancer were given full information about the risks and benefits of different treatments.

"I would want all surgeons to look closely at these figures, and for primary care trusts to examine them closely too," Miss McArthur added.

Dr Jane Maher, chief medical officer for Breakthrough Breast Cancer, said it should not be assumed that women in areas most likely to have mastectomies were necessarily being put under pressure to undergo the procedure. Many women given information about the risks and benefits of both procedures chose the more drastic surgery, because they felt more able to put their fears behind them if they took the most extreme option.

From:

http://www.telegraph.co.uk/Breast-removal-for-cancer-is-postcode-lottery-study-shows.html

Dramatic postcode lottery for cancer survival rates shock charities

Department of Health figures have shown a wide variation in cancer survival between different parts of the UK with lung cancer patients in Herefordshire three times more likely to die within a year than those in Kensington and Chelsea.

The country's biggest cancer charity has expressed shock at government figures revealing huge variations in patients' chances of surviving from one area of the UK to another. The biggest survival gap was in lung cancer, where Department of Health figures showed patients in Herefordshire were three times more likely to die within a year of diagnosis than those in Kensington and Chelsea. 

In the London borough, 44% of patients survived the first year after diagnosis, compared with only 15% in Herefordshire.

In bowel cancer there was also a big gap in survival – 80% in Telford and Wrekin after one year, but only 58% in Waltham Forest and Hastings and Rother. The gap was less pronounced in breast cancer, with the best rate in Torbay, where 99% survived for one year, compared with 89% in Tower Hamlets.

"There is no excuse for such a big difference between different areas," said Harpal Kumar, chief executive of Cancer Research UK. "It is appalling that someone with lung cancer in Herefordshire should be three times more likely to die within a year than a patient in Kensington, or that a person diagnosed with bowel cancer in Waltham Forest or Hastings should be 22% more likely to die within a year than a patient in Telford. This is the worst kind of postcode lottery."

Very few primary care trusts (PCTs) had survival rates that were as good as other countries in Europe now or even as good as Europe was achieving 10 years ago, which Kumar called "a disgrace".

"We're pleased that the Department of Health have been bold enough to publish these figures," he said. "The NHS now needs to take them very seriously."

One-year survival figures highlight the issues around delayed diagnosis of cancer. That can be partly the responsibility of the GP, who may not see many cancer cases in a year, but is often to do with the reluctance of the patient to seek medical advice when they suspect a problem.

The figures are contained in the Cancer Reform Strategy second annual report from national cancer director Mike Richards, who points out that cancer deaths continue to fall and that prevention efforts, such as the cervical cancer vaccination programme for schoolgirls and better screening, will further help.

Jeremy Hughes, chief executive of Breakthrough Breast Cancer, said the charity shared the concerns. "Although progress has been made in some parts of the country, in others key Cancer Reform Strategy initiatives are still yet to be implemented," he said. "In particular, urgent action must be taken to ensure that digital mammography is in place by the December 2010 deadline and that, as previously committed by the government, all women with breast problems referred by their GP will see a specialist within two weeks by the end of this year."

Here are the PCTs with the best and worst records for dealing with common types of cancer, in terms of the proportion of patients who are still alive one year after diagnosis:

Breast cancer- Worst
Tower Hamlets (89.3pc)
Hillingdon (89.5)
Barking and Dagenham (90.2)
Hastings and Rother (90.3)
West Hertfordshire (90.6)

Breast cancer- Best
Torbay Care Trust (99.0)
Darlington (97.9)
Stockport (97.6)
Warrington (97.6)
Western Cheshire (97.6)

Colorectal cancer- Worst
Hastings and Rother (57.8)
Waltham Forest (57.9)
Tameside and Glossop (61.5)
Derby City (62.6)
Enfield (62.6)

Colorectal cancer- Best
Telford and Wrekin (80.0)
City and Hackney (77.5)
Shropshire County (77.0)
Peterborough (76.7)
Plymouth Teaching (76.6)

Lung cancer- Worst
Herefordshire (15.4)
Milton Keynes (17.5)
Blackpool (18.3)
East and North Hertfordshire (20.3)
Hartlepool (21.1)

Lung cancer- Best
Kensington and Chelsea (43.7)
Hammersmith and Fulham (35.3)
Richmond and Twickenham (35.2)
Islington (34.8)
South Birmingham (34.6)

Health Direct has compiled this post from:

http://www.guardian.co.uk/society/2009/nov/30/cancer-survival-rates-figures
and
http://www.telegraph.co.uk/health/healthnews/6693438/Cancer-survival-rates-best-and-worst-trusts.html

Cancer drugs fail to win NHS funding killer quango NICE

Four drugs for treating various stages of kidney cancer have been turned down for health service funding in England by NICE, in spite of price cuts by the manufacturers.

The decisions by the National Institute for Curbing Expenditure (NICE) underline that new guidance last year for “end of life” treatments will not produce a wave of new approvals for costly drugs that can extend life but where there is not yet evidence of dramatic results.

This year Nice approved Pfizer’s Sutent as a “first line” treatment for kidney cancer. But the institute has now rejected it as a second line treatment – where an initial therapy has failed – and has turned down rival products from Roche, Bayer and Wyeth for first line use.

It has done so in spite of Pfizer, Roche and Bayer agreeing deals with the Department of Health, which effectively cut the price of the drugs to the National Health Service.

The decisions were described as “a bitter blow” by the patients’ charity the Rarer Cancers Forum, which claimed they “went against the spirit” of last year’s amended guidance giving greater weight to end-of-life care.

Roche, whose product Avastin was rejected, was also furious, saying it was “considering all options”, including legal action. It attacked the decision as “illogical” when its product costs broadly the same as Sutent.

Professor Peter Littlejohns, clinical director of Nice, said that in spite of the revised guidance and price cuts “the benefit [from these drugs] was still too small, set against their cost”.

From:
http://www.ft.com/cms/s/0/10069bfc-91bc-11de-879d-00144feabdc0.html?nclick_check=1

Breast cancer screening blamed for false alarms

One in three breast cancer cases diagnosed in routine public screening programmes is harmless and would not have caused problems if it had gone undetected, researchers say.

The revelation re-opens the debate about screening, which helps some women but harms others. Doctors say thousands of women undergo unnecessary treatment, including mastectomies, to investigate and treat disease that would have been better left alone.

Peter Gotzsche, director of the Nordic Cochrane Centre in Copenhagen and a critic of screening programmes, joined forces with the researcher Karsten Jorgensen to compare breast cancer trends before and after screening was introduced in the UK, Canada, Australia, Sweden and Norway. They found that the level of over-diagnosis was comparable in all five countries.

As it is not possible to distinguish lethal from harmless cancers, all detected cancers are treated.

It is known that a type of early breast cancer often detected in screening, ductal carcinoma in situ, can resolve itself without treatment but the latest study says this also applies to other cases of invasive breast cancer. The authors, whose findings are published in the British Medical Journal, say many experts find this "difficult to accept".

Screening for cancer detects the disease earlier, when it is easier to treat. The NHS Cancer Screening Service estimates that breast cancer screening saves 1,400 lives every year, one for every eight women diagnosed.

But the researchers say that for each woman who is saved by screening, up to 10 will be overdiagnosed and have unnecessary treatment and up to 500 will have at least one false alarm, half of whom will have a biopsy (removal of a sample of breast tissue).

Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy in the US, says in an editorial published with the research: "The question is no longer whether, but how often, overdiagnosis occurs.

"Mammography is one of medicine's close calls – a delicate balance between benefits and harms. Mammography undoubtedly helps some women but hurts others. No right answer exists, instead it is a personal choice."

In the NHS, women between the ages of 50 and 72 are invited for breast screening every three years. The age range is to be extended to 47-73 by 2012. Figures for 2006-07 show screening detected almost 13,500 cancers.

Some doctors argue that the money spent on the breast screening programme – about £40m a year – would save more lives if it were used to provide more treatment.

The Cancer Screening Service is revising its screening advisory leaflet. A spokeswoman said the new version should be available later this year.

Dr Sarah Cant, from Breakthrough Breast Cancer, said she hoped that the research would not discourage women from attending screening: "Based on all the current evidence, we believe the benefits of detecting breast cancer early still outweigh the risks."

Women will have a false alarm for every one saved by breast cancer screening.

http://www.independent.co.uk/breast-cancer-screening-blamed-for-false-alarms

Drugs denied to sick - against the rules of NICE NHS watchdog

Patients in many parts of Britain are being denied effective and sometimes life-saving treatments because of funding shortages in the National Health Service by NICE.

This is despite rulings from the labour Government's new prescribing watchdog that the treatments should be freely available on the NHS.

Doctors say that diabetes, arthritis and Alzheimer's patients are suffering because they are being refused drugs or treatment programmes approved by the National Institute for Curbing Expenditure (NICE).

The agency was set up in 1999 following concerns that patients in some health authority areas were being denied new treatments because they were too expensive. Nice recommends which new treatments should be given to all patients and which are too costly or ineffective to be funded by the taxpayer.

Doctors say that many hospitals still lack the resources to prescribe drugs recommended by Nice. Patients are continuing to miss out, they say, because of staff shortages and a failure to fund the equipment needed to administer the treatments.

In March last year Nice ruled that anti-TNF alpha therapy - a revolutionary infusion for rheumatoid arthritis - should be available to about 25,000 patients who fail to respond to conventional drugs. Anti-TNF can prevent those with severe arthritis from becoming crippled by the condition, which afflicts 380,000 people in the United Kingdom and is the country's commonest cause of disability.

A year later, however, a survey by the Arthritis and Musculoskeletal Alliance (Arma), which groups 27 patient organisations, found that more than a third of rheumatologists were still unable to prescribe the drugs to all the patients who needed them.

The 152 consultants in England and Wales who responded to the survey identified more than 1,000 people who were still on waiting lists for the treatment.

Many specialists said that a key factor in the failure to give the drugs to patients was the lack of funding for the specialist nursing needed to administer the treatment. Sophie Edwards, Arma's chief executive, said: "There are patients around the country who are being denied the treatment they drastically need.

"The survey results show that access to this clinically proven and cost-effective treatment still depends on where you live."

Dr Andrew Bamji, of Queen Mary's hospital in Sidcup, Kent, told The Telegraph that he was relying on his secretary to take on the clinical duties needed to administer the treatment to patients with severe arthritis.

"I'm having to rely on my secretary to do some of the work that should be done by a nurse," he said. "But even with her help, we're getting to the point where we can't see any more patients."

Dr Richard Sullivan, the head of clinical programmes at Cancer Research UK, said that a lack of resources was also affecting cancer patients.

He revealed that Herceptin, a breast-cancer treatment that costs £20,000 a year per patient, was not available in many parts of the country despite a Nice ruling last summer that it should be available to all women with advanced breast cancer who might benefit from it. This means about 5,000 people each year.

"There are plenty of places around the country that aren't giving Herceptin because they're not able to do the tests needed before the drug is given," he said.

Diabetes sufferers are also being denied effective treatments.

In January, Nice ruled that all patients whose blood sugar was not properly controlled by traditional insulin injections - at least 4,000 people - should be given funding for insulin pumps. Without them, sufferers risk blindness, amputations, kidney failure and even death.

It is now becoming clear, however, that not all health authorities are abiding by Nice's ruling. John Davis, 64, a patient at the Royal Bournemouth Hospital, is having to pay £1,000 a year for a pump because his local health authority is not funding the service.

Mr Davis set up a support group in April, and has since been contacted by dozens of fellow diabetics, mostly from Dorset, Oxfordshire and Northamptonshire, who are also unable to get the treatment on the NHS. "We have people who've been refused treatment even though their consultant has told them they should have it," he said. "But many other patients are getting it. It isn't fair."

The extent of the so-called postcode lottery - in which treatment is available in some health authority areas but not others - is also illustrated by the patchy availability of the latest treatments for Alzheimer's disease.

In the Greater Manchester area, no new patients in Salford have received anti-dementia drugs since January. Only 10 miles away in Bolton, however, people are being seen quickly by a service tailor-made to administer the treatments.

Dr Mahendra Gonsalkorale, a consultant geriatrician at Hope Hospital in Salford, said: "This really is not acceptable or fair. In the UK in general there should be similar access to these drugs for everybody."

The Alzheimer's Society says similar problems exist in Lancashire, Shropshire and Yorkshire. The reason is not a lack of drugs but the lack of staff to administer them.

Dr Evan Harris, the Liberal Democrats' health spokesman, said: "The Government doesn't figure in the total cost of Nice recommendations, let alone ring-fence funding for their recommendations."

Professor Sir Michael Rawlins, the chairman of Nice, said that careful audits by the revamped Commission for Health Improvement might be needed to ensure that the agency's rulings are followed across the health service.

Another senior Nice official, Anne-Toni Rogers, the director of corporate affairs, pointed out, however, that its rulings had proved effective in improving treatment for tens of thousands of patients. "After we recommended taxane treatment for breast cancer, usage went from one in five patients to three in four in just three months," she said. "You have to ask whether 100 per cent take-up is possible."

She said it was the Department of Health's responsibility to ensure that the medicines it recommended for use were provided by health authorities.

A spokesman for the DoH said: "Where it comes to our attention that there is non-compliance with Nice guidance on drugs, this is raised with the strategic health authority concerned, who will need to sort it out at the local level with relevant NHS trusts and primary care trusts.

"We fully expect primary care trusts to meet their statutory obligations, and strategic health authorities to follow up any allegations of non-compliance."

From:
Drugs-denied-to-sick-against-the-rules-of-new-NHS-watchdog.html

NHS risks losing cancer drugs after NICE blights patients

One of the world’s leading drug companies is threatening to withdraw some of its new cancer treatments from the process by which they are approved for use in the National Health Service.

Cancer patients in Britain will consequently be denied more effective drugs that are available to sufferers in other countries.

Roche, the Swiss pharmaceutical giant, has already refused to supply economic data on its drug Avastin for treatment of lung and breast cancer to the National Institute for Health and Clinical Excellence (Nice), the authority that evaluates the cost-effectiveness of medicines for the NHS. This means Avastin will not be available on the NHS for those diseases.

Avastin is said to double the time a breast cancer patient’s condition remains stable when compared with existing treatments. Studies have also shown improved survival rates for lung cancer victims.

Roche said last week it will consider withdrawing from other evaluations rather than submit products only for them to be rejected by Nice as too expensive.

The statement is the latest twist in the growing row over decisions by Nice. Earlier this month Nice caused an outcry in a preliminary decision when it rejected the use of Avastin (also known as bevacizumab), Sutent (sunitinib), Nexavar (sorafenib) and Torisel (temsirolimus) as too expensive to treat kidney cancer.

“The alternative to these drugs for many patients is death,” said Jonathan Waxman, professor of oncology at Imperial College, London. “Nice is making terrible mistakes.”

The survival rates for cancer in Britain are already among the lowest in Europe — on a par with Poland, Slovenia and the Czech Republic, according to data published last year.

However, cancer charities acknowledge there has been significant improvement in rates since the government made the issue a priority with its NHS Cancer Plan, first launched in 2000.

Some consultants argue, however, that Britain already spends less on cancer drugs than many other European countries and that it is “crazy” to reject drugs proven to prolong life.

Richard Barker, director- general of the Association of the British Pharmaceutical Industry, which represents the drug companies, said: “Nice does a tough and necessary job, but is making errors because of a very mechanistic approach.

It relies too much on arithmetic and not enough on clinical judgment.”

Nice was created in 1999 with the aim of ensuring that decisions on the best and most cost-effective drugs for the NHS were made at a national level, were transparent and could be challenged.

When the drug companies scrutinised the economic modelling used by Nice, they realised that the estimated costs of their drugs and effectiveness could vary widely.

Even more seriously, some of the calculations were wrong. There was an outcry in the medical community in February 2006 when Nice stated that Temodal (temozolomide) — declared as the biggest breakthrough in treating brain tumours for decades — did not offer value for money.

Temodal had won approval from the European regulator in 2004, but many British patients were denied treatment as Nice wrangled over costs.

Peter Davison, 48, a manager for Cambridge University Press, was among the few British patients who received the drug — because he was diagnosed with a brain tumour while working in Singapore.

“I was lucky to be abroad,” said Davison, who is now in remission. “Four months after I had the operation to remove the tumour, I was running and climbing mountains.”

When Schering-Plough — the pharmaceutical company which markets Temodal — prepared its appeal against the Nice decision, it identified an error in the modelling. Once corrected, the model showed the drug was cost-effective — and as a result it was ultimately approved for NHS use.

Not surprisingly, the drugs companies now want full access to the economic models, with the chance to check the accuracy of the calculations. In May, the High Court ruled that Pfizer and Esai, the companies which market the Alzheimer drug Aricept, should be given full access to these models.

“We believe this modelling might not be fit for purpose and we want to check it,” said a Pfizer spokesman last week. Nice said it was seeking leave to appeal to the House of Lords after the High Court decision.

Even where the models are correct, consultants and patients’ groups say Nice fails to give proper weight to the evidence from clinicians and patients’ groups.

The Sunday Times has highlighted the fact that NHS patients do not even have the option of paying for the drugs privately because of government ban on “co-payments”. The labour government has said it will review the issue.

Professor Sir Michael Rawlins, chairman of Nice, said the evaluation process was recognised internationally and Nice had been commended by the World Health Organisation for the quality of its work. He said: “We have a finite amount of money to spend on healthcare and we have to divide it up in as fair and as equitable a way as we can. We can’t say to yes to everything. It’s awkward, it’s difficult, it’s unpleasant.”

From:
http://www.timesonline.co.uk/tol/news/uk/health/article4538256.ece