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How serious is the NHS cancer backlog?

Professor Gordon Wishart joins OnFocus to discuss the backlog of cancer referrals, diagnoses and treatments in the NHS and offer some suggestions on ways forward. Professor Wishart is founder, Chief Medical Officer and CEO of Check4Cancer, a leading early cancer detection and cancer prevention organisation. As the former Director of the Cambridge Breast Unit from 2005-2010, and current Professor of Cancer Surgery at Anglia Ruskin School of Medicine since 2008, Professor Wishart has a strong track record in clinical research and modernisation of cancer diagnosis and treatment, with more than 100 peer-reviewed papers in scientific journals. In 2010 he led a team of clinicians and scientists that developed the PREDICT breast cancer treatment and survival model, now used worldwide.

https://www.check4cancer.com

Clare Delmar

Hello and welcome to On Focus brought to you by The Focal Therapy Clinic, where we connect you with issues facing men diagnosed with prostate cancer that are little known, less understood, often avoided or even ignored. Prostate cancer is now the most commonly diagnosed cancer amongst men in the UK. And with this sombre fact, comes a multitude of challenges and opportunities. I’m Clare Delmar. Joining me today is Professor Gordon Wishart, founder, chief medical officer and CEO of Check4Cancer, a leading early cancer detection and prevention organisation. As the former director of the Cambridge Breast Unit from 2005 to 2010 and current professor of cancer surgery at Anglia Ruskin School of Medicine since 2008. Professor Wishart has a strong track record in clinical research and modernisation of cancer diagnosis and treatment, with more than one hundred peer reviewed papers in scientific journals. In 2010, he led a team of clinicians and scientists that developed the PREDICT breast cancer treatment and survival model, which is now used worldwide. He’s a vocal critic of the government’s handling of the current backlog of cancer patients in the NHS, and he’s here today to chat with me about this. Professor Wishart, welcome. Thanks so much for joining me today.

Gordon Wishart

Great to be here, Clare. Thank you for the invitation.

Clare Delmar

This is such an important issue. And you’ve been very vocal, but I say very constructively vocal. So I guess my first question to you is, how bad is this cancer backlog?

Gordon Wishart

Well, it’s probably one of the biggest challenges, certainly in my career as a cancer surgeon. But essentially the lockdown restrictions have had a devastating impact on cancer diagnosis, really throughout 2020 as a result of several things. I think, firstly, the stay at home government message, a lack of access to GPs and the reduction in access to non-covid NHS services. And as a result of that, there were approximately 350,000 less urgent cancer referrals in 2020 compared to 2019. And out of that, throughout the UK, we’ve seen almost 40,000 less cancers diagnosed in 2020 compared to the previous year, and out of that number, about 8000 were screen detected cancers. So because of the suspension of screening services, a large number of early stage cancers have not yet come to light. So really a devastating impact.

Clare Delmar

Yeah, I want to dig into that data a little bit more. But before we do, what elements of variability are you seeing in these numbers that you reference so across region or against disease area in particular?

Gordon Wishart

Yes, well, I think throughout the UK screening services were suspended. So I think that has really been a universal effect. With regard to actual cancer treatment continuing, then some parts of the country were better than others. As you know, the NHS took over all the independent sector hospitals. But unfortunately, they were not all used by the NHS and many of them lay fallow throughout April to July. So, for instance, in Cambridge, I know one of the local independent hospitals has really done a large number of NHS procedures in the last 12 months. But that’s not the case countrywide. If we look at which particular cancers have been most affected, then sadly, because of delays in diagnosis, we see patients presenting with cancers at a later stage when there’s less chance of cure and in general they require much more treatment. And that has been particularly seen in lung cancer and colorectal cancer. And in terms of prostate cancer, which I know you’re very interested in, almost a four percent increase in patients presenting with stage four prostate cancer so the most advanced stage.

Clare Delmar

I haven’t heard that number. Where does that come from? That piece of data?

Gordon Wishart

Yeah, that’s data from the Southeast London Cancer Alliance. And I’m happy to send you that paper that you want to share with with any of the people that listen to the podcast.

Clare Delmar

Indeed, indeed. Thank you. I will do that. Yeah. So four percent and again, it picks up on something else that I’m very interested in, which is some of the numbers that get a little bit masked because so for example, that men will get treated. So wouldn’t be part of the numbers you cite in terms of not getting treated, but they might be treated inappropriately. Can you comment on that?

Gordon Wishart

I think whatever cancer we’re talking about, the professional bodies that look after the cancer specialists that manage cancer really issued guidelines to try and help clinicians guide their way through the various lock down restrictions. And that has meant that some people might have had what would have been a traditional treatment pathway changed. So there might have been less people having surgery and more people having non-invasive treatment like radiotherapy, for instance, and we know that a number of people had chemotherapy deferred, delayed or sometimes even cancelled. So there have been changes. I’ve just seen a paper published on variations in breast cancer treatment throughout the last 12 months. And actually, although there were quite a number who had their treatment varied, it was fairly minor differences. But again, I think that will be cancer specific and some cancers will have been affected much more than others. In particular, those cancers that need intensive care treatment after surgery because those intensive care places were just not available because of so many people being unwell with covid.

Clare Delmar

So do you see this improving any time soon?

Gordon Wishart

I think it’s fair to say that we are probably back to pre pandemic levels of activity in terms of cancer screening, cancer diagnosis and cancer treatment. But in my opinion, that’s not really good enough because we know from a Cancer Research UK report in 2019 that the state of cancer services in the UK was really poor, with quite mediocre national survival rates compared to many other Western countries, and that was largely due to inadequate early cancer detection and lack of access to optimal treatment. So, yes, we’ve gone back to pre pandemic levels of activity, but as I’ve just said, they were not great. So I think this has to be a time not just to be saying we need more money to employ more cancer specialists and get better access to imaging and treatment. But we should take this as an opportunity to really review all our cancer services and really try and improve things for the UK as a whole going forward.

Clare Delmar

Yeah, I mean, it’s interesting when you talk about variability and levels of diagnosis and modernisation of diagnosis, because, of course, as we’ve spoken about before, this is very much the case in prostate cancer, that the diagnostic pathway has improved radically over the last 10 years.

Gordon Wishart

Yeah, that’s absolutely right. Two recent studies, PROMISE and PRECISION, have shown that if you add multi parametric MRI scanning to the pathway for someone with an elevated PSA, then it really improves that pathway. It reduces the number of unnecessary biopsies and detects more patients with a clinically relevant prostate cancer. And so that’s been a big, big improvement. We’ve known for a long time that PSA screening does actually reduce the number of deaths from prostate cancer. But it has had a lot of bad press because of the number of unnecessary biopsies and because of the complications from prostate biopsy.

Clare Delmar

Indeed.

Gordon Wishart

But I think these two studies really address that issue. And I think the great challenge is to to make sure that that expertise in reporting these very complicated MRI scans is now rolled out across all hospitals, apart from those that were involved in those two important studies.

Clare Delmar

Absolutely. And indeed, that was beginning to happen. Do you think that the pandemic and the lockdowns and the things you’ve just been discussing have affected that?

Gordon Wishart

I think they’ll probably have slowed down that rollout. But now is the time for things to accelerate. And so I would hope that that would now continue. There are shortages of radiologists. We have to… You know, there’s going to be a big workforce issue, I think, in terms of delivering cancer services and radiology is one of those critical parts of that equation.

Clare Delmar

Indeed, indeed. We hear that all the time. So let’s shift now to patients themselves. What can men who are concerned about their prostate health do about this?

Gordon Wishart

I think there are two groups really. There are the men who might be having some symptoms: needing to rush to the toilet to pass urine or feeling maybe that they’re not emptying their bladder properly or getting up during the night. And I think my message, as in all cancers, is that if there are people sitting at home with new symptoms, you should come forward and get checked. It’s safe to do so. In fact, it’s probably much safer to come and get checked than stay at home. And with most men over 50, they will now have been vaccinated. So it’s very safe to to see your GP. And if your GP thinks you should be referred, then that’s the right thing to do. So I would encourage anybody with symptoms to come and get checked. On the other hand, we know that men have had real problems, men over 50, getting a check with their GP during lockdown and many GPs were only taking video conferences. And so that’s been something that’s hard to do. So I think we know that there are certain people who have an increased risk of prostate cancer and family history is really important. So, you know, if men have a close family history, maybe their brother or their father or maybe even their son who’s had prostate cancer, then they’re at increased risk. And I would encourage them to go and get their PSA checked. And then also if men come from a family where there’s a strong family history of breast cancer caused by one of the BRCA genes, then again, there’s an increased risk of prostate cancer there. So I think if people are in those increased risk groups, I would encourage them to seek screening either through their GP or if that’s not possible, then there are other ways to do that. And it’s now even possible to do a finger prick blood test for PSA at home now.

Clare Delmar

So can you talk about that a little bit, how men might access that and how they can be reassured that it is indeed effective?

Gordon Wishart

This is something that we’ve been doing it at Check4Cancer for a couple of years now. And we know that through some laboratory tests that the fingerprint test is just as relevant and accurate as the traditional blood draw. And so it can be done really very easily. And we know what the ranges are for different age groups. And so men aged 40 plus can now access a very simple test that they register online, a kit is sent to their home. They take the fingerprint test, send it back to the lab. We get the results and we let them know the results. And then depending on what that result is, that also helps work out what future risk is. And so you can let them know when they should next have a test.

Clare Delmar

How do they find out about this test? How would they go online to register, as you describe?

Gordon Wishart

Well, you could look online on the Check4Cancer website, but there are a number of different companies now offering similar tests. So I think if you just search for PSA fingerprint blood test and there will be several opportunities to do that. I’m now particularly interested in risk stratification. So if someone’s got a PSA less than one at age 40, then their future risk is really very, very low. And so they don’t really need to be having a check every year. They could wait for six to eight years before their next blood test is done. So I think that element of risk stratification is important for prostate cancer and I think will become important for the management of all cancers going forward.

Clare Delmar

OK, interesting. So, I mean, the finger prick test will be of interest to, I think, a lot of men. And I will make sure that that gets highlighted on the programme notes. But while we’re talking about sort of innovations like that, there has been a lot of talk about a whole range of innovations in health care that the pandemic has generated, not only around the covid vaccines themselves and the treatments for covid, but also in fundamental health care processes, for example, such as telemedicine and home testing, as we’ve just been discussing and monitoring, for example.So I guess my final question to you is, do you think men with suspected or diagnosed prostate cancer will benefit from any of this?

Gordon Wishart

Well, I’m sure that’s the case. I think we’ve just talked about easier access to screening and testing. I think there are key parts of that. I think we have to be careful when applying tele medicine to cancer and video conferencing. We’re taught throughout our career to treat the patient, not the scan. But I think there are a number of follow up consultations and results consultations that can be done by videoconference, and stop people going to hospital unnecessarily. So I think clinicians will need to have access both to the traditional face to face consultations with people with prostate symptoms and prostate cancer, but also supported by video conferencing when that can be done and just to make the whole cancer treatment pathway easier to manage as patients go through it.

Clare Delmar

Interesting. I’m very excited to hear about the pin prick test, and I will refer, as I said, on the programme notes our listeners to to that. And I guess they can also learn a bit more about risk stratification as well, which, as you say, is really, really important to benefit from any of the innovations we’re discussing.

Gordon Wishart

You’re absolutely right that some developments in cancer diagnosis and treatment have been accelerated during lockdown. And I think there will be many more to come. The technology that’s been developed for covid vaccine, some of that could be applied to cancer treatments and to cancer vaccines in the future. So that’s really exciting. In breast cancer, traditionally radiotherapy has been for three weeks after surgery and the Fast Forward trial, was really pushed through quickly, because that showed that for a large number of patients, having one week of radiotherapy was the same as three weeks. So that was actually introduced during lockdown to benefit breast cancer patients. So I think we’re going to see really an avalanche of innovations coming through, which is great in cancer services in the next three to five years.

Clare Delmar

That’s very good news, which I think will end there. Professor Gordon Wishart, thanks so much for speaking with me today. It’s been a real pleasure. And I know for many of our listeners they will really benefit from your comments.

Gordon Wishart

Thank you very much.

Clare Delmar

Further information on Professor Gordon Wishart is available on our website, along with the transcript of this interview and additional interviews and stories about living with prostate cancer. Please visit www.thefocaltherapyclinic.co.uk. Thanks for listening and from me, Clare Delmar, see you next time.

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