Managers & Medicine

The government statements on the right are laudable. But The New NHS white paper and the public health green paper are short on specifics.

Cancer's global incidence is soaring due to rapidly ageing populations in most countries. By 2020, the number of new cancer patients every year will double to 20 million.

Infection as a major cause of suffering and death is giving way to new epidemics of noncommunicable disorders such as cardiovascular disease, diabetes and cancer.

Many governments are now targeting cancer with a two- pronged approach - improved public health and better treatment services.

Why cancer? Politicians realise it is the public's most feared disease. Therefore doing something about it draws strong public approval and, of course, votes.

Are we getting our priorities right in the UK? Getting patients who may have cancer fast-tracked from primary to secondary care seems reasonable. But there is already no evidence of significant delay, so the effort spent trying to break an imaginary log-jam could be more usefully targeted elsewhere.

The white paper implies that any patient with any symptom that could be due to cancer has a right to a consultant appointment within two weeks. This would flood surgical and medical clinics immediately.

When the concept appeared in the Labour Party manifesto last year it came as a surprise to most of us in the cancer field. Studies show that for several cancers, treatment results in terms of survival are poorer among socio-economically disadvantaged people. But there is no evidence that this is due to delay, as the stage distribution (the degree of spread at time of presentation) is the same.

The inequity is clearly something to do with differences in how the patient is treated.

Investing in cancer treatment services and implementing the Calman-Hine report, with its hub and spoke network and implicit quality control, would be a better investment - though not such a vote-catcher.

The green paper makes better sense. We know 75 per cent of cancer is caused by tobacco, diet or infections such as hepatitis (liver cancer) or papilloma virus (cervical cancer). Even the most effective public health strategy cannot prevent three quarters of all cancers. But we could reduce cancer deaths in people aged under 65 by 20 per cent quite easily (see box below). As most cancer patients are over 65, the target is not that challenging.

The main killers of people under 65 are lung and colorectal cancer in men - 45 per cent of cancer deaths - and breast, lung and colorectal cancer in women, together causing 53 per cent of deaths. The two logical health targets are thus smoking and diet.

In 12 years as a clinical director I never met anyone involved in public health. For too long those involved in cancer treatment have been divorced from prevention. Yet their expertise, organisational skills and local knowledge, coupled with strong communications, could become a powerful public health tool.

A central plank in the World Health Organisation cancer strategy is to encourage cancer centre directors worldwide to own the total cancer problem - education, prevention, detection and care. A priority ladder is made for each country. The embryonic Calman-Hine network is an ideal launch-pad for a new holistic vision of the cancer problem for Britain.

The New NHS : modern, dependable , 1997 'Everyone with suspected cancer will be able to see a specialist within two weeks of their GP deciding they need to be seen urgently, and requesting an appointment. We will guarantee these arrangements for everyone with suspected breast cancer by April 1999 and for all other cases of suspected cancer by 2000.'

Our Healthier Nation: a contract for health , 1998 'Many cancer deaths are preventable either by tackling factors such as diet, smoking or the environment which cause them or by ensuring speedy diagnosis and treatment.'

'Cancer target: to reduce the death rate from cancer amongst people aged under 65 years by at least a further fifth.'

Karol Sikora is professor of clinical oncology at Imperial College school of medicine, Hammersmith Hospital. He is on secondment as chief of the WHO cancer programme.