The dominant theme of the new guidance on services for upper gastro-intestinal (UGI) cancers (see box 1) is the need for greater specialisation. A wide-ranging review of research evidence, summarised in the latest Effective Health Care bulletin, reveals the magnitude of the gulf between outcomes that prevail in England and Wales and outcomes achieved elsewhere (see box 2).
1Together, cancers of the UGI system - oesophagus, stomach and pancreas - account for almost 10 per cent of cancers in men and about 7.5 per cent in women. These are tumours for which the prognosis is often poor; only about a quarter of patients remain alive a year after diagnosis in the UK.
The research review reveals some of the reasons for the gloomy prognosis. The first problem is that cancer may not be diagnosed until it is far advanced because early symptoms, notably dyspepsia, are very common and rarely due to cancer. These symptoms may not, therefore, be investigated. The guidance calls for increased availability of open access endoscopy services and draws attention to the influence of the patient's age on cancer risk.
Potentially curative surgery may be possible when cancer is diagnosed sufficiently early, but it can be difficult and hazardous. Rates of morbidity and mortality for resection of UGI cancers are among the highest of any elective surgical procedures.
For example, procedure-related mortality from surgery for pancreatic cancer in Yorkshire is almost 18 per cent - eight times that for coronary artery bypass grafts. The call for specialised management is based partly on the discrepancy between such figures as this and those achieved by specialist centres (see box 2), and partly on consistent evidence for associations between higher patient numbers and better outcomes in these types of cancer.
Services in England and Wales have been fragmented and poorly organised. The structure of services recommended in Improving Outcomes in Upper Gastro-intestinal Cancers: the manual is intended to remedy these deficiencies. Patients will be managed by a network of specialist teams based in large cancer units and cancer centres and serving populations for which minimum sizes have been specified (see box 3).
Initial diagnosis will be carried out by diagnostic teams working at local hospitals, which will refer patients to specialist teams for further assessment and treatment. There will also be local cancer care teams that will include members of the local diagnostic team; these teams will provide palliative interventions in accordance with agreed local network policy. The key recommendations agreed by the national cancer guidance group UGI editorial committee are given in The Manual and precised in the summary for GPs and primary healthcare teams (see box 4).
Management by specialist multidisciplinary teams is likely to lead to changes in patterns of treatment, particularly more widespread use of chemotherapy. More patients will receive active treatment for their cancers but this could, paradoxically, reduce hospitalisation times.
Inevitably, improving outcomes will require additional funding. The annual cost of implementing the recommendations in The Manual has been estimated at£87.5m, but there is considerable uncertainty around this figure.
The main areas in which higher costs will be incurred are chemotherapy, centralisation of surgical services and increased use of resection, rapid-access endoscopy services, and new diagnostic equipment.
1 NHS Centre for Reviews and Dissemination. Management of Upper Gastro-intestinal Cancers. Effective Health Care 2000; 6 (4).