Cancer Research (Hansard, 9 February 1998)

§ Dr. Ian Gibson (Norwich, North)

Cancer remains a major medical problem in the United Kingdom. One in three people suffer some form of cancer. One in four die of it. Given the demographic changes—the population's increasing age—it is estimated that one in two people will suffer some form of cancer by 2020. A wide range of cancers was targeted as a priority in last week's Government Green Paper, "Our Healthier Nation".

Cancer research is an integral part of cancer medicine. Progress in cancer treatment has been steady, but very slow. Significant advances have been made by both scientists and clinicians working together to develop new treatments and to refine the results of such treatments. There have been important success stories in relation to testicular cancers, lymphomas and tumours of childhood, but, with common cancers such as lung, colon and breast cancer, there has been less spectacular progress. Prostate cancer has emerged as a major threat to male lives, and will require a severe strategic and clinical approach to have some form of cure.

We are at a watershed in cancer treatment and entering a new age of entirely novel therapies, where we will be able to identify people who are genetically at risk—for example, women who are at risk from breast cancer. In the past decade, an understanding of the fundamental cell defects that cause cancer, the mutant genes, has allowed us to consider discarding conventional treatments with agents such as cytotoxic drugs, in favour of a range of new, specific and effective agents.

Those new treatments include the use of the mutant gene, the so-called oncogene, as a target, which is thus selective; preventing cancer from spreading; and selectively re-engineering cancer cells to make them normal.

Such specific treatments should, we hope, eliminate many of the present debilitating side effects. At the same time, we must consider research into the care of patients and the role of organisations such as BACUP—the British Association of Cancer United Patients—the Royal College of Nursing, and MacMillan Cancer Relief, which provide information, counselling, support and nursing research for individuals, families and patients, and are key players in this area of research.

Other important research has disclosed that social class V individuals suffer more cancer than social class I; the same is true where there are marked social inequalities. That shows that environment and diet are strong influences in the differentiation between the classes, and therefore need further investigation. After all, it was in Britain that the definitive research into the link between smoking and lung cancer was carried out. The Food Standards Agency will offer support with diet and its link on cancers.

Cancer medicine requires a rigorous, reductionist, analytical approach to the disease. A knowledge of genetics, cell biology and molecular biology is increasingly needed so that clinicians can think of the clinical problem of cancer in fundamental terms and understand the scientific rationale for new treatments. 119 This essential core knowledge is included only at a very superficial level in the postgraduate training of cancer specialists.

In the past, research posts and research projects have been essential components of oncology training, but the opportunity to engage in such activities has been vitiated by the new strategies for national health service research and development introduced by the previous Government, which are heavily weighted in favour of operational and economic projects while providing very little support for clinicians wishing to pursue laboratory-based biomedical research.

Clinical research is the most widespread research activity in which clinicians participate. Clinical trials are the only way to evaluate and validate new treatments. It is vital that they are done, and done well. In the present state of knowledge, it is important that as many patients as possible with a malignant disease are offered the opportunity to participate in clinical trials. That is especially true of patients with the rarer malignancies. It is therefore important that there is support and encouragement for clinical trial participation at central and local level.

the last round of health service reforms by the previous Government unfortunately erected many obstacles in the path of clinical researchers. They have had the effect of severely restricting the scope for trial participation by non-academic departments. A recent article in the British Medical Journal by a senior consultant—sadly unsigned, even in this day and age, for fear of reprisals—illustrates the frustrations of trying to be both a clinician and a researcher. The lack of central support for and local commitment to clinical research activities, with NHS chief executives regarding clinical research with suspicion and as a potential drain on resources, is a major problem awaiting a solution.

Cancer research gets huge support from charities, and millions of pounds are donated each year by a generous British public. The Government can work with those private sources to underwrite long-term support. At the same time, the pharmaceutical industry—one of the success stories, we are told, in this country—seeks interaction with the wider scientific base in universities and research institutes.

I avidly await the views of Glaxo Wellcome and SmithKline Beecham on the effect of their proposed merger on these scientific issues—and, indeed, whether it will better the development of treatment for patients. The ground rules for applications to the National Lottery Charities Board need to be widened to support some of the initiatives that are needed.

We have a model—the National Cancer Institute in the United States. It supports cancer research and medicine throughout the USA. It supports a huge research and development operation in oncology, including laboratory science and clinical science at the highest level. It has pilot plant arrangements for the production of new compounds to be used in clinical studies.

Where there is co-development of new drugs with a pharmaceutical company, it has a degree of control over the pricing of the drug when it comes to market. That is extremely important for new drugs such as the Taxanes, which have been the subject of concern and rationing on 120 ground of cost. Some women have been denied treatment for breast cancer because NHS trusts have run out of money. We need some control nationally over that process.

Moreover, the NCI is a comprehensive organisation for conducting and monitoring clinical trials. It makes comprehensive information resources available to clinicians and patients on the Internet—at www.nih.gov—and not only provides but maintains those information resources in the light of emerging data. In some cases, information is reviewed and re-edited monthly. The United Kingdom has no comparable resource.

The United Kingdom urgently needs a national cancer institute that could and should work in concert with its US counterpart. The idea has support from the director general of the Imperial Cancer Research team, in London, from many consultants, and locally, as demonstrated today in our newspaper. The local Norfolk and Norwich Big C charity each year collects some quarter of a million pounds from the good people of Norwich and Norfolk, and supports the initiative to establish a national organisation.

The Royal Marsden hospital is an obvious candidate centre, but the site of the new flagship hospital, in Norwich, which is so beloved by my hon. Friend the Minister, might also be a fine place to site such an institute.

There certainly needs to be a national research initiative with support rather than obstruction at central and local level. In the USA, Clinton has given a massive budget increase to the National Institute of Health and the National Cancer Institute to boost scientific and clinical research. Those organisations have strong links with the Imperial Cancer Research laboratories, in London, and many individual scientists and clinicians collaborate with each other on both sides of the big pond.

There is currently a great opportunity to forge links and engage in jointly funded projects—all it needs is central organisation and political momentum. The failure of Nixon's so-called war on cancer will be forgotten if our new knowledge of the causes and biological basis of cancer is accepted and applied, and a proper infrastructure is established to move discoveries from laboratory to clinic to bedside.

§ The Minister of State, Department of Health (Mr. Alan Milburn)

I am grateful—as I am sure that the House is—to my hon. Friend the Member for Norwich, North (Dr. Gibson) for raising an extremely important subject, and for giving me the opportunity to stress the Government's determination to improve cancer services and our commitment to cancer research.

As my hon. Friend rightly said, cancer is a major problem. Each year, more than 200,000 new cases of cancer are diagnosed in England and Wales. Most of us are likely to know someone who has suffered from cancer. Tragically, in the United Kingdom, one in four people currently die from cancer. After coronary heart disease, cancers are the most common cause of death in our country. All that makes it vital that the Government have a strategy both for cancer care and for cancer research.

Before outlining the Government's strategy, I should like to record—I hope on behalf of the whole House—my thanks to all the organisations that help in tackling cancer, 121 whether they work in the field of research—organisations such as the Cancer Research Campaign or the Imperial Cancer Research Fund—or in helping patients and their families to deal with cancer, such as the services offered through MacMillan Cancer Relief and Marie Curie Cancer Care.

As hon. Members will know, cancer has an impact on the lives of most people in the United Kingdom, whether as patients, relatives, friends, neighbours or workmates. I know that the work of those organisations has often proved invaluable. I certainly join my hon. Friend in congratulating members of the public who each year donate huge sums to help in the fight against cancer.

Over the next 20 years, there are likely to be a number of major changes that will impact upon cancer care and cancer research. Research will have an important role in addressing those developments. The pattern of cancer incidence, for example, will change as the population becomes older. Cancer is mainly a disease of older age, with the majority of people in the UK who develop it aged over 70. We need also to ensure that our screening programmes continue to meet high-quality assurance standards, and that other potential population screening methodologies for other specific cancers are considered as research becomes available.

Just as important, with an increasing older population, it is likely that more people will have to live with cancer. This means that we need to ensure that research continues to improve our knowledge of palliative care so that we can further develop our support systems and improve the control of symptoms and side effects following treatment, thereby allowing patients, as far as possible, to lead a fulfilling, pain-free life.

Research can help to identify ways of preventing cancer, or spotting it in its early stages. Not all cancer deaths are preventable, but many are. Factors such as diet, smoking or the environment can cause cancer. As my hon. Friend rightly said, just last week the Government set out in the Green Paper "Our Healthier Nation" proposals to reduce the death rate from cancer among people aged under 65 years by at least a further one fifth.

That is a very challenging target, but one that it is important to meet. Had that reduction taken place in 1996, it would have resulted in some 6,000 deaths in this age group being avoided. We set out proposals for concerted action by the Government as a whole, in partnership with local organisations, to improve people's living conditions and health.

The Government believe that all cancer patients should be confident of uniform access to high-quality services, regardless of where they live. The care and treatment of cancer patients forms a substantial part of NHS work in both the primary and secondary care sectors—it accounts for around 7 per cent. of NHS resources. We want to ensure that the good working practices that already exist in many areas are developed more widely, so that we can get rid of some of the unacceptable variations in provision.

That is why the Government wish to progress the Calman/Hine framework set out in the document "A Policy Framework for Commissioning Cancer Services". As my hon. Friend will know, that recommended a strategic framework for delivering cancer services so that variations are eliminated.

122 A great deal of work has already been undertaken within the NHS to implement the recommendations of the Calman/Hine framework, with much being achieved locally. A key element has been the identification of cancer units and centres and local agreement on where and what cancers should be treated at individual hospitals. In many regions, this has involved site visits by multi-disciplinary teams to assess cancer provision against agreed cancer standards, to identify strengths and weaknesses, and to agree a time scale for change.

Full implementation cannot be achieved overnight, but we are determined to see some early improvements in services. We have set out a commitment in our White Paper "The New NHS" to improve prompt access to specialist services so that 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. As my hon. Friend also knows, we have already made £10 million available to be used specifically for breast cancer services. It is being used already to give women rapid access to good diagnostic services and shorter waiting times for treatment. Indeed, some £120,000 of this investment has gone into services in Norwich.

The current reorganisation of our cancer services, based on the Calman/Hine recommendations, will enable patients to move through the system more effectively and to benefit from earlier diagnosis and treatment given by specialised multidisciplinary teams. It has been estimated that this alone could increase survival by as much as 10 per cent. when fully implemented. The publication of evidence-based guidance in support of the cancer strategy and the guidelines issued by the professions for the various cancer sites is allowing the benefits of research to be disseminated and translated into practice across the country.

I deal now with some of the specific issues raised by my hon. Friend. Let me assure him that the Government remain committed to encouraging research into the causes, prevention, early detection and treatment of all cancers. There are three main routes by which the Government currently fund research: through the Department of Health policy research programme, the NHS research and development programme, and the Medical Research Council.

First, the Department of Health's policy research programme funds high-quality research to provide a sound knowledge base for health services policy, social services policy, and central policies directed at the health of the population. It has an extensive portfolio of work on research into cancer. It provides long-term funding for two well-established and highly regarded research groups: the cancer screening evaluation unit at the Institute of Cancer Research, and the childhood cancer research group at the university of Oxford.

The programme also contributes to research external to the Department of Health. For example, it is making a substantial contribution to the United Kingdom Co-ordinating Committee on Cancer Research's breast cancer screening trials, one of which is studying the potential value of screening women from the comparatively earlier age of 40. Other cancers being 123 researched include lung cancer, liver cancer and childhood tumours, and there are also studies on smoking and radon in houses.

Secondly, there is the NHS research and development programme which funds more than 300 studies and plays a key role in strengthening the scientific basis of health care. There is a specific NHS research and development cancer programme, which, after a detailed consultation process with key organisations in the cancer field, identified 25 priority areas including aetiology, palliative care, screening and treatment. Through the NHS research and development levy, the NHS also provides service support for externally funded clinical and basic research undertaken in NHS trusts. About £30 million was spent on service support for cancer research.

Thirdly, there is the main agency through which the Government support medical and clinical research—the Medical Research Council, which receives its grant in aid from the Department of Trade and Industry. The council is an independent body, deciding what research to support on its own expert judgment.

In 1994–95, the latest year for which figures are available, the council spent almost £15 million directly on research into cancer. The figure would rise considerably if a proportion of the council's spend on metabolism, molecular structure, genes and chromosomes, the immune system and other areas of basic medical research that may yield results relevant to cancer were included. The Department of Health has a concordat with the Medical Research Council that ensures discussion between the two organisations on their priorities for research.

The Medical Research Council is currently funding a number of research projects that will have a significant impact on the future of cancer services. For instance, the MRC is funding research looking at the application of new technologies, including imaging and molecular pathology, for improving tumour diagnosis, and for the prediction of tumour behaviour and response to therapy.

As my hon. Friend said, invaluable work is undertaken by the cancer research charities, such as the Cancer Research Campaign and the Imperial Cancer Research Fund. In 1995–96, it is estimated that charities affiliated to the Association of Medical Research Charities spent £124 million on cancer research. Together with the estimated £115 million spent each year on cancer research by the pharmaceutical companies, that means that, in total, an identified £263 million a year is spent on cancer research. It is a considerable sum of money, but it is not simply a matter of funding. We must be confident that appropriate research is undertaken, and that we build on the lessons from research.

124 My hon. Friend has called for a strategic body for cancer research. The National Cancer Institute in the United States of America is a well-respected and effective organisation. It is an interesting proposal, but the current arrangements in the United Kingdom are different, although equally effective.

Here, we have a national forum with representatives from the NHS, the pharmaceutical industry, the medical research charities and the research councils. It was established to ensure that the NHS fully understands the priorities, strategies and requirements of its research partners, and in turn ensures that they understand where NHS priorities lie. It covers research generally, but provides a forum for sharing information and taking a strategic overview of research activity.

On cancer in particular, there is the United Kingdom Co-ordinating Committee on Cancer Research, which is jointly funded by the Cancer Research Campaign, the Imperial Cancer Research Fund and the Medical Research Council. It provides a useful forum for the exchange of views and information among funding bodies and other organisations specifically on cancer. It plays a major role in facilitating and co-ordinating joint initiatives. Importantly, it recommends proposals for the co-ordination of policies to sponsors, and advises on issues of relevance to the conduct of cancer research.

The co-ordinating committee also has a number of site-specific sub-committees developing basic science and clinical trial initiatives, including ones on breast, colorectal and gynaecological cancers and melanoma, as well as ad hoc groups advising on the current status of biomarkets and new technologies in clinical cancer research. I assure my hon. Friend that the co-ordinating committee maintains close links with my Department, and we have observer status on it.

I agree with my hon. Friend that clinical trials are the best way of evaluating and validating new treatments. All treatments in the NHS should be subject to clinical trials. We have recently appointed a clinical trials adviser to support and develop trials.

The debate has highlighted the potential for cancer prevention and, we hope, cure. Our knowledge of cancer is increasing year by year—indeed, day by day. We need to be confident that we have in place co-ordinated and appropriate research, and, most importantly, that we have the ability fully to exploit the results of that research for the benefit of the population. That is the challenge for the national health service and the country. I assure my hon. Friend and the House that we shall work with all concerned to help meet that challenge.