SCOTLAND'S health system is being put under strain by doctors offering patients pill after pill in the search for cures for cancer, rather than letting nature take its course, experts warned yesterday.
With an accelerating number of expensive new
drugs coming onto the market, patients and families are increasingly keen to try anything that could help prolong life. But with some predicting the NHS could be bankrupted by the sheer number of treatments available, experts are now warning that doctors must stop "just trying something else" for the sake of the health service and patients.
John Smyth, professor of medical oncology at Edinburgh University, said doctors needed to embrace the advances in palliative care being made in the UK, and Scotland in particular. He said there were concerns the UK could become more like the United States, where patients are expected to be on active treatment until the day they die.
"I know that's driven by patients and doctors, but I am genuinely concerned that the doctors we are now training are finding there are more and more things they could do and there's a temptation to think, 'What's next, is there something else we can try?'" he said.
"This is a mistake both for the patients and the NHS because there are financial consequences of prescribing medicines which are inappropriate."
Professor Smyth's concerns were echoed by charities, which said doctors needed to be quicker in referring patients for palliative and end-of-life care rather than trying one pill after another.
Professor Smyth and Professor Marie Fallon, an expert in palliative medicine also from Edinburgh University, recently contributed to a special edition of the European Journal of Cancer focusing on care towards the end of life.
They said the NHS, university and the voluntary sector in Scotland were working together to improve the care of patients with terminal illness. But they voiced concerns about reluctance among some doctors to accept patients were dying and so needed a different type of care.
Prof Smyth said: "What we have done in the last 20 years is develop a lot of treatments, but it is important to realise as cancer doctors and palliative care doctors that there is a time when you have to stop just trying something else.
"In the old days we had one or two treatments and when you had finished those you stopped, and you'd say, 'I'm sorry your tumour has progressed, but now we'll turn our focus on to different things, such as pain control, symptom control'."
Prof Smyth said that in the US medicine was practised in a very different way.
"There is a ghastly advertisement they have with a young woman who has lost all her hair and it says underneath 'so what's next?'
"I hate it because in America, because it is their culture, the idea is that you should be taking medicine the day you die because there is always the miracle or the next chance."
Prof Smyth said doctors needed to be honest with patients, rather than reaching for the prescription pad and trying more drugs.
He said helping patients prepare for death was an enriching experience and doctors should not deprive people of that.
"I am not saying that people shouldn't have appropriate treatment, because of course they should," he said.
"But I'm concerned that as we get more and more options, people will forget that one of the most important things in medicine is to accept nature.
"And when enough is enough you need to address that. The issue is often with families. I've had so many conversations where I'm sure the patient wants to be left alone, to compose themselves and prepare for the end of life, but the family aren't ready to face that."
In one article in the European Journal of Cancer, palliative care expert David Jeffrey from Borders General Hospital and Ray Owen discuss the difficulties faced by doctors having to talk about death with patients and families.
"Death and dying may be viewed as medical failure and society still views these as taboo subjects," they said. "Since there is genuine uncertainty about what will happen to the individual, the issue is often left until the patient is weak and exhausted."
Like Prof Smyth, the experts say it is key for doctors to know when to stop trying new treatments.
Prof Smyth said cancer medicines were a particular challenge for NHS, as about 30 per cent of drug research focused on this area. "Research and development is expensive, so these products when they come out are very expensive," he said.
"It's no good criticising the government or the regulators.
"There are difficult questions that need to be answered and the public have to join in with these discussions."
But the research going on in Edinburgh could help reduce the costs of research and development by targeting the treatments where they are most likely to be effective.
Prof Fallon said they were in the early stages of developing a technique to predict which patients would respond to which painkillers. The trials will also mean that in future clinical trials, treatments can be taken from "bench to bedside" more quickly and cheaply.
Charities also voiced concerns about the reluctance of many doctors to accept that a patient is dying and needs a different type of care. Dr Sheila McKay, a palliative care consultant at the Marie Curie Hospice in Glasgow, said: "It is a constant frustration that doctors don't contact us earlier in a patient's care.
"Many doctors are scared to have the conversation with patients to say that the chemotherapy is not working any more, that they cannot be cured.
"In those cases they need to bring in the palliative care team to help look after the patient.
"But the doctors are systematically working away trying to cure people and find it hard to say that this is not working."
Macmillan Cancer Support also urged doctors to face up to difficult conversations with patients.
IN NUMBERS1967palliative care is pioneered by St Christopher's Hospice in London
200 families a year given support by the Children's Hospice Association Scotland
||1918||
Marie Curie Hospices in the UK
2 weeksaverage stay at a Marie Curie Hospice
£16 millioncost of building a replacement Marie Curie Hospice for Glasgow
£5.7 millionannual cost of running St Columba's Hospice In Edinburgh
12,749men diagnosed with cancer in Scotland in 2005
13,760 women diagnosed with cancer in Scotland in 2005
15,025deaths from cancer in Scotland in 2006.
8per cent – fall in cancer death rates in Scotland in ten years.
Board's decision too late for one patient DEMAND for ever more expensive drugs on the NHS has been driven by a number of high-profile cases led by patients and their families.
Earlier this year Michael Gray and his partner Tina McGeever launched a battle against NHS Grampian after they refused to fund the drug Erbitux (cetuximab).
Mr Gray, from Buckie, Moray, had bowel cancer and funded the drug privately after it was recommended by his doctor.
Erbitux is not recommended by the Scottish Medicines Consortium for the treatment of bowel cancer because it is not deemed cost-effective.
But Mr Gray, 53, chose to pay for the drug himself, at a cost of £3,400 every fortnight.
Eventually the health board agreed to fund the treatment. But Mr Gray died in April.
Mr Gray and Ms McGeever took their fight for fairer access to cancer drugs to the Scottish Parliament and urged MSPs to make sure access was equal.
Last month Holyrood's public petitions committee demanded more clarity in how health boards decide whether cancer patients can receive drugs not on the approved NHS list, calling for action from the Scottish Government.
Ms McGeever said Mr Gray would have been delighted with the report. "It really is a legacy that Michael has left in his fight to make sure people in his position don't have to go through the same process we went through," she said.
The committee said there was concerns about the extra burden placed on patients as a result of the procedures they would have to go through to get a non-approved drug.
The report also expressed fears about the lack of clarity about co-payments on the NHS. At present such payments, which allow patients to pay privately for part of their treatment and still receive some of their care on the NHS, are banned.
Palliative care means much more than simply pain reliefPALLIATIVE is derived from the Greek word pallium, meaning cloak.
The term palliative care was first used in 1890 by Dr Herbert Snow, a surgeon at what is now known as the Royal Marsden Hospital in London.
In his book The Palliative Treatment of Incurable Cancer, he included an appendix on the use of the opium pipe.
Since then, palliative care has changed dramatically, pioneered by the launch of St Christopher's Hospice in London in 1967.
Palliative care is now described as the holistic care of patients with advanced progressive illness, taking into account all a person's needs.
This includes the management of pain and other symptoms, as well as providing psychological, social and spiritual support.
Staff working in palliative care help patients and their families have the best quality of life possible.
But palliative care is not just delivered right at the end of life, with many patients benefiting from this kind of all-round treatment much earlier in the course of their illness.
According to the National Council for Palliative Care, the aims of this form of treatment are to:
• Affirm life and regard dying as a normal process.
• Provide relief from pain and other distressing symptoms.
• Integrate the psychological and spiritual aspects of patient care.
• Offer a support system to help patients live as actively as possible until death.
• Offer a support system to help the family cope during the patient's illness and in their own bereavement.
Patients around the UK report mixed access to palliative care services.
But the NHS is increasingly investing in links with the voluntary sector to improve the care of patients approaching the end of life.
The full article contains 1718 words and appears in The Scotsman newspaper.
