Cancer crisis looming: all talk no action

As the number of cases rise, the future of cancer care is caught up in a debate between the federal government and a coalition of experts over spending strategy

OTTAWA -- Lawrence Smith doesn't mince words when he predicts the future of Canada's cancer care system.

The 69-year-old retired lawyer was diagnosed with prostate cancer earlier this year, underwent drug therapy and radiation, and has nothing but praise for the treatment he received. But he's worried that as the number of cancer cases grows in coming years, others won't be so lucky.

"They are going to be overwhelmed," he says of health-care professionals.

"And the thing that I'm concerned about is that the country is not going to be prepared to pay for the medical care it demands."

He says Canada must respond to the gravity of the situation with solutions ranging from an innovative cancer plan to, if necessary, private health care.

Smith is one of 149,000 Canadians diagnosed with cancer this year. To these people, the state of the country's cancer system is crucial -- in many cases, the difference between living and dying.

But the future of cancer care is caught up in a debate that has pitted the federal government against a coalition of the country's cancer experts.

The experts have developed a detailed cancer control plan and have asked the federal government to spend $260 million over five years on a strategy that would help provinces co-ordinate strategies, share information and set cancer control targets. The money would also establish clinical practice guidelines that outline proven ways to improve cancer care, create a database and plan to deal with the shortage of cancer care workers, and improve the palliative care provided to dying patients.

The strategy would be implemented by a council that would include federal representatives as well as experts from the provincial cancer agencies, the Canadian Cancer Society and a national advocacy network for cancer patients.

Prime Minister Paul Martin's government has instead opted to spend $300 million over five years on an "integrated disease strategy" that attempts to persuade Canadians to lead healthier lives, thereby reducing their risk of getting three diseases -- cancer, heart disease and diabetes.

Much of that money will be allocated to programs designed to attack all three diseases, but part of the $300 million will be directed to "disease specific" efforts -- $90 million for diabetes, $59.5 million for cancer and $18.9 million to develop a cardiovascular disease "action plan."

The rationale for an integrated approach is that different chronic diseases can often stem from the same causes, such as smoking, obesity and a lack of exercise. Better to attack them with a joint campaign, says the government.

That decision has frustrated experts like Dr. Simon Sutcliffe, a longtime cancer physician and president of the B.C. Cancer Agency, who heads the coalition behind the proposal.

He supports the federal strategy's emphasis on health promotion, but says that only deals with part of the problem. A comprehensive strategy must also include ways to better treat patients who already have cancer, he says.

"We have provinces that have cancer screening programs that are widely adapted within their populations, and in other provinces we do not. Waiting times for procedures vary considerably across the provinces. Drugs on formularies (that are publicly insured) vary from province to province. The use of guidelines for accepted or best practices are variably taken up across the provinces. Standards differ on how chemotherapy is practised, prescribed and administered. There are very great differences in terms of guidelines for good palliative care."

Without a national strategy to ensure a more even level of care, he says, Canadians in future years will be confronted with a horrible dilemma.

"You'll have a perverse situation that you might decide where you want to live based upon how big you think your cancer risk is and what sort of approach you think the province might take to your health care."

Dr. David Butler-Jones, the country's chief public health officer and head of the Public Health Agency of Canada, acknowledges the threat of cancer caseloads.

"Every year we don't make the investments we need in prevention is another year lost and a bigger hole to try to fill," he says. "The lineups just get longer and they're going to get longer.

"At the end of the day, we could triple the resources we spend on cancer and it would not be enough in a couple of decades down the road."

Butler-Jones says an integrated strategy is best able to battle the common "underlying risk factors" that increase someone's odds of getting cancer, heart disease or diabetes.

"If we focus only on one aspect, we actually risk the health of the population because often we risk not making the best use of whatever resources we have."

The federal strategy's $59.5-million allocation for cancer will be spent in areas such as: public education about cancer risks such as exposure to the sun; Internet sites to give patients information about the "complexities" of cancer treatment; improved registries and databases on the extent of cancer in Canada; and a federal pledge to "champion a pan-Canadian process" to encourage more co-operation among cancer experts so that standards and guidelines can be developed.

Butler-Jones says the coalition's proposal is flawed because, while it includes the support of provincial cancer agencies, it may not necessarily have the backing of cabinets in those jurisdictions.

"We can't just as a federal government just adopt it. Because we're in a partnership here with the provinces and territories. They deliver these programs."

Butler-Jones says the only way to get "durable" results is through a plan developed with the provinces.

Health Minister Ujjal Dosanjh notes Canada is already spending more than $100 million on cancer research and has pledged to shorten waiting times for treatment of the disease.

He pays tribute to the "huge reservoir of energy" among the cancer experts, but he's not convinced their approach is better than the government's.

"If you're talking about clinical common guidelines for clinical practice in cancer -- for that, you don't have to have a stand-alone cancer strategy. You could do that as part of the overall strategy, the integrated disease strategy. If there is a place for federal leadership on these issues, I think that can be accommodated within the context of that strategy."

In May, the World Health Organization warned of a "cancer epidemic" and urged countries to implement comprehensive cancer control programs that include strategies for prevention, early detection, diagnosis, treatment, rehabilitation and palliative care.

"Efforts to prevent and control cancer are hampered by the low priority frequently given to the disease by governments and health ministries, excessive reliance and expenditure on treatment, and a considerable imbalance between resources allocated for basic cancer research and those devoted to its prevention and control," WHO said.

Dr. Jean Lariviere, a former federal public servant who spent many years as a senior medical adviser within Health Canada and who represented Canada at the World Health Organization, helped lay the the groundwork for that resolution.

Lariviere has doubts about the merits of battling cancer through an integrated -- or "mainstreaming" -- approach.

"By trying to do everything, you end up doing nothing. If it is mainstream, it means that everything is of equal importance, which means people stop listening."

Peter Boyle, director of the WHO's International Agency for Research on Cancer, notes that countries like Britain and France have made great strides forward with cancer plans that set goals and targets to reduce cancer rates of incidence and mortality, and improved the quality of life for patients.

"It brought everyone together -- the people treating cancer, the basic researchers trying to understand cancer, the social scientists trying to change people's lifestyles to reduce the risk of cancer, patient groups, administrators, politicians."

Michael Decter, one of this country's most prominent health-care experts, agrees it makes sense to battle cancer through a "disease-specific" plan because "people identify with the disease they have, not with broad integrated things.

"I'm totally with the advocacy groups," says Decter, who was appointed in 2003 by the federal government and provinces to chair the Health Council of Canada, the independent advisory body that monitors medicare. "I'm absolutely convinced it's the right way to do this."

Decter says the council has not examined the cancer strategy, but his personal view is that the cancer system is unique and requires unique approaches.

Barbara Whylie, chief executive officer of the Canadian Cancer Society, says it's hard to understand why the government is "dragging its heels." She says it is an "embarrassment" that Canada is currently playing host to an international conference on combatting cancer while it lacks a comprehensive program itself.

"We already know that the cancer care system is straining at the seams," Whylie says. " We know that, from time to time, people have to be sent out of country or from province to province to get care. That's already happening. Every year that passes, that challenge is just going to grow and multiply if we don't do something now to try to deal with it."

Just a few kilometres away from Parliament Hill, Dr. Hartley Stern, a cancer doctor for 22 years and the senior administrator at the Ottawa Hospital Regional Cancer Centre, shakes his head in amazement at the lack of progress on such a critical public policy.

What's needed, he says, is federal leadership. Cancer control must become a priority.

"The case can be made simply on bang for your buck. If you're going to make an investment as a government and see some value added for society, cancer is a very good bet."

For instance, Stern says the federal government could introduce "tied funding", forcing the provinces to spend the money in areas such as improved cancer screening programs and palliative care.

If politicians don't act, Stern says, they will likely be forced by the thousands of Canadians who, in the years ahead, are told they have cancer.

"I think there is hope. It will come from the public just finally saying, 'This revolts me and I cannot tolerate this, and I will not vote for this government if they don't change their ways.' I don't know when, but I think that time is coming."

© The Edmonton Journal 2005