In Saturday's Globe and Mail, Globe public health reporter André Picard tells the story of the evolution of Britain's cancer strategy -- and what Canada can learn from it.
In Heal, Britannia: U.K. gets cancer care right, he wrote: "In a country where cancer care is oft-described as our national shame, the partnership has its work cut out for it. But so too did Britain."
Mr. Picard was online earlier to take your questions on our health-care system's ability to cope with cancer in this country and the anticipated impact of the recently announced Canadian Partnership Against Cancer. Your questions and Mr. Picard's answers appear at the bottom of this page.
Mr. Picard has written extensively on public health issues and has been honoured by many bodies for his outstanding work over the years. He has been nominated for National Newspaper Awards in beat reporting for his work on such stories as the impact of the SARS outbreak on nurses; the dangers to young hockey players from body-checking; and the health effects of trans fatty acids. He has also been honoured numerous times by the Pan American Health Organization's Centennial Journalism award program, the Canadian Nurses Association; and has won the Canadian Policy Research Media Award and a Michener Award. Mr. Picard, who is based in Montreal, was on the forefront of reporting on Canada's tainted blood crisis in 1992, going on to write hundreds of stories about the men who died. He wrote On The Gift of Death: Confronting Canada's Tainted Blood Tragedy about this low point in Canada's health care history.
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Rasha Mourtada, globeandmail.com: Welcome, André, and thank you for coming online today to take globeandmail.com questions. While researching Heal, Britannia: U.K. gets cancer care right, what would you say stood out as the main disparity between our cancer care and theirs? What were you most struck by?
André Picard: Cancer care in Canada and Britain is very similar. Our hospitals look alike, we have specialized cancer doctors and institutions. Now we even have cancer strategies that are very similar. But what struck me most about Britain's approach was the co-ordination of care and the support provided to patients. British cancer patients have the benefit of "nurse-navigators" who assist them on the cancer journey. The nurse is an educator and an advocate, in addition to her regular duties as a healthcare professional. In Canada, there are a couple of nurse-navigator pilot projects but, unfortunately, they have not been rolled out nationally. The other big differences it that Britain has a national health system, and Canada has a far more complicated federal-provincial-territorial system. When the government of Tony Blair decided to implement a Cancer Plan, the National Health Service acted immediately.
Krista Clement, Canada: Britain was able to set national goals, funding, and processes within the NHS. Even with the new Canadian Partnership (and hurrah for them!!), we do not have a Canadian Healthcare System - we have a dozen provinces defending their turf. Will that difference become a massive speed bump to change in cancer care here?
André Picard: There is no question that the nature of our health system 10 provinces, three territories and the federal government responsible for native, the RCMP and the military makes it much more difficult to implement national strategies.
The new Canadian Partnership Against Cancer hopes to overcome those "speed bumps" by publishing good data, guidelines and policy recommendations and using moral suasion to have them implemented by the provinces. However, there is some troubling precedent. The Common Drug Review is a similar body that examines new drugs and determines whether they should be on provincial formularies but the final decision rests with individual provinces; whenever there is political heat, the provinces tend to back away from the recommendations.
The result is that we have the same uneven access, the issue the CDR was supposed to resolve. Hopefully, the issues of inequality in access to care and in treatment will not persist after the new cancer strategy is in place. The other issue is funding. Britain has spent the equivalent of $4-billion over five years on improving cancer care. In Canada, Ottawa has provided $260-million in seed money to identify what needs to be done differently, but it will be up to the provinces to find the money to implement improvements. For example, if the new CPAC (Canadian Partnership Against Cancer) decides there should be a national screening program for colorectal cancer, what happens if some provinces balk at the cost? There is not doubt that federal-provincial-territorial issues will be a challenge in cancer care, as they are throughout the health system.
Cryin Outloud, Canada: Mr. Picard, how much do we know about the polluted environment and the poor quality of the food we are eating being a cause for cancers?
I mean, we can now purchase salmonella, botulism, meat with syringes, E. coli, genetically altered foods that are not required to be labelled, etc., right in our grocery stores. I'm finding this very distressing and we DO KNOW that stress causes cancer!
André Picard: Cancers (there are about 200 different types) have their roots in a combination of genetic and environmental causes. With few exceptions such as smoking and exposure to radiation or asbestos - it is difficult to pinpoint the exact cause of cancer. There is no doubt that our lifestyle, and our diet in particular, plays a role in a number of cancers. A diet high in fibre, for example, lowers the risk of colorectal cancer. Chronic exposure to h. pylori increases the risk of stomach cancer. But it is difficult to point to specific foods, good or bad, that can cause or prevent cancer. A lot of associations have been identified, but these interactions are complex.
Sylvia Ralphs-Thibodeau, Ottawa: Can you tell me more about the "nurse navigator" pilot projects in Canada? Thanks.
André Picard: Unfortunately, I do not know a lot about nurse-navigator projects in this country. Canada is the land of pilot projects there are hundreds, if not thousands, of good initiatives underway at any given time, and it is difficult to keep track of them. But I do promise that we will be writing about nurse-navigator initiatives in The Globe in the near future.
John Penturn, Toronto: This article covers much of what needs to be covered, especially giving some sense of what Canada would have to do to emulate England. What is utterly inexplicable is, having read on numerous occasions in The Globe (over many years) how France is rated the number one health system in the world by the World Health Organization, and how it's done for less money than we spend, why has there never been an article on what it would take to emulate them?
André Picard: The reason Britain was chosen was because it has a system that, on the ground, is similar to Canada. It is also, without a doubt, the country that has acted the most forcefully on dealing with cancer. We also considered Australia, New Zealand and France, but none of their cancer strategies are as advanced or as sweeping as the one in Britain.
Personally, I have written a number of stories about the French health system and why it has been identified as the #1 health system in the world. (That crown has recently gone to the United Arab Emirates.) Without getting into the arguments of policy analysts on whether the World Health Organization uses the proper measures for determining what qualifies as the "best," it needs to be pointed out that France scored very high marks because the system puts a lot of emphasis on choice and speed. There is virtually no waiting for care in France whether it is for cancer care or any other health issue. To do so, they have tremendous over-capacity. (Canada, on the other hand, has a certain amount of rationing, which is more cost-efficient.) For example, there are twice as many cancer specialists in France as in Britain countries of about the same size. So why is French health care not tremendously more expensive? Because health professionals in France are paid significantly less than their counterparts in Britain and Canada.
And France has extensive user fees, which Canada does not. In other words, there are trade-offs in every system.
Terry Maurice, Guelph: The medical system has for many years been focused primarily on treatment of the disease, while so little has been done from the standpoint of prevention. Most probably, pollution plays a major role in the ever increasing frequency of cancer. Only when we clean up our environment and bring in much stricter controls on pollutants will we see a drop. Do you think that the environment argument has validity, and do you think it's likely that a stronger effort to control pollutants in our environment, food chain, etc., will gain greater attention?
André Picard: There is no question that our health care system if far more focused on treatment than prevention. Only about four per cent of our health dollars are spent on prevention. Our health system is, in effect, a sickness care system. Research has demonstrated that the most effective intervention against cancer is tobacco-cessation programs. Getting people to eat better more fibre, more fruits and veggies, less saturated and trans fats, less alcohol can also have a tangible benefit. Clearly, living in unhealthy surroundings, near factories with dirty emissions, on farms where chemicals are sprayed routinely, near landfill sites, close to major roadways, has negative health effects. But, again, making these links is very difficult. We know for example, that people who are poor tend to live in these less-desirable and polluted areas. So, what is the cause of their poor health outcomes: Is it the environment, poverty itself, or a combination of the two? We have to be careful, though, not to be too hung up on quantifying those precise effects before acting. A clean environment is obviously associated with better health, so reducing toxic emissions, cleaning up waterways, reducing motor vehicle use, will be beneficial even if we do not know the precise links to cancer.
Alan Casesels, Victoria: I wonder if you might have any theories on why so much media about new treatments for cancer generally present a consistently unbalanced picture of the benefits of the treatment versus the potential risks? Given that the safety data can be easily unearthed up by any competent journalists, why is there a consistent and even predictable blaming of governments for not making quick and favourable coverage decisions for these new treatments? Is it possible that the reluctance of some governments to pay for new cancer drugs is due to the fact--often unexplored by the journalist--that these drugs are certainly not the wonder drugs the medical establishment portrays them as?
André Picard: I agree that there is a consistent lack of critical analysis of new treatments, particularly drug treatments. Side effects and potential harms should get a lot more attention up-front, and not just retrospectively after a drug is withdrawn from the market. Why does this happen? I'm not sure. Perhaps it's human nature to hope for miracles otherwise there would not be so many lottery tickets sold each week. The media is a messenger; it parrots the messages that come from elsewhere: Reputable medical journals too often grossly oversell the benefits of drugs, and underplay their risks. So too do "expert" researchers, who are not always up-front about their ties to drug companies. Are these good excuses? No, not really. But far too few media have journalists who specialize in specific areas like health, and who can interpret research. Patient and consumer groups are also very influential. They really push for new drugs, and provide human interest stories that are very compelling. More compelling than drug data and statistics. Finally, governments do a very poor job of explaining their positions. If, in refusing to fund a drug, they would clearly explain the reasons why, I believe much of the public would accept the reasoning of marginal benefit compared to cost, or the risk of harm vs. limited benefit. But they don't explain and when experts review bodies like the Common Drug Review make decisions based on the data, the politicians often overturn them based on emotion or political motivation.
Seymore Applebaum, Toronto: My concern is about the lack of attention paid to cancer prevention particularly for men. I recently attended a prostate cancer information session provided by a Toronto hospital. The auditorium was packed. So it was apparent that there is a great deal of interest in prostate cancer. Unfortunately, most of the people (mostly men) had already been diagnosed with prostate problems, therefore, the limited prevention information provided was of relatively little interest to the attendees. They were primarily concerned with treatment options. I think we have to get through to men (and women) that men's cancers can be addressed through proactive behaviour change and early detection through regular physical check ups. We also need to look at some of the men's health initiatives being undertaken in other countries. Unfortunately, when we compare what is going on in other countries to promote men's health, we find that Canada is significantly behind. We need to catch up, fast!
André Picard: As I mentioned earlier, we do not do a good enough job of prevention or screening in either men or women. It is true, though, that, to date, screening programs have been aimed exclusively at women screening mammography for breast cancer and Pap tests for cervical cancer.
The number one cancer killer of men is lung cancer, followed by colorectal cancer. The evidence for the benefits of colorectal cancer screening, using a fecal occult blood test, is strong. However, in speaking of the lack of cancer prevention in men, I believe you are making reference to the PSA test. Many men are currently tested for PSA (prostate specific antigen) but there is no universal screening program. The reason is that many experts believe that PSA is not a good screening tool that it has the potential to cause more harm than good. But the test and the research is evolving so that may change. And that does not mean that individual men should not get a PSA test, which can provide some valuable clues about disease progression.
Nadejda Aletkina, Kingston: Do you have any thoughts on why the idea of detoxification for cancer prevention and treatment doesn't attract much attention?
André Picard: Generally speaking, a lot of cancer patients use alternative therapies. Many may very well work but they need to be subjected to the same rigorous testing as mainstream pharmaceutical products, and they need to be used with the same cautions, i.e. there are not miracle cures. It is also important for cancer patients to tell their physicians they are using alternative products as there may be interactions with prescribed drugs.
Pam Wilkinson, Canada: I'm a 56-year-old woman with estrogen positive breast cancer. Having read about cancerous stem cells being resistant to chemo, am reluctant to go through that again should it return. Are there any upcoming trials for women like me with aggressive cancers?
André Picard: I am not a physician and cannot offer any medical advice. What I can do is urge patients to discuss these issues with their treating physicians and nurses. A caution too about the new research that indicates that some stem cells may be resistant to chemotherapy: While this will influence researchers and may change approaches to treatment down the road, no one should make a decision to receive treatment (or not) based on a single study.
Brenda McGuire, Ottawa: Are there any effective (and practical) preventive strategies, other than the obvious, like not smoking and exercising?
André Picard: Roy Romanow was fond of saying that the top 10 things a person can do to ensure good health were:
1. Don't be poor.
2. Pick your parents well.
3. Graduate from high school or, better yet, university.
4. Don't work at a stressful, low-paid job. Find a job where you have decision-making power and control.
5. Learn to control stress levels.
6. Be able to afford a foreign holiday and sunbathe (with SPF 30).
7. Don't be unemployed.
8. Live in a community where you have a sense of belonging.
9. Don't live in a ghetto, near a major road or polluting factory.
10. Learn to make friends and keep them.
In other words, a lot of our health risks cancer included depend on genetics and the broader socio-economic environment we live in.
Beyond that, there are lifestyle factors that have some impact: Don't smoke, be active, eat well. And with cancer, getting screened and being treated quickly are important.
Rasha Mourtada, globeandmail.com: Thank you, André, for joining us today to take questions from globeandmail.com readers. Any last thoughts you'd like to leave us with?
André Picard: Thank you to everyone for your challenging questions. In closing, I would just say that while our on-going series has focused on cancer, the issues raised about prevention, treatment and research apply generally to a broad range of chronic conditions. What we have learned about improving cancer care using nurse-navigators, broadening screening efforts, providing specialized care in specific facilities, setting wait-time benchmarks, knowing the benefits and limitations of drug treatments and so on has applications throughout the health system. While cancer touches many Canadians, the lessons of cancer should be applied broadly to improve and modernize our health system across the board. The last thing we want or need is disparities of care based on a person's affliction.