INTRODUCTION

  1.  The Society of Academic Surgeons is an organisation, which represents principally Consultant Surgeons who are employed by Universities, or other research organisations such as the MRC. Many of the members are Professors of Surgery and all will practice surgery in teaching hospitals associated with undergraducate or post-graduate medical school. The Sugical Research Society is the premier academic organisation devoted to surgical research. Its membership (of more than 500 individuals) comprises research active individuals employed either by Universities or the NHS. This includes both clinical staff and non-clinical basic scientists. It organises biannual scientific meetings providing a forum for high quality research in surgery and related areas.

  2.  The relevance of these organisations to the subject is the involvement of surgeons in treating patients with cancer. Surgeons (see below) either primarily or solely treat the majority of solid cancers (ie non-haematological malignancies). These tumours represent the bulk of the disease and most of the mortality.

BACKGROUND

  3.  Although the current emphasis with respect to improving cancer outcomes has focused on numbers of non-surgical oncologists (physicians who treat cancer) it remains a fact that the majority of patients who are cured of cancer are cured by surgery alone. Non-surgical treatments, such as chemotherapy and radiotherapy), at present contribute only a small amount to survival.

  4.  Surgeons treat (principally) solid cancers. In addition, surgery is the mainstay of treatment for almost all solid cancers. These tumours include the principal causes of cancer deaths—lung, breast, colorectal and prostate cancer. Although lung cancer is frequently not amenable to surgical treatment, virtually all patients with colorectal and breast cancer will undergo surgical treatment.

  5.  Colorectal cancer is a suitable case to illustrate the process. This disease is the second commonest cancer killer in England and Wales with over 17,000 deaths annually. Somewhat over 50 per cent of patients with colon cancer will be cured by surgery alone. The addition of adjuvant (additional) chemotherapy and/or radiotherapy to certain groups of such patients will improve the overall survival by 10 per cent at most. Furthermore, there is no evidence that non-surgical treatments alone will result in cure. The same arguments apply to breast cancer.

RESEARCH IN CANCER

  6.  Most cancer research funded by cancer charities and organisations such as the MRC focuses on cell and molecular biology. The basis for this focus is that only through novel strategies based on an understanding of cancer biology will treatments emerge that will be effective in treating disease not amenable to cure by surgery alone. In the long term it is our assessment that this is likely to be correct. However, these approaches have to date had virtually no impact in cancer treatment and it may be a considerable length of time before such treatments have any utility. In common with most bodies giving evidence we believe that the level of funding being apportioned to laboratory research in cancer is inadequate. Most bodies, such as the Cancer Research Campaign are able to fund only a proportion of the research rated as alpha by the grant committees. The severe competition for funding leads to a severe limitation on the development of research excellence in the UK. The climate in cancer research in the UK compares very unfavourably with the USA.

SURGICAL RESEARCH IN CANCER

  7.  By comparison with molecular and biological approaches research-driven improvements in surgical treatment stand to make significant inroads into cancer mortality. Most areas of malignancy treated by surgeons currently can demonstrate research-based improvements in outcome. Again colorectal cancer serves as a paradigm. Research on the technical aspects of rectal excision demonstrating the importance of radial margins of tumour excision (1) and the corresponding surgical techniques to encompass the tumour have resulted in radically lower rates of tumour recurrence after rectal excision (2). The introduction of these techniques appears to have led to a significant fall in overall mortality from the disease in Scandinavia (3). Similarly, it is now established that the surgical treatment of liver metastases from colorectal cancer may achieve cure in approximately 30 per cent of suitable patients, again with an impact on cancer survival (4).

  8.  It is a singular feature that despite tangible benefits to patients in terms of cancer outcomes virtually none of this research has been supported by any funding body. Indeed the proportion of cancer research funding that is directed to surgically related projects is extremely small. It seems likely that the wider application of best practice in cancer treatment has been inhibited by the lack of resource put into the field. This has led to the evidence base supporting these new approached being less abundant than would otherwise be the case. In addition the available data are also lacking in critical health economic and quality of life correlates.

REDRESSING THE BALANCE

  9.  Funding for surgical research could potentially come from a number of funding bodies. The lack of funding from bodies such as the MRC is multifactorial but in part relates to the make up of the grant committees.

  10.  Much surgical research could potentially and legitimately be funded by the NHS Health Technologies Assessment (HTA) Programme. This is the largest component of NHS R&D spending but a relatively small proportion funds surgically orientated cancer research, notwithstanding its remit to Health Services Research in general. On reason for this may be the HTA method of commissioning and funding research. The HTA commissions research on areas it considers to be of value to the NHS, in part on the basis of proffered commissioned research. The consequence of this system are:

(i)  a long lead time from the original idea of the research to the funding decision;

(ii)  research ideas produced by a committee rather than an expert in the field;

(iii)  no straightforward means for experts in the field of surgical cancer research to have their ideas funded.

  11.  One major improvement to the system is to allow workers with expertise in cancer research direct access to this funding stream by allowing the HTA funding to be in responsive mode. This would allow workers with expertise the opportunity to present their ideas in a preliminary form for consideration of funding. The consequences may be to allow a more favourable funding environment for surgically orientated cancer research.

SUMMARY AND CONCLUSIONS
  (i)  In spite of the fact that research based innovations in surgical cancer treatment have demonstrated tangible benefit to patients in terms of cure rate, little has ever been directly funded by a funding body.

  (ii)  There is no conceivable advance in the treatment of cancer based on molecular medicine that could compare with bringing the worst surgical practice up to that of the best.

  (iii)  Mechanisms should be found to direct funding to surgically orientated cancer research.

  (iv)  Overall, cancer research in the UK is underfunded.

Professor JN Primrose, Honorary Secretary, Society of Academic Surgeons, Academic Surgical Unit, Southampton General Hospital, Southampton SO16 6YD.

Professor JRT Monson, Honorary Secretary, Surgical Research Society, Academic Surgical Unit, Castle Hill Hospital, Cottingham, East Yorkshire HU16 5JQ.

REFERENCES

  1.  The Lancet 1986;8514:996-9.

  2.  The Lancet 1993;8843:457-60.

  3.  Br J Surg 1995;82:1297-9.

  4.  Guidance note for purchasers 99/02 Trent Institute for Health Services Research.

10 March 2000