1.  The Pelican Centre is a charity specialising in surgery for cancers in the pelvis. For two of the commonest cancers—colon and rectal—there is a wide variability in survival depending on the surgery performed. Yet these cancers are among the most curable of all cancers provided that optimal surgery is undertaken. Given the significance of bowel cancer to morbidity and mortality, but also this potential for survival, the Pelican Centre welcomes the Committee's inquiry, which we hope may lead to changes which will bring more cures and less suffering.

  2.  The Pelican Centre is committed to excellence in research and in surgery, and to improving outcomes for cancer patients.

  3.  The public is generous in its financial support for cancer charities and in its support for the NHS and its staff in treating cancer. One in three of the public will be affected by cancer and so everyone has a very direct interest in seeing the best possible use of available resources in its prevention, detection and treatment.

  4.  It is surprising how little attention is given to surgery in the debate on cancer in that the major curative treatment of all the common cancers is surgery.

  5.  It follows that the best way to improve outcome for diagnosed patients is to improve surgical treatment. It has long been recognised that, for colorectal cancers, the largest variable in outcome is the surgeon undertaking the surgery.i,ii

  6.  Despite these findings, it is regrettably the case that the vast majority of cancer research goes on laboratory science rather than surgery. For surgeons in training, their one year of research is almost invariably spent in the laboratory rather than in researching surgical techniques or in studying the outcomes of surgery.

  7.  This lack of a research culture around the single major contributor to surviving cancer is reflected, to an extent, in the Committee's own terms of reference.

  8.  More dramatically, it is reflected in the report of the ICRF iii, where, of the 56 labs and units funded by ICRF, not one specialises in surgery. The joint ICRF/MRC/BHF Clinical Trials Unit, whilst concentrating on the common cancers and "areas where progress is most plausible", works only on hormonal and cytotoxic treatment to the exclusion of surgery. For colorectal cancer, the ICRF estimates that cytotoxic treatment could possibly reduce mortality by 10 per cent. Improved surgery could have much greater impact.

  9.  Of 275 government-funded MRC awards in 1999, just three related to surgery. iv

  10.  Despite the CRC's commitment "to support the highest quality research relevant to cancer and its application for the benefit of the individual cancer patient", there is no surgeon on the CRC Council and only one of its 33 honorary vice-councillors is a surgeon.v

  11.  None of this is to criticise the work undertaken by the cancer charities. It is simply to point out that the current decision making processes and allocation of research funds have resulted in grossly inadequate attention being given to the major curative treatment for many cancers.

  12.  Where surgery has been scrutinised, and its outcome analysed, as in Basingstokevi, Swedenvii, Norwayviii, Denmark, Hollandix and Germany, it is clear that improvements in surgical techniques occurred, which directly led to vastly increased survival. In the case of Stockholm, for example, a research and training exercise led to a halving of local recurrence following surgery for rectal cancer from 14-15 per cent to 6 per cent, with surgically preventable cancer related deaths dropping from 15-16 per cent to 9 per cent. Yet no coherent approach to such research has developed. Randomised clinical trials are not appropriate for surgeryx yet continue to be seen as the "gold standard" for all treatment guidelines. A different and surgical-related equivalent protocol needs to be developed. In the case of colorectal cancer, this would need to involve pre-operative assessments, specimen audit and five year follow-up. Unless for each cancer site, an appropriate—though simple and usable—protocol is developed, surgical research will not achieve the scientific status accorded to drug trials and other similar interventions which are intrinsically incapable of having more than a marginal impact on outcomes.

  13.  The fact that such a methodology, and required standard of audit practice, has not developed, together with the paucity of research funding for cancer surgery has had the following consequences:

—  Neither the MRC nor Department of Health have evolved, with the necessary funding, a research ethos and approach to enable the development of academic surgery not as an end in itself but to enable research to continuously monitor, audit, feedback and hence improve cancer surgery.

—  UK cancer research has not been effectively co-ordinated to produce this situation, or to direct research funding to areas of potential benefit to outcome.

—  The definition of centres of cancer research excellence has ignored surgical research.

—  The concentration on medical oncology, to the exclusion of cancer surgery, has given insufficient attention to the treatment of the major cancers, and has only marginal impact on the outcome of most of the common cancers.

—  NHS research and development funds have likewise not included surgical research.

  14.  Should the Committee finally favour a UK National Cancer Institute, it would be imperative that this had surgery in its remit.

  15.  On balance, however, the population would benefit more from a spread of cancer centres of excellence, including tumour-specific centres, throughout the UK so that patients have easier access to the very best of treatment.

  16.  The Committee will be aware that survival rates for the common cancers are below the European and USA averages. In the case of rectal cancer, five year survival rate for men is 37 per cent in England and Wales against 43 per cent for Europe and 60 per cent in the States. For colon cancer, a 39 per cent England and Wales rate compares with 47 per cent in Europe and 64 per cent in the USA. Improvements in surgical outcome could have a major impact on these rates yet today's cancer research virtually ignores this aspect of treatment.

  17.  We therefore urge the Committee to ensure that future research priorities give adequate coverage to the major cancers, and to their effective treatment through surgery.

22 February 2000

REFERENCES

  i  McArdle and Hole concluded "There were significant variations in patient outcome among surgeons after surgery for colorectal cancer such differences compromise survival". Survival at 10 years varied from 20 to 63 per cent. See "Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival", CS McArdle & D Hole, BMJ, vol 302, 22 June 1991.

  ii  "The Prognosis of Rectal Carcinoma: Experiences from the German Prospective Multicenter Study on Colorectal Carcinoma", P. Hermanek et al, Tumori, 1995; 81:60-64.

  iii  ICRF, Scientific Report, 1998.

  iv  MRC website and MRC Annual Report, 1998-1999.

  v  CRC, Annual Review, 1998-1999.

  vi  "Rectal Cancer: The Basingstoke Experience of Total Mesorectal Excision, 1978-1997," R J Heald et al, Archives of Surgery, vol 133, August 1998.

  vii  "The Impact of a Surgical Training Programme on Rectal Cancer Outcomes in the County of Stockholm", A Lehander et al, forthcoming.

  viii  "Local Recurrence after operative treatment of rectal carcinoma: a strategy for change", O Soreide and J Norstein, J Am Coll Surg, 1997, 184 and "Local Recurrence following Total Mesorectal Excision for Rectal Cancer", G Arbman et al, British Journal of Surgery, 1996, 83.

  ix  Professor C van de Velde presented in the UK in early February the result of a prospective randomised trial to assess whether the Dutch carefully monitored introduction of a supervised, standardised Total Mesorectal Excision did or did not require to be complemented by preoperative radiotherapy. He presented data from both arms of the trial which showed a huge reduction of surgical failure from over 25 per cent to 7 per cent. This demonstrated that surgical training achieved a far greater impact on outcome than all the adjuvant modalities.

  x  "Mesorectal excision for rectal cancer", W Silen, Lancet, 15 May 1993.