The c-word: cancer looms large in our lives
Half of us will get one cancer of some kind at some point in our lives; there are 200+ kinds on offer; but half of sufferers will survive for ten years or more
If you’re my age—mid-forties; I know, I don’t look it; what’s my secret? Oh shush—the word “cancer” is a scary one. It looms menacingly, partly because of and partly in spite of what we know or think we know about the disease (or group of diseases). The announcement last Friday that the Princess of Wales is undergoing chemotherapy, added to last month’s revelation that the King had been diagnosed with an unspecified cancer, has focused the public’s attention on metastatic cells. So we need to think more deeply and carefully, and in a well-informed way, about cancer’s role in our lives.
A decade ago, whenever I was asked by a doctor in a routine set of questions if there was any history of cancer in my family, I would say there was hardly any and we’d move on. Cancer is not hereditary in a straightforward sense, but we can carry genetic predispositions to some kinds, especially breast, ovarian, colorectal and prostate cancer. Now? Well, my father died suffering from multiple myeloma in 2017, and my mother died of spindle cell sarcoma (well, and Covid-19) in 2020. My paternal grandfather had died of throat cancer, though smoking unfiltered Capstan Navy Cut cigarettes for many years may have been a contributory factor. I think my maternal grandfather also died of cancer, though he died in 1953, so it’s before my time.
I have some skin in the game, then. I’ve never been a regular cigarette smoker but I smoke cigars, I don’t exercise or eat very healthily and I was a very heavy drinker for years, so I haven’t helped myself. It doesn’t preoccupy me especially, and I’m not really a hypochondriac, I don’t think: I can’t generalise but I wonder if you are less or more prone to hypochondria if you have actually been seriously ill, or if it makes no difference. In any event, I’m not the sort of person who imagines lumps and lets grim and fearful imagination grow like the malignant cells that might be there. I don’t avoid physicians the way many men do, but I don’t haunt my local practice either.
I’m not at all afraid of death. I’m an atheist and I don’t believe in an afterlife, but I’m not militant: none of us knows, of course, so you believe what you like, what feels real or logical or authentic or comforting, and cleave to that as tightly as you will. All I ask is that you accept that not everyone shares your view, and, specifically, that I don’t. We can each have our views, neither need impinge on the other. But I have no sense whatever that people “exist” after their deaths in any way except as memories and influences. That’s no small or mean thing; in fact it’s huge. But I don’t think it has an independent, external reality. Given all of that, death is simply the negation of being. We live, and then we stop living, and we have no experience of that because we are no longer entities. So what could there be to fear?
On the other hand I am afraid of dying, of having a messy, squalid, painful end, and we know, it is drummed into us, that cancer can lead to that destination. My parents were lucky in not, so far as they communicated, suffering dreadfully before they died. Each left peacefully, and (I think) painlessly. They had both known they were dying, even if the exact and final timing was a little unexpected, and neither wanted to prolong life at all costs. Even my grandfather’s last days were not absolutely terrible, though he ended his life in a hospice having had a laryngectomy, waiting for the end. But cancer can lead to extensive surgery, and I’ve never been under the knife except for dental surgery, and that frightens me.
That said, the mental link between cancer and death is probably stronger, or at least more automatic, than the evidence now suggests. More and more often, doctors tell their patients that they will more likely die with cancer than from cancer, especially if they are diagnosed later in life. Sir Roger Moore, to take an example at random from the celebrity sphere, was diagnosed with prostate cancer in 1993, but it was treated successfully, and he lived to the age of 89, dying in 2017 after cancer had reappeared in his liver and lungs. I am as sure as I can be that he did not feel cheated of life or span.
We still know that it can be very different, though. My former fiancée’s father was diagnosed, quite unexpectedly, with pancreatic cancer many years ago; it is one of the worst manifestations of a horrible malady, debilitating and excruciatingly painful, and, because it is often diagnosed at an advanced stage, the prognosis is often extremely poor. He died within seven or eight weeks, if I recall the dates correctly. It was tragic, harrowing, heartbreaking for his family.
Cancer seems very much an illness of the modern age. That is partly due to the ability of diagnosis, of course; there is a record of diagnosis and surgical intervention in a case of breast cancer from Egypt in 1600 BC, and Hippocrates (c. 460 BC–c. 370 BC) describes various forms of cancer, but unless a tumour was visible to the naked eye or could be felt distinctly, there was no way of detecting cancer. Medical imaging is a phenomenon of the 20th century and since.
Retrospective, historical cancer diagnoses are therefore speculative in the extreme. Hatshepsut, a female pharoah of Egypt of the 18th Dynasty, died in around 1458 BC of bone cancer, perhaps caused by a carcinogenic benzopyrene skin lotion. The Greek empress Theodora, wife of Justinian the Great, died in AD 548 of what was described as “cancer”, although it could have referred either to a malignant tumour or some kind of ulceration. Ferdinand I, King of Naples from 1458 to 1494, died of colorectal cancer, a diagnosis made in 2006 after an examination of his mummy showed levels of carbon 13 and nitrogen 15 consistent with historical reports of considerable consumption of meat. And my own beloved Mary I, when she died on 17 November 1558, aged only 42, was probably suffering from some kind of uterine cancer; she had experienced a number of phantom pregnancies, and longed desperately for a child both personally and dynastically, but the pregnancies may in fact have been tumours or some other symptoms of cancer. Three weeks after her death, her widower, Philip II of Spain, wrote to his sister, “I felt a reasonable regret for her death”.
Here are some statistics (I take these from Macmillan Cancer Support and the House of Commons Library).
There are around three million people in the United Kingdom living with cancer, about 4.5 per cent of the population; if you prefer, that’s half the size of the National Trust’s membership, or slightly less than the population of Wales.
1,100 people are diagnosed with cancer in the United Kingdom every day. But the increased incidence is slowing: in the last 20 years it has grown by 40 per cent, but by only 19 per cent in the last decade.
460 people die of cancer ever day. But death rates are falling, and falling significantly; since 2001, the rate of cancer deaths has fallen by 23 per cent among men and 16 per cent among women.
The highest one-year survival rate is for melanoma: 97.3 per cent of men and 98.6 per cent of women survive at least a year after diagnosis.
The worst prognosis is, as mentioned above, for pancreatic cancer: in England, fewer than one in 10 survive more than five years from diagnosis (8.4 per cent of men and 8.2 per cent of women).
There are substantial waiting times for cancer diagnosis and treatment, and they were exacerbated by the pressure the Covid-19 pandemic put on the NHS. In March 2020, the backlog of patients waiting more than 62 days for treatment after an urgent GP referral with suspected cancer was around 11,000, which trebled within three months before falling again to 16,000 by the end of the year. The backlog grew again in late 2021 and mid-2022, and at the end of January 2024, it stood at 22,459.
In 2020/21, various government-funded bodies in the UK spent £250 million on cancer research. Much more is spent by charities: in the same year, five charitable bodies spent £4 billion, of which £3.3 billion was spent by Cancer Research UK.
What’s the political response to this? The government planned a strategy for cancer. The NHS Long Term Plan, published in January 2019 (when Theresa May was still prime minister!), included an objective of “diagnosing three quarters of cancers at Stage one or two by 2028”. In February 2022, Sajid Javid, during his brief stint as health and social care secretary, used the occasion of a visit to the Francis Crick Institute on World Cancer Day to issue a call for evidence to inform a new 10-year plan to tackle cancer. More than 5,500 responses were taken into consideration when formulating the response, and it identified prevention and early diagnosis as the priorities for the government. However, in February 2023, Steve Barclay, appointed health secretary by Rishi Sunak the previous October, announced in the House of Commons that cancer would be included in a “Major Conditions Strategy”. He told MPs:
Strategies alone will not change outcomes. Delivery will require concerted effort from government and the NHS working in tandem, alongside social care, patient representatives, industry and partners across the health and care system.
In August, the Department of Health and Social Care published a strategic framework for this new project.
NHS Wales published a Cancer Improvement Plan in January 2023, while the Scottish Government unveiled a cancer strategy in June. The Northern Ireland Executive had issued a 10-year cancer strategy in March 2022 but this may well be refined or revised since the re-establishment of a devolved government in February 2024; however, the minister of health, Robin Swann of the Ulster Unionist Party, previously held the position from January 2020 to October 2022 so there may be a higher degree of continuity than in some other areas.
There are so many different strands to try to weave together here. More people are being diagnosed with cancer, but the rate of growth is slowing. Survivability is improving and the number of deaths from cancer is falling substantially. We know that prevention and early diagnosis are the best ways to control cancer mortality and improve the quality of life of those who develop cancer. The pressure the pandemic placed on the NHS has exacerbated what were already serious backlogs for cancer treatment.
There is an emotional and intellectual component too. We talk much more openly now about cancer and try to present the most positive aspects of diagnosis, treatment and remission, and medical research makes enormous strides every day, week and month. It is possible to construct a narrative around cancer which is positive and encouraging, yet cancer retains a stubborn and baleful grip on our imagination and our most instinctive assumptions. The difficulty is that embracing this narrative involves clear and well-informed thought about cancer, but our reflex is to shy away from the whole subject, ignore or suppress our imaginations and pretend it is something which doesn’t exist or doesn’t affect us.
From a narrow political point of view, a serious impediment is that clinicians, researchers and other stakeholders are of one voice in saying that cancer is best addressed by a long-term, carefully plotted strategy with sustained and consistent activity and investment. But in crude political terms that is rarely how the NHS works. Health is a huge spending commitment for the United Kingdom government and the devolved administrations: NHS England consumes more than £150 billion every year, and still we know and see that it is barely scraping by. Therefore its funding is one of the fiercest subjects of debate between the political parties, and policy is forever subject to small and large changes. Stability is almost impossible to achieve.
I can’t propose any answers at this stage. But the news from the Princess of Wales, and her words of support and solidarity for others living with cancer, gives us an opportunity to stop and think with a little more care and depth about the condition, how it affects us and how we deal with it.