The financial and emotional cost of cancer

Outside, the wind blasted through the trees, raging and rustling through the branches as it wound its way up from the mouth of the Tay. Inside the hospice, like a fading echo of the living world, the storm seemed all but over.

Hushed tones; the sound of impossible kindness. Flowers in still life; the scent of forlorn hope.

Along the corridor my mother lay dying.

As our feet squeaked over the linoleum to the far end, the doors of some rooms were open, perhaps to let in a little life. In one dimly-lit room, you could see a patient in a gown sitting alone. He was hunched motionless in a chair by the window, seemingly pondering the darkness through the glass. I glanced through another open door. A pale white-haired woman lay in bed, as if life were leaving her. Her elderly husband raised himself gently to lie by her side. I’d swear I heard her speak his name and whisper “I love you.” How is it that the heart can hold out when all hope is gone?

As for my mum, cancer held her in a grim embrace and would not let her go, at least not peacefully.

For many people, cancer seems the most bitter of human afflictions. It is the body’s ultimate betrayal. Our own cells go haywire – dividing and multiplying uncontrollably, growing and spreading, destroying us from within.

For good reason, we are afraid of The Big C. The prognosis for successful treatment for many types of cancer has improved dramatically over recent decades. Yet we all know that cancer can be a horrendous, life-limiting condition.

But perhaps we are not scared enough. There are over 200 different types of cancer – each with complex, varied causation and baffling pathologies. While some cancers spring from genetic causes (c.10%) or infections (c.20%), many are linked to human factors – smoking (c.25%), diet and obesity (c.25%), alcohol (6%), sun exposure (4%) and lack of exercise (1%).

We can’t say that such human choices ‘cause’ cancer – they simply skew the odds in the game of chance we call living.

At its most basic, cancers occur when our cell reproduction goes badly wrong. When you consider that you have around 37.2 trillion cells in your body, you’d think the odds of some of them misfiring would be pretty strong. In fact, our bodies are very good at making new cells – we do so by dividing existing cells. In effect, the new cells are copies of the old cell.

As a simplistic analogy, imagine each cell is like a sheet of paper, printed with instructions on how to make a copy of itself. When you need a new copy, you simply photocopy it.

But, like a photocopy of a photocopy, the new sheets aren’t quite as good as the previous one. Over time, as the process is repeated, the image degenerates. So, the more often copies are made, the bigger the chance of passing on ‘bad information’ – hence the greater probability of a serious malfunction.

That’s why age is one of the risk factors for cancer. Similarly, (stretching the analogy to breaking point), imagine that the photocopies are also exposed to tobacco smoke or left in strong sunlight, becoming yellowed or faded over the years. The risk is that the instructions become damaged – ‘bad copies’ start to proliferate, endlessly copying themselves and spreading dysfunction.

So, cancer is a risky business for all of us – some more than others – with serious implications for end-of-life care. It’s also a costly business for the NHS in Scotland. Around 30,000 Scots are diagnosed with cancer every year with an average treatment cost of £30,000. The all-in cost to society is probably over £1 billion. And the figures are on the rise. Cancer cases are increasing, and new treatments often have astonishing price tags.

This isn’t just painful and heart-wrenching for patients and families. It’s also one of the truly awful challenges for our medical decision-makers. How do you fairly and rationally allocate precious health resources to the marginal extension of life? What cost just a few months more? And at what quality of life?

In England, David Cameron set up a special Cancer Drugs Fund, worth £200 million a year, to pay for expensive treatments not normally available on the NHS.

In Scotland, decisions are made differently. The Scottish Medicines Consortium (SMC) advises health boards on the efficacy and value-for-money of all new treatments. This includes judging whether a new drug really does more to extend life, and improve quality of life, compared to existing treatments. Does the added benefit to the patient justify the inevitable rise in cost? This is an incredibly difficult call for ‘end-of-life’ scenarios, or very rare conditions.

There’s also perhaps a shift in thinking. As part of his review for the Scottish Parliament, Professor Philip Routledge of Cardiff University stated that he would be “loath to single out cancer from other conditions which shorten life or reduce the quality of life.”

Predictably, there are differences in the availability of some drugs north and south of the border, creating pressure from charities and patient groups. There’s also PR from drug companies pushing to get the green light for expensive treatments.But what’s the opportunity cost of paying up? By spending more, are we valuing one life more than another? Could these funds be better spent on other conditions, or for more general, long-term benefit?

It’s reflective of the wider issues facing a financially-constrained NHS. The wonder of science and the art of the possible are part of the problem.

Financially speaking, we are victims of our own success. People are living longer. We can treat more elderly and frailer folk with more radical therapies. It’s not just that we have an ageing population. We often have people who become chronically-ill relatively young and, thanks to the NHS, keep living.

Like many of the risk factors for cancer, some of the biggest threats to public health – obesity, smoking, alcohol and drugs, anxiety and depression – are also hard to deal with. If not exactly self-inflicted, they seem to be built-in risks in a modern high-consumption, over-stressed, under-active lifestyle. As a result, they aren’t just a financial strain on Scotland’s NHS, they’re an emotional drain on everyone working in our health services.

Earlier this year, after battling bravely with cancer, my brother also passed away. Like many others in life’s cruel lottery, he was a victim of blind bad luck. Too many other families know too well the anguish of seeing their loved ones live in hope and suffer in vain.

Undeniably, we wish the best for those facing perhaps the most difficult challenge in human life and death. Modern medicine can achieve so much, and we want to focus our health spending on those whom luck has let down most badly. Because that could be any of us.

For society and for the future, this creates a range of painful decisions. Ever-rising treatment costs can’t be the answer. That’s like jamming the stable door closed with a big wedge of public money.

For me, there is only one responsible solution, and I hope it’s not building more hospices. When maybe 60% of cancers are linked to our own life choices, there’s only one real way we can afford the best treatments for those in greatest peril. And that’s for the rest of us to take better care of ourselves.

To reduce pressure on Scotland’s health service, we need to avoid the predictable risks and live healthy as long as we can. The idea, as Ashley Montagu put it, is to die young as late as possible. It will take strong public action to help every segment of society do so. But, in truth, better prevention is our best hope.