Shortly after turning 40, I experienced an abnormal tiredness that I ignored for as long as I could. When I began pulling over to catch a microsleep before clinic, I was moved to see my GP who diagnosed severe iron deficiency. She suggested that along with replenishing the iron, I have a workup for “less common causes”. I am an oncologist; I knew what she meant.
In corridor consults with my former classmates, I tried to convince myself and them that an iron infusion was all I needed for my presumed nutritional deficit. My gastroenterologist friend, fresh from a “his and her” colonoscopy to celebrate the couple’s 40th birthday, dissuaded me but the cancer surgeon was blunt: “I operate on people like you every week, so I’d get that scope.” The worst thing about the colonoscopy was the trepidation because I was asleep for the procedure and thankfully, it found nothing sinister. Sobered, I resolved not be my own doctor again.
I have been thinking about my experience as I come face to face with growing numbers of patients under 50 diagnosed with cancer who for one reason or another did not come to attention sooner.
Two-thirds of cancers are diagnosed in those over 65, and by age 85, one in two people will receive a diagnosis although it won’t be equally harmful for them all. No wonder cancer is viewed by doctors and patients as an inevitable risk of growing old, having outlived cardiovascular and infectious diseases, the killers of the past.
But data analysing global cases found the incidence of early onset cancers including breast, colon and pancreas has increased around the rich world since 1990. People born in 1960 had a higher risk of early onset cancer than those born in 1950 and the risk of each successive cohort is predicted to rise.
Of the 14 cancers studied, eight affected the digestive tract, with the increases not explained by improved screening. Instead, the researchers posit this “dramatic” rise in incidence may be explained by excessive alcohol consumption, sleep deprivation, obesity, smoking, reduced physical activity and a diet rich in highly processed foods and sugary drinks. Diet affects the gut microbiome whose influence extends to not only gut health but also conditions as diverse as cancer, eczema, diabetes and depression.
Bundled almost dismissively as “lifestyle factors”, future studies may nail them as the main culprits. In the hospital, this trend is already evident.
Every week, cancer professionals are discussing more cancer patients in the prime of their lives. Quite apart from the technical aspects, they present thorny dilemmas around fertility, parenthood, employment, and most tragically, end-of-life care that should have arrived decades later.
I recently met an asymptomatic octogenarian who had two requests. One, save him from the trauma of the MRI machine and two, let him die without fanfare. The decision to palliate him was uncontroversial. But next door, someone less than half his age had a lot of questions. What came after “last line” therapy? Why couldn’t doctors remove her liver? Why did she still feel OK if the tests were bad? My sadness mounting, I counted many “sorry, one more thing” before the heartbreaker, “What am I going to tell my kids?” A single mother, her kids were still in kindergarten.
Now we recognise that cancer is a disease of the old and young, what can we do to improve outcomes?
Take seriously the role of diet as a risk factor
A significant fraction of my time is spent tackling dietary myths.
Doesn’t cancer “feed” on sugar or dairy? Isn’t meat dangerous and superfoods truly super? Will an infusion of vitamins and minerals “flush” out toxins? I see people starve themselves of essential nutrients while their cancer grows.
The basic message hasn’t changed – don’t smoke, drink alcohol sparingly, eat less and move more – but it’s clear that relying on education and individual behaviour is not enough. As a recent analysis from the UK recommends, we need good social policies and interventions including regulation and taxation to shape population health which will deliver benefits for all.
Young people must be better advocates for themselves
A 95-year-old patient undergoes surgery for a small breast cancer. It feels unkind to tell her that she took on the pain for no gain. Meanwhile, a 40-year-old’s weight loss is initially attributed to stress until the bowel cancer has spread. Overdiagnosis and underdiagnosis hurt the patient and cost the system in different ways.
I am sympathetic to GPs who see just a few cancer patients among the thousands. Most lumps and bumps are not malignant; and pain, fatigue, bleeding or weight loss have many possible reasons. GPs walk a tightrope, where indiscriminate testing would overwhelm the system while a delayed diagnosis causes its own woes. Primary care is also hampered by shortened appointments, lack of continuity, and sometimes, a lack of awareness. There is a new focus on educating GPs about cancer in the younger-than-50 cohort. Meanwhile, people should not ignore persistent symptoms of any sort and be aware of a family history of cancer. Young patients must advocate for themselves, knowing that it typically takes a few presentations for most people, even older ones, to be diagnosed with cancer.
The healthcare system must better serve doctors and patients
If you have ever tried to make it through the labyrinth of the public hospital outpatient system, you will sympathise with the doctors who do daily battle with it. Several failings were illustrated by a recent supreme court decision.
Australian public hospitals provide a high standard of cancer care that is free at the point of delivery, encompassing tests, surgery, chemotherapy, groundbreaking clinical trials, and years of followup, all leading to one of the highest survival rates in the world. (Admittedly, the ancillary costs build up for incidental medication, fuel and parking.)
Still many people, understandably anxious to avoid any wait, resort to self-funding various tests and biopsies only to arrive at a bottleneck when it comes to seeing a public hospital specialist.
For the patient, the very notion of cancer strikes fear but my colleagues and I observe every day how “urgent” has lost its meaning; it now takes an acute emergency to receive the attention patients deserve.
Systems improvement is not just about pouring in more money but designing better processes with the input of frontline clinicians.
Every society faces competing demands over its priorities, focus and funding. But when one disease costs taxpayers more than $10bn a year and constitutes nearly 10% of the total healthcare expenditure (and this doesn’t even include the staggering, multibillion dollar cost of informal caregiving), it behoves us to scrutinise every aspect to help patients in the best possible way.
• Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death