Cancer 2015
Executive summary
The Cancer 2015 report provides an assessment of the state of cancer in Finland in the near future. The report draws on predictive data analysis that, despite uncertainties in the development of the prevalence of the disease and in the diagnostic and treatment of it, has generally proved reliable. The scope for improvements in cancer prevention are in part well known, though changes in trends of people’s behavioural habits are difficult to predict.
It is nevertheless clear that in the coming years cancer prevalence will increase and that the costs associated with it will rise. There are, in addition, a number of factors that further the reliability of the assessment of future trends and how to respond to them. In Finland it has been possible to reduce mortality from cancer more markedly than in many other countries. It has also been possible to control healthcare costs during periods of crisis. Demographic change in the form of population ageing entails trends that have been forecast for some time. This setting makes it possible to envisage the sorts of responses needed in the response to cancer in maintaining the quality of healthcare, improving health promotion, the prevention of cancer risks and the ways to improve the rehabilitative aspects of care.
Cancer is a common disease, affecting some 200,000 people in Finland. A proportion of these people recover from the disease, while for others the disease or its treatment is severely debilitating. About 10,000 people die from the disease each year, making it a main cause of death, accounting for one in five deaths. This number has long remained the same. In 2004, there were over 26,000 cases of the disease. The most usual form of cancer among women was breast cancer (over 3,900 cases), while among men it was prostate cancer (over 5,200 cases). Altogether 2,500 men and women were found to have colorectal cancer.
The trends in cancer have changed over the decades. Stomach and lung cancers have declined over the last 30-40 years. At the same time cancer prevalence has increased threefold during the period that the Finnish Cancer Registry has operated. There has been a 15-fold increase in prostate cancer diagnoses in 2004 compared to 1960. However, the numbers of cases alone are not enough to give an accurate picture of the development of the cancer situation, as population ageing impacts on prevalence.
It is important to forecast future cancer prevalence in deciding on and planning the healthcare resources needed – hospital beds, technical apparatus and personnel. Predictions also help with directing cancer prevention work and early detection and in estimating the efficacy of methods of fighting cancer. The Finnish Cancer Registry has made predictions based on the latest information, to 2003, on developments in prevalence and mortality.
In 2015 about 30,000 people in Finland will be found to have cancer, the number split evenly between men and women. This is getting on for 6,000 more cases annually than at present. The most usual types of cancer will remain breast cancer and prostate cancer. Though the latter is expected to have peaked by 2015, the report stresses that prevalence of this cancer is hard to predict. Breast cancer incidence, however, is expected to increase, accounting for 42% of overall cancer prevalence among women. Lung cancer incidence among women has been increasing, but it is probable that the current trend may have declined by 2015 due to the impact of health promotion and firmer tobacco control legislation. Cancer types that generally carry bad prognoses, such as cancers of the lung, stomach and oesophagus will have declined, meaning that a larger proportion of cancers will be ones with better prognoses.
Overall, though, cancer prevalence among the population is changing more slowly and evenly. The rise in the numbers of cases by 2015 reflects the course of population ageing, even though the proportion of prevalence may remain generally unchanged, with about one in three people developing cancer in their lifetime. At present there is, for instance, no prospect of a new cancer screening process that would greatly change the prevalence of cancer by 2015.
Information drawn from cancer trends among different social classes provides a useful predictive tool. Trends among higher classes on average have a perceptible 10-15 year lead over the rest of the population. This is because models of health promoting lifestyles tend to be taken up by the more educated sections of the population first, and it is therefore among them that we should look for the direction of trends. Regional differences in the prevalence of types of cancer also mirror social-economic status to some extent, information on which is provided by the Finnish Cancer Registry’s website www.cancerregistry.fi.
Alongside changes in trends in prevalence and the development of diagnostic, treatment and recovery methods, there are also continual developments in the psychological and social challenges that cancer poses. Much has changed since the days when the disease was regarded as an automatic death sentence and was generally taboo. Nowadays the engagement of patients in terms of their knowledge of the disease helps greatly diminishes the stress and anxiety aroused by cancer. A better understanding of cancer in the mass media has eroded many prejudices and false fears. By 2015 cancer will continue to be an extremely personal experience, but minus the shame and isolation once associated with it.
Cancer Diagnostics
Cancer diagnostics have changed remarkably in recent years, developing greater precision and new dimensions. New imaging methods and laboratory analysis help detect tumours earlier and their characteristics are generally better known before surgery or other treatment. This is possible because tissue and cell samples can now be taken from nearly all organs and parts of the anatomy. The use of bioscopes enables the collection of gastrointestinal, respiratory and body cavity biopsies. Modern imaging allows biopsy needles to be guided exactly to take samples from very small tumours.
The increase in treatment options requires increasingly detailed diagnoses. Patient prognoses need to be supported by as precise knowledge as possible so that the appropriate methods of treatment can be selected.
In many cancers, especially lymphatic, blood and supportive tissue malignant tumours (lymphomas, leukaemia and sarcomas), distinctive genetic changes have been identified, for instance chromosome translocation. The manifestation of such molecular genetic changes is used in the diagnostics of many types of tumour. Such analyses will clearly be come more common as new genetic changes in cancers are located. In addition, the great advances in biomedicine strongly shape pathological and cancer genetic laboratory work. In the future it will be possible to determine the molecular changes related to diseases in addition to ocular observations and microscopic findings. Molecular profiling also produces much information in this respect. New diagnostic possibilities may also be opened up, for instance, by the fact that the microRNA affecting gene reading regulates the appearance of cancer. New discoveries concerning the links between stem cells and tumours may lead to speedy diagnostic applications. Many individual molecules have been identified in animals that regulate the ability of tumours’ metastasis. If such molecules were to be found in humans, it would be possible to determine groups among cancer patients whose disease needs aggressive treatment. It would also be useful to detect new markers that are only found in cancerous tissue. The discovery of these kinds of molecules would ease both tissue analysis and imaging diagnostics.
Magnetic imaging and computer tomography are effective basic means of taking images of cancers, and PET technology is used widely together with computer tomography. A major step forward has been taken with digital imaging, and in 2015 nearly all mammography analysis, for instance, will be done by direct digital equipment. Various artificial intelligence programmes can also be of use in analysis of digital images.
The cost efficiency and impact of imaging technology needs to be examined impartially. So does the organisation of medical imaging. Under the current national Health Project, this has been organised by central hospital districts that both produce imaging services and procure tem from outside. Outside procurement contains risks associated with price competition and needs to be under the direction of experts, preferably professors of radiology. Clinical and radiological collaboration must become seamless and smooth.
In 2015, cancer imaging may be slightly more expensive than now but of better quality, and involving new imaging technologies, such as nanotechnology. The principles of authorisation and optimisation in the use of radiation and the protection of individuals will be better informed about and taken into consideration.
Cancer screening to enable the early detection of cancers aims to reduce mortality, and improve patients’ quality of life through early intervention. Screening for breast cancer and cervical cancer is part of the healthcare system. Mass screening for colorectal cancer has been started recently with the aim of extending it nationwide, and prostrate cancer screening is now being used. The use of screening in Finland has played a greater role than in most countries.
Megatrends will significantly pose a challenge to the role of screening in the future as cancer becomes more common in the ageing population and as the direction of the healthcare system tends more towards outsourcing, financial competition and less overall guidance. The impact of the long chain of operations entailed by screening processes requires that each one functions properly and is supported by a centralised system of decision-making. In this, the future of screening cannot be divorced from the overall direction of health policy. It is realistic to assume that screening as a routine part of healthcare will develop slowly.
Cancer treatment
The most important forms of treatment for cancer are, respectively, surgery, radiotherapy and chemotherapy. Surgery has long been the most important means of treatment, though lately chemotherapy has become as important, and the use of radiotherapy has increased. In the near future the average size of tumours treated will be smaller and a greater number of them will be primary. This is due to improved imaging, enabling the majority of tumours to be detected earlier on, and it in turn enables more timely intervention.
Developments in imaging enable surgery to be performed increasingly using viewing and video equipment. In the future, too, the main change in surgical treatment will probably be to do with accessory treatment, whereby procedures are used to reduce the size of tumours before surgery using precision medication or radiotherapy.
The use of radiotherapy is increasing as improvements continue to be made in its effectiveness and precision. The development of imaging methods also markedly improves the accuracy of radiotherapy. At present improvements in radiotherapy and methods for assigning it are being researched. In the future the more extensive uses of radiotherapy could include chemoradiotherapy, intensity modulated radiotherapy, radiotherapy using antibodies, boron neutron capture therapy and photodynamic therapy.
Accessory pharmacotherapy involves the administering of cancer medication immediately following surgery to eliminate any microscopic cancerous focus from the body that cannot be detected by imaging. Its use has become more common as the effectiveness of cancer drugs has increased. Many new precision cancer drugs affect only a small part of the body’s enzymes or other proteins, enabling the majority of cellular activity to remain unaffected during treatment and so diminishing adverse effects. Antioangiogenic treatment to prevent the growth of blood vessels of the cancerous focus is a new treatment method, used especially to back up cytostate treatment.
There is and will be a continual need for palliative treatment, as cancer becomes more widespread in the population. Palliative treatment takes precedence when the disease spreads and cannot be cured. It entails patients’ comprehensive treatment and care with the aim of ensuring as good a quality of life as possible. Nearly all terminally ill cancer patients require palliative treatment. Palliative, symptomatic, treatment is carried out at two levels of healthcare. Basic treatment encompasses patient’s physical symptoms, psychological, social and existential needs. Specialised treatment is carried out by specialists and generally planned in multi-professional teams. The diverse needs of palliative treatment demand that in the future physicians and other healthcare professionals need to be specialised in the field. By 2015 there should be professors of palliative medicine at all medical faculties, enabling better training planning and more research.
Recovering from cancer
The process of recovering from cancer aims to safeguard patients’ quality of life and functional capacity. This entails minimising the long-term drawbacks of treatment, controlling the stress brought about by the disease and different means of medicinal and psychosocial rehabilitation. These are also the challenges of the future of cancer care and treatment. Special attention needs to be put on patients’ comprehensive rehabilitation, which is diverse and takes account of varying individual needs. All patients need to have rehabilitation plans based around their particular requirements. Not all need extensive psychosocial or medicinal rehabilitation, but all should receive guidance and counselling. The need for follow-up will expand as the cancer rate increases and prognoses improve. There will need to be more resources for follow-up measures, which are at present arranged sporadically in Finland. The Cancer Society of Finland and the Social Insurance Institute of Finland aim to increase the knowledge and expertise of rehabilitation nationwide in existing rehabilitation units.
The impact of cancer on employment is fairly minor, as the majority of people who have been ill with cancer return to work. This varies with the types of cancer and treatments involved. More highly educated people return to work more often than people with low levels of education, and people who are unemployed or in heavy manual jobs are generally in a less advantageous position in terms of coping in the aftermath of the disease. Working conditions impact greatly on people’s ability to manage at work when they have been ill, and the majority of employees who have been treated for cancer wish they received more support from their supervisors and the occupational healthcare system. Support for cancer patients returning to work could be developed within the pension and rehabilitative systems.
Cancer and society
The numbers of people with cancer are increasing amidst and due to demographic change, treatment possibilities are multiplying and more people are surviving the disease. The possibilities for prevention hinge on how well the factors causing cancers are known. Choices related to lifestyles offer the biggest opportunities for furthering cancer prevention, but preventive measures require decision-making in social and health policy. Existing prevention means are not enough to have an impact on the forecasts for the cancer situation in 2015. Health and health information are increasingly subject to the market, with the result that services are products and commercialised. The future impact of this trend needs to be recognised and assessed.
The report contains a number of proposals:
1. Clarification is needed on the duties and division of labour between specialised treatment and primary healthcare to cope with the growing numbers of cancer patients and to safeguard improvements, as well as provide more productive care for all.
2. There is a need to increase the resources and expertise in symptomatic treatment especially in primary healthcare, social work and private healthcare. Follow-up care should be available for all who want it. Strong competition can bring about irredeemable problems in these areas.
3. Health inequalities must be reduces by ensuring the high quality of cancer treatment throughout the country. Social and psychological care must in particular reduce the isolation and insecurity faced by cancer patients.
4. Methods need to be developed alongside improvements in diagnostics that avoid over-diagnostics and the resulting needless or even hazardous treatment.
5. The interpretation of information produced by research needs to be more effective, and the use of research information as a basis of social and health policy needs to be reinforced.
6. The Cancer Society’s most important task is to increase social capital, act when necessary as a reliable producer, interpreter, communicator and promoter of information, as well as to be an opinion leader and social conscience of society in its own area of expertise.
7. Societal decision-making must be developed and strengthened to improve cancer prevention. This requires implementing tobacco control policy, drug and alcohol policy changes and increasing exercise among the population.
8. The Cancer Society must ensure that it offers community support to all who want it, creates opportunities for common activity and provides expertise for all.
