Plotting the Cancer Revolution

'We will not write out to the whole population saying please go for a test for prostate cancer, but we will make it available to men if they want it.'

Cancer tsar Mike Richards tells Lynn Eaton about how he is trying to reform services — for men and women.

Mike Richards sits almost buried among pile upon pile of stacked A4 documents and papers in his office at St Thomas' Hospital in London. 'Sorry about the mess,' he jokes from behind a foot-high stack, 'but I know where everything is.'

He certainly needs to have his finger on the pulse politically. His office is just across the Thames from Westminster. With an election not so far off, he has only to look out of his window for a reminder of the importance this government puts on delivering better cancer services for all — both men and women.

Most commentators acknowledge that, since he was appointed in 1999, Professor Richards has helped make headway on local stop smoking projects and been active in banning tobacco advertising. More recently, he announced improvements in diagnostic and treatment services, particularly in prostate cancer. He also chairs the Prostate Cancer Advisory Group, set up by the Department of Health in January 2003 in response to lobbying by a coalition of voluntary sector and professional groups under the umbrella of the Prostate Cancer Charter for Action.

He seems most pleased, though, with what has happened on smoking, particularly in men, and proudly shows me a graph from the National Audit Office report 'Tackling Cancer in England', published in March, which shows the fall in the number of men smoking, alongside falling lung cancer incidence and death rates.

'But we still need to do more, and we need to do better. We know smoking is highly addictive and people need help. That is what the stop smoking services provide.'

But while the message has got through to many men, progress has been slower among working-class men  and younger women. Why is that — and what can be done about it?

'There are somewhat higher numbers of women coming through the stop smoking services, but it is not vastly different,' he says. 'Now we have had two or three years' experience, we are looking at what we can do to increase awareness and increase referrals.'

Ever the academic, Professor Richards is reluctant to endorse a gender-specific health promotion policy until he is convinced, scientifically, of its value. Science doesn't yet have those answers, nor has it been able to explain so far why, in nearly all the categories of cancer, many more men die than women.

'For lung cancer we know exactly why it is: historically, men have smoked much more than women, and that is why they have a higher incidence and more deaths. It is more difficult to pin it down for bowel cancer, where the overall incidence is the same in men and women, but there are some differences in the age-standardised death rates. Whether that is due to women perhaps coming forward sooner than men, the evidence at the moment is not sufficiently strong on that.'

But even he is prepared to acknowledge anecdotal evidence.'I think we all suspect that men are probably slower coming forward than women, although when they are prompted — for example in the pilot studies we have been doing for bowel screening — there is no evidence they are less good at taking up the opportunity.'

The government is carrying out two pilot studies into bowel cancer screening. 'Those studies have told us what the take-up rate is likely to be and enabled us to look at some of the practical issues in delivering a service to a large population,' says Professor Richards.

'There is at least a suspicion that men and women in social classes 4 and 5 may be less likely to take up health messages and to come forward with symptoms of cancer at an early age. That is certainly something we have to look at. We also have to look at age factors. We know for breast cancer that it is older women over 70 that are less likely to come forward when they have a breast lump.

'We do know that for women, if they haven't got someone in whom to confide their symptoms — their husband, or a friend — they are less likely to seek medical help. Not having that confidante seems to be a factor.'

Professor Richards' clinical experience has been with women — treating breast cancer.

'With men, we are still very much at the learning stage. I'm quite sure there are some men who come forward very quickly and others who do not. It is partly about raising awareness of what the symptoms might be.

'But one of the things for people to know about is the importance of being diagnosed early, that these cancers exist, and that with a lot of these cancers — like bowel cancer — if it is caught early, there is a high rate of cure.'

Professor RIchards cites the highly successful 'slip slap slop' message Australia has promoted to encourage people not just  to cover up in the sun but to come forward early if they notice any skin changes. 'Although they have an awful lot more melanoma cases than we do, they actually have a lot fewer deaths. The importance of early presentation for melanoma is well proven by the Australian experience. Here, there are about 2,500 cases a year in men and 3,300 in women. But there are 786 deaths in men and 690 in women. It is not a huge difference, but considering there are more cases in women, there are fewer deaths.

That says to me it is almost certainly due to women coming forward more quickly.'

So might more screening be the way forward? We're back to the academic's benefit analysis approach:

'The jury is still out on screening for prostate cancer. The test may pick up cancers that would never cause trouble during a man's life, so you diagnose the cancer, and then they feel they need to have it treated. The treatments for prostate cancer have side effects and problems.

'We will not write out to the whole population saying please go for a test for prostate cancer, but we will make it available to men if they want it. And if they have received information on the pros and cons so they can make their own choices.'

Professor Richards is expecting results soon from research into men's experiences of prostate cancer treatment, but for the time being, appears reluctant to be drawn too far down the gender-specific approach.

'We would target health promotion specifically for men and women if we felt that was the best way to get to people. But before we go down that line, we need to find out what works. We are not going to do something for the sake of doing it.'

• This article first appeared in MHF, the Forum's magazine.