Some 2 million people in the UK – about 1 in every 33 – are cancer survivors. Doctors expect this figure to reach 4 million by 2030.1 Advances in screening, diagnosis and treatment mean that more and more people with cancer are cured or survive for longer. According to Macmillan Cancer Support, people now live nearly ten times longer after their cancer diagnosis than they did 40 years ago. In the early 1970s, half of people diagnosed with cancer in England and Wales lived for at least a year. By 2007, half of people with cancer lived for at least six years. Today, experts predict that half of people diagnosed with cancer in England and Wales in 2010–11 will survive for at least ten years.1
Indeed, the prognosis for certain cancers is better than that for some other common diseases. For example, between half and up to more than 9 in 10 (50–99 per cent) of men with prostate cancer, and at least three-quarters (73–89 per cent) of women with breast cancer, live for more than five years. By way of comparison, half (50 per cent) of people who have a stroke and about 3 in 5 (62 per cent) of those who develop heart failure live for at least five years.2
Reduction in cancer-related deaths
Since the early 1970s, the number of people dying from cancer has fallen by about a fifth (22 per cent) in females and by about a tenth (8 per cent) in men, according to Cancer Research UK. The improved prospects have been even more dramatic in some cancers. For instance, the number of children under 15 years of age who die from cancer in Great Britain fell by about a third (32 per cent) between 1994/1996 and 2013/2015. Chemotherapy – an important class of anti-cancer drugs – is responsible for most of the reduction in cancer-related deaths among children.
Indeed, about 403,000 fewer people in the UK are expected to die from cancer over the next 20 years because of improved detection, diagnosis and treatments than if mortality remained the same as it is today. Cancer Research UK estimate that, compared to 2014, deaths from cancer will drop by about a seventh (15 per cent) by 2035. The prospects for some cancers will probably improve by much more. For instance, Cancer UK estimates that deaths from bowel cancer will fall by about a quarter (23 per cent) by 2035.
Catching cancer early – such as when it is still small enough for surgeons to remove totally – remains the best chance for a cure. Nevertheless, there are grounds for cautious optimism even for some advanced and metastatic cancers (malignancies that have spread to another part of the body). In the early 1970s, for example, 19 in 20 men with metastatic testicular cancers died, usually within 1 year of diagnosis, according to the National Institutes of Health in the USA. Modern treatments cure 4 in 5 metastatic testicular cancers. Moreover, the cancer team can draw on a growing array of modern medical advances – often at biology’s cutting edge – to help you live as full a life as possible, for as long as possible. Even if the cancer is incurable, the cancer team might be able to control the malignancy, sometimes for many years.
Long-term health
Being given the all-clear from cancer doesn’t necessarily mean your health problems are over. The physical and psychological effects of cancer can linger, sometimes for several years. Radiotherapy and chemotherapy can also cause late effects that might emerge many years after treatment ends. Even a decade after being diagnosed with the malignancy, survivors of breast and colorectal cancer were still more likely to see their GP than people who had not had cancer.3
Certain physical symptoms may not arise until months or even years after cancer treatment ends, such as osteoporosis (brittle bones) following endocrine (hormonal) therapies, heart disease after certain types of chemotherapy or radiotherapy, and malignancies caused by the treatment of the initial cancer.1 Macmillan Cancer Support notes that, in the UK, 1 in 4 people faces poor health or disability after cancer treatment ends. Lifestyle changes and active management by the cancer team can often help lift this long-term burden.
Cancer – a common concern
Cancer is probably the most feared disease. Indeed, more than half (55 per cent) of us worry about cancer occasionally or sometimes, according to researchers who interviewed 2,048 people in England between 18 and 70 years old. The study, presented at the 2016 National Cancer Research Institute conference, also found that about 1 in 14 (7 per cent) of us worries about cancer often or very often.
There’s often good reason for our fears. After all, half of us who were born after 1960 will probably be diagnosed with cancer at some point, according to Cancer Research UK. So the risk of developing cancer is about the same as correctly calling ‘heads’ when flipping a coin, and everyone knows a friend, family member or colleague who has had cancer. Doctors diagnosed 356,860 new cancers in the UK during 2014. In other words, doctors give someone a diagnosis of cancer every two minutes or so. During 2014, 163,444 people died from cancer: 1 death from cancer every 3 minutes.
Cancer is also increasingly common (partly because we are, on average, living longer), which helps fuel the fears. Cancer Research UK says that since the late 1970s, the number of cancer cases has risen by two-fifths (37 per cent) in females and by almost a fifth in males (17 per cent). If current trends continue, the number of cancer cases could rise by two-fifths (40 per cent) between 2014 and 2035.4 But it’s not all bad news.
Improvements across the board
All areas of cancer care – from screening to palliative care – have improved dramatically over recent years. For example, the outcomes for surgical procedures have been improved by technological advances, better aftercare and improved rehabilitation. These advances do not just mean that the operation is more likely to remove all the cancer than in the past; they also cause less collateral damage to healthy tissue. So the cosmetic appearance is better and the operation is less likely to have effects on your health (complications).
For example, advances in robotic surgery allow surgeons to perform incredibly delicate operations, such as removing cancers from the prostate gland, which is surrounded by a network of important nerves.3 Robotic surgery seems to reduce the number of men who develop some complications commonly linked to conventional prostate surgery, such as lifelong erectile dysfunction and incontinence.
Meanwhile, radiotherapists can now target X-rays to the tumour with unprecedented accuracy. Cancers are not regular solid balls of cells. They are irregularly shaped and vary in density. Sophisticated computer programs vary the focus and intensity of the beam of X-rays to match the cancer’s shape and density. Treating a cancer always means treading a fine line between killing as many malignant cells as possible and avoiding damage to healthy tissue that causes short-term (acute) and persistent (chronic) adverse events. These new programs maximize the number of cancer cells killed while limiting the damage to the healthy tissue. So the radiotherapist might be able to deliver a higher dose of X-rays to the tumour and less to the surrounding tissue. This, in turn, increases the chance of a good outcome with fewer complications.
Hardly a day goes by without a new study elucidating some fresh insight into cancer biology, such as how a tumour emerges, grows and spreads. This increasing understanding of cancer biology is revealing new targets in critical pathways that drive the malignancy’s development and, in turn, inspiring innovative new treatments. Indeed, in 2016, the European Society for Medical Oncology estimated that 225 new cancer treatments would be introduced by 2020.5 Even if they do not all reach the clinic, the figure underscores the remarkable pace of innovation.
For example, some older cancer drugs are relatively indiscriminate, killing malignant cells but also harming healthy tissue, hence the hair loss and other ‘classic’ side effects of chemotherapy. Doctors can mix-and-match the chemotherapy drugs in the cocktail and increase or decrease the dose of one or more medicines, but in general, ‘one size fits all’. Modern cancer drugs are increasingly tailored to your particular cancer at that stage, often based on insights from genetic studies (called ‘personalized medicine’).
A genetic disease
As we will see, cancer is predominately a genetic disease. Your genetic code is a series of instructions that control your body’s structure, appearance and function. Some genes, for example, determine whether you are naturally a blonde, brunette or redhead. Others partly determine your height, and other genes determine the way cells divide in order to, for instance, repair damage in the body or replace old cells. In many cases, several genes interact to exert their effects.
Cells are the building blocks of our body – and they are highly specialized. The skin cells that touch this book are very different from the light-sensitive cells at the back of your eye that detect the words on the page. The light-sensitive cells are very different from the nerve cells in the brain that interpret what the words mean.
Too many cells – even if they are not malignant – and too few can harm health and well-being, so a complex network of signals controls the production of new cells and the destruction of old ones. But changes to the genetic code – mutations – can send abnormal signals to the cells. This means cells begin to divide out of control – one of the hallmarks of cancer. Other mutations drive the cancer’s progression, such as when the tumour invades the surrounding healthy tissue or fragments break off and spread to other parts of the body (metastases). Mutations are also responsible for changes that mean cancer treatments may stop working (resistance).
Increasingly, however, these mutations are also cancer’s Achilles heel. For example, researchers can now look at the pattern of mutations in the genetic code of a cancer and sometimes use these to develop new drugs. For example, by binding to a protein produced by the mutated gene, the drug might be able to stop the cancer from dividing. The drug, however, will work only if the cancer has ‘switched on’ (expresses) that gene.
The cancer team
During your cancer journey you will draw on the expertise of a range of healthcare professionals. The team’s multidisciplinary membership will depend on your needs but typically will include:
•a surgeon with expertise in your cancer: operating for head and neck cancer is very different from removing a breast tumour, for example;
•a pathologist who looks at cancer samples to diagnose the malignancy and assess the tumour’s characteristics – so the pathologist might assess how aggressive the cancer is and, in some cases, use the cancer’s biology to tailor treatment;
•a radiologist, who might use high-tech imaging to look inside your body and deliver X-rays to treat the cancer;
•an oncologist – a doctor specializing in cancer treatment – might discuss which drugs you need based on the cancer’s characteristics, any other diseases you might have and how well you are generally;
•nurse specialists who have particular expertise in cancer care.
In other cases, the team might include a dietician or speech and language therapist, who can help if you have difficulties eating or with speech. If you develop emotional or mental health issues, the team might include a counsellor or psychiatrist. Also, you will probably see your GP more often than you did before you were diagnosed with cancer.
In many cases you will receive high-tech cancer treatments. Do not worry if you find the details difficult to understand at first. Some new treatments are highly sophisticated scientifically and at the very edge of our biological understanding – even non-specialist healthcare professionals can have difficulty understanding how they work. So always ask your cancer team and patient groups, such as Cancer Research UK and Macmillan Cancer Support, if you do not understand something or have questions.
A personal journey
Broadly, a cancer journey has three stages.
•Soon after diagnosis the cancer team tries to cure or limit the damage caused by the malignancy. This might involve surgery, radiotherapy, medicines or, for most people, a mixture of approaches. Although you might feel that your life is in your cancer team’s hands, you can still deal with side effects, remain positive and understand what the cancer team is doing and why. Do not underestimate the importance of these steps: they give cancer treatment the best chance of working, help limit collateral damage and maximize your quality of life.
•The recovery phase during which you get over the worst effects of treatment and restore your physical and mental well-being. The cancer team will monitor you to detect any relapses.
•The maintenance phase during which you take steps to prevent or delay a recurrence, prevent additional malignancies and reduce the risk of other diseases.6
This book focuses on the first of these stages and if the cancer recurs. My book The Holistic Guide for Cancer Survivors places more emphasis on the second two stages. There is some overlap, however, especially when we consider the steps you can take to deal with effects of the cancer and its treatment.
The bravery people show when they face cancer never ceases to amaze me. Nevertheless, your cancer journey will be deeply personal, often difficult and at times frightening. Cancer is enigmatic, capricious and unpredictable. Despite advances in imaging and genetics, no one can precisely define what will happen (your prognosis). No one can accurately predict the severity of side effects or long-term complications or the extent to which the cancer and its treatment will disrupt your life. Your cancer team offers educated guesses based on scientific data, but there are countless cases where patients have defied their doctors’ expectations.
Likewise, no one can guarantee that the general information and suggestions in this book will definitely work for or apply to you. These suggestions do not replace the advice from your cancer team, which is tailored to you, your cancer and your circumstances. Always contact your GP or cancer team if you feel unwell or think your disease is getting worse, even if it is between your routine appointments.
A note about references
It is impossible to cite all the medical and scientific studies that I used to write this book (apologies to anyone whose work I missed). I’ve highlighted certain papers to illustrate important points and themes. You can find a summary of most of the papers by visiting the website: <www.ncbi.nlm.nih.gov/pubmed>. Some full papers are available online free or at a reduced rate for patients. Larger libraries might stock or allow you to access some medical journals. Some of the papers might seem rather erudite if you do not have a medical or biological background, but do not let that put you off. If you feel that you do not understand something, please ask your GP, pharmacist, cancer team or a helpline run by a charity, such as Cancer Research UK or Macmillan Cancer Support.