With 37,000 new diagnoses per year, cancer has become a major public health issue. Oncologist Thomas Cerny explains what can be done to combat it, where there is need for political action, and which treatments offer promise for the future.
Helsana: Mr Cerny, which foods can help reduce cancer risk? Diet is said to play a certain role.
Thomas Cerny: I have an apple on my desk every day, sometimes two. Fruit and vegetables are an integral part of my daily meal plan. I do not know what effect this will have for me in the long run; after all, I eat other things as well and I indulge in a glass of red wine every now and then. But long-term studies suggest that a diet that is low in calories, fat and meat and contains fish on a regular basis can help prevent cancer.
In the USA, sugar is also being pilloried as a possible risk factor.
That is an established fact. Diabetics develop cancer much more frequently than non-diabetics.
We know that smoking and excessive amounts of sun are detrimental to our health. However, Switzerland has twice as many cancer patients today than it did in 1990. Switzerland is near the top of the European rankings in terms of lung cancer, and even leads the pack for skin tumours. Are we too reckless?
It has less to do with our lifestyle, and more to do with the fact that there are a lot more people living in Switzerland now than there were in the 1990s. What is more, baby boomers have now reached their 50s and 60s. Generally speaking, people are living a lot longer nowadays thanks to medical advances. When Old Age and Survivors' Insurance (AHV) was introduced in 1948, the average life span was 66. Today, it is over 80 for men and over 84 for women. What is more, cancer is an age-related disease. From age 50 onwards, tumour disease rates increase considerably and only level out again after age 85. All of these factors play a role in the higher number of cases we have today.
But why does Switzerland lead Europe in skin cancer? There must be a reason?
Switzerland lies at a high altitude. Berne is approximately 540m above sea level, Zurich 400m. Added to this, we like to spend our holidays in the mountains. The higher up you go, the more you are exposed to damaging UV rays. It is therefore vital that you protect yourself, even when working out in the garden. We need to be more careful about things like this. The cancer rate will decrease among the generation of children who are no longer allowed to play outside without sun protection. This trend will take decades to establish itself, however. Tobacco is a different story: once you stop smoking, the positive effects set in after just a few weeks. Unfortunately, the tobacco lobby is extremely powerful. The most effective measure against lung cancer would be to dramatically increase the price per package. In Australia, where the percentage of smokers is very low, a packet of cigarettes costs an average of 15 francs, while here, people are up in arms if a package costs over 8 francs.
You said that the risk of cancer increases from age 50. As an elderly person, can you also do something to lower your risk?
Stay active and go for regular check-ups. I advise my friends and colleagues to get a colonoscopy when they turn 50, and to repeat the procedure every ten years after that. If they don't want to get a colonoscopy, I recommend they visit their GP to run some tests that check for blood in the large intestine. Women aged between 50 and 70 should have a mammogram every two years. It is now even being discussed that these tests should be continued until age 75. Procedures likes these help reduce mortality rates for the most common forms of cancer.
Are you satisfied with cancer screening programmes in Switzerland?
The problem we face is that we have not one health system, but 26; and these systems are sometimes very different from one another. Early detection and prevention can only be performed effectively at national level, however. And Switzerland is a country that doesn't like the state sticking its nose in where it's not wanted. That is why it rejected the Prevention Act in 2013. Health insurance premiums are still manageable financially at the current time. Only when they really start to hit hard will be begin to ask ourselves why we were so stupid to allow diseases to develop that could have been prevented, and are now having to pay through the nose to treat them as a result.
So, depending on which canton I live in, I have better or worse chances of surviving cancer?
As a woman living in French-speaking Switzerland, you have a lower risk of dying from breast cancer than women in German-speaking cantons due to the Romandie region's comprehensive mammography screening programme. In Geneva or Lausanne, the tumours discovered are 4-5mm smaller than those in Zurich or Lucerne, for example. Differences in attitude also play a role.
What do you mean by that?
In some rural regions of Switzerland, people often leave it too late before they go and get checked out. In Sarganserland in the canton of St. Gallen, breast tumours, for example, are usually discovered in more advanced stages than those in the city of St. Gallen. Women wait longer after they notice something, and they go for check-ups less frequently. On the flipside, however, there are also less doctors. That has its disadvantages as well.
When it comes to prevention, gene testing could prove beneficial, since genetic mutations always play a role in cancer development. Will they soon become standard for all?
I wouldn't think so. At the moment there is no gene test that I would recommend on a general basis. Either the results are ambiguous or the statistics derived are too impractical. What is someone meant to do with the prognosis that they have a seven percent chance of developing early-onset Alzheimer's? That would only worry them unnecessarily. Some people have committed suicide in the past following the results of gene tests. Naturally, in the case of certain disorders that can be avoided or influenced and that are known to run in the family, a reliable gene test is always an option. Here, too, however, this step needs to be given careful consideration.
Once cancer has been diagnosed, there is at least the good news that one in every two cases is cured.
Depending on whether you're dealing with breast cancer, leukaemia or a brain tumour, the journey can be very different. Cancer is not just one illness, but rather a generic term encompassing more than 200 different diseases. For that reason, statements about cancer need to be considered in context, even if today in general more than one half of those affected recover.
But we have come a long way in the past few decades.
A very long way! There are more and more forms of cancer that are no longer life-limiting and do not develop into a chronic condition. Many chemotherapy treatments are much more tolerable today than they were before and have become much shorter. Often, four to six months are sufficient. In the past, patients didn't know whether the treatment would take one or two years.
What should patients bear in mind when embarking on a course of treatment?
It is important that you go to a clinic where surgeons, anaesthetists, oncologists, radiologists, pathologists and the postoperative team work well together. Specialists must see the patients often and be intimately acquainted with their cases. Ideally, treatment should be sought in special centres at university and cantonal hospitals, or in private hospitals that are adequately specialised in the type of cancer in question and where each case is discussed by an interdisciplinary team.
How can you find these as a patient?
In Switzerland, there are quality standards for breast centres. These clinics have to comply with specific quality requirements in line with international standards. Additional certifications for centres that specialise in treating colon and lung cancer are in discussion. I would welcome it if, in future, health insurers would also give greater consideration to quality aspects and ensure that their clients get the best possible care. Health insurers have a wealth of data at their disposal and know which hospitals are better at their job than others.
Let's talk about specific treatments. In 2013 respected science magazine Science celebrated immunotherapy as the cancer treatment breakthrough of the year. Is that the future?
The idea that the immune system is able to successfully fight even tumour diseases has been around for decades. There has been extensive research into why multiple immune cells are always grouped around tumour cells, but are unable to attack the tumour itself. We have since come to understand these mechanisms and have developed targeted drugs. They are already being used to successfully treat melanoma and are also being tested on other tumour diseases such as lung and kidney cancer. Immunotherapy works in principle, but it is still an extremely complex procedure, since it also activates other immune cells in the process, leading to side effects and in some cases triggering undesirable inflammations.
Personalised medicine is becoming more and more important. The cost of drugs that target and attack tumours rose by 187 percent between 2007 and 2012, according to Helsana medication statistics. In 2012 a course of treatment with breast cancer medication Herceptin cost CHF 28,590 per person. This places a massive financial burden on the entire healthcare system – and thus on us all. Does the financial cost always justify the benefit?
I have been working as an oncologist for 35 years now, and the newest, most effective drugs have always been more expensive than the next best thing. But the fact that they are suddenly ten or twenty times more expensive than the previously preferred drugs, that is completely new. The expenses and risks cited by the pharmaceuticals companies do not justify this mark-up by a long shot. The pricing of innovative medications has become untenable, and international price guidelines – usually set by the USA – are coming under increasing pressure.
What can be done with regard to prices?
Politics must continue to exert pressure. It would seem to me that, when it comes to drug prices, we have still not yet reached our political pain threshold. Controlled parallel imports should also be allowed for drugs like these.
When seeking treatment, sometimes patients want a second opinion. When is this appropriate?
It is appropriate when patients are unsure whether what doctors have prescribed is the best course of action, or if trust and confidence is lacking. A second opinion also makes sense when very serious, extraordinary and high-risk operations are on the cards. However, in centres where specialists work together in an interdisciplinary fashion and take decisions together on what will be the most effective treatment based on current medical knowledge, in most cases second opinions are superfluous.
Therapies and drugs are just one aspect. What role do people's attitudes play in overcoming cancer or learning to live with it?
As far as quality of life is concerned, it is important that patients take an active role in the management of their disease and do not become passive victims. This helps them cope with the entire treatment process – consisting of operations, chemotherapy and radiation – as effectively as possible. Experience shows that this leads to less complications, and patients are able to get their health under control more quickly.
Some people need support to do this. Do patients today get the psychological support they need?
Hospitals have psycho-oncologists, but the offering is still modest in some areas and the discipline is not widely accepted – at least at the outset. Many of those affected think they are able to deal with everything on their own and overestimate how strong they are. But cancer involves a lot of uncertainty; phases of weakness and depression are not uncommon. It is impossible for partners and families to carry all of the burden on their own. At the end of the day, however, it is up to each individual patient to decide whether or not they want this support. And naturally not everyone needs it.
How important is personal environment?
It is an established fact that people who are totally alone find it harder to overcome many illnesses. Even with something as comparatively harmless as pneumonia, having someone around – even a pet – is good for your prognosis. The importance of a patient's personal environment cannot be expressed in figures; however, in oncology it is not just the individual but the whole support system that is important.
If, in spite of all available treatments, a person's life is drawing to an end, how are the most severely ill cancer patients and the terminally sick cared for in Switzerland?
Palliative oncology and medicine has evolved continually in Switzerland over the last 20 years. Lausanne has been a trailblazer in French-speaking Switzerland, while St. Gallen has taken a pioneering role in developing palliative oncology for German-speaking Switzerland Today St. Gallen is home to an entire network for the region. In large cities and oncology departments of other hospitals, work has begun on setting up similar networks. But there are still regions in Switzerland where care is lacking.
And finally: In spite of everything, can cancer also be an opportunity?
Someone who falls victim to cancer is forced to re-evaluate their entire existence. Sometimes an illness can instil the courage the change things, to make decisions and to set priorities. The realisation suddenly dawns that life is finite. I have also been fortunate to get to know people who – even though they had but a short time left to live – have blossomed immensely and achieved amazing things. In that sense, cancer can also be an opportunity.
Interview: Juliane Lutz