This interview for CANCERactive is with Professor Karol Sikora (Originally published in Issue 2 2006 icon).
By Madeleine Kingsley
Photography by Paul Chave
Come the year 2025, cancer prevention will be as natural as cleaning your teeth. Based on individual risk assessment, you will plan your lifestyle for optimum health, with nutriceuticals or smart foods built into your chocolate bar. More people - some 3.3 million people in the UK will actually have cancer than the present 1.2 million, but that´s because they will be living longer and living with, rather than suffering from the disease. A reformed health system will provide good, free core treatment, with ´extras´ such as the Herceptins and Avastins of that still-distant day factored in for those who want to pay. Gone will be (and good riddance to) the iron-bedded oncology ward, where you wait around, stressed and pyjama passive, for your turn in surgery, or for tests and consultant visits at any old time to please the medical powers-that-be.
Professor Karol Sikora - whose vision of the coming, consumer-led cancer culture this is - predicts relaxing hotel-style treatment centres where you book in to suit your self, where there are no patients, only people, no waiting rooms with antiquated faux-leather seating and where minimally-invasive surgery (think advanced radio-imaging and robotics) involves no more than an overnight stay. Just as we now have our Sheratons and Holiday Inns, so we will have international cancer providers for specialist care that will be ours to choose and book.
Come the year 2025, cancer prevention will be as natural as cleaning your teeth
Most radically, Professor Sikora anticipates the key to the future lying not in new drugs or new technologies but in personalised cancer medicine: ´Costs will be saved because people will not be given across-the-board drugs that might not work for them. Doctors will understand the molecular cogs that have led to the cancer, the pathways by which the cancer has arisen. Essentially they will prescribe specific drugs to correct the abnormal pathways.´ The microscope could be defunct for pathologists of 2025 ´as they use all sorts of fancy molecular probes on tissue samples, guiding the oncologist to increase the effectiveness of treatment for each individual.´
If this new model of medicine comes to pass, Professor Sikora will be its Romulus or Remus, a vital founding father. The Professor of Cancer Medicine. Clinical Director and honorary consultant oncologist at Imperial College School of Medicine, Hammersmith Hospital, London is also a special adviser to the World Health Organisation and a member of the 900 strong doctors Steering Committee for Reform. Prostate cancer is his clinical speciality A once-cynical convert to complementary medicine, he set up the first, then still controversial holistic clinic at Hammersmith, where it flourishes still. He takes an open-minded, intensely human approach to demystifying cancer and empowering those who confront it. For speaking out against the sacred cow of NHS and the shortcomings of the National Cancer Plan he is something of a thorn in the government´s flesh.
Privately, Karol Sikora lives in Beaconsfield with his wife, a practice nurse, and their rescued dog. They have three children, now grown up. Hill walking is Sikora´s favourite pastime and he recently spent five days exploring the Dorset coastal paths. Publicly, the Professor has found a rightful place on Saga magazine´s 2006 wise list, where his entry as a ´trailblazing oncologist´ falls between that of Monica Siddiqui, Islamic scholar and fashion designer Paul Smith. This particular honour raises a rich laugh from the neat, authoritative sage sipping strong black coffee in his Harley Street office: ´It´s very strange how the media deals with us´ he reflects. ´They know where to put pop singers and artists, but doctors they can´t really assess. I´m probably on the list because I´ve made a lot of public statements and so acquired a profile. How much does that have to do with skill or ability? It amuses me and my oncology friends to vie for the media slot of ´world´s top cancer specialist. I´ve made ´leading British slot´ but we joke about making the ´top international´ label. It´s not serious: I guess if I was looking for an oncologist, I wouldn´t just seek out the ´world´s top.´ You´re looking for someone with a special interest in the problem you have, and someone who communicates well with patients and their families.´
I wanted to see money go to the right places
Karol Sikora has seen - and initiated - change aplenty in the 20 years since he became a consultant at Hammersmith. His environment is unrecognisable as the rundown place he found: ´The hospital was very exciting in research terms, especially in cardiology and gastro-enterology, but our cancer ward was an old workhouse. I wanted to see money go to the right places. We built a new cancer centre, got a big research grant from the Imperial Cancer Research Fund (now CRUK) and really started growing again.´
Only on reaching consultant status, says Professor Sikora, did he realise how significantly cancer care in Britain lagged behind Europe. ´About 18 years ago, the first published Eurocare study showed that our mortality for cancer was much higher, disease by disease, than other countries of Western Europe. And the reason for that was, I think, that in previous generations the treatment of cancer patients was the forgotten speciality medicine´s underinvested Cinderella. Radiotherapy patients were treated in the twilight zones of hospital basements. Staff were demotivated and their numbers depleted.´ As a registrar Sikora remembers seeing up to 60 cancer patients - maybe 10 new, 50 on follow-up - in a single morning. ´Neither staff nor patients were satisfied, even in those days of briefer consultations, before doctors took time to give their patients adequate information and sat down to discuss the relative risk analyses of treatment options. I realised then that to transform the whole system massive investment was needed. And there has indeed been transformation.´
Coming Round to the Complementary
Not least of these changes was the shift in Sikora´s attitude to allopathic alternatives.
Three of his early Hammersmith patients reported themselves blossoming under the wing of the then revolutionary Bristol Cancer Help Centre. ´I was a cynic then´ says Sikora ´because 20 years ago, most complementary medicines for cancer were, in truth, rigidly alternative. There were people charging a lot of money for supposed cancer cures, like Joseph Issels in the Bavarian Alps, and many of them are still out there. But then a former medical student of mine who´d gone on to work at Bristol invited me to come and see the work for myself. "You´ll be shocked" he said "It´s not what you think." I went down still thinking that I would spend the morning laughing. Instead I was amazed: they weren´t using a medical model for cancer and that I´d never seen. That medical model created hassled doctors who couldn´t really care how people felt, because they were too busy looking for blood count results or patient x-rays."
´The model of complementary options I saw in Bristol was very different and it struck me that you could transpose the two models so people had choice. In Bristol I saw how people could express themselves by trying different things, so that some were drawn to aromatherapy, some to art therapy and others reflexology. The great thing about complementary medicine is that, unlike orthodox medicine, it is very individual. No longer a passenger, the patient has to be the driver and the main participant. Another advantage is that it is relatively very cheap: one vial of Herceptin costs about 2000: you can buy an awful lot of complementary treatments for that.´ Professor Sikora also foresees that complementary therapy will increasingly come into its own as people live longer with cancer and also, therefore, with ongoing uncertainty.
By promoting wellbeing and stress relief, complementary therapies can help people deal with the unknowable: ´I personally don´t think that complementary medicine is itself a cure´ says Sikora, but I do believe that it helps the whole person, so that they can handle the reality of their condition and come through their orthodox treatment better. I think that complementary medicine allows you to get on top of the fact that you have cancer and live with it in a way that doesn´t disturb you psychologically too much.´ Before the decline of spirituality, he reminds, the vicar would have played a major consoling role. In earlier times, the family matriarch would have stepped in to care for the cancer patient. Social change, says Sikora, has left many people without a vital shoulder to cry on, and complementary care can help to fill that spirit-sapping vacuum.
His interest aroused by Bristol, Karol Sikora started reading more, and visiting other centres, including the Gerson Clinic in Tijuana, Mexico. ´What struck me over time was that Bristol had what was really needed - a balanced range on offer. A lot of places offered one thing only, be it coffee enemas or massage. which felt too much like the single modality therapy of orthodox medicine. If you look at the Internet you will still find very bizarre websites offering all manner of alternatives which are difficult to explain. I have one patient who is taking some sort of hitting or slapping therapy from a Chinese gent. My view on this is that if it suits him, why stop? But what I feel is really needed is a boutique approach to the complementary - a package of services for the patient to choose and use. That´s what Bristol has done so well, offering much in the way of nutrition and exercise that has now become almost, if not entirely, orthodox.´
Over the years Professor Sikora has seen all the major US cancer centres open their doors to complementary
So impressed was Sikora that in 1991, with help from Bristol, he set up a complementary centre in his own Hammersmith hospital, ´orthodoxising´ it by recruiting qualified nurses to train in the therapies that particularly interested them. ´Everyone felt more comfortable because these holistic practitioners had qualifications backed by the authority of a grade in the nursing hierarchy.´ The centre still flourishes free - thus far - for cancer patients, and over the years Professor Sikora has seen all the major US cancer centres open their doors to complementary medicine, whilst Europe - and Germany in particular - follow suit.
No Scan For Happiness
For the Professor, under-researching is complementary medicine´s critical stumbling block. ´There is no funding to undertake the research that could produce the evidence that complementary medicine works. It´s a Catch 22. And how, anyway, do you validate results for people feeling better? ´We have tried all sorts of assessments like scales and scorings, but there is no blood test for feeling happy. If there was, we´d be all right.´
What of the three women patients who first attuned Sikora to the complementary wavelength? ´Two are flourishing still. One lady whom I remember very well, worked for an airline and had a very unpleasant pelvic tumour. She´d had a great deal of trouble with the side effects of chemotherapy, following surgery and radiotherapy. Having stopped her chemo because she couldn´t tolerate it, she returned from Bristol and completed it. We know that people who don´t complete their course have a much poorer survival chance than those who do. Nobody can say definitively, but you could argue that in those circumstances complementary therapy saved her life.´
One-to-One Cancer Prevention
In cancer prevention, as in cancer care, personalisation is the Sikora way forward. ´Broad brush prevention is never going to work´ he maintains. ´Ideally I have to come to you, take a sample of DNA, and work out your genetic risk for a range of cancers. Unfortunately we´re still lacking a good bio-marker for the cancers, in the way that cholesterol levels identify heart disease risk. Increasingly doctors are interested in risk-banding people by genetics. We know that some people carry the BRACA1 gene which give a very high risk of breast cancer and that there are very strong familial links in colon cancer. But if you are looking for abnormal genes in the population it is a rare subset among many that collectively relate to cancer risk. Individual genes are relatively low in their relationship to cancer, but if you had enough of them, you could look at patterns emerging from which you could band people, so that there might be a band a for breast, band c for colon and d for pancreatic.´
Broad brush prevention is never going to work
Given such risk recognition, medics could then look at an individual´s lifestyle and tailor a preventative programme. For Sikora, individual risk assessment is the most effective - and cost-efficient - step to prevention: ´Targeting whole populations, as with the government message advocating five fruit and veg isn´t the best answer´ he says firmly. ´If we knew who was going to get colon or breast cancer and targeted those it would be a lot more efficient and less wasteful. A lot of people are not going to get these cancers with or without their daily broccoli and raspberries. They will be all right either way.´
Dr Rosy Daniel, the cancer consultant best known for her Health Creation Programme, and Cancer Lifeline Kit, has already set off on the route that Professor Sikora sketches: ´I see Dr Daniel as a great self-empowerer of patients´ says the Prof. ´She wants them to do the work which is the way it´s got to go for patients and prevention. If you have cancer, the most important member of the team working for you is yourself. You can´t forget that. You don´t have to be in charge all of the time. If you get low, you can ask others to help, but you do have to be on the ball. Dr Daniel´s risk-reducing approach looks at lifestyle and diet, and putting together information packages for healthy eating and behaviour styles. It´s very useful, but though a kit for 100-200 seems reasonable, it´s a lot for those with less money. So looking ahead, the problem here is, can you persuade health care systems to take up this kind of prevention, and if not how is it going to be paid for? To get funding you will again have to prove that it works.´
Hope - The Ultimate Complementary Medicine?
There´s a further area in which orthodox and complementary medicines make difficult bedfellows. ´And that´ says Sikora ´is the unfathomable quality of hope. If you have had, for argument´s sake, three different types of chemotherapy for, let us say, metastatic colon cancer, there is, realistically, not much more orthodox medicine can do for you. A doctor may not want to force that information on somebody, but if asked directly whether there is anything else to be tried, you have to say "probably not." People then react in different ways: some curl up and die, some embark on a round-theworld or Internet odyssey searching out secret cancer cures.´
Many complementary practitioners, says Sikora, take a different view. ´They won´t give up. I remember having a real dingdong at a group meeting with Bristol and the Hammersmith about the issue of hope. Is it ethical to say there is nothing more to be done, even if you are approaching medicine as a hospital technician? If you don´t convey that message are you offering false hope, which was the accusation levelled by the orthodox against the complementary.´ Not so, says Sikora, clearly a clinician with heart. ´To improve quality of life is an aim in itself. And if part of that quality of life stems from imparting hope, then delivering it must be part of the package.´
On The Difficulty of Shaking Up our Health System
"We must define what to give patients as a core package for cancer and be ruthless that everyone gets the same. We don´t have postcode prescribing; we tell NICE that we need drug assessments fast - the month after a drug is released. The current noise about Herceptin is very special and one-off. But Avastin is also going to be very noise and expensive. It´s primarily for colon cancer, but is likely to be approved for lung and breast this year in the States, possibly for pancreatic in due course.
"Economically a health service can live with a single high cost drug like Herceptin, with a cost about 120m. But the cost of adding Avastin could be 3-400m, or 100,000 for every patient, in every year of his or her life. That is totally going to distort the budget in a way that was unpredicted and is not achievable without major funding changes. So over and above a core package which is fair, but not extreme. we must involve patients in assessing their own cost benefits. If it was your money, you would be more cautious about it. Using a motoring analogy, do you really need a flash, souped up car, when wheels and reliability will take you to the same place? It´s a matter of where people want to go."
On Funding Reform for Cancer Care
"Everyone loves the National Health. It´s the nearest thing we have in Britain to a national religion. For any doctor to stand up and criticise the NHS is like a priest saying he doesn´t believe in God. But everyone knows it´s not right and that is so frustrating.
"The Labour government hesitates to move because they think they invented the NHS with Bevan, when in fact it was created by the Liberals under Beveridge. The political right are too scared to fiddle with it, so you end up with an impasse."
On the Flaws in Government Investment
"We have an unreformed health system where the money has gone in - no doubt about that - and will continue to do so until next year, when investment stops. But the money going in isn´t connected with what comes out. Doctors are seeing more patients, so more people are getting care which you´d think is good but, because of the system, it´s not. As productivity goes up, so do costs with patients using more chemotherapy and equipment running out. So more costs are involved and managers say one is ´overperforming.´ I just want to see the money go to the right places and the people responsible for delivering services in charge of their own finances."
So What´s Next? Doctors for Reform
"Our 900 Doctors for Reform are basically bent on opening the box no one wants to open. How can we get more money into health care - not necessarily through the tax payer. We should first look at what services the NHS (or whatever you want to call it next) is able to charge for, because people would want to buy it, over and above basic cover. The second thing is to look at ways of reducing demand for services that don´t give much benefit: in cancer a lot of follow-up, for instance is pretty wasteful, just going along to see a different registrar each time. The practice persists just because it´s gone on for 50 to 100 years. We also need to make the whole area of cancer treatment more consumer efficient. Before treatment a colon cancer patient has to have a whole set of investigations - scans, MRIs, blood tests, biopsies. To do these all on the same day costs exactly the same as doing it over the next 6 months causing half a year´s delay and distress for the patient. We must develop systems to do the lot next Tuesday!
"Such systems for efficient service delivery are possible - and on the way. The NHS is consumer-based just like supermarkets, though you wouldn´t think so from the information it currently utilises. The reason why supermarkets are so clever at putting the right goods on shelves is that their systems can predict where demand is going to be in populations. The health service is just beginning to recognise this. But we are 10 years too late. Cancer is a very predictable disease in terms of age, gender and socio-economic status. You can identify where there are delays and inadequate capacity for diagnostics and radiotherapy. We need to be dealing with these issues now and model cancers services around areas of future need. I want to be optimistic that we can get there in the end, because we have the skill and the ability in this country to do it."