POLITICS OF CANCER CARE
There are clearly many angles to the politics of cancer care, and these are linked closely to the economics of the disease. Here it will focus on the differences in cases diagnosed and death rates and how they drive the politics of the disease, using breast and prostate cancer to illustrate gender differences and breast and lung cancer to illustrate social class effects.
In many ways, prostate cancer is the male counterpart of breast cancer. The similarities extend to a number of levels: both organs have a role in sexuality and reproduction; both change during life in response to hormone levels; both cancers can be treated by changes in the hormone environment, and treatments for the cancers arising in the respective organs cause profound changes in sexual function. Politically, the powerful sexual and emotional imagery of the breast has been used to great effect to channel research and treatment funds into breast cancer for many decades. This has resulted in steady and progressive improvement in outcomes for women with breast cancer, reflected both in improved survival and reduced damage from successful treatment. For example, women are increasingly offered less mutilating surgery or breast reconstructions rather than radical mastectomy. On the drug funding issue, women have again been very effective at campaigning for new treatments – witness the rapid uptake of trastuzumab (better known as Herceptin) across the European and North American healthcare systems.
Until recently, despite the biological parallels, there was no analogous movement to support men with prostate cancer or campaigning to improve treatments and outcomes. As recently as 1995, for example, spending on prostate cancer research in the UK was only one-tenth that of breast cancer. In the last 10 years, this has changed, partly driven by the PSA test. This shifted the spectrum of prostate cancer substantially to the ‘left’, with a decrease in late cases and increase in early cases for which the treatment options are more varied and the possibility exists for a cure or prolonged survival with the disease. This historical lack of public health and research interest is particularly surprising given the general concentration of political and economic power in the hands of men of middle age and above – those most at risk of the disease and with a very little risk of breast cancer (though men can get it). The difference appears to be rooted in the differing psychologies of men and women – its fine for women to talk about breast cancer, and women are not seen as diminished but often rather strengthened by it – witness Kylie Minogue’s recent world tour. On the other hand, it has previously been very difficult for men to talk about the disease, particularly when treatments carry ‘unmacho’ risks such as impotence and incontinence, quite apart from the fundamentally embarrassing route needed for diagnosis (via the rectum). Coupled with most men’s general ‘ostrich’ approach to all matters related to health, the result has been a price paid by men living shorter, less healthy lives than women.
More recently, however, there has been a shift in public and economic policies, with more money spent on treatment for men and research into the disease. This has been driven no doubt in part by the pharmaceutical industry’s belated realization that there is a lot of money to be made from one of the biggest male cancer killers in the West. There has also been a change in that major public figures such as Colin Powell, Roger Moore, and Rudolph Giuliani have been prepared to talk about their treatment for the disease.
Finally, the issue of smoking and public policy is worth mentioning in the context of the politics of cancer care, as this has varied widely across the world and over the decades. Not too long ago, tobacco companies actually ran adverts with the strap-line that a particular cigarette was the preferred brand for doctors. The linkage of smoking to increased risk of various cancers has been one of the triumphs of epidemiological research and has resulted in massive reductions in the rates of smoking and diseases linked to it in the developed world. A range of measures has driven this, from legal (smoking bans) through educational (advertising and sponsorship bans, health warnings) through to fiscal (tax the stuff, which has the additional benefit of paying for the healthcare needed to pick up the consequences for smokers). In the developing world, things are different, however: smoking is still seen as ‘cool’, underpinned by advertising and marketing to young people, rather than the pariah activity banished to chilly doorways it has increasingly become in Europe and North America. Furthermore, the money brought in to developing countries by the big multinational tobacco companies carries with it much political clout, and this can be used to tone down the public health assault on the habit that has occurred in the West. Coupled with the young age structures of developing countries, an epidemic of developing world smoking-related cancers – lung, bladder, throat, mouth – can be anticipated in the coming years. In countries like China which are rapidly modernizing and improving living standards and life expectancy, this can be expected to result in particularly large increases in these cancers.