Head and Neck Cancer

Paul Beresford Excerpts

Tuesday 1st July 2014 Commons Chamber

[Sir Paul Beresford (Mole Valley) (Con)]

I thank my hon. Friend the Minister for coming. She is smiling slightly, because we have had this discussion on a number of occasions and it will continue, at least until I get my way, if that is at all possible over the coming years.

I must begin by declaring a short list of potential interests. I am still a part-time practising dentist—very part-time. I am also chairman of the all-party parliamentary group on dentistry and the APPG on skin, which has a link to this debate.

In an earlier debate, I focused on oral cancer and, in particular, on the causative role of the human papillomavirus. I have been trying to persuade the Minister to encourage the Joint Committee on Vaccination and Immunisation, or JCVI for short—don’t the medicos always do that?—to broaden its horizons beyond the inoculation of teenage girls against cervical cancer. The results in relation to cervical cancer are very encouraging, but the virus is key to the cause of many other cancers, and that applies predominantly to two variations of it.

In a previous debate, the Minister was very nice, and explained sweetly that I must rely on the advice of the JCVI—or, at least, that she must do so. She explained that the committee was expanding its sights. Although it was enlightening to hear that it would be examining the HPV-related effects of men having sex with men, it did not help me very much because I am looking beyond that. I think that the committee should be looking above the waist, and, more specifically, looking at the trauma of pain, suffering and death—a very horrible death—as well as at the financial costs to the NHS of the existence of the virus elsewhere in the human body. I am aware that the virus plays a part in skin cancer, but I have decided to concentrate on the head and neck.

A quick cruise through the latest papers on head and neck cancer makes for frightening reading. Despite the reduction in smoking, the number of head and neck cancer cases is rising steadily and rapidly. The stark reality is that the number of new cases is growing year on year, at a much higher rate than the experts expected. Some are talking of an epidemic. The problem is now so acute that one form of cancer which falls into the “head and neck” category, oropharyngeal cancer, is the fastest-growing cancer in Scotland, and is a significant and growing problem in the rest of the United Kingdom.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Gentleman on raising this subject. In the past year in Northern Ireland, 1,218 people have been diagnosed with head and neck cancers, and 64 people die of such cancers every year. Does he think that that is because this is seen as a lesser cancer—if that is the right way in which to put it—than others which seem to catch the eye of the public? If so, does more need to be done to increase the focus on head and neck cancer?

[Sir Paul Beresford]

I am focusing on it, because worldwide it constitutes about 5% of cancers and causes 6% of the deaths, and because, as I think is generally accepted, in a large proportion of cases HPV is a causative agent, or the root cause. There is a way of dealing with that and I think that we ought to adopt it.

In the United Kingdom, the latest findings put the incidence of HPV at 23.5% for oral cancer, 35.6% for oropharyngeal cancer, and 24% for laryngeal squamous cell carcinomas. I have no data for skin cancer, but obviously it applies to head and neck skin. On a personal note, my brother-in-law recently died from a squamous cell carcinoma on his head, which was undiagnosed and untreated, and when it was found it was too late. Head and neck cancers are fifth in the global rankings of cancer incidence, and sixth in the global rankings of cancer deaths.

The cost of oropharyngeal cancer to our health services is enormous. A new report is due to be published following extensive research on the economic cost of head and neck cancer. The findings of the research suggest that the official estimate of the burden placed on the national health service is significantly less than the actual total. The data I have seen of the report that is coming out soon conclude that the cost of oropharyngeal cancer was approximately £115 million at 2011 prices, laryngeal cancer £96 million and oral cavity cancer £98 million. The total at 2011 costs is just under £310 million. We must add that that is almost certainly low because of under-reporting, that we have three years of inflation and, worst of all, three years of increasing numbers of cases. I am not sure, but I suspect that that does not include peripheral rehabilitation costs such as physiotherapy and speech therapy and some cosmetic dentistry in appropriate cases, nor does it cover the unquantifiable cost to quality of life, with the pain and disfigurement that much head and neck cancers produce, and the treatment that is required peripherally for patients.

Perhaps what is most surprising—I have only just discovered this—is that these cancers are more prevalent in men than women at a ratio of approximately two to one. It is common knowledge that the NHS is under immense financial pressure. In fact, demand for access to the NHS is at unprecedented levels. The Government have taken commendable steps towards ensuring that the health service is protected from spending cuts, which have been necessary in so many other areas, but that does not mean budgets have not come under pressure and resources have not been stretched. It is therefore a matter of the very gravest concern that the full economic burden of head and neck cancer, and by extension HPV, is not taken into account. It should be. The whole of the problem of HPV and the way it infects different parts of the body should be addressed by the Joint Committee on Vaccination and Immunisation.

Australia has a policy of vaccination of both males and females. That is producing what is called a herd immunity. Although I am specifically looking at head and neck, with the role of the HPV virus, it is quite clear that there could be a dramatic reduction in a number of cancers, including head and neck cancer, over time with gender-neutral vaccination. Clearly, men currently face a significantly greater, and rising, risk of HPV-associated head and neck cancers.

I therefore again put it to the Minister that it is not fair, ethical or socially responsible to have a public health policy that leaves 50% of the population vulnerable to infection. Such vaccination, combined with early detection and action on smoking and heavy drinking of alcohol, could save a huge number of lives just as we are facing a dramatic increase in head and neck cancer. I hope that the Minister will be able to persuade the JCVI to broaden its horizons and to look at the human suffering, as well as the total costs of HPV to our national health service.

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

I congratulate my hon. Friend the Member for Mole Valley (Sir Paul Beresford) on securing this debate on this important issue and on continuing to champion it. It shows Parliament at its best when Members bring to bear here the expertise and insight they have acquired outside this place, and that is certainly what my hon. Friend is doing and I commend him on it.

Let me set the scene before dealing with some of my hon. Friend’s specific concerns. As he said, we have debated this issue before and I am anxious to try to keep him up to date with any developments as well as to make sure the House has a general picture of what we are doing in this area.

The Government want England to lead the world in tackling cancer. That is why our 2011 cancer outcomes strategy set the ambition to save a further 5,000 lives a year from cancer by 2014-15, including head and neck cancer. As my hon. Friend rightly said, the incidence of head and neck cancer has been increasing since the 1970s, with over 6,500 people in England diagnosed with oral cancer alone in 2012. That is due to the prevalence of the major risk factors for oral cancer, such as heavy alcohol consumption and smoking. Chewing betel quid, which is more common among south-east Asian communities, is also a risk factor for oral cancer and that may have contributed to the trend. As the House knows, we have major programmes of work in place to tackle smoking and excessive alcohol consumption —and it is heartening that, although there is a long way to go yet, we did see smoking prevalence rates dip below 20% for the first time in England in the most recent figures.

There is now growing evidence that HPV, already linked to the development of nearly all cervical cancer in women, is also a major risk factor for oral cancer. That is not disputed. The types of HPV that are found in the mouth are almost entirely sexually transmitted, and they have been associated with about a quarter of head and neck cancers. So if we can reduce the incidence of HPV in females through a high uptake of the national vaccination programme, a reduction of other HPV-associated cancers in females and males is likely to follow. I note, however, that my hon. Friend feels that that herd immunity is not going far enough and there is further to go. It is worth restating that the aim of the current HPV vaccination programme is to prevent cervical cancer related to HPV infection—that is where it started. When introducing the vaccine in 2008 the Joint Committee on Vaccination and Immunisation, which advises the Government on all immunisation matters, did not recommend HPV vaccination for boys because the reasoning was that once 80% coverage among girls had been achieved there would be little benefit in vaccinating boys to prevent cervical cancer in girls.

Judged by any standard, the HPV immunisation programme has been very successful. More than 7.8 million doses have been given so far in the UK since 2008, and we have among the highest rates of HPV vaccine coverage achieved in the world. I encourage hon. Members to look at their own local statistics, because although we achieve a very high average vaccination rate, there is some local variation. That matter is worth pursuing, particularly with schools, as this vaccine is delivered in schools almost universally. Some 86% of girls who are eligible for routine vaccination in England in the 2012-13 academic year have completed the three-dose course and 90% have received at least two doses, but in some schools the rates are lower and we want to get those up.

There is an increasing evidence base on the association between the HPV infection and oral, throat, anal and penile cancers, and on the impact of HPV vaccination on those infections. As a result, the JCVI issued a call for evidence in August 2012 to inform a review of HPV vaccination. The JCVI is very much aware of the issues concerning HPV vaccination for men who have sex with men, and at its October 2013 meeting recognised that the current immunisation programme may be of little benefit to those men and agreed to create an HPV sub-committee to consider the evidence for extending that vaccination programme. The sub-committee will aim to identify and evaluate the full range of options.

[Sir Paul Beresford]

The Minister has just talked about extending the programme, but to what or to whom?

[Jane Ellison]

On to my next paragraph. The sub-committee will look to identify and evaluate the full range of options for extending the protection from HPV infection to men who have sex with men, including by vaccinating them, and the potential extension of the programme to include adolescent boys. That deals with the point my hon. Friend was making. The JCVI HPV sub-committee—I apologise for all the acronyms but they are inevitable in a health debate—met for the first time on 20 January 2014 to review the available evidence on the impact and cost-effectiveness of potential extensions to the HPV programme. Any recommendation by the JCVI must be based on cost-effectiveness; there is a particular formula it uses to look at that within our health economy. The sub-committee will report its findings to the JCVI following consideration of a yet to be completed study by Public Health England into the cost-effectiveness of extending the HPV vaccination in both those directions. I hope I can give my hon. Friend some reassurance by confirming that the study will consider the impact of vaccination against penile, anal and oropharyngeal—head and neck—cancers and genital warts. Those things definitely form part of the studies that will be made and of the calculation about cost-effectiveness. There is no evidence to suggest that the current HPV vaccines will offer protection against skin cancer—I do not know whether he wishes to develop things further in that area, but we are aware of no evidence that makes that link.

The decision on the vaccination of adolescent boys requires the development of complex models to determine whether or not it would be cost-effective. Obviously, this would mean extending an already big programme to a much larger group. These models may identify a need to generate additional evidence, and therefore a decision on vaccination of adolescent males is not likely before 2015 at the earliest.

[Sir Paul Beresford]

One difficulty with models is that they take absolutely no account of the unpleasantness of the disease and the damage it does. Head and neck cancer is one of the most frightful conditions to deal with and to live with.

[Jane Ellison]

My hon. Friend makes a good point, but I will have to come back to him on it. I will not speculate at the Dispatch Box. Many factors go into these calculations, but I will make inquiries with regard to other JCVI decisions. I think that the severity of effect is taken into account and is part of the calculation, but I will clarify that and come back to the hon. Gentleman. None the less, he is right to remind the House of that matter.

The evidence to support a decision on a selective programme to target men who have sex with men may become available at the end of this year, which is earlier than expected. Obviously, the Department will consider carefully the advice from JCVI once the Committee has completed its assessment. As that is all in the future, it is worth talking about some of the things that we have at our disposal now in terms of early diagnosis. In addition to taking steps to tackle unhealthy lifestyle factors and the virus linked to head and neck cancer, we have also set out, through the mandate to NHS England, a clear ambition for the NHS to improve outcomes for all people with cancer.

One of the most common symptoms of oral cancer is a persistent sore or lump on the lip or in the mouth, so there is an opportunity for both doctors and dentists to play a role in supporting earlier diagnosis.

Since 2005, the referral guidelines for suspected cancer, published by the National Institute for Health and Care Excellence, has supported GPs to identify symptoms of oral cancer and urgently refer patients. The National Institute for Health and Care Excellence is currently updating that guidance to ensure that it reflects the latest available evidence.

[Sir Paul Beresford]

With great respect, on the question of the sore or the ulcer, the problem with cancer is that it is not sore until it is too late.

[Jane Ellison]

I will reflect on that point. I do not pretend to have the hon. Gentleman’s professional expertise. He has corrected the record, if he feels that it needs correcting. I hope that he will not disagree with me when I say that dentists have a key role to play in the early detection of oral cancer.

[Sir Paul Beresford]

indicated assent.

[Jane Ellison]

All dentists are trained as undergraduates to look for such signs during routine check-ups and to pay close attention to patients’ self-reported history of smoking and drinking—both key risk factors. A new patient pathway, currently being piloted in 94 practices, includes an oral health assessment, which requires dentists to examine the soft tissue of the mouth; assess a patient’s risk in relation to oral cancer; and offer advice on lifestyle changes.

I am also pleased to say that the General Dental Council has confirmed that improving early detection of oral cancer is to be included as a recommended topic in its continuing professional development scheme.

The hon. Gentleman will also be aware that the Department has run a series of “Be Clear on Cancer” campaigns, and we keep all forms of cancer under review to see whether they might be considered within that campaign. As he made the case that oral cancers and head and neck cancer are becoming more common, they too will be kept under review.

As I have mentioned in previous debates, the NICE improving outcomes guidance in head and neck cancer, which was published in 2004, provides advice on the organisation of health care for adults with those cancers. Head and neck cancer has also been referred to NICE as a topic for quality standard development.

The NICE guidance has informed the development of NHS England's service specification for head and neck cancer, which was published last summer. This clearly sets out what NHS England expects to be in place for providers to offer evidence-based, safe and effective services.

Of particular relevance to patients with oral cancer is the £23 million radiotherapy innovation fund, which supports the radiotherapy centres across England to deliver increased levels of intensity-modulated radiotherapy. That is a more precise form of radiotherapy, which reduces the risk of patients with oral cancers suffering from a permanent dryness of the mouth as a result of treatment.