Josep Maria Borràs, epidemiologist: "In Spain there is no national cancer registry because it has not been prioritized"

Humanity is facing an appalling paradox: pharmaceutical companies are putting cancer treatments on the market that are saving more and more lives, but they are so expensive – some cost more than 300,000 euros per patient – ​​that many countries cannot afford them.

Cancer causes one in three deaths in men and one in five in women, according to the latest official data in Spain.

The epidemiologist Josep Maria Borràs, born in Barcelona 63 years ago, is the scientific coordinator of the Cancer Strategy of the National Health System, the main Spanish initiative to face this enormous challenge.

The strategy itself, approved last year, warns of a surprising obstacle when it comes to acting: there is no global data.

In Spain there is no national cancer registry.

There are barely fifteen regional archives that only cover 27% of the population.

Borràs, professor at the University of Barcelona, ​​answers the questions of this newspaper after participating in the summer courses at the Menéndez Pelayo International University, in Santander.

Ask.

Why is there no national cancer registry in Spain?

Response.

The cancer registry has very clear rules, established by the International Agency for Research on Cancer, which must be met.

An increasing percentage of the information, about 80% of tumors, can be collected in an automated way, but then there have to be people who go to check if a new tumor is really a new tumor or if it is an old tumor of eight years ago.

Many times there is no computerized data for this and you have to go manually to the medical record.

Everyone knows what you have to do to have a national registry, but you have to spend money and resources and you have to prioritize it.

It hasn't been done because it's not that easy and probably because it hasn't been prioritized enough.

P.

When you say that it has not been prioritized, do you mean that Spain does not have a national cancer registry because they have not wanted to invest money?

R.

Yes, of course, it has not been prioritized in this regard.

To make a cancer registry you have to invest resources and you have to dedicate people and time.

If it hasn't been done, then it must be because it wasn't thought to be a good way to spend money, even though all oncologists agree it's important.

P.

In the last international reference study on cancer survival, Concord-3, it included some regional data from Spain, but nothing from Madrid and Barcelona, ​​for example.

There were striking differences between countries.

Lung cancer survival is 33% in Japan, 21% in the United States and 13% in Spain.

A.

The differences in survival, without knowing the stage [of the tumor at the time of diagnosis], are complicated to interpret.

They may be due to delays in diagnosis or differences in the quality of treatment.

It is better to compare yourself with the European environment.

And, in the European environment, Spain is in the average.

P.

The Concord-3 study spoke of 90% survival against breast cancer in Australia, being 85% in Spain.

What's the point?

A.

In Australia they have an early detection program that has been in place for many more years, they have a remarkable quality of treatment and they record it well.

But a difference of 4% or 5% in this context is not so relevant.

I think you have to worry when the differences exceed 5% and get closer to 10%.

P.

That already happens in stomach cancer.

Survival in Spain is 28%, compared to 69% in South Korea and 60% in Japan.

Also in colon cancer, with a survival rate of 63% in Spain and 72% in South Korea.

R.

The diagnostic aggressiveness and the expense that these countries have, we do not have in Europe.

In Japan you get confused and they do a gastroscopy, because they have a lot of stomach and esophageal cancer from drinking boiling tea.

In the United States you also get confused and they do a CAT scan [an X-ray scanner].

What they achieve is to advance the time of diagnosis a little and then there is a better survival at five years.

It would be necessary to see if it is a real gain in survival or if it is due to that advance in the diagnosis of three or four months.

These differences wouldn't bother me too much.

We must also take into account that these countries spend much more money on health than we do.

If we didn't smoke, in 13 or 14 years we would eliminate a third of cancers "

P.

The last map of mortality in Spain showed great differences even crossing some streets.

In the Raval neighborhood in Barcelona, ​​the risk of dying from lung cancer increases by 42%.

In Cabanyal, in Valencia, it rises 58%.

In the 3,000 homes in Seville it grows by 112%.

Is this just from smoking?

R.

For smoking, fundamentally.

80% of lung cancer is directly associated with tobacco, but there is also an issue of air pollution and, probably, access to treatment and diagnosis.

Q.

Is it because of worse treatment available or because they don't go to the hospital?

A.

It will probably be a combination of both.

Q.

The first map of cancer in Spain and Portugal also came out a few months ago.

The differences in lung cancer were brutal, with a large red spot of higher risk in Spain.

In breast and laryngeal tumors, a red spot shared by Spain and Portugal was seen in the southeast of the peninsula.

What accounts for these differences and similarities?

A.

We are talking about mortality data, so the reasons may be delays in diagnosis or differences in the quality of treatment.

In addition, in the mortality maps there are differences in incidence.

It is known that there are north-south gradients in many tumors and that there are territories in which the incidence is especially higher.

We do not have such precise maps because we have few cancer registries, but we do know that there is a north-south gradient in breast cancer in Spain and Europe.

This has to do with the number of children, pregnancy, lactation and other factors that we do not know well enough.

P.

20% of Spanish adults smoke, compared to just over 11% of the Portuguese.

Is it a failure of the Spanish authorities that so many people smoke at this point?

R.

I would not know what to say.

I believe that in Spain enormous steps have been taken in the control of smoking.

Are they enough?

Perhaps the population responds better in Portugal than in Spain?

I have no information or clear knowledge to say.

What is a fact is that in Portugal fewer people smoke.

P.

A pack of tobacco costs about 25 euros in Australia, compared to about five euros in Spain.

A.

The price is a huge deterrent to starting smoking, but once you are into smoking, as it is a drug addiction, the price can harm the poor more than the rich, because the part of the income they dedicate tobacco is higher.

In countries like Australia, people have to think hard about starting to smoke.

P.

Do you think that the price of tobacco in Spain should skyrocket?

Not just raise it, but shoot it.

R.

The increase in the price of tobacco is a strategy, certainly.

Regarding whether to shoot it or not, it is a subject that I do not know enough to give an informed opinion.

We have to discuss to what extent we want to continue devoting so many resources to cancer, leaving resources to other things”

Q.

Your main recommendations to avoid cancer are to stop smoking and not to start smoking.

R.

One in three cancers are directly related to tobacco.

So if we didn't smoke, in 13 or 14 years—because the impact of the benefit of quitting smoking is slow relative to cancer—we would eliminate a third of cancers.

And some of them would be among the most lethal, such as those of the lung, pancreas, kidney, bladder, head and neck.

Quitting smoking is the first thing we should do.

The second thing we need to do is participate in cancer screening programs.

And do moderate physical exercise: climb stairs and walk every day for half an hour or an hour.

And also have a balanced diet.

One of the great risks for the future is childhood obesity, because we have some of the highest levels in Europe.

When I was in primary or secondary school, I would come home, do my homework and go out to play.

Q.

Canada is considering putting a warning on every cigarette, “Smoking kills” style.

Are you in favor of that strategy?

R.

All the strategies that constantly remind people that smoking puts their health at risk seems to me not bad.

P.

Public spending on cancer treatments has doubled in five years in Spain, according to a recent report from the Ministry of Health.

Survival has not doubled in five years.

Some advanced cancer treatments, such as those called CAR-T from the pharmaceutical companies Gilead and Bristol Myers Squibb, cost more than 300,000 euros per patient.

The public version developed by the Hospital Clínic de Barcelona costs 90,000.

How can there be these differences?

A.

We would all like the pricing of these treatments to be more easily explained.

The problem is that the budget dedicated to cancer treatments grows every year much more than the global health budget.

It is an issue that we must discuss at a social level, to see to what extent we want to continue devoting so many resources to one thing, stopping devoting resources to others.

Society must be aware of the impact of the cost of cancer drugs on the health budget as a whole.

Q.

The American scientist James Allison, the father of immunotherapy, declared in EL PAÍS in May that the price of some cancer drugs is ridiculous, unrelated to what it costs to develop them.

Do you share that it is nonsense?

A.

They are words that come out well in the newspaper, but I don't think they are useful for a discussion.

It seems to me that the discussion should be based on the data and how we think the value of a drug should be evaluated in the treatment of cancer.

The European Society of Medical Oncology and the American Society of Clinical Oncology have developed scales to assess the value and only 30% of approved drugs have a high value.

We need to discuss whether or not it's worth it, but we need to discuss it with data.

About 40% of approved cancer drugs in the EU add value, the rest do not”

P.

More than half of the new drugs that are approved in Germany do not provide relevant therapeutic improvements, according to an official analysis published three years ago.

R.

These are data that are consistent with the application of the scale of the European Society of Medical Oncology to new drugs approved by the European Medicines Agency in recent years.

Around 40% of drugs add value, the rest do not add enough value, according to this scale agreed by professionals.

These are numbers to ponder.

Q.

Do more than 50% of the new drugs approved against cancer not add value to the existing ones?

R.

According to this scale of the European Society of Medical Oncology.

And their price is indifferent to the value they provide.

We pay the same for the drugs that contribute as for the drugs that do not contribute as much.

P.

The oncologist Miguel Martín, former president of the Spanish Society of Medical Oncology, said in this newspaper four years ago that the national health system is "aberrant", because it is like managing 17 countries: the 17 autonomous communities.

Martín criticized “grotesque” situations, in which a drug was approved in one community and not in another.

Do you think it's aberrational?

R.

No, I am not at all in agreement with this type of expression.

It seems to me that clinical practice does not vary in Spain by 17, but rather by 60 or 70. There is more variability within an autonomous community —between rural and metropolitan areas— than between two autonomous communities, in many cases.

The decision to decentralize health was approved and it is the health system that we have.

And it is, by the way, quite similar to that of other countries.

What matters is whether, under equal circumstances, the patient's survival is the same or not.

And in this country we have a great deficit in measuring this.

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