Interview: David Khayat, Head of the Department of Medical Oncology, Pitié-Salpêtrière Hospital, France

David Khayat - Head of the Department of Medical Oncology - Pitié-Salpêtrière HospitalThe Head of the Department of Medical Oncology at the Pitié-Salpêtrière Hospital reveals how France is the only country in the world with universal and unlimited access to healthcare, how the oncology world in France is committed to changing the perception of cancer and why the only way to prevent people from smoking is through a steep increase in the cost of tobacco.

You have been active in the fight against cancer for over 30 years. How has the cancer research environment in France evolved over this period?

We can separate the past 30 years into a few distinct periods. When I started training as an oncologist, in the late 1970s, France was a leading country in the field of cancer, just behind the United States. During the 1980s we lost this leadership position and by the mid-1990s France was ranked sixth or seventh globally, behind numerous other European countries such as the UK, Germany and Italy. Looking at parameters such as the investment in research, the spending per capita on cancer research, it became clear that France was losing its leading position. At the end of the 1990s I convinced the then President of France, Jacques Chirac, of the need to reverse this trend, and return France to its position as global leader. In 2002 Jacques Chirac asked me to set up a national cancer plan, a very ambitious, well-funded plan, receiving an investment of an extra 2.8 billion euros (USD 3.16 billion), and the first of its kind in the world. The National Cancer Plan was set up with 71 measures, each with the required funding and mechanisms to evaluate their success and failures.

In France we lack the start-up mentality, setting up small innovative companies. We do not adequately reward success. This plan completely changed the cancer landscape in France, allowing us to return to a position of global leadership. The treatment of cancer in France is what it is now thanks to the actions taken between 2002 and 2007.

Tell us more about the benefits delivered by this National Cancer Plan?

There used to be 1,500 research units in France, with a total of around 4,000 to 5,000 researchers. The average independent unit had three to four researchers, rendering it impossible to compete with the Americans or the British. At the same time, France was spending three dollars per capita on cancer research per year, compared to fourteen dollars in the US. In 2004 we set up seven cancer poles in France. Instead of dealing with 1,500 units, we dealt with seven cancer poles, the smallest of which had the research capacity of a country such as the Netherlands. If a research unit wanted to continue to receive public funding, they had no alternative but to join one of the seven research units.

We also discovered that around one thousand hospitals in France, both small and big, public and private, were treating at least one case of cancer per year. We set up threshold levels, ensuring that a hospital had the required expertise and knowledge to treat a certain cancer. After I finished my work, 60 percent of hospitals were no longer allowed to treat a cancer patient. France was the first country in the world to set up a threshold for a hospital to treat each type of cancer.

You have been the Head of the Department of Medical Oncology at the Pitié-Salpetrière Hospital since 1990. What have been the key developments and milestones for the department over this period?

I think that I am the longest serving head of a medical department in France! At the time I was appointed to the position of Head of the Department of Medical Oncology, we had just six beds and four doctors. Today our hospital is famous for the treatment of cancer. 70 percent of my patients are not from France. We are an international hospital, treating patients from all over the world with the latest treatments. We have come a long way. I set up the Medical Oncology Department in 1990. Previously organ specialists were dealing with cancer. Today there is a specific oncology department, ensuring that cancer patients receive advice from an oncologist rather than an organ specialist alone.

What are the main strengths regarding the cancer environment in France?

Amongst the 40 countries of the OECD, we have the longest survival rates for cancer patients from first diagnoses. While we are less strong in prevention, with more cases of cancer in France than in the United Kingdom, once diagnosed with cancer, we are the number one place to be treated in Europe. The reason for this high survival rate is because we are the only country in the world with universal and unlimited access to healthcare. In France you can be treated at the best hospital, by the leading doctors, all free of charge.

You have said that nearly 55 percent of people in France will overcome cancer this year. What can be done to change the public perception that cancer is fatal?

It is important to remember how far we have come as a country. When I first started practicing, we would not even pronounce the word cancer to our patients. Previously cancer was killing the patient twice over; first when receiving the diagnoses, one already had an uphill battle to climb, and secondly, one also had to face the stigma attached to the disease. While the perception of cancer is beginning to change, it is a long process that will take time. The oncology world in France is committed to changing the perception of cancer. Cancer is curable and when it is not, in many cases you can still live a long life.

As one of the leading oncology departments in Europe, what importance does the Pitié-Salpêtrière Hospital attach to partnering with international colleagues in the rest of Europe, the US and beyond?

This hospital, as most of the big teaching university hospitals in France, is open to the rest of the world. We collaborate with institutions from many different countries. There is no research unit in a given country that can claim to cure cancer by itself. We will only defeat cancer by reinforcing the alliance between all stakeholders: researchers, patients, doctors, and politicians, in France and across the world.

In October 2014, you published a book titled “Prévenir le cancer, ça dépend aussi de vous! (Preventing Cancer, it also depends on you!)”. To what extent do you believe cancer can be prevented by ones actions?

Lifestyle choices can certainly prevent the development of cancer. Looking at the causes of cancer, 30 percent of cases are due to tobacco, and the only way to prevent people from smoking is through a steep increase in the cost of tobacco. We did exactly that in 2003 and 2004, for the first time ever in France. In two years the cost of a pack of cigarettes went up substantially, resulting in 180,000 less smokers. Unfortunately, since 2004, we have not seen any more substantial increases in the price of cigarettes.  The last figures that were published show that we are now back to where we were before the implementation of the National Cancer Plan, with around 45 percent of 15 to 25 year olds smoking today in France. The average in Europe is 30 percent. I don’t think plain packaging will work – as seen in Australia, the only country in the world where they have implemented such a policy. In 2014 the percentage of the population smoking increased by two percent in the country despite the measure. Again, in my opinion, only a steep increase in the price of cigarettes has an impact.

Before you were either a smoker or a non-smoker. Today, you can be a smoker, a non-smoker or you can smoke e-cigarettes. I am a big believer in e-cigarettes. The risk of cancer with such cigarettes is far lower. Dreaming of a tobacco-free world is not realistic. What we need to do is come up with cigarettes that considerably reduce the risk of cancer. One such cigarette is now coming to Europe

The second main cause of cancer is hormonal, but here there is nothing we can do about that.

The third main cause is related to nutrition, accounting for 20 percent of cancers. We can spend more money on nutrigenomics, the science of looking at the relationship between what you eat and your health conditions. Diversity in one’s diet is the key, and we should eat by following the seasons.

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