Can­cer suc­cess one to boast about

Euro­pean doc­tors hope to learn how Aus­tralia’s health sys­tem gets such good re­sults in treat­ing can­cer. Bianca No­grady re­ports

The Weekend Australian - Travel - - Health -

ONE in two Aus­tralian men and one in three Aus­tralian women will be di­ag­nosed with can­cer by age 85. If they hap­pen to be liv­ing in Den­mark at the time, around half of them could ex­pect to still be alive and kick­ing within five years. Luck­ily though, they’re in Aus­tralia, which means nearly two-thirds can ex­pect to sur­vive for five years af­ter di­ag­no­sis, which for many is as good as a to­tal cure.

The dif­fer­ence be­tween one-half and twothirds might not sound like much, but with an es­ti­mated 106,000 new cases of can­cer di­ag­nosed in Aus­tralia each year, the num­bers soon add up and paint an im­pres­sive pic­ture of can­cer sur­vival Down Un­der.

Dan­ish clin­i­cal on­col­o­gist Frede Don­skov is cer­tainly im­pressed. Don­skov first ex­pe­ri­enced the Aus­tralian health sys­tem in ac­tion when he spent a year with the med­i­cal on­col­ogy de­part­ment of Syd­ney’s West­mead Hospi­tal in 2006/07. The visit had such an ef­fect on him that he re­cently re­turned to Aus­tralia, this time with a del­e­ga­tion of Dan­ish pol­icy mak­ers, to lis­ten and learn from the Aus­tralian ex­am­ple.

‘‘ The five-year sur­vival rates for can­cer in NSW are as good as any­where in the world,’’ says Don­skov, staff spe­cial­ist in clin­i­cal on­col­ogy at Aarhus Univer­sity Hospi­tal in Den­mark. ‘‘ It’s ac­tu­ally 63 per cent — it means, in other words, that two-thirds of all can­cer pa­tients are po­ten­tially cured, and that’s im­pres­sive.’’

Pro­fes­sor Jim Bishop, de­spite be­ing CEO of the Can­cer In­sti­tute NSW, be­lieves the credit for this can be shared around the na­tion. ‘‘ I guess the first thing to say is re­sults in NSW are some­what sim­i­lar around the coun­try, so I think it’s a na­tional story as well.’’

Over­all, more than 60 per cent of Aus­tralian can­cer pa­tients can ex­pect to sur­vive for at least five years, al­though there is some vari­a­tion at the state level. Ac­cord­ing to 2005 data from the Can­cer In­sti­tute NSW, the sur­vival rate in NSW for all can­cers is 60 per cent in men, and 66 per cent in women. In Vic­to­ria the rates are 58 per cent and 64 per cent re­spec­tively.

In con­trast, Den­mark lan­guishes far down the list, with sur­vival rates of just 45 per cent in men and 56 per cent in women.

Not sur­pris­ingly, the NSW state Gov­ern­ment is happy to blow its health trum­pet. ‘‘ There are very few places in the world where a per­son’s chances of beat­ing can­cer are as high as they are here in NSW,’’ says NSW Health Min­is­ter Reba Meagher. ‘‘ In 10 years, death rates from can­cer have fallen by 16 per cent in men and 10 per cent in women.’’

How­ever, Aus­tralia can ill af­ford to rest on its lau­rels, says doc­tor Andrew Pen­man, CEO of the Can­cer Coun­cil NSW.

‘‘ It’s very dan­ger­ous to say we’re do­ing as well as any­one else, be­cause the proper bench­mark is how well can we do — and there’s a lot of ev­i­dence we can do bet­ter,’’ Pen­man says. ‘‘ Be­cause in some ar­eas there’s strong ev­i­dence for sav­ing lives, and we don’t do it.’’

One of th­ese ar­eas is bowel can­cer screen­ing. ‘‘ We have, on pa­per, a na­tional ini­tia­tive on bowel can­cer screen­ing, but its reach into the pop­u­la­tion is mi­nus­cule,’’ Pen­man says. The pre­lim­i­nary stage of a na­tional bowel can­cer screen­ing pro­gram was rolled out in 2006. The fed­eral Gov­ern­ment has since com­mit­ted $87 mil­lion to screen all Aus­tralians aged 50, 55 and 65, with a full roll­out fore­cast for 2012.

And while some can­cers are man­aged well in Aus­tralia, in par­tic­u­lar melanoma, prostate and thy­roid, oth­ers are ne­glected.

‘‘ We’ve done very well . . . in some of the pop­u­lar can­cers such as breast and cer­vi­cal, but there are also some un­pop­u­lar can­cers where we re­ally haven’t made much dif­fer­ence,’’ Pen­man says.

Th­ese less ‘‘ pop­u­lar’’ can­cers in­clude pan­cre­atic, oe­sophageal and blad­der can­cer.

But gen­er­ally, the in­ci­dence of can­cer in Aus­tralia is greater than in other de­vel­oped na­tions such as the UK and Canada, yet our mor­tal­ity rates are lower. Aus­tralian mor­tal­ity rates also com­pare favourably to the United States and New Zealand, which have higher can­cer in­ci­dence.

So what is the Aus­tralian health sys­tem do­ing that is so dif­fer­ent to other coun­tries, and leads to such im­proved out­comes?

Top of Don­skov’s list of virtues is ‘‘ a very strong fo­cus on pre­ven­tion and early de­tec­tion’’. Deaths from breast and cer­vi­cal can­cer in Aus­tralia have been in steady de­cline since na­tional screen­ing pro­grams were in­tro­duced around 17 years ago, and Bishop says our suc­cess in pre­ven­tion is par­tic­u­larly ev­i­dent in anti-smok­ing ef­forts.

As of 2006 in Aus­tralia, 18.6 per cent of men and 16.3 per cent of women smoked daily. ‘‘ In Den­mark, the daily rate is around 26 per cent, so all the nasty smok­ing-re­lated can­cers are still in full flight in Den­mark and that’s ac­tu­ally drag­ging a lot of their rates down,’’ Bishop says.

An­other as­pect of can­cer man­age­ment that Don­skov praises is what he calls the ‘‘ lean pro­duc­tion process’’ — smaller can­cer units op­er­at­ing in­de­pen­dently as op­posed to larger, cen­tralised treat­ment cen­tres. This move away from cen­tralised in­sti­tu­tions hap­pened in the early 1990s, ac­cord­ing to Pen­man, and it led to sig­nif­i­cant im­prove­ments in can­cer care out­side metropoli­tan ar­eas.

‘‘ I think that there has been quite a lot of ben­e­fit flow­ing from plac­ing can­cer care cen­tres closer to the pop­u­la­tions,’’ says Pen­man. Smaller units are more ac­ces­si­ble, and while the pre­vail­ing view be­fore the shift was that larger de­part­ments were needed to sup­port treat­ments such as ra­dio­ther­apy, his­tory has shown oth­er­wise.

There are now multi-dis­ci­plinary can­cer care units, of­fer­ing treat­ments in­clud­ing ra­dio­ther­apy in re­gional cen­tres such as Wol­lon­gong and Coffs Har­bour.

Ac­cord­ing to Meagher, pa­tient ac­cess to ra­dio­ther­apy in NSW has in­creased by 34 per cent over the past 10 years.

But Pen­man would like to see this in­crease fur­ther, and faster. ‘‘ We’ve not been able to ex­pand ra­dio­ther­apy’s to­tal ca­pac­ity fast enough to beat the num­ber of peo­ple we should be treat­ing,’’ he says. In NSW, around 36 per cent of all peo­ple di­ag­nosed with can­cer are treated with ra­dio­ther­apy, yet the ac­knowl­edged bench­mark de­mands a fig­ure closer to 52 per cent.

‘‘ I’d be hap­pier if it’s 36 per cent and the trend is pos­i­tive,’’ Pen­man says.

John Dwyer agrees that ac­cess to ra­dio­ther­apy still leaves a lot to be de­sired. ‘‘ We’ve got prob­lems of in­equity for rural pa­tients,’’ says Dwyer, emer­i­tus pro­fes­sor at the Univer­sity of NSW. ‘‘ To me the big­gest chal­lenge is to ex­tend the bet­ter care to rural and re­mote NSW, and rural and re­mote Aus­tralia.’’

While an on­col­ogy cen­tre in ev­ery rural town is im­prac­ti­cal, Dwyer would like to see bet­ter net­work­ing of can­cer ser­vices out to the bush — for ex­am­ple, hav­ing spe­cial­ists and nurses visit rural cen­tres on a reg­u­lar ba­sis to save some pa­tients hav­ing to travel to metropoli­tan cen­tres.

But there’s cer­tainly noth­ing wrong with net­work­ing be­tween spe­cial­ists and spe­cialised can­cer units. ‘‘ Pre­vi­ously a can­cer unit was an is­land in an ocean of health care, but didn’t in­ter­act very much with other peo­ple in­ter­ested in the same spe­cial­ity,’’ Dwyer says. The cre­ation of the Can­cer In­sti­tute NSW changed that for the bet­ter.

‘‘ One of the bet­ter things the Gov­ern­ment has done is to fund the Can­cer In­sti­tute NSW, which has worked hard with all the on­col­o­gists to net­work their ser­vices and to fos­ter the rep­u­ta­tion of in­di­vid­ual hos­pi­tals for the can­cers they have real ex­per­tise in,’’ he says. One ex­am­ple is the melanoma unit at Syd­ney’s Royal Prince Al­fred hospi­tal, which achieves ‘‘ world-class’’ out­comes in melanoma treat­ment be­cause of its sin­gu­lar fo­cus.

Don­skov agrees that the In­sti­tute is a unique and suc­cess­ful en­deav­our. ‘‘ I think the Can­cer In­sti­tute NSW is one of the in­stru­ments we would like to cut and paste — the en­tire idea.’’

And while wait­ing times might cause headaches in some ar­eas of health, Don­skov is im­pressed with the speed with which the state’s can­cer pa­tients are at­tended to. ‘‘ I think the best thing is to say that here in NSW, can­cer care is or­gan­ised with ur­gent man­age­ment and that’s prob­a­bly the main se­cret be­hind the good re­sults,’’ Don­skov says.

Time to breast or head and neck surgery is around nine days ac­cord­ing to Bishop, while an ur­gent case can ex­pect to see a med­i­cal on­col­o­gist in ap­prox­i­mately two days. In con­trast, Dan­ish pa­tients may wait weeks, even months, he says.

Once a pa­tient is re­ferred to an on­col­o­gist, that doc­tor takes re­spon­si­bil­ity for that pa­tient. It might seem like a no-brainer, but in fact it’s some­thing that Aus­tralia does well, and Den­mark doesn’t, Bishop says.

‘‘ What I said to him, and I think he agreed with, was that re­ally doc­tors here take in­di­vid­ual re­spon­si­bil­ity for their case and so we feel there’s a higher level of pro­fes­sional en­gage­ment of doc­tor and pa­tient.’’ It means one per­son is re­spon­si­ble for the pa­tient, rather than them sim­ply be­ing at­tached to a clinic or an out­pa­tient unit. ‘‘ It’s some­thing that pa­tients re­ally ap­pre­ci­ate,’’ Bishop says.

How­ever, all the ex­perts be­lieve there is room for im­prove­ment and even amid his praise, Don­skov says there is still much to be ac­com­plished. ‘‘ Of course things can be done bet­ter — but your foun­da­tion is good.’’

Pic­ture: James Croucher

Fact-find­ing: Doc­tor Frede Don­skov, left, talks can­cer with West­mead Hospi­tal’s pro­fes­sor Paul Harnett

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