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