UICC World Cancer Congress 2006

Introduction

The Commonwealth of Australia is a federation of six states and two territories, each with its own government, which is elected every three to four years, with citizens aged 18 or more years being required to vote. The responsibility for health is divided between the federal (national / commonwealth) and state and territory governments, with the federal government being responsible for Medicare, the national health scheme which effectively provides all Australians with free health care in public hospitals.  About two thirds of Australians receive free primary health care through Medicare with the remainder paying a small out of pocket proportion. The federal government also provides highly subsidised pharmaceutical drugs, and free national public health programs such as cancer screening and immunisation against communicable diseases. Specialist medical and other services are also highly subsidised. The federal government is also responsible for national aged care and rehabilitation programs. The state and territory governments contribute a significant proportion of the costs of the public hospitals in their jurisdictions through an agreement with the federal government, which is negotiated at regular intervals, and they are responsible for implementing national programs funded by the federal government, such as breast cancer screening. The national government also provides incentives for its citizens to pay private health insurance, and about 40% of the population are covered. This is largely used for elective hospital services, and additional extras such as dental and optical services. Most high technology cancer care is administered in the public hospital system, however the private sector has become increasingly involved so that in Victoria about 40% of women diagnosed with breast cancer would be totally treated in the private sector.

Australia is a wealthy developed country with about 20,000,000 people, and one of the highest longevities in the world: women 82 years and men 77 years. The two major drivers of the incidence of cancer and the other chronic non-communicable diseases (NCD) are longevity and risk factor exposure. Therefore, Australia has the

world's second highest age-adjusted cancer incidence rates of cancer: one in three men and one in four women will develop cancer by the age of 75 years. In 2001, there were 88,398 new cases and over 35,000 deaths attributable to cancer¹. Non-melanoma skin cancers are excluded from this discussion, because of the very high incidence of this “non-fatal form of cancer in Australia (it is estimated that 374,000 people were treated for NMSC in 2002). The number of new cancer cases of potentially fatal cancer is increasing at about 4% per annum, and is estimated to reach 115,000 in 2011. It is estimated that more than 350,000 adults and children are now living in the Australia with a cancer diagnosis of a potentially fatal cancer. The direct health expenditure due to cancer in 2000-2001 was estimated to be $USD 2.1billion. Australia currently has one of the best cancer control systems in the world with the largest recorded fall in national adult male cigarette smoking prevalence, without substituting another tobacco product, and cervical mortality rates which are about one third of those thirty years ago. The Australian five year relative survival rates for all cancers reported for the period 1992 to 1997 were the highest in the world for women (63%), and the second highest for men (57%).

Australian National Cancer Control Plans (NCCP)

National cancer control planning began in early 1987 when the Australian Health Ministers Advisory Council (AHMAC) established the Health Targets and Implementation (Health for All) Committee, to develop health goals and targets for Australia for the year 2000 ². In 1987 in Australia cancer was the second most common cause of death, and cancer death rates were increasing. Cancer of the lung, breast, colon, prostate and melanoma were ranked as the top five cancers based incidence and years of life lost, and NMSC were recognized to be the commonest cancers. It was also recognized that lung, beast, skin and cervical cancer could be influenced by primary and/or secondary prevention strategies. The Health For All Australians report recommended specific goals and targets for reducing the level of preventable illness, disability and premature death. With respect to cancer, nine goals and 15 targets relating to lung, breast, cervical, and skin cancer were recommended. These goals, targets and strategies were those that had been proposed in that same year by the Australian Cancer Society (ACS), as part of its first National Cancer Prevention Policy for Australia ³.

There has been strong non-government organization involvement in cancer control for over half a century in Australia, with cancer councils in all states and territories and a national body established in 1971, the ACS, now the Cancer Council Australia (TCCA). The state and territory cancer councils advocate for cancer control to their respective governments, work with their governments in developing and implementing programs and criticize their governments when they judge their cancer control policies and actions are insufficient. The cancer councils have been conducting cancer prevention and early detection programs, funded by their charitable contributions, for over half a century, with the initial emphasis being on early detection, the seven early warning signs of cancer, and tobacco control. Some state cancer councils have introduced screening tests for cancer to their state, with Pap smear screening for cervical cancer being introduced in the 1960's, and mammographic screening for breast cancer in the 1980's. By contrast, the federal and state governments concentrated very much on treatment services until the 1980's, when they began to make regulations about tobacco control. In 1991 the national government, through agreement with the sate and territory governments, established the free national cervical and breast cancer screening services for women. In 2005 a comparable national service for screening for colorectal cancer in men and women aged 50 to 75 years will begin.

The state and territory cancer prevention programs have been an outstanding success, with adult male smoking prevalence falling from 70% in 1950 to less than 30% by the mid 1980's, when the governments first became active in this area. This cancer council tobacco control activity has resulted in lung cancer mortality rates peaking in men about 1985, and now falling steeply. The lung cancer mortality rate for women is now on a plateau. Today about 16% of adult Australians smoke cigarettes; 17% of men and 15% of women, and 25 years of state and territory cancer council programs of sensible sun behaviours, the exemplar of which is SunSmart Victoria, are now paying off with stable and falling skin cancer rates in those aged less than 50 years.

 In 1993 the ACS produced its second National Cancer Prevention Policy ³, which was based on a series of national expert workshops. The goals and targets presented in this report related to the prevention of skin, breast, cervix, colorectal and smoking related cancers, and were considered to be achievable by the year 2000. The third edition of this Policy was produced in 2004 ⁴.

In 1993 the Australian Health Ministers Advisory Council (AHMAC) outlined an undertaking to better both individual and population health, by improving health outcomes, and in 1994 a joint AHMAC/ National Health and Medical Research Council working group was established to select initial health focus areas for national agreement and action. The 1994 publication: Better Health Outcomes for Australians ⁵, resulted, and opportunities for improving the health of all Australians through better cancer control were identified. General goals, targets and strategies with the potential to improve cancer control were outlined and these spanned the continuum of cancer control from prevention to palliation. Priority cancers: breast, prostate, cervix, lung, colon & rectum, melanoma & NMSC, were selected on the basis of burden of illness, preventability, potential for early detection, person years of life lost, increasing incidence, and changing management practices.

In 1995 the Better Health Outcomes Overseeing Committee carried out an evaluation of the national health goals and targets process, and in 1996 the National Health Priority Areas (NHPA) initiative was launched to provide a framework for a national collaborative approach to address five identified priority areas: cardiovascular health, cancer control, injury prevention and control, mental health and diabetes mellitus These NHPA represented conditions that had substantial impact on the community, and where a collaborative and focused strategy was felt to be able to achieve substantial health gains . In the First Report on National Health Priority Areas 1996 ⁶, 26 indicators in the area of cancer control were outlined. These indicators spanned the continuum of care and included primary outcome indicators such as incidence, mortality and five-year survival rates, indicators relating to patient satisfaction with treatment and process indicators such as screening participation rates, and the use of hospital based cancer registries.

In 1997, the first NHPA cancer control report ⁷ was produced and it identified major issues relating to the priority cancers and opportunities to improve cancer control in Australia. The report also identified other opportunities for improvements in cancer control including: the role of GPs in prevention and early detection, best practice guidelines, multidisciplinary care, palliative care, psychosocial care, supportive care, the development of consumer networks, special populations, familial cancers, research and data collection. Furthermore, a concept of using a framework for fostering a national approach to cancer control was outlined, which encompassed different cancer types, stages along the continuum of care and other health system activities that may be relevant to cancer control. It was proposed that using such a framework would facilitate the identification of gaps and problems which could be dealt with, leading to further improvements in health outcomes.

 Priorities for Action in Cancer Control (PACC): 2001-2003

 Priorities for Action in Cancer Control 2001 – 2003 ⁸  was the culmination of a process that began with the establishment of Australia's first national cancer body, the National Cancer Control Initiative (NCCI) in 1996, as a contract between the national government and TCCA, with direct funding from the national government and in-kind support from TCCA and cancer councils. In 1997 the NCCI undertook an extensive national consultation with over 600 stakeholders to decide on the major priorities for cancer control in Australia: those actions which if implemented would improve cancer control in a 5-10 year timeframe. This process, which resulted in 276 initial priorities which were reduced by consultation and review of the evidence for efficacy to 21 priorities, of which13 were considered to be the most important, is shown below:

This ‘bottom-up' approach to the development of a NCCP has served Australia well, with the national government providing resources to implement all thirteen of the agreed top priority actions during the three year life span of PACC. A key element in this was undoubtedly the completion of a program budgeting marginal analysis of eight of these 13 PACC priorities; there was insufficient data to use this analysis for the remaining five. This cost effective analysis revealed, for example, that the cost per disability adjusted life year (DALY) saved ranged from less than $1000 for tobacco control, increased fruit and vegetable intake and a national Sunsmart program, to almost $14,000s for colorectal cancer screening based on faecal occult blood testing screening. These were all considered to be good buys by the national government.

Cancer control in Australia after PACC

Priorities and systems approaches to the control of chronic diseases are expected to be more effective and cost effective than tackling cancer on its own. For example, the integrated prevention of cardiovascular disease, cancer, chronic lung disease and diabetes, which share some or all of the common risk factors of tobacco use, unhealthy nutrition, physical inactivity and alcohol abuse has already begun in some countries, for example the Mag HL Tayo coalition in the Philippines and the Australian Chronic Disease Prevention Alliance. National screening programs for these chronic diseases, whether the screening test is for cervical cancer or hypertension, require conceptually similar systems. Similar systems are needed to for people diagnosed with any chronic disease, who spend at least 90% of their disease journey in the community being cared for by a primary health care provider with specialist consultation. For example, the information system requirements in treatment institutes, and for effective communication between primary and tertiary health care professionals are the same. So are the needs for evidence based clinical practice guidelines and protocols. Therefore a national chronic disease strategic approach to cancer, cardiovascular disease, chronic lung disease and diabetes makes both scientific and economic sense.

National Planning for Chronic Disease Control

The National Health Priority Action Council (NHAPAC), which is now responsible for the NHPA, has been developing a national chronic disease strategy based on National Service Improvement Frameworks (NSIF) for each of the chronic diseases in the NHPA: Cardiovascular, Chronic Lung, Arthritis, and Diabetes. This was completed at the end of 2005. The NSIF for cancer ⁹, which was the first to be developed, has served as a blueprint for these other NHPA chronic diseases.

 The development of this next Australian NCCP began in 2003, and used a systems based approach that had been suggested in 1997 in the first NHPA cancer control report. It was modelled on that which had been implemented in the United Kingdom by the National Health Service to address systematic deficiencies in cancer control.  This NSIF for cancer was developed by an expert institution using a top down iterative approach via repeated circulation of drafts, and a round of workshops for stakeholder input. Most importantly, this Australian NSIF for cancer was created by considering the expectations an Australian citizen should have of a system which aimed to control cancer. This is illustrated by the matrix below, which was used at all phases of cancer planning, and is now being used in planning for control of the other NHPA chronic diseases:

Reference List

     (1)   Australian Institute of Health and Welfare, Australasian Association of Cancer Registries. Cancer in Australia 2000. AIHW cat. no. CAN 18, i-136. 1-11-2003. Canberra, AIHW (Cancer Series no. 23).

     (2)   Health Targets and Implementation (Health for All) Committee to Australian Health Ministers. Health for all Australians.  1-169. 1988. Canberra, Department of Community Services and Health.

     (3)   MacLennan R. A national cancer prevention policy for Australia.  Volume 1. Australian Cancer Society; 1987.

     (4)   The Cancer Council Australia. National Cancer Prevention Policy 2004-06.  1-135. 2004. NSW, The Cancer Council Australia.

     (5)   Commonwealth Department of Human Services and Health. Better health outcomes for Australians. National goals, targets and strategies for better health outcomes into the next century. Canberra: Commonwealth Department of Human Services and Health; 1994.

     (6)   Australian Institute of Health and Welfare. First report on national health priority areas 1996. AIHW Cat. No. PHE 1, 1-193. 1997. Canberra, Australian Institute of Health and Welfare.

     (7)   Commonwealth Department of Health and Family Services, Australian Institute of Health and Welfare. National health priority areas report: cancer control 1997. AIHA Cat. No. PHE 4, 1-76. 1998. Canberra, Commonwealth Department of Health and Family Services and Australian Institute of Health and Welfare. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubs-cancer-index.htm/$FILE/cancer.pdf

     (8)   Cancer Strategies Group. Priorities for action in cancer control 2001-2003.  1-112. 2001. Canberra, Commonwealth Department of Health and Ageing. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pq-cancer-pubs-pacc.htm

     (9)   National Health Priority Action Council (NHPAC). National Service Improvement Framework for Cancer.  1-72. 2005. Canberra, Department of Health and Ageing.