Access to Cancer Treatment in Non-Metropolitan Areas of Australia

Access to cancer treatment in non-metropolitan areas of Australia

Amgen Australia Pty Ltd

September 2011

Access to cancer treatment in Australia

Contents

Glossary ...... i Executive Summary ...... i 1 An overview of cancer ...... 8 1.1 What is cancer? ...... 8 1.2 Prostate and breast cancer ...... 9 2 A literature review on access to cancer treatment ...... 13 2.1 Variations in cancer epidemiology ...... 13 2.2 Access to cancer treatment ...... 17 2.3 Improving access to cancer treatment ...... 19 3 Mapping access to cancer treatment ...... 21 3.1 Incidence of breast and prostate cancer ...... 21 3.2 Hospitals that deliver cancer treatment ...... 25 3.3 Average distance to cancer treatment ...... 44 4 Focusing on specific FEDs...... 50 4.1 Choosing FEDs ...... 50 4.2 Postcodes with the greatest distance to cancer treatment ...... 53 4.3 Potential improvements in providing cancer treatment ...... 56 References ...... 63 Appendix A – Estimated number of new cancer cases ...... 67 Appendix B - Hospitals offering cancer treatment ...... 69 Appendix C – Distance versus population among postcodes ...... 78 Limitation of our work...... 81 Charts

Chart 1.1 : Incidence and mortality rates for breast cancer in females ...... 10 Chart 1.2 : Incidence and mortality rates for prostate cancer ...... 10 Chart 2.1 : Proportion of resident population by remoteness areas ...... 16 Chart 2.2 : Proportion of cancer patients who receive treatment, by type ...... 16 Tables

Table 1.1 : Estimated leading causes of the cancer burden of disease ...... 9 Table 1.2 : Hospitalisations with a principal diagnosis of cancer, 2008-09 ...... 11 Table 2.1 : Incidence and mortality of prostate and breast cancer, by remoteness 2003-07 .... 14

Table 3.1 : Estimated breast and prostate cancer incidence rates, by state/territory ...... 21 Table 3.2 : Estimated breast and prostate cancer incidence rates, by age and gender, 2011 .. 22 Table 3.3 : Estimated number of new cases of breast and prostate cancer, 2011 ...... 23 Table 3.4 : Estimated average distance to cancer-related infusion services, by state/territory 45 Table 3.5 : Estimated average distance to radiotherapy services, by state/territory ...... 45 Table 3.6 : Estimated average distance to cancer-related infusion services, by FED ...... 46 Table 3.6 : Estimated average distance to cancer-related infusion services, by FED continued 47 Table 3.7 : Estimated average distance to radiotherapy services, by FED ...... 47 Table 3.7 : Estimated average distance to radiotherapy services, by FED continued ...... 48 Table 4.1 : Average distance to cancer treatment and estimated number of new cancer cases for selected FEDs ...... 52 Table 4.2 : The five furthest postcodes to cancer-related infusion services, by selected FEDs . 54 Table 4.3 : The five furthest postcodes to cancer-related infusion services, by selected FED continued ...... 55 Table 4.4 : Distance to nearest GP versus distance to nearest cancer-related infusion service 58 Table A.1 : Estimated number of new breast and prostate cancer cases by FEDs, 2011 ...... 67 Table B.1 : Planned cancer treatment sites by state/territory...... 69 Table B.2 : Hospitals offering cancer-related infusion services in Australia ...... 69 Table B.3 : Hospitals offering radiotherapy services in Australia ...... 77 Table C.1 : Distance to nearest cancer-related infusion service versus population of postcode78 Figures

Figure 3.1 : Estimated number of new cases of breast and prostate cancer by FEDs, 2011 ..... 24 Figure 3.2 : Location of radiotherapy and cancer-related infusion services across Australia ... 28 Figure 3.3 : Incidence of breast and prostate cancer compared to location of cancer treatment in Australia, 2011 ...... 30 Figure 3.4 : Incidence of breast and prostate cancer compared to location of cancer treatment in ACT, 2011 ...... 31 Figure 3.5 : Incidence of breast and prostate cancer compared to location of cancer treatment in NSW, 2011 ...... 32 Figure 3.6 : Incidence of breast and prostate cancer compared to location of cancer treatment in Sydney, 2011 ...... 33 Figure 3.7 : Incidence of breast and prostate cancer compared to location of cancer treatment in Northern Territory, 2011 ...... 34 Figure 3.8 : Incidence of breast and prostate cancer compared to location of cancer treatment in Queensland, 2011 ...... 35

Deloitte Access Economics

Figure 3.9 : Incidence of breast and prostate cancer compared to location of cancer treatment in Brisbane, 2011 ...... 36 Figure 3.10 : Incidence of breast and prostate cancer compared to location of cancer treatment in South Australia, 2011 ...... 37 Figure 3.11 : Incidence of breast and prostate cancer compared to location of cancer treatment in Adelaide, 2011 ...... 38 Figure 3.12 : Incidence of breast and prostate cancer compared to location of cancer treatment in Tasmania, 2011 ...... 39 Figure 3.13 : Incidence of breast and prostate cancer compared to location of cancer treatment in Victoria, 2011 ...... 40 Figure 3.14 : Incidence of breast and prostate cancer compared to location of cancer treatment in Melbourne, 2011 ...... 41 Figure 3.15 : Incidence of breast and prostate cancer compared to location of cancer treatment in Western Australia, 2011 ...... 42 Figure 3.16 : Incidence of breast and prostate cancer compared to location of cancer treatment in Perth, 2011 ...... 43 Figure 4.1 : Map of selected FEDs ...... 51

Deloitte Access Economics Access to cancer treatment in Australia

Glossary

ABS Australian Bureau of Statistics AEC Australian Electoral Commission AIHW Australian Institute of Health and Welfare BCCA British Columbia Cancer Agency CanNET Cancer Service Networks CON Communities Oncology Network COSA Clinical Oncological Society of Australia DoHA Department of Health and Ageing FED federal electoral division GP general practitioner NBOCC National Breast and Ovarian Cancer Centre PATS Patient access and travel scheme PBS pharmaceutical benefits scheme PSA prostate specific antigen RCCE Regional Cancer centre of Excellence RICS Rural/Regional Integrated Cancer Services SLA statistical local area SMU single machine unit

Executive Summary

Cancer imposes a substantial burden on Australian society, from a financial and personal perspective. Around 50% of males and 33% of females will develop cancer within their lifetime, and 20% will die from cancer before they turn 85 years of age (AIHW 2010). Cancer is the second leading cause of mortality in Australia (behind cardiovascular disease), accounting for 39,884 deaths in 2007 (AIHW 2010).

Of all cancers, prostate and breast cancer are some of the most burdensome, imposing years of poor health and reducing total years of life. Prostate cancer is the second leading cause of cancer disease burden among males (behind lung cancer), and breast cancer is the leading cause of cancer disease burden among females. In 2007, there were 19,403 new cases of prostate cancer and 12,567 new cases of breast cancer (AIHW 2010). Prostate and breast cancer combined is the second leading cause of death, accounting for 2,938 and 2,680 deaths respectively in 2007 (AIHW 2010).

Deloitte Access Economics was commissioned by Amgen Australia Pty Ltd to evaluate the literature surrounding cancer treatment and cancer outcomes in non-metropolitan Australia, and to quantify access to cancer-related treatments. Access was defined as the distance to the nearest cancer-related treatment, including the nearest infusion service for the intravenous delivery of cancer-related treatment (i.e., chemotherapy) and radiotherapy service.

This study has found large disparities in cancer outcomes between people living in metropolitan versus non-metropolitan regions. Incidence rates and mortality rates for prostate cancer are higher in non-metropolitan regions, along with breast cancer mortality rates. Heathcote and Armstrong (2007) note possible reasons for the disparity in cancer survival, including: • more difficult access to cancer treatment due to poor transport links and shortage of healthcare providers in non-metropolitan regions; • higher proportion of Indigenous Australians in non-metropolitan regions who are generally more economically disadvantaged than other populations; and • a higher proportion of people from lower socioeconomic backgrounds living in non- metropolitan regions, leading to: • differences in cancer knowledge and health behaviours; • later tumour stage at diagnosis; • issues with affordability of care; and • reduced ability to access the full spectrum of cancer detection and care.

Government recognises a need to improve access to cancer treatment within non- metropolitan regions (Adams et al 2009). Poorer access to cancer treatment is a major contributor to lower survival rates among people living in non-metropolitan regions. There are two primary reasons for a lack of access, including: • a shortage of specialist treatment facilities and health care providers; and • a lower quality of treatment and care in non-metropolitan regions.

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Contributing to poor access is the long distance people living in non-metropolitan often travel to receive cancer treatment. Hegney et al (2005) examined the experiences of people with cancer who commuted from Toowoomba to Brisbane for radiotherapy treatment. The authors concluded patients experienced many difficulties, including a large travel burden, difficulties with being away from home, family and friends, and an excessive financial burden caused by relocation or travel costs.

To highlight the travel burden some people face in accessing cancer treatment, this study calculated the distance from the midpoint of every Statistical Local Area (SLA) 1 to the nearest infusion service and radiotherapy service in Australia.2 Each SLA covers a smaller geographical area compared to a Federal Electorate Division (FED) 3 and hence enabled greater accuracy in calculating distance. Distance from individual SLAs within a FED (using a best fit method) to the nearest facility was used to derive an average distance for each FED. Results are summarised in Table i to Table iv.

Table i: Estimated average distance to cancer-related infusion services, by state/territory Average Maximum Minimum All Metro Non- All Metro Non- All Metro Non- metro metro metro km km km km km km km km km ACT 6.7 6.7 N/A 7.4 7.4 N/A 5.9 5.9 N/A NSW 12.2 4.9 20.9 44.1 15.7 44.1 0.9 0.9 4.2 NT 147.3 7.8 286.7 286.7 7.8 286.7 7.8 7.8 286.7 Qld 23.6 7.8 35.6 120.5 20.3 120.5 2.2 2.2 5.3 SA 13.7 4.2 30.3 69.0 7.2 69.0 2.4 2.4 14.1 Tas 16.1 11.7 19.1 25.9 21.1 25.9 2.3 2.3 11.9 Vic 8.6 5.0 16.3 22.6 15.3 22.6 1.1 1.1 8.0 WA 25.7 11.5 82.4 137.4 30.0 137.4 2.5 2.5 20.0 National 17.1 6.5 31.8 286.7 30.0 286.7 0.9 0.9 4.2 Source: Deloitte Access Economics calculations. Table ii: Estimated average distance to radiotherapy services, by state/territory Average Maximum Minimum All Metro Non- All Metro Non- All Metro Non- metro metro metro km km km km km km km km km ACT 10.5 10.5 N/A 13.8 13.8 N/A 7.1 7.1 N/A NSW 34.1 6.8 66.3 245.8 20.6 245.8 0.9 0.9 4.2 NT 402.0 7.8 796.2 796.2 7.8 796.2 7.8 7.8 796.2 Qld 100.6 11.7 168.6 845.9 26.2 845.9 2.5 2.5 6.0

Continued next page.

1 SLAs are statistical boundaries set by the Australian Bureau of Statistics (ABS) and comprises of a number of Census Collection Districts (CCDs). 2 Using Pitney Bowes Map Info Professional software. 3 FED boundaries are determined by a Redistribution Committee to ensure each FED contains the same number of electors, and may contain a number of SLAs.

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SA 57.3 7.5 144.5 332.5 15.5 332.5 3.9 3.9 28.2 Tas 52.9 20.0 74.9 129.5 35.5 129.5 4.4 4.4 44.3 Vic 26.8 8.7 64.6 194.0 29.9 194.0 1.2 1.2 9.4 WA 83.5 20.6 335.4 472.8 70.7 472.8 2.8 2.8 170.9 National 58.9 11.7 124.3 845.5 100.1 845.9 0.9 0.9 4.2 Source: Deloitte Access Economics calculations.

Table iii: Estimated average distance to cancer-related infusion services, by FED

Metropolitan Non-metropolitan FED km FED km FED km FED km Australian Capital Territory Canberra 5.9 Fraser 7.4 New South Wales Banks 4.3 Lindsay 3.2 Calare 22.8 Newcastle 4.2 Barton 0.9 Macarthur 12.3 Charlton 12.2 Page 20.6 Bennelong 3.3 Mackellar 9.7 Cowper 44.1 Parkes 39.2 Berowra 15.7 McMahon 5.7 Cunningham 6.4 Paterson 38.6 Blaxland 4.6 Mitchell 2.5 Dobell 6.8 Richmond 21.1 North Eden- Bradfield 3.5 2.2 11.6 Riverina 27.4 Sydney Monaro Chifley 8.7 Parramatta 2.5 Farrer 39.3 Robertson 7.9 Cook 4.5 Reid 3.6 Gilmore 17.8 Shortland 4.6 Fowler 4.0 Sydney 1.5 Hume 19.0 Throsby 20.0 Grayndler 3.7 Warringah 2.3 Hunter 23.2 Greenway 1.2 Watson 2.4 Lyne 16.8 Hughes 6.2 Wentworth 4.9 Macquarie 32.6 Kingsford 4.8 Werriwa 10.1 New England 22.7 Smith Northern Territory Solomon 7.8 Lingiari 286.7 Queensland Bonner 9.7 Oxley 6.3 Blair 19.9 Kennedy 95.1 Bowman 20.3 Petrie 5.2 Capricornia 54.8 Leichhardt 120.5 Brisbane 2.2 Rankin 8.0 Dawson 37.3 Longman 11.4 Dickson 8.0 Ryan 5.9 Fairfax 5.3 Maranoa 114.1 Fadden 8.2 Fisher 13.9 McPherson 6.6 Forde 17.7 Flynn 38.8 Moncrieff 6.5 Griffith 2.4 Groom 15.9 Wide Bay 18.1 Lilley 4.2 Herbert 6.0 Wright 24.9 Moreton 2.8 Hinkler 16.6 South Australia Adelaide 2.4 Makin 4.3 Barker 23.5 Port Boothby 3.5 5.5 Grey 69.0 Adelaide Hindmarsh 2.4 Sturt 4.1 Mayo 14.6 Kingston 7.2 Wakefield 14.1 Tasmania Denison 2.3 Bass 11.9 Lyons 25.9 Franklin 21.1 Braddon 19.4 Continued next page.

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Table iii: Estimated average distance to cancer-related infusion services, by FED continued

Metropolitan Non-metropolitan FED km FED km FED km FED km Victoria Aston 4.8 Hotham 2.0 Ballarat 12.8 Batman 3.6 Isaacs 6.9 Bendigo 8.0 Bruce 5.4 Jagajaga 5.8 Corangamite 14.9 Calwell 5.8 Kooyong 2.5 Corio 9.4 Casey 15.3 Lalor 7.2 Flinders 15.4 Chisholm 1.3 La Trobe 4.9 Gippsland 22.6 Deakin 1.9 Maribyrnong 5.3 Indi 18.1 Dunkley 3.8 Melbourne 1.1 Mallee 21.6 Melbourne Gellibrand 5.3 2.3 McEwen 15.2 Ports Goldstein 2.2 Menzies 6.2 McMillan 22.6 Gorton 12.9 Scullin 4.6 Murray 17.9 Higgins 2.6 Wills 1.8 Wannon 17.1 Holt 8.3 Western Australia Brand 25.8 Moore 3.7 Durack 137.4 Canning 30.0 Pearce 25.6 Forrest 20.0 Cowan 10.1 Perth 3.6 O'Connor 89.9 Curtin 2.5 Stirling 7.5 Fremantle 3.1 Swan 5.8 Hasluck 15.7 Tangney 5.1 Source: Deloitte Access Economics.

Table iv: Estimated average distance to radiotherapy services, by FED

Metropolitan Non-metropolitan FED km FED km FED km FED km Australian Capital Territory Canberra 7.1 Fraser 13.8 New South Wales Banks 4.3 Lindsay 3.3 Calare 62.5 Newcastle 4.2 Barton 0.9 Macarthur 12.3 Charlton 20.3 Page 32.0 Bennelong 3.3 Mackellar 14.2 Cowper 63.1 Parkes 245.8 Berowra 20.6 McMahon 5.7 Cunningham 11.8 Paterson 45.7 Blaxland 7.8 Mitchell 8.5 Dobell 19.2 Richmond 23.1 North Eden- Bradfield 3.5 2.9 94.8 Riverina 102.9 Sydney Monaro Chifley 14.0 Parramatta 5.0 Farrer 200.5 Robertson 13.8 Cook 4.5 Reid 7.7 Gilmore 58.7 Shortland 14.2 Continued next page .

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Table iv: Estimated average distance to radiotherapy services, by FED continued

Metropolitan Non-metropolitan FED km FED km FED km FED km Fowler 4.0 Sydney 1.5 Hume 88.1 Throsby 34.5 Grayndler 3.7 Warringah 6.7 Hunter 97.7 Greenway 5.1 Watson 8.4 Lyne 55.1 Hughes 10.0 Wentworth 4.9 Macquarie 36.5 Northern Territory Solomon 7.8 Lingiari 796.2 Queensland Bonner 12.2 Oxley 12.1 Blair 39.3 Kennedy 413.2 Bowman 23.6 Petrie 13.5 Capricornia 365.9 Leichhardt 845.9 Brisbane 2.5 Rankin 17.4 Dawson 134.7 Longman 34.9 Dickson 12.6 Ryan 7.0 Fairfax 6.0 Maranoa 347.7 Fadden 9.5 Fisher 16.5 McPherson 6.9 Forde 26.2 Flynn 329.4 Moncrieff 6.5 Griffith 2.9 Groom 18.8 Wide Bay 79.5 Lilley 4.6 Herbert 7.9 Wright 30.8 Moreton 7.7 Hinkler 181.4 South Australia Adelaide 3.9 Makin 4.3 Barker 172.9 Port Boothby 4.3 5.5 Grey 332.5 Adelaide Hindmarsh 4.0 Sturt 4.1 Mayo 44.2 Kingston 15.5 Wakefield 28.2 Tasmania Denison 4.4 Bass 44.3 Lyons 51.0 Franklin 35.5 Braddon 129.5 Victoria Aston 9.3 Hotham 3.6 Ballarat 21.5 Batman 4.9 Isaacs 14.5 Bendigo 20.0 Bruce 10.6 Jagajaga 5.8 Corangamite 41.2 Calwell 8.2 Kooyong 3.0 Corio 9.4 Casey 29.9 Lalor 21.6 Flinders 32.7 Chisholm 4.9 La Trobe 14.6 Gippsland 77.9 Deakin 4.2 Maribyrnong 5.6 Indi 72.4 Dunkley 6.9 Melbourne 1.2 Mallee 194.0 5.3 Melbourne 3.6 31.8 Gellibrand Ports McEwen Goldstein 5.6 Menzies 6.2 McMillan 56.5 Gorton 13.3 Scullin 7.3 Murray 84.8 Higgins 3.2 Wills 8.4 Wannon 132.6 Holt 16.8 Western Australia Brand 32.4 Moore 17.6 Durack 472.8 Canning 70.7 Pearce 59.6 Forrest 170.9 Cowan 13.2 Perth 3.7 O'Connor 362.6 Curtin 2.8 Stirling 5.6 Fremantle 8.2 Swan 5.8 Hasluck 18.3 Tangney 9.0 Source: Deloitte Access Economics.

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Results highlight some key themes regarding access to cancer treatment throughout Australia. • There are large variations in average distances across FEDs. For example, the FED with the least average distance required to access infusion services is Barton in NSW, with 0.9 kilometres. The FED with the largest average distance is Lingiari in the Northern Territory, with 286.8 kilometres. • Average distances to cancer-related infusion services and radiotherapy services are larger in non-metropolitan FEDs. For example, for cancer-related infusion services, the average distance among metropolitan FEDs in Western Australia is 6.5 kilometres, while the average distance among its non-metropolitan FEDs is 31.8 kilometres. For radiotherapy services in Western Australia, the average distance among metropolitan FEDs is 20.6 kilometres, while the average distance among its non-metropolitan FEDs is 335.4 kilometres. This suggests that access to cancer care for people living in non- metropolitan regions is less compared to people living in metropolitan regions. • The average distance to cancer-related infusion services is much less compared to the average distance to radiotherapy services, with disparities greater for non-metropolitan regions. This is because radiotherapy services are primarily located in capital cities or large regional cities. • The average distance to cancer-related infusion services and radiotherapy services is generally larger for states/territories with a larger geographical area (e.g., Northern Territory, Western Australia and Queensland).

A detailed evaluation of 20 FEDs was also undertaken, where the five post codes with least access to cancer-related infusion services (as measured by the furthest distance) in each FED was determined.

Some FEDs have relatively good access to cancer-related infusion services. For example, all postcodes within Newcastle in New South Wales are less than 12 kilometres away from infusion services. Other FEDs are more remote, which means people are a long distance away from cancer-related infusion services. For example, postcode 6799 in Lingiari (Northern Territory) is 2,128.8 kilometres away from the nearest cancer-related infusion service.

Given the disparity in cancer outcomes between metropolitan and non-metropolitan regions, it is imperative that federal and state/territory governments continue to improve access to cancer treatment services in non-metropolitan regions.

To date, focus has been on developing better coordination of existing cancer treatment services, with services being delivered in large specialist centres but linked to smaller centres. The federal government has invested in Cancer Service Networks (CanNET) to improve coordination of existing cancer services across primary, secondary and tertiary health care professionals (Adams et al 2009). State/territory governments are also implementing their own programs. For example, Victoria has established the Rural/Regional Integrated Cancer Services (RICS) to bring radiation oncology closer to people living in non-metropolitan areas.

Access improvements could potentially be made through the delivery of a wider range of cancer-related treatment by primary care physicians. To test whether access to treatment would be improved if offered in a primary rather than secondary care setting, the five

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furthest postcodes from infusion services for each of the 20 selected FEDs were investigated to determine whether that postcode contained a GP. If the postcode did not, the distance that must be travelled to the nearest GP was estimated and compared to the current distance required to receive an infusion.

Of the 100 postcodes that are furthest away from infusion services, 62 postcodes contain a GP. If cancer-related treatment could be appropriately delivered through these GPs, on average, cancer patients would save 101.2 kilometres on travel for care. However, people in some postcodes would experience a much greater reduction in travel distance. For example, postcode 6799 (Cocos (Keeling) Islands) in Lingiari (in the Northern Territory) contains at least one GP, which means any cancer patients living within this postcode could reduce their travel to receive cancer-related treatment by 2,128.8 kilometres.

Of the 38 postcodes that do not contain a GP, there is generally a GP close by. If cancer- related treatment could be appropriately delivered through these GPs, on average cancer patients would save travelling 55.6 kilometres for care. Once again, cancer patients in some postcodes would benefit from using GPs more than others. For example, people in postcode 4871 in Leichhardt in Queensland are expected to reduce their distance by 309.2 kilometres if they received cancer-related treatment from their nearest GP rather than current infusion service arrangements, which are currently located in Cairns.

Although most postcodes with the greatest expected benefit from reduced travel distances are not heavily populated, there are some notable exceptions. For example, postcode 4871 in Leichhardt (Queensland) had a population of 16,344 in the 2006 ABS Census. Similarly, postcode 4306 in Blair (Queensland) had a population of 29,059, and the expected reduction in distance is 53.8 kilometres.

Evidence within the literature and from this study suggests some people with breast or prostate cancer travel long distances to receive appropriate cancer care. This imposes significant costs on the patient, and can lead to worse survival outcomes. As GP access is generally better compared to current infusion service providers in non-metropolitan regions, improvements to access for people living in these areas could be made through the delivery of a wider range of cancer-related treatments by primary care physicians.

Deloitte Access Economics

Deloitte Access Economics vii Access to cancer treatment in Australia

1 An overview of cancer

This chapter provides a definition of cancer and broad overview of breast and prostate cancer in Australia. It shows that of all cancers (excluding basal and squamous cell carcinomas of the skin), prostate and breast cancer has the greatest incidence and prevalence among males and females respectively, and imposes a large burden of disease on Australians. 1.1 What is cancer?

In its most general form, cancer is a class of over 100 diseases characterised by uncontrolled division of cells (i.e. the mutations of genes that encode proteins controlling cell division). These blood cells have the ability to detach from the original cancer site (localised cancer), and then spread to other regions of the body.

There are several known cancer risk factors. Some can be modified (e.g., lifestyle risk factors), while others cannot (e.g., genetic risk factors). Common cancer risk factors include: • Biomedical factors, including: • genetic susceptibility; and • hormonal factors in females. • Lifestyle factors, including: • smoking; • alcohol consumption; • physical inactivity and obesity; • chronic infections; and • diet. • Environmental factors, including: • sunlight; • radiation; • occupational exposure; and • pollution (AIHW 2010).

Cancer imposes the greatest burden of disease 4 on Australians, accounting for around 19% of the total burden. Around 50% of males and 33% of females will develop cancer within their lifetime, and 20% will die from cancer before they turn 85 years of age (AIHW 2010). Cancer is the second leading cause of mortality in Australia (behind cardiovascular disease), accounting for 39,884 deaths in 2007 (AIHW 2010).

4 The burden of disease is measured using the disability adjusted life year (DALY). This is a measurement unit that quantifies morbidity and mortality associated with various diseases and injuries (Murray and Acharya 1997). DALY weights are measured on a scale of zero to one, where a zero represents a year of perfect health and a one represents death. Other health states that result from specific diseases or injuries are given a weight between zero and one to reflect the quality of life that is lost due to a particular condition.

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1.2 Prostate and breast cancer

Prostate and breast cancer are leading causes of disease burden among Australians, imposing years of poor health and reducing total years of life. Prostate cancer is the second leading cause of disease burden among males (behind lung cancer), and breast cancer is the leading cause of disease burden among females (see Table 1.1). Around 19.1% of the total burden of disease associated with cancer can be attributed to prostate and breast cancer (AIHW 2010).

Table 1.1: Estimated leading causes of the cancer burden of disease Males Females % of cancer % of cancer Cancer type DALYs Cancer type DALYs burden burden Lung 56,800 20 Breast 61,100 24 Prostate 42,500 15 Lung 41,300 16 Bowel 37,800 13 Bowel 30,300 12 Melanoma 15,200 5 Ovary 12,900 5 Lymphoma 14,200 5 Pancreas 12,400 5 Other 121,200 42 Other 94,100 38 Total 287,700 100 Total 252,100 100 Note: DALY = Disability Adjusted Life Year. Source: AIHW (2010).

Of all cancers, prostate and breast cancer are the most prevalent among males and females respectively. In 2007, there were 19,403 new cases of prostate cancer and 12,567 new cases of breast cancer (AIHW 2010). In addition, prostate and breast cancer combined were the second leading causes of cancer death, accounting for 2,938 and 2,680 deaths in 2007 respectively (AIHW 2010). In total, these two types of cancer accounted for 14.1% of all cancer deaths in Australia.

Although age is not specifically categorised as a risk factor, breast and prostate cancer primarily affects older people, as shown in Chart 1.1 and Chart 1.2 respectively. These charts show a steep increase in incidence rates and mortality rates for breast and prostate cancer, although the slope increases at a substantially younger age for breast cancer in females compared to prostate cancer.

Recently, the incidence of prostate cancer has been increasing. Between 1997 and 2007 the incidence rate increased from 130 cases per 100,000 males to 184 cases per 100,000 males. This increase has been due to alternative prostate specific antigen (PSA) testing (AIHW 2010). The number of new prostate cancer cases continues to increase at an annual growth rate of 5.3% (AIHW 2008a). Although the incidence rate for prostate cancer has been increasing, the mortality rate has declined, from 44 deaths per 100,000 males in 1993 to 31 deaths per 100,000 males in 2007. This improvement is due to better treatment (AIHW 2010).

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Chart 1.1: Incidence and mortality rates for breast cancer in females

350

300

250

200

150

100

cases per 100,000 people 100,000 per cases 50

0 0–4 5–9 85+ 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84

New cases Mortality

Source: AIHW (2011a).

Chart 1.2: Incidence and mortality rates for prostate cancer

1200

1000

800

600

400

200

cases cases per 100,000 people 0 0–4 5–9 85+ 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84

New cases Mortality

Source: AIHW (2011a).

Between 1995 and 2007, the incidence rate of breast cancer decreased from 116 cases per 100,000 females to 109 cases per 100,000 females. However, the number of breast cancer cases continues to increase at an average rate of around 2.2% (AIHW 2009). The mortality rate declined from 31 deaths per 100,000 females in 1994 to 22 deaths per 100,000 females in 2007 (AIHW 2010). Some of the factors contributing to this decline are earlier diagnosis through BreastScreen Australia (established in 1991), and better treatment (AIHW 2010).

Deloitte Access Economics 10 Access to cancer treatment in Australia

The high burden of prostate and breast cancer means a large amount of health care resources must be allocated to diagnosis and treatment. Although people with cancer use a wide variety of acute and primary health care services, the largest cost is associated with admitted patient hospitalisations related to treatment or palliative care.

In 2008-09, there were 836,906 hospitalisations with a principle diagnosis of cancer. Cancer patients occupied 2.3 million bed days, with an average length of stay of approximately 7.7 days (excluding same day hospitalisations). Patients diagnosed with prostate cancer accounted for 34,289 hospitalisations, while patients diagnosed with breast cancer accounted for 25,119 hospitalisations (see Table 1.2). Between 2007-08 and 2008- 09, hospitalisations with a principal diagnosis of prostate cancer and breast cancer increased by 10.4% and 4.8% respectively (AIHW 2010).

Table 1.2: Hospitalisations with a principal diagnosis of cancer, 2008-09 Type Same-day Overnight Total Non-melanoma skin 70,962 14,040 85,002 Unknown primary site 7,267 32,922 40,189 Prostate 16,458 17,831 34,289 Bowel 9,182 21,112 30,294 Breast 6,296 18,823 25,119 Other 515,402 106,431 621,833 Total 625,567 211,159 836,906 Source: AIHW (2010).

Cancer patients are likely to receive chemotherapy and radiotherapy as part of their treatment regime.

Chemotherapy (cancer treatment delivered by intravenous infusion) forms a substantial proportion of total cancer related hospitalisations. For example, in 2009-10 there were 335,353 hospital admissions for chemotherapy (nearly all same day procedures), which accounted for approximately 33% of all cancer related hospitalisations. Of these, 41.3% were undertaken in public hospitals. Between 2008-09 and 2009-10, hospitalisations for chemotherapy grew by 21,280, or approximately 5% (AIHW 2011). It is important to note that chemotherapy usually involves a course of treatment, requiring individual patients to attend chemotherapy clinics on a regular basis.

In addition, some hospitals provide chemotherapy services on a non-admitted basis (i.e., as an outpatient). In 2009-10 there were 123,275 outpatient occasions of service for chemotherapy, where 66% was undertaken in NSW hospitals (AIHW 2011).

Most radiotherapy services are located in major hospitals in capital cities and large regional centres. Radiotherapy is generally given on a non-admitted basis, either through a public or private hospital. In 2009-10 there were around 922,000 megavoltage (the main form of radiotherapy used to treat cancer) Medicare Benefit Schedule (MBS) claims (Medicare 2011). Radiotherapy can be particularly burdensome on the patient given the time and intensity associated with treatment. For example, some people may require radiotherapy five days per week over a period of six weeks. On occasions, radiotherapy may be required

Deloitte Access Economics 11 Access to cancer treatment in Australia

twice per day. This means being close to radiotherapy services is advantageous as it reduces a patient’s need to travel long distances or relocate.

Deloitte Access Economics 12 Access to cancer treatment in Australia

2 A literature review on access to cancer treatment

This chapter presents a literature review on issues surrounding access to cancer treatment in Australia. It first presents variations found in cancer epidemiology, focusing on regional variations and the Indigenous population. The chapter also explores access to cancer treatment, including screening, diagnosis, treatment and care. 2.1 Variations in cancer epidemiology

Many studies have examined differences in health outcomes between people diagnosed with cancer living in non-metropolitan regions compared to those living in metropolitan areas (Heathcote and Armstrong 2007). These studies have largely focused on the effects of regionality on incidence and mortality rates, suggesting regional variations may be attributed to a combination of factors. Heathcote and Armstrong (2007) note possible reasons for this result, including: • more difficult access to cancer treatment due to poor transport links and shortage of healthcare providers in non-metropolitan regions; • higher proportion of Indigenous Australians in non-metropolitan regions who are generally more economically disadvantaged than other populations; and • a higher proportion of people from lower socioeconomic backgrounds living in non- metropolitan regions, leading to: • differences in cancer knowledge and health behaviours; • later tumour stage at diagnosis; • issues with affordability of care; and • reduced ability to access the full spectrum of cancer detection and care.

2.1.1 Regional variations

Research on regional variations in cancer patterns have largely focused on cancer incidence and mortality rates. According to the Australian Institute of Health and Welfare (AIHW), people living in non-metropolitan regions fare worse than their metropolitan counterparts across a wide spectrum of cancers (AIHW 2008).

However, regional variations are not uniform across all cancer types. For example, people living in inner regional areas have higher incidence rates of bowel cancer, melanoma of the skin and prostate cancer. 5 Furthermore, the incidence of breast cancer and lymphoid cancer decreases with remoteness despite higher health risk behaviours and lower socioeconomic status. For example, remote and very remote areas have a 20% lower

5 Remoteness was classified according to the Australian Standard Geographical Classification (ASGC) Remoteness Areas.

Deloitte Access Economics 13 Access to cancer treatment in Australia

incidence rate of breast cancer compared to major cities between 2003 and 2007 (AIHW 2010). Some reasons for breast cancer include (Access Economics 2007): • risk of breast cancer is greater in women who have never had children or have them later in life, which generally relates to urban areas given greater competing demands (e.g., work); • breastfeeding can help reduce the risk of breast cancer and it is likely that women in urbanised areas will restrict the period of breastfeeding; and • there may be more environmental risk factors (pollutants and toxins) in urban areas.

The incidence and mortality associated with prostate and breast cancer by remoteness over 2003-07 is shown in Table 2.1. For prostate cancer, the incidence rate is highest for inner regional areas, while the mortality rate is highest for outer regional areas. For breast cancer, the incidence rate is highest for major cities, while the mortality rate is highest for inner and outer regional areas.

Table 2.1: Incidence and mortality of prostate and breast cancer, by remoteness 2003-07

Prostate cancer Breast cancer Incidence Mortality Incidence Mortality Major cities 164.7 30.1 113.2 22.5 Inner regional 176.0 37.5 110.8 24.7 Outer regional 169.1 40.0 105.5 24.7 Remote and 145.7 33.0 93.0 22.7 very remote Total 167.5 32.8 111.8 23.2 Note: The rates were age-standardised to the Australian population as at 30 June 2001 and are expressed per 100,000 population. The rates are based on the total number of cases over the 5-year period from 2003–2007. Source: AIHW (2010).

Survival rates also vary across remoteness. For diagnosed cancers between 1997 and 2004, AIHW (2008) found the following results. • One-year and five-year relative survival rates for all cancers decreased as remoteness of residence increased, with significant differences between major cities, inner regional and outer regional. • There are significant differences in relative five-year survival for breast and prostate cancer between major cities and outer regional areas.

These findings mirror those in other studies. Using recent data, AIHW (2010) found that although the mortality rate for all cancers combined was similar for outer regional areas and remote/very remote areas (207 and 206 deaths per 100,000 respectively), there was a significantly lower mortality rate for major cities (172 deaths per 100,000) between 2003- 07. Coory and Baade (2005) also found that the prostate cancer mortality rate for men in rural and regional regions was higher than for men in capital cities (though this was not statistically significant) and that the differences were increasing over time.

Deloitte Access Economics 14 Access to cancer treatment in Australia

2.1.2 Cancer among Indigenous Australians

Condon et al (2003) notes there are differences in cancer incidence and mortality between Indigenous and non-Indigenous Australians. While Indigenous Australians have a higher incidence rate for lung, liver and cervical cancer, they have a lower incidence rate for breast and prostate cancer (68.0 versus 102.5 per 100,000 people for breast cancer and 61.1 versus 136.5 per 100,000 people for prostate cancer) (AIHW 2010). However, mortality rates for breast and all cancers are higher compared to the non-Indigenous population. (AIHW 2010).

In addition, for prostate and breast cancer, the mortality rate ratio between Indigenous and non-Indigenous Australians is higher than the incidence rate ratio. This suggests Indigenous Australians experience poorer breast and prostate cancer outcomes despite having lower incidence rates.

Even after taking into account the stage of cancer at diagnosis, cancer treatment and higher rates of comorbidities in Indigenous Australians, the likelihood of death from cancer is still about 30% higher for the Indigenous population (Valery et al 2006). The reasons underlying the differences in cancer outcomes between Indigenous and non-Indigenous people are multifaceted and require further research (Roder 2007; Valery et al 2006; WHGNE 2010).

One possible reason for poorer cancer outcomes for Indigenous Australians is their higher rate of residence in non-metropolitan regions. Chart 2.1 shows that there is a larger proportion of the Indigenous population who live in remote areas compared to the non- Indigenous population. Together with the fact that Indigenous Australians generally have poorer health outcomes due to a range of socioeconomic dimensions (AIHW 2008), this may be contributing to significant differences in cancer outcomes.

Valery et al (2006) identified that the stage of cancer at diagnosis was significantly different between Indigenous and non-Indigenous patients, contributing to differences in treatment and cancer outcomes. There is also a higher prevalence of comorbidities among Indigenous patients including acute coronary syndrome, diabetes, respiratory disease and chronic renal disease (Valery et al 2006). According to Valery et al (2006), Indigenous patients were 1.7 times more likely to have three comorbidities or more compared with non-Indigenous patients.

Another reason for poorer cancer outcomes is less access to cancer treatment (Coory et al 2008). Chart 2.2 shows that a lower proportion of Indigenous Australians received chemotherapy, radiotherapy and surgery compared to the non-Indigenous population. Disadvantage in treatment utilisation for Indigenous Australians remained even after adjusting for cancer type, stage at diagnosis and comorbidities (Coory et al 2008).

Deloitte Access Economics 15 Access to cancer treatment in Australia

Chart 2.1: Proportion of resident population by remoteness areas

% 80

0 Major Cities Inner Regional Outer regional Remote Very Remote

Indigenous Non-Indigenous

Source: ABS (2006)

Chart 2.2: Proportion of cancer patients who receive treatment, by type

% 80

0 Chemotherapy Radiotherapy Surgery Any active treatment

Indigenous Non-Indigenous

Source: ABS (2006).

The absolute differences in survival after diagnosis for Indigenous people with cancer are greatest for cancers with the highest survival in non-Indigenous people (Condon 2004). These are cancers that have a high probability of cure and effective treatment if diagnosed early, such as breast cancer. Condon (2004) also noted that some of the most common cancers (such as lung and cervical cancer) among Indigenous people are preventable by reduced tobacco use, increased use of Pap tests, hepatitis B immunisation, and reduced

Deloitte Access Economics 16 Access to cancer treatment in Australia

alcohol use. In addition, Indigenous patients with breast cancer are more likely to be diagnosed with localised disease than the non-Indigenous population, but they are less likely to survive (Heathcote and Armstrong 2007; Roder 2007).

Valery et al (2006) and Condon et al (2006) found that Indigenous patients are less likely to receive treatment for cancer, and were more likely to refuse when offered treatment. This is consistent with Coory et al (2008), which found that Indigenous Australians received much less active cancer treatment when diagnosed.

Heathcote and Armstrong (2007) suggested that language and cultural beliefs about cancer and treatment impacted on their decisions to receive treatment. WHGNE (2010) found that Indigenous women regard cancer with a high level of fear and associate the disease with a fatal prognosis. In addition, they often feel intimidated due to communication difficulties and hence many Indigenous women feel uncomfortable in accessing mainstream health services (WHGNE 2010). 2.2 Access to cancer treatment

When stage at diagnosis, socioeconomic disadvantage and Indigenous identification are accounted for, poorer survival rates appear to persist in non-metropolitan regions. This suggests that one reason for differences in cancer outcomes for people in non- metropolitan regions is reduced access to cancer treatment. This can be due to (Heathcote and Armstrong 2007): • geographic isolation; • inadequate transport links; • differences in cancer screening and diagnostic services; • later stage of cancer at diagnosis; • shortage of healthcare providers; and • differences in attitudes towards cancer and its management.

2.2.1 Cancer screening and diagnosis

Lack of access to cancer screening may be contributing to higher mortality rates for people living in remote areas. Coory and Baade (2005) note that while prostate cancer screening is widespread across Australia, it is less common in non-metropolitan regions compared to capital cities. Lack of access to screening and early diagnosis may be masking more aggressive cancers in non-metropolitan regions, possibly partly explaining the higher mortality rates. However, Coory and Baade (2005) suggest that screening and diagnosis is not the only factor contributing to higher mortality rates in non-metropolitan regions.

According to Jong et al (2004), cancer stages at diagnosis differ by geographic remoteness. People outside the ‘highly accessible’ areas were more likely to have non-localised cancers, including cancers of the prostate. When stage of cancer at diagnosis was accounted for, men in remote areas were still at increased risk of death from prostate cancer while women remained with an increased risk of death from cervical cancer.

From a series of in-depth, semi-structured interviews with 18 participants in three rural Western Australian health regions, McConigley et al (2010) found that participants often

Deloitte Access Economics 17 Access to cancer treatment in Australia

delayed screening and therefore were less likely to receive an early diagnosis. Reasons for the delays include: • participants did not recognise symptoms of cancer; • GPs often did not recognise symptoms, or did not give an immediate referral for testing; and • some participants waited until symptoms were acute so they could enter the emergency department and have their symptoms checked immediately.

2.2.2 Access to cancer care

Another possible reason for higher mortality in non-metropolitan regions may be differences in cancer management (Coory and Baade 2005). Poorer access to cancer treatment is a major contributor to lower survival rates among people living in non- metropolitan regions. There are two primary reasons for a lack of access, including: • a shortage of specialist treatment facilities and health care providers; and • a lower quality of treatment and care in non-metropolitan regions compared to metropolitan areas.

Shortage of specialist treatment facilities and health care providers

In 2005, the Clinical Oncological Society of Australia (COSA) conducted a comprehensive national survey of regional hospitals administering chemotherapy to map oncology services in non-metropolitan regions around Australia. Of the 761 public hospitals and 543 private hospitals in Australia in 2003-04, only 159 in non-metropolitan regions administered chemotherapy (COSA 2006). As a result, people from rural areas who may be prescribed with chemotherapy (or even radiotherapy and surgery) may be disadvantaged in terms of accessibility and availability of treatment facilities.

Often, people have to travel long distances to capital cities for cancer treatment. Hegney et al (2005) examined the experiences of people with cancer who commuted from Toowoomba to Brisbane for radiotherapy treatment. The authors concluded there were many difficulties associated with people having to travel for radiotherapy. • The burden of travel for cancer treatment is large. This is particularly the case for people who are not emotionally or financially prepared to relocate to a capital city and thus have to commute on a daily basis for treatment. • For those who do relocate, there are difficulties associated with being away from home, family and friends during their treatment period. • There is an excessive financial burden caused by relocation or having to travel for treatment, especially for people who are not able to continue work during their treatment period.

These findings are consistent with a similar study by McConigley et al (2010) on the treatment decisions of cancer patients in rural Western Australia. People were not offered options to have cancer care closer to home, while some were required to receive treatment in a metropolitan area due to the lack of radiotherapy services in rural areas.

Coory and Baade (2005) and COSA (2006) found accessibility to specialist surgical oncology services problematic in non-metropolitan regions. In the COSA (2006) survey, there were

Deloitte Access Economics 18 Access to cancer treatment in Australia

no surgical oncologists in remote and very remote areas and general and other surgeons provided the majority of oncology surgery in rural areas. This is consistent with Coory and Baade (2005), which found lower rates of radical prostatectomy and prostate cancer screening for men in non-metropolitan regions compared to those in capital cities.

Even though non-metropolitan hospitals administering chemotherapy offer access to allied healthcare services such as multidisciplinary clinics and psychosocial services, long waiting lists and few services dedicated to oncology make it difficult for patients to obtain additional support during their course of treatment. In particular, the COSA survey found a big gap in physical rehabilitation such as physiotherapy and occupational therapy services (COSA 2006).

Lower quality of treatment and care

Not only is there a shortage of treatment facilities and health care providers for people with cancer in non-metropolitan regions, the treatment they are able to access is generally of lower quality.

Much of the differences in treatment quality stems from a qualified workforce shortage in non-metropolitan regions. The COSA survey found that, of the 157 non-metropolitan hospitals administering chemotherapy that responded, only 21% had a resident medical oncology service, with availability of medical oncologists decreasing as remoteness increased (COSA 2006). For non-metropolitan hospitals administering chemotherapy in very remote areas, there were no medical oncologists (whether resident or visiting). As a result, chemotherapy was often not referred by medical oncologists in more remote areas but by ‘other’ doctors and general practitioners (COSA 2006).

In addition, the percentage of chemotherapy that is administered by a chemotherapy- trained nurse decreased significantly for remote and very remote areas compared to major cities, inner regional and outer regional areas (COSA 2006). In these more remote areas, other trained nurses or GPs are likely to administer chemotherapy for cancer patients. Given the narrow band of safe and effective doses for chemotherapy drugs, it is extremely important they are administered precisely by trained health professionals (COSA 2006).

There is also a difference in the quality of surgery between remote and metropolitan areas. For example, Hall et al (2004) and Kricker et al (2001) found that women with breast cancer residing in rural areas were less likely to receive conservative treatment and more likely to have mastectomies compared to women living in metropolitan areas. Mitchell et al (2006) analysed linked data in Western Australia and found that breast cancer treatment in rural areas was sub-optimal for open biopsies with frozen section, adjuvant radiotherapy and hormonal therapy. 2.3 Improving access to cancer treatment

Recent studies have explored ways to improve access to cancer treatment in order to achieve better outcomes for people living in non-metropolitan regions. In general, there are no formal models of cancer service delivery in non-metropolitan regions drafted in any government policy and planning documents, but state/territory governments are beginning to implement coordinated and networked systems where services to non-metropolitan regions can be formalised (Adams et al 2009).

Deloitte Access Economics 19 Access to cancer treatment in Australia

According to the Cancer in the Bush report, there were eight areas that needed to be improved to enhance oncology services in non-metropolitan regions (Goldstein and Underhill 2007). • Transportation and the need to remove inequities in the current Isolated Patient Travel and Accommodation Assistance Scheme arrangements. Currently, Patient Access and Travel Schemes (PATS) are problematic due to variations across states/territories and restrictive and unclear eligibility rules (COSA et al 2003). • Improved patient support, including the provision of breast cancer nurses nationally and a cancer nurse demonstration project. • Training to be nationally coordinated and funded. • Workforce planning for disciplines covering the special needs of rural areas. COSA et al (2003) suggested that to address the workforce shortage issue in non-metropolitan regions, there needs to be more professional incentives to undertake training in non- metropolitan settings rather than in major centres. • Networks and the development of national accreditation, and the development of a regional cancer demonstration project. • Further research into comparative outcomes in survival, access, psychological support and quality of life in rural and urban areas. • Reimbursement for item numbers for rural services and tele-oncology. • Addressing issues of national priority such as make specific cancer drugs available on the Pharmaceutical Benefits Scheme.

Goldstein and Underhill (2007) indicated that while there has been some progress made to these issues, there remains much to be done for rural access to oncology services to improve.

Deloitte Access Economics 20 Access to cancer treatment in Australia

3 Mapping access to cancer treatment

This chapter presents estimates of access to cancer treatment in each federal electorate division (FED) using the distance required to travel to the nearest hospital, and compares this to estimated incidence of breast and prostate cancer. The chapter presents 14 maps of states/territories and capital cities showing the location of hospitals that deliver cancer treatment, the average distance to the hospital that has been derived from the midpoints of post codes, and the incidence of breast and prostate cancer. 3.1 Incidence of breast and prostate cancer

The method used to estimate incidence of breast and prostate cancer in Australia was to multiply estimated Australian breast and prostate cancer incidence rates by Australian population estimates. A search of the literature was undertaken to source cancer incidence rate data. While there are several sources of publicly available cancer incidence data in Australia, cancer incidence data reported by each state/territory often differ in methods of reporting (e.g. the level of disaggregation and age-standardised incidence rate versus age- specific incidence rate) and the period used to extrapolate trends. There are no consistent age and gender specific cancer incidence rates by cancer type across all states/territories.

Although there are variations in breast and prostate cancer incidence rates across states/territories (e.g., lower estimated breast and prostate cancer incidence rates are observed in the Northern Territory while higher estimated breast and prostate cancer rates are found in the Australian Capital Territory) variations in incidence rates across most states/territories are minor (Table 3.1). These differences may be explained by factors such as variations in underlying cancer risk, access to cancer services, and normal incidence rate fluctuations (AIHW 2006).

Table 3.1: Estimated breast and prostate cancer incidence rates, by state/territory State/territory Breast cancer in females Prostate cancer 2002-2006 1999-2003 cases per 100,000 cases per 100,000 Australian Capital Territory 129.2 143.8 New South Wales 113.1 132.5 Northern Territory 83.3 103.6 Queensland 114.6 129.5 South Australia 113.5 135.8 Tasmania 114.8 139.6 Victoria 111.4 134.3 Western Australia 114.9 131.1 Source: AIHW (2009), AIHW (2006).

Deloitte Access Economics 21 Access to cancer treatment in Australia

Given that variations in breast and prostate cancer incidence rates across most states/territories are small, the Australian projected five-year age and gender specific breast and prostate cancer incidence rates for the year 2011 published by AIHW were used (AIHW 2005). These projections were based on trends in cancer incidence data from 1982 to 2001 and are presented in Table 3.2.

Table 3.2: Estimated breast and prostate cancer incidence rates, by age and gender, 2011

Breast cancer Prostate cancer Male Female Male

cases per 100,000 cases per 100,000 cases per 100,000 0–4 0.0 0.0 0.0 5–9 0.0 0.0 0.0 10–14 0.0 0.0 0.0 15–19 0.0 0.2 0.0 20–24 0.1 1.5 0.0 25–29 0.1 7.0 0.0 30–34 0.2 23.4 0.0 35–39 0.3 59.2 0.3 40–44 0.5 117.1 2.7 45–49 0.7 188.5 16.1 50–54 1.1 256.8 66.0 55–59 1.6 307.5 181.5 60–64 2.2 335.2 357.1 65–69 3.1 342.5 549.4 70–74 4.3 336.0 719.4 75–79 5.7 322.1 858.0 80–84 7.6 305.7 976.5 85+ 10.0 289.5 1090.8 Source: AIHW (2005).

The number of new cases of breast and prostate cancer in 2011 was estimated by multiplying the national projected five-year age and gender specific incidence rates by the estimated FED population. This implicitly assumes that incidence rates do not differ across FEDs and are the same as the Australian average. Although most FEDs are expected to have incidence rates similar to the Australian average, caution must be exercised when evaluating incidence rates for FEDs with a relatively high Indigenous population. As noted in Section 2.1.2, incidence rates for breast and prostate cancer among the Indigenous population is significantly lower than incidence rates for the non-indigenous population (68.0 versus 102.5 per 100,000 people for breast cancer and 61.1 versus 136.5 per 100,000 people for prostate cancer) (AIHW 2010).

FED population was estimated using Deloitte Access Economics’ in-house demographic model called AE-Dem. 6 AE-Dem is an in-house demographic model based on the 2006 national census undertaken by the ABS. Building up from the demographic ‘first principles’

Deloitte Access Economics 22 Access to cancer treatment in Australia

of births, deaths, migration and household formation, the model projects population by age and gender for each state/territory. The model contains population by Statistical Local Area (SLA) at the lowest level of disaggregation.

The estimated number of new cases of breast and prostate cancer in 2011 by state/territory is presented in Table 3.3. A detailed breakdown of the estimated number of new cases by FEDs is presented in Appendix A.

Figure 3.1 graphically presents estimated new cases of breast and prostate cancer in 2011 by FEDs. As shown by the alternative shades there are variance in the estimated number of new cases of breast and prostate cancer across Australia. For example, Grey (in South Australia) has the darkest shade indicating the number of new cases of breast and prostate cancer for this FED was greater than 245 in 2011. In comparison, Lingiari (in the Northern Territory) has a lighter shade indicating it less new cases. However these shades are mainly a function of different age composition of FED populations as incidence rates are assumed constant across all FEDs, and the populations within FEDs are similar.

Table 3.3: Estimated number of new cases of breast and prostate cancer, 2011 Breast cancer Prostate cancer Total Australian Capital Territory 220 195 415 New South Wales 4,889 4,970 9,858 Northern Territory 107 89 195 Queensland 2,904 2,913 5,818 South Australia 1,193 1,228 2,420 Tasmania 374 390 764 Victoria 3,719 3,718 7,438 Western Australia 1,453 1,441 2,894 Total 14,859 14,944 29,802 Source: Deloitte Access Economics.

Deloitte Access Economics 23 Access to cancer treatment in Australia

Figure 3.1: Estimated number of new cases of breast and prostate cancer by FEDs, 2011

Access to cancer treatment in Australia

3.2 Hospitals that deliver cancer treatment

To determine the average distance that needs to be travelled to access cancer treatment, the location of hospitals by postcode was first identified. However, there is no one source of information so two different methods were used to determine hospitals that deliver chemotherapy, radiation, or both.

3.2.1 Cancer-related infusion services

A list of facilities providing infusion services was compiled by combining information from three separate sources, including: • directory of Breast Cancer Services (Cancer Australia, 2011); • Department of Health and Ageing (pers. comm. Healthcare Services Information Branch, Hospital Services Section, Departmental Officer, 15 July 2011); and • state/territory health departments and cancer council directory of cancer services (Cancer Council ACT 2011; Cancer Council NSW 2011; Department of Health and Families NT 2009; Queensland Health 2010; pers comm. Cancer Council SA 14 July 2011; Department of Health and Human Services Tas 2011; Cancer Council Vic 2010; Department of Health WA 2011).

The online national service directory (the Directory) for women with breast cancer was established by the National Breast and Ovarian Cancer Centre (NBOCC) in 2002. NBOCC had been funded by the Australian government and was recognised as ‘ Australia’s authority and source of evidence-based information on breast and ovarian cancer’ (AIHW 2009, pp. ii). The Centre has since amalgamated with Cancer Australia.

All private and public hospitals throughout Australia were invited to be included in the Directory. Hospitals can access and update their online listing any time and the Directory is updated on a regular basis.

The Directory details the full range of breast cancer services and expertise available at each of these facilities. Services range from diagnostic services to radiotherapy and cancer- related infusion service counselling and administration. Facilities listed as providing on site administration of cancer-related infusion services were noted as a facility providing cancer- related infusion services across Australia. Facilities listed as providing counselling on cancer-related infusion services but not the administration of cancer-related infusion services were excluded.

The Department of Health and Ageing list of facilities providing cancer-related infusion services includes public hospitals, private hospitals and day hospital facilities. This list was compiled by the Department based on information provided to the Department by each of the facilities at the time the information was collected.7 Additional facilities found in this list were amalgamated with the list from Cancer Australia.

7 Between 2008 and 2011 (pers. comm. Healthcare Services Information Branch, Hospital Services Section, Departmental Officer, 15 July 2011).

Deloitte Access Economics 25 Access to cancer treatment in Australia

Furthermore, to supplement the above two sources of information, omitted cancer treatment centres providing cancer-related infusion services sourced from the state/territory health department websites or state/territory cancer councils were added. Where type of cancer services provided by cancer treatment centres was not specified, treatment centres were contacted by telephone to confirm the provision of cancer-related infusion service.

There were significant overlap of facilities between the three sources, however, none was a full subset of another. The discrepancy suggests that there is variability in the accuracy of information from any one source. As a measure to improve the accuracy of the complied list, evaluators contacted a sample of facilities to confirm their cancer-related infusion service provision status by telephone, however, depending on the staff answering the phone, response received was not always definitive or consistent. This is particularly the case for rural sites where infusion services are infrequently administered.

A list of new cancer-related infusion sites planned for each of the states/territories was also composed through undertaking a desktop search for publically available documents detailing strategic plans for cancer treatment services as well as contacting state/territory department of health.

3.2.2 Radiotherapy

A list of facilities providing radiotherapy treatment in each state/territory was sourced from the Department of Health and Ageing (DoHA 2011). The list was further supplemented by searches for more recently operational sites through state/territory Cancer Council websites and government documents on radiotherapy cancer treatment planning. Two additional radiotherapy treatment centres (Orange base hospital in NSW and Sunshine hospital in Victoria) were added to the list after contacting personnel at each of the facilities to confirm the facility was operational. Cross checks were performed with sites listed on the National Breast and Ovarian Cancer Centre (NBOCC) service directory as administrating radiotherapy. Similarly, a list of new radiotherapy sites planned for each state/territory was constructed after undertaking a desktop search of publically available documents detailing strategic plans for cancer treatment services and contacting the state/territory health departments.

3.2.3 Hospitals delivering cancer treatment

There are currently a total of 528 facilities administrating radiotherapy or cancer-related infusion services across Australia. Of these, 61 facilities deliver radiotherapy treatment and 516 facilities deliver cancer-related infusion treatment. Of these, 49 facilities provide both radiotherapy and cancer-related infusion services.

Direct comparison of our compiled list of facilities identified as providing cancer-related infusion services with the list of identified infusion sites in COSA (2006) was not possible as the compiled list does not distinguish facilities by remoteness. However, the number of facilities delivering cancer-related infusion services in our consolidated list greatly exceeds the 157 regional hospitals listed in COSA (2006). Similarly, the number of facilities delivering radiotherapy in our list exceeds the 11 regional radiation units identified in COSA (2006).

Deloitte Access Economics 26 Access to cancer treatment in Australia

Nationally, two addition cancer-related infusion sites (one in Victoria and one in Western Australia) and eight new radiotherapy sites (four in NSW, one in Queensland, one in Tasmania, and two in Victoria) are planned. A list of planned cancer-related infusion and radiotherapy sites are presented in Appendix B.

Figure 3.2 shows the geographic distribution of operational and planned radiotherapy and cancer-related infusion sites across Australia. A complete list of operational facilities offering cancer-related infusion and radiotherapy services are listed in Appendix B.

Deloitte Access Economics 27 Access to cancer treatment in Australia

Figure 3.2: Location of radiotherapy and cancer-related infusion services across Australia

Access to cancer treatment in Australia

Each facility as mapped at the midpoint of their 2006 postal area using postcodes. 8 Where discrepancies exist between the current listed postcode and 2006 postal area, longitude and latitude of the facility was obtained using Google Maps. The maps were developed using Pitney Bowes MapInfo Professional software and information from the Australian Bureau of Statistics (ABS) and Australian Electoral Commission (AEC) on digital boundaries. 9

There are many more facilities administering cancer-related infusion than radiotherapy. The high cost of initial investment in equipment and infrastructure, specialist workforce training and availability, engineering support, integration with other specialist cancer services limits the number and location of radiotherapy treatment centres across Australia (DoHA & VDHS 2009). Consequently the majority of radiotherapy services are clustered around capital cities. Compared to radiotherapy service locations, there are more sites administering infusion services in regional areas. However, the capacity of the medical team delivering infusion services may differ between hospitals located in metropolitan areas and hospitals located in rural areas of Australia (COSA 2006).

3.2.4 Hospital locations relative to estimated cancer incidence

Hospital locations and estimated breast and cancer incidence were mapped together by FEDs to compare access to cancer-related infusion services and radiation therapy to the need for services. A map was developed for Australia, each state/territory and capital city (except Darwin and Hobart due to their small size). These are shown in the following figures.

8 Postal Areas are ABS approximations of Australia Post postcodes, created by allocating whole Collection Districts (CDs) on a ‘best fit’ basis to postcodes. 9 Digital boundaries used for this study were statistical local areas (SLA) 2010 digital boundaries (ABS, 2010) and postal areas (POA) 2006 digital boundaries (ABS, 2007) from the ABS and federal electoral boundary from the AEC (AEC, 2011).

Deloitte Access Economics 29 Access to cancer treatment in Australia

Figure 3.3: Incidence of breast and prostate cancer compared to location of cancer treatment in Australia, 2011

Access to cancer treatment in Australia

Figure 3.4: Incidence of breast and prostate cancer compared to location of cancer treatment in ACT, 2011

Deloitte Access Economics 31 Access to cancer treatment in Australia

Figure 3.5: Incidence of breast and prostate cancer compared to location of cancer treatment in NSW, 2011

Access to cancer treatment in Australia

Figure 3.6: Incidence of breast and prostate cancer compared to location of cancer treatment in Sydney, 2011

Access to cancer treatment in Australia

Figure 3.7: Incidence of breast and prostate cancer compared to location of cancer treatment in Northern Territory, 2011

Deloitte Access Economics 34 Access to cancer treatment in Australia

Figure 3.8: Incidence of breast and prostate cancer compared to location of cancer treatment in Queensland, 2011

Deloitte Access Economics 35 Access to cancer treatment in Australia

Figure 3.9: Incidence of breast and prostate cancer compared to location of cancer treatment in Brisbane, 2011

Deloitte Access Economics 36 Access to cancer treatment in Australia

Figure 3.10: Incidence of breast and prostate cancer compared to location of cancer treatment in South Australia, 2011

Deloitte Access Economics 37 Access to cancer treatment in Australia

Figure 3.11: Incidence of breast and prostate cancer compared to location of cancer treatment in Adelaide, 2011

Deloitte Access Economics 38 Access to cancer treatment in Australia

Figure 3.12: Incidence of breast and prostate cancer compared to location of cancer treatment in Tasmania, 2011

Deloitte Access Economics 39 Access to cancer treatment in Australia

Figure 3.13: Incidence of breast and prostate cancer compared to location of cancer treatment in Victoria, 2011

Access to cancer treatment in Australia

Figure 3.14: Incidence of breast and prostate cancer compared to location of cancer treatment in Melbourne, 2011

Access to cancer treatment in Australia

Figure 3.15: Incidence of breast and prostate cancer compared to location of cancer treatment in Western Australia, 2011

Deloitte Access Economics 42 Access to cancer treatment in Australia

Figure 3.16: Incidence of breast and prostate cancer compared to location of cancer treatment in Perth, 2011

Deloitte Access Economics 43 Access to cancer treatment in Australia

3.3 Average distance to cancer treatment

The average distance to cancer treatment was calculated by measuring kilometres (as the crow flies) from the midpoint of every SLA to the nearest hospital administering cancer- related infusion or radiotherapy. The location of the hospital was represented by the midpoint of the postcode within which the hospital is located 10 . The nearest hospital was not restricted to the same FED so an SLA in one FED may have the distance recorded to a hospital located within another FED. Each SLA covers a smaller geographical area compared to a Federal Electorate Division (FED) 11 and hence enables greater accuracy in distance calculations. Distance from individual SLAs within a FED (using a best fit method) to the nearest facility is used to derive an average distance for each FED.

Calculations were undertaken using the specialist mapping program called Pitney Bowes MapInfo Professional software. The concordance from SLA to FED was sourced from the ABS. For those SLAs that sit within more than one FED, the SLA was allocated to the FED where the majority of the SLA’s boundary sits.

A summary of the average, maximum and minimum distance to cancer-related infusion services and radiotherapy treatment by metropolitan and non-metropolitan FEDs for each state/territory is shown in Table 3.4 and Table 3.5, respectively. The average distance to cancer-related infusion services and radiotherapy by FED is shown in Table 3.6 and Table 3.7, respectively.

In summary, the average distance for each state/territory to cancer-related infusion services was estimated to be: • 6.7 kilometres for ACT; • 12.2 kilometres for NSW; • 147.2 kilometres for the Northern Territory; • 23.6 kilometres for Queensland; • 13.7 kilometres for South Australia; • 16.1 kilometres for Tasmania; • 8.6 kilometres for Victoria; and • 25.7 kilometres for Western Australia.

The average distance for each state/territory to radiotherapy services was estimated to be: • 10.5 kilometres for ACT; • 39.6 kilometres for NSW; • 402.0 kilometres for the Northern Territory; • 100.6 kilometres for Queensland; • 57.3 kilometres for South Australia;

10 Except for facilities where the current listed postcode does not map to a 2006 postal area. For these facilities, precise geographic positioning of each of the facilities by longitude and latitude was used. 11 FED boundaries are determined by a Redistribution Committee to ensure each FED contains the same number of electors, and may contain a number of SLAs.

Deloitte Access Economics 44 Access to cancer treatment in Australia

• 52.9 kilometres for Tasmania; • 26.8 kilometres for Victoria; and • 83.5 kilometres for Western Australia.

Table 3.4: Estimated average distance to cancer-related infusion services, by state/territory

Average Maximum Minimum All Metro Non- All Metro Non- All Metro Non- metro metro metro km km km km km km km km km ACT 6.7 6.7 N/A 7.4 7.4 N/A 5.9 5.9 N/A NSW 12.2 4.9 20.9 44.1 15.7 44.1 0.9 0.9 4.2 NT 147.3 7.8 286.7 286.7 7.8 286.7 7.8 7.8 286.7 Qld 23.6 7.8 35.6 120.5 20.3 120.5 2.2 2.2 5.3 SA 13.7 4.2 30.3 69.0 7.2 69.0 2.4 2.4 14.1 Tas 16.1 11.7 19.1 25.9 21.1 25.9 2.3 2.3 11.9 Vic 8.6 5.0 16.3 22.6 15.3 22.6 1.1 1.1 8.0 WA 25.7 11.5 82.4 137.4 30.0 137.4 2.5 2.5 20.0 Source: Deloitte Access Economics.

Table 3.5: Estimated average distance to radiotherapy services, by state/territory Average Maximum Minimum All Metro Non- All Metro Non- All Metro Non- metro metro metro km km km km km km km km km ACT 10.5 10.5 N/A 13.8 13.8 N/A 7.1 7.1 N/A NSW 34.1 6.8 66.3 245.8 20.6 245.8 0.9 0.9 4.2 NT 402.0 7.8 796.2 796.2 7.8 796.2 7.8 7.8 796.2 Qld 100.6 11.7 168.6 845.9 26.2 845.9 2.5 2.5 6.0 SA 57.3 7.5 144.5 332.5 15.5 332.5 3.9 3.9 28.2 Tas 52.9 20.0 74.9 129.5 35.5 129.5 4.4 4.4 44.3 Vic 26.8 8.7 64.6 194.0 29.9 194.0 1.2 1.2 9.4 WA 83.5 20.6 335.4 472.8 70.7 472.8 2.8 2.8 170.9 Source: Deloitte Access Economics.

Deloitte Access Economics 45 Access to cancer treatment in Australia

Table 3.6: Estimated average distance to cancer-related infusion services, by FED

Deloitte Access Economics 46 Access to cancer treatment in Australia

Table 3.6: Estimated average distance to cancer-related infusion services, by FED continued

Table 3.7: Estimated average distance to radiotherapy services, by FED

Deloitte Access Economics 47 Access to cancer treatment in Australia

Table 3.7: Estimated average distance to radiotherapy services, by FED continued

Metropolitan Non-metropolitan FED km FED km FED km FED km Northern Territory Solomon 7.8 Lingiari 796.2 Queensland Bonner 12.2 Oxley 12.1 Blair 39.3 Kennedy 413.2 Bowman 23.6 Petrie 13.5 Capricornia 365.9 Leichhardt 845.9 Brisbane 2.5 Rankin 17.4 Dawson 134.7 Longman 34.9 Dickson 12.6 Ryan 7.0 Fairfax 6.0 Maranoa 347.7 Fadden 9.5 Fisher 16.5 McPherson 6.9 Forde 26.2 Flynn 329.4 Moncrieff 6.5 Griffith 2.9 Groom 18.8 Wide Bay 79.5 Lilley 4.6 Herbert 7.9 Wright 30.8 Moreton 7.7 Hinkler 181.4 South Australia Adelaide 3.9 Makin 4.3 Barker 172.9 Port Boothby 4.3 5.5 Grey 332.5 Adelaide Hindmarsh 4.0 Sturt 4.1 Mayo 44.2 Kingston 15.5 Wakefield 28.2 Tasmania Denison 4.4 Bass 44.3 Lyons 51.0 Franklin 35.5 Braddon 129.5 Victoria Aston 9.3 Hotham 3.6 Ballarat 21.5 Batman 4.9 Isaacs 14.5 Bendigo 20.0 Bruce 10.6 Jagajaga 5.8 Corangamite 41.2 Calwell 8.2 Kooyong 3.0 Corio 9.4 Casey 29.9 Lalor 21.6 Flinders 32.7 Chisholm 4.9 La Trobe 14.6 Gippsland 77.9 Deakin 4.2 Maribyrnong 5.6 Indi 72.4 Dunkley 6.9 Melbourne 1.2 Mallee 194.0 Melbourne Gellibrand 5.3 3.6 McEwen 31.8 Ports Goldstein 5.6 Menzies 6.2 McMillan 56.5 Gorton 13.3 Scullin 7.3 Murray 84.8 Higgins 3.2 Wills 8.4 Wannon 132.6 Holt 16.8 Western Australia Brand 32.4 Moore 17.6 Durack 472.8 Canning 70.7 Pearce 59.6 Forrest 170.9 Cowan 13.2 Perth 3.7 O'Connor 362.6 Curtin 2.8 Stirling 5.6 Fremantle 8.2 Swan 5.8 Hasluck 18.3 Tangney 9.0 Source: Deloitte Access Economics.

The average distance to cancer-related infusion and radiotherapy services is larger for states/territories with a large geographical area (e.g., Northern Territory, Western Australia and Queensland). ACT has the lowest average distance with 6.6 kilometres for cancer- related infusion and 10.5 kilometres for radiotherapy. However, the ACT does not contain

Deloitte Access Economics 48 Access to cancer treatment in Australia

any non-metropolitan regions. Victoria has the next lowest average distance for cancer- related infusion and radiotherapy, at 8.6 kilometres and 26.8 kilometres respectively. The Northern Territory has the largest distances, which is representative of its relatively large geographical size and low population.

A larger average distance to radiotherapy services was found compared to cancer-related infusion services across all states/territories. However, the disparity between metropolitan and non-metropolitan regions is greater for radiotherapy services. This is anticipated due to the fewer number of radiotherapy facilities located across Australia compared to cancer- related infusion facilities, and the tendency of radiotherapy services to be located in capital cities and large regional cities.

There are large variations in average distances to cancer-related infusion and radiotherapy services across FEDs. For example, the FED with the least average distance required to access cancer-related infusion is Barton in NSW, with 0.9 kilometres. The FED with the largest average distance is Lingiari in the Northern Territory, with 286.8 kilometres.

Average distances to cancer-related infusion and radiotherapy services are larger in non- metropolitan FEDs across all states/territories (with the exception of ACT where there is no non-metropolitan FED). 12 For example, the average distance to radiotherapy services among metropolitan FEDs in Western Australia is 20.6 kilometres, while the average distance among the non-metropolitan FEDs is 335.4 kilometres. This highlights that access to cancer treatment for people living in non-metropolitan regions is less compared to people living in metropolitan regions. For some non-metropolitan FEDs, the average distance to the nearest radiotherapy service is hundreds of kilometres away. For example, in the Northern Territory the minimum distance for non-metropolitan FEDs is 796.2 kilometres.

12 Metropolitan and non-metropolitan FEDS categorised according to the Australian Electoral Commission demographic rating classification. Inner metropolitan and outer metropolitan are categorised as metropolitan, while provincial and rural are categorised as non-metropolitan.

Deloitte Access Economics 49 Access to cancer treatment in Australia

4 Focusing on specific FEDs

This chapter presents an evaluation of 20 specific federal electorate divisions (FEDs) to determine the five postcodes with least access to cancer-related infusion treatment. The average distance between general practitioners (GPs) and the five postcodes with the least access to cancer-related infusion treatment has also been estimated to determine whether access to care would be better if cancer-related infusion could be delivered through a GP. 4.1 Choosing FEDs

A more detailed evaluation of access to facilities delivering cancer-related infusion and radiotherapy services compared to access to GPs was undertaken for a sample of 20 selected regional FEDs across Australia.

The sample of federal electorates was chosen by Amgen. The aim was to capture a broad experience of rural federal electorates across Australia. The breakdown of the 20 FEDs by state/territory is listed below. • Six in NSW – Eden-Monaro, Gilmore, Lyne, Newcastle, New England, and Throsby. • One in Northern Territory - Lingiari. • Five in Queensland – Blair, Capricornia, Leichhardt, Longman, and Oxley. • One in South Australia - Wakefield. • One in Tasmania - Braddon. • Three in Victoria – Ballarat, Corangamite, and Corio. • Three in Western Australia – Forrest, O’Connor, and Tangney.

The distribution of the selected sample of electorates was mapped and is presented in Figure 4.1.

Deloitte Access Economics 50 Access to cancer treatment in Australia

Figure 4.1: Map of selected FEDs

Access to cancer treatment in Australia

The average distance to cancer-related infusion and radiotherapy treatment and estimated new cases of breast and prostate cancer for selected FEDs are presented in Table 4.1. The FED with the lowest average distance to cancer treatment is Newcastle (NSW), which was estimated to be 4.2 kilometres, both for access to cancer-related infusion and radiotherapy services. The estimated number of new cases of breast and prostate cancer in Newcastle is 192 persons in 2011. The FED with the greatest average distance to cancer-related infusion and radiotherapy services is Lingiari (Northern Territory), which was estimated to be 286.7 kilometres and 796.2 kilometres, respectively. The estimated number of new cases of breast and prostate cancer in Lingiari is 95 persons in 2011.

Table 4.1: Average distance to cancer treatment and estimated number of new cancer cases for selected FEDs Federal electorate Distance Estimated incidence Infusion Radio Total Breast Prostate kilometres persons persons persons New South Wales Eden-Monaro 11.6 94.8 236 112 124 Gilmore 17.8 58.7 250 115 136 Lyne 16.8 55.1 261 118 143 Newcastle 4.2 4.2 192 96 96 New England 22.7 133.7 234 112 122 Throsby 20.0 34.5 216 105 111 Northern Territory Lingiari 286.7 796.2 95 54 41 Queensland Blair 19.9 39.3 167 84 83 Capricornia 54.8 365.9 186 91 95 Leichhardt 120.5 845.9 191 99 92 Longman 11.4 34.9 200 97 103 Oxley 6.3 12.1 154 83 71 South Australia Wakefield 14.1 28.2 203 102 100 Tasmania Braddon 19.4 129.5 159 76 83 Victoria Ballarat 12.8 21.5 203 103 100 Corangamite 14.9 41.2 230 110 119 Corio 9.4 9.4 200 98 102 Western Australia Forrest 20.0 170.9 197 97 100 O'Connor 89.9 362.6 207 98 109 Tangney 5.1 9.0 199 102 96 Note: Estimated new number of breast and prostate cancer cases may not add up to total estimated number of new cases due to rounding. Source: Deloitte Access Economics.

Deloitte Access Economics 52 Access to cancer treatment in Australia

4.2 Postcodes with the greatest distance to cancer treatment

In order to gain a greater insight into access to cancer treatment within rural locations, the five postcodes in each selected FED with the furthest distance away from the closest cancer-related infusion service was calculated. Postal area was used to calculate minimum distance since the geographic area covered by a postal area is smaller, allowing greater precision of the facility’s location when midpoint of an area is used to approximate geographic location. The minimum distance calculation was undertaken using Pitney Bowes MapInfo Professional software. Table 4.2 shows the five furthest postcodes to cancer-related infusion services, by selected FED.

Some FEDs have good access to cancer-related infusion services and therefore the distance for the each postcode within that FED is relatively small. For example, the postcode furthest away from cancer-related infusion services in Newcastle (NSW) is 2322, but is only 11.9 kilometres away. However, other FEDs are more remote, which means the five furthest postcodes are a long distance away from services. For example, Lingiari (Northern Territory) has a postcode 6799 (Cocos (Keeling) Islands) that is 2,128.8 kilometres away from the nearest cancer-related infusion service.

Of course, access to cancer-related infusion services must also be weighed against the number of people within each postcode. In general, the more remote a location from a cancer-related infusion service, the less likely there will be a large population, and therefore the lower demand for these types of services. For example, Cocos (Keeling) Islands has a population of 573 people. A comparison of distances to population for each postcode, along with the closest hospital, is shown in Appendix C.

Deloitte Access Economics 53 Access to cancer treatment in Australia

Table 4.2: The five furthest postcodes to cancer-related infusion services, by selected FEDs Federal electorate Postcode 1 Postcode 2 Postcode 3 Postcode 4 Postcode 5 Postcode km Postcode km Postcode km Postcode km Postcode km New South Wales Eden-Monaro 2551 53.4 2546 49.4 2624 43.9 2629 42.5 2626 36.1 Gilmore 2533 23.9 2534 20.5 2538 19.9 2540 17.6 2528 14.0 Lyne 2424 35.4 2439 29.5 2441 26.7 2427 23.8 2443 21.7 Newcastle 2322 11.9 2295 6.9 2304 5.4 2294 4.1 2307 3.9 New England 2359 46.4 2475 45.9 2358 45.6 2343 43.6 2339 41.9 Throsby Northern Territory Lingiari 6799 2128.8 6798 1571.4 862 534.5 852 471.9 860 454.3 Queensland Blair 4306 53.8 4515 48.4 4311 25.9 4346 17.1 4313 16.5 Capricornia 4804 144.4 4706 105.6 4743 100.3 4739 94.4 4757 84.4 Leichhardt 4871 309.2 4895 219.6 4874 192.9 4873 91.3 4877 43.9 Longman 4514 24.1 4507 19.1 4504 12.8 4511 12.4 4503 11.9 Oxley 4300 14.5 4301 10.1 4078 8.2 4110 6.5 4076 6.1 South Australia Wakefield 5501 33.5 5502 33.1 5372 30.7 5400 30.7 5360 30.1 Tasmania Braddon 7468 72.5 7331 49.6 7321 43.4 7470 34.1 7469 28.0 Continued next page.

Access to cancer treatment in Australia

Table 4.3: The five furthest postcodes to cancer-related infusion services, by selected FED continued Federal electorate Postcode 1 Postcode 2 Postcode 3 Postcode 4 Postcode 5 Postcode km Postcode km Postcode km Postcode km Postcode km Victoria Ballarat 3460 33.4 3458 32.2 3370 29.0 3461 26.9 3345 24.3 Corangamite 3330 39.8 3333 36.0 3328 32.3 3322 31.8 3351 29.2 Corio 3223 25.3 3222 21.8 3212 20.6 3221 10.3 3224 9.4 Western Australia Forrest 6282 61.3 6281 58.7 6275 49.5 6280 44.5 6284 43.2 O'Connor 6440 640.8 6434 510.8 6436 459.2 6437 349.5 6435 306.5 Tangney 6155 7.3 6148 6.9 6153 4.3 6156 3.9 6149 3.3 Source: Deloitte Access Economics.

Access to cancer treatment in Australia

4.3 Potential improvements in providing cancer treatment

A large body of literature suggests cancer outcomes are worse for people living in non- metropolitan regions compared to people living in metropolitan regions. A number of factors contribute to these disparities. For non-metropolitan regions these include: • late stage diagnosis; • limited access to treatment facilities; • socioeconomic disadvantage; and • greater proportion of Indigenous Australians living in isolated areas (Heathcote and Armstrong 2007).

COSA (2006) also found that people in non-metropolitan locations have relatively poor access to cancer treatment compared to people living in major cities. A number of recommendations were made, including building regional oncology centres of excellence to improve access to cancer treatment in rural areas, address the workforce shortage, and make specific cancer drugs more accessible through the Pharmaceutical Benefit Scheme (PBS) (CASA 2006, Goldstein and Underhill 2007).

Access to cancer treatment is crucial to improving survival chances. Simply put, better access means better survival. Federal and state/territory governments have recognised the need for improved cancer treatment services in non-metropolitan regions and have implemented programs to reduce the disparity.

Most of the focus has been on developing better coordination of existing cancer treatment services, with specialist cancer services being delivered in large specialist centres but linked to smaller centres. Non-metropolitan cancer service provision usually occurs through outreach programs with metropolitan centres.

The federal government has invested in Cancer Service Networks (CanNET) to improve coordination of existing cancer services across primary, secondary and tertiary health care professionals (Adams et al 2009). State/territory governments are also implementing their own programs. For example, Victoria has established the Rural/Regional Integrated Cancer Services (RICS) to bring radiation oncology closer to people living in rural areas.

Although outreach programs offer greater access to care and can improve health outcomes, there are some recognised issues. Some of these include: • additional cost to service provision and high administration costs; • inconvenience for travelling specialists and an inefficient use of their time spent travelling; • the opportunity cost of taking specialists out of their main practice; and • the need to invest in specialist medical infrastructure that is used intermittently (Powell et al 2002, Gruen et al 2003).

Given better outcomes from outreach programs and the greater patient satisfaction, the general consensus is that outreach programs are generally cost effective.

Deloitte Access Economics Commercial-in-confidence 56 Access to cancer treatment in Australia

The importance of primary care in the delivery of cancer treatment has been outlined by Campbell et al (2002). GPs play a significant role through all stages of cancer, from presentation to death. The vast majority of people with early stages of cancer first present to GPs with symptoms, and GPs are heavily involved in managing co-morbidity. Furthermore, GPs play an active role in co-ordinating primary and specialist care, directing patients to appropriate care and therefore avoiding unnecessary investigations and delays.

Access improvements for cancer treatment in non-metropolitan regions could potentially be made through delivery of a wider range of services by primary care physicians. To test whether access to treatment would be improved if offered in a primary care setting compared to a secondary care setting, the five furthest postcodes from cancer-related infusion services for each FED were investigated to determine whether that postcode contained a GP. If the postcode did not, the distance to the nearest GP was estimated. This was done using Pitney Bowes MapInfo Professional software and a list of all GPs in Australia (by postcode) supplied by Amgen Australia. Results are presented in Table 4.4.

Of the 100 postcodes that are furthest away from cancer-related infusion services, 62 postcodes contain a GP. If cancer-related infusion services could be appropriately delivered through these GPs, on average cancer patients would save travelling 101.2 kilometres for treatment. However, people in some postcodes would experience a much greater reduction in travel distance. For example, postcode 6799 (Cocos (Keeling) Islands) in Lingiari contains at least one GP, which means any cancer patients living within this postcode could reduce their travel to cancer-related infusion services by 2,128.8 kilometres.

Of the 34 postcodes that do not contain a GP, there is generally a GP close by in another postcode. If cancer-related infusion services could be appropriately delivered through these GPs, on average cancer patients would save travelling 55.6 kilometres for care. Once again, cancer patients in some postcodes would benefit from using GPs more than others. For example, people in postcode 4871 in Leichhardt (Queensland) are expected to reduce their distance by 309.2 kilometres if they received cancer-related infusion services from their nearest GP rather than their current closest cancer-related infusion service, which is located in Cairns.

In general postcodes with the greatest expected benefit from reduced travel distances are not heavily populated, however there are some notable exceptions. For example, postcode 4871 in Leichhardt (Queensland) had a population of 16,344 in the 2006 ABS Census. Similarly, postcode 4306 in Blair (Queensland) had a population of 29,059, and the expected reduction in distance is 53.8 kilometres.

Deloitte Access Economics Commercial-in-confidence 57 Access to cancer treatment in Australia

Table 4.4: Distance to nearest GP versus distance to nearest cancer-related infusion service Postcode Electorate Distance to nearest Distance to nearest Potential travel Population GP infusion service saving km km km people 3345 Ballarat 7.7 24.3 16.6 974 3461 Ballarat 8.3 26.9 18.5 3,980 3370 Ballarat - 29.0 29.0 1,605 3458 Ballarat 17.1 32.2 15.0 1,387 3460 Ballarat - 33.4 33.4 2,096 4313 Blair 16.5 16.5 - 2,155 4346 Blair 17.1 17.1 - 536 4311 Blair - 25.9 25.9 8,671 4515 Blair - 48.4 48.4 2,364 4306 Blair - 53.8 53.8 29,059 7469 Braddon 20.2 28.0 7.8 847 7470 Braddon - 34.1 34.1 1,032 7321 Braddon 31.1 43.4 12.3 4,370 7331 Braddon 46.6 49.6 3.0 461 7468 Braddon 72.5 72.5 - 636 4757 Capricornia 42.7 84.4 41.7 347 4739 Capricornia 64.8 94.4 29.6 339 4743 Capricornia - 100.3 100.3 1,116 4706 Capricornia 76.1 105.6 29.5 111 4804 Capricornia - 144.4 144.4 2,400 3351 Corangamite 23.1 29.2 6.1 7,082 3322 Corangamite 28.1 31.8 3.7 122

Deloitte Access Economics 58

Access to cancer treatment in Australia

3328 Corangamite 14.4 32.3 17.9 1,465 3333 Corangamite 15.3 36.0 20.6 508 3330 Corangamite 33.7 39.8 6.2 242 3224 Corio - 9.4 9.4 8,747 3221 Corio 5.2 10.3 5.0 7,122 3212 Corio - 20.6 20.6 13,731 3222 Corio - 21.8 21.8 10,892 3223 Corio - 25.3 25.3 5,818 2626 Eden-Monaro 36.1 36.1 - 171 2629 Eden-Monaro 42.5 42.5 - 521 2624 Eden-Monaro 16.5 43.9 27.4 455 2546 Eden-Monaro - 49.4 49.4 8,313 2551 Eden-Monaro - 53.4 53.4 3,799 6284 Forrest 22.5 43.2 20.7 1,340 6280 Forrest - 44.5 44.5 19,684 6275 Forrest 38.0 49.5 11.5 1,188 6281 Forrest - 58.7 58.7 4,611 6282 Forrest 14.7 61.3 46.6 1,059 2528 Gilmore - 14.0 14.0 23,029 2540 Gilmore - 17.6 17.6 38,395 2538 Gilmore - 19.9 19.9 1,962 2534 Gilmore - 20.5 20.5 4,657 2533 Gilmore - 23.9 23.9 14,326 4877 Leichhardt - 43.9 43.9 4,166 4873 Leichhardt - 91.3 91.3 5,989 4874 Leichhardt - 192.9 192.9 3,930 4895 Leichhardt - 219.6 219.6 3,644

Deloitte Access Economics 59

Access to cancer treatment in Australia

4871 Leichhardt - 309.2 309.2 16,344 860 Lingiari - 454.3 454.3 2,923 852 Lingiari - 471.9 471.9 7,680 862 Lingiari 97.8 534.5 436.7 2,165 6798 Lingiari 976.6 1,571.4 594.8 1,349 6799 Lingiari - 2,128.8 2,128.8 573 4503 Longman - 11.9 11.9 27,206 4511 Longman - 12.4 12.4 6,137 4504 Longman - 12.8 12.8 13,001 4507 Longman - 19.1 19.1 15,914 4514 Longman - 24.1 24.1 5,475 2443 Lyne - 21.7 21.7 8,470 2427 Lyne - 23.8 23.8 2,345 2441 Lyne - 26.7 26.7 3,545 2439 Lyne 15.2 29.5 14.3 2,303 2424 Lyne 33.1 35.4 2.2 278 2339 New England 25.1 41.9 16.8 539 2343 New England - 43.6 43.6 5,161 2358 New England - 45.6 45.6 3,845 2475 New England - 45.9 45.9 387 2359 New England 46.4 46.4 - 787 2307 Newcastle 3.6 3.9 0.3 4,177 2294 Newcastle 1.1 4.1 3.0 1,794 2304 Newcastle - 5.4 5.4 14,671 2295 Newcastle - 6.9 6.9 4,734 2322 Newcastle - 11.9 11.9 17,272 6435 O'Connor 56.8 306.5 249.7 145

Deloitte Access Economics 60

Access to cancer treatment in Australia

6437 O'Connor - 349.5 349.5 728 6436 O'Connor 305.4 459.2 153.8 136 6434 O'Connor 270.5 510.8 240.3 95 6440 O'Connor - 640.8 640.8 1,175 4076 Oxley - 6.1 6.1 6,396 4110 Oxley - 6.5 6.5 7,779 4078 Oxley - 8.2 8.2 21,357 4301 Oxley - 10.1 10.1 15,436 4300 Oxley - 14.5 14.5 34,344 6149 Tangney - 3.3 3.3 19,248 6156 Tangney - 3.9 3.9 14,896 6153 Tangney - 4.3 4.3 18,198 6148 Tangney - 6.9 6.9 16,304 6155 Tangney - 7.3 7.3 40,532 2506 Throsby - 6.0 6.0 7,411 2502 Throsby - 6.6 6.6 11,749 2529 Throsby - 15.1 15.1 19,788 2527 Throsby - 20.6 20.6 19,921 2577 Throsby - 26.9 26.9 14,150 5360 Wakefield 3.2 30.1 26.9 688 5400 Wakefield 13.9 30.7 16.8 783 5372 Wakefield 13.2 30.7 17.5 1,638 5502 Wakefield - 33.1 33.1 1,308 5501 Wakefield - 33.5 33.5 6,592 Note: A distance equal to zero means there is at least one GP located in the postcode. Source: Deloitte Access Economics and ABS (2011).

Deloitte Access Economics 61

Access to cancer treatment in Australia

Evidence within the literature and through this study suggests some people with breast or cancer travel long distances to receive appropriate cancer-related infusion treatment. This imposes significant costs on the patient, and can lead to worse survival outcomes. As accessing a GP is generally better compared to accessing cancer-related infusion services in non-metropolitan regions, improvements to access for people living in these areas could be made through the delivery of a wider range of services by primary care physicians.

Deloitte Access Economics 62 Access to cancer treatment in Australia

References

Access Economics 2007, ‘Management of metastatic breast cancer: an examination of socioeconomic and regional impacts’, http://www.google.com.au/url?sa=t&source=web&cd=2&ved=0CCEQFjAB&url=http %3A%2F%2Fwww.accesseconomics.com.au%2Fpublicationsreports%2Fgetreport.php %3Freport%3D127%26id%3D169&rct=j&q=access%20economics%20cancer&ei=t77x TbOvL5CsugOGybSpBA&usg=AFQjCNGfXUlBW_5Gh6N391OGm9aPGdw7pA&cad=rja

Adams P, Hardwick J, Embree V, Sinclair S, Conn B, Bishop J 2009, ‘Literature Review: Models of Cancer Services for Rural and Remote Communities’, Cancer Institute NSW, Cat no. CR-2009-02.

Armstrong K, O’Connell DL, Leong D, et al 2004, ‘The New South Wales colorectal cancer care survey — part 1 surgical management, Sydney’, The Cancer Council NSW.

Australian Bureau of Statistics (ABS) 2011, ‘Census CDATA online’, http://www.abs.gov.au/CDATAOnline, accessed 16 June 2011.

- 2006, ‘Population Distribution, Aboriginal and Torres Strait Islander Australians’, Cat no. 4705.0, Canberra.

Australian Institute of Health and Welfare (AIHW) 2011, ‘Australian hospital statistics 2009- 10’, Cat. no. HSE 107, Canberra.

- 2011a, ‘Australian cancer incidence and mortality (ACIM) books’, http://www.aihw.gov.au/acim-books/, accessed 19 July 2011.

- 2010, ‘Cancer in Australia. An overview 2010’, Cat no. CAN56, Canberra.

- 2009, ‘Breast cancer in Australia: An overview’, Cancer series no. 50, Cat no. CAN46, Canberra.

- 2008, ‘Cancer survival and prevalence in Australia’, Cat. no. CAN 38, Canberra.

- 2008a, ‘Cancer in Australia: An overview’, Cancer series no. 46, Cat no. CAN 42, Canberra.

- 2006, ‘Cancer in Australia: an overview, 2006’, Cat No. CAN 29, Canberra.

BCCA (British Columbia Cancer Agency) 2011, ‘Communities oncology network’, http://www.bccancer.bc.ca/RS/CommunitiesOncologyNetwork/default.htm, accessed 15 June 2011.

Begbie S, Underhill C 2007, ‘Cancer service to be proud of in rural Australia: lessons learnt from the Clinical Oncological Society of Australia Cancer Service Audit’, CancerForum, 31(2).

Deloitte Access Economics 63 Access to cancer treatment in Australia

Boothroyd L, Lehoux P 2004, ‘Home-based chemotherapy for cancer: issues for patients, caregivers, and the health care system’, Agence d’évaluation des technologies et des modes d’intervention en santé, AETMIS 04-02, Montreal.

Campbell, NC, MacLeod, U, Weller, D 2002, ‘Primary care oncology: essential if high quality cancer care is to be achieved for all’, Family Practice , 19: 577-578.

Cancer Australia 2011, ‘Directory of hospital breast cancer services’, http://canceraustralia.nbocc.org.au/hospital-services-directories/directory-of- hospital-breast-cancer-services/home, accessed 18 July 2011.

Cancer Council ACT 2011, ‘Cancer services 2011-2012: a directory of cancer services in the ACT’, http://www.actcancer.org/patients-family-friends/cancer-services- directory.aspx, accessed 20 July 2011.

Cancer Council NSW 2011, ‘Cancer service directory’, http://www.cancercouncil.com.au/html/patientsfamiliesfriends/cancer_services_dir ectory/search_oncall.asp, accessed 20 July 2011.

Cancer Council Vic 2010, ‘Cancer services 2010’, http://www.cancervic.org.au/how-we-can- help/cancer_services_directory, accessed 20 July 2011.

Chapman A, Shakespeare T, Turner MB 2007, ‘Improving access to radiotherapy for regional cancer patients — the National Radiotherapy Single Machine Unit Trial’, CancerForum, 31(2).

Clinical Oncological Society of Australia (COSA) 2006, ‘Mapping Rural and Regional Oncology Services in Australia’, March.

Clinical Oncological Society of Australia (COSA), The Cancer Council Australian, the National Cancer Control Initiative 2002, ‘Optimising cancer care in Australia’, National Cancer Control Initiative, Melbourne.

Condon J 2004, ‘Cancer, health services and indigenous Australians’, Aboriginal and Torres Strait Islander Primary Health Care Review: Consultant Report No 5 , Department of Health and Ageing, Canberra.

Condon JR, Armstrong BK, Barnes A, Cunningham J 2003, ‘Cancer in Indigenous Australians: a review’, Cancer Causes & Control, 14(2): 109-121.

Coory MD, Baade PD 2005, ‘Urban-rural differences in prostate cancer mortality, radical prostatectomy and prostate-specific antigen testing in Australia’, Medical Journal of Australia, 182(3):112-115.

Coory MD, Green AC, Stirling J, Valery PC 2008, ‘Survival of Indigenous and non-Indigenous Queenslanders after a diagnosis of lung cancer: a matched cohort study’, Medical Journal of Australia, 188:562-566.

Department of Health and Ageing (DOHA) 2002, ‘A Vision for Radiotherapy’, Canberra.

Deloitte Access Economics 64 Access to cancer treatment in Australia

Department of Health and Families NT 2009, ‘Cancer services: Northern Territory directory’, http://www.health.nt.gov.au/library/scripts/objectifyMedia.aspx?file=pdf/41/06.pdf &siteID=1&str_title=NT%20Directory%20of%20Services.pdf, accessed 20 July 2011.

Department of Health and Human Services Tas 2011, ‘Cancer treatment centres’, http://www.dhhs.tas.gov.au/cancercare/directory_of_services/cancer_treatment_ce ntres accessed, 20 July 2011.

Department of Health Western Australia 2011, ‘WA caner and palliative care network: directory of cancer services’, http://www.healthnetworks.health.wa.gov.au/cancer/service/index.cfm accessed 20 July 2011.

Goldstein D, Underhill C 2007, ‘Regional cancer services in Australia: Some evidence of improvement but a long way to go’, CancerForum, 31(2).

Gruen, RL, Weeramanthri, TS, Knight, SE, et al 2003, ‘Specialist outreach clinics in primary care and rural hospital settings’, Cochrane Database of Systematic Reviews , Issue 4.

Hall SE, Holman CDJ, Della V, et al 2004, ‘Unequal Access to Breast-Conserving Surgery in Western Australia 1982:2000, ANZ Journal of Surgery, 74(6):413-419.

Heathcote KE, Armstrong BK 2007, ‘Disparities in cancer outcomes in regional and rural Australia’, CancerForum, 31(2).

Hegney D, Pearce S, Rogers-Clark C, Martin-McDonald K, Buikstra E 2005, ‘Close, but still too far. The experience of Australian people with cancer commuting from a regional to a capital city for radiotherapy treatment’, European Journal of Cancer Care, 14:75- 82

Kricker A, Haskill J, Armstrong BK 2001, ‘Breast conservation, mastectomy and axillary in New South Wales women in 1992 and 1995’, British Journal of Cancer, 85(5):668-673.

Jong KE, Smith DP, Yu XQ, O’Connell DL, Goldstein D, Armstrong BK 2004, ‘Remoteness of residence and survival from cancer in New South Wales’, Medical Journal of Australia, 180:618-622.

Jong KE, Vale PJ, Armstrong BK 2005, ‘Rural inequalities in cancer care and outcome’, Medical Journal of Australia, 182(1):13-14.

McConigley R, Holloway K, Smith J, Halkett G, Keyser J, Aoun S, Monterosso L 2010, ‘The Diagnosis and Treatment Decisions of Cancer Patients in Rural Western Australia, Cancer Nursing, 0:1-9.

Medicare 2011, ‘Medicare Australia statistics’, https://www.medicareaustralia.gov.au/cgi- bin/broker.exe?_PROGRAM=sas.mbs_item_standard_report.sas&_SERVICE=default& _DEBUG=0&VAR=services&STAT=count&PTYPE=finyear&START_DT=200907&END_D T=201006&RPT_FMT=by+state&DRILL=ag&GROUP=T0203, accessed 20 July 2011.

Deloitte Access Economics 65 Access to cancer treatment in Australia

Mitchell KJ, Fritschi L, Reid A, et al 2006, ‘Rural-urban differences in the presentation, management and survival of breast cancer in Western Australia’, Breast, 15(6):769- 76.

Morris M, Platell C, Fritschi L, et al 2007, ‘Failure to complete adjuvant chemotherapy is associated with adverse survival in stage III colon cancer patients’, British Journal of Cancer, 96:707-707.

Murray CJL, Acharya, AK 1997, ‘Understanding DALYs’, Journal of Health Economics, 16: 703-730.

Olver I, Shepherd L, Selva-Nayagam S 2007, ‘Beyond the bush telegraph: telehealth for remote cancer control and support’, CancerForum, 31(2).

Powell, J 2002, ‘Systematic review of outreach clinics in primary care in the UK’, Journal of Health Services Research & Policy , 7(3): 177-183.

Queensland Health 2010, ‘Queensland directory of cancer services’, https://qccat.health.qld.gov.au/docs/, accessed 20 July 2011.

Roder D 2007, ‘Epidemiology of cancer in Indigenous Australians: implications for service delivery’, CancerForum, 31(2).

Underhill CR, Goldstein D, Grogan PB 2006, ‘Inequity in rural cancer survival in Australia is not an insurmountable problem’, Medical Journal of Australia, 185(9):479-480.

Valery PC, Coory M, Stirling J, Green AC 2006, ‘Cancer diagnosis, treatment, and survival in Indigenous and non-Indigenous Australians: a matched cohort study’, Lancet, 367:1842-48.

Women’s Health Goulburn North East (WHGNE) 2010, ‘A literature review of the issues of women’s cancers in Australian Indigenous Communities’, Victoria.

Deloitte Access Economics 66 Access to cancer treatment in Australia

Appendix A– Estimated number of new cancer cases

Table A.1: Estimated number of new breast and prostate cancer cases by FEDs, 2011 FED Breast Prostate Total FED Breast Prostate Total persons persons persons persons persons persons Australian Capital Territory Canberra 114 104 218 Fraser 106 92 197 New South Wales Banks 106 104 211 Lyne 118 143 261 Barton 99 105 203 Macarthur 85 70 154 Bennelong 106 101 206 Mackellar 103 104 208 Berowra 97 90 187 Macquarie 99 92 192 Blaxland 95 97 192 McMahon 91 85 177 Bradfield 110 111 221 Mitchell 93 84 177 New Calare 106 114 220 England 112 122 234 Charlton 102 111 213 Newcastle 96 96 192 North Chifley 95 77 172 Sydney 103 93 196 Cook 102 102 204 Page 112 124 236 Cowper 117 132 250 Parkes 109 129 238 Cunningha m 106 114 220 Parramatta 98 93 192 Dobell 106 112 218 Paterson 108 129 237 Eden- Monaro 112 124 236 Reid 103 96 199 Farrer 109 127 236 Richmond 114 128 242 Fowler 93 85 178 Riverina 102 110 212 Gilmore 115 136 250 Robertson 111 117 228 Grayndler 94 86 179 Shortland 103 113 216 Greenway 88 75 162 Sydney 88 82 169 Hughes 95 87 181 Throsby 105 111 216 Hume 105 114 220 Warringah 105 100 205 Hunter 93 93 186 Watson 103 106 209 Kingsford Smith 102 97 198 Wentworth 104 104 207 Lindsay 89 75 164 Werriwa 85 68 153 Northern Territory Lingiari 54 41 95 Solomon 53 47 100 Queensland Blair 84 83 167 Hinkler 115 136 251 Bonner 95 91 186 Kennedy 105 121 225 Bowman 102 99 201 Leichhardt 99 92 191 Brisbane 83 73 156 Lilley 102 95 196 Capricornia 91 95 186 Longman 97 103 200 Dawson 97 99 196 Maranoa 108 122 230 Dickson 82 70 152 McPherson 108 111 219

Deloitte Access Economics 67 Access to cancer treatment in Australia

Fadden 104 105 209 Moncrieff 115 129 244 Fairfax 108 111 219 Moreton 92 89 181 Fisher 104 115 219 Oxley 83 71 154 Flynn 89 95 183 Petrie 100 99 198 Forde 84 80 164 Rankin 91 75 166 Griffith 83 72 154 Ryan 90 81 171 Groom 101 101 203 Wide Bay 114 130 245 Herbert 87 82 169 Wright 91 89 180 South Australia Adelaide 106 102 208 Makin 98 97 195 Barker 112 127 239 Mayo 112 111 223 Port Boothby 110 111 221 Adelaide 110 109 219 Grey 108 129 237 Sturt 115 114 229 Hindmarsh 114 122 235 Wakefield 102 101 203 Kingston 106 100 206 Tasmania Bass 73 74 148 Franklin 74 77 152 Braddon 76 83 159 Lyons 77 84 162 Denison 74 71 144 Victoria Aston 93 84 177 Hotham 96 97 193 Ballarat 103 100 203 Indi 105 112 217 Batman 91 94 185 Isaacs 106 105 211 Bendigo 108 117 225 Jagajaga 98 94 192 Bruce 101 107 209 Kooyong 94 89 183 Calwell 96 82 178 La Trobe 93 81 174 Casey 91 86 177 Lalor 111 88 198 Chisholm 100 102 202 Mallee 101 114 215 Corangamit e 110 119 230 Maribyrnong 93 95 189 Corio 98 102 200 McEwen 115 109 224 Deakin 97 98 194 McMillan 103 110 213 Dunkley 107 108 215 Melbourne 86 78 165 Melbourne Flinders 119 139 257 Ports 92 89 181 Gellibrand 95 91 185 Menzies 102 110 212 Gippsland 110 124 234 Murray 99 118 217 Goldstein 107 101 208 Scullin 89 83 173 Gorton 107 94 201 Wannon 101 113 214 Higgins 95 93 188 Wills 99 102 200 Holt 108 90 198 Western Australia Brand 95 98 193 Moore 94 80 174 Canning 106 119 226 O'Connor 98 109 207 Cowan 89 79 169 Pearce 94 91 184 Curtin 101 100 200 Perth 96 97 193 Durack 84 92 176 Stirling 100 99 199 Forrest 97 100 197 Swan 102 96 197 Fremantle 97 92 189 Tangney 102 96 199 Hasluck 98 94 192 Source: Deloitte Access Economics.

Deloitte Access Economics 68 Access to cancer treatment in Australia

Appendix B - Hospitals offering cancer treatment

Table B.1: Planned cancer treatment sites by state/territory State/territory Hospital Postcode Radiotherapy services NSW Gosford Hospital 2250 Shoalhaven District Memorial Hospital 2541 St George Private Hospital 2217 Tamworth Rural Referral Hospital 2340 Qld Rockhampton Hospital 4700 Tas North West Regional Hospital 7320 Vic Ballarat Health Services 3350 South West Health Care Warrnambool Campus 3280 Infusion services Vic Sunbury Day Hospital 3429 WA South West Health Campus 6230 Source: Deloitte Access Economics.

Table B.2: Hospitals offering cancer-related infusion services in Australia Hospital Postcode Hospital Postcode Australia Capital Territory Calvary Health Care - ACT 2617 National Capital Private Hospital 2605 John James Memorial Hospital 2600 The Canberra Hospital 2605 New South Wales Albury Base Hospital 2640 Lismore Base Hospital 2480 Albury Wodonga Private Hospital 2640 Lithgow Integrated Health Service 2790 Armidale Rural Referral Hospital 2350 Liverpool Hospital 2170 Balranald Health Service 2715 Lottie Stewart Hospital 2117 Lourdes Hospital & Community Bankstown Hospital 2200 Health Services 2830 Baradine Multi Purpose Service 2396 Macquarie University Hospital 2109 Barham Hospital 2732 Manilla Health Service 2346 Barraba Multi Purpose Service 2347 Manly Hospital 2095 Bathurst Base Hospital 2795 Manly Waters Private Hospital 2095 Batlow Hospital 2730 Manning Rural Referral Hospital 2430 Bega District Hospital 2550 Mayo Private Hospital 2430 Berrigan Hospital 2628 Mercy Care Centre 2594 Bingara Multipurpose Service 2404 Milton Ulladulla Hospital 2539 Blacktown Hospital Oncology Unit 2148 Molong Hospital 2866 Boggabri Health Service 2382 Moree District Health Service 2400 Bombala Hospital 2630 Moruya District Hospital 2537 Boorowa Hospital 2586 Mudgee Health Service 2850

Deloitte Access Economics 69 Access to cancer treatment in Australia

Muswellbrook District Health Bourke Multi Purpose Service 2840 Service 2333 Bowral Day Surgery 2576 Narrabri Health Service 2390 Braidwood District Hospital 2622 Narromine Health Service 2821 Brisbane Waters Private Hospital 2256 Nepean Hospital 2750 Broken Hill Health Service 2880 Newcastle Private Hospital 2305 Calvary Hospital - Wagga Wagga 2650 North Gosford Private Hospital 2250 Calvary Mater Newcastle 2298 North Shore Private Hospital 2065 2560 Northern Cancer Institute - Frenchs Campbelltown Hospital Forest 2086 Canowindra Hospital 2804 Nowra Private Hospital 2541 Castlecrag Private Hospital 2068 Nyngan Health Service 2825 Cessnock District Hospital 2325 Oberon Multi Purpose Service 2787 Coffs Harbour Health Campus 2450 Orange Base Hospital 2800 Collarenebri Health Service 2833 Parkes Health Service 2870 Concord Repatriation General Hospital 2139 Peak Hill Hospital 2869 Coolah Multi Purpose Service 2843 Port Macquarie Base Hospital 2444 Cooma Health Service 2630 Portland Tabulam Health Centre 2847 Coonamble Health Service 2829 President Private Hospital 2232 Cootamundra Hospital 2590 Prince Albert Memorial Tenterfield 2372 Corowa Hospital 2646 Prince of Wales Hospital 2031 Cowra Health Service 2794 Queanbeyan District Hospital 2620 Culcairn Hospital 2660 Riverina Cancer Care Centre 2650 Delegate District Hospital 2633 Royal Hospital for Women 2031 Deniliquin Hospital 2710 Royal Prince Alfred Hospital 2050 Dorrigo Multi Purpose Service 2453 Rylstone Health Service 2849 Shoalhaven District Memorial Dubbo Base Hospital 2830 Hospital 2541 Dunedoo War Memorial Health Southern Highlands Private Service 2844 Hospital 2576 Southern Highlands Private Emmaville Mulit Purpose Service 2371 Hospital Specialist Centre 2576 Eugowra Hospital 2806 Southern Medical Day Care Centre 2500 Eurobodalla Oncology Service 2537 St George Private Hospital 2217 Gilgandra Multi Purpose Service 2827 St George Public Hospital 2217 Glen Innes Hospital 2370 St Vincent's Clinic (Sydney) 2010 Gloucester Soldiers Memorial St Vincents Private Hospital - Hospital 2422 Lismore 2480 Gosford Hospital 2250 St Vincents Private Hospital Sydney 2010 Governor Phillip Hospital 2751 St Vincents Public Hospital 2010 Gower Wilson Memorial Hospital 2898 Strathfield Private Hospital 2135 Grafton Base Hospital 2460 Sydney Adventist Hospital 2076 Grenfell Multipurpose Health Service 2810 Sydney Children's Hospital 2031 Sydney Haematology and Oncology Griffith Base Hospital 2680 Clinic 2077 Gulargambone Multi Purpose Service 2828 Tamworth Rural Referral Hospital 2340 Gulgong Health Service 2850 The Bourke Street Health Service 2580

Deloitte Access Economics 70 Access to cancer treatment in Australia

Gundagai Hospital 2722 The Children's Hospital Westmead 2145 Gunnedah Health Service 2380 The John Hunter Hospital 2305 Guyra Multi Purpose Service 2365 The Mater Hospital, Sydney 2060 Harden Hospital 2587 The Sutherland Hospital 2228 Hay District Hospital 2711 The Tweed Hospital 2485 Henty Hospital 2658 The Wollongong Hospital 2500 Trangie Multi Purpose Health Hills Private Hospital 2153 Service 2823 Hobart Private Hospital / St Helens Hospital 7001 Tumbarumba District Hospital 2653 Holbrook Hospital 2644 Tumut District Hospital 2720 Hornsby Ku-ring-gai Hospital 2077 Wagga Wagga Base Hospital 2650 Illawarra Private Cancer Care & Research Centre 2500 Walcha Multi Purpose Service 2354 Inverell District Hospital 2360 Warialda Health Service 2402 Warren Multi Purpose Health Junee Hospital 2663 Service 2824 Kyogle Memorial Multi Purpose Service 2474 Werris Creek Community Hospital 2341 Lake Cargelligo Multi Purpose Service 2672 West Wyalong Hospital 2671 Lake Macquarie Private Hospital 2290 Westmead Hospital 2145 Leeton Hospital 2705 Westmead Private Hospital 2145 Lightning Ridge Multipurpose Health Service 2834 Wyong Hospital 2259 Lingard Private Hospital 2291 Young Health Service 2594 Northern Territory Alice Springs Hospital 0870 Gove District Hospital 0880 Darwin Private Hospital 0810 Royal Darwin Hospital 0810 Queensland Allamanda Private Hospital 4215 Mater Hospital, Rockhampton 4700 4883 Mater Misericordiae Hospital Atherton Hospital Bundaberg 4670 Mater Misericordiae Hospital Bamaga Hospital 4876 Gladstone 4680 Mater Misericordiae Hospital Biggenden Hospital 4621 Townsville Ltd 4810 Brisbane Private Hospital 4000 Mater Private Hospital Redland 4101 Bundaberg Base Hospital 4670 Mater Private Hospital, Brisbane 4101 4510 Mater Women's & Children's Caboolture Private Hospital Private Health Services 4101 4870 Mater Women's and Children's Cairns Base Hospital Hospital Hyde Park 4812 Cairns Private Hospital 4870 Millmerran Hospital 4357 Canossa Services 4075 Monto Health Service 4630 Charleville Hospital 4470 Moranbah Hospital 4744 Cherbourg Hospital 4605 Mount Isa Base Hospital 4825 Clermont Multi Purpose Health Service 4721 Mundubbera Health Service 4626 Cloncurry Hospital 4824 Nambour General Hospital 4560

Deloitte Access Economics 71 Access to cancer treatment in Australia

Cooloola Community Private Hospital 4570 Noosa Hospital 4566 Cunnamulla Hospital 4490 Normanton Hospital 4890 Dalby Hospital 4405 Northwest Private Hospital 4053 Dysart Hospital 4745 Oakey Hospital 4401 Pindara - Gold Coast Private Emerald Hospital 4720 Hospital 4214 Esk Hospital 4312 Princess Alexandra Hospital 4102 Friendly Society Private Hospital 4670 Redcliffe Hospital 4020 Gayndah Hospital 4625 Richmond Hospital 4822 Gin Gin Hospital 4671 Rockhampton Hospital 4700 Gladstone Hospital 4680 Roma Hospital 4455 Royal Brisbane & Women's Gold Coast Hospital 4215 Hospital 4029 Goondiwindi Hospital 4413 Royal Children's Hospital 4029 South Burnett Community Private Greenslopes Private Hospital 4120 Hospital 4610 Gympie Hospital 4570 Springsure Hospital 4722 Gympie Private hospital 4570 St Andrews Toowoomba Hospital 4350 St Andrew's War Memorial Hervey Bay Hospital 4655 Hospital 4000 St Stephen's Hospital - HOCA Chermside 4035 Maryborough 4650 HOCA Gold Coast 4215 St Stephen's Hospital Hervey Bay 4655 Holy Spirit Northside 4032 St Vincent's Hospital - Toowoomba 4350 Hughenden Hospital 4821 Stanthorpe Hospital 4380 Ingham Health Service 4850 Sunnybank Private Hospital 4109 Inglewood Multipurpose Health Sunshine Coast Haematology and Service 4387 Oncology Clinic 4558 Innisfail Hospital 4860 Tara Health Service 4421 Ipswich Hospital 4305 Taroom Hospital 4420 John Flynn - Gold Coast Private Hospital 4224 Texas Hospital 4385 Kingaroy Hospital - South Burnett Health Services 4610 The Prince Charles Hospital 4032 The Sunshine Coast Private Kirwan Hospital 4817 Hospital 4556 Mackay Base Hospital 4740 The Townsville Hospital 4814 Maryborough Hospital 4650 Theodore Hospital 4719 Mater Adult Hospital, Brisbane 4101 Toowoomba Health Services 4350 Mater Children's Hospital 4101 Warwick Hospital 4370 Mater Hospital Yeppoon 4703 Wesley Hospital 4066 Mater Hospital, Mackay 4740 Yeppoon Hospital 4703 South Australia Ardrossan Community Hospital 5571 Modbury Public Hospital 5092 Mount Gambier District Health Ashford Community Hospital 5035 Service 5290 Balaklava & Riverton Districts Mount Pleasant District Hospital (a Health Service Inc - Balaklava SMD Campus of Northern Adelaide Hills Hospital 5461 Health Service) 5235 Booleroo Centre District Hospital Mt Barker District Soldiers and Health Service 5482 Memorial Hospital 5251 Murray Bridge Soldiers Memorial Bordertown Memorial Hospital 5268 Hospital 5253

Deloitte Access Economics 72 Access to cancer treatment in Australia

Burnside War Memorial Hospital Inc 5065 Naracoorte Health Service 5271 Burra Hospital 5417 Noarlunga Health Services 5168 Calvary Central Districts Hospital 5112 Orroroo and District Hospital 5431 Calvary North Adelaide Hospital 5006 Penola War Memorial Hospital 5277 Peterborough Soldiers Memorial Calvary Wakefield Hospital 5000 Hospital 5422 Ceduna District Health Services Inc 5690 Port Augusta Hospital 5700 Clare Hospital 5453 Port Broughton District Hospital 5522 Cleve Hospital 5640 Port Lincoln Health Service 5606 Cowell Community Health & Aged Care 5602 Port Pirie Regional Health Service 5540 Crystal Brook & District Hospital 5523 Quorn Health Services 5433 Cummins & District Memorial Renmark Paringa District Hospital Hospital 5631 inc 5341 Eastern Eyre Health and Aged Care - Kimba Campus 5641 Repatriation General Hospital 5041 Eudunda Campus, Eudunda & Kapunda Health Service 5374 Riverland Regional Hospital, Berri 5343 Riverton District Soldiers Memorial Flinders Medical Centre 5042 Hospital 5412 Flinders Private Hospital (Acha Health) 5042 Roxby Downs Health Service 5725 Home Nurses Infusion Centre 5067 Royal Adelaide Hospital 5000 Jamestown Hospital and Health Services Inc 5491 South Coast District Hospital 5211 Southern Flinders Health - Laura Kangaroo Island Health Service 5223 and Gladstone 5480 Keith & District Hospital 5267 St Andrews Hospital, Adelaide 5000 Kimba District Health and Aged Care 5641 Tennyson Centre Day Hospital 5037 Kingston Soldiers' Memorial Hospital 5275 Tennyson Infusion Centre 5037 Lameroo District Health Services 5302 The Queen Elizabeth Hospital, SA 5011 Lower North Health - Clare Centre 5453 Tumby Bay Hospital 5605 Loxton Hospital Complex Inc 5333 Wallaroo Hospital 5556 Lyell McEwin Hospital 5112 Western Hospital 5022 Maitland Hospital 5573 Whyalla Hospital 5600 Mannum District Hospital Inc 5238 Women's and Children's Hospital 5006 Millicent and District Hospital and Health Services Inc 5280 Yorke Penninsula Health Service 5576 Tasmania Calvary Health Care Tasmania - St Vincent's Campus 7250 May Shaw Health Centre 7190 Calvary Health Care Tasmania (Hobart) 7008 Mersey Community Hospital 7307 Calvary Health Care Tasmania, St Midlands Multipurpose Health Johns 7004 Centre 7120 Calvary Health Care Tasmania, St Lukes Campus 7250 North West Regional Hospital 7320 Campbell Town Multipurpose Centre 7210 Royal Hobart Hospital 7001 Esperance Multipurpose Centre 7117 Smithton District 7330

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Flinders Island Multi Purpose Centre 7255 St Helens District Hospital 7216 George Town Hospital and Community Care 7253 Toosey Aged and Community Care 7301 King Island Hospital & Health Centre 7256 West Coast District Hospital 7467 Launceston General Hospital 7250 Victoria Alpine Health (Mount Beauty) 3699 Melbourne Private Hospital 3052 Alpine Health (Myrtleford) 3736 Mercy Hospital for Women 3084 Angliss Hospital 3156 Mildura Base Hospital 3502 Austin Health 3084 Mildura Private Hospital 3502 Monash Medical Centre - Bairnsdale Regional Health Service 3875 Moorabbin Campus 3165 Ballarat Day Procedure Centre 3350 Moyne Health Services 3284 Ballarat Health Services 3350 Mt Alexander Hospital 3450 Ballarat Health Services (Queen Elizabeth Centre) 3350 Murray Valley Private Hospital 3690 Ballarat Oncology & Haematology Services 3355 Nathalia District Hospital 3638 Barwon Health - The Geelong Northeast Health Wangaratta/ Hospital 3220 Wangaratta Base Hospital 3677 Bass Coast Regional Health 3995 Northern Hospital 3076 Beaufort & Skipton Health Services - Beaufort Campus 3373 Numurkah District Health Service 3636 Beaufort & Skipton Health Services - Skipton Campus 3361 Omeo District Health 3898 3931 Otway Health and Community Beleura Private Hospital Services 3233 Benalla and District Memorial Hospital 3672 Peninsula Oncology Centre 3199 3552 Penninsula Private Hospital, Bendigo Health Victoria 3199 Boort District Health 3537 Peter James Centre 3131 Box Hill Hospital 3128 Peter MacCallum Cancer Centre 3002 Bundoora Extended Care Centre 3083 Portland District Health 3305 Cabrini Brighton 3186 Ringwood Private Hospital 3135 Cabrini Hospital, Malvern 3144 Robinvale District Health Services 3549 Rochester and Elmore District Casterton Memorial Hospital 3311 Health Service 3561 Central Gippsland Health Service 3850 Rosebud Hospital 3939 Royal Melbourne Hospital - City Cobram District Hospital 3644 Campus 3052 Cohuna District Hospital 3568 Seymour District Memorial Hospital 3660 Colac Area Health 3250 Shepparton Private Hospital 3630 Craigieburn Health Service 3064 South Eastern Private Hospital 3174 Djerriwarrh Health Services 3340 South Gippsland Hospital 3960 South West Health Care East Grampians Health Service 3777 Warrnambool Campus 3280 East Wimmera Health Service South West Healthcare, (Birchip) 3483 Camperdown Campus 3260 East Wimmera Health Service Southern Health - Monash Medical (Charlton) 3525 Centre 3165

Deloitte Access Economics 74 Access to cancer treatment in Australia

East Wimmera Health Service St Frances Xavier Cabrini Hospital - (Donald) 3480 Malvern 3144 East Wimmera Health Service (St Arnaud) 3478 St George's Health Service 3101 East Wimmera Health Service (Wycheproof) 3527 St John of God Health Care Bendigo 3550 St John of God Health Care, Echuca Regional Health 3564 Berwick 3806 Edenhope & District Memorial St John of God Hospital Hospital 3318 (Warrnambool) 3280 Epworth Eastern Hospital 3128 St John of God Hospital, Ballarat 3350 Epworth Freemasons Hospital 3002 St John of God Hospital, Geelong 3220 St Vincents & Mercy Private Epworth Hospital 3121 Hospital (Mercy Campus) 3002 Frankston Hospital (Peninsula Health) 3199 St Vincent's Hospital Melbourne 3065 Gippsland Southern Health Service 3953 St Vincent's Private Hospital 3065 Goonawarra Day Hospital 3429 Stawell Regional Health 3380 Goulburn Valley Health 3630 Swan Hill District Hospital 3585 Hamilton Base Hospital 3300 Tallangatta Health Service 3700 Terang and Mortlake Health Hesse Rural Health Service 3241 Service 3264 Heywood Rural Health 3304 The Alfred - Melbourne 3004 Inglewood and District Health Service 3517 The Royal Melbourne Hospital 3050 Upper Murray Health and Jessie McPherson Private Hospital 3168 Community Services 3707 John Fawkner Private Hospital 3058 Vaucluse Hospital 3056 Warringal Private Hospital (Ramsay Kerang District Health 3579 Health Care) 3084 Kilmore and District Hospital 3764 Waverley Private Hospital 3149 Kingston Centre 3192 Werribee Mercy Hospital 3030 Kooweerup Regional Health Service 3981 West Gippsland Hospital 3820 West Wimmera Health Service Kyabram & District Health Services 3620 (Nhill) 3418 West Wimmera Health Service Kyneton District Health Service 3444 (Rainbow) 3424 Western District Health Service - Coleraine and District Health Latrobe Regional Hospital 3844 Service Campus 3315 Western District Health Service - Penshurst and District Health Lorne Community Hospital 3232 Service Campus 3289 Western District Health Service, Maldon Hospital 3463 Victoria 3300 Mallee Track Health and Western Health (Sunshine Hospital Community Service 3490 & Western Hospital) 3021 Manangatang and District Hospital 3546 Western Hospital 3011 Mansfield District Hospital 3722 Western Private Hospital 3011 Wimmera Health Care Group - Maroondah Hospital 3135 Horsham Base Hospital 3400 Maryborough District Health Service (Dunolly) 3472 Yarra Ranges Health 3140

Deloitte Access Economics 75 Access to cancer treatment in Australia

Maryborough District Health Service (Maryborough) 3465 Yarram & District Health Service 3971 Maryvale Private Hospital 3831 Yarrawonga District Health Service 3730 Masada Private Hospital 3183 Yea and District Memorial Hospital 3717 McIvor Health and Community Services 3523 Western Australia Albany Hospital 6330 Kellerberrin Health Services 6410 Augusta Hospital 6290 King Edward Memorial Hospital 6008 Beverley Hospital 6304 Kununoppin Hospital 6489 Boyup Brook Soldiers Memorial Lake Grace & Districts Health Hospital 6244 Service 6353 Bridgetown Hospital 6255 Merredin Hospital 6415 Bruce Rock Memorial Hospital 6418 Mount Hospital 6000 Bunbury Hospital 6230 Mullewa Hospital 6630 Carnarvon Hospital 6701 Northam Hospital 6401 Concept Day Hospital 6008 Northampton Hospital 6535 Corrigin Hospital 6375 Peel Health Campus 6210 Plantagenet Cranbrook Health Denmark Health Service 6333 Service 6324 Derby Hospital 6728 Ravensthorpe Hospital 6346 Donnybrook Hospital 6239 Royal Perth Hospital 6847 Esperance Health Service 6450 Sir Charles Gairdner Hospital 6009 Exmouth District Hospital 6707 Southern Cross Hospital 6426 Fremantle Hospital 6160 St John of God Hospital, Bunbury 6230 Geraldton Regional Hospital 6530 St John of God Hospital, Geraldton 6530 Halls Creek District Hospital 6770 St John of God Hospital, Murdoch 6150 Harvey District Hospital 6220 St John of God Hospital, Subiaco 6008 Hollywood Private Hospital 6009 Wagin Hospital 6315 Joondalup Health Campus 6027 Wyalkatchem Hospital 6485 Kalgoorlie Hospital 6430 York Hospital 6302 Source: Cancer Australia and DoHA.

Deloitte Access Economics 76 Access to cancer treatment in Australia

Table B.3: Hospitals offering radiotherapy services in Australia Hospital Postcode Hospital Postcode Australia Capital Territory The Canberra Hospital 2605 New South Wales Calvary Mater Newcastle 2298 St George Hospital 2217 Campbelltown Hospital 2560 St Vincent's Hospital 2010 Coffs Harbour Health Campus 2450 Westmead Hospital 2145 Lismore Base Hospital 2480 Wollongong Hospital 2500 Liverpool Hospital 2170 Riverina Cancer Care Centre 2650 Gosford - Radiation Oncology Nepean Hospital 2750 Institute 2250 Orange Base Hospital 2800 Macquarie University Hospital 2109 Port Macquarie Base Hospital 2444 Mater Sydney 2060 Prince of Wales Hospital 2031 St Vincent's Clinic 2010 Royal North Shore Hospital 2065 Sydney Adventist Hospital 2076 Royal Prince Alfred Hospital 2050 Northern Territory Royal Darwin Hospital 0810 Queensland Royal Brisbane and Women's Hospital 4006 Premion, Nambour 4560 Princess Alexandra Hospital 4102 Premion, Southport 4215 The Townsville Hospital 4814 John Flynn Private Hospital 4224 The Mater Hospital 4101 St Andrew's Toowoomba Hospital 4350 The Wesley Medical Centre 4066 Oceania Oncology 4558 Chermside Medical Complex 4032 South Australia Royal Adelaide Hospital 5000 Flinders Private Hospital 5042 Lyell McEwin Hospital 5112 Adelaide Cancer Centre 5037 Adelaide Radiotherapy Centre 5000 Tasmania Launceston General Hospital 7250 Royal Hobart Hospital 7000 Victoria Austin Health - Heidelberg Peter MacCallum Cancer Institute - Repatriation Hospital 3084 East Melbourne 3002 St John of God Hospital Ballarat 3350 Epworth-Freemason's Hospital 3002 Barwon Health - Geelong Hospital Campus 3220 Frankston Private 3199 Bendigo Radiotherapy Centre 3550 Western Private Hospital 3011 Epworth Eastern Medical Centre 3126 Ringwood Private Hospital 3135 Epping Medical and Specialist Monash Cancer Centre 3165 Centre 3076 The Alfred 3004 Murray Valley Private Hospital 3690 Latrobe Regional Hospital 3844 Tattersalls Cancer Centre 3121 Sunshine Hospital 3021 Western Australia Sir Charles Gairdner Hospital 6009 Royal Perth Hospital 6000 Perth Radiation Oncology Centre 6014 Source: DoHA.

Deloitte Access Economics 77 Access to cancer treatment in Australia

Appendix C– Distance versus population among postcodes

Table C.1: Distance to nearest cancer-related infusion service versus population of postcode Postcode Electorate Nearest infusion service Distance Population 3345 Ballarat Ballarat Health Services 24.3 974 3461 Ballarat Mt Alexander Hospital 26.9 3,980 Ballarat Oncology & Haematology 3370 Ballarat Services 29.0 1,605 3458 Ballarat Kyneton District Health Service 32.2 1,387 3460 Ballarat Mt Alexander Hospital 33.4 2,096 4313 Blair Esk Hospital 16.5 2,155 4346 Blair Ipswich Hospital 17.1 536 4311 Blair Esk Hospital 25.9 8,671 4515 Blair Esk Hospital 48.4 2,364 4306 Blair Esk Hospital 53.8 29,059 7469 Braddon West Coast District Hospital 28.0 847 7470 Braddon West Coast District Hospital 34.1 1,032 7321 Braddon North West Regional Hospital 43.4 4,370 7331 Braddon Smithton District 49.6 461 7468 Braddon West Coast District Hospital 72.5 636 4757 Capricornia Mackay Base Hospital 84.4 347 4739 Capricornia Mackay Base Hospital 94.4 339 4743 Capricornia Moranbah Hospital 100.3 1,116 4706 Capricornia Yeppoon Hospital 105.6 111 4804 Capricornia Moranbah Hospital 144.4 2,400 3351 Corangamite Ballarat Health Services 29.2 7,082 3322 Corangamite Colac Area Health 31.8 122 3328 Corangamite Hesse Rural Health Service 32.3 1,465 3333 Corangamite Ballarat Health Services 36.0 508 3330 Corangamite Hesse Rural Health Service 39.8 242 Barwon Health - The Geelong 3224 Corio Hospital 9.4 8,747 Barwon Health - The Geelong 3221 Corio Hospital 10.3 7,122 Barwon Health - The Geelong 3212 Corio Hospital 20.6 13,731 Barwon Health - The Geelong 3222 Corio Hospital 21.8 10,892 3223 Corio Werribee Mercy Hospital 25.3 5,818

Deloitte Access Economics 78 Access to cancer treatment in Australia

2626 Eden-Monaro Cooma Health Service 36.1 171 2629 Eden-Monaro Cooma Health Service 42.5 521 2624 Eden-Monaro Berrigan Hospital 43.9 455 2546 Eden-Monaro Moruya District Hospital 49.4 8,313 2551 Eden-Monaro Bega District Hospital 53.4 3,799 6284 Forrest Augusta Hospital 43.2 1,340 6280 Forrest St John of God Hospital, Bunbury 44.5 19,684 6275 Forrest Augusta Hospital 49.5 1,188 6281 Forrest St John of God Hospital, Bunbury 58.7 4,611 6282 Forrest Augusta Hospital 61.3 1,059 2528 Gilmore The Wollongong Hospital 14.0 23,029 Shoalhaven District Memorial 2540 Gilmore Hospital 17.6 38,395 2538 Gilmore Milton Ulladulla Hospital 19.9 1,962 Shoalhaven District Memorial 2534 Gilmore Hospital 20.5 4,657 Shoalhaven District Memorial 2533 Gilmore Hospital 23.9 14,326 4877 Leichhardt Cairns Base Hospital 43.9 4,166 4873 Leichhardt Cairns Base Hospital 91.3 5,989 4874 Leichhardt Bamaga Hospital 192.9 3,930 4895 Leichhardt Cairns Base Hospital 219.6 3,644 4871 Leichhardt Cairns Base Hospital 309.2 16,344 860 Lingiari Alice Springs Hospital 454.3 2,923 852 Lingiari Darwin Private Hospital 471.9 7,680 862 Lingiari Alice Springs Hospital 534.5 2,165 6798 Lingiari Exmouth District Hospital 1571.4 1,349 6799 Lingiari Exmouth District Hospital 2128.8 573 4503 Longman HOCA Chermside 11.9 27,206 4511 Longman Caboolture Private Hospital 12.4 6,137 4504 Longman Caboolture Private Hospital 12.8 13,001 4507 Longman Caboolture Private Hospital 19.1 15,914 4514 Longman Caboolture Private Hospital 24.1 5,475 2443 Lyne Mayo Private Hospital 21.7 8,470 2427 Lyne Mayo Private Hospital 23.8 2,345 2441 Lyne Port Macquarie Base Hospital 26.7 3,545 2439 Lyne Port Macquarie Base Hospital 29.5 2,303 Gloucester Soldiers Memorial 2424 Lyne Hospital 35.4 278 2339 New England Werris Creek Community Hospital 41.9 539 2343 New England Werris Creek Community Hospital 43.6 5,161 2358 New England Manilla Health Service 45.6 3,845 Kyogle Memorial Multi Purpose 2475 New England Service 45.9 387

Deloitte Access Economics 79 Access to cancer treatment in Australia

2359 New England Bingara Multipurpose Service 46.4 787 2307 Newcastle Calvary Mater Newcastle 3.9 4,177 2294 Newcastle Lingard Private Hospital 4.1 1,794 2304 Newcastle Calvary Mater Newcastle 5.4 14,671 2295 Newcastle Calvary Mater Newcastle 6.9 4,734 2322 Newcastle Calvary Mater Newcastle 11.9 17,272 6435 O'Connor Kalgoorlie Hospital 306.5 145 6437 O'Connor Kalgoorlie Hospital 349.5 728 6436 O'Connor Kalgoorlie Hospital 459.2 136 6434 O'Connor Esperance Health Service 510.8 95 6440 O'Connor Kalgoorlie Hospital 640.8 1,175 4076 Oxley Canossa Services 6.1 6,396 4110 Oxley Sunnybank Private Hospital 6.5 7,779 4078 Oxley Canossa Services 8.2 21,357 4301 Oxley Ipswich Hospital 10.1 15,436 4300 Oxley Ipswich Hospital 14.5 34,344 6149 Tangney St John of God Hospital, Murdoch 3.3 19,248 6156 Tangney Hollywood Private Hospital 3.9 14,896 6153 Tangney St John of God Hospital, Murdoch 4.3 18,198 6148 Tangney St John of God Hospital, Murdoch 6.9 16,304 6155 Tangney St John of God Hospital, Murdoch 7.3 40,532 2506 Throsby The Wollongong Hospital 6.0 7,411 2502 Throsby The Wollongong Hospital 6.6 11,749 2529 Throsby The Wollongong Hospital 15.1 19,788 2527 Throsby The Wollongong Hospital 20.6 19,921 Shoalhaven District Memorial 2577 Throsby Hospital 26.9 14,150 Mount Pleasant District Hospital (a Campus of Northern Adelaide 5360 Wakefield Hills Health Service) 30.1 688 Riverton District Soldiers 5400 Wakefield Memorial Hospital 30.7 783 Riverton District Soldiers 5372 Wakefield Memorial Hospital 30.7 1,638 Balaklava & Riverton Districts Health Service Inc - Balaklava SMD 5502 Wakefield Hospital 33.1 1,308 5501 Wakefield Lyell McEwin Hospital 33.5 6,592 Source: Deloitte Access Economics.

Deloitte Access Economics 80

Limitation of our work

General use restriction

This report is prepared solely for the internal use of Amgen Australia Pty Ltd. This report is not intended to and should not be used or relied upon by anyone else and we accept no duty of care to any other person or entity. The report has been prepared for the purpose of gaining greater insight into the estimated distance to cancer-related infusion services and radiation therapy treatment. You should not refer to or use our name or the advice for any other purpose.

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