The State of Cancer Control in 1987-2007: Changes in cancer incidence and mortality 2 • The State of Cancer Control in Australia

Cancer Council NSW November 2013

Authors Eleonora Feletto Alison Gibberd Clare Kahn Katie Armstrong Karen Canfell May Chiew Paul Grogan Carolyn Nickson Dianne O’Connell Andrew Penman Monica Robotin David P Smith Megan A Smith Rajah Supramaniam Louiza Velentzis Marianne Weber Xue Qin Yu Freddy Sitas

Acknowledgments The authors would like to thank Mark Short at the Australian Institute of Health and Welfare and Julia Fitzgerald from the Australian Bureau of Statistics for compiling the tables for us, and for providing invaluable advice on ICD changes and conversion codes. We would also like to thank Priscilla Johnson, Associate Professor Peter Baade and Professor Bernard W Stewart for reviewing the document. ISBN 978-1-921619-95-3 Key words: Cancer control, Australia, neoplasms, incidence, mortality, cancer Suggested citation: Feletto E, Gibberd A, Kahn C, Armstrong K, Canfell K, Chiew M, Grogan P, Nickson C, O’Connell D, Penman A, Robotin M, Smith DP, Smith MA, Supramaniam R, Velentzis L, Weber MF, Yu XQ, Sitas F. The State of Cancer Control in Australia: 1987–2007: Changes in cancer incidence and mortality. Sydney: Cancer Council NSW; 2013.

Published by Cancer Council NSW 2013

November, 2013 Table of Contents 1. Abbreviations 9 2. Report Overview 11 3. Executive Summary 13 3.1. Background 13 3.2. Aims 13 3.3. Methods 14 3.4. Results 14 3.4.1. 14 3.4.2. Cervical cancer 14 3.4.3. 15 3.4.4. Liver cancer 15 3.4.5. 15 3.4.6. Melanoma 15 3.4.7. 16 3.4.8. Stomach cancer 16 3.4.9. Australian approach to health care and cancer control 16 3.5. Discussion 17 3.6. Conclusion 17 4. Introduction 21 5. Methods 25 5.1. Incidence and mortality changes 25 5.2. National policy development 26 6. Results: analysis of findings overall – incidence and mortality 29 6.1. Changes in mortality 29 6.2. Changes in incident cases 30 6.3. Overall changes 34 7. Results: analysis of cancer types - incidence and mortality 37 7.1. Breast cancer (C50) 39 7.1.1. Background 39 7.1.2. Incidence and mortality rates in Australia, 1987–2007 42 7.2. Cervical cancer (C53) 44 7.2.1. Background 44 7.2.2. Incidence and mortality rates in Australia, 1987–2007 49 7.3. Colorectal cancer (C18–C20) 55

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7.3.1. Background 55 7.3.2. Incidence and mortality rates in Australia, 1987–2007 58 7.4. Liver cancer (C22) 63 7.4.1. Background 63 7.4.2. Incidence and mortality rates in Australia, 1987–2007 65 7.5. Lung cancer (C33–C34) 68 7.5.1. Background 68 7.5.2. Incidence and mortality rates in Australia, 1987–2007 72 7.6. Melanoma (C43) 77 7.6.1. Background 77 7.6.2. Incidence and mortality rates in Australia, 1987–2007 79 7.7. Prostate cancer (C61) 83 7.7.1. Background 83 7.7.2. Incidence and mortality rates in Australia, 1987–2007 85 7.8. Stomach cancer (C16) 89 7.8.1. Background 89 7.8.2. Incidence and mortality rates in Australia, 1987–2007 91 8. Cancer control policies, programs and emerging issues 95 8.1. Cancer as a non-communicable disease and cancer control 95 8.2. Cancer control globally 96 8.2.1. Role of NGOs 97 8.3. Australian approach to cancer control 98 8.3.1. 98 8.3.2. Evolution of cancer control and related policies in Australia 99 8.3.3. Government agencies 102 8.3.4. Australian cancer control policy 102 8.3.5. Existing cancer control–related programs and initiatives 103 8.3.6. Cancer control data sources: monitoring of trends 110 8.4. Cancer control in practice 111 8.4.1. Cancer care: key elements and emerging issues 111 8.4.2. Discovery and advancement in prevention, diagnosis and treatment 113 8.4.3. Cancer control implementation process and leadership 114 8.5. Summary of cancer control policies, programs and emerging issues 116

November, 2013 9. Discussion and future research 127 9.1. Burden of early diagnosis 128 9.2. Health records 128 9.3. Implications for the ageing population 128 9.4. Focus on prevention 129 9.5. Evidence-based interventions and government decision-making 129 9.6. Dilemmas in cancer control 129 9.7. Future research 130 10. Conclusion 133 11. References 135

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Figures Figure 6–1 Age-standardised cancer mortality rates in Australia 1987–2007, 0–74 years 30 Figure 6–2 Age-standardised cancer incidence rates in Australia 1987–2007, 0–74 years 31 Figure 6–3 Change in cancer incident cases and mortality in Australia from 1987–2007 – MALES 34 Figure 6–4 Change in cancer incident cases and mortality in Australia from 1987–2007 – FEMALES 35 Figure 6–5 Change in cancer incident cases and mortality in Australia from 1987–2007 – PERSONS 36 Figure 7–1 Breast cancer: age-standardised cancer mortality rates in Australia 1987–2007, 0–74 years 42 Figure 7–2 Breast cancer: age-standardised cancer incidence rates in Australia 1987–2007, 0–74 years 42 Figure 7–3 Cervical cancer: age-standardised cancer mortality rates in Australia 1987–2007, 0–74 years 50 Figure 7–4 Cervical cancer: age-standardised cancer incidence rates in Australia 1987–2007, 0– 74 years 50 Figure 7–5 Colorectal cancer: age-standardised cancer mortality rates in Australia 1987–2007, 0–74 years 58 Figure 7–6 Colorectal cancer: age-standardised cancer incidence rates in Australia 1987–2007, 0–74 years 58 Figure 7–7 Liver cancer: age-standardised cancer mortality rates in Australia 1987–2007, 0–74 years 66 Figure 7–8 Liver cancer: age-standardised cancer incidence rates in Australia 1987–2007, 0–74 years 66 Figure 7–9 Lung cancer: age-standardised cancer mortality rates in Australia 1987–2007, 0–74 years 72 Figure 7–10 Lung cancer: age-standardised cancer incidence rates in Australia 1987–2007, 0–74 years 72 Figure 7–11 Melanoma: age-standardised cancer mortality rates in Australia 1987–2007, 0–74 years 80 Figure 7–12 Melanoma: age-standardised cancer incidence rates in Australia 1987–2007, 0–74 years 80 Figure 7–13 Prostate cancer: age-standardised cancer mortality rates in Australia 1987–2007, 0–74 years 86 Figure 7–14 Prostate cancer: age-standardised cancer incidence rates in Australia 1987–2007, 0–74 years 86 Figure 7–15 Stomach cancer: age-standardised cancer mortality rates in Australia 1987–2007, 0–74 years 92 Figure 7–16 Stomach cancer: age-standardised cancer incidence rates in Australia 1987–2007, 0–74 years 92 Figure 8–1 and preventive health structure 99

November, 2013 Figure 8–2 Cancer control implementation process 115

Tables Table 6–1 Mortality: number of observed deaths in Australia in 2007 compared to expected number of deaths based on 1987 rates 32 Table 6–2 Incidence: number of observed new cases in Australia in 2007 compared to expected number of new cases based on 1987 rates 33 Table 7–1 Breast cancer deaths and incident cases in Australia 1987–2007 42 Table 7–2 Breast cancer: average annual percentage change (AAPC) 42 Table 7–3 Cervical cancer deaths and incident cases in Australia 1987–2007 50 Table 7–4 Cervical cancer: average annual percentage change (AAPC) 50 Table 7–5 Colorectal cancer deaths and incident cases in Australia 1987–2007 58 Table 7–6 Colorectal cancer: average annual percentage change (AAPC) 58 Table 7–7 Liver cancer deaths and incident cases in Australia 1987–2007 66 Table 7–8 Liver cancer: average annual percentage change (AAPC) 66 Table 7–9 Lung cancer deaths and incident cases in Australia 1987–2007 72 Table 7–10 Lung cancer: average annual percentage change (AAPC) 72 Table 7–11 Melanoma deaths and incident cases in Australia 1987–2007 80 Table 7–12 Melanoma: average annual percentage change (AAPC) 80 Table 7–13 Prostate cancer deaths and incident cases in Australia 1987–2007 86 Table 7–14 Prostate cancer: average annual percentage change (AAPC) 86 Table 7–15 Stomach cancer deaths and incident cases in Australia 1987–2007 92 Table 7–16 Stomach cancer: average annual percentage change (AAPC) 92 Table 8–1 Key health policies and strategies relating to cancer control 101

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November, 2013 November, 2013

1 Abbreviations

Abbreviations APC Annual percentage change AAPC Average annual percentage change ABS Australian Bureau of Statistics AHMAC Australian Health Ministers Advisory Council AIHW Australian Institute of Health and Welfare BMI Body mass index DoHA Australian Government Department of Health and Ageing DRE Digital rectal examination NPAPH National Partnership Agreement on EPIC European Prospective Investigation into Cancer Preventive Health and Nutrition NPHP National Public Health Partnership FOBT Faecal occult blood test NSIF National Service Improvement Framework HIV - 1 Human immunodeficiency virus 1 NSW New South Wales HPV Human papillomavirus PBS Pharmaceutical Benefits Scheme HRT Hormone replacement therapy PSA Prostate-specific antigen HWA Health Workforce Australia RFA Radiofrequency ablation IARC International Agency for Research on Cancer SES Socioeconomic status MBS Medicare Benefits Scheme UICC Union for International Cancer Control NCD Non-communicable diseases UK United Kingdom NGO Non-government organisation USA United States of America NHMRC National Health and Medical Research Council WHO World Health Organization NHRA National Health Reform Agreement Cancer Council NSW • 9 10 • The State of Cancer Control in Australia

November, 2013 November, 2013

2 Report overview

Cancer is currently the largest disease burden in Australia and is growing in incidence, primarily due to an ageing population.1-3 The aim of this report is to quantify the changes in cancer incidence and mortality from 1987 to 2007, thus providing a simple summary of the progress over two decades. Additionally, we document some past and present public health policies and programs that have influenced cancer control in Australia, to begin understanding their impact on cancer incidence and mortality. Cancer control refers to any population-based initiative aimed at reducing incidence and mortality and improving the quality of life of cancer sufferers and their carers.4 This can include prevention, screening, diagnosis, treatment and palliative care.4 For the purpose of this report, we focus predominantly on prevention, screening and diagnosis changes, while acknowledging major In the second section, the changes are put into context for breakthroughs and/or future areas for discovery in treatment. eight specific cancer sites that are amenable to cancer control discovery, evidence and interventions that may affect cancer The first section of the report outlines our findings in incidence and mortality – breast, cervical, colorectal, liver, comparing cancer incident cases and deaths observed in lung, melanoma, prostate and stomach cancers. These have 2007 to those expected in 2007 based on 1987 rates. We been selected based on a consolidated list of the top five took the view that the late 1980s were an appropriate period cancer sites for males and females in incidence and mortality to benchmark comparisons, as a number of cancer control according to the International Agency for Research on Cancer programs increased in intensity after then. This report compiles (IARC) GLOBOCAN 2008 working estimates, and cancers of information on changes in cancer incident cases and deaths to significant importance in Australia.5, 6 contrast two time periods over which many changes in cancer control were implemented. These simple statistics, coupled Finally, the third section of the report highlights the approach to with information on the current political landscape, will enable cancer control recommended globally, and presents the major researchers, advocates and the broader community to identify issues relating to health care and cancer control in Australia. areas for improvement and where progress has been made, as In doing this, the political decision-making environment well as outlets for advocacy in an effort to affect change and to in Australia – illustrating how cancer control programs are fit calls to action within the broader health care landscape. planned, implemented and evaluated – is broadly outlined.

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2 Report Overview

References 1 Australian Institute of Health and Welfare. Australia’s health 2012. Canberra: Australian Institute of Health and Welfare; 2012 (Australia’s health no.13. Cat. no. AUS 156). 2 Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez A. The burden of disease and injury in Australia 2003. Canberra: AIHW; 2007 (Cat. no. PHE 82). 3 Australian Institute of Health and Welfare. Cancer survival and prevalence in Australia period estimates from 1982 to 2010. Canberra: Australian Institute of Health and Welfare; 2012 (Cancer series no. 69. Cat. no. CAN 65). 4 Elwood M, Sutcliffe S. Cancer control and the burden of cancer. In: Elwood JM, Sutcliffe S. Cancer Control. New York: Oxford University Press, 2010: 3-19. 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. GLOBOCAN 2008 v2.0, Cancer incidence and mortality worldwide: IARC CancerBase No. 10: Lyon, France: IARC, 2010. 6 Australian Institute of Health and Welfare and Australasian Association of Cancer Registries. Cancer in Australia: an overview Canberra: Australian Institute of Health and Welfare; 2012 (Cancer series no. 74. Cat. no. CAN 70). November, 2013

3 Executive Summary

3.1 Background In 2008, an estimated 12.4 million new cases and 7.6 million deaths were attributed to cancer worldwide.7 Cancer is currently the largest disease burden in Australia and is growing in incidence, primarily due to an ageing population.1-3 With a population of 22.6 million, Australia has one of the highest incidence rates of all cancers globally, with an age standardised incidence rate of 314/100,000 and an age- standardised mortality rate of 103/100,000 for all people of all ages.5 The high ranking of Australia’s cancer incidence compared to other countries may give the impression that local cancer control programs are failing. The Australian Institute of Health and Welfare (AIHW) publishes reports on cancer in Australia to allow for comparisons of cancer-related information and indicators.6, 8 This is an 3.2 Aims important initiative, which provides annual tabulated figures on The aims of this report are to: incidence and mortality.9 The AIHW has also recently provided projections of cancer incidence to 2020, and a summary 1. Provide simple summary measures of changes in of survival and prevalence statistics for all cancer types up cancer deaths and incident cases for individuals under to 2010.3, 10 Rather than reviewing trends and projections 75 years in Australia by comparing expected and across all ages, aptly done by AIHW,11 we focus on changes observed figures for 2007, using 1987 as the baseline between 2 time periods in those under 75 years of age, as 2. Analyse in greater detail eight specific cancer sites that intervention programs need significant time to build coverage are important in Australia, either because of their public and effectiveness, and to show an impact on mortality and health programs and/or high or changing incidence or incidence. The AIHW’s year-by-year trends illustrate gradual mortality changes, to highlight how policy, programs or changes in incidence and mortality. In this report, we analyse other changes may have affected these measures the change over a 20-year period to provide greater contrast between 2 time periods (1987 and 2007). Assessing change 3. Provide key information on past and current cancer using key indicators aids the planning for cancer control control programs and approaches, and map the initiatives and future evaluations of effectiveness.12-15 relevant policies and programs in Australia. 14 • The State of Cancer Control in Australia

3.3 Methods Eight specific cancer sites were chosen for more detailed We conducted an analysis of incidence and mortality to analysis, based a consolidated list of the top five cancer assess the changes between 1987 and 2007 in individuals sites for males and females in incidence and mortality 74 years of age or younger in Australia. The age- and according to IARC GLOBOCAN 2008 working estimates 5, 6 sex-specific rates in 1987 and 2007 were estimated by and/or the existing public health programs in Australia. averaging the observed rates from 1986 to 1988 and 2006 to 2008, respectively. These rates were applied to the 2007 population to calculate the expected and observed number 3.4.1 Breast cancer of deaths and incident cases (events) for 2007. Finally, the Breast cancer is the most common cancer found in females 2007 observed number of events was compared to the globally. Non-modifiable risk factors for breast cancer 2007 expected number of events based on 1987 estimates. include being female, age, hormonal and reproductive Joinpoint regression analysis was used, to determine circumstances, family history and breast density.7, 18- statistical significance, using direct standardisation with the 20 Risk of disease is influenced by body weight and 1997 Australian population (the mid-point) as the standard physical activity.18 Proven exogenous causes of breast are population. Analyses were performed in R 2.15.116 and restricted to ionising radiation, alcohol consumption and Joinpoint Regression Program 3.5.4.17 pharmacological steroids through hormone replacement 21, 22 As a starting point for understanding the influence of therapy (HRT). Our analysis shows that breast cancer change on cancer incidence and mortality, we looked at the mortality has reduced from the expected numbers by 31%, national health policies relevant to cancer control and their while incidence has risen by 34%. Both were statistically development over time. A descriptive-analysis, narrative significant changes. The former is largely attributed to literature review of public documents and existing research the national screening program (BreastScreen), improved has been used to document the policy and public health management of breast cancer, and reduced population 23-25 campaigns relating to cancer control in Australia from the risk through changing behaviour. BreastScreen is part 1980s to the current day. of the Australian Government’s cancer-prevention strategy and developed nationally but managed at a state/territory level. Its evaluation suggested that improved national policy leadership was required to facilitate the availability of an 3.4 Results equitable service across the nation.26 Over the 20-year period, there was a 28% fall in cancer mortality (7,827 fewer deaths) and a 21% increase in new cancer cases (13,012 more incident cases). The greatest 3.4.2 Cervical cancer falls in mortality were for Hodgkin lymphoma (-70%) and cervical cancer (-62%), and among the leading cancer Cervical cancer is the third most common cancer in types we observed falls in stomach cancer (-50%), females worldwide5 and is caused by persistent infection colorectal (-47%), head and neck (-46%), lung (-34%) and of human papillomavirus (HPV), making it preventable. It female breast (-31%). Mortality from prostate cancer fell has high survival rates if diagnosed early.7 Risk factors by 27% and by 43% in childhood cancers. There were include parity and low socioeconomic status (SES). Proven small changes in mortality for cancers of the thyroid (-6%), exogenous causes include smoking, oral contraceptive pancreas (-6%) and oesophagus (-9%), and melanoma use and human immunodeficiency virus 1 (HIV-1)/immune (-11%). Of the remaining major cancer types, an increase suppression. Co-infection with other sexually transmitted in mortality was observed for liver cancer only (+70%). diseases such as Chlamydia trachomatis or herpes Cancer types that showed the greatest increase in number simplex virus 2 is highly correlated with HPV infection.7, 20, of incident cases were prostate (+276%), thyroid (+198%) 27 Our analysis shows that cervical cancer incidence and and liver cancer (+132%), while the largest falls in incidence mortality both decreased by 52% and 62% respectively, were seen for cancers of the cervix (-52%), bladder (-51%) both statistically significant. Much of this improvement and unknown primary (-41%). is attributed to the national screening program. These findings do not include the time period when the National HPV Vaccination Program was in place.

November, 2013 3.4.3 Colorectal cancer half of the increasing mortality and incidence in Australia.38 From 1988, the Australian Government began integrating Colorectal cancer is the third most common cancer in the hepatitis B vaccination into the National Immunisation 5 males and the second most common in females. The Program. Additionally, public health campaigns to curb most prominent non-modifiable risk factor for colorectal excessive alcohol consumption may contribute to disease cancer is age, with over 90% of cases being diagnosed prevention. in people over 50 years of age.20 Another established non-modifiable risk is adult-attained height.28 A personal or family history of colorectal cancer, polyps and specific inherited genetic conditions (eg familial adenomatous 3.4.5 Lung cancer polyposis and hereditary nonpolyposis colorectal cancer), Lung cancer is the leading cause of cancer-related death or a personal history of inflammatory bowel disease worldwide, resulting in 1.38 million deaths in 2008.5 The 20, significantly increase the likelihood of colorectal cancer. predominant cause of lung cancer, worldwide and in Australia, 29 Consumption of processed meat, and to a lesser extent, is .7 Other causes include passive smoking, red meat, is established as increasing risk of colorectal certain occupational exposures (including those involving cancer; and obesity increases risk, whilst physical asbestos and coal-based industry), pulmonary tuberculosis 28 activity decreases risk. Colorectal cancer had a small and atmospheric pollution.7, 20, 39 Lung cancer had a higher overall change in incidence (2%). In contrast, there was a incidence in males; however, the percentage change showed statistically significant overall decline of 47% in mortality, a statistically significant decrease of 38%. Female incident being slightly higher for females (50% decline). Reduced cases have risen by 26%. Overall mortality has dropped mortality is probably due to improved treatment technology by 34%, an encouraging, statistically significant fall. This is and better adherence to national management and treatment predominantly due to the 46% reduction in male mortality. 30-33 guidelines. Early detection may also have had an impact, There was a slight increase in mortality for females (7%), although there was no organised screening during the time which was not statistically significant (based on linear trends). period analysed, apart from the dissemination of faecal These changes can be largely explained by changes in long- occult blood test (FOBT) kits to a limited age group from late term tobacco consumption.40, 41 Despite the high burden 2006. The greatest future reductions in colorectal cancer associated with lung cancer, specific programs (such as mortality across the whole population are expected to be organised screening programs for high-risk groups42-44) are 34 gained from population-wide screening. Attaining sufficient not present. The nature of the disease is such that smoking coverage of screening is, however, an ongoing challenge in cessation or avoidance is the most fruitful way of addressing countries that have tried to implement such programs. the problem, thus lung cancer is a primary focus in public health initiatives through tobacco control strategies.40 It is also important to note that lung cancer survival after diagnosis has 3.4.4 Liver cancer not improved significantly over past decades. Liver cancer is the fifth most common cancer in males and the seventh most common in females.7 Worldwide, 70–80% of all liver cancers are associated with chronic hepatitis 3.4.6 Melanoma viruses B and C infection or liver cirrhosis.20, 35 Smoking and alcohol consumption increase risk of liver cancer.22, 36 Survival Of the 160,000 new cases of melanoma each year worldwide, from liver cancer is low and, as a result, it is the third most approximately 80% are in individuals from North America, common cause of death globally.5, 35 Liver cancer increased Australia and New Zealand.7 The incidence of melanoma in both incidence and mortality over two decades, both being in Australia, and particularly in Queensland, is the highest statistically significant changes. Overall, there has been a recorded globally.3 The major cause of melanoma is ultraviolet 70% rise in mortality, which was slightly higher in males radiation exposure resulting in direct cellular damage and than females. Incidence increased by 132%. The substantial modifications to immunologic function, especially in people burden of undiagnosed chronic hepatitis B infections in who are fair skinned.45, 46 Mortality associated with melanoma some Asian-born Australians, coupled with the natural of the skin has decreased 11% from expected to observed history of chronic hepatitis B infection in populations where deaths. Incidence, on the other hand, has increased by 17%, the infection is acquired early in life,37 contribute to about indicating that melanoma is still an ongoing concern. In the

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1990s, broad-spectrum sunscreen, which filtered out both both males and females. There has been a 50% decrease ultraviolet A and B radiation, became widely available and in mortality and a 34% decrease in incidence, both of used in Australia.47 This may result in future reductions which are statistically significant. The observed falls in in incidence and mortality. Initiatives, especially through mortality and incidence reflect improvements in living awareness programs, have successfully raised awareness standards from the 1920s, when the prevalence of H. and improved behaviours in Australia.48, 49 pylori began to fall.7, 57 Current public health initiatives run by the Australian Government aimed at reducing tobacco and alcohol consumption and promoting healthy eating practices, address many of the environmental factors that 3.4.7 Prostate cancer can increase the incidence of stomach cancer. Prostate cancer is the most common cancer in males in Australia. There are no proven exogenous causes of prostate cancer. The incidence of prostate cancer has risen 3.4.9 Australian approach to health care globally, whereas mortality has seen a lower rate of change overall.7 The only risk factors clearly associated with and cancer control prostate cancer are advanced age and family history of the Cancer control policy in Australia, predominantly focused 20 cancer. Our analysis shows that prostate cancer incidence on primary and secondary prevention, has evolved over the has risen dramatically, by 276%. Mortality has declined last few decades.58 Beginning in the 1980s, cancer control by 27%. Both are statistically significant has been incorporated into the national strategic direction changes. As very few lifestyle or other as well as in specific public health campaigns. Currently, risk factors have been identified for the range of public health and preventive services in prostate cancer, it is likely that Australia are coordinated and administered by intra- prostate-specific antigen (PSA) Cancer related and intergovernmental agencies. The services that testing is largely responsible for deaths have relate to cancer control are:1 the 276% increase in the number reduced by of cases diagnosed from this • Immunisation services and other analysis. Pressure is mounting 28% from communicable disease control for governments to address the expected • Programs to reduce the use and harmful prostate cancer screening more numbers. effects of tobacco and alcohol formally. • Prevention programs to reduce weight gain and to promote physical activity and healthy eating choices 3.4.8 Stomach cancer • Programs to promote sun protection Stomach cancer is the fourth most common cancer globally, with an estimate of new cases just short of 1 • Environmental monitoring and control, including million in 2008.5, 7 Stomach cancer is largely attributed to management of harmful chemicals environmental causes.7, 50 Infection with Helicobacter pylori • Screening programs for breast, cervical and colorectal (H. pylori) can cause inflammation of the gastric muscosa cancer. and is the main risk factor of stomach cancer; however, only a small proportion of people with H. pylori will develop cancer.51-53 Excessive consumption of salted fish, pickled vegetables, cured meats and soy sauce is also associated with increasing risk.52, 54 Additional lifestyle influences on stomach cancer include the consumption of alcohol and tobacco.52, 55, 56 Incidence and mortality have decreased in

November, 2013 3.5 Discussion practically applicable to epidemiology, public health and clinical settings.62 Our findings illustrate that significant The two decades selected for analysis in this study progress has been made over two decades. However, there coincide with the inception and launch of a number of are still a number of cancer types requiring greater focus. programs and changes in treatment that either directly For example, cancers with unknown or predominantly address the cancer burden or address modifiable risk unmodifiable risk factors currently have limited scope for factors. This analysis has shown that cancer-related deaths prevention. Placing greater emphasis on these cancer sites have reduced by 28% from the expected numbers, based to improve detection and treatment ought to be a growing on 1987 rates, to the observed numbers in 2007. Cancer priority in research and patient support. incidence, however, has increased over the same period by 21%, predominantly due to the rise in incident cases of prostate cancer. The reduction in mortality can be partially explained by improvements in prevention programs, 3.6 Conclusion screening, diagnosis and treatment. Cancer control A number of cancer control measures in Australia have initiatives have played a critical role in reducing the burden contributed to reducing the number of cancer deaths, of cancer through systematic changes and encouraging despite an overall increase in the number of cases individual behavioural change. They will continue to be diagnosed. However, cancers that require more emphasis central to combating cancer. Having said that, there are in research, policy support and preventive health action factors that are still unknown which would have played a are those with little or no improvement, and these are role in mortality reduction. not always at the forefront of activities by lobby groups A large proportion of government investment is on or of the cancer control agenda. Cancer control needs cancer treatment. As the cost of treatment rises, there to be a collaborative effort in the broader community. has been increasing attention on preventive health and Governments, researchers, NGOs and industry need to screening both to address the disease earlier and reduce work together in creating a sound evidence base for cancer costs. Health care systems are challenged by the need control. Local communities can also play an important role to transition from a focus on acute service provision to in advocating and demonstrating change in their social community-based services.59 The capacity of the existing environments to support the implementation of initiatives. system will be placed under pressure through the resource The current level of financial and resource commitment and financial burden of new cancer cases as a result of to cancer control needs to be maintained and increased, the ageing population, increased detection, and improved especially in high-need areas, such as improving screening survival requiring increased levels of care. With the majority participation in culturally diverse population groups that are of guidelines focusing on treatment and management at high risk of cancer. Cancer control will never be finished. restricted to patients under 75 years, reassessment of It needs to be integrated into long-term health policy to current protocols are needed to meet the needs of ageing result in long-term benefit for the community, to sustain populations.60, 61 and build on the improvements that have already been achieved. Moving forward, further understanding the role of current and emerging potential , and the integration of biomarker science to better detect exposures, pre- neoplastic conditions or populations at risk, are all areas of discovery that could pave the way for new prevention strategies or treatment techniques.62, 63 This requires ongoing investment in sound research to support the evidence base for such initiatives.64 In order to take full advantage of empirical research, studies of basic science need to have a translational phase which makes them

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3 Executive Summary

References 1 Australian Institute of Health and Welfare. Australia’s health 19 Cummings SR, Tice JA, Bauer S, Browner WS, Cuzick J, 2012. Canberra: Australian Institute of Health and Welfare; 2012 Ziv E, Vogel V, Shepherd J, Vachon C, Smith-Bindman (Australia’s health no.13. Cat. no. AUS 156). R, Kerlikowske K. Prevention of breast cancer in 2 Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez A. The postmenopausal women: approaches to estimating and burden of disease and injury in Australia 2003. Canberra: AIHW; reducing risk. J Natl Cancer Inst. 2009;101 (6):384-98. 2007 (Cat. no. PHE 82). 20 American Cancer Society. Cancer facts & figures 2012. 3 Australian Institute of Health and Welfare. Cancer survival and Atlanta: American Cancer Society; 2012. prevalence in Australia period estimates from 1982 to 2010. 21 IARC Working Group on the Evaluation of Carcinogenic Canberra: Australian Institute of Health and Welfare; 2012 Risks to Humans. IARC Monographs: Pharmaceuticals. (Cancer series no. 69. Cat. no. CAN 65). Volume 100A A review of human carcinogens. Lyon: IARC; 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. 2012. GLOBOCAN 2008 v2.0, Cancer incidence and mortality 22 IARC Working Group on the Evaluation of Carcinogenic worldwide: IARC CancerBase No. 10: Lyon, France: IARC, 2010. Risks to Humans. IARC Monographs: Personal habits 6 Australian Institute of Health and Welfare and Australiasian and indoor combustions. Volume 100E A review of human Association of Cancer Registries. Cancer in Australia: an carcinogens. Lyon: IARC; 2012. overview Canberra: Australian Institute of Health and Welfare; 23 Nickson C, Mason KE, English DR, Kavanagh AM. 2012 (Cancer series no. 74. Cat. no. CAN 70). Mammographic screening and breast cancer mortality: a 7 Boyle P, Levin B, editors. World Cancer Report 2008. Geneva: case-control study and meta-analysis. Cancer Epidemiol IARC; 2008. Biomarkers Prev. 2012;21 (9):1479-88. 8 Australian Institute of Health and Welfare and Australiasian 24 White V, Pruden M, Giles G, Collins J, Jamrozik K, Inglis Association of Cancer Registries. Cancer in Australia: an G, Boyages J, Hill D. The management of early breast overview. Canberra: Australian Institute of Health and Welfare; carcinoma before and after the introduction of clinical 2010 (Cancer series no. 60 Cat. no. CAN 56). practice guidelines. Cancer. 2004;101 (3):476-85. 9 Australian Institute of Health and Welfare. GRIM books. 25 Canfell K, Banks E, Clements M, Kang YJ, Moa A, Canberra: Australian Institute 2013 [updated July 9; cited 2013 Armstrong B, Beral V. Sustained lower rates of HRT July 9]; Available from: http://www.aihw.gov.au/grim-books/. prescribing and breast cancer incidence in Australia since 2003. Breast Cancer Res Treat. 2009;117 (3):671-3. 10 Australian Institute of Health and Welfare. Cancer incidence projections, Australia 2011 to 2020. Canberra: Australian 26 Australian Government Department of Health and Institute of Health and Welfare 2012 (Cancer series no. 66. Cat. Ageing. Evaluation of the BreastScreen Australia no. CAN 62). Program – Evaluation Final Report – June 2009. Canberra: Commonwealth of Australia 2009. 11 Australian Institute of Health Welfare. Cancer in Australia: actual incidence and mortality data from 1982 to 2007 and 27 Vesco KK, Whitlock EP, Eder M, Burda BU, Senger projections to 2010. Asia Pac J Clin Oncol. 2011;7 (4):325-38. CA, Lutz K. Risk factors and other epidemiologic considerations for cervical cancer screening: a narrative 12 Bray F, Lortet-Tieulent J, Ferlay J, Forman D, Auvinen A. review for the U.S. Preventive Services Task Force. Ann Prostate cancer incidence and mortality trends in 37 European Intern Med. 2011;155 (10):698-705, W216. countries: an overview. Eur J Cancer. 2010;46 (17):3040-52. 28 World Cancer Research Fund / American Institute for 13 Ren J-S, Chen W-Q, Shin H-R, Ferlay J, Saika K, Zhang S-W, Cancer Research. Continuous Update Project Report. Bray F. A comparison of two methods to estimate the cancer Food, Nutrition, Physical Activity, and the Prevention of incidence and mortality burden in China in 2005. Asian Pac J Colorectal Cancer. Washington, DC: American Institute for Cancer Prev. 2010;11 (6):1587-94. Cancer Research; 2011. 14 Jemal A, Bray F, Center M, Ferlay J, Ward E, Forman D. Global 29 van Wezel T, Middeldorp A, Wijnen JT, Morreau H. A review cancer statistics. CA - Cancer J Clin. 2011;61 (2):69-90. of the genetic background and tumour profiling in familial 15 Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J, Rosso S, colorectal cancer. Mutagenesis. 2012;27 (2):239-45. Coebergh JW, Comber H, Forman D, Bray F. Cancer incidence 30 Australian Cancer Network Colorectal Cancer Guidelines and mortality patterns in Europe: estimates for 40 countries in Revision Committee. Guidelines for the Prevention, Early 2012. Eur J Cancer. 2013;49 (6):1374-403. Detection and Management of Colorectal Cancer. Sydney: 16 R Core Team. R: A language and environment for statistical The Cancer Council Australia and Australian Cancer computing. Vienna, Austria: R Foundation for Statistical Network; 2005. Computing, 2012. 31 Clinical Oncological Society of Australia and Australian 17 Statistical Research and Applications Branch. Joinpoint Cancer Network. The prevention, early detection Regression Program Version 3.5.4., August: National Cancer and management of colorectal cancer. Canberra: Institute, 2012. Commonwealth of Australia; 1999. 18 Petracci E, Decarli A, Schairer C, Pfeiffer RM, Pee D, Masala 32 Jeffery GM, Hickey BE, Hider P. Follow-up strategies for G, Palli D, Gail MH. Risk factor modification and projections patients treated for non-metastatic colorectal cancer. of absolute breast cancer risk. J Natl Cancer Inst. 2011;103 Cochrane Database Syst Rev. 2002 (1):CD002200. (13):1037-48.

November, 2013 33 Renehan AG, Egger M, Saunders MP, O’Dwyer ST. Impact 48 Hirst N, Gordon L, Scuffham P, Green A. Lifetime cost- on survival of intensive follow up after curative resection for effectiveness of prevention through promotion colorectal cancer: systematic review and meta-analysis of of daily sunscreen use. Value Health. 2012;15 (2):261-8. randomised trials. BMJ. 2002;324 (7341):813. 49 Montague M, Borland R, Sinclair C. Slip! Slop! Slap! and 34 Olver I, Grogan P. Early success for Australia’s bowel screening SunSmart, 1980-2000: Skin cancer control and 20 years program: let’s move it along. Med J Aust. 2013;198 (6):300-1. of population-based campaigning. Health Educ Behav. 35 Lavanchy D. Chronic viral hepatitis as a public health issue in the 2001;28 (3):290-305. world. Best Pract Res Clin Gastroenterol. 2008;22 (6):991-1008. 50 Kelley JR, Duggan JM. Gastric cancer epidemiology and 36 World Cancer Research Fund / American Institute for Cancer risk factors. J Clin Epidemiol. 2003;56 (1):1-9. Research. Food, Nutrition, Physical Activity, and the Prevention of 51 Compare D, Rocco A, Nardone G. Risk factors in gastric Cancer: a Global Perspective. Washington, DC: American Institute cancer. Eur Rev Med Pharmacol Sci. 2010;14 (4):302-8. for Cancer Research; 2007. 52 Nagini S. Carcinoma of the stomach: A review of 37 Yuen MF. Revisiting the natural history of chronic hepatitis B: epidemiology, pathogenesis, molecular genetics and impact of new concepts on clinical management. J Gastroenterol chemoprevention. World J Gastro Oncol. 2012;4 (7):156-69. Hepatol. 2007;22 (7):973-6. 53 IARC Working Group on the Evaluation of Carcinogenic 38 Law MG, Roberts SK, Dore GJ, Kaldor JM. Primary hepatocellular Risks to Humans. IARC Monographs: Biological Agents. carcinoma in Australia, 1978-1997: increasing incidence and Volume 100B A review of human carcinogens. Lyon: IARC; mortality. Med J Aust. 2000;173 (8):403-5. 2012. 39 Lo Y-L, Hsiao C-F, Chang G-C, Tsai Y-H, Huang M-S, Su W-C, 54 Wang X-Q, Terry P-D, Yan H. Review of salt consumption Chen Y-M, Hsin C-W, Chang C-H, Yang P-C, Chen C-J, Hsiung and stomach cancer risk: epidemiological and biological C. Risk factors for primary lung cancer among never smokers by evidence. World J Gastroenterol. 2009;15 (18):2204-13. gender in a matched case-control study. Cancer Causes Control. 55 Bonequi P, Meneses-González F, Correa P, Rabkin C, 2013;24 (3):567-76. Camargo M. Risk factors for gastric cancer in Latin America: 40 Adair T, Hoy D, Dettrick Z, Lopez A. Reconstruction of long-term a meta-analysis. Cancer Causes Control. 2013;24 (2):217-31. tobacco consumption trends in Australia and their relationship to 56 Pichandi S, Pasupathi P, Rao Y, Farook J, Ponnusha B, lung cancer mortality. Cancer Causes Control. 2011;22 (7):1047- Ambika A, Subramaniyam S. The effect of smoking on 53. cancer-a review. Int J Biol Med Res. 2011;2 (2):593-602. 41 De Matteis S, Consonni D, Pesatori A, Bergen A, Bertazzi P, 57 Roder D. The epidemiology of gastric cancer. Gastric Caporaso N, Lubin J, Wacholder S, Landi M. Are women who Cancer. 2002;5 (Suppl 1):5-11. smoke at higher risk for lung cancer than men who smoke? Am J 58 Anderiesz C, Elwood M, Hill DJ. Cancer control policy in Epidemiol. 2013;177 (7):601-12. Australia. Aust NZ Heal Policy. 2006;3:12. 42 Dominioni L, Poli A, Mantovani W, Pisani S, Rotolo N, Paolucci 59 Burton R, Leowski Jr J, de Courten M. Integrating cancer M, Sessa F, Conti V, D’Ambrosio V, Paddeu A, Imperatori A. control with control of other non-communicable diseases. Assessment of lung cancer mortality reduction after chest X-ray In: Elwood JM, Sutcliffe S. Cancer Control. New York: screening in smokers: A population-based cohort study in Varese, Oxford University Press, 2010: 399-416. Italy. Lung Cancer. 2013;80 (1):50-4. 60 Zulman D, Sussman J, Chen X, Cigolle C, Blaum C, 43 Couraud S, Cortot A, Greillier L, Gounant V, Mennecier B, Girard Hayward R. Examining the evidence: a systematic review N, Besse B, Brouchet L, Castelnau O, Frappé P, Ferretti G, of the inclusion and analysis of older adults in randomized Guittet L, et al. From randomized trials to the clinic: is it time to controlled trials. J Gen Intern Med. 2011;26 (7):783-90. implement individual lung-cancer screening in clinical practice? A multidisciplinary statement from French experts on behalf of the 61 Van Spall H, Toren A, Kiss A, Fowler R. Eligibility criteria french intergroup (IFCT) and the groupe d’Oncologie de langue of randomized controlled trials published in high-impact francaise (GOLF). Ann Oncol. 2013;24 (3):586-97. general medical journals: a systematic sampling review. JAMA. 2007;297 (11):1233-40. 44 Kovalchik SA, Tammemagi M, Berg CD, Caporaso NE, Riley TL, Korch M, Silvestri GA, Chaturvedi AK, Katki HA. Targeting of low- 62 Franceschi S, Wild C. Meeting the global demands of dose CT screening according to the risk of lung-cancer death. N epidemiologic transition - The indispensable role of cancer Engl J Med. 2013;369 (3):245-54. prevention. Mol Oncol. 2013;7 (1):1-13. 45 Lucas R, McMichael A, Armstrong B, Smith W. Estimating the 63 Wang D, Dubois R. Urinary PGE-M: A Promising Cancer global disease burden due to ultraviolet radiation exposure. Int J Biomarker. Cancer Prev Res. 2013;6 (6):507-10. Epidemiol. 2008;37 (3):654-67. 64 Commonwealth of Australia. Budget 2005-2006 Health 1: 46 Narayanan D, Saladi R, Fox J. Ultraviolet radiation and skin Investing in Australia’s health: Strengthening Cancer Care. cancer. Int J Dermatol. 2010;49 (9):978-86. Canberra: Commonwealth of Australia; 2005. 47 National Industrial Chemicals Notification and Assessment Scheme. Proposal to adopt the revised Australian/New Zealand Sunscreen Standard (AS/NZS 2604:2012 Sunscreen products – Evaluation and classification) for cosmetic sunscreen products. Consultation on Regulatory Impacts – December 2012. Canberra: National Industrial Chemicals Notification and Assessment Scheme; 2012. 20 • The State of Cancer Control in Australia

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4 Introduction

In 2008, an estimated 12.4 million new cases and 7.6 million deaths were attributed to cancer worldwide.7 Cancer is currently the largest disease burden in Australia.1-3 With a population of 22.6 million, Australia has one of the highest incidence rates of all cancers globally, with an age-standardised incidence rate of 314/100,000 and an age-standardised mortality rate of 103/100,000 for people of all ages.5 The high ranking of Australia’s cancer incidence compared to other countries can leave the impression that local cancer control‡ programs are failing.

Cancer survival statistics published by the AIHW have shown all cancer types up to 2010.3, 10 Rather than reviewing trends an improvement over time (5-year relative survival improved and projections across all ages, aptly done by the AIHW,11 from 41.3% to 58.4% in males and 53.2% to 64.1% in females we focus on changes between 2 time periods in those under over 2 time periods: 1982–1986 and 1998–2004).11 Although 75 years of age, as intervention programs need significant survival rates serve to indicate the potential burden on the time to build coverage and effectiveness, and to show an health care system, they may not be as easy to interpret as impact on mortality and incidence. The AIHW’s year-by-year changes in incidence and mortality. Incidence and mortality trends illustrate gradual changes in incidence and mortality. represent the pressing and emerging issues for public health In this report, we analyse the change over a 20-year period concern and health care systems. Mortality statistics indicate to provide greater contrast between 2 time periods (1987 the importance of a given illness relative to others, hence its and 2007). Assessing change using key indicators aids the extensive use in determining the cancer burden.65, 66 Mortality planning for cancer control initiatives and future evaluations of is simple and unambiguous to interpret.66 Incidence data effectiveness.12-15 assist in determining where preventive actions are most useful and to reduce burden on health services.65 Australian mortality data are regarded as accurate and complete, so we focused on mortality in the first instance, and The AIHW publishes reports on cancer in Australia to allow for then augmented this information with data on incidence, ie comparisons of cancer-related information and indicators.6, 8 This is an important initiative which provides national annual ‡ tabulated figures on incidence and mortality.9 The AIHW has Cancer control is deemed to be any population-based initiative also recently provided projections of cancer incidence to aimed at reducing incidence and mortality rates and improving 2020, and a summary of survival and prevalence statistics for the quality of life of cancer sufferers and their carers. Cancer Council NSW • 21 22 • The State of Cancer Control in Australia

newly diagnosed cases. For simplicity, we refer to diagnosed cases as incident cases, while acknowledging that changes in incidence may be caused by diagnoses being brought forward by improvements in screening and/or diagnostic methods, or increase artificially because of improvements in registration. Section 5 outlines the methods used. The aims of this report are to: 1. Provide simple summary measures of changes in cancer deaths and incident cases for individuals under 75 years in Australia by comparing expected and observed figures for 2007, using 1987 as the baseline 2. Analyse in greater detail eight specific cancer sites that are important in Australia either because of their public health programs and/or high or changing incidence or mortality changes, to highlight how policy, programs or other changes may have affected these measures 3. Provide key information on past and current cancer control programs and approaches, and map the relevant policies and programs in Australia. Considering that the intensity of cancer treatment is less uniform in older age groups, and that screening programs stop at about 70 years of age, restricting analyses to individuals aged under 75 more accurately reports premature deaths and incident cases relating to cancer. This cohort is more likely to receive intensive cancer treatment, and cancer control programs are generally targeted at this age range.67-71 Thus we conducted an analysis of incidence and mortality to assess the changes between 1987 and 2007 in individuals 74 years of age or younger in Australia.

November, 2013 4 Introduction

References 1 Australian Institute of Health and Welfare. Australia’s health 15 Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J, Rosso 2012. Canberra: Australian Institute of Health and Welfare; 2012 S, Coebergh JW, Comber H, Forman D, Bray F. Cancer (Australia’s health no.13. Cat. no. AUS 156). incidence and mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer. 2013;49 (6):1374- 2 Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez A. The 403. burden of disease and injury in Australia 2003. Canberra: AIHW; 2007 (Cat. no. PHE 82). 65 Black R, Bray F, Ferlay J, Parkin D. Cancer incidence and mortality in the European Union: cancer registry 3 Australian Institute of Health and Welfare. Cancer survival and data and estimates of national incidence for 1990. Eur J prevalence in Australia period estimates from 1982 to 2010. Cancer. 1997;33 (7):1075-107. Canberra: Australian Institute of Health and Welfare; 2012 (Cancer series no. 69. Cat. no. CAN 65). 66 Pisani P, Parkin D, Bray F, Ferlay J. Estimates of the worldwide mortality from 25 cancers in 1990. Int J 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. Cancer. 1999;83 (1):18-29. GLOBOCAN 2008 v2.0, Cancer incidence and mortality worldwide: IARC CancerBase No. 10: Lyon, France: IARC, 2010. 67 Australian Government Department of Health and Ageing. National Bowel Cancer Screening Program: 6 Australian Institute of Health and Welfare and Australiasian About the Program. Canberra: Australian Government Association of Cancer Registries. Cancer in Australia: an Department of Health and Ageing; 2012 [updated June overview Canberra: Australian Institute of Health and Welfare; 14; cited 2012 November 5]; Available from: http://www. 2012 (Cancer series no. 74. Cat. no. CAN 70). cancerscreening.gov.au/internet/screening/publishing. 7 Boyle P, Levin B, editors. World Cancer Report 2008. Geneva: nsf/Content/bowel-about. IARC; 2008. 68 Australian Government Department of Health and 8 Australian Institute of Health and Welfare and Australiasian Ageing. BreastScreen Australia Program: About the Association of Cancer Registries. Cancer in Australia: an Program. Canberra Australian Government Department overview. Canberra: Australian Institute of Health and Welfare; of Health and Ageing; 2012 [updated February 3; 2010 (Cancer series no. 60 Cat. no. CAN 56). cited 2012 November 5]; Available from: http://www. 9 Australian Institute of Health and Welfare. GRIM books. cancerscreening.gov.au/internet/screening/publishing. Canberra: Australian Institute 2013 [updated July 9; cited 2013 nsf/Content/breastscreen-about. July 9]; Available from: http://www.aihw.gov.au/grim-books/. 69 Australian Government Department of Health and 10 Australian Institute of Health and Welfare. Cancer incidence Ageing. National Cervical Screening Program: About the projections, Australia 2011 to 2020. Canberra: Australian Program. Canberra: Australian Government Department Institute of Health and Welfare 2012 (Cancer series no. 66. Cat. of Health and Ageing; 2009 [updated November 11; no. CAN 62). cited 2012 November 5]; Available from: http://www. cancerscreening.gov.au/internet/screening/publishing. 11 Australian Institute of Health Welfare. Cancer in Australia: actual nsf/Content/cervical-about. incidence and mortality data from 1982 to 2007 and projections to 2010. Asia Pac J Clin Oncol. 2011;7 (4):325-38. 70 Stangelberger A, Waldert M, Djavan B. Prostate cancer in elderly men. Rev Urol. 2008;10 (2):111-9. 12 Bray F, Lortet-Tieulent J, Ferlay J, Forman D, Auvinen A. Prostate cancer incidence and mortality trends in 37 European 71 van de Water W, Markopoulos C, van de Velde C, countries: an overview. Eur J Cancer. 2010;46 (17):3040-52. Seynaeve C, Hasenburg A, Rea D, Putter H, Nortier J, de Craen A, Hille E, Bastiaannet E, Hadji P, et al. 13 Ren J-S, Chen W-Q, Shin H-R, Ferlay J, Saika K, Zhang S-W, Association between age at diagnosis and disease- Bray F. A comparison of two methods to estimate the cancer specific mortality among postmenopausal women incidence and mortality burden in China in 2005. Asian Pac J with hormone receptor-positive breast cancer. JAMA. Cancer Prev. 2010;11 (6):1587-94. 2012;307 (6):590-7. 14 Jemal A, Bray F, Center M, Ferlay J, Ward E, Forman D. Global cancer statistics. CA - Cancer J Clin. 2011;61 (2):69-90. 24 • The State of Cancer Control in Australia

November, 2013 November, 2013

5 Methods

5.1 Incidence and mortality changes This analysis compares the observed deaths and incident profile of recorded cases in Australia in 2007 to the expected numbers using 1987 rates as a baseline. The annual numbers of deaths from 1986 to 2008 for each major cancer type, by age group and sex, were obtained from the Australian Bureau of Statistics (ABS). Age groups were 0–14 years, 15–34 years Counts of incident cancer cases from 1986 to 2008, by and 5-year age groups from 35 to 74 years for all cancer sites, sex and five-year age group, were obtained from the with the exception of Hodgkin lymphoma (where the groups AIHW.72 Annual estimates of deaths of the Australian were 0–14 years, 15–49 years, 50–64 years and 65–74 years). population, also by sex and five-year age group, were obtained from the ABS and used to estimate mortality Where a death count was from 1 to 4 for a given age, sex, and incidence rates.73 Age groups in the AIHW and ABS cancer site and year, the ABS did not publish the counts for population data were collapsed to match the categories 2 age groups within that cancer site, sex and year. The total listed above. number of deaths for those 2 cells was known (the difference between the total number of deaths for that cancer site, sex The years of analysis were 1987 and 2007 and – to and year for all ages and the sum of the published counts for establish the average number of events for the single the other age groups). Also known was the expected ratio year – an additional year before and after was used. That of deaths for those 2 age groups from unpublished data, is, the age- and sex-specific rates in 1987 and 2007 were obtained by averaging the surrounding 4 years of data for estimated by averaging the observed rates from 1986 to each age group for that sex and cancer site (eg an average 1988 and 2006 to 2008, respectively. These rates were ratio of 0.4 deaths in the 35–39 years age group to 0.6 deaths applied to the 2007 population to calculate the expected in the 45–49 years age group). Death counts were then and observed number of deaths and incident cases for assigned to the 2 unpublished cells as expected proportions 2007. These expected and observed numbers were then of the known total number of deaths for those 2 cells. compared.

Cancer Council NSW • 25 26 • The State of Cancer Control in Australia

Joinpoint regression was used to test the statistical mortality. These have been selected based a combined significance of the mortality and incidence changes over list of the top five cancer sites for males and females in time, allowing annual data for this period to be used. incidence and mortality according to the International Joinpoint regression summarises trends over successive Agency for Research on Cancer (IARC) GLOBOCAN 2008 segments of time. A series of joined linear segments is working estimates, and cancers of significant importance fitted to time series (eg annual rates). The connection in Australia.5, 6 The first four cancer sites have vaccination, of two segments is referred to as a ‘joinpoint’ and it immunisation or screening programs that are reflected in the represents a point in time where the rate of increase changing data from 1987 to 2007. The other cancer sites are or decrease changed significantly. The annual percent addressed through prevention strategies such as tobacco change (APC) is calculated for each time segment. To control policies and programs and public health campaigns obtain a single measure that was the same for all cancers attempting to curb alcohol consumption. Additionally, from 1987 to 2007, we calculated the average annual improvements in sanitation have been fundamental in percent change (AAPC), a weighted average of the APCs. reducing the burden of stomach cancer. Melanoma of the Details of this methodology are outlined by Clegg et al.74 skin and prostate cancer have been added to the in-depth analysis. Globally, the highest incidence of melanoma of the Annual age-standardised rates for each cancer site and skin is found in Australia and prostate cancer incidence is all cancer sites combined were obtained by the method rising, making them both local public concerns. of direct standardisation. The standard population used was the 1997 Australian population under the age of 75, the mid-point of the time period analysed. The analysis covered the years from 1986 to 2008 for mortality and 5.2 National policy development incidence. However, AAPCs were calculated for the period Following the analysis of change over time, we reviewed of interest, 1987 to 2007. Analyses were performed in R the national health policies relevant to cancer control and 16 17 2.15.1 and Joinpoint Regression Program 3.5.4. mapped their development over time, as a starting point for Models were fitted to the logarithms of annual age- understanding the influence of change on cancer incidence standardised mortality and incidence rates; between and mortality. The aim was to document the relevant policies 0 and 4 joinpoints were allowed; standard errors of the and programs used in Australia in an effort to uncover how rates were inputted; and the permutation method was priorities are set relating to cancer control, and how policies used to determine the optimal number of joinpoints. The and programs could affect cancer. regression mean functions for males and females were A descriptive-analysis, narrative literature review of public 75 tested for parallelism. documents and existing research was used to document the To ensure that disease groups were standard for the entire policy and public health campaigns relating to cancer control period of analysis, changes between ICD-9 and ICD-10§ in Australia from the 1980s to current day. This included in 1996/97 were accounted for with the use of appropriate policies and associated agencies relating to known cancer bridging codes. Mesothelioma was excluded because the risk factors, cancer screening programs and treatment or figures were too affected by the changes. A few cancer care strategies. types (eg ‘head and neck’) were grouped differently by the The framework to guide this review was divided into three ABS and the AIHW; these discrepancies are noted in the stages. The first stage focused on the cancer control tabulations. initiatives at a global level and looked at the overarching Firstly, the overall findings are presented in Section 6. policies and recommendations released through international The cancers with the greatest changes in mortality and agencies, such as the World Health Organization (WHO) and incidence are examined. Secondly, eight specific cancer the IARC, to form cancer control initiatives. This information sites were chosen for more detailed analysis (Section 7). was identified through publicly released reports, organisation The chosen cancer sites – breast, cervical, colorectal, websites and key publications in academic journals by liver, lung, melanoma, prostate and stomach cancers representatives from relevant international agencies. The – are amenable to cancer control discovery, evidence search was restricted to information from 1980 to the present and interventions that may affect cancer incidence and day.

§ ICD is the International Classification of Diseases established by WHO. It is the standard diagnostic tool used worldwide.

November, 2013 Secondly, government policies and intra- and intergovernmental programs in Australia relating to cancer control were identified, to track the evolution of 5 Methods cancer control over time. This was done predominantly by manually searching existing policies in hard copy or References electronically, or records of programs and their evaluations, and backtracking to incorporate previous iterations of 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. similar policies or programs. Once the policy and program GLOBOCAN 2008 v2.0, Cancer incidence and mortality worldwide: IARC CancerBase No. 10: Lyon, France: IARC, names were determined, they were searched in Medline to 2010. identify any published reviews or critiques of cancer control in Australia. No date range was used to limit the search – in 6 Australian Institute of Health and Welfare and Australiasian Association of Cancer Registries. Cancer in Australia: an order to incorporate any possible evolution in cancer control overview Canberra: Australian Institute of Health and Welfare; activities. 2012 (Cancer series no. 74. Cat. no. CAN 70). Finally, Cancer Council Australia’s National Prevention 16 R Core Team. R: A language and environment for statistical Policy topics were used as the outline to identify and computing. Vienna, Austria: R Foundation for Statistical Computing, 2012. further explore specific cancer prevention programs and initiatives. This policy was used in the absence of a national 17 Statistical Research and Applications Branch. Joinpoint framework from the Australian Government relating uniquely Regression Program Version 3.5.4., August: National Cancer Institute, 2012. to cancer control. The focus on prevention in Cancer Council Australia’s policy omitted important issues relating 72 Australian Institute of Health and Welfare. Australian Cancer to cancer care, medical discoveries and the monitoring of Incidence and Mortality books. Canberra: Australian Institute of Health and Welfare; 2012. population trends. These issues were outlined in additional sections. In following these three stages, we assess public 73 Australian Bureau of Statistics. 3105.0.65.001 - Australian documentation and research to provide key information on Historical Population Statistics - Population Age-Sex Structure, Table 4.1 Population (a), age and sex, Australia past and current cancer control programs and approaches, (b), 30 June, 1901 onwards, Data cube: Australian Bureau of and map the relevant policies and programs in Australia. Statistics, Canberra, 2008. 74 Clegg LX, Hankey BF, Tiwari R, Feuer EJ, Edwards BK. Estimating average annual per cent change in trend analysis. Stat Med. 2009;28 (29):3670-82. 75 Kim HJ, Fay MP, Yu B, Barrett MJ, Feuer EJ. Comparability of segmented line regression models. Biometrics. 2004;60 (4):1005-14.

Cancer Council NSW • 27 28 • The State of Cancer Control in Australia

November, 2013 November, 2013

6 Results: analysis of findings overall - incidence and mortality

Table 6–1 and Table 6–2 show the number of deaths and incident cases observed in 2007 by cancer site, compared to those expected using the 1987 mortality profile, together with the AAPC changes estimated from the age- standardised mortality and incidence rates.

6.1 Incidence and mortality changes Overall, 7,827 (-28%) fewer deaths occurred in 2007 than from melanoma was 11% (848 fewer deaths). In addition, over would have been expected based on 1987 rates (20,104 this period we observed a 43% fall in deaths from childhood observed vs. 27,931 expected), and over the full period cancers (87 observed vs. 151 expected). Only small changes from 1987 to 2007, there were 61,190 fewer deaths than have occurred in mortality for cancers of the pancreas (69 expected, had the death rate remained constant. fewer deaths, -6%), brain and related (148 fewer deaths, -15%) and oesophagus (64 fewer deaths, -9%). No changes Improvements in mortality for five cancer types, namely in mortality were observed for thyroid cancer (4 fewer deaths, lung, colorectal, breast, stomach, and head and neck, -6%), but mortality from this condition has always been low. account for 74% of all the decrease in deaths (5,779 out of 7,827). The greatest reduction in deaths was for male Mortality has fallen for all cancers with a few exceptions. lung cancer (2,259 fewer deaths,-46%), colorectal cancer Deaths caused by lung cancer in females have increased, while (1,797 fewer deaths, -47%), female breast cancer (773 the number of deaths in males has decreased, resulting in an fewer deaths, -31%), stomach cancer (577 fewer deaths, overall decrease in lung cancer mortality (2,154 fewer deaths -50%), and head and neck cancer (478 fewer deaths, -46%). overall, -34%). This gender difference is statistically significant. Additionally, Hodgkin lymphoma (84 fewer deaths, -70%) Thyroid cancer in males has also shown a small (non- and cervical cancer (242 fewer deaths, -62%) had high significant) increase. Liver and intrahepatic bile duct cancer percentage falls in mortality. Mortality from prostate cancer in both males and females, and ‘other cancers’ in both males fell by 27% during this period with 295 fewer deaths in 2007 and females have increased (overall 304 more deaths, +15%). than expected based on 1987 rates. The decline in mortality Liver cancer had the largest increase in mortality, increasing by

Cancer Council NSW • 29 30 • The State of Cancer Control in Australia

70% overall (267 more deaths). Figure 6–1 shows the age- the highest absolute numbers of new incident cases are standardised mortality rates for all Australians under the female breast (2,736, 34%), a sum of other minor cancer age of 75 from 1987 to 2007 for all cancers combined, and types (1,353, 18%), melanoma (1,138, 17%) and thyroid then individually for 8 common cancer sites in Australia. (1,107, 198%). Liver and kidney cancers also recorded This illustrates the mortality trends for these cancers in this a significantly higher number of cases in 2007 than target group. would have been expected based on 1987 rates, with an additional 465 (132%) and 676 (55%) cases respectively. When separated by gender, female lung cancer incident cases have increased by 26% (468), whereas overall 6.2 Changes in incident cases incident cases of lung cancer have decreased by 22% In contrast to the decrease in observed deaths from cancer (1,705), and reported cases of melanoma in males have over this period, there was a 21% increase in the expected increased more than in females (26% vs. 6%) over this and observed number of incident cases, with 13,012 period – both of which are statistically significant changes. more cases observed in 2007 than would be expected Despite the overall increase in cancer incidence, fewer based on 1987 rates. Prostate cancer had the largest cases were recorded in 2007 for several cancer types increase, with 10,245 more cases recorded in 2007 than than would have been expected based on 1987 incidence would be expected based on 1987 rates, an increase of rates. Cancer types with the largest reductions in incidence 276%. Excluding prostate cancer, the cancer types with

Figure 6–1 Age-standardised cancer mortality rates in Australia 1987-2007, 0-74 years

November, 2013 include cervical cancer (690 fewer cases than 6.3 Overall changes expected, a reduction of 52%), bladder cancer (1,110 fewer cases, 51%), cancer of unknown primary (904 The percentage changes for mortality and incident cases fewer cases, 41%), stomach cancer (578 fewer cases, for males (Figure 6–3), females (Figure 6–4) and both males 34%), head and neck cancers (562 fewer cases, 27%) and females (Figure 6–5) highlight the areas of greatest and lung cancer (1,705 fewer cases, 22%). There were change. After comparing the changes for mortality and few other cancer types with lower incidence in 2007 incidence, the cancer sites with greatest reductions for both than in 1987. Incidence of oesophageal cancer in genders and overall are stomach, head and neck, cancer of females showed a statistically significant reduction of unknown primary, bladder, and brain and related. Only liver 32% (74 fewer cases). and intrahepatic bile duct cancer and other cancers showed increases in both incidence and mortality. Figure 6–2 shows the age-standardised incidence rates for all Australians under the age of 75 from 1987 to 2007 for all cancers combined and then individually for 8 common cancer sites in Australia. This illustrates the incidence trends for these cancers in this target group.

Figure 6–2 Age-standardised cancer incidence rates in Australia 1987-2007, 0-74 years

Cancer Council NSW • 31 32 • The State of Cancer Control in Australia 32 • The State of Cancer Control in Australia

Table 6–1 Mortality: number of observed deaths in Australia in 2007 compared to expected number of deaths based on 1987 rates**

Observed deaths Change in deaths (%) Annual average percentage change Cancer type Expected deaths in 2007 (E) Difference (O-E) in 2007 (O) (O-E)/Ea (95% CI)

Male Female Persons Male Female Persons Male Female Persons Male Female Persons Male Female Persons

Lung (C33-34) 2,668 1,555 4,223 4,927 1,450 6,377 -2,259 105 -2,154 -46 7 -34 -3.0 (-3.3, -2.7) 0.2 (-0.1, 0.4)* -2.1 (-2.3, -1.8) Colorectal (C18-20) 1,197 791 1,988 2,205 1,580 3,785 -1,008 -789 -1,797 -46 -50 -47 -2.9 (-3.3, -2.5) -3.3 (-4.4, -2.2) -3.0 (-3.4, -2.7) Breast (female) (C50) - 1,691 1,691 - 2,464 2,464 - -773 -773 - -31 -31 - -1.8 (-2.2, -1.5) -1.8 (-2.2, -1.5) Stomach (C16) 368 203 572 809 340 1,149 -441 -137 -577 -54 -40 -50 -3.8 (-4.5, -3.1) -2.8 (-3.3, -2.3) -3.4 (-3.6, -3.2) Head and neck (C00-C14, C30-C32) 450 109 560 843 196 1,038 -393 -87 -478 -47 -44 -46 -3.0 (-3.5, -2.4) -2.7 (-3.4, -2.0) -2.9 (-3.5, -2.3) Unknown primary (C77-C80) 594 422 1,017 891 573 1,465 -297 -151 -448 -33 -26 -31 -1.9 (-3.5, -0.3) -1.5 (-2.4, -0.5) -1.8 (-3.1, -0.5) Prostate (C61) 799 - 799 1,094 - 1,094 -295 - -295 -27 - -27 -1.5 (-2.1, -1.0) - -1.5 (-2.1, -1.0) Cervix uteri (C53) - 152 152 - 394 394 - -242 -242 - -62 -62 - -5.2 (-5.8, -4.6) -5.2 (-5.8, -4.6) Non-Hodgkin lymphoma (C82-C85) 394 220 614 504 350 854 -110 -130 -240 -22 -37 -28 -1.3 (-2.1, -0.4) -1.8 (-2.5, -1.0) -1.5 (-2.0, -1.0) Bladder (C67) 218 68 286 400 120 520 -182 -52 -234 -46 -43 -45 -2.6 (-3.0, -2.2) -2.4 (-3.1, -1.7) -2.6 (-2.9, -2.2) Kidney (C64) 299 139 438 402 265 668 -103 -126 -230 -26 -48 -34 -1.5 (-1.9, -1.1) -3.0 (-3.6, -2.4) -1.9 (-2.4, -1.4) Ovary (C56) - 487 487 - 690 690 - -203 -203 - -30 -30 - -1.8 (-2.2, -1.5) -1.8 (-2.2, -1.5) Brain and related (C69-C72) 535 334 869 607 411 1,017 -72 -77 -148 -12 -19 -15 -0.7 (-1.2, -0.2) -0.8 (-1.6, -0.0)* -0.6 (-1.2, -0.1) Myeloid leukaemia (C92) 275 174 450 341 241 582 -66 -67 -132 -19 -28 -23 -1.4 (-1.9, -0.9) -1.5, (-2.1, -1.0) -1.2 (-1.9, -0.6) Melanoma (C43) 506 252 759 556 292 848 -50 -40 -89 -9 -14 -11 -0.5 (-0.8, -0.1) -0.9 (-1.5, -0.4) -0.6 (-0.9, -0.4) Lymphoid leukaemia (C91) 126 60 185 184 90 274 -58 -30 -89 -32 -34 -32 -1.6 (-2.9, -0.4) -1.8 (-3.5, -0.1) -1.9 (-2.8, -0.9) Hodgkin lymphoma (C81) 22 14 36 76 44 120 -54 -30 -84 -71 -68 -70 -5.7 (-7.0, -4.5) -5.2 (-6.3, -4.1) -5.6 (-6.4, -4.8) Pancreas (C25) 678 442 1,120 698 491 1,189 -20 -49 -69 -3 -10 -6 -0.3 (-0.7, 0.1)* -0.4 (-0.8, 0.0)* -0.4 (-0.9, 0.1)* Oesophagus (C15) 506 112 618 504 178 682 2 -66 -64 0 -37 -9 -0.1 (-0.4, 0.2)* -1.8 (-2.5, -1.1) -0.3 (-1.0, 0.3)* Uterus (C54-C55) - 176 176 - 220 220 - -44 -44 - -20 -20 - -1.0 (-2.4, 0.4)* -1.0 (-2.4, 0.4)* Thyroid (C73) 29 30 59 26 37 63 3 -7 -4 12 -19 -6 0.1 (-1.4, 1.7)* -0.9 (-2.4, 0.6)* -0.3 (-1.3, 0.7)* Liver and intrahepatic bile ducts (C22) 460 189 649 265 117 382 195 72 267 73 62 70 2.3 (1.9, 2.7) 2.7 (2.0, 3.3) 2.4 (2.1, 2.7) Other cancers 1,410 951 2,361 1,233 823 2,057 177 128 304 14 16 15 0.6 (0.3, 0.9) 0.6 (-0.2, 1.4)* 0.7 (0.4, 1.0) All cancers (C00-C97, D45-D46, 11,535 8,569 20,104 16,566 11,365 27,931 -5,031 -2,796 -7,827 -30 -25 -28 -1.8 (-1.9, -1.6) -1.4 (-1.5, -1.2) -1.6 (-1.7, -1.5) D47.1, D47.3) 0-14 years (All cancers) 46 41 87 86 65 151 -40 -24 -64 -47 -37 -43 -2.9 (-4.5, -1.2) -2.3 (-3.0, -1.5) -2.7 (-3.8, -1.5)

* Trend is not statistically significant at the significance level of 0.05 ** All figures have been rounded a This change is the standardised ratio: (O/E)-1

November, 2013 Table 6–2 Incidence: number of observed new cases in Australia in 2007 compared to expected number of new cases based on 1987 rates**

Observed incidence Expected incidence Change in incidence (%) Annual average percentage change Cancer type† Difference (O-E) in 2007 (O) in 2007 (E) (O-E)/Ea (95% CI)

Male Female Persons Male Female Persons Male Female Persons Male Female Persons Male Female Persons

Lung (C33-34) 3,612 2,302 5,915 5,786 1,834 7,620 -2,174 468 -1,705 -38 26 -22 -2.4 (-2.6, -2.2) 1.1 (0.9, 1.3) -1.3 (-1.5, -1.1) Colorectal (C18-20) 5,121 3,653 8,774 4,921 3,680 8,600 200 -27 174 4 -1 2 0.2 (-0.1, 0.4)* -0.1 (-0.3, 0.1)* 0.1 (-0.2, 0.4)* Breast (female) (C50) - 10,681 10,681 - 7,945 7,945 - 2,736 2,736 - 34 34 - 1.5 (1.1, 1.9) 1.5 (1.1, 1.9) Stomach (C16) 765 365 1,131 1,201 508 1,709 -436 -143 -578 -36 -28 -34 -2.2 (-2.5, -2.0) -1.6 (-2.0, -1.3) -2.0 (-2.2, -1.8) Head and neck (C00-C02, C32)§ 1,209 307 1,517 1,735 344 2,079 -526 -37 -562 -30 -11 -27 -1.8 (-2.5, -1.0) -0.5 (-1.3, 0.3)* -1.5 (-2.1, -0.8) Unknown primary (C77-C80) 748 532 1,281 1,303 882 2,185 -555 -350 -904 -43 -40 -41 -2.5 (-3.2, -1.7) -2.7 (-3.5, -1.9) -2.6 (-3.1, -2.2) Prostate (C61) 13,961 - 13,961 3,716 - 3,716 10,245 - 10,245 276 - 276 6.6 (3.7, 9.6) - 6.6 (3.7, 9.6) Cervix uteri (C53) - 649 649 - 1,339 1,339 - -690 -690 - -52 -52 - -3.6 (-4.3, -2.8) -3.6 (-4.3, -2.8) Non-Hodgkin lymphoma (C82-C85) 1,617 1,168 2,785 1,253 948 2,201 364 220 584 29 23 27 1.3 (0.9, 1.8) 1.1 (0.7, 1.5) 1.2 (0.7, 1.6) Bladder (C67) 844 218 1,062 1,633 539 2,172 -789 -321 -1,110 -48 -60 -51 -3.2 (-3.4, -2.9) -4.2 (-5.3, -3.1) -3.3 (-3.5, -3.0) Kidney (C64) 1,285 620 1,904 789 439 1,228 496 181 676 63 41 55 2.1 (1.8, 2.4) 1.6 (1.3, 2.0) 2.2 (1.6, 2.7) Ovary (C56) - 910 910 - 1,077 1,077 - -167 -167 - -16 -16 - -1.1 (-1.4, -0.8) -1.1 (-1.4, -0.8) Brain and related (C71)‡ 704 459 1,162 739 490 1,229 -35 -31 -67 -5 -6 -5 -0.1 (-0.4, 0.2)* -0.4 (-1.5, 0.8)* -0.3 (-1.6, 1.0)* Melanoma (C43) 4,569 3,446 8,015 3,635 3,242 6,877 934 204 1,138 26 6 17 1.3 (0.7, 1.9) 0.6 (0.2, 0.9) 0.9 (0.6, 1.2) Hodgkin lymphoma (C81) 267 213 479 226 157 384 41 56 95 18 35 25 1.1 (0.7, 1.5) 1.8 (1.3, 2.3) 1.4 (1.0, 1.7) Pancreas (C25) 781 527 1,308 730 540 1,269 51 -13 39 7 -2 3 0.2 (-0.2, 0.6)* 0.1 (-0.4, 0.5)* 0.1 (-0.2, 0.4)* Oesophagus (C15) 573 161 734 524 235 759 49 -74 -25 9 -32 -3 0.3 (0.0, 0.6) -1.7 (-2.3, -1.1) -0.2 (-0.5, 0.1)* Uterus (C54-C55) - 1,521 1,521 - 1,311 1,311 - 210 210 - 16 16 - 0.9 (0.6, 1.1) 0.9 (0.6, 1.1) Thyroid (C73) 408 1,258 1,666 147 412 559 261 846 1,107 177 205 198 5.1 (4.6, 5.5) 5.8 (5.4, 6.1) 5.6 (5.3, 5.9) Liver and intrahepatic bile ducts (C22) 622 194 816 264 87 351 358 107 465 135 122 132 4.0 (3.6, 4.3) 4.5 (3.9, 5.1) 4.1 (3.8, 4.4) Other cancers 5,611 3,371 8,982 4,899 2,729 7,629 712 642 1,353 15 24 18 0.8 (0.5, 1.0) 1.0 (0.7, 1.3) 0.8 (0.6, 1.0) All cancers (C00-C97, D45-D46, 42,698 32,554 75,252 33,502 28,738 62,240 9,196 3,816 13,012 27 13 21 1.2 (0.7, 1.7) 0.7 (0.5, 0.8) 0.9 (0.5, 1.4) D47.1, D47.3) 0-14 years (All cancers) 321 271 592 294 245 538 27 26 54 9 11 10 0.3 (-0.2, 0.9)* 0.5 (0.1, 0.9) 0.3 (0.1, 0.6)

* Trend is not statistically significant at the significance level of 0.05 ** All figures have been rounded † Leukaemias not available for full time period. ‡ Brain and related not available. Only brain § Head and neck not available. Incidence data on lip, tongue and pharyngeal a This change is the standardised ratio: (O/E)-1

Cancer Council NSW • 33 34 • The State of Cancer Control in Australia

Figure 6–3 Change in cancer incident cases and mortality in Australia from 1987–2007 – MALES

Incident cases (%) Mortality (%)

Percentage change 1987-2007 100 x (O-E)/E

November, 2013 Figure 6–4 Change in cancer incident cases and mortality in Australia from 1987–2007 – FEMALES

Incident cases (%) Mortality (%)

Percentage change 1987-2007 100 x (O-E)/E

Cancer Council NSW • 35 36 • The State of Cancer Control in Australia

Figure 6–5 Change in cancer incident cases and mortality in Australia from 1987–2007 – PERSONS

Incident cases (%) Mortality (%)

Percentage change 1987-2007 100 x (O-E)/E

November, 2013 7 Results: analysis of cancer types - incidence and mortality

In this section, eight cancer types are outlined briefly as a way of contextualising the analysis and highlighting cancer types that are important in Australia – either because of their public health programs or because of large incidence or mortality percentage changes – to illustrate how policy, programs or other changes may have affected these measures. These have been selected based on a combined list of the top five cancer sites for males and females in incidence and mortality according to IARC GLOBOCAN 2008 working estimates, and cancer types of national importance in Australia.5 Firstly, trends in incidence and mortality for the cancer type are described – including data from the IARC GLOBOCAN project to illustrate global incidence and mortality working estimates for 2008 in individuals aged 74 years and under. Additionally, the most current survival data available for Australia from the AIHW are also provided.3 The AIHW survival data are presented to provide context rather than to facilitate a comparison between survival trends and our 7 Results findings. However, the AIHW data were only available for all ages combined. The relative survival and five-year conditional References relative survival data reported by the AIHW show the 3 Australian Institute of Health and Welfare. Cancer survival and probability of surviving a given number of years, provided that prevalence in Australia period estimates from 1982 to 2010. an individual has already survived a specific amount of time Canberra: Australian Institute of Health and Welfare; 2012 after diagnosis.3 (Cancer series no. 69. Cat. no. CAN 65). 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. A brief overview of current prevention strategies, screening GLOBOCAN 2008 v2.0, Cancer incidence and mortality programs and treatment methods in use globally and in worldwide: IARC CancerBase No. 10: Lyon, France: IARC, 2010. Australia are also provided. The results of our analysis for the specific cancer type are then presented and discussed.

Cancer Council NSW • 37 38 • The State of Cancer Control in Australia

November, 2013 7.1 Breast cancer (C50)

7.1.1 Background Breast cancer is the most common cancer diagnosed in females globally. Males can also develop breast cancer but it is a rare condition, with less than 1% of breast cancer cases 7.1.1.1 Causes and risk factors reported in males.7 IARC GLOBOCAN 2008 working estimates Having first-degree relatives with breast cancer doubles show that the incidence for breast cancer was 36.3/100,000 the relative risk, while having second-degree relatives with in females up to 74 years of age, with considerable variability breast cancer increases risk to a lesser extent.78 Other by region.5 Incidence is much higher in Western Europe and non-modifiable risk factors for breast cancer include being Australia/New Zealand than in less developed regions such female, age, breast density, and hormonal factors such as as Eastern Africa.5 Improved diagnosis and increased use of early menarche and late menopause.7, 18-20 The risk of breast screening partially accounted for rising number of incident cancer is higher in females who have a high concentration of cases of breast cancer until a recent reversal of trends in the endogenous hormone oestradiol.78 Multiple risk factors Western countries, attributed to the reduced use of HRT.20, 76, 77 are associated with reproductive history (including low parity, The mortality rate for breast cancer is 10.9/100,000 in females lack of breast feeding and late age for first birth). Obesity under 75 years of age and is decreasing globally.7, 20, 77 is correlated with increased risk.18 Proven causative agents include alcohol consumption, certain oral contraceptive and The incidence of breast cancer in Australia rose until the late HRT formulations, and ionising radiation.7, 18-20 1990s but has recently levelled off, and has been decreasing since about 2000. Relative survival is high with an 89% Environmental and lifestyle factors account for more cases probability of surviving for at least 5 years at diagnosis. The of breast cancer than familial history and inherited genetic 5-year conditional relative survival was 90% at 1 year and characteristics.7, 78 Childbearing is reported to have a 95% at 5 years after diagnosis. Survival rates, however, are protective effect; however, this effect has been isolated to negatively affected by remoteness and socioeconomic group, particular age groups, with younger females who have ever with more disadvantaged groups having lower survival.3 given birth being at higher breast cancer risk.79 Cancer Council NSW • 39 40 • The State of Cancer Control in Australia

An evaluation of existing evidence, led by the World The findings of a global collaboration found that risk was Cancer Research Fund, has found80: increased (1.07–1.24) in premenopausal females either currently using contraception or having ceased it within • Convincing evidence for : 10 years; however, there was no increase in risk 10 years ºº Lactation decreasing risk of breast cancer in pre- after cessation.85 Similarly, a South African study found and postmenopausal women negligible risk in breast cancer patients 5 years after cessation.86 ºº Consuming alcoholic drinks increasing risk of breast cancer in pre- and postmenopausal women There are a number of breast tumour subtypes that are associated with differing risk factors.87-89 Hormone ºº Body fatness and factors leading to greater adult- receptor–positive tumours, in comparison to hormone attained height increasing risk of breast cancer in receptor–negative tumours, have been more strongly postmenopausal women associated with reproductive factors such as menarche at • Probably evidence for: an early age, lack of childbearing, higher body mass index (BMI) in younger females and increased age at first full- ºº Body fatness decreasing risk of breast cancer in term birth.88 Hormone receptor–negative tumour risk was premenopausal women inversely associated with vegetable consumption.87 Core ºº Physical activity decreasing risk of breast cancer in basal phenotype breast cancer appears to have a different postmenopausal women (evidence is only limited aetiology to other breast cancer types and consequently for premenopausal women) other risk factors.88 Importantly, this would suggest that certain breast cancer subtypes may, in future, require ºº Greater birth weight and factors leading to greater specialised risk models and specialised screening and adult-attained height increasing risk of breast prevention programs.87-89 cancer in premenopausal women ºº Abdominal fatness and adult weight gain increasing risk of breast cancer in premenopausal women 7.1.1.2 International prevention/ No dietary factors apart from alcohol consumption have been consistently associated with risk of breast screening/treatment programs cancer. Despite earlier indications, consumption of fruit Some potential chemopreventive drugs have been or vegetables is not established at the level of ‘limited– identified for the prevention of breast cancer. Both suggestive’ evidence as decreasing risk of breast cancer tamoxifen and raloxifene reduce the risk of breast cancer, overall in premenopausal or postmenopausal females.80 especially in high-risk females.19, 21 However, further research is required to confirm the exact treatment effects During menopause, limited or no use of HRT has been and adverse outcomes. For example, tamoxifen has been shown to reduce risk in comparison to continuous use. convincingly identified as a cause of endometrial cancer, In an Australian study, a reduction in prescribing of HRT and its use in breast cancer treatment must incorporate between 2001 and 2003 coincided with a fall in breast additional risk to females.21 cancer incidence in females aged 50 and over.81 HRT users, depending on the type of treatment, have an Population-based screening programs for breast cancer elevated risk, which reduces when use is ceased.78, 82 have been established in many countries for females aged 50 years and over, and overall, showed a reduction Additional modifiable risk factors for all females include in breast cancer mortality in past randomised controlled 83 80 X- and y-radiation and alcohol consumption, with trials.7, 90, 91 National screening programs, however, have an estimated 12% of all breast cancer cases in females been clouded by conflicting expert opinion on their 19, 78, 84 18 and over attributable to alcohol consumption. effectiveness.90-94 Some experts argue that screening Combined oestrogen and progestogen oral contraceptive plays an important role in identifying cancerous growths 21 use is also linked to slight increased risk of breast cancer. when they are small and more easily treated, leading to

November, 2013 earlier intervention and more successful treatment.20 Others females aged 50–69 participated in the screening program.6 claim that the benefit provided by screening is outweighed by An analysis of BreastScreen participation in South Australia overdiagnosis, a combination of diagnoses brought forward in showed a 30–41% reduction in mortality for females aged detection time and asymptomatic cancers detected through 50 or over.103 A Western Australian study also suggests screening.95 Generally, overdiagnosis is compensated for a reduction in mortality by about half due to screening.23 by the lack of screening in older age groups, but adequate In 2007, the BreastScreen Australia Evaluation Advisory follow-up is required for this to be reflected accurately in study Committee undertook an appraisal of the program, and their results.95 Claims of overdiagnosis resulting from screening recommendations supported the program’s continuation – have stemmed from differing study methods used to assess but suggested changes to the target groups and frequency.26 its impact.90, 95 It has been suggested that the frequency of Not all these recommendations have been implemented yet.68 mammographies could be personalised for individuals based Treatment options depend on the extent and subtype of the on risk factors, to reduce overdiagnosis and unnecessary cancer, and can range from lumpectomy (removal of the screening.96 tumour) to mastectomy (complete removal of the breast). Reductions in mortality resulting from organised screening This may be followed by , , programs are similar to, but not greater than, those from past hormone therapy or other .20 Short-term randomised controlled trials, suggesting that more survival and recurrence can be positively influenced by time may be needed to identify any further trends the use of aspirin, according to an American study.104 of screening impact.97 Population studies are Tamoxifen is also used to treat patients with often used in national program assessment, oestrogen receptor–positive breast cancer to which are an important starting point, but No dietary factors reduce the risk of recurrence during treatment need to be supported by cohort or case- apart from alcohol and for up to 10 years after treatment.105 The control studies based on individual data consumption have use of tamoxifen generally ceases after 5 which is closer to the evaluation method been consistenty years, but a recent study has suggested used in the original randomised controlled value in continuing treatment for 10 years associated with risk of trials.91 It may take many years before after initial treatment, as it reduces recurrence population data show a true change due to breast cancer. and mortality.105 Tamoxifen, however, has screening; and realising full implementation side effects that need to be considered before of a national program also requires time and recommending prolonged use.21 When examining relies on a larger number of professionals to deliver long-term survival, the most important predictors are the service.90 This suggests that ecological studies††, tumour size, lymph node status and grade. although commonly used, are not always appropriate to In Australia, the management of early breast cancer assess results of screening programs.91 improved with the introduction of clinical practice guidelines Taking this into account, reportedly two lives are saved for in 1995. These guidelines led to increased use of adjuvant every case overdiagnosed in Europe.98 After adjusting for radiotherapy, chemotherapy and hormone therapy in differing study methods, an approximate 26% reduction in oestrogen receptor–positive patients.24, 106 In contrast to the mortality was found after 6–11 years of follow-up in a number AIHW findings, a review of the literature found that factors of European studies.99 Advances in treatment explain a such as age and SES have a lower association with long-term proportion of the fall in mortality rates, and further advances survival when other prognostic factors are also taken into in technology will continue to change programs and affect account.107 incidence and mortality rates.90, 92-94, 100, 101 Recurrent incidence of breast cancer can increase in The Australian national screening program (BreastScreen) was survivors with regular alcohol consumption – especially in initiated in 1991, and under this scheme, females are invited to postmenopausal and overweight/obese females.108 A healthy participate in fully funded mammograms every two years (see lifestyle is associated with increased long-term survival. section 8.3.5.8).1, 102 Recently, screening has been extended Other risk factors can increase recurrence and impact the from females aged 50–69 to those aged 50–74102; however, clinical behaviour of a tumour and, therefore, affect survival.107 the scientific rationale for this is unclear. In 2009–2010, 55% of

††Ecological studies are where the units of observation are populations rather than individuals Cancer Council NSW • 41 42 • The State of Cancer Control in Australia

7.1.2 Incidence and mortality rates in Figure 7–1 Australia 1987-2007 Breast cancer: Age-standardised cancer mortality rates in Australia 1987-2007, 0-74 Years Our analysis shows that between 1987 and 2007, breast cancer incidence has increased from the expected 2525 numbers by 34%, while mortality has reduced by 31% (Table 7–1). Both changes were statistically significant 20 (Table 7–2) and are largely attributed to the national 20 screening program, improved management of breast cancer and reduced population risk through changing 1515 behaviour.23-25 For example, after the use of HRT was linked to breast cancer incidence in 2001, its use 1010 dropped dramatically among females aged 50 and over, corresponding with a concomitant 6.7% fall in incidence.25 Mortality per 100,000 people 5 Incidence and mortality rates from 1987 to 2007 are 5 illustrated in Figure 7–1 and Figure 7–2. Mortality per 100,000 people

Figure 7–1 00 Breast cancer deaths and incident cases in Australia 19901990 19951995 20002000 20052005 1987-2007 YearYear

Female Figure 7–2 Breast cancer: Age-standardised cancer incidence Incident Deaths† Cases† rates in Australia 1987-2007, 0-74 Years Observed in 2007 (O)# 1,691 10,681

Expected in 2007 (E)§ 2,464 7,945 100100

Difference (O-E) -773 2,736 75 Change in (O-E)/E (%) -31 34 75

# An average of the observed rates for 2006 to 2008 was applied to the 50 2007 population to calculate the observed number of deaths and incident 50 cases for 2007. §An average of the observed rates for 1986 to 1988 was applied to the 2007 population to calculate the expected number of deaths and incident 2525 cases for 2007. Incidence per 100,000 people †All figures have been rounded to the nearest whole number. 100,000 people per Incidence

00 Table 7–2 19901990 19951995 20002000 20052005 Breast cancer: average annual percentage change YearYear (AAPC)

Mortality Incidence

Confidence Confidence AAPC AAPC Interval (95%) Interval (95%) Male - - - - Female -1.8 -2.2, -1.5 1.5 1.1, 1.9 Persons - - - -

November, 2013 Increase in breast cancer incidence globally has been attributed to changes over time in screening practices, childbearing and breastfeeding; HRT intake; and other lifestyle factors, such as obesity and limited physical activity.109 Evidence has shown that earlier detection, modern therapy and healthier lifestyles can improve the long-term survival of breast cancer patients.107 Long-term survivors of breast cancer generally have a good quality of life.110, 111 Patient factors positively influencing quality of life, as evidenced in a systematic review, were not undergoing chemotherapy treatment, receiving emotional support from family and friends, and having a relatively high income.111 Breast cancer in females under 50 years of age is sometimes more aggressive and presents with a different set of issues, including infertility, early menopause and recurrence of breast cancer.112 This group was also more likely to suffer from depression and the anxiety about the prospect of breast cancer recurrence.112 In 2004/05, 24% of Australian government expenditure for cancer was allocated to breast cancer. The largest proportion of this was spent on screening services, followed by hospital admitted–patient services. The total value of this expenditure on breast cancer was approximately AUS$331 million. Breast cancer incidence (2004–2008) decreased with geographical remoteness and increased with improving SES. Breast cancer is also a high health system burden with an increase of 72% in the number of females hospitalised due to breast cancer between 2000/01 and 2009/10.113 In Australia, the increase in incidence is attributed to the success of the BreastScreen program, which is part of the Australian Government’s cancer prevention strategy developed nationally but managed at a state/territory level. Continuous evaluation of the BreastScreen program’s effectiveness is essential to maintaining an optimal use of budgetary health care spending and ensuring the most at-risks groups are being targeted.114 As outlined in the BreastScreen evaluation, the current system capacity will not be able to meet demand in the years to come. Revisions have been recommended to various aspects of the program to improve its efficiency.26 A key recommendation of the evaluation was improved national policy leadership to facilitate the availability of an equitable service across the nation. The national accreditation process for the provision of screening services is also being reviewed to improve the standardisation of the program across locations.26 No reliable national data currently exist on mammography screening coverage.

Cancer Council NSW • 43 44 • The State of Cancer Control in Australia

7.1 Breast cancer

References 1 Australian Institute of Health and Welfare. Australia’s health 76 Seradour B, Allemand H, Weill A, Ricordeau P. Sustained 2012. Canberra: Australian Institute of Health and Welfare; lower rates of breast cancer incidence in France in 2007. 2012 (Australia’s health no.13. Cat. no. AUS 156). Breast Cancer Res Treat. 2010;121 (3):799-800. 3 Australian Institute of Health and Welfare. Cancer survival and 77 Autier P, Boniol M, La Vecchia C, Vatten L, Gavin A, prevalence in Australia period estimates from 1982 to 2010. Hery C, Heanue M. Disparities in breast cancer mortality Canberra: Australian Institute of Health and Welfare; 2012 trends between 30 European countries: retrospective (Cancer series no. 69. Cat. no. CAN 65). trend analysis of WHO mortality database. BMJ. 2010;341:c3620. 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. GLOBOCAN 2008 v2.0, Cancer incidence and mortality 78 Key TJ, Verkasalo PK, Banks E. Epidemiology of breast worldwide: IARC CancerBase No. 10: Lyon, France: IARC, cancer. Lancet Oncol. 2001;2 (3):133-40. 2010. 79 Beral V, Reeves G. Childbearing, oral contraceptive use, 6 Australian Institute of Health and Welfare and Australiasian and breast cancer. Lancet. 1993;341 (8852):1102. Association of Cancer Registries. Cancer in Australia: an 80 World Cancer Research Fund / American Institute for overview Canberra: Australian Institute of Health and Welfare; Cancer Research. Continuous Update Project Report. 2012 (Cancer series no. 74. Cat. no. CAN 70). Food, Nutrition, Physical Activity, and the Prevention of 7 Boyle P, Levin B, editors. World Cancer Report 2008. Geneva: Breast Cancer. Washington, DC: American Institute for IARC; 2008. Cancer Research; 2010. 18 Petracci E, Decarli A, Schairer C, Pfeiffer RM, Pee D, Masala 81 Canfell K, Banks E, Moa AM, Beral V. Decrease in breast G, Palli D, Gail MH. Risk factor modification and projections cancer incidence following a rapid fall in use of hormone of absolute breast cancer risk. J Natl Cancer Inst. 2011;103 replacement therapy in Australia. Med J Aust. 2008;188 (13):1037-48. (11):641-4. 19 Cummings SR, Tice JA, Bauer S, Browner WS, Cuzick J, 82 Chlebowski RT, Anderson GL. Changing concepts: Ziv E, Vogel V, Shepherd J, Vachon C, Smith-Bindman R, Menopausal hormone therapy and breast cancer. J Natl Kerlikowske K. Prevention of breast cancer in postmenopausal Cancer Inst. 2012;104 (7):517-27. women: approaches to estimating and reducing risk. J Natl 83 IARC Working Group on the Evaluation of Carcinogenic Cancer Inst. 2009;101 (6):384-98. Risks to Humans. IARC Monographs: Radiation. Volume 20 American Cancer Society. Cancer facts & figures 2012. Atlanta: 100D A review of human carcinogens. Lyon: IARC; 2012. American Cancer Society; 2012. 84 Ridolfo B, Stevenson C. The quantification of drug- 21 IARC Working Group on the Evaluation of Carcinogenic Risks caused mortality and morbidity in Australia, 1998. to Humans. IARC Monographs: Pharmaceuticals. Volume 100A Canberra: Australian Institute of Health and Welfare; 2001 A review of human carcinogens. Lyon: IARC; 2012. (Drug Statistics Series no.7. Cat. no. PHE 29). 23 Nickson C, Mason KE, English DR, Kavanagh AM. 85 Collaborative Group on Hormonal Factors in Breast Mammographic screening and breast cancer mortality: a Cancer. Breast cancer and hormonal contraceptives: case-control study and meta-analysis. Cancer Epidemiol collaborative reanalysis of individual data on 53 297 Biomarkers Prev. 2012;21 (9):1479-88. women with breast cancer and 100 239 women without breast cancer from 54 epidemiological studies. Lancet. 24 White V, Pruden M, Giles G, Collins J, Jamrozik K, Inglis G, 1996;347 (9017):1713-27. Boyages J, Hill D. The management of early breast carcinoma before and after the introduction of clinical practice guidelines. 86 Urban M, Banks E, Egger S, Canfell K, O’Connell D, Beral Cancer. 2004;101 (3):476-85. V, Sitas F. Injectable and oral contraceptive use and cancers of the breast, cervix, ovary, and endometrium in 25 Canfell K, Banks E, Clements M, Kang YJ, Moa A, Armstrong black South African women: case-control study. PLoS B, Beral V. Sustained lower rates of HRT prescribing and Med. 2012;9 (3):e1001182. breast cancer incidence in Australia since 2003. Breast Cancer Res Treat. 2009;117 (3):671-3. 87 Jung S, Spiegelman D, Baglietto L, Bernstein L, Boggs D, van den Brandt P, Buring J, Cerhan J, Gaudet M, Giles 26 Australian Government Department of Health and Ageing. G, Goodman G, Hakansson N, et al. Fruit and Vegetable Evaluation of the BreastScreen Australia Program – Evaluation Intake and Risk of Breast Cancer by Hormone Receptor Final Report – June 2009. Canberra: Commonwealth of Status. J Natl Cancer Inst. 2013;105 (3):219-36. Australia 2009. 88 Yang XR, Chang-Claude J, Goode EL, Couch FJ, 68 Australian Government Department of Health and Ageing. Nevanlinna H, Milne RL, Gaudet M, Schmidt MK, Broeks BreastScreen Australia Program: About the Program. A, Cox A, Fasching PA, Hein R, et al. Associations of Canberra Australian Government Department of Health and breast cancer risk factors with tumor subtypes: a pooled Ageing; 2012 [updated February 3; cited 2012 November 5]; analysis from the Breast Cancer Association Consortium Available from: http://www.cancerscreening.gov.au/internet/ studies. J Natl Cancer Inst. 2011;103 (3):250-63. screening/publishing.nsf/Content/breastscreen-about.

November, 2013 89 Thomson CA, Thompson PA. Fruit and Vegetable Intake and 102 Australian Government. Budget 2013-14: Health and Ageing. Breast Cancer Risk: A Case for Subtype-Specific Risk? J Natl Canberra: Commonwealth of Australia; 2013 [updated July Cancer Inst. 2013;105 (3):164-5. 9; cited 2013 July 9]; Available from: http://www.budget.gov. 90 Broeders M, Moss S, Nyström L, Njor S, Jonsson H, Paap au/2013-14/content/bp2/html/bp2_expense-13.htm. E, Massat N, Duffy S, Lynge E, Paci E, Euroscreen Working 103 Roder D, Houssami N, Farshid G, Gill G, Luke C, Downey P, Group. The impact of mammographic screening on breast Beckmann K, Iosifidis P, Grieve L, Williamson L. Population cancer mortality in Europe: a review of observational studies. J screening and intensity of screening are associated with reduced Med Screen. 2012;19 (Suppl 1):14-25. breast cancer mortality: evidence of efficacy of mammography 91 Moss S, Nyström L, Jonsson H, Paci E, Lynge E, Njor S, screening in Australia. Breast Cancer Res Treat. 2008;108 Broeders M, Euroscreen Working Group. The impact of (3):409-16. mammographic screening on breast cancer mortality in 104 Holmes MD, Chen WY, Li L, Hertzmark E, Spiegelman D, Europe: a review of trend studies. J Med Screen. 2012;19 Hankinson SE. Aspirin intake and survival after breast cancer. J (Suppl 1):26-32. Clin Oncol. 2010;28 (9):1467-72. 92 Gotzsche PC, Nielsen M. Screening for breast cancer 105 Davies C, Pan H, Godwin J, Gray R, Arriagada R, Raina V, with mammography. Cochrane Database Syst Rev. 2011 Abraham M, Alencar V, Badran A, Bonfill X, Bradbury J, Clarke (1):CD001877. M, et al. Long-term effects of continuing adjuvant tamoxifen to 93 Jorgensen KJ, Keen JD, Gotzsche PC. Is mammographic 10 years versus stopping at 5 years after diagnosis of oestrogen screening justifiable considering its substantial overdiagnosis receptor-positive breast cancer: ATLAS, a randomised trial. rate and minor effect on mortality? Radiology. 2011;260 (3):621- Lancet. 2013;381:805-16. 7. 106 Luke C, Gill G, Birrell S, Humeniuk V, Borg M, Karapetis C, 94 Independent UK Panel on Breast Cancer Screening. The Koczwara B, Olver I, Penniment M, Pittman K, Price T, Walsh D, benefits and harms of breast cancer screening: an independent et al. Treatment and survival from breast cancer: the experience review. Lancet. 2012;380 (9855):1778-86. of patients at South Australian teaching hospitals between 1977 and 2003. J Eval Clin Pract. 2007;13 (2):212-20. 95 Puliti D, Duffy S, Miccinesi G, de Koning H, Lynge E, Zappa M, Paci E, Euroscreen Working Group. Overdiagnosis in 107 Soerjomataram I, Louwman MW, Ribot JG, Roukema JA, mammographic screening for breast cancer in Europe: a Coebergh JW. An overview of prognostic factors for long-term literature review. J Med Screen. 2012;19 (Suppl 1):42-56. survivors of breast cancer. Breast Cancer Res Treat. 2008;107 (3):309-30. 96 Schousboe JT, Kerlikowske K, Loh A, Cummings SR. Personalizing mammography by breast density and other risk 108 Kwan ML, Kushi LH, Weltzien E, Tam EK, Castillo A, Sweeney factors for breast cancer: analysis of health benefits and cost- C, Caan BJ. Alcohol consumption and breast cancer recurrence effectiveness. Ann Intern Med. 2011;155 (1):10-20. and survival among women with early-stage breast cancer: the life after cancer epidemiology study. J Clin Oncol. 2010;28 97 Schopper D, de Wolf C. How effective are breast cancer (29):4410-6. screening programmes by mammography? Review of the current evidence. Eur J Cancer. 2009;45 (11):1916-23. 109 Ferlay J, Hery C, Autier P, Sankaranarayanan R. Global Burden of Breast Cancer. In: Li C. Breast Cancer Epidemiology. New York: 98 Zappa M, Federici A. The potential for systematic early Springer, 2010. detection and treatment of breast cancer to reduce the burden of disease is widely recognized in the European Union (EU). 110 Wani SQ, Khan T, Teeli AM, HKhan NA, Wani SY, Ashfaq-ul- Introduction. J Med Screen. 2012;19 (Suppl 1):3-4. Hassan. Quality of life assessment in survivors of breast cancer. J Cancer Res Ther. 2012;8 (2):272-6. 99 Njor S, Nyström L, Moss S, Paci E, Broeders M, Segnan N, Lynge E, Euroscreen Working Group. Breast cancer mortality 111 Mols F, Vingerhoets AJ, Coebergh JW, van de Poll-Franse in mammographic screening in Europe: a review of incidence- LV. Quality of life among long-term breast cancer survivors: a based mortality studies. J Med Screen. 2012;19 (Suppl 1):33-41. systematic review. Eur J Cancer. 2005;41 (17):2613-9. 100 Burton R, Bell R, Thiagarajah G, Stevenson C. Adjuvant 112 Howard-Anderson J, Ganz PA, Bower JE, Stanton AL. Quality of therapy, not mammographic screening, accounts for most of life, fertility concerns, and behavioral health outcomes in younger the observed breast cancer specific mortality reductions in breast cancer survivors: a systematic review. J Natl Cancer Inst. Australian women since the national screening program began 2012;104 (5):386-405. in 1991. Breast Cancer Res Treat. 2012;131 (3):949-55. 113 Australian Institute of Health and Welfare & Cancer Australia. 101 Paci E, Euroscreen Working Group. Summary of the evidence Breast cancer in Australia: an overview. Canberra Australian of breast cancer service screening outcomes in Europe and Institute of Health and Welfare 2012 (Cancer series no. 71. Cat. first estimate of the benefit and harm balance sheet. J Med no. CAN 67). Screen. 2012;19 (Suppl 1):5-13. 114 Roder D. Impact of population screening programs on cancer outcomes. CancerForum. 2012;36 (1):4 -10. 46 • The State of Cancer Control in Australia

November, 2013 November, 2013

7. 2 Cervical cancer (C53)

7.2.1 Background Cervical cancer is the third most common cancer in females worldwide.5 Cervical cancer is caused by persistent infection of HPV, making it potentially preventable, and if diagnosed early, survival rates are high.7 IARC GLOBOCAN 2008 working estimates show that the global incidence for cervical cancer was 14.9/100,000 in females under 75 years of age.5 Incidence rates vary between developed and developing countries quite dramatically.7 In 2008, approximately 85% of cervical cancer cancers were found in less-developed regions of the world,115 and deaths from cervical cancer in developing countries compared to immigrant females.117 Higher incidence and represent approximately 88% of cervical cancer deaths mortality are observed in females residing in areas of lower globally.5 Global mortality was estimated to be 7.3/100,000 SES, compared to those residing in areas of higher SES,116 in females under 75 years of age.5 High-risk areas include potentially reflecting that females residing in higher SES sub-Saharan Africa along with South Central Asia, areas of areas are more likely to participate in cervical screening.116 Melanesia, Latin America and the Caribbean.5 Cervical cancer changes for immigrant females compared to Australian-born females in NSW showed that incidence rates Squamous cell carcinomas are the most common type of were falling for all except the European-born and those from cervical cancer, and the remainder are adenocarcinomas the Rest of World category.117 Additionally, mortality rates 7 and adenosquamous cancers. Globally, squamous cell were also decreasing at an increasing rate since the launch 7 carcinomas account for approximately 85–90% of cases, but of the organised program for all groups except the Rest of this proportion is highly setting-specific. Cervical screening World category, reflective of recent immigrants from high-risk can dramatically reduce squamous cell carcinomas over regions.117 time, but has little impact on glandular cancers such as adenocarcinomas.116 In 2008, Australian data showed 65% of The 5-year relative survival rate is good, with a 72% probability cervical cancer cases were squamous cell carcinomas and of surviving at diagnosis. The 5-year conditional relative 26% were adenocarcinomas.116 survival rate was increased to 82% at 1 year after diagnosis and 95% at 5 years after diagnosis.3 Survival rates, however, The incidence of cervical cancer in Australia has decreased are negatively affected by remoteness of residence and since the 1980s. Survival, however, has not improved greatly SES group.3 Additionally, the more common squamous cell 3 since the early 1990s. No great difference has been found carcinomas have a lower survival rate when compared to in the cervical cancer trends of Australian-born females adenocarcinomas.3 Cancer Council NSW • 47 48 • The State of Cancer Control in Australia

7.2.1.1 Causes and risk factors comparatively short follow-up from clinical trials; however, efficacy and immunogenicity have remained high for over Virtually all cases of cervical cancer are associated with five years.124-126 The early impacts of vaccination are being persistent HPV infection. However, cervical cancer is a observed in Australia, including a reduction in diagnoses relatively rare outcome of infection. Typically, persistent of genital warts in young females and young heterosexual HPV infection can be followed by a long phase of males, and a reduction in high-grade cervical abnormalities preinvasive disease and may be followed by invasive in females aged less than 18 years.116, 127-130 Vaccination of cervical cancer.7 The prevalence of HPV infection is higher pre-adolescent girls and regular cervical screening tests in for adolescents and females in their early 20s, while adult females are considered the most effective preventative cervical cancer peaks approximately 2 to 3 decades later, strategies for cervical cancer.124 Notably, vaccines prevent making age a risk factor.27 HPV infection in those who were previously uninfected, but Additional risk factors are parity, smoking, oral do not have any preventive or therapeutic effect on females contraceptive use, low SES and HIV-1/immune with existing HPV-associated lesions.131-133 suppression.7, 20, 27, 53 Co-infection with other sexually Gardasil® is approved in Australia not only for administration transmitted diseases such as Chlamydia trachomatis to females but also to males. Vaccination of males can or herpes simplex virus 2 is highly correlated with HPV prevent HPV transmission to their unvaccinated female infection.7, 20, 27 Multiple sexual partners and initiation of partners, as well as potentially preventing HPV-related sexual activity at an early age are also associated with disease and cancers in males, such as cancers of the anus, cervical cancer, but reflect the probability penis and oropharynx, and associated lesions.20 The vaccine of being infected with HPV, and are is not routinely recommended or administered to all young not considered to be co-factors for males globally, as the incremental effectiveness and progression of HPV.7 The accessibility cost-effectiveness of both-sex compared to female- The World Cancer Research of Pap tests is only vaccination is strongly dependent on price and Fund found only limited evidence coverage of the female-only program.134, 135 linking carrot consumption with considered a HPV vaccination was included in the reduced risk of cervical cancer.36 contributing factor immunisation schedule for adolescent males Other food and nutritional factors to the positive in Australia commencing in 2013, in spite of are not associated with risk of impact of cervical relatively high coverage in females (over 70%)136 cervical cancer.36 The long-term cancer screening. and following an initial rejection of public funding use of oral contraception has been on cost-effectiveness grounds. It has been suggested associated with an increased risk that the vaccine has been heavily discounted to allow of cervical cancer.7, 21, 118, 119 However, full program rollout.137 Modelling has generally found that hormonal contraceptive use is still advocated, vaccination of both genders is of most benefit when coverage as the benefits of its use, especially in the developing in an existing female-only vaccination program is low.134, world, outweigh the moderate causal relationship with 138 However, even in this situation, increasing coverage in cervical cancer.120 females is likely to be a more cost-effective approach if it is possible.139 Targeted vaccination of high-risk groups of males, such as males who have sex with males, could potentially 7.2.1.2 International prevention/ be of benefit and cost effective140 but requires further 135 screening/treatment programs investigation and consideration of implementation issues. Vaccination programs against HPV have been The Papanicolaou (Pap) test (cytology) is the most widely implemented in many settings.121 Two vaccines, Gardasil® used screening technique and is easily administered in (Merck & Co., Whitehouse Station NJ, USA) and Cervarix® primary care facilities. In Australia, the accessibility of Pap (GlaxoSmithKline Biologicals, Rixensart, Belgium), tests is considered a contributing factor to the positive 141 have been approved for use in many countries.122, 123 impact of cervical cancer screening. Screening for However, the cost of the vaccine means that it remains cervical cancer, generally using cytology, is widely used in inaccessible for inclusion in the public health strategy of developed nations and proven to aid in the identification of most developing countries, where approximately 80% precancerous lesions of the cervix. The IARC recommends of cervical cancer occurs.7 The long-term efficacy of the screening every 3 years for females aged 25–49 years, vaccine has not been conclusively proven, due to the and every 5 years for females aged 50–65 years; however,

November, 2013 individual countries vary the frequency and starting age Other technologies include alternative cytology at which screening is recommended to the population.142, technologies, such as liquid-based cytology and 143 For example, Australian guidelines recommend 2-yearly automation-assisted reading of their results; and direct screening, starting from age 18–20 years. testing for HPV, in some cases with partial genotyping results. These technologies are all being considered as Very similar reductions in cervical cancer incidence and part of the ‘Renewal’ process in Australia. Implementation mortality have been observed in Australia and the United of HPV testing as the primary screening test would mean Kingdom (UK).144 The UK program recommended three- screening intervals could be safely lengthened to at least yearly screening and has since moved to recommending five years, as risk is substantially reduced in females screening at IARC-recommended intervals.144 Modelled who test negative for HPV, compared to those who test analyses have also found that lengthening the negative by cytology.149 It would also open the possibility recommended screening interval in Australia from two to of self-collection of samples for testing, potentially a more three years would not increase rates of cervical cancer, acceptable strategy for females who are averse to having but would decrease the number of females undergoing Pap smears. HPV testing can be provided with less training diagnostic and treatment procedures.142 The screening for personnel and is more reproducible than cytology, but program in Australia is currently undergoing a process it is still costly in comparison to the current Pap test on a called the ‘Renewal’. This aims to review the program in per test basis.150 Economies of scale and the lengthening of order to take into account the current understanding of the screening intervals which HPV testing would allow would natural history of the disease, evidence around the optimal potentially compensate for this.150 A review in 2002 by the ages and intervals for screening and the latest screening Medical Services Advisory Committee did not endorse the technologies, and the advent of a vaccinated cohort of use of public funding for HPV testing.151 young females into the screening program.145 The slow development of cancerous cells for cervical In 2004/05, approximately AUS$103 million was spent cancer means that almost all cases can be caught with on cervical cancer screening: 57% of the total Australian regular screening.20 Early diagnosis results in more effective government spend on gynaecological cancers.146 However, and successful treatment techniques. Preinvasive cases this did not include all screening-related costs, such as are treated with electrocoagulation, cryotherapy, laser those associated with diagnosis and follow-up of screen- ablation or local surgery.20 Invasive cancers require surgery, detected abnormalities. It has been estimated that when radiation or a combination of both, as well as chemotherapy these costs are fully accounted for, AUS$194.8 million in some cases.20 Currently, there are immunomodulatory would have been spent on the National Cervical Screening and chemotherapeutic agents being researched for cervical Program in 2010 (excluding administrative overheads), cancer treatment efficacy that show promising results.131, 152 approximately half of which was related to primary screening smears.147 Modifying the current two-yearly screening recommendation in Australia to a three-year interval would result in a more cost-effective system, 7.2.2 Incidence and mortality rates in resulting from the reduced number of screening and Australia 1987-2007 diagnostic tests and a lower burden of treatment for pre- Our analysis shows that cervical cancer incidence and cancer, without compromising women’s health.142 mortality both decreased, by 52% and 62% respectively Australian findings are in line with other international between 1987 and 2007, both statistically significant studies and practices supporting a three-yearly interval changes (see Table 7–3 and Table 7–4). Much of this for screening.142, 143 Furthermore, the cost-effectiveness of improvement is attributed to the national screening current screening programs will decrease as vaccinated program. These findings do not include the time period in cohorts enter the program, as there is less risk of disease when the National HPV Vaccination Program was in place, in these females, and thus the absolute benefit which they and the impact of this program on cancer is likely to take at can receive from screening will be smaller.148 The reported least a decade. Therefore, it is assumed that these figures participation in the National Cervical Screening Program will improve in the future. The drop in cervical cancer has recently declined.6 Nonetheless, the overall benefit incidence and mortality rates from 1987 to 2007 can be of this program has been seen beyond the incidence and seen in Figure 7–3 and Figure 7–4. mortality trends: hospitalisations caused by cervical cancer fell by 6% between 2000/01 and 2009/10.146

Cancer Council NSW • 49 50 • The State of Cancer Control in Australia

Table 7–3 Figure 7–3 Cervical cancer deaths and incident cases in Australia Cervical cancer: age-standardised cancer mortality 1987–2007 rates in Australia 1987–2007, 0–74 years

Female 44 Incident Deaths† Cases† 33 Observed in 2007 (O)# 152 649 Expected in 2007 (E)§ 394 1,339 22 Difference (O-E) -242 -690 Change in (O-E)/E (%) -62 -52 1

Mortality per 100,000 people 1

#An average of the observed rates for 2006 to 2008 was applied to the 2007 Mortality per 100,000 people population to calculate the observed number of deaths and incident cases 0 for 2007. 0 §An average of the observed rates for 1986 to 1988 was applied to the 2007 19901990 19951995 20002000 20052005 Year population to calculate the expected number of deaths and incident cases Year for 2007. †All figures have been rounded to the nearest whole number. Figure 7–4 Table 7–4 Cervical cancer: age-standardised cancer incidence Cervical cancer: average annual percentage change rates in Australia 1987–2007, 0–74 years (APPC)

Mortality Incidence

Confidence Confidence AAPC AAPC Interval (95%) Interval (95%) Male - - - - 1010 Female -5.2 -5.8, -4.6 -3.6 -4.3, -2.8 Persons - - - -

55 Incidence per 100,000 people Incidence per 100,000 people per Incidence

00 19901990 19951995 20002000 20052005 Year Year

November, 2013 As a result of the high survival for cervical cancer, quality of life can sometimes be underemphasised.153 A review of the literature relating to cervical cancer suggested that survivors report good general health but have a higher number of comorbidities than the general population.154 There are a number of reproductive, sexuality and intercourse concerns for survivors as a result of the location of the cancer, requiring specialised supportive care to address these. Cervical cancer has received significant political attention since it was included as one of the specific cancers listed in the 1996 National Health Priority Areas. It still significantly contributes to the cancer- related burden of disease and is continuously monitored through the National Cervical Screening Program. Cancer Australia administers a Gynaecological Cancers Program, which attracts ongoing Australian government funding.146 It is currently one of the five cancers listed in the Australian Government’s Health Indicators Framework.145 Integrating HPV vaccination and the current screening program may prove challenging in managing changing public expectations and improving their understanding of safe and accurate programs.150 A major focus area for improvement is reaching unscreened and under-screened females, including by investigating screening options which are more appropriate for these populations.145

Cancer Council NSW • 51 52 • The State of Cancer Control in Australia

7.2 Cervical Cancer (C53)

References 3 Australian Institute of Health and Welfare. Cancer survival and 121 Markowitz LE, Tsu V, Deeks SL, Cubie H, Wang SA, Vicari AS, prevalence in Australia period estimates from 1982 to 2010. Brotherton JM. Human papillomavirus vaccine introduction-- Canberra: Australian Institute of Health and Welfare; 2012 the first five years. Vaccine. 2012;30 (Suppl 5):F139-48. (Cancer series no. 69. Cat. no. CAN 65). 122 Einstein MH, Baron M, Levin MJ, Chatterjee A, Edwards RP, 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. Zepp F, Carletti I, Dessy FJ, Trofa AF, Schuind A, Dubin G, GLOBOCAN 2008 v2.0, Cancer incidence and mortality HPV-010 Study Group. Comparison of the immunogenicity and worldwide: IARC CancerBase No. 10: Lyon, France: IARC, safety of Cervarix and Gardasil human papillomavirus (HPV) 2010. cervical cancer vaccines in healthy women aged 18-45 years. Hum Vaccin. 2009;5 (10):705-19. 6 Australian Institute of Health and Welfare and Australiasian Association of Cancer Registries. Cancer in Australia: an 123 Tomljenovic L, Wilyman J, Vanamee E, Bark T, Shaw C. HPV overview Canberra: Australian Institute of Health and Welfare; vaccines and cancer prevention, science versus activism. 2012 (Cancer series no. 74. Cat. no. CAN 70). Infect Agent Cancer. 2013;8 (1):6. 7 Boyle P, Levin B, editors. World Cancer Report 2008. Geneva: 124 Rey-Ares L, Ciapponi A, Pichon-Riviere A. Efficacy and safety IARC; 2008. of human papillomavirus vaccine in cervical cancer prevention: systematic review and meta-analysis. Arch Argent Pediatr. 20 American Cancer Society. Cancer facts & figures 2012. Atlanta: 2012;110 (6):483-9. American Cancer Society; 2012. 125 Romanowski B, de Borba PC, Naud PS, Roteli-Martins CM, 21 IARC Working Group on the Evaluation of Carcinogenic Risks De Carvalho NS, Teixeira JC, Aoki F, Ramjattan B, Shier RM, to Humans. IARC Monographs: Pharmaceuticals. Volume 100A Somani R, Barbier S, Blatter MM, et al. Sustained efficacy A review of human carcinogens. Lyon: IARC; 2012. and immunogenicity of the human papillomavirus (HPV)-16/18 27 Vesco KK, Whitlock EP, Eder M, Burda BU, Senger CA, Lutz AS04-adjuvanted vaccine: analysis of a randomised placebo- K. Risk factors and other epidemiologic considerations for controlled trial up to 6.4 years. Lancet. 2009;374 (9706):1975- cervical cancer screening: a narrative review for the U.S. 85. Preventive Services Task Force. Ann Intern Med. 2011;155 126 Villa LL, Costa RL, Petta CA, Andrade RP, Paavonen J, Iversen (10):698-705, W216. OE, Olsson SE, Hoye J, Steinwall M, Riis-Johannessen G, 36 World Cancer Research Fund / American Institute for Andersson-Ellstrom A, Elfgren K, et al. High sustained efficacy Cancer Research. Food, Nutrition, Physical Activity, and the of a prophylactic quadrivalent human papillomavirus types Prevention of Cancer: a Global Perspective. Washington, DC: 6/11/16/18 L1 virus-like particle vaccine through 5 years of American Institute for Cancer Research; 2007. follow-up. Brit J Cancer. 2006;95 (11):1459-66. 53 IARC Working Group on the Evaluation of Carcinogenic Risks 127 Leval A, Herweijer E, Ploner A, Eloranta S, Fridman Simard J, to Humans. IARC Monographs: Biological Agents. Volume Dillner J, Young C, Netterlid E, Sparén P, Arnheim-Dahlström 100B A review of human carcinogens. Lyon: IARC; 2012. L. Quadrivalent Human Papillomavirus Vaccine Effectiveness: 115 de Martel C, Ferlay J, Franceschi S, Vignat J, Bray F, Forman A Swedish National Cohort Study. J Natl Cancer Inst. 2013;105 D, Plummer M. Global burden of cancers attributable to (7):469-74. infections in 2008: a review and synthetic analysis. Lancet 128 Donovan B, Franklin N, Guy R, Grulich A, Regan D, Ali H, Wand Oncol. 2012;13 (6):607-15. H, Fairley C. Quadrivalent human papillomavirus vaccination 116 Australian Institute of Health and Welfare. Cervical screening and trends in genital warts in Australia: analysis of national in Australia 2009–2010. Canberra Australian Institute of Health sentinel surveillance data. Lancet Infect Dis. 2011;11 (1):39-44. and Welfare 2012 (Cancer series 67. Cat. no. CAN 63). 129 Ali H, Guy R, Wand H, Read T, Regan D, Grulich A, Fairley 117 Aminisani N, Armstrong BK, Egger S, Canfell K. Impact of C, Donovan B. Decline in in-patient treatments of genital organised cervical screening on cervical cancer incidence and warts among young Australians following the national HPV mortality in migrant . BMC Cancer. 2012;12 vaccination program. BMC Infect Dis. 2013;13 (1):140. (1):491. 130 Brotherton JM, Fridman M, May CL, Chappell G, Saville AM, 118 Smith JS, Green J, Berrington de Gonzalez A, Appleby P, Peto Gertig DM. Early effect of the HPV vaccination programme J, Plummer M, Franceschi S, Beral V. Cervical cancer and on cervical abnormalities in Victoria, Australia: an ecological use of hormonal contraceptives: a systematic review. Lancet. study. Lancet. 2011;377 (9783):2085-92. 2003;361 (9364):1159-67. 131 Peralta-Zaragoza O, Bermudez-Morales VH, Perez-Plasencia 119 Moreno V, Bosch FX, Munoz N, Meijer CJ, Shah KV, C, Salazar-Leon J, Gomez-Ceron C, Madrid-Marina V. Walboomers JM, Herrero R, Franceschi S, International Targeted treatments for cervical cancer: a review. Onco Agency for Research on Cancer. Multicentric Cervical Cancer Targets Ther. 2012;5:315-28. Study Group. Effect of oral contraceptives on risk of cervical 132 Hildesheim A, Herrero R, Wacholder S, Rodriguez AC, cancer in women with human papillomavirus infection: the Solomon D, Bratti MC, Schiller JT, Gonzalez P, Dubin G, Porras IARC multicentric case-control study. Lancet. 2002;359 C, Jimenez SE, Lowy DR. Effect of human papillomavirus (9312):1085-92. 16/18 L1 viruslike particle vaccine among young women with 120 Miller K, Blumenthal P, Blanchard K. Oral contraceptives and preexisting infection: a randomized trial. JAMA. 2007;298 cervical cancer: critique of a recent review. Contraception. (7):743-53. 2004;69 (5):347-51.

November, 2013 133 Paavonen J, Naud P, Salmeron J, Wheeler CM, Chow SN, 147 Lew JB, Howard K, Gertig D, Smith M, Clements M, Nickson Apter D, Kitchener H, Castellsague X, Teixeira JC, Skinner C, Shi JF, Dyer S, Lord S, Creighton P, Kang YJ, Tan J, et al. SR, Hedrick J, Jaisamrarn U, et al. Efficacy of human Expenditure and resource utilisation for cervical screening in papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against Australia. BMC Health Serv Res. 2012;12:446. cervical infection and precancer caused by oncogenic HPV 148 Canfell K, Lew J, Clements M, Smith M, Harris J, Simonella types (PATRICIA): final analysis of a double-blind, randomised L, Nickson C, Walker R, Neal H, Lewis H. Impact of HPV study in young women. Lancet. 2009;374 (9686):301-14. vaccination on cost-effectiveness of existing screening 134 Canfell K, Chesson H, Kulasingam SL, Berkhof J, Diaz M, programs: Example from New Zealand 28th International Kim JJ. Modeling preventative strategies against human Human Papillomavirus Conference & Clinical and Public Health papillomavirus-related disease in developed countries. Workshops San Juan, Puerto Rico, 2012. Vaccine. 2012;30 (Suppl 5):F157-67. 149 Dillner J, Rebolj M, Birembaut P, Petry KU, Szarewski A, Munk 135 Georgousakis M, Jayasinghe S, Brotherton J, Gilroy N, Chiu C, de Sanjose S, Naucler P, Lloveras B, Kjaer S, Cuzick J, van C, Macartney K. Population-wide vaccination against human Ballegooijen M, et al. Long term predictive values of cytology papillomavirus in adolescent boys: Australia as a case study. and human papillomavirus testing in cervical cancer screening: Lancet Infect Dis. 2012;12 (8):627-34. joint European cohort study. BMJ. 2008;337:a1754. 136 Australian Government Department of Health and Ageing. 150 Franco EL, de Sanjosé S, Broker TR, Stanley MA, Chevarie- Immunise Australia Program: Human Papillomavirus (HPV). Davis M, Isidean SD, Schiffman M. Human Papillomavirus Canberra Australian Government Department of Health and and Cancer Prevention: Gaps in Knowledge and Prospects Ageing; 2013 [updated February 14; cited 2013 April 18]; for Research, Policy, and Advocacy. Vaccine. 2012;30 (Suppl Available from: http://www.immunise.health.gov.au/internet/ 5):F175-82. immunise/publishing.nsf/Content/immunise-hpv. 151 Medical Services Advisory Committee. Human papillomavirus 137 Brill D. Australia launches national scheme to vaccinate boys testing in women with cytological prediction of low-grade against HPV. BMJ. 2013;346 (Feb 12):f924. abnormality. Canberra: Commonwealth of Australia; 2003. 138 Marra F, Cloutier K, Oteng B, Marra C, Ogilvie G. Effectiveness 152 Zagouri F, Sergentanis TN, Chrysikos D, Filipits M, Bartsch R. and cost effectiveness of human papillomavirus vaccine: a Molecularly targeted therapies in cervical cancer. A systematic systematic review. Pharmacoeconomics. 2009;27 (2):127-47. review. Gynecol Oncol. 2012;126 (2):291-303. 139 Chesson HW, Ekwueme DU, Saraiya M, Dunne EF, Markowitz 153 Ashing-Giwa KT, Lim JW, Tang J. Surviving cervical cancer: LE. The cost-effectiveness of male HPV vaccination in the does health-related quality of life influence survival? Gynecol United States. Vaccine. 2011;29 (46):8443-50. Oncol. 2010;118 (1):35-42. 140 Kim JJ. Targeted human papillomavirus vaccination of men 154 Zeng YC, Ching SS, Loke AY. Quality of life in cervical cancer who have sex with men in the USA: a cost-effectiveness survivors: a review of the literature and directions for future modelling analysis. Lancet Infect Dis. 2010;10 (12):845-52. research. Oncol Nurs Forum. 2011;38 (2):E107-17. 141 Taylor R, Morrell S, Mamoon H, Wain G, Ross J. Decline in cervical cancer incidence and mortality in New South Wales in relation to control activities (Australia). Cancer Causes Control. 2006;17 (3):299-306. 142 Creighton P, Lew JB, Clements M, Smith M, Howard K, Dyer S, Lord S, Canfell K. Cervical cancer screening in Australia: modelled evaluation of the impact of changing the recommended interval from two to three years. BMC Public Health. 2010;10:734. 143 IARC Working Group on the Evaluation of Cancer. IARC Handbooks of Cancer Prevention Volume 10: Cervix Cancer Screening. Lyon, France: IARC Press 2005. 144 Canfell K, Sitas F, Beral V. Cervical cancer in Australia and the United Kingdom: comparison of screening policy and uptake, and cancer incidence and mortality. Med J Aust. 2006;185 (9):482-6. 145 Australian Government Department of Health and Ageing. National Cervical Screening Program Renewal. Canberra Australian Government Department of Health and Ageing 2012 [updated 22 November; cited 2013 19 March ]; Available from: http://www.cancerscreening.gov.au/internet/screening/ publishing.nsf/Content/ncsp-renewal. 146 Australian Institute of Health and Welfare & Cancer Australia. Gynaecological cancers in Australia: an overview. Canberra Australian Institute of Health and Welfare 2012 (Cancer series no. 70. Cat. no. CAN 66). 54 • The State of Cancer Control in Australia

November, 2013 November, 2013

7.3 Colorectal cancer (C18-C20)

7.3.1 Background Colorectal cancer, also referred to as bowel cancer, is the third commonly in the more advanced stages.156 Early-stage most common cancer in males and the second most common in colorectal cancer typically has no symptoms, therefore females worldwide.5 IARC GLOBOCAN 2008 working estimates screening is currently the only method through which early state that the incidence for colorectal cancer was 11.4/100,000 diagnosis can be made.20 in females and 15.9/100,000 in males under the age of 75.5 In Australia, colorectal cancer is the second most Incidence is higher in developed countries and as such it is often commonly diagnosed cancer and the second most considered a Western lifestyle disease.5, 7, 155 In the United States common cause of death. In 2006, a National Bowel of America (USA), incidence trends have shown a reduction Cancer Screening Program was implemented to improve in colorectal cancer.20 However, incidence has increased in early detection rates. The prognosis improves over time, Americans under 50 years of age, who are not eligible for the beginning with a 66% probability of survival for at least screening program.20 Approximately 8% of cancer-related 5 years at the time of diagnosis. The conditional relative deaths worldwide are from colorectal cancer, with higher rates in survival for 5 years was 76% at 1 year after diagnosis and males (6.8/100,000) than females (4.9/100,000) under 75.5 almost 100% for 5 years after diagnosis. Survival rates are Colorectal cancer includes cancers of the colon, rectosigmoid higher in major cities in comparison to inner regional and junction and rectum.3 It is more often found in the elderly; outer regional areas. Survival is also influenced by SES, however, it can present in people under 40 years of age but with lower SES associated with lower survival rates.3

Cancer Council NSW • 55 56 • The State of Cancer Control in Australia

7.3.1.1 Causes and risk factors a reduced risk of colorectal cancer.161 This relationship still The most prominent risk factor for colorectal cancer requires confirmation in larger randomised trials with longer is age, with over 90% of cases being diagnosed in term follow-up.161 people over 50 years of age.20 In addition to this, there A recent Norwegian cohort study showed that females who are a number of genetic or personal history factors that consumed more than 60 grams of processed meats per increase risk.29 A personal or family history of colorectal day were at higher risk of colorectal cancer, especially distal cancer, polyps and specific inherited genetic conditions cases, compared to those who consume 15 grams or less a (eg familial adenomatous polyposis and hereditary day.162 Additionally, higher risk of recurrence is suggested in nonpolyposis colorectal cancer) or a personal history of patients who continued with a diet of processed meats, more inflammatory bowel disease significantly increases the prominently in Western cultures.155, 163 An Australian study likelihood of colorectal cancer.20, 29 found that obesity, specifically higher central adiposity, prior A distinction has been identified in the increased risk by to cancer diagnosis was associated with poorer survival of dietary patterns between colon and rectal cancers.157, colorectal cancer.164 The Mediterranean diet, as measured by 158 An evaluation of existing evidence, led by the World the Italian Mediterranean Index, has been associated with Cancer Research Fund, has found28: lower risk for all types of colorectal cancer except proximal cancer, when introduced a priori.165 A link between particular • Convincing evidence for : gene variations and dietary patterns has been shown, but »» Physical activity protecting against colon cancer requires further investigation.166 »» Consumption of red meat and Alcohol consumption causes colorectal cancer, according processed meat increasing risk to the most recent IARC evaluation.22 A pooled analysis of colorectal cancer found that consumption of over 30 grams of alcohol per day was significantly associated with increased »» Consuming alcoholic Recent analyses risk in males and females, for all types of alcoholic drinks increasing risk of showed a beverages and in all subtypes of colorectal colorectal cancer in men significant cancer.167 The association appeared to be (probably in women) increased risk stronger in subjects with a lower BMI.167 Coffee »» Body fatness and of colorectal consumption has been linked to a lower risk of abdominal fatness, and cancer with colon cancer but not rectal cancer for individuals factors leading to greater with higher levels of consumption.168 The antioxidant adult-attained height smoking. properties of coffee are thought to be the reason increasing risk of colorectal for this effect.168 Despite large international variations cancer in colorectal cancer, a search for definitive lifestyle and dietary causes has been elusive, and it is thought that a • Probably evidence for: still unidentified dietary or lifestyle factor is more likely the »» Consumption of garlic, milk and calcium cause.169 decreasing risk of colorectal cancer An additional modifiable risk factor of colorectal cancer is Other food products do not have a conclusive association smoking.22, 170-172 This was previously considered a possible with decreased risk.28 A high-fibre diet consisting risk factor, but more recent analyses showed a significant predominantly of fruits and vegetables, whole grains, fish, increased risk of colorectal cancer with smoking.22 A pooled poultry, legumes and soy products is considered optimal, analysis looking at the risk after quitting smoking showed as it minimises the risk of other chronic conditions.155, that the risk can continue for up to 25 years after quitting.170 159 Later studies have found that high consumption of However, risk begins to decline as soon as smoking is milk and other dairy products is statistically associated ceased for proximal colon and rectal cancer, but for distal with a reduction in colorectal cancer compared to low colon cancer, a point of decline is only reached after 25 years consumption, as a result of their calcium content and its of cessation.170 Further, higher risk of colorectal cancer was protective effect.7, 160 However, high dairy consumption found in individuals who smoked for more than 30 years may have an adverse effect on other diseases.160 Use for and smokers of more than 20 a day compared one year or more of oral bisphosphonate, often prescribed to never smokers, as well as in male smokers over female in the treatment of osteoporosis, has been associated with smokers.171 Perhaps controversially, Tsoi et al’s171 analysis

November, 2013 of cohort studies found that there was no statistically impact – is colorectal cancer screening. Screening significant increase in risk for current female smokers, for programs are in place worldwide and are recommended males or females who smoked less than 20 cigarettes per for people over 50 years of age.7 Screening can detect day and smoked for less than 20 years, and for females precancerous polyps and cancer at its early stage. If caught who had smoked less than 20 packs per year. A proposition early, treatment is more successful and less invasive.20 that antioxidant micronutrients could mediate the effect of Precancerous polyps can be removed via a polypectomy.7 smoking and reduce the risk of colorectal cancer has been Specifically, for people who have previously undergone refuted in a Danish study.173 polypectomy, calcium and anti-inflammatory medications such as aspirin and celecoxib play a chemoprevention role.179 The relationship between physical activity and risk of colorectal cancer varies by sites. There is convincing A number of screening methods can be used, and evidence indicating reduced risk for colon cancer, but no suggestions have been made encouraging patient autonomy conclusion has been drawn for rectal cancer.28 An Australian in choosing preferred screening methods.180 However, study found poorer survival in colorectal cancer patients FOBT followed by a colonoscopy is the most common who did not undertake regular physical activity prior to their process. Two types of FOBT are available. Guaiac FOBT has diagnosis.164 The lack of conclusive evidence relating to restrictions on dietary consumption and medications taken physical activity and colorectal cancer risk is largely due to for the three days prior to testing. Many countries, such as the study measurements used and design limitations.174 A Australia, have shifted to use immunochemical FOBT, as it recent analysis of a cohort of females in the USA found a is not as restrictive. Colonoscopy and sigmoidoscopy have reduction in mortality risk for females who had a score of 18 recently increased in use as first-line screening techniques.181 or more metabolic equivalent hours of recreational physical The latter options are more invasive than the FOBT and more activity pre- and post-diagnosis of colorectal cancer.175 labour intensive to administer. Newer screening tests are However, increased physical activity is promoted as being available, but have not yet been proven to be cost effective of overall benefit and providing a protective effect.7, 20 and are not used extensively.182 Additional lifestyle factors also alter the risk of colorectal As previously mentioned, Australia has a screening program, cancer. There is evidence suggesting reduced incidence with a one-time immunochemical FOBT at ages 50, 55, 60 of colorectal cancer in females using oestrogen-only and 65, despite the National Health and Medical Research menopause therapy, but there is no evidence of elevated Council (NHMRC) recommendation for biennial screening.183 risk when combined therapies are used.21 Evidence also Those turning 60 in 2013 were recruited, beginning on 1 July suggests an inverse relationship between oral contraceptive 2013, and 70-year-olds will be incorporated into the program use and risk of colorectal cancer.21 Additionally, a cohort from 1 July 2015.67 The Australian program has previously study suggests that short (five hours or less) or long been critiqued for the lack of resources available to perform (nine hours or more) sleep duration increases the risk of follow-up colonoscopies when required.184 A comparison of colorectal cancer in females.176 This is the first prospective patients participating and not participating in the national study of its kind. Sleep duration may become an emerging program in South Australia showed that diagnoses occurred issue in the area of cancer causation. Occupational at earlier stages for individuals participating in the screening exposure to asbestos is also associated with higher risk of program, illustrating positive program outcomes.185 Attaining colorectal cancer.177 Evidence suggests that the association sufficient coverage of colorectal screening is, however, an may be greater for colon cancer than rectal cancer.177 ongoing challenge in countries that have tried to implement X- and y-radiation have been positively associated with such programs. A recent evaluation of the national program rectal cancer; for colon cancer there is convincing evidence reported reduced participation rates in the past year, making X- and y-radiation a cause of this subtype.83 dropping from 38.4% in 2008–2011 to 35% in 2011–2012.186 Surgery is the most common treatment for colorectal cancer. Chemotherapy, with or without radiation therapy, 7.2.1.2 International prevention/ is used before or after surgery if the cancer has spread screening/treatment programs into the bowel wall or the lymph nodes.20 There are also chemoprevention drugs available that have been shown Prevention of colorectal cancer is largely based on to benefit some patients.187 Anti-inflammatory medications addressing the modifiable risk factors which can also such as aspirin as prophylaxis can be used against further decrease the likelihood of diagnosis of other chronic adenoma development in those with a previous removal of illnesses.178 The major focus – which has had the greatest an adenoma.188

Cancer Council NSW • 57 58 • The State of Cancer Control in Australia

7.2.2 Incidence and mortality rates in Table 7-6 Australia 1987–2007 Colorectal cancer: average annual percentage change (AAPC) Colorectal cancer had a small, non-statistically significant overall change in incidence (2%), (see Table 7–5 and Table Mortality Incidence 7–6). A substantial, statistically significant difference is Confidence Confidence AAPC AAPC seen in mortality. Overall, there has been a 47% decline Interval (95%) Interval (95%) in mortality, only slightly higher for females (50% decline) Male -2.9 -3.3, -2.5 0.2 -0.1, 0.4 (see Table 7–5). Reduced mortality is probably due to improved treatment technology and adherence to national Female -3.3 -4.4, -2.2 -0.1 -0.3, 0.1 management and treatment guidelines.30-33 Early detection Persons -3.0 -3.4, -2.7 0.1 -0.2, 0.4 may also have had an impact, although there was no organised screening during the time period analysed, apart from the dissemination of FOBT kits to a limited age group from late 2006. Both incidence and mortality age Figure 7–5 standardised rates have shown downwards trends over the Colorectal cancer: age-standardised cancer last 20 years (Figure 7–5 and Figure 7–6). Therefore, it is mortality rates in Australia 1987–2007, 0–74 years assumed that these figures will improve in the future. The

drop in cervical cancer incidence and mortality rates from 5050 1987 to 2007 can be seen in Figure 7–5 and Figure 7–6.

4040 Table 7–5

Colorectal cancer deaths and incident cases in 3030 Australia 1987–2007

2020 Deaths† Incident Cases†

Male Female Persons Male Female Persons 1010 Incidence per 100,000 people Mortality per 100,000 people Observed in 1,197 791 1,988 5,121 3,653 8,774 00 2007 (O)# 19901990 19951995 20002000 20052005 Expected in YearYear 2007 (E)§ 2,205 1,580 3,785 4,921 3,680 8,600  Persons Persons Male Male Female Female Difference -1,008 -789 -1,797 200 -27 174 (O-E) Figure 7–6 Change in -46 -50 -47 4 -1 2 Colorectal cancer: age-standardised cancer (O-E)/E (%) incidence rates in Australia 1987–2007, 0–74 years #An average of the observed rates for 2006 to 2008 was applied to the 2007 population to calculate the observed number of deaths and incident cases 2020 for 2007. §An average of the observed rates for 1986 to 1988 was applied to the 2007 population to calculate the expected number of deaths and incident cases 1515 for 2007. †All figures have been rounded to the nearest whole number.

1010

Mortality per 100,000 people 55 Incidence per 100,000 people per Incidence

00 19901990 19951995 20002000 2005 YearYear Persons Male Female  Persons  Male  Female

November, 2013 The issue of quality of life in colorectal cancer survivors 50 –74. 67 To facilitate the program’s expansion, the 2013/14 is becoming more important as mortality decreases federal budget incorporated AUS$16.1 million to potentiate and incidence increases or remains stable. Survival has the program register by incorporating electronic reporting by improved over time. As expected, long-term survivors (five health professionals.102 Independent public health and medical years after diagnosis) of colorectal cancer have higher authorities continue to call on the Australian Government for an health-related and global quality-of-life in comparison expedited expansion of the screening program. to patients at baseline (five months after diagnosis).189 A UK study showed that survivors up to five years post- diagnosis had comparable health behaviour outcomes to the general population.190 Survivors of colorectal cancer have shown very high quality-of-life when they were at least 15 years after diagnosis and had no disease recurrence.191 Differences are apparent in survivors of different subtypes, with rectal cancer survivors reporting lower quality- of-life compared to the controls than the colon cancer survivors when compared to controls.191 Physical activity has not been found to have a positive effect on quality of life, perhaps a result of low levels of physical activity in patient groups.189 However, a Taiwanese study found that supervised exercise programs resulted in improved health outcomes and quality-of-life indicators in colorectal cancer patients compared to usual care, although the scores for usual care were also high.192 Caring for colorectal cancer patients has high associated costs, especially in later phases of the disease. To this end, an analysis of first-degree relatives of colorectal patients and their adherence to screening guidelines showed that there are low levels of screening for this high-risk group; and interventions should be developed to improve this.193 Screening and early diagnosis are becoming more important from a budgetary point of view, and the greatest future reductions in mortality across the whole population are expected to be gained from population- wide screening.34, 183 Later data have shown earlier-stage diagnosis due to participation in the national screening program, potentially leading to reductions in mortality in the future.194 Individual behaviour modifications, such as increased physical activity, can also reduce colorectal cancer risk.7, 20 The recommended biennial program of FOBT, not currently in place in Australia, would be cost effective for people aged 50–74.183 Given the rising cost of treating colorectal cancer patients, it would seem that improving and expanding the screening program would result in the best, most cost-effective long-term outcome. However, the program in its current form cannot be upgraded to support biennial screening, due to the limited capacity of health care facilities to perform follow-up colonoscopies.183 In light of this, the Australian Government has committed resources to the program until 2034, to ensure biennial screening is eventually available to all individuals aged

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7.3 Colorectal Cancer (C18-C20)

References 3 Australian Institute of Health and Welfare. Cancer survival and 155 Yusof AS, Isa ZM, Shah SA. Dietary patterns and risk of prevalence in Australia period estimates from 1982 to 2010. colorectal cancer: a systematic review of cohort studies Canberra: Australian Institute of Health and Welfare; 2012 (2000-2011). Asian Pac J Cancer Prev. 2012;13 (9):4713- (Cancer series no. 69. Cat. no. CAN 65). 7. 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. 156 Blanke CD, Bot BM, Thomas DM, Bleyer A, Kohne CH, GLOBOCAN 2008 v2.0, Cancer incidence and mortality Seymour MT, de Gramont A, Goldberg RM, Sargent worldwide: IARC CancerBase No. 10: Lyon, France: IARC, 2010. DJ. Impact of young age on treatment efficacy and safety in advanced colorectal cancer: a pooled analysis 7 Boyle P, Levin B, editors. World Cancer Report 2008. Geneva: of patients from nine first-line phase III chemotherapy IARC; 2008. trials. J Clin Oncol. 2011;29 (20):2781-6. 20 American Cancer Society. Cancer facts & figures 2012. Atlanta: 157 Magalhaes B, Peleteiro B, Lunet N. Dietary patterns American Cancer Society; 2012. and colorectal cancer: systematic review and meta- 21 IARC Working Group on the Evaluation of Carcinogenic Risks to analysis. Eur J Cancer Prev. 2012;21 (1):15-23. Humans. IARC Monographs: Pharmaceuticals. Volume 100A A 158 Egeberg R, Olsen A, Christensen J, Halkjær J, review of human carcinogens. Lyon: IARC; 2012. Jakobsen M, Overvad K, Tjønneland A. Associations 22 IARC Working Group on the Evaluation of Carcinogenic Risks between Red Meat and Risks for Colon and Rectal to Humans. IARC Monographs: Personal habits and indoor Cancer Depend on the Type of Red Meat Consumed. J combustions. Volume 100E A review of human carcinogens. Nutrit. 2013;143 (4):464-72. Lyon: IARC; 2012. 159 Park Y, Hunter DJ, Spiegelman D, Bergkvist L, 28 World Cancer Research Fund / American Institute for Cancer Berrino F, van den Brandt PA, Buring JE, Colditz GA, Research. Continuous Update Project Report. Food, Nutrition, Freudenheim JL, Fuchs CS, Giovannucci E, Goldbohm Physical Activity, and the Prevention of Colorectal Cancer. RA, et al. Dietary fiber intake and risk of colorectal Washington, DC: American Institute for Cancer Research; 2011. cancer: a pooled analysis of prospective cohort 29 van Wezel T, Middeldorp A, Wijnen JT, Morreau H. A review studies. JAMA. 2005;294 (22):2849-57. of the genetic background and tumour profiling in familial 160 Aune D, Lau R, Chan DS, Vieira R, Greenwood DC, colorectal cancer. Mutagenesis. 2012;27 (2):239-45. Kampman E, Norat T. Dairy products and colorectal 30 Australian Cancer Network Colorectal Cancer Guidelines cancer risk: a systematic review and meta-analysis of Revision Committee. Guidelines for the Prevention, Early cohort studies. Ann Oncol. 2012;23 (1):37-45. Detection and Management of Colorectal Cancer. Sydney: The 161 Thosani N, Thosani S, Kumar S, Nugent Z, Jimenez C, Cancer Council Australia and Australian Cancer Network; 2005. Singh H, Guha S. Reduced risk of colorectal cancer 31 Clinical Oncological Society of Australia and Australian Cancer with use of oral bisphosphonates: a systematic review Network. The prevention, early detection and management of and meta-analysis. J Clin Oncol. 2013;31 (5):623-30. colorectal cancer. Canberra: Commonwealth of Australia; 1999. 162 Parr C, Hjartåker A, Lund E, Veierød M. Meat intake, 32 Jeffery GM, Hickey BE, Hider P. Follow-up strategies for cooking methods, and risk of proximal colon, distal patients treated for non-metastatic colorectal cancer. Cochrane colon, and rectal cancer: The Norwegian Women and Database Syst Rev. 2002 (1):CD002200. Cancer (NOWAC) cohort study. Int J Cancer. 2013;EPub 33 Renehan AG, Egger M, Saunders MP, O’Dwyer ST. Impact Feb 8. on survival of intensive follow up after curative resection for 163 Zhu Y, Wu H, Wang P, Savas S, Woodrow J, Wish T, colorectal cancer: systematic review and meta-analysis of Jin R, Green R, Woods M, Roebothan B, Buehler S, randomised trials. BMJ. 2002;324 (7341):813. Dicks E, et al. Dietary patterns and colorectal cancer 34 Olver I, Grogan P. Early success for Australia’s bowel screening recurrence and survival: a cohort study. BMJ Open. program: let’s move it along. Med J Aust. 2013;198 (6):300-1. 2013;3 (2):e002270. 67 Australian Government Department of Health and Ageing. 164 Haydon AM, Macinnis R, English D, Giles G. Effect National Bowel Cancer Screening Program: About the Program. of physical activity and body size on survival after Canberra: Australian Government Department of Health and diagnosis with colorectal cancer. Gut. 2006;55 (1):62-7. Ageing; 2012 [updated June 14; cited 2012. November 5]; 165 Agnoli C, Grioni S, Sieri S, Palli D, Masala G, Sacerdote Available from: http://www.cancerscreening.gov.au/internet/ C, Vineis P, Tumino R, Giurdanella M, Pala V, Berrino F, screening/publishing.nsf/Content/bowel-about. Mattiello A, et al. Italian mediterranean index and risk 83 IARC Working Group on the Evaluation of Carcinogenic Risks to of colorectal cancer in the Italian section of the EPIC Humans. IARC Monographs: Radiation. Volume 100D A review cohort. Int J Cancer. 2013;132 (6):1404-11. of human carcinogens. Lyon: IARC; 2012. 166 Andersen V, Holst R, Vogel U. Systematic review: 102 Australian Government. Budget 2013-14: Health and Ageing. diet-gene interactions and the risk of colorectal cancer. Canberra: Commonwealth of Australia; 2013 [updated July Aliment Pharmacol Ther. 2012;37 (4):383-91. 9; cited 2013 July 9]; Available from: http://www.budget.gov. au/2013-14/content/bp2/html/bp2_expense-13.htm.

November, 2013 167 Cho E, Smith-Warner SA, Ritz J, van den Brandt PA, Colditz 181 Pizzo E, Pezzoli A, Stockbrugger R, Bracci E, Vagnoni E, GA, Folsom AR, Freudenheim JL, Giovannucci E, Goldbohm Gullini S. Screenee perception and health-related quality RA, Graham S, Holmberg L, Kim DH, et al. Alcohol intake of life in colorectal cancer screening: a review. Value and colorectal cancer: a pooled analysis of 8 cohort studies. Health. 2011;14 (1):152-9. Ann Intern Med. 2004;140 (8):603-13. 182 Lansdorp-Vogelaar I, Knudsen AB, Brenner H. Cost- 168 Li G, Ma D, Zhang Y, Zheng W, Wang P. Coffee consumption effectiveness of colorectal cancer screening. Epidemiol and risk of colorectal cancer: a meta-analysis of Rev. 2011;33 (1):88-100. observational studies. Public Health Nutr. 2013;16 (2):346-57. 183 Pignone MP, Flitcroft KL, Howard K, Trevena LJ, Salkeld 169 Aune D, Chan DS, Lau R, Vieira R, Greenwood DC, GP, St John DJ. Costs and cost-effectiveness of full Kampman E, Norat T. Carbohydrates, glycemic index, implementation of a biennial faecal occult blood test glycemic load, and colorectal cancer risk: a systematic screening program for bowel cancer in Australia. Med J review and meta-analysis of cohort studies. Cancer Causes Aust. 2011;194 (4):180-5. Control. 2012;23 (4):521-35. 184 Flitcroft KL, Salkeld GP, Gillespie JA, Trevena LJ, Irwig 170 Gong J, Hutter C, Baron JA, Berndt S, Caan B, Campbell LM. Fifteen years of bowel cancer screening policy in PT, Casey G, Chan AT, Cotterchio M, Fuchs CS, Gallinger Australia: putting evidence into practice? Med J Aust. S, Giovannucci E, et al. A pooled analysis of smoking and 2010;193 (1):37-42. colorectal cancer: timing of exposure and interactions with 185 Cole S, Tucker G, Osborne J, Byrne S, Bampton P, environmental factors. Cancer Epidemiol Biomarkers Prev. Fraser R, Young G. Shift to earlier stage at diagnosis as 2012;21 (11):1974-85. a consequence of the National Bowel Cancer Screening 171 Tsoi KK, Pau CY, Wu WK, Chan FK, Griffiths S, Sung JJ. Program. Med J Aust. 2013;198 (6):327-30. smoking and the risk of colorectal cancer: a meta- 186 Australian Institute of Health and Welfare. National Bowel analysis of prospective cohort studies. Clin Gastroenterol Cancer Screening Program monitoring report: July 2011– Hepatol. 2009;7 (6):682-8. June 2012. Canberra: Australian Institute of Health and 172 Zhao J, Halfyard B, Roebothan B, West R, Buehler S, Sun Welfare; 2013 (Cancer series no. 75. Cat. no. CAN 71). Z, Squires J, McLaughlin JR, Parfrey PS, Wang PP. Tobacco 187 Bokemeyer C, Van Cutsem E, Rougier P, Ciardiello F, smoking and colorectal cancer: a population-based case- Heeger S, Schlichting M, Celik I, Kohne CH. Addition of control study in Newfoundland and Labrador. Can J Public cetuximab to chemotherapy as first-line treatment for Health. 2010;101 (4):281-9. KRAS wild-type metastatic colorectal cancer: pooled 173 Hansen RD, Albieri V, Tjonneland A, Overvad K, Andersen analysis of the CRYSTAL and OPUS randomised clinical KK, Raaschou-Nielsen O. Effects of Smoking and trials. Eur J Cancer. 2012;48 (10):1466-75. Antioxidant Micronutrients on Risk of Colorectal Cancer. Clin 188 Australian Cancer Network Colorectal Cancer Guidelines Gastroenterol Hepatol. 2013;11 (4):406–15. Revision Committee. Clinical practice guidelines for the 174 Spence RR, Heesch KC, Brown WJ. A systematic review prevention, early detection and management of colorectal of the association between physical activity and colorectal cancer. Sydney: Cancer Council Australia and Australian cancer risk. Scand J Med Sci Sports. 2009;19 (6):764-81. Cancer Network; 2005. 175 Kuiper J, Phipps A, Neuhouser M, Chlebowski R, Thomson 189 Chambers SK, Meng X, Youl P, Aitken J, Dunn J, Baade C, Irwin M, Lane D, Wactawski-Wende J, Hou L, Jackson P. A five-year prospective study of quality of life after R, Kampman E, Newcomb P. Recreational physical activity, colorectal cancer. Qual Life Res. 2012;21 (9):1551-64. body mass index, and survival in women with colorectal 190 Grimmett C, Bridgewater J, Steptoe A, Wardle J. Lifestyle cancer. Cancer Causes Control. 2012;23 (12):1939-48. and quality of life in colorectal cancer survivors. Qual Life 176 Jiao L, Duan Z, Sangi-Haghpeykar H, Hale L, White D, El- Res. 2011;20 (8):1237-45. Serag H. Sleep duration and incidence of colorectal cancer 191 Caravati-Jouvenceaux A, Launoy G, Klein D, Henry-Amar in postmenopausal women. Brit J Cancer. 2013;108 (1):213- M, Abeilard E, Danzon A, Pozet A, Velten M, Mercier M. 21. Health-related quality of life among long-term survivors of 177 IARC Working Group on the Evaluation of Carcinogenic Risks colorectal cancer: a population-based study. Oncologist. to Humans. IARC Monographs: , Metals, Fibres and 2011;16 (11):1626-36. Dusts. Volume 100C A review of human carcinogens. Lyon: 192 Lin KY, Shun SC, Lai YH, Liang JT, Tsauo JY. Comparison IARC; 2012. of the Effects of a Supervised Exercise Program 178 Chan AT, Giovannucci EL. Primary prevention of colorectal and Usual Care in Patients With Colorectal Cancer cancer. Gastroenterology. 2010;138 (6):2029-43. Undergoing Chemotherapy. Cancer Nurs. 2013;EPub Jan 179 Squires H, Tappenden P, Cooper K, Carroll C, Logan R, Hind 25. D. Cost-effectiveness of aspirin, celecoxib, and calcium 193 Courtney R, Paul C, Carey M, Sanson-Fisher R, Macrae chemoprevention for colorectal cancer. Clin Ther. 2011;33 F, D Este C, Hill D, Barker D, Simmons J. A population- (9):1289-305. based cross-sectional study of colorectal cancer 180 van Dam L, Kuipers EJ, Steyerberg EW, van Leerdam screening practices of first-degree relatives of colorectal ME, de Beaufort ID. The price of autonomy: should we cancer patients. BMC Cancer. 2013;13 (1):13. offer individuals a choice of colorectal cancer screening 194 Ananda S, McLaughlin S, Chen F, Hayes I, Hunter A, strategies? Lancet Oncol. 2013;14 (1):e38-46. Skinner I, Steel M, Jones I, Hastie I, Rieger N, Shedda S, Compston D, et al. Initial impact of Australia’s National Bowel Cancer Screening Program. Med J Aust. 2009;191 (7):378-81. 62 • The State of Cancer Control in Australia

November, 2013 November, 2013

7.4 Liver cancer (C22)

7.4.1 Background Liver cancer is the fifth most common cancer in males and the seventh most common in females.7 For individuals under the age of 75, incidence was 14.1/100,000 in males and 5/100,000 in females.5 Incidence rates are higher in developing countries and Southern Europe in comparison to other developed areas.5 In Western countries, liver cancer is more prevalent in people aged 75 or over, and more common in males than females, but in African countries this trend is variable.195 Worldwide, 70–80% of all liver cancers are associated with chronic hepatitis viruses B and C infection or liver cirrhosis.20, 35 Mortality from liver cancer is 12.5/100,000 in males and 4.6/100,000 in females under the age of 75.5 Survival from liver cancer is low and, as a result, liver cancer is the third most common cause of death globally.5, 35 Low survival leads to a higher burden from premature mortality than morbidity.195 Approximately 80% of liver cancer cases are hepatocellular In Australia, liver cancer is 3 times more common in carcinomas, resulting from hepatocytes.7 The remaining 20% of males than in females, and relative survival is 16% for cases are made up of intrahepatic cholangiocarcinoma (affecting 5 years after diagnosis. The 5-year conditional relative the bile duct epothelium), hepatoblastoma (a malignant tumour survival was 38% at 1 year after diagnosis, and 75% at 5 in infants and children) and angiosarcoma (tumours arising in years after diagnosis. Survival rates are similar for both the liver’s blood vessels).7, 196 Prognosis of the disease is often genders but are higher in major cities. Changes from measured by the Child–Pugh score, which assesses the level of 1988–1993 to 2006–2010 indicated an improvement in cirrhosis in the liver.197, 198 It is often used to determine treatment survival from 7% to 16%.3 requirements and need for transplantation.

CancerCancer Council Council NSW NSW • 63• 63 64 • The State of Cancer Control in Australia

7.4.1.1 Causes and risk factors risk of liver cancer, but the evidence is not conclusive.36, 207-210 A positive relationship has not been found with other Chronic infection with hepatitis B and C viruses is caffeinated beverages such as green tea.208 Smoking responsible for approximately 80% of liver cancer has a causal relationship with hepatocellular carcinoma, cases worldwide.199 With hepatitis B, the progression with consistent findings across different geographic to hepatocellular carcinoma can bypass the cirrhosis regions.22 Additionally, X- and y-radiation are associated stage in approximately 30% of individuals, which makes with increased risk of liver cancer, but the exact dose- hepatocellular carcinoma surveillance more challenging and response relationship is not clear.83 Combined oestrogen- less reliable.200 On the other hand, hepatitis C infection – the progestogen oral contraceptive use has been linked to pathway to hepatocellular carcinoma – is mediated through increased risk of liver cancer.21 There are also autoimmune liver fibrosis or cirrhosis, which makes cirrhosis screening and metabolic diseases associated with hepatocellular a valuable indicator.200 HIV-1 has also been positively carcinomas.198 Research in iron metabolic disorders has associated with liver cancer.53 suggested that iron overload is a risk factor.7, 196 Liver cirrhosis is associated with hepatocellular carcinoma, Obesity and diabetes mellitus, both together and especially in Western countries, with at least 80% of cases independently, have been linked to increased risk of having a history of cirrhosis before tumour development.197, fatty liver disease and hepatocellular carcinomas.195, 196, 198 High alcohol intake is a significant contributing risk factor 211 Diabetes mellitus and liver cancer share similar risk for liver cirrhosis and alcohol-related liver cancer.7, 20, 36, 195, factors, such as alcohol consumption and obesity, and 196, 201, 202 Although assumed to be beneficial, alcohol diabetes has been suggested as a potential risk cessation has no clear association with reduced factor for liver cancer.195, 211 Even after adjusting risk.195, 201 for confounders, the risk of hetpatocellcular From 1982, hepatitis B vaccine was The hepatitis carcinomas in diabetics was double that of 211 commercially available, but not immediately B vaccination non-diabetics. Other food- and nutrition- administered as part of a population- related evidence has only isolated fruit wide prevention program, because of is now part consumption as having a limited– the high associated cost, especially in of the infant suggestive association with decreased the developing world.195, 203 The hepatitis immunisation risk of liver cancer.36 B vaccination is now part of the infant program in 179 Exposure to aflatoxins through immunisation program in 179 countries. As countries. contaminated food consumption has been the vaccine is not effective in people already convincingly associated with liver cancer infected, 350 million people worldwide are still in developing tropical countries, especially in at risk of developing hepatocellular carcinoma. In individuals with chronic hepatitis infections.7, 20, 36, 195, 212 Australia, the prevalence of hepatitis B is relatively low, Aflatoxins develop when mould develops on grains that are except in immigrants from countries where the prevalence stored in poorly ventilated sites in hot and humid climates.7, is high.38, 204 People with a large number of sexual partners 20, 196 and those who inject drugs with contaminated needles are also considered high-risk population groups for hepatitis For intrahepatic cholangiocarcinomas, liver fluke infestation B.38 through consumption of raw or undercooked freshwater fish increases cancer risk; this occurs mainly in Thailand No vaccine is as yet available against the hepatitis C and South East Asia.7, 196, 205, 213 An Italian case-control virus.205, 206 Hepatitis C infection prevention relies on the study showed that asbestos exposure increased the risk use of sterilised equipment in medical and on public of intrahepatic cholangiocarcinoma; however, the number health interventions, such as safe blood transfusions, safe of cases was too small to confirm an association in all injection practices, safe tattooing and adequate screening environments.214 of blood and organ donors.7, 205, 206 Coffee consumption has been associated with a reduced

November, 2013 7.4.1.2 International prevention/ Approximately half the cases of hepatocellular carcinomas screening/treatment programs have high fetal antigen α-fetoprotein levels, which could be used as a marker for screening in future.196 As the prognosis for liver cancer is poor, major emphasis is placed on prevention.7 Primary prevention strategies include The treatment of liver cancer is largely dependent on hepatitis B infant immunisation programs, optimising grain disease stage and the existence of other associated liver storage to avoid aflatoxin contamination in the tropics, and diseases. Liver resection is a commonly used technique, 7 public health campaigns addressing excessive alcohol with portal vein embolisation if there is little remaining liver. 7 consumption.196 Addressing excessive alcohol consumption Liver transplantation is also a possibility for patients. In could, theoretically, eliminate the incidence of alcohol- the case of hepatocellcular carcinomas, liver resection and related liver disease, responsible for approximately 10.7% of transplantation are the only two curative treatment options 223 deaths from liver cancer globally.202 available. If liver failure is likely, the cancer can be treated with radiofrequency ablation (RFA) or cryoablation.7 RFA The hepatitis B vaccine is available worldwide as part is considered a safe treatment option with low mortality; of many national immunisation programs. The initial however, there is a high chance of disease recurrence immunisation approach targeting high-risk groups was associated with the technique.223 Additional regional found to be ineffective and, with falling costs of vaccination, therapies, such as transarterial chemoembolisation, have 203 universal vaccination became a reality. shown more promising results when used in combination 224, 225 In Australia, the risk of liver cancer is high, and its with RFA. Hepatocellular carcinomas are resistant to 7 management is challenging.215 The prevalence of hepatitis radiotherapy, thus limiting its use in treatment. However, B is high in Australians born in countries where hepatitis chemotherapy can be used, despite little evidence to 7 B infection is endemic, and transmission occurs in the suggest resulting improvement in survival. Sorafenib, neonatal period and early infancy, such as in many Asian a molecular-targeted drug, is the first agent to show countries.204 Estimates for the year 2025 suggest that there improvements in survival of advanced hepatocellular will be an increase of hepatocellular carcinomas caused carcinoma and is now more commonly used in treatment 198 by hepatitis B in population groups from the Asia–Pacific programs. region.204 The Australian Government has developed National Hepatitis B and C strategies to address these issues.216, 217 Programs such as Cancer Council NSW’s ‘B 7.4.2 Incidence and mortality rates in Positive’ Project, aim to raise awareness and educate these Australia 1987–2007 communities – and the health professionals who serve them – about the link between hepatitis B and liver cancer, and Liver cancer incidence and mortality rates have both ensure regular follow-up and timely institution of antiviral increased over two decades (Figure 7–7 and Figure 7–8). therapy to prevent hepatocellular carcinomas.218 Overall, there has been a 70% rise in mortality, which was slightly higher in males than females, and incidence Population-wide screening programs for liver cancer increased by 132% in comparison to expected estimates 219, 220 are not recommended. It is thought that it is more (Table 7–7). This increase was higher in males, increasing effective to identify high-risk patients via a relatively simple by 165% over this period. Mortality and incidence results 219 test for hepatitis B and C, or liver cirrhosis screening. were statistically significant for both genders and overall Population-based hepatocellular carcinoma screening is (Table 7–8). The substantial burden of undiagnosed chronic not systematically practised in Australia, but expert groups hepatitis B infections in some Asian-born Australians, recommend it in high-risk populations, including Asian- coupled with the natural history of chronic hepatitis B born individuals (commencing at age 40 for males and age infection in populations where the infection is acquired early 50 for females), African-born people aged over 20 years, in life,37 contribute to about half of the increasing mortality people with cirrhosis, or those with a family history of liver and incidence in Australia.38 cancer.221, 222 Screening, as well as diagnosis, can also be conducted in primary care facilities using ultrasounds.7, 219

Cancer Council NSW • 65 66 • The State of Cancer Control in Australia

Table 7–7 Figure 7–8 Liver cancer deaths and incident cases in Australia Liver cancer: age-standardised cancer incidence 1987–2007 rates in Australia 1987–2007, 0–74 years

† † Deaths Incident Cases 66

Male Female Persons Male Female Persons

Observed in 460 189 649 622 194 816 44 2007 (O)# Expected in 2007 (E)§ 265 117 382 264 87 351

22 Difference 195 72 267 358 107 465 (O-E) Incidence per 100,000 people per 100,000 Incidence Incidence per 100,000 people Change in 73 62 70 135 122 132 (O-E)/E (%) 00 #An average of the observed rates for 2006 to 2008 was applied to the 2007 19901990 19951995 20002000 20052005 population to calculate the observed number of deaths and incident cases Year Year for 2007. Persons Male Female §An average of the observed rates for 1986 to 1988 was applied to the 2007  Persons  Male  Female population to calculate the expected number of deaths and incident cases for 2007. †All figures have been rounded to the nearest whole number. Hepatocellcular carcinoma patients have poor quality of life in comparison to the general population, specifically Table 7–8 in physical aspects.226 Particular treatment courses, such Liver cancer: average annual percentage change as sorafenib, can have significant adverse effects which (AAPC) impede a patient’s ability to continue treatment and also affect their physical wellbeing.227 Fan et al226 found that the Mortality Incidence emotional functioning of these patients was higher than Confidence Confidence AAPC AAPC that of other cancer sufferers, proposed to be due to their Interval (95%) Interval (95%) resolve in combating their illness. Liver transplantation Male 2.3 1.9, 2.7 4.0 3.6, 4.3 occurs more often in younger patients, and their quality Female 2.7 2.0, 3.3 4.5 3.9, 5.1 of life post-transplant has been studied.228, 229 Transplant recipients have lower quality of life than their healthy peers, Persons 2.4 2.1, 2.7 4.1 3.8, 4.4 with physical and psychosocial health being lower than average in the healthy population, especially in school functioning.228 Figure 7–7 Liver cancer: age-standardised cancer mortality From 1988, the Australian Government began integrating rates in Australia 1987–2007, 0–74 years the hepatitis B vaccination into the National Immunisation Program. It is now provided in infancy through a general 5 5 practitioner.230 National strategies focusing on a reduction in transmission of hepatitis B and C have been developed 44 in partnership with the community sector.216, 217 Additionally, public health campaigns to curb excessive alcohol

33 consumption address one of the main risk factors for liver cancer, thus working towards disease prevention. Globally, governments are encouraged to take a harder 22 stance on preventing alcohol-attributed harm through public health initiatives, taxation and legislation restricting Mortality per 100,000 people 1 1 alcohol availability.202 High-risk groups with higher rates of

Mortality per 100,000 people hepatitis B and C infections are a key focus of the national 00 strategies, as well as NGOs such as Hepatitis Australia and 19901990 19951995 20002000 20052005 Cancer Council to further reduce liver cancer incidence and Year Year mortality.218, 231  Persons Persons Male Male Female Female

November, 2013 7.4 Liver Cancer (C22)

References 3 Australian Institute of Health and Welfare. Cancer survival and 199 Hepatitis B Foundation. Hepatitis B and Primary Liver Cancer. prevalence in Australia period estimates from 1982 to 2010. 2013 [updated February 18; cited 2013 February 18]; Available Canberra: Australian Institute of Health and Welfare; 2012 from: http://www.hepb.org/professionals/hepb_and_liver_ (Cancer series no. 69. Cat. no. CAN 65). cancer.htm. 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. 200 Schiff ER. Prevention of mortality from hepatitis B and hepatitis GLOBOCAN 2008 v2.0, Cancer incidence and mortality C. Lancet. 2006;368 (9539):896-7. worldwide: IARC CancerBase No. 10: Lyon, France: IARC, 201 Heckley G, Jarl J, Asamoah B, G-Gerdtham U. How the risk 2010. of liver cancer changes after alcohol cessation: a review 7 Boyle P, Levin B, editors. World Cancer Report 2008. Geneva: and meta-analysis of the current literature. BMC Cancer. IARC; 2008. 2011;11:446. 20 American Cancer Society. Cancer facts & figures 2012. Atlanta: 202 Rehm J, Samokhvalov A, Shield K. Global burden of alcoholic American Cancer Society; 2012. liver diseases. J Hepatol. 2013;59 (1):160-8. 21 IARC Working Group on the Evaluation of Carcinogenic Risks 203 Heffernan M, Garland S, Kane M. Global reduction of cervical to Humans. IARC Monographs: Pharmaceuticals. Volume 100A cancer with human papillomavirus vaccines: insights from A review of human carcinogens. Lyon: IARC; 2012. the hepatitis B virus vaccine experience. Sex Health. 2010;7 (3):383-90. 22 IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. IARC Monographs: Personal habits and indoor 204 Nguyen VT, Razali K, Amin J, Law M, Dore G. Estimates and combustions. Volume 100E A review of human carcinogens. projections of hepatitis B-related hepatocellular carcinoma Lyon: IARC; 2012. in Australia among people born in Asia-Pacific countries. J Gastoen Hepatol. 2008;23 (6):922-9. 35 Lavanchy D. Chronic viral hepatitis as a public health issue in the world. Best Pract Res Clin Gastroenterol. 2008;22 (6):991- 205 Union for International Cancer Control. Protection against 1008. cancer-causing infections: World Cancer Campaign 2010. Geneva: UICC 2010. 36 World Cancer Research Fund / American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention 206 Wakeham K, Newton R, Sitas F. Cancer in the Tropics. In: of Cancer: a Global Perspective. Washington, DC: American Magill AJ RE, Hill DR, Solomon T Hunter’s Tropical Medicine Institute for Cancer Research; 2007. and Emerging Infectious Diseases, 9th. London: Elsevier, 2013. 37 Yuen MF. Revisiting the natural history of chronic hepatitis 207 Bravi F, Bosetti C, Tavani A, La Vecchia C. Coffee drinking and B: impact of new concepts on clinical management. J hepatocellular carcinoma: an update. Hepatology. 2009;50 Gastroenterol Hepatol. 2007;22 (7):973-6. (4):1317-8. 38 Law MG, Roberts SK, Dore GJ, Kaldor JM. Primary 208 Inoue M, Kurahashi N, Iwasaki M, Shimazu T, Tanaka Y, hepatocellular carcinoma in Australia, 1978-1997: increasing Mizokami M, Tsugane S, Japan Public Health Center-Based incidence and mortality. Med J Aust. 2000;173 (8):403-5. Prospective Study Group. Effect of coffee and green tea consumption on the risk of liver cancer: cohort analysis by 53 IARC Working Group on the Evaluation of Carcinogenic Risks hepatitis virus infection status. Cancer Epidemiol Biomarkers to Humans. IARC Monographs: Biological Agents. Volume Prev. 2009;18 (6):1746-53. 100B A review of human carcinogens. Lyon: IARC; 2012. 209 Leung W, Ho S, Chan H, Wong V, Yeo W, Mok T. Moderate 83 IARC Working Group on the Evaluation of Carcinogenic Risks coffee consumption reduces the risk of hepatocellular to Humans. IARC Monographs: Radiation. Volume 100D A carcinoma in hepatitis B chronic carriers: a case-control study. review of human carcinogens. Lyon: IARC; 2012. J Epidemiol Commun Health. 2011;65 (6):556-8. 195 Nordenstedt H, White DL, El-Serag HB. The changing pattern 210 Shimazu T, Tsubono Y, Kuriyama S, Ohmori K, Koizumi Y, of epidemiology in hepatocellular carcinoma. Digest Liver Dis. Nishino Y, Shibuya D, Tsuji I. Coffee consumption and the risk 2010;42 (Suppl 3):S206-S14. of primary liver cancer: pooled analysis of two prospective 196 Chuang SC, La Vecchia C, Boffetta P. Liver cancer: descriptive studies in Japan. Int J Cancer. 2005;116 (1):150-4. epidemiology and risk factors other than HBV and HCV 211 Wang C, Wang X, Gong G, Ben Q, Qiu W, Chen Y, Li G, Wang infection. Cancer Lett. 2009;286 (1):9-14. L. Increased risk of hepatocellular carcinoma in patients with 197 Tandon P, Garcia-Tsao G. Prognostic indicators in diabetes mellitus: a systematic review and meta-analysis of hepatocellular carcinoma: a systematic review of 72 studies. cohort studies. Int J Cancer. 2012;130 (7):1639-48. Liver Int. 2009;29 (4):502-10. 212 IARC Working Group on the Evaluation of Carcinogenic Risks 198 Alves RCP, Alves D, Guz B, Matos C, Viana M, Harriz M, to Humans. IARC Monographs: Chemical agents and related Terrabuio D, Kondo M, Gampel O, Polletti P. Advanced occupations. Volume 100F A review of human carcinogens. hepatocellular carcinoma. Review of targeted molecular drugs. Lyon: IARC; 2012. Ann Hepatol. 2011;10 (1):21-7. 68 • The State of Cancer Control in Australia

213 Bouvard V, Baan R, Straif K, Grosse Y, Secretan B, El Ghissassi 228 Alonso E, Limbers C, Neighbors K, Martz K, Bucuvalas J, F, Benbrahim-Tallaa L, Guha N, Freeman C, Galichet L, Webb T, Varni J, Studies of Pediatric Liver Transplantation Cogliano V. A review of human carcinogens--Part B: biological (SPLIT) Functional Outcomes Group. Cross-sectional analysis agents. Lancet Oncol. 2009;10 (4):321-2. of health-related quality of life in pediatric liver transplant 214 Brandi G, Di Girolamo S, Farioli A, de Rosa F, Curti S, Pinna A, recipients. J Pediatr. 2010;156 (2):270-60. Ercolani G, Violante F, Biasco G, Mattioli S. Asbestos: a hidden 229 Mohammad S, Hormaza L, Neighbors K, Boone P, Tierney player behind the cholangiocarcinoma increase? Findings M, Azzam R, Butt Z, Alonso E. Health status in young adults from a case-control analysis. Cancer Causes Control. 2013;24 two decades after pediatric liver transplantation. Am J (5):911-8. Transplantation. 2012;12 (6):1486-95. 215 Fisher D, Huffam S. Management of chronic hepatitis B virus 230 Australian Government Department of Health and Ageing. infection in remote-dwelling Aboriginals and Torres Strait Immunise Australia Program: Hepatitis B. Canberra Australian Islanders: an update for primary healthcare providers. Med J Government Department of Health and Ageing; 2011 [updated Aust. 2003;178 (2):82-5. May 18; cited 2012 November 5]; Available from: http://www. 216 Commonwealth of Australia. National Hepatitis B Strategy immunise.health.gov.au/internet/immunise/publishing.nsf/ 2010–2013. In: Australian Government Department of Health Content/immunise-hepb. and Ageing, ed. Canberra: Commonwealth of Australia, 2010. 231 Hepatitis Australia. Purpose. 2013 [updated June 17; cited 217 Commonwealth of Australia. Third National Hepatitis C 2013 July 1]; Available from: http://www.hepatitisaustralia.com/ Strategy 2010–2013. In: Australian Government Department of purpose/. Health and Ageing, ed. Canberra: Commonwealth of Australia, 2010. 218 Cancer Council NSW. An agenda for cancer control – 2011 and beyond. Sydney: Cancer Council NSW 2010. 219 Cabibbo G, Craxi A. Epidemiology, risk factors and surveillance of hepatocellular carcinoma. Eur Rev Med Pharmacol Sci. 2010;14:352-5. 220 Bridges JF, Joy SM, Gallego G, Kudo M, Ye SL, Han KH, Cheng AL, Blauvelt BM. Needs for hepatocellular carcinoma control policy in the Asia-Pacific region. Asian Pac J Cancer Prev. 2011;12 (10):2585-91. 221 Sherman M. Pathogenesis and screening for hepatocellular carcinoma. Clin Liver Dis. 2004;8 (2):419-43. 222 Gastroenterological Society of Australia and Digestive Health Foundation. Australian and New Zealand chronic hepatitis B (CHB) recommendations. Clinical update; 2008. 223 Tiong L, Maddern G. Systematic review and meta-analysis of survival and disease recurrence after radiofrequency ablation for hepatocellular carcinoma. Brit J Surg. 2011;98 (9):1210-24. 224 Robotin M. Randomised Controlled Trials in the Primary Treatment of Hepatocellular Carcinoma. In: Qiao L, Li Y, Yan X, George J. Molecular aspects of hepatocellular carcinoma: Bentham E-Books, 2012: 174-95. 225 Peng ZW, Zhang YJ, Chen MS, Xu L, Liang HH, Lin XJ, Guo RP, Zhang YQ, Lau WY. Radiofrequency ablation with or without transcatheter arterial chemoembolization in the treatment of hepatocellular carcinoma: a prospective randomized trial. J Clin Oncol. 2013;31 (4):426-32. 226 Fan SY, Eiser C, Ho MC, Lin CY. Health-related quality of life in patients with hepatocellular carcinoma: the mediation effects of illness perceptions and coping. Psychooncology. 2013;22 (6):1353-60. 227 Brunocilla P, Brunello F, Carucci P, Gaia S, Rolle E, Cantamessa A, Castiglione A, Ciccone G, Rizzetto M. Sorafenib in hepatocellular carcinoma: prospective study on adverse events, quality of life, and related feasibility under daily conditions. Med Oncol. 2013;30 (1):345.

November, 2013 November, 2013

7.5 Lung cancer (C33-34)

7.5.1 Background Lung cancer is the leading cause of cancer-related death Symptoms of lung cancer include a persistent cough, worldwide, resulting in 1.38 million deaths in 2008.5 Tobacco coughing blood, chest pains, changes in voice register smoking is heralded as the predominant cause of lung and recurring cases of bronchitis or pneumonia.20 carcinomas.7 IARC GLOBOCAN 2008 working estimates The main subtypes of lung cancer are squamous cell state the incidence for lung cancer in males and females carcinomas, small-cell carcinoma, adenocarcinomas under 75 years as 27.3/100,000 and 11/100,000 respectively.5 and large-cell carcinoma. Over time, there has been a Many suggest the higher incidence in males is due to the reduction in squamous cell carcinomas and an increase in historical differences in the tobacco consumption uptake adenocarcinomas. This is largely attributed to changes in of males and females.20 However, an American study found tobacco products and smoking behaviours.7 that the mortality rate in male never smokers is higher than In 2007, lung cancer was the leading cause of burden in female never smokers suggesting that there are also other of disease in Australia. The prognosis for lung cancer is factors at play.232 IARC GLOBOCAN 2008 working estimates very poor, with a 14% relative survival for at least 5 years for mortality indicate a 22.5/100,000 rate in males and at diagnosis. The 5-year conditional relative survival was 8.5/100,000 in females under 75 years of age.5 Developing 34% for 1 year after diagnosis, and 74% for 5 years after countries have high rates of new cases, but Northern America diagnosis. Survival rates were higher for females, patients still has the highest incidence rates globally.5 Middle and living in major cities and in high SES groups.3 Western Africa have low rates of lung cancer.5 Cancer Council NSW • 69 70 • The State of Cancer Control in Australia

7.5.1.1 Causes and risk factors The results for multiparity, age at first parity, and use of oral contraception or HRT are conflicting in the Lung cancer is predominantly caused by the carcinogenic literature.238 An Italian study found an association of effects of long-term tobacco smoking. While the relationship later age at menopause, later age at first live birth and between smoking and lung cancer has been known since longer reproductive cycle with a reduced risk of lung the 1950s, the extent of the association has only been cancer, suggesting that longer oestrogen production is appreciated by the passage of time. The relative risk of lung associated with a greater protective effect.239 This study cancer in current smokers was 2.74 in females and 12.49 in showed no evidence of a relationship with early menarche, males in the 1960s and rose to 26.18 in females and 27.32 in cycle duration, breastfeeding or parity in general and males in contemporary cohorts (from 2000-2010) from the an increased lung cancer risk.239 Larger cohort studies USA.233 Evidence from China suggests other underlying risk focusing on reproductive factors and biomarkers are factors for lung cancer.234 Despite populations previously essential to confirm causation. thought less susceptible to the hazards of smoking, they are no different to Western populations once sufficient time has Chronic obstructive pulmonary disease not only increases elapsed (eg in Japan).235 risk of lung cancer but also shares many risk factors.240 Studies, reviews and pooled analyses have illustrated Other causes include passive smoking, certain occupational the causal relationship between previous lung disease exposures (including those involving asbestos and coal- and lung cancer of both smokers and never smokers, based industry), pulmonary tuberculosis and atmospheric suggesting that tobacco consumption does not have pollution.7, 20, 39 A predictive model for lung confounding effect.241, 242 Inflammation of the lung cancer in the USA found that the risk was associated with lung diseases and the pathogenesis higher for older people, males, African of lung disease are believed to be the cause of this Americans, individuals with chronic relationship.241, 242 obstructive pulmonary disease, Lung cancer is a lower education level, family predominantly Fruit and vegetable intake have traditionally been 7, history of lung cancer, history of caused by the associated with a decreased risk of lung cancer. recent chest X-rays, lower BMI 243 More recent studies have not conclusively and smokers of many cigarettes carcinogenic effects found protective effects from overall fruit and per day or over long durations of of long-term tobacco vegetable consumption.36, 244, 245 There is some time.236 smoking. evidence to suggest that subgroups of fruits and vegetable can reduce the risk of lung cancer in The association between family specific cohorts. The World Cancer Research Fund history and risk of lung cancer is found convincing evidence linking arsenic in drinking difficult to establish, but is at least water and beta-carotene supplements with increased risk partially genetically determined. The specific of lung cancer, and probable evidence linking fruits and genes responsible for elevated risk of lung cancer are foods containing carotenoids with decreased risk of lung not well understood.22 The similarity in environmental cancer.36 factors and difficulty in adjusting for smoking makes isolating genetic causes problematic.237 Despite this, there Studies analysing the association between weight and is evidence to suggest that having an affected relative lung cancer risk suggest that a low BMI is a predictor increases an individual’s risk of developing lung cancer.237 of lung cancer.36, 236, 246-248 In a study of postmenopausal females, ever smokers exhibited an inverse association The high rates of lung cancer in individuals who never between BMI and risk of lung cancer, whereas waist smoked have led to the further investigation of additional circumference was positively associated with increased causes. Incidence and mortality rates have increased risk.246 A meta-analysis of both males and females also in females and have not been associated with tobacco, found an inverse relationship between BMI and lung cancer leading to the investigation of reproductive and hormone incidence, which was more pronounced in ever smokers.248 factors. In an analysis by cancer subtype, it was found that Analyses of never smokers have produced inconsistent early menarche was associated with an increased risk of results.246, 248 Later French and American studies also found adenocarcinomas, and early menopause also resulted in inconsistencies using cohorts of both genders, even when an increased risk of adenocarcinomas and squamous cell adjusted for smoking status as a confounder.247, 249 The cancers.238 difference could potentially be due to the confounding effect of the preclinical weight loss associated with lung

November, 2013 cancer.246 There is limited evidence suggesting a reduction Recently developed testing techniques, including low- in risk of lung cancer in people who have high to moderate dose spiral computed tomography scans and molecular levels of leisure time physical activity.36, 243 That is, although markers in sputum, are reportedly more successful in early weight may not have a clear relationship, fitness could identification of lung cancer in high-risk groups.20, 43, 44, reduce the likelihood of lung cancer in smokers and non- 257-259 Results from a screening trial in the USA claim that smokers.243 approximately 12,000 deaths per year could be averted in heavy smokers through the full implementation of low-dose The environmental causes of lung cancer include exposure spiral computed tomography scans.259 Thus, high-risk to asbestos or coal tar pitch in the working environment, groups could benefit from screening for lung cancer.44 or occupational exposure during aluminium production, Rolling out a screening program for high-risk groups (based coke production, coal gasification, iron or steel founding on age and smoking history) has been endorsed by the US and rubber manufacturing, or working as a painter.7, 20, 212 Preventive Services Task Force, and in Australia is being Additionally, there is sufficient evidence linking exposure assessed for its feasibility.260, 261 to , cadmium, , compounds, nickel metal, X-radiation, y-radiation, plutonium-239, and Recently a proof of concept has been released to suggest underground haematite mining with exposure to that a breath print could detect the presence of a malignant and crystalline silica in the form of quartz or cristobalite tumour. 262 This has led to a larger-scale study that will dust as causes of lung cancer.83, 177 Mustard gas, radiation, confirm or deny these results.262 As with many screening bis(chloromethyl)ether and chloromethyl methyl ether are programs, lung cancer screening trials have been subject to also considered causes of lung cancer.83, 212 the overdiagnosis vs. benefit debate, despite the claim that the minimal overdiagnosis is insignificant.263-265 A major focus has been on asbestos, as approximately 125 million people across the globe were reportedly exposed The poor survival rate for lung cancer has resulted in a as at 2010.250 The link between asbestos exposure in the number of clinical trials being conducted in search of workplace and an increase in the risk of lung cancer has innovative treatment methods. Depending on the subtype of been established across a number of occupations.251, 252 cancer and stage, surgery, radiation therapy, chemotherapy A recent study in China showed the increased risk of lung and other targeted drug therapies can be used. For cancer when using smoky coal for domestic purposes small-cell cancer, chemotherapy or a combination of compared to the use of smokeless coal.253 However, risk chemotherapy with radiation therapy is used. Generally, this is increased with active tobacco smoking and exposure removes the cancerous cells, but these patients have a high to these carcinogens potentially due to the inflammatory probability of relapse. In non–small cell cancers, localised state of the airways.254 Canadian research has refuted cases are usually treated with surgery and then treatment is the speculation that lead is a by showing no supplemented with chemotherapy at a later stage. If in the relationship between organic and inorganic lead exposure advanced stage, chemotherapy is often used in conjunction and risk of lung cancer.255 with targeted drug therapies. Vinod et al’s266 study of radiotherapy use for lung cancer treatment suggested a gap in the existing system in NSW. The findings, which can be 7.5.1.2 International prevention/ extrapolated to Australia overall, showed that usage was not in line with the estimated optimal level of radiotherapy. screening/treatment programs This is thought to be a result of the profile of radiotherapy Prevention techniques for lung cancer focus on the as an effective treatment for lung cancer, and the attitude of reduction in modifiable risk factors, specifically smoking physicians to its use.266 cessation. Currently there is no universally endorsed Recent improvements in treatment techniques have screening method for lung cancer.7 In 2006, a seminal paper translated to modest improvements in survival rates.20 was published advocating the use of computed tomography However, an analysis of survival by SES area in NSW scans as an annual screening method for lung cancer.256 between 1996 and 2001 showed that people in the highest Initial screening detection results were encouraging, SES quintile had lower excess relative risk of lung cancer, positioning it as a viable method, but it requires further with 9,673 excess deaths that might have been extended for testing.256 5 years beyond diagnosis.267 Overall, lung cancer patients in NSW received the same treatment between 1996 and 2002. 268 Only small-cell lung cancer patients were less likely to receive treatment in 2002, in comparison to previous years.268

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Table 7–10 7.5.2 Incidence and mortality rates in Lung cancer: average annual percentage change Australia 1987–2007 (AAPC)

Overall mortality has dropped by 34%, an encouraging, Mortality Incidence statistically significant fall (Table 7–9). This is predominantly Confidence Confidence due to the 46% reduction in male mortality. Age- AAPC AAPC Interval (95%) Interval (95%) standardised mortality trends reflect this finding (Figure 7–9). There was a slight increase in mortality for females Male -3.0 -3.3, -2.7 -2.4 -2.6, -2.2 (7%), not statistically significant based on linear trends Female 0.2 -0.1, 0.4 1.1 0.9, 1.3 (Table 7–10). Lung cancer incidence has decreased overall Persons -2.1 -2.3, -1.8 -1.3 -1.5, -1.1 (22%), also reflected in the age-standardised incidence rates (Figure 7-10). The drop was due to 2,174 fewer Figure 7–9 incident cases in males whereas the number of females Lung cancer: age-standardised cancer mortality increased by 468. These changes can be largely explained rates in Australia 1987–2007, 0–74 years by changes in long-term tobacco consumption rather than differing susceptibility between genders.40, 41 A large 5050 proportion of lung cancer cases in Australia are attributed 84 to tobacco use (65% in females, 90% in males). The 4040 popularity of smoking in Australian females peaked at a later time than in males. We are yet to see the relative 3030 declines in lung cancer in females that have been observed in males, and there is usually a time lag between smoking behaviour and lung cancer diagnosis.40, 269 Australian males 2020 smoke at higher rates than females in all but one age

270 Mortality per 100,000 people group (12- to 17-year-olds) and lung cancer deaths in 1010 Tablemales 7–9are still significantly higher than in females.72 Lung cancer deaths and incident cases in Australia Mortality per 100,000 people 0 1987–2007 0 19901990 19951995 20002000 20052005 Deaths† Incident Cases† Year Year  Persons Persons Male Male Female Female Male Female Persons Male Female Persons Figure 7–10 Observed in 2,668 1,555 4,223 3,612 2,302 5,915 2007 (O)# Lung cancer: age-standardised cancer incidence rates in Australia 1987–2007, 0–74 years Expected in 2007 (E)§ 4,927 1,450 6,377 5,786 1,834 7,620

Difference -2,259 105 -2,154 -2,174 468 -1,705 (O-E)

40 40 Change in -46 7 -34 -38 26 -22 (O-E)/E (%)

#An average of the observed rates for 2006 to 2008 was applied to the 2007 population to calculate the observed number of deaths and incident cases 20 20 for 2007. §An average of the observed rates for 1986 to 1988 was applied to the 2007 population to calculate the expected number of deaths and incident cases Incidence per 100,000 people for 2007. Incidence per 100,000 people per Incidence † All figures have been rounded to the nearest whole number. 0 0 19901990 19951995 20002000 20052005 Year Year Persons Male Female  Persons  Male  Female

November, 2013 An early study of quality of life in a small sample of lung It is important to note that while reduced numbers of lung cancer patients found that marital status has a moderate cancer deaths in the past 20 years are a success story for effect on improved quality of life, and was a statistically tobacco control, lung cancer survival after diagnosis has significant predictor of survival.271 It was posited that not improved significantly, and research into improved lung married patients had an improved survival rate due to cancer outcomes should be a high priority. The 2013/14 early diagnosis, better treatment, and support from their federal budget included a AUS$5.9 million allocation over 4 spouse.271 The use of multidisciplinary teams for the years to improve care for lung cancer patients, their carers management of lung cancer patients can also improve their and families through Cancer Australia.102 treatment and, potentially, their quality of life.272, 273 However, no direct impact on survival has been reported.272 The stigma associated with lung cancer diagnosis affects sufferers’ quality of life. Sufferers are often blamed or looked down on by society for their disease because of the association between tobacco consumption and lung cancer.274 They are often held responsible for their illness, as causes other than tobacco can be overlooked by the general public.274, 275 Patients also felt that treatment may have been delayed or denied as a result of negative stigma.275 Studies of non-invasive supportive interventions for lung cancer sufferers benefit all aspects of their quality of life – emotional, psychological and physical. Nurse- led interventions focused on breathlessness, as well as general follow-up interventions, produced positive effects on patients’ wellbeing and satisfaction. Counselling or educational interventions can provide some benefit in improving quality of life through improvements in coping skills. Physical activity and nutritional-based interventions did not show any positive or lasting effects on quality of life in this group of patients. Reflexology also showed some beneficial short-term effects in improving patient quality of life. Despite the variable effects on survival and quality of life of specific interventions, the act of administering an intervention showed the development of a positive relationship with involved health care professionals.276 Lung cancer is the nation’s biggest ‘killer’, but specific programs are not present (eg organised screening programs for high-risk groups).42-44 The nature of the disease is such that smoking cessation is the most fruitful way of addressing the problem; thus lung cancer is represented in Australian public health initiatives through tobacco control strategies.40 The emphasis placed on quitting smoking should go a long way to reduce the burden of lung cancer while alternative screening and treatment methods are being explored.

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7.5 Lung Cancer (C33-34)

References 3 Australian Institute of Health and Welfare. Cancer survival 83 IARC Working Group on the Evaluation of Carcinogenic and prevalence in Australia period estimates from 1982 to Risks to Humans. IARC Monographs: Radiation. Volume 2010. Canberra: Australian Institute of Health and Welfare; 100D A review of human carcinogens. Lyon: IARC; 2012. 2012 (Cancer series no. 69. Cat. no. CAN 65). 84 Ridolfo B, Stevenson C. The quantification of drug-caused 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. mortality and morbidity in Australia, 1998. Canberra: GLOBOCAN 2008 v2.0, Cancer incidence and mortality Australian Institute of Health and Welfare; 2001 (Drug worldwide: IARC CancerBase No. 10: Lyon, France: IARC, Statistics Series no.7. Cat. no. PHE 29). 2010. 102 Australian Government. Budget 2013-14: Health and Ageing. 7 Boyle P, Levin B, editors. World Cancer Report 2008. Canberra: Commonwealth of Australia; 2013 [updated July Geneva: IARC; 2008. 9; cited 2013 July 9]; Available from: http://www.budget.gov. 20 American Cancer Society. Cancer facts & figures 2012. au/2013-14/content/bp2/html/bp2_expense-13.htm. Atlanta: American Cancer Society; 2012. 177 IARC Working Group on the Evaluation of Carcinogenic 22 IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. IARC Monographs: Arsenic, Metals, Fibres Risks to Humans. IARC Monographs: Personal habits and Dusts. Volume 100C A review of human carcinogens. and indoor combustions. Volume 100E A review of human Lyon: IARC; 2012. carcinogens. Lyon: IARC; 2012. 212 IARC Working Group on the Evaluation of Carcinogenic 36 World Cancer Research Fund / American Institute for Risks to Humans. IARC Monographs: Chemical agents Cancer Research. Food, Nutrition, Physical Activity, and the and related occupations. Volume 100F A review of human Prevention of Cancer: a Global Perspective. Washington, carcinogens. Lyon: IARC; 2012. DC: American Institute for Cancer Research; 2007. 232 Thun MJ, Henley SJ, Burns D, Jemal A, Shanks TG, Calle 39 Lo Y-L, Hsiao C-F, Chang G-C, Tsai Y-H, Huang M-S, Su EE. Lung cancer death rates in lifelong nonsmokers. J Natl W-C, Chen Y-M, Hsin C-W, Chang C-H, Yang P-C, Chen Cancer Inst. 2006;98 (10):691-9. C-J, Hsiung C. Risk factors for primary lung cancer among 233 Thun M, Carter B, Feskanich D, Freedman N, Prentice R, never smokers by gender in a matched case-control study. Lopez A, Hartge P, Gapstur S. 50-year trends in smoking- Cancer Causes Control. 2013;24 (3):567-76. related mortality in the United States. N Engl J Med. 40 Adair T, Hoy D, Dettrick Z, Lopez A. Reconstruction of 2013;368 (4):351-64. long-term tobacco consumption trends in Australia and 234 Mu L, Liu L, Niu R, Zhao B, Shi J, Li Y, Swanson M, Scheider their relationship to lung cancer mortality. Cancer Causes W, Su J, Chang SC, Yu S, Zhang ZF. Indoor air pollution and Control. 2011;22 (7):1047-53. risk of lung cancer among Chinese female non-smokers. 41 De Matteis S, Consonni D, Pesatori A, Bergen A, Bertazzi Cancer Causes Control. 2013;24 (3):439-50. P, Caporaso N, Lubin J, Wacholder S, Landi M. Are women 235 Sakata R, McGale P, Grant EJ, Ozasa K, Peto R, Darby who smoke at higher risk for lung cancer than men who SC. Impact of smoking on mortality and life expectancy smoke? Am J Epidemiol. 2013;177 (7):601-12. in Japanese smokers: a prospective cohort study. BMJ. 42 Dominioni L, Poli A, Mantovani W, Pisani S, Rotolo N, 2012;345:e7093. Paolucci M, Sessa F, Conti V, D’Ambrosio V, Paddeu A, 236 Tammemagi CM, Pinsky PF, Caporaso NE, Kvale PA, Imperatori A. Assessment of lung cancer mortality reduction Hocking WG, Church TR, Riley TL, Commins J, Oken MM, after chest X-ray screening in smokers: A population-based Berg CD, Prorok PC. Lung cancer risk prediction: Prostate, cohort study in Varese, Italy. Lung Cancer. 2013;80 (1):50-4. Lung, Colorectal And Ovarian Cancer Screening Trial models 43 Couraud S, Cortot A, Greillier L, Gounant V, Mennecier and validation. J Natl Cancer Inst. 2011;103 (13):1058-68. B, Girard N, Besse B, Brouchet L, Castelnau O, Frappé 237 Matakidou A, Eisen T, Houlston RS. Systematic review of the P, Ferretti G, Guittet L, et al. From randomized trials to relationship between family history and lung cancer risk. Brit the clinic: is it time to implement individual lung-cancer J Cancer. 2005;93 (7):825-33. screening in clinical practice? A multidisciplinary statement 238 Brinton LA, Gierach GL, Andaya A, Park Y, Schatzkin A, from French experts on behalf of the french intergroup Hollenbeck AR, Spitz MR. Reproductive and hormonal (IFCT) and the groupe d’Oncologie de langue francaise factors and lung cancer risk in the NIH-AARP Diet and (GOLF). Ann Oncol. 2013;24 (3):586-97. Health Study cohort. Cancer Epidemiol Biomarkers Prev. 44 Kovalchik SA, Tammemagi M, Berg CD, Caporaso NE, 2011;20 (5):900-11. Riley TL, Korch M, Silvestri GA, Chaturvedi AK, Katki HA. 239 Pesatori AC, Carugno M, Consonni D, Caporaso NE, Targeting of low-dose CT screening according to the risk of Wacholder S, Tucker M, Landi MT. Reproductive and lung-cancer death. N Engl J Med. 2013;369 (3):245-54. hormonal factors and the risk of lung cancer: The EAGLE 72 Australian Institute of Health and Welfare. Australian Cancer study. Int J Cancer. 2013;132 (11):2630-9. Incidence and Mortality books. Canberra: Australian Institute of Health and Welfare; 2012.

November, 2013 240 Punturieri A, Szabo E, Croxton TL, Shapiro SD, Dubinett SM. 253 Barone-Adesi F, Chapman RS, Silverman DT, He X, Hu W, Lung cancer and chronic obstructive pulmonary disease: Vermeulen R, Ning B, Fraumeni JF, Jr., Rothman N, Lan needs and opportunities for integrated research. J Natl Cancer Q. Risk of lung cancer associated with domestic use of Inst. 2009;101 (8):554-9. coal in Xuanwei, China: retrospective cohort study. BMJ. 241 Brenner DR, McLaughlin JR, Hung RJ. Previous lung diseases 2012;345:e5414. and lung cancer risk: a systematic review and meta-analysis. 254 Tang L, Lim WY, Eng P, Leong SS, Lim TK, Ng AW, Tee PLoS One. 2011;6 (3):e17479. A, Seow A. Lung cancer in Chinese women: evidence for 242 Brenner DR, Boffetta P, Duell EJ, Bickeboller H, Rosenberger an interaction between tobacco smoking and exposure A, McCormack V, Muscat JE, Yang P, Wichmann HE, to inhalants in the indoor environment. Environ Health Brueske-Hohlfeld I, Schwartz AG, Cote ML, et al. Previous Perspect. 2010;118 (9):1257-60. lung diseases and lung cancer risk: a pooled analysis from 255 Wynant W, Siemiatycki J, Parent M-É, Rousseau M-C. the International Lung Cancer Consortium. Am J Epidemiol. Occupational exposure to lead and lung cancer: results 2012;176 (7):573-85. from two case-control studies in Montreal, Canada. Occup 243 Koutsokera A, Kiagia M, Saif M, Souliotis K, Syrigos K. Environ Med. 2013;70 (3):164-70. Nutrition Habits, Physical Activity, and Lung Cancer: An 256 Henschke CI, Yankelevitz DF, Libby DM, Pasmantier MW, Authoritative Review. Clin Lung Cancer. 2013;14 (4):342-50. Smith JP, Miettinen OS. Survival of patients with stage I lung 244 Wakai K, Matsuo K, Nagata C, Mizoue T, Tanaka K, Tsuji cancer detected on CT screening. N Engl J Med. 2006;355 I, Sasazuki S, Shimazu T, Sawada N, Inoue M, Tsugane S. (17):1763-71. Lung cancer risk and consumption of vegetables and fruit: an 257 Bach PB. Inconsistencies in findings from the early lung evaluation based on a systematic review of epidemiological cancer action project studies of lung cancer screening. J evidence from Japan. Jpn J Clin Oncol. 2011;41 (5):693-708. Natl Cancer Inst. 2011;103 (13):1002-6. 245 Wright ME, Park Y, Subar AF, Freedman ND, Albanes D, 258 Aberle DR, Berg CD, Black WC, Church TR, Fagerstrom Hollenbeck A, Leitzmann MF, Schatzkin A. Intakes of fruit, RM, Galen B, Gareen IF, Gatsonis C, Goldin J, Gohagan JK, vegetables, and specific botanical groups in relation to lung Hillman B, Jaffe C, et al. The National Lung Screening Trial: cancer risk in the NIH-AARP Diet and Health Study. Am J overview and study design. Radiology. 2011;258 (1):243-53. Epidemiol. 2008;168 (9):1024-34. 259 Ma J, Ward E, Smith R, Jemal A. Annual number of lung 246 Kabat GC, Kim M, Hunt JR, Chlebowski RT, Rohan TE. Body cancer deaths potentially avertable by screening in the mass index and waist circumference in relation to lung cancer United States. Cancer. 2013;119 (7):1381-5. risk in the Women’s Health Initiative. Am J Epidemiol. 2008;168 260 Hew M, Stirling R, Abramson M. Should we screen for lung (2):158-69. cancer in Australia? Med J Aust. 2013;199 (2):82-3. 247 Tarnaud C, Guida F, Papadopoulos A, Cenee S, Cyr D, 261 U.S. Preventive Services Task Force. Screening for Schmaus A, Radoi L, Paget-Bailly S, Menvielle G, Buemi A, Lung Cancer: U.S. Preventive Services Task Force Woronoff AS, Luce D, et al. Body mass index and lung cancer Recommendation Statement DRAFT. Rockville: U.S. risk: results from the ICARE study, a large, population-based Preventive Services Task Force; 2013 [updated July; case-control study. Cancer Causes Control. 2012;23 (7):1113- cited 2013 August 21]; Available from: http://www. 26. uspreventiveservicestaskforce.org/draftrec.htm. 248 Yang Y, Dong J, Sun K, Zhao L, Zhao F, Wang L, Jiao Y. 262 Broza Y, Kremer R, Tisch U, Gevorkyan A, Shiban A, Best Obesity and incidence of lung cancer: a meta-analysis. Int J L, Haick H. A nanomaterial-based breath test for short-term Cancer. 2013;132 (5):1162-9. follow-up after lung tumor resection. Nanomedicine. 2013;9 249 Smith L, Brinton LA, Spitz MR, Lam TK, Park Y, Hollenbeck (1):15-21. AR, Freedman ND, Gierach GL. Body mass index and risk of 263 Marcus PM, Bergstralh EJ, Zweig MH, Harris A, Offord KP, lung cancer among never, former, and current smokers. J Natl Fontana RS. Extended lung cancer incidence follow-up in Cancer Inst. 2012;104 (10):778-89. the Mayo Lung Project and overdiagnosis. J Natl Cancer 250 World Health Organization. Asbestos: elimination of asbestos- Inst. 2006;98 (11):748-56. related diseases. Geneva: World Health Organization; 2010 264 Reich JM. Cost-effectiveness of computed tomography lung [updated July; cited 2013 January 7]; Available from: http:// cancer screening. Brit J Cancer. 2009;101 (6):879-80. www.who.int/mediacentre/factsheets/fs343/en/index.html. 265 Castleberry AW, Smith D, Anderson C, Rotter AJ, Grannis 251 Villeneuve PJ, Parent ME, Harris SA, Johnson KC. FW, Jr. Cost of a 5-year lung cancer survivor: symptomatic Occupational exposure to asbestos and lung cancer in men: tumour identification vs proactive computed tomography evidence from a population-based case-control study in eight screening. Brit J Cancer. 2009;101 (6):882-96. Canadian provinces. BMC Cancer. 2012;12 (1):595. 266 Vinod SK, Simonella L, Goldsbury D, Delaney GP, Armstrong 252 Goodman M, Morgan RW, Ray R, Malloy CD, Zhao K. Cancer B, O’Connell DL. Underutilization of radiotherapy for lung in asbestos-exposed occupational cohorts: a meta-analysis. cancer in New South Wales, Australia. Cancer. 2010;116 Cancer Causes Control. 1999;10 (5):453-65. (3):686-94. 76 • The State of Cancer Control in Australia

267 Yu XQ, O’Connell DL, Gibberd RW, Armstrong BK. Assessing the impact of socio-economic status on cancer survival in New South Wales, Australia 1996-2001. Cancer Causes Control. 2008;19 (10):1383-90. 268 Simonella L, O’Connell DL, Vinod SK, Delaney GP, Boyer M, Esmaili N, Hensley M, Goldsbury D, Supramaniam R, Hui A, Armstrong B. No improvement in lung cancer care: the management of lung cancer in 1996 and 2002 in New South Wales. Intern Med J. 2009;39 (7):453-8. 269 Shibuya K, Inoue M, Lopez A. Statistical modeling and projections of lung cancer mortality in 4 industrialized countries. Int J Cancer. 2005;117 (3):476-85. 270 Australian Institute of Health and Welfare. 2010 National Drug Strategy Household Survey report. Canberra: Australian Institute of Health and Welfare; 2011 (Drug statistics series no. 25. Cat. no. PHE 145). 271 Ganz PA, Lee JJ, Siau J. Quality of life assessment. An independent prognostic variable for survival in lung cancer. Cancer. 1991;67 (12):3131-5. 272 Boxer MM, Vinod SK, Shafiq J, Duggan KJ. Do multidisciplinary team meetings make a difference in the management of lung cancer? Cancer. 2011;117 (22):5112-20. 273 Vinod SK, Delaney GP, Bauman AE, Barton MB. Lung cancer patterns of care in south western Sydney, Australia. Thorax. 2003;58 (8):690-4. 274 Chapple A, Ziebland S, McPherson A. Stigma, shame, and blame experienced by patients with lung cancer: qualitative study. BMJ. 2004;328 (7454):1470. 275 Chambers S, Dunn J, Occhipinti S, Hughes S, Baade P, Sinclair S, Aitken J, Youl P, O’Connell D. A systematic review of the impact of stigma and nihilism on lung cancer outcomes. BMC Cancer. 2012;12:184. 276 Rueda JR, Sola I, Pascual A, Subirana Casacuberta M. Non- invasive interventions for improving well-being and quality of life in patients with lung cancer. Cochrane Database Syst Rev. 2011 (9):CD004282. November, 2013

7.6 Melanoma (C43)

7.6.1 Background Skin cancer is divided into non-melanoma and melanoma of the skin. Non-melanoma skin cancer is the most common form of skin cancer; however, new cases are not routinely registered in many countries and it is not often a life-threatening disease. On the other hand, melanoma of the skin has greater potential for metastasis, and thus can be more fatal if not diagnosed early. This section focuses on melanoma of the skin, which is recorded in Australian cancer registries.7, 277 Of the 160,000 new cases of melanoma each year worldwide, approximately 80% are in individuals from North America, Australia and New Zealand.7 IARC GLOBOCAN 2008 working against ultraviolet radiation from the epidermal melanin, estimates state that the incidence of melanoma of the skin in resulting in lower incidence of melanoma.46 Physical males and females under the age of 75 was 2.6/100,000 and symptoms of melanoma are naevi which can develop 2.4/100,000 respectively.5 Although not a cancer of overall into pigmented lesions. Pigmented lesions often appear global importance, incidence for all ages in Australia is high: on the trunk, especially in males, or on the lower legs in 42.4/100,000 in males and 31.7/100,000 in females, making it a females.46 The degree of risk associated with a melanoma cancer of concern nationally.5 Overall, mortality rates are high, is determined by its thickness.277 Melanoma skin cancer considering that this is a highly curable disease if detected is visually recognisable, suggesting that screening could and treated early.46 IARC GLOBOCAN 2008 working mortality play an important role in early diagnosis. estimates were 0.6/100,000 in males and 0.4/100,000 in females In Australia, the prognosis for melanoma is good, with under 75 years of age. Melanoma appears to be more aggressive 91% relative survival for at least 5 years at diagnosis. in males, with higher survival rates in females.278, 279 Females have The 5-year conditional relative survival was 92% for 1 been found to have a lower risk of developing metastases than year after diagnosis and rising to 100% 14 years after males.278 diagnosis. Survival varies greatly with the thickness of the Melanoma occurs in the melanocytes in the epidermis and is tumour. A thicker tumour (more than 4 millimetres) has a more common in fairer-skinned individuals.46, 280 Individuals with 55% 5-year survival rate, in comparison to a 100% rate for darker skin pigmentations have higher levels of photoprotection thinner tumours.3

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7.6.1.1 Causes and risk factors Ultraviolet radiation exposure is essential for the development of vitamin D, important for bone health, but Environmental factors are the predominant cause of all in excess can result in higher risk of skin cancer, especially types of skin cancer, suggesting its preventability through in people with a light skin pigmentation.45, 289 Vitamin D has their adequate control. The major cause of skin cancer also shown evidence of containing anticancer properties is ultraviolet radiation exposure resulting in direct cellular that could inhibit melanoma.289, 290 The combination of damage and modifications to immunologic function.45, harm and benefit associated with sun exposure can result 46 However, no simple dose-response relationship in mixed public health messages that dilute the sun- between exposure and melanoma has been identified.281 safe practices commonly promoted. Ultraviolet radiation Occupational exposure, childhood exposure and exposure passing through after the application of sunscreen has during holidays in sunny locations have all been related to been shown to be sufficient to produce levels of vitamin D higher risk of skin cancer.282 There is recent evidence to that will prevent skin cancer.290 suggest that not all exposure is the same and that type of exposure (ie recreational or occupational) and period of Hormonal factors have not conclusively been associated exposure in life are important factors to be considered.83, 281, with skin cancer. The development of skin cancer 283, 284 Purdue et al284 suggest intrinsic factors may also play as a result of HRT use has been proposed but not a role in melanoma risk. conclusively proven for either non-melanoma skin cancer or melanoma.291, 292 Other hormone-related medications In the USA, incidence of melanoma is high in people of or issues, including oral contraception and pregnancy, higher SES but their survival rates are higher, potentially have not conclusively been associated with melanoma.292 reflective of vacationing in locations with greater sun However, there could be a protective factor that is present exposure and better access to care.279 This reasoning only in females, or a factor that promotes the development has not been supported by an Australian study.285 of melanoma in males, that could explain a Melanoma is associated with severe sunburn and proportion of the gender differences in survival.278 intermittent exposure to ultraviolet radiation, rather than chronic exposure.280, 285 An Prevention The World Cancer Research Fund found inability to tan is also associated with higher of melanoma probable evidence associating arsenic risk of melanoma. The relevant gene is focuses on in drinking water to increased risk of also commonly associated with red hair, public education skin cancer (both melanoma and non- 279, a propensity to freckle and fair skin. and modifying melanoma). Other food products and 286 Individuals who have had melanoma supplements have not been conclusively have a higher risk of developing a behaviour to linked to risk of melanoma.36 second primary melanoma, making it a encourage sun- The incidence of melanoma and non- life-threatening disease.279, 287 Additionally, safe practices. melanoma skin cancer in females has first-degree relatives who have suffered been steadily increasing in the USA, partially skin cancer double the risk for family members attributed to the rising use of artificial tanning developing melanoma compared with the general devices (i.e. tanning beds, sunbeds and solaria).288 population.279, 287 However, the exact gene responsible for Increased incidence resulting from tanning beds is increasing risk has not yet been described.288 Phototherapy, predominantly cases of non-melanoma skin cancer, but used to treat some cutaneous diseases, can result in higher is also associated with increased risk of melanoma.46, 83, morbidity from skin cancer.46 288, 293 Sunbed use is most prevalent in young females, Actinic keratoses are a common precursor to skin cancer, especially those whose parents are of a lower SES, and but are most commonly associated with squamous cell exposure at a younger age results in a higher risk of skin carcinomas.280 Individuals with acquired melanocytic naevi, cancer.279, 293-297 Risk in sunbed users is estimated to or moles, are at higher risk of developing melanoma.279, 286 increase by approximately 20%.294 The tanning industry Their development is highly influenced by sun exposure at does not self-regulate and has been found to provide a young age.282 Naevi, both melanocytic and dysplastic, clients with information that does not accurately represent are considered to be important independent markers of the associated risks.294, 298 In many nations, sunbed use melanoma.279, 280, 282 Lower numbers of naevi were found has been restricted to over–18-year-olds and there have in children who frequently used sunscreen, suggesting an been calls for regulations to be changed where restrictions association with reduced risk in melanoma.279 do not currently exist.294, 298 A Danish study suggested that focusing anti-sunbed messages to preteens, specifically 14-year-olds, would be most effective.295

November, 2013 7.6.1.2 International prevention/ Treatment for melanoma of the skin is commonly surgery, 277, screening/treatment programs with non-surgical methods used in adjuvant treatments. 308 For many years, the most common treatment for Prevention of melanoma focuses on public education and melanoma has been excision.277, 279 Melanoma can also 46, 299 modifying behaviour to encourage sun-safe practices. be successfully treated with interferon alfa-2b, an antiviral Sun-safe programs include the use of sunscreen, seeking drug.309 If untreatable by surgery, the BRAF inhibitor drug, protective shade cover, and wearing protective clothing, dabrafenib, can be used to improve survival from melanoma 46, 282 a hat and sunglasses. Although initially considered with little toxicity.310 Melanoma has been classified as a controversial, the use of sunscreen has been shown to radio-resistant disease, thus radiotherapy has not been 300 reduce the incidence of skin cancer. In the 1990s, broad- used extensively in its treatment.308 However, radiotherapy spectrum sunscreen, which filtered out both ultraviolet has been shown to decrease risk of regional relapse, but A and B radiation, became widely available and used in does not improve survival.308 Emerging evidence suggests 47 Australia. This may result in future reductions in incidence that treatment of melanoma with β-blockers within 90 days 47 and mortality. of diagnosis could improve survival.311 As part of public health initiatives, individuals are advised to seek medical attention if any moles change colour or increase in size at any stage.46 New initiatives to change 7.6.2 Incidence and mortality rates in individual behaviour are being trialled, such as the use of Australia 1987–2007 text messages to promote healthy behaviours to improve prevention and early detection.301 Campaigns encouraging Mortality rates of melanoma of the skin have decreased reduced sun exposure, increasing sun safe practices, marginally over the 20-year period, while incidence rates and educating health care and education workers to be have increased (Figure 7–11 and Figure 7–12). There sun-smart are more effective if coupled with government has been an 11% reduction in mortality associated policies mandating changes in physical environments and with melanoma of the skin and a 17% increase in practices.46 incidence (Table 7–11). This suggests that melanoma is still an ongoing concern, despite positive survival rates. Although a commonly diagnosed cancer, no existing Considering the extensive sun protection campaigns 282, screening programs have been endorsed for skin cancer. implemented in Australia, the 11% decline in mortality over 299, 302 In 2009, the US Preventive Services Task Force the study period seems low. This could be associated with found that there was insufficient empirical evidence to broad-spectrum sunscreen use only starting the 1990s, support the beneficial outcomes of a screening program, and the delayed effect of childhood exposure.47 Studies and limited information on how a screening program could including a more detailed age-specific incidence analysis 302 be integrated into usual care. Other nations, however, found a fall in incidence in younger age cohorts.312, 313 differ in their approach and have implemented pilot Research has also shown a general positive change in 303 screening programs. In Australia, specialised clinics behaviour and attitudes in younger generations.312-314 run by dermatologists became popular in the 1980s and 1990s, and have been suggested to be an effective method of screening.304-306 Self-examination, in conjunction with a visit to the general practitioner, has been shown to reduce risk.307 Currently work is being done to develop a computer- assisted digital analysis of pigmented lesions to aid in early diagnosis that could be developed into a population-wide screening program.277 In the USA, much of the associated cost (approximately 90%) of melanoma is from individuals with advanced lesions.48, 288 Thus, earlier detection would reduce the health care system costs related to this disease.288, 303 The required evidence to support this from a randomised controlled trial would be costly and difficult to source, because of relatively low incidence and mortality rates.303, 305

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Table 7–11 Figure 7–12 Melanoma deaths and incident cases in Australia Melanoma: age-standardised cancer incidence rates 1987–2007 in Australia 1987–2007, 0–74 years Deaths† Incident Cases†

Male Female Persons Male Female Persons 4040

Observed in # 506 252 759 4,569 3,446 8,015 2007 (O) 3030 Expected in § 556 292 848 3,635 3,242 6,877 2007 (E) 2020

Difference -50 -40 -89 934 204 1,138 (O-E) 1010 Incidence per 100,000 people Incidence per 100,000 people per 100,000 Incidence Change in -9 -14 -11 26 6 17 (O-E)/E (%) 00 19901990 19951995 20002000 20052005 #An average of the observed rates for 2006 to 2008 was applied to the 2007 YearYear population to calculate the observed number of deaths and incident cases Persons Male Female for 2007.  Persons  Male  Female §An average of the observed rates for 1986 to 1988 was applied to the 2007 population to calculate the expected number of deaths and incident cases for 2007. The prognosis for melanoma of the skin is good, despite its †All figures have been rounded to the nearest whole number. life-threatening nature. Patients require ongoing, long-term monitoring, which can become demanding and require a shared-care model between health care professionals.315 Table 7–12 Ongoing monitoring can help reduce anxiety associated Melanoma average annual percentage change (AAPC) with the prospect of recurrence.315 As with most cancer types, at diagnosis and post-treatment, patients’ quality Mortality Incidence of life is lower than the general population.287 However, it Confidence Confidence AAPC AAPC increases over time. Quality of life can decrease during Interval (95%) Interval (95%) treatment with drugs such as interferon alfa-2b, but then Male -0.5 -0.8, -0.1 0.3 0.7, 1.9 return to normal after treatment has ceased.309 A German Female -0.9 -1.5, -0.4 0.6 0.2, 0.9 quality-of-life study has shown that patients’ scores are comparable to the general population two years after Persons -0.6 -0.9, -0.4 0.9 0.6, 1.2 diagnosis without recurrence.316 It has been suggested that providing sufficient information to patients regarding Figure 7–11 melanoma improves their quality of life significantly.316 Melanoma age-standardised cancer mortality rates in Australia 1987–2007, 0–74 years Initiatives in Australia, including the SunSmart Program; the Mole Patrol; Slip! Slop! Slap!; and Slip! Slop! Slap! Seek! Slide! have successfully raised awareness and improved behaviours – these programs are described in section 8.3.5.5.48, 49, 306 Modifying exposure to ultraviolet radiation 45 44 could significantly reduce health care costs. A balance in sun exposure recommendations needs to be determined which takes into account both its vitamin D–related benefits and its harmful effects.45 This balance should 45 22 be reflected in public policy and programs. Evidence of positive changes to individual behaviours as a result of Mortality per 100,000 people Australian campaigns, and their cost-effectiveness, have seen them continue to the present day.317, 318 Mortality per 100,000 people 0 0 Skin cancer prevention in Australia is evolving. A skin 19901990 19951995 20002000 20052005 cancer prevention policy has been developed in NSW to Year Year encourage the reduction of overexposure to ultraviolet Persons Male Female  Persons  Male  Female radiation.319 Additionally, NSW and Victoria have planned legislation on the operation of solaria that will bring in a ban on all solaria by the end of 2014.320

November, 2013 7.6 Melanoma (C43)

References 3 Australian Institute of Health and Welfare. Cancer survival and 282 Greinert R, Boniol M. Skin cancer--primary and secondary prevalence in Australia period estimates from 1982 to 2010. prevention (information campaigns and screening)--with a Canberra: Australian Institute of Health and Welfare; 2012 focus on children & sunbeds. Prog Biophys Mol Biol. 2011;107 (Cancer series no. 69. Cat. no. CAN 65). (3):473-6. 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. 283 Gandini S, Sera F, Cattaruzza M, Pasquini P, Picconi O, Boyle GLOBOCAN 2008 v2.0, Cancer incidence and mortality P, Melchi C. Meta-analysis of risk factors for cutaneous worldwide: IARC CancerBase No. 10: Lyon, France: IARC, melanoma: II. Sun exposure. Eur J Cancer. 2005;41 (1):45-60. 2010. 284 Purdue M, From L, Armstrong B, Kricker A, Gallagher 7 Boyle P, Levin B, editors. World Cancer Report 2008. Geneva: R, McLaughlin J, Klar N, Marrett L, Genes Environment IARC; 2008. Melanoma Study Group. Etiologic and other factors predicting 36 World Cancer Research Fund / American Institute for nevus-associated cutaneous malignant melanoma. Cancer Cancer Research. Food, Nutrition, Physical Activity, and the Epidemiol Biomarkers Prev. 2005;14 (8):2015-22. Prevention of Cancer: a Global Perspective. Washington, DC: 285 Cust A, Jenkins M, Goumas C, Armstrong B, Schmid H, American Institute for Cancer Research; 2007. Aitken J, Giles G, Kefford R, Hopper J, Mann G. Early-life sun 45 Lucas R, McMichael A, Armstrong B, Smith W. Estimating the exposure and risk of melanoma before age 40 years. Cancer global disease burden due to ultraviolet radiation exposure. Int Causes Control. 2011 (6):885-97. J Epidemiol. 2008;37 (3):654-67. 286 McMeniman E, De’Ambrosis K, De’Ambrosis B. Risk factors 46 Narayanan D, Saladi R, Fox J. Ultraviolet radiation and skin in a cohort of patients with multiple primary melanoma. cancer. Int J Dermatol. 2010;49 (9):978-86. Australas J Dermatol. 2010;51 (4):254-7. 47 National Industrial Chemicals Notification and Assessment 287 Cornish D, Holterhues C, van de Poll-Franse L, Coebergh J, Scheme. Proposal to adopt the revised Australian/New Nijsten T. A systematic review of health-related quality of life Zealand Sunscreen Standard (AS/NZS 2604:2012 Sunscreen in cutaneous melanoma. Ann Oncol. 2009;20 (Suppl 6):vi51- products – Evaluation and classification) for cosmetic vi8. sunscreen products. Consultation on Regulatory Impacts 288 Rigel D. Epidemiology of melanoma. Semin Cutan Med Surg. – December 2012. Canberra: National Industrial Chemicals 2010;29 (4):204-9. Notification and Assessment Scheme; 2012. 289 Garibyan L, Fisher D. How sunlight causes melanoma. Curr 48 Hirst N, Gordon L, Scuffham P, Green A. Lifetime cost- Oncol Report. 2010;12 (5):319-26. effectiveness of skin cancer prevention through promotion of 290 van der Pols J, Russell A, Bauer U, Neale R, Kimlin M, Green daily sunscreen use. Value Health. 2012;15 (2):261-8. A. Vitamin D status and skin cancer risk independent of 49 Montague M, Borland R, Sinclair C. Slip! Slop! Slap! and time outdoors: 11-year prospective study in an Australian SunSmart, 1980-2000: Skin cancer control and 20 years of community. J Invest Dermatol. 2013;133 (3):637-41. population-based campaigning. Health Educ Behav. 2001;28 291 Tang J, Spaunhurst K, Chlebowski R, Wactawski-Wende (3):290-305. J, Keiser E, Thomas F, Anderson M, Zeitouni N, Larson J, 83 IARC Working Group on the Evaluation of Carcinogenic Risks Stefanick M. Menopausal hormone therapy and risks of to Humans. IARC Monographs: Radiation. Volume 100D A melanoma and nonmelanoma skin cancers: women’s health review of human carcinogens. Lyon: IARC; 2012. initiative randomized trials. J Natl Cancer Inst. 2011;103 277 Martinez J, Otley C. The management of melanoma and (19):1469-75. nonmelanoma skin cancer: a review for the primary care 292 Gupta A, Driscoll M. Do hormones influence melanoma? physician. Mayo Clin Proc. 2001;76 (12):1253-65. Facts and controversies. Clin Dermatol. 2010;28 (3):287-92. 278 Joosse A, de Vries E, Eckel R, Nijsten T, Eggermont AM, 293 Wehner M, Shive M, Chren M-M, Han J, Qureshi A, Linos E. Hölzel D, Coebergh JW, Engel J, Munich Melanoma G. Gender Indoor tanning and non-melanoma skin cancer: systematic differences in melanoma survival: female patients have a review and meta-analysis. BMJ. 2012;345:e5909. decreased risk of metastasis. J Invest Dermatol. 2011;131 294 Boniol M, Autier P, Boyle P, Gandini S. Cutaneous melanoma (3):719-26. attributable to sunbed use: systematic review and meta- 279 Russak J, Rigel D. Risk factors for the development of primary analysis. BMJ. 2012;345:e4757. cutaneous melanoma. Dermatol Clin. 2012;30 (3):363-8. 295 Bentzen J, Krarup A, Castberg I-M, Jensen P, Philip A. 280 Einspahr J, Stratton S, Bowden G, Alberts D. Determinants of sunbed use in a population of Danish Chemoprevention of human skin cancer. Crit Rev Oncol adolescents. Eur J Cancer Pr. 2013;22 (2):126-30. Hematol. 2002;41 (3):269-85. 296 Demko C, Borawski E, Debanne S, Cooper K, Stange K. Use 281 Chang YM, Barrett J, Bishop D, Armstrong B, Bataille V, of indoor tanning facilities by white adolescents in the United Bergman W, Berwick M, Bracci P, Elwood J, Ernstoff M, States. Arch Pediatr Adolesc Med. 2003;157 (9):854-60. Gallagher R, Green A, et al. Sun exposure and melanoma risk at different latitudes: a pooled analysis of 5700 cases and 7216 controls. Int J Epidemiol. 2009;38 (3):814-30. 82 • The State of Cancer Control in Australia

297 El Ghissassi F, Baan R, Straif K, Grosse Y, Secretan B, 312 Coory M, Baade P, Aitken J, Smithers M, McLeod GR, Ring Bouvard V, Benbrahim-Tallaa L, Guha N, Freeman C, Galichet I. Trends for in situ and invasive melanoma in Queensland, L, Cogliano V, WHO International Agency for Research on Australia, 1982-2002. Cancer Causes Control. 2006;17 (1):21- Cancer Monograph Working Group. A review of human 7. carcinogens--part D: radiation. Lancet Oncol. 2009;10 (8):751- 313 Hill D, Marks R. Health promotion programs for melanoma 2. prevention: screw or spring? Arch Dermatol. 2008;144 (4):538- 298 Balk S, Fisher D, Geller A. Stronger laws are needed to 40. protect teens from indoor tanning. Pediatrics. 2013;131 314 Volkov A, Dobbinson S, Wakefield M, Slevin T. Seven-year (3):586-8. trends in sun protection and sunburn among Australian 299 Goulart J, Quigley E, Dusza S, Jewell S, Alexander G, Asgari adolescents and adults. Aust N Z J Public Health. 2013;37 M, Eide M, Fletcher S, Geller A, Marghoob A, Weinstock (1):63-9. M, Halpern A, et al. Skin cancer education for primary care 315 Rychetnik L, Morton R, McCaffery K, Thompson J, Menzies physicians: a systematic review of published evaluated S, Irwig L. Shared care in the follow-up of early-stage interventions. J Gen Intern Med. 2011;26 (9):1027-35. melanoma: a qualitative study of Australian melanoma 300 Green A, Williams G, Logan V, Strutton G. Reduced clinicians’ perspectives and models of care. BMC Health Serv melanoma after regular sunscreen use: randomized trial Res. 2012;12:468. follow-up. J Clin Oncol. 2011;29 (3):257-63. 316 Schlesinger-Raab A, Schubert-Fritschle G, Hein R, Stolz W, 301 Janda M, Youl P, Marshall A, Soyer H, Baade P. The Volkenandt M, Hölzel D, Engel J. Quality of life in localised HealthyTexts study: A randomized controlled trial to improve malignant melanoma. Ann Oncol. 2010;21 (12):2428-35. skin cancer prevention behaviors among young people. 317 Cancer Council Australia. Sun Protection: Campaigns and Contemp Clin Trial. 2013;35 (1):159-67. Events. Sydney: Cancer Council Australia; 2012 [updated 302 Wolff T, Tai E, Miller T. Screening for skin cancer: an update of February 9; cited 2012 October 29]; Available from: http:// the evidence for the U.S. Preventive Services Task Force. Ann www.cancer.org.au/preventing-cancer/sun-protection/ Intern Med. 2009;150 (3):194-8. campaigns-and-events/. 303 Curiel-Lewandrowski C, Kim C, Swetter S, Chen S, Halpern A, 318 Shih S, Carter R, Sinclair C, Mihalopoulos C, Vos T. Economic Kirkwood J, Leachman S, Marghoob A, Ming M, Grichnik J, evaluation of skin cancer prevention in Australia. Prev Med. Melanoma Prevention Working Group-Pigmented Skin Lesion 2009;49 (5):449-53. Sub-Committee. Survival is not the only valuable end point in 319 Cancer Institute NSW. NSW Skin Cancer Prevention Strategy melanoma screening. J Invest Dermatol. 2012;132 (5):1332-7. 2012–15. Sydney: Cancer Institute NSW 2012. 304 Aitken J, Youl P, Janda M, Lowe J, Ring I, Elwood M. 320 NSW EPA. Solaria (tanning units). Sydney: NSW EPA; 2013 Increase in skin cancer screening during a community-based [updated June 16; cited 2013 July 1]; Available from: http:// randomized intervention trial. Int J Cancer. 2006;118 (4):1010- www.epa.nsw.gov.au/radiation/Solaria.htm. 6. 305 Stratigos A, Katsambas A. The value of screening in melanoma. Clin Dermatol. 2009;27 (1):10-25. 306 McCarthy W. The Australian experience in sun protection and screening for melanoma. J Surg Oncol. 2004;86 (4):236-45. 307 Titus L, Clough-Gorr K, Mackenzie T, Perry A, Spencer S, Weiss J, Abrahams-Gessel S, Ernstoff M. Recent skin self- examination and doctor visits in relation to melanoma risk and tumour depth. Brit J Dermatol. 2013;168 (3):571-6. 308 Allan C, Smithers B. Surgery and the management of cutaneous melanoma. Brit J Surg. 2013;100 (3):313-5. 309 Brandberg Y, Aamdal S, Bastholt L, Hernberg M, Stierner U, von der Maase H, Hansson J. Health-related quality of life in patients with high-risk melanoma randomised in the Nordic phase 3 trial with adjuvant intermediate-dose interferon alfa- 2b. Eur J Cancer. 2012;48 (13):2012-9. 310 Menzies A, Long G, Murali R. Dabrafenib and its potential for the treatment of metastatic melanoma. Drug Des Devel Ther. 2012;6:391-405. 311 Lemeshow S, Sørensen H, Phillips G, Yang E, Antonsen S, Riis A, Lesinski G, Jackson R, Glaser R. β-Blockers and survival among Danish patients with malignant melanoma: a population-based cohort study. Cancer Epidemiol Biomarkers Prev. 2011;20 (10):2273-9.

November, 2013 November 2013

7.7 Prostate cancer (C61)

7.7.1 Background Prostate cancer is the most common cancer in males in Australia. The incidence of prostate cancer has risen globally, whereas mortality has seen a lower rate of change overall.7 IARC GLOBOCAN 2008 working estimates reported the incidence for prostate cancer was 20.4/100,000 in males under 75 years of age.5 Developed countries have higher rates of prostate cancer, attributed to the prevalence of PSA testing, with Australia recording the highest incidence rates of 105/100,000 for all ages.5 Mortality rates are 3.6/100,000 in males under 75 years of age globally and 6.6/100,000 in Australia.5 Prostate cancer has no known carcinogen associated with its aetiology.321 It does not present in the early stages with any specific symptoms. Symptoms of advanced stage prostate cancer (eg weak or interrupted flow; difficulty stopping or starting the flow; frequent urination and blood; pain or burning associated with urination) are also generally symptoms of benign enlargement of the prostate.20 Higher The incidence of prostate cancer in Australia increased than usual levels of PSA will be present in the blood if dramatically in the early 1990s with the expansion of PSA the prostate is enlarged, diseased or infected, not only if testing. Incidence rates remain relatively high in Australia, again cancer is present.322 Although there is a strong association due to continued testing; however, mortality has changed to between PSA levels and prostate cancer, its specificity is a lesser extent. Relative survival is relatively high, with a 92% 3 only moderate.321, 323 The Gleason score grades the prostate probability of surviving for at least 5 years at diagnosis. The cancer tissue to determine the stage of the cancer. The 5-year conditional relative survival was 93% at 1 year and 92% 3 clinical and histopathological staging, Gleason score and at 5 years after diagnosis. Five-year survival rates are higher PSA levels are used independently and in combination to for males in the highest SES group, and lower for males who 3 assess the stage of prostate cancer. are younger at diagnosis.

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7.7.1.1 Causes and risk factors International analyses have identified an inverse association between ultraviolet radiation and prostate The only risk factors clearly associated with prostate cancer cancer incidence.330-334 Studies have varied in their strength are advanced age and family history of the cancer.20 There of association between sun exposure and vitamin D with is speculation regarding the impact of early-life exposures, prostate cancer incidence but results indicate that less such as sex hormones, on the likelihood of developing exposure to solar radiation leads to a higher incidence prostate cancer that has stimulated further research.324 of prostate cancer. This is an area of active research. A Research linking food and nutrition to prostate cancer positive association has been found between exposure to risk has found probable evidence of foods containing cadmium and cadmium compounds and risk of prostate selenium or lycopene and selenium (administered through cancer.177 a supplement) having a protective effect.36 On the other hand, there is probable evidence that diets high in calcium increase risk of prostate cancer.36 A review of studies analysing the association between 7.7.1.2 International prevention/ BMI and prostate cancer showed a significant relationship screening/treatment programs between high BMI and increased risk of future prostate Currently, finasteride and dutasteride are two cancer mortality in the general population.325 Overall, an chemoprevention drugs available which can reduce the estimated 12% to 20% of prostate cancer deaths have amount of male hormones in the body to prevent prostate been attributed to BMI in the overweight and obese cancer. Their use decreases the incidence of low-grade ranges.325 Unlike cancer in other sites, it has been cancers and increases the diagnosis of high- suggested that diabetes mellitus reduces the grade cancers.335 Both drugs have been found risk of prostate cancer, possibly explained by to lower the risk of cancer by 25%, but are lifestyle changes recommended to diabetes Screening for also associated with side effects such as sufferers, which include a diet low in prostate cancer reduced libido and erectile dysfunction.20 calories and fat that also reduces the risk using PSA Existing evidence surrounding primary of prostate cancer.326 chemoprevention for prostate cancer is testing has been inconclusive, but shows some promising A link between increased risk of prostate subject to much results requiring confirmation.336, 337 cancer and tobacco consumption has not been conclusively proven.22 However, debate. PSA testing and digital rectal examination a recent study showed a higher risk for (DRE) are used to screen for prostate cancer. prostate cancer mortality in current smokers DRE is not considered to be as effective a at diagnosis, and a moderate, but statistically method of screening as PSA testing, but generally insignificant, increase in risk for former smokers who quit recommendations suggest that the two tests are used 10 years before diagnosis, compared to never smokers.327 in combination.321 Screening for prostate cancer using A pooled analysis of various cohort studies has shown PSA testing has been subject to much debate, with a moderate increase in prostate cancer incidence and doubt cast on the benefits being greater than the harm mortality with elevated levels of tobacco consumption.328 caused.323 PSA testing often detects cancer that may Conversely, a large European cohort study, the European have otherwise gone unnoticed and not caused any harm Prospective Investigation into Cancer and Nutrition or shortened survival.321 There has not been sufficient (EPIC) study, found that current smokers had a reduced evidence from randomised controlled trials to support any risk of prostate cancer incidence in low-grade cases of population-based screening programs.20, 338 Professional the disease.329 However, heavy smokers or long-term associations commonly recommend the use of PSA smokers have an increased risk of prostate cancer–related testing if the individual can potentially benefit and are well mortality.329 informed as to the uncertainty involved.339 For PSA testing to be recommended on a population basis, there need to be more specific trials to identify the thresholds for

November, 2013 ‘positive’ and ‘negative’ results, to limit overdiagnosis and Active surveillance replaced watchful waiting as unnecessary follow-up.323 This has resulted in larger studies, the preferred ‘passive’ treatment method as part of notably the European Randomized Study of Screening standard care.349 Watchful waiting defers treatment until for Prostate Cancer and Prostate, Lung, Colorectal, and a symptomatic, metastatic stage has been reached.349 Ovarian Cancer Screening Trial, to track the long-term effect Active surveillance follows the disease progression more of screening on prostate cancer trends, including a revised closely with repeated and systematic monitoring of PSA method for determining the level of overdiagnosis.321, 323, 338, tests and biopsies.349 These methods of closer monitoring 340 before treatment have been proposed as a solution to overdiagnosis and overtreatment.349, 350 The results of Treatment of prostate cancer can result in side effects existing trials of this method suggest similar mortality rates that impact on quality of life, such as sexual dysfunction, to that of the ‘overtreated’ population.350 The Prostate incontinence and other adverse reactions that can cause Cancer Research International: Active Surveillance Study, longer-term harm.321, 338 In an analysis of incidence trends a worldwide observational prospective study, has thus in the USA, it was estimated that over a million males far found that active surveillance is a viable option for had been diagnosed and treated for prostate cancer as a monitoring patients without compromising their long-term result of PSA testing.341 This increase was most notable health.351 Further trials are required with clear guidelines on in males younger than 50 years of age, and it is claimed patient selection and psychological counselling for patients that a large proportion of these males do not benefit managed by active surveillance and specific surveillance from early detection.341 Current findings do not present methods.350 screening programs in a positive and cost-effective light. It has been shown that over a 13-year period, there is Current evidence suggests that following watchful waiting no benefit gained from organised annual screening over or active surveillance could benefit survival.352 Treatment opportunistic screening as part of usual care.340 As a result, for prostate cancer varies depending on age, stage and recommendations suggest that males with a life expectancy grade of the cancer. The number of males receiving curative of 10–15 years or less be informed of the limited usefulness treatment increased substantially from the early 1990s of screening.323 Additionally, PSA testing is prostate-specific to 2011 in Victoria.346 Other medical conditions may also rather than prostate cancer–specific. The identification of influence the treatment course chosen. Early-stage cancer alternative prostate cancer–specific biomarkers is urgently can be addressed using surgery, external beam radiation or required.323 It has been concluded that screening does radioactive seed implants. Hormonal therapy, chemotherapy reduce mortality, but is associated with considerable and/or radiation are required for more advanced cancers.20 overdiagnosis.342 In light of this, it has been found that males Radiation is now using more advanced techniques are willing to trade off the risk of prostate cancer if they are associated with conformal radiotherapy and intensity- not subjected to unnecessary treatment for non–clinically modulated radiation therapy, as well as the introduction of concerning prostate cancer.343 tomotherapy, which are varying the treatment options for prostate cancer patients.347, 353 In Australia, media surrounding the diagnosis of celebrities with prostate cancer has resulted in spikes in levels of PSA test claims through the Medicare Benefits Scheme (MBS), and confusing messages, despite the known associated 7.7.2 Incidence and mortality rates in harms.344, 345 A Victorian study has recently shown that Australia 1987–2007 there has been a shift to earlier diagnosis of prostate Our analysis shows that prostate cancer incidence has cancer, with the majority of males diagnosed with localised risen dramatically, by 276%, from expected numbers disease.346 There is currently division between organisations (Table 7–13). Mortality has declined by 27% (Table 7–13). in their support of PSA testing.347 Routine screening is not Both are statistically significant changes (Table 7–14). The recommended by the NHMRC, but is funded through the age-standardised mortality rates for prostate cancer also MBS for males who have not previously presented with a showed a decline in cancer deaths following a peak in the prostate disease.348 early 1990s (Figure 7–13). Figure 7–14 shows the change in incidence rates, illustrating the rise in the number of incident cases over the same period of time.

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Table 7–13 Figure 7–14 Prostate cancer deaths and incident cases in Prostate cancer: age-standardised cancer incidence Australia 1987–2007 rates in Australia 1987–2007, 0–74 years

Male Incident Deaths† Cases† 100100 Observed in 2007 (O)# 799 13,961 Expected in 2007 (E)§ 1,094 3,716

Difference (O-E) -295 10,245 5050 Change in (O-E)/E (%) -27 276 Incidence per 100,000 people #An average of the observed rates for 2006 to 2008 was applied to the 2007 Incidence per 100,000 people Incidence 0 population to calculate the observed number of deaths and incident cases 0 for 2007. 19901990 19951995 20002000 20052005 § An average of the observed rates for 1986 to 1988 was applied to the 2007 YearYear population to calculate the expected number of deaths and incident cases for 2007. The increased in incidence can be attributed to PSA testing †All figures have been rounded to the nearest whole number. and the high-profile nature of prostate cancer in the media. As a result of the uncertainty surrounding the effectiveness Table 7–14 of screening, prostate cancer initiatives have not been fully Prostate cancer average annual percentage change integrated into the Australian political agenda beyond the (AAPC) current reimbursement through the MBS and the recent Mortality Incidence allocation of funds to further prostate cancer research.102, 344, 348 Despite this, prostate cancer receives considerable Confidence Confidence AAPC AAPC Interval (95%) Interval (95%) publicity from initiatives such as Movember and the Prostate Cancer Foundation of Australia, raising concerns Male -1.5 -2.1, -1.0 6.6 3.7, 9.6 relating to the advocacy for annual screening tests without Female - - - - adequate information on the associated benefits and harm 354 Persons - - - - provided consistently. In recent years, Movember has broadened its focus to incorporate male mental health and testicular cancer as well as prostate cancer in its key messages.355 Figure 7–13 Prostate cancer age-standardised cancer mortality Quality-of-life studies of prostate cancer patients often rates in Australia 1987–2007, 0–74 years separate males according to the treatment they received. Treatment methods can result in specific side effects, such as declined sexual function, that affect physical and 12 12 psychological elements of a patient’s quality of life.356, 357 A review of quality-of-life studies and the association with physical activity showed that exercise is an important part

88 of survivorship and should be a regular and encouraged element of usual care.358 An Australian study comparing the longer-term quality of life of patients with localised prostate cancer found that there was little difference 4 4 between groups based on the type of treatment they Mortality per 100,000 people received.359 The most common negative effect of treatment

Mortality per 100,000 people in males with localised prostate cancer was sexual 00 dysfunction, with poor urinary function also present but 357 19901990 19951995 20002000 20052005 less common. Those having undergone external beam 357 YearYear radiotherapy reported poor bowel function as a result. It has been shown that patients with advanced prostate cancer have differing issues to those with localised cancer, and these differences are often only apparent in the results of longitudinal studies.356 Further research could be conducted in comparing different treatment types and identifying which types can maximise quality of life.

November, 2013 7.7 Prostate cancer (C61)

References 3 Australian Institute of Health and Welfare. Cancer survival and 329 Rohrmann S, Linseisen J, Allen N, Bueno-de-Mesquita H, prevalence in Australia period estimates from 1982 to 2010. Johnsen N, Tjønneland A, Overvad K, Kaaks R, Teucher B, Canberra: Australian Institute of Health and Welfare; 2012 Boeing H, Pischon T, Lagiou P, et al. Smoking and the risk of (Cancer series no. 69. Cat. no. CAN 65). prostate cancer in the European Prospective Investigation into Cancer and Nutrition. Brit J Cancer. 2013;108 (3):708-14. 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. GLOBOCAN 2008 v2.0, Cancer incidence and mortality 330 Loke TW, Seyfi D, Khadra M. Prostate cancer incidence in worldwide: IARC CancerBase No. 10: Lyon, France: IARC, 2010. Australia correlates inversely with solar radiation. BJU Int. 2011;108 (Suppl 2):66-70. 7 Boyle P, Levin B, editors. World Cancer Report 2008. Geneva: IARC; 2008. 331 Nair-Shalliker V, Smith DP, Egger S, Hughes AM, Kaldor JM, Clements M, Kricker A, Armstrong BK. Sun exposure may 20 American Cancer Society. Cancer facts & figures 2012. Atlanta: increase risk of prostate cancer in the high UV environment American Cancer Society; 2012. of New South Wales, Australia: a case-control study. Int J 22 IARC Working Group on the Evaluation of Carcinogenic Risks Cancer. 2012;131 (5):E726-32. to Humans. IARC Monographs: Personal habits and indoor 332 Chia SE, Wong KY, Cheng C, Lau W, Tan PH. Sun exposure combustions. Volume 100E A review of human carcinogens. and the risk of prostate cancer in the Singapore Prostate Lyon: IARC; 2012. Cancer Study: a case-control study. Asian Pac J Cancer 36 World Cancer Research Fund / American Institute for Cancer Prev. 2012;13 (7):3179-85. Research. Food, Nutrition, Physical Activity, and the Prevention 333 Gilbert R, Metcalfe C, Oliver SE, Whiteman DC, Bain C, Ness of Cancer: a Global Perspective. Washington, DC: American A, Donovan J, Hamdy F, Neal DE, Lane JA, Martin RM. Life Institute for Cancer Research; 2007. course sun exposure and risk of prostate cancer: population- 102 Australian Government. Budget 2013-14: Health and Ageing. based nested case-control study and meta-analysis. Int J Canberra: Commonwealth of Australia; 2013 [updated July Cancer. 2009;125 (6):1414-23. 9; cited 2013 July 9]; Available from: http://www.budget.gov. 334 John EM, Schwartz GG, Koo J, Van Den Berg D, Ingles SA. au/2013-14/content/bp2/html/bp2_expense-13.htm. Sun exposure, vitamin D receptor gene polymorphisms, 177 IARC Working Group on the Evaluation of Carcinogenic Risks to and risk of advanced prostate cancer. Cancer Res. 2005;65 Humans. IARC Monographs: Arsenic, Metals, Fibres and Dusts. (12):5470-9. Volume 100C A review of human carcinogens. Lyon: IARC; 2012. 335 Rittmaster RS. Chemoprevention of prostate cancer. Acta 321 Vickers AJ, Roobol MJ, Lilja H. Screening for prostate cancer: Oncol. 2011;50 (Suppl 1):127-36. early detection or overdetection? Annu Rev Med. 2012;63:161- 336 Van Poppel H, Tombal B. Chemoprevention of prostate 70. cancer with nutrients and supplements. Cancer Manag Res. 322 Medical Services Advisory Committee. Prostate specific antigen 2011;3:91-100. (PSA) near patient testing for diagnosis and management of 337 Violette PD, Saad F. Chemoprevention of prostate cancer: prostate cancer. Canberra: Commonwealth of Australia 2005 myths and realities. J Am Board Fam Med. 2012;25 (1):111-9. (MSAC Application 1068). 338 Frankel S, Smith GD, Donovan J, Neal D. Screening for 323 Ilic D, O’Connor D, Green S, Wilt TJ. Screening for prostate prostate cancer. Lancet. 2003;361 (9363):1122-8. cancer: an updated Cochrane systematic review. BJU Int. 2011;107 (6):882-91. 339 Jackson B. Prostate-specific antigen, prostate cancer screening, and the pathologist: what should be our role? Arch 324 Sutcliffe S, Colditz G. Prostate cancer: is it time to expand Pathol Lab Med. 2013;137 (3):308-9. the research focus to early-life exposures? Nat Rev Cancer. 2013;13:208-518. 340 Andriole GL, Crawford ED, Grubb 3rd RL, Buys SS, Chia D, Church TR, Fouad MN, Isaacs C, Kvale PA, Reding DJ, 325 Cao Y, Ma J. Body mass index, prostate cancer-specific Weissfeld JL, Yokochi LA, et al. Prostate cancer screening mortality, and biochemical recurrence: a systematic review and in the randomized Prostate, Lung, Colorectal, and Ovarian meta-analysis. Cancer Prev Res. 2011;4 (4):486-501. Cancer Screening Trial: mortality results after 13 years of 326 Xu H, Jiang HW, Ding GX, Zhang H, Zhang LM, Mao SH, Ding follow-up. J Natl Cancer Inst. 2012;104 (2):125-32. Q. Diabetes mellitus and prostate cancer risk of different grade 341 Welch HG, Albertsen PC. Prostate cancer diagnosis or stage: A systematic review and meta-analysis. Diabetes Res and treatment after the introduction of prostate-specific Clin Pract. 2013;99 (3):241-9. antigen screening: 1986-2005. J Natl Cancer Inst. 2009;101 327 Gong Z, Agalliu I, Lin D, Stanford J, Kristal A. Cigarette smoking (19):1325-9. and prostate cancer-specific mortality following diagnosis in 342 Schroder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto middle-aged men. Cancer Causes Control. 2008;19 (1):25-31. S, Nelen V, Kwiatkowski M, Lujan M, Lilja H, Zappa M, Denis 328 Huncharek M, Haddock K, Reid R, Kupelnick B. Smoking as a LJ, Recker F, et al. Screening and prostate-cancer mortality risk factor for prostate cancer: a meta-analysis of 24 prospective in a randomized European study. N Engl J Med. 2009;360 cohort studies. Am J Public Health. 2010;100 (4):693-701. (13):1320-8. 88 • The State of Cancer Control in Australia

343 de Bekker-Grob E, Rose J, Donkers B, Essink-Bot ML, Bangma 359 Newton F, Burney S, Frydenberg M, Millar J, Ng K. C, Steyerberg E. Men’s preferences for prostate cancer Assessing mood and general health-related quality of life screening: a discrete choice experiment. Brit J Cancer. 2013;108 among men treated in Australia for localized prostate cancer. (3):533-41. Int J Urol. 2007;14 (4):311-6. 344 Smith DP, Clements MS, Wakefield MA, Chapman S. Impact of Australian celebrity diagnoses on prostate cancer screening. Med J Aust. 2009;191 (10):574-5. 345 Del Mar C, Glasziou P, Hirst G, Wright R, Hoffmann T. Should we screen for prostate cancer? A re-examination of the evidence. Med J Aust. 2013;198 (10):525-7. 346 Evans S, Millar J, Davis I, Murphy D, Bolton D, Giles G, Frydenberg M, Andrianopoulos N, Wood J, Frauman A, Costello A, McNeil J. Patterns of care for men diagnosed with prostate cancer in Victoria from 2008 to 2011. Med J Aust. 2013;198 (10):540-5. 347 Izard M. Early management of prostate cancer. Aust Fam Physician. 2010;39 (1-2):61-2. 348 Stone CA, May FW, Pinnock CB, Elwood M, Rowett DS. Prostate cancer, the PSA test and academic detailing in Australian general practice: an economic evaluation. Aust NZ J Publ Heal. 2005;29 (4):349-57. 349 Klotz L. Active Surveillance for Prostate Cancer: Overview and Update. Curr Treat Option On. 2013;14 (1):97-108. 350 Klotz L. Active surveillance for prostate cancer: a review. Arch Esp Urol. 2011;64 (8):806-14. 351 Bul M, Zhu X, Valdagni R, Pickles T, Kakehi Y, Rannikko A, Bjartell A, van der Schoot D, Cornel E, Conti G, Boevé E, Staerman F, et al. Active surveillance for low-risk prostate cancer worldwide: the PRIAS study. Eur Urol. 2013;63 (4):597- 603. 352 Xie F. Cost Effectiveness of Treatment Options for Early Prostate Cancer: Can We Put the Puzzle Pieces Together? Eur Urol. 2012;63 (2):411-2. 353 Davis ID, Lynam J, Sluka P. Prostate Cancer. CancerForum. 2013;37 (1):56-8. 354 McCartney M. Is Movember misleading men? BMJ. 2012;345:e8046. 355 Movember Foundation. About Movember. 2013 [updated October 1; cited 2013 October 8]; Available from: http:// au.movember.com/about/. 356 Eton DT, Lepore SJ. Prostate cancer and health-related quality of life: a review of the literature. Psychooncology. 2002;11 (4):307-26. 357 Smith D, King M, Egger S, Berry M, Stricker P, Cozzi P, Ward J, O’Connell D, Armstrong B. Quality of life three years after diagnosis of localised prostate cancer: population based cohort study. BMJ. 2009;339:b4817. 358 Keogh JW, MacLeod RD. Body composition, physical fitness, functional performance, quality of life, and fatigue benefits of exercise for prostate cancer patients: a systematic review. J Pain Symptom Manage. 2012;43 (1):96-110.

November, 2013 November, 2013

7.8 Stomach cancer (C16)

7.8.1 Background Stomach cancer, or gastric cancer, is the fourth most common cancer globally with an estimate of new cases just short of 1 million in 2008.5, 7 IARC GLOBOCAN 2008 working estimates reported the incidence for stomach cancer was 16.2/100,000 in males under 75 and 7.3/100,000 in females in the same cohort.5 Large variations in incidence and mortality are apparent between regions across the globe, with concentrations in Eastern Asia and Latin America.5, 7, 55, 360 Recent trends have shown a decline in incidence in Western countries.20, 361 Risk is remaining two sections of the stomach. Stomach cancers reduced for immigrants moving from a high-risk country to a are also often divided into cardia or non-cardia groupings, low-risk country, where they acquire the risk of the host nation as incidence rates for these two groups vary significantly, within a generation of migration.50, 51, 362 Approximately 70% of with larger increases in incidence in industrialised new cases are found in developing countries, and the highest countries.7 Distal gastric cancer is more prevalent in mortality rate was for Eastern Asia and the lowest in Northern developing countries and in lower socioeconomic America.5 The global mortality rates for individuals aged under populations, whereas proximal tumours are common in 75 years of age are 11/100,000 in males and 5.2/100,000 in developed countries.52 In contrast to this trend, there is a females.5 high prevalence of distal gastric cancer in Japan.52 The prognosis for stomach cancer is generally poor, as patients In Australia, twice as many males are affected by stomach are often diagnosed late and at quite an advanced stage.7 cancer than females.6 This is thought to result from Stomach cancer is largely asymptomatic, or associated with non- environmental factors, with differing diets and poorer specific symptoms, which is the reason for its late presentation refrigeration of food products, but the relative importance of and poor prognosis.52, 362 Beginning with precancerous lesions these factors is unknown.57 Relative survival is initially poor, and often a progression from chronic gastritis, stomach cancers with a 27% probability of surviving for at least 5 years at can largely be divided into subtypes. Cancers of the gastric diagnosis. The 5-year conditional relative survival increases cardia (the area of the stomach attached to the oesophagus), to 51% at 1 year.3 At 15 years after diagnosis, conditional fundus and body of the stomach are referred to as proximal survival jumps to 100%.3 Survival rates are higher for gastric cancers.52 Distal gastric cancers are found in the patients in major cities and decrease as SES decreases.3

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7.8.1.1 Causes and risk factors cancer.7, 53 Although this is the strongest risk factor, only a small proportion of individuals with H. pylori will develop Stomach cancer is largely attributed to environmental gastric cancer.365, 368 H. pylori is most prevalent in developing causes.7, 50 It is more commonly diagnosed in individuals countries and is often acquired during childhood and present between the ages of 50 and 70 and is not common in through to adulthood, but can be cured with antibiotics.7, individuals under 30 years of age, making age a risk 369 An increase in incidence of stomach cancer has been factor.50 Overall, stomach cancer is more common in males, associated with the Epstein-Barr virus but the evidence is not especially for the cardia subtype.50 For obvious reasons, conclusive, and the reason for the association has not been diet has been associated with stomach cancer: specific clearly established.53, 213, 365, 370 dietary patterns are associated with distal tumours whereas obesity is commonly associated with proximal tumours.52 In conjunction with specific dietary elements, cooking Infection with H. pylori, officially listed by IARC as a practices including broiling of meat, roasting, grilling, baking, carcinogen in 19947, can cause inflammation of the gastric deep frying in open furnaces, sun drying, salting, curing and mucosa and is the main risk factor of stomach cancer; pickling can increase the formation of N-nitroso compounds however, only a small proportion of people with H. pylori will which can increase the risk of stomach cancer.36, 52 However, develop cancer.51-53 the evidence supporting this is limited.36 Excessive consumption of salted fish, pickled vegetables, cured meats It has been suggested that a diet high in fruit and protein- and soy sauce can promote the development of Helicobacter quality and non-starchy vegetables can lower the risk pylori (H. pylori) that causes damage in the gastric mucosa, of stomach cancer.7, 52, 363 The World Cancer Research thus increasing risk.52, 54 Fund found probable evidence to support the decrease in stomach cancer risk with the specific Additional lifestyle influences on stomach cancer include consumption of non-starchy vegetables, the consumption of alcohol and tobacco.52, 55, 56 Alcohol is allium vegetables and fruits.36 On an irritant on the stomach and regular consumption could the other hand, there is probable increase the risk of stomach cancer.52, 371 The interaction evidence associating salt and History of between alcohol consumption and stomach cancer, consumption of salted or salty while biologically plausible, is confounded by dietary foods with increased risk stomach cancer factors and smoking.371, 372 A pooled analysis of stomach cancer.36, 364, 365 in first-degree has shown that there is no association between Evidence of risk associated with relatives can moderate alcohol consumption and increased risk other food and nutritional factors double or triple of stomach cancer; however, when consumption was not conclusive, according to the risk. is heavy (four or more drinks per day), the risk of the World Cancer Research Fund’s stomach cancer is significantly increased, especially report.36 in non-cardia tumours.371 Conclusive evidence has not been found to support this association in some cultural A recent meta-analysis has suggested groups, such as the Japanese population.372 that the consumption of cruciferous vegetables has an inverse association with risk of Tobacco smoke is associated with increased likelihood of gastric cancer.366 Following a Mediterranean diet has precancerous lesions and damage of the gastric mucosa been associated with a significant reduction in stomach leading to stomach cancer.52, 55, 373 A meta-analysis showed cancer incidence.367 This association was not as strong that the risk of stomach cancer is 60% higher in male for individual components of the diet: the overall diet smokers and 20% higher in female smokers compared to had stronger protective effect, often associated with the never smokers, with similar but not as strong relationships higher proportion of plant-based rather than animal-based for current and former smokers.374 A cohort study of ethnic products.367 minority groups in the USA showed similar results; however, only male former smokers were at higher risk than never The bacterium H. pylori is present in the stomach appears smokers.375 Nomura et al’s375 findings suggested there was to be transmitted by saliva or faecal contamination.205, 368 All a higher incidence of cancer of the cardia in ever smokers infected will develop gastritis.368 H.pylori infection has been than distal gastric cancers in the cohort. Other cohort studies shown to have causal relationship with non-cardia gastric have shown similar results.373

November, 2013 Evidence suggests that there may be some genetic could be researched.360 The radiolabelled urea breath influence on stomach cancer incidence.7, 50, 369 History test, which is used to diagnose H.pylori, has been trialled of stomach cancer in first-degree relatives can double and proposed as a potential mass-screening method for or triple the risk, depending on the number of relatives stomach cancer.380 with the disease.362, 376 Approximately 10% of cases are Very small tumours can be treated using an endoscopy; hereditary.52 Because family members often share the same otherwise, the gold standard treatment for stomach cancer environments, hereditary cases of stomach cancer are also is a total or subtotal gastrectomy.360, 381 Radiotherapy and influenced by similar environmental risk factors in addition chemotherapy in advanced cases of stomach cancer to genetic disposition.50, 52 The protective effect of aspirin are limited in their usefulness because of poor survival against non-cardia gastric cancer, especially for individuals prognoses.52 However, adjuvant therapies used to treat infected with H. pylori, has been suggested.377 Sufficient recurrence can be of some benefit to survival.360, 361 Adjuvant evidence also exists linking heavy long-term asbestos chemotherapy can improve survival when compared to best exposure, X- and y-radiation exposure or working in rubber supportive care.381 Combined agent use, rather than single manufacturing to stomach cancer.83, 177, 212 agent, is largely used in Western countries and proven to be statistically more effective, but is not widely used as standard treatment in countries such as Japan.381 The role 7.8.1.2 International prevention/ of radiotherapy in treatment is considered controversial in its screening/treatment programs clinical benefit, but was shown to have a significant impact on five-year survival.361 Treatment of non-curative patients Prevention strategies are the best hope of continuing the has not shown evidence of improvements in survival or trend of declining incidence and mortality associated mortality rates.382 Often surgery is undertaken in this patient with stomach cancer.369 Prevention initiatives for stomach group to relieve specific obstructions or to ease suffering, cancer revolve around dietary controls and reducing the but these procedures often have poor outcomes.382 possibility of H. pylori infection.7, 364 Promoting positive dietary habits could reduce the burden of stomach cancer by approximately 50%.54, 57 Healthy living and eating campaigns work towards reducing associated risk factors.52 7.8.2 Incidence and mortality rates in For stomach cancer, this also includes modified cooking Australia 1987–2007 practices and correct refrigeration of food items.52, 369 Clean Incidence and mortality dropped in both males and water, sanitation and good hygiene are believed to limit the females over two decades (Figure 7–15 and Figure 7–16). spread of H. pylori infection. Prevention of H. pylori is more There has been a 50% decrease in mortality and a 34% effective if targeted at young individuals, before the infection decrease in incidence over this time period, both of which has the opportunity to develop.364 are statistically significant (Table 7–15 and Table 7–16). As a significant cause of stomach cancer, screening of The observed falls in mortality and incidence reflect H.pylori would be a simple test that could be of benefit improvements in living standards from the 1920s, when the despite the declining prevalence of bacterial infection in prevalence of H. pylori began to decline.7 There is some some countries.378, 379 Modelling simulations in the UK evidence of lower prevalence of H. pylori in younger adult suggest a long-term benefit from a once-off test at age groups,383 suggesting further reductions in stomach cancer 40.378 Screening for stomach cancer involves imaging may occur in the future. and endoscopy with a biopsy. Nationwide screening is not essential in all nations; however, in Korea and Japan, where incidence and mortality are high, mass-screening programs have been implemented as cost-effective ways of improving survival rates.360 No randomised trials have been conducted to objectively evaluate the efficacy of screening for stomach cancer to date.362 Use of the endoscopy screening method outside of Japan may not prove to be cost effective or practical, so a more appropriate method

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Table 7–15 Figure 7–16 Stomach cancer deaths and incident cases in Stomach cancer: age-standardised cancer incidence Australia 1987–2007 rates in Australia 1987–2007, 0–74 years Deaths† Incident Cases† 1212

Male Female Persons Male Female Persons 9 9 Observed in 368 203 572 765 365 1,131 2007 (O)#

Expected in 66 2007 (E)§ 809 340 1,149 1,201 508 1,709 3 Difference -441 -137 -577 -436 -143 -578 3 (O-E) Incidence per 100,000 people Incidence per 100,000 people Incidence Change in -54 -40 -50 -36 -28 -34 (O-E)/E (%) 00 19901990 19951995 20002000 20052005 #An average of the observed rates for 2006 to 2008 was applied to the 2007 Year population to calculate the observed number of deaths and incident cases for 2007.  Persons Persons Male Male Female Female §An average of the observed rates for 1986 to 1988 was applied to the 2007 population to calculate the expected number of deaths and incident cases for 2007. Considering the low survival rates of stomach cancer †All figures have been rounded to the nearest whole number. initially, quality of life has been compared for various Table 7–16 treatment types to assess the impact of necessary and 360 Stomach cancer average annual percentage change unnecessary treatments. In a group having undergone a (AAPC) subtotal or total gastrectomy, quality of life was significantly reduced after surgery and took approximately six months Mortality Incidence to stabilise.384 Total gastrectomy patients had lower quality- Confidence Confidence of-life scores than those who having undergone a subtotal AAPC AAPC Interval (95%) Interval (95%) gastrectomy, up to 12 months after surgery.385 In comparing Male -3.8 -4.5, -3.1 -2.2 -2.5, -2.0 the laparoscopy-assisted distal gastrectomy with open distal subtotal gastrectomy, it was found that although the Female -2.8 -3.3, -2.3 -1.6 -2.0, -1.3 former is preferred because of reduced pain and faster Persons -3.4 -3.6, -3.2 -2.0 -2.2, -1.8 recovery in the individual, the quality of life associated with a laparoscopy-assisted distal gastrectomy was lower up to five years after treatment.386 Figure 7–15 Current public health initiatives run by the Australian Stomach cancer age-standardised cancer mortality Government aimed at reducing tobacco and alcohol rates in Australia 1987–2007, 0–74 years consumption and promoting healthy eating practices address many of the environmental factors that can

4.57.5 increase the incidence of stomach cancer. Although analyses of stomach cancer trends in areas of Australia 3.5 have suggested lower risk for Australian-born individuals compared to other nations,57 specific groups, including 5.0 immigrants from high-prevalence countries, present a more immediate issue for policymakers.

2.52.5 Mortality per 100,000 people Mortality per 100,000 people

0.00 19901990 19951995 20002000 20052005 YearYear  PersonsPersons  Male Female  Female

November, 2013 7.8 Stomach Cancer (C16)

References 3 Australian Institute of Health and Welfare. Cancer survival and 205 Union for International Cancer Control. Protection against prevalence in Australia period estimates from 1982 to 2010. cancer-causing infections: World Cancer Campaign 2010. Canberra: Australian Institute of Health and Welfare; 2012 Geneva: UICC 2010. (Cancer series no. 69. Cat. no. CAN 65). 212 IARC Working Group on the Evaluation of Carcinogenic Risks 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. to Humans. IARC Monographs: Chemical agents and related GLOBOCAN 2008 v2.0, Cancer incidence and mortality occupations. Volume 100F A review of human carcinogens. worldwide: IARC CancerBase No. 10: Lyon, France: IARC, Lyon: IARC; 2012. 2010. 213 Bouvard V, Baan R, Straif K, Grosse Y, Secretan B, El Ghissassi 6 Australian Institute of Health and Welfare and Australiasian F, Benbrahim-Tallaa L, Guha N, Freeman C, Galichet L, Association of Cancer Registries. Cancer in Australia: an Cogliano V. A review of human carcinogens--Part B: biological overview Canberra: Australian Institute of Health and Welfare; agents. Lancet Oncol. 2009;10 (4):321-2. 2012 (Cancer series no. 74. Cat. no. CAN 70). 360 Lee J, Kim K, Cheong JH, Noh S. Current management and 7 Boyle P, Levin B, editors. World Cancer Report 2008. Geneva: future strategies of gastric cancer. Yonsei Med J. 2012;53 IARC; 2008. (2):248-57. 20 American Cancer Society. Cancer facts & figures 2012. Atlanta: 361 Valentini V, Cellini F, Minsky B, Mattiucci G, Balducci M, American Cancer Society; 2012. D’Agostino G, D’Angelo E, Dinapoli N, Nicolotti N, Valentini 36 World Cancer Research Fund / American Institute for Cancer C, La Torre G. Survival after radiotherapy in gastric cancer: Research. Food, Nutrition, Physical Activity, and the Prevention systematic review and meta-analysis. Radiol Oncol. 2009;92 of Cancer: a Global Perspective. Washington, DC: American (2):176-83. Institute for Cancer Research; 2007. 362 Catalano V, Labianca R, Beretta G, Gatta G, de Braud F, Van 50 Kelley JR, Duggan JM. Gastric cancer epidemiology and risk Cutsem E. Gastric cancer. Crit Rev Oncol Hematol. 2009;71 factors. J Clin Epidemiol. 2003;56 (1):1-9. (2):127-64. 51 Compare D, Rocco A, Nardone G. Risk factors in gastric 363 Navarro Silvera S, Mayne S, Risch H, Gammon M, Vaughan cancer. Eur Rev Med Pharmacol Sci. 2010;14 (4):302-8. T, Chow WH, Dubin J, Dubrow R, Schoenberg J, Stanford J, West A, Rotterdam H, et al. Principal component analysis of 52 Nagini S. Carcinoma of the stomach: A review of epidemiology, dietary and lifestyle patterns in relation to risk of subtypes pathogenesis, molecular genetics and chemoprevention. World of esophageal and gastric cancer. Ann Epidemiol. 2011;21 J Gastro Oncol. 2012;4 (7):156-69. (7):543-50. 53 IARC Working Group on the Evaluation of Carcinogenic Risks 364 Giordano A, Cito L. Advances in gastric cancer prevention. to Humans. IARC Monographs: Biological Agents. Volume World J Clin Oncol. 2012;3 (9):128-36. 100B A review of human carcinogens. Lyon: IARC; 2012. 365 Guggenheim D, Shah M. Gastric cancer epidemiology and risk 54 Wang X-Q, Terry P-D, Yan H. Review of salt consumption and factors. J Surg Oncol. 2013;107 (3):230-6. stomach cancer risk: epidemiological and biological evidence. World J Gastroenterol. 2009;15 (18):2204-13. 366 Wu Q-J, Yang Y, Wang J, Han L-H, Xiang Y-B. Cruciferous vegetable consumption and gastric cancer risk: A meta- 55 Bonequi P, Meneses-González F, Correa P, Rabkin C, Camargo analysis of epidemiological studies. Cancer Sci. 2013;104 M. Risk factors for gastric cancer in Latin America: a meta- (8):1067-73. analysis. Cancer Causes Control. 2013;24 (2):217-31. 367 Buckland G, Agudo A, Luján L, Jakszyn P, Bueno-de-Mesquita 56 Pichandi S, Pasupathi P, Rao Y, Farook J, Ponnusha B, Ambika H, Palli D, Boeing H, Carneiro F, Krogh V, Sacerdote C, Tumino A, Subramaniyam S. The effect of smoking on cancer-a review. R, Panico S, et al. Adherence to a Mediterranean diet and risk Int J Biol Med Res. 2011;2 (2):593-602. of gastric adenocarcinoma within the European Prospective 57 Roder D. The epidemiology of gastric cancer. Gastric Cancer. Investigation into Cancer and Nutrition (EPIC) cohort study. Am 2002;5 (Suppl 1):5-11. J Clin Nut. 2010;91 (2):381-90. 83 IARC Working Group on the Evaluation of Carcinogenic Risks 368 Polk D, Peek R. Helicobacter pylori: gastric cancer and beyond. to Humans. IARC Monographs: Radiation. Volume 100D A Nat Rev Cancer. 2010;10 (6):403-14. review of human carcinogens. Lyon: IARC; 2012. 369 Correa P, Piazuelo M, Camargo M. The future of gastric cancer 177 IARC Working Group on the Evaluation of Carcinogenic Risks prevention. Gastric Cancer. 2004;7 (1):9-16. to Humans. IARC Monographs: Arsenic, Metals, Fibres and Dusts. Volume 100C A review of human carcinogens. Lyon: IARC; 2012. 94 • The State of Cancer Control in Australia

370 Camargo M, Murphy G, Koriyama C, Pfeiffer R, Kim W, 381 Wagner A, Unverzagt S, Grothe W, Kleber G, Grothey A, Herrera-Goepfert R, Corvalan A, Carrascal E, Abdirad A, Haerting J, Fleig W. Chemotherapy for advanced gastric Anwar M, Hao Z, Kattoor J, et al. Determinants of Epstein-Barr cancer. Cochrane Database Syst Rev. 2010 (3):CD004064. virus-positive gastric cancer: an international pooled analysis. 382 Mahar A, Coburn N, Singh S, Law C, Helyer L. A systematic Brit J Cancer. 2011;105 (1):38-43. review of surgery for non-curative gastric cancer. Gastric 371 Tramacere I, Negri E, Pelucchi C, Bagnardi V, Rota M, Scotti L, Cancer. 2012;15 (Suppl 1):S125-37. Islami F, Corrao G, La Vecchia C, Boffetta P. A meta-analysis 383 Pandeya N, Whiteman DC. Prevalence and determinants on alcohol drinking and gastric cancer risk. Ann Oncol. 2012;23 of Helicobacter pylori sero-positivity in the Australian adult (1):28-36. community. J Gastroenterol Hepatol. 2011;26 (8):1283-9. 372 Shimazu T, Tsuji I, Inoue M, Wakai K, Nagata C, Mizoue T, 384 Munene G, Francis W, Garland S, Pelletier G, Mack L, Tanaka K, Tsugane S, Research Group for the Development Bathe O. The quality of life trajectory of resected gastric Evaluation of Cancer Prevention Strategies in Japan. Alcohol cancer. J Surg Oncol. 2012;105 (4):337-41. drinking and gastric cancer risk: an evaluation based on a systematic review of epidemiologic evidence among the 385 Kim A, Cho J, Hsu YJ, Choi M, Noh J, Sohn T, Bae J, Yun Y, Japanese population. Jpn J Clin Oncol. 2008;38 (1):8-25. Kim S. Changes of quality of life in gastric cancer patients after curative resection: a longitudinal cohort study in 373 González C, Pera G, Agudo A, Palli D, Krogh V, Vineis P, Korea. Ann Surg. 2012;256 (6):1008-13. Tumino R, Panico S, Berglund G, Simán H, Nyrén O, Agren A, et al. Smoking and the risk of gastric cancer in the European 386 Lee S, Ryu S, Kim I, Sohn S. Quality of life beyond the Prospective Investigation Into Cancer and Nutrition (EPIC). Int J early postoperative period after laparoscopy-assisted Cancer. 2003;107 (4):629-34. distal gastrectomy: the level of patient expectation as the essence of quality of life. Gastric Cancer. 2012;15 (3):299- 374 Ladeiras-Lopes R, Pereira A, Nogueira A, Pinheiro-Torres 304. T, Pinto I, Santos-Pereira R, Lunet N. Smoking and gastric cancer: systematic review and meta-analysis of cohort studies. Cancer Causes Control. 2008;19 (7):689-701. 375 Nomura A, Wilkens L, Henderson B, Epplein M, Kolonel L. The association of cigarette smoking with gastric cancer: the multiethnic cohort study. Cancer Causes Control. 2012;23 (1):51-8. 376 Dhillon P, Farrow D, Vaughan T, Chow W, Risch H, Gammon M, Mayne S, Stanford J, Schoenberg J, Ahsan H, Dubrow R, West A, et al. Family history of cancer and risk of esophageal and gastric cancers in the United States. Int J Cancer. 2001;93 (1):148-52. 377 Yang P, Zhou Y, Chen B, Wan HW, Jia GQ, Bai HL, Wu XT. Aspirin use and the risk of gastric cancer: a meta-analysis. Digest Dis Sci. 2010;55 (6):1533-9. 378 Roderick P, Davies R, Raftery J, Crabbe D, Pearce R, Bhandari P, Patel P. The cost-effectiveness of screening for Helicobacter pylori to reduce mortality and morbidity from gastric cancer and peptic ulcer disease: a discrete-event simulation model. Health Technol Assess. 2003;7 (6):1-86. 379 Parsonnet J, Harris R, Hack H, Owens D. Modelling cost- effectiveness of Helicobacter pylori screening to prevent gastric cancer: a mandate for clinical trials. Lancet. 1996;348 (9021):150-4. 380 Xu Z, Broza Y, Ionsecu R, Tisch U, Ding L, Liu H, Song Q, Pan Y, Xiong F, Gu K, Sun G, Chen Z, et al. A nanomaterial-based breath test for distinguishing gastric cancer from benign gastric conditions. Brit J Cancer. 2013;108 (4):941-50.

November, 2013 November, 2013

8 Cancer control policies, programs and emerging issues

8.1 Cancer as a non-communicable disease and cancer control In 2008, an estimated 63.5% of deaths worldwide were attributed to non-communicable diseases (NCDs).387 Estimates from 1990 to 2010 show the shifting contribution of risk factors to the global burden of disease moving from communicable diseases in children to NCDs – cardiovascular disease, cancer, diabetes and chronic lung disease – in adults.388, 389 The world’s population is growing, life However, governments traditionally focused on cancer expectancy is increasing, and the demographic composition care. Cancer care and treatment are limited to cancer is shifting to comprise a higher proportion of older people, patients and their support networks, whereas control leading to a continued rise in the burden of NCDs.387, 389 As a incorporates the potential to prevent cancer occurrence consequence, healthy ageing is prominent in health agendas and recurrence and improve quality of life, using current with a key focus on control of chronic disease risk factors.389 knowledge and modern techniques for prevention, care The existing body of evidence shows that addressing the and treatment.392 Specifically, cancer control has been known and modifiable risk factors of NCDs can reduce described by WHO in the following way: a large proportion of these deaths and their associated social impact, consistent with healthy ageing public health Cancer control aims to reduce the incidence, campaigns.389, 390 Despite this, the likelihood of a cure for morbidity and mortality of cancer and to improve NCDs is low once they have developed, except in some the quality of life of cancer patients in a defined cases.7, 391 Changing population trends suggest that existing population, through the systematic implementation programs require revision to incorporate older cohorts, who of evidence-based interventions for prevention, are generally outside the target groups for interventions and early detection, diagnosis, treatment, and palliative treatment.7, 60 care. Comprehensive cancer control addresses the whole population, while seeking to respond to In 2008, an estimated 12.4 million new cases and 7.6 the needs of the different subgroups at risk. 393 million deaths were attributed to cancer globally.7 The importance of addressing cancer control is undeniable.

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This shift from care to control stems from the 8.2 Cancer control globally preventability of NCDs, where a whole-of-population approach can ease the disease burden by addressing WHO is leading the drive to integrate issues relating to 393, modifiable risk factors and implementing appropriate NCDs and cancer control in national health agendas. 400 7, 59, 394-396 The WHO-developed cancer control program outlines screening programs. Analysis of the American population has suggested that approximately 60% of actions for cancer control program development cancer deaths were potentially avoidable, as they were incorporating the six elements of planning, prevention, early attributed to modifiable risk factors.397 There is not one detection, diagnosis and treatment, palliative care, and 393 main risk factor for all cancers, and risk factors can policy and advocacy. WHO encourages governments to vary depending on the background genetic makeup of combat cancer through a systematic approach, with the a population and the presence of other risk factors or involvement of stakeholders and effective partnerships 392 co-factors.62 Investing in rigorous local research in cancer to support implementation. WHO has more recently control to understand the relative importance of known incorporated cancer control into their action plan and and emerging risk factors is needed to underpin the strategy for NCD prevention and control, to facilitate 389, 393 strategic basis for cancer control implementation and the integration of key principles in practice. The health care system transition. complexity of cancer control can overshadow basic steps that can be implemented, especially in developing nations, Since the early 1980s, greater public awareness has such as vaccination for hepatitis B, improved sanitation and increased the prominence of cancer. This is not solely a safe blood transfusions to reduce the burden of disease result of increasing diagnosis rates, but due to changes associated with cancer.206 in societal attitudes and the health care context.396 In developed countries, cancer is now better understood – Frameworks and recommendations need to be 401 socially – than in the past, and discussed more openly. implemented at both regional and country levels. In With treatments and survival rates improving, there is now response, some regions have formed collaborations less of a stigma around cancer, with some exceptions.274, to meet targets. For example, the European Union has 275 However, the plethora of confusing messages about acknowledged capacity and resource limitations in the the cancer burden can leave the impression that control region to meet WHO recommendations. A collaborative measures are underperforming.398 Improved care and project across member nations to determine cancer health 402, 403 treatment of other NCDs such as heart disease and indicators was subsequently funded. stroke, traditionally major causes of death, have resulted The inherent diversity in populations and geographies in cancer becoming a leading cause of death.4, 396 This must be applied to a global framework, and incorporate increases the likelihood of the elderly dying of cancer. differences in treatment settings and government policy to Time exposes the elderly to more carcinogens and be effective.404 Political processes and legislation often fail genetic changes, resulting in higher cancer incidence and to set adequate disease-prevention priorities at national mortality.399 levels.401, 405 However, responsibility for cancer control is not This section presents a snapshot of cancer control as a solely reliant on government policy. Cancer control is the health policy priority globally and nationally over recent responsibility of all stakeholders, from governments and years. Tracking these changes in public health initiatives their agencies to for-profit organisations in the health sector and developments in cancer control provides a context and non-health sector, as well as NGOs and the broader 406 in which trends in cancer incidence and mortality can be community. understood more completely. WHO provides leadership Working with WHO recommendations, the Australian on global health and guidance for cancer control Government has begun integrating cancer control into the programs, beginning with preventive health and moving health agenda at a federal and state/territory level. This through to palliative care, and policy and advocacy work has involved collaboration between a number of initiatives.393 Here we outline the broader guidelines for government agencies and NGOs. Other stakeholders play a cancer control established at global and regional levels, role in various facets of the process, as exemplified by key which are used as recommendations for the cancer NGOs. The specific role of NGOs in cancer control is not control approach in Australia. well described or defined, but they are generally seen to play an important part in promoting and supporting cancer control.

November, 2013 8.2.1 The role of NGOs control, such as the Canadian Strategy for Cancer Control and the National Cancer Research Institute in the As no individual institution has the capacity to provide UK.414, 415 comprehensive NCD or cancer control initiatives and care services, a consortium of agencies from government, for- The effectiveness of NGOs is not widely reported in the profit and not-for-profit sectors come together to provide the area of cancer control. The broader literature on NGOs spectrum of services required. Traditionally, NGOs are formed details the debate surrounding ownership and its effect by groups with common interests or to provide a service, often on health outcomes.416 Public perception reportedly associated with religious institutions and generally more active favours for-profit organisations for their provision of in health care, delivering welfare and other community service perceived better care.416 However, studies have indicated areas.407-410 NGOs generally operate at a local level and have more positive results in NGOs, with lower numbers of strong local community ties through their formal and informal deaths, lower cost of care and higher quality of care.417-420 networks – often undertaking activities that are not deemed In Australia, the government and the not-for-profit sector viable in for-profit organisations or the government sector.408, 409 have recently entered into a partnership to establish Generally speaking, NGOs have brought about changes a shared vision for NGOs: the National Compact. in government policy and attitude by stimulating political This followed the 2010 Productivity Commission processes to drive action from the ground up through social Report claiming that the sector was uncoordinated, movements.405 Their independence from the government with differences between Commonwealth and state/ allows NGOs to advocate for issues that may not be on territory level directives.421 Australian cancer control the political agenda411 and, as such, NGOs play an collaborations between NGOs and other important role in increasing the awareness of the agencies appear to be on an ad hoc basis. general public and key decision-makers about In 2008, an There are a number of NGOs with an 412 cancer control issues. Further, because estimated 12.4 interest in cancer control, and they of their community links, NGOs can extend are often specifically focused on a the reach of prevention programs, take on million new cases particular cancer site. One of the their implementation, or take the lead in and 7.6 million largest groups of all cancer NGOs cancer control planning in the absence of deaths were is Cancer Council Australia and its government leadership.412 NGOs can trial attributed to independent members in each state and pilot programs or interventions that may cancer globally. and territory. Cancer Council aims be considered too risky or impractical by to help beat cancer through research, governments until detailed data are available.407 and also provides patient information and Cancer advocacy has traditionally begun with cancer support services.422 The national coverage societies and other related NGOs.411 NGOs provide a link available through the state and territory–based between the clinical setting and the community. Cancer Council offices provide a breadth of services that is not always possible through NGOs.422 The role of NGOs in cancer control is more often assumed rather than explicitly defined. At a global level, the Union for Collaborations have also been born from particular International Cancer Control (UICC) drives cancer control elements of cancer control, such as the Cancer advocacy globally through member states, WHO and Research Leadership Forum, which brings together government agencies.412 Recently, the UICC produced a NGO cancer research funding bodies in an effort to collaboratively established World Cancer Declaration, with improve collaboration and coordination of investments. the aim of gaining commitment from all stakeholders to NGOs are part of a larger approach to cancer control reduce the global cancer burden through improved screening involving a number of government agencies and policies and diagnosis, adequate access to treatment, adequate guiding specific initiatives and programs. The approach vaccination programs, sufficient training programs for health taken in Australia is outlined in section 8.3. This also care professionals, and prevention.413 At a national level, describes some NGO activities relating to cancer control there are some examples of formalised approaches to cancer in Australia.

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8.3 Australian approach to cancer with 1 in 10 hospitalisations a result of cancer-related 6 control issues in 2010/11. Maintaining a system which provides the most effective and efficient level of service is an Cancer is the largest cause of disease burden in Australia, ongoing challenge.8 resulting in approximately 30% of all deaths in 2010.1, 2 A greater proportion of older people are affected by cancer, with the mean age of diagnosis being 67 for males 8.3.1 Health care in Australia and 64 for females in 2007. With a population of 22.6 Health is a state/territory issue but is made more complex million, Australia had one of the highest incidence rates by national frameworks on primary health care, and of all cancers globally in 2008, with an age-standardised drug and alcohol consumption. Cancer control can be incidence rate of 314/100,000 and an age-standardised considered a national issue and, as will be shown, many 5 mortality rate of 103/100,000. According to the IARC national policies affecting cancer are developed nationally GLOBOCAN 2008 working estimates, the age-standardised but jointly coordinated by the Australian Government and incidence rate of cancer was higher in Australia than in any the individual State or Territory Governments. The precise other country, largely due to the higher rate of melanoma of nature of the split between these government levels 5 the skin and prostate cancer. varies by specific initiative. For example, the MBS and the Pharmaceutical Benefits Scheme (PBS) are both managed Geographic and demographic characteristics specific to federally by the Australian Government Department Australia affect cancer control and its implementation. of Health and Ageing (DoHA) and administered by the For example, the composition of Australia is such that the Department of Human Services. The MBS, the federally population is concentrated on the eastern coastline, while funded public health care system, allows access to hospital Western Australia and the central parts of the continent are treatment and services as well as some out-of-hospital 423 sparsely populated. Geographic location can affect the treatment and services, and dictates the services that are ability to access health care services and cancer survival subsidised by the Australian Government. The PBS outlines rates, depending on the type of cancer, with survival subsidised pharmaceutical products. The public health care 424 decreasing as remoteness increases. Cancer incidence system operates alongside private health care offerings and mortality can also vary in different population groups. available, and various other medical and complementary Immigrant population groups have cancer incidence and medicine treatments and services.429 mortality trends that vary from Australian-born people.6 With 29% of the Australian population over 15 years of age Recent health system reforms have divided the funding for 425 born overseas, this is an emerging issue. In 2010/11, the primary care and hospitals, which has made the federal main places of birth for Australia’s resident population were and state/territory separation more challenging.430, 431 A 426 the UK, New Zealand, China, India, Vietnam and Italy. national funding pool, the Health and Hospitals Fund, was Cancer risk factors can affect these groups differently, recently created for public hospitals, removing the financial based on their host nation trends, such as a higher responsibility from the states and territories.430 Recent prevalence of hepatitis B in Vietnamese immigrants. primary care reform addressed the accessibility of health services, through GP Super Clinics and Medicare Locals, Keeping in line with global trends, the current focus of the by providing care in underserviced areas and boosting Australian Government is on improvements in preventive healthcare workers in areas of need.430 Ideally, this will health, healthy ageing, acute care and primary health care; relieve the pressure in public hospitals.432 equality in funding and access to services; integration of technology; and retention and continuing development of Changes to the health care system have been stimulated 427 the health workforce. by increasing health care costs. Specifically, the financial burden of cancer is high and rising. Mainly attributed to The treatment of all NCDs, including cancer, requires treatment costs, estimated health expenditure on cancer distinct functionality from the health care system. Almost from 2003 to 2033, assuming a decrease in cancer universally, health care systems have traditionally serviced incidence over this period, has been projected to increase patients with acute conditions and are now challenged by a total of AUS$6.6 billion to AUS$10.1 billion.433 Rises by chronic illness management and addressing NCD risk are attributable to increased services required per cancer factors.395, 428 The need for hospital services is increasing,

November, 2013 case, population growth, an ageing population and price Shifts in funding uses and policy position on health care inflation. The total lifetime economic cost of cancer for often coincide with changes in government leadership. people from diagnosis onwards in Australia was estimated Evidence-based decision models are not used as to be approximately AUS$94.6 billion in 2005, with 29% commonly in public health to guide policy implementation representing health care costs (including treatment).434 as in clinical practice.440, 441 The relationships and policies relevant to cancer control are depicted in Figure 8–1 to aid The direct and indirect health care costs can constrain our understanding of the evolution in policy and high-level nations to prioritising cancer care investment over decision-making. integrated cancer control programs or research initiatives, especially in times of financial strain.391 The cost of cancer treatment in the public health system and to the individual 8.3.2 Evolution of cancer control and patient is increasing at a greater rate than the launch related policies in Australia of treatment innovations to market.391, 435, 436 Even when new drugs are released to market, the cost-effectiveness Beginning in the 1980s, cancer control has been ratio is often above acceptable thresholds.437 Over the incorporated into the national strategic direction for last 20 years, there has only been a handful of new health.58 In 1996, cancer control became a National Health drug treatments that have significantly changed cancer Priority Area and officially on the political agenda.442 The care.438, 439 Novel interventions have been developed, first National Action Plan for cancer was created in 2001443 but the cost-effectiveness of their use in cancer care and led to the Priorities for Action in Cancer Control: has limited their adoption.391, 435 Public funding for new 2001–2003 plan outlining prevention, screening, early drugs or treatments is subject to scrutiny by committees detection, treatment, support and palliative care.443 The independent of government decision-makers, to ensure 2001–2003 plan was followed by the National Service objective assessments of their cost-effectiveness. There Improvement Framework (NSIF) for Cancer in 2005.443, 444 is considerable public funding associated with health The NSIF outlined high-level policy priorities across the care: in 2009/10 more than two-thirds of the total health cancer control spectrum.444 All governments in Australia expenditure was funded by the Federal, State, Territory – federal, state and local – endorsed the NSIF; however, and Local Governments.1 there was no implementation plan. A number of the NSIF initiatives have nonetheless been implemented over At a national level, health priorities and allocation of subsequent years. Individual states and territories were funding has been done by the Council of Australian encouraged to form their own localised plans in the place Governments, which represents Federal, State and of a national plan. Territory Governments and the Australian Local Government Association. It promotes policies of national significance and is involved in key decisions pertaining to the health care system, with the input of health ministers through the Standing Figure 8-1 Council on Health. This Council is a Australian government and preventive health structure grouping of all health ministers and is National Women’s Health Policy • National Health Reform National Male Health Plan responsible for the overall coordination Council of Australian Governments Agreement National Primary Health Care Strategy: • National Partnership Agreement of public health care delivery. The • National Drug Strategy on Preventive Health —— National Alcohol Strategy Australian Health Ministers Advisory • National Cancer Work Plan —— National Tobacco Strategy Council (AHMAC) advises the Standing Medical Services Advisory Committee Council on Health and is a group Pharmaceutical Benefits Advisory Standing Council on Health of the head health authorities from Committee Australian Health Ministers all government levels. The Medical Australian Government State and Territory Department Advisory Council Services Advisory Committee and Department of Health and Ageing / Ministry of Health the Pharmaceutical Benefits Advisory Committee are the independent National Health Australian National Australian Cancer Health committees that advise Australian and Medical Institute of Health National Australia Workforce Research Health and Performance Preventive Government on the cost-effectiveness Australia of new drugs or treatments. Then there Council Welfare Authority Health Agency Policy are a number of agencies that feed recommendations National Palliative Information and Performance and National National Cancer Care Strategy statistics on all Accountability Preventative Health Workforce information back to this central point National health outcomes - Framework Strategy Strategic (Figure 8–1). Guidelines including cancer Framework

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Up to this point, policy was leading cancer control in 452-469 The focus on modifiable risk factors aligns with cancer the correct direction but the lack of national leadership control principles and emphasises prevention. Past and inhibited overall implementation. A national agency, present policies are outlined in Table 8–1 as far as they relate Cancer Australia, was established in 2006, designed to to cancer screening, modifiable risk factors and other health guide related policy recommendations and the direction issues. The key national policies and strategies relating to of cancer control nationally.445 However, since 2005, specific cancers or risk factors are detailed in section 8.3.5. there has not been any updated national plan. In 2010, Some of the more recent strategies around women’s health, a National Cancer Expert Reference Group was brought men’s health and primary health care are not directly related together and was expected to issue a National Cancer to cancer, but effective cancer control relies on a well- Work Plan in 2011 (not publicly released at the time functioning public health system, improved infrastructure of writing).446, 447 The National Cancer Work Plan and and coordinated primary care.454, 463, 464 In this way, these the National Cancer Workforce Strategic Framework strategies improve the platform from which cancer control will set the framework for providing coordinated care initiatives are provided. National strategies pave the way for and fostering a workforce to support ‘best practice’ policies and implementation plans in individual jurisdictions. care in the future.448 On a regional level, NSW has For this reason, many recent strategies have detailed the established a statewide government cancer-control overarching primary health care issues or health system agency, Cancer Institute NSW, responsible for design, reform. The aim is to establish an equitable system across delivery and evaluation of public awareness campaigns. the nation to reduce chronic diseases in all Australians. 449 Their mission is to improve outcomes in cancer diagnosis, treatment, care and The National Partnership Agreement on Preventive ultimately, survival.450 This model has Health (NPAPH) is the most recent policy to provide not been adopted by other states and For cancer practical interventions aimed at creating healthier territories at this stage. environments for all Australians.460 In 2009, the control, further Taskforce developed the National Preventative Since the early 1980s, much of regulation is Health Strategy, which focused on seven the policy-related activity has required on strategic directions to reduce premature revolved around the known risk the tobacco, death, illness and suffering through preventive factors of cancer – tobacco alcohol and food strategies. Funding has been allocated to these control, alcohol control and industries. initiatives through the NPAPH, with a maximum nutrition. During the same period, total of AUS$872 million committed from 2009 to prevention became part of the health 2015.460 The focus on modifiable risk factors aligns agenda. In 1996, the National Public with many cancer control strategies that are focused on Health Partnership (NPHP) was established cancer prevention.460 The targets set are: to develop a national approach to public health • To stop and reverse the increase in overweight and issues, with a prevention focus.451 Beginning in 1997, obese Australians prevention was incorporated into a series of Public • To reduce daily smoking rates to 10% or less by 2020 Health Outcome Funding Agreements, including funding • To reduce short-term risky/high-risk alcohol intake levels for the breast and cervical cancer screening programs, to 14% and long-term risky/high-risk levels to 7% by and later colorectal cancer screening, and placed 2020 cancer in the spotlight.452 The NPHP was disbanded • To contribute to the National Partnership Agreement and replaced with two subcommittees of AHMAC in on Closing the Gap in Indigenous Health Outcomes 2006. In 2008, as these agreements were coming to an targets.461 end, the Minister for Health and Ageing announced the formation of the National Preventative Health Taskforce Health care reform overall was formalised in July 2012 (the Taskforce), with the aim of developing strategies to through the National Health Reform Agreement (NHRA), tackle the health challenges caused by tobacco, alcohol after two years of negotiation between the Federal, State and obesity,453 all issues relating to cancer control. and Territory Governments, with the aim of improving the delivery of health and aged care.431 The focus of the NHRA Current key health polices, strategies and agencies is around patient access to services and improving the relating to cancer control predominantly revolve around efficiency of public hospitals, which are run by the State the modifiable risk factors of tobacco control, alcohol and Territory Governments and primary health care. Public consumption, nutrition, physical activity and obesity.448,

November, 2013 Table 8-1 Past and present policies on modifiable risk factors in Australia

Modifiable risk factors Health care Cancer system and Screening Physical primary care Tobacco Alcohol Nutrition Obesity activity issues 1979 Food and Nutrition Policy  National Health Policy on 1989 Alcohol in Australia  National Health Policy on 1991 Tobacco in Australia  1992 Food and Nutrition Policy  1995 National Alcohol Action Plan 1995-1997  Stage 1: National Public Health 1996 Nutrition Strategy   1st Public Health Outcome 1997/98- 1997 Funding Agreement 1998/99    National Drug Strategic 1998/99- 1998 Framework 2002/03   National Tobacco Strategy: A 1999- 1999 framework in action 2002/03  2nd Public Health Outcome 1999/00- 1999 Funding Agreement 2003/04    National Public Health Partnership’s Nutrition Strategy 2000 2000-2010 and Action Plan: Eat Well   Australia 1st National Palliative Care 2000 Strategy  National Alcohol Strategy: A 2001- 2001 plan for action 2003/04  3rd Public Health Outcome 2004/05- 2004 Funding Agreement 2008/09     2004 National Tobacco Strategy 2004-2009  2006 National Alcohol Strategy 2006-2011  National Preventative Health 2009 Strategy     National Partnership 2009 Agreement on Preventive 2009-2018     Health 2nd National Palliative Care 2010 Strategy  National Primary Health Care 2010 Strategy  National Women’s Health 2010 Strategy  2010 National Male Health Strategy 2010-2014  2011 National Drug Strategy   National Health Reform 2012 Agreement  2012 National Tobacco Strategy 2012-2018  National Cancer Workforce 2013 Strategic Framewrok 

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funding and quality standards are also major elements of influence and indeed modify individual behaviours. Working this reform, with initiatives to improve transparency and at a national level, there is also the potential for duplication of accountability through the Health and Hospitals Fund.462 roles or responsibilities, with existing organisations at both All elements of cancer control rely on a well-functioning national and regional levels. These factors, combined with public health system and coordinated primary care. In the political agenda set by the Australian Government, can this way, the NHRA intends to improve the platform from take the focus off the main aim of cancer control initiatives which cancer control initiatives are provided. in practice. In these situations, NGOs, which often have goodwill in the community and reputable backgrounds, can The National Drug Strategy is a policy framework to drive be effective in promoting the cancer control programs in the the minimisation of alcohol, tobacco and other drug- long term. related harm to Australians. It aims to improve health, Leadership in health care and cancer control is important social and economic outcomes. Individual policies to the success of new initiatives. Laws and regulations for drug types are being developed with the National can be used as tools to modify behaviour of populations, Tobacco Strategy and National Alcohol Strategy already through legislation restricting or changing access to harmful released. There are also state-based strategies that substances or limiting harmful situations, and improving mandate requirements at the grassroots level. access and availability of health services for primary and secondary prevention. Health promotion activities conducted in parallel to legislative changes promote the sustainability 8.3.3 Government agencies of behavioural changes initiated by an individual, and can Changes in the 2000s led to the inception of a number modify the local environment to support healthier living. For of government agencies designed to guide health cancer control, further regulation is required on the tobacco, reform implementation (Figure 8–1). The National Health alcohol and food industries. To date, only changes to Performance Authority, the Australian National Preventive tobacco consumption have had a notable effect on modifying Health Agency and Health Workforce Australia (HWA) the behavioural risk associated with cancer.474 have all been created from 2009 onwards, and have been given the brief of monitoring the performance of the public health system, improving health outcomes through 8.3.4 Australian cancer control policy prevention, and building capacity of the health workforce, respectively.470-472 Individual states and territories have developed specialised cancer control plans. In NSW, for example, the Cancer Other related agencies include the AIHW, the ABS and Institute NSW led the process for the development of a the NHMRC. The AIHW is a national monitoring agency cancer plan aimed at increasing the survival rate for cancer established in 1987 for the collation and provision of patients, reducing the incidence of cancer, improving the information and statistics. All health and welfare issues quality of life of cancer survivors, and developing expertise are covered, and cancer-based reports are produced in cancer control for the region.450 In Victoria, the State using data from the ABS, the national statistical agency, Government prepared a cancer action plan to ensure all and state and territory cancer registries.6 The NHMRC’s individuals have access to services throughout the process role is to promote the development and maintenance of of cancer control.475 The overall aim is to increase the cancer public and individual health standards through managing survival rate to 74% by 2015.475 research funding, and developing advice on health- related issues.473 It assists in setting research priorities The uniquely diverse population of Australia has resulted in and directing funding to important health and medical some differences in health outcomes among some minority research areas.473 and ethnic groups. Many reasons for these differences have been debated, but generally revolve around more limited The complexities of the systems governing cancer control access to screening, diagnostic and treatment services. and the number of policies and programs that exist Participation in preventive health programs and clinical present a challenge for the Australian Government to trials could also have influenced these differences apparent manage effectively. Additionally, many of the government between minority groups and the overall population. Notable agencies working in the healthy ageing and preventive exceptions are lower incidence and mortality rates of health space have been established only relatively melanoma and colorectal cancer in immigrants – with the recently. As a result, in their initial phases, these agencies exception of those who are New Zealand–born for colorectal have had to develop a proven reputation to be able to cancer, compared with Australian-born individuals. Higher

November, 2013 rates of melanoma are thought to be because of the higher address the underlying modifiable risk factors. They are exposure of Australian-born people to ultraviolet radiation outlined using the National Cancer Prevention Policy as in early childhood.58, 319 Considering this cultural diversity, a framework. The policy detailed recommendations for ethnic differences are a specific focus of the Australian cancer prevention that require action on national level from Government. However, reliable data in relation to incidence governmental and non-governmental stakeholders.476 and mortality of immigrant populations is not routinely available. 8.3.5.1 Indigenous people 8.3.5 Existing cancer control-related Aboriginal and Torres Strait Islander people (hereafter respectfully referred to as Indigenous people) comprise programs and initiatives approximately 2.5% of the Australian population.477 Overall, Government spending on public health programs has the life expectancy of is 10 years been steadily increasing. Most recently, the Australian lower than non-Indigenous people, and is similar to that Government allocated AUS$872 million over 6 years to of the life expectancy reported for low–middle income the NPAPH, the largest government spending on health countries.478 The high burden of cancer contributed promotion and associated activities to date. For the greatly to this difference in overall disease burden and life financial year 2009/10, the public health investment in expectancy.478 Australia by government and non-government agencies Although not a key element of the analysis, it is was AUS$2 billion. This was down from the previous important to acknowledge Australia’s diverse years, when spending reached a high of AUS$2.3 ethnic composition affects cancer incidence billion in 2007/08. The level of spending and mortality rates.1, 3 Since 2008, efforts fluctuates depending on the particular Estimates to quantify the effects of ethnicity on initiatives being conducted in a given time of tobacco- incidence and mortality have led to period, and although not all expenditure attributed deaths improvements in recording Aboriginal is cancer-related, the higher levels of in Australia from and Torres Strait Islander status spending before 2009/10 were attributed on pathology, hospital admission, to the implementation of the National HPV all causes range outpatients forms and the death 1 from 15,000 to Vaccination Program. 479 19,000 per annum. certificate. To specifically address Currently, the range of public health and issues relevant to Indigenous people, preventive services in Australia are coordinated the DoHA released an Indigenous Chronic and administered by the previously mentioned Disease Package as part of the National agencies in conjunction with additional stakeholders Partnership Agreement on Closing the Gap made up of both intra- and intergovernmental agencies. in Indigenous Health Outcomes, to initiate preventive Broadly, the services that relate to cancer control are:1 programs and improve access to primary care services.454 • Immunisation services and other communicable disease control 8.3.5.2 Tobacco control • Programs to reduce the use and harmful effects of tobacco and alcohol Globally, tobacco smoking is the most serious risk factor of premature mortality and cause of cancer.22, 480 Not only • Prevention programs to reduce weight gain and to is smoking a cause of cancer, but environmental smoking promote physical activity and healthy eating choices has a causal relationship with increased cancer risk in 22 • Programs to promote sun protection males and females. Preliminary studies linking smoking and cancer came to light in the 1940s, but anti-smoking • Environmental monitoring and control, including campaigns gained more powerful momentum in the 1960s management of harmful chemicals and 1970s, with landmark reports in the USA and the UK, • Screening programs for breast, cervical and colorectal and Doll and Peto’s reporting of the association between cancer. excess risk of lung cancer and number of cigarettes smoked.481 Tobacco control is one of the main areas of Programs, positions and other non-government agency cancer prevention, as smoking is the number one most initiatives are not always specific to cancer control but preventable cause of poor health, and the disease burden

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caused by smoking is still considered unacceptably high introduced to reduce the affordability of tobacco and, in Australia.457, 482 Estimates of tobacco-attributed deaths in hopefully, to discourage more people from smoking.454 In Australia from all causes range from 15,000 to 19,000 per August 2013, it was announced that the excise tax would annum,483 and smokers reduce their life expectancy by an be increased again by a further 12.5% over a 4-year period estimated 10 years.484, 485 to reduce premature deaths and diseases caused by smoking.491 Historically, there have been higher mortality rates in males associated with smoking than females. Recently, the rates for females have risen and risk of mortality is almost identical to males.233, 485 The Million Women’s study 8.3.5.3 Alcohol control in the UK showed that females who ceased smoking at Alcohol is similar to tobacco in that it is one of the known 40 years of age avoid approximately 90% of the risk of lifestyle factors associated with increased cancer risk.492 current smoking, despite their higher mortality rate than Changes to legislation on a global scale have been 485 never smokers. This supports other analyses which have recommended to address the harmful use of alcohol and shown that smoking cessation, rather than a reduction support behavioural change.493 Alcohol drinks and ethanol in smoking, is most effective in reducing death from any are carcinogenic to humans, and there is a dose-response 233 cause. association with cancers of the oral cavity, pharynx, larynx, In Australia, public health campaigns to promote smoking oesophagus, colon and rectum, liver and female breast.22 cessation began in the early 1980s.486, 487 Adult smoking Limited consumption of alcohol is recommended to reduce prevalence (regular smokers) in 1980 was 30% in females the risk of cancer,494 as existing evidence does not indicate and 41% in males.487 The Australian Government’s a level of consumption where the risk of cancer is increased approach to tobacco control was formalised in 1991, with or decreased.36 However, emerging evidence identifies the National Health Policy on Tobacco, raising the issue heavy alcohol consumption (≥50 grams per day) as having to the status of national health concern.488 Over time, a positive association with increased risk of all cancers national strategies relating to tobacco have been released, and low alcohol consumption (≤12.5 grams per day) with a and have increased the legislation pertaining to tobacco reduced risk of cancer.492 These new findings, along with the advertising, distribution and consumption.487, 488 In 2010, beneficial effect of low-level consumption on cardiovascular prevalence of regular smokers dropped to 18% in females health,495, 496 suggest that further research is needed to and 22% in males.487 The overall number of daily smokers establish the dose-response relationship in specific cancer dropped between 2007 and 2010 in people over 14 years types. of age, but the number of smokers remained stable of this Beginning with a national health policy on alcohol in 270 period. The drop is attributed to a variety of policies, Australia in 1989, levels of alcohol consumption have been restrictions, taxes and public health campaigns. addressed in various legislations through to the National National public health awareness campaigns are being Alcohol Strategy (2006–2011; not updated at the time of conducted to further reduce prevalence. Over 4 years, writing) and incorporated into the National Drug Strategy AUS$61 million of the NPAPH is being used for a national framework (2010–2015).457, 458, 497 NHMRC guidelines, social marketing campaign on tobacco risks, with specific beginning in 1986, have consistently recommended limited campaigns initiated to access particular groups of consumption of alcohol to avoid the harmful effects of people, such as pregnant females and people living in low alcohol.498 In 2010, the number of people over 14 years socioeconomic areas.489 The national QuitNow program of age consuming alcohol on a daily basis declined in aims to support individuals through the whole smoking comparison to 2007.270 There was only very little change to cessation process by providing personalised support.489 the number of people drinking at risky levels over the same period of time.270 The current public health initiative related Currently, a National Tobacco Strategy exists and is a to alcohol consumption focuses on binge drinking among guide for legislation at a State and Territory Government young people.499 Although the guidelines and campaigns are level. Additional restrictions are in place to improve not exclusively focused on reducing risk factors for chronic tobacco control, such as advertising regulations for disease, it is raising awareness of safe drinking practices (ie tobacco products limiting their promotion, and smoking following recommended guidelines) and healthy behaviours 454 bans in restaurants, pubs and other public places. at a young age with the hope that these responsible drinking Packaging of cigarettes has undergone major changes practices will continue later in life. to include graphic warnings and, more recently, the plain packaging of cigarettes.490 Higher excise taxes have been

November, 2013 Aside from increasing the risk of some NCDs, alcohol abuse also associated with a modest increase in risk of thyroid has a large social cost to the community. An estimated cancer in females.508 Weight control, through a reduced- AUS$15.3 billion made up the total social cost of alcohol calorie diet, is one of the important modifiable risk factors abuse in 2004/05. Changes to public policy and specific for cancer.509 Additionally, obesity is linked with a number interventions to reduce the social cost would include of other chronic diseases, which can make it both difficult increasing the taxation on alcohol, restricting the promotion to study in relation to a single disease type and more of alcohol, continued reduction of drink driving through more important to understand.509 Obesity can also limit the random breath testing and/or lowering the legal blood alcohol ability to provide treatment to cancer patients, such as concentration level and, finally, through the implementation external beam radiation.510 of brief interventions by primary care workers to reduce The 2011/12 National Health Survey in Australia showed alcohol consumption. Although these interventions may not the increasing prevalence of overweight and obese be exhaustive or practically plausible, they can guide policy adults aged 18 years and over since 1995.511 Much of this development with a broad-reaching positive impact in the increase is attributed to the increased consumption of long term.500 energy-dense foods and junk food, and an increasingly Changes to legislation in relation to alcohol consumption sedentary lifestyle.406, 505, 506 In 2011/12, 63.4% of the have not been as forthcoming as tobacco-related changes. adult population were classified as overweight or obese, Alcohol, while being harmful in excess, is still socially rising from 56.3% in 1995.511 However, the obesity rate acceptable to consume, and is not as stigmatised as in Australian children aged 5–17 has remained stable at smoking is becoming. The alcohol industry has become 25.3%;511 but only limited time points are available to track increasingly active in political discussions, which may affect changes in children.512 Addressing the obesity epidemic the consumption or demand for alcohol both nationally cannot be achieved without supporting government and internationally.400, 501 The alcohol industry’s role and policy to endorse change.513 The NHMRC provides responsibilities in public health is being debated.406 The dietary guidelines for all Australians to promote health advertising code for alcoholic beverage promotions, issued and wellbeing, as well as to reduce the risk of conditions in 2009, recommends that a responsible approach to caused by poor diet.514 alcohol consumption is depicted, and that advertising is not The association between improved nutrition and targeted directly at children or adolescents.502 Experts in the cancer risk is not always clear. However, Willett515 area have suggested that implementation of the new code estimated in 1995 that approximately 32% of cancer have not been effective in reaching underage exposure to cases could be avoided through dietary changes. As alcohol advertising.503 Current debate also exists around the such, recommendations for healthy living, and cancer implementation of minimum pricing of alcohol and tax reform, prevention, incorporate a balanced diet and maintaining opposed by large industry players as affecting moderate regular physical activity.514, 516 The EPIC study has been drinkers rather than the problematic heavy drinkers.503, 504 It designed to investigate this relationship and that of other has been claimed that a reallocation of resources dedicated lifestyle factors with cancer, as well as their association to reducing alcohol-associated harm could achieve a greater with other chronic diseases.517 Preliminary evidence from reduction in health burden than is currently seen.501 EPIC shows that improved nutrition can reduce the risk of cancer, although this relationship varies depending on nutrient intake and cancer type.518 The World Cancer 8.3.5.4 Community wellbeing: nutrition Research Fund and the American Institute for Cancer and physical activity initiatives Research also produce reports evaluating existing evidence on food, nutrition and the prevention of cancer Obesity is a growing epidemic in Australia as well as in other to produce a more solid evidence base and to guide developed countries.505, 506 The Global Burden of Disease future research.36 Study in 2010 identified high BMI as the leading risk factor in Australasia, with physical inactivity and low activity ranking Physical activity was not publicly accepted as a fourth for the region, indicating the growing nature of the modifiable risk factor related to cancer until the late problem.388 Obesity in the USA was estimated to have caused 1990s, when supporting research was released. To this up to 14% of all cancer mortality in males and up to 20% in day, the association is supported predominantly by females over 50 years of age.507 Obesity has been linked to an observational studies rather than randomised control increased risk of cancers of the colon, kidney, oesophagus, trials. However, increased physical activity is now widely endometrial and breast (in postmenopausal females).508 It is accepted as having an overall positive association with

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health improvements, and is incorporated into management The national Go for 2&5 campaign also began in 2005 guidelines for cancer.519 Increased physical activity can as a joint initiative by the Federal, State and Territory reduce the risk of many chronic diseases, including cancer. Governments.524 Initially, AUS$4.76 million was invested Positive associations between increased physical activity to promote the consumption of fruit and vegetables in and reduced risk of cancer have been established for children and their parents. The Measure Up Campaign colorectal, breast and endometrial cancers.508 Some studies targeted nutrition and obesity in adults aged 25–50 suggest that prostate, kidney and lung cancer risk are with children, and 45–65-year-old adults, in an effort to reduced with increased physical activity, but the evidence reduce chronic disease risk factors.462 An offshoot of this is still inconclusive.508 Public health messages encourage campaign is the Swap It, Don’t Stop It initiative, which increased physical activity, but there are no specific encourages all Australians to choose healthier meals and physical activity recommendations that could apply to all increase levels of physical activity.525 Evaluations of these cancers.520 programs have shown their success in raising awareness, but there was little behavioural change found.526-528 State- Public health campaigns to promote physical activity based programs have also been initiated to promote and reduce obesity have been in place since the late healthier lifestyles, such as Cancer Council NSW’s Eat It To 1970s, beginning with the Life. Be In It.TM campaign,521 Beat It campaign.529 the first Food and Nutrition Policy in 1979, and in 1989 when dietary guidelines were developed.465 The 1992 The federal Healthy Communities Initiative funds Local Food and Nutrition Policy was formalised the Australian Governments to implement community-based physical Government’s commitment to improving nutrition activity and healthy eating programs, and policies in all Australians.456 Through the 1990s, the promoting healthier lifestyles.530 Healthy Spaces Food and Nutrition Policy led to the Stage and Places is a service for building and design 1 National Public Health Nutrition practitioners, to educate them in design principles Strategy, developed through NPHP, and development types that promote healthy and represented the framework for Over 1,000 and active living.531 These initiatives are broadly government authorities working in Australians are targeting wellbeing and the reduction of all 465 this area. The Eat Well Australia estimated to die chronic illnesses. Their benefit is indirectly program was the NPHP’s nutrition transferable to cancer control. strategy and action plan launched of melanoma Many individuals, organisations and industries in 2000. The strategy aimed to guide every year. play a part in the responsibility of reversing public investment into improving the obesity epidemic.507 In 2008, obesity was nutrition through to 2010. The Eat Well established as a National Health Priority Area, campaign, stemming from this strategy, highlighting the focus on obesity prevention.532 The was launched the following year.466 Australian Government is responsible for modifying policy In 2005, Be Active Australia: A Framework for Health Sector and supporting initiatives to create an environment that Action for Physical Activity, 2005–2010 was released. Its supports healthy behaviours. The onus is also on the aim was to provide strategic guidance in the promotion of food manufacturers, food retailers, the school system and physical activity through public policy and public action, the individual.505 Government has largely funded public and to enable behavioural change. Its recommendations health campaigns, some infrastructure changes, and included a highlighting of the need to consolidate the programs run through schools and workplaces to promote various investments in programs and other funding from healthy eating – while the food industry has been largely government, NGOs and industry.522 This framework has unregulated in how their products are marketed to society spawned a series of programs. and especially children.506 The National Preventative Health Strategy460 includes International debate exists concerning the responsibility of many preventive programs specific to social groups or unhealthy industries in addressing the prevention of NCDs communities of people. For example, the healthy children through modifiable risk factors such as obesity.406 Some initiative aims to encourage healthy lifestyles at a young claim that it is only through legislative action to modify the age, which is a reportedly cost-effective method of existing environmental pressures that the prevalence of beginning to combat obesity.512 The Get Set 4 Life – Habits obesity can be truly reduced.506, 533 Legislation around all for Healthy Kids guide provides information to encourage facets of food production systems, food advertising and healthy habits in children, and incorporates health checks targeting of children, as well as those issues influencing for four-year-olds to assess all health indicators.523

November, 2013 533 the physical environment, can benefit obesity prevention. the American Cancer Society’s Mole Patrol, advising the public The complexity of food policy structures and the decision- of sun-safe practices.306 making process affecting change create barriers to the implementation of prevention policy around obesity.513 In addition, the Australian Government has been active in encouraging changes to current practices. For example, run until 2010, the National Skin Cancer Awareness Campaign invested approximately AUS$5 million in increasing awareness 8.3.5.5 Skin cancer: prevention and of sun protection behaviours.538 An evaluation of the program screening showed that it impacted the behaviour of the target group, with increased use of protective clothing, hats, sunscreen, shade Australia has the highest rate of melanoma of the skin and sunglasses.539 Modifications to the target groups of the worldwide.8 Over 1,000 Australians are estimated to die of campaign reduced the impact of the campaign on knowledge melanoma every year,534 and it is almost entirely preventable and awareness of safe practices in people outside the targeted through appropriate sun protection. Although there has been groups.539 evidence to suggest that screening may be effective,304 there is currently no population-based screening for skin cancer. The gravity of unsafe sun practices has encouraged the Individuals being encouraged to report any unusual changes development of policies to guide regulations. NSW has led and medical monitoring of any high-risk patients is deemed the way with the recent release of a Skin Cancer Prevention to be sufficient.114 The emerging purported link between a Strategy to encourage the reduction of overexposure to deficiency of vitamin D (which is normally obtained from ultraviolet radiation.319 States such as NSW and Victoria sunlight) and chronic diseases has complicated the sun have stringent legislation placed on the operation of solaria protection message.318 In the early 2000s, there was a rapid and will bring in a ban on all solaria by the end of 2014.320 increase in the number of skin cancer clinics in Australia, The recent announcement of the 2014 ban in Victoria has which has resulted in clinics and general practitioners being resulted in outrage from solarium owners, but despite this involved in the treatment and management of skin cancer, negative reaction, the Australian Government is committed both with similar diagnostic accuracy.306, 535, 536 to developing a nationwide ban.540 Melanoma of the skin is discussed in more detail in section 7.6. Over the years, there have been a number of public health campaigns aimed at minimising skin cancer risk through education, and discouraging the use of sun beds and solaria. NGOs have played a large part in promoting sun protection 8.3.5.6 Colorectal cancer: screening behaviour.49 The sun protection public health campaign International evidence of effectiveness of colorectal (bowel) in Victoria by the then Anti-Cancer Council has prevented cancer screening emerged in the early 1990s541-543 and the more than 100,000 skin cancers.537 In 1981, the Slip! Slop! first population-wide programs were established in Japan Slap! campaign was introduced, which evolved into Slip! and Israel in 1992 and 1993 respectively; however, Australian Slop! Slap! Seek! Slide! in 1989, which recommended the adoption has been slow.544 Australian national guidelines have public wear long-sleeved clothes, sunscreen, sunglasses advocated screening since 1999 for asymptomatic people and a hat, and seek shade.49 The SunSmart Program was from the age of 50 years.30, 31 FOBTs have been available from also born out of the initial Slip! Slop! Slap! campaign in 1988, 1982 via the Rotary program Bowelscan, which is run annually and is being run throughout Australia by the respective state throughout most states of Australia at a nominal cost to the and territory Cancer Councils in an effort to influence sun individual. An awareness, education and screening campaign, protection behaviour and an awareness of the link between Bowelscreen Australia®, is also run through community ultraviolet exposure and vitamin D.49, 537 A central part of the pharmacies, which makes FOBT kits available to asymptomatic program is the membership of early childhood care centres people over 50.545 A nationally organised and funded Bowel and primary schools. Members receive SunSmart status and Cancer Screening pilot was conducted from 2002 to 2004, to recognition, and make a commitment to abide by sun safe establish the feasibility and cost-effectiveness of a population- practices and to model sun protection behaviour.537 Action based program of its kind in Australia.67 was developed using epidemiological findings which raised the community’s concern regarding skin cancer and enabled A federally funded National Bowel Cancer Screening Program them to seek change.49 Evidence of positive changes to was then developed, and all Australians turning 50 and 55 individual behaviours as a result of the program, and its cost- were invited to participate from 2006, and those turning 50, effectiveness, has seen it continue to the present day.317, 318 55 and 65 from 2008.6 The program was extended to include The Melanoma Foundation also ran an Australian version of Australians turning 60 from 2013, and will incorporate people

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turning 70 from 2015.67 Eligible participants are contacted of debate in the scientific community as to the safety via mail and asked to complete an immunochemical and efficacy of the vaccine.548 The objective approval FOBT kit in their home, which is then sent to a pathology process, through the Pharmaceutical Benefits Advisory laboratory.67 Committee, was undertaken in 2006 but its rejection of the proposal to include the vaccine on the PBS did not receive The program was suspended from May 2009 to December positive public response, and the Australia Government 2009, due to a higher than normal number of negative was pressured to overrule this recommendation.548, 549 results in the six months prior. The kits being used were The cost-effectiveness of the vaccine, the reason for changed and the program recommenced.546 The program which it had been rejected, was revised when the DoHA has received some criticism for being poorly planned, not reportedly negotiated a revised price of the vaccine with incorporating sufficient forward planning based on evidence the manufacturer.548 The results of extensive lobbying were to cope with the volume of follow-up required, and not seen in the approval of the vaccine and its administration in meeting the recommendations of biennial screening.184 practice from 2007. The 2012/13 federal budget included details of program expansion through to 2034, when all Australians aged 50–74 Currently, the quadrivalent vaccine against high-risk should be provided with the opportunity to be screened types HPV16 and HPV18 and low-risk types 6 and 11 is every two years.547 The 2013/14 federal budget incorporated administered in Australia. Australia was the first country to AUS$16.1 million to potentiate the program register by begin a vaccination program for females aged 12–13 years incorporating electronic reporting by health professionals.102 from 20 07.136 When the program was first introduced, there Colorectal cancer and screening are discussed in more was also a catch-up program run for cohorts of females up detail in section 7.3. to 26 years of age.136 Moving forward, the challenge will be to integrate the HPV vaccination program and screening to maintain a cost-effective system for cervical cancer prevention and screening. Since February 2013, boys aged 8.3.5.7 Cervical cancer: vaccination and 12–13 years have also been eligible for vaccination, with a screening 2-year catch-up for boys aged 14–15 years.136 Others have Following international trends, Australia introduced the spoken out regarding the vaccination of boys, claiming it 550 National Cervical Screening Program in 1991. The program is of little to no proven benefit, especially in light of an 551 recommends that all females aged 18 or over (or 2 years effective program among girls. The boys’ program has after their first sexual encounter) have a Pap test until begun in Australia and there are calls for its introduction in 137 the age of 69, to check for precancerous or cancerous the UK. Cervical cancer, vaccination and screening are cells. The test is funded through the National Healthcare discussed in more detail in section 7.2. Agreements and the MBS, and conducted in a primary care facility by either a general practitioner or a qualified practice nurse (in rural or remote locations).69 8.3.5.8 Breast cancer: screening Each State or Territory Government is responsible for the BreastScreen Australia is the national breast cancer implementation of the program locally. This involves a screening program, which started in 1991 and is register of all females who have been screened, to enable dually funded by the Federal and State and Territory timely reminders at 27 months after a negative test result, Governments.1 Females aged 50–69 are targeted for if required, and diagnostic facilities required to administer 2-yearly mammograms, though women from 40–49 years screening.116 Screening intervals of two years are currently of age and 70 years and over were also considered eligible. being used in Australia, a more intensive approach than An evaluation of the BreastScreen program in 2006/07 followed by some nations such as the UK, as it has been showed that participation in the program was declining. argued that the initial phases of implementation require The report recommended a change to the age groups that a safety margin.145 A program renewal is currently being have access to the program. Recommendations focused conducted to ensure all recent advancements in cervical on changes to the age groups eligible for screening. If the cancer screening are incorporated into the program.145 report’s recommendations were implemented, females Persistent HPV infection has been linked to cervical cancer. aged 40–44 and 75+ would no longer be eligible, and the A HPV vaccine was developed and approved for use in invited target group for screening would be extended to 2006.548 Prior to its administration, there was evidence include females aged 45–49 and 70–74, despite the limited evidence to support the effectiveness of their inclusion.26

November, 2013 Despite the lack of conclusive evidence, the target group 2001–2003 plan included a call to disseminate information has recently been extended to 74 years of age.102 In addition to promote informed decision-making relating to PSA to the targeted age group, females aged 40–49 and 75 and testing.443 over are also eligible to attend.68 Screening is conducted in A survey of males in 2012 found that 64% of respondents specialised facilities with national accreditation for service between the ages of 40 and 74 had been tested at least provision. In addition, a federal government initiative supports once for prostate cancer, and 41% were tested in the 12 the placement of specialist breast cancer nurses in regional months prior to being surveyed.555 Despite these high and remote locations through the McGrath Foundation.552 The numbers of participants, Australia does not currently issues with the existing program revolve around the limited support the use of PSA testing as a population screening national guidelines and the current accreditation system test.555 The Australian Government has recently allocated that results in jurisdictional differences in service delivery AUS$4 million to fund a new prostate cancer research and inequity across screening locations; limited workforce centre and to continue funding of existing centres focused resources; and non-comparable data sources across states.26 on this issue.102 Prostate cancer and screening are Recently, some BreastScreen facilities have begun using discussed in more detail in section 7.7. digital screening technology for mammograms. A review in South Australia has raised some concerns, finding 95 fewer smaller cancers than expected. The process is currently under independent review.553 Breast cancer and screening 8.3.5.11 Occupational cancer prevention are discussed in more detail in section 7.1. Occupational cancers have decreased in high- resource countries over the past 50 years, due to the move away from heavy industries where the risk of exposure was higher, and the 8.3.5.9 Liver cancer: hepatitis B In Australia, it has immunisation implementation of procedures and processes been estimated that addressing occupational exposure.7, 212 A large proportion of liver cancer cases 5,000 cancers each Industrialised countries have banned or are associated with hepatitis B and C year are caused restricted use of carcinogenic materials; infection.7, 197, 199 A vaccine for hepatitis B by occupational however, in developing nations, their use 556 was developed over 20 years ago; however, exposure to is still common. In Australia, industries hepatitis C is still without a vaccine.7, 205 The susceptible to occupational cancers have hepatitis B vaccine has been administered to carcinogens. been mandated to put in place preventive at-risk groups from 1988 and was later phased measures and minimise the risk to workers.557 in as part of the adolescent program in Australia from Primary prevention through workplace regulation, 1997. 230, 554 After the 1996 update to NHMRC guidelines, worker education, removing carcinogenic substances hepatitis B vaccination became part of the National Infant from the workplace, and adhering to safe practices are the Immunisation Program Schedule in 2000.554 most efficient and cost-effective measures to overcome occupational cancer.557, 558 Screening of people working in Various preventive practices can be implemented to limit the high-exposure environments has been suggested but is not prevalence of hepatitis B and C. These include safe injection used in practice, as no screening program has been found practices and safe blood transfusions.205 These initiatives effective.7 Occupational cancers are difficult to distinguish are covered by the National Hepatitis B Strategy 2010–2013 from other cancers, with the exception of mesothelioma, and the Third National Hepatitis C Strategy 2010–2013, which is caused by exposure to asbestos; thus the extent of partnerships between governments and the community.216, 217 harm caused cannot always be fully be understood.557 Liver cancer and immunisation are outlined in more detail in section 7.4. In Australia, it has been estimated that 5,000 cancers each year are caused by occupational exposure to carcinogens.559 Asbestos, one such carcinogen, was widely 8.3.5.10 Prostate cancer: testing used in Australia until its ban in 2003 and, as a result, Australia has high rates of asbestos-related diseases Prostate cancer is very common, with incidence rates rising across the globe.7 There are two common purported screening procedures for prostate cancer: the PSA blood test and the DRE. The Priorities for Action in Cancer Control:

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including cancer, and in particular, mesothelioma.560 number of tobacco-attributed deaths varies from 15,000 The responsibility for asbestos management is shared to 19,000 depending on the method used.483 Considering by all levels of government, but the majority of daily the diversity present in the Australian population, more management falls on local councils.560 There are cases accurate data-collection methods could be sought.483 associated with childhood exposure to these materials. Including questions on the death certificate, for example, A Western Australian community located close to an have been useful in gaining insight into tobacco-related asbestos mine has higher all-cancer incidence and deaths in South Africa.564, 565 If similar information were mortality from childhood exposure.561 A recent Asbestos gathered in Australia, it would vastly improve evidence to Management Review, commissioned by the Australian support tobacco control activities.483 It could also improve Government, recommended the development of a National the quality of data collected for disadvantaged population Strategic Plan to lead the way and eliminate jurisdictional groups, which become problematic when comparing differences.560 As a result, the Government announced cancer indicators in subgroups.566 the launch of the Office of Asbestos Safety, to develop the Australia is one of the few countries that has complete National Strategic Plan which is currently underway.562 national cancer registration. Data on new cancer cases in Australia have been recorded in the Australian Cancer Database from 1982. The data are sourced from state and 8.3.6 Cancer control data sources: territory registries. In Australia, it is a legal requirement monitoring of trends to register any new cases of cancer with the local cancer registry.566 The AIHW Cancer and Screening Unit is Cancer-related data are critical in establishing an responsible for monitoring, investigating and reporting understanding of the cancer burden and past, present on cancer incidence, prevalence, mortality and survival. and future trends.412 In many countries, the registration of The unit compiles data from the individual registries and new cases of cancer has not been a legal requirement. from other sources through the National Cancer Statistics Historical data are not always accurate and, although Clearing House, in collaboration with the Australasian improving, estimates can often be incomplete and not Association of Cancer Registries. These data are used to of high quality. WHO and NGOs play a significant role in calculate incidence rates in Australia. The National Mortality advocating for the improvement of recording of cancer Database is also used to compute prevalence, mortality cases and tracking of global trends of cancer-related and survival rates. Again, this is maintained by the AIHW statistics.150 with data provided by the Registrars of Births, Deaths and 6 In Australia, indicators to measure chronic diseases Marriages, and coded into disease states by the ABS. The have been developed by the AIHW. In relation to cancer, only two points at which mandatory recording are required the specific indicators focus on incidence, prevalence, are diagnosis and death. The ABS also provides information mortality and survival of particular cancer types. There on the demographic profile of the Australian population are also a number of indicators relating to risk factors that is used in analyses. Along with the Australian Cancer associated with cancer and an overall risk index for chronic Database, the AIHW also maintains databases for disease, which will improve analyses of trends over time.563 BreastScreen, the National Cervical Cancer Screening Program and the National Bowel Cancer Screening Indicators of the prevalence of cancer risk factors are Program.567 calculated by the ABS. Relevant data are largely available through the National Health Survey results.511 Information The National Cancer Data Strategy addresses the relating to cancer risk factors and social trends, such as current lack of information on family history, incomplete tobacco and alcohol consumption and obesity indicators, identification of Indigenous status, limited country of are also available through these data sources. Often the birth data, limited occupational data collected and no 568 sampling methods used allow trends to be generalised to collection of information on precursor lesions. This the total population. lack of information limited our ability to compare trends across groups and for different grades of disease. These The AIHW has had an ongoing program to estimate are all being targeted as areas for improvement.568 Cancer tobacco- and alcohol-related mortality and morbidity using Australia has recently been allocated AUS$2.4 million in a number of indirect methods based on risk estimates funding to collate national cancer data pertaining to the of effect from all over the world. These have been key to stage of cancer at diagnosis, treatment and frequency of identifying the enormous burden caused by tobacco, but these methods do yield varying results: for example, the

November, 2013 recurrence to address the current gap.102 Analysis of cancer 8.4.1 Cancer care: key elements and treatment pathways require linked data from more than one emerging issues source in the health system. Record linkage is becoming a more important component of cancer research, and can Aside from the policy-specific actions and programs currently help identify causal relationship and expand on existing being rolled out, there are additional issues relating to health understanding of relationships.566 provision and cancer care. These issues relate to available funding for cancer care infrastructure, costs and accessibility Additionally, MyHospitals has been established to gather to treatment, healthcare workforce capacity, and electronic information in relation to Australian public hospitals and linkages of patient records to facilitate transitions through is managed by the AIHW. A 2012 report recorded hospital the system. Although steps are being taken to address these waiting time for cancer surgery for the first time. Waiting times, concerns, at times their importance to comprehensive cancer it stated, were dependent on the urgency of surgery, and control can be overlooked if only a prevention focus is used. benchmarking will now be take place to track performance in public hospitals.569 8.4.1.1 Cancer care infrastructure, costs 8.4 Cancer control in practice and accessibility In practice, cancer control is implemented in varying ways. In As previously discussed, the health expenditure on cancer both the first and second line stages of prevention, screening care is high and treatment-related costs are often inaccessible and diagnosis of cancer, primary health care professionals for an individual patient. Subsidies from governments play a pivotal role. General practitioners, pharmacists, nurses and other sources are required, as not all cancer-related and other allied health care professionals can help individuals. medications and treatments are included on the MBS or PBS, Initially, health care professionals play a role in endorsing because of high production costs. preventive health measures. Also, the administration The geography of Australia accentuates the inherent of vaccination and immunisation programs takes place difficulties in providing and accessing adequate health care predominantly in the primary care setting. Screening and services, especially for cancer patients. The limited access diagnosis can also occur in the primary health setting, but to health services in rural and remote locations has resulted often require the involvement of specialised professionals, in a high number of hospitalisations for acute conditions. or primary care professionals with specialised training. Once These rural and remote locations lack the infrastructure and diagnosed, the patient is referred to oncology specialists for the health care professionals to provide the level of service individual treatment. required. Presumably, the number of acute episodes could In 2003, the now disbanded National Cancer Control Initiative, be greatly reduced through adequate access to primary, 574 a collaboration of the Australian Government DoHA and diagnostic and early intervention services. Cancer Council Australia, worked with the lead oncologist Cancer incidence and survival rates are lower in remote association, the Clinical Oncological Society of Australia, areas compared to major cities.6, 575 This suggests that, in to prepare a report outlining the reforms needed in cancer general, cancer sufferers in remote locations either do not care.570 The focus was on continuity of care and integration of have the access to screening and diagnostic services to the health care system to improve the treatment experience accurately measure incidence of cancer in these locations, or of cancer patients.570 Cancer care and treatment is generally lack adequate access to treatment and monitoring services provided by a multidisciplinary team of oncology specialists to improve survival rates. Analysing survival by individual and other members of the primary care team. In theory, cancer site shows some variations. A NSW study showed multidisciplinary teams deliver in the best treatment outcome that patients in remote locations have an excess risk of for an individual patient’s condition.571 However, the logistics 35% of dying of cancer in comparison to those in highly involved in organising these initiatives are intensive, and accessible locations, especially for prostate and cervical require substantial leadership and follow-up.571, 572 Evidence cancers.424 Movement of patients from remote locations to suggests that positive outcomes are possible but require treatment centres for lengthy periods of time are speculated investment in team infrastructure and training.571, 573 to contribute to this trend.424 A review of treatment of breast and prostate cancer patients in non-metropolitan locations suggested that improvements to treatment would be possible if general practitioner–based interventions were available.576

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There are distinct differences in patterns of care for Even when initial treatment has finished, patients require cancer patients in different locations where consistency is support. Patients in remission require ongoing monitoring needed.577 The Australian Government allocated AUS$560 at less regular intervals. This means that the continuous million to the establishment of regional cancer centres and management of cancer patients needs to be incorporated associated accommodation facilities in the 2009/10 budget, into the increasing demand on the system caused by the as part of the Health and Hospitals Fund.578 A total of 24 increased incidence rates. This also includes rehabilitation additional regional cancer centres have been proposed services. Psychosocial support is funded through the MBS, and approved, notably the Alan Walker Cancer Centre in but is not the central emphasis of current policies and Darwin, which has been built to service cancer patients in programs. Services in this area are also provided by NGOs the Northern Territory.578 A total of 57 breast cancer nurses such as Cancer Councils. Palliative care funding is critical, dedicated to providing coordinated care are also part of and is supported by the National Palliative Care Strategy this funding, which was boosted by AUS$19.5 million in the and Program, which aim to improve palliative care through 2013/14 federal budget.102 support for patients and families, access to appropriate medications, health workforce training, palliative care– In recognition of the challenges faced by people in specific research and quality improvements.586 rural and remote locations, governments – and some NGOs – provide subsidies for travel and accommodation when required to access health services. The schemes are not limited to cancer patients, and can be used 8.4.1.2 Cancer control workforce issues by any individuals who require specialist services. A Globally, health care workforce trends indicate current major criticism of the government program is the lack of and future shortages across many disciplines. This awareness in groups that could benefit the most, and the leads to increasingly difficult access to preventive health 579 amount of documentation required to receive funding. programs and adequate health services. All forecasting A review of radiotherapy services in Australia called for relating to primary care health workers and specific an improvement in availability through better outreach medical specialties highlight geographic distribution as services, and reimbursement for rural and remote one of the major challenges now and moving forward.587, residents.580 The high costs associated with radiotherapy 588 The ageing population not only impacts the workforce centres and equipment in the initial set-up limits the by increasing demand, it also brings an ageing health potential for growth. Once established, radiotherapy workforce. In Australia, it has been recently acknowledged facilities are a relatively cost-effective treatment option.581 that the current arrangements in the health workforce As at December 2009, there were 50 fewer linear are not sustainable and reform is required, leading to the accelerators than required to service the Australian inception of HWA.587 Patterns of retirement are changing, population’s needs, based on the estimated 52.3% of retention rates are decreasing, and there is a trend of cancer patients who could benefit from the service.581 They feminisation in many health professions.589 580 were distributed unequally around the nation. This meant Integration and substitution between health care that only 38% of patients could be treated at the time if all professions has been suggested as a solution to the health 581 linear accelerators were at full capacity. Radiotherapy workforce shortage. Integration can improve the work services have increased with the rising incidence of cancer, between existing stakeholders by improving collaborations. but do not meet the reportedly optimal level of servicing The Australian Primary Care Collaborative was established 581-583 required for cancer patients. However, the situation through a federal government initiative to implement this in Australia is not as problematic as in low- and middle- idea for NCDs and has been successfully implemented.590, income countries where the supply of equipment and staff 591 On the other hand, substitution requires the adequate 584 do not meet predicted demand. and credentialed training of workers to facilitate the transfer Chemotherapy services will also undergo a review, of tasks and acceptance from all interested parties. For announced in the 2013/14 federal budget, to outline the example, nurse practitioners have limited prescribing current arrangements in place and establish a long-term rights, can request pathology tests and can provide solution to funding for chemotherapy.102 As an interim referrals in some cases, upon their successful completion measure, an additional AUS$29.6 million was allocated to of a Masters program.592 increase dispensing fees of chemotherapy medications Now that key issues and opportunities have been for a 6-month period, from 1 July 2013 to 31 December identified, the HWA aims to establish a national agreement 102, 585 2013. on strategies to alleviate the foreseen problems and act

November, 2013 on these items through collaboration, consultation and 8.4.2 Discovery and advancement in 588, 593 leadership of health workforce reform. The HWA prevention, diagnosis and treatment released a National Cancer Workforce Strategic Framework, detailing recommended actions to overcome the current The discovery and use of new cancer prevention drugs, workforce issues in cancer-related health professions.448 diagnosis techniques and curative treatments affect incidence and mortality rates. The rise in incidence rates is largely reflective of improvements in diagnostic techniques and 8.4.1.3 Electronic linkage of patient new screening practices that are becoming more diffused. It is important to identify advancements of these methods information when interpreting cancer-related data. Modern discoveries Increasing the emphasis on multidisciplinary care and the in medicine and technology can greatly influence cancer involvement of multiple health care professionals in a cancer control policies and actions. Treatment methods for cancer patient’s treatment requires the transfer of knowledge and are constantly evolving; however, the therapeutic pathway for information between all interested parties. The high volume most cancer sites consistently include surgery, radiotherapy of transactions that make up NCD management, and the and chemotherapy. However, recently complementary and time period over which it is conducted, support the use of alternative therapies have been integrated into treatment more advanced information management systems.594 Health options.602 Acupuncture, for example, is becoming more widely information management systems can include decision- used as an adjuvant treatment for chemotherapy-induced making support tools for health professionals, nausea or vomiting.603 information sources for patients and their A significant area of development in carers, and electronic patient records and Much of the treatment is in therapeutic vaccines. Work provider order entries.595, 596 In theory, using emerging cancer in immunotherapy, which aims to induce these systems can also allow health care control research is specific immune responses to cancer professionals to spend more face-to-face focused on cancer cells, is an important part of this line of time with patients; however, supporting cells and altering research.604 In prostate cancer, for example, evidence has not been found in practice.597 immunotherapy is one of the novel strategies The most pertinent issue relating to cancer their states through being explored to treat recurring cases. There appears to be the electronic linkage of gene therapy and are a number of tumour-associated antigens treatment records. genomics. that can be targeted at the specific tumour cells. The electronic linkages of patient records can One of the purported benefits associated with facilitate the large number of transitions through therapeutic vaccines in comparison to other treatment the system, but have been typically difficult to administer methods is their less toxic nature. There is also potential to and maintain.595, 597 Electronic records can help identify use therapeutic vaccines in conjunction with other treatment adverse drug events, highlight medication errors, and methods, which can potentially improve the efficacy of the track prescribed medications and prescribed dosage.595 vaccine.604 Widespread adoption by physicians and other health Much of the emerging cancer control research is focused on professionals is difficult to achieve and maintain.596, 597 In cancer cells and altering their states through gene therapy Australia, linkage programs have been established to enable and genomics. A subset of this stream is epigenetics, a research into health services and assess the performance line of research focused on early modifications in cancer and safety of the health care system, including cancer cell’s deoxyribonucleic acid and genomic information.605, 606 care.598 Epigenomes differ from genomes in that they change with cell In 2010, the Australian Government approved a personally type and age.606 Understanding the components generating controlled electronic health record system, eHealth.599 The non-coding ribonucleic acids is essential to analysing the eHealth system aims to improve information exchange by biology of the cancer cell and abnormalities or alterations moving from paper-based to electronic keeping of clinical found which can be reversible with chemicals.605, 606 Unlike records.600 The National eHealth Transition Authority has other biomarkers, epigenetic biomarkers respond not only to been established to facilitate this change.599 Program an individual’s genetic composition but also their environmental development has been challenged by short timeframes exposure.606 Epigenomics could be used to define cancer and the overwhelming size of the undertaking.601 Currently, subtypes and become indicators of patient responses to consumers can choose to enrol in the eHealth system, but it therapies or their outcomes.605 is purely on a voluntary basis.600

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Diagnosis can also be aided by the use of microfluidic 8.4.3 Cancer control implementation technology, a study of the control and manipulation of process and leadership fluids. It can be used to analyse fluids in vitro and can be developed into a non-invasive diagnosis and treatment All of the elements described are part of a process of technique. Microfluidics can help understand the biology cancer control implementation. In Australia, this process of the tumour, isolate tumour cells, detect and identify is spread across a number of government agencies, tumour cells, and provide high-throughput screening. industry partners, NGOs and other stakeholders. There The affordability of this technology creates a more cost- are four key stages apparent in the current process, as effective alternative to be explored.607 depicted in Figure 8–2. The stages give an overview of how stakeholders and their actions are brought together. Metabolomics is the study of the chemical processes of molecules in a biological cell, and measures the output Stage 1 is the design, trial and pilot phase. It is the of biological pathways.605, 606, 608 It provides a snapshot innovative and conceptual period of an initiative that can of cellular activity in a normal or disruptive state.606, 608 be initiated by researchers, NGOs, governments, industry Research in metabolomics is focused on identifying still representatives or clinicians and their institutions. The unknown causes of cancer, improving early diagnosis, or motivation of these groups can vary greatly, and new developing targeted drugs.605 Biomarkers can be more initiatives can stem from emerging international or national rapidly identified using metabolomics, and used for evidence, pecuniary interests or observed need in the earlier diagnosis of cancer and as predictors of treatment community. Pecuniary interests, in the case of industry, responses.608 Cancer staging and tumour characterisation focus on the trialling of medications before market launch can also be improved using this method.608 By analysing to prove their clinical benefit and financial viability. In the chemical processes of molecules, metabolomic the case of governments, pilot studies are essential to analysis can measure the biochemical response to new establish the cost and benefit to the health care system drugs and their pathways to aid drug development.608 overall. The majority of action in this phase is focused on conceptual design of initiatives and rigorous clinical trials or Nanotechnology is now being explored in medicine as pilot studies. a way of improving cancer from prevention through to treatment.605 Nanodevices are being developed to improve Especially in the case of cancer control, this stage detection of cancer at early stages, isolating its exact generally occurs once, but is typically lengthy. For trials or location, and delivering therapeutic drugs.602 It is the study pilots to show evidence of clinical significance that is cost of nanoparticles in cancer sites and the development of effective and applicable to the real world, approximately nanodrugs which can reduce the ability for the body’s 5–10 years must pass. Often findings from trials will be defences to capture nanoparticles.605 Treating the interpreted in conjunction with outcomes from additional nanoparticles can improve imaging in diagnosis and trials in other research environments. In order to reach reduce side effects associated with traditional cancer the trial phase, there must be a solid evidence base for therapies.609 Nanoparticle treatment can treat hard- the efficacy of an intervention. Pilot studies are generally to-reach cancerous growths and improve delivery of used to understand the local application of the concept. medication to allow more particles to access the tumour Although governments are not always an active player in site.610 Several nanodrugs are successfully being used to this stage, they are important stakeholders. If governments treat cancer as targeted therapies.605, 610 Nanoparticles are not aware of the concept and the benefits of the trial or have also been used in analysing volatile organic pilot, movement to Stage 2 will be more challenging. Often compounds in exhaled breath to detect the presence of governments are involved in pilot studies, especially if they cancer.262, 380 are national studies. Pilots can sometimes overlap with the proof of concept element of Stage 2. Although developments are being made, only a few treatments and discoveries have radically changed cancer Stage 2 builds on the previous phase and focuses on prevention and care.438, 439 Drug discovery is plagued strategic planning, budgeting, legislative development, by the often slow development period of cancers or protocol and guideline development and proof of identification in late, advanced stages of the disease. This concept. The aim of Stage 2 is to integrate the concept makes trials and testing lengthy processes, which do not into the existing systems, with practical application. always conclusively illustrate the positive aspects of new Governments play an essential role in this phase of treatments. Monitoring cancer incidence and mortality implementation. Approval processes and decisions, trends over time can help identify critical points in history albeit being lengthy and usually a one-off occurrence, are where treatments or technology had a significant impact. influenced by changes in government and the overall health

November, 2013 Figure 8–2 other stakeholders are brought Cancer control implementation process together to define the activity and make recommendations Innovative and Integration into Application to Track performance and around practical implementation, conceptual existing systems the real world identify need for change such as credentialing of health professionals to provide a given service or accreditation programs Stage Stage • Large scale Stage Stage for service provision centres. PLANNING 1 2 • BUDGETING 3 4 • Program DESIGN • Protocol/guideline • Clinical TRIALS • IMPLEMENTATION • MONITORING AND Stage 3 focuses on the DEVELOPMENT EVALUATION • PILOT studies • Legislative DEVELOPMENT implementation of the activity • PROOF OF CONCEPT and is a continuous process over the lifetime of the program. Application to the real world Independent Federal Federal Governement requires the involvement of researchers and Governement Governement data collection all levels of government and institutions State/Territory State/Territory agencies clinicians or other providers. Industry partners Government Government Independent Already established examples NGOs Lobby and Local researchers of national screening and institutions Clinicians and advocacy groups: Government programs illustrate the variety Industry and NGOs (including NGOs) their institutions Clinicians and of implementation options Federal Clinicians and their their institutions institutions available. The National Bowel Government Cancer Screening Program Health economists and publich health is administered nationally, experts with home kits sent directly to individuals in the target age groups. BreastScreen is provided agenda. Budgetary issues also greatly affect the viability of a through specialised centres and administered on a state/ program’s integration in the health system. territory level. The National Cervical Cancer Screening Program is run through primary health care facilities and also The new concept must work with the existing or future health administered on a state/territory level. Implementation can agenda and be of benefit to a sufficient number of people to also involve Local Governments, which are established by the make it feasible. The proof of concept element establishes State or Territory Governments and are responsible for local the commercial viability of the project from a government community services, planning approvals for buildings and perspective as well as an individual perspective, if required. public spaces, and limited public health protection measures. Input from health economists and public health experts is often required at this stage. In the case of specific medical Stage 4 is the continuous monitoring and evaluation treatment options, the Therapeutic Goods Administration is phase, which should feedback into any or all of the previous specifically involved in regulating medications that can be used stages. This phase tracks and appraises the performance in Australia. Additionally, the Pharmaceutical Benefits Advisory of activities and identifies the need for change to existing Committee is an independent body of experts that advises the structures and processes. Generally the role of monitoring government on which medications should be included on the activities is conducted by government data-collection PBS, hence reducing the cost to consumers and impacting agencies, predominantly the role of the ABS and the AIHW for the health budget. The Medical Service Advisory Committee cancer control. Evaluations of activities are ideally conducted advises the Health Minister on inclusions on the MBS. by independent researchers who can critical appraise performance and systems to make recommendations for Some initiatives require underpinning by legislative changes improvement. to effect change and require the involvement of multiple levels of government. Both federal and state tiers of government are Small-scale projects can be implemented – moving through involved in cancer control, and are lobbied by industry and all four stages – at a local community level, largely through consumer stakeholders. NGOs play a large role in advocacy NGOs and Local Government. This involves direct lobbying by giving a voice to the consumer groups they represent. to Local Governments by NGOs and community advocates Prior to widespread implementation, protocols and guidelines for issues such as banning smoking in busy outdoor areas, are required. In this part of the process, clinical experts and including children’s playgrounds and alfresco dining areas on

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Local Government land. When the success of the program a series of government agreements and strategies has is proven on a small scale at a Local Government level, been launched to further promote the preventive health the concept can be integrated at a state/territory level agenda. As part of these agreements, as well as continuing or in other local areas following the four-stage process. activities from past initiatives, the Australian Government Isolated incidents at Local Government levels illustrate has made a substantial financial and resource contribution potential resistance to national or state based legislations. to programs relating to cancer control. Legislative action In Sydney, this resistance was shown by Parramatta has not always been used to support systematic change City Council when a previous smoking ban was recently as opposed to efforts to encourage individual change. rescinded in outdoor dining areas due to industry pressure. Currently, the range of public health and preventive State legislation will be brought in from 2015 which will services in Australia are coordinated and administered by ban outdoor smoking across NSW, and in this instance intra- and intergovernmental agencies. the Local Government made the decision to allow smoking Services that relate to cancer control include:1 until 2015.611 • Immunisation services and other communicable As described in the individual stages, the leadership of disease control cancer control implementation is spread across a number of stakeholders – depending on the stage of the process • Programs to reduce the use and harmful effects of and the specific initiative. Engagement at government and tobacco and alcohol clinician levels is most important as they can create the • Prevention programs to reduce weight gain, and to bottlenecks in the process. Communication is integral in promote physical activity and healthy eating choices moving the process from one stage to the next, and for the overall success of the process. Much of the communication • Programs to promote sun protection to the public stems from the final two stages: relaying • Environmental monitoring and control, including information about programs being implemented and management of harmful chemicals how they are progressing. Data used to communicate the results of programs and initiatives are integral to their • Screening programs for breast, cervical and colorectal continued development. cancer. A number of recently formed national government agencies are predominantly responsible for cancer control initiatives, 8.5 Summary of cancer control policies, as well as the longstanding ABS, AIHW and NHMRC. programs and emerging issues The current capacity of the newer agencies to influence change is yet to be fully released. The plethora of cancer Cancer control policy in Australia has evolved over the past control activity requires the involvement of a number of few decades.58 Since the 1980s, cancer control has been government agencies and other stakeholders – including incorporated into the national strategic direction, beginning NGOs – to most effectively disseminate preventive health with the inclusion of cancer as a National Health Priority messages and provide cancer support programs. Area in 1996.612 Additionally, there have been specific public health campaigns and cancer screening for three cancer The Australian healthcare system has limitations in treating types and to reduce modifiable risk factors. However, few the needs of patients with chronic illnesses, as it has are the cancer types that are given the majority of the historically focused more on acute care. The challenges attention in most publically funded prevention, screening of caring for an increased number of cancer patients at a and treatment initiatives. In 2005, the intergovernmental time when population ageing will place other pressures on NSIF for cancer was released, outlining high-level the health system will be significant. We can expect to see policy priorities across the cancer control spectrum.444 increases in the numbers of cancers related to obesity, All Australian Governments – federal, state and local – with the high and increasing numbers of people being endorsed the NSIF; however, there was no implementation classified overweight and obese – as well as increases in plan. A number of the NSIF initiatives have nonetheless cases of other prevalent diseases such as cardiovascular been implemented over subsequent years. disease and diabetes. Furthermore, most population-based preventive interventions are targeted at people under the Evaluations of past cancer control activities have shown age of 75 years, where actions could prevent cancer and varying levels of impact in their specific target areas. Often, mortality benefit is likely to be greater.613 they have been supported by public policy. More recently,

November, 2013 8 Cancer control policies, programs and emerging issues

References 1 Australian Institute of Health and Welfare. Australia’s health 59 Burton R, Leowski Jr J, de Courten M. Integrating 2012. Canberra: Australian Institute of Health and Welfare; 2012 cancer control with control of other non-communicable (Australia’s health no.13. Cat. no. AUS 156). diseases. In: Elwood JM, Sutcliffe S. Cancer Control. New York: Oxford University Press, 2010: 399-416. 2 Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez A. The burden of disease and injury in Australia 2003. Canberra: AIHW; 60 Zulman D, Sussman J, Chen X, Cigolle C, Blaum C, 2007 (Cat. no. PHE 82). Hayward R. Examining the evidence: a systematic review of the inclusion and analysis of older adults in 3 Australian Institute of Health and Welfare. Cancer survival and randomized controlled trials. J Gen Intern Med. 2011;26 prevalence in Australia period estimates from 1982 to 2010. (7):783-90. Canberra: Australian Institute of Health and Welfare; 2012 (Cancer series no. 69. Cat. no. CAN 65). 62 Franceschi S, Wild C. Meeting the global demands of epidemiologic transition - The indispensable role of 4 Elwood M, Sutcliffe S. Cancer control and the burden of cancer. cancer prevention. Mol Oncol. 2013;7 (1):1-13. In: Elwood JM, Sutcliffe S. Cancer Control. New York: Oxford University Press, 2010: 3-19. 67 Australian Government Department of Health and Ageing. National Bowel Cancer Screening Program: 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. About the Program. Canberra: Australian Government GLOBOCAN 2008 v2.0, Cancer incidence and mortality Department of Health and Ageing; 2012 [updated June worldwide: IARC CancerBase No. 10: Lyon, France: IARC, 2010. 14; cited 2012 November 5]; Available from: http://www. 6 Australian Institute of Health and Welfare and Australiasian cancerscreening.gov.au/internet/screening/publishing. Association of Cancer Registries. Cancer in Australia: an nsf/Content/bowel-about. overview Canberra: Australian Institute of Health and Welfare; 68 Australian Government Department of Health and 2012 (Cancer series no. 74. Cat. no. CAN 70). Ageing. BreastScreen Australia Program: About 7 Boyle P, Levin B, editors. World Cancer Report 2008. Geneva: the Program. Canberra Australian Government IARC; 2008. Department of Health and Ageing; 2012 [updated 8 Australian Institute of Health and Welfare and Australiasian February 3; cited 2012 November 5]; Available from: Association of Cancer Registries. Cancer in Australia: an http://www.cancerscreening.gov.au/internet/screening/ overview. Canberra: Australian Institute of Health and Welfare; publishing.nsf/Content/breastscreen-about. 2010 (Cancer series no. 60 Cat. no. CAN 56). 69 Australian Government Department of Health and 22 IARC Working Group on the Evaluation of Carcinogenic Risks Ageing. National Cervical Screening Program: About to Humans. IARC Monographs: Personal habits and indoor the Program. Canberra: Australian Government combustions. Volume 100E A review of human carcinogens. Department of Health and Ageing; 2009 [updated Lyon: IARC; 2012. November 11; cited 2012 November 5]; Available from: 26 Australian Government Department of Health and Ageing. http://www.cancerscreening.gov.au/internet/screening/ Evaluation of the BreastScreen Australia Program – Evaluation publishing.nsf/Content/cervical-about. Final Report – June 2009. Canberra: Commonwealth of Australia 102 Australian Government. Budget 2013-14: Health and 2009. Ageing. Canberra: Commonwealth of Australia; 2013 30 Australian Cancer Network Colorectal Cancer Guidelines [updated July 9; cited 2013 July 9]; Available from: Revision Committee. Guidelines for the Prevention, Early http://www.budget.gov.au/2013-14/content/bp2/html/ Detection and Management of Colorectal Cancer. Sydney: The bp2_expense-13.htm. Cancer Council Australia and Australian Cancer Network; 2005. 114 Roder D. Impact of population screening programs on 31 Clinical Oncological Society of Australia and Australian Cancer cancer outcomes. CancerForum. 2012;36 (1):4 -10. Network. The prevention, early detection and management of 116 Australian Institute of Health and Welfare. Cervical colorectal cancer. Canberra: Commonwealth of Australia; 1999. screening in Australia 2009–2010. Canberra Australian 36 World Cancer Research Fund / American Institute for Cancer Institute of Health and Welfare 2012 (Cancer series 67. Research. Food, Nutrition, Physical Activity, and the Prevention Cat. no. CAN 63). of Cancer: a Global Perspective. Washington, DC: American 136 Australian Government Department of Health Institute for Cancer Research; 2007. and Ageing. Immunise Australia Program: Human 49 Montague M, Borland R, Sinclair C. Slip! Slop! Slap! and Papillomavirus (HPV). Canberra Australian Government SunSmart, 1980-2000: Skin cancer control and 20 years of Department of Health and Ageing; 2013 [updated population-based campaigning. Health Educ Behav. 2001;28 February 14; cited 2013 April 18]; Available from: http:// (3):290-305. www.immunise.health.gov.au/internet/immunise/ publishing.nsf/Content/immunise-hpv. 58 Anderiesz C, Elwood M, Hill DJ. Cancer control policy in Australia. Aust NZ Heal Policy. 2006;3:12. 137 Brill D. Australia launches national scheme to vaccinate boys against HPV. BMJ. 2013;346 (Feb 12):f924. 118 • The State of Cancer Control in Australia

145 Australian Government Department of Health and 270 Australian Institute of Health and Welfare. 2010 National Ageing. National Cervical Screening Program Renewal. Drug Strategy Household Survey report. Canberra: Canberra Australian Government Department of Health Australian Institute of Health and Welfare; 2011 (Drug and Ageing 2012 [updated 22 November; cited 2013 19 statistics series no. 25. Cat. no. PHE 145). March ]; Available from: http://www.cancerscreening. 274 Chapple A, Ziebland S, McPherson A. Stigma, shame, gov.au/internet/screening/publishing.nsf/Content/ and blame experienced by patients with lung cancer: ncsp-renewal. qualitative study. BMJ. 2004;328 (7454):1470. 150 Franco EL, de Sanjosé S, Broker TR, Stanley MA, 275 Chambers S, Dunn J, Occhipinti S, Hughes S, Baade P, Chevarie-Davis M, Isidean SD, Schiffman M. Human Sinclair S, Aitken J, Youl P, O’Connell D. A systematic Papillomavirus and Cancer Prevention: Gaps in review of the impact of stigma and nihilism on lung cancer Knowledge and Prospects for Research, Policy, and outcomes. BMC Cancer. 2012;12:184. Advocacy. Vaccine. 2012;30 (Suppl 5):F175-82. 304 Aitken J, Youl P, Janda M, Lowe J, Ring I, Elwood M. 184 Flitcroft KL, Salkeld GP, Gillespie JA, Trevena LJ, Irwig Increase in skin cancer screening during a community- LM. Fifteen years of bowel cancer screening policy in based randomized intervention trial. Int J Cancer. 2006;118 Australia: putting evidence into practice? Med J Aust. (4):1010-6. 2010;193 (1):37-42. 306 McCarthy W. The Australian experience in sun protection 197 Tandon P, Garcia-Tsao G. Prognostic indicators in and screening for melanoma. J Surg Oncol. 2004;86 hepatocellular carcinoma: a systematic review of 72 (4):236-45. studies. Liver Int. 2009;29 (4):502-10. 317 Cancer Council Australia. Sun Protection: Campaigns and 199 Hepatitis B Foundation. Hepatitis B and Primary Events. Sydney: Cancer Council Australia; 2012 [updated Liver Cancer. 2013 [updated February 18; cited 2013 February 9; cited 2012 October 29]; Available from: http:// February 18]; Available from: http://www.hepb.org/ www.cancer.org.au/preventing-cancer/sun-protection/ professionals/hepb_and_liver_cancer.htm. campaigns-and-events/. 205 Union for International Cancer Control. Protection 318 Shih S, Carter R, Sinclair C, Mihalopoulos C, Vos T. against cancer-causing infections: World Cancer Economic evaluation of skin cancer prevention in Campaign 2010. Geneva: UICC 2010. Australia. Prev Med. 2009;49 (5):449-53. 206 Wakeham K, Newton R, Sitas F. Cancer in the Tropics. 319 Cancer Institute NSW. NSW Skin Cancer Prevention In: Magill AJ RE, Hill DR, Solomon T Hunter’s Tropical Strategy 2012–15. Sydney: Cancer Institute NSW 2012 Medicine and Emerging Infectious Diseases, 9th. 320 NSW EPA. Solaria (tanning units). Sydney: NSW EPA; London: Elsevier, 2013. 2013 [updated June 16; cited 2013 July 1]; Available from: 212 IARC Working Group on the Evaluation of Carcinogenic http://www.epa.nsw.gov.au/radiation/Solaria.htm. Risks to Humans. IARC Monographs: Chemical agents 380 Xu Z, Broza Y, Ionsecu R, Tisch U, Ding L, Liu H, and related occupations. Volume 100F A review of Song Q, Pan Y, Xiong F, Gu K, Sun G, Chen Z, et al. A human carcinogens. Lyon: IARC; 2012. nanomaterial-based breath test for distinguishing gastric 216 Commonwealth of Australia. National Hepatitis B cancer from benign gastric conditions. Brit J Cancer. Strategy 2010–2013. In: Australian Government 2013;108 (4):941-50. Department of Health and Ageing, ed. Canberra: 387 World Health Organization. Deaths from NCDs. Geneva: Commonwealth of Australia, 2010. World Health Organization; 2012 [updated October 31; 217 Commonwealth of Australia. Third National Hepatitis cited 2012 October 31]; Available from: http://www.who. C Strategy 2010–2013. In: Australian Government int/gho/ncd/mortality_morbidity/ncd_total/en/index.html. Department of Health and Ageing, ed. Canberra: 388 Lim S, Vos T, Flaxman A, Danaei G, Shibuya K, Adair- Commonwealth of Australia, 2010. Rohani H, Amann M, Anderson H, Andrews K, Aryee 230 Australian Government Department of Health and M, Atkinson C, Bacchus L, et al. A comparative risk Ageing. Immunise Australia Program: Hepatitis B. assessment of burden of disease and injury attributable Canberra Australian Government Department of to 67 risk factors and risk factor clusters in 21 regions, Health and Ageing; 2011 [updated May 18; cited 2012 1990-2010: a systematic analysis for the Global Burden of November 5]; Available from: http://www.immunise. Disease Study 2010. Lancet. 2012;380 (9859):2224-60. health.gov.au/internet/immunise/publishing.nsf/ 389 World Health Organization. Global status report on Content/immunise-hepb. noncommunicable diseases 2010. Geneva: World Health 233 Thun M, Carter B, Feskanich D, Freedman N, Prentice Organization 2011. R, Lopez A, Hartge P, Gapstur S. 50-year trends in 390 World Health Organization. Noncommunicable Diseases smoking-related mortality in the United States. N Engl Country Profiles 2011. Geneva: World Health Organization J Med. 2013;368 (4):351-64. 2011. 262 Broza Y, Kremer R, Tisch U, Gevorkyan A, Shiban A, 391 Sullivan R, Peppercorn J, Sikora K, Zalcberg J, Meropol Best L, Haick H. A nanomaterial-based breath test NJ, Amir E, Khayat D, Boyle P, Autier P, Tannock IF, Fojo T, for short-term follow-up after lung tumor resection. Siderov J, et al. Delivering affordable cancer care in high- Nanomedicine. 2013;9 (1):15-21. income countries. Lancet Oncol. 2011;12 (10):933-80.

November, 2013 392 World Health Organization, editor. National cancer control 408 Organisation for Economic Co-operation and Development. programmes: Policies and managerial guidelines 2nd. Geneva: The Non-profit Sector in a Changing Economy. Paris: World Health Organization; 2002. Organisation for Economic Co-operation and Development, 393 World Health Organization. Cancer Control: knowledge in action 2003. - WHO guide for effective programmes. Geneva: World Health 409 Productivity Commission. Contribution of the Not-for-Profit Organization 2006. Sector, Research Report. Canberra: Commonwealth of 394 Kelly P, Friedman W, Addis T, Elwood M, Neal C, Sarner M, Australia 2010. Sutcliffe S. Getting the public involved in cancer control - doing 410 Williams C. New Trends in Financing the Non-profit Sector something besides worrying. In: Elwood JM, Sutcliffe S. Cancer in the United States: The Transformation of Private Capital Control. New York: Oxford University Press, 2010: 297-316. – Reality or Rhetoric? . In: Organisation for Economic 395 Caron L. Organizational structures for cancer control. In: Elwood Co-operation and Development. The Non-profit Sector in JM, Sutcliffe S. Cancer Control. New York: Oxford University a Changing Economy. Paris: Organisation for Economic Co- Press, 2010: 317-40. operation and Development, 2003: 109-38. 396 Doll R, Peto R. The Causes of Cancer. New York: Oxford 411 Sloan FA, Gelband H. Cancer Control Opportunities in University Press, 1981. Low- and Middle-Income Countries. Washington DC: The National Academies Press, 2007. 397 Schottenfeld D, Beebe-Dimmer J, Buffler P, Omenn G. Current perspective on the global and United States cancer burden 412 Union for International Cancer Control. National Cancer attributable to lifestyle and environmental risk factors. Annu Rev Control Planning Resources for Non-Governmental Public Health. 2013;34:97-117. Organizations. Geneva: UICC 2006. 398 Forbes L, Simon A, Warburton F, Boniface D, Brain K, Dessaix A, 413 Union for International Cancer Control. World Cancer Donnelly C, Haynes K, Hvidberg L, Lagerlund M, Lockwood G, Declaration. Geneva: Union for International Cancer Tishelman C, et al. Differences in cancer awareness and beliefs Control; 2012 [updated October 30; cited 2012 October between Australia, Canada, Denmark, Norway, Sweden and the 30]; Available from: http://www.uicc.org/world-cancer- UK (the International Cancer Benchmarking Partnership): do declaration. they contribute to differences in cancer survival? Brit J Cancer. 414 Fairclough L, Hill J, Bryant H, Kitchen-Clarke L. 2013;108 (2):292-300. Accelerating knowledge to action: the pan-Canadian 399 Peto R, Roe F, Lee P, Levy L, Clack J. Cancer and ageing in mice cancer control strategy. Curr Oncol. 2012;19 (2):70-7. and men. Brit J Cancer. 1975;32 (4):411-26. 415 National Cancer Research Institute. National Cancer 400 Ho J, Batniji R. Targets for non-communicable disease: what has Research Institute. London 2013 [updated January 29; happened since the UN summit? BMJ. 2013;346:f3300. cited 2013 January 29]; Available from: http://www.ncri.org. uk /. 401 Atun R, Ogawa T, Martin-Moreno JM. Analysis of National Cancer Control Programmes in Europe. London: Imperial College 416 Schlesinger MJ, Gray B. Nonprofit Organizations and London, Business School; 2009. Health Care: The Paradox of Persistent Attention. In: Powell W, Steinberg R. The Nonprofit Sector: A Research 402 Micheli A, Capocaccia R, Martinez C, Mugno E, Coebergh JW, Handbook, 2nd. New Haven: Yale University Press, 2006. Baili P, Verdecchia A, Berrino F, Coleman M. Cancer control in Europe: a proposed set of European cancer health indicators. 417 Comondore V, Devereaux P, Zhou Q, Stone S, Busse J, Eur J Public Health. 2003;13 (3 Suppl):116-8. Ravindran N, Burns K, Haines T, Stringer B, Cook D, Walter S, Sullivan T, et al. Quality of care in for-profit and not-for- 403 Micheli A, Baili P, Ciampichini R, Verdecchia A. Evaluating the profit nursing homes: systematic review and meta-analysis. outcomes of cancer control. In: Elwood JM, Sutcliffe S. Cancer BMJ. 2009;339:b2732. Control. New York: Oxford University Press, 2010: 341-61. 418 Devereaux P, Choi P, Lacchetti C, Weaver B, Schünemann 404 Sutcliffe S. From cancer care to cancer control: organization H, Haines T, Lavis J, Grant B, Haslam D, Bhandari M, of population-based cancer control systems. In: Elwood JM, Sullivan T, Cook D, et al. A systematic review and meta- Sutcliffe S. Cancer Control. New York: Oxford University Press, analysis of studies comparing mortality rates of private for- 2010: 279-96. profit and private not-for-profit hospitals. Can Med Assoc J. 405 Beaglehole R, Bonita R, Magnusson R. Global cancer prevention: 2002;166 (11):1399-406. an important pathway to global health and development. Public 419 Devereaux P, Heels-Ansdell D, Lacchetti C, Haines T, Burns Health. 2011;125 (12):821-31. K, Cook D, Ravindran N, Walter S, McDonald H, Stone S, 406 Moodie R, Stuckler D, Monteiro C, Sheron N, Neal B, Patel R, Bhandari M, et al. Payments for care at private Thamarangsi T, Lincoln P, Casswell S. Profits and pandemics: for-profit and private not-for-profit hospitals: a systematic prevention of harmful effects of tobacco, alcohol, and ultra- review and meta-analysis. Can Assoc Med J. 2004;170 processed food and drink industries. Lancet. 2013;381 (12):1817-24. (9867):670-9. 420 Himmelstein D, Woolhandler S, Hellander I, Wolfe S. Quality 407 Lyons M. Non-profit organisations, social capital and social of care in investor-owned vs not-for-profit HMOs. JAMA. policy in Australia. In: Winter I. Social Capital and Public Policy in 1999;282 (2):159-63. Australia. Melbourne: Australian Institute of Family Studies, 2000: 165-91. 120 • The State of Cancer Control in Australia

421 Australian Charities and Not-for-profit Commission. 437 Smith TJ, Hillner BE. Bending the cost curve in cancer Not-for-profit Reform and the Australian Government. care. N Engl J Med. 2011;364 (21):2060-5. Canberra: Commonwealth of Australia 2013. 438 O’Reilly SE, Venkatesh J. Managing the costs of new 422 Cancer Council Australia. What we do. Sydney Cancer therapies: the challenge of funding new drugs. In: Council Australia; 2012 [updated July 3; cited 2012 Elwood JM, Sutcliffe S. Cancer Control. New York: October 29]; Available from: http://www.cancer.org.au/ Oxford University Press, 2010: 185-204. about-us/what-we-do.html. 439 Weir S, DeGennaro L, Austin C. Repurposing approved 423 Australian Bureau of Statistics. 3101.0 - Australian and abandoned drugs for the treatment and prevention Demographic Statistics June 2012. Canberra: Australian of cancer through public-private partnership. Cancer Bureau of Statistics 2012. Res. 2012;72 (5):1055-8. 424 Jong K, Smith D, Yu X, O’Connell D, Goldstein D, 440 Stieber J. Preventive Health Care in Australia: The Shape Armstrong B. Remoteness of residence and survival of the Elephant, Reliance on Evidence and Comparisons from cancer in New South Wales. Med J Aust. 2004;180 to U.S. Medicare. Canberra: Department of Health and (12):618-22. Ageing; 2006. 425 Australian Bureau of Statistics. 6250.0.25.002 - 441 Frommer M, Rychetnik L. From Evidence-Based Microdata: Characteristics of Recent Migrants, Australia, Medicine to Evidence-Based Public Health. In: Lin V, Nov 2010. Canberra: Australian Bureau of Statistics Gibson B. Evidence-based health policy: problems & 2012. possibilities. Melbourne: Oxford University Press, 2003: 426 Australian Bureau of Statistics. 3412.0 - Migration, 56-69. Australia, 2010-11. Canberra: Australian Bureau of 442 Australian Institute of Health and Welfare. National Statistics 2012. Health Priority Areas. Canberra: Australian Institute 427 Australian Government Department of Health and of Health and Welfare; 2013 [updated May 30; cited Ageing. Department of Health and Ageing Annual Report 2013 May 30 ]; Available from: http://www.aihw.gov.au/ 2011-2012 Canberra: Commonwealth of Australia, 2012. national-health-priority-areas/. 428 Hogerzeil H, Liberman J, Wirtz V, Kishore S, Selvaraj 443 Cancer Strategies Group. Priorities for Action in S, Kiddell-Monroe R, Mwangi-Powell F, von Schoen- Cancer Control: 2001-2003. Canberra: Commonwealth Angerer T, on behalf of The Lancet NCD Action Group. Department of Health and Ageing, 2001. Promotion of access to essential medicines for non- 444 National Health Priority Action Council. National communicable diseases: practical implications of the UN Service Improvement Framework for cancer. Canberra: political declaration. Lancet. 2013;381 (9867):680-9. Australian Government Department of Health and 429 Korda R, Butler J, Clements M, Kunitz S. Differential Ageing; 2005. impacts of health care in Australia: trend analysis of 445 Cancer Australia. Strategic Plan 2011–2014. Sydney: socioeconomic inequalities in avoidable mortality. Int J Cancer Australia; 2011. Epidemiol. 2007;36 (1):157-65. 446 Cancer Australia. Cancer Australia Annual Report 2011- 430 Marinos S. Steering the Course Ahead Tranforming 2012. Sydney: Cancer Australia; 2012. the Nation’s Healthcare Bondi Junction: Government 447 Commonwealth of Australia. A National Health and Services Group, 2011:30-7. Hospitals Network for Australia’s Future Delivering the 431 McIlwraith J. Re-shaping the course Tranforming the Reforms Canberra: Commonwealth of Australia; 2010 Nation’s Healthcare Bondi Junction: Government (6803). Services Group, 2011:38-43. 448 Health Workforce Australia. National Cancer Workforce 432 Hamilton J. Covering all bases Tranforming the Nation’s Strategic Framework. Adelaide: Health Workforce Healthcare Bondi Junction: Government Services Group, Australia 2013. 2011:96-9. 449 NSW Ministry of Health. NSW Tobacco Strategy 2012- 433 Goss J. Projection of Australian health care expenditure 2017. Sydney: NSW Ministry of Health 2012. by disease, 2003 to 2033. Canberra: Australian Institute 450 Cancer Institute NSW. NSW Cancer Plan 2011–15. of Health and Welfare 2008 (Health and welfare Sydney: Cancer Institute NSW 2010. expenditure series no. 36 Cat. no. HWE 43). 451 National Public Health Partnership. Background. 434 Access Economics. Cost of Cancer in NSW. Sydney: Canberra: National Public Health Partnership; 2005 Access Economics 2006. [updated July 1; cited 2013 June 6]; Available from: 435 Kefford RF. Drug treatment for melanoma: progress, but http://www.nphp.gov.au/about/background.htm. who pays? Med J Aust. 2012;197 (4):198-9. 452 Australian Government Department of Health and 436 Greenberg D, Earle C, Fang CH, Eldar-Lissai A, Ageing. Public Health Outcome Funding Agreements Neumann PJ. When is cancer care cost-effective? A (PHOFAs). Canberra: Australian Government systematic overview of cost-utility analyses in oncology. Department of Health and Ageing,; 2006 [updated 27 J Natl Cancer Inst. 2010;102 (2):82-8. March; cited 2013 31 May]; Available from: http://www. health.gov.au/internet/main/publishing.nsf/Content/ health-pubhlth-about-phofa-phofa.htm.

November, 2013 453 Commonwealth of Australia. Taking Preventative Action – A 471 Commonwealth of Australia. Australian National Response to Australia: The Healthiest Country by 2020 – The Preventive Health Agency. Canberra 2012 [updated Report of the National Preventative Health Taskforce. Canberra: November 21; cited 2012 November 21]; Available from: Commonwealth of Australia; 2010. http://www.anpha.gov.au/internet/anpha/publishing.nsf. 454 Australian Government Department of Health and Ageing. Building 472 Commonwealth of Australia. National Health Performance a 21st Century Primary Health Care System: Australia’s First Authority. Canberra 2013 [updated May 23; cited 2013 National Primary Health Care Strategy. Canberra: Commonwealth June 4]; Available from: http://www.nhpa.gov.au/internet/ of Australia; 2010. nhpa/publishing.nsf. 455 Australian Government Department of Health and Ageing. 473 National Health and Medical Research Council. NHMRC’s National Palliative Care Strategy 2010. Canberra: Commonwealth role. Canberra: NHMRC; 2012 [updated June 1; cited 2013 of Australia; 2010. May 1]; Available from: http://www.nhmrc.gov.au/about/ 456 Australian Government Department of Health and Ageing. Food organisation-overview/nhmrcs-role. and Nutrition Policy. Canberra: Commonwealth of Australia; 1992 474 Magnusson R. Using a legal and regulatory framework (Ref: 92/22328). to identify and evaluate priorities for cancer prevention. 457 Ministerial Council on Drug Strategy. National Drug Strategy, Public Health. 2011;125 (12):854-75. 2010-2015: A framework for action on alcohol, tobacco and other 475 Victorian Government Department of Human Services. drugs. Canberra: Commonwealth of Australia; 2011. Victoria’s Cancer Action Plan 2008-2011. Melbourne: State 458 Ministerial Council on Drug Strategy. National Alcohol Strategy: of Victoria; 2008. 2006-2011. Canberra: Commonwealth of Australia 2006. 476 Cancer Council Australia. National Cancer Prevention 459 National Preventative Health Taskforce. Australia: The Healthiest Policy. Sydney: Cancer Council Australia; 2013 [updated Country by 2020 – National Preventative Health Strategy – April 16; cited 2013 July 1]; Available from: http://www. Overview. Canberra: Commonwealth of Australia 2009. cancer.org.au/policy-and-advocacy/prevention-policy/ national-cancer-prevention-policy.html. 460 Council of Australian Governments. National Partnership Agreement on Preventive Health Canberra: Council of Australian 477 Australian Bureau of Statistics. 3238.0 - Experimental Governments, 2009. Estimates and Projections, Aboriginal and Torres Strait Islander Australians, 1991 to 2021. Canberra: Australian 461 Council of Australian Governments. National Partnership Bureau of Statistics 2009. Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan. Canberra: Commonwealth of Australia 2009. 478 Australian Institute of Health and Welfare. Life expectancy and mortality of Aboriginal and Torres Strait Islander 462 Council of Australian Governments. National Health Reform people. Canberra: Australian Institute of Health and Agreement Canberra: Council of Australian Governments, 2011. Welfare 2011 (Cat. no. AIHW 51). 463 Australian Government Department of Health and Ageing. National 479 Australian Institute of Health and Welfare. Towards better Women’s Health Policy. Canberra: Commonwealth of Australia; Indigenous health data. Canberra: Australian Institute of 2010 (D0102). Health and Welfare 2013 (Cat. no. IHW 93). 464 Australian Government Department of Health and Ageing. National 480 Secretan B, Straif K, Baan R, Grosse Y, El Ghissassi Male Health Policy. Canberra: Commonwealth of Australia; 2010 F, Bouvard V, Benbrahim-Tallaa L, Guha N, Freeman (6575). C, Galichet L, Cogliano V, WHO International Agency 465 Strategic Inter-Governmental Nutrition Alliance of the National for Research on Cancer Monograph Working Group. A Public Health Partnership. Eat Well Australia An Agenda for Action review of human carcinogens--Part E: tobacco, areca for Public Health Nutrition. Canberra: National Public Health nut, alcohol, coal smoke, and salted fish. Lancet Oncol. Partnership; 2001. 2009;10 (11):1033-4. 466 Strategic Inter-Governmental Nutrition Alliance of the National 481 Doll R, Peto R. Cigarette smoking and bronchial Public Health Partnership. Eat Well Australia A Strategic carcinoma: dose and time relationships among regular Framework for Public Health Nutrition. Canberra: National Public smokers and lifelong non-smokers. J Epidemiol Health Partnership; 2001. Community Health. 1978;32 (4):303-13. 467 Intergovernmental Committee on Drugs. National Tobacco 482 Australian Institute of Health and Welfare. Risk factors Strategy, 2012-2018. Canberra: Commonwealth of Australia; 2012 contributing to chronic disease. Canberra Australian (D1013). Institue of Health and Welfare; 2012 [updated March 29; 468 Commonwealth Department of Health and Aged Care. National cited 2012 November 2]; Available from: http://www.aihw. Tobacco Strategy 1999 to 2002-03. Framework for action. gov.au/publication-detail/?id=10737421466. Canberra: Commonwealth of Australia; 1999. 483 Sitas F, O’Connell D, Jamrozik K, Lopez A. Smoking 469 Ministerial Council on Drug Strategy. National Tobacco Strategy questions on the Australian death notification form: 2004-2009. Canberra: Commonwealth of Australia; 2005. adopting international best practice? Med J Aust. 2009;191 (3):166-8. 470 Health Workforce Australia. About. Canberra: Commonwealth of Australia; 2013 [updated June 6; cited 2013 June 6]; Available 484 Jha P, Ramasundarahettige C, Landsman V, Rostron B, from: http://www.hwa.gov.au/about. Thun M, Anderson R, McAfee T, Peto R. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med. 2013;368 (4):341-50. 122 • The State of Cancer Control in Australia

485 Pirie K, Peto R, Reeves G, Green J, Beral V, Million Women 500 Collins DJ, Lapsley HM. The avoidable costs of alcohol Study Collaborators. The 21st century hazards of smoking abuse in Australia and the potential benefits of effective and benefits of stopping: a prospective study of one million policies to reduce the social costs of alcohol. Canberra: women in the UK. Lancet. 2013;381 (9861):133-41. Commonwealth of Australia 2008 (Monograph Series No. 486 Pierce J, Dwyer T, Frape G, Chapman S, Chamberlain A, 70). Burke N. Evaluation of the Sydney “Quit. For Life” anti- 501 Doran C, Hall W, Shakeshaft A, Vos T, Cobiac L. Alcohol smoking campaign. Part 1. Achievement of intermediate policy reform in Australia: what can we learn from the goals. Med J Aust. 1986;144 (7):341-4. evidence? Med J Aust. 2010;192 (8):468-70. 487 Scollo M, Winstanley M. Tobacco in Australia: Facts and 502 The ABAC Scheme. The ABAC Scheme: Alcohol issues. 4th Ed. Melbourne: Cancer Council Victoria, 2012. beverages advertising (and packaging) code, 2009. 488 Ministerial Council on Drug Strategy. Background paper: 503 Fogarty A, Chapman S. What should be done about A companion document to the National Tobacco Strategy policy on alcohol pricing and promotions? Australian 1999 to 2002-03. Canberra: Commonwealth of Australia; experts’ views of policy priorities: a qualitative interview 1999. study. BMC Public Health. 2013;13:610. 489 Australian Government Department of Health and Ageing. 504 Chalmers J, Carragher N, Davoren S, O’Brien P. Real or Quit Now. Canberra Australian Government Department perceived impediments to minimum pricing of alcohol in of Health and Ageing; 2012 [updated May 30; cited 2012 Australia: Public opinion, the industry and the law. Int J October 29]; Available from: http://www.quitnow.gov.au/. Drug Policy. 2013;EPub June 14. 490 Australian Government Department of Health and Ageing. 505 Stanton R. Who will take responsibility for obesity in Tobacco. Canberra Australian Government Department of Australia? Public Health. 2009;123 (3):280-2. Health and Ageing; 2012 [updated August 24; cited 2012 506 MacKay S. Legislative solutions to unhealthy eating and October 29]; Available from: http://www.health.gov.au/ obesity in Australia. Public Health. 2011;125 (12):896- internet/main/publishing.nsf/Content/tobacco. 904. 491 Australian Government Department of Health and Ageing. 507 Calle E, Rodriguez C, Walker-Thurmond K, Thun M. Government to Increase Tobacco Excise. Canberra: Overweight, obesity, and mortality from cancer in a Australian Government Department of Health and Ageing; prospectively studied cohort of U.S. adults. N Engl J 2013 [updated August 1; cited 2013 August 8]; Available Med. 2003;348 (17):1625-38. from: http://www.health.gov.au/internet/ministers/ 508 Vainio H, Bianchini F, editors. Weight Control and publishing.nsf/Content/mr-yr13-tp-tp093.htm. Physical Activity, vol. 6. Lyon: IARC; 2002. 492 Jin M, Cai S, Guo J, Zhu Y, Li M, Yu Y, Zhang S, Chen K. 509 Percik R, Stumvoll M. Obesity and cancer. Exp Clin Alcohol drinking and all cancer mortality: a meta-analysis. Endocrinol Diabetes. 2009;117 (10):563-6. Ann Oncol. 2013;24 (3):807-16. 510 Wolin K, Carson K, Colditz G. Obesity and cancer. 493 Taylor A, Dhillon I. An international legal strategy for alcohol Oncologist. 2010;15 (6):556-65. control: not a framework convention-at least not yet. Addiction. 2013;108 (3):450-5. 511 Australian Bureau of Statistics. 4364.0.55.001 - Australian Health Survey: First Results, 2011-12. 494 Winstanley MH, Pratt IS, Chapman K, Griffin HJ, Croager Canberra: ABS 2012 [updated 29 October; cited 2013 EJ, Olver IN, Sinclair C, Slevin TJ. Alcohol and cancer: a 28 February]; Available from: http://www.abs.gov. position statement from Cancer Council Australia. Med J au/ausstats/[email protected]/Lookup/4364.0.55.001Chapt Aust. 2011;194 (9):479-82. er1002011-12. 495 Vasdev S, Gill V, Singal PK. Beneficial effect of low ethanol 512 Gill T, Baur L, Bauman A, Steinbeck K, Storlien L, intake on the cardiovascular system: possible biochemical Fiatarone Singh M, Brand-Miller J, Colagiuri S, Caterson mechanisms. Vasc Health Risk Manag. 2006;2 (3):263-76. I. Childhood obesity in Australia remains a widespread 496 Di Castelnuovo A, Costanzo S, Donati MB, Iacoviello L, de health concern that warrants population-wide prevention Gaetano G. Prevention of cardiovascular risk by moderate programs. Med J Aust. 2009;190 (3):146-8. alcohol consumption: epidemiologic evidence and plausible 513 Crammond B, Van C, Allender S, Peeters A, Lawrence M, mechanisms. Intern Emerg Med. 2010;5 (4):291-7. Sacks G, Mavoa H, Swinburn B, Loff B. The possibility 497 Ministerial Council on Drug Strategy. Alcohol in Australia: of regulating for obesity prevention - understanding Issues and Strategies. Canberra: Commonwealth of regulation in the Commonwealth Government. Obs Rev. Australia; 2001. 2013;14 (3):213-21. 498 National Health and Medical Research Council. Australian 514 National Health and Medical Research Council. guidelines to reduce health risks from drinking alcohol. Australian Dietary Guidelines. Canberra: Commonwealth Canberra: Commonwealth of Australia 2009. of Australia 2013. 499 Australian Government Department of Health and Ageing. 515 Willett W. Diet, nutrition, and avoidable cancer. Environ Alcohol. Canberra Australian Government Department Health Perspect. 1995;103 (Suppl 8):165-70. of Health and Ageing 2012 [updated April 17; cited 2012 November 16]; Available from: http://www.alcohol.gov.au/.

November, 2013 516 Kushi L, Doyle C, McCullough M, Rock C, Demark-Wahnefried 530 Australian Government Department of Health and W, Bandera E, Gapstur S, Patel A, Andrews K, Gansler T, Ageing. Healthy Communities Initiative. Canberra American Cancer Society 2010 Nutrition Physical Activity Australian Government Department of Health and Guidelines Advisory Committee. American Cancer Society Ageing; 2012 [updated October 20; cited 2012 Guidelines on nutrition and physical activity for cancer November 21]; Available from: http://www.healthyactive. prevention: reducing the risk of cancer with healthy food gov.au/internet/healthyactive/publishing.nsf/Content/ choices and physical activity. CA - Cancer J Clin. 2012;62 healthy-communities. (1):30 - 67. 531 Australian Government Department of Health and 517 International Agency for Research on Cancer. EPIC Project. Ageing. Healthy spaces and places. Canberra Lyon: International Agency for Research on Cancer 2013 Australian Government Department of Health and [updated June 3; cited 2013 June 3]; Available from: http://epic. Ageing 2009 [updated July 22; cited 2012 November 21]; iarc.fr/. Available from: http://www.healthyplaces.org.au/site/. 518 Gonzalez C, Riboli E. Diet and cancer prevention: Contributions 532 Australian Health Ministers’ Conference. Delivering from the European Prospective Investigation into Cancer and Results. Press Release. Canberra Australian Health Nutrition (EPIC) study. Eur J Cancer. 2010;46 (14):2555-62. Ministers’ Advisory Council; 2008 [updated April 18; 519 O’Hanlon L. Studying the Connection Between Exercise and cited 2013 March 6]; Available from: http://www.health. Cancer Risk Reduction. J Natl Cancer Inst. 2013;105 (11):753-4. gov.au/internet/main/publishing.nsf/Content/7C44FB 98DE33E717CA25742F001A75C8/$File/Australian%20 520 Clague J, Bernstein L. Physical activity and cancer. Curr Onc Health%20Ministers%20Conference%20Communique. Report. 2012;14 (6):550-8. pdf. 521 Recreation Australia Limited. Life. Be In It. Health Promotion. 533 Sacks G, Swinburn B, Lawrence M. A systematic policy Recreation Australia Limited; 2013 [updated May 6; cited 2013 approach to changing the food system and physical May 6]; Available from: http://www.lifebeinit.org/. activity environments to prevent obesity. Aust NZ Heal 522 National Public Health Partnership. Be Active Australia: A Policy. 2008;5:13. Framework for Health Sector Action for Physical Activity. 534 Baade P, Coory M. Trends in melanoma mortality Melbourne (VIC): NPHP; 2005. in Australia: 1950-2002 and their implications for 523 Australian Government Department of Health and Ageing. melanoma control. Aust NZ J Publ Heal. 2005;29 Get set for life - Habits for healthy kids. Canberra Australian (4):383-6. Government Department of Health and Ageing; 2009 [updated 535 Wilkinson D, Askew DA, Dixon A. Skin cancer clinics in April 2; cited 2012 November 21]; Available from: http://www. Australia: workload profile and performance indicators healthyactive.gov.au/internet/healthyactive/publishing.nsf/ from an analysis of billing data. Med J Aust. 2006;184 Content/getset4life-index. (4):162-4. 524 Australian Government Department of Health and Ageing. Go 536 Youl PH, Baade PD, Janda M, Del Mar CB, Whiteman For 2 & 5. Canberra Department of Health and Ageing; 2008 DC, Aitken JF. Diagnosing skin cancer in primary care: [updated November 10; cited 2012 November 19]; Available how do mainstream general practitioners compare with from: http://www.healthyactive.gov.au/internet/healthyactive/ primary care skin cancer clinic doctors? Med J Aust. publishing.nsf/Content/2and5. 2007;187 (4):215-20. 525 Australian National Preventive Health Agency. Swap It, Don’t 537 Cancer Council Victoria. Sun Smart. 2012 [updated Stop It. Canberra Australian National Preventive Health Agency; October 16; cited 2012 November 19]; Available from: 2012 [updated September 20; cited 2012 October 29]; Available http://www.sunsmart.com.au/. from: http://swapit.gov.au/. 538 Australian Government Department of Health and 526 Myers P. Evaluation of the ‘Swap It, Don’t Stop It’ Social Ageing. National Skin Cancer Awareness Campaign. Marketing Campaign February 2012 Evaluation Report (Wave 6) Canberra Australian Government Department of Health FINAL. Melbourne: The Social Research Centre; 2012. and Ageing; 2010 [updated July 22; cited 2012 October 527 The Social Research Centre. Evaluation of the Australian Better 29]; Available from: http://www.skincancer.gov.au/. Health Initiative Measure Up Social Marketing Campaign Phase 539 Ipsos Eureka. Evaluation of National Skin Cancer 1. Melbourne: The Social Research Centre; 2010. Awareness Campaign - Third Phase (2009-2010). 528 Woolcott Research. Evaluation of the national Go for 2 & 5® Sydney: Australian Government Department of Health campaign. Sydney: Woolcott Research; 2007. and Ageing 2010. 529 Cancer Council NSW. Eat It To Beat It – Program overview. 540 McArthur G. Solariums to be banned in Victoria Herald 2012; Available from: http://www.cancercouncil.com. Sun Melbourne: News Limited, 2012. au/20614/reduce-risks/eating-moving/eat-it-to-beat-it/ overview/?pp=36572. 124 • The State of Cancer Control in Australia

541 Hardcastle J, Chamberlain J, Robinson M, Moss S, 553 Government of South Australia. Independent review Amar S, Balfour T, James P, Mangham C. Randomised into digital screening mammograms. Adelaide: Premier controlled trial of faecal-occult-blood screening for South Australia; 2012 [updated December 14; cited colorectal cancer. Lancet. 1996;348 (9040):1472-7. 2012 December 14]; Available from: http://www.premier. 542 Mandel J, Bond J, Church T, Snover D, Bradley sa.gov.au/images/news_releases/12_12Dec/bssa.pdf. G, Schuman L, Ederer F. Reducing mortality from 554 Australian Government Department of Health and colorectal cancer by screening for fecal occult blood. Ageing. The Australian Immunisation Handbook Minnesota Colon Cancer Control Study. N Engl J Med. 9th Edition: 3.6 Hepatitis B. Canberra Australian 1993;328 (19):1365-71. Government Department of Health and Ageing; 2008. 543 Mandel J, Church T, Bond J, Ederer F, Geisser M, 555 Lowe A, Bennett M, Badenoch S. Research , Mongin S, Snover D, Schuman L. The effect of fecal Awareness, Support: Ten Years of Progress in Prostate occult-blood screening on the incidence of colorectal Cancer. Sydney: Prostate Cancer Foundation of cancer. N Engl J Med. 2000;343 (22):1603-7. Australia, 2012. 544 Benson V, Patnick J, Davies A, Nadel M, Smith R, 556 Straif K, Benbrahim-Tallaa L, Baan R, Grosse Y, Atkin W, International Colorectal Cancer Screening Secretan B, El Ghissassi F, Bouvard V, Guha N, Network. Colorectal cancer screening: a comparison Freeman C, Galichet L, Cogliano V. A review of human of 35 initiatives in 17 countries. Int J Cancer. 2008;122 carcinogens--part C: metals, arsenic, dusts, and fibres. (6):1357- 67. Lancet Oncol. 2009;10 (5):453-4. 545 Bowel Cancer Australia. Bowelscreen Australia. 2013 557 AFOM Working Party on Occupational Cancer. [updated July 18; cited 2013 July 18]; Available from: Occupational Cancer: A guide to prevention, http://www.bowelscreenaustralia.org. assessment and investigation. Sydney: The Australasian 546 Australian Government Department of Health and Faculty of Occupational Medicine 2003. Ageing. Program Suspension - May to November 558 Landrigan PJ, Espina C, Neira M. Global prevention of 2009. Canberra Australian Government Department environmental and occupational cancer. Environ Health of Health and Ageing; 2010 [updated May 31; cited Perspect. 2011;119 (7):A280-1. 2012 December 14]; Available from: http://www. 559 Fritschi L, Driscoll T. Cancer due to occupation in cancerscreening.gov.au/internet/screening/publishing. Australia. Aust NZ J Publ Heal. 2006;30 (3):213-9. nsf/Content/program-suspension. 560 Department of Education Employment and Workplace 547 Australian Government. Budget 2012-13: Health and Relations. Asbestos Management Review Report. Ageing. Canberra: Commonwealth of Australia; 2012 Canberra: Department of Education, Employment and [updated July 9; cited 2013 July 10]; Available from: Workplace Relations 2012. http://www.budget.gov.au/2012-13/content/bp2/html/ 561 Reid A, Franklin P, Olsen N, Sleith J, Samuel L, bp2_expense-12.htm. Aboagye-Sarfo P, de Klerk N, Musk A. All-cause 548 Haas M, Ashton T, Blum K, Christiansen T, Conis E, mortality and cancer incidence among adults exposed Crivelli L, Lim MK, Lisac M, Macadam M, Schlette S. to blue asbestos during childhood. Am J Ind Med. Drugs, sex, money and power: an HPV vaccine case 2013;56 (2):133-45. study. Health Policy. 2009;92 (2-3):288-95. 562 Department of Education Employment and Workplace 549 Roughead EE, Gilbert AL, Vitry AI. The Australian Relations. A national approach to asbestos funding debate on quadrivalent HPV vaccine: a case management. Canberra: Department of Education, study for the national pharmaceutical policy. Health Employment and Workplace Relations; 2012 [updated Policy. 2008;88 (2-3):250-7. September 4; cited 2013 February 15]; Available 550 Kirby T. Australia to be first country to vaccinate boys from: http://ministers.deewr.gov.au/shorten/national- against HPV. Lancet Oncol. 2012;13 (8):e333. approach-asbestos-management. 551 Smith M, Lew J-B, Walker R, Brotherton J, Nickson C, 563 Australian Institute of Health and Welfare. Key indicators Canfell K. The predicted impact of HPV vaccination of progress for chronic disease and associated on male infections and male HPV-related cancers in determinants: technical report. Canberra: Australian Australia. Vaccine. 2011;29 (48):9112-22. Institue of Health and Welfare 2009 (Cat. no. PHE 114). 552 Australian Government Department of Health and 564 Sitas F, Urban M, Bradshaw D, Kielkowski D, Bah S, Ageing. New Breast Cancer Nurses for Regional Peto R. Tobacco attributable deaths in South Africa. Tob Australia. 2008 [updated October 13; cited 2012 Control. 2004;13 (4):396-9. November 5]; Available from: http://www.health.gov.au/ internet/ministers/publishing.nsf/Content/mr-yr08-nr- nr134.htm.

November, 2013 565 Sitas F, Egger S, Bradshaw D, Groenewald P, Laubscher R, 579 National Rural Health Alliance. Fact Sheet 10: Patient Kielkowski D, Peto R. Differences in the coloured, white, black Assisted Travel Schemes. Deakin West: National Rural and other South African Populations in smoking attributed Health Alliance; 2009 [updated May; cited 2012 December mortality at ages 35-74 years: a case control study of 481640 12]; Available from: http://ruralhealth.org.au/sites/default/ deaths. Lancet. 2013;682:685-93. files/fact-sheets/fact-sheet-10-patient%20assisted%20 566 Australian Institute of Health and Welfare. National Centre travel%20schemes_0.pdf. for Monitoring Cancer Framework: 2012. Canberra Australian 580 Baume (chairperson) P. Radiation Oncology Inquiry. A Institute of Health and Welfare 2012 (Cancer series no. 68. Cat. vision for radiotherapy. Canberra: Commonwealth of no. CAN 64). Australia 2002. 567 Australian Institute of Health and Welfare. Australian Institute of 581 Morgan G, Barton M, Atkinson C, Millar J, Kumar Gogna Health and Welfare annual report 2011-12. Canberra Australian N, Yeoh E. ‘GAP’ in radiotherapy services in Australia and Institute of Health and Welfare 2012 (Cat. no. AUS 161). New Zealand in 2009. J Med Imag Radiat On. 2010;54 568 Cancer Australia. A National Cancer Data Strategy for Australia. (3):287-97. Canberra: Commonwealth of Australia 2008. 582 Barton M, Delaney G. A decade of investment in 569 Australian Government Department of Health and Ageing. radiotherapy in New South Wales: why does the gap New data reveals how long patients wait for cancer surgery. between optimal and actual persist? J Med Imag Radiat Canberra: Commonwealth of Australia 2012 [updated 29 May; On. 2011;55 (4):433-41. cited 2013 July 1]; Available from: http://www.health.gov.au/ 583 Delaney G, Jacob S, Featherstone C, Barton M. The role internet/ministers/publishing.nsf/Content/mr-yr12-tp-tp050.htm. of radiotherapy in cancer treatment: estimating optimal 570 Clinical Oncological Society of Australia The Cancer Council utilization from a review of evidence-based clinical Australia and the National Cancer Control Initiative. Optimising guidelines. Cancer. 2005;104 (6):1129-37. Cancer Care in Australia. Melbourne: National Cancer Control 584 Barton M, Frommer M, Shafiq J. Role of radiotherapy Initiative 2002. in cancer control in low-income and middle-income 571 Fleissig A, Jenkins V, Catt S, Fallowfield L. Multidisciplinary countries. Lancet Oncol. 2006;7 (7):584-95. teams in cancer care: are they effective in the UK? Lancet 585 Australian Government Department of Health and Ageing. Oncol. 2006;7 (11):935-43. PBS Chemotherapy Medicines Review. Canberra: 572 Jiwa M, Longman G, Sriram D, Briffa K, Musiello T. Cancer care Australian Goverment Department of Health and Ageing; coordinator: Promoting multidisciplinary care—A pilot study in 2013 [updated June 29; cited 2013 July 9]; Available from: Australian general practice. Collegian. 2013;20 (1):67-73. http://www.health.gov.au/chemo-review. 573 Zorbas H, Barraclough B, Rainbird K, Luxford K, Redman S. 586 Australian Government Department of Health and Ageing. Multidisciplinary care for women with early breast cancer in the Palliative Care. Canberra: Australian Government Australian context: what does it mean? Med J Aust. 2003;179 Department of Health and Ageing; 2009 [updated (10):528-31. September 29; cited 2012 November 19]; Available from: http://www.health.gov.au/internet/main/publishing.nsf/ 574 National Rural Health Alliance. An overview of the shortage of Content/palliativecare-program.htm. primary care services in rural and remote areas. Deakin West: National Rural Health Alliance 2011. 587 Health Workforce Australia. Health Workforce 2025 - Doctors, Nurses and Midwives - Volume 1. Adelaide: 575 National Rural Health Alliance. Fact Sheet 8: Cancer in rural Health Workforce Australia 2012. Australia. Deakin West: National Rural Health Alliance; 2012 [updated January; cited 2012 December 12]; Available from: 588 Health Workforce Australia. Health Workforce 2025 http://ruralhealth.org.au/sites/default/files/publications/fact- - Volume 3 - Medical Specialties. Adelaide: Health sheet-08-cancer-rural-australia.pdf. Workforce Australia 2012. 576 Deloitte Access Economics. Access to cancer treatment in non- 589 Leach MJ, Segal L, May E. Lost opportunities with metropolitan areas of Australia. Sydney: Amgen Australia Pty Australia’s health workforce? Med J Aust. 2010;193 (3):167- Ltd 2011. 72. 577 Hayen A, Smith D, Patel M, O’Connell D. Patterns of surgical 590 Knight A, Caesar C, Ford D, Coughlin A, Frick C. Improving care for prostate cancer in NSW, 1993-2002: rural/urban and primary care in Australia through the Australian Primary socio-economic variation. Aust NZ J Publ Heal. 2008;32 (5):417- Care Collaboratives Program: a quality improvement 20. report. BMJ Qual Safety. 2012;21 (11):948-55. 578 Australian Government Department of Health and Ageing. 591 Improvement Foundation. Improvement Foundation. 2012 Health and Hospitals Fund. Canberra Australian Government [updated October 20; cited 2013 February 6]; Available Department of Health and Ageing; 2012 [updated October 19; from: http://improve.org.au/index.php. cited 2012 December 13]; Available from: http://www.health.gov. 592 Leach MJ. Using role substitution to address the health au/hhf. workforce shortage and to facilitate integration? J Complement Integr Med. 2012;9:Article 30. 126 • The State of Cancer Control in Australia

593 Health Workforce Australia. Health Workforce Australia 2012-13 607 Zhang Z, Nagrath S. Microfluidics and cancer: are we Work Plan. Adelaide: Health Workforce Australia 2012. there yet? Biomed Microdevices. 2013;EPub Jan 29. 594 Dorr D, Bonner L, Cohen A, Shoai R, Perrin R, Chaney E, Young 608 Claudino W, Goncalves P, di Leo A, Philip P, Sarkar A. Informatics systems to promote improved care for chronic F. Metabolomics in cancer: a bench-to-bedside illness: a literature review. JAMIA. 2007;14 (2):156-63. intersection. Crit Rev Oncol Hematol. 2012;84 (1):1-7. 595 Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, 609 Rahman M, Ahmad M, Kazmi I, Akhter S, Afzal M, Morton S, Shekelle P. Systematic review: impact of health Gupta G, Jalees Ahmed F, Anwar F. Advancement information technology on quality, efficiency, and costs of in multifunctional nanoparticles for the effective medical care. Ann Intern Med. 2006;144 (10):742-52. treatment of cancer. Expert Opin Drug Del. 2012;9 596 DesRoches C, Campbell E, Rao S, Donelan K, Ferris T, Jha A, (4):367-81. Kaushal R, Levy D, Rosenbaum S, Shields A, Blumenthal D. 610 Kennedy L, Bickford L, Lewinski N, Coughlin A, Hu Electronic health records in ambulatory care--a national survey Y, Day E, West J, Drezek R. A new era for cancer of physicians. N Engl J Med. 2008;359 (1):50-60. treatment: gold-nanoparticle-mediated thermal 597 Poissant L, Pereira J, Tamblyn R, Kawasumi Y. The impact of therapies. Small. 2011;7 (2):169-83. electronic health records on time efficiency of physicians and 611 Bartok D. Parramatta Council overturns smoking ban nurses: a systematic review. JAMIA. 2005;12 (5):505-16. in alfresco dining areas The Daily Telegraph Sydney: 598 Holman C, Bass A, Rouse I, Hobbs M. Population-based News Limited, 2013. linkage of health records in Western Australia: development of a 612 Australian Government Department of Health and health services research linked database. Aust NZ J Publ Heal. Ageing. Australia’s first national cancer report predicts 1999;23 (5):453-9. lower death rates - but more cancers. Canberra: 599 Authority NET. The National E-Health Transition Authority Australian Government DoHA; 1998 [updated 1998 Strategic Plan Refresh. 2013 [updated February 18; cited 2013 July 6; cited 2013 March 11]; Available from: http:// February 18]; Available from: http://www.nehta.gov.au/about-us/ www.health.gov.au/internet/main/publishing.nsf/ strategy. Content/health-archive-mediarel-1998-mw14198.htm. 600 Australian Government Department of Health and Ageing. 613 Balducci L, Lyman G. Cancer in the elderly. eHealth. Canberra Australian Government Department of Epidemiologic and clinical implications. Clin Geriatr Health and Ageing; 2012 [updated October 31; cited 2013 Med. 1997;13 (1):1-14. February 15]; Available from: http://www.health.gov.au/internet/ main/publishing.nsf/Content/eHealth. 601 Williams PAH, McCauley V. Sound Foundations: Leveraging International Standards for Australia’s National Ehealth System. Eur J Biomed Inform. 2012;8 (4):50-5. 602 Sebastian M, Ninan N, Elias E. Nanomedicine and Cancer Therapies. In: Thomas S, Sebastian M, George A, Weimin Y. Advances in Nanoscience and Nanotechnology, vol. 2. Toronto: Apple Academic Press, 2013. 603 Garcia M, McQuade J, Haddad R, Patel S, Lee R, Yang P, Palmer J, Cohen L. Systematic Review of Acupuncture in Cancer Care: A Synthesis of the Evidence. J Clin Oncol. 2013;31 (7):952-60. 604 Bilusic M, Madan R. Therapeutic cancer vaccines: the latest advancement in targeted therapy. Am J Ther. 2012;19 (6):e171- 81. 605 Cantley L, Dalton W, DuBois R, Finn O, Futreal P, Golub T, Hait W, Lozano G, Maris J, Nelson W, Sawyers C, Schreiber S, et al. AACR Cancer Progress Report 2012. Clin Cancer Res. 2012;18 (21 Suppl):100. 606 Verma M, Khoury M, Ioannidis J. Opportunities and challenges for selected emerging technologies in cancer epidemiology: mitochondrial, epigenomic, metabolomic, and telomerase profiling. Cancer Epidemiol Biomarkers Prev. 2013;22 (2):189- 200.

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9 Discussion and future research

The two decades selected for analysis in this study coincide with the inception and launch of a number of public health programs (around the early 1990s) that either directly addressed the cancer burden or focused on modifiable risk factors. This analysis has shown that cancer- related deaths have reduced by 28% from the expected numbers based on 1987 rates to the observed numbers in 2007. Cancer incidence, however, has increased over the same period by 21%, predominantly due to the rise in incident cases of prostate cancer. The population analysed – those aged under 75 years – are individuals in the age range who would have trials, nor is cancer treatment as aggressive as in younger benefited most from the programs available. patients.60, 614 Better and more cost-effective treatment for By comparing ‘before and after’ estimates for 2007, we other NCDs increases the likelihood of the elderly dying of estimated a fall in mortality of 28% (for people below than cancer.389 Time exposes the elderly to more carcinogens 75 years) for the time period, which included widespread and genetic changes, resulting in higher cancer incidence implementation of cancer control programs for individuals under and mortality.399 75. Previous AIHW estimates of age-standardised mortality Mortality and incidence trends have been analysed here (for all ages) were 212.1/ 100000 in 1987 and 176.1/100000 in for their clear and concise representation of change over 72 2007, indicating a 17% reduction in mortality. We estimated time. Over three decades ago, Doll and Peto396 suggested a 21% rise in incidence and, similarly, the AIHW rates rose a shift in focus to cancer types with increasing incidence. from 408.2/100000 in 1987 to 490.1/100000 in 2007, a 20% At the time, rising incidence suggested the introduction of 72 increase. The dominant reason for the difference in these a number of cause(s) of a cancer with a realistic possibility estimates is our restriction to people under the age of 75, the that they could be controlled or eradicated once identified. primary target population for cancer control interventions. However, enhanced detection techniques have also caused People over 75 years were excluded to more accurately report diagnoses to be brought forward and thus have artificially premature deaths and incident cases relating to cancer. increased the incidence of certain cancers. Further artificial Additionally, the elderly are not always included in clinical increases in incidence include improvements in cancer Cancer Council NSW • 127 128 • The State of Cancer Control in Australia

registration methods, all of which have an important initiative will contribute to improvements in the continuity influence on the measurement of survival and prevalence. of care, and the de-identified data could be used for future In light of this, there has been a more recent shift to assess analysis of service provision and use of the health care cancer mortality trends, augmented by incidence rather system.1 Current research in cancer patients’ experiences than prevalence and survival.13, 15, 65, 615 The latter two is moving towards the use of linked data from various statistics serve other important purposes in health planning sources to better understand their treatment patterns in such as the potential burden on the health care system order to improve care. The use of linked administrative and the length of time over which relevant services may be health data has been identified as valuable, despite the required. Incidence and mortality represent the pressing lack of information relating to diagnostic interventions and emerging issues for public health concern and health and accurate descriptions of disease stage to explain the care systems. complete scenario.619 Government initiatives, including the Cancer Data Strategy, are working towards closing this

gap. 9.1 Burden of early diagnosis Virtually all cases of cervical cancer are associated with 9.3 Implications for the ageing persistent The increasing burden of cancer represented in this analysis by early diagnosis means health care population systems are challenged by the need to transition from a The resource and financial burden of new cancer cases will focus on acute service provision based in large hospital continue to weigh on the Australian health system because facilities to building community-based services for of the shift in the age distribution of the population, which preventive health, screening and diagnosis, treatment and is ever-increasing, with a larger proportion of elderly 59 ongoing monitoring. Complex interactions associated people.620 Demographic projections suggest that this trend with cancer diagnosis have given rise to a patient-focused will continue into the future. Conditional life expectancy at and integrated approach to care. In Australia, consumer age 60 is now another 24 years. With ageing populations empowerment supports a more active role of the patient. and most guidelines focusing on treatment and To align with this change, the health system needs to adopt management restricted to patients under 75, reassessment 427, 445, a more patient-centred approach to cancer control. of current protocols is needed.60, 61 Clinical trials often 454, 616 Success in these endeavours requires improved exclude older patients from participating, limiting the infrastructure in order to optimise quality, efficacy and evidence base for the treatments or interventions under 1 timeliness of service provision. Reform, through the various evaluation.60, 61, 621 Older individuals are often excluded as national agreements and health performance frameworks, they have more complex health issues and comorbidities is working towards this goal. Additionally, integrated care which are difficult to allow for in a trial.60, 61 There is often a is often multidisciplinary, and incorporates alternative lack of statistical power to show any statistically significant treatment and therapies alongside more traditional effects of treatment in older age groups.60 Trials with 617 techniques. alternative study designs to accommodate the differences in older subjects may be required.621, 622

9.2 Health records Maintaining adequate and cost-effective access to health care is one of the major challenges moving forward.454 It is The transfer of patient-related information is becoming often difficult to assess the cost-benefit of cancer control a more important issue with the increasing number of in comparison to other health priority areas. Benchmarking professionals involved in care, and the increasing number cancer against other disease states such as cardiovascular of cancer patients entering the health system at older disease is challenging.438 Cost-benefit analyses often ages and with more complex comorbidities. In Australia, revolve around preventive services and treatment. much emphasis has been given to optimising the use of However, there are also indirect costs – such as health electronic portals to share information between health system infrastructure upgrades, and patient and carer care professionals and across care sites. Such portals travel and accommodation expenses – which are important are an important enabler of patient-centred care.618 This elements of cancer control.570

November, 2013 9.4 Focus on prevention time interval is safer during the implementation phase.145 The ‘Renewal’ of the screening program will address this issue and A recent overview of Australia’s health care system the effect of HPV vaccination of future target cohorts, to provide a reiterates the importance of prevention programs in more cost-effective program. reducing the cancer burden in the future.620 Actions currently being taken by the Australian Government The government priority-setting process is critical for the broader indicate a move towards an emphasis on preventive community to understand and interpret. The growing emphasis on health and screening. The ongoing management of translational research and implementation feeding into an evidence the cancer burden is incorporated into the initiatives base that can be used for the launch of new initiatives means that for public health care system reform and improved researchers need to be cognisant of the political framework within performance and transparency. This may reduce the which they are working and facilitate the process. The gap between emphasis on cancer specifically, but takes a global research discovery and practical implementation needs to be approach to population wellness and prevention rather minimised, and this can be achieved through transparent decision- than cure. Focusing on primary prevention will not only making and priority-setting processes with clear public health– reduce the impact of chronic diseases such as cancer, improvement goals. The evidence supporting changes to public but also improve the overall health of Australians. programs must be communicated effectively to the public to foster The potential benefit is illustrated in a study from support for the changes. Other interested stakeholders, such as the USA showing that adherence to guidelines for NGOs, can also be more effective and increase their impact in the ideal cardiovascular health has reduced the community if their actions and directions are more closely aligned incidence of all cancers over a 20-year with public policy and use evidence to support action. period.623 However, optimal outcomes can only be reached using evidence- Leadership based approaches to prevention 9.6 Dilemmas in cancer control and screening initiatives.184, 624, 625 and clear decision-making Although there are different issues for the health in health care policy care system, preventive strategies and treatment and cancer control requirements for different cancer types, an overall 9.5 Evidence-based approach to cancer control is important to incorporate are important to the interventions into policy. Recommendations can be contradictory and government success of new across cancer types or other disease states at times, initiatives. and public health initiatives should incorporate the decision-making breadth of evidence available. For example, alcohol intake Cancer control initiatives are is said to be associated with increased risk for some generally preceded by evidence-based trials cancer types. However, moderate consumption reduces the to support their implementation. However, criticism risk of cardiovascular disease, yet alcohol in general is linked to has been expressed of the practical applications accidents, violence and increased extraneous causes of death.167 of findings in Australia, especially in relation to the Also, the use of oral contraception is often analysed as a risk National Bowel Cancer Screening Program.183, 184 factor for some cancer types. Increased use has been shown Guidelines for screening are not always used as the to increase risk in cancer types such as breast and cervical model for implementation in practice. Leadership cancer.626 However, there is no significant relationship between and clear decision-making in health care policy and oral contraceptive use and increased risk of cancer overall,626 cancer control are important to the success of new and it appears that long-term hormonal contraception imparts initiatives. Transparency and fairness are imperative lifelong protection against ovarian and endometrial cancers.86 in government priority-setting, and are guided by the As with a number of risk factors, there is a beneficial effect in broader interpretation of social justice in a society.144 reducing incidence of some cancer types, but the general health For example, the National Cervical Cancer Screening or societal-related benefits or harms could be more important than Program recommends two-yearly screening intervals, any protective effect. The implications of not recommending oral despite the evidence suggesting three-yearly intervals contraception or recommending alcohol consumption could cause are sufficient.69, 144, 145 It has been argued that a shorter other public health issues.

Cancer Council NSW • 129 130 • The State of Cancer Control in Australia

Assessments of many cancer types describe an increase in incidence resulting from improved screening and diagnostic techniques. This can give the impression that cancer control is not effective. To address this, overdiagnosis resulting from advances in technology needs to be incorporated into analyses. There is no clear methodological consensus on how to deal with and interpret overdiagnosis, especially in the context of screening;114 however, in a comprehensive review of European breast cancer screening programs, ecological studies were found to be the least informative.98

9.7 Future research Further understanding the role of current and emerging potential carcinogens and the integration of biomarker science to better detect exposures, pre-neoplastic conditions or populations at risk are all areas of discovery that could pave the way for new prevention strategies or treatment techniques.62, 63 This requires ongoing investment in sound research to support the evidence-based grounding for initiatives, as has previously been provided.64 In order to take full advantage of empirical research, studies of basic science need to have a translational phase which makes them practically applicable to epidemiology and public health.62 Our findings illustrate that significant progress has been made over two decades. However, there are still a number of cancer types requiring greater focus. Cancers with unknown or predominantly unmodifiable risk factors currently have limited scope for prevention. Placing greater emphasis on these cancer sites to improve detection and treatment ought to be a growing priority in research and patient support.

November, 2013 9 Discussion

References 1 Australian Institute of Health and Welfare. Australia’s health 114 Roder D. Impact of population screening programs on 2012. Canberra: Australian Institute of Health and Welfare; cancer outcomes. CancerForum. 2012;36 (1):4 -10. 2012 (Australia’s health no.13. Cat. no. AUS 156). 144 Canfell K, Sitas F, Beral V. Cervical cancer in Australia and 13 Ren J-S, Chen W-Q, Shin H-R, Ferlay J, Saika K, Zhang S-W, the United Kingdom: comparison of screening policy and Bray F. A comparison of two methods to estimate the cancer uptake, and cancer incidence and mortality. Med J Aust. incidence and mortality burden in China in 2005. Asian Pac J 2006;185 (9):482-6. Cancer Prev. 2010;11 (6):1587-94. 145 Australian Government Department of Health and Ageing. 15 Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J, Rosso National Cervical Screening Program Renewal. Canberra S, Coebergh JW, Comber H, Forman D, Bray F. Cancer Australian Government Department of Health and Ageing incidence and mortality patterns in Europe: estimates for 40 2012 [updated 22 November; cited 2013 19 March ]; countries in 2012. Eur J Cancer. 2013;49 (6):1374-403. Available from: http://www.cancerscreening.gov.au/ internet/screening/publishing.nsf/Content/ncsp-renewal. 59 Burton R, Leowski Jr J, de Courten M. Integrating cancer control with control of other non-communicable diseases. In: 167 Cho E, Smith-Warner SA, Ritz J, van den Brandt PA, Elwood JM, Sutcliffe S. Cancer Control. New York: Oxford Colditz GA, Folsom AR, Freudenheim JL, Giovannucci University Press, 2010: 399-416. E, Goldbohm RA, Graham S, Holmberg L, Kim DH, et al. Alcohol intake and colorectal cancer: a pooled analysis of 8 60 Zulman D, Sussman J, Chen X, Cigolle C, Blaum C, cohort studies. Ann Intern Med. 2004;140 (8):603-13. Hayward R. Examining the evidence: a systematic review of the inclusion and analysis of older adults in randomized 183 Pignone MP, Flitcroft KL, Howard K, Trevena LJ, Salkeld controlled trials. J Gen Intern Med. 2011;26 (7):783-90. GP, St John DJ. Costs and cost-effectiveness of full implementation of a biennial faecal occult blood test 61 Van Spall H, Toren A, Kiss A, Fowler R. Eligibility criteria of screening program for bowel cancer in Australia. Med J randomized controlled trials published in high-impact general Aust. 2011;194 (4):180-5. medical journals: a systematic sampling review. JAMA. 2007;297 (11):1233-40. 184 Flitcroft KL, Salkeld GP, Gillespie JA, Trevena LJ, Irwig LM. Fifteen years of bowel cancer screening policy in Australia: 62 Franceschi S, Wild C. Meeting the global demands of putting evidence into practice? Med J Aust. 2010;193 (1):37- epidemiologic transition - The indispensable role of cancer 42. prevention. Mol Oncol. 2013;7 (1):1-13. 389 World Health Organization. Global status report on 63 Wang D, Dubois R. Urinary PGE-M: A Promising Cancer noncommunicable diseases 2010. Geneva: World Health Biomarker. Cancer Prev Res. 2013;6 (6):507-10. Organization 2011. 64 Commonwealth of Australia. Budget 2005-2006 Health 1: 396 Doll R, Peto R. The Causes of Cancer. New York: Oxford Investing in Australia’s health: Strengthening Cancer Care. University Press, 1981. Canberra: Commonwealth of Australia; 2005. 399 Peto R, Roe F, Lee P, Levy L, Clack J. Cancer and ageing in 65 Black R, Bray F, Ferlay J, Parkin D. Cancer incidence and mice and men. Brit J Cancer. 1975;32 (4):411-26. mortality in the European Union: cancer registry data and estimates of national incidence for 1990. Eur J Cancer. 427 Australian Government Department of Health and Ageing. 1997;33 (7):1075-107. Department of Health and Ageing Annual Report 2011-2012 Canberra: Commonwealth of Australia, 2012. 69 Australian Government Department of Health and Ageing. National Cervical Screening Program: About the Program. 438 O’Reilly SE, Venkatesh J. Managing the costs of new Canberra: Australian Government Department of Health and therapies: the challenge of funding new drugs. In: Elwood Ageing; 2009 [updated November 11; cited 2012 November 5]; JM, Sutcliffe S. Cancer Control. New York: Oxford Available from: http://www.cancerscreening.gov.au/internet/ University Press, 2010: 185-204. screening/publishing.nsf/Content/cervical-about. 445 Cancer Australia. Strategic Plan 2011–2014. Sydney: Cancer 72 Australian Institute of Health and Welfare. Australian Cancer Australia; 2011. Incidence and Mortality books. Canberra: Australian Institute 454 Australian Government Department of Health and Ageing. of Health and Welfare; 2012. Building a 21st Century Primary Health Care System: 86 Urban M, Banks E, Egger S, Canfell K, O’Connell D, Beral V, Australia’s First National Primary Health Care Strategy. Sitas F. Injectable and oral contraceptive use and cancers Canberra: Commonwealth of Australia; 2010. of the breast, cervix, ovary, and endometrium in black South 570 Clinical Oncological Society of Australia The Cancer African women: case-control study. PLoS Med. 2012;9 Council Australia and the National Cancer Control Initiative. (3):e1001182. Optimising Cancer Care in Australia. Melbourne: National 98 Zappa M, Federici A. The potential for systematic early Cancer Control Initiative 2002. detection and treatment of breast cancer to reduce the 614 Chen RC, Royce TJ, Extermann M, Reeve BB. Impact of burden of disease is widely recognized in the European Union age and comorbidity on treatment and outcomes in elderly (EU). Introduction. J Med Screen. 2012;19 (Suppl 1):3-4. cancer patients. Semin Radiat Oncol. 2012;22 (4):265-71. 132 • The State of Cancer Control in Australia

615 Beral V, Peto R. UK cancer survival statistics. BMJ. 2010;341:309-10. 616 Armstrong BK, Gillespie JA, Leeder SR, Rubin GL, Russell LM. Challenges in health and health care for Australia. Med J Aust. 2007;187 (9):485-9. 617 Leis A, Sagar S, Verhoef M, Balneaves L, Seely D, Oneschuk D. Shifting the paradigm: from complementary and alternative medicine (CAM) to integrative oncology. In: Elwood JM, Sutcliffe S. Cancer Control. New York: Oxford University Press, 2010: 239-58. 618 Epstein RM, Fiscella K, Lesser CS, Stange KC. Why the nation needs a policy push on patient-centered health care. Health Aff. 2010;29 (8):1489-95. 619 Goldsbury D, Armstrong K, Simonella L, Armstrong B, O’Connell D. Using administrative health data to describe colorectal and lung cancer care in New South Wales, Australia: a validation study. BMC Health Serv Res. 2012;12:387. 620 Youl P, Baade P, Meng X. Impact of Prevention on Future Cancer Incidence in Australia. CancerForum. 2012;36 (1). 621 Scher K, Hurria A. Under-representation of older adults in cancer registration trials: known problem, little progress. J Clin Oncol. 2012;30 (17):2036-8. 622 van de Water W, Bastiaannet E, Van de Velde C, Liefers G. Inclusion and analysis of older adults in RCTs. J Gen Intern Med. 2011;26 (8):831. 623 Rasmussen-Torvik L, Shay C, Abramson J, Friedrich C, Nettleton J, Prizment A, Folsom A. Ideal Cardiovascular Health is Inversely Associated with Incident Cancer: The Atherosclerosis Risk in Communities Study. Circulation. 2013;127:1270-5. 624 Hingston GR. Fifteen years of bowel cancer screening policy in Australia: putting evidence into practice? Comment. Med J Aust. 2010;193 (10):622. 625 Saunders MH, Peerson A. Fifteen years of bowel cancer screening policy in Australia: putting evidence into practice? Comment. Med J Aust. 2010;193 (10):621-2. 626 Hannaford PC, Selvaraj S, Elliott AM, Angus V, Iversen L, Lee AJ. Cancer risk among users of oral contraceptives: cohort data from the Royal College of General Practitioner’s oral contraception study. BMJ. 2007;335 (7621):651.

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10 Conclusion

Cancer control measures in Australia have largely been effective in reducing the number of cancer deaths, despite an overall increase in the number of cases diagnosed. This analysis shows that in 2007, for Australians under 75 years of age, cancer mortality had decreased by 28% compared with 1987 statistics. Incidence, however, increased by 21%, largely due to diagnoses brought forward by the use of more modern technologies and the increased coverage of screening programs. Prevention, by means of smoking reductions, improvements in treatment, and screening programs, all played an significant role and are still important elements of cancer control. Overall, Australia is progressing well with life expectancies by governments, researchers, NGOs, industry and local for males and females (of 84 years for females and 80 years communities play an important role in advocating and for males) exceeding those of the UK, the USA and Canada, demonstrating change in their social environments to support and just below those of Japan (87 years for females and 80 the implementation of cancer control initiatives. years for males).627 While the increasing cancer incidence rates necessitate some action to understand the drivers of increased The Australian Government has shifted the health agenda diagnoses, much of this rise is focused on few cancer types. to incorporate an increasing focus on preventive health over However, cancers that require more emphasis in research, the last few decades. Longer-term benefits of addressing policy support and preventive health action are those with the modifiable risk factors causing all NCDs are a key element poorest survival and are not always at the forefront of activities of public health messages. Many of the interventions by lobby groups or of the cancer control agenda. This creates encourage lifestyle-based changes and involve a higher level an imbalance in the emphasis on cancer types, which requires of commitment by individuals to improve their own health continued investment in research to provide an evidence- status. The extent to which this can be achieved is a moot based understanding of their causes. point, but progress and improvements can always be made. The tobacco industry has been successfully constrained by The health care system has inherent limitations, which become legislation, but food and alcohol industries that also provide more apparent when assessing health equality between a large number of potentially harmful commodities to the population groups. Governments are working to address community need further action. The current level of financial these issues through infrastructure changes to provide and resource commitment to cancer control needs to be services as required, as well as encouraging behavioural maintained and increased in high-need areas. Specialised change in individuals. Government investment has also programs focused on high-risk groups are in development, focused on additional funding for health care professionals but need to continue. Cancer control will never be a task in specialisation areas with shortages or where demand is that can be finished. It needs to be integrated into long-term expected to rise. health policy to result in long-term benefit for the community, Cancer control needs to be a collaborative effort in the to sustain and build on the improvements that have already broader community. Beginning with a sound base developed been achieved.

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10. Conclusion

References 627 United Nations Statistics Division. Social indicators. Geneva: United Nations; 2012 [updated October 20; cited 2013 March 27]; Available from: http://unstats.un.org/unsd/demographic/ products/socind/.

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11 References

Cancer Council NSW • 135 136 • The State of Cancer Control in Australia

11 References 1 Australian Institute of Health and Welfare. Australia’s 12 Bray F, Lortet-Tieulent J, Ferlay J, Forman D, health 2012. Canberra: Australian Institute of Health Auvinen A. Prostate cancer incidence and and Welfare; 2012 (Australia’s health no.13. Cat. no. mortality trends in 37 European countries: an AUS 156). overview. Eur J Cancer. 2010;46 (17):3040-52. 2 Begg S, Vos T, Barker B, Stevenson C, Stanley 13 Ren J-S, Chen W-Q, Shin H-R, Ferlay J, Saika K, L, Lopez A. The burden of disease and injury in Zhang S-W, Bray F. A comparison of two methods Australia 2003. Canberra: AIHW; 2007 (Cat. no. PHE to estimate the cancer incidence and mortality 82). burden in China in 2005. Asian Pac J Cancer Prev. 2010;11 (6):1587-94. 3 Australian Institute of Health and Welfare. Cancer survival and prevalence in Australia period estimates 14 Jemal A, Bray F, Center M, Ferlay J, Ward E, from 1982 to 2010. Canberra: Australian Institute of Forman D. Global cancer statistics. CA - Cancer J Health and Welfare; 2012 (Cancer series no. 69. Cat. Clin. 2011;61 (2):69-90. no. CAN 65). 15 Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J, 4 Elwood M, Sutcliffe S. Cancer control and the Rosso S, Coebergh JW, Comber H, Forman D, burden of cancer. In: Elwood JM, Sutcliffe S. Cancer Bray F. Cancer incidence and mortality patterns in Control. New York: Oxford University Press, 2010: Europe: estimates for 40 countries in 2012. Eur J 3-19. Cancer. 2013;49 (6):1374-403. 5 Ferlay J, Shin H, Bray F, Forman D, Mathers C, 16 R Core Team. R: A language and environment Parkin D. GLOBOCAN 2008 v2.0, Cancer incidence for statistical computing. Vienna, Austria: R and mortality worldwide: IARC CancerBase No. 10: Foundation for Statistical Computing, 2012. Lyon, France: IARC, 2010. 17 Statistical Research and Applications Branch. 6 Australian Institute of Health and Welfare and Joinpoint Regression Program Version 3.5.4., Australiasian Association of Cancer Registries. August: National Cancer Institute, 2012. Cancer in Australia: an overview Canberra: 18 Petracci E, Decarli A, Schairer C, Pfeiffer RM, Australian Institute of Health and Welfare; 2012 Pee D, Masala G, Palli D, Gail MH. Risk factor (Cancer series no. 74. Cat. no. CAN 70). modification and projections of absolute breast 7 Boyle P, Levin B, editors. World Cancer Report cancer risk. J Natl Cancer Inst. 2011;103 (13):1037- 2008. Geneva: IARC; 2008. 48. 8 Australian Institute of Health and Welfare and 19 Cummings SR, Tice JA, Bauer S, Browner WS, Australiasian Association of Cancer Registries. Cuzick J, Ziv E, Vogel V, Shepherd J, Vachon C, Cancer in Australia: an overview. Canberra: Smith-Bindman R, Kerlikowske K. Prevention Australian Institute of Health and Welfare; 2010 of breast cancer in postmenopausal women: (Cancer series no. 60 Cat. no. CAN 56). approaches to estimating and reducing risk. J Natl Cancer Inst. 2009;101 (6):384-98. 9 Australian Institute of Health and Welfare. GRIM books. Canberra: Australian Institute 2013 [updated 20 American Cancer Society. Cancer facts & figures July 9; cited 2013 July 9]; Available from: http://www. 2012. Atlanta: American Cancer Society; 2012. aihw.gov.au/grim-books/. 21 IARC Working Group on the Evaluation of 10 Australian Institute of Health and Welfare. Cancer Carcinogenic Risks to Humans. IARC Monographs: incidence projections, Australia 2011 to 2020. Pharmaceuticals. Volume 100A A review of human Canberra: Australian Institute of Health and Welfare carcinogens. Lyon: IARC; 2012. 2012 (Cancer series no. 66. Cat. no. CAN 62). 22 IARC Working Group on the Evaluation of 11 Australian Institute of Health Welfare. Cancer in Carcinogenic Risks to Humans. IARC Monographs: Australia: actual incidence and mortality data from Personal habits and indoor combustions. Volume 1982 to 2007 and projections to 2010. Asia Pac J 100E A review of human carcinogens. Lyon: IARC; Clin Oncol. 2011;7 (4):325-38. 2012.

November, 2013 23 Nickson C, Mason KE, English DR, Kavanagh 33 Renehan AG, Egger M, Saunders MP, O’Dwyer AM. Mammographic screening and breast cancer ST. Impact on survival of intensive follow up after mortality: a case-control study and meta-analysis. curative resection for colorectal cancer: systematic Cancer Epidemiol Biomarkers Prev. 2012;21 (9):1479- review and meta-analysis of randomised trials. 88. BMJ. 2002;324 (7341):813. 24 White V, Pruden M, Giles G, Collins J, Jamrozik K, 34 Olver I, Grogan P. Early success for Australia’s Inglis G, Boyages J, Hill D. The management of early bowel screening program: let’s move it along. Med breast carcinoma before and after the introduction of J Aust. 2013;198 (6):300-1. clinical practice guidelines. Cancer. 2004;101 (3):476- 35 Lavanchy D. Chronic viral hepatitis as a public 85. health issue in the world. Best Pract Res Clin 25 Canfell K, Banks E, Clements M, Kang YJ, Moa A, Gastroenterol. 2008;22 (6):991-1008. Armstrong B, Beral V. Sustained lower rates of HRT 36 World Cancer Research Fund / American Institute prescribing and breast cancer incidence in Australia for Cancer Research. Food, Nutrition, Physical since 2003. Breast Cancer Res Treat. 2009;117 (3):671- Activity, and the Prevention of Cancer: a Global 3. Perspective. Washington, DC: American Institute 26 Australian Government Department of Health and for Cancer Research; 2007. Ageing. Evaluation of the BreastScreen Australia 37 Yuen MF. Revisiting the natural history of chronic Program – Evaluation Final Report – June 2009. hepatitis B: impact of new concepts on clinical Canberra: Commonwealth of Australia 2009. management. J Gastroenterol Hepatol. 2007;22 27 Vesco KK, Whitlock EP, Eder M, Burda BU, Senger (7):973-6. CA, Lutz K. Risk factors and other epidemiologic 38 Law MG, Roberts SK, Dore GJ, Kaldor JM. Primary considerations for cervical cancer screening: a hepatocellular carcinoma in Australia, 1978-1997: narrative review for the U.S. Preventive Services Task increasing incidence and mortality. Med J Aust. Force. Ann Intern Med. 2011;155 (10):698-705, W216. 2000;173 (8):403-5. 28 World Cancer Research Fund / American Institute for 39 Lo Y-L, Hsiao C-F, Chang G-C, Tsai Y-H, Huang Cancer Research. Continuous Update Project Report. M-S, Su W-C, Chen Y-M, Hsin C-W, Chang C-H, Food, Nutrition, Physical Activity, and the Prevention Yang P-C, Chen C-J, Hsiung C. Risk factors for of Colorectal Cancer. Washington, DC: American primary lung cancer among never smokers by Institute for Cancer Research; 2011. gender in a matched case-control study. Cancer 29 van Wezel T, Middeldorp A, Wijnen JT, Morreau H. A Causes Control. 2013;24 (3):567-76. review of the genetic background and tumour profiling 40 Adair T, Hoy D, Dettrick Z, Lopez A. Reconstruction in familial colorectal cancer. Mutagenesis. 2012;27 of long-term tobacco consumption trends in (2):239-45. Australia and their relationship to lung cancer 30 Australian Cancer Network Colorectal Cancer mortality. Cancer Causes Control. 2011;22 (7):1047- Guidelines Revision Committee. Guidelines for the 53. Prevention, Early Detection and Management of 41 De Matteis S, Consonni D, Pesatori A, Bergen A, Colorectal Cancer. Sydney: The Cancer Council Bertazzi P, Caporaso N, Lubin J, Wacholder S, Australia and Australian Cancer Network; 2005. Landi M. Are women who smoke at higher risk for 31 Clinical Oncological Society of Australia and Australian lung cancer than men who smoke? Am J Epidemiol. Cancer Network. The prevention, early detection 2013;177 (7):601-12. and management of colorectal cancer. Canberra: 42 Dominioni L, Poli A, Mantovani W, Pisani S, Rotolo Commonwealth of Australia; 1999. N, Paolucci M, Sessa F, Conti V, D’Ambrosio V, 32 Jeffery GM, Hickey BE, Hider P. Follow-up strategies Paddeu A, Imperatori A. Assessment of lung cancer for patients treated for non-metastatic colorectal mortality reduction after chest X-ray screening cancer. Cochrane Database Syst Rev. 2002 in smokers: A population-based cohort study in (1):CD002200. Varese, Italy. Lung Cancer. 2013;80 (1):50-4.

Cancer Council NSW • 137 138 • The State of Cancer Control in Australia

43 Couraud S, Cortot A, Greillier L, Gounant V, 52 Nagini S. Carcinoma of the stomach: A review of Mennecier B, Girard N, Besse B, Brouchet L, epidemiology, pathogenesis, molecular genetics Castelnau O, Frappé P, Ferretti G, Guittet L, et and chemoprevention. World J Gastro Oncol. 2012;4 al. From randomized trials to the clinic: is it time (7):156-69. to implement individual lung-cancer screening in 53 IARC Working Group on the Evaluation of clinical practice? A multidisciplinary statement Carcinogenic Risks to Humans. IARC Monographs: from French experts on behalf of the french Biological Agents. Volume 100B A review of human intergroup (IFCT) and the groupe d’Oncologie carcinogens. Lyon: IARC; 2012. de langue francaise (GOLF). Ann Oncol. 2013;24 (3):586 -97. 54 Wang X-Q, Terry P-D, Yan H. Review of salt consumption and stomach cancer risk: 44 Kovalchik SA, Tammemagi M, Berg CD, epidemiological and biological evidence. World J Caporaso NE, Riley TL, Korch M, Silvestri GA, Gastroenterol. 2009;15 (18):2204-13. Chaturvedi AK, Katki HA. Targeting of low-dose CT screening according to the risk of lung-cancer 55 Bonequi P, Meneses-González F, Correa P, Rabkin C, death. N Engl J Med. 2013;369 (3):245-54. Camargo M. Risk factors for gastric cancer in Latin America: a meta-analysis. Cancer Causes Control. 45 Lucas R, McMichael A, Armstrong B, Smith W. 2013;24 (2):217-31. Estimating the global disease burden due to ultraviolet radiation exposure. Int J Epidemiol. 56 Pichandi S, Pasupathi P, Rao Y, Farook J, Ponnusha 2008;37 (3):654-67. B, Ambika A, Subramaniyam S. The effect of smoking on cancer-a review. Int J Biol Med Res. 2011;2 (2):593- 46 Narayanan D, Saladi R, Fox J. Ultraviolet radiation 602. and skin cancer. Int J Dermatol. 2010;49 (9):978- 86. 57 Roder D. The epidemiology of gastric cancer. Gastric Cancer. 2002;5 (Suppl 1):5-11. 47 National Industrial Chemicals Notification and Assessment Scheme. Proposal to adopt the 58 Anderiesz C, Elwood M, Hill DJ. Cancer control policy revised Australian/New Zealand Sunscreen in Australia. Aust NZ Heal Policy. 2006;3:12. Standard (AS/NZS 2604:2012 Sunscreen 59 Burton R, Leowski Jr J, de Courten M. Integrating products – Evaluation and classification) for cancer control with control of other non- cosmetic sunscreen products. Consultation on communicable diseases. In: Elwood JM, Sutcliffe S. Regulatory Impacts – December 2012. Canberra: Cancer Control. New York: Oxford University Press, National Industrial Chemicals Notification and 2010: 399-416. Assessment Scheme; 2012. 60 Zulman D, Sussman J, Chen X, Cigolle C, Blaum C, 48 Hirst N, Gordon L, Scuffham P, Green A. Lifetime Hayward R. Examining the evidence: a systematic cost-effectiveness of skin cancer prevention review of the inclusion and analysis of older adults through promotion of daily sunscreen use. Value in randomized controlled trials. J Gen Intern Med. Health. 2012;15 (2):261-8. 2011;26 (7):783-90. 49 Montague M, Borland R, Sinclair C. Slip! Slop! 61 Van Spall H, Toren A, Kiss A, Fowler R. Eligibility Slap! and SunSmart, 1980-2000: Skin cancer criteria of randomized controlled trials published in control and 20 years of population-based high-impact general medical journals: a systematic campaigning. Health Educ Behav. 2001;28 sampling review. JAMA. 2007;297 (11):1233-40. (3):290-305. 62 Franceschi S, Wild C. Meeting the global demands of 50 Kelley JR, Duggan JM. Gastric cancer epidemiologic transition - The indispensable role of epidemiology and risk factors. J Clin Epidemiol. cancer prevention. Mol Oncol. 2013;7 (1):1-13. 2003;56 (1):1-9. 63 Wang D, Dubois R. Urinary PGE-M: A Promising 51 Compare D, Rocco A, Nardone G. Risk factors Cancer Biomarker. Cancer Prev Res. 2013;6 (6):507- in gastric cancer. Eur Rev Med Pharmacol Sci. 10. 2010;14 (4):302-8.

November, 2013 64 Commonwealth of Australia. Budget 2005-2006 Health 74 Clegg LX, Hankey BF, Tiwari R, Feuer EJ, Edwards 1: Investing in Australia’s health: Strengthening Cancer BK. Estimating average annual per cent change in Care. Canberra: Commonwealth of Australia; 2005. trend analysis. Stat Med. 2009;28 (29):3670-82. 65 Black R, Bray F, Ferlay J, Parkin D. Cancer incidence 75 Kim HJ, Fay MP, Yu B, Barrett MJ, Feuer EJ. and mortality in the European Union: cancer registry Comparability of segmented line regression models. data and estimates of national incidence for 1990. Eur Biometrics. 2004;60 (4):1005-14. J Cancer. 1997;33 (7):1075-107. 76 Seradour B, Allemand H, Weill A, Ricordeau P. 66 Pisani P, Parkin D, Bray F, Ferlay J. Estimates of the Sustained lower rates of breast cancer incidence in worldwide mortality from 25 cancers in 1990. Int J France in 2007. Breast Cancer Res Treat. 2010;121 Cancer. 1999;83 (1):18-29. (3):799-800. 67 Australian Government Department of Health and 77 Autier P, Boniol M, La Vecchia C, Vatten L, Gavin Ageing. National Bowel Cancer Screening Program: A, Hery C, Heanue M. Disparities in breast cancer About the Program. Canberra: Australian Government mortality trends between 30 European countries: Department of Health and Ageing; 2012 [updated June retrospective trend analysis of WHO mortality 14; cited 2012 November 5]; Available from: http:// database. BMJ. 2010;341:c3620. www.cancerscreening.gov.au/internet/screening/ 78 Key TJ, Verkasalo PK, Banks E. Epidemiology of publishing.nsf/Content/bowel-about. breast cancer. Lancet Oncol. 2001;2 (3):133-40. 68 Australian Government Department of Health and 79 Beral V, Reeves G. Childbearing, oral contraceptive Ageing. BreastScreen Australia Program: About use, and breast cancer. Lancet. 1993;341 (8852):1102. the Program. Canberra Australian Government Department of Health and Ageing; 2012 [updated 80 World Cancer Research Fund / American Institute for February 3; cited 2012 November 5]; Available from: Cancer Research. Continuous Update Project Report. http://www.cancerscreening.gov.au/internet/screening/ Food, Nutrition, Physical Activity, and the Prevention publishing.nsf/Content/breastscreen-about. of Breast Cancer. Washington, DC: American Institute for Cancer Research; 2010. 69 Australian Government Department of Health and Ageing. National Cervical Screening Program: About 81 Canfell K, Banks E, Moa AM, Beral V. Decrease in the Program. Canberra: Australian Government breast cancer incidence following a rapid fall in use Department of Health and Ageing; 2009 [updated of hormone replacement therapy in Australia. Med J November 11; cited 2012 November 5]; Available from: Aust. 2008;188 (11):641-4. http://www.cancerscreening.gov.au/internet/screening/ 82 Chlebowski RT, Anderson GL. Changing concepts: publishing.nsf/Content/cervical-about. Menopausal hormone therapy and breast cancer. J 70 Stangelberger A, Waldert M, Djavan B. Prostate cancer Natl Cancer Inst. 2012;104 (7):517-27. in elderly men. Rev Urol. 2008;10 (2):111-9. 83 IARC Working Group on the Evaluation of 71 van de Water W, Markopoulos C, van de Velde C, Carcinogenic Risks to Humans. IARC Monographs: Seynaeve C, Hasenburg A, Rea D, Putter H, Nortier Radiation. Volume 100D A review of human J, de Craen A, Hille E, Bastiaannet E, Hadji P, et al. carcinogens. Lyon: IARC; 2012. Association between age at diagnosis and disease- 84 Ridolfo B, Stevenson C. The quantification of drug- specific mortality among postmenopausal women caused mortality and morbidity in Australia, 1998. with hormone receptor-positive breast cancer. JAMA. Canberra: Australian Institute of Health and Welfare; 2012;307 (6):590-7. 2001 (Drug Statistics Series no.7. Cat. no. PHE 29). 72 Australian Institute of Health and Welfare. Australian 85 Collaborative Group on Hormonal Factors in Breast Cancer Incidence and Mortality books. Canberra: Cancer. Breast cancer and hormonal contraceptives: Australian Institute of Health and Welfare; 2012. collaborative reanalysis of individual data on 53 297 73 Australian Bureau of Statistics. 3105.0.65.001 - women with breast cancer and 100 239 women Australian Historical Population Statistics - Population without breast cancer from 54 epidemiological Age-Sex Structure, Table 4.1 Population (a), age and studies. Lancet. 1996;347 (9017):1713-27. sex, Australia (b), 30 June, 1901 onwards, Data cube: Australian Bureau of Statistics, Canberra, 2008.

Cancer Council NSW • 139 140 • The State of Cancer Control in Australia

86 Urban M, Banks E, Egger S, Canfell K, O’Connell D, 96 Schousboe JT, Kerlikowske K, Loh A, Cummings Beral V, Sitas F. Injectable and oral contraceptive SR. Personalizing mammography by breast use and cancers of the breast, cervix, ovary, and density and other risk factors for breast cancer: endometrium in black South African women: case- analysis of health benefits and cost-effectiveness. control study. PLoS Med. 2012;9 (3):e1001182. Ann Intern Med. 2011;155 (1):10-20. 87 Jung S, Spiegelman D, Baglietto L, Bernstein L, 97 Schopper D, de Wolf C. How effective are Boggs D, van den Brandt P, Buring J, Cerhan J, breast cancer screening programmes by Gaudet M, Giles G, Goodman G, Hakansson N, et al. mammography? Review of the current evidence. Fruit and Vegetable Intake and Risk of Breast Cancer Eur J Cancer. 2009;45 (11):1916-23. by Hormone Receptor Status. J Natl Cancer Inst. 98 Zappa M, Federici A. The potential for 2013;105 (3):219-36. systematic early detection and treatment of 88 Yang XR, Chang-Claude J, Goode EL, Couch breast cancer to reduce the burden of disease FJ, Nevanlinna H, Milne RL, Gaudet M, Schmidt is widely recognized in the European Union (EU). MK, Broeks A, Cox A, Fasching PA, Hein R, et al. Introduction. J Med Screen. 2012;19 (Suppl 1):3- Associations of breast cancer risk factors with tumor 4. subtypes: a pooled analysis from the Breast Cancer 99 Njor S, Nyström L, Moss S, Paci E, Broeders Association Consortium studies. J Natl Cancer Inst. M, Segnan N, Lynge E, Euroscreen Working 2011;103 (3):250-63. Group. Breast cancer mortality in mammographic 89 Thomson CA, Thompson PA. Fruit and Vegetable screening in Europe: a review of incidence-based Intake and Breast Cancer Risk: A Case for Subtype- mortality studies. J Med Screen. 2012;19 (Suppl Specific Risk? J Natl Cancer Inst. 2013;105 (3):164-5. 1):33-41. 90 Broeders M, Moss S, Nyström L, Njor S, Jonsson 100 Burton R, Bell R, Thiagarajah G, Stevenson C. H, Paap E, Massat N, Duffy S, Lynge E, Paci Adjuvant therapy, not mammographic screening, E, Euroscreen Working Group. The impact of accounts for most of the observed breast cancer mammographic screening on breast cancer mortality specific mortality reductions in Australian women in Europe: a review of observational studies. J Med since the national screening program began in Screen. 2012;19 (Suppl 1):14-25. 1991. Breast Cancer Res Treat. 2012;131 (3):949- 55. 91 Moss S, Nyström L, Jonsson H, Paci E, Lynge E, Njor S, Broeders M, Euroscreen Working Group. The 101 Paci E, Euroscreen Working Group. Summary of impact of mammographic screening on breast cancer the evidence of breast cancer service screening mortality in Europe: a review of trend studies. J Med outcomes in Europe and first estimate of the Screen. 2012;19 (Suppl 1):26-32. benefit and harm balance sheet. J Med Screen. 2012;19 (Suppl 1):5-13. 92 Gotzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database Syst Rev. 102 Australian Government. Budget 2013-14: Health 2011 (1):CD001877. and Ageing. Canberra: Commonwealth of Australia; 2013 [updated July 9; cited 2013 July 9]; 93 Jorgensen KJ, Keen JD, Gotzsche PC. Is Available from: http://www.budget.gov.au/2013- mammographic screening justifiable considering its 14/content/bp2/html/bp2_expense-13.htm. substantial overdiagnosis rate and minor effect on mortality? Radiology. 2011;260 (3):621-7. 103 Roder D, Houssami N, Farshid G, Gill G, Luke C, Downey P, Beckmann K, Iosifidis P, Grieve L, 94 Independent UK Panel on Breast Cancer Screening. Williamson L. Population screening and intensity The benefits and harms of breast cancer screening: of screening are associated with reduced an independent review. Lancet. 2012;380 (9855):1778- breast cancer mortality: evidence of efficacy of 86. mammography screening in Australia. Breast 95 Puliti D, Duffy S, Miccinesi G, de Koning H, Lynge Cancer Res Treat. 2008;108 (3):409-16. E, Zappa M, Paci E, Euroscreen Working Group. 104 Holmes MD, Chen WY, Li L, Hertzmark E, Overdiagnosis in mammographic screening for breast Spiegelman D, Hankinson SE. Aspirin intake and cancer in Europe: a literature review. J Med Screen. survival after breast cancer. J Clin Oncol. 2010;28 2012;19 (Suppl 1):42-56. (9):1467-72.

November, 2013 105 Davies C, Pan H, Godwin J, Gray R, Arriagada R, Raina 115 de Martel C, Ferlay J, Franceschi S, Vignat J, Bray V, Abraham M, Alencar V, Badran A, Bonfill X, Bradbury F, Forman D, Plummer M. Global burden of cancers J, Clarke M, et al. Long-term effects of continuing attributable to infections in 2008: a review and adjuvant tamoxifen to 10 years versus stopping at 5 synthetic analysis. Lancet Oncol. 2012;13 (6):607- years after diagnosis of oestrogen receptor-positive 15. breast cancer: ATLAS, a randomised trial. Lancet. 116 Australian Institute of Health and Welfare. Cervical 2013;381:805-16. screening in Australia 2009–2010. Canberra 106 Luke C, Gill G, Birrell S, Humeniuk V, Borg M, Karapetis Australian Institute of Health and Welfare 2012 C, Koczwara B, Olver I, Penniment M, Pittman K, Price (Cancer series 67. Cat. no. CAN 63). T, Walsh D, et al. Treatment and survival from breast 117 Aminisani N, Armstrong BK, Egger S, Canfell K. cancer: the experience of patients at South Australian Impact of organised cervical screening on cervical teaching hospitals between 1977 and 2003. J Eval Clin cancer incidence and mortality in migrant women Pract. 2007;13 (2):212-20. in Australia. BMC Cancer. 2012;12 (1):491. 107 Soerjomataram I, Louwman MW, Ribot JG, Roukema 118 Smith JS, Green J, Berrington de Gonzalez A, JA, Coebergh JW. An overview of prognostic factors for Appleby P, Peto J, Plummer M, Franceschi S, long-term survivors of breast cancer. Breast Cancer Res Beral V. Cervical cancer and use of hormonal Treat. 2008;107 (3):309-30. contraceptives: a systematic review. Lancet. 108 Kwan ML, Kushi LH, Weltzien E, Tam EK, Castillo 2003;361 (9364):1159-67. A, Sweeney C, Caan BJ. Alcohol consumption and 119 Moreno V, Bosch FX, Munoz N, Meijer CJ, Shah breast cancer recurrence and survival among women KV, Walboomers JM, Herrero R, Franceschi S, with early-stage breast cancer: the life after cancer International Agency for Research on Cancer. epidemiology study. J Clin Oncol. 2010;28 (29):4410-6. Multicentric Cervical Cancer Study Group. Effect 109 Ferlay J, Hery C, Autier P, Sankaranarayanan R. Global of oral contraceptives on risk of cervical cancer Burden of Breast Cancer. In: Li C. Breast Cancer in women with human papillomavirus infection: Epidemiology. New York: Springer, 2010. the IARC multicentric case-control study. Lancet. 2002;359 (9312):1085-92. 110 Wani SQ, Khan T, Teeli AM, HKhan NA, Wani SY, Ashfaq-ul-Hassan. Quality of life assessment in 120 Miller K, Blumenthal P, Blanchard K. Oral survivors of breast cancer. J Cancer Res Ther. 2012;8 contraceptives and cervical cancer: critique of a (2):272-6. recent review. Contraception. 2004;69 (5):347-51. 111 Mols F, Vingerhoets AJ, Coebergh JW, van de Poll- 121 Markowitz LE, Tsu V, Deeks SL, Cubie H, Wang SA, Franse LV. Quality of life among long-term breast cancer Vicari AS, Brotherton JM. Human papillomavirus survivors: a systematic review. Eur J Cancer. 2005;41 vaccine introduction--the first five years. Vaccine. (17):2613-9. 2012;30 (Suppl 5):F139-48. 112 Howard-Anderson J, Ganz PA, Bower JE, Stanton 122 Einstein MH, Baron M, Levin MJ, Chatterjee A, AL. Quality of life, fertility concerns, and behavioral Edwards RP, Zepp F, Carletti I, Dessy FJ, Trofa health outcomes in younger breast cancer survivors: a AF, Schuind A, Dubin G, HPV-010 Study Group. systematic review. J Natl Cancer Inst. 2012;104 (5):386- Comparison of the immunogenicity and safety of 405. Cervarix and Gardasil human papillomavirus (HPV) cervical cancer vaccines in healthy women aged 113 Australian Institute of Health and Welfare & Cancer 18-45 years. Hum Vaccin. 2009;5 (10):705-19. Australia. Breast cancer in Australia: an overview. Canberra Australian Institute of Health and Welfare 2012 123 Tomljenovic L, Wilyman J, Vanamee E, Bark T, (Cancer series no. 71. Cat. no. CAN 67). Shaw C. HPV vaccines and cancer prevention, science versus activism. Infect Agent Cancer. 114 Roder D. Impact of population screening programs on 2013;8 (1):6. cancer outcomes. CancerForum. 2012;36 (1):4 -10.

Cancer Council NSW • 141 142 • The State of Cancer Control in Australia

124 Rey-Ares L, Ciapponi A, Pichon-Riviere A. Efficacy 133 Paavonen J, Naud P, Salmeron J, Wheeler CM, and safety of human papillomavirus vaccine in cervical Chow SN, Apter D, Kitchener H, Castellsague X, cancer prevention: systematic review and meta- Teixeira JC, Skinner SR, Hedrick J, Jaisamrarn U, analysis. Arch Argent Pediatr. 2012;110 (6):483-9. et al. Efficacy of human papillomavirus (HPV)- 16/18 AS04-adjuvanted vaccine against cervical 125 Romanowski B, de Borba PC, Naud PS, Roteli-Martins infection and precancer caused by oncogenic CM, De Carvalho NS, Teixeira JC, Aoki F, Ramjattan HPV types (PATRICIA): final analysis of a double- B, Shier RM, Somani R, Barbier S, Blatter MM, et al. blind, randomised study in young women. Lancet. Sustained efficacy and immunogenicity of the human 2009;374 (9686):301-14. papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine: analysis of a randomised placebo-controlled trial up to 134 Canfell K, Chesson H, Kulasingam SL, Berkhof J, 6.4 years. Lancet. 2009;374 (9706):1975-85. Diaz M, Kim JJ. Modeling preventative strategies against human papillomavirus-related disease 126 Villa LL, Costa RL, Petta CA, Andrade RP, Paavonen in developed countries. Vaccine. 2012;30 (Suppl J, Iversen OE, Olsson SE, Hoye J, Steinwall M, 5):F157- 67. Riis-Johannessen G, Andersson-Ellstrom A, Elfgren K, et al. High sustained efficacy of a prophylactic 135 Georgousakis M, Jayasinghe S, Brotherton quadrivalent human papillomavirus types 6/11/16/18 L1 J, Gilroy N, Chiu C, Macartney K. Population- virus-like particle vaccine through 5 years of follow-up. wide vaccination against human papillomavirus Brit J Cancer. 2006;95 (11):1459-66. in adolescent boys: Australia as a case study. Lancet Infect Dis. 2012;12 (8):627-34. 127 Leval A, Herweijer E, Ploner A, Eloranta S, Fridman Simard J, Dillner J, Young C, Netterlid E, Sparén 136 Australian Government Department of Health P, Arnheim-Dahlström L. Quadrivalent Human and Ageing. Immunise Australia Program: Human Papillomavirus Vaccine Effectiveness: A Swedish Papillomavirus (HPV). Canberra Australian National Cohort Study. J Natl Cancer Inst. 2013;105 Government Department of Health and Ageing; (7):469-74. 2013 [updated February 14; cited 2013 April 18]; Available from: http://www.immunise.health.gov. 128 Donovan B, Franklin N, Guy R, Grulich A, Regan au/internet/immunise/publishing.nsf/Content/ D, Ali H, Wand H, Fairley C. Quadrivalent human immunise-hpv. papillomavirus vaccination and trends in genital warts in Australia: analysis of national sentinel surveillance 137 Brill D. Australia launches national scheme to data. Lancet Infect Dis. 2011;11 (1):39-44. vaccinate boys against HPV. BMJ. 2013;346 (Feb 12):f924. 129 Ali H, Guy R, Wand H, Read T, Regan D, Grulich A, Fairley C, Donovan B. Decline in in-patient treatments 138 Marra F, Cloutier K, Oteng B, Marra C, Ogilvie G. of genital warts among young Australians following the Effectiveness and cost effectiveness of human national HPV vaccination program. BMC Infect Dis. papillomavirus vaccine: a systematic review. 2013;13 (1):140. Pharmacoeconomics. 2009;27 (2):127-47. 130 Brotherton JM, Fridman M, May CL, Chappell G, 139 Chesson HW, Ekwueme DU, Saraiya M, Dunne Saville AM, Gertig DM. Early effect of the HPV EF, Markowitz LE. The cost-effectiveness of male vaccination programme on cervical abnormalities HPV vaccination in the United States. Vaccine. in Victoria, Australia: an ecological study. Lancet. 2011;29 (46):8443-50. 2011;377 (9783):2085-92. 140 Kim JJ. Targeted human papillomavirus 131 Peralta-Zaragoza O, Bermudez-Morales VH, Perez- vaccination of men who have sex with men in the Plasencia C, Salazar-Leon J, Gomez-Ceron C, Madrid- USA: a cost-effectiveness modelling analysis. Marina V. Targeted treatments for cervical cancer: a Lancet Infect Dis. 2010;10 (12):845-52. review. Onco Targets Ther. 2012;5:315-28. 141 Taylor R, Morrell S, Mamoon H, Wain G, Ross J. 132 Hildesheim A, Herrero R, Wacholder S, Rodriguez AC, Decline in cervical cancer incidence and mortality Solomon D, Bratti MC, Schiller JT, Gonzalez P, Dubin in New South Wales in relation to control activities G, Porras C, Jimenez SE, Lowy DR. Effect of human (Australia). Cancer Causes Control. 2006;17 papillomavirus 16/18 L1 viruslike particle vaccine (3):299-306. among young women with preexisting infection: a randomized trial. JAMA. 2007;298 (7):743-53.

November, 2013 142 Creighton P, Lew JB, Clements M, Smith M, Howard 151 Medical Services Advisory Committee. Human K, Dyer S, Lord S, Canfell K. Cervical cancer papillomavirus testing in women with cytological screening in Australia: modelled evaluation of the prediction of low-grade abnormality. Canberra: impact of changing the recommended interval from Commonwealth of Australia; 2003. two to three years. BMC Public Health. 2010;10:734. 152 Zagouri F, Sergentanis TN, Chrysikos D, Filipits M, 143 IARC Working Group on the Evaluation of Cancer. Bartsch R. Molecularly targeted therapies in cervical IARC Handbooks of Cancer Prevention Volume 10: cancer. A systematic review. Gynecol Oncol. 2012;126 Cervix Cancer Screening. Lyon, France: IARC Press (2):291-303. 2005. 153 Ashing-Giwa KT, Lim JW, Tang J. Surviving cervical 144 Canfell K, Sitas F, Beral V. Cervical cancer in cancer: does health-related quality of life influence Australia and the United Kingdom: comparison of survival? Gynecol Oncol. 2010;118 (1):35-42. screening policy and uptake, and cancer incidence 154 Zeng YC, Ching SS, Loke AY. Quality of life in cervical and mortality. Med J Aust. 2006;185 (9):482-6. cancer survivors: a review of the literature and 145 Australian Government Department of Health and directions for future research. Oncol Nurs Forum. Ageing. National Cervical Screening Program 2011;38 (2):E107-17. Renewal. Canberra Australian Government 155 Yusof AS, Isa ZM, Shah SA. Dietary patterns and risk Department of Health and Ageing 2012 [updated of colorectal cancer: a systematic review of cohort 22 November; cited 2013 19 March ]; Available studies (2000-2011). Asian Pac J Cancer Prev. 2012;13 from: http://www.cancerscreening.gov.au/internet/ (9):4713-7. screening/publishing.nsf/Content/ncsp-renewal. 156 Blanke CD, Bot BM, Thomas DM, Bleyer A, Kohne 146 Australian Institute of Health and Welfare & Cancer CH, Seymour MT, de Gramont A, Goldberg RM, Australia. Gynaecological cancers in Australia: an Sargent DJ. Impact of young age on treatment efficacy overview. Canberra Australian Institute of Health and and safety in advanced colorectal cancer: a pooled Welfare 2012 (Cancer series no. 70. Cat. no. CAN analysis of patients from nine first-line phase III 66). chemotherapy trials. J Clin Oncol. 2011;29 (20):2781-6. 147 Lew JB, Howard K, Gertig D, Smith M, Clements M, 157 Magalhaes B, Peleteiro B, Lunet N. Dietary patterns Nickson C, Shi JF, Dyer S, Lord S, Creighton P, Kang and colorectal cancer: systematic review and meta- YJ, Tan J, et al. Expenditure and resource utilisation analysis. Eur J Cancer Prev. 2012;21 (1):15-23. for cervical screening in Australia. BMC Health Serv Res. 2012;12:446. 158 Egeberg R, Olsen A, Christensen J, Halkjær J, Jakobsen M, Overvad K, Tjønneland A. Associations 148 Canfell K, Lew J, Clements M, Smith M, Harris J, between Red Meat and Risks for Colon and Rectal Simonella L, Nickson C, Walker R, Neal H, Lewis H. Cancer Depend on the Type of Red Meat Consumed. J Impact of HPV vaccination on cost-effectiveness Nutrit. 2013;143 (4):464-72. of existing screening programs: Example from New Zealand 28th International Human Papillomavirus 159 Park Y, Hunter DJ, Spiegelman D, Bergkvist L, Conference & Clinical and Public Health Workshops Berrino F, van den Brandt PA, Buring JE, Colditz GA, San Juan, Puerto Rico, 2012. Freudenheim JL, Fuchs CS, Giovannucci E, Goldbohm RA, et al. Dietary fiber intake and risk of colorectal 149 Dillner J, Rebolj M, Birembaut P, Petry KU, cancer: a pooled analysis of prospective cohort Szarewski A, Munk C, de Sanjose S, Naucler P, studies. JAMA. 2005;294 (22):2849-57. Lloveras B, Kjaer S, Cuzick J, van Ballegooijen M, et al. Long term predictive values of cytology and 160 Aune D, Lau R, Chan DS, Vieira R, Greenwood DC, human papillomavirus testing in cervical cancer Kampman E, Norat T. Dairy products and colorectal screening: joint European cohort study. BMJ. cancer risk: a systematic review and meta-analysis of 2008;337:a1754. cohort studies. Ann Oncol. 2012;23 (1):37-45. 150 Franco EL, de Sanjosé S, Broker TR, Stanley MA, 161 Thosani N, Thosani S, Kumar S, Nugent Z, Jimenez C, Chevarie-Davis M, Isidean SD, Schiffman M. Human Singh H, Guha S. Reduced risk of colorectal cancer Papillomavirus and Cancer Prevention: Gaps in with use of oral bisphosphonates: a systematic review Knowledge and Prospects for Research, Policy, and and meta-analysis. J Clin Oncol. 2013;31 (5):623-30. Advocacy. Vaccine. 2012;30 (Suppl 5):F175-82.

Cancer Council NSW • 143 144 • The State of Cancer Control in Australia

162 Parr C, Hjartåker A, Lund E, Veierød M. Meat 171 Tsoi KK, Pau CY, Wu WK, Chan FK, Griffiths intake, cooking methods, and risk of proximal S, Sung JJ. Cigarette smoking and the risk of colon, distal colon, and rectal cancer: The colorectal cancer: a meta-analysis of prospective Norwegian Women and Cancer (NOWAC) cohort cohort studies. Clin Gastroenterol Hepatol. 2009;7 study. Int J Cancer. 2013;EPub Feb 8. (6):682-8. 163 Zhu Y, Wu H, Wang P, Savas S, Woodrow J, Wish 172 Zhao J, Halfyard B, Roebothan B, West R, Buehler T, Jin R, Green R, Woods M, Roebothan B, Buehler S, Sun Z, Squires J, McLaughlin JR, Parfrey S, Dicks E, et al. Dietary patterns and colorectal PS, Wang PP. Tobacco smoking and colorectal cancer recurrence and survival: a cohort study. cancer: a population-based case-control study in BMJ Open. 2013;3 (2):e002270. Newfoundland and Labrador. Can J Public Health. 164 Haydon AM, Macinnis R, English D, Giles G. Effect 2010;101 (4):281-9. of physical activity and body size on survival after 173 Hansen RD, Albieri V, Tjonneland A, Overvad K, diagnosis with colorectal cancer. Gut. 2006;55 Andersen KK, Raaschou-Nielsen O. Effects of (1):62-7. Smoking and Antioxidant Micronutrients on Risk 165 Agnoli C, Grioni S, Sieri S, Palli D, Masala G, of Colorectal Cancer. Clin Gastroenterol Hepatol. Sacerdote C, Vineis P, Tumino R, Giurdanella 2013;11 (4):406–15. M, Pala V, Berrino F, Mattiello A, et al. Italian 174 Spence RR, Heesch KC, Brown WJ. A systematic mediterranean index and risk of colorectal cancer review of the association between physical activity in the Italian section of the EPIC cohort. Int J and colorectal cancer risk. Scand J Med Sci Cancer. 2013;132 (6):1404-11. Sports. 2009;19 (6):764-81. 166 Andersen V, Holst R, Vogel U. Systematic review: 175 Kuiper J, Phipps A, Neuhouser M, Chlebowski R, diet-gene interactions and the risk of colorectal Thomson C, Irwin M, Lane D, Wactawski-Wende cancer. Aliment Pharmacol Ther. 2012;37 (4):383- J, Hou L, Jackson R, Kampman E, Newcomb P. 91. Recreational physical activity, body mass index, 167 Cho E, Smith-Warner SA, Ritz J, van den Brandt and survival in women with colorectal cancer. PA, Colditz GA, Folsom AR, Freudenheim JL, Cancer Causes Control. 2012;23 (12):1939-48. Giovannucci E, Goldbohm RA, Graham S, 176 Jiao L, Duan Z, Sangi-Haghpeykar H, Hale L, White Holmberg L, Kim DH, et al. Alcohol intake and D, El-Serag H. Sleep duration and incidence of colorectal cancer: a pooled analysis of 8 cohort colorectal cancer in postmenopausal women. Brit J studies. Ann Intern Med. 2004;140 (8):603-13. Cancer. 2013;108 (1):213-21. 168 Li G, Ma D, Zhang Y, Zheng W, Wang P. Coffee 177 IARC Working Group on the Evaluation of consumption and risk of colorectal cancer: a meta- Carcinogenic Risks to Humans. IARC Monographs: analysis of observational studies. Public Health Arsenic, Metals, Fibres and Dusts. Volume 100C A Nutr. 2013;16 (2):346-57. review of human carcinogens. Lyon: IARC; 2012. 169 Aune D, Chan DS, Lau R, Vieira R, Greenwood DC, 178 Chan AT, Giovannucci EL. Primary prevention of Kampman E, Norat T. Carbohydrates, glycemic colorectal cancer. Gastroenterology. 2010;138 index, glycemic load, and colorectal cancer risk: (6):2029-43. a systematic review and meta-analysis of cohort studies. Cancer Causes Control. 2012;23 (4):521- 179 Squires H, Tappenden P, Cooper K, Carroll C, 35. Logan R, Hind D. Cost-effectiveness of aspirin, celecoxib, and calcium chemoprevention for 170 Gong J, Hutter C, Baron JA, Berndt S, Caan colorectal cancer. Clin Ther. 2011;33 (9):1289-305. B, Campbell PT, Casey G, Chan AT, Cotterchio M, Fuchs CS, Gallinger S, Giovannucci E, et al. 180 van Dam L, Kuipers EJ, Steyerberg EW, van A pooled analysis of smoking and colorectal Leerdam ME, de Beaufort ID. The price of cancer: timing of exposure and interactions autonomy: should we offer individuals a choice of with environmental factors. Cancer Epidemiol colorectal cancer screening strategies? Lancet Biomarkers Prev. 2012;21 (11):1974-85. Oncol. 2013;14 (1):e38-46.

November, 2013 181 Pizzo E, Pezzoli A, Stockbrugger R, Bracci E, 191 Caravati-Jouvenceaux A, Launoy G, Klein D, Vagnoni E, Gullini S. Screenee perception and Henry-Amar M, Abeilard E, Danzon A, Pozet A, health-related quality of life in colorectal cancer Velten M, Mercier M. Health-related quality of life screening: a review. Value Health. 2011;14 (1):152-9. among long-term survivors of colorectal cancer: 182 Lansdorp-Vogelaar I, Knudsen AB, Brenner H. a population-based study. Oncologist. 2011;16 Cost-effectiveness of colorectal cancer screening. (11):1626-36. Epidemiol Rev. 2011;33 (1):88-100. 192 Lin KY, Shun SC, Lai YH, Liang JT, Tsauo JY. 183 Pignone MP, Flitcroft KL, Howard K, Trevena Comparison of the Effects of a Supervised Exercise LJ, Salkeld GP, St John DJ. Costs and cost- Program and Usual Care in Patients With Colorectal effectiveness of full implementation of a biennial Cancer Undergoing Chemotherapy. Cancer Nurs. faecal occult blood test screening program for bowel 2013;EPub Jan 25. cancer in Australia. Med J Aust. 2011;194 (4):180-5. 193 Courtney R, Paul C, Carey M, Sanson-Fisher R, 184 Flitcroft KL, Salkeld GP, Gillespie JA, Trevena LJ, Macrae F, D Este C, Hill D, Barker D, Simmons Irwig LM. Fifteen years of bowel cancer screening J. A population-based cross-sectional study of policy in Australia: putting evidence into practice? colorectal cancer screening practices of first- Med J Aust. 2010;193 (1):37-42. degree relatives of colorectal cancer patients. BMC Cancer. 2013;13 (1):13. 185 Cole S, Tucker G, Osborne J, Byrne S, Bampton P, Fraser R, Young G. Shift to earlier stage at diagnosis 194 Ananda S, McLaughlin S, Chen F, Hayes I, Hunter as a consequence of the National Bowel Cancer A, Skinner I, Steel M, Jones I, Hastie I, Rieger Screening Program. Med J Aust. 2013;198 (6):327-30. N, Shedda S, Compston D, et al. Initial impact of Australia’s National Bowel Cancer Screening 186 Australian Institute of Health and Welfare. National Program. Med J Aust. 2009;191 (7):378-81. Bowel Cancer Screening Program monitoring report: July 2011–June 2012. Canberra: Australian Institute 195 Nordenstedt H, White DL, El-Serag HB. The of Health and Welfare; 2013 (Cancer series no. 75. changing pattern of epidemiology in hepatocellular Cat. no. CAN 71). carcinoma. Digest Liver Dis. 2010;42 (Suppl 3):S206-S14. 187 Bokemeyer C, Van Cutsem E, Rougier P, Ciardiello F, Heeger S, Schlichting M, Celik I, Kohne CH. 196 Chuang SC, La Vecchia C, Boffetta P. Liver cancer: Addition of cetuximab to chemotherapy as first-line descriptive epidemiology and risk factors other treatment for KRAS wild-type metastatic colorectal than HBV and HCV infection. Cancer Lett. 2009;286 cancer: pooled analysis of the CRYSTAL and OPUS (1):9-14. randomised clinical trials. Eur J Cancer. 2012;48 197 Tandon P, Garcia-Tsao G. Prognostic indicators in (10):1466-75. hepatocellular carcinoma: a systematic review of 72 188 Australian Cancer Network Colorectal Cancer studies. Liver Int. 2009;29 (4):502-10. Guidelines Revision Committee. Clinical practice 198 Alves RCP, Alves D, Guz B, Matos C, Viana M, guidelines for the prevention, early detection and Harriz M, Terrabuio D, Kondo M, Gampel O, Polletti management of colorectal cancer. Sydney: Cancer P. Advanced hepatocellular carcinoma. Review of Council Australia and Australian Cancer Network; targeted molecular drugs. Ann Hepatol. 2011;10 2005. (1):21-7. 189 Chambers SK, Meng X, Youl P, Aitken J, Dunn J, 199 Hepatitis B Foundation. Hepatitis B and Primary Baade P. A five-year prospective study of quality of Liver Cancer. 2013 [updated February 18; cited life after colorectal cancer. Qual Life Res. 2012;21 2013 February 18]; Available from: http://www.hepb. (9):1551-64. org/professionals/hepb_and_liver_cancer.htm. 190 Grimmett C, Bridgewater J, Steptoe A, Wardle J. 200 Schiff ER. Prevention of mortality from hepatitis B Lifestyle and quality of life in colorectal cancer and hepatitis C. Lancet. 2006;368 (9539):896-7. survivors. Qual Life Res. 2011;20 (8):1237-45. 201 Heckley G, Jarl J, Asamoah B, G-Gerdtham U. How the risk of liver cancer changes after alcohol cessation: a review and meta-analysis of the current literature. BMC Cancer. 2011;11:446.

Cancer Council NSW • 145 146 • The State of Cancer Control in Australia

202 Rehm J, Samokhvalov A, Shield K. Global burden of 212 IARC Working Group on the Evaluation of alcoholic liver diseases. J Hepatol. 2013;59 (1):160- Carcinogenic Risks to Humans. IARC Monographs: 8. Chemical agents and related occupations. Volume 100F A review of human carcinogens. Lyon: IARC; 203 Heffernan M, Garland S, Kane M. Global reduction 2012. of cervical cancer with human papillomavirus vaccines: insights from the hepatitis B virus vaccine 213 Bouvard V, Baan R, Straif K, Grosse Y, Secretan experience. Sex Health. 2010;7 (3):383-90. B, El Ghissassi F, Benbrahim-Tallaa L, Guha N, Freeman C, Galichet L, Cogliano V. A review of 204 Nguyen VT, Razali K, Amin J, Law M, Dore G. human carcinogens--Part B: biological agents. Estimates and projections of hepatitis B-related Lancet Oncol. 2009;10 (4):321-2. hepatocellular carcinoma in Australia among people born in Asia-Pacific countries. J Gastoen Hepatol. 214 Brandi G, Di Girolamo S, Farioli A, de Rosa F, 2008;23 (6):922-9. Curti S, Pinna A, Ercolani G, Violante F, Biasco G, Mattioli S. Asbestos: a hidden player behind 205 Union for International Cancer Control. Protection the cholangiocarcinoma increase? Findings from against cancer-causing infections: World Cancer a case-control analysis. Cancer Causes Control. Campaign 2010. Geneva: UICC 2010. 2013;24 (5):911-8. 206 Wakeham K, Newton R, Sitas F. Cancer in the 215 Fisher D, Huffam S. Management of chronic Tropics. In: Magill AJ RE, Hill DR, Solomon T hepatitis B virus infection in remote-dwelling Hunter’s Tropical Medicine and Emerging Infectious Aboriginals and Torres Strait Islanders: an update Diseases, 9th. London: Elsevier, 2013. for primary healthcare providers. Med J Aust. 207 Bravi F, Bosetti C, Tavani A, La Vecchia C. Coffee 2003;178 (2):82-5. drinking and hepatocellular carcinoma: an update. 216 Commonwealth of Australia. National Hepatitis B Hepatology. 2009;50 (4):1317-8. Strategy 2010–2013. In: Australian Government 208 Inoue M, Kurahashi N, Iwasaki M, Shimazu T, Department of Health and Ageing, ed. Canberra: Tanaka Y, Mizokami M, Tsugane S, Japan Public Commonwealth of Australia, 2010. Health Center-Based Prospective Study Group. 217 Commonwealth of Australia. Third National Effect of coffee and green tea consumption on the Hepatitis C Strategy 2010–2013. In: Australian risk of liver cancer: cohort analysis by hepatitis virus Government Department of Health and Ageing, ed. infection status. Cancer Epidemiol Biomarkers Prev. Canberra: Commonwealth of Australia, 2010. 2009;18 (6):1746-53. 218 Cancer Council NSW. An agenda for cancer control 209 Leung W, Ho S, Chan H, Wong V, Yeo W, Mok T. – 2011 and beyond. Sydney: Cancer Council NSW Moderate coffee consumption reduces the risk of 2010. hepatocellular carcinoma in hepatitis B chronic carriers: a case-control study. J Epidemiol Commun 219 Cabibbo G, Craxi A. Epidemiology, risk factors and Health. 2011;65 (6):556-8. surveillance of hepatocellular carcinoma. Eur Rev Med Pharmacol Sci. 2010;14:352-5. 210 Shimazu T, Tsubono Y, Kuriyama S, Ohmori K, Koizumi Y, Nishino Y, Shibuya D, Tsuji I. Coffee 220 Bridges JF, Joy SM, Gallego G, Kudo M, Ye consumption and the risk of primary liver cancer: SL, Han KH, Cheng AL, Blauvelt BM. Needs for pooled analysis of two prospective studies in hepatocellular carcinoma control policy in the Asia- Japan. Int J Cancer. 2005;116 (1):150-4. Pacific region. Asian Pac J Cancer Prev. 2011;12 (10):2585-91. 211 Wang C, Wang X, Gong G, Ben Q, Qiu W, Chen Y, Li G, Wang L. Increased risk of hepatocellular 221 Sherman M. Pathogenesis and screening for carcinoma in patients with diabetes mellitus: a hepatocellular carcinoma. Clin Liver Dis. 2004;8 systematic review and meta-analysis of cohort (2):419-43. studies. Int J Cancer. 2012;130 (7):1639-48. 222 Gastroenterological Society of Australia and Digestive Health Foundation. Australian and New Zealand chronic hepatitis B (CHB) recommendations. Clinical update; 2008.

November, 2013 223 Tiong L, Maddern G. Systematic review and meta- 233 Thun M, Carter B, Feskanich D, Freedman N, analysis of survival and disease recurrence after Prentice R, Lopez A, Hartge P, Gapstur S. 50-year radiofrequency ablation for hepatocellular carcinoma. trends in smoking-related mortality in the United Brit J Surg. 2011;98 (9):1210-24. States. N Engl J Med. 2013;368 (4):351-64. 224 Robotin M. Randomised Controlled Trials in the Primary 234 Mu L, Liu L, Niu R, Zhao B, Shi J, Li Y, Swanson M, Treatment of Hepatocellular Carcinoma. In: Qiao L, Li Y, Scheider W, Su J, Chang SC, Yu S, Zhang ZF. Indoor Yan X, George J. Molecular aspects of hepatocellular air pollution and risk of lung cancer among Chinese carcinoma: Bentham E-Books, 2012: 174-95. female non-smokers. Cancer Causes Control. 2013;24 (3):439-50. 225 Peng ZW, Zhang YJ, Chen MS, Xu L, Liang HH, Lin XJ, Guo RP, Zhang YQ, Lau WY. Radiofrequency 235 Sakata R, McGale P, Grant EJ, Ozasa K, Peto R, ablation with or without transcatheter arterial Darby SC. Impact of smoking on mortality and life chemoembolization in the treatment of hepatocellular expectancy in Japanese smokers: a prospective carcinoma: a prospective randomized trial. J Clin Oncol. cohort study. BMJ. 2012;345:e7093. 2013;31 (4):426-32. 236 Tammemagi CM, Pinsky PF, Caporaso NE, Kvale 226 Fan SY, Eiser C, Ho MC, Lin CY. Health-related quality PA, Hocking WG, Church TR, Riley TL, Commins J, of life in patients with hepatocellular carcinoma: the Oken MM, Berg CD, Prorok PC. Lung cancer risk mediation effects of illness perceptions and coping. prediction: Prostate, Lung, Colorectal And Ovarian Psychooncology. 2013;22 (6):1353-60. Cancer Screening Trial models and validation. J Natl Cancer Inst. 2011;103 (13):1058-68. 227 Brunocilla P, Brunello F, Carucci P, Gaia S, Rolle E, Cantamessa A, Castiglione A, Ciccone G, Rizzetto M. 237 Matakidou A, Eisen T, Houlston RS. Systematic Sorafenib in hepatocellular carcinoma: prospective review of the relationship between family history and study on adverse events, quality of life, and related lung cancer risk. Brit J Cancer. 2005;93 (7):825-33. feasibility under daily conditions. Med Oncol. 2013;30 238 Brinton LA, Gierach GL, Andaya A, Park Y, Schatzkin (1):345. A, Hollenbeck AR, Spitz MR. Reproductive and 228 Alonso E, Limbers C, Neighbors K, Martz K, Bucuvalas hormonal factors and lung cancer risk in the J, Webb T, Varni J, Studies of Pediatric Liver NIH-AARP Diet and Health Study cohort. Cancer Transplantation (SPLIT) Functional Outcomes Group. Epidemiol Biomarkers Prev. 2011;20 (5):900-11. Cross-sectional analysis of health-related quality of 239 Pesatori AC, Carugno M, Consonni D, Caporaso NE, life in pediatric liver transplant recipients. J Pediatr. Wacholder S, Tucker M, Landi MT. Reproductive and 2010;156 (2):270-60. hormonal factors and the risk of lung cancer: The 229 Mohammad S, Hormaza L, Neighbors K, Boone P, EAGLE study. Int J Cancer. 2013;132 (11):2630-9. Tierney M, Azzam R, Butt Z, Alonso E. Health status 240 Punturieri A, Szabo E, Croxton TL, Shapiro SD, in young adults two decades after pediatric liver Dubinett SM. Lung cancer and chronic obstructive transplantation. Am J Transplantation. 2012;12 (6):1486- pulmonary disease: needs and opportunities for 95. integrated research. J Natl Cancer Inst. 2009;101 230 Australian Government Department of Health and (8):554-9. Ageing. Immunise Australia Program: Hepatitis B. 241 Brenner DR, McLaughlin JR, Hung RJ. Previous lung Canberra Australian Government Department of diseases and lung cancer risk: a systematic review Health and Ageing; 2011 [updated May 18; cited 2012 and meta-analysis. PLoS One. 2011;6 (3):e17479. November 5]; Available from: http://www.immunise. health.gov.au/internet/immunise/publishing.nsf/ 242 Brenner DR, Boffetta P, Duell EJ, Bickeboller H, Content/immunise-hepb. Rosenberger A, McCormack V, Muscat JE, Yang P, Wichmann HE, Brueske-Hohlfeld I, Schwartz AG, 231 Hepatitis Australia. Purpose. 2013 [updated June Cote ML, et al. Previous lung diseases and lung 17; cited 2013 July 1]; Available from: http://www. cancer risk: a pooled analysis from the International hepatitisaustralia.com/purpose/. Lung Cancer Consortium. Am J Epidemiol. 2012;176 232 Thun MJ, Henley SJ, Burns D, Jemal A, Shanks (7):573-85. TG, Calle EE. Lung cancer death rates in lifelong nonsmokers. J Natl Cancer Inst. 2006;98 (10):691-9.

Cancer Council NSW • 147 148 • The State of Cancer Control in Australia

243 Koutsokera A, Kiagia M, Saif M, Souliotis K, Syrigos 253 Barone-Adesi F, Chapman RS, Silverman DT, He K. Nutrition Habits, Physical Activity, and Lung X, Hu W, Vermeulen R, Ning B, Fraumeni JF, Jr., Cancer: An Authoritative Review. Clin Lung Cancer. Rothman N, Lan Q. Risk of lung cancer associated 2013;14 (4):342-50. with domestic use of coal in Xuanwei, China: retrospective cohort study. BMJ. 2012;345:e5414. 244 Wakai K, Matsuo K, Nagata C, Mizoue T, Tanaka K, Tsuji I, Sasazuki S, Shimazu T, Sawada N, Inoue 254 Tang L, Lim WY, Eng P, Leong SS, Lim TK, Ng AW, M, Tsugane S. Lung cancer risk and consumption Tee A, Seow A. Lung cancer in Chinese women: of vegetables and fruit: an evaluation based on a evidence for an interaction between tobacco systematic review of epidemiological evidence from smoking and exposure to inhalants in the indoor Japan. Jpn J Clin Oncol. 2011;41 (5):693-708. environment. Environ Health Perspect. 2010;118 (9):1257-60. 245 Wright ME, Park Y, Subar AF, Freedman ND, Albanes D, Hollenbeck A, Leitzmann MF, Schatzkin A. Intakes 255 Wynant W, Siemiatycki J, Parent M-É, Rousseau of fruit, vegetables, and specific botanical groups in M-C. Occupational exposure to lead and lung relation to lung cancer risk in the NIH-AARP Diet and cancer: results from two case-control studies in Health Study. Am J Epidemiol. 2008;168 (9):1024-34. Montreal, Canada. Occup Environ Med. 2013;70 (3):164-70. 246 Kabat GC, Kim M, Hunt JR, Chlebowski RT, Rohan TE. Body mass index and waist circumference in 256 Henschke CI, Yankelevitz DF, Libby DM, relation to lung cancer risk in the Women’s Health Pasmantier MW, Smith JP, Miettinen OS. Survival Initiative. Am J Epidemiol. 2008;168 (2):158-69. of patients with stage I lung cancer detected on CT screening. N Engl J Med. 2006;355 (17):1763- 247 Tarnaud C, Guida F, Papadopoulos A, Cenee S, Cyr 71. D, Schmaus A, Radoi L, Paget-Bailly S, Menvielle G, Buemi A, Woronoff AS, Luce D, et al. Body mass 257 Bach PB. Inconsistencies in findings from the index and lung cancer risk: results from the ICARE early lung cancer action project studies of lung study, a large, population-based case-control study. cancer screening. J Natl Cancer Inst. 2011;103 Cancer Causes Control. 2012;23 (7):1113-26. (13):1002-6. 248 Yang Y, Dong J, Sun K, Zhao L, Zhao F, Wang L, Jiao 258 Aberle DR, Berg CD, Black WC, Church TR, Y. Obesity and incidence of lung cancer: a meta- Fagerstrom RM, Galen B, Gareen IF, Gatsonis C, analysis. Int J Cancer. 2013;132 (5):1162-9. Goldin J, Gohagan JK, Hillman B, Jaffe C, et al. The National Lung Screening Trial: overview and 249 Smith L, Brinton LA, Spitz MR, Lam TK, Park Y, study design. Radiology. 2011;258 (1):243-53. Hollenbeck AR, Freedman ND, Gierach GL. Body mass index and risk of lung cancer among never, 259 Ma J, Ward E, Smith R, Jemal A. Annual number former, and current smokers. J Natl Cancer Inst. of lung cancer deaths potentially avertable by 2012;104 (10):778-89. screening in the United States. Cancer. 2013;119 (7):1381-5. 250 World Health Organization. Asbestos: elimination of asbestos-related diseases. Geneva: World Health 260 Hew M, Stirling R, Abramson M. Should we Organization; 2010 [updated July; cited 2013 January screen for lung cancer in Australia? Med J Aust. 7]; Available from: http://www.who.int/mediacentre/ 2013;199 (2):82-3. factsheets/fs343/en/index.html. 261 U.S. Preventive Services Task Force. Screening 251 Villeneuve PJ, Parent ME, Harris SA, Johnson KC. for Lung Cancer: U.S. Preventive Services Occupational exposure to asbestos and lung cancer Task Force Recommendation Statement in men: evidence from a population-based case- DRAFT. Rockville: U.S. Preventive Services control study in eight Canadian provinces. BMC Task Force; 2013 [updated July; cited 2013 Cancer. 2012;12 (1):595. August 21]; Available from: http://www. uspreventiveservicestaskforce.org/draftrec.htm. 252 Goodman M, Morgan RW, Ray R, Malloy CD, Zhao K. Cancer in asbestos-exposed occupational cohorts: 262 Broza Y, Kremer R, Tisch U, Gevorkyan A, Shiban a meta-analysis. Cancer Causes Control. 1999;10 A, Best L, Haick H. A nanomaterial-based breath (5):453-65. test for short-term follow-up after lung tumor resection. Nanomedicine. 2013;9 (1):15-21.

November, 2013 263 Marcus PM, Bergstralh EJ, Zweig MH, Harris A, 275 Chambers S, Dunn J, Occhipinti S, Hughes S, Baade P, Offord KP, Fontana RS. Extended lung cancer Sinclair S, Aitken J, Youl P, O’Connell D. A systematic incidence follow-up in the Mayo Lung Project and review of the impact of stigma and nihilism on lung overdiagnosis. J Natl Cancer Inst. 2006;98 (11):748- cancer outcomes. BMC Cancer. 2012;12:184. 56. 276 Rueda JR, Sola I, Pascual A, Subirana Casacuberta M. 264 Reich JM. Cost-effectiveness of computed Non-invasive interventions for improving well-being and tomography lung cancer screening. Brit J Cancer. quality of life in patients with lung cancer. Cochrane 2009;101 (6):879-80. Database Syst Rev. 2011 (9):CD004282. 265 Castleberry AW, Smith D, Anderson C, Rotter AJ, 277 Martinez J, Otley C. The management of melanoma Grannis FW, Jr. Cost of a 5-year lung cancer survivor: and nonmelanoma skin cancer: a review for the primary symptomatic tumour identification vs proactive care physician. Mayo Clin Proc. 2001;76 (12):1253-65. computed tomography screening. Brit J Cancer. 278 Joosse A, de Vries E, Eckel R, Nijsten T, Eggermont 2009;101 (6):882-96. AM, Hölzel D, Coebergh JW, Engel J, Munich 266 Vinod SK, Simonella L, Goldsbury D, Delaney GP, Melanoma G. Gender differences in melanoma survival: Armstrong B, O’Connell DL. Underutilization of female patients have a decreased risk of metastasis. J radiotherapy for lung cancer in New South Wales, Invest Dermatol. 2011;131 (3):719-26. Australia. Cancer. 2010;116 (3):686-94. 279 Russak J, Rigel D. Risk factors for the development of 267 Yu XQ, O’Connell DL, Gibberd RW, Armstrong BK. primary cutaneous melanoma. Dermatol Clin. 2012;30 Assessing the impact of socio-economic status on (3):363-8. cancer survival in New South Wales, Australia 1996- 280 Einspahr J, Stratton S, Bowden G, Alberts D. 2001. Cancer Causes Control. 2008;19 (10):1383-90. Chemoprevention of human skin cancer. Crit Rev Oncol 268 Simonella L, O’Connell DL, Vinod SK, Delaney Hematol. 2002;41 (3):269-85. GP, Boyer M, Esmaili N, Hensley M, Goldsbury 281 Chang YM, Barrett J, Bishop D, Armstrong B, Bataille D, Supramaniam R, Hui A, Armstrong B. No V, Bergman W, Berwick M, Bracci P, Elwood J, Ernstoff improvement in lung cancer care: the management M, Gallagher R, Green A, et al. Sun exposure and of lung cancer in 1996 and 2002 in New South Wales. melanoma risk at different latitudes: a pooled analysis Intern Med J. 2009;39 (7):453-8. of 5700 cases and 7216 controls. Int J Epidemiol. 269 Shibuya K, Inoue M, Lopez A. Statistical modeling 2009;38 (3):814-30. and projections of lung cancer mortality in 4 282 Greinert R, Boniol M. Skin cancer--primary and industrialized countries. Int J Cancer. 2005;117 secondary prevention (information campaigns and (3):476-85. screening)--with a focus on children & sunbeds. Prog 270 Australian Institute of Health and Welfare. 2010 Biophys Mol Biol. 2011;107 (3):473-6. National Drug Strategy Household Survey report. 283 Gandini S, Sera F, Cattaruzza M, Pasquini P, Picconi Canberra: Australian Institute of Health and Welfare; O, Boyle P, Melchi C. Meta-analysis of risk factors for 2011 (Drug statistics series no. 25. Cat. no. PHE 145). cutaneous melanoma: II. Sun exposure. Eur J Cancer. 271 Ganz PA, Lee JJ, Siau J. Quality of life assessment. 2005;41 (1):45-60. An independent prognostic variable for survival in 284 Purdue M, From L, Armstrong B, Kricker A, Gallagher lung cancer. Cancer. 1991;67 (12):3131-5. R, McLaughlin J, Klar N, Marrett L, Genes Environment 272 Boxer MM, Vinod SK, Shafiq J, Duggan KJ. Do Melanoma Study Group. Etiologic and other factors multidisciplinary team meetings make a difference in predicting nevus-associated cutaneous malignant the management of lung cancer? Cancer. 2011;117 melanoma. Cancer Epidemiol Biomarkers Prev. 2005;14 (22):5112-20. (8):2015-22. 273 Vinod SK, Delaney GP, Bauman AE, Barton MB. Lung 285 Cust A, Jenkins M, Goumas C, Armstrong B, Schmid cancer patterns of care in south western Sydney, H, Aitken J, Giles G, Kefford R, Hopper J, Mann G. Australia. Thorax. 2003;58 (8):690-4. Early-life sun exposure and risk of melanoma before age 40 years. Cancer Causes Control. 2011 (6):885-97. 274 Chapple A, Ziebland S, McPherson A. Stigma, shame, and blame experienced by patients with lung cancer: qualitative study. BMJ. 2004;328 (7454):1470.

Cancer Council NSW • 149 150 • The State of Cancer Control in Australia

286 McMeniman E, De’Ambrosis K, De’Ambrosis B. Risk 298 Balk S, Fisher D, Geller A. Stronger laws are factors in a cohort of patients with multiple primary needed to protect teens from indoor tanning. melanoma. Australas J Dermatol. 2010;51 (4):254-7. Pediatrics. 2013;131 (3):586-8. 287 Cornish D, Holterhues C, van de Poll-Franse L, 299 Goulart J, Quigley E, Dusza S, Jewell S, Coebergh J, Nijsten T. A systematic review of health- Alexander G, Asgari M, Eide M, Fletcher S, related quality of life in cutaneous melanoma. Ann Geller A, Marghoob A, Weinstock M, Halpern Oncol. 2009;20 (Suppl 6):vi51-vi8. A, et al. Skin cancer education for primary care physicians: a systematic review of published 288 Rigel D. Epidemiology of melanoma. Semin Cutan evaluated interventions. J Gen Intern Med. Med Surg. 2010;29 (4):204-9. 2011;26 (9):1027-35. 289 Garibyan L, Fisher D. How sunlight causes 300 Green A, Williams G, Logan V, Strutton G. melanoma. Curr Oncol Report. 2010;12 (5):319-26. Reduced melanoma after regular sunscreen use: 290 van der Pols J, Russell A, Bauer U, Neale R, Kimlin randomized trial follow-up. J Clin Oncol. 2011;29 M, Green A. Vitamin D status and skin cancer risk (3):257-63. independent of time outdoors: 11-year prospective 301 Janda M, Youl P, Marshall A, Soyer H, Baade P. study in an Australian community. J Invest Dermatol. The HealthyTexts study: A randomized controlled 2013;133 (3):637-41. trial to improve skin cancer prevention behaviors 291 Tang J, Spaunhurst K, Chlebowski R, Wactawski- among young people. Contemp Clin Trial. Wende J, Keiser E, Thomas F, Anderson M, Zeitouni 2013;35 (1):159-67. N, Larson J, Stefanick M. Menopausal hormone 302 Wolff T, Tai E, Miller T. Screening for skin cancer: therapy and risks of melanoma and nonmelanoma an update of the evidence for the U.S. Preventive skin cancers: women’s health initiative randomized Services Task Force. Ann Intern Med. 2009;150 trials. J Natl Cancer Inst. 2011;103 (19):1469-75. (3):194-8. 292 Gupta A, Driscoll M. Do hormones influence 303 Curiel-Lewandrowski C, Kim C, Swetter S, melanoma? Facts and controversies. Clin Dermatol. Chen S, Halpern A, Kirkwood J, Leachman S, 2010;28 (3):287-92. Marghoob A, Ming M, Grichnik J, Melanoma 293 Wehner M, Shive M, Chren M-M, Han J, Qureshi Prevention Working Group-Pigmented Skin A, Linos E. Indoor tanning and non-melanoma skin Lesion Sub-Committee. Survival is not the only cancer: systematic review and meta-analysis. BMJ. valuable end point in melanoma screening. J 2012;345:e5909. Invest Dermatol. 2012;132 (5):1332-7. 294 Boniol M, Autier P, Boyle P, Gandini S. Cutaneous 304 Aitken J, Youl P, Janda M, Lowe J, Ring I, melanoma attributable to sunbed use: systematic Elwood M. Increase in skin cancer screening review and meta-analysis. BMJ. 2012;345:e4757. during a community-based randomized intervention trial. Int J Cancer. 2006;118 (4):1010- 295 Bentzen J, Krarup A, Castberg I-M, Jensen P, Philip 6. A. Determinants of sunbed use in a population of Danish adolescents. Eur J Cancer Pr. 2013;22 (2):126- 305 Stratigos A, Katsambas A. The value of 30. screening in melanoma. Clin Dermatol. 2009;27 (1):10-25. 296 Demko C, Borawski E, Debanne S, Cooper K, Stange K. Use of indoor tanning facilities by white 306 McCarthy W. The Australian experience in sun adolescents in the United States. Arch Pediatr protection and screening for melanoma. J Surg Adolesc Med. 2003;157 (9):854-60. Oncol. 2004;86 (4):236-45. 297 El Ghissassi F, Baan R, Straif K, Grosse Y, Secretan 307 Titus L, Clough-Gorr K, Mackenzie T, Perry B, Bouvard V, Benbrahim-Tallaa L, Guha N, Freeman A, Spencer S, Weiss J, Abrahams-Gessel S, C, Galichet L, Cogliano V, WHO International Agency Ernstoff M. Recent skin self-examination and for Research on Cancer Monograph Working Group. doctor visits in relation to melanoma risk and A review of human carcinogens--part D: radiation. tumour depth. Brit J Dermatol. 2013;168 (3):571- Lancet Oncol. 2009;10 (8):751-2. 6.

November, 2013 308 Allan C, Smithers B. Surgery and the management of 319 Cancer Institute NSW. NSW Skin Cancer Prevention cutaneous melanoma. Brit J Surg. 2013;100 (3):313-5. Strategy 2012–15. Sydney: Cancer Institute NSW 2012. 309 Brandberg Y, Aamdal S, Bastholt L, Hernberg M, Stierner U, von der Maase H, Hansson J. Health- 320 NSW EPA. Solaria (tanning units). Sydney: NSW related quality of life in patients with high-risk EPA; 2013 [updated June 16; cited 2013 July 1]; melanoma randomised in the Nordic phase 3 trial Available from: http://www.epa.nsw.gov.au/radiation/ with adjuvant intermediate-dose interferon alfa-2b. Solaria.htm. Eur J Cancer. 2012;48 (13):2012-9. 321 Vickers AJ, Roobol MJ, Lilja H. Screening for 310 Menzies A, Long G, Murali R. Dabrafenib and its prostate cancer: early detection or overdetection? potential for the treatment of metastatic melanoma. Annu Rev Med. 2012;63:161-70. Drug Des Devel Ther. 2012;6:391-405. 322 Medical Services Advisory Committee. Prostate 311 Lemeshow S, Sørensen H, Phillips G, Yang E, specific antigen (PSA) near patient testing for Antonsen S, Riis A, Lesinski G, Jackson R, Glaser R. diagnosis and management of prostate cancer. β-Blockers and survival among Danish patients with Canberra: Commonwealth of Australia 2005 (MSAC malignant melanoma: a population-based cohort Application 1068). study. Cancer Epidemiol Biomarkers Prev. 2011;20 323 Ilic D, O’Connor D, Green S, Wilt TJ. Screening for (10):2273-9. prostate cancer: an updated Cochrane systematic 312 Coory M, Baade P, Aitken J, Smithers M, McLeod review. BJU Int. 2011;107 (6):882-91. GR, Ring I. Trends for in situ and invasive melanoma 324 Sutcliffe S, Colditz G. Prostate cancer: is it time to in Queensland, Australia, 1982-2002. Cancer Causes expand the research focus to early-life exposures? Control. 2006;17 (1):21-7. Nat Rev Cancer. 2013;13:208-518. 313 Hill D, Marks R. Health promotion programs for 325 Cao Y, Ma J. Body mass index, prostate cancer- melanoma prevention: screw or spring? Arch specific mortality, and biochemical recurrence: a Dermatol. 2008;144 (4):538-40. systematic review and meta-analysis. Cancer Prev 314 Volkov A, Dobbinson S, Wakefield M, Slevin T. Seven- Res. 2011;4 (4):486-501. year trends in sun protection and sunburn among 326 Xu H, Jiang HW, Ding GX, Zhang H, Zhang LM, Mao Australian adolescents and adults. Aust N Z J Public SH, Ding Q. Diabetes mellitus and prostate cancer Health. 2013;37 (1):63-9. risk of different grade or stage: A systematic review 315 Rychetnik L, Morton R, McCaffery K, Thompson and meta-analysis. Diabetes Res Clin Pract. 2013;99 J, Menzies S, Irwig L. Shared care in the follow- (3):241-9. up of early-stage melanoma: a qualitative study of 327 Gong Z, Agalliu I, Lin D, Stanford J, Kristal A. Australian melanoma clinicians’ perspectives and Cigarette smoking and prostate cancer-specific models of care. BMC Health Serv Res. 2012;12:468. mortality following diagnosis in middle-aged men. 316 Schlesinger-Raab A, Schubert-Fritschle G, Hein R, Cancer Causes Control. 2008;19 (1):25-31. Stolz W, Volkenandt M, Hölzel D, Engel J. Quality 328 Huncharek M, Haddock K, Reid R, Kupelnick B. of life in localised malignant melanoma. Ann Oncol. Smoking as a risk factor for prostate cancer: a 2010;21 (12):2428-35. meta-analysis of 24 prospective cohort studies. Am J 317 Cancer Council Australia. Sun Protection: Campaigns Public Health. 2010;100 (4):693-701. and Events. Sydney: Cancer Council Australia; 329 Rohrmann S, Linseisen J, Allen N, Bueno-de- 2012 [updated February 9; cited 2012 October 29]; Mesquita H, Johnsen N, Tjønneland A, Overvad K, Available from: http://www.cancer.org.au/preventing- Kaaks R, Teucher B, Boeing H, Pischon T, Lagiou P, cancer/sun-protection/campaigns-and-events/. et al. Smoking and the risk of prostate cancer in the 318 Shih S, Carter R, Sinclair C, Mihalopoulos C, Vos T. European Prospective Investigation into Cancer and Economic evaluation of skin cancer prevention in Nutrition. Brit J Cancer. 2013;108 (3):708-14. Australia. Prev Med. 2009;49 (5):449-53.

Cancer Council NSW • 151 152 • The State of Cancer Control in Australia

330 Loke TW, Seyfi D, Khadra M. Prostate cancer 341 Welch HG, Albertsen PC. Prostate cancer incidence in Australia correlates inversely with solar diagnosis and treatment after the introduction of radiation. BJU Int. 2011;108 (Suppl 2):66-70. prostate-specific antigen screening: 1986-2005. J Natl Cancer Inst. 2009;101 (19):1325-9. 331 Nair-Shalliker V, Smith DP, Egger S, Hughes AM, Kaldor JM, Clements M, Kricker A, Armstrong 342 Schroder FH, Hugosson J, Roobol MJ, Tammela BK. Sun exposure may increase risk of prostate TL, Ciatto S, Nelen V, Kwiatkowski M, Lujan cancer in the high UV environment of New South M, Lilja H, Zappa M, Denis LJ, Recker F, et al. Wales, Australia: a case-control study. Int J Cancer. Screening and prostate-cancer mortality in a 2012;131 (5):E726-32. randomized European study. N Engl J Med. 2009;360 (13):1320-8. 332 Chia SE, Wong KY, Cheng C, Lau W, Tan PH. Sun exposure and the risk of prostate cancer in the 343 de Bekker-Grob E, Rose J, Donkers B, Essink- Singapore Prostate Cancer Study: a case-control Bot ML, Bangma C, Steyerberg E. Men’s study. Asian Pac J Cancer Prev. 2012;13 (7):3179- preferences for prostate cancer screening: 85. a discrete choice experiment. Brit J Cancer. 2013;108 (3):533-41. 333 Gilbert R, Metcalfe C, Oliver SE, Whiteman DC, Bain C, Ness A, Donovan J, Hamdy F, Neal DE, 344 Smith DP, Clements MS, Wakefield MA, Lane JA, Martin RM. Life course sun exposure and Chapman S. Impact of Australian celebrity risk of prostate cancer: population-based nested diagnoses on prostate cancer screening. Med J case-control study and meta-analysis. Int J Cancer. Aust. 2009;191 (10):574-5. 2009;125 (6):1414-23. 345 Del Mar C, Glasziou P, Hirst G, Wright R, 334 John EM, Schwartz GG, Koo J, Van Den Berg D, Hoffmann T. Should we screen for prostate Ingles SA. Sun exposure, vitamin D receptor gene cancer? A re-examination of the evidence. Med polymorphisms, and risk of advanced prostate J Aust. 2013;198 (10):525-7. cancer. Cancer Res. 2005;65 (12):5470-9. 346 Evans S, Millar J, Davis I, Murphy D, Bolton 335 Rittmaster RS. Chemoprevention of prostate D, Giles G, Frydenberg M, Andrianopoulos cancer. Acta Oncol. 2011;50 (Suppl 1):127-36. N, Wood J, Frauman A, Costello A, McNeil J. Patterns of care for men diagnosed with prostate 336 Van Poppel H, Tombal B. Chemoprevention of cancer in Victoria from 2008 to 2011. Med J prostate cancer with nutrients and supplements. Aust. 2013;198 (10):540-5. Cancer Manag Res. 2011;3:91-100. 347 Izard M. Early management of prostate cancer. 337 Violette PD, Saad F. Chemoprevention of prostate Aust Fam Physician. 2010;39 (1-2):61-2. cancer: myths and realities. J Am Board Fam Med. 2012;25 (1):111-9. 348 Stone CA, May FW, Pinnock CB, Elwood M, Rowett DS. Prostate cancer, the PSA test 338 Frankel S, Smith GD, Donovan J, Neal D. Screening and academic detailing in Australian general for prostate cancer. Lancet. 2003;361 (9363):1122-8. practice: an economic evaluation. Aust NZ J 339 Jackson B. Prostate-specific antigen, prostate Publ Heal. 2005;29 (4):349-57. cancer screening, and the pathologist: what should 349 Klotz L. Active Surveillance for Prostate Cancer: be our role? Arch Pathol Lab Med. 2013;137 (3):308- Overview and Update. Curr Treat Option On. 9. 2013;14 (1):97-108. 340 Andriole GL, Crawford ED, Grubb 3rd RL, Buys SS, 350 Klotz L. Active surveillance for prostate cancer: a Chia D, Church TR, Fouad MN, Isaacs C, Kvale PA, review. Arch Esp Urol. 2011;64 (8):806-14. Reding DJ, Weissfeld JL, Yokochi LA, et al. Prostate cancer screening in the randomized Prostate, Lung, 351 Bul M, Zhu X, Valdagni R, Pickles T, Kakehi Colorectal, and Ovarian Cancer Screening Trial: Y, Rannikko A, Bjartell A, van der Schoot D, mortality results after 13 years of follow-up. J Natl Cornel E, Conti G, Boevé E, Staerman F, et al. Cancer Inst. 2012;104 (2):125-32. Active surveillance for low-risk prostate cancer worldwide: the PRIAS study. Eur Urol. 2013;63 (4):597-603.

November, 2013 352 Xie F. Cost Effectiveness of Treatment Options for 365 Guggenheim D, Shah M. Gastric cancer Early Prostate Cancer: Can We Put the Puzzle Pieces epidemiology and risk factors. J Surg Oncol. Together? Eur Urol. 2012;63 (2):411-2. 2013;107 (3):230-6. 353 Davis ID, Lynam J, Sluka P. Prostate Cancer. 366 Wu Q-J, Yang Y, Wang J, Han L-H, Xiang Y-B. CancerForum. 2013;37 (1):56-8. Cruciferous vegetable consumption and gastric cancer risk: A meta-analysis of epidemiological 354 McCartney M. Is Movember misleading men? BMJ. studies. Cancer Sci. 2013;104 (8):1067-73. 2012;345:e8046. 367 Buckland G, Agudo A, Luján L, Jakszyn P, Bueno- 355 Movember Foundation. About Movember. 2013 de-Mesquita H, Palli D, Boeing H, Carneiro F, [updated October 1; cited 2013 October 8]; Available Krogh V, Sacerdote C, Tumino R, Panico S, et from: http://au.movember.com/about/. al. Adherence to a Mediterranean diet and risk 356 Eton DT, Lepore SJ. Prostate cancer and health-related of gastric adenocarcinoma within the European quality of life: a review of the literature. Psychooncology. Prospective Investigation into Cancer and Nutrition 2002;11 (4):307-26. (EPIC) cohort study. Am J Clin Nut. 2010;91 (2):381- 90. 357 Smith D, King M, Egger S, Berry M, Stricker P, Cozzi P, Ward J, O’Connell D, Armstrong B. Quality of life 368 Polk D, Peek R. Helicobacter pylori: gastric cancer three years after diagnosis of localised prostate cancer: and beyond. Nat Rev Cancer. 2010;10 (6):403-14. population based cohort study. BMJ. 2009;339:b4817. 369 Correa P, Piazuelo M, Camargo M. The future of 358 Keogh JW, MacLeod RD. Body composition, physical gastric cancer prevention. Gastric Cancer. 2004;7 fitness, functional performance, quality of life, and (1):9-16. fatigue benefits of exercise for prostate cancer patients: 370 Camargo M, Murphy G, Koriyama C, Pfeiffer R, a systematic review. J Pain Symptom Manage. 2012;43 Kim W, Herrera-Goepfert R, Corvalan A, Carrascal (1):96-110. E, Abdirad A, Anwar M, Hao Z, Kattoor J, et al. 359 Newton F, Burney S, Frydenberg M, Millar J, Ng K. Determinants of Epstein-Barr virus-positive gastric Assessing mood and general health-related quality cancer: an international pooled analysis. Brit J of life among men treated in Australia for localized Cancer. 2011;105 (1):38-43. prostate cancer. Int J Urol. 2007;14 (4):311-6. 371 Tramacere I, Negri E, Pelucchi C, Bagnardi V, Rota 360 Lee J, Kim K, Cheong JH, Noh S. Current management M, Scotti L, Islami F, Corrao G, La Vecchia C, and future strategies of gastric cancer. Yonsei Med J. Boffetta P. A meta-analysis on alcohol drinking and 2012;53 (2):248-57. gastric cancer risk. Ann Oncol. 2012;23 (1):28-36. 361 Valentini V, Cellini F, Minsky B, Mattiucci G, Balducci 372 Shimazu T, Tsuji I, Inoue M, Wakai K, Nagata C, M, D’Agostino G, D’Angelo E, Dinapoli N, Nicolotti N, Mizoue T, Tanaka K, Tsugane S, Research Group for Valentini C, La Torre G. Survival after radiotherapy in the Development Evaluation of Cancer Prevention gastric cancer: systematic review and meta-analysis. Strategies in Japan. Alcohol drinking and gastric Radiol Oncol. 2009;92 (2):176-83. cancer risk: an evaluation based on a systematic review of epidemiologic evidence among the 362 Catalano V, Labianca R, Beretta G, Gatta G, de Braud Japanese population. Jpn J Clin Oncol. 2008;38 F, Van Cutsem E. Gastric cancer. Crit Rev Oncol (1):8-25. Hematol. 2009;71 (2):127-64. 373 González C, Pera G, Agudo A, Palli D, Krogh V, 363 Navarro Silvera S, Mayne S, Risch H, Gammon M, Vineis P, Tumino R, Panico S, Berglund G, Simán Vaughan T, Chow WH, Dubin J, Dubrow R, Schoenberg H, Nyrén O, Agren A, et al. Smoking and the risk J, Stanford J, West A, Rotterdam H, et al. Principal of gastric cancer in the European Prospective component analysis of dietary and lifestyle patterns in Investigation Into Cancer and Nutrition (EPIC). Int J relation to risk of subtypes of esophageal and gastric Cancer. 2003;107 (4):629-34. cancer. Ann Epidemiol. 2011;21 (7):543-50. 374 Ladeiras-Lopes R, Pereira A, Nogueira A, Pinheiro- 364 Giordano A, Cito L. Advances in gastric cancer Torres T, Pinto I, Santos-Pereira R, Lunet N. prevention. World J Clin Oncol. 2012;3 (9):128-36. Smoking and gastric cancer: systematic review and meta-analysis of cohort studies. Cancer Causes Control. 2008;19 (7):689-701.

Cancer Council NSW • 153 154 • The State of Cancer Control in Australia

375 Nomura A, Wilkens L, Henderson B, Epplein M, 386 Lee S, Ryu S, Kim I, Sohn S. Quality of life Kolonel L. The association of cigarette smoking with beyond the early postoperative period after gastric cancer: the multiethnic cohort study. Cancer laparoscopy-assisted distal gastrectomy: the Causes Control. 2012;23 (1):51-8. level of patient expectation as the essence of quality of life. Gastric Cancer. 2012;15 (3):299- 376 Dhillon P, Farrow D, Vaughan T, Chow W, Risch H, 304. Gammon M, Mayne S, Stanford J, Schoenberg J, Ahsan H, Dubrow R, West A, et al. Family history of 387 World Health Organization. Deaths from NCDs. cancer and risk of esophageal and gastric cancers in Geneva: World Health Organization; 2012 the United States. Int J Cancer. 2001;93 (1):148-52. [updated October 31; cited 2012 October 31]; Available from: http://www.who.int/gho/ncd/ 377 Yang P, Zhou Y, Chen B, Wan HW, Jia GQ, Bai HL, Wu mortality_morbidity/ncd_total/en/index.html. XT. Aspirin use and the risk of gastric cancer: a meta- analysis. Digest Dis Sci. 2010;55 (6):1533-9. 388 Lim S, Vos T, Flaxman A, Danaei G, Shibuya K, Adair-Rohani H, Amann M, Anderson H, 378 Roderick P, Davies R, Raftery J, Crabbe D, Pearce Andrews K, Aryee M, Atkinson C, Bacchus L, R, Bhandari P, Patel P. The cost-effectiveness of et al. A comparative risk assessment of burden screening for Helicobacter pylori to reduce mortality of disease and injury attributable to 67 risk and morbidity from gastric cancer and peptic ulcer factors and risk factor clusters in 21 regions, disease: a discrete-event simulation model. Health 1990-2010: a systematic analysis for the Global Technol Assess. 2003;7 (6):1-86. Burden of Disease Study 2010. Lancet. 2012;380 379 Parsonnet J, Harris R, Hack H, Owens D. Modelling (9859):2224-60. cost-effectiveness of Helicobacter pylori screening to 389 World Health Organization. Global status report prevent gastric cancer: a mandate for clinical trials. on noncommunicable diseases 2010. Geneva: Lancet. 1996;348 (9021):150-4. World Health Organization 2011. 380 Xu Z, Broza Y, Ionsecu R, Tisch U, Ding L, Liu H, 390 World Health Organization. Noncommunicable Song Q, Pan Y, Xiong F, Gu K, Sun G, Chen Z, et al. Diseases Country Profiles 2011. Geneva: World A nanomaterial-based breath test for distinguishing Health Organization 2011. gastric cancer from benign gastric conditions. Brit J Cancer. 2013;108 (4):941-50. 391 Sullivan R, Peppercorn J, Sikora K, Zalcberg J, Meropol NJ, Amir E, Khayat D, Boyle P, Autier 381 Wagner A, Unverzagt S, Grothe W, Kleber G, Grothey P, Tannock IF, Fojo T, Siderov J, et al. Delivering A, Haerting J, Fleig W. Chemotherapy for advanced affordable cancer care in high-income countries. gastric cancer. Cochrane Database Syst Rev. 2010 Lancet Oncol. 2011;12 (10):933-80. (3):CD004064. 392 World Health Organization, editor. National 382 Mahar A, Coburn N, Singh S, Law C, Helyer L. A cancer control programmes: Policies and systematic review of surgery for non-curative gastric managerial guidelines 2nd. Geneva: World Health cancer. Gastric Cancer. 2012;15 (Suppl 1):S125-37. Organization; 2002. 383 Pandeya N, Whiteman DC. Prevalence and 393 World Health Organization. Cancer Control: determinants of Helicobacter pylori sero-positivity knowledge in action - WHO guide for effective in the Australian adult community. J Gastroenterol programmes. Geneva: World Health Organization Hepatol. 2011;26 (8):1283-9. 2006. 384 Munene G, Francis W, Garland S, Pelletier G, Mack 394 Kelly P, Friedman W, Addis T, Elwood M, Neal C, L, Bathe O. The quality of life trajectory of resected Sarner M, Sutcliffe S. Getting the public involved gastric cancer. J Surg Oncol. 2012;105 (4):337-41. in cancer control - doing something besides 385 Kim A, Cho J, Hsu YJ, Choi M, Noh J, Sohn T, Bae worrying. In: Elwood JM, Sutcliffe S. Cancer J, Yun Y, Kim S. Changes of quality of life in gastric Control. New York: Oxford University Press, cancer patients after curative resection: a longitudinal 2010: 297-316. cohort study in Korea. Ann Surg. 2012;256 (6):1008-13.

November, 2013 395 Caron L. Organizational structures for cancer control. 407 Lyons M. Non-profit organisations, social capital In: Elwood JM, Sutcliffe S. Cancer Control. New York: and social policy in Australia. In: Winter I. Social Oxford University Press, 2010: 317-40. Capital and Public Policy in Australia. Melbourne: 396 Doll R, Peto R. The Causes of Cancer. New York: Oxford Australian Institute of Family Studies, 2000: 165-91. University Press, 1981. 408 Organisation for Economic Co-operation and 397 Schottenfeld D, Beebe-Dimmer J, Buffler P, Omenn G. Development. The Non-profit Sector in a Changing Current perspective on the global and United States Economy. Paris: Organisation for Economic Co- cancer burden attributable to lifestyle and environmental operation and Development, 2003. risk factors. Annu Rev Public Health. 2013;34:97-117. 409 Productivity Commission. Contribution of the 398 Forbes L, Simon A, Warburton F, Boniface D, Brain K, Not-for-Profit Sector, Research Report. Canberra: Dessaix A, Donnelly C, Haynes K, Hvidberg L, Lagerlund Commonwealth of Australia 2010. M, Lockwood G, Tishelman C, et al. Differences in 410 Williams C. New Trends in Financing the Non-profit cancer awareness and beliefs between Australia, Sector in the United States: The Transformation Canada, Denmark, Norway, Sweden and the UK (the of Private Capital – Reality or Rhetoric? . In: International Cancer Benchmarking Partnership): do Organisation for Economic Co-operation and they contribute to differences in cancer survival? Brit J Development. The Non-profit Sector in a Changing Cancer. 2013;108 (2):292-300. Economy. Paris: Organisation for Economic Co- 399 Peto R, Roe F, Lee P, Levy L, Clack J. Cancer and operation and Development, 2003: 109-38. ageing in mice and men. Brit J Cancer. 1975;32 (4):411- 411 Sloan FA, Gelband H. Cancer Control Opportunities 26. in Low- and Middle-Income Countries. Washington 400 Ho J, Batniji R. Targets for non-communicable disease: DC: The National Academies Press, 2007. what has happened since the UN summit? BMJ. 412 Union for International Cancer Control. National 2013;346:f3300. Cancer Control Planning Resources for Non- 401 Atun R, Ogawa T, Martin-Moreno JM. Analysis of Governmental Organizations. Geneva: UICC 2006. National Cancer Control Programmes in Europe. 413 Union for International Cancer Control. World London: Imperial College London, Business School; Cancer Declaration. Geneva: Union for 2009. International Cancer Control; 2012 [updated 402 Micheli A, Capocaccia R, Martinez C, Mugno E, October 30; cited 2012 October 30]; Available from: Coebergh JW, Baili P, Verdecchia A, Berrino F, Coleman http://www.uicc.org/world-cancer-declaration. M. Cancer control in Europe: a proposed set of 414 Fairclough L, Hill J, Bryant H, Kitchen-Clarke European cancer health indicators. Eur J Public Health. L. Accelerating knowledge to action: the pan- 2003;13 (3 Suppl):116-8. Canadian cancer control strategy. Curr Oncol. 403 Micheli A, Baili P, Ciampichini R, Verdecchia A. 2012;19 (2):70-7. Evaluating the outcomes of cancer control. In: Elwood 415 National Cancer Research Institute. National JM, Sutcliffe S. Cancer Control. New York: Oxford Cancer Research Institute. London 2013 [updated University Press, 2010: 341-61. January 29; cited 2013 January 29]; Available from: 404 Sutcliffe S. From cancer care to cancer control: http://www.ncri.org.uk/. organization of population-based cancer control 416 Schlesinger MJ, Gray B. Nonprofit Organizations systems. In: Elwood JM, Sutcliffe S. Cancer Control. and Health Care: The Paradox of Persistent New York: Oxford University Press, 2010: 279-96. Attention. In: Powell W, Steinberg R. The Nonprofit 405 Beaglehole R, Bonita R, Magnusson R. Global cancer Sector: A Research Handbook, 2nd. New Haven: prevention: an important pathway to global health and Yale University Press, 2006. development. Public Health. 2011;125 (12):821-31. 417 Comondore V, Devereaux P, Zhou Q, Stone S, 406 Moodie R, Stuckler D, Monteiro C, Sheron N, Neal Busse J, Ravindran N, Burns K, Haines T, Stringer B, Thamarangsi T, Lincoln P, Casswell S. Profits and B, Cook D, Walter S, Sullivan T, et al. Quality of pandemics: prevention of harmful effects of tobacco, care in for-profit and not-for-profit nursing homes: alcohol, and ultra-processed food and drink industries. systematic review and meta-analysis. BMJ. Lancet. 2013;381 (9867):670-9. 2009;339:b2732.

Cancer Council NSW • 155 156 • The State of Cancer Control in Australia

418 Devereaux P, Choi P, Lacchetti C, Weaver B, 428 Hogerzeil H, Liberman J, Wirtz V, Kishore S, Schünemann H, Haines T, Lavis J, Grant B, Selvaraj S, Kiddell-Monroe R, Mwangi-Powell Haslam D, Bhandari M, Sullivan T, Cook D, et al. F, von Schoen-Angerer T, on behalf of The A systematic review and meta-analysis of studies Lancet NCD Action Group. Promotion of access comparing mortality rates of private for-profit and to essential medicines for non-communicable private not-for-profit hospitals. Can Med Assoc J. diseases: practical implications of the UN political 2002;166 (11):1399-406. declaration. Lancet. 2013;381 (9867):680-9. 419 Devereaux P, Heels-Ansdell D, Lacchetti C, 429 Korda R, Butler J, Clements M, Kunitz S. Differential Haines T, Burns K, Cook D, Ravindran N, Walter impacts of health care in Australia: trend analysis of S, McDonald H, Stone S, Patel R, Bhandari M, socioeconomic inequalities in avoidable mortality. et al. Payments for care at private for-profit and Int J Epidemiol. 2007;36 (1):157-65. private not-for-profit hospitals: a systematic review 430 Marinos S. Steering the Course Ahead Tranforming and meta-analysis. Can Assoc Med J. 2004;170 the Nation’s Healthcare Bondi Junction: (12):1817-24. Government Services Group, 2011:30-7. 420 Himmelstein D, Woolhandler S, Hellander I, Wolfe 431 McIlwraith J. Re-shaping the course Tranforming S. Quality of care in investor-owned vs not-for- the Nation’s Healthcare Bondi Junction: profit HMOs. JAMA. 1999;282 (2):159-63. Government Services Group, 2011:38-43. 421 Australian Charities and Not-for-profit 432 Hamilton J. Covering all bases Tranforming the Commission. Not-for-profit Reform and the Nation’s Healthcare Bondi Junction: Government Australian Government. Canberra: Commonwealth Services Group, 2011:96-9. of Australia 2013. 433 Goss J. Projection of Australian health care 422 Cancer Council Australia. What we do. Sydney expenditure by disease, 2003 to 2033. Canberra: Cancer Council Australia; 2012 [updated July 3; Australian Institute of Health and Welfare 2008 cited 2012 October 29]; Available from: http://www. (Health and welfare expenditure series no. 36 Cat. cancer.org.au/about-us/what-we-do.html. no. HWE 43). 423 Australian Bureau of Statistics. 3101.0 - Australian 434 Access Economics. Cost of Cancer in NSW. Demographic Statistics June 2012. Canberra: Sydney: Access Economics 2006. Australian Bureau of Statistics 2012. 435 Kefford RF. Drug treatment for melanoma: 424 Jong K, Smith D, Yu X, O’Connell D, Goldstein progress, but who pays? Med J Aust. 2012;197 D, Armstrong B. Remoteness of residence and (4):198-9. survival from cancer in New South Wales. Med J Aust. 2004;180 (12):618-22. 436 Greenberg D, Earle C, Fang CH, Eldar-Lissai A, Neumann PJ. When is cancer care cost-effective? 425 Australian Bureau of Statistics. 6250.0.25.002 - A systematic overview of cost-utility analyses in Microdata: Characteristics of Recent Migrants, oncology. J Natl Cancer Inst. 2010;102 (2):82-8. Australia, Nov 2010. Canberra: Australian Bureau of Statistics 2012. 437 Smith TJ, Hillner BE. Bending the cost curve in cancer care. N Engl J Med. 2011;364 (21):2060-5. 426 Australian Bureau of Statistics. 3412.0 - Migration, Australia, 2010-11. Canberra: Australian Bureau of 438 O’Reilly SE, Venkatesh J. Managing the costs of Statistics 2012. new therapies: the challenge of funding new drugs. In: Elwood JM, Sutcliffe S. Cancer Control. New 427 Australian Government Department of Health and York: Oxford University Press, 2010: 185-204. Ageing. Department of Health and Ageing Annual Report 2011-2012 Canberra: Commonwealth of 439 Weir S, DeGennaro L, Austin C. Repurposing Australia, 2012. approved and abandoned drugs for the treatment and prevention of cancer through public-private partnership. Cancer Res. 2012;72 (5):1055-8.

November, 2013 440 Stieber J. Preventive Health Care in Australia: The Shape 453 Commonwealth of Australia. Taking Preventative of the Elephant, Reliance on Evidence and Comparisons Action – A Response to Australia: The Healthiest to U.S. Medicare. Canberra: Department of Health and Country by 2020 – The Report of the National Ageing; 2006. Preventative Health Taskforce. Canberra: Commonwealth of Australia; 2010. 441 Frommer M, Rychetnik L. From Evidence-Based Medicine to Evidence-Based Public Health. In: Lin V, 454 Australian Government Department of Health and Gibson B. Evidence-based health policy: problems & Ageing. Building a 21st Century Primary Health possibilities. Melbourne: Oxford University Press, 2003: Care System: Australia’s First National Primary 56-69. Health Care Strategy. Canberra: Commonwealth of Australia; 2010. 442 Australian Institute of Health and Welfare. National Health Priority Areas. Canberra: Australian Institute 455 Australian Government Department of Health and of Health and Welfare; 2013 [updated May 30; cited Ageing. National Palliative Care Strategy 2010. 2013 May 30 ]; Available from: http://www.aihw.gov.au/ Canberra: Commonwealth of Australia; 2010. national-health-priority-areas/. 456 Australian Government Department of Health 443 Cancer Strategies Group. Priorities for Action in and Ageing. Food and Nutrition Policy. Canberra: Cancer Control: 2001-2003. Canberra: Commonwealth Commonwealth of Australia; 1992 (Ref: 92/22328). Department of Health and Ageing, 2001. 457 Ministerial Council on Drug Strategy. National 444 National Health Priority Action Council. National Drug Strategy, 2010-2015: A framework for action Service Improvement Framework for cancer. Canberra: on alcohol, tobacco and other drugs. Canberra: Australian Government Department of Health and Commonwealth of Australia; 2011. Ageing; 2005. 458 Ministerial Council on Drug Strategy. National 445 Cancer Australia. Strategic Plan 2011–2014. Sydney: Alcohol Strategy: 2006-2011. Canberra: Cancer Australia; 2011. Commonwealth of Australia 2006. 446 Cancer Australia. Cancer Australia Annual Report 2011- 459 National Preventative Health Taskforce. Australia: 2012. Sydney: Cancer Australia; 2012. The Healthiest Country by 2020 – National Preventative Health Strategy – Overview. Canberra: 447 Commonwealth of Australia. A National Health and Commonwealth of Australia 2009. Hospitals Network for Australia’s Future Delivering the Reforms Canberra: Commonwealth of Australia; 2010 460 Council of Australian Governments. National (6803). Partnership Agreement on Preventive Health Canberra: Council of Australian Governments, 448 Health Workforce Australia. National Cancer Workforce 2009. Strategic Framework. Adelaide: Health Workforce Australia 2013. 461 Council of Australian Governments. National Partnership Agreement on Closing the Gap in 449 NSW Ministry of Health. NSW Tobacco Strategy 2012- Indigenous Health Outcomes: Implementation Plan. 2017. Sydney: NSW Ministry of Health 2012. Canberra: Commonwealth of Australia 2009. 450 Cancer Institute NSW. NSW Cancer Plan 2011–15. 462 Council of Australian Governments. National Health Sydney: Cancer Institute NSW 2010. Reform Agreement Canberra: Council of Australian 451 National Public Health Partnership. Background. Governments, 2011. Canberra: National Public Health Partnership; 2005 463 Australian Government Department of Health and [updated July 1; cited 2013 June 6]; Available from: Ageing. National Women’s Health Policy. Canberra: http://www.nphp.gov.au/about/background.htm. Commonwealth of Australia; 2010 (D0102). 452 Australian Government Department of Health and 464 Australian Government Department of Health and Ageing. Public Health Outcome Funding Agreements Ageing. National Male Health Policy. Canberra: (PHOFAs). Canberra: Australian Government Commonwealth of Australia; 2010 (6575). Department of Health and Ageing,; 2006 [updated 27 March; cited 2013 31 May]; Available from: http://www. health.gov.au/internet/main/publishing.nsf/Content/ health-pubhlth-about-phofa-phofa.htm.

Cancer Council NSW • 157 158 • The State of Cancer Control in Australia

465 Strategic Inter-Governmental Nutrition Alliance of the 476 Cancer Council Australia. National Cancer National Public Health Partnership. Eat Well Australia Prevention Policy. Sydney: Cancer Council An Agenda for Action for Public Health Nutrition. Australia; 2013 [updated April 16; cited 2013 July Canberra: National Public Health Partnership; 2001. 1]; Available from: http://www.cancer.org.au/ policy-and-advocacy/prevention-policy/national- 466 Strategic Inter-Governmental Nutrition Alliance of the cancer-prevention-policy.html. National Public Health Partnership. Eat Well Australia A Strategic Framework for Public Health Nutrition. 477 Australian Bureau of Statistics. 3238.0 - Canberra: National Public Health Partnership; 2001. Experimental Estimates and Projections, Aboriginal and Torres Strait Islander Australians, 467 Intergovernmental Committee on Drugs. National 1991 to 2021. Canberra: Australian Bureau of Tobacco Strategy, 2012-2018. Canberra: Statistics 2009. Commonwealth of Australia; 2012 (D1013). 478 Australian Institute of Health and Welfare. Life 468 Commonwealth Department of Health and Aged expectancy and mortality of Aboriginal and Torres Care. National Tobacco Strategy 1999 to 2002-03. Strait Islander people. Canberra: Australian Framework for action. Canberra: Commonwealth of Institute of Health and Welfare 2011 (Cat. no. Australia; 1999. AIHW 51). 469 Ministerial Council on Drug Strategy. National Tobacco 479 Australian Institute of Health and Welfare. Strategy 2004-2009. Canberra: Commonwealth of Towards better Indigenous health data. Canberra: Australia; 2005. Australian Institute of Health and Welfare 2013 470 Health Workforce Australia. About. Canberra: (Cat. no. IHW 93). Commonwealth of Australia; 2013 [updated June 6; 480 Secretan B, Straif K, Baan R, Grosse Y, El cited 2013 June 6]; Available from: http://www.hwa.gov. Ghissassi F, Bouvard V, Benbrahim-Tallaa L, au/about. Guha N, Freeman C, Galichet L, Cogliano V, WHO 471 Commonwealth of Australia. Australian National International Agency for Research on Cancer Preventive Health Agency. Canberra 2012 [updated Monograph Working Group. A review of human November 21; cited 2012 November 21]; Available from: carcinogens--Part E: tobacco, areca nut, alcohol, http://www.anpha.gov.au/internet/anpha/publishing. coal smoke, and salted fish. Lancet Oncol. nsf. 2009;10 (11):1033-4. 472 Commonwealth of Australia. National Health 481 Doll R, Peto R. Cigarette smoking and bronchial Performance Authority. Canberra 2013 [updated May carcinoma: dose and time relationships among 23; cited 2013 June 4]; Available from: http://www. regular smokers and lifelong non-smokers. J nhpa.gov.au/internet/nhpa/publishing.nsf. Epidemiol Community Health. 1978;32 (4):303-13. 473 National Health and Medical Research Council. 482 Australian Institute of Health and Welfare. Risk NHMRC’s role. Canberra: NHMRC; 2012 [updated factors contributing to chronic disease. Canberra June 1; cited 2013 May 1]; Available from: http://www. Australian Institue of Health and Welfare; 2012 nhmrc.gov.au/about/organisation-overview/nhmrcs- [updated March 29; cited 2012 November role. 2]; Available from: http://www.aihw.gov.au/ publication-detail/?id=10737421466. 474 Magnusson R. Using a legal and regulatory framework to identify and evaluate priorities for cancer prevention. 483 Sitas F, O’Connell D, Jamrozik K, Lopez A. Public Health. 2011;125 (12):854-75. Smoking questions on the Australian death notification form: adopting international best 475 Victorian Government Department of Human Services. practice? Med J Aust. 2009;191 (3):166-8. Victoria’s Cancer Action Plan 2008-2011. Melbourne: State of Victoria; 2008. 484 Jha P, Ramasundarahettige C, Landsman V, Rostron B, Thun M, Anderson R, McAfee T, Peto R. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med. 2013;368 (4):341-50.

November, 2013 485 Pirie K, Peto R, Reeves G, Green J, Beral V, Million 496 Di Castelnuovo A, Costanzo S, Donati MB, Iacoviello Women Study Collaborators. The 21st century L, de Gaetano G. Prevention of cardiovascular risk hazards of smoking and benefits of stopping: a by moderate alcohol consumption: epidemiologic prospective study of one million women in the UK. evidence and plausible mechanisms. Intern Emerg Lancet. 2013;381 (9861):133-41. Med. 2010;5 (4):291-7. 486 Pierce J, Dwyer T, Frape G, Chapman S, 497 Ministerial Council on Drug Strategy. Alcohol Chamberlain A, Burke N. Evaluation of the Sydney in Australia: Issues and Strategies. Canberra: “Quit. For Life” anti-smoking campaign. Part 1. Commonwealth of Australia; 2001. Achievement of intermediate goals. Med J Aust. 498 National Health and Medical Research Council. 1986;144 (7):341-4. Australian guidelines to reduce health risks from 487 Scollo M, Winstanley M. Tobacco in Australia: Facts drinking alcohol. Canberra: Commonwealth of and issues. 4th Ed. Melbourne: Cancer Council Australia 2009. Victoria, 2012. 499 Australian Government Department of Health and 488 Ministerial Council on Drug Strategy. Background Ageing. Alcohol. Canberra Australian Government paper: A companion document to the National Department of Health and Ageing 2012 [updated April Tobacco Strategy 1999 to 2002-03. Canberra: 17; cited 2012 November 16]; Available from: http:// Commonwealth of Australia; 1999. www.alcohol.gov.au/. 489 Australian Government Department of Health and 500 Collins DJ, Lapsley HM. The avoidable costs of Ageing. Quit Now. Canberra Australian Government alcohol abuse in Australia and the potential benefits Department of Health and Ageing; 2012 [updated of effective policies to reduce the social costs of May 30; cited 2012 October 29]; Available from: alcohol. Canberra: Commonwealth of Australia 2008 http://www.quitnow.gov.au/. (Monograph Series No. 70). 490 Australian Government Department of Health and 501 Doran C, Hall W, Shakeshaft A, Vos T, Cobiac L. Ageing. Tobacco. Canberra Australian Government Alcohol policy reform in Australia: what can we learn Department of Health and Ageing; 2012 [updated from the evidence? Med J Aust. 2010;192 (8):468-70. August 24; cited 2012 October 29]; Available from: 502 The ABAC Scheme. The ABAC Scheme: Alcohol http://www.health.gov.au/internet/main/publishing. beverages advertising (and packaging) code, 2009. nsf/Content/tobacco. 503 Fogarty A, Chapman S. What should be done about 491 Australian Government Department of Health and policy on alcohol pricing and promotions? Australian Ageing. Government to Increase Tobacco Excise. experts’ views of policy priorities: a qualitative Canberra: Australian Government Department of interview study. BMC Public Health. 2013;13:610. Health and Ageing; 2013 [updated August 1; cited 2013 August 8]; Available from: http://www.health. 504 Chalmers J, Carragher N, Davoren S, O’Brien P. Real gov.au/internet/ministers/publishing.nsf/Content/mr- or perceived impediments to minimum pricing of yr13-tp-tp093.htm. alcohol in Australia: Public opinion, the industry and the law. Int J Drug Policy. 2013;EPub June 14. 492 Jin M, Cai S, Guo J, Zhu Y, Li M, Yu Y, Zhang S, Chen K. Alcohol drinking and all cancer mortality: a 505 Stanton R. Who will take responsibility for obesity in meta-analysis. Ann Oncol. 2013;24 (3):807-16. Australia? Public Health. 2009;123 (3):280-2. 493 Taylor A, Dhillon I. An international legal strategy for 506 MacKay S. Legislative solutions to unhealthy eating alcohol control: not a framework convention-at least and obesity in Australia. Public Health. 2011;125 not yet. Addiction. 2013;108 (3):450-5. (12):896-904. 494 Winstanley MH, Pratt IS, Chapman K, Griffin HJ, 507 Calle E, Rodriguez C, Walker-Thurmond K, Thun M. Croager EJ, Olver IN, Sinclair C, Slevin TJ. Alcohol Overweight, obesity, and mortality from cancer in a and cancer: a position statement from Cancer prospectively studied cohort of U.S. adults. N Engl J Council Australia. Med J Aust. 2011;194 (9):479-82. Med. 2003;348 (17):1625-38. 495 Vasdev S, Gill V, Singal PK. Beneficial effect of 508 Vainio H, Bianchini F, editors. Weight Control and low ethanol intake on the cardiovascular system: Physical Activity, vol. 6. Lyon: IARC; 2002. possible biochemical mechanisms. Vasc Health Risk Manag. 2006;2 (3):263-76.

Cancer Council NSW • 159 160 • The State of Cancer Control in Australia

509 Percik R, Stumvoll M. Obesity and cancer. Exp Clin 520 Clague J, Bernstein L. Physical activity and Endocrinol Diabetes. 2009;117 (10):563-6. cancer. Curr Onc Report. 2012;14 (6):550-8. 510 Wolin K, Carson K, Colditz G. Obesity and cancer. 521 Recreation Australia Limited. Life. Be In It. Health Oncologist. 2010;15 (6):556-65. Promotion. Recreation Australia Limited; 2013 [updated May 6; cited 2013 May 6]; Available 511 Australian Bureau of Statistics. 4364.0.55.001 - from: http://www.lifebeinit.org/. Australian Health Survey: First Results, 2011-12. Canberra: ABS 2012 [updated 29 October; cited 522 National Public Health Partnership. Be Active 2013 28 February]; Available from: http://www.abs. Australia: A Framework for Health Sector Action gov.au/ausstats/[email protected]/Lookup/4364.0.55.001Ch for Physical Activity. Melbourne (VIC): NPHP; apter1002011-12. 2005. 512 Gill T, Baur L, Bauman A, Steinbeck K, Storlien 523 Australian Government Department of Health L, Fiatarone Singh M, Brand-Miller J, Colagiuri and Ageing. Get set for life - Habits for healthy S, Caterson I. Childhood obesity in Australia kids. Canberra Australian Government remains a widespread health concern that warrants Department of Health and Ageing; 2009 population-wide prevention programs. Med J Aust. [updated April 2; cited 2012 November 21]; 2009;190 (3):146-8. Available from: http://www.healthyactive.gov.au/ internet/healthyactive/publishing.nsf/Content/ 513 Crammond B, Van C, Allender S, Peeters A, getset4life-index. Lawrence M, Sacks G, Mavoa H, Swinburn B, Loff B. The possibility of regulating for obesity 524 Australian Government Department of Health prevention - understanding regulation in the and Ageing. Go For 2 & 5. Canberra Department Commonwealth Government. Obs Rev. 2013;14 of Health and Ageing; 2008 [updated November (3):213-21. 10; cited 2012 November 19]; Available from: http://www.healthyactive.gov.au/internet/ 514 National Health and Medical Research Council. healthyactive/publishing.nsf/Content/2and5. Australian Dietary Guidelines. Canberra: Commonwealth of Australia 2013. 525 Australian National Preventive Health Agency. Swap It, Don’t Stop It. Canberra Australian 515 Willett W. Diet, nutrition, and avoidable cancer. National Preventive Health Agency; 2012 Environ Health Perspect. 1995;103 (Suppl 8):165-70. [updated September 20; cited 2012 October 29]; 516 Kushi L, Doyle C, McCullough M, Rock C, Demark- Available from: http://swapit.gov.au/. Wahnefried W, Bandera E, Gapstur S, Patel A, 526 Myers P. Evaluation of the ‘Swap It, Don’t Stop Andrews K, Gansler T, American Cancer Society It’ Social Marketing Campaign February 2012 2010 Nutrition Physical Activity Guidelines Advisory Evaluation Report (Wave 6) FINAL. Melbourne: Committee. American Cancer Society Guidelines on The Social Research Centre; 2012. nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food 527 The Social Research Centre. Evaluation of the choices and physical activity. CA - Cancer J Clin. Australian Better Health Initiative Measure Up 2012;62 (1):30-67. Social Marketing Campaign Phase 1. Melbourne: The Social Research Centre; 2010. 517 International Agency for Research on Cancer. EPIC Project. Lyon: International Agency for Research on 528 Woolcott Research. Evaluation of the national Cancer 2013 [updated June 3; cited 2013 June 3]; Go for 2 & 5® campaign. Sydney: Woolcott Available from: http://epic.iarc.fr/. Research; 2007. 518 Gonzalez C, Riboli E. Diet and cancer prevention: 529 Cancer Council NSW. Eat It To Beat It – Contributions from the European Prospective Program overview. 2012; Available from: Investigation into Cancer and Nutrition (EPIC) study. http://www.cancercouncil.com.au/20614/ Eur J Cancer. 2010;46 (14):2555-62. reduce-risks/eating-moving/eat-it-to-beat-it/ overview/?pp=36572. 519 O’Hanlon L. Studying the Connection Between Exercise and Cancer Risk Reduction. J Natl Cancer Inst. 2013;105 (11):753-4.

November, 2013 530 Australian Government Department of Health and 539 Ipsos Eureka. Evaluation of National Skin Cancer Ageing. Healthy Communities Initiative. Canberra Awareness Campaign - Third Phase (2009-2010). Australian Government Department of Health Sydney: Australian Government Department of and Ageing; 2012 [updated October 20; cited Health and Ageing 2010. 2012 November 21]; Available from: http://www. healthyactive.gov.au/internet/healthyactive/publishing. 540 McArthur G. Solariums to be banned in Victoria nsf/Content/healthy-communities. Herald Sun Melbourne: News Limited, 2012. 531 Australian Government Department of Health and 541 Hardcastle J, Chamberlain J, Robinson M, Moss Ageing. Healthy spaces and places. Canberra S, Amar S, Balfour T, James P, Mangham C. Australian Government Department of Health and Randomised controlled trial of faecal-occult-blood Ageing 2009 [updated July 22; cited 2012 November screening for colorectal cancer. Lancet. 1996;348 21]; Available from: http://www.healthyplaces.org.au/ (9040):1472-7. site/. 542 Mandel J, Bond J, Church T, Snover D, Bradley 532 Australian Health Ministers’ Conference. Delivering G, Schuman L, Ederer F. Reducing mortality from Results. Press Release. Canberra Australian Health colorectal cancer by screening for fecal occult Ministers’ Advisory Council; 2008 [updated April blood. Minnesota Colon Cancer Control Study. N 18; cited 2013 March 6]; Available from: http:// Engl J Med. 1993;328 (19):1365-71. www.health.gov.au/internet/main/publishing.nsf/ 543 Mandel J, Church T, Bond J, Ederer F, Geisser M, Content/7C44FB98DE33E717CA25742F001A75 Mongin S, Snover D, Schuman L. The effect of C8/$File/Australian%20Health%20Ministers%20 fecal occult-blood screening on the incidence of Conference%20Communique.pdf. colorectal cancer. N Engl J Med. 2000;343 (22):1603- 533 Sacks G, Swinburn B, Lawrence M. A systematic 7. policy approach to changing the food system and 544 Benson V, Patnick J, Davies A, Nadel M, Smith R, physical activity environments to prevent obesity. Atkin W, International Colorectal Cancer Screening Aust NZ Heal Policy. 2008;5:13. Network. Colorectal cancer screening: a comparison 534 Baade P, Coory M. Trends in melanoma mortality of 35 initiatives in 17 countries. Int J Cancer. in Australia: 1950-2002 and their implications for 2008;122 (6):1357-67. melanoma control. Aust NZ J Publ Heal. 2005;29 545 Bowel Cancer Australia. Bowelscreen Australia. (4):383-6. 2013 [updated July 18; cited 2013 July 18]; Available 535 Wilkinson D, Askew DA, Dixon A. Skin cancer clinics from: http://www.bowelscreenaustralia.org. in Australia: workload profile and performance 546 Australian Government Department of Health and indicators from an analysis of billing data. Med J Aust. Ageing. Program Suspension - May to November 2006;184 (4):162-4. 2009. Canberra Australian Government Department 536 Youl PH, Baade PD, Janda M, Del Mar CB, Whiteman of Health and Ageing; 2010 [updated May 31; DC, Aitken JF. Diagnosing skin cancer in primary care: cited 2012 December 14]; Available from: http:// how do mainstream general practitioners compare www.cancerscreening.gov.au/internet/screening/ with primary care skin cancer clinic doctors? Med J publishing.nsf/Content/program-suspension. Aust. 2007;187 (4):215-20. 547 Australian Government. Budget 2012-13: Health and 537 Cancer Council Victoria. Sun Smart. 2012 [updated Ageing. Canberra: Commonwealth of Australia; 2012 October 16; cited 2012 November 19]; Available from: [updated July 9; cited 2013 July 10]; Available from: http://www.sunsmart.com.au/. http://www.budget.gov.au/2012-13/content/bp2/ html/bp2_expense-12.htm. 538 Australian Government Department of Health and Ageing. National Skin Cancer Awareness Campaign. 548 Haas M, Ashton T, Blum K, Christiansen T, Conis E, Canberra Australian Government Department of Crivelli L, Lim MK, Lisac M, Macadam M, Schlette S. Health and Ageing; 2010 [updated July 22; cited 2012 Drugs, sex, money and power: an HPV vaccine case October 29]; Available from: http://www.skincancer. study. Health Policy. 2009;92 (2-3):288-95. gov.au/.

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549 Roughead EE, Gilbert AL, Vitry AI. The Australian 561 Reid A, Franklin P, Olsen N, Sleith J, Samuel L, funding debate on quadrivalent HPV vaccine: a case Aboagye-Sarfo P, de Klerk N, Musk A. All-cause study for the national pharmaceutical policy. Health mortality and cancer incidence among adults Policy. 2008;88 (2-3):250-7. exposed to blue asbestos during childhood. Am J Ind Med. 2013;56 (2):133-45. 550 Kirby T. Australia to be first country to vaccinate boys against HPV. Lancet Oncol. 2012;13 (8):e333. 562 Department of Education Employment and Workplace Relations. A national approach to 551 Smith M, Lew J-B, Walker R, Brotherton J, asbestos management. Canberra: Department Nickson C, Canfell K. The predicted impact of HPV of Education, Employment and Workplace vaccination on male infections and male HPV-related Relations; 2012 [updated September 4; cited cancers in Australia. Vaccine. 2011;29 (48):9112-22. 2013 February 15]; Available from: http:// 552 Australian Government Department of Health and ministers.deewr.gov.au/shorten/national- Ageing. New Breast Cancer Nurses for Regional approach-asbestos-management. Australia. 2008 [updated October 13; cited 2012 563 Australian Institute of Health and Welfare. Key November 5]; Available from: http://www.health.gov. indicators of progress for chronic disease and au/internet/ministers/publishing.nsf/Content/mr- associated determinants: technical report. yr08-nr-nr134.htm. Canberra: Australian Institue of Health and 553 Government of South Australia. Independent review Welfare 2009 (Cat. no. PHE 114). into digital screening mammograms. Adelaide: 564 Sitas F, Urban M, Bradshaw D, Kielkowski D, Bah Premier South Australia; 2012 [updated December S, Peto R. Tobacco attributable deaths in South 14; cited 2012 December 14]; Available from: Africa. Tob Control. 2004;13 (4):396-9. http://www.premier.sa.gov.au/images/news_ releases/12_12Dec/bssa.pdf. 565 Sitas F, Egger S, Bradshaw D, Groenewald P, Laubscher R, Kielkowski D, Peto R. Differences 554 Australian Government Department of Health and in the coloured, white, black and other South Ageing. The Australian Immunisation Handbook African Populations in smoking attributed 9th Edition: 3.6 Hepatitis B. Canberra Australian mortality at ages 35-74 years: a case control Government Department of Health and Ageing; study of 481640 deaths. Lancet. 2013;682:685- 2008. 93. 555 Lowe A, Bennett M, Badenoch S. Research , 566 Australian Institute of Health and Welfare. Awareness, Support: Ten Years of Progress National Centre for Monitoring Cancer in Prostate Cancer. Sydney: Prostate Cancer Framework: 2012. Canberra Australian Institute Foundation of Australia, 2012. of Health and Welfare 2012 (Cancer series no. 68. 556 Straif K, Benbrahim-Tallaa L, Baan R, Grosse Y, Cat. no. CAN 64). Secretan B, El Ghissassi F, Bouvard V, Guha N, 567 Australian Institute of Health and Welfare. Freeman C, Galichet L, Cogliano V. A review of Australian Institute of Health and Welfare annual human carcinogens--part C: metals, arsenic, dusts, report 2011-12. Canberra Australian Institute of and fibres. Lancet Oncol. 2009;10 (5):453-4. Health and Welfare 2012 (Cat. no. AUS 161). 557 AFOM Working Party on Occupational Cancer. 568 Cancer Australia. A National Cancer Data Occupational Cancer: A guide to prevention, Strategy for Australia. Canberra: Commonwealth assessment and investigation. Sydney: The of Australia 2008. Australasian Faculty of Occupational Medicine 2003. 569 Australian Government Department of Health and 558 Landrigan PJ, Espina C, Neira M. Global prevention Ageing. New data reveals how long patients wait of environmental and occupational cancer. Environ for cancer surgery. Canberra: Commonwealth Health Perspect. 2011;119 (7):A280-1. of Australia 2012 [updated 29 May; cited 2013 559 Fritschi L, Driscoll T. Cancer due to occupation in July 1]; Available from: http://www.health.gov. Australia. Aust NZ J Publ Heal. 2006;30 (3):213-9. au/internet/ministers/publishing.nsf/Content/mr- yr12-tp-tp050.htm. 560 Department of Education Employment and Workplace Relations. Asbestos Management Review Report. Canberra: Department of Education, Employment and Workplace Relations 2012.

November, 2013 570 Clinical Oncological Society of Australia The Cancer 581 Morgan G, Barton M, Atkinson C, Millar J, Kumar Council Australia and the National Cancer Control Gogna N, Yeoh E. ‘GAP’ in radiotherapy services Initiative. Optimising Cancer Care in Australia. in Australia and New Zealand in 2009. J Med Imag Melbourne: National Cancer Control Initiative 2002. Radiat On. 2010;54 (3):287-97. 571 Fleissig A, Jenkins V, Catt S, Fallowfield L. 582 Barton M, Delaney G. A decade of investment in Multidisciplinary teams in cancer care: are they effective radiotherapy in New South Wales: why does the in the UK? Lancet Oncol. 2006;7 (11):935-43. gap between optimal and actual persist? J Med Imag Radiat On. 2011;55 (4):433-41. 572 Jiwa M, Longman G, Sriram D, Briffa K, Musiello T. Cancer care coordinator: Promoting multidisciplinary 583 Delaney G, Jacob S, Featherstone C, Barton M. care—A pilot study in Australian general practice. The role of radiotherapy in cancer treatment: Collegian. 2013;20 (1):67-73. estimating optimal utilization from a review of evidence-based clinical guidelines. Cancer. 573 Zorbas H, Barraclough B, Rainbird K, Luxford K, 2005;104 (6):1129-37. Redman S. Multidisciplinary care for women with early breast cancer in the Australian context: what does it 584 Barton M, Frommer M, Shafiq J. Role of mean? Med J Aust. 2003;179 (10):528-31. radiotherapy in cancer control in low-income and middle-income countries. Lancet Oncol. 2006;7 574 National Rural Health Alliance. An overview of the (7):584-95. shortage of primary care services in rural and remote areas. Deakin West: National Rural Health Alliance 2011. 585 Australian Government Department of Health and Ageing. PBS Chemotherapy Medicines Review. 575 National Rural Health Alliance. Fact Sheet 8: Cancer Canberra: Australian Goverment Department of in rural Australia. Deakin West: National Rural Health Health and Ageing; 2013 [updated June 29; cited Alliance; 2012 [updated January; cited 2012 December 2013 July 9]; Available from: http://www.health.gov. 12]; Available from: http://ruralhealth.org.au/sites/ au/chemo-review. default/files/publications/fact-sheet-08-cancer-rural- australia.pdf. 586 Australian Government Department of Health and Ageing. Palliative Care. Canberra: Australian 576 Deloitte Access Economics. Access to cancer treatment Government Department of Health and Ageing; in non-metropolitan areas of Australia. Sydney: Amgen 2009 [updated September 29; cited 2012 November Australia Pty Ltd 2011. 19]; Available from: http://www.health.gov.au/ 577 Hayen A, Smith D, Patel M, O’Connell D. Patterns of internet/main/publishing.nsf/Content/palliativecare- surgical care for prostate cancer in NSW, 1993-2002: program.htm. rural/urban and socio-economic variation. Aust NZ J 587 Health Workforce Australia. Health Workforce Publ Heal. 2008;32 (5):417-20. 2025 - Doctors, Nurses and Midwives - Volume 1. 578 Australian Government Department of Health and Adelaide: Health Workforce Australia 2012. Ageing. Health and Hospitals Fund. Canberra 588 Health Workforce Australia. Health Workforce 2025 Australian Government Department of Health and - Volume 3 - Medical Specialties. Adelaide: Health Ageing; 2012 [updated October 19; cited 2012 Workforce Australia 2012. December 13]; Available from: http://www.health.gov.au/ hhf. 589 Leach MJ, Segal L, May E. Lost opportunities with Australia’s health workforce? Med J Aust. 2010;193 579 National Rural Health Alliance. Fact Sheet 10: Patient (3):167-72. Assisted Travel Schemes. Deakin West: National Rural Health Alliance; 2009 [updated May; cited 2012 590 Knight A, Caesar C, Ford D, Coughlin A, Frick C. December 12]; Available from: http://ruralhealth.org.au/ Improving primary care in Australia through the sites/default/files/fact-sheets/fact-sheet-10-patient%20 Australian Primary Care Collaboratives Program: assisted%20travel%20schemes_0.pdf. a quality improvement report. BMJ Qual Safety. 2012;21 (11):948-55. 580 Baume (chairperson) P. Radiation Oncology Inquiry. A vision for radiotherapy. Canberra: Commonwealth of 591 Improvement Foundation. Improvement Australia 2002. Foundation. 2012 [updated October 20; cited 2013 February 6]; Available from: http://improve.org.au/ index.php.

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592 Leach MJ. Using role substitution to address 602 Sebastian M, Ninan N, Elias E. Nanomedicine and the health workforce shortage and to facilitate Cancer Therapies. In: Thomas S, Sebastian M, integration? J Complement Integr Med. George A, Weimin Y. Advances in Nanoscience and 2012;9:Article 30. Nanotechnology, vol. 2. Toronto: Apple Academic Press, 2013. 593 Health Workforce Australia. Health Workforce Australia 2012-13 Work Plan. Adelaide: Health 603 Garcia M, McQuade J, Haddad R, Patel S, Lee R, Workforce Australia 2012. Yang P, Palmer J, Cohen L. Systematic Review of Acupuncture in Cancer Care: A Synthesis of the 594 Dorr D, Bonner L, Cohen A, Shoai R, Perrin R, Evidence. J Clin Oncol. 2013;31 (7):952-60. Chaney E, Young A. Informatics systems to promote improved care for chronic illness: a literature review. 604 Bilusic M, Madan R. Therapeutic cancer vaccines: JAMIA. 2007;14 (2):156-63. the latest advancement in targeted therapy. Am J Ther. 2012;19 (6):e171-81. 595 Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, Morton S, Shekelle P. Systematic review: 605 Cantley L, Dalton W, DuBois R, Finn O, Futreal impact of health information technology on quality, P, Golub T, Hait W, Lozano G, Maris J, Nelson efficiency, and costs of medical care. Ann Intern W, Sawyers C, Schreiber S, et al. AACR Cancer Med. 2006;144 (10):742-52. Progress Report 2012. Clin Cancer Res. 2012;18 (21 Suppl):100. 596 DesRoches C, Campbell E, Rao S, Donelan K, Ferris T, Jha A, Kaushal R, Levy D, Rosenbaum S, 606 Verma M, Khoury M, Ioannidis J. Opportunities and Shields A, Blumenthal D. Electronic health records challenges for selected emerging technologies in in ambulatory care--a national survey of physicians. cancer epidemiology: mitochondrial, epigenomic, N Engl J Med. 2008;359 (1):50-60. metabolomic, and telomerase profiling. Cancer Epidemiol Biomarkers Prev. 2013;22 (2):189-200. 597 Poissant L, Pereira J, Tamblyn R, Kawasumi Y. The impact of electronic health records on time 607 Zhang Z, Nagrath S. Microfluidics and cancer: are efficiency of physicians and nurses: a systematic we there yet? Biomed Microdevices. 2013;EPub Jan review. JAMIA. 2005;12 (5):505-16. 29. 598 Holman C, Bass A, Rouse I, Hobbs M. Population- 608 Claudino W, Goncalves P, di Leo A, Philip P, Sarkar based linkage of health records in Western F. Metabolomics in cancer: a bench-to-bedside Australia: development of a health services research intersection. Crit Rev Oncol Hematol. 2012;84 (1):1- linked database. Aust NZ J Publ Heal. 1999;23 7. (5):453-9. 609 Rahman M, Ahmad M, Kazmi I, Akhter S, Afzal M, 599 Authority NET. The National E-Health Transition Gupta G, Jalees Ahmed F, Anwar F. Advancement Authority Strategic Plan Refresh. 2013 [updated in multifunctional nanoparticles for the effective February 18; cited 2013 February 18]; Available treatment of cancer. Expert Opin Drug Del. 2012;9 from: http://www.nehta.gov.au/about-us/strategy. (4):367-81. 600 Australian Government Department of Health and 610 Kennedy L, Bickford L, Lewinski N, Coughlin A, Hu Ageing. eHealth. Canberra Australian Government Y, Day E, West J, Drezek R. A new era for cancer Department of Health and Ageing; 2012 [updated treatment: gold-nanoparticle-mediated thermal October 31; cited 2013 February 15]; Available from: therapies. Small. 2011;7 (2):169-83. http://www.health.gov.au/internet/main/publishing. 611 Bartok D. Parramatta Council overturns smoking nsf/Content/eHealth. ban in alfresco dining areas The Daily Telegraph 601 Williams PAH, McCauley V. Sound Foundations: Sydney: News Limited, 2013. Leveraging International Standards for Australia’s 612 Australian Government Department of Health and National Ehealth System. Eur J Biomed Inform. Ageing. Australia’s first national cancer report 2012;8 (4):50-5. predicts lower death rates - but more cancers. Canberra: Australian Government DoHA; 1998 [updated 1998 July 6; cited 2013 March 11]; Available from: http://www.health.gov.au/internet/ main/publishing.nsf/Content/health-archive- mediarel-1998-mw14198.htm.

November, 2013 613 Balducci L, Lyman G. Cancer in the elderly. 626 Hannaford PC, Selvaraj S, Elliott AM, Angus V, Iversen L, Epidemiologic and clinical implications. Clin Geriatr Lee AJ. Cancer risk among users of oral contraceptives: Med. 1997;13 (1):1-14. cohort data from the Royal College of General Practitioner’s oral contraception study. BMJ. 2007;335 614 Chen RC, Royce TJ, Extermann M, Reeve BB. (7621):651. Impact of age and comorbidity on treatment and outcomes in elderly cancer patients. Semin Radiat 627 United Nations Statistics Division. Social indicators. Oncol. 2012;22 (4):265-71. Geneva: United Nations; 2012 [updated October 20; cited 2013 March 27]; Available from: http://unstats. 615 Beral V, Peto R. UK cancer survival statistics. BMJ. un.org/unsd/demographic/products/socind/. 2010;341:309-10. 616 Armstrong BK, Gillespie JA, Leeder SR, Rubin GL, Russell LM. Challenges in health and health care for Australia. Med J Aust. 2007;187 (9):485-9. 617 Leis A, Sagar S, Verhoef M, Balneaves L, Seely D, Oneschuk D. Shifting the paradigm: from complementary and alternative medicine (CAM) to integrative oncology. In: Elwood JM, Sutcliffe S. Cancer Control. New York: Oxford University Press, 2010: 239-58. 618 Epstein RM, Fiscella K, Lesser CS, Stange KC. Why the nation needs a policy push on patient-centered health care. Health Aff. 2010;29 (8):1489-95. 619 Goldsbury D, Armstrong K, Simonella L, Armstrong B, O’Connell D. Using administrative health data to describe colorectal and lung cancer care in New South Wales, Australia: a validation study. BMC Health Serv Res. 2012;12:387. 620 Youl P, Baade P, Meng X. Impact of Prevention on Future Cancer Incidence in Australia. CancerForum. 2012;36 (1). 621 Scher K, Hurria A. Under-representation of older adults in cancer registration trials: known problem, little progress. J Clin Oncol. 2012;30 (17):2036-8. 622 van de Water W, Bastiaannet E, Van de Velde C, Liefers G. Inclusion and analysis of older adults in RCTs. J Gen Intern Med. 2011;26 (8):831. 623 Rasmussen-Torvik L, Shay C, Abramson J, Friedrich C, Nettleton J, Prizment A, Folsom A. Ideal Cardiovascular Health is Inversely Associated with Incident Cancer: The Atherosclerosis Risk in Communities Study. Circulation. 2013;127:1270-5. 624 Hingston GR. Fifteen years of bowel cancer screening policy in Australia: putting evidence into practice? Comment. Med J Aust. 2010;193 (10):622. 625 Saunders MH, Peerson A. Fifteen years of bowel cancer screening policy in Australia: putting evidence into practice? Comment. Med J Aust. 2010;193 (10):621-2.

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