Cancer Control in Australia: Into the 21St Century

Jpn J Clin Oncol 2002;32(Supplement 1)S3–S9 Original Articles Cancer Control in Australia: Into the 21st Century Robert C. Burton Anti-Cancer Council of Victoria, Carlton, Victoria, Australia Received September 11, 2000; accepted August 13, 2001 Australia ranks highly internationally for cancer control, in part because cancer registries pro- vide comprehensive national incidence and mortality and other cancer data annually. This has facilitated short- and long-term planning over the last quarter of a century. For example, male death rates from lung cancer in Australia peaked around 1985 and are now falling steeply, whereas female rates are still rising. In women, cervical cancer incidence and mortality have fallen owing to cervical screening over the last quarter of a century. Breast cancer mortality is now trending downwards after a half-century plateau, probably because of better treatment protocols. Cancer registry based State and national population treatment surveys over the last 15 years have identified both deficiencies and strengths in evidenced-based treatment of cancer in Australia. For example, in the State of Victoria, 5-yearly population based breast cancer treatment surveys have shown that the proportion of women who had a mastectomy versus a lumpectomy as their primary surgical operation fell from 78% in 1986 to 47% 1995. All Austral- ians are covered by a universal health care system. Therefore, socio-economic status is not a barrier to accessing high quality cancer control, whether it be prevention, screening, treatment or education. In addition, non-government organizations (NGOs) specializing in cancer control have been providing free or highly subsidized support services to patients and their families for over half a century in most states. These NGOs have also been very active in public education about cancer, especially cancer prevention. Key words: cancer – Australia – treatment – prevention – education – statistics INTRODUCTION Australia, but most of this is disability and very little is due to death. Cancer control is defined internationally as all actions which reduce the burden of cancer in the community: research, prevention, early detection, treatment, palliation, patient and CANCER INCIDENCE AND MORTALITY family support and education. Implicit is continuous monitor- National Australian data on cancer mortality has been avail- ing of population cancer outcomes: incidence, mortality, the able for over a century, based on information in medical certifi- treatments employed and the burden of cancer on the society. cates of causes of death provided to State registrars of births, What is the burden of cancer in Australia? There is a mea- deaths and marriages. State based cancer registries began to be sure developed through the World Health Organization called established over half a century ago (Victoria in 1936) to vali- Disability Adjusted Life Years or DALYs. In Australia, cancer date this death certificate data and to collect cancer treatment caused the second greatest burden of DALYs in 1996 and most and follow-up information from hospitals. Some State cancer of these DALYs were years of life lost due to premature death registries began to collect new case (incidence) data (New (1). Cardiovascular disease is the greatest cause of DALYs in South Wales from 1972) and national and State laws making Australia, but in terms of premature death, cancer is equal. It is cancer a notifiable disease came into effect in 1982. From 1982 worth noting that mental illness ranked third for DALYs in there has been universal registration of new cancer cases in Australia and an Australian Association of Cancer Registries which, together with the Australian Institute of Health and Welfare, produces an annual report: Cancer in Australia (2). For reprints and all correspondence: Robert C. Burton, Anti-Cancer Council of Victoria, 1 Rathdowne Street, Carlton, Victoria 3053, Australia. This network of State cancer registries has made it possible E-mail: [email protected] to undertake State and national population based treatment © 2002 Foundation for Promotion of Cancer Research S4 Cancer control in Australia Figure 1. The number of new cases and deaths from the 14 most common cancers (excluding non-melanocytic skin cancer) in Australia in 1996. surveys (described later) and other valuable epidemiological which was only the third commonest cause of cancer death in research, in addition to reporting cancer incidence and mortal- men in 1950, became the commonest fatal male cancer by ity. These registry data reveal that for females and males the 1960 (Fig. 2). As night follows day, so lung cancer mortality in world age standardized incidence of all cancers in Australia all populations peaks about 30 years after the peak prevalence peaked around 1995 and is now falling. These data also reveal of cigarette smoking. Australian male lung cancer mortality that male and female world age standardized cancer mortalities peaked around 1980 and 70% of adult Australian males have been falling slowly since the end of the 1980s. Australia smoked cigarettes in 1950. Stomach cancer, which was the is one of the few countries in the world where the whole popu- commonest fatal cancer in 1954, is disappearing and bowel and lation world age standardized cancer incidence and mortality prostate cancer have been on a plateau over the last half rates are both falling. century. The male melanoma mortality rate rose during the last In 1996 there were 14 potentially fatal cancers recorded in half century, plateaued in the early 1990s and is now falling. Australia, for which there were more than 1000 new cases (2). The commonest of these was colorectal cancer; however, it is worth noting that the gender specific cancers, prostate cancer in men and breast cancer in women, ranked second and third (Fig. 1). For many of these cancers, the incidence rate was twice or more the mortality rate, reflecting improvements in treatments that have occurred during the twentieth century. However, for cancers of the lung, pancreas and brain, incidence and mortality were almost the same, reflecting the very poor prognosis that these cancers still have. This pattern of cancer incidence and mortality is typical of westernized developed countries, where lifestyle factors such as cigarette smoking and consumption of diets high in calories and fats and low in vegetables are common. TRENDS IN CANCER MORTALITY RATES IN AUSTRALIA Between 1990 and 1996 the world age standardized cancer mortality rates in Australia for both males and females fell by 0.4% per year (2). Mortality trends for the five commonest potentially fatal cancers in Australia, together with stomach and cervical cancers, are considered below. Cancer mortality Figure 2. Mortality trends of five common cancers in Australian men, 1950– trends in men over the last half century reveal that lung cancer, 1995. Jpn J Clin Oncol 2002;32(Supplement 1) S5 GOVERNMENT FUNDING OF CANCER CONTROL IN AUSTRALIA The Commonwealth (National or Federal) Government has the major responsibility for funding health in Australia and in respect of cancer there are three major mechanisms. Cancer research is funded via the National Health and Medical Research Council (NHMRC). In 1995 an NHMRC National Breast Cancer Centre was created to improve breast cancer management in Australia. In 1996 government funding from all sources for cancer research was about 71 million dollars (Australian dollars are quoted throughout). There is now a National Cancer Control Initiative, the counterpart of the National Cancer Institutes in other countries, which was established in 1997 to advise the Commonwealth Government about cancer policy, to produce and facilitate the implementation of a national cancer control plan and to develop and manage cancer control projects. A major mechanism for Commonwealth Government funding of health care is via funding grants to the eight State and Territory governments, all of which have health departments. Figure 3. Mortality trends of six common cancers in Australian women, 1950– 1995. There is an Australian Health Ministers Advisory Council, where the Commonwealth and State Health Ministers meet to coordinate their respective government activities in health For women, the commonest potentially fatal cancer is breast care. In respect of cancer most of these funding grants are cancer and it has been on a plateau of mortality for most of the expended on the diagnosis, treatment and palliation of cancer twentieth century (Fig. 3). Mortality from breast cancer is now in public (government) hospitals. In addition, there are the two falling in Australia as of 1995 and this is probably attributable national cancer screening programmes mentioned above and in to adjuvant chemotherapy and hormone drug treatment. The the 2000 Commonwealth Budget a feasibility study on colo- national mammographic screening programme is not expected rectal cancer screening was funded. These National Cancer to have an effect until later this decade. Bowel cancer is screening programmes are largely implemented by the State becoming less fatal in women. In the first half of the twentieth and Territory governments, using Commonwealth funding. century Australian men and women had almost the same bowel The third major mechanism of Commonwealth Government funding is via direct payments to health care professionals on a cancer fatality rates. The fall in the women’s rate, but not in the fee for service basis and via subsidization of the pharmaceuti- men’s, has been attributed to a number of factors. A likely cal drugs which they prescribe. This effectively provides free cause is the introduction of synthetic oestrogens to the treat- primary health care to all Australians via primary health care ment of women beginning in the 1950s and 1960s, in the form physicians (General Practitioners), who can refer patients to of hormone replacement therapy and the contraceptive pill. appropriately qualified specialist medical practitioners. For Stomach cancer is disappearing in women as it is in men and cancer, these are medical practitioners who have specialist for the same reasons.

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