Last post: My Story: Next One
Ageing and Cancer. My Experience
My Submission For the 2014 Cancer Council Essay Competition.
"You're a little young to be in here aren't ya, son?"
"Aren't we all?" The man slouching in the chair opposite me
chuckled, adjusting the tubes attached to his forearm.
"What did you have?"
"Multiple Myeloma," he said, struggling to turn in his chair as the pump's alarm went off. "Had a few goes of chemotherapy, and it's going to stop soon."
"That's great news! Congrats!" I exclaimed. I could only hope
to be in his position.
But the next thing he said shocked me.
"Yeah, I've lived long enough. I'm ready to move on."
I was diagnosed with leukemia at 17. After being diagnosed, I was in
shock... miserable and depressed. I'd been told I had a 10% chance of living to
see 21..
But, after a while, I saw a second way of looking at things. I saw my
youth as a blessing. It meant that I could get the hardest, most effective
treatment possible and survive, possibly even thrive after it. I didn't have
heart disease or kidney issues or a family to have to look after - I would have
the best chances possible for the disease I had.
I was ready, willing, almost looking forward to start chemotherapy by
the time my central line was put in.
So his words, only weeks after starting chemo, really got to me... I
mean why would someone just give up, especially after they'd gone through
so much already?
Today, it doesn't surprise me as much. I've overheard my doctors ask other, older patients, with similar diseases, at similar, sometimes better stages than mine, if they'd considered not continuing treatment. And I get why too. Cancer treatment is horrible. And after 3 year of it, featuring I can't remember how many bags of chemo, 2 stem cell transplants and
a near-fatal dose of radiation, I know what it's like to be tired. So tired
that death wouldn't be that scary... it'd be almost welcome. It
would DEFINITELY be easier than living.
That's me at 20. I can barely imagine going through that at 70.
Introduction: The Link Between Age and Cancer:
Young people, like me, do get cancer, and they get it in large numbers too. But cancer is still a diseases of the elderly. In 2009, 73.5% of all male, and 63.6% of all women in Australia
diagnosed with cancer were over the age of 60 [1]. For a variety of reasons, increased exposure to carcinogens and weaker immune systems being the major ones, cancer incidence increases
exponentially with age, and this can be seen in the graph below.
Incidence of Cancers in the UK by Age
As seen above, cancer incidence increases almost exponentially with age
in developed countries[2-5]
Our Population Is Getting Older:
A challenge faced by many developed countries, including Australia, is
an ageing population, due to low fertility rates combined with increased life
expectancy. Australia's fertility rate lies at around 1.88 [6], and is projected
to stay below the replacement fertility rate of 2.1 [7], and the life
expectancy of all developed countries, has historically, and is expected to
continue to rise over time too. Australian men are expected to live 5.5 years
longer, and women 4 years by 2060 [10], and 1/3 babies born in developed
countries today are expected to make it to 100 years of age [8].
The impact of a longer life expectancy and lowered fertility rate is
clear in the skewing of Australia's population demographics over time [12].
The Ageing Population's Impact on Prevalence of Cancer
Considering this trend of an ageing population, and the fact that cancer incidence increases greatly with
age, cancer is bound to become more prevalent than it already is. Indeed, Australia is on the brink of a
cancer epidemic. 128,000 new cases of cancer were detected in 2013, and that
number is set to increase to 150,000 by 2020. Overall, that's a 40% increase since 2007 [9]. That number
stands to rise even more by 2060 when more people will be above 50 years of age
than under. With peak incidence of cancer striking between 65 and 80 years of
age for men, and plateauing at 60 for women, an ageing population is the major
factor in the increase in cancer prevalence.
Proportion of the Australian Population aged 65 or older.
The proportion of Australians over 65 years of age is set to increase
and increase at a steady rate. With 1/2 men, and 1/3 women expected to get
cancer by 85 [11] and with about 2/3 of people with cancer
developing it beyond 65[1] cancer rates are only bound to rise too.
Cancer's
Current Burden on the Economy:
Cancer cost Australia $4.5billion in direct healthcare expenditure in
the 2008-09 financial year [13], and that number only stands to rise
as cancer becomes more prevalent. The impact on productivity is even greater.
Cancer treatment is a long process, that often leaves many unable to work. In
terms of productivity, 551,300 healthy years of life (measured in DALYs) were
lost to cancer in 2012 [14] and the average cost of cancer per person, including loss in
productivity, lies at $966,000 per person [15], totalling a staggering $83.4billion
of lost productivity for all patients with cancer in 2005, over their lifetime [15].
Accommodating for the Increase in Burden of Cancer.
Making sure we're ready for the cancer epidemic is critical to keeping
its already high economic and social burden of healthcare from increasing even
further. And It's imperative that Australia acts early in tailoring
infrastructure, policies and education to mitigate its impacts.
Catching and treating cancer in the early stages, through effective,
accessible screening protocols, quicker diagnosis and the use of preventative,
early phase treatment options not only leads to better treatment and quality of
life outcomes for patients, but is also more cost effective than treating
cancer at later stages and hence should be prioritised in future policies.
With 43% of cancers in developed countries being caused by correctable
lifestyle choices [16], focusing on reducing incidence of preventable cancers will also help
reduce the burden of cancer.
But though prevention and early treatment is the best way to mitigate
the burden of cancer, elderly patients
in particular are not always able or willing to progress with treatment and are
the highest users of palliative care facilities [33]. Therefore improving access and
quality of palliative care, and grief councelling facilities should also be a
high priority.
Education about these issues at the undergraduate level is the most
effective way of ensuring that Australia's health professionals are ready for
the cancer epidemic to come.
Improving Screening And Prevention of Cancer:
In most cancers, early detection is correlated with better prognoses and
better quality of life post treatment.
Bowel Cancer 5 year survival statistics based on classification:
Stage A cancers, those which haven't penetrated through the inside of
the bowels have a very high 5 year survival rate, while Stage C and D cancers,
which have spread to the lymph nodes or all around the body have low 5year
survival rates.
Because symptoms of many cancers are non-specific and present in later
stages of diseases, as many as 1/2 bowel cancers and 1/3 breast cancers present
in later stages [23].
Screening is often the only effective way of catching cancers early on,
when they are more easily curable. Biennial Fetal Occult Blood Tests (FOBT)
which detect bowel cancers with minimal invasiveness, has been proven in
multiple randomised controlled trials, each comprising of at least 48,000
subjects, to reduce mortality rates by 15 - 21% [16 - 19]. One Minnesota
study found annual tests reduced mortality by a staggering 33% [16], all because
cancers were detected earlier, in their more curable stages.
The BreastScreen Australia program Evaluation Report found that breast
cancer mortality had decreased by 21-28% in all breast cancers [20] since its
implementation, and regular cancer screening for colorectal cancer has been
shown reduce deaths by as much as 60% [22].
The Benefits of Improving
Screening and Early Intervention Infrastructure:
Screening services for cancer costs our government $332million a year[13], but despite the
high cost in both the setting up of facilities and utilisation of them, the offset price in direct treatment alone recovers for it. That's not even considering the wider implications of having a healthier, work-fit, more productive population.
Treatment at early stages is almost always cheaper, and more effective than
managing late-stage-cancer. For example, resecting precancerous polyps costs
$2,000 and has a 70% greater chance of success compared to $66,000 a year to
treat advanced bowel cancer [21].
Per member per month (pmpm) cost paid by insurance companies for later
stage, invasive cancers showing the benefit of treating diseases early, before
hospitalisation and more interventional medicines and procedures make it less
likely to succeed and more expensive too [25]
Health economists agree that the intervention plus screening costs
involved are effective if they cost less than $50,000 per year of life saved
(pyols) [22]. Colorectal cancer screening, mammograms in women over 65, and 3 yearly
pap smears have been shown to fall well below that figure, the former costing $11,592 and $36,843 respectively and the latter only
costing $5,392 pyols [22]. These life years saved pay off economically through increasing the
workforce and consumption.
Insurance companies in other developed countries have proven the cost
effectiveness of covering screening tests too. Investing $2.95pmpm yields up to
$3.75 in savings[28]. Also, those with cancer claimed on average $2,390per member per year, versus $360
for those without cancer. Thus insurance companies investing in screening is definitely
economically viable for the companies, as it would save on having to pay out those increased claims,
and will enhance the governments efforts in getting Australia screened.
Issues Facing Australia's Screening Programs:
For screening tests to be effective in reducing the rising burden of
cancer, tests need to be cheap, accurate, affordable and targeted to the right
locations.
Currently, due to an insufficient workforce and lack of access to
screening facilities, Australia's compliance with the BreastScreen program has
plateaued at 56% compared to America's compliance rate of 81.2% [23].
Policies, such as Australia's National Bowel Cancer Screening Program
(NBCSP) need to target the correct populations too. Currently, 61% of bowel
cancers occur in those aged 70 and older [29], but no-one over 65 is included in
the current program. Only 15million dollars a year, on top of $37million
already put in is required to provide screening to 75 years of age [29], probably because
facilities to act on early detection tests aren't adequate. When looking at the
costs of later intervention however, it becomes clear this is most likely worth
it, and should be rolled out as soon as possible.
Mammograms in women in the 40 - 49 age group have been proven to not
decrease mortality over time [24] due to denser breasts in younger
populations. Thus there are limitations to current screening technologies that
practitioners should be aware of.
Issues of equality in access to screening and treatment is of import
too, especially in Indigenous and rural settings. Indigenous Australians still
face a huge gap in cancer mortality and screening rates, and are also less
willing to accept treatment [27]. They have a 1.3x greater mortality
rate due to cancer, are 3-3.9x more likely to develop preventable cancers (such
as lung and liver cancer), and only have a 36% rate of compliance with breast
cancer screening programs[26] due to a cultural, socio-economic, distance and awareness reasons. Mortality rates increase
with increasing remoteness in rural Australia [41] due to problems in accessing care
and screening facilities.
Designing an Effective Screening/Early Intervention Program
Scotland's Detect Cancer Early Program attacks the issue of an
increasing burden of cancer by working on a variety of aspects concerning
screening and prevention of cancer.
The program focuses on raising public awareness, ensuring diagnostic and
imaging departments are well equipped for the increasing rates of screening and
early treatment and working with GPs to promote referral for investigation at
earlier opportunities and in raising data too, which "constitutes a
priority for early diagnosis initiatives and research" [44]. In its first year
there was a 4.3% increase in people being diagnosed at stage 1 for the 3
cancers targeted, showing it to be an effective strategy.
Australia needs to model its future policies regarding this issue in a
similar, all-encompassing manner to reduce the burden of cancer.
Preventing Cancer:
As stated above, 43% of cancers can be linked to lifestyle choices, and
these usually manifest due to decades of bad health habits. Reducing these not
only reduces the burden of cancer, but also that of other diseases too.
Preventable, Lifestyle Choices that directly cause cancer. [16]
Reducing Risk Factors
A huge proportion of disease is directly attributed to tobacco use.
Hence policies and tobacco cessation rehabilitation measures proven to work,
such as tax increases and anti-smoking media campaigns [30], to where they're
needed, in areas like Northern Queensland with a very high 38% age-adjusted
smoking male Indigenous population [31] will be greatly beneficial. The same applies
for providing HPV vaccines in Indigenous women. Poor diet and alcohol
consumption also leads to increased likelihood of cancer, and needs to be
addressed through better patient education.
Systemic Changes that Promise Better Care
The increasing use of multidisciplinary teams to manage patients before
hospitalisation, along with databases like the E-Health Record, will hopefully
mean these lifestyle choices can be better managed and tracked over time by
GPs. TeleHealth and other long distance medical services are also looking to
provide better access to good health and treatment to rural and remote
communities too.
Improving Palliative Care
What is Palliative care?
Palliative care encompasses a
holistic approach to end of life care, and hence encompasses a broad variety of
roles in healthcare, from hospital, hospice or nursing home care, to grief
counseling to radiological intervention to reduce pain.
World Health Organisation outline of the role of
palliative care. [32] Below is its aims.
Current
Trends in Palliative Care
Palliative care needs to be up-scaled and optimised to cope with the
increase in cancer prevalence at older ages. 54,446 patients accessed
palliative care in 2013, 88% of whom were 55 years or older [33] and 77% of whom had cancer [34]. That number had increased by 56% over a 10 year
period, as the prevalence of elderly patients with cancer, those most likely to
seek palliative care, will increase. Hospital facilities provided 653,000 days
of care to cancer patients at the end of life between 1998 and 2008[34], in addition to the $3.5million/year in subsidies
for prescription medications to ease symptoms at the end of life [33].
Improving
Palliative Care
Obtaining Data on Palliative Care
But palliative care isn't just
restricted to hospital settings. Community and GP management of palliative care
isn't being monitored at present, making it hard to determine what services
exist and what needs to be improved. However, this is set to change soon with
an NDMS (National Data Minimal Set) been deemed to be feasible [35].
Increasing the role of GPs in
Palliative Care
To cope with the increased
seeking of palliative care, primary care physicians should be trained to
deliver and manage palliative care in a multidisciplinary team setting.
Currently, 56% of GPs feel that they
should be responsible for palliative care [36], but many doubt their ability to
fulfill the role due to lack of training [37] and don't seek further training
for workload, cost of course and loss of time reasons[38]. Thus additional
training within GP specialisation and at an undergraduate level would make
palliative care more accessible in the future.
Increasing Palliative Care Specialists
Specialists in palliative care
currently make up 0.38% [33] of all health specialists, with only 92, servicing
108 registered palliative care services; this already indicated a shortage but
is more concerning when considering that many more services exist without being
registered or providing data. More training and education of this already
shorthanded field is required.
Technology's role in Improving
Access to Improve Access
Though Australia is ranked 2nd
in the world in the Quality of Death Index, we are ranked 19th in terms of
providing access to a basic end of life healthcare environment [42] indicating
both a lack of specialisation and lack of access by rural communities. Again,
TeleHealth is promising in delivering care to rural communities and this, along
with the Personally Controlled E-Health Record will make palliative care more
accessible to rural populations [43].
Conclusion:
Why Medical Students Need To Be
Aware of These Trends
Cancer is already a prevalent
disease in Australia. 339,077 people were diagnosed with cancer from 2007 -
2012 alone [14]. With our ageing population, this figure is set to
rise in the following years.
Implementing proper,
accessible screening protocols nation-wide, advocating healthy lifestyle habits
and improving palliative care access and facilities is vital to ensure
Australia can deal with the increased cancer burden due to an ageing
population, and education of future doctors and health professionals is a
priority.
The Cancer Council's Ideal
Oncology Curriculum [40] mandates that awareness of the public health
factors, including epidemiology, screening and the impact of cancer on
psychosocial health is as important as the learning of cancer biology and
treatment. They are our future GPs and specialists and they should be aware of
these trends, and on how to deal with them.
Education on the benefits and
limitations of screening technologies, on the economic and health benefits of
catching cancer early, methods and the importance of reducing cancer risk
factors and the accessing and importance of palliative care are all best learnt
at the medical student level.
Hence, ensuring that our next
generation of doctors are aware of the trends and impacts of cancer, and
ensuring more are trained in this field is crucial to ensuring the burden of
disease remains low.
References:
[1] Australian Cancer Incidence and Mortality (ACIM) Books – All Cancers
combined for Australia (ICD10 C00-C97, D45-46, D47.1, D47.3). www.aihw.gov.au/cancer/data/acim_books [Accessed January 2013].
[2] Cancer Statistics Registrations, England (Series MB1) , No. 42, 2011
[3] Cancer Incidence in Scotland,
Information and Services Division, April
2013
[4] Cancer In Wales, Welsh Cancer Intelligence and Surveillance
Unit, April 2014
[5] Cancer in N. Ireland, http://www.qub.ac.uk/research-centres/nicr/FileStore/PDF/Incidence/Filetoupload,31480,en.pdf
1993 - 1995
[6] Births, Australia, ABS 3301.0, 2011
[7]
http://www.immi.gov.au/media/fact-sheets/15population.htm#b
[8] Historic and Projected
Mortality Data 1951 to 2060, Office
For National Statistics,
http://www.ons.gov.uk/ons/rel/lifetables/historic-and-projected-mortality-data-from-the-uk-life-tables/2010-based/index.html, March 2012
[9] Cancer
incidence projections: Australia, 2011 to 2020. Cancer Series no. 66.
Cat. No. CAN 62. Canberra: AIHW, 2012
[10] Population
Projections, Australia, 2012 (base) to 2101, ABS 3222.0, November, 2013
[11] Non-melanoma
skin cancer: general practice consultations, hospitalisation and mortality.
Cancer series no. 43. Cat. no. 39.Canberra: AIHW. 2008.
[12] Population projection 1997-2051,
Australia, 1350.0 -
Australian Economic Indicators, Dec 1998, p 11
[13] Health system expenditure on cancer and
other neoplasms in Australia 2008-09. Cancer series 81.
Cat. no. CAN 78. Canberra: AIHW, December 2013
[14] Cancer
in Australia: an overview, 2012, Cancer series no. 74. Cat. no. CAN 70. Canberra: AIHW
[15] Cost of Cancer
in NSW, The Cancer Council NSW, April 2007.
http://www.cancercouncil.com.au/wp-content/uploads/2010/11/costofcancer_summary.pdf
[16] Professor R Peto, The fraction of cancer attributable to lifestyle and environmental
factors in the UK in 2010, British Journal of Cancer (2011) 105,
S1–S1. doi:10.1038/bjc.2011.473, Dec 2011
[17] Shaukat A, Mongin SJ,
Geisser MS, et al.: Long-term mortality after screening for colorectal
cancer. N Engl J Med 369 (12):
1106-14, 2013.[18] Mandel JS, Church TR, Bond JH, et al.: The effect of
fecal occult-blood screening on the incidence of colorectal cancer. N Engl J Med 343 (22): 1603-7, 2000.
[18] Hardcastle JD,
Chamberlain JO, Robinson MH, et al.: Randomised controlled trial of
faecal-occult-blood screening for colorectal cancer. Lancet 348 (9040): 1472-7, 1996.
[19] Kronborg O, Fenger C,
Olsen J, et al.: Randomised study of screening for colorectal cancer with
faecal-occult-blood test. Lancet 348
(9040): 1467-71, 1996.
[20] BreastScreen
Australia Evaluation Advisory Committee Final Report 2009
[21] Cancer Council
Australia, Australia's response to the social determinants of health
Pre-Budget Submission, 2012 - 2013,
http://www.cancer.org.au/content/pdf/CancerControlPolicy/Submissions/Cancer_Council_Australia_pre-budget_submission_2012-13_bowel_cancer%20screening.pdf
[22] Screening to Prevent
Cancer Deaths, US Department of
Health Centers for Disease Control and Prevention Report, 2008,
http://www.cdc.gov/nccdphp/publications/factsheets/prevention/pdf/cancer.pdf
[23] S Jane Hadley et al, Surveillance of Screening-Detected Cancers (Colon and
Rectum, Breast, and Cervix) --- United
States, 2004--2006 Morbidity
and Mortality Weekly Report, Surveilance Summaries, November 26, 2010 /
59(SS09);1-25
[24] Anthony B Miller et al, 25 year follow up of breast
cancer incidence and mortality of the Canadian National Breast Screening Study:
Randomised Screening Trial, British
Medical Journal 2014;348:g366, January 2014
[25] Bruce Pyenson et al, Cancer Screening: Payer Cost/Benefit
thru Employer Benefits Programs, C-Change
and the American Cancer Society, November 2005 http://c-changetogether.org/Websites/cchange/images/Publications%20and%20Reports/Milliman_Report.pdf
[26] Chun Chen and Ellen Connel, Cancer in Aboriginal and
Torrest Straight Islander peoples of Australia: an overview, Australian Institute of Health and Welfare, 2013.
[27] Condon
J, Barnes T, Armstrong B, Selva-Nayagam S, Elwood M. Stage at diagnosis and
cancer survival for Indigenous Australians in the Northern Territory. Med J Aust. 2004;182(6):277-80,
[28] C-Change Together, Making the business case: How engaging
employees in preventative care can reduce healthcare costs, http://c-changetogether.org/Websites/cchange/images/Risk_Reduction/C-Change_Business_Case_White_Paper_(1).pdf,
Spring 2008
[30]
http://www.anpha.gov.au/internet/anpha/publishing.nsf/Content/smoking-disadvantage-evidence-brief~existing-interventions, Australian National Preventative Health
Agency website, Accessed April 2014
[31] Cunningham J, Rumbold AR, Zhang X & Condon JR . Incidence,
aetiology, and outcomes of cancer in Indigenous peoples in Australia. The lancet oncology 9:585–95. 2008
[32] http://www.who.int/cancer/palliative/definition/en/, World Health Organisation Palliative Care
Page, Accessed April 2014
[33] Australian Institute of Health and Wellness. Palliative
care services in Australia 2013. Cat.
no. HWI 123. Canberra: AIHW. 2013.
[34] AIHW 2011.
Trends in palliative care in Australian hospitals. Cat. no. HWI 112. Canberra: AIHW. Viewed 21 April 2014
[35] Australian
Institute of Health and Welfare (AIHW) 2004. National palliative care
information collection: a way forward for community-based palliative care. AIHW Cat. No. HWI 77.
[36] Burt
J, Shipman C, White P, Addington-Hall J. Roles, service knowledge and
priorities in the provision of palliative care: a postal survey of London GPs.
Palliat Med 2006; 20(5): 487-92
[37] Field
D. Special not different: General practitioners’ accounts of their care of
dying people. Soc Sci Med 1998; 46:
1111-1120
[38] Dowling
S,Leary A, Broomfield D. Palliative care education: a Delphi survey of Irish
general practitioners. Education for
Primary Care 2005; 16(4): 458-466(9)
[40] Cancer Council Australia. (2007). Ideal
Oncology Curriculum for Medical Schools, accessed April 2014
[41] COAG Reform Council 2012, Healthcare
2010-11: comparing outcomes by remoteness, COAG Reform Council, Sydney, 2012
[42] Sarah Murray et al, The quality of death,
Ranking end-of-life care around the world, Report by the Economist Intelligence Unit 2010.
[43] National Rural Health Alliance Inc,
Palliative care in rural and remote areas, Fact sheet 34, October 2012.
[44] Lyratzopoulos, G., Abel, G. A., McPhail, S.,
Neal, R. D. & Rubin, G. P. Measures of promptness of cancer diagnosis in
primary care: secondary analysis of national audit on patients with 18 common
and rarer cancers. British Journal of
Cancer, 108(3), 686-690, 2013
