How Australia (and other developed countries) Can Prepare For An Impending Cancer Epidemic. Improving Early Detection/Treatment and Palliative Care.

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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:

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http://www.ons.gov.uk/ons/rel/lifetables/historic-and-projected-mortality-data-from-the-uk-life-tables/2010-based/index.html, March 2012

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[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

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[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