Dr Chris JacksonConsultant Medical Oncologist

Southern Blood and Cancer Service (SDHB)

University of Otago

9:15 - 9:45 The Changing Landscape of Cancer Care in NZ

The Changing Landscape of Cancer Care in NZ

Dr. Chris Jackson

Medical Oncologist, Southern DHB

Medical Director, CSNZ

Cancer29%

Cerebrovascular disease9%

Ischaemic heart disease

18%

Motor vehicle accidents1%

Diabetes 3%

Pneumonia / flu 2%

Other heart disease 4%

Respiratory disease 6%

Suicide2%

Assault0%

Other26%

Cancer is NZ’s leading cause of death

Smoking – 22%

Alcohol

UV radiation

Obesity

Inactivity

Infectious diseases – 22%eg HPV; Hep B, C; H Pylori

Environmental and industrial

carcinogens – 4%

Lower mortality, more cases, more survivors.

0

2000

4000

6000

8000

10000

12000

1955

1958

1961

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1967

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

2003

2006

2009

Male registrations

Female registrations

Male deaths

Female deaths

Cancer has increased in importance.

5 types account for the majority of cases

Prostate

14%

Breast

14%

Colorectal

14%

Melanoma

11%

Lung

9%

Non-Hodgkins

4%

Leukaemia

3%

Uterus

2%

Kidney

2%

Pancreas

2%

Other

25%

Cancer Care – 50 years ago

• Breast Cancer Surgery

• Lymphoedema

• Extensive Radiotherapy

• Chemo including high dose

• Tamoxifen for all

Improvements in Cancer Staging

• Improved local staging means more precise extent of surgery

• Futile surgery is avoided for those with distant disease

• Some patients with stage 4 disease can undergo extensive resections

Radio-isotope scanning

• Bone scanning

• Iodine scanning

• FDG-PET

• PSMA

• Gallium-DOTATATE

PET scan - melanoma

PET scan - lymphoma

Improvements in Surgery

• All visible disease and a margin must be treated– R0 / R1 / R2

• Extent of margin is cancer specific• Often draining lymph nodes excised• Vital organ preservation• Infection control• Haemostasis• Patient co-morbidity• Post-operative supportive care

Surgery: luminal excision

http://colorectalsurgeonssydney.com.au/?page_id=1152

Surgery: metastasectomy and ablation

Surgery: palliative

• A complete resection not always needed to alleviate symptoms

• Indications include pain, fungation (ulceration), obstruction (eg bowel obstruction) that cannot be relieved by non-surgical means

• Often has a recovery period that is important to consider in a palliative situation

Radiotherapy: 3D Conformal

Brachytherapy: Interstitial implantation of radioisotopes

Systemic therapies

• Chemotherapy

• Hormonal Therapy

• Monoclonal Antibodies

• Targeted therapies

• Immunotherapy

EGFR family

– activated in many cancers

Ciardiello F and Tortora G. N Engl J Med 2008

Ras

RAF

MEK

EGFR

Cell growth, proliferation,

invasion and metastases

Ras

RAF

MEK

EGFR

Cell growth, proliferation,

invasion and metastases

Ras

RAF

MEK

EGFR

Cell growth, proliferation,

invasion and metastases

Vemurafenib in V600E mutated melanoma

• “Objective response”: 57%

• Rapid: days

• Well tolerated

• Photosensitivity, diarrhoea, HFS, KA and SCC

Immunotherapy: T-cell priming and evading inhibition

• APC’s present antigens to T cells

• T-cells become activated

• T-cells replicate

• Have to be “switched off”

• Cancers can inactivate T-cells via PD1/L1

Ribas NEJM June 28 2012

PD-1 like a “fend”

Anti PD-1/PDL-1

PDL-1 PD-1

TCRMHC

No inhibition of killing response tumour killingInhibition of killing response no tumour killingNo inhibition of killing response tumour killing

PDL-1PD-1

Anti PDL-1

Anti PD-1

Responses with Pembrolizumab

Robert C et al. N Engl J Med 2015;372:2521-2532.

Immune-related adverse events

People with cancer in 2017

• Triple pop > 65 by 2050

• Double the deaths in next 15 years

• One quarter of patients are already > 80

• Frailty

• Multi-morbidity

• Social dependency

• Increasing expectations

• Uptake of lower toxicity treatment • e.g. immune therapies

• Changing role of Dr, Nurse, Allied Health

Priorities

1. Prevention– Smoking– Alcohol– Obesity– Exercise– UV

2. Screening– Cervical– Breast– Colorectal– Lung

Cost-effective implementation

Preparing for the future

Cancer is changing.

Patients are changing.

Treatments are changing.

Staying the same is going backwards.

Conclusions

• Increasing burden of cancer

• Risk factors modifiable with social policy, primary prevention

• Future patients are elderly, have multi-system diseases

• Sustainable health services will need to re-organise diagnosis, chronic management, survivorship, surveillance

• Governments will need to critically assess and carefully implement all new health technologies

• Major role for central planning, big data

• Providers roles are evolving at a rapid rate.