PROMOTING BEST PRACTICE IN CANCER

Tom Reeve LectureTuesday 4 May 2010

Professor Jim Bishop AO

Chief Medical Officer

Australian Government Department of Health and Ageing

Born November 23, 1923 – Queanbeyan NSWQualifications: MB BS, MD (Hon), DDU, FRACS, FACS, FRACR (Hon)Special Interests and Appointments• Emeritus Professor of Surgery, University of Sydney• Emeritus Consultant Surgeon, Royal North Shore Hospital• Executive Officer, Australian Cancer NetworkCareer

Nat. Cancer Control Initiative 1998-2003, Nat. Breast Cancer Centre 1997-2003, Exec. Off. Aust. Cancer Network 1994-2002, Snr. Med. Adv; Chrmn Bd Dirs Inst. Magnetic Resonance Res. 1998-99, Pres. Aust. Socy Ultrasound Med. 1984-85, V-Pres. 1979-82, V-Pres. Aust. and Oceania Thyroid Assn 1980-89, Memb. Exec. Internat. Assn Endocrine Surgery 1979-87, Pres. 1987-89, Cl RACS 1979-91, Pres. 1989-91, Memb. NSW State Cttee 1970-78, Vstg Surgn Royal Nth Shore Hosp. 1976-88, Emeritus Consult. since 1989, Consult. Ultrasonics Inst. Aust. Dept Health 1974-90, Pres. Kur-ing-gai Dist Med. Assn 1972-73, Surgical Res. Socy A'asia 1967, Hon. Surgn Royal Nth Shore Hosp. 1963-76, SnrSurgical Res. Off. 1958-61, Retail Traders Fell. Surgical Res. 1956-57, Unit Clinical Investigation; Emeritus Prof. Surgery Univ. Syd. 1989, Hon. Memb. American Surgical Assn 1989, Coller Surgical Assn 1988, Assoc. Prof. Surgery 1963, Snr Lectr 1961, Surgical Training Albany Med. Centre USA 1950-55, Supt Collinsville Hosp. Qld 1950, MO Marrickville Dist Hosp. NSW 1947-48; Memb. Bd Royal Nth Shore Hosp. 1989-96, Chrmn Nthn Syd. Area Health Svce 1988-96; Diplomate American Bd Surgery 1958

Publications: Following Fortunes Path 2004; var. papers on thyroid disease and surgery Awards: recipient Sir Hugh Devine Medal RACS 2000 Tom’s words or thoughts (work ethic, life ethic) "The greatest fun comes from making it work."

Cancer in NSW 1972 - 2005

1972 % 2005 %

All sites 5,827 19,316

Lung 1,245 21% 1,784 9%

Bowel 772 13% 2,448 13%

Prostate 675 12% 5,913 31%

Stomach 380 7% 426 2%

Melanoma 380 7% 2,024 10%

Tracey et al Cancer in NSW 2005

MALES

Cancer in NSW 1972 - 2005

1972 % 2005 %

All sites 5,725 14,911

Breast 1,456 25% 4,035 27%

Bowel 949 17% 2,035 14%

Melanoma 465 8% 1,481 10%

Cervix 343 6% 208 1%

Tracey et al Cancer in NSW, 2005

FEMALES

Changes in Incidence Rates for all Cancer in Males using Joinpoint Analysis

Changes in Incidence Rates in Females using Joinpoint Analysis

Changes in Deaths rates in Males using Joinpoint Analysis

Changes in Deaths Rates in Femalesusing Joinpoint Analysis

Cancers with reducing death rates 1997 to 2006 – all ages

Lung, -18.5Colon, -19.6 Prostate, -19.7

Leukaemia, -23.7

Stomach, -29.4

Head and Neck, -23.7

Bladder, -18.5

Testicular, -42.2

Breast, -13.8

Cervix, -38.3

NHL, -25.1

Unknown, -24.8

Rectum, -19.9

Bowel, -19.7

All cancers, -13.8

, -24.3

-18.5

Kidney, -24.1

, -15.2

-31.9

, -21.1

-19.0-19.0

, -18.9

-7.9

-45

-40

-35

-30

-25

-20

-15

-10

-5

0

Male Female

Mortality/Incidence ratios 2002 for Selected Countries

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Egypt

Russia

Kenya

Viet N

am

Nigeria

Turkey

China

India

South

Africa

Czech

Repub

lic

Greec

eJa

pan UK

Brazil

Italy

German

y

Sweden

Canad

a

New Zea

land

Austra

liaUSA

Mor

talit

y/In

cide

nce

Male

Female

ALL CANCER

CANCERMilestones in Survival Improvement

• Preventions – Tobacco control

• Early detection

– Screening

– Interventions

• Better treatments – medical research

• Clinical trials of better approaches

• Evidence based standard practice

Projected YLLs – Three scenarios Australia, 1980 - 2016

IMPROVING CANCER CONTROL5 KEY PRINCIPLES

Prevention

Early Detection

Optimal Treatment

Research and Innovation

Monitoring and Reporting

The Keys to Prevention

0.0 2.0 4.0 6.0 8.0

Tobacco

Blood pressure

Overweight/obesity

Physical inactivity

Blood cholesterol

Alcohol

Fruit/vegetables

Illicit drugs

Air pollution

Unsafe sex

% DALYs

Total of 32%

Source: Table 4.1 AIHW Australia’s Health 2008

SMOKING IN AUSTRALIA

SMOKINGSTATUS

NSW VIC QLD WA SA TAS ACT NT AUS

Daily 16.4 16.5 17.2 14.8 16.5 22.7 14.7 25.3 16.6

Weekly 1.2 1.5 1.4 1.2 1.5 0.6 0.9 1.2 1.3

Less than Weekly

1.4 1.7 1.3 1.4 1.8 1.6 1.6 1.3 1.5

Ex-smoker 24.7 24.4 25.7 28.3 24.1 26.5 24.8 22.4 25.1

Neversmoked

56.3 55.9 54.5 54.3 56.2 48.6 57.9 49.8 55.4National Drug Strategy Household Survey 2007

AUSTRALIA’S INITIATIVES IN TOBACCO CONTROL

• Advertising Bans

• Under the counter at retail sites

• Banning smoking in restaurants, pubs and cars

• Anti-tobacco campaigns

• Increase in tobacco excise

• Plain packaging

Lung CancerTime trends - incidence

NSW Smoking Prevalence Rates (1977-2036)

OBESTITY INCREASING FOR ALL

High BMI Prevalence rates

New South WalesPrevalence Rate of Population Risk Factor Simulated: BMI Greater than 25Total Population, Male and Female, All Age Groups Simulated Expectation

Life at Cancer Risk Output LG12Historical Risk Factor Data: Centre for Epidemiology and Research. 2005 Report on Adult Health from the New South Wales Population

Simulations and Analysis: Smetanin, P. and Kobak, P. RiskAnalytica Life at Cancer Risk Analysis for New South Wales Cancer Institute,November 2006.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1990

1993

1996

1999

2002

2005

2008

2011

2014

2017

2020

2023

2026

2029

2032

2035

Year

Perc

enta

ge o

f Peo

ple

per Y

ear

TotalMalesFemales

OBESITY and CANCER

Increased Risk Body Fatness OesophagusPancreasColorectalBreast (PM)Endometrum

Abnormal Fatness ColorectalReduced Risk Physical exercise Colon

World Cancer Research Fund: Food, nutrition, physical activity and prevention of cancer, 2007

The difference between localised and regional extent of disease at diagnosis

1%10%

1%11%

14%6%

23%23%26%

21%38%

28%24%

28%22%23%

29%20%21%21%

40%26%

33%9%

12%5%

0% 20% 40% 60% 80% 100% 120%

Pancreatic

Liver

Oesophageal

Lung

Gallbladder

Unknown

Stomach

Tongue

Mouth

Head and Neck

Bladder

Larynx

Small intestine

Connective tissue

All cancer

Cervix

Ovary

Large bowel

Colon

Rectal

Kidney

Uterine

Melanoma

Prostate

Breast

Thyroid

RegionalLocalised

Results: Comparison of total costs by stage of disease

(per cent deviation from average costs)

Total cancer cases and deaths per year (1972 to 2036)

NSW Cancer Deaths, MajorCancer Types (2007-2036)

CLINICAL GUIDELINESSupports for Clinical Decision Making

Evidence Base

Highest Impact

Range of best practice tools

Successful implementation methods

Monitor and report

Breast cancer mortality

NEJM 2005

CLINICAL GUIDELINESHighest Impact

Greatest burden of disease

Greatest harm from poor practice

Greatest demonstrated need:

- New Standard of Care

- Proven variation in practice

Greatest time spent/cost to health system

REVIEW OF CLINICAL GUIDELINES

N – 313

N %

CANCER 17 5%

CARDIOVASCULAR 18 6%

RENAL 22 7%

MENTAL ILLNESS 22 7%

NEUROLOGICAL 0 0%

INJURIES 13 14%

CHRONIC RESPIRATORY 0 0%

DIABETES 11 4%

OTHER 173 67%

TOTAL 313 100%

Buchan et al 2006

www.clinicalguidelines.gov.au

NICE: TYPES OF GUIDANCE

CLINICAL GUIDELINES

CLINICAL GUIDELINE UPDATES

SHORT CLINICAL GUIDELINES

PUBLIC HEALTH INTERVENTIONS

PUBLIC HEALTH PROGRAMS

INTERVENTIONAL PROCEDURES

TECHNOLOGY APPRAISALS

CLINICAL GUIDELINESRange of best practice tools

• Literature review

• Check lists

• Decision aids

• Clinical Guidelines

• Access to national/overseas websites

NATIONAL COMPREHENSIVE CANCER NETWORK (NCCN)

www.nccn.org/index.asp

BEST PRACTICE IN CANCER CARECONCLUSIONS

Cancer incidence and mortality by cancer type 1972 – 2036 represent changes in needsBest practice is needed in all aspects of effective cancer controlCollaborative and strategic approach is now needed for clinical decision making supports