- Email: [email protected]
Context of cancer control in New Zealand
Journal of Cancer Policy xxx (xxxx) xxxx
Contents lists available at ScienceDirect
Journal of Cancer Policy journal homepage: www.elsevier.com/locate/jcpo
Context of cancer control in New Zealand Diana Sarfatia,*, Christopher Jacksonb a b
Department of Public Health, University of Otago, Wellington, Mein St, Newtown, Wellington, New Zealand Senior Lecturer in Medicine, Otago Medical School, University of Otago, Dunedin, New Zealand
A R T I C LE I N FO
A B S T R A C T
Keywords: Cancer systems Cancer policy New Zealand Inequalities Indigenous Māori Pacific
Cancer is the leading cause of death in New Zealand and the burden of cancer is growing. The number of people who will be diagnosed with cancer will continue to increase and the costs of cancer care are sky-rocketing beyond our capacity to afford it. Cancer outcomes vary depending on where you live and New Zealand’s survival rates are falling behind those in comparable countries. New Zealand leads the world in terms of colorectal cancer and melanoma incidence, with prostate, breast, and lung cancers rounding out the top five cancers in terms of incidence. Māori and Pacific people have higher incidence for several preventable cancers, and worse survival than other New Zealanders. New Zealand has a largely publically-funded healthcare system, with the overall responsibility for cancer control planning and policy resting with the Ministry of Health. New Zealand’s most recent cancer control strategy was published in 2003, and since then there have been a series of short-term operational plans. Opportunities to strengthen preventive strategies have been missed. This series aims to identify the challenges and opportunities across the cancer control continuum, with lessons that are likely to resonant with many other countries around the world.
1. Introduction New Zealand is a small country in the South Pacific with a population of 4.8 million people, of whom 74 % identify as NZ Europeans, 15 % as (Indigenous) Māori and 8 % as Pacific (immigrants or descendants of immigrants from Pacific Islands). Cancer is the leading cause of death in New Zealand. Like many other high income countries, the population in New Zealand is both ageing and growing, leading to an increase in the projected number of cases of cancer by 50 % in next 15 years (Fig. 1). Additionally, due to a reduction in competing causes of mortality such as cardiovascular disease, the number of elderly people affected by cancer is increasing, impacting on the prevalence of frailty and comorbidity in patients with cancer, increasing treatment complexity and cost. As a result of these factors as well as the price of new technologies and drugs, the costs of cancer care are increasing beyond our ability to afford them. The pace of change in cancer management is creating ongoing pressure on our cancer care systems and services, with innovations frequently implemented unevenly or in an ad hoc manner between providers. There are persistent inequalities in both cancer incidence and survival, which are most marked between the Māori and Pacific populations on one hand and other New Zealanders on the other [1–3]. At the same time, our performance in terms of cancer survival is
⁎
lagging behind other comparable countries, including our closest neighbour, Australia [4,5]. 2. Cancer incidence and trends The overall patterns of cancer incidence in New Zealand are similar to many other HICs; prostate, breast, colorectal and lung and melanoma are all in the top five cancers for incidence overall (excluding nonmelanoma skin cancers) [7]. Along with Australia, New Zealand leads the world in terms of both melanoma and colorectal cancer incidence (Figs. 2 and 3). There are well-documented and persistent social inequalities in incidence for many cancers, within high income countries. These inequalities reflect a complex interplay of the political, historical, economic, social and environmental contexts in which people and communities live. These contexts in turn, impact on risk of cancer through pathways which are reflected in differential exposure to risk factors such as living conditions (housing / overcrowding), and behavioural factors (tobacco use, unhealthy diet). New Zealand is no exception [1,2]. Prevalence of smoking is declining in general in New Zealand, from 25 % in the 1995/6–13% currently [9,10]. However, Māori continue to have substantially higher smoking rates of 31 %.
Corresponding author. E-mail addresses: [email protected] (D. Sarfati), [email protected] (C. Jackson).
https://doi.org/10.1016/j.jcpo.2019.100211 Received 30 May 2019; Accepted 18 November 2019 2213-5383/ © 2019 Published by Elsevier Ltd.
Please cite this article as: Diana Sarfati and Christopher Jackson, Journal of Cancer Policy, https://doi.org/10.1016/j.jcpo.2019.100211
Journal of Cancer Policy xxx (xxxx) xxxx
D. Sarfati and C. Jackson
Fig. 1. projected number of cancer cases in New Zealand to 2040 (Globocan 2018) [6].
Fig. 2. Age-standardised incidence and mortality rates for melanoma in 2018 [8].
increasing in generally but much more rapidly for Pacific women, with inequalities opening up at an alarming rate [2,14] (Fig. 4).
These smoking patterns are reflected in the very high rates of lung cancer among Māori, relative to the rest of the population (Fig. 3). Cancers associated with oncogenic infections, including stomach cancer (Helicobacter pylori), liver cancer (hepatitis B virus) and cervical cancer (human papilloma virus) all occur at substantially higher rates among Māori and Pacific people. Hepatitis B vaccination was introduced in the national vaccination schedule in the mid-1980s, and is expected to have an impact on both absolute rates of liver cancer, and inequalities in liver cancer in coming years. Cervical cancer incidence has decreased substantially, and ethnic inequalities have declined both on a relative and absolute scale, a testament to a well-functioning screening programme, which emphasises equitable access. Marked inequalities in stomach cancer incidence remain, however, due to a high prevalence of H pylori infections among Māori and Pacific people in New Zealand, which is in turn driven largely by poverty and overcrowded housing conditions among children [11–13]. Obesity is a particularly important driver of cancer incidence and emerging inequalities. For example, rates of endometrial cancer are
3. Cancer survival Cancer survival is improving over time in New Zealand, but those improvements are less rapid and of a smaller magnitude than in comparable countries [5]. There are also persisting social and geographic inequalities in cancer survival [3,15]. These inequalities are driven by a range of factors including barriers to access to early diagnosis and screening, differential rates of comorbidity and poorer quality treatment among disadvantaged groups [16,17]. While the New Zealand Cancer Registry collects high quality information on cancer incidence, the quality of stage information is more restricted and less complete, limiting detailed understanding of stage-specific survival amongst most cancers. There is little high-quality data collected on cancer surgery or chemotherapy, with the quality of radiation treatment data improving substantially in recent years. A lack of high-quality data is a key barrier 2
Journal of Cancer Policy xxx (xxxx) xxxx
D. Sarfati and C. Jackson
Fig. 3. Age-standardised incidence and mortality rates for colorectal cancer in 2018 [8].
Cancer treatment standards (standards of service provision) were introduced in 2013, in an attempt to improve consistency of care around the country [21]. However these were issued as “draft” standards and remain draft at present. Many of the standards were aspirational, had few if any defined measures, and were not clearly defined. DHBs were not required to report publicly on adherence to the standards, and there was no mechanisms to ensure that DHBs were compliant, rendering them largely ineffective as a policy tool. In the last decade, several important opportunities to strengthen preventive activities relating particularly to addressing rising rates of obesity, alcohol and tobacco supply reduction and Sunsmart initiatives have been missed [22]. A national target to be Smokefree by 2025 was set 2011 but will not be achieved, with slow progress in policy development since that time [23–25]. A Cancer Control Council was established following the introduction of the Cancer Strategy, but did not have clear authority over Ministry of Health cancer activity, and acted as an advisory group to the Minister of Health. The Council was disestablished in 2015 and there has not been an effective replacement governance structure with responsibility for the continuum of cancer control, leaving a void in sector leadership [26]. Many in the sector had observed that the Cancer Strategy was outdated and that a series of short term plans were not a sustainable approach to planning health services [27]. Patient, clinical and academic groups continued to highlight regional variations in outcomes and access to investigations, technologies, and treatments. Many experts considered that the core problems of quality, variation in care and governance were increasing rather than reducing, and that the existing bureaucratic structures and ministry capability was insufficient to address the present and future challenges of cancer control [27].
to prioritising areas for investment and for prioritising areas for policy focus, and measuring the impact of any specific interventions.
4. Organisation of the health system In New Zealand, the development of cancer strategy, planning and policy is largely the responsibility of a small cancer team within the Ministry of Health, although several key elements sit outside the remit of this team including cancer screening and workforce development [18]. Four Regional Cancer Networks which are geographically based, and closely aligned to District Health Boards, provide planning and cancer care delivery at a more local level. Secondary and tertiary care are provided free of charge. However, private surgery and increasingly private radiation and medical oncology treatments, are being delivered alongside publically funded care, creating a two-tiered system. Primary care is provided within general practices, under a capitated system. Patient part charges exist for both primary care visits and prescriptions, although exemptions exist. Cancer drugs are closely regulated through a publically funded agency (PHARMAC) which decides the range and specific indications for pharmaceutical agents that are freely available in public hospitals. However no such processes exist for broader technology assessment, for example radiation fractionation schedules or techniques, genomic technologies, or highly complex or technology dependent surgeries. New Zealand’s first Cancer Control Strategy was released in 2003 [19]. This strategy was broad-based, had strong sector buy in and was equity focused. Since that time the emphasis of cancer control has narrowed substantially with a focus almost exclusively on hospital treatment, and little national coordination of cancer control activities, other than a national child cancer network, breast and cervical cancer screening programmes, and more recently implementation of a bowel screening programme. The Cancer Control Strategy has not been updated, rather there have been a series of more operational ‘action plans’, supported by treatment related targets, not clearly linked to improved outcomes. Examples of this include a focus on waiting times for first specialist assessment and for time to treatment following diagnosis [20]. There have been funded initiatives for supportive care such as psychological support and care coordination, but outside of screening, few new initiatives that have a direct and measurable impact on cancer incidence, mortality or survival.
5. Conclusion New Zealand, like countries around the world, is grappling with how to manage the challenge of addressing the burden of cancer now and into the future. The gap in outcomes between groups in New Zealand and the responses, or lack of responses, are instructive for many countries with indigenous populations, with profound consequences. Further, the increasing gap in outcomes between New Zealand and similar countries such as Australia and Canada only serves to underscore the importance of sustained cancer control efforts. In this 3
Journal of Cancer Policy xxx (xxxx) xxxx
D. Sarfati and C. Jackson
Fig. 4. Trends in age-standardised cancer incidence by ethnic group and sex for selected cancers for ages 1–74 yrs.1981–2011.
series, we explore the current challenges and opportunities facing New Zealand. The lessons learned from our successes and failures, and reflections on our preparedness for the future burden of cancer, can in some cases be a template for success, and in others, a cautionary tale.
[4] [5]
Funding [6]
No specific funding was received for this work. [7]
Declaration of Competing Interest
[8]
None declared. [9]
References [10] [1] A.M. Teng, J. Atkinson, G. Disney, N. Wilson, T. Blakely, Changing socioeconomic inequalities in cancer incidence and mortality: cohort study with 54 million personyears follow-up 1981–2011, Int. J. Cancer 140 (6) (2017) 1306–1316. [2] A.M. Teng, J. Atkinson, G. Disney, N. Wilson, D. Sarfati, M. McLeod, T. Blakely, Ethnic inequalities in cancer incidence and mortality: census-linked cohort studies with 87 million years of person-time follow-up, BMC Cancer 16 (1) (2016) 755. [3] M. Soeberg, T. Blakely, D. Sarfati, Trends in ethnic and socioeconomic inequalities
[11]
[12]
[13]
4
in cancer survival, New Zealand, 1991–2004, Cancer Epidemiol. 39 (6) (2015) 860–862. P. Aye, J. Elwood, V. Stevanovic, Comparison of cancer survival in New Zealand and Australia, 2006–2010, N. Z. Med. J. 127 (1407). F. Bray, ICBP SURVMARK-2 A Comprehensive and Innovative Approach to International Cancer Survival Benchmarking. Presentation at the 2018 World Cancer congress, (2018) (Accessed 30 May 2019), https://www. worldcancercongress.org/sites/congress/files/atoms/files/T3-112.pdf. J. Ferlay, M. Ervik, F. Lam, M. Colombet, L. Mery, M. Piñeros, A. Znaor, I. Soerjomataram, F. Bray, Global Cancer Observatory: Cancer Tomorrow, (2019) (Accessed 15 Jan 2019), https://gco.iarc.fr/tomorrow. Ministry of health, New Cancer Registrations 2016, (2018) https://www.health. govt.nz/publication/new-cancer-registrations-2016. J. Ferlay, M. Colombet, I. Soerjomataram, et al., Global and Regional Estimates of the Incidence and Mortality for 38 Cancers: GLOBOCAN 2018, International Agency for Research on Cancer/World Health Organization, Lyon, 2018. Ministry of Health, Annual Update of Key Results 2017/18, New Zealand Health Survey, Ministry of Health, Wellington, 2018. Ministry of Health, Tobacco Use 2012/13, NZ Health Survey, Ministry of Health, Wellington, 2014. A.M. Teng, T. Blakely, M.G. Baker, D. Sarfati, The contribution of Helicobacter pylori to excess gastric cancer in Indigenous and Pacific men: a birth cohort estimate, Gastric Cancer 20 (4) (2017) 752–755. A.M. Teng, G. Kvizhinadze, N. Nair, M. McLeod, N. Wilson, T. Blakely, A screening program to test and treat for Helicobacter pylori infection: cost-utility analysis by age, sex and ethnicity, BMC Infect. Dis. 17 (1) (2017) 156. A.M. McDonald, D. Sarfati, M.G. Baker, T. Blakely, Trends in Helicobacter pylori
Journal of Cancer Policy xxx (xxxx) xxxx
D. Sarfati and C. Jackson
[14]
[15]
[16]
[17] [18]
[19] [20] [21]
[22] L. Signal, R. Edwards, R. Gage, N. Jackson, C. McKerchar, D. Sarfati, The State of Cancer prevention in Aotearoa new Zealand: slow progress requires political leadership and investment for health and equity, J. Cancer Policy (2019) (In press). [23] J. Ball, R. Edwards, A. Waa, S.K. Bradbrook, H. Gifford, C. Cunningham, J. Hoek, T. Blakely, N. Wilson, G. Thomson, Is the NZ Government responding adequately to the Māori Affairs Select Committee’s 2010 recommendations on tobacco control? A brief review, N. Z. Med. J. 129 (2016) 1428. [24] J. Ball, J. Stanley, N. Wilson, T. Blakely, R. Edwards, Smoking prevalence in New Zealand from 1996-2015: a critical review of national data sources to inform progress toward the Smokefree 2025 goal, N. Z. Med. J. (Online) 129 (1439) (2016) 11–22. [25] F.S. van der Deen, N. Wilson, C.L. Cleghorn, G. Kvizhinadze, L.J. Cobiac, N. Nghiem, T. Blakely, Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: two modelling studies to inform the tobacco endgame, Tob. Control Published Online First 24 (June 2017) (2017) tobaccocontrol-2016-053585. [26] Ministry of Health, Cancer Control New Zealand (Accessed 30 May 2019), https:// www.health.govt.nz/about-ministry/ministry-health-websites/cancer-control-newzealand. [27] D. Sarfati, C. Jackson, S. Macfarlane, I. Bissett, B. Robson, J. Gurney, R. Kemp, N. James, J. Adler, N. Scott, J. McMenamin, Cancer care at a crossroads: time to make a choice, N.Z. Med. J. 132 (1493) (2019) 6–11.
infection among maori, Pacific, and european birth cohorts in New Zealand, Helicobacter 20 (2) (2015) 139–145. I. Meredith, D. Sarfati, T. Ikeda, J. Atkinson, T. Blakely, High rates of endometrial cancer among Pacific women in New Zealand: the role of diabetes, physical inactivity, and obesity, Cancer Causes Control 23 (6) (2019) 875–885. B. Robson, G. Purdie, D. Cormack, Unequal Impact II: Maori and Non-Maori Cancer Statistics by Deprivation and Rurality 2002–2006, Ministry of Health, Wellington, 2010. S. Hill, D. Sarfati, T. Blakely, B. Robson, G. Purdie, E. Dennett, D. Cormack, K. Dew, J.Z. Ayanian, I. Kawachi, Ethnic disparities in treatment of Māori and non-Māori New Zealanders with colon cancer, Cancer 116 (2010) 3205–3214. S. Hill, D. Sarfati, B. Robson, T. Blakely, Indigenous inequalities in cancer – what role for health care? Aust. N.Z. J. Surg. 83 (2013) 36–41. Ministry of Health, National Cancer Programme (Accessed 30 May 2019), https:// www.health.govt.nz/our-work/diseases-and-conditions/national-cancerprogramme. Minister of Health, The New Zealand Cancer Control Strategy, Ministry of Health and the New Zealand Cancer Control Trust, Wellington, 2003. Ministry of Health, New Zealand Cancer plan: Better, Faster Cancer Care 2015–2018, Ministry of Health, Wellington, 2014. Ministry of Health, National Tumour Standards (Accessed 30 May 2019), https:// www.health.govt.nz/our-work/diseases-and-conditions/national-cancerprogramme/cancer-initiatives/review-national-tumour-standards.
5
Contents lists available at ScienceDirect
Journal of Cancer Policy journal homepage: www.elsevier.com/locate/jcpo
Context of cancer control in New Zealand Diana Sarfatia,*, Christopher Jacksonb a b
Department of Public Health, University of Otago, Wellington, Mein St, Newtown, Wellington, New Zealand Senior Lecturer in Medicine, Otago Medical School, University of Otago, Dunedin, New Zealand
A R T I C LE I N FO
A B S T R A C T
Keywords: Cancer systems Cancer policy New Zealand Inequalities Indigenous Māori Pacific
Cancer is the leading cause of death in New Zealand and the burden of cancer is growing. The number of people who will be diagnosed with cancer will continue to increase and the costs of cancer care are sky-rocketing beyond our capacity to afford it. Cancer outcomes vary depending on where you live and New Zealand’s survival rates are falling behind those in comparable countries. New Zealand leads the world in terms of colorectal cancer and melanoma incidence, with prostate, breast, and lung cancers rounding out the top five cancers in terms of incidence. Māori and Pacific people have higher incidence for several preventable cancers, and worse survival than other New Zealanders. New Zealand has a largely publically-funded healthcare system, with the overall responsibility for cancer control planning and policy resting with the Ministry of Health. New Zealand’s most recent cancer control strategy was published in 2003, and since then there have been a series of short-term operational plans. Opportunities to strengthen preventive strategies have been missed. This series aims to identify the challenges and opportunities across the cancer control continuum, with lessons that are likely to resonant with many other countries around the world.
1. Introduction New Zealand is a small country in the South Pacific with a population of 4.8 million people, of whom 74 % identify as NZ Europeans, 15 % as (Indigenous) Māori and 8 % as Pacific (immigrants or descendants of immigrants from Pacific Islands). Cancer is the leading cause of death in New Zealand. Like many other high income countries, the population in New Zealand is both ageing and growing, leading to an increase in the projected number of cases of cancer by 50 % in next 15 years (Fig. 1). Additionally, due to a reduction in competing causes of mortality such as cardiovascular disease, the number of elderly people affected by cancer is increasing, impacting on the prevalence of frailty and comorbidity in patients with cancer, increasing treatment complexity and cost. As a result of these factors as well as the price of new technologies and drugs, the costs of cancer care are increasing beyond our ability to afford them. The pace of change in cancer management is creating ongoing pressure on our cancer care systems and services, with innovations frequently implemented unevenly or in an ad hoc manner between providers. There are persistent inequalities in both cancer incidence and survival, which are most marked between the Māori and Pacific populations on one hand and other New Zealanders on the other [1–3]. At the same time, our performance in terms of cancer survival is
⁎
lagging behind other comparable countries, including our closest neighbour, Australia [4,5]. 2. Cancer incidence and trends The overall patterns of cancer incidence in New Zealand are similar to many other HICs; prostate, breast, colorectal and lung and melanoma are all in the top five cancers for incidence overall (excluding nonmelanoma skin cancers) [7]. Along with Australia, New Zealand leads the world in terms of both melanoma and colorectal cancer incidence (Figs. 2 and 3). There are well-documented and persistent social inequalities in incidence for many cancers, within high income countries. These inequalities reflect a complex interplay of the political, historical, economic, social and environmental contexts in which people and communities live. These contexts in turn, impact on risk of cancer through pathways which are reflected in differential exposure to risk factors such as living conditions (housing / overcrowding), and behavioural factors (tobacco use, unhealthy diet). New Zealand is no exception [1,2]. Prevalence of smoking is declining in general in New Zealand, from 25 % in the 1995/6–13% currently [9,10]. However, Māori continue to have substantially higher smoking rates of 31 %.
Corresponding author. E-mail addresses: [email protected] (D. Sarfati), [email protected] (C. Jackson).
https://doi.org/10.1016/j.jcpo.2019.100211 Received 30 May 2019; Accepted 18 November 2019 2213-5383/ © 2019 Published by Elsevier Ltd.
Please cite this article as: Diana Sarfati and Christopher Jackson, Journal of Cancer Policy, https://doi.org/10.1016/j.jcpo.2019.100211
Journal of Cancer Policy xxx (xxxx) xxxx
D. Sarfati and C. Jackson
Fig. 1. projected number of cancer cases in New Zealand to 2040 (Globocan 2018) [6].
Fig. 2. Age-standardised incidence and mortality rates for melanoma in 2018 [8].
increasing in generally but much more rapidly for Pacific women, with inequalities opening up at an alarming rate [2,14] (Fig. 4).
These smoking patterns are reflected in the very high rates of lung cancer among Māori, relative to the rest of the population (Fig. 3). Cancers associated with oncogenic infections, including stomach cancer (Helicobacter pylori), liver cancer (hepatitis B virus) and cervical cancer (human papilloma virus) all occur at substantially higher rates among Māori and Pacific people. Hepatitis B vaccination was introduced in the national vaccination schedule in the mid-1980s, and is expected to have an impact on both absolute rates of liver cancer, and inequalities in liver cancer in coming years. Cervical cancer incidence has decreased substantially, and ethnic inequalities have declined both on a relative and absolute scale, a testament to a well-functioning screening programme, which emphasises equitable access. Marked inequalities in stomach cancer incidence remain, however, due to a high prevalence of H pylori infections among Māori and Pacific people in New Zealand, which is in turn driven largely by poverty and overcrowded housing conditions among children [11–13]. Obesity is a particularly important driver of cancer incidence and emerging inequalities. For example, rates of endometrial cancer are
3. Cancer survival Cancer survival is improving over time in New Zealand, but those improvements are less rapid and of a smaller magnitude than in comparable countries [5]. There are also persisting social and geographic inequalities in cancer survival [3,15]. These inequalities are driven by a range of factors including barriers to access to early diagnosis and screening, differential rates of comorbidity and poorer quality treatment among disadvantaged groups [16,17]. While the New Zealand Cancer Registry collects high quality information on cancer incidence, the quality of stage information is more restricted and less complete, limiting detailed understanding of stage-specific survival amongst most cancers. There is little high-quality data collected on cancer surgery or chemotherapy, with the quality of radiation treatment data improving substantially in recent years. A lack of high-quality data is a key barrier 2
Journal of Cancer Policy xxx (xxxx) xxxx
D. Sarfati and C. Jackson
Fig. 3. Age-standardised incidence and mortality rates for colorectal cancer in 2018 [8].
Cancer treatment standards (standards of service provision) were introduced in 2013, in an attempt to improve consistency of care around the country [21]. However these were issued as “draft” standards and remain draft at present. Many of the standards were aspirational, had few if any defined measures, and were not clearly defined. DHBs were not required to report publicly on adherence to the standards, and there was no mechanisms to ensure that DHBs were compliant, rendering them largely ineffective as a policy tool. In the last decade, several important opportunities to strengthen preventive activities relating particularly to addressing rising rates of obesity, alcohol and tobacco supply reduction and Sunsmart initiatives have been missed [22]. A national target to be Smokefree by 2025 was set 2011 but will not be achieved, with slow progress in policy development since that time [23–25]. A Cancer Control Council was established following the introduction of the Cancer Strategy, but did not have clear authority over Ministry of Health cancer activity, and acted as an advisory group to the Minister of Health. The Council was disestablished in 2015 and there has not been an effective replacement governance structure with responsibility for the continuum of cancer control, leaving a void in sector leadership [26]. Many in the sector had observed that the Cancer Strategy was outdated and that a series of short term plans were not a sustainable approach to planning health services [27]. Patient, clinical and academic groups continued to highlight regional variations in outcomes and access to investigations, technologies, and treatments. Many experts considered that the core problems of quality, variation in care and governance were increasing rather than reducing, and that the existing bureaucratic structures and ministry capability was insufficient to address the present and future challenges of cancer control [27].
to prioritising areas for investment and for prioritising areas for policy focus, and measuring the impact of any specific interventions.
4. Organisation of the health system In New Zealand, the development of cancer strategy, planning and policy is largely the responsibility of a small cancer team within the Ministry of Health, although several key elements sit outside the remit of this team including cancer screening and workforce development [18]. Four Regional Cancer Networks which are geographically based, and closely aligned to District Health Boards, provide planning and cancer care delivery at a more local level. Secondary and tertiary care are provided free of charge. However, private surgery and increasingly private radiation and medical oncology treatments, are being delivered alongside publically funded care, creating a two-tiered system. Primary care is provided within general practices, under a capitated system. Patient part charges exist for both primary care visits and prescriptions, although exemptions exist. Cancer drugs are closely regulated through a publically funded agency (PHARMAC) which decides the range and specific indications for pharmaceutical agents that are freely available in public hospitals. However no such processes exist for broader technology assessment, for example radiation fractionation schedules or techniques, genomic technologies, or highly complex or technology dependent surgeries. New Zealand’s first Cancer Control Strategy was released in 2003 [19]. This strategy was broad-based, had strong sector buy in and was equity focused. Since that time the emphasis of cancer control has narrowed substantially with a focus almost exclusively on hospital treatment, and little national coordination of cancer control activities, other than a national child cancer network, breast and cervical cancer screening programmes, and more recently implementation of a bowel screening programme. The Cancer Control Strategy has not been updated, rather there have been a series of more operational ‘action plans’, supported by treatment related targets, not clearly linked to improved outcomes. Examples of this include a focus on waiting times for first specialist assessment and for time to treatment following diagnosis [20]. There have been funded initiatives for supportive care such as psychological support and care coordination, but outside of screening, few new initiatives that have a direct and measurable impact on cancer incidence, mortality or survival.
5. Conclusion New Zealand, like countries around the world, is grappling with how to manage the challenge of addressing the burden of cancer now and into the future. The gap in outcomes between groups in New Zealand and the responses, or lack of responses, are instructive for many countries with indigenous populations, with profound consequences. Further, the increasing gap in outcomes between New Zealand and similar countries such as Australia and Canada only serves to underscore the importance of sustained cancer control efforts. In this 3
Journal of Cancer Policy xxx (xxxx) xxxx
D. Sarfati and C. Jackson
Fig. 4. Trends in age-standardised cancer incidence by ethnic group and sex for selected cancers for ages 1–74 yrs.1981–2011.
series, we explore the current challenges and opportunities facing New Zealand. The lessons learned from our successes and failures, and reflections on our preparedness for the future burden of cancer, can in some cases be a template for success, and in others, a cautionary tale.
[4] [5]
Funding [6]
No specific funding was received for this work. [7]
Declaration of Competing Interest
[8]
None declared. [9]
References [10] [1] A.M. Teng, J. Atkinson, G. Disney, N. Wilson, T. Blakely, Changing socioeconomic inequalities in cancer incidence and mortality: cohort study with 54 million personyears follow-up 1981–2011, Int. J. Cancer 140 (6) (2017) 1306–1316. [2] A.M. Teng, J. Atkinson, G. Disney, N. Wilson, D. Sarfati, M. McLeod, T. Blakely, Ethnic inequalities in cancer incidence and mortality: census-linked cohort studies with 87 million years of person-time follow-up, BMC Cancer 16 (1) (2016) 755. [3] M. Soeberg, T. Blakely, D. Sarfati, Trends in ethnic and socioeconomic inequalities
[11]
[12]
[13]
4
in cancer survival, New Zealand, 1991–2004, Cancer Epidemiol. 39 (6) (2015) 860–862. P. Aye, J. Elwood, V. Stevanovic, Comparison of cancer survival in New Zealand and Australia, 2006–2010, N. Z. Med. J. 127 (1407). F. Bray, ICBP SURVMARK-2 A Comprehensive and Innovative Approach to International Cancer Survival Benchmarking. Presentation at the 2018 World Cancer congress, (2018) (Accessed 30 May 2019), https://www. worldcancercongress.org/sites/congress/files/atoms/files/T3-112.pdf. J. Ferlay, M. Ervik, F. Lam, M. Colombet, L. Mery, M. Piñeros, A. Znaor, I. Soerjomataram, F. Bray, Global Cancer Observatory: Cancer Tomorrow, (2019) (Accessed 15 Jan 2019), https://gco.iarc.fr/tomorrow. Ministry of health, New Cancer Registrations 2016, (2018) https://www.health. govt.nz/publication/new-cancer-registrations-2016. J. Ferlay, M. Colombet, I. Soerjomataram, et al., Global and Regional Estimates of the Incidence and Mortality for 38 Cancers: GLOBOCAN 2018, International Agency for Research on Cancer/World Health Organization, Lyon, 2018. Ministry of Health, Annual Update of Key Results 2017/18, New Zealand Health Survey, Ministry of Health, Wellington, 2018. Ministry of Health, Tobacco Use 2012/13, NZ Health Survey, Ministry of Health, Wellington, 2014. A.M. Teng, T. Blakely, M.G. Baker, D. Sarfati, The contribution of Helicobacter pylori to excess gastric cancer in Indigenous and Pacific men: a birth cohort estimate, Gastric Cancer 20 (4) (2017) 752–755. A.M. Teng, G. Kvizhinadze, N. Nair, M. McLeod, N. Wilson, T. Blakely, A screening program to test and treat for Helicobacter pylori infection: cost-utility analysis by age, sex and ethnicity, BMC Infect. Dis. 17 (1) (2017) 156. A.M. McDonald, D. Sarfati, M.G. Baker, T. Blakely, Trends in Helicobacter pylori
Journal of Cancer Policy xxx (xxxx) xxxx
D. Sarfati and C. Jackson
[14]
[15]
[16]
[17] [18]
[19] [20] [21]
[22] L. Signal, R. Edwards, R. Gage, N. Jackson, C. McKerchar, D. Sarfati, The State of Cancer prevention in Aotearoa new Zealand: slow progress requires political leadership and investment for health and equity, J. Cancer Policy (2019) (In press). [23] J. Ball, R. Edwards, A. Waa, S.K. Bradbrook, H. Gifford, C. Cunningham, J. Hoek, T. Blakely, N. Wilson, G. Thomson, Is the NZ Government responding adequately to the Māori Affairs Select Committee’s 2010 recommendations on tobacco control? A brief review, N. Z. Med. J. 129 (2016) 1428. [24] J. Ball, J. Stanley, N. Wilson, T. Blakely, R. Edwards, Smoking prevalence in New Zealand from 1996-2015: a critical review of national data sources to inform progress toward the Smokefree 2025 goal, N. Z. Med. J. (Online) 129 (1439) (2016) 11–22. [25] F.S. van der Deen, N. Wilson, C.L. Cleghorn, G. Kvizhinadze, L.J. Cobiac, N. Nghiem, T. Blakely, Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: two modelling studies to inform the tobacco endgame, Tob. Control Published Online First 24 (June 2017) (2017) tobaccocontrol-2016-053585. [26] Ministry of Health, Cancer Control New Zealand (Accessed 30 May 2019), https:// www.health.govt.nz/about-ministry/ministry-health-websites/cancer-control-newzealand. [27] D. Sarfati, C. Jackson, S. Macfarlane, I. Bissett, B. Robson, J. Gurney, R. Kemp, N. James, J. Adler, N. Scott, J. McMenamin, Cancer care at a crossroads: time to make a choice, N.Z. Med. J. 132 (1493) (2019) 6–11.
infection among maori, Pacific, and european birth cohorts in New Zealand, Helicobacter 20 (2) (2015) 139–145. I. Meredith, D. Sarfati, T. Ikeda, J. Atkinson, T. Blakely, High rates of endometrial cancer among Pacific women in New Zealand: the role of diabetes, physical inactivity, and obesity, Cancer Causes Control 23 (6) (2019) 875–885. B. Robson, G. Purdie, D. Cormack, Unequal Impact II: Maori and Non-Maori Cancer Statistics by Deprivation and Rurality 2002–2006, Ministry of Health, Wellington, 2010. S. Hill, D. Sarfati, T. Blakely, B. Robson, G. Purdie, E. Dennett, D. Cormack, K. Dew, J.Z. Ayanian, I. Kawachi, Ethnic disparities in treatment of Māori and non-Māori New Zealanders with colon cancer, Cancer 116 (2010) 3205–3214. S. Hill, D. Sarfati, B. Robson, T. Blakely, Indigenous inequalities in cancer – what role for health care? Aust. N.Z. J. Surg. 83 (2013) 36–41. Ministry of Health, National Cancer Programme (Accessed 30 May 2019), https:// www.health.govt.nz/our-work/diseases-and-conditions/national-cancerprogramme. Minister of Health, The New Zealand Cancer Control Strategy, Ministry of Health and the New Zealand Cancer Control Trust, Wellington, 2003. Ministry of Health, New Zealand Cancer plan: Better, Faster Cancer Care 2015–2018, Ministry of Health, Wellington, 2014. Ministry of Health, National Tumour Standards (Accessed 30 May 2019), https:// www.health.govt.nz/our-work/diseases-and-conditions/national-cancerprogramme/cancer-initiatives/review-national-tumour-standards.
5