Dr Chris Jackson. Consultant Medical Oncologist Southern Blood and Cancer Service (SDHB) University of Otago

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1 Dr Chris Jackson Consultant Medical Oncologist Southern Blood and Cancer Service (SDHB) University of Otago 14:50-15:15 Priorities for Cancer Care in NZ - The Cancer Society's View

2 Priorities for Cancer Care in NZ Dr Christopher Jackson Medical Director, CSNZ Medical Oncologist and Senior Lecturer

3 Cancer Care 50 years ago

4 Cancer has increased in importance.

5 Cancer is NZ s leading cause of death Assault 0% Suicide 2% Respiratory disease 6% Other 26% Other heart disease 4% Cancer 29% Cerebrovascular disease 9% Smoking 22% Alcohol UV radiation Obesity Inactivity Infectious diseases 22% eg HPV; Hep B, C; H Pylori Environmental and industrial carcinogens 4% Pneumonia / flu 2% Diabetes 3% Motor vehicle accidents 1% Ischaemic heart disease 18%

6 Lower mortality, more cases, more survivors Male registrations Female registrations Male deaths Female deaths

7 5 types account for the majority of cases Other 25% Prostate 14% Breast 14% Pancreas 2% Kidney 2% Uterus 2% Colorectal 14% Leukaemia 3% Non-Hodgkins 4% Lung 9% Melanoma 11%

8 What have we done well? Prevention Screening Early detection & diagnosis Treatment Follow-up and survivorship Palliative care

9 What have we done well? Prevention Screening Early detection & diagnosis Treatment Follow-up and survivorship Palliative care

10 What have we done well? Prevention Screening Early detection & diagnosis Treatment Follow-up and survivorship Palliative care

11 What are the gaps? WHO International Comparison 2014

12 Smoking and Cancer 22% of all cancers Most sites, particularly respiratory and aerodigestive 100m deaths in 20 th Century 1 billion deaths projected in 21 st Century Current smoking rates: 15% nmnp 38% Maori / Pacific; 42% Aboriginal / Torres Strait Islanders Youth rates: 12%, declining Māori Adult (age 15+) Daily Smokers (%) Census NZHS (U) HLS

13 Evidence based interventions Price Plain packaging Advertising restrictions Restrictions in public places, workplaces Pack sizing Flavours Ecigs reduce rates for current smokers, likely to increase uptake in non-smokers. Remains an area of research

14 Alcohol and cancer Mechanism: Acetaldehyde Reactive oxygen species Direct effect of ethanol Nutrient malabsorption / metasbolism Hormonal dysregulation (incr estrogen) Interaction with smoking, alcohol dehydrogenase

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16 Connor: Attributable deaths, alcohol and cancer Female Breast 29% Mouth / Oropharynx 16% Oesophagus 16% Laryngeal 3% Liver 10% Rectum 11% Colon 15%

17 Obesity and cancer Major risk factor for: Bowel, breast, kidney, uterine, stomach cancer?? Mechanism other than incr oestrogen Often co-exists with sarcopenia and inactivity Relationship with diet composition Adult obesity rate, 1977* 2012/13 Ministry of Health Understanding excess body weight. NZ Health Survey.

18 Exercise Reduces risk of CRC and breast cancer CALGB (adjuvant colon) <18 MET vs > 18 MET DFS HR 0.57 (95% CI ) MET <3 vs >27 DFS 0.55 ( ) p 0.01 Overall Survival 0.37 ( ) p 0.01

19 Sun exposure

20 Gaps - Diagnosis Rapid, direct access Reorganise diagnostic pathways Increase in high risk clinics not specialty specific, eg Rectal Bleeding, Haematuria, Lymph node Faster Cancer Treatment Rk DHB 1 Waitemata 92% 2 Canterbury 87% 3 Auckland 87% 4 Waikato 86% 5 Nelson Marlborough 85% 6 West Coast 83% 7 Southern 83% 8 Northland 83% 9 Bay of Plenty 82% 10 South Canterbury 81% 11 Lakes 80% 12 Wairarapa 79% 13 Tairawhiti 79% 14 Capital & Coast 78% 15 Counties Manukau 76% 16 MidCentral 75% 17 Taranaki 72% 18 Hutt Valley 70% 19 Whanganui 69% 20 Hawke's Bay 69% Progress towards national goal 85% % 50% 100%

21 Treatment Increasing cost and complexity Quality assurance Data systems Centralisation v Regional Cost control / value for investment Whole-of-system costs

22 Treatment

23 Survivorship Surveillance is not evidence based Focus on secondary prevention Late effects of treatment Rehabilitation End-of-life debate

24 Are we prepared for the future?

25 People with cancer in 2017 One quarter of patients are > 80 Frailty Multi-morbidity Social dependency Increasing expectations Uptake of lower toxicity treatment e.g. immune therapies

26 Preparing for the future Cancer is changing. Patients are changing. Treatments are changing. Staying the same is going backwards.

27 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 Doctors roles are evolving at a rapid rate.

28 The role of the specialist will be to provide the most up to date, accurate and advanced cancer diagnosis and treatment available. The GP will need to protect the patients from the harm that might do.