Colorectal cancer New Zealand s place in the world. Inequities in outcomes? Assoc Prof Diana Sarfati
Today s talk Mortality Internationally In New Zealand Incidence Trends in New Zealand Primary prevention Survival Internationally Unequal outcomes? Screening pilot
4.8 5.5 11.0 11.1 11.6 11.9 Source: OECD Health Data 2011. 14.3 12.6 17.1 14.0 21.3 14.3 16.5 14.5 12.7 14.8 21.6 15.6 18.2 16.2 18.3 16.3 18.5 16.3 17.6 16.6 18.0 16.8 21.5 17.0 17.2 17.0 20.2 17.8 18.3 20.4 18.5 19.5 18.9 22.8 19.2 23.1 19.5 19.9 20.2 21.0 20.6 19.8 20.9 24.3 21.2 20.7 21.4 27.0 24.8 27.0 25.3 24.5 25.5 34.3 26.0 31.0 27.7 37.6 33.1 NZ has high death rates from colorectal cancer Age-standardised rates per 100 000 population 2000 2009 40 35 30 25 20 15 10 5 0
4.8 5.5 11.0 11.1 11.6 11.9 Source: OECD Health Data 2011. 14.3 12.6 17.1 14.0 21.3 14.3 16.5 14.5 12.7 14.8 21.6 15.6 18.2 16.2 18.3 16.3 18.5 16.3 17.6 16.6 18.0 16.8 21.5 17.0 17.2 17.0 20.2 17.8 18.3 20.4 18.5 19.5 18.9 22.8 19.2 23.1 19.5 19.9 20.2 21.0 20.6 19.8 20.9 24.3 21.2 20.7 21.4 27.0 24.8 27.0 25.3 24.5 25.5 34.3 26.0 31.0 27.7 37.6 33.1 NZ has high death rates from colorectal cancer Age-standardised rates per 100 000 population 2000 2009 40 35 30 25 20 15 10 5 0
In New Zealand Around 3000 CRC every year of which about a third are rectal cancers in New Zealand Colorectal cancer is the second highest cause of cancer death in New Zealand
Today s talk Mortality Internationally In New Zealand Incidence Trends in New Zealand Primary prevention Survival Internationally Unequal outcomes? Screening pilot
Incidence rates of CRC are coming down Males Females Ministry of Health. 2010. Cancer Projections: Incidence 2004 08 to 2014 18. Wellington: Ministry of Health.
Number of cases of CRC are going up Ministry of Health. 2012. Cancer: New registrations and deaths 2009. Wellington: Ministry of Health.ealth.
Colorectal cancer: incidence is lower for Maori... But increasing Point number hdgdhu skjojsd asdsd Sdfsd sdfsds lkl; Sdasd gh fgdfg dfg d dfgg Maori Pacific European/ Other Asian Blakely et al. CancerTrends: Trends in Incidence by Ethnic and Socioeconomic Group, New Zealand 1981-2004.
Primary prevention of CRC Strong cohort effects Early life exposures? Dietary factors Physical inactivity Overweight/ obesity Smoking Alcohol Daily aspirin
Today s talk Mortality Internationally In New Zealand Incidence Trends in New Zealand Primary prevention Survival Internationally Unequal outcomes? Screening pilot
International comparison: Five-year relative survival in OECD countries 2004-2009 1997-2002 Japan Iceland Belgium United States Korea Canada Norway Austria New Zealand Finland Netherlands Malta Sweden Germany OECD (16) Singapore Portugal France Slovenia Denmark United Kingdom Ireland Czech Republic Latvia 68.0 67.3 66.1 64.7 64.5 62.5 63.7 52.6 63.4 59.1 63.1 57.0 63.1 57.1 62.1 57.0 61.8 58.9 61.0 57.9 60.8 60.7 57.3 60.4 53.3 59.9 54.6 57.8 57.5 57.4 57.0 55.8 45.5 55.5 50.1 53.3 48.1 52.9 49.0 49.6 41.1 38.6 0 25 50 75 100
Survival rates are improving over time Excess mortality rate has been reducing by 27% each 10 years since early 1990 s for those diagnosed with colorectal cancer Soeberg M, Blakely T, Sarfati D et al (2012). Cancer Trends: Trends in Survival by Ethnic and Socioeconomic Group, New Zealand 1991 2004. Wellington: University of Otago and Ministry of Health.
Not all good news (inequities)
Why ethnic inequities in cancer survival? More aggressive/ advanced tumours? Patient comorbidity? Health care quality and/or access?
Ethnic inequities in colon cancer survival 40% Excess mortality risk (Maori/non-Maori) 30% 20% 10% Comorbidity and treatment/health service factors each accounted for a third of the survival difference. 0% Unadjusted Demographics + Disease factors + Patient factors Risk adjustments + Treatment + Health service access Hill S, Sarfati D et al. Cancer. 2010: 116; 3205-14.
Ethnic inequities in colon cancer survival Percentage of cohort (stage III) 100 90 80 70 60 50 40 30 20 Referred to oncologist Reviewed by oncologist Offered adjuvant chemo Received adjuvant chemo Started within 8 weeks 10 0 Māori non-māori Hill S, Sarfati D, et al J Epidemiol Comm Health 2010: 64; 117-23
Not just colon cancer Māori were four times less likely to receive curative rather than palliative anticancer treatment for nonmetastatic disease compared with Europeans even after adjusting for age, gender, NZDep, CCI [comorbidity], tumor type, stage and patient declining management. Stevens W, Stevens G et al. Ethnic differences in the management of lung cancer in NZ. J Thoracic Oncol 2008.
Bowel cancer mortality: What s happening over time? Shaw C, Blakely T, Sarfati D, et al. Trends in colorectal cancer mortality by ethnicity and socioeconomic position in New Zealand 1981-1999: One country, many stories. Aust NZ J Public Health. 2006; 30 (1): 64-70. Point number hdgdhu skjojsd asdsd Sdfsd sdfsds lkl; Sdasd gh fgdfg dfg d dfgg
Today s talk Mortality Internationally In New Zealand Incidence Trends in New Zealand Primary prevention Survival Internationally Unequal outcomes? Screening pilot
Screening Waitemata DHB 2 yearly ifobt for those aged 50-74 years.
How is the pilot programme going? Participation: Participation rate 70% 60% 50% 40% 30% 20% 10% Desirable rate 0% Maori Pacific Asian Other Ministry of Health 2013
How is the pilot programme going? Around 130 cancers detected to Sept last year High detection of advanced adenomas Very high acceptance of colonoscopy
How is the pilot programme going? 50 45 40 35 30 25 20 15 Screened diagnoses Colon Cancer study 10 5 0 1 2 3 4 TNM Stage at diagnosis
Where to from here for bowel cancer? Primary prevention Screening programme Minimum treatment standards Data availability