Vulnerable to the Big C

By CATHRIN SCHAER

Last month New Zealanders received some unsettling news. It wasn't just rugby, cricket or the economy we needed to worry about when comparing ourselves with Australia - it was also cancer.

A study by two Dunedin researchers, published in the New Zealand Medical Journal, revealed that New Zealanders are more likely to die of cancer than Australians.

In developed countries cancer is the second most common cause of death - the World Health Organisation suggests this is because of an ageing population, the ability of modern medicine to cure other once-fatal diseases and the rise of certain forms of cancer - for instance, lung cancer caused by tobacco smoking.

Australia and New Zealand are no different from anywhere else. In Australia cancer is one of the most common causes of premature death. There, one in three men and one in four women will be affected by cancer before they are 75.

In New Zealand it's also one of the most common causes of premature death and a major cause of hospitalisation. One in three New Zealanders will get a major cancer; every year around 16,000 develop cancer and around 7500 die of the disease.

But what the Otago University study also found was this: "If Australian rates had been applied," writes Professor David Skegg of the department of preventive and social medicine at the University of Otago, in his paper, "there would have been 215 fewer cancer deaths per year in New Zealand males and 616 fewer in females."

That's more than 800 lives - twice the road toll.

Worryingly, Skegg's study also found that overall our cancer patients' survival rates after treatment were not as good as those of Australian cancer patients.

According to various experts, modern medicine can help to prevent one-third of all cancers, cure another third and adequately control symptoms in the rest. The two former possibilities must account, at least in part, for the differing cancer mortality rates in different countries. All of which makes the average New Zealander want to ask just one question: why?

Is it that our medical system is letting us down, not doing as good a job as the Australian one? Are we just not picking up the disease early enough? Or could it be that there's something inherently wrong with the New Zealand lifestyle? Do we not eat as much fruit and veg as the Aussies do?

The answer to all of the above is yes - and no. Start asking around experts in the field and you will find that no one can give you a definitive answer. Everyone has a theory, and most of those theories have a place in the final explanation.

First, is this just a statistical storm in a teacup? Should we really be comparing ourselves with Australia like this? While some pundits have argued this point, the question is probably moot.

Skegg's figures are based on cancer mortality figures - that is, the figures that show how many people die from cancer - and these have been recorded in many countries for many decades. And after all, despite the sporting and cultural clashes, can you think of a more appropriate country to compare ourselves with?

Is it because of the kinds of cancers that New Zealanders get? Yes, it is important to look at the kinds of cancers, mainly because some cancers are more deadly than others. While New Zealand has one of the highest rates of skin cancer (melanoma) in the world, the most common killers in this country are lung cancer, bowel cancer and breast cancer. Bowel cancer can often be treated with success. Breast cancer is less easy to treat and lung cancer even less so.

"And nearly all cancers caused by smoking have a poor survival rate," says Dr Alan Gray, previously medical director of the Cancer Society.

But look closely at Skegg's study and you will find that Australians have fairly similar patterns of cancer. Nonetheless, New Zealanders are more likely to die.

For example, as Sandra Coney, executive director of Women's Health Action, says, "The fact that Australian and New Zealand women have similar rates of breast cancer but more New Zealand women are dying points to the fact that we are doing something wrong."

Is it because certain segments of our population are at risk? Dr Colin Feek, a Health Ministry spokesman, says, "New Zealand is a Pacific Island country. Nearly one-quarter of our population is either Maori or Pacific Islander and that makes a fundamental difference."

Feek believes that Maori and Pacific Islanders have much poorer survival rates because they are coming to the doctor later with cancers that are more advanced - which means there's less chance of surviving.

"We don't know at what stage patients present with cancer," says Dr John Childs, Auckland Hospital's clinical director of radiation oncology. "But anecdotally I have the feeling that, yes, Maori and Pacific Islanders do present later. With cervical cancer Maori and Pacific Island women did tend to turn up in the system later, after having had the symptoms for longer. Which means they're more likely to have a worse outcome."

Dr Keri Ratima, a senior adviser in Maori health with the Ministry of Health, believes this reflects the fact that Maori "are systematically over-represented in lower socio-economic groups".

Ratima, a former GP who is on the steering committee for cancer control and who is also a representative of Te Ohurata o Aotearoa, the Maori medical practitioners' association, says, "We have a situation where there's high unemployment and no money. Families go into survival mode. And when you're in survival mode, doctors' visits don't come as a priority."

Additionally Ratima believes that a lot of Maori are living in rural areas where they cannot access the same healthcare services as those living in the city.

The other factor that needs to be considered here is that Maori have some of the highest rates of smoking, which obviously puts them at more risk of the deadlier smoking-related cancers.

However this obviously isn't the whole answer: Skegg's study also points out that among non-Maori there were still more than 533 more cancer deaths.

Are our cancer-screening services working properly? Do the Australians pick up cancer earlier?

"The Gisborne inquiry has shown us we do need to consider the quality of our screening programme very seriously," says Dr Peter Dady, the Medical Director of the Cancer Society. He also notes that our breast cancer screening programme effectively started a decade later than the Australian one, which could add to our mortality rate in this particular area.

However, Coney remains certain that "screening programmes are not a magical answer". She suspects that "we may not be doing that well in the area of early diagnosis. I've come across a number of cases where GPs have not referred women on, which has led to long delays in treatment."

And that's if you even get to your GP. As several other doctors say, primary healthcare in New Zealand is among the most expensive in the world, which could be preventing patients from going to their doctors in the first place.

Is it because of our medical system? Is the system failing cancer patients?

This is a tricky one and opinions are divided.

"You might say I am biased but I believe the treatment that people get once they get into the system is equivalent to that which they would get in the best centres in the world," argues Childs, who works daily in this field. But even he concedes that delays getting into the system may be a factor in our higher mortality rates. "However, when you look at something like lung cancer it has nothing to do with waiting lists," he argues, "because it always gets a priority. And these types of delays are not that different from what Australia is experiencing."

Too true. Headlines from newspapers across the Tasman suggest that, for instance, the state of Victoria is also going through a shortage of trained radiotherapists.

And as Gray points out, such a shortage can play havoc with survival rates. "For instance, if you have breast cancer and you excise the lump, radiotherapy can be used as a follow-up treatment," he explains. "You should wait six weeks at the longest to have this, otherwise it reduces chances of survival. And some New Zealand women were having to wait 14 to 16 weeks."

But it's not just waiting lists. Others are far more scathing of our healthcare system in general.

"We don't invest in health in this country," complains one pathologist, who preferred to remain anonymous. "We don't invest in primary care or prevention. We don't invest in up-to-date technology and everyone who works in the health sector is struggling."

"There's been no emphasis on quality in healthcare, only cost-cutting," agrees Dady.

"Cancer is a paradigm for just how effective the health system is," concludes Gray. "Because cancer patients go through all sorts of hands, right from the district nurse to their GP to the palliative care specialist. And this study is indicative of a creaky health service."

Is it because Australia is a wealthier nation and can afford more cancer treatment technology, research and drugs?

This one is a red herring. As one expert points out, if it was just about finance why do New Zealand women have the sixth-highest cancer-mortality rate in the world, out of 176 countries? Surely if it had to do with the wealth of our nation, we'd be doing better than that?

Looking at international figures, it is clear that less developed countries don't necessarily have higher cancer mortality rates (often this is because they have less cancer developing among their populations). Or that more developed countries necessarily have lower rates.

For example, Britain is doing worse than many of its European counterparts. As the Observer newspaper reported earlier this year: "Britons are less likely to survive almost any form of cancer than citizens of any other country in Western Europe." This was reported amid calls for a cancer control programme in that country.

Is there something wrong with the New Zealand lifestyle?

When it comes to cancer prevention there are certainly areas in which we could do better. All the experts say our meat-and-dairy-heavy diet is too high in animal fat. Besides other health issues such as cardiovascular disease, such a diet of animal fat has also been linked to some cancers.

And by all accounts, while New Zealanders are happy in the land of steak and chips, the Australians are eating a far more Mediterranean diet - more grains, vegetables, olive oil, garlic, seafood and fruit, and less meat, with no butter, cream or lard.

Some researchers have also found links between the high use of organochloride pesticides, such as DDT, and breast cancer. We should also stay out of the sun more and smoke less. The latter is especially true for young New Zealand women, who are taking up smoking at alarming rates.

Is it because we don't have a cancer control strategy and the Australians do?

"That's probably got something to do with it," agrees Dr Colin Tukuitonga, who is the Director of Public Health at the Ministry of Health and chairman of the Cancer Control Steering Group.

"Countries that have had a cancer control strategy have made a significant impact on [mortality rates]. We've had cancer as part of an overall strategy but we've never focused on it in a comprehensive or co-ordinated way before."

Dady puts it more forcefully. "Until recently cancer has almost been swept under the carpet and there's been no co-ordinated approach. We need to focus on cancer and we need an independent body to do it."

So where to from here? As you can probably tell from all of the above, no one has a final answer.

But the one thing that most of our local cancer experts agree upon is the need for some form of national cancer control programme.

"We need to take a deep breath and ask why this is happening," maintains Childs. "Clearly we have some big issues. There are a whole lot of potential areas we might look at and we have some big gaps in our knowledge."

This is where the Cancer Control Steering Group comes into it. It is a partnership between the Cancer Control Trust (which is partially funded by the Cancer Society) and the Ministry of Health. Several working parties of experts are looking at areas such as cancer prevention, screening, treatment, rehabilitation and data collection and management. Each kind of cancer also needs to be looked at separately.

The expert working parties are expected to report back this year, after which there will be consultation with health professionals and the community at large. Then, according to Tukuitonga, we can expect a final report early next year.

Those at the Cancer Control Trust are hoping that final report will recommend further research into why cancer is more likely to kill you in New Zealand than in Australia.

"If we were then able to take steps to limit that cause, there could be a substantial saving of life," concludes Professor John Gavin, the executive director of the trust.

Whatever the problem, Gavin agrees it's likely to be multi-faceted and we will need some time to remedy it.

"For instance," he explains, "if some action needs to be taken in relation to reducing smoking, it could be 20 to 40 years before we see any effect.

"If we're talking about, say, a modification in the treatment of a particular tumour, we might see measurable results within two to three years."

nzherald.co.nz/health