Journal of the New Zealand Medical Association, 18-June-2004, Vol 117 No 1196
Lung cancer management concerns in New Zealand
Tim Christmas and Michael Findlay’s evaluation of lung cancer management in New Zealand raises a number of concerns.1 Their postal questionnaire-based survey sought responses from respiratory physicians, medical oncologists, and radiation oncologists on what treatment they (or their department) would currently offer six hypothetical patients with varying stages of non-small cell lung cancer (NSCLC).
Respiratory physicians were more likely than oncologists to state that chemotherapy for managing locally advanced or advanced NSCLC in their District Health Board (DHB) was not available. This diversity of opinion is concerning, as was the fact that many DHBs had obviously not implemented treatment guidelines for patients with lung cancer. The conclusion from this study is that lung cancer services in this country are suboptimal and that a diversity of opinion exists about which treatments are currently available and who should be offered them.
The inability to offer acceptable levels of lung cancer care in New Zealand is likely to be multifactorial and related to such things as: poor regional and national coordination of cancer services; poor networking and strategic planning; inadequate guideline development; poor implementation of guidelines; an absence of data collection to assess quality of care; slow assimilation and funding of new drugs and technologies; and unacceptable waiting times for radiotherapy.
At least some of these issues would be addressed if the New Zealand Cancer Control Strategy2 were to be immediately implemented with adequate resourcing by both the DHBs and the Ministry of Health (MOH). The strategy provides a framework for an integrated set of activities covering: primary prevention, screening and early diagnosis; treatment and symptom control; rehabilitation and support, and palliative care. Such a framework is of critical importance to the development of lung cancer management strategies, which have been implemented in most other developed countries.
Grade A level evidence of benefit (palliation of symptoms, prolongation of life, and occasional cure) exists as a result of utilising various combinations of chemotherapy, radiotherapy, and surgery in locally advanced NSCLC.3,4 Whilst insufficient funding is a frequently offered reason for non-implementation of new treatment strategies, it is pertinent to point out that less than 5% of direct costs of lung cancer management is spent on therapeutic modalities in New Zealand.5 Furthermore, many chemotherapeutic regimens have been shown to be more cost-effective3,4 than best supportive care.
Decisions on new treatment modalities would be better made by a national committee (with a more comprehensive overview of the economic and therapeutic issues) than by individual hospitals or DHBs.
Most DHBs in New Zealand have therefore not implemented the Australian Lung Cancer guidelines3—which have been endorsed by the Thoracic Society of Australia and New Zealand (TSANZ). If we cannot implement Australasian treatment guidelines, then at the very least this needs to be recognised and debated. Whilst we could conceivably write our own guidelines to initiate new treatment strategies and accommodate the lesser funding available in New Zealand, there is insufficient funding or resources for guideline development.
Furthermore, no money exists to support the implementation of guidelines (developed in New Zealand or by Australasian Societies), and no mandate exists for DHBs to implement them. The amount of money each of the 21 DHBs spends on a variety of medical treatments is largely self-determined and remains the most logical explanation for the diversity of responses noted in Dr Christmas’ study.
This being the case, we need to maintain (at the very least) a lung cancer database in New Zealand to compare the quality of care offered across the 21 DHBs and in turn to compare New Zealand outcomes with those in Australia and elsewhere. Indeed, a cancer register was established in New Zealand in 1975; and since 1994, all new cases of lung cancer have been recorded.
The data provides basic information which allows age, sex and race standardised incidence rates and survival figures to be calculated. The registry records insufficient detail, however, to allow us to understand why 5 year survival rates for lung cancer in New Zealand are only 5% (compared with 11% in Australia). Factors which may account for the difference include:
Dr Christmas’ results would infer that under-treatment and therapeutic nihilism may indeed be part of the reason for the poorer survival rates in New Zealand. Financial barriers to primary healthcare and poor access to radiology services by primary care physicians (leading to delays in investigation) are also likely contributing factors. However, without more detailed information, one cannot draw any strong conclusions and healthcare planning is subsequently compromised.
There is, therefore, an overwhelming need to implement the New Zealand Cancer Control Strategy immediately, and to develop the framework envisaged to provide better coordination of care—only then will the treatment offered be of a more uniform and higher quality standard.
Author information: Jeff Garrett, Associate Professor (and President of the NZ Branch of TSANZ), Department of Medicine, Middlemore Hospital, Auckland
Correspondence: Associate Professor Jeff Garrett, Department of Medicine, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland. Fax: (09) 6307128 email: email@example.com
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