This report on cancer control is one of a series of biennial reports to Health Ministers on each of the five National Health Priority Areas (NHPA). It is part of a process that involves various levels of government and draws on expert advice from non-government sources, with the primary goal being to reduce the incidence of, mortality from, and impact of cancer on the Australian population.
Cancer has a major impact on the Australian community, in terms of morbidity, mortality and costs. On average, one in three men and one in four women are likely to develop cancer before the age of 75. The number of new cases of cancer has been steadily rising. Many of these new cases are due to population growth, the aging of the population and increased rates for the detection of some cancers.
Mortality from cancer is decreasing, reflecting changes in patterns of exposure to risk factors, changes in treatment and early detection techniques and the use of medical services. The direct costs of cancer were estimated at $1.361 billion in 1993–94.
The NHPA process has identified specific cancers which represent issues of major concern in all States and Territories, and where significant gains can be achieved through prevention and control. The status of these cancers in 1997 and major issues for the future is summarised as follows.
Lung cancer is the most common cause of cancer deaths among Australian males and the second most common cancer in Australia with approximately 7,300 new cases diagnosed each year, most of which go on to be fatal. Lung cancer rates in males exceed those in females by approximately three to one. Incidence and mortality rates are decreasing in males while those of females are increasing.
Prevention is the key to reducing the burden of lung cancer; smoking is by far its largest preventable cause. Actions to reduce lung cancer rates have focused on promoting cessation and decreased uptake of smoking, and on legislative changes to restrict tobacco sales and consumption. Knowledge of lung cancer is rapidly expanding, with new techniques for early detection and improved treatment being evaluated.
There is a wide range of strategies for tobacco control already in place at Commonwealth, State and Territory, local health authority and community level. However, community groups and health bodies want to further restrict tobacco sales and consumption.
Non-melanocytic skin cancer is the most common cancer in Australia and Australia has the highest incidence rate in the world with between 250,000 and 300,000 new cases diagnosed each year. Non-melanocytic skin cancers even though more numerous are generally less life threatening than melanoma. Melanoma and non-melanocytic skin cancers show the greatest geographical variation in prevalence of any cancer across Australia, with Queensland having the highest rates. The estimated treatment costs for skin cancers are higher than the costs for any other cancer in Australia.
Primary prevention programs in Australia have been very successful in raising awareness of the dangers of exposure to sunlight and are generally effective in decreasing exposure to sunlight. Opportunistic detection by general practitioners and targeting of specific high-risk population groups remain useful methods for early detection and diagnosis of skin cancer.
Future preventive efforts may need to concentrate more on structural changes within the community, to decrease time in the sun and to increase protective shade structures and other physical means of protection. If an impact is to be made on future incidence rates of skin cancer in Australia, the nature and amount of sun exposure in children and adolescents need to be reduced.
Cancer of the cervix
Cancer of the cervix is the eighth most common cancer among Australian women, with approximately 1,000 new cases diagnosed each year. Both its incidence and mortality rates have been falling for many years, due mainly to the widespread use of Pap smear screening tests and the subsequent treatment of precancerous abnormalities. This is one of the few cancers where precancerous lesions are detectable and treatable. Hence, mortality from this cancer could be largely prevented with current screening and treatment methods.
The development and implementation of effective and culturally appropriate strategies for screening groups with a higher incidence of cancer of the cervix would assist in increasing overall participation in the national screening program.
The participation of Indigenous and older women is crucial if health gains from this screening program are to be optimised. Increased quality assurance measures for laboratories and further encouragement for women and general practitioners to adhere to two-yearly screening would improve both the quality and cost-effectiveness of the national program.
Breast cancer remains the most common cause of female cancer deaths in Australia, with nearly 9,800 new cases diagnosed and 2,600 deaths in 1994. In the ten years to 1994, breast cancer incidence rose by an average of 3 per cent. This rise in incidence results partly from improved and easier detection of breast cancers by the BreastScreen Australia program, although some proportion of the increase may be attributable to a real increase in disease rates. However, based on changes in incidence between 1994 and 1996, breast cancer incidence is expected to fall slightly by 1999.
Breast cancer cannot be prevented, so the major scope for reducing the impact of its mortality and morbidity is early detection through the national mammographic screening program, prompt diagnosis, and effective treatment based on the latest evidence.
Issues in breast cancer control, such as rates of participation in the national BreastScreen program and the need for models of coordinated care, could be addressed by the establishment of a more integrated approach to the screening, diagnosis and management of the disease.
Colorectal cancer is the second most common cancer affecting both males and females in Australia, with about 10,000 new cases diagnosed each year and 4,600 deaths. Incidence and mortality have remained stable over the past decade.
Currently there is no national screening program for colorectal cancer, because of uncertainties about which test to use, which groups to test and the likely degree of public acceptance. There is ad hoc screening of high-risk groups, such as those with a family history of colorectal cancer.
There is great potential for control of colorectal cancer, through early diagnosis which allows for comparatively simple surgery, low morbidity and minimal community cost. Advanced disease demands the use of complex and costly treatment. The Australian Health Technology Advisory Committee (AHTAC) has undertaken a review of the benefits, risks and costs of national screening for colorectal cancer, and has recommended commencing pilot programs using faecal occult blood testing (FOBT) for the average risk population aged 50 years or more.
With nearly 13,000 new cases diagnosed each year, prostate cancer is the most common cancer, excluding non-melanocytic skin cancer, in Australian men. The reported incidence rose rapidly since the introduction of better detection methods in 1990. However, since 1994 incidence rates have declined, although not quite to their original level.
There is no evidence of any reduction in mortality associated with early detection in asymptomatic men. The current National Health and Medical Research Council (NHMRC) recommendation is that men without symptoms should not be screened for prostate cancer.
The optimum treatment for prostate cancer is subject to debate. The current trend is to adopt a watchful waiting approach in men aged over 75 years and with low grade tumours. Treatments such as radiotherapy or radical prostatectomy are being offered to younger men. This approach is seen by some as being a reasonable compromise until evidence from randomised controlled trials becomes available.
Screening for prostate cancer should be discouraged unless evidence of benefit emerges which supports the development of a national screening program. Ongoing audit is necessary as few Australian studies have reported outcomes of any form of treatment and there are often insufficient staging data to allow any comparison with international studies. Clarification of the role of various treatments in prostate cancer is severely restricted by the lack of reliable evidence-based information. Most importantly, there is a need for the development, testing and evaluation of appropriate information for men and their general practitioners.
Opportunities for improving cancer control
A focus on cancer types is useful in determining progress in cancer control, but other common factors should also be considered. Issues such as the identification and control of risk factors, the transfer of existing or new knowledge that is available through research into strategies against cancer, the kinds of data systems that are available, whether aspects of cancer services or treatment are different among particular population groups, and the role and rights of consumers, are all important in building a full picture of cancer control in the nation.
A comprehensive, rational approach at the national level can be promoted by discussing opportunities for improving cancer control within a systematic framework. This would consider the cancer types, the stages along the continuum of care and other categories of health system activity that are relevant to cancer. Such a framework would provide a blueprint for collaborative action under the NHPA process, which also draws in non-government expertise. Opportunities for improving cancer control include:
- promoting comprehensive consumer participation in all aspects of cancer control;
- ensuring that preventive and screening strategies are accessible and effective, with a particular focus on special populations;
- promoting research which addresses important gaps in our knowledge of cancer prevention, early detection and treatment;
- improving the linkages between research and decision-making processes in cancer prevention and treatment;
- ensuring that treatment, rehabilitation, supportive care and palliation are accessible and effective;
- considering financial and other incentives for the promotion of evidence-based practice;
- improving and maximising the use of data as an essential tool in decision making;
- improving the integration of care across the health continuum; and
- encouraging the development of model centres of excellence in cancer care.
Cancer has a large impact on the Australian community. Some reduction of mortality and morbidity is possible, but there is still much work to be done to realise the full potential for cancer prevention control.
Overview (61K PDF)
- Profile of cancer
National Health Priority Areas cancer sites - current status (295K PDF)
- Lung cancer
- Skin cancer
- Cancer of the cervix
- Breast cancer
- Colorectal cancer
- Prostate cancer
- Other cancers
Opportunities for cancer control in Australia (162K PDF)
- A framework for change
- Specific issues for priority cancers
- Evidence-based practice in cancer control
- Special populations
- Familial cancers
- Research and data collection
- Setting priorities and future directions
Appendix 1: Quality of evidence ratings
Appendix 2: Data and statistical issues
End matter (138K PDF): References