Correcting several major deficiencies in the way cancer care services are delivered will improve the survival and quality of life of people living with cancer, according to the new report, Optimizing Cancer Care in Australia (OCCA).
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In Australia, not all patients have access to treatment that is appropriate to their needs and environment. "The problem is that cancer treatment has been uncoordinated and not patient focused," said Sally Crossing, co-chair of Cancer Voices New South Wales, a not-for-profit coalition of cancer consumer, advocacy, and support groups. "We rarely experience the seamless cancer journey regarded as best practice."
Responsibility for health services in Australia is shared between the federal and state governments, with universal health care coverage being guaranteed to all residents through public hospitals, subsidized visits to private doctors offices, and a pharmaceutical benefits strategy. Health insurance is available for private hospitalization, but only one-third of the population is insured. Patient reimbursement for medical services is governed by a Medical Benefits Scheme (MBS) according to a schedule set by the federal government. Activities for which there is no item number attract no reimbursement. Absent from the MBS are provisions for integrated multidisciplinary cancer care.
The model of multidisciplinary cancer care is applied in somebut not allAustralian hospitals. A team of medical and allied health specialists assess a newly diagnosed patient and agree on the best treatment course, taking the patients preferences into account before proceeding further. This contrasts with the traditional care model in which a patient is referred to a specialist who conducts the primary intervention, and other specialists and health care professionals are seen later.
Major cancer centers that care for public and fee-paying privately insured patients more commonly use the multidisciplinary approach. But, many public hospitals do not provide this service. Meanwhile, its use in the private sector is limited both by logistic considerations and the fact that the MBS does not allow reimbursement for multiple simultaneous consultations. The OCCA report recommends the inclusion of a differential item number in the MBS to provide for these consultations at accredited cancer centers.
But applying these principles to rural and remote areas poses challenges for patients who must travel long distances for cancer treatment and specialists who practice in different locations. NCCI director Mark Elwood, M.D., said he believes that these problems can be reduced by improvements in local facilities, better support for patient travel, and linking specialists to major centers. "Theres no reason why [patients] cant be treated according to the same standards," he said. "Cancer physicians working in the smaller centers can relate to the major centers and follow the same treatment protocol when local facilities are adequate." The report recommends an urgent review of these issues.
To provide cancer care services more effectively, the OCCA report recommends that cancer centers be accredited, based broadly on the U.S. Commission on Cancer model. "We envisage having several levels of accreditation: a tertiary level at the major capital city cancer centers, a secondary level in the outer suburbs and provincial areas, and a [primary] level in rural communities," said Lester Peters, M.D., chair of the steering committee that developed the report. Each accreditation level would be associated with a range of services that are appropriate to the facilities and expertise available. Patients requiring higher levels of service would be referred to a center with the requisite accreditation. All cases would receive multidisciplinary care consideration.
Reorganizing cancer services is not a panacea if resources are limited. Currently, Australia is facing a radiation oncology crisis, a problem that was addressed 2 years ago in the report, the National Strategic Plan for Radiation Oncology (see News, Oct. 17, 2001, Vol. 93, No. 20, p. 1516). According to that report, there are shortages in equipment and personnel (radiation oncologists, physicists, and therapists) relative to the demand for services. Radiation therapists are leaving the profession, and there are long waiting lists for treatment at many facilities.
"The staff of radiation oncology centers are under a great burden," said Liz Kenny, M.D., radiation oncologist and COSA president. "Many centers are working with aging equipment and old technology. In addition, staff find the delays facing patients very distressing." In Australia, only 38% of newly diagnosed cancer patients receive radiotherapy treatment, compared with the benchmark of 50% to 55% recommended by the Australian Health Technology Advisory Committee. According to the report, this represented 10,000 patients not accessing radiotherapy in 2000.
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But these and other recommendations are only useful if they are actually implemented. "We are heartened by the fact that the process of developing the report (which included discussions with key bureaucrats) has already helped to inform cancer policy," said Peters.
Although one of the main recommendations of the OCCA reportto set up a Ministerial Task Forcewas rejected in February by Australias Federal Minister for Health and Aging, two committees spanning federal and state jurisdictions have been set up: one specifically to address the crisis in radiation oncology and another to develop a National Cancer Services Improvement Framework.
It will take time to implement change at the national level, but the two most populated Australian states have taken the lead and formulated plans. The recently re-elected New South Wales Premier Bob Carr has pledged to allocate Au $290.2 million (US $174 million) over 4 yearsin addition to the Au $450 million (US $270 million) it already spends each year on cancer servicesto create a New South Wales Cancer Institute, which will oversee the implementation of standards for improved cancer care; to purchase new linear accelerators for regional and metropolitan radiotherapy centers; and to develop tailored, professional development programs to retain and retrain radiation physicists and therapists.
Carrs counterpart in Victoria, Steve Bracks, has earmarked funding for cancer prevention and screening programs and upgraded and expanded radiotherapy and chemotherapy facilities, cancer service networks, and training and recruitment programs for radiation therapists.
Assuming that federal, state, and territory health ministers reach consensus on how national policy reform is implemented, there is the possibility of change taking place for the benefit of patients. Crossing is delighted. "Something good is going to be done," she said. "People have actually got together and agreed that this is the way forward. Thats what is so terrific. We have done it together."
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