Japanese Journal of Clinical Oncology 32:S3-S9 (2002)
© 2002 Foundation for Promotion of Cancer Research
Cancer Control in Australia: Into the 21st Century
Anti-Cancer Council of Victoria, Carlton, Victoria, Australia
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCANCER INCIDENCE AND MORTALITYGOVERNMENT FUNDING OF CANCER...NON-GOVERNMENT FUNDING OF CANCER...REFERENCES |
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Australia ranks highly internationally for cancer control, in part because cancer registries provide comprehensive national incidence and mortality and other cancer data annually. This has facilitated short- and long-term planning over the last quarter of a century. For example, male death rates from lung cancer in Australia peaked around 1985 and are now falling steeply, whereas female rates are still rising. In women, cervical cancer incidence and mortality have fallen owing to cervical screening over the last quarter of a century. Breast cancer mortality is now trending downwards after a half-century plateau, probably because of better treatment protocols. Cancer registry based State and national population treatment surveys over the last 15 years have identified both deficiencies and strengths in evidenced-based treatment of cancer in Australia. For example, in the State of Victoria, 5-yearly population based breast cancer treatment surveys have shown that the proportion of women who had a mastectomy versus a lumpectomy as their primary surgical operation fell from 78% in 1986 to 47% 1995. All Australians are covered by a universal health care system. Therefore, socio-economic status is not a barrier to accessing high quality cancer control, whether it be prevention, screening, treatment or education. In addition, non-government organizations (NGOs) specializing in cancer control have been providing free or highly subsidized support services to patients and their families for over half a century in most states. These NGOs have also been very active in public education about cancer, especially cancer prevention.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCANCER INCIDENCE AND MORTALITYGOVERNMENT FUNDING OF CANCER...NON-GOVERNMENT FUNDING OF CANCER...REFERENCES |
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Cancer control is defined internationally as all actions which reduce the burden of cancer in the community: research, prevention, early detection, treatment, palliation, patient and family support and education. Implicit is continuous monitoring of population cancer outcomes: incidence, mortality, the treatments employed and the burden of cancer on the society.
What is the burden of cancer in Australia? There is a measure developed through the World Health Organization called Disability Adjusted Life Years or DALYs. In Australia, cancer caused the second greatest burden of DALYs in 1996 and most of these DALYs were years of life lost due to premature death (1). Cardiovascular disease is the greatest cause of DALYs in Australia, but in terms of premature death, cancer is equal. It is worth noting that mental illness ranked third for DALYs in Australia, but most of this is disability and very little is due to death.
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CANCER INCIDENCE AND MORTALITY |
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TOPABSTRACTINTRODUCTIONCANCER INCIDENCE AND MORTALITYGOVERNMENT FUNDING OF CANCER...NON-GOVERNMENT FUNDING OF CANCER...REFERENCES |
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National Australian data on cancer mortality has been available for over a century, based on information in medical certificates of causes of death provided to State registrars of births, deaths and marriages. State based cancer registries began to be established over half a century ago (Victoria in 1936) to validate this death certificate data and to collect cancer treatment and follow-up information from hospitals. Some State cancer registries began to collect new case (incidence) data (New South Wales from 1972) and national and State laws making cancer a notifiable disease came into effect in 1982. From 1982 there has been universal registration of new cancer cases in Australia and an Australian Association of Cancer Registries which, together with the Australian Institute of Health and Welfare, produces an annual report: Cancer in Australia (2). This network of State cancer registries has made it possible to undertake State and national population based treatment surveys (described later) and other valuable epidemiological research, in addition to reporting cancer incidence and mortality. These registry data reveal that for females and males the world age standardized incidence of all cancers in Australia peaked around 1995 and is now falling. These data also reveal that male and female world age standardized cancer mortalities have been falling slowly since the end of the 1980s. Australia is one of the few countries in the world where the whole population world age standardized cancer incidence and mortality rates are both falling.
In 1996 there were 14 potentially fatal cancers recorded in Australia, for which there were more than 1000 new cases (2). The commonest of these was colorectal cancer; however, it is worth noting that the gender specific cancers, prostate cancer in men and breast cancer in women, ranked second and third (Fig. 1). For many of these cancers, the incidence rate was twice or more the mortality rate, reflecting improvements in treatments that have occurred during the twentieth century. However, for cancers of the lung, pancreas and brain, incidence and mortality were almost the same, reflecting the very poor prognosis that these cancers still have. This pattern of cancer incidence and mortality is typical of westernized developed countries, where lifestyle factors such as cigarette smoking and consumption of diets high in calories and fats and low in vegetables are common.
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Trends in Cancer Mortality Rates in Australia
Between 1990 and 1996 the world age standardized cancer mortality rates in Australia for both males and females fell by 0.4% per year (2). Mortality trends for the five commonest potentially fatal cancers in Australia, together with stomach and cervical cancers, are considered below. Cancer mortality trends in men over the last half century reveal that lung cancer, which was only the third commonest cause of cancer death in men in 1950, became the commonest fatal male cancer by 1960 (Fig. 2). As night follows day, so lung cancer mortality in all populations peaks about 30 years after the peak prevalence of cigarette smoking. Australian male lung cancer mortality peaked around 1980 and 70% of adult Australian males smoked cigarettes in 1950. Stomach cancer, which was the commonest fatal cancer in 1954, is disappearing and bowel and prostate cancer have been on a plateau over the last half century. The male melanoma mortality rate rose during the last half century, plateaued in the early 1990s and is now falling.
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For women, the commonest potentially fatal cancer is breast cancer and it has been on a plateau of mortality for most of the twentieth century (Fig. 3). Mortality from breast cancer is now falling in Australia as of 1995 and this is probably attributable to adjuvant chemotherapy and hormone drug treatment. The national mammographic screening programme is not expected to have an effect until later this decade. Bowel cancer is becoming less fatal in women. In the first half of the twentieth century Australian men and women had almost the same bowel cancer fatality rates. The fall in the women’s rate, but not in the men’s, has been attributed to a number of factors. A likely cause is the introduction of synthetic oestrogens to the treatment of women beginning in the 1950s and 1960s, in the form of hormone replacement therapy and the contraceptive pill. Stomach cancer is disappearing in women as it is in men and for the same reasons. These are the widespread introduction of refrigeration into Australia in the 1950s, together with more hygienic cattle slaughtering practices. This reduced the consumption of preserved meats, where smoking, drying and salting had been common and reduced contamination with Helicobacter pylori, which is thought to cause about 40% of all stomach cancer world-wide. Cervical cancer mortality has halved in the last half century and this is all attributable to cervical cancer screening programmes. Melanoma mortality has been falling in women since the mid-1980s. Unfortunately lung cancer, which was ranked seventh in 1950 for mortality, is now third. The peak of cigarette smoking in Australian women was around 1980 and so the peak lung cancer mortality rate is not expected until about 2010. So for all these female cancers there are now declining mortality rates except for lung cancer and this, unfortunately, has used up most of these gains.
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GOVERNMENT FUNDING OF CANCER CONTROL IN AUSTRALIA |
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TOPABSTRACTINTRODUCTIONCANCER INCIDENCE AND MORTALITYGOVERNMENT FUNDING OF CANCER...NON-GOVERNMENT FUNDING OF CANCER...REFERENCES |
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The Commonwealth (National or Federal) Government has the major responsibility for funding health in Australia and in respect of cancer there are three major mechanisms. Cancer research is funded via the National Health and Medical Research Council (NHMRC). In 1995 an NHMRC National Breast Cancer Centre was created to improve breast cancer management in Australia. In 1996 government funding from all sources for cancer research was about 71 million dollars (Australian dollars are quoted throughout). There is now a National Cancer Control Initiative, the counterpart of the National Cancer Institutes in other countries, which was established in 1997 to advise the Commonwealth Government about cancer policy, to produce and facilitate the implementation of a national cancer control plan and to develop and manage cancer control projects.
A major mechanism for Commonwealth Government funding of health care is via funding grants to the eight State and Territory governments, all of which have health departments. There is an Australian Health Ministers Advisory Council, where the Commonwealth and State Health Ministers meet to coordinate their respective government activities in health care. In respect of cancer most of these funding grants are expended on the diagnosis, treatment and palliation of cancer in public (government) hospitals. In addition, there are the two national cancer screening programmes mentioned above and in the 2000 Commonwealth Budget a feasibility study on colorectal cancer screening was funded. These National Cancer screening programmes are largely implemented by the State and Territory governments, using Commonwealth funding.
The third major mechanism of Commonwealth Government funding is via direct payments to health care professionals on a fee for service basis and via subsidization of the pharmaceutical drugs which they prescribe. This effectively provides free primary health care to all Australians via primary health care physicians (General Practitioners), who can refer patients to appropriately qualified specialist medical practitioners. For cancer, these are medical practitioners who have specialist knowledge in medical oncology, surgical oncology, radiation oncology, gynaecological oncology, haematology and palliative care. Increasingly, cancer is being managed by multi-disciplinary teams and most of these are found in the 20 or so comprehensive cancer centres in Australia. Most cancer patients, however, are still treated in the community through hospitals and clinics. About 40% of Australians have private health insurance, so these treatments can be administered in public or private clinics and hospitals.
Cancer Treatment in Australia
Despite being the commonest cause of premature loss of life in Australia, cancer rates only eighth in direct health care expenditure: about 2 billion dollars in 1993–94 (3). Australia is unique in the world in spending more on skin cancer than any other cancer. About 5% of the population of almost 20 million Australians have one or more skin lesions removed every year and for about a third of these Australians, or 260 000 persons, the lesion is a non-melanocytic skin cancer (4). This is the penalty we pay for being a white skinned people who have migrated to a country which is much closer to the equator than our native lands. If Australia were superimposed on Europe, then most of our country would lie over the Sahara Desert, so it is no surprise that indigenous Australians (Aboriginals and Torres Strait Islanders) have dark skins. Canberra, our capital city in the south-eastern corner of Australia, is at latitude 35°S; Tokyo is at latitude 35°N.
In Australia in 1900, the cure rate for non-skin cancer was essentially zero. By 1950, the cure rate for all cancers was about 25% and this was all due to surgery. In 1991–98 the 5-year survival after a diagnosis of a potentially fatal cancer in the State of South Australia was 59% and in Queensland 60%; these figures should apply to the whole country (5). Most of this improvement in the cure rate since 1950 has come from radiotherapy, cytotoxic chemotherapy and hormone treatment (6). The revolution in our understanding of cancer biology over the last 25 years has now resulted in thousands of potential new pharmaceutical agents for the control of cancer and scores of these are currently in clinical trials. So, if we about half conquered cancer in the twentieth century, it is difficult to believe that we will not complete the task by the middle of the twenty-first century.
Evidence Based Treatment
In Australia today, the Commonwealth Government funding of health care is increasingly based on the evidence which supports the diagnostic tests and treatments being used. For cancer and many other diseases, this is increasingly achieved through the implementation of clinical practice guidelines, which are developed according to rules and recommendations set down by the NHMRC (7). When guidelines are being developed for treatment, levels of evidence must be assigned to each of the recommendations (Table 1). If there is no empirical evidence, then the guidelines must state that the recommendations are not evidence-based, but based on opinion or consensus. This has been a revolution in my lifetime. When I was a medical student in the 1960s, the highest level of opinion was the opinion of the great man (there weren’t any great women).
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The first NHMRC cancer guidelines published were for the management of early breast cancer and there was a wealth of level 1 and level 2 evidence to support the recommendations being made (8). In contrast, the NHMRC guidelines for the management of melanoma contain many recommendations based on opinion and consensus and the only randomized controlled trials (level 2 evidence) that were available addressed the excision margins and the efficacy of adjuvant and palliative chemotherapy and immunotherapy (9). Currently in Australia, there are nine clinical practice guideline publications for the management of different cancers, of which five have already been endorsed by the NHMRC. The remainder should have been endorsed by the end of 2000. By then most of the common and serious cancers will have had evidence-based guidelines available for their treatment.
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NON-GOVERNMENT FUNDING OF CANCER CONTROL IN AUSTRALIA |
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TOPABSTRACTINTRODUCTIONCANCER INCIDENCE AND MORTALITYGOVERNMENT FUNDING OF CANCER...NON-GOVERNMENT FUNDING OF CANCER...REFERENCES |
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The non-government cancer control organizations are made up of the State and Territory Cancer Councils with their national Australian Cancer Society and additional State and Territory bodies in the form of cancer institutes, cancer foundations and cancer trials groups. The Australian Cancer Society coordinates the activities of the State and Territory Cancer Councils, the Clinical Oncological Society of Australia and Palliative Care Australia, so that national cancer initiatives are developed logically and advocacy to the Federal Government is coordinated and unanimous. Whereas the Commonwealth and State Governments direct most of their expenditure to fund cancer diagnosis, treatment and palliation, the non-government organizations have focused on funding cancer research, cancer prevention, patient support and education services. In addition to the 71 million dollars a year provided for cancer research by governments, the non-government cancer organizations provide another 15 million dollars per year, most of which comes from the Cancer Councils. This means that Australia spends about $85 million a year on cancer research or about 4 dollars per head of population and about $2 billion a year on the diagnosis, treatment and palliation of cancer.
The non-government organizations have been spectacularly successful in some areas of prevention. As described previously, about 70% of Australian males smoked cigarettes in 1950 and by 1999 total adult smoking prevalence had fallen to 22% (10). A large part of that fall came after 1970 when targeted programmes were provided to the public on quitting and prevention of uptake of cigarette smoking, many of which were developed by the Anti-Cancer Council of Victoria. Behaviour change has always been a major activity of the Anti-Cancer Council of Victoria and much of cancer control depends upon changing the behaviour of the general public and health care providers. The most recent reduction in adult cigarette smoking is due to Australia’s National Tobacco Campaign, which was largely developed by behavioural scientists at the Cancer Control Research Institute of the Anti-Cancer Council of Victoria (10).
The impact of cigarette smoking on lung cancer mortality in Australia has been profound. In 1910 about 110 per 100 000 Australian males died of all cancers each year (Fig. 4). If Australian men had not started to smoke cigarettes with the First World War, then this total cancer mortality rate would have remained on a plateau for the whole century. Lung cancer produced a rise in total cancer mortality to 160 per 100 000 Australian males by the 1980s. Thankfully, with current adult male cigarette smoking rates only one-third of what they were in the 1950s, that mortality curve is now falling steeply. However, more than 100 000 Australian men died of cigarette smoking induced lung cancer in the twentieth century, more than have been killed in all the conflicts in which we have ever been engaged.
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Population Cancer Research
The Anti-Cancer Council of Victoria has established the world’s first multi-disciplinary population Cancer Control Research Institute. It consists of research units of behavioural science, epidemiology, clinical trials research and education research. Therefore, it is heavily focused on prevention, early detection and best evidenced-based practice. One of the many unique features of this new cancer research institute is the Victorian Co-operative Oncology Group (VCOG), which consists of 12 sub-speciality committees: Breast, Gastrointestinal, Lung, Gynaecological, Urological, Skin, Neuro-Oncology, Head and Neck, Genetics, Palliative Medicine, Psyco-Oncology and Trials Data Management. Established in 1976, the VCOG now involves more than 350 cancer specialists who meet to design clinical trials, to audit treatment and to provide advice to the Anti-Cancer Council of Victoria and State and Commonwealth Governments. In recent years, cooperative oncology groups, modelled on the VCOG, have been established in most other States.
One of the innovations of the VCOG is the population treatment survey, based on cancer registry data. All persons diagnosed with a particular cancer in a particular period of time have their initial treatment documented. The first of these in Australia was for breast cancer in 1986 in Victoria and this was repeated in Victoria in 1990 and for the whole of Australia for 1995, by scientists from the Centre for Behavioural Research in Cancer in the Anti-Cancer Council of Victoria (11). One or more treatment surveys for 10 different cancers have now been conducted in Victoria and the technique has been adopted by the cancer registries in Western Australia and New South Wales for treatment surveys of breast and colorectal cancer in those States. All of the State registries have collaborated to complete the Australian survey of breast cancer treatment, mentioned above, and a national colorectal cancer treatment survey is currently under way.
A comparison of the Victorian data from the 1986, 1990 and 1995 breast cancer surveys, where the doctors who treated all women newly diagnosed in a 6-month period in each of those years were approached via the Victorian Cancer Registry to complete a questionnaire of the treatment the women had received, is revealing (12). In 1986, 89% of women had complete treatment details obtained and by 1995, this had risen to 97%, attesting to the cooperation of all oncologists. The proportion of women who had a mastectomy versus a lumpectomy fell from 78% in 1986 to 47% in 1995. So for the State of Victoria, we now know that about half of all newly diagnosed women with breast cancer are having a mastectomy and about half are having a lumpectomy. This gives us a measure of how the whole population is being treated, in contrast to data from a comprehensive cancer centre where a select group of patients will be treated by the most advanced means. This may have limited application to the ‘real world’.
These three surveys also reveal that the average number of breast cancer cases treated per surgeon rose from three to seven in that 10-year period and so there is an increasing focus of breast cancer on specialists. In 1986 less than half of women who had a lumpectomy had adjuvant radiotherapy and this improved only by about 15% in 10 years. The evidenced-based guidelines for the management of early breast cancer recommend that all women who have less than mastectomy should receive adjuvant radiotherapy. Therefore, at the whole population level, the women of Victoria are receiving considerably less than best evidenced-based practice. Finally, one would expect that all women who have lymph nodes positive for breast cancer would receive chemotherapy or hormonal therapy and adjuvant drug therapy was used in 82% of such women in 1986. This indicates that best evidenced-based practice had probably been instituted in Victoria by 1986. Hormonal treatment for post menopausal women with breast cancer almost tripled between 1986 to 1995 and would now meet the criteria for best evidenced-based practice. These are all positive changes and, in fact, the 5-year survival after diagnosis of breast cancer increased from 72% to 82% between 1972 and 1995, in our most populous State of New South Wales (13). We are currently ranked second in the world for 5-year survival following treatment for breast cancer, after the white female population of the USA.
Skin Cancer Prevention and Early Detection in Australia
Australia has a very special problem with skin cancer. Non-melanocytic skin cancer has not been registered by our cancer registries, because more than a quarter of a million Australians are diagnosed with such a cancer every year and the numbers would simply overwhelm the registries. There have, however, been three population surveys, done in 1985, 1990 and 1995 (14). These show that non-melanocytic skin cancer incidence is increasing in Australians aged more than 50 years, but falling in Australians aged less than 50 years. This fall has been attributed to a quarter century of strong public health campaigns which have stressed protecting children and adults from the sun. These have been largely run by non-government organizations of which the Anti-Cancer Council of Victoria has been a leader. Epidemiological research has shown that most skin cancers begin in childhood and that childhood sunburn is a critical factor. Therefore, the Anti-Cancer Council of Victoria began a programme entitled Slip (on a T-shirt), Slop (on sunscreen) and Slap (on a hat) in the early 1980s and this was succeeded by SunSmart over the last decade (15). Population measures conducted over summer time in Melbourne (population 3.3 million), the capital city of the State of Victoria (population 4.7 million) have shown that sunburn rates have halved in the last decade. Taken together with data which show that non-melanocytic skin cancer and melanoma incidence is falling in Australians aged less than 50 years, this is good evidence that these sun protection campaigns have had an effect.
Public health messages to ‘get to know your skin’, in order to diagnose melanoma early, began in some States of Australia in the 1950s and have been part of the SunSmart campaign in later years. The early detection of melanoma is almost equivalent to a cure. These public health campaigns have had their effect. More than 75% of invasive melanomas now diagnosed in Australia are less than 1.5 mm in thickness and the overall 5-year survival for melanoma exceeds 90%. Australia is the only country in the world where age standardized mortality rates for melanoma for men and women are now falling (16).
Services for Patients and Their Families
The burden of cancer in Australia in DALYs is high and it is also high when measured by the American Cancer Society criteria of the number of incident cases in a given year, plus the number of deaths in a given year, plus the number of patients diagnosed with cancer in the previous 5 years who are still alive. Using that measure, the burden of cancer in Australia in 1996 was ~300 000 persons. Given that 95% of cancer occurs after the age of 40, most of these Australians would have had a spouse, parents perhaps, brothers and sisters and children. If we assume an average of six close relatives per patient, then about 1.8 million Australians were having a first hand experience of cancer in that year or about 10% of the whole population.
Therefore, support for patients, their families and their carers is a crucial element of cancer control. This has also been an area where non-government agencies have been pre-eminent. There is an Australian telephone number, where for the cost of a local call the caller can contact the cancer information and support service in their own State. In Victoria in 1999, the Anti-Cancer Council of Victoria received over 30 000 calls to its cancer Helpline and the commonest reason to call was for breast cancer. The cancer Helpline operates five days per week and the staff consists of about two-thirds trained counsellors, most of whom are oncology nurses, and about one-third information officers. The telephone answering is hands free and the staff enter details into a database developed for this purpose, so that accurate demographics on the nature of the caller and the calls can be recorded as part of our quality assurance and tailoring the system to meet needs. Calls are all anonymous, unless the caller wishes to have material mailed, faxed or e-mailed to them. This service also provides no-interest loans and small grants to help patients and their families at times of great financial need and together with LaTrobe University, runs a breast cancer support nurse training scheme which has had over 200 graduates. This is a distance learning course and at least two Japanese nurses have graduated.
In conclusion, we are somewhat of an anomaly in Asia: a white population living in a very alien solar environment which has made skin cancer our commonest and most expensive cancer. We share with the developed northern hemisphere countries the outcomes of high calorie, high fat, low vegetable diets, past high cigarette consumption and decreasing exercise rates. So heart disease, obesity, diabetes and a range of cancers which result in part or in whole from these risk factors are common: lung, colorectal, breast and prostate cancers. We are, however, bringing many cancers under control through effective programmes of prevention and early detection. Further, we have one of the highest total population 5-year survival after treatment for cancer in the world. A consistent approach by government and non-government agencies, with comprehensive population measures and effective programmes across the continuum of cancer control, have resulted in Australia being one of the most successful countries in controlling cancer for its citizens.
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FOOTNOTES |
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+ For reprints and all correspondence: Robert C. Burton, Anti-Cancer Council of Victoria, 1 Rathdowne Street, Carlton, Victoria 3053, Australia. E-mail: director@accv.org.au
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REFERENCES |
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TOPABSTRACTINTRODUCTIONCANCER INCIDENCE AND MORTALITYGOVERNMENT FUNDING OF CANCER...NON-GOVERNMENT FUNDING OF CANCER...REFERENCES |
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12 Hill D, White V, Pruden M, Giles G, Collins J. Surgical Management of Breast Cancer in Victoria in 1995. Melbourne: Cancer Control Research Institute, Anti-Cancer Council of Victoria 2000.
13 Supramaniam R, Smith DP, Coates MS, Armstrong BK. Survival from Cancer in New South Wales in 1980 to 1995. Sydney: NSW Cancer Council 1998.
14 Staples M, Marks R, Giles G. Trends in the incidence of non-melanocytic skin cancer (NMSC) treated in Australia 1985–1995: are primary prevention programmes starting to have an effect? Int J Cancer 1998;78:144–8.[Web of Science][Medline]
15 SunSmart Evaluation Studies Number 6: the Anti-Cancer Council of Victoria’s Skin Cancer Control Program 1996/1997 and 1997/1988 and Related Research Evaluation. Melbourne: Anti-Cancer Council of Victoria 1999.
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Giles GG, Armstrong BK, Burton RC, Staples MP, Thursfield VJ. Has mortality from melanoma stopped rising in Australia? Analysis of trends between 1931 and 1994. Br Med J 1996;312:1121–5.
Received September 11, 2000; accepted August 13, 2001.
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