Japanese Journal of Clinical Oncology 32:S43-S51 (2002)
© 2002 Foundation for Promotion of Cancer Research
Developing Areas in Cancer in New Zealand
Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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ABSTRACT |
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 TOP ABSTRACT NEW ZEALAND GENERAL...CANCER OCCURRENCE IN NEW...CANCERS WITH ACTIVE OR...CANCERS WITH ACTIVE PRIMARY...CANCERS WITH PARTICULAR RESEARCH...CANCER STRATEGYAcknowledgmentsREFERENCES |
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New Zealand has a cancer profile similar to those of Western developed countries, with a high rate of melanoma, similar to Australia. Statistics separating the Maori from the non-Maori population, although open to difficulties in interpretation, show higher rates in Maori of liver, stomach, lung and cervix uterine cancer and lower rates of colorectal cancer and of melanoma. Screening and prevention programmes are limited by resource constraints; there is population screening for cervical cancer and breast cancer screening is being developed. Screening for hepatitis B and liver cancer is proposed, despite conflicting scientific opinions, while screening for colorectal cancer is not planned, despite randomized trial evidence of benefit. There is no clear national cancer control programme at present. Investigation of stomach cancer in Maori families had identified a new gene.
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NEW ZEALAND GENERAL CHARACTERISTICS |
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New Zealand is an island between the south Pacific Ocean and the Tasman Sea, which extends from about 33° to 47° of latitude and has a land area of 270 000 km2 and a population of only 3.7 million, giving a population density only 4% of that of Japan. The indigenous population are Maori, of Polynesian origin, who first settled in New Zealand ~1000 years ago and now make up 15% of the population. Pacific Island groups, from Samoa and other islands, constitute 5%, with the other 80% are of predominantly European origin. The legal constitution of New Zealand is based on the Treaty of Waitangi, a treaty between Maori chieftains and Queen Victoria, signed in 1840. This has legal status; public services are obligated to conform to Treaty criteria, which means that all public health services and all research must fulfil specific criteria of cultural appropriateness for the Maori population.
The New Zealand Health System
Until about 10 years ago, New Zealand health services were primarily publicly provided, with a modest user fee at the primary care level, partial payment for prescribed drugs, but free hospital treatment. Government efforts since 1984 have sought to impose market-forces financial controls on health and have included several major restructuring exercises (1–3). These have been aimed primarily at controlling cost and New Zealand costs are currently around 7.7% of GDP, compared with 8.8% in Australia, 7.1% in the UK and 6.9% in Japan. Cost control is primarily by rationing of service availability, with hospitals being paid on a contractual basis for an agreed volume of services, set by a central purchasing agency and related as much to budgetary requirements as to any objective assessment of health needs. Private sector health care has increased considerably in the last decade, currently being 24% of total health expenditure (3). Life expectancy in Japan is currently 77 years for men and 83 for women, compared with 74 and 79 years, respectively, for non-Maori New Zealanders and 68 and 73 years, respectively, for Maori.
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New Zealand has a national cancer registry, operating since 1948, but with a legal requirement for registration introduced from July 1994, because of concerns about the confidentiality issues raised by a voluntary system (4,5). It shows a cancer incidence pattern similar in general to other developed countries such as Australia, the USA, Canada and European countries. In terms of total cases in both genders, the leading sites of cancer incidence are colorectal cancer, prostate cancer, breast cancer, lung cancer and melanoma (Table 1). These latest published data for 1994 include only 6 months of the operation of the revised cancer registry, with a legal requirement to report cases. The change has led to increases in registrations, especially for cancers often diagnosed without a hospital admission, such as melanoma. Later data will probably show an increase in the rank order of melanoma. New Zealand and Australia have the highest rates of melanoma in the world and this is the most specific cancer problem in New Zealand.
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Differences between the Maori and non-Maori population are of particular interest, although the data have to be interpreted cautiously because of difficulties in ethnic definition from different data sources (Table 2). The cancers with markedly higher rates in Maori include cancer of the liver, stomach, lung and cervix uteri, while melanoma and colorectal cancer are much less frequent in Maori.
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Comparisons of New Zealand, Japanese and United States Data
The Cancer Incidence in Five Continents data, 1988–92 (6), have been used to compare cancer incidence in Maori and non-Maori New Zealanders with US data from the SEER registries and from the combined data from the five Japanese registries reporting for this time period (Miyagi, Nagasaki, Osaka, Saga, Yamagata) (Table 3). The most striking difference is in melanoma, where New Zealand non-Maori rates are 80 times higher than Japanese rates in men and 120 times higher in women and twice to three times as high as US rates. Even melanoma in New Zealand Maori is 12 times commoner than that recorded in Japan. A somewhat similar pattern is seen for cancer of the lip, this being the only non-melanoma skin cancer recorded in the registry.
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The incidence of breast cancer in women is about three times higher in New Zealand and in the USA than Japan and, interestingly, a somewhat similar pattern is seen for male breast cancer. The pattern is generally similar for cancers of the endometrium and the ovary. Cancer of the cervix uteri is moderately higher in New Zealand non-Maori than in Japanese, whose rate is similar to that in the SEER Registry, but the rate in New Zealand Maori is considerably higher. This is likely to be related to a lower participation in screening programmes (7).
Cancer of the prostate and also the testis is 4–5 times commoner in New Zealand populations than in Japan, being similar to the US rate for testis, but the US rate for prostate cancer in these data is much higher. The recorded incidence for prostate cancer depends greatly on the use of screening tests such as prostate-specific antigen and perhaps at this time, that was more advanced in the USA than it is in New Zealand. Prostate cancer incidence in New Zealand has risen rapidly in recent years.
For the cancers largely determined by smoking, lung cancer rates are modestly increased in New Zealand non-Maori compared with Japan, but much more increased in New Zealand Maori, whose rates are substantially higher for both men and women than the US rates. For laryngeal cancer, New Zealand rates are generally similar to US rates, although relative to Japan there is a considerable excess of laryngeal cancer in women. The rate recorded in Japanese women is extremely low, one fourteenth of the rate in men, whereas in New Zealand and the USA there is only a moderate male excess. Oral cavity cancer shows similar rates in New Zealand Maori and the USA, with lower rates in New Zealand non-Maori, and a somewhat similar pattern is seen for pharyngeal cancer. For cancers of the bladder and kidney, New Zealand rates are generally higher than Japanese rates, but lower than those reported from the SEER Registry.
Colorectal cancer is of interest. Rates in New Zealand non-Maori are somewhat higher than rates in the US SEER registries. However, rates in New Zealand Maori are somewhat lower and are similar or even slightly reduced in men, compared with colorectal cancer rates in Japan (8,9). Oesophageal cancer has a similar frequency in women in all four countries. In men, there is a substantially higher rate in Japan and lower rates in the USA and in New Zealand non-Maori. The New Zealand Maori have a high rate of oesophageal cancer, which is close to that of Japanese males. Pancreatic cancer is generally rather similar in all four countries.
Stomach cancer is also of interest, as the rates in the USA and in New Zealand non-Maori are similar and are much lower than rates in Japan. Differences in pathology criteria may contribute substantially to this (10). Rates in New Zealand Maori are, however, substantially higher than in New Zealand non-Maori, being intermediate between those rates and the Japanese rates. A somewhat similar pattern is seen for primary liver cancer, which is common in Japan, particularly amongst men, relatively low, although still with a male excess, in the SEER registries and in New Zealand non-Maori, with New Zealand Maori showing intermediate rates in each gender (11).
For cancers of the brain and connective tissue and for the leukaemias and lymphomas, rates in the USA, New Zealand non-Maori and New Zealand Maori are approximately comparable and are higher than the equivalent rates in Japan. These groupings hide considerably heterogeneity, but some of the data may suffer from classification problems if more specific diagnostic groups are used.
Thyroid cancer shows relatively high rates in New Zealand Maori compared with non-Maori and Japan, although the rates are similar to those in the USA.
In summary, there are several cancer sites for which rates in New Zealand are much higher than those in Japan. These are melanoma, other skin cancers, prostate cancer, testicular cancer and breast cancer, all of which have at least a three times higher incidence in New Zealand non-Maori. Cancers with substantially lower incidence rates in New Zealand non-Maori compared with Japan include cancer of the liver, the stomach and the oesophagus in men, although not in women.
If the comparison is made between Japanese rates and New Zealand Maori rates, the main differences are that cancers with substantially higher rates in New Zealand Maori include laryngeal cancer in women, cancer of the endometrium and also of the cervix uteri and lung cancer. The same group of cancers as noted before have substantially lower rates in New Zealand Maori than in Japanese. Of interest is the fact that the cancer showing the greatest excess on comparing New Zealand Maori with Japanese is still melanoma, followed by lip cancer, which would probably reflect non-melanoma skin cancer if it were recorded.
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CANCERS WITH ACTIVE OR PROPOSED SCREENING PROGRAMMES |
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Cervical Cancer
The only universally available screening programme for cancer in New Zealand is Papanicolaou smear screening for cervical cancer. This has a rather unfortunate history in New Zealand, which is relevant as it has had considerable effect on all aspects of the practice of medical care and especially of research. Briefly, from the 1960s through the 1980s, a senior gynaecologist in the country’s leading women’s hospital had concluded that cervical dysplasia was not progressive and undertook to prove this by following women with dysplasia by colposcopy and biopsy, but no definite intervention. He ignored pathological evidence of progression. Several women developed invasive cancer; several died. The story was broken by a pathologist who published data showing progression in these patients in the medical journals (12), but little action resulted until a magazine article in June 1987, ‘The Unfortunate Experiment’, made the issue public. It led to a judicial inquiry in 1987–88 (13), which was a major event in New Zealand news (14). This inquiry has greatly influenced the practice of medicine, and particular research and ethical review procedures, in New Zealand ever since. Many women’s health groups concluded from that experience that the problem with the cervical cytology system was not merely that certain doctors had performed inadequately, (which was the majority view of the medical profession), but that doctors in general could not be trusted with women’s health issues. Because of this, it was argued that the organization of screening services and other women’s health services should be controlled by women, rather than by health professionals. A publicly funded national programme of cervical screening was started only in 1991. Individual written informed consent was required for a woman’s name to be recorded in the screening register after she had had a smear, leading to a low registration rate and difficulties in follow-up and evaluation; ironically, exactly the type of problem which had contributed to the previous debacle. In 1993, after much debate, this was changed to an opt off register, with great improvements (15). By the end of 1995, about 70% of eligible women, aged 20–69 years, were enrolled with the national programme. The coverage ranging from 85% at ages 25–29 years to about 65% at ages 55–59 years (16). As with other programmes, concerns about a decreasing threshold for action in reporting of mildly abnormal smears is of concern, with a high recall and colposcopy rate resulting in part from concerns about medico-legal issues (17). A lower cervical screening rate amongst Maori women continues to be of concern, despite much investment in specific culturally appropriate invitation methods, organized within and by Maori communities. A 1993 study showed that about half of Maori women with invasive cervical cancer had never had a smear (7).
Breast Cancer Screening
Breast cancer screening is currently being introduced nationally in New Zealand and population-based programmes have been operating in two areas of the country, covering 20% of at-risk women, since 1991. Following a review of international research (18), two pilot programmes started in 1991, offering 2-yearly, two-view mammography, read by two radiologists independently, (2 by 2 by 2 screening) for women aged 50–64 years (19). Each project used both fixed mammography units in hospitals and a mobile unit which visited smaller centres. Invitations were sent to women identified from GP’s lists and from the electoral roll. The evaluation was based on performance targets derived from the randomised trials. Acceptability was high: the first round uptake was 76% of the census population (20). The programmes showed a considerably higher than expected cancer detection rate and the detection rate of small invasive tumours compared well with the Swedish two-counties study being taken as a standard of excellence (20). Measures of satisfaction and of process measurements of the services were generally favourable. The costs were favourable in comparison with other programmes, particularly those in Australia (21).
These results were available by early 1994 and a national programme was planned to start in July 1995. However, the responsibility for the breast cancer screening programme then moved from the Ministry of Health to the four newly created Regional Health Authorities. These were set up as health purchasers and under the Commerce Act had to be competitive. Cooperation to determine, for example, service specifications or prices for screening was illegal as a form of anti-competitive practice. The by now quite experienced staff within the Ministry lost their control over the screening programme. This led to further delays (22). In 1998, the four Regional Health Authorities were abolished and a new national body took over and screening providers were contracted by the end of 1998.
The first meta-analysis of available randomized trials on breast cancer screening in younger women was done in New Zealand and showed with about 7 years’ follow-up no mortality benefit in screening younger women, in contrast to a substantial and significant benefit in women over age 50 (23). Therefore, the decision was made to exclude women under 50 from the screening programme. As more data have become available, it is now clear that there is some benefit to women under 50, although this is still lesser and delayed in comparison to the benefits in women over 50 (24–27). The issue is now one of cost benefit, as on recent data the relative benefits expressed by cost per year of life gained are about five times less favourable in women under 50 (28). The programme therefore still is restricted to women over age 50. The upper age limit was also controversial. It was initially set at 64, on the basis of the original review done in 1987. The professional advisory group reviewing more recent data, particularly from the Swedish trials (29), recommended an upper age limit of 69 and permissive screening of women up to age 74 if their family doctor felt that it was justified by their general health status, but this recommendation has not yet been accepted (30).
Colorectal Screening
Colorectal cancer is the most common major cancer in New Zealand, which has one of the highest rates in the world. This is likely to be related to the traditional New Zealand diet, which has a high consumption of meat and of animal fat. Population screening with faecal occult blood tests has been demonstrated to produce an approximately one-third mortality reduction, using a hydrated test with a high positivity rate and intensive investigation. In the American trial, about one-third of subjects tested underwent a colonoscopy at some stage during the 14-year trial (31). The results of this programme have been universally regarded in New Zealand as impossible to implement within the New Zealand health care system and budgets. The results of European trials, using a non-hydrated test with a much lower positivity rate, are much more relevant (32,33).
An expert group of the Ministry of Health has recently concluded, however, that screening for colorectal cancer should not be introduced in New Zealand, even in a pilot form (34). In their judgment, the size of the benefit is insufficient to outweigh the risks and costs and the extra requirement for colonoscopies could not be met by available resources. This conclusion seems unfortunate, given the very high frequency and death rate from colorectal cancer and the evidence of a modest but significant mortality reduction from population-based screening (35); it contrasts with a recent Australian assessment (36). The cost estimates are in general similar to those for breast cancer screening, the hazards of colonoscopy are small compared with the estimated benefit and the report did not consider ways in which the capacity to perform colonoscopies could be increased.
Melanoma
Early detection and screening for melanoma are clearly a high priority (37). Early detection has been pursued primarily through educational programmes to the general public on the warning signs of melanoma and this is a disease for which data on depth of diagnosis are collected nationally by the Cancer Registry. Current data show that 60% of melanomas are diagnosed at 
0.75 mm in depth, which is comparable to the results from Australian and North American programmes, including, for example, the results of self-screening clinics organized in the USA (38). The accuracy of diagnoses and clinical decisions made by primary care doctors in managing suspicious skin lesions is comparable to that of specialist dermatologists and to decisions made by Australian practitioners (39). The general level of both public and professional education in regard to early diagnosis of melanoma is high. Some screening activities, either promoting self-screening or making available free access in formal skin check clinics, have been held over the past several years. However, New Zealand policy is now to discourage these informal skin check clinics, because of concerns about adequacy of follow-up, adequacy of clinical examination under non-ideal circumstances and potential medico-legal reasons. Screening programmes for skin cancer have not been adopted as there is no evidence that either self-screening or doctor screening reduces melanoma mortality, apart from one case-control study which does suggest a benefit (40–42). Proposals to mount either case-control studies or a randomized trial of screening for melanoma within New Zealand have been pursued, but the country is hardly large enough to support a major randomized trial. For that reason, New Zealand investigators have contributed to a proposed randomized trial of a community-based melanoma screening programme which is in the pilot phase of operation in Queensland, Australia.
Hepatitis B and Liver Cancer
A very controversial area is screening for hepatitis B. Hepatitis B is of fairly high prevalence (about 5% for HBsAg) in the north part of New Zealand and particularly amongst Maori and Pacific Island people (43). New Zealand has universal infant immunization against hepatitis B, screening of all pregnant women and pre-immunization screening of older children and adults in high risk groups. An activist pressure group has been arguing strongly for the implementation of screening, partially on the basis that regular screening by serum 
-fetoprotein and ultrasound would lead to the earlier detection of primary liver cancer. The incidence of liver cancer is about 0.5% per year in male hepatitis B carriers over age 40 and is increased in those with cirrhosis (43). Liver cancer incidence is 1.9 per 100 000 in non-Maori New Zealanders, but 11.4 in Maori and 28.2 in Pacific Island people in New Zealand (44). Many experts have recommended against such screening on the basis that there is no good evidence that such screening will reduce mortality from primary liver cancer (43); no randomized trials have been done, although one is in progress in China and one has been planned in Canada. A New Zealand government working party in 1994 failed to reach any consensus on screening for hepatitis B. However, the latest political decision is to support screening for hepatitis B and screening for liver cancer in carriers, as there is considerable political pressure, particularly perhaps because of the ethnic concentration of this disease.
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Smoking
The main preventive focus has been on smoking-related cancers; the most consistent public education regarding smoking, monitoring of smoking and lobbying for government action to reduce it has come from the Cancer Society and other voluntary organizations such as the Heart Foundation, the Asthma Society and Action for Smoking and Health. These groups have emphasized the total mortality burden attributed to smoking, and the very high smoking rates in Maori, particularly in Maori women, which are amongst the highest in the world (45,46). Government actions in regard to smoking have varied considerably. In general, smoking advertising has been banned, but attempts to ban totally tobacco sponsorship of sport, which is a powerful method of advertising, have not been vigorously pursued by the current government and there has been great pressure for major exemptions in regard to international sporting events such as motor racing and yachting. The government public health system does not support health education staff or programmes of smoking reduction in any systematic way, although most schools have health education programmes. The doctors cannot legitimately charge within the public system for risk factor assessment or preventive advice in regard to issues such as smoking. Regular surveys have concentrated primarily on schoolchildren and young adults (47) and have shown increases in smoking in the last few years, particularly amongst females, following considerable decreases over several years earlier. Current survey data show that about 25% of European New Zealanders currently smoke, compared with 33% of Pacific Islanders and 50% of Maori (48). This differential has increased, as there has been a greater reduction in non-Maori smoking rates over the last 20 years than there has been in Maori smoking. Cohort analyses show that smoking prevalence decreases by age within birth cohorts beyond age 30. Total amount smoked has shown greater decreases than smoking prevalence, as the average number of cigarettes per day has fallen from around 25 in 1983 to around 15 in 1995 (48). The decreasing trend in cigarette equivalents per adult has been greater than in the UK or Sweden over that time period. However, trends over the last few years suggest stabilization of overall smoking prevalence in adults and a slight increase in adolescents. The cost of tobacco products has risen about 50% in real terms over the last approximately 8 years and total tax revenues have been approximately constant since 1990.
Sun Exposure
The primary prevention of melanoma and other skin cancer by reductions in excess sun exposure has been the other main educational focus of the Cancer Society for over a decade. This is carried out through public education by the media, encouraging television and radio stations to show ultraviolet index levels or burn times in news and weather forecasts, educational efforts specifically in schools and attempts to get schools to change policies on outdoor exposure and outdoor activities in peak sunshine hours. There have been some major surveys of sun exposure behaviour, but these have not yet been done consistently over a long enough time to assess trends (49). The surveys have in general been based on similar methods to those used in Australia by Hill et al. (50), using telephone interviews of population samples on activities and sun exposure and sunburn during the previous weekend.
Diet and Exercise
In regard to colorectal cancer and also several other cancers, preventive activities would logically relate to health education concerning diet and exercise. Public education and diet have been spearheaded by the Heart Foundation, but joined by the Cancer Society in regard to a prudent diet with reduced animal fat consumption and increased consumption of fruit and vegetables.
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CANCERS WITH PARTICULAR RESEARCH ISSUES |
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In general, there is only a modest amount of primary research on the development of new treatments and approaches to cancer in New Zealand, although the amount of primary research is very reasonable in regard to a population of three million. There are expert groups which have made considerable contributions to new drug development and fundamental carcinogenesis mechanisms, including studies of antioxidants. Clinical research tends to be closely linked to Australia, with active clinical groups involved in collaborative clinical trials, and these in turn are often linked into major groups in North America and Europe.
Genetic Basis for Stomach Cancer
One of the most interesting specifically New Zealand research efforts is the identification of a specific gene for stomach cancer, based on intensive investigation of a Maori family with a very high rate of stomach cancer, in northern New Zealand. Stomach cancer is particularly high in Maori, is higher in men than women in each ethnic group and despite a substantial decline over the last several decades, has a substantial incidence (51). There is only a slight and non-significant excess in lower socioeconomic groups. The high rate in Maori had been linked to possible genetic factors, to unspecified dietary differences and to socioeconomic effects or to smoking (51). In a large Maori kindred in northern New Zealand, an excess rate of gastric cancer has been recognized within the family for many years and was reported in 1964 (52). The recent investigation was initiated by the family members themselves, who took it on themselves to document the family history using their intimate knowledge of family relationships and sought out a laboratory research group to study the issue further. The family history showed an excess of gastric cancer in several generations (28 cases among 98 persons in nine generations) with no clear evidence of an elevated rate of any other cancers. The cancers were usually diffuse (53), producing the thickened stomach described in some older literature as a ‘leather-bottle’ stomach. Most deaths occurred in subjects under age 40, one as young as 14. Blood samples were compared by genetic linkage analysis to a large range of candidate genes suggested by other work and linkage demonstrated to the D16S752 marker on chromosome 16q22.1, which contains the E-cadhedrin gene (54). Linkage to five other markers in the same region was also shown. The linkage was seen in all cases and in all obligate carriers of the gene, in two individuals with colorectal cancer and in a proportion of unaffected individuals. The penetrance was estimated at 70% by age 60. Mutation analysis using the single-stranded conformational polymorphism (SSCP) technique showed a band shift in exon 7 in some subjects and direct sequencing identified a G to T transversion at the last nucleotide. This band shift was not seen in any of 150 unrelated chromosomes. A somatic mutation at this position, being a G to A mutation, had been previously reported in a subject with gastric carcinoma. Germline mutations of the E-cadhedrin gene were also sought in two other families with early onset histologically diffuse gastric cancer and mutations were identified.
This is the first demonstration of E-cadhedrin germline mutations in familial cancer, although somatic mutations had been previously identified in sporadic gastric cancer, lobular breast cancer and in endometrial and ovarian cancer. The E-cadhedrin gene is widely regarded as an invasion suppressor gene and the early accumulation of mutations associated with late events such as invasion and metastasis may explain the unpredictable clinical progression of certain tumour types. The findings suggest a direct role for an intracellular adhesion protein in cancer susceptibility and this gene may also confer inherited susceptibility to other cancers.
Although not apparent in the published report, a major impact of this study has been the collaboration between the family members and a technical laboratory research team in the European tradition (P. Guilford, personal communication). Four members of the Maori community, who worked with the family to document the family history, are co-authors on the report published in Nature (54). The study has been regarded in New Zealand as one of the most successful cross-cultural collaborations. Family members are now currently being tested for the gene susceptibility, after much discussion about the issues involved in such tests. Barium meal screening is being offered to gene positive individuals, although there is no strong evidence from randomized trials of the efficacy of this. The cohesion of the family allowing information to be shared has been a major feature and it will be important to see if this cohesion is maintained when the availability of the genetic test results effectively separates those carrying the gene from those not.
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There is little specific planning for cancer control in New Zealand (55). A national advisory committee on cancer treatment existed in the early 1980s, but was disbanded in 1991 with the health service reorganization and the purchaser–provider split (56). There have been attempts to set up a cancer control programme in New Zealand, but these have not been supported. The nearest thing to a cancer strategy is the policy of the voluntary Cancer Society, which identifies targets and programmes within the areas of prevention, but has a weaker voice in early diagnosis and very little role in the provision or quality control of treatment services. Planning for cancer services in New Zealand has in recent years emphasized the concentration of specialist techniques, such as stereotactic radiotherapy, brachytherapy and bone marrow transplantation, each in one centre. Although reasonably successful, the frequent reorganizations of health service administration raise issues with payment and with transport and support facilities for patients and their families. A major concern is that there is no planned capital replacement programme for major radiotherapy equipment, most of which was replaced in the early 1980s and is now reaching the end of its useful life. There is also a lack of a good programme of drug evaluation; the emphasis on cost reduction has meant that there is little consideration to the funding of new drugs, even where these do suggest considerable therapeutic gains. Clinical guidelines and audit have been developed in certain areas, such as the surgical management of early breast cancer, but have not been vigorously pursued in oncology in general. Health service funding has moved more to a population-based funding, which takes inadequate account of variation in oncology needs, for example, due to different age structures.
There are virtually no data available on the outcome or quality control of cancer treatment in New Zealand. Survival statistics for cancer are not routinely generated and little information is available on follow-up or outcome outside specific clinical studies. A national Cancer Registry has been in existence since 1948 and, until the early 1980s, operated reasonably successfully in documenting cancer incidence, although systematic attempts at monitoring survival were not carried out. In the 1980s, the very high level of concerns about confidentiality, which arose in part from the cervical cancer investigations, made many pathologists cease to report cancers to the Registry, because they feared being accused of breaching patient confidentiality. Lobbying from the Cancer Society resulted in a change in legislation to make registration compulsory (5), and although this has not been enforced on hospitals or pathology laboratories, reporting has increased because the legislation provides protection against threatened confidentiality breaches. As a result, the incidence of most cancers as recorded increased considerably from 1994; melanoma increased by ~40%.
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Acknowledgments |
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This paper was prepared for the 3rd Shizuoka Forum on Health and Longevity, December 1998. I thank Drs D. Perez, S. Costello and P. Guilford for helpful information.
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FOOTNOTES |
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+ For reprints and all correspondence (present address): Mark Elwood, National Cancer Control Initiative, 1 Rathdowne Street, Carlton, Victoria 3053, Australia. E-mail: melwood@ncci.org.au
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Received September 11, 2000; accepted September 18, 2000.
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