Prevention in the oncology setting has traditionally focused on the progression of cancer, recurrence and development of new cancers. Increasingly, the focus has moved to a more holistic view of prevention that pursues prevention of suffering and maintaining quality of life. The cancer treatment team has the opportunity to play an active role in the promotion of healthy lifestyles for patients, and the relatives for whom the patient’s cancer conveys risk. Assisting patients to adhere to ‘non-cancer’ care is important for their mortality and morbidity. Given patient’s reluctance to disclose physical and emotional side-effects they may be experiencing, there is a need for health providers to regularly initiate discussions with their patients about their needs. Similarly, an oncology service that actively seeks to understand patient preferences will be better equipped to provide individualised care. A systems-minded approach to prevention may ensure that cancer care is organised to anticipate and to prevent of poor quality care. As the cancer treatment team will continue to play a more complex role in prevention, they must be supported by organisational factors that facilitate evidence-based practice.
Consumer engagement has blossomed in recent decades into a comprehensive approach not only engaging people in their own care, but also in key health care system improvements at a range of levels including health services, research, governance and policy. These changes parallel international progress in patient based care and culminate in the recognition of the need for consumer partnerships in recent national and state frameworks. Striving to deliver patient-based care means that we need to rise above the ‘disease-based’ model of care. Consumer engagement to improve Australian cancer care has grown to support all aspects of the journey.
Cancer patients face psychological and physical challenges after diagnosis, and can benefit greatly from appropriate psychosocial care. This paper presents a brief history of psychosocial oncology care and recent developments in Australia. Consumers, doctors, nurses, allied health and psychosocial health professionals have all played an important role in this area. Some highlights include: the Australian psychosocial clinical practice guidelines;the development of key patient reported outcome measures; documentation of stress and burnout in oncology health professionals; the development and evaluation of communication resources; a recent focus on survivorship; and a growing body of intervention research which is aiming to be clinically feasible and implementable. The Clinical Oncological Society of Australia hosted the first psycho-oncology professional group in Australia, supporting the development of psychosocial guidelines for adolescents and young adults and undertaking key work in survivorship and rural issues.
Over the last five years there have been tremendous changes in the care of adolescent and young adult cancer patients in Australia, generally accepted as 15-25 years old. There has been recognition that the needs of adolescent and young adults with cancer are different from both adults and younger children, and warrant specialised services. A cancer diagnosis during this period of transition has the potential to significantly impact upon many areas of normal development including physical, psychological, social, sexual, educational and financial domains. Relatively little is known about the basic biology, genetic, epidemiologic, therapeutic and economic factors that affect incidence, disease outcomes and cancer related quality of life in this population. This paper explores the medical and psychosocial needs for these patients and summarises the recent progress of the Youth Cancer program in Australia, which has led to the development of this new subspeciality and the creation of youth cancer services.
It is increasingly evident that inequalities exist for Indigenous people with cancer. Incidence for all cancers combined is similar to or lower than that of non-Indigenous people, but incidence of cancers with a poorer prognosis, such as lung cancer, is higher among Indigenous people, largely due to higher rates of smoking. Indigenous Australians with cancer are diagnosed with more advanced disease and are less likely to receive or complete curative treatment than non-Indigenous Australians. Wide disparities exist in cancer survival between Indigenous and non-Indigenous Australians, particularly in the first year after diagnosis. The need to improve cancer-related health services for Indigenous Australians is apparent, however the available evidence is currently inadequate to effectively direct efforts. For example, despite high cancer mortality rates, there is little information about palliative care services, their models of care or their uptake by Indigenous cancer patients. Through an increased understanding of how cancer affects Indigenous Australians and the establishment of collaborations, in particular the recently funded Centre for Research Excellence DISCOVER-TT, and networks such as the Clinical Oncological Society of Australia, an opportunity for targeted efforts in improving cancer outcomes for Indigenous Australians is tangible.
Cancer is the leading cause of illness in Australia and is a national health priority. Primary care in Australia is well positioned to support individuals diagnosed with cancer and their family/caretakers. However, obstacles exist that impact on the quality and continuity of care that primary care providers and community health professionals can provide. A rapid review of the research available revealed that the knowledge, attitudes and beliefs held by health professionals and patients can impact engagement in early detection, treatment and follow-up care. Health professionals have limited knowledge of evidence-based practices while cancer literacy among minority groups, including Aboriginal Australians, is lower than the population overall. In this paper, we provide a summary of the rapid review of the literature and provide some recommendations based on our research.
Over the past 40 years, the nature and scope of cancer nursing practice has been shaped to a large extent by scientific and medical advances, as well as by social, economic and political factors. Nurses’ role in cancer care has evolved from being predominantly functional and dependent in its approach to being a specialty with clearly defined standards of practice underpinned by a growing evidence base and an agreed set of professional performance capabilities. The unique contribution that nurses make to minimising the effects of cancer on a person’s life and improving the patient experience is now well established and Australian cancer nurses are recognised as leaders in the field internationally. Nurses have achieved improved outcomes for people affected by cancer as part of a multidisciplinary team. By being active participants in the Clinical Oncological Society of Australia for at least 30 of the organisation’s 40 year history, Australian cancer nurses have been provided unique opportunities for professional development and inter-professional collaboration. To meet future challenges in delivering quality cancer care, cancer nurses will need to be full partners with consumers and with other health professionals in redesigning health care systems that are more responsive to changes in social, demographic, scientific and technological contexts.
In parallel with the rapid development of oncology in Australia, palliative and supportive care has evolved rapidly. The sponsorship for such development was largely generated by oncology services in response to unmet needs that were encountered daily. Development of state, territory and national strategies has mirrored the professional development in service delivery, education (of existing practitioners and tomorrow’s clinicians) and research. More recently, national programs are delivering better outcomes for palliative care patients and their families, world-leading clinical research, improved access to essential medications in the community and the ability to access quality evidence to inform practice and policy. These initiatives provide a valuable foundation for continuing to improve access to high quality clinical care wherever people live.
Radiotherapy is a cornerstone of modern integrated cancer care. It combines the real human face of caring for people with cancer with extraordinary science and technology. Its history is rich and our modern specialty of radiation oncology is built on the shoulders of giants, both in technology and biology. It is a highly cost-effective treatment that stands proudly on a large and robust evidence base. Quality radiation treatment can add significantly to the chance of curing many people with cancer and remains an invaluable palliative treatment for others. About half of all cancer patients benefit from having radiotherapy, mostly through improved survival. The specialty and what it can bring to patients continues to evolve apace and the high quality of treatment delivery is critical to its success.
Surgery was the only recognised and available treatment for centuries; until radiotherapy entered the scene. Surgery was a single discipline approach to management underpinned by a sound knowledge of anatomy which has been established for centuries. Surgeons were among the early receptors of multidisciplinary care and were the leading groups in establishing the Clinical Oncological Society of Australia, 40 years ago. Multidisciplinary care frequently involves surgery and has led to cooperation between a range of disciplines of clinicians. This has led to better decision making, more rigorous strategies and improved safety. These factors have increased expectation of all the activities and have seen cancer screening and neoadjuvant therapies and better outcomes. Surgeons are now involved in cancer genetics and preventive surgery. Surgeons and their health care collaborators are helping patients through embracing the multidisciplinary approach espoused by the Clinical Oncological Society of Australia.
Although efforts to encourage presentation with early signs of cancer has had some impact in down-staging disease at diagnosis, notably in breast cancer and melanoma, assertive, physician-initiated screening for cancer in asymptomatic patients has demonstrably resulted in earlier diagnosis, as well as reduced mortality in some cancers. Although systematic population-wide screening programs optimise the population benefit of cancer screening, there is a long lag time to adoption of public screening programs, during which physician vigilance fills the void. Furthermore, some cancers will never achieve the prevalence threshold for mass screening, and in some common cancers clinical context and physician judgement are essential in screenee selection. The potential for early diagnosis through screening is broader than the scope of organised mass public cancer screening. Organised professional groups such as the Clinical Oncological Society of Australia need to develop the evidence base for screening in a range of cancers, and develop guidelines to optimise physician-initiated screening and early detection. Doctors at all levels need to apply risk assessment tools in practice, and be alert to opportunities where screening can benefit their patients.
Breast cancer and its treatment have changed enormously over the last four decades. Most newly diagnosed patients will not die of breast cancer, and the burdens of treatment are substantially less than formerly. Biological understanding of breast cancer has increased at an exponential rate, and has yielded many new therapeutic options. Clinical trials, to which Australian groups have made major contributions, provide the evidence base to utilise these discoveries to provide more effective, less onerous therapies.
The field of prostate cancer treatment and research is finally growing up after many years as the orphan child in oncology. It is sobering to reflect that the first Therapeutic Goods Administration approval of a cytotoxic therapy for metastatic castrate-resistant prostate cancer, docetaxel, occurred less than 10 years ago. No further improvements in the treatment of this condition occurred until the last two to three years. Since then, several new treatments targeting various aspects of prostate cancer biology have shown clinical benefit, including improved survival, and are now entering clinical practice. All of these advances have been made on the basis of better understanding of the unique biology of prostate cancer and its interaction with host tissues and systems. For example, the pivotal role of ongoing signaling through the androgen receptor axis, even in the setting of apparent resistance to manipulation of this pathway, has led to rethinking of long-held dogmas and the development of effective new therapies. Significant advances have also been made in surgical and radiation techniques, and in imaging, that are expected to lead to improved outcomes.
Major advances in the prevention, diagnosis and both curative and palliative management of colorectal cancer have occurred in the past 40 years. Australian clinicians have been at the forefront through involvement in basic, translational and clinical trials research, through the Clinical Oncological Society of Australia and the various cooperative trials groups, including the Australasian Gastrointestinal Trials Group and the Trans Tasman Radiation Oncology Group. The Australasian Gastrointestinal Trials Group has successfully facilitated more than 50 clinical trials across all disciplines and allows national investigators to bring to fruition clinical and translational research questions in an academic environment. The Clinical Oncological Society of Australia’s role in facilitating research, education and multidisciplinary interaction in colorectal cancer has impacted on improving patient care.
Almost untreatable in 1973, except by surgery, lung cancer is now susceptible to radiotherapy and chemotherapy as well and is often treated by all three modalities in combination. Although tobacco is the major cause of lung cancer, specific subtypes of the disease due to mutations unrelated to smoking have been recently identified, and have opened up opportunities for ‘personalised’ therapy. While these developments in treatment have led to a reduction in lung cancer mortality, by far the biggest factor contributing to the declining death rate has been the success of public health campaigns directed at reducing tobacco consumption.
Haematological malignancies have identified the path forward for oncology, initially with systemic treatment and combination chemotherapy and limiting the need for or extent of radiotherapy. In recent years, important targeted therapies were first demonstrated as practical with the first tyrosine kinase inhibitors, the first monoclonal antibodies and the extensive genetic characterisation and classification of these diseases. The genomic era holds the promise of further, more rapid progress, with remaining intractable problems such as poor outcomes overall with acute myeloid leukaemia, both primary and secondary, and possibly new therapy that could avoid the short and long-term side-effects of curative chemotherapy. The extensive sub-classification of leukaemia and lymphoma into smaller sub-sets have made some large scale clinical trials a challenge and may have flagged an emerging obstacle to progress in cancer trials more generally.
Forty years ago the causes, incidence and natural history of melanoma were still poorly understood. Little was known about prognostic factors, and radical surgery was routine for all melanomas. However, dedicated melanoma treatment centres had been established in Sydney and Brisbane and Australians were at the forefront of early epidemiological research into melanoma. Today, the natural history of melanoma is much better understood, and a detailed staging system has been developed. Great prognostic accuracy can now be achieved, based on the histological features of the primary melanoma (particularly Breslow thickness, ulcerative state and mitotic rate), and knowledge of whether or not there is metastatic disease in a ‘sentinel’ lymph node. The extent of surgery is now based on the staging, with 1cm excision margins for ‘thin’ invasive melanomas (≤1mm), and 1-2cm margins for thicker tumours. Sentinel node biopsy is routinely offered for melanomas ≥1mm in thickness, and for thinner melanomas with adverse prognostic features. In recent times, huge advances have been made in the medical management of systemic melanoma metastases, with the introduction of signal pathway inhibitors (BRAF and MEK inhibitors) and effective immunological agents (anti-CTLA4 and anti-PD1 antibodies). In parallel, the roles of surgery and radiation therapy in the treatment of metastatic melanoma have become much better defined. As a result, the importance of multidisciplinary care for all patients with metastatic melanoma has become apparent.
Basic scientific and clinical translational progress in oncology has progressed at an exponential rate over the last 40 years. Much of this progress was germinated in the laboratory, where rigorous scientific dissection of the biological milieu that is neoplasia has been undertaken. Our basic understanding of cancer stems largely from interrogation of this very process, in human tissue samples. In Australia, tumour and tissue banks spawned in the latter half of the last century are now beginning to bear the fruit of scientific and translational discovery, as the critical mass required to definitively crystallise the biological and genetic principles of malignant proliferation has been achieved. This will only continue to be the case if clinicians and scientists alike continue their commitment to development and maintenance of high volume and high quality tissue banks.
A revolution is underway in cancer therapy and care. Now, based on identifying in a patient’s cancer those genetic alterations that drive cancer growth, use of cancer therapy is more targeted and cancer care is more personalised. Many genetic alterations are ‘passenger mutations’ in the oncogenic process, but other ‘driver mutations’ promote cancer growth and survival. These harmful genetic alterations usually result in the production of abnormal proteins such as V600-mutant BRAF in melanoma, or in the overproduction of normal proteins such as HER2 in breast cancer. In drug development, the abnormal or excess proteins are described as ‘druggable targets’, and drugs developed to selectively inhibit the function of these proteins are called ‘targeted therapies’. Since a driver mutation can be found in more than one different type of cancer, an approved and available targeted therapy can make the mutation ‘clinically actionable’. Examples of targeted therapies include the small-molecule drug, vemurafenib, for advanced V600-mutant BRAF melanoma, and the monoclonal antibody, trastuzumab (Herceptin®), for HER2-positive breast cancer. Although targeted therapies are generally considered less toxic than conventional cytotoxic chemotherapy, the toxicities may be problematic and dose limiting. However, careful clinical management of these toxicities can allow patients to continue to receive effective therapy.
Investigator initiated clinical trials are critical to the advancement of cancer care in Australia. Cooperative clinical trials groups in Australia and New Zealand contribute greatly to independent investigator initiated research across a wide spectrum of cancer types and interventions. Achievements of the groups and their contributions to improvement in cancer care over the past 40 years are highlighted. Future challenges in the field of clinical trials are discussed with particular regard to cooperative clinical trials groups.
Cancer is a major health problem in Australia. As such, improving cancer outcomes is a priority. Traditionally, cancer outcomes such as mortality, survival rates and local recurrence rates have dominated clinical decision making. The past several decades has seen a paradigm shift in that there has been an increased emphasis on patient reported outcomes, both in the research arena as well as clinical practice. However, despite the rapidly expanding volume of outcomes research, uptake into clinical practice has been slow. As treatments in oncology often involve complex tradeoffs between survival and functional sequelae, it is important that the patient is involved in clinical decision making. In order to allow patients to make an informed decision, patient reported outcomes need to accompany and complement traditional objective outcomes such as survival and treatment efficacy.