University of Tasmania and Royal Hobart Hospital
* Professor Ray Lowenthal is Director of Medical Oncology at the Royal Hobart Hospital. He was a member of the Board of the Australian Cancer Society/The Cancer Council Australia for eight years, including periods as Vice-President (1998-2001) and President (2001-2004).
Alan Coates was appointed the inaugural Chief Executive Officer of The Cancer Council Australia (then the Australian Cancer Society) in 1998 and has since amassed achievements in the areas of advocacy, alliances and member services. Under his stewardship, The Cancer Council Australia has become recognised as Australia’s peak non-government cancer control organisation, influencing and guiding national cancer control policy and action. His rare combination of intellect, clinical knowledge, leadership, skilful advocacy and diplomacy has greatly contributed to reducing the burden and impact of cancer in Australia.
When in 1998 Professor Alan Coates accepted appointment as the first full-time CEO of the Australian Cancer Society (ACS) – soon to be renamed The Cancer Council Australia – it was a gamble on both parts. The appointment followed a strategic review carried out by the ACS which desired to strengthen the role of the national organisation. Alan came from a background as a respected academic oncologist, but scientific knowledge clearly was going to be only one requirement of a job that would demand skills of many orders. He was untested, for example, in high politics and financial management. Although he had an impressive track record of publication in peer-reviewed technical journals, his output until then had been largely on the theme of cancer management rather than prevention, whereas the latter obviously would be a major focus of a national cancer organisation. And from Alan’s perspective, there must have been concern that the demands of the position would stifle, if not suppress completely, the opportunity to continue to contribute to oncological knowledge through scientific publication.
Fortunately any reservations the appointments committee may have had were quickly quelled. Under Alan’s stewardship, the ACS almost at once became recognised as Australia’s peak non-government cancer control organisation. What had been an efficient and well-run secretariat soon became noticed by the Federal Government and the public as much more. Successive Ministers for Health were soon turning to Alan for authoritative advice. Indeed, the respect accorded him is exemplified by a quote from current minister Tony Abbott, who in 2005 stated that he had made policy decisions in the hope of getting “a better report card from Professor Coates”. By astutely making appointments of staff with the appropriate skills, Alan presided over an organisation that cooperated with its member bodies (the state and territory Cancer Councils) to: greatly increase income from donations, sales and grants; largely unify the organisations by creating a common logo and (mostly) common nomenclature; and effectively address differences or disputations to ensure clear and consistent public communications.
For Alan too this was a ‘win-win’ situation. Despite the demands of the new job, Alan was able to carry on and indeed extend his work with global cancer organisations, including his involvement in international breast cancer trials groups. During the period of his appointment Alan continued to publish prodigiously. In fact, he has been a key author on a number of important recent papers that have advanced the treatment of breast cancer.1,2
None of this came easily. Let’s not pretend otherwise. As in the political sphere, federal-state disagreements sometimes were stark, especially in the early days. There were times when wrangling between Alan’s upstart federal organisation and some of its larger, longer-established state counterparts threatened to break the new entity. But Alan had a vision for the role of a national cancer body and held his ground. In the end all recognised that the greater good would come from collaboration rather than conflict.
The defined mission of the ACS/The Cancer Council was and is “to lead in the development and promotion of national cancer control policy”. This was to be achieved through advocacy, alliances and member services, and these were headings Alan used to report his activities to The Cancer Council Board. (In this context ‘members’ are the state and territory cancer organisations, now mostly known as The Cancer Council of each jurisdiction.) Let us see how his achievements stack up against these yardsticks.
There is an ‘alphabet soup’ of organisations involved in cancer policy in Australia: government, non-government and mixed. A short list includes ACN (Australian Cancer Network), COSA (Clinical Oncological Society of Australia), NCCI (National Cancer Control Initiative), NHPAC (National Health Priorities Action Council), CSG (Cancer Strategies Group) and NBCC (National Breast Cancer Centre). One of Alan’s regular party tricks was to produce a slide purporting to demonstrate the relationship between these organisations. Even after having seen the presentation several times I cannot say that I am much the wiser. That Alan was able effectively to steer his way through this maze and use this knowledge to further the cancer control cause is a triumph of his intellect.
Illustrative of the way in which policy development within The Cancer Council has had a major influence on government has been the area of tobacco control. Australia now leads the OECD in tobacco control, in part through Federal Government reforms over the past eight years initiated through liaison with The Cancer Council. The introduction in March 2006 of stark pictures on tobacco packs illustrating the adverse medical consequences of tobacco use, albeit not as potentially effective as the model The Cancer Council Australia proposed, came about through representations over many years. Of course Alan and The Cancer Council Australia did not achieve this alone, however he spearheaded a grand coalition and was unrelenting in his efforts. As in everything he does, his advocacy was backed by an all-inclusive knowledge of the facts. Constantly he repeated to politicians the unequivocal evidence that if one aims to reduce the impact of cancer, the biggest ‘bang for the buck’ comes from tobacco control. These advocacy efforts are now well and truly bearing fruit.
Arguably the single most influential policy document produced by The Cancer Council Australia and allies is the 2003 publication Optimising Cancer Care in Australia.3 This is a carefully crafted, evidence-based work that has had, and continues to have, considerable sway over the development of government policies at both state and federal levels. There is no other work like it and it proved to be an influential tool in The Cancer Council’s efforts to convince governments of the need for reform to enhance the treatment and care of people affected by cancer in this country. Another publication that has greatly influenced public policy for the better is Cancer in the Bush,4 the report of a conference that was held at The Cancer Council Australia’s initiative. It highlighted the inequities suffered by cancer patients residing in Australia’s rural and remote communities and their need for special assistance was made pointedly self-evident. The specific cancer control needs of Australia’s Indigenous people were brought into the spotlight too, following a 2004 workshop convened by The Cancer Council.
Publication of two revisions (2001-2003 and 2004-2006) of The Cancer Council Australia’s National Cancer Prevention Policy, the only comprehensive guide to effective measures for preventing cancer in Australia, also occurred during Alan’s tenure.
The Australian Cancer Network, an organisation supported by The Cancer Council Australia – which was and continues to be superbly steered by Emeritus Professor Tom Reeve AC CBE – has produced a number of highly influential Clinical Practice Guidelines.5,6 The aim is to guide clinical behaviour to minimise unjustified variability between treatment recommendations arising from different specialists or different geographical locations. Although initially some clinicians were fearful the guidelines would adversely affect their freedom to make decisions in the best interests of their individual patients, in fact the opposite has proved to be the case. Guidelines give the evidence base that underlies optimal clinical decision-making. Overall there is little doubt they have contributed significantly to improving the survival statistics of cancer patients in Australia, which now are among the best in the world. Alan, through his work in this sphere, has shown how a clinician can influence more widespread treatment decisions than just those of oneself and one’s immediate colleagues, to the benefit of thousands of cancer patients.
During his term Alan met a succession of federal Ministers for Health and their opposition counterparts, as well as the health spokespersons for the minor parties, most of them on several occasions. Through Alan’s efforts, this direct advocacy was complemented by representation on many government forums and by influential submissions made to numerous government inquiries. Cancer has become recognised as a National Health Priority Area. Alan proved to have a high degree of political astuteness which had not been apparent in his previous employment, but which met the hopes of those who appointed him. From a clinician’s perspective, the recent decision of the Federal Government – following persistent lobbying – to actively support the independent cancer clinical trials organisations was an enormous step forward. To illustrate Alan’s overall success, one can, perhaps unfairly, concatenate eight years of effort into a single set of figures from 1998 to 2005, in which the Federal Government increased its four-year cancer-specific funding from $8 million to $189 million. Although The Cancer Council did not act alone in bringing about this outcome, its role was crucial. In particular, for the 2004 federal election The Cancer Council produced a policy document, Cancer Priorities: Issues for the Federal Election, the core elements of which were largely adopted by both major parties. The setting up of the new national umbrella organisation Cancer Australia, due to be established in 2006, will be a prime tribute to the success of Alan’s advocacy. For patients and the general public it will spearhead the introduction of many of the outstanding cancer control initiatives for which The Cancer Council has been advocating for years.
Alan’s success in advocacy is underpinned by his experience as a cancer clinician and his encyclopaedic familiarity with the scientific literature – he never makes statements that cannot be supported by evidence, which he can quote chapter and verse. But he also has a knack of being able to explain complex technical points in ways that are understandable by the non-expert; thus he is much in demand by the media. In this role he has greatly enhanced the public profile of the Cancer Councils and their recognition as a trusted, independent source of information. Furthermore, he has shown an understanding of the need to think beyond the scientific – successful advocacy means also facing up to the financial, political and social aspects of policy-making. Although not shying away from making points firmly where he deems this necessary, his overall approach to government has been collaborative rather than antagonistic. Much work never gets public recognition – for example the central behind-the-scenes role of The Cancer Council in the 2003 decision of the Pharmaceutical Benefits Advisory Committee to add a special category of Pharmaceutical Benefits Service listing to palliative care medications that enabled people with cancer to remain at home.
Any advocacy organisation is more effective if it is able to forge alliances with bodies of like mind. Internal contradictions must be avoided at all costs. Thus the first hurdle faced by the new CEO was to gain the confidence of the ACS’s members, the state and territory Cancer Councils, and that of the Clinical Oncological Society of Australia (COSA). With COSA there was never any serious disagreement. As a new player in town though there was certainly initial jostling for position in the relationship with some of the state and territory bodies, but ultimately unity of purpose was achieved within the organisation.
Collaboration with government occurred at many levels. Probably the most significant was that which resulted in the National Cancer Control Initiative, ably headed by Professor Mark Elwood. Alan was an adviser for its establishment and management. He has also chaired the National Cancer Strategies Group, Australia’s only multi-jurisdictional government cancer advisory body, and has contributed significantly to its work.
In influencing government policy, alliances with other non-government bodies are vital. Among many, one could perhaps single out the setting up of the Australian Chronic Disease Alliance as a particularly important step.
Alan has strongly fostered The Cancer Council Australia’s international collaborations including support for the International Union Against Cancer (UICC). He was invited to be among the first signatories to the Charter of Paris Against Cancer, an international charter of cancer control strategies. Our relationship with the American Society of Clinical Oncology, the world’s premier clinical cancer organisation, was strengthened when Alan was elected as the first non-American member of its Board of Directors, a tribute to his international reputation.
All this was done in a way that enhanced rather than subsumed the standing and independence of The Cancer Council. Indeed, the leadership role of The Cancer Council was greatly reinforced by these activities.
In Australia, community cancer organisations commenced separately in each state and federal collaboration came later. This history resulted in each state initially developing its own methods of fundraising. However the state and territory organisations (each being a member of the ACS/The Cancer Council Australia) soon realised that they could gain considerable benefit by coordinating these activities. Indeed, such collaboration was one of the major activities of the ACS prior to the appointment of Alan as its first CEO. Under Alan’s stewardship, such activities have been greatly strengthened, with measurable success. There has been reduction of duplication and conflict, coordination of effort and production of uniform supporting materials for events such as Australia’s Biggest Morning Tea, Daffodil Day, Pink Ribbon Day, and so on. There have been annual increases in fundraising event income, with almost quadrupling of national revenue since 1998, from $7.3 million to $27.3 million in 2005.
These funds underwrite cancer research projects and sustain state and territory prevention, patient support and information services – the vital local face of the Cancer Councils.
A small triumph has been the near uniform national adoption of The Cancer Council brand. In 1998 each state and territory had its own name and logo. The federal body, the Australian Cancer Society, was distinct again. Now there is a national logo – the daffodil – and, with the exception in 2006 of only one state, uniformity in identity. Some organisations with long-established local recognition had understandable reservations about change, but ultimately the greater value of a single Australia-wide outer shell became apparent. Along with this came the evolution of the national organisation from a secretariat to an umbrella body through which interchange of staff and ideas encouraged best national practice. Cohesive, national coordination of The Cancer Council brand has provided a combined dividend worth more than the sum of its parts. Among other benefits is an enhanced capacity to engage national corporate partners, due to a preference to deal with a single national agency, resulting in much increased sponsorship revenue.
In a short article one can select only a few of Alan’s many activities and successes from a very long list. Those who have worked closely with him, as I have, are in awe of his intellect, stamina, perspicacity, determination and resilience (both mental and physical). As the inaugural CEO, he has set a very high bar. His contribution to reducing the burden and impact of cancer in this country will be felt for many years to come.
1. International Breast Cancer Study Group. A randomised trial comparing axillary clearance versus no axillary clearance in older patients with breast cancer: First results of International Breast Cancer Study Group (IBCSG) Trial 10-93. J Clin Oncol. 2006; 24: 337-344.
2. Thurlimann B, Keshaviah A, Coates AS, Mouridsen H, Mauriac L, Forbes JF, et al. Breast International Group (BIG) 1-98Collaborative Group. A comparison of letrozole and tamoxifen in postmenopausal women with early breast cancer. N Engl J Med. 2005; 353:2747-57.
3. Clinical Oncological Society of Australia, The Cancer Council Australia and the National Cancer Control Initiative. 2002. Optimising Cancer Care in Australia. Melbourne: National Cancer Control Initiative.
5. Australian Cancer Network Diagnosis and Management of Lymphoma Guidelines Working Party. Guidelines for the Diagnosis and Management of Lymphoma. The Cancer Council Australia and Australian Cancer Network, Sydney 2005.
6. Australian Cancer Network Colorectal Cancer Guidelines Revision Committee. Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer. The Cancer Council Australia and Australian Cancer Network, Sydney 2005.