1. Clinical Conjoint Professor UNSW, Department of Medical Oncology, Prince of Wales Hospital, Randwick, NSW Visiting Medical Oncologist, Tamworth Base Hospital NSW.
2. Conjoint Senior Lecturer UNSW, Border Medical Oncology, Albury-Wodonga
It is six years since the Clinical Oncological Society of Australia (COSA) held the first Cancer in the Bush summit in Canberra. This meeting brought together a multidisciplinary group of oncology health professionals and government representatives to discuss rural oncology services. It seemed timely to us to take stock of what has happened since then, by examining some of the key issues that were identified for cancer patients and their carers in regional and rural Australia.
In the Cancer in the Bush report eight issues were identified that needed to be addressed as priorities.1
We have invited a number of authors who have been involved in aspects of rural cancer service delivery to share their understanding. There are many issues common to both metropolitan and regional areas, centred on management of the various malignancies, the ageing population and special interest groups such as adolescent and young adults and rare cancers. These issues, while not unique to rural Australia, are often exacerbated by the tyranny of distance and small patient numbers, as well as limited resources.
Transport, to date, has not been reviewed or addressed in any systematic way. We are therefore very pleased to note that a Senate inquiry will investigate this issue in 2007 and we look forward to a strong government response to what many regard as a chronic, unresolved problem.
Enhancing educational opportunities is also an area not covered in this forum, however several initiatives have been undertaken or are in development. The National Breast Cancer Centre (NBCC) and the Medical Oncology Group of Australia (MOGA) ran a series of workshops in 15 regional centres around Australia, covering issues around adjuvant therapy of breast 2 and bowel cancer.3 Materials from these workshops are available on CD-ROM for use by any centre wishing to hold such workshops from either the NBCC or MOGA. The Federal Government has funded several national projects, currently in late stages of development, that are aimed at up-skilling oncology professionals. The National Education Framework Cancer Nursing project will develop a national framework for cancer nursing, curricula for undergraduate and specialist cancer nursing practice and enhance access to education with online resource materials provided through a consortium of university and hospital partners.4 A web-based project in development by MOGA on palliative cancer treatments underscores additional ways that information technology can overcome issues of access to educational opportunities (Personal communication, K Francis, MOGA).
Cancer Australia is funding the development of continuing professional education modules for cancer professionals, counsellors and general practitioners, managed by the University of Sydney’s Centre for Innovation in Professional Health Education and Research, together with The Cancer Council Australia, COSA, National Breast Cancer Centre and The Royal Australian College of General Practitioners. This initiative will provide a national framework for the delivery of cancer care continuing professional development including: workplace-based, multi-professional packages, targeting skills in a variety of practice environments (including general practice) and; targeted educational resources for practitioner groups in priority areas such as psychosocial assessment and appropriate referral for psychosocial care.5
Epidemiological issues have been examined in more detail since the Cancer in the Bush report. In this issue, Katharine Heathcote and Bruce Armstrong review the evidence for differences in outcomes between rural and metropolitan areas. They review data, some of which they have generated, which shows significant disparities between regional and rural Australia compared to metropolitan areas. They investigated what data there was that might explain this and came up with some important possible answers relating to both service delivery differences and the different levels of service received by minority groups, in particular Indigenous Australians.
Their findings, previously published but overviewed and updated here, make a strong case for more attention on improving services in order to improve outcomes. They also support a call for more health services research, specifically targeted at overcoming regional/rural disparities. Internationally there is paucity of data in this field6 and Heathcote and Armstrong make the practical suggestion of gathering much more specific data, which would require an investment in hospital-based data registries and epidemiologists, as well as researchers, who examine heath service delivery. Lack of investment in clinical data systems and health services research may be putting the national oncology reform agenda at risk. How can we travel the road to reform if we are driving in the dark without headlights?
David Roder provides an in-depth analysis of outcomes data for Indigenous Australians, including a relative increase in the rate of less curable malignancies, more advanced stage at presentation, less treatment and higher co-morbidities. This data adds to reports in other chronic diseases suggesting that a large challenge lies ahead and Roder offers some pathways to follow.
Indeed, both articles point to the importance of enhancing awareness of differences in cultural values and approaches to heath and illness. These need to be recognised and incorporated into health management, with ownership given to the communities. Nationally, while governments are making efforts to improve cancer services, there is a lack of specific programs for regional/rural services and other areas of demonstrated need. In particular, the most deserving group in terms of lack of progress are Indigenous Australians.7
Training, workforce planning and networks are issues that are better understood as a result of a recently completed COSA survey of cancer services in regional and rural Australia. Stephen Begbie and Craig Underhill review the data from the COSA survey showing significant deficiencies in services and training and propose a number of ways of overcoming the problem. In the area of training, they recommend ensuring that rural rotations are a part of oncology training and providing a critical mass of senior staff in each regional centre to allow new graduates to feel encouraged to move. The most successful way of implementing such a strategy would involve establishing regional comprehensive cancer centres, requiring the support of health service management to encourage development of local services. Establishing networks with metropolitan centres could include the enhanced use of novel information technology, such as telemedicine for provision of subspecialties and inclusion in clinical trials and academic activities which can all ensure high quality and peer support.
In addition to recognising these problems, it is important to acknowledge that progress has been made towards solutions. At least three of the priority areas identified at the Cancer in the Bush summit (telehealth initiatives, improved patient support and radiation oncology) are starting to be addressed.
Ian Olver, Louise Shepherd and Sid Selva-Nayagam review the value of telehealth for diagnosis, including both radiology and pathology, and management of patients, especially promoting access to multidisciplinary care. The difficult problem of insufficient psychosocial support is often as much due to lack of personnel as it is a lack of recognition of the need for it. The ability of remote technology to allow patients access to counselling and to enhance the skills of local staff are improvements that local research has demonstrated can work.
Overcoming barriers is the theme of another highly successful project in cancer coordination to address patient needs in perhaps the most difficult exercise – managing a cancer service crossing two state boundaries and through public and private partnership. The Border Cancer Care Coordination Project demonstrated that a willingness to ignore perceived barriers by individual health area management led to improvements in care coordination.8-9 The review by Nicola Melville describes the collaborative approach of a project that delivered seamless cancer care coordination through the support of patients on the one hand and busy clinicians on the other, leading to more multidisciplinary care as well as speedier access to care. It suggests a model that can be used to overcome the systemic issues in rural cancer service delivery, which often is a victim of the overlap and disconnect between state and federal cancer service jurisdictions, and the separation of care between public and private heath systems.
By planning services across all public/private and community/acute facilities, both state and federally funded, the project developed probably the first truly integrated cancer service in Australia. No single facility can solve service delivery problems on its own and adopting a collaborative approach led to efficiency gains for all facilities, improved care for patients and carers and better support for oncology professionals. If we are to continue to have health services delivered by both state and federal governments, improved planning at a local level may help overcome some of the jurisdictional tensions.
Another example of novel approaches to improved service delivery is demonstrated in the report on the Single Machine Radiotherapy Trial by Adam Chapman, Tom Shakespeare and Mary Turner. By ensuring adequate linkages with central service providers, the trial was able to demonstrate dramatic increases in local delivery of radiation services; a staggering 63% increase in numbers of patients receiving radiation in one area. This was not at the expense of adequate quality, as a clinical audit showed the single units exceeding hubs in meeting clinical criteria of quality.
These last two projects, the Border Care Coordination Project and the Single Machine Unit Trial, demonstrate the value in investment in regional cancer services. Not only have they addressed gaps in services and improving access, but in doing so have developed innovative systems that lead the nation in quality clinical service and support service delivery. There are lessons learnt for services everywhere, not just those in the bush.
While some progress has been made, not all of the recommendations of the Cancer in the Bush report have been adequately addressed and much remains to be done. The articles in this issue demonstrate some pathways to follow for solutions. There is a need for political will and leadership from both state and federal authorities to work in partnership to further improve regional and rural cancer services.
2. Dalton L, Luxford K, Boyle F, Goldstein D, Underhill C, Yates P. An educational workshop program for rural nurses and general practitioners to encourage best practice for delivery of systemic adjuvant therapy. J. Cancer Education 2006, Vol. 21, No. 1, Pages 35-39.
3. Medical Oncology Group of Australia. Rural Health Support, Education and Training (RHSET) Program: Training of rural health workers in the management of adjuvant and systemic chemotherapy for colorectal cancer, Final report. [monograph on the Internet]. 2003 Aug [accessed 2007 May 22]. Available from: http://www.moga.org.au/downloads/RHSET_Report.pdf.
5. Cancer Australia [homepage on the Internet]. Australia. Priorities and Programs. [updated 2007 Apr 18, accessed 2007 May 22]. Available from: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/ cancer_australia_priorities_programs.
8. Border Cancer Collaboration. Border Cancer Care Coordination Project, Final Report. [monograph of the Internet]. 2006 Jun. [accessed 2007 May 22]. Available from:
9. Border Cancer Collaboration [homepage on the Internet]. Australia. Border Cancer Care Coordination Project External Review CCORE Michael Barton. 2006 Apr. Available from: