Post on 15-Jul-2020
Assoc Prof Diana Sarfati
Colorectal cancerNew Zealand’s place in the world.
Inequities in outcomes?
Today’s talk…• Mortality
– Internationally– In New Zealand
• Incidence– Trends in New Zealand– Primary prevention
• Survival– Internationally– Unequal outcomes?
• Screening pilot
NZ has high death rates from colorectal cancer4.8
11.0
11.6
14.3
17.1
21.3
16.5
12.7
21.6
18.2
18.3
18.5
17.6
18.0
21.5
17.2
20.2
18.3
20.4
19.5
22.8
23.1
19.9 21.0
19.8
24.3
20.7
27.0
27.0
24.5
34.3
31.0
37.6
5.5
11.1
11.9
12.6 14.0
14.3
14.5
14.8
15.6
16.2
16.3
16.3
16.6
16.8
17.0
17.0
17.8
18.5
18.9
19.2
19.5
20.2
20.6
20.9
21.2
21.4
24.8
25.3
25.5
26.0 2
7.7
33.1
0
5
10
15
20
25
30
35
40
2000 2009Age-standardised rates per 100 000 population
Source: OECD Health Data 2011.
NZ has high death rates from colorectal cancer4.8
11.0
11.6
14.3
17.1
21.3
16.5
12.7
21.6
18.2
18.3
18.5
17.6
18.0
21.5
17.2
20.2
18.3
20.4
19.5
22.8
23.1
19.9 21.0
19.8
24.3
20.7
27.0
27.0
24.5
34.3
31.0
37.6
5.5
11.1
11.9
12.6 14.0
14.3
14.5
14.8
15.6
16.2
16.3
16.3
16.6
16.8
17.0
17.0
17.8
18.5
18.9
19.2
19.5
20.2
20.6
20.9
21.2
21.4
24.8
25.3
25.5
26.0 2
7.7
33.1
0
5
10
15
20
25
30
35
40
2000 2009Age-standardised rates per 100 000 population
Source: OECD Health Data 2011.
In New Zealand…
• Around 3000 CRC every year of which about a third are rectal cancers in New Zealand
• Colorectal cancer is the second highest cause of cancer death in New Zealand
Today’s talk…• Mortality
– Internationally– In New Zealand
• Incidence– Trends in New Zealand– Primary prevention
• Survival– Internationally– Unequal outcomes?
• Screening pilot
Incidence rates of CRC are coming down
Ministry of Health. 2010. Cancer Projections: Incidence 2004–08 to 2014–18. Wellington:
Ministry of Health.
Males Females
Number of cases of CRC are going up
Ministry of Health. 2012. Cancer: New registrations and deaths 2009. Wellington: Ministry
of Health.ealth.
Colorectal cancer: incidence is lower for Maori... But
increasing…
► Point number hdgdhu skjojsd asdsd
► Sdfsd sdfsds lkl;
► Sdasd gh fgdfg dfg d dfgg
Blakely et al. CancerTrends: Trends in Incidence by Ethnic and Socioeconomic Group, New Zealand 1981-2004.
Maori Pacific European/ Other Asian
Primary prevention of CRC
• Strong cohort effects– Early life exposures?
• Dietary factors
• Physical inactivity
• Overweight/ obesity
• Smoking
• Alcohol
• Daily aspirin
Today’s talk…• Mortality
– Internationally– In New Zealand
• Incidence– Trends in New Zealand– Primary prevention
• Survival– Internationally– Unequal outcomes?
• Screening pilot
International comparison:
Five-year relative survival in OECD countries
41.1
49.0
48.1
50.1
45.5
57.0
57.5
54.6
53.3
57.3
60.8
57.9
58.9
57.0
57.1
57.0
59.1
52.6
62.5
67.3
38.6
49.6
52.9
53.3
55.5
55.8
57.4
57.8
59.9
60.4
60.7
61.0
61.8
62.1
63.1
63.1
63.4
63.7
64.5
64.7
66.1
68.0
0 25 50 75 100
Latvia
Czech Republic
Ireland
United Kingdom
Denmark
Slovenia
France
Portugal
Singapore
OECD (16)
Germany
Sweden
Malta
Netherlands
Finland
New Zealand
Austria
Norway
Canada
Korea
United States
Belgium
Iceland
Japan
Age-standardised rates (%)
2004-2009 1997-2002
Survival rates are improving over time…
Excess mortality rate has been reducing by 27% each 10 years since early 1990’s for those
diagnosed with colorectal cancer
Soeberg M, Blakely T, Sarfati D et al (2012). Cancer Trends: Trends in Survival by Ethnic and Socioeconomic
Group, New Zealand 1991–2004. Wellington: University of Otago and Ministry of Health.
Not all good news… (inequities)
Why ethnic inequities in cancer survival?
Health care quality and/or access?
Patient comorbidity?
More aggressive/ advanced tumours?
Ethnic inequities in colon cancer survival
0%
10%
20%
30%
40%
Unadjusted Demographics + Disease
factors
+ Patient
factors
+ Treatment + Health
service access
Risk adjustments
Ex
ce
ss
mo
rta
lity
ris
k (
Ma
ori
/no
n-M
ao
ri)
Comorbidity and treatment/health service factors each accounted for a third of the survival difference.
Hill S, Sarfati D et al. Cancer. 2010: 116; 3205-14.
0
10
20
30
40
50
60
70
80
90
100
Māori non-Māori
Pe
rce
nta
ge
of
co
ho
rt (
sta
ge
III)
Referred to oncologist
Reviewed by oncologist
Offered adjuvant chemo
Received adjuvant chemo
Started within 8 weeks
Hill S, Sarfati D, et al J Epidemiol Comm Health 2010: 64; 117-23
Ethnic inequities in colon cancer survival
Not just colon cancer…
“Māori were four times less likely to receive curative rather than palliative anticancer treatment for nonmetastatic disease compared with Europeans
even after adjusting for age, gender, NZDep, CCI [comorbidity], tumor type, stage and patient declining management. “
Stevens W, Stevens G et al. Ethnic differences in the management of lung
cancer in NZ. J Thoracic Oncol 2008.
Bowel cancer mortality: What’s happening over
time?
► Point number hdgdhu skjojsd asdsd
► Sdfsd sdfsds lkl;
► Sdasd gh fgdfg dfg d dfgg
Shaw C, Blakely T, Sarfati D, et al. Trends in colorectal cancer mortality by ethnicity and socioeconomic position in New
Zealand 1981-1999: One country, many stories. Aust NZ J Public Health. 2006; 30 (1): 64-70.
Today’s talk…• Mortality
– Internationally– In New Zealand
• Incidence– Trends in New Zealand– Primary prevention
• Survival– Internationally– Unequal outcomes?
• Screening pilot
Screening
• Waitemata DHB
• 2 yearly iFOBT for those aged 50-74 years.
How is the pilot programme going?
Participation:
0%
10%
20%
30%
40%
50%
60%
70%
Maori Pacific Asian Other
Participation rate
Desirable rate
Ministry of Health 2013
How is the pilot programme going?
• Around 130 cancers detected to Sept last year
• High detection of advanced adenomas
• Very high acceptance of colonoscopy
How is the pilot programme going?
0
5
10
15
20
25
30
35
40
45
50
1 2 3 4
TNM Stage at diagnosis
Screened diagnoses
Colon Cancer study
Where to from here for bowel cancer?
• Primary prevention
• Screening programme
• Minimum treatment standards
• Data availability