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…

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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?

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► 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