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Cancer in the Northern Region of New Zealand Health Needs Assessment - 2009 August 2009 Dr Geeta Gala Public Health Physician Northern Cancer Network Disclaimer Information within the report may be freely used provided the source is acknowledged. Every effort has been made to ensure that the information in this report is correct. Northern Cancer Network and the author will not accept any responsibility for information which is incorrect and where action has been taken as a result of the information in this report. Published in August 2009 By Northern Cancer Network Level 2, 650 Great South Road, Penrose Auckland New Zealand ISBN 978-0-473-15694-7 Suggested citation: Gala G. Cancer in the Northern Region of New Zealand: Health Needs Assessment-2009. Northern Cancer Network; August 2009. 2 Northern Cancer Network’s Health Needs Assessment - 2009 Executive summary This needs assessment will provide an overview of the cancer burden in the Northern Cancer Network (NCN) region and inform the network’s strategic plan. Results from this report may be used to support the strategic, service planning, and research activities of cancer care stakeholders. Data for this report was collated from the National Cancer Registry, National Minimum Dataset, National Mortality Collection Dataset, and Census 2006. Additional data on cancer screening, survival rates, and treatment was sourced from the Ministry of Health. A summary of key points is provided in each chapter of this report. Population demography The Northern Region comprises a population of 1.54 million, representing 37% of the New Zealand population. Waitemata is the largest and Northland, the smallest District Health Board (DHB) in the region. Counties Manukau and Northland DHBs have a higher proportion of children, Maori, and the most deprived population, where as Waitemata DHB has a higher proportion of elderly and the least deprived population. The projected population growth over the next 20 years is highest for the Northern Region (32%), compared to the other regions of New Zealand. The Auckland DHBs in the Northern Region are very ethnically diverse and have a high proportion of New Zealand’s Pacific and Asian populations. Cancer incidence There were 6,028 new registrations of cancer in the Northern Region in 2006. The cancer incidence increased approximately 15% over the ten year period 1996-2006. The age-standardised rate (ASR) for all cancer for the period 2003-2006 was 351 per 100,000 for ‘Other’ ethnicity, 378 per 100,000 for Maori, 333 per 100,000 for Pacific and 200 per 100,000 for Asian ethnicity in the Northern Region; similar to national rates. Cancer incidence increases with age. Less than 1% of total cancer cases were in children less than 15 years. Cancer incidence increases more than seven fold between 15-44 years and 45-64 years age groups, and by three fold between 45-64 years and 65+ years. The leading five female cancer registrations were breast, colorectal, melanoma, lung and uterine cancers in the Northern Region and nationally for the period 2003-2006, accounting for approximately 65% of all female cancers. The leading five male cancer registrations for the same period were prostate, colorectal, melanoma, lung and nonHodgkin’s lymphoma in the Northern Region and nationally, accounting for approximately 65% of all male cancers. Cancer mortality There were 2,378 cancer deaths in the Northern Region in 2005. Cancer deaths have increased approximately 6% over the ten year period 1995-2005. The ASR for all cancer mortality for the period 2003-2006 was 129 per 100,000 for ‘Other’ ethnicity, 219 per 100,000 for Maori, 172 per 100,000 for Pacific and 81 per 100,000 for Asian ethnicity in the Northern Region, almost similar to national rates. Cancer mortality increases with age. Less than 1% of total cancer deaths were in children less than 15 years. Cancer mortality increases more than ten fold between 15-44 years and 45-64 years age groups, and by six fold between 45-64 years and 65+ years. 3 Northern Cancer Network’s Health Needs Assessment - 2009 The leading five fatal female cancers in the Northern Region and nationally for the period 2003-2006 were cancers of the breast, lung, colorectal, ovary and pancreas, accounting for approximately 58% of all cancer deaths. The leading five fatal cancers for men for the same period were cancers of the lung, prostate, colorectal, stomach and non-Hodgkin’s lymphoma in the Northern Region, accounting for approximately 55% of all cancer deaths. The fifth most common male cancer nationally was pancreatic cancer instead of non-Hodgkin’s lymphoma. The leading mortality cancers are a reflection of the incidence and survival of each specific cancer. Although breast cancer was the leading female cancer for both incidence and mortality, the mortality contribution of 17% was significantly lower than the incidence contribution of 28% due to its higher survival rate. In comparison, the proportion of fatal female cancers from lung cancer was 17% compared to 9% for incidence reflecting the low survival rate for this cancer. Melanoma and uterine cancer ranked in the top five cancers for incidence but did not feature in the top five female fatal cancers reflecting high survival rates. The proportion of deaths from prostate cancer for all males in the Northern Region (13%) was lower than the incidence proportion (28%), reflecting high survival rates for this cancer. Lung cancer was the leading cause of cancer deaths (20%), higher than the incidence proportion (10%), reflecting low survival rates for this cancer. The proportion of deaths and incidence for colorectal cancer were similar reflecting a mid level survival rate. Cancer Survival The one and five year relative survival rate (RSR) for all cancer for the period 20022006 were significantly higher for the Northern Region compared to that nationally and the other regions. In fact, cancer survival in the Northern Region was comparable to that in Victoria (Australia) for most major cancers. Among the major cancers, prostate cancer had the highest one and five year RSR followed by cancers of the breast, cervix, colorectal and lung. The five year RSR for lung and prostate cancer was significantly higher for the Northern Region than all other regions and New Zealand for the period 2002-2006. The five year RSR for cervical cancer was significantly lower in the Northern Region when compared to the Southern Region. Cancer treatment The main methods of treatment for cancer are surgery, chemotherapy and radiotherapy. The estimated radiotherapy intervention rate for the Northern Region had increased progressively over the last few years and was approximately 36% in 2006/07, similar to that nationally. However, this was lower than the recommended 46% radiotherapy intervention rate. The radiotherapy waiting time target of less than eight weeks between the first specialist assessment and the start of radiation treatment was generally met in the Northern Region with less than 10% fluctuations. In future, the Network with its tumour stream work could provide more meaningful data on chemotherapy, surgery and other key performance indicators in regards to cancer treatment in future. Cancer screening The national target for breast screening coverage of 70% and cervical screening coverage of 75% is currently not met by any of the Northern Region DHBs. 4 Northern Cancer Network’s Health Needs Assessment - 2009 Ethnic inequalities Ethnic inequalities exist within the Northern Region for cancer screening, cancer incidence, cancer mortality and cancer survival. Maori, Pacific and Asian women had lower rates of screening coverage than ‘Other’ ethnicity for cervical and breast screening. The ranking for and the contribution proportion of the leading five common cancers, for both incidence and mortality varied in the different ethnic groupings. However, the ranking within the ethnic groups was similar for the Northern Region and New Zealand. The ASR for cancer incidence and mortality (all sites) was higher for Maori and lower for Asian people than ‘Other’ ethnicity in the Northern Region, for the period 20022006. While Maori had 12% higher cancer incidence rates compared to non-Maori, the cancer mortality rates were 83% higher than that of non-Maori. Maori had significantly higher incidence rates for cancers of the lung, cervix, stomach, liver, pancreas, testes and multiple myeloma than the non-Maori population. Maori had significantly higher death rates for cancers of the lung, prostate, testes, cervix, ovary, uterus, stomach, liver and pancreas than the non-Maori population. Lung cancer was more prevalent in Maori men and women. Uterine cancer was more prevalent in Pacific women. Cervical cancer was among the leading five female cancers in Maori, Pacific and Asian women in the Northern Region but not so for the ‘Other’ ethnicity. Stomach and liver cancer were more common among Maori, Pacific and Asian men than ‘Other’ ethnicity. Melanoma of the skin featured in the top five cancers for both genders in the ‘Other’ ethnicity but not in the other ethnic groups. While lung cancer was the leading fatal cancer in Maori women, colorectal cancer was the leading fatal cancer for ‘Other’ ethnicity, and breast cancer was the leading fatal cancer in Pacific and Asian women. Colorectal cancer deaths were more prominent in men of ‘Other’ ethnicity and liver cancer deaths in Pacific and Asian men. Deaths from melanoma of the skin ranked in the leading five fatal cancers for men of ‘Other’ ethnicity but this was not the case for other ethnic groups. Nationally, Maori had significantly lower five year RSR than those of Pacific and ‘Other’ ethnicity for cancers of the lung, bowel, and prostate; lower RSR than those of ‘Other’ ethnicity for cancers of breast, cervix and uterus. The five year RSR for ovarian and cervical cancer was lowest in Pacific women, when compared with other ethnicities. Northern Region DHB inequalities Regional inequalities exist between Northern Region DHBs for cancer screening, cancer incidence, cancer outcomes and treatment. Auckland and Counties Manukau had the lower breast and cervical screening coverage when compared to Waitemata and Northland DHB. The cervical screening coverage for Asian women was significantly lower in Auckland DHB compared to other Northern Region DHBs. Northland Maori had higher age-standardised incidence rate for all cancer than that for Maori in other Northern Region DHBs. The age-standardised incidence rate for all cancer was higher in Maori than non-Maori in Counties Manukau and Northland, but not so in Auckland and Waitemata DHBs. Inequalities in lung cancer and testicular cancer incidence were higher (three times) between Maori and non-Maori in Northland and Counties Manukau DHBs. 5 Northern Cancer Network’s Health Needs Assessment - 2009 The age-standardised cancer mortality rates for Maori and total population were significantly higher for Northland and Counties Manukau DHB. Northland had higher age-specific death rates in all age groups for all cancer, compared to other Northern Region DHBs. The age-standardised cancer mortality for all cancer was almost two times higher in Maori than non-Maori in Northland and Counties Manukau but approximately 1.5 times higher in Waitemata and Auckland DHBs. The inequalities in cancer mortality from cancers of the lung, prostate, cervix, uterus and stomach were significantly higher in Northland than in other Northern Region DHBs. Although not statistically significant, Northland and to some extent Counties Manukau had lower five year RSR for most major cancers. Waitemata DHB had significantly lower five year RSR for ovarian cancer, when compared to the Auckland DHB. Some of the inequalities in Northland could be related to the lower radiotherapy intervention rates. Northland has an approximately 27% radiotherapy intervention rate for the year 2006/07 compared to 37% for the other Northern Region DHBs. Summary In regards to cancer, the Northern Region by comparison is similar or slightly better than the national picture. The Northern Region has similar ASR for cancer incidence and deaths as national rates. The relative survival rates for all cancer and major cancers are higher in the Northern Region compared to national rates and are comparable to survival rates in Australia. There are concerns regarding screening coverage, ethnic and regional inequalities. Maori do worse; Pacific people have intermediate cancer incidence, mortality and survival rates compared to ‘Other’ ethnicity. Northland has significant inequalities in regards to cancer prevalence, treatment and outcomes. The regional inequalities in fact may reflect the ethnic inequalities, which are related to the ethnic distribution of population. The Northern Region population is projected to grow significantly in the next 20 years, particularly the elderly population. This has significant implications for cancer service planning. Priority actions for cancer services in the Northern Region over the next 3-5 years are to increase the screening coverage and to reduce ethnic inequalities. 6 Northern Cancer Network’s Health Needs Assessment - 2009 Table of Contents Executive summary ........................................................................................................ 3 List of Figures ................................................................................................................. 9 List of Tables................................................................................................................. 12 Acknowledgments......................................................................................................... 14 Abbreviations ................................................................................................................ 14 1. Chapter One: Introduction and Aims ................................................................ 15 1.1. Introduction .................................................................................................... 15 1.2. Aims ............................................................................................................... 15 1.3. Scope .............................................................................................................. 15 1.4. Methods .......................................................................................................... 15 2. Chapter Two: Population demography.............................................................. 17 2.1. Overall population distribution – 2006........................................................... 17 2.2. Age distribution .............................................................................................. 17 2.3. Gender distribution ......................................................................................... 18 2.4. Ethnicity distribution ...................................................................................... 18 2.5. Deprivation distribution.................................................................................. 19 2.6. Rural/urban distribution.................................................................................. 20 2.7. Population projections .................................................................................... 20 2.8. Key points....................................................................................................... 23 3. Chapter Three: Cancer screening....................................................................... 25 3.1. Overview ........................................................................................................ 25 3.2. Breast cancer screening coverage................................................................... 25 3.3. Cervical cancer screening coverage ............................................................... 27 3.4. Key points....................................................................................................... 30 4. Chapter Four: Cancer incidence......................................................................... 31 4.1. Overview ........................................................................................................ 31 4.2. Cancer incidence by ethnicity ........................................................................ 32 4.3. Cancer incidence by age and gender .............................................................. 33 4.4. Leading cancers .............................................................................................. 34 4.5. Inequalities in cancer incidence...................................................................... 43 4.6. Key points....................................................................................................... 47 5. Chapter Five: Cancer mortality.......................................................................... 49 5.1. Overview ........................................................................................................ 49 5.2. Cancer mortality by ethnicity ......................................................................... 50 5.3. Cancer mortality by age.................................................................................. 51 5.4. Leading fatal cancers ...................................................................................... 52 5.5. Inequalities in cancer mortality ...................................................................... 60 5.6. Key points....................................................................................................... 64 6. Chapter Six: Cancer survival .............................................................................. 67 6.1. Overview ........................................................................................................ 67 6.2. Relative survival rates for all cancer .............................................................. 67 6.3. Relative survival rates by cancer type ............................................................ 68 6.4. Relative survival rate of common cancers by ethnicity.................................. 75 6.5. International comparison of survival of common cancers.............................. 76 6.6. Key points....................................................................................................... 76 7. Chapter Seven: Cancer treatment ...................................................................... 78 7.1. Overview ........................................................................................................ 78 7 Northern Cancer Network’s Health Needs Assessment - 2009 7.2. Radiotherapy................................................................................................... 78 7.3. Radiotherapy waiting times ............................................................................ 79 7.4. Key points....................................................................................................... 80 8. Chapter Eight: Conclusions................................................................................. 80 9. Chapter Nine: References .................................................................................... 81 10. Appendices ........................................................................................................ 83 10.1. World Health Organisation Standard Population ....................................... 83 10.2. ICD -10 AM codes ..................................................................................... 83 10.3. Calculation of radiotherapy intervention rate............................................. 84 10.4. Radiotherapy treatment booking priorities ................................................. 85 8 Northern Cancer Network’s Health Needs Assessment - 2009 List of Figures Figure 1: Population distribution by DHB in 2006 ....................................................................... 17 Figure 2: Population distribution by DHB and ethnicity in 2006 .................................................. 19 Figure 3: Population distribution by DHB and NZDep06............................................................. 19 Figure 4: Projected population growth to 2026 by Northern Region DHBs and New Zealand ... 21 Figure 5: Breast Screen Aotearoa (BSA) coverage of Total women aged 45-69 years by Northern Region DHBs for the 24 months ending June 2008..................................................... 25 Figure 6: Breast Screen Aotearoa (BSA) coverage of Maori women aged 45-69 years by Northern Region DHBs for the 24 months ending June 2008..................................................... 26 Figure 7: Breast Screen Aotearoa (BSA) coverage of Pacific women aged 45-69 years by Northern Region DHBs for the 24 months ending June 2008..................................................... 26 Figure 8: Breast Screen Aotearoa (BSA) coverage of European/Other women aged 45-69 years by Northern Region DHBs for the 24 months ending June 2008................................................ 27 Figure 9: National Cervical Screening Programme (NCSP) coverage of Total women aged 2069 years by DHB for the 36 months ending June 2008 .............................................................. 27 Figure 10: National Cervical Screening Programme (NCSP) coverage of Maori women aged 2069 years by DHB for the 36 months ending June 2008 .............................................................. 28 Figure 11: National Cervical Screening Programme (NCSP) coverage of Pacific women aged 20-69 years by DHB for the 36 months ending June 2008 ......................................................... 28 Figure 12: National Cervical Screening Programme (NCSP) coverage of Asian women aged 2069 years by DHB for the 36 months ending June 2008 .............................................................. 29 Figure 13: National Cervical Screening Programme (NCSP) coverage of European/Other women aged 20-69 years by DHB for the 36 months ending June 2008 ................................... 29 Figure 14: Number of cancer registrations for all cancer, both sexes by DHBs and Northern Cancer Network Region, 1996-2006 ........................................................................................... 31 Figure 15: Age-specific rates for all cancer registrations, both sexes by DHB, NCN and NZ, 2003-2006 ................................................................................................................................... 34 Figure 16: Distribution of cancer registrations in Northern Region by site for females, all age and ethnic groups combined, 2003-2006 ........................................................................................... 35 Figure 17: Distribution of cancer registrations in New Zealand by site for females, all age and ethnic groups combined, 2003-2006 ........................................................................................... 35 Figure 18: Distribution of cancer registrations in Northern Region by site for males, all age and ethnic groups combined, 2003-2006 ........................................................................................... 36 Figure 19: Distribution of cancer registrations in New Zealand by site for males, all age and ethnic groups combined, 2003-2006 ........................................................................................... 37 9 Northern Cancer Network’s Health Needs Assessment - 2009 Figure 20: Most common cancers in Northern Region in less than 15 years, 2003-2006 .......... 38 Figure 21: Most common cancers in Northern Region in 15-44 years, 2003-2006 .................... 38 Figure 22: Most common cancers in Northern Region in 45-64 years, 2003-2006 .................... 39 Figure 23: Most common cancers in Northern Region in 65+ years, 2003-2006 ....................... 39 Figure 24: Cancer deaths from all cancer. Both sexes by DHBs and NCN Region, 1995-2005 49 Figure 25: Age-specific rates for all cancer mortality, both sexes by DHB, NCN and NZ, 20032006............................................................................................................................................. 51 Figure 26: Age-specific rates by ethnicity for all cancer mortality, both sexes, for the Northern Region, 2003-2006 ...................................................................................................................... 52 Figure 27: Distribution of cancer deaths in Northern Region by site for females, all age and ethnic groups combined, 2003-2006 ........................................................................................... 53 Figure 28: Distribution of cancer deaths in New Zealand by site for females, all age and ethnic groups combined, 2003-2006...................................................................................................... 53 Figure 29: Distribution of cancer deaths in Northern Region by site for males, all age and ethnic groups combined, 2003-2006...................................................................................................... 54 Figure 30: Distribution of cancer deaths in New Zealand by site for males, all age and ethnic groups combined, 2003-2006...................................................................................................... 55 Figure 31: Most common fatal cancers in the Northern Region in less than 15 years, 2003-2006 ..................................................................................................................................................... 56 Figure 32: Most common fatal cancers in the Northern Region in 15-44 years, 2003-2006 ...... 56 Figure 33: Most common fatal cancers in the Northern Region in 45-64 years, 2003-2006 ...... 57 Figure 34: Most common fatal cancers in the Northern Region in 65+ years, 2003-2006 ......... 57 Figure 35: Relative survival rates (1 and 5 years) by Regions and New Zealand, 2002-2006... 68 Figure 36: Relative survival rates (1 and 5 years) by cancer site, Northern Region, 2002-2006 68 Figure 37: Five year relative survival rates for breast cancer by Regions and New Zealand, 2002-2006 ................................................................................................................................... 69 Figure 38: Five year relative survival rates for breast cancer by Northern Region DHBs, 20022006............................................................................................................................................. 69 Figure 39: Five year relative survival rates for lung cancer by Regions and New Zealand, 20022006............................................................................................................................................. 70 Figure 40: Five year relative survival rates for lung cancer by Northern Region DHBs, 20022006............................................................................................................................................. 70 Figure 41: Five year relative survival rates for colorectal cancer by Regions and New Zealand, 2002-2006 ................................................................................................................................... 71 Figure 42: Five year relative survival rates for colorectal cancer by Northern Region DHBs, 2002-2006 ................................................................................................................................... 71 10 Northern Cancer Network’s Health Needs Assessment - 2009 Figure 43: Five year relative survival rates for prostate cancer by Regions and New Zealand, 2002-2006 ................................................................................................................................... 72 Figure 44: Five year relative survival rates for prostate cancer by Northern Region DHBs, 20022006............................................................................................................................................. 72 Figure 45: Five year relative survival rates for cervical cancer by Regions and New Zealand, 2002-2006 ................................................................................................................................... 73 Figure 46: Five year relative survival rates for cervical cancer by Northern Region DHBs, 20022006............................................................................................................................................. 73 Figure 47: Five year relative survival rates for uterine cancer by Northern Region DHBs, 20022006............................................................................................................................................. 74 Figure 48: Five year relative survival rates for ovarian cancer by Northern Region DHBs, 20022006............................................................................................................................................. 74 Figure 49: Five year relative survival rates for lung, bowel and prostate cancer by ethnicity, New Zealand, 2002-2006 .................................................................................................................... 75 Figure 50: Five year survival rates of cancers of the ovary, uterus, cervix and breast by ethnicity, New Zealand, 2002-2006 ............................................................................................................ 75 11 Northern Cancer Network’s Health Needs Assessment - 2009 List of Tables Table 1: Population distribution by DHB and age in 2006 .......................................................... 17 Table 2: Population distribution by DHB and gender in 2006 ..................................................... 18 Table 3: Population distribution by DHB and ethnicity in 2006 ................................................... 18 Table 4 : Rural/urban population distribution by DHB in 2006 .................................................... 20 Table 5: Projected total population growth for Northern Region DHBs and New Zealand ......... 20 Table 6: Projected population to 2026 by ethnicity for Northern Region..................................... 21 Table 7: Projected population to 2026 by ethnicity for New Zealand.......................................... 22 Table 8: Projected population to 2026 by ethnicity for ADHB ..................................................... 22 Table 9: Projected population to 2026 by ethnicity for CMDHB.................................................. 22 Table 10: Projected population to 2026 by ethnicity for NDHB................................................... 23 Table 11: Projected population to 2026 by ethnicity for WDHB .................................................. 23 Table 12: Number of cancer registrations for all cancer, both sexes by NCN Region and New Zealand, 1996-2006 .................................................................................................................... 31 Table 13: All cancer registrations, all ages, both sexes by DHB, NCN and NZ, 2003-2006 ...... 32 Table 14: Age-standardised rates for all cancer registrations, all ages, both sexes by DHB, NCN and NZ, 2003-2006, per 100,000 population .............................................................................. 32 Table 15: All cancer registrations, by age groups, both sexes by DHB, NCN and NZ, 2003-2006 ..................................................................................................................................................... 33 Table 16: Leading female cancers by ethnicity for Northern Region, 2003-2006...................... 40 Table 17: Leading female cancers by ethnicity for New Zealand, 2003-2006 ........................... 40 Table 18: Leading male cancers by ethnicity for Northern Region, 2003-2006......................... 41 Table 19: Leading male cancers by ethnicity for New Zealand, 2003-2006 .............................. 41 Table 20: Maori and non-Maori inequalities in cancer registrations by tumour site, 2003- 2006, Northern Region .......................................................................................................................... 43 Table 21: Maori and non-Maori inequalities in cancer registrations by tumour site, 2003-2006, ADHB........................................................................................................................................... 44 Table 22: Maori and non-Maori inequalities in cancer registrations by tumour site, 2003-2006, CMDHB ....................................................................................................................................... 45 Table 23: Maori and non-Maori inequalities in cancer registrations by tumour site, 2003-2006, NDHB .......................................................................................................................................... 46 Table 24: Maori and non-Maori inequalities in cancer registrations by tumour site, 2003-2006, WDHB.......................................................................................................................................... 47 12 Northern Cancer Network’s Health Needs Assessment - 2009 Table 25: All cancer mortality, all ages, both sexes by DHB, NCN and NZ, by ethnicity, 20032006............................................................................................................................................. 50 Table 26: Age-standardised rates for all cancer deaths by ethnicity, by DHB, NCN Region and NZ, 2003-2006, per 100,000 population ..................................................................................... 50 Table 27: Leading female fatal cancers by ethnicity for Northern Region, 2003-2006 .............. 58 Table 28: Leading fatal female cancers by ethnicity for New Zealand, 2003-2006 .................... 58 Table 29: Leading fatal male cancers by ethnicity for Northern Region, 2003-2006 .................. 59 Table 30: Leading fatal male cancers by ethnicity for New Zealand, 2003-2006 ....................... 59 Table 31: Maori and non-Maori inequalities in cancer mortality by tumour site, 2003-2006, Northern Region .......................................................................................................................... 60 Table 32: Maori and non-Maori inequalities in cancer mortality by tumour site, 2003-2006, ADHB........................................................................................................................................... 61 Table 33: Maori and non-Maori inequalities in cancer mortality by tumour site, 2003-2006, CMDHB ....................................................................................................................................... 62 Table 34: Maori and non-Maori inequalities in cancer mortality by tumour site, 2003-2006, NDHB .......................................................................................................................................... 63 Table 35: Maori and non-Maori inequalities in cancer mortality by tumour site, 2003-2006, WDHB.......................................................................................................................................... 64 Table 36: Five year relative survival rate (%) for major cancers by Northern Region, New Zealand, Australia (Victoria) and USA ........................................................................................ 76 Table 37: Estimated radiotherapy treatment intervention rates by Northern Region DHBs and New Zealand, 2004/05 – 2006/07 ............................................................................................... 78 13 Northern Cancer Network’s Health Needs Assessment - 2009 Acknowledgments The report was prepared for Northern Cancer Network and the author would like to acknowledge the invaluable assistance of the following people. Dean Papa, Anrie Weidemann and Keming Wang for providing statistical and analytical support. Simon Bidwell, Vladimir Stevanovic and Amanda Borich from the Ministry of Health for providing various datasets. Dr Gary Jackson for peer reviewing the draft copy of this report. Annette Mortensen and my team for all their support. Abbreviations ADHB Auckland District Health Board ASR Age Standardised Rate BSA Breast Screen Aotearoa CMDHB Counties Manukau District Health Board HNA Health Needs Assessment ICD-10-AM ICD-O International Classification of Diseases, tenth revision, Australian Modification International Classification of Diseases for Oncology NCN Northern Cancer Network NCSP National Cervical Screening Programme NDHB Northland District Health Board NZCR New Zealand Cancer Registry NZDep06 New Zealand Deprivation Score 2006 RSR Relative Survival Rate WDHB Waitemata District Health Board 14 Northern Cancer Network’s Health Needs Assessment - 2009 1. Chapter One: Introduction and Aims 1.1. Introduction The Northern Cancer Network (NCN) is one of four regional cancer networks in New Zealand established to implement the New Zealand Cancer Control Strategy Action Plan 2005-2010.[1] The NCN works across the cancer continuum, providing leadership, facilitation and coordination with cancer control stakeholders to achieve the goals of the Cancer Control Strategy. The NCN region comprises four District Health Boards (DHBs): Auckland, Counties Manukau, Northland and Waitemata. The Health Needs Assessment (HNA) in respect to cancer for the Northern Region is undertaken to inform the Northern Cancer Network Strategic Plan. The report will also assist cancer care stakeholders to identify priorities for their districts or areas, in turn informing their district annual and strategic planning. 1.2. Aims o To inform the NCN Strategic Plan 2009-14 o To provide evidence to make decisions about the priorities in respect to cancer care and control o To provide an interpretation of key results in order to support strategic, service planning and research activities in the Northern Region 1.3. Scope The focus of this report is to inform the strategic plan of the NCN. It is recognised that this HNA does not cover all the data across the cancer continuum. From the Network point of view, the emphasis is on early cancer diagnosis and treatment. Hence the focus has been on the analyses and interpretation of the key findings in cancer diagnosis and treatment. However, this has been limited by the data available. It is recognised that many other analyses would be useful, including cancer prevention, rehabilitation and palliative care. It is hoped that future work will build on the findings of this report. Further, the work of the Networks, the Ministry of Health, and that of the other cancer control stakeholders will improve the availability of data. 1.4. Methods The key data sets used in this HNA are from the New Zealand Cancer Registry, the National Minimum Dataset and the National Mortality Collection Dataset. Population demography information is from the Census 2006. The population projections from 2007 were obtained from Statistics New Zealand and Ministry of Health. The deprivation index is from NZDep06, where 1 represents the least deprived area and 10 the most deprived area.[2] Additional data on cancer screening, survival rates, and treatment are sourced from the Ministry of Health. 15 Northern Cancer Network’s Health Needs Assessment - 2009 The New Zealand Cancer Registry uses the International Statistical Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) Third Edition [3] to classify the site or topography. The International Classification of Diseases for Oncology (ICD-O) Third Edition is used to classify the morphology (histology type and behaviour) of tumours. It is important to note that there were changes to the coding of cancers since 1 January 2003. For some tumour types, particularly haematological, ovarian and bladder cancers, these changes may affect incidence reporting. Polycythaemia vera, myelodysplastic syndromes and chronic myeloproliferative disorders (D45 -D47) are now considered to be malignant and are included in all cancer coding. The cancer incidence and mortality analysis in this HNA includes codes C00 to C96 and D45-D47, excluding non-melanocytic skin cancer (ICD -10 code C44). For the ICD10 codes for specific cancers, refer to Appendix 10.2. Depending upon the codes used and whether changes in code definitions were included, there may be slight variations when data in this report is compared to other reports. The ethnicity data is collected and classified according to the Ministry of Health ethnicity data protocols for the health and disability sector [4] by New Zealand Cancer Registry. In this report, the ethnicity data is based on prioritised ethnicity classification. Each individual is assigned to a single ethnic group using the priority system, in the following order: Maori, Pacific, Asian, European/Other group. Age-standardised rates are calculated using direct standardisation to the WHO standard population in most analyses and expressed as rates per 100,000 populations (Appendix 10.1). The data is often categorised into four age groups for ease of interpretation: 0-14 years, 15-44 years, 45-64 years and 65+ years. The age structure of the population has an important implication for service provision in any given area. Cancer incidence increases with age and older populations generally have a greater demand for services. Data presentation The data in this HNA is presented for the Northern Region and their respective DHBs where possible, and comparisons are made with all New Zealand cancer data. The cancer incidence and mortality data including leading cancers and Maori/non-Maori inequality data is aggregated for 4 years (2003-2006) to increase the numbers and the reliability. Cancer survival data consists of relative survival rates based on period analysis from 2002-2006. Radiotherapy intervention rates are for a three year period from 2004/05 to 2006/07. The breast and cervical screening data are for two and three years respectively ending June 2008. More details are given in the specific chapters. 16 Northern Cancer Network’s Health Needs Assessment - 2009 2. Chapter Two: Population demography 2.1. Overall population distribution – 2006 The 2006 census population for the region is estimated to be 1.54 million (estimated resident population), representing 37% of New Zealand’s population. Waitemata is the largest DHB in the region with a population of 504,710; the smallest DHB is Northland with a population of 152,650. Auckland and Counties Manukau have a population of 428,280 and 454,790 respectively. This population is distributed as follows: Figure 1: Population distribution by DHB in 2006 Population distribution by DHB in 2006 27.8% 32.8% ADHB CMDHB NDHB WDHB 9.9% 29.5% Source: Ministry of Health projections, Statistics New Zealand. The 2006 census population is “estimated usually resident” census population count which is adjusted for undercounts. 2.2. Age distribution Table 1: Population distribution by DHB and age in 2006 DHB 0-14 15-24 25-44 45-64 65+ ADHB 78,950 (18.4%) 71,820 (16.8%) 145,400 (33.9%) 91,690 (21.4%) 40,420 (9.4%) Total (% Northern Region) 428,280 (27.8%) CMDHB 115,500 (25.4%) 70,220 (15.4%) 130,700 (28.7%) 98,530 (21.7%) 39,840 (8.8%) 454,790 (29.5%) NDHB 35,330 (23.1%) 18,360 (12.0%) 36,450 (23.9%) 40,410 (26.5%) 22,100 (14.5%) 152,650 (9.9%) WDHB 107,500 (21.3%) 72,460 (14.4%) 150,360 (29.8%) 119,290 (23.6%) 55,100 (10.9%) NCN 337,280 (21.9%) 232,860 (15.1%) 462,910 (30.1%) 349,920 (22.7%) 157,460 (10.2%) 504,710 (32.8%) 1,540,430 (36.8% of NZ) NZ 888,170 (21.2%) 604,740 (14.5%) 1,181,270 (28.2%) 998,335 (23.9%) 511,580 (12.2%) 4,184,095 Source: Ministry of Health projections, Statistics New Zealand. The 2006 census population is “estimated usually resident” census population count which is adjusted for undercounts. 17 Northern Cancer Network’s Health Needs Assessment - 2009 Age distribution in the Northern Region is very similar to age distribution in New Zealand but there are some variations by DHB. Counties Manukau and Northland have higher proportions of children less than 15 years; Auckland DHB has proportionally more people aged 15-44 years; and Northland has the highest proportion of older people aged 65+ (14.5%). The proportion of older people aged 65+ in the Northern Region is 10.2%. However, Waitemata DHB has the largest number of older people 65+ (approximately 55,000). 2.3. Gender distribution The Northern Region has slightly more females than males (51.0% and 49.0% respectively). Similar distribution is seen in the Northern Region DHBs and New Zealand. Table 2: Population distribution by DHB and gender in 2006 ADHB CMDHB NDHB WDHB NCN NZ Female Percentage 218,680 (51.1%) 232,350 (51.1%) 77,580 (50.8%) 257,740 (51.1%) 786,350 (51.0%) 2,136,125 (51.1%) Male Percentage 209,600 (48.9%) 222,440 (48.9%) 75,070 (49.2%) 246,970 (48.9%) 754,080 (49.0%) 2,047,970 (48.9%) Source: Ministry of Health projections, Statistics New Zealand. The 2006 census population is “estimated usually resident” census population count which is adjusted for undercounts. 2.4. Ethnicity distribution The Northern Region has higher proportions of Pacific (11.9%) and Asian (15.7%) people when compared to New Zealand. Table 3: Population distribution by DHB and ethnicity in 2006 DHB ADHB CMDHB NDHB WDHB NCN NZ Maori Pacific Asian European/Other 34,930 (8.2%) 76,060 (16.7%) 48,040 (31.5%) 48,860 (9.7%) 207,890 (13.5%) 624,280 (14.9%) 51,330 (12.0%) 95,420 (21.0%) 2,270 (1.5%) 34,320 (6.8%) 183,340 (11.9%) 256,865 (6.1%) 97,182 (22.7%) 73,299 (16.1%) 2,031 (1.3%) 69,611 (13.8%) 242,122 (15.7%) 356,066 (8.5%) 244,838 (57.2%) 210,011 (46.2%) 100,309 (65.7%) 351,919 (69.7%) 907,078 (58.9%) 2,946,884 (70.4%) Total (% Northern Region) 428,280 454,790 152,650 504,710 1,540,430 4,184,095 Source: Ministry of Health projections, Statistics New Zealand. The 2006 census population is “estimated usually resident” census population count which is adjusted for undercounts. 18 Northern Cancer Network’s Health Needs Assessment - 2009 Counties Manukau DHB has the largest number of Maori living in the region (76,060) while Northland has the highest proportion of Maori (31.5%). Counties Manukau has both the largest number of and the largest proportion of Pacific peoples. Northland has the lowest number of and the lowest proportion of Asian and Pacific peoples. The four DHBs have diverse ethnic distributions as shown in the figure below: Figure 2: Population distribution by DHB and ethnicity in 2006 Population distribution by DHB & ethnicity in 2006 NZ NCN WDHB NDHB CMDHB ADHB 0 10 20 30 40 Maori Pacific 50 Asian 60 70 80 90 100 European/other 2.5. Deprivation distribution Figure 3: Population distribution by DHB and NZDep06 Population distribution by DHB and NZDep06 decile 9 & 10 160000 40% 140000 Total 9&10 35% 120000 9 & 10% 30% 100000 25% 80000 20% 60000 15% 40000 10% 20000 5% 0 0% ADHB CMDHB NDHB WDHB There are marked differences in population distribution by deprivation across the Northern Region. The deprivation indexes are further grouped into deciles where decile 1 refers to the least deprived area while decile 10 refers to the most deprived areas. Counties Manukau and Northland have the largest proportion of people living in the most deprived areas (34% and 33% in decile 9 & 10). Waitemata has the least proportion of people living in the most deprived areas (8%). 19 Northern Cancer Network’s Health Needs Assessment - 2009 2.6. Rural/urban distribution Approximately 9.2% of the Northern Region population live in rural areas while 90.8% of the population live in urban areas. Except for Northland, the Northern Region is highly urbanised like New Zealand. Northland has a high proportion of people living in rural areas (49%). Auckland has the least proportion of people living in rural areas (0.2%). Table 4 : Rural/urban population distribution by DHB in 2006 ADHB CMDHB NDHB WDHB NCN NZ Rural Percentage 1,005 (0.2%) 31,212 (7.2%) 72,717 (49.0%) 30,498 (6.3%) 135,432 (9.2%) 565,509 (14.0%) Urban Percentage 403,551 (99.8%) 401,841 (92.8%) 75,687 (51.0%) 451,206 (93.7%) 1,332,285 (90.8%) 3,462,636 (86.0%) Source: Statistics New Zealand Area Concordance data 2006 Census. The 2006 census population is “usually resident” census population count which is not adjusted for undercounts. 2.7. Population projections Table 5: Projected total population growth for Northern Region DHBs and New Zealand DHB 2006 2011 2016 2021 2026 % increase 2006-26 ADHB 428,280 464,260 500,980 538,170 574,660 34% CMDHB 454,790 499,590 541,310 583,510 625,930 38% NDHB 152,650 158,620 163,530 167,690 170,960 12% WDHB 504,710 544,600 583,000 621,200 658,940 31% NCN 1,540,430 1,667,070 1,788,820 1,910,570 2,030,490 32% NZ 4,184,095 4,401,460 4,591,035 4,771,395 4,939,850 18% Source: Ministry of Health projections, Statistics New Zealand. The 2006 census population is “estimated usually resident” census population count which is adjusted for undercounts. 2007-2026 growth extrapolated from MoH (2007) medium projection. In comparison to the 18% growth projected for New Zealand in the next 20 years from 2006, the Northern Region’s population is projected to grow by 32% - the largest projected increase of any of the regions in New Zealand. Within the Northern Region, the Auckland Region DHBs are expected to have a growth increase of approximately 31-38% while Northland is expected to have a growth increase of 12%. 20 Northern Cancer Network’s Health Needs Assessment - 2009 Figure 4: Projected population growth to 2026 by Northern Region DHBs and New Zealand % of projected population growth 2006-26 Projected population grow th By Northern Region DHBs & New Zealand 140 0-14 120 15-64 65+ 100 80 60 40 20 0 -20 ADHB CMDHB NDHB WDHB NCN NZ Projections to 2026 by age group indicate that there are increases in population growth in all age groups in the Northern Region DHBs except Northland. By 2026, a decline of 8% is projected for the younger population in Northland. The proportion of the aging population (65+ years) is expected to grow more rapidly than the rest of the population. Counties Manukau is projected to have the largest growth (130%) in the 65+ age population. Population projection by ethnicity The ethnic composition of the Northern Region is likely to become more diverse by 2026 with the increasing proportion of Maori, Pacific and Asian peoples. Similar growth is projected in New Zealand but to a lesser extent than in the Northern Region. Further, the Asian population is projected to increase by 22% in the Northern Region, compared to an increase of 11% for New Zealand. See Table 6 and 7. Table 6: Projected population to 2026 by ethnicity for Northern Region DHB NCN 21 Ethnicity % increase 2006-26 2006 2011 2016 2021 2026 Maori 207,890 225,110 241,620 258,410 275,820 33% Pacific 183,340 204,840 225,790 247,320 269,840 47% Asian 242,122 258,071 271,631 283,782 294,758 22% Other 907,078 979,049 1,049,779 1,121,058 1,190,072 31% Northern Cancer Network’s Health Needs Assessment - 2009 Table 7: Projected population to 2026 by ethnicity for New Zealand DHB New Zealand Ethnicity % increase 2006-26 2006 2011 2016 2021 2026 Maori 624,280 672,220 717,800 763,780 810,730 30% Pacific 256,865 284,310 311,165 338,525 367,100 43% Asian 356,066 372,815 384,944 394,786 403,153 13% Other 2,946,884 3,072,115 3,177,126 3,274,304 3,358,867 14% All the Northern Region DHBs are projected to have an increase in Maori, Pacific and European/other populations. With the exception of Northland, the other Northern Region DHBs are projected to have increases in the Asian population by 2026. CMDHB and NDHB have the highest projected increase in the Maori population, 37% and 26% respectively. Waitemata and CMDHB have a high projected increase in the Pacific population, approximately 63% and 58% respectively. In ADHB the Asian population is projected to increase by 29%, compared to a decrease of 22% in NDHB. See Table 8-11. Table 8: Projected population to 2026 by ethnicity for ADHB DHB ADHB Ethnicity % increase 2006-26 2006 2011 2016 2021 2026 Maori 34,746 36,900 38,470 39,800 40,960 18% Pacific 51,330 53,880 56,200 58,450 60,730 18% Asian 97,182 104,837 111,927 118,677 124,888 29% Other 244,838 268,643 294,383 321,243 348,082 42% Table 9: Projected population to 2026 by ethnicity for CMDHB DHB CMDHB 22 Ethnicity % increase 2006-26 2006 2011 2016 2021 2026 Maori 76,060 83,200 90,000 97,030 104,530 37% Pacific 95,420 108,930 122,230 135,980 150,430 58% Asian 73,299 77,681 81,288 84,475 87,219 19% Other 210,011 229,779 247,792 266,025 283,751 35% Northern Cancer Network’s Health Needs Assessment - 2009 Table 10: Projected population to 2026 by ethnicity for NDHB DHB NDHB Ethnicity % increase 2006-26 2006 2011 2016 2021 2026 Maori 48,040 51,140 54,250 57,450 60,720 26% Pacific 2,270 2,370 2,460 2,550 2,660 17% Asian 2,031 1,944 1,825 1,703 1,584 -22% Other 100,309 103,166 104,995 105,987 105,996 6% Table 11: Projected population to 2026 by ethnicity for WDHB DHB WDHB Ethnicity % increase 2006-26 2006 2011 2016 2021 2026 Maori 48,860 53,870 58,900 64,130 69,610 42% Pacific 34,320 39,660 44,900 50,340 56,020 63% Asian 69,611 73,609 76,591 78,927 81,067 16% Other 351,919 377,461 402,609 427,803 452,243 29% 2.8. Key points o The Northern Region represents 37% of New Zealand’s population. Waitemata is the largest DHB in the region and nationally, o Counties Manukau has a higher proportion of children, the most deprived population and the largest number of Maori, o Northland has a high proportion of children, elderly aged 65+, Maori, and the most deprived population but the numbers are higher in other Northern DHBs, o Waitemata has the lowest proportion of the most deprived population, and the largest number of elderly 65+ population, o Except for Northland, the Northern Region is highly urbanised, o The Northern Region’s population is projected to grow in the next 20 years by 32% - the largest projected increase of any of the regions in New Zealand, o The Auckland DHBs are expected to have 31-38% growth increase, compared to 12% for Northland, o The Northern Region DHBs have positive population growth projections for all ages except for a decline in younger populations (8%) in Northland by 2026. The elderly 65+ population is projected to grow more rapidly than the rest of the population, o 23 The Northern Region is going to be more diverse by 2026 with increasing proportion of Maori, Pacific and Asian populations, Northern Cancer Network’s Health Needs Assessment - 2009 o Waitemata and Counties Manukau DHB will have an increase of 63% and 58% in their Pacific populations, o In Auckland DHB the Asian population is projected to increase by 29%, compared to a decrease of 22% in NDHB, o 24 In the Northern Region the projected increase in the Asian population by 2026 is double than that projected for the New Zealand overall. Northern Cancer Network’s Health Needs Assessment - 2009 3. Chapter Three: Cancer screening 3.1. Overview New Zealand currently has national screening programmes for breast cancer and cervical cancer. Planning for bowel cancer screening is in its early stages. The second goal of the New Zealand Cancer Control Strategy is ‘to ensure effective screening and early detection to reduce cancer incidence and mortality’. [5] Breast Screen Aotearoa (BSA) was established nationally in 1998 to provide free mammograms and follow-up for asymptomatic women aged 50-64 years. In July 2004, the eligible age for publicly funded breast screening was extended to 45-69 years. The current coverage target is two-yearly screening of 70% of eligible women. The programme is delivered throughout the country by lead providers, their sub-contracted providers, and by mobile units that deliver services to rural and some urban communities. The National Cervical Screening programme (NCSP) in New Zealand was established in 1990. The NCSP encourages women between 20 and 70 years of age to have three yearly cervical smear tests. The current coverage target is to screen 75% of eligible women. 3.2. Breast cancer screening coverage The BSA 24-month or 2 year coverage is the number of BSA screened women aged 45-69 years during the 24-month period as a proportion of all eligible women in New Zealand aged 45-69 years (as derived from the 2001 Census population projections for that screening period). The breast screening coverage in Northland for total women (65.4%) exceeded the national average (61.9%) and that for Waitemata DHB (59.4%) was close to the national average. The breast screening coverage for Auckland (49.3%) and Counties Manukau (50.3%) were significantly lower compared to the national average. The national target for breast screening coverage of 70% had not been met by any of the Northern Region DHBs. Figure 5: Breast Screen Aotearoa (BSA) coverage of Total women aged 45-69 years by Northern Region DHBs for the 24 months ending June 2008 Northern DHBs & National Target (70%) 80% Coverage rate 70% 60% 50% 40% 30% 20% 10% 0% Auckland 25 Counties Manukau Northland Waitemata National Northern Cancer Network’s Health Needs Assessment - 2009 Figure 6: Breast Screen Aotearoa (BSA) coverage of Maori women aged 45-69 years by Northern Region DHBs for the 24 months ending June 2008 Northern DHBs & National Target (70%) 80% Coverage rate 70% 60% 50% 40% 30% 20% 10% 0% Auckland Counties Manukau Northland Waitemata National Maori women had significantly lower BSA screening rates compared to European/Other women. While the coverage for ‘Other’ women was between 50-60%, the coverage for Maori women was 40-50% in the Northern Region. The breast screening coverage for Maori women in the Northern Region was comparable to the national average but significantly lower than the national target of 70% coverage. Auckland and Counties Manukau DHB had lower rates of coverage when compared to Northland and Waitemata DHBs. Figure 7: Breast Screen Aotearoa (BSA) coverage of Pacific women aged 45-69 years by Northern Region DHBs for the 24 months ending June 2008 Northern DHBs & National Target (70%) 80% Coverage rate 70% 60% 50% 40% 30% 20% 10% 0% Auckland Counties Manukau Northland Waitemata National The breast screening coverage for Pacific women in the Northern Region was comparable to the national average but generally lower than ‘Other’ women. The high coverage in Northland may be due to skewed results because of the small numbers of Pacific women in the region. 26 Northern Cancer Network’s Health Needs Assessment - 2009 Figure 8: Breast Screen Aotearoa (BSA) coverage of European/Other women aged 45-69 years by Northern Region DHBs for the 24 months ending June 2008 Northern DHBs & National Target (70%) 80% Coverage rate 70% 60% 50% 40% 30% 20% 10% 0% Auckland Counties Manukau Northland Waitemata National There were many inequalities in the breast screening coverage of European/Other women in the Northern Region. The breast screening coverage of 69.2% for Northland was very close to the target of 70% coverage. Waitemata had coverage of 60.3% but the coverage rates for Auckland (49.1%) and for Counties Manukau DHBs (51.7%) were significantly lower than the national average of 64.1%. 3.3. Cervical cancer screening coverage The NCSP 36-month or 3 year coverage is the number of NCSP screened women aged 20-69 years during the 36-month period as a proportion of all eligible women in New Zealand aged 20-69 years (as derived from the 2001 Census population projections for that screening period). All NCSP coverage rates are hysterectomyadjusted. Coverage rate Figure 9: National Cervical Screening Programme (NCSP) coverage of Total women aged 20-69 years by DHB for the 36 months ending June 2008 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% Auckland Counties Manukau Northland Northern DHBs & National 27 Waitemata National Target (75%) Northern Cancer Network’s Health Needs Assessment - 2009 The national target for cervical cancer screening coverage of 75% was not being met by any of the Northern Region DHBs. All the Northern Region DHBs had cervical screening coverage rates that were lower than the national average (72.1%). Auckland (65.5%) and Counties Manukau (66.1%) had significantly lower coverage rates. Coverage rate Figure 10: National Cervical Screening Programme (NCSP) coverage of Maori women aged 20-69 years by DHB for the 36 months ending June 2008 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% Auckland Counties Manukau Northland Northern DHBs & National Waitemata National Target (75%) The Cervical screening coverage in Maori women was significantly lower than that of the European/Other ethnicity. While the coverage for Maori women in the Northern Region ranged between 40-50%, the coverage for ‘Other’ women was between 8087% coverage. Cervical screening coverage for Maori women in Auckland and Waitemata DHB was lower than the national average of 49.7% coverage. Coverage rate Figure 11: National Cervical Screening Programme (NCSP) coverage of Pacific women aged 20-69 years by DHB for the 36 months ending June 2008 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% Auckland Counties Manukau Northland Northern DHBs & National Waitemata National Target (75%) The cervical screening coverage for Pacific women was similar to that of Maori women but significantly lower than of the ‘Other’ ethnicity. All Northern DHBs, except Counties 28 Northern Cancer Network’s Health Needs Assessment - 2009 Manukau DHB had cervical screening coverage rates lower than the national average for Pacific women. Coverage rate Figure 12: National Cervical Screening Programme (NCSP) coverage of Asian women aged 20-69 years by DHB for the 36 months ending June 2008 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% Auckland Counties Manukau Northland Northern DHBs & National Waitemata National Target (75%) The Cervical screening coverage for Asian women, similar to that for Maori and Pacific women in the Northern Region, was significantly lower than that of ‘Other’ ethnicity. Auckland DHB had significantly lower cervical screening coverage rates for Asian women (38.9%) when compared with other Northern Region DHBs. Figure 13: National Cervical Screening Programme (NCSP) coverage of European/Other women aged 20-69 years by DHB for the 36 months ending June 2008 100% Coverage rate 90% 80% 70% 60% 50% 40% 30% Auckland Counties Manukau Northland Northern DHBs & National Waitemata National Target (75%) The cervical screening coverage rates for European/Other women in the Northern Region were significantly higher than the other ethnic groups and reach the national target of 75% coverage. 29 Northern Cancer Network’s Health Needs Assessment - 2009 3.4. Key points 30 o There were significant disparities in breast and cervical screening coverage between different ethnic groups in the Northern Region, o The national target for breast screening coverage of 70% and cervical screening coverage of 75% was not met for total women by any of the Northern Region DHBs, o Auckland and Counties Manukau had significantly lower breast and cervical screening rates when compared to Waitemata and Northland DHBs, o Maori and Pacific women in the Northern Region had lower breast screening coverage rates compared to those of ‘Other’ ethnicity, o Maori, Pacific and Asian women in the Northern Region had lower cervical screening rates when compared to that of ‘Other’ ethnicity, o The cervical screening coverage for European/Other women in all Northern Region DHBs was significantly higher and reached the national target of 75%, o The cervical screening coverage for Asian women in Auckland DHB was significantly lower (38.9%), compared to other Northern DHBs and nationally. Northern Cancer Network’s Health Needs Assessment - 2009 4. Chapter Four: Cancer incidence 4.1. Overview Cancer registrations are used as a measure of cancer incidence. There were 6,028 new registrations of cancer (malignant cancers, C00-C96 & D45-D47) in the Northern Region compared to 19,534 in New Zealand in 2006. The cancer registrations peaked in 2004, slightly decreased in 2005 but showed an upward trend in 2006 across the Northern Region. It should be noted that from 1 January 2005 superficial transitional cell carcinoma of the bladder was no longer coded as invasive cancer [6] and this may account for the decline in cancer registrations in 2005. Figure 14: Number of cancer registrations for all cancer, both sexes by DHBs and Northern Cancer Network Region, 1996-2006 ADHB CMDHB NDHB WDHB NCN 8000 7000 2500 6000 2000 5000 4000 1500 3000 1000 2000 500 noof registrations(NCN) Number of registrations(DHB) 3000 1000 0 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Calendar Year The cancer incidence in the Northern Region has increased approximately 15% over the ten year period from 1996-2006, compared to a 20% increase nationally. However, there were variations among the Northern Region DHBs. While CMDHB and NDHB showed an increase of 24 and 23% respectively, WDHB had an increase of 17% and ADHB had the smallest increase of 3.6%. Table 12: Number of cancer registrations for all cancer, both sexes by NCN Region and New Zealand, 1996-2006 Region 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 199606 ADHB 1,628 1,593 1,568 1,591 1,775 1,666 1,633 1,640 1,748 1,686 1,686 3.6% CMDHB 1,247 1,234 1,307 1,336 1,513 1,444 1,469 1,518 1,662 1,605 1,548 24.1% NDHB 665 712 753 767 787 809 823 813 907 769 817 22.9% WDHB 1,840 1,689 1,732 1,822 1,968 2,049 2,060 2,114 2,177 2,035 2,157 17.2% NCN 5,380 5,228 5,360 5,516 6,043 5,968 5,985 6,085 6,494 6,095 6,208 15.4% 16,332 16,263 16,815 17,362 18,319 18,448 18,476 19,183 19,876 19,435 19,534 19.6% NZ 31 Northern Cancer Network’s Health Needs Assessment - 2009 4.2. Cancer incidence by ethnicity The Northern Region had approximately a third of all cancers in New Zealand, proportionate to the population. The following table shows the number of all cancers for different ethnic groups by Northern Region DHBs and New Zealand for a four year period 2003-2006. Table 13: All cancer registrations, all ages, both sexes by DHB, NCN and NZ, 2003-2006 DHB Maori Pacific European/ Other Asian Total ADHB 306 552 508 5,139 6,505 CMDHB 604 781 391 4,347 6,123 NDHB 587 14 14 2,568 3,183 WDHB 343 281 352 7,206 8,182 NCN region 1,840 1,628 1,265 19,260 23,993 NZ 5,724 2,147 1,858 65,168 74,897 All cancer age-standardised rates (ASR) across the Northern Region were generally similar to the national rates for the all ethnic groups during the period 2004-2006. The ASR for all cancer for the Maori population was higher than the Other/European population both in the Northern Region and nationally. In contrast, the ASR rates for all cancer for the Asian population were significantly lower than the other ethnic groups both in the Northern Region and nationally. Table 14: Age-standardised rates for all cancer registrations, all ages, both sexes by DHB, NCN and NZ, 2003-2006, per 100,000 population DHB Maori Pacific European/ Other Asian Total ADHB 346 360 195 369 341 CMDHB 378 341 191 343 328 NDHB 403 * * 352 356 WDHB 346 345 191 348 334 NCN region 375 345 194 353 337 NZ 378 333 200 351 344 • Rates not represented for groups with small numbers. Age-standardised to the WHO standard population. 32 Northern Cancer Network’s Health Needs Assessment - 2009 The ASR for all cancer for Maori was similar in the Northern Region and nationally. However, the ASR for Maori for all cancer was highest in Northland, approximately 403 per 100,000 population. 4.3. Cancer incidence by age and gender Cancer risk increases with age. During the time period 2003-2006, there were 192 cancers diagnosed in children (under 15 years), less than 1% of total cancer cases in the Northern Region. The numbers of cancer registrations for people aged 15-44 years were 2,563 (11%), for 45-64 years were 8,602 (36%) and 65+ years were 12,636 (53%) respectively. In general, males had a greater incidence of cancer compared to females, but the difference between genders in the Northern Region for total cancer during the time period 2003-2006 was much less. The cancer incidence was significantly higher in females aged 15-44 years than in males across the Northern Region and nationally. In contrast, males aged 65+ years had significantly higher rates than females. Table 15: All cancer registrations, by age groups, both sexes by DHB, NCN and NZ, 2003-2006 Age & gender 0-14 yrs 15-44 yrs 45-64 yrs 65+ yrs Total ADHB CMDHB NDHB WDHB NCN NZ F 24 24 8 26 82 251 M 25 40 13 32 110 249 T 49 64 21 58 192 500 F 528 413 152 540 1,633 4,162 M 275 257 94 304 930 2,502 T 803 670 246 844 2,563 6,664 F 1,154 1,177 538 1,474 4,343 12,869 M 1,155 1,139 557 1,408 4,259 12,396 T 2,309 2,316 1,095 2,882 8,602 25,265 F 1,509 1,312 733 1,910 5,464 18,381 M 1,835 1,761 1,088 2,488 7,172 24,087 T 3,344 3,073 1,821 4,398 12,636 42,468 F 3,215 2,926 1,431 3,950 11,522 35,663 M 3,290 3,197 1,752 4,232 12,471 39,234 T 6,505 6,123 3,183 8,182 23,993 74,897 During the period 2003-2006, age-specific rates for all cancer in the Northern region was 15 per 100,000 for the less than 15 years age group, 98 per 100,000 for the 15-44 years age group, 680 per 100,000 for the 45-64 years age group and 2,144 per 100,000 for the 65+ years age group. The age-specific rates for all cancer increased approximately seven fold between the 15-44 years and 45-64 years age group, and three fold between the 45-64 years and 33 Northern Cancer Network’s Health Needs Assessment - 2009 65+ years age group. A similar trend was seen across the Northern Region DHBs and nationally as shown in the Figure 15. Figure 15: Age-specific rates for all cancer registrations, both sexes by DHB, NCN and NZ, 2003-2006 ADHB CMDHB NDHB WDHB NCN NZ Age specific rate per 100,000 2,500 2,000 1,500 1,000 500 0 0-14yrs 15-44yrs 45-64yrs 65+yrs Age group 4.4. Leading cancers The following section outlines the leading types of cancer in the Northern Region and nationally. Common cancers are discussed for different age groups and ethnicities for the combined period 2003-2006. The results are presented for both genders and comparisons are made between the Northern Region and New Zealand. There were a total of 11,522 female cancer registrations during the period 2003-2006. The most common cancer was breast cancer (3,210 cases), which made up approximately 28% of all cancers and had almost double the number of cases of the second most common cancer, colorectal cancer (1,564 cases, 14%). The next three most common cancers were melanoma of the skin (1,170 cases), lung cancer (1,015 cases) and uterine cancer (505 cases). The top five cancers accounted for over 65% of all cancers. There were a total of 35,663 female cancer registrations nationally during the period 2003-2006. Breast cancer (9,679 cases, 27%), colorectal cancer (5,411 cases, 15%), melanoma of skin (3,674 cases, 10%), lung cancer (3,027 cases, 9%) and uterine cancer (1,416 cases, 4%) were the five most common cancers in females nationally, similar to that in the Northern Region. Figures 16 and 17 show rankings of cancers in females for the Northern Region and New Zealand during the period 2003-2006: 34 Northern Cancer Network’s Health Needs Assessment - 2009 Figure 16: Distribution of cancer registrations in Northern Region by site for females, all age and ethnic groups combined, 2003-2006 Northern Re gion, Cancer Re gistrations Females 2003-2006 Breast Lung Colorectal Unknown Site Ovary Pancreas Other Stomach Non-Hodgkins Lymphomas Leukaemia Liver, biliary tract Melanoma Eye, Brain, CNS Uterus Myeloma Oesophagus Cervix Bladder Myeloproliferate Kidney Lip & Oral Thyroid & Endocrine Small Intestine Hodgkins 0 100 200 300 400 500 600 700 800 900 Figure 17: Distribution of cancer registrations in New Zealand by site for females, all age and ethnic groups combined, 2003-2006 National, Cancer Registrations Females 2003-2006 Breast Colorectal Melanoma Lung Uterus Non-Hodgkins Lymphomas Other Leukaemia Ovary Unknown Site Myeloproliferate Pancreas Cervix Thyroid & Endocrine Stomach Kidney Eye, Brain, CNS Liver, biliary tract Bladder Myeloma Lip & Oral Oesophagus Hodgkins Small Intestine 0 35 2000 4000 6000 8000 10000 Northern Cancer Network’s Health Needs Assessment - 2009 12000 There were a total of 12,471 male cancer registrations in the Northern Region during the period 2003-2006 (See Figure 18). The most common cancer was prostate cancer (3,344 cases), which made up approximately 27% of all cancers and more than double the number of cases of the second most common cancer, colorectal cancer (1,566 cases, 13%). The next three most common cancers were melanoma of the skin (1,385 cases), lung cancer (1,253 cases) and non-Hodgkin’s lymphoma (498 cases). The top five cancers accounted for approximately 65% of all cancers. The following figure shows the ranking of other cancers according to the number of cases. Figure 18: Distribution of cancer registrations in Northern Region by site for males, all age and ethnic groups combined, 2003-2006 Northern Region, Cancer Registrations Males 2003-2006 Lung Prostate Colorectal Other Unknown Site Stomach Non-Hodgkins Lymphomas Liver, biliary tract Eye, Brain, CNS Leukaemia Melanoma Pancreas Bladder Oesophagus Lip & Oral Kidney Myeloma Myeloproliferate Small Intestine Testis Thyroid & Endocrine Hodgkins 0 200 400 600 800 1000 1200 There were a total of 39,234 male cancer registrations nationally during the period 2003-2006 (See Figure 19). Prostate cancer (10,356 cases, 26%), colorectal cancer (5,548 cases, 14%), melanoma of skin (4,062 cases, 11%), lung cancer (3,994 cases, 10%) and non-Hodgkin’s cancer (1,469 cases, 4%) were the five most common cancers in males nationally, similar to that of the Northern Region. The following figure shows rankings of other cancers according to the number of cases. 36 Northern Cancer Network’s Health Needs Assessment - 2009 Figure 19: Distribution of cancer registrations in New Zealand by site for males, all age and ethnic groups combined, 2003-2006 National, Cancer Registrations Males 2003-2006 Prostate Colorectal Melanoma Lung Other Non-Hodgkins Lymphomas Leukaemia Bladder Myeloproliferate Kidney Unknown Site Stomach Lip & Oral Eye, Brain, CNS Pancreas Liver, biliary tract Oesophagus Testis Myeloma Thyroid & Endocrine Hodgkins Small Intestine 0 37 2000 4000 6000 8000 10000 Northern Cancer Network’s Health Needs Assessment - 2009 12000 Common cancers by age and gender The following figures show the ranking of cancer sites according to the numbers of new cases by age and gender during the period 2003-2006. Figure 20: Most common cancers in Northern Region in less than 15 years, 20032006 Fem ales 0-14 years Males 0-14 years Leukaemia Leukaemia CNS CNS Kidney Non Hodgkins Lymphoma Bone Bone Non Hodgkins Lymphoma Kidney 0 5 10 15 20 25 30 0 10 Number of cases • 20 Number of cases 30 40 Leukaemia, cancers of the central nervous system, kidney, bone and nonHodgkin’s lymphoma were the most common malignancies in children aged 014 years. Figure 21: Most common cancers in Northern Region in 15-44 years, 2003-2006 Females 15-44 years Males 15-44 years Melanoma Breast Testis Melanoma Cervix Non Hodgkins Lymphoma Throid Colrectal Colorectal CNS 0 38 100 200 300 400 Number of cases 500 600 0 50 100 150 200 Number of cases • Breast, melanoma of the skin, cervical, thyroid and colorectal cancers were the most common cancers in females aged 15-44 years, • Melanoma of the skin, followed by testicular cancer, non-Hodgkin’s lymphoma, colorectal and central nervous system cancers were the most common cancers in males aged 15-44 years. Northern Cancer Network’s Health Needs Assessment - 2009 Figure 22: Most common cancers in Northern Region in 45-64 years, 2003-2006 Males 45-64 years Females 45-64 years Breast Prostate Melanoma Melanoma Colorectal Colorectal Lung Lung Uterine Non Hodgkins Lymohoma 0 500 1000 1500 2000 0 200 Number of cases 400 600 800 1000 1200 1400 Number of cases • Breast, melanoma of the skin, colorectal, lung and uterine cancers were the most common cancers in females aged 45-64 years, • Prostate, melanoma of the skin, colorectal, lung cancers and non-Hodgkin’s lymphoma were the most common malignancies in males aged 45-64 years. Figure 23: Most common cancers in Northern Region in 65+ years, 2003-2006 Males 65+ years Females 65+ years Colorectal Prostate Breast Colorectal Lung Lung Melanoma Melanoma Non Hodgkins Lymphoma Bladder 0 200 400 600 800 Number of cases 39 1000 1200 0 500 1000 1500 Number of cases 2000 2500 • Colorectal, breast, lung cancers, melanoma of skin and non-Hodgkin’s lymphoma were the five most common cancers in females aged 65+ years, • Prostate, colorectal, lung cancers, melanoma of skin and bladder cancers were the most common cancers in males aged 65+ years. Northern Cancer Network’s Health Needs Assessment - 2009 Common cancers by ethnicity Females The following tables (Tables 16 and 17) present the five most common cancers by ethnicity for females during the period 2003-2006 for the Northern Region and New Zealand. Although the analysis is combined for four years, the numbers of cancers are small when ethnic groups are compared and a few additional cancers can change the ranking order, particularly for the fourth and fifth most common cancers. Table 16: Leading female cancers by ethnicity for Northern Region, 2003-2006 Maori Cancer Breast Lung Colorectal Uterus Cervix No. 287 215 53 49 38 % 28 21 5 5 4 Pacific Cancer Breast Uterus Lung Colorectal Cervix No. 240 106 77 50 37 % 29 13 9 6 5 Asian Cancer Breast Colorectal Thyroid Cervix Lung No. 245 66 51 49 44 % 34 9 7 7 6 Other/European Cancer No. Breast 2,438 Colorectal 1,395 Melanoma 1,146 Lung 679 Uterus 309 % 27 16 13 8 4 Table 17: Leading female cancers by ethnicity for New Zealand, 2003-2006 Maori Cancer Breast Lung Colorectal Uterus Stomach No. 928 612 195 162 114 % 29 19 6 5 4 Pacific Cancer Breast Uterus Lung Colorectal Ovary No. 333 131 95 73 46 % 29 12 8 7 4 Asian Cancer Breast Colorectal Cervix Thyroid Uterus No. 359 105 66 62 50 % 34 10 6 6 5 Other/European Cancer No. Breast 8,059 Colorectal 5,038 Melanoma 3,613 Lung 2,246 Uterus 1,073 % 27 17 12 7 4 Breast cancer was consistently the leading female cancer across all ethnicities, both for the Northern Region and New Zealand, contributing to approximately 28% of all female cancers. However, Asian women had a higher percentage of breast cancers (34%); both in the Northern Region and nationally. In the Northern Region, colorectal cancer ranked second for European/Other (16%) and Asian ethnicity (9%), third for Maori women (5%) and fourth for Pacific women (7%) respectively. Similar ranking and distribution was seen nationally. Lung cancer ranked second in Maori women (19-21%); uterine cancer ranked second in Pacific women (12-13%), both in the Northern Region and nationally. Lung cancer contributed to a higher proportion of female Maori cancers, probably due to higher prevalence of smoking in this group. Melanoma of the skin ranked third for European/Other ethnicity (12-13%) both in the Northern Region and nationally. However, it did not feature in the five most common cancers in Maori, Pacific and Asian women, both in Northern Region and nationally. Lung cancer ranked third in Pacific women (8-9%) in the Northern Region and nationally. Thyroid cancer (6-7%) and cervical cancer (6-7%) were the other common cancers for Asian women, both in the Northern Region and nationally. In the Northern Region, cervical cancer was the fifth most common cancer for Maori (4%) and Pacific (5%) women. However, cervical cancer did not feature in the five most common cancers in 40 Northern Cancer Network’s Health Needs Assessment - 2009 the European/Other women. This could be related to low cervical cancer screening rates in Maori, Pacific and Asian women; particularly in the Northern Region.[7] Uterine cancer was the second most common cancer among Pacific women, contributing to approximately 12-13% of all female cancers, both in the Northern Region and nationally. However, they account for 4-5% of all cancers for European/Other, Maori and Asian women. The ranking of leading cancers by ethnicity for women was generally similar in the Northern Region to that nationally with few exceptions. However, the ranking order was different and there were some cancers more common in some ethnic groups, both in the Northern Region and nationally. Stomach cancer features in the five most common cancers in Maori women nationally but not in the Northern Region. Males The following tables (Tables 18 and 19) present the five most common cancers for men during the period 2003-2006 by ethnicity for the Northern Region and New Zealand. Although the analysis is combined for four years, the numbers of cancers are small when ethnic groups are compared and a few additional cancers can change the ranking order, particularly for the fourth and fifth most common cancers. Table 18: Leading male cancers by ethnicity for Northern Region, 2003-2006 Maori Cancer Lung Prostate Colorectal Stomach Testis No. 172 144 58 47 41 % 21 18 7 6 5 Pacific Cancer Prostate Lung Liver Colorectal Myeloproliferative No. 180 146 57 49 42 % 23 18 7 6 5 Asian Cancer Prostate Colorectal Lung Liver Lip & Oral No. 97 80 68 50 35 % 18 15 12 9 6 Other/European Cancer No. Prostate 2,923 Colorectal 1,379 Melanoma 1,364 Lung 867 Non399 Hodgkin’s % 28 13 13 8 4 Table 19: Leading male cancers by ethnicity for New Zealand, 2003-2006 Maori Cancer Lung Prostate Colorectal Stomach Liver No. 510 463 220 138 125 % 20 18 9 5 5 Pacific Cancer Prostate Lung Liver Colorectal Myeloproliferative No. 225 179 74 69 56 % 22 18 7 7 6 Asian Cancer Prostate Colorectal Lung Liver Lip & Oral No. 144 110 109 66 45 % 18 14 14 8 6 Other/European Cancer No. Prostate 9,524 Colorectal 5,149 Melanoma 4,016 Lung 3,196 Bladder 1,317 Prostate cancer was the leading male cancer for all ethnicities except Maori men, both in the Northern Region and nationally. The proportion of prostate cancer in European/Other (27-28%) was higher than the Pacific (22-23 %) and Asian men (18%), in the Northern Region and nationally. Prostate cancer contributed to approximately 18% of all cancers in Maori men and ranked second. Lung cancer was the leading cancer for Maori men both nationally (20%) and in the Northern Region (21%), due to higher prevalence of smoking among Maori. Lung cancer ranked second for Pacific men (18% both in the Northern Region and nationally), third for Asian men (12% NCN Region, 14% nationally) and fourth for European/Other men (8% NCN Region, 9% nationally). 41 Northern Cancer Network’s Health Needs Assessment - 2009 % 27 15 12 9 4 Melanoma of the skin ranked third for European/Other men both in the Northern Region (13%) and nationally (12%). However, as in the case of women this cancer did not feature in the five most common cancers in other ethnic groups both nationally and in the Northern Region. Colorectal cancer ranked second in European/Other and Asian men both nationally (13 and 15% respectively) and in the Northern Region (15 and 14% respectively). However, it accounted for approximately 6-9% of all male cancers in Maori and Pacific men, both in the Northern Region and nationally. Stomach cancer ranked fourth for Maori men both nationally (5%) and in the Northern Region (6%). Although not ranked in the five most common cancers, stomach cancer accounted for 4-5% of all cancer in Pacific and Asian men both nationally and in the Northern Region. However, it contributed to approximately 2% of all cancer in European/Other men, both in the Northern Region and nationally. Liver cancer ranked in the top five cancers for Maori, Pacific and Asian men (5-8%) nationally and in Pacific and Asian men (7-9%) in the Northern Region. Liver cancer accounted for less than 2% of all male cancer for the European/other ethnicity, both nationally and in the Northern Region. This may relate to the high prevalence of hepatitis B infection in Maori, Pacific and Asian populations compared to that of the European population. [8] Chronic myeloproliferative cancers (codes D45-D47) in Pacific men (5-6%) and lip and oral cancer in Asian men (4%) ranked fifth, both in the Northern Region and nationally. Testicular cancer in Maori men (5%) and Non-Hodgkin’s lymphoma in European/other men (4%) ranked fifth in the Northern Region. Bladder cancer ranked fifth in European/Other men (4%) nationally. The ranking of leading cancers by ethnicity were generally similar in the Northern Region when compared with New Zealand with some exceptions. Testicular cancer ranked fifth in Maori men in Northern Region, compared to liver cancer nationally. NonHodgkin’s cancer ranked fifth in European/Other men in the Northern Region compared to the bladder cancer nationally. The small numbers of cancers in different ethnic groups should be noted when considering the reliability of ranking of cancers by ethnicity, particularly the fourth and fifth most common cancers. 42 Northern Cancer Network’s Health Needs Assessment - 2009 4.5. Inequalities in cancer incidence This section provides an overview of cancer registrations for Maori and non-Maori for the period 2003-2006. The data is sourced from the New Zealand Cancer Registry (NZCR). Maori and non-Maori cancer incidence (from adjusted cancer registrations) were calculated for the combined period 2003 to 2006. No adjustments were made for the undercounting of Maori in cancer registrations. Age-standardised rates were calculated by direct standardisation with the WHO standard population. This can result in an under estimation of some disparities as the Maori population is younger than the WHO world population. Further, it is recognised that the disparities in cancer outcomes is due to delayed presentation and the differences in the stage at diagnosis between Maori and non-Maori. [9] There is variation in the completeness of staging information from NZCR and therefore this analysis was not undertaken. The data is presented according to tumour sites for the Northern Region and the Northern Region DHBs. The NCN plans to work in collaboration with the clinical staff in the DHBs to improve the cancer patient journey by working across different tumour streams. The numbers of cancers are very small when the tumour site is considered at a DHB level and hence statistics with reasonable numbers (>5) are presented. Table 20: Maori and non-Maori inequalities in cancer registrations by tumour site, 2003- 2006, Northern Region Cancer site All sites Lung Colorectal Breast* Genito-urinary Prostate* Testis * Bladder Kidney Melanoma Haematological Hodgkin’s disease Non-Hodgkin’s lymphomas Leukaemia Myeloma CNS Gynaecological Uterine* Ovarian* Cervix* Upper GI Oesophagus Stomach Pancreas Hepato-biliary Other Number Maori non-Maori 1,840 22,153 387 1,881 111 3,019 287 2,923 Registrations Rate Maori non-Maori 374.6 334.5 85.7 27.6 24.5 43.7 95.8 87.7 Rate ratio 1.12 3.11 0.56 1.09 144 41 21 39 24 3,200 148 557 408 2,531 85.6 11.5 5.4 6.7 4.1 103.3 5.7 7.8 6.3 39.2 0.83 2.01 0.69 1.06 0.11 8 60 55 29 25 108 817 741 273 402 1.1 11.8 10.7 6.8 3.6 2.0 12.5 11.4 4.0 6.6 0.57 0.94 0.94 1.68 0.55 49 31 38 456 297 245 17.0 9.8 11.2 13.6 8.6 7.8 1.25 1.14 1.43 18 81 50 59 283 241 465 422 392 2,600 4.0 16.2 11.3 13.1 55.4 3.4 6.7 5.9 5.9 38.8 1.16 2.43 1.91 2.23 1.40 • Rates are calculated per 100,000 and were age-standardised to the WHO standard population. Rates not represented for tumour sites with small numbers. Rates are sex –specific. 43 Northern Cancer Network’s Health Needs Assessment - 2009 In the Northern Region, during the period 2003-2006, there were a total of 1,840 new Maori cancer registrations, an average of approximately 460 Maori cancer cases each year. For the same period, there were 22,153 new non-Maori cancer registrations, averaging 5,538 new registrations each year. The age-standardised incidence rate for cancer overall (all sites) in the Northern Region was 374.6 per 100,000 in Maori for the period 2003-2006. This rate was 12% higher than for the non-Maori rate of 334.5 per 100,000. Maori had significantly high incidence rates for cancers of the lung, cervix, multiple myeloma, stomach, liver, pancreas and testis. Cancers of the breast, uterus, ovary, and oesophagus were also more common among Maori than non-Maori. Maori had significantly lower incidence rates for colorectal cancer, cancers of the central nervous system, Hodgkin’s disease, and melanoma of the skin. Inequalities in common cancers by Northern Region DHBs Auckland District Health Board (ADHB) Table 21: Maori and non-Maori inequalities in cancer registrations by tumour site, 2003-2006, ADHB Cancer site Maori All sites Lung Colorectal Breast* Genito-urinary Prostate* Testis* Melanoma Haematological Non-Hodgkin’s lymphomas Leukaemia Gynaecological Uterine* Cervix* Upper GI Stomach Pancreas Hepato-biliary Number non-Maori 306 6,199 54 534 22 843 62 844 Registrations Rate Maori non-Maori 345.4 340.3 66.9 29.0 25.7 44.4 119.5 91.3 Rate ratio 1.01 2.31 0.58 1.31 19 6 * 825 55 689 67.7 8.8 * 102.1 6.4 38.0 0.66 1.37 * 16 8 227 208 17.2 9.8 12.6 11.6 1.37 0.85 8 7 131 78 14.3 12.5 14.1 8.2 1.01 1.52 11 11 13 131 117 125 10.9 14.1 17.9 6.9 5.8 7.0 1.59 2.42 2.55 • Rates are calculated per 100,000 and were age-standardised to the WHO standard population. Rates not represented for tumour sites with small numbers. Rates are sex –specific. 44 • There were a total of 306 new Maori and 6,199 non-Maori cancer registrations in ADHB, during the period 2003-2006, • The age-standardised incidence rate for cancer overall (all sites) was similar between Maori (345.4 per 100,000) and Non-Maori (340.3 per 100,000), • Maori had significantly high incidence rates for cancers of the lung, liver, pancreas, stomach, breast, cervix and testis, • Lung, Stomach and pancreatic was more than twice as common in Maori compared to non-Maori. Northern Cancer Network’s Health Needs Assessment - 2009 Counties Manukau District Health Board (CMDHB) Table 22: Maori and non-Maori inequalities in cancer registrations by tumour site, 2003-2006, CMDHB Cancer site Maori All sites Lung Colorectal Breast* Genito-urinary Prostate* Testis* Melanoma Haematological Non-Hodgkin’s lymphomas Leukaemia Gynaecological Uterine* Ovary* Cervix* Upper GI Oesophagus Stomach Pancreas Hepato-biliary Number non-Maori 604 5,519 138 507 84 724 84 720 Registrations Rate Maori non-Maori 378.5 322.5 94.6 29.3 44.2 42.5 81.4 81.2 Rate ratio 1.17 3.22 1.04 1.00 36 17 9 788 34 525 58.6 14.8 4.0 98.3 4.9 30.8 0.60 3.06 0.13 18 19 196 177 17.6 12.1 11.4 10.6 1.54 1.15 12 12 15 141 87 70 17.9 10.6 12.2 16.1 9.8 8.3 1.11 1.08 1.46 7 34 12 22 66 132 95 109 4.4 22.0 6.7 15.8 3.8 7.5 5.3 6.4 1.18 2.93 1.26 2.47 • Rates are calculated per 100,000 and were age-standardised to the WHO standard population. Rates not represented for tumour sites with small numbers. Rates are sex –specific. 45 • There were a total of 604 new Maori and 5,519 non-Maori cancer registrations in CMDHB, during the period 2003-2006, • The age-standardised incidence rate for cancer overall (all sites) was 378.5 per 100,000 in Maori and 322.5 per 100,000 in Non-Maori, a 17% higher rate in Maori than non-Maori, • Maori had significantly higher incidence rates for cancers of the lung, testis, cervix and non-Hodgkin’s lymphoma, • Lung and testicular cancer was more than three times more common in Maori compared to non-Maori. Northern Cancer Network’s Health Needs Assessment - 2009 Northland District Health Board (NDHB) Table 23: Maori and non-Maori inequalities in cancer registrations by tumour site, 2003-2006, NDHB Cancer site Maori All sites Lung Colorectal Breast* Genito-urinary Prostate* Testis* Melanoma Haematological Non-Hodgkin’s lymphomas Leukaemia Gynaecological Uterine* Ovary* Cervix* Upper GI Stomach Pancreas Hepato-biliary Number non-Maori 587 2,596 140 210 34 377 79 297 Registrations Rate Maori non-Maori 404.5 349.6 98.9 26.2 24.4 45.3 94.9 89.7 Rate ratio 1.16 3.78 0.54 1.06 63 9 8 488 7 316 117.2 11.4 5.2 123.8 3.7 46.1 0.95 3.10 0.11 17 18 94 94 10.2 11.3 13.2 13.3 0.77 0.85 16 10 9 41 23 27 18.3 11.8 10.2 10.6 7.4 10.6 1.73 1.59 0.95 25 19 14 48 43 36 16.8 14.4 9.6 6.2 5.3 4.5 2.69 2.75 2.13 • Rates are calculated per 100,000 and were age-standardised to the WHO standard population. Rates not represented for tumour sites with small numbers. Rates are sex –specific. 46 • There were a total of 587 new Maori and 2,596 non-Maori cancer registrations in NDHB, during the period 2003-2006, • The age-standardised incidence rate for cancer overall (all sites) was 404.5 per 100,000 in Maori and 349.6 per 100,000 in Non-Maori, a 16% higher rate in Maori than non-Maori, • Maori from NDHB had the highest age-standardised rate for cancer overall when compared with other Northern Region DHBs, • Maori had significantly higher incidence rates for cancers of the lung, testis, uterus, ovary, stomach, pancreas and liver, • Lung and testicular cancer was more than three times more common in Maori compared to non-Maori, • Stomach, pancreatic and liver cancer was more than twice common in Maori compared to non-Maori. Northern Cancer Network’s Health Needs Assessment - 2009 Waitemata District Health Board (WDHB) Table 24: Maori and non-Maori inequalities in cancer registrations by tumour site, 2003-2006, WDHB Cancer site Maori All sites Lung Colorectal Breast* Genito-urinary Prostate* Testis* Melanoma Haematological Non-Hodgkin’s lymphomas Leukaemia Gynaecological Uterine* Cervix* Upper GI Stomach Pancreas Hepato-biliary Number non-Maori 343 7,839 55 630 17 1,059 62 1,062 Registrations Rate Maori non-Maori 343.6 334.1 63.0 25.8 19.3 43.2 103.8 90.1 Rate ratio 1.03 2.44 0.45 1.15 26 9 7 1,099 52 1,001 76.9 9.7 5.3 100.8 6.1 44.2 0.76 1.58 0.12 9 10 300 262 6.2 9.8 12.9 11.4 0.48 0.85 13 7 143 70 20.9 8.7 12.0 6.6 1.74 1.32 11 8 10 154 167 122 12.1 8.6 12.0 6.1 6.7 5.0 1.97 1.28 2.40 • Rates are calculated per 100,000 and were age-standardised to the WHO standard population. Rates not represented for tumour sites with small numbers. Rates are sex –specific. • There were a total of 343 new Maori and 7,839 non-Maori cancer registrations in WDHB, during the period 2003-2006, • The age-standardised incidence rate for cancer overall (all sites) was similar between Maori (343.6 per 100,000) and Non-Maori (334.1 per 100,000), • Maori had significantly higher incidence rates for cancers of the lung, testis, uterus, cervix, stomach, pancreas and liver, • Cancers of the lung, stomach and liver were almost twice as common in Maori compared to Non-Maori. 4.6. Key points 47 o There were 6,028 new cancer registrations in the Northern Region in 2006, approximately 30% of the cancer registrations nationally, o The cancer incidence increased 15% over the ten year period 1996 to 2006 in the Northern Region, compared to a 20% increase nationally, o The proportion of increase over the same ten year period was 17%, 24% and 23% respectively in WDHB, NDHB and CMDHB; compared to a 3.6% increase in the ADHB region, Northern Cancer Network’s Health Needs Assessment - 2009 o For the combined period 2003-2006, there were no significant differences in all cancer ASR amongst all ethnic groups, when comparisons were made between the Northern Region and nationally, o For the combined period 2003-2006, all cancer ASR was higher for Maori and lower for Asian people than the Other/European population both in the Northern Region and nationally, o Northland Maori had significantly higher all cancer ASR (403 per 100,000) than that of Maori in other Northern Region DHBs and New Zealand, o For the combined period 2003-2006, there were 192 cancers diagnosed in children (under 15 years), less than 1% of all cancer cases in the Northern Region, o For the same period, the number of cancer cases were 2,563 (11%) for people aged 15-44 years, 8,602 (36%) for 45-64 years and 12,636 (53%) for 65+ years respectively, o The age-specific rates for all cancer increased seven fold between the age groups 15-44 years and 45-64 years and three fold between 45-64 years and 65+years, o The leading five female cancer registrations were breast, colorectal, melanoma, lung and uterus in the Northern Region and nationally for the period 2003-2006, accounting for approximately 65% of all female cancers, o The leading five male cancer registrations were cancers of the prostate, colorectal, melanoma, lung and non-Hodgkin’s cancer in the Northern Region and nationally for the period 2003-2006, accounting for approximately 65% of all male cancers, o Uterine cancer was the second most common cancer (12%) amongst Pacific women, both nationally and in the Northern Region, o Cervical cancer was among the five most common female cancers in Maori, Pacific and Asian women but not in European/Other women in the Northern Region. Nationally, cervical cancer was in the top five female cancers for Asian women only, o Prostate cancer was the leading cancer in all ethnic groups except Maori men, lung cancer was the leading cancer in Maori men both in the Northern Region and nationally, o Melanoma of the skin featured in the top five cancers for both genders in the European/Other ethnic group, but not for other ethnic groups, o Stomach cancer ranked in the top five cancers in Maori men both in the Northern Region and nationally, but not for other ethnic groups, o The age-standardised incidence rate for all cancer was 12% higher in Maori than non-Maori in the Northern Region for the period 2003-2006, this difference was higher in NDHB and CMDHB, o Maori had significantly higher incidence rates for cancers of the lung, cervix, multiple myeloma, stomach, liver, pancreas and testes; and lower rates for cancers of the central nervous system, colorectal, Hodgkin’s diseases and melanoma of the skin, o The inequalities in lung and testicular cancer were three times higher between Maori and non-Maori in NDHB and CMDHB. 48 Northern Cancer Network’s Health Needs Assessment - 2009 5. Chapter Five: Cancer mortality 5.1. Overview Cancer is the leading cause of death in New Zealand, accounting for almost a third of all deaths. The cancer mortality data presented below is sourced from the New Zealand Mortality Collections. Cancer trends are presented for 10 years from 19952005 for the Northern Region and the Northern Region DHBs. Further detailed analysis of cancer mortality by age and ethnicity is presented for the years 2003-2006. Analyses are based on date of death (as opposed to date of death registration) and as a result the data is subject to change as some deaths are registered in subsequent years. For example, deaths occurring in 2006 but registered in 2007 are not yet available. The death data is manually processed and there is a time lag in receiving all the coroner’s finding for a particular year. In 2005, there were approximately 7,865 cancer deaths (30% of all deaths) nationally [6] compared to 2,376 cancer deaths in the Northern Region. Cancer deaths decreased in 2005 from 2004 but generally have increased by approximately 6% over a ten year period from 1995-2005, both in the Northern Region and nationally. Cancer mortality decreased in ADHB by 13% while it increased in the other Northern region DHBs; 9% in CMDHB, 12% in NDHB and 19% in WDHB respectively. Figure 24: Cancer deaths from all cancer. Both sexes by DHBs and NCN Region, 1995-2005 WDHB ADHB CMDHB NDHB NCN 900 2500 2450 700 2400 600 500 2350 400 2300 300 200 2250 100 0 2200 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Calendar Year 49 Northern Cancer Network’s Health Needs Assessment - 2009 Number of cancer deaths (NCN) Number of cancer deaths (DHB) 800 5.2. Cancer mortality by ethnicity Table 25 shows the number of cancer deaths by ethnicity in the Northern Region and nationally for the period 2003-2006. Table 26 shows the age-standardised rates for all cancer by ethnicity for the same period. Table 25: All cancer mortality, all ages, both sexes by DHB, NCN and NZ, by ethnicity, 2003-2006 DHB Maori Pacific European/ Other Asian Total ADHB 148 245 129 1,999 2,521 CMDHB 323 405 140 1,689 2,557 NDHB 364 5 6 1,057 1,432 WDHB 163 115 110 2,799 3,187 NCN region 998 770 385 7,544 9,697 3,030 1,000 618 27,083 31,731 NZ Table 26: Age-standardised rates for all cancer deaths by ethnicity, by DHB, NCN Region and NZ, 2003-2006, per 100,000 population DHB Maori Pacific European/ Other Asian Total ADHB 191 172 57 124 123 CMDHB 237 193 77 122 135 NDHB 258 * * 131 152 WDHB 183 153 83 121 122 NCN region 224 178 71 123 129 NZ 219 172 81 129 135 * Rates not represented for groups with small numbers. Age-standardised to the New Zealand population For the period 2003-2006, the cancer mortality ASR was 129 per 100,000 population, slightly lower than that for New Zealand (135 per 100,000). Among the Northern Region DHBs the cancer mortality ASR was higher in Northland and Counties 50 Northern Cancer Network’s Health Needs Assessment - 2009 Manukau, compared to Auckland and Waitemata DHB. This is probably related to the higher Maori population in these DHBs. All cancer age-standardised mortality rates were significantly higher for Maori than European/Other ethnicity, both nationally and in the Northern Region. The agestandardised mortality rates for Pacific people were higher and for Asian people were lower than the European/Other ethnicity, both nationally and in the Northern Region. Northland and Counties Manukau DHB had higher age-standardised mortality rates for all cancer for Maori when compared to the other Northern Region DHBs. However, no significant variability is seen in all cancer mortality rates for other ethnic groups across the Northern Region DHBs. 5.3. Cancer mortality by age The number of cancer deaths increases with age. For the period 2003-2006, agespecific death rates for all cancer in the Northern Region were 3 per 100,000 for less than 15 years age, 20 per 100,000 for 15-44 years, 197 per 100,000 for 45-64 years and 1,125 for 65+ years respectively. The age-specific death rates for all cancer in the Northern Region increased ten fold between the ages 15-44 years and 45-64 years, and six fold between the ages 45-64 years and 65+ years. Northland had higher age-specific death rates for all cancer compared with the other Northern Region DHBs and nationally. Figure 25: Age-specific rates for all cancer mortality, both sexes by DHB, NCN and NZ, 2003-2006 ADHB CMDHB NDHB WDHB NCN NZ Age specific rate per 100,000 1,400 1,200 1,000 800 600 400 200 0 0-14yrs 15-44yrs 45-64yrs 65+yrs Age group Ethnic disparities in age-specific all cancer mortality in the Northern Region was apparent at 45-64 years and 65+ year. Maori had the highest rates, followed by Pacific, European/Other and Asian populations (Figure 17). Elderly Asian people (65+) had significantly low all cancer mortality compared to other ethnic groups. This may reflect 51 Northern Cancer Network’s Health Needs Assessment - 2009 selection processes, the healthy migrant effect and can also be explained by the young demography of this population. [10] Figure 26: Age-specific rates by ethnicity for all cancer mortality, both sexes, for the Northern Region, 2003-2006 Maori Pacific Asian European/Other Age specific rate per 100,000 1,600 1,400 1,200 1,000 800 600 400 200 0 0-14yrs 15-44yrs 45-64yrs 65+yrs Age group 5.4. Leading fatal cancers The following section outlines the leading types of fatal cancer in the Northern Region and nationally. Common fatal cancers are discussed for different age groups and ethnicity for the combined period 2003-2006. The results are presented for both gender and comparisons made between the Northern Region and nationally. There were a total of 4,616 female cancer deaths in the Northern Region during the period 2003-2006. The most common fatal cancer was breast cancer (776 cases), which accounted for 16.8% of all female cancer deaths. Lung cancer deaths (769) were the second most common (16.6%) and almost the same numbers as breast cancer. The next three most common fatal cancers were colorectal cancer (669 cases, 14.5%), ovarian cancer (224 cases, 4.9%) and pancreatic cancer (214 cases, 4.6%). The leading five fatal cancers accounted for 57.5% of all cancer deaths. There were a total of 15,170 female cancer deaths nationally during the period 20032006. Breast cancer (2,539 cases, 16.7%), lung cancer (2,482 cases, 16.4%), colorectal cancer (2,391, 15.8%), ovarian cancer (751 cases, 5%) and pancreatic cancer (704 cases, 4.6%) were the five most common fatal cancers in women nationally, similar to that in the Northern Region. Figures 27 and 28 show rankings of cancer deaths in females for the Northern Region and nationally during the period 2003-2006. 52 Northern Cancer Network’s Health Needs Assessment - 2009 Figure 27: Distribution of cancer deaths in Northern Region by site for females, all age and ethnic groups combined, 2003-2006 Northern Region, Cance r Morta lity Fe ma les 2003-2006 Breast Lung Colorectal Unknown Site Ovary Pancreas Other Stomach Non-Hodgkins Lymphomas Leukaemia Liver, biliary tract Melanoma Eye, Brain, CNS Uterus Myeloma Oesophagus Cervix Bladder Myeloproliferate Kidney Lip & Oral Thyroid & Endocrine Small Intestine Hodgkins 0 100 200 300 400 500 600 700 800 900 Figure 28: Distribution of cancer deaths in New Zealand by site for females, all age and ethnic groups combined, 2003-2006 Na tional, Cance r Morta lity Female s 2003-2006 Breast Lung Colorectal Unknown Site Ovary Pancreas Other Non-Hodgkins Lymphomas Leukaemia Stomach Melanoma Liver, biliary tract Eye, Brain, CNS Uterus Oesophagus Myeloma Kidney Cervix Bladder Myeloproliferate Lip & Oral Thyroid & Endocrine Small Intestine Hodgkins 0 53 500 1000 1500 2000 Northern Cancer Network’s Health Needs Assessment - 2009 2500 3000 There were a total of 5,081 male cancer deaths in the Northern Region during the period 2003-2006 (See Figure 29). The most common fatal cancer was lung cancer (1,020 cases), which accounted for 20.1% of all male cancer deaths. Prostate cancer deaths (660) were the second most common (13%) and the next three most common fatal cancers were colorectal cancer (646 cases, 12.7%), stomach cancer (238 cases, 4.7%) and non-Hodgkin’s lymphoma (214 cases, 4.2%). The leading five fatal cancers accounted for 54.7% of all cancer deaths. Figure 29: Distribution of cancer deaths in Northern Region by site for males, all age and ethnic groups combined, 2003-2006 Northern Re gion, Ca ncer Morta lity Males 2003-2006 Lung Prostate Colorectal Other Unknown Site Stomach Non-Hodgkins Lymphomas Liver, biliary tract Eye, Brain, CNS Leukaemia Melanoma Pancreas Bladder Oesophagus Lip & Oral Kidney Myeloma Myeloproliferate Small Intestine Testis Thyroid & Endocrine Hodgkins 0 200 400 600 800 1000 There were a total of 16,561 male cancer deaths nationally during the period 20032006 (See Figure 30). The five most common fatal cancers nationally were lung cancer (3,430 cases, 20.7%), colorectal cancer (2,301 cases, 13.9%), prostate cancer (2,260 cases, 13.7%), stomach cancer (695 cases, 4.2%) and pancreatic cancer (657 cases, 4%). The rankings of the five most fatal cancers in the Northern Region and nationally were similar. It should be noted that featuring in the leading cancer mortality were cancers from unknown sites (5-6%). Although unknown site cancers rank in the top five leading cancer deaths, they have not been included in the top five to highlight the top five cancer sites. Further, the coding of cancers to this category will lesson the contribution of specific site cancers. 54 Northern Cancer Network’s Health Needs Assessment - 2009 1200 Figure 30: Distribution of cancer deaths in New Zealand by site for males, all age and ethnic groups combined, 2003-2006 National, Cancer Mortality Males 2003-2006 Lung Colorectal Prostate Other Unknown Site Stomach Pancreas Melanoma Non-Hodgkins Lymphomas Leukaemia Eye, Brain, CNS Liver, biliary tract Oesophagus Bladder Kidney Myeloma Lip & Oral Myeloproliferate Small Intestine Thyroid & Endocrine Hodgkins Testis 0 500 1000 1500 2000 2500 3000 3500 4000 Leading mortality cancers are a reflection of the incidence and survival rates for each specific cancer. Although breast cancer was the leading female cancer for both incidence and mortality, the mortality contribution of 17% was significantly lower than the incidence contribution of 28% due to higher survival rates. In comparison, the proportion of fatal female cancers from lung cancer was 17% compared to a 9% incidence reflecting the low survival rates for this cancer. Melanoma and uterine cancer ranked in the top five cancers for incidence but did not feature in the top five fatal cancers reflecting high survival rates. The proportion of deaths from prostate cancer for all males in the Northern Region (13%) was lower than the incidence proportion (28%), reflecting high survival rates for this cancer. Lung cancer was the leading cause of cancer deaths (20%), higher than the incidence proportion (10%), reflecting low survival rates for this cancer. The proportion of deaths and incidence for colorectal cancer were similar reflecting mid level survival rates. 55 Northern Cancer Network’s Health Needs Assessment - 2009 Common fatal cancers by age and gender The following figures show the ranking of cancer deaths by age and gender for the period 2003-2006. Figure 31: Most common fatal cancers in the Northern Region in less than 15 years, 2003-2006 Fem ales 0-14 years Males 0-14 years Leukaemia Leukaemia CNS CNS Bone Bone 0 1 2 3 4 5 6 7 0 2 4 Number of cases • 6 8 Number of cases Leukaemia, cancers of the central nervous system and bone cancers were the leading causes of cancer deaths in children aged 0-14 years. Figure 32: Most common fatal cancers in the Northern Region in 15-44 years, 2003-2006 Males 15-44 years Females 15-44 years Breast CNS Colorectal Non Hodgkins Lymphoma Lung Leukaemia cervix Lung CNS Melanoma 0 20 40 60 Number of cases 56 80 100 0 5 10 15 20 25 30 35 Number of cases • Cancers of the breast, colorectal, lung, cervix and central nervous system were the leading causes of cancer deaths in females aged 15-44 years, • Cancers of the central nervous system, non-Hodgkin’s lymphoma, leukaemia, lung cancer and melanoma of the skin were the leading causes of cancer deaths in males aged 15-44 years. Northern Cancer Network’s Health Needs Assessment - 2009 Figure 33: Most common fatal cancers in the Northern Region in 45-64 years, 2003-2006 Fem ales 45-64 years Males 45-64 years Breast Lung Lung Colorectal Colorectal CNS Ovary Stomach CNS Liver 0 50 100 150 200 250 300 0 350 50 100 150 200 250 300 Number of cases Number of cases • Cancers of the breast, lung, colorectal, ovary and central nervous system were the leading causes of cancer deaths in females aged 45-64 years, • Lung cancer, colorectal cancer, cancer of the central nervous system, stomach and liver cancers were the leading causes of cancer deaths in males aged 4564 years. Figure 34: Most common fatal cancers in the Northern Region in 65+ years, 20032006 Fem ales 65+ years Males 65+ years Colorectal Lung Lung Prostate Colorectal Breast Stomach Pancreas Melanoma Ovary 0 0 57 100 200 300 400 Number of cases 500 600 200 400 600 800 Number of cases • Colorectal cancer, lung cancer, cancers of the breast, pancreas and ovary were the leading causes of cancer deaths in females aged 65+ years, • Lung cancer, prostate cancer, colorectal cancer, stomach cancer and melanoma of the skin were the leading causes of cancer deaths in males aged 65+ years. Northern Cancer Network’s Health Needs Assessment - 2009 Common fatal cancers by ethnicity Females The following tables (Table 27 and 28) present the leading fatal cancers for females during the period 2003-2006 by ethnicity for the Northern Region and New Zealand. It should be noted that although the analysis is combined for four years, the absolute cancer numbers are small when ethnic groups are compared. Few additional cancers can change the ranking order, particularly for the fourth and fifth most common fatal cancers. By ethnicity, it is apparent that the ranking and contribution of fatal female cancers differs between, Maori, Pacific, Asian, and European/Other people. Colorectal cancer was the leading fatal cancer in Europeans/Other women, accounting for approximately 17% of all female cancer deaths, both in the Northern Region and nationally. Colorectal cancer accounted for 6-8% of all female cancer deaths in other ethnic groups, both in the Northern Region and nationally. Lung cancer was the leading cause of cancer deaths in Maori women in the Northern Region, and nationally contributing to approximately 34% of all female cancer deaths. This finding is related to the high prevalence of smoking in Maori women compared with other ethnicities. Breast cancer (16%), colorectal cancer (6%), stomach cancer (5%), ovarian cancer (4%) and pancreatic cancer (4%) were the remaining leading fatal cancers in Maori women for the Northern Region and nationally. Colorectal cancer deaths in Maori women were notably less prominent when compared to European/Other women both in the Northern Region and nationally. Table 27: Leading female fatal cancers by ethnicity for Northern Region, 20032006 Maori Cancer Lung Breast Colorectal Stomach Ovary No. 178 83 31 27 23 % 34 16 6 5 4 Pacific Cancer Breast Lung Colorectal Uterus Stomach No. 72 60 30 29 25 % 19 16 8 8 7 Asian Cancer Breast Lung Liver Colorectal Ovary No. 39 21 14 11 9 % 23 12 8 8 5 Other/European Cancer No. Colorectal 594 Breast 582 Lung 510 Pancreas 179 Ovary 173 % 17 16 14 5 5 Table 28: Leading fatal female cancers by ethnicity for New Zealand, 2003-2006 Maori Cancer Lung Breast Colorectal Stomach Pancreas No. 513 279 101 73 63 % 33 18 7 5 4 Pacific Cancer Breast Lung Colorectal Uterus Stomach No. 97 73 40 35 32 % 20 15 8 7 7 Asian Cancer Breast Lung Colorectal Liver Leukaemia No. 68 41 32 19 14 % 23 14 11 7 5 Other/European Cancer No. Colorectal 2,218 Breast 2,095 Lung 1,855 Ovary 650 Pancreas 618 % 17 16 15 5 5 Breast cancer was the leading cause of female cancer deaths in both Pacific and Asian women. Breast cancer deaths were much more prominent in Asian women (23%) both in the Northern Region and nationally. This could relate to a higher proportion of breast cancer registrations in Asian women. For all ethnicities there were several types of cancer that contributed to between 4-8% of all cancer deaths and there was variability depending upon the ethnic group. 58 Northern Cancer Network’s Health Needs Assessment - 2009 Males The following tables (Table 29 and 30) present the leading fatal cancers for males during the period 2003 -2006 by ethnicity for the Northern Region and New Zealand. It should be noted that although the analysis is combined for four years, the absolute cancer numbers are small when ethnic groups are compared. Few additional cancers can change the ranking order, particularly for the fourth and fifth most common fatal cancers. In the period 2003-2006, lung cancer was the leading cause of male cancer death in all ethnic groups, both in the Northern Region and nationally. Deaths due to lung cancer were particularly prominent in Maori men, accounting for 31-32% of all male cancer deaths, both in the Northern Region and nationally. Again, this is related to high smoking rates in Maori men. Lung cancer deaths were also high in Pacific men (2829%) compared to Asian men (21-25%) and European/Other men (18-19%) respectively. Prostate and colorectal cancers contributed to a similar proportion (14-15%) of cancer deaths in European/Other men, both in the Northern Region and nationally. Although prostate cancer was the second most common cancer in Maori men, it accounted for only 9% of all cancer deaths. Deaths from liver cancer were second most common in Pacific and Asian men, contributing 12-16% of all cancer deaths, both in the Northern Region and nationally. The contribution of colorectal cancer to all cancer deaths was significantly lower in Maori, Pacific and Asian men (6-10%) when compared to European/Other men (1415%) both in the Northern Region and nationally. Stomach cancer contributed to approximately 7% of all cancer deaths in Maori and Pacific men (Northern Region and nationally). Table 29: Leading fatal male cancers by ethnicity for Northern Region, 2003-2006 Maori Cancer Lung Prostate Colorectal Stomach Liver No. 153 45 34 32 25 % 32 9 7 7 5 Pacific Cancer Lung Liver Prostate Stomach Colorectal No. 115 47 37 28 24 % 29 12 9 7 6 Asian Cancer Lung Liver Colorectal Lip & Oral Pancreas No. 45 33 19 14 13 % 21 16 9 7 6 Other/European Cancer No. Lung 707 Prostate 570 Colorectal 569 Melanoma 198 CNS 177 % 18 14 14 5 4 Table 30: Leading fatal male cancers by ethnicity for New Zealand, 2003-2006 Maori Cancer Lung Prostate Colorectal Stomach Liver No. 450 131 116 111 94 % 31 9 8 8 6 Pacific Cancer Lung Liver Prostate Stomach Colorectal No. 142 62 47 35 31 % 28 12 9 7 6 Asian Cancer Lung Liver Colorectal Pancreas Lip & Oral No. 82 45 31 20 19 % 25 14 10 6 6 Other/European Cancer No. Lung 2,755 Colorectal 2,123 Prostate 2,065 Melanoma 632 Pancreas 563 % 19 15 15 4 4 Deaths from melanoma of the skin ranked fourth in European/Other men nationally and in the Northern Region but did not feature in the top five leading cancer deaths in other ethnic groups. For all ethnicities there were several types of cancer that contributed to between 4-8% of all cancer deaths and there was variability depending upon the ethnic group. 59 Northern Cancer Network’s Health Needs Assessment - 2009 5.5. Inequalities in cancer mortality This section provides an overview of cancer mortality for Maori and non-Maori for the period 2003-2006. The data is sourced from New Zealand Cancer Registry and the New Zealand Mortality Collection. The data is presented according to tumour sites for the Northern Region and the Northern Region DHBs. The numbers of cancer deaths are very small when the tumour site is considered at a DHB level and hence statistics with reasonable numbers (>5) are presented. Age-standardised rates were calculated by direct standardisation with the WHO standard population. This can result in an under estimation of some disparities as the Maori population is younger than the WHO world population. Further, it is recognised that the disparities in cancer outcomes is due to delayed presentation and the differences in the stage at diagnosis between Maori and non-Maori. [9] There is variation in the completeness of staging information from NZCR and therefore this analysis was not undertaken. Table 31: Maori and non-Maori inequalities in cancer mortality by tumour site, 2003-2006, Northern Region Mortalities Cancer site Maori All sites Lung Colorectal Breast* Genito-urinary Prostate* Testis* Bladder Kidney Melanoma Haematological Hodgkin’s disease Non-Hodgkin’s lymphomas Leukaemia Myeloma CNS Gynaecological Uterine* Ovarian* Cervix* Upper GI Oesophagus Stomach Pancreas Hepato-biliary Other Number non-Maori 998 8,699 331 1,458 65 1,250 83 700 Maori Rate non-Maori 223.5 122.3 75.2 20.9 15.0 17.2 16.9 10.4 Rate ratio 1.83 3.60 0.87 1.63 45 7 13 11 6 615 11 200 146 332 36.3 1.9 3.5 2.2 1.4 18.7 0.4 2.6 2.1 4.8 1.94 4.59 1.36 1.08 0.29 3 31 28 13 23 346 333 173 * 6.8 6.0 2.9 0.4 4.9 4.8 2.5 * 0.94 0.94 1.68 19 315 3.1 4.9 0.64 18 23 15 92 201 67 6.8 8.6 5.0 2.5 5.3 2.0 2.70 1.61 2.56 15 59 37 42 134 197 343 375 312 1,210 3.4 12.3 9.3 9.0 29.6 2.8 4.7 5.2 4.6 16.7 1.23 2.61 1.80 1.96 1.77 • Rates are calculated per 100,000 and were age-standardised to the WHO standard population. Rates not represented for tumour sites with small numbers. Rates are sex –specific. In the period 2003-2006, there were a total of 998 Maori and 8,699 non-Maori cancer deaths in the Northern Region. This averaged to 250 Maori and 2,175 non-Maori cancer deaths each year in the Northern Region. The age-standardised mortality rate 60 Northern Cancer Network’s Health Needs Assessment - 2009 for all cancer was 223.5 per 100,000 in Maori and 122.3 per 100,000 in non-Maori. Maori had approximately 1.83 times higher all cancer mortality rates than that of nonMaori. Maori had significantly higher death rates for cancers of the lung, prostate, testis, liver, pancreas, stomach, breast, cervix, ovary and uterus. Deaths from cancers of the bladder, kidney, oesophagus and haematological cancers like leukaemia, nonHodgkin’s lymphoma and multiple myeloma were more common among Maori than non-Maori. Maori had significantly lower mortality rates for melanoma of the skin. Further, mortality from colorectal cancer and cancers of the central nervous system were relatively less common among Maori, compared to non-Maori. Inequalities in cancer mortality by Northern Region DHBs Auckland District Health Board (ADHB) Table 32: Maori and non-Maori inequalities in cancer mortality by tumour site, 2003-2006, ADHB Mortalities Cancer site Maori All sites Lung Colorectal Breast* Prostate* Melanoma Haematological Non-Hodgkin’s lymphomas Leukaemia Upper GI Stomach Pancreas Hepato-biliary Number non-Maori 148 2,373 42 400 11 340 16 211 11 825 * 73 Maori Rate non-Maori 190.2 119.6 55.4 20.9 13.2 16.6 31.7 21.1 67.7 102.1 * 3.7 Rate ratio 1.59 2.65 0.80 1.50 0.66 * 8 5 89 84 10.5 5.7 4.7 4.3 2.26 1.34 6 7 7 107 98 96 6.1 10.8 8.5 5.4 4.6 5.2 1.13 2.33 1.63 • Rates are calculated per 100,000 and were age-standardised to the WHO standard population. Rates not represented for tumour sites with small numbers. Rates are sex –specific. 61 • There were a total of 148 Maori and 2,373 non-Maori cancer deaths in ADHB, during the period 2003-2006, • The age-standardised mortality rate for all cancer was 190.2 per 100,000 in Maori and 119.6 per 100,000 in non-Maori, a 59% higher rate in Maori than non-Maori, • Maori had significantly higher mortality rates from cancers of the lung, breast, pancreas, liver and non-Hodgkin’s lymphoma, • Mortality from colorectal and prostate cancer was lower in Maori than nonMaori. Northern Cancer Network’s Health Needs Assessment - 2009 Counties Manukau District Health Board (CMDHB) Table 33: Maori and non-Maori inequalities in cancer mortality by tumour site, 2003-2006, CMDHB Mortalities Cancer site Maori All sites Lung Colorectal Breast* Prostate* Melanoma Haematological Non-Hodgkin’s lymphomas Leukaemia Gynaecological Uterine* Ovary* Cervix* Upper GI Stomach Pancreas Hepato-biliary Number non-Maori 323 2,234 114 416 18 315 27 165 8 146 * 89 Maori Rate non-Maori 237.8 126.2 83.5 23.8 16.2 17.5 36.7 17.9 23.6 18.8 * 5.0 Rate ratio 1.88 3.51 0.93 2.05 1.26 * 10 8 103 84 9.4 3.9 5.8 4.9 1.61 0.80 6 9 5 29 57 20 8.4 9.3 4.1 3.1 6.1 2.4 2.67 1.53 1.74 26 11 15 96 82 89 17.8 8.7 10.3 5.4 4.5 5.1 3.28 1.92 2.01 • Rates are calculated per 100,000 and were age-standardised to the WHO standard population. Rates not represented for tumour sites with small numbers. Rates are sex –specific. 62 • There were a total of 323 Maori and 2,234 non-Maori cancer deaths in CMDHB, during the period 2003-2006, • The age-standardised mortality rate for all cancer was 237.8 per 100,000 in Maori and 126.2 per 100,000 in non-Maori, an 88% higher rate in Maori than non-Maori, • Maori had significantly higher mortality rates from cancers of the lung, breast, uterus, cervix, ovary, stomach, pancreas, liver and non-Hodgkin’s lymphoma, • Lung cancer mortality in Maori was 3.5 times that of non-Maori, • Cancer mortality from colorectal cancer was less common and that from prostate cancer more common in Maori. Northern Cancer Network’s Health Needs Assessment - 2009 Northland District Health Board (NDHB) Table 34: Maori and non-Maori inequalities in cancer mortality by tumour site, 2003-2006, NDHB Mortalities Cancer site Maori All sites Lung Colorectal Breast* Prostate* Melanoma Haematological Non-Hodgkin’s lymphomas Leukaemia Gynaecological Uterine* Ovary* Cervix* Upper GI Stomach Pancreas Hepato-biliary Number non-Maori 364 1,068 125 181 22 191 24 67 20 88 * 26 Maori Rate non-Maori 259.4 130.5 88.8 21.6 16.1 21.7 30.6 19.6 40.6 20.1 * 7.1 Rate ratio 1.99 4.12 0.74 1.56 2.02 * 7 11 39 48 4.4 8.2 5.0 6.4 0.86 1.29 9 7 7 12 17 6 9.9 8.8 8.1 2.9 4.2 1.6 3.44 2.13 5.18 20 16 12 35 42 29 13.6 12.6 7.9 4.4 5.3 3.5 3.10 2.38 2.24 • Rates are calculated per 100,000 and were age-standardised to the WHO standard population. Rates not represented for tumour sites with small numbers. Rates are sex –specific. 63 • There were a total of 364 Maori and 1,068 non-Maori cancer deaths in NDHB, during the period 2003-2006, • The age-standardised mortality rate for all cancer was 259.4 per 100,000 in Maori and 130.5 per 100,000 in non-Maori, an almost two times higher rate in Maori than non-Maori, • Maori had significantly higher mortality rates from cancers of the lung, prostate, breast, uterus, cervix, ovary, stomach, pancreas and liver, • The inequality in cancer mortality for lung cancer was highest in the NDHB when compared to other Northern Region DHBs and four times higher in Maori than non-Maori, • Prostate cancer mortality rates were also significantly higher for Maori in the NDHB when compared to other Northern DHBs, • The cancer mortality rates for uterus, cervix and stomach were significantly higher in Maori in NDHB, compared with other Northern DHBs. However, the numbers of these cancer were very small and a few additional numbers can skew the data, • The cancer mortality from colorectal cancer was less common in Maori in NDHB, similar to other Northern DHBs. Northern Cancer Network’s Health Needs Assessment - 2009 Waitemata District Health Board (WDHB) Table 35: Maori and non-Maori inequalities in cancer mortality by tumour site, 2003-2006, WDHB Mortalities Cancer site Maori All sites Lung Colorectal Breast* Prostate* Melanoma Number non-Maori 163 3,024 50 461 14 404 16 250 6 214 * 122 Maori Rate non-Maori 181.4 119.1 57.2 18.5 15.7 15.8 24.4 19.4 27.8 18.2 * 4.9 Rate ratio 1.52 3.09 0.99 1.26 1.53 * Upper GI Stomach Hepato-biliary 7 8 105 98 9.5 9.5 3.9 3.9 2.44 2.41 Non –Hodgkin’s Lymphoma 6 115 5.4 4.6 1.17 • Rates are calculated per 100,000 and were age-standardised to the WHO standard population. Rates not represented for tumour sites with small numbers. Rates are sex –specific. • There were a total of 163 Maori and 3,024 non-Maori cancer deaths in WDHB, during the period 2003-2006, • The age-standardised mortality rate for all cancer was 181.4 per 100,000 in Maori and 119.1 per 100,000 in non-Maori, a 52% higher rate in Maori than non-Maori, • Maori had significantly higher mortality rates from cancers of the lung, stomach and liver, • The lung cancer mortality in Maori was 3.5 times that of non-Maori, • Mortality from cancers of the breast, prostate and non-Hodgkin’s lymphoma were more common in Maori compared to non-Maori, • There was no inequality in cancer mortality from colorectal cancer between Maori and non-Maori. However, small numbers for Maori may have skewed the data. 5.6. Key points 64 o There were 2,376 cancer deaths in the Northern Region in 2005, approximately 30% of the cancer deaths nationally, o The cancer mortality increased 6% over the ten year period 1995 to 2005 in the Northern Region and nationally, o The proportion of cancer mortality increase over the same ten year period was 19%, 12% and 9% respectively in WDHB, NDHB and CMDHB; compared to a 13% decrease in the ADHB region, Northern Cancer Network’s Health Needs Assessment - 2009 o For the combined period 2003-2006, there were no significant differences in ASR of all cancer mortality amongst all ethnic groups when comparisons were made between the Northern Region and New Zealand, o For the combined period 2003-2006, all cancer ASR was higher for Maori and Pacific people, and lower for Asian people than the Other/European population both in the Northern Region and nationally, o For the combined period 2003-2006, the cancer mortality ASR were higher for NDHB and CMDHB, compared to WDHB and ADHB, particularly for Maori, o For the combined period 2003-2006, there were 37 cancer deaths in children (under 15 years), less than 1% of all cancers deaths in the Northern Region, 65 o For the same period, the number of cancer deaths were 534 (6%) for people aged 15-44 years, 2,495 (26%) for 45-64 years and 6,631 (68%) for 65+ years respectively, o The age-specific rates for all cancer increased ten fold between the age groups 15-44 years and 45-64 years, and six fold between 45-64 years and 65+years. Northland DHB had higher age specific all cancer death rates compared to other Northern Region DHBs and nationally, o Ethnic disparities were evident in the Northern Region at 45-64 years and 65+ years. Maori had the highest all cancer mortality rate, followed by Pacific, European/Other, and Asian people, o The leading five fatal cancers for females were cancers of the breast, lung, colorectal, ovary and pancreas in the Northern Region and nationally for the period 2003-2006, accounting for approximately 58% of all female cancer deaths, o The leading five fatal cancers for men were cancers of the lung, prostate, colorectal, stomach and non-Hodgkin’s lymphoma in the Northern Region for the period 2003-2006, accounting for approximately 55% of all male cancers, o Nationally, lung, colorectal, prostate, stomach and pancreatic cancer were the leading five fatal cancers in men for the combined period 2003-2006, o Colorectal cancer was the leading fatal cancer in the European/Other women (17%) in the Northern Region and nationally, but not so in the other ethnic groups, where it accounted for 6-8% of all female cancer deaths, o Lung cancer was the leading fatal cancer in Maori women, contributing to 34% of all female can deaths, both in the Northern Region and nationally, o Breast cancer was the leading fatal cancer in Pacific (19-205) and Asian women (23%), both in the Northern Region and nationally, o Lung cancer deaths were significantly higher in Maori men (31-32%), compared to other ethnic groups, both in the Northern Region and nationally for the combined period 2003-2006, o Liver cancer was the second most common cause of cancer death in Pacific and Asian men, contributing 12-16% of all cancer deaths, both in the Northern Region and nationally. By contrast, liver cancer deaths don’t feature in the five most common cancer deaths in the European/Other men, o Colorectal cancer deaths in European/Other men is relatively more common (14-15%) than in other ethnic groups (6-10%), both in the Northern Region and nationally, Northern Cancer Network’s Health Needs Assessment - 2009 o Stomach cancer contributed to approximately 7% of cancer deaths in Maori and Pacific men but not in other ethnic groups, both in the Northern Region and nationally, o Deaths from melanoma of the skin ranked fourth in European/Other men, but did not feature in the leading cancer deaths for other ethnic groups, both in the Northern Region and nationally, o Breast cancer was the leading female cancer for both incidence and mortality. However, the mortality contribution of 17% was significantly lower than the incidence contribution of 28%, due to its relatively higher survival rate. In contrast, lung cancer mortality in females of 17% was significantly higher than the incidence contribution of 9%, reflecting the relatively low survival rate, o In men, the proportion of deaths due to prostate cancer (13%) was lower than the incidence proportion (28%), reflecting high survival rates. By contrast the proportion of lung cancer deaths (20%) was higher than the incidence proportion (10%), reflecting low survival rates. The colorectal cancer death and incidence proportion were similar, reflecting a mid survival rate, o Age-standardised cancer mortality rates for all cancers was 1.83 times higher in Maori compared to non-Maori, in the Northern Region for the period 2003-2006 and this difference was highest in the NDHB, o Maori had significantly higher death rates for cancers of the lung, prostate, testes, cervix, ovary, uterus, stomach, liver and pancreas and lower rates for cancers of the central nervous system, colorectal and melanoma of the skin, o The inequalities in cancer mortality rates resulting from lung, prostate, cervix, uterus and stomach cancers were significantly higher in the NDHB, compared to the other Northern DHBs. 66 Northern Cancer Network’s Health Needs Assessment - 2009 6. Chapter Six: Cancer survival 6.1. Overview The length of time that a person survives after a cancer diagnosis is one means of evaluating cancer treatment effectiveness. While cancer registrations measure the incidence of cancer, the relative survival rate is an important measure of the impact of cancer (the incidence combined with survival determines mortality). The relative survival analysis compares the survival of persons diagnosed with cancer (observed survival) with the survival of the entire population of the same sex and age in the same calendar year as the cancer cohort (expected survival). This method of analysis does not require the cause of death. Relative survival is defined as the observed survival divided by the expected survival and is usually given as a proportion.[11] Relative cancer survival rates can be calculated by the traditional cohort method or by the newer method of period analysis. The following section presents relative survival rates calculated by the period analysis and sourced from the Ministry of Health. This method examines the survival experience of people who were alive at the beginning of a particular recent calendar period and who were diagnosed with cancer before this period. [11] Therefore, the period method might provide more up-to-date estimates of survival, and therefore a better reflection of current cancer management. There is evidence of ethnic inequalities in cancer survival from national and international studies. [9,12-15] Age-standardised, five year relative survival rates were lowest for Maori, intermediate for Pacific peoples and highest for non-Maori/non-Pacific peoples for many cancers.[12] The stage at diagnosis explained some but not all of the ethnic disparities in cancer survival in New Zealand. [9,13] The possible factors responsible for ethnic inequalities might include access to specialised cancer services and the quality of care received. Data presented below are based on period analysis for the study period 1 January 2002 to 31 December 2006, with follow up until 31 December 2007. Results are expressed as a ratio; with the closer a result is to one, the better the survival estimate. For example, a relative survival rate of 0.85 indicates an 85% survival estimate for a given time period. In this analysis, one year and five year relative survival rates are presented. No adjustment has been made for stage at diagnosis. Survival analysis by ethnicity is presented for the national data. Similar ethnic inequalities would be expected in the Northern Region. 6.2. Relative survival rates for all cancer The following graph presents one and five year relative survival rates (RSR) for all cancer for New Zealand and the four regions for the study period 2002-2006. The one year and five year RSR for all cancer was approximately 76% and 63% for Northern Region, compared to 75% and 60% nationally. The one and five year RSR for all cancer was significantly higher for the Northern Region than for all the other regions and New Zealand (See Figure 26). 67 Northern Cancer Network’s Health Needs Assessment - 2009 Figure 35: Relative survival rates (1 and 5 years) by Regions and New Zealand, 2002-2006 1.0 0.9 Northern Central Midland Southern NZ Relative survival rate 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 1 year 5 year Time interval 6.3. Relative survival rates by cancer type The following graph (Figure 27) shows the one year and five year RSR for major cancers in the Northern Region for the period 2002-2006. Among the major cancers, prostate cancer had the highest one and five year RSR (96% and 90%) followed by breast cancer (97% and 84%), cervix (86% and 71%), colorectal (78 and 61%) and lung cancer (29% and 11%) respectively. Figure 36: Relative survival rates (1 and 5 years) by cancer site, Northern Region, 2002-2006 Relative survival rate Lung Colorectal Cervix Breast Prostate 1.2 1.1 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 1 year 5 year Time interval 68 Northern Cancer Network’s Health Needs Assessment - 2009 Breast cancer There were no significant differences in one and five year RSR for breast cancer between all regions and New Zealand. Figure 37: Five year relative survival rates for breast cancer by Regions and New Zealand, 2002-2006 Northern Central Midland Southern NZ 1.0 0.9 Relative survival rate 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 1 year Time interval 5 year Among the Northern Region DHBs, the five year RSR for breast cancer was lowest in Northland (82%). The Auckland region DHBs had 84-85% five year RSR for breast cancer, but this was not statistically significantly higher than Northland. Figure 38: Five year relative survival rates for breast cancer by Northern Region DHBs, 2002-2006 0.90 Relative survival rate 0.85 0.80 0.75 0.70 0.65 Northland 69 Waitemata Auckland Counties Manukau Northern Cancer Network’s Health Needs Assessment - 2009 Lung cancer The one year RSR for lung cancer was higher in the Northern Region compared to other regions and with New Zealand. The one year RSR for lung cancer in the Northern Region was significantly higher than that for Midland, while the five year RSR was significantly higher than that for all regions and New Zealand. Figure 39: Five year relative survival rates for lung cancer by Regions and New Zealand, 2002-2006 0.50 0.45 Northern Central Midland Southern NZ Relative survival rate 0.40 0.35 0.30 0.25 0.20 0.15 0.10 0.05 0.00 1 year 5 year Time interval The five year RSR for lung cancer was higher in the Auckland DHB (15%) and Waitemata DHB (14%), compared to Counties Manukau (12%) and Northland DHB (12%). However, this was not statistically significant. Figure 40: Five year relative survival rates for lung cancer by Northern Region DHBs, 2002-2006 0.20 0.18 Relative survival rate 0.16 0.14 0.12 0.10 0.08 0.06 0.04 0.02 0.00 Northland 70 Waitemata Auckland Counties Manukau Northern Cancer Network’s Health Needs Assessment - 2009 Colorectal cancer There were no significant differences in the one and five year RSR for colorectal cancer between regions. Figure 41: Five year relative survival rates for colorectal cancer by Regions and New Zealand, 2002-2006 1.0 0.9 Northern Central Midland Southern NZ Relative survival rate 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 1 year 5 year Time interval The five year RSR for colorectal cancer was higher in the Waitemata and Auckland DHB (63%) compared to Counties Manukau (58%) and Northland (57%) but this was not statistically significant. Figure 42: Five year relative survival rates for colorectal cancer by Northern Region DHBs, 2002-2006 0.80 Relative survival rate 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Northland 71 Waitemata Auckland Counties Manukau Northern Cancer Network’s Health Needs Assessment - 2009 Prostate cancer There were no significant differences in the one year RSR for prostate cancer between regions. However, the five year RSR for prostate cancer in the Northern Region (90%) was significantly higher than that for other regions and New Zealand. Figure 43: Five year relative survival rates for prostate cancer by Regions and New Zealand, 2002-2006 Northern Central Midland Southern NZ 1.0 0.9 Relative survival rate 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 1 year 5 year Time interval Although the five year RSR for prostate cancer was lower in the Counties Manukau (87%) and Northland DHBs (89%) compared to Waitemata (95%) and Auckland (93%), this was not statistically significant. Figure 44: Five year relative survival rates for prostate cancer by Northern Region DHBs, 2002-2006 1.00 0.95 Relative survival rate 0.90 0.85 0.80 0.75 0.70 0.65 0.60 0.55 0.50 Northland 72 Waitemata Auckland Counties Manukau Northern Cancer Network’s Health Needs Assessment - 2009 Cervical cancer There were no significant differences in the one year RSR for cervical cancer between regions. However, the five year RSR for cervical cancer was significantly lower in the Northern Region (70.5%) compared to that of the Southern Region (81.1%). Figure 45: Five year relative survival rates for cervical cancer by Regions and New Zealand, 2002-2006 1.0 Northern Central Midland Southern NZ 0.9 Relative survival rate 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 1 year 5 year Time interval Although not significant, Waitemata DHB had lower five year RSR for cervical cancer (64%) compared with other Northern Region DHBs. Figure 46: Five year relative survival rates for cervical cancer by Northern Region DHBs, 2002-2006 1.00 0.90 Relative survival rate 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Northland 73 Waitemata Auckland Counties Manukau Northern Cancer Network’s Health Needs Assessment - 2009 Uterine cancer Although not significant, Northland has lower five year RSR for uterine cancer compared to other Northern Region DHBs and New Zealand. Figure 47: Five year relative survival rates for uterine cancer by Northern Region DHBs, 2002-2006 1.00 Relative survival rate 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Northland Waitemata Auckland Counties Manukau NZ Ovarian cancer Auckland DHB had significantly higher five year RSR for ovarian cancer (55%) than Waitemata DHB (34%) and New Zealand (40%) respectively. Figure 48: Five year relative survival rates for ovarian cancer by Northern Region DHBs, 2002-2006 0.70 Relative survival rate 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Northland 74 Waitemata Auckland Counties Manukau Northern Cancer Network’s Health Needs Assessment - 2009 NZ 6.4. Relative survival rate of common cancers by ethnicity Figure 40 and 41 shows the difference in relative survival rates for major cancers by ethnicity nationally. Data was not available for the Northern Region but ethnic differences similar to that nationally, would be expected in the Northern Region. Maori had lower five year RSR for lung, bowel and prostate cancer compared to European/Other and Pacific people. The five year RSR for lung cancer was significantly lower in Maori people (7.7%) compared to Pacific (16.9%) and European/Other people (10.4%). The five year RSR for colorectal cancer was higher in the European/Other people (61.5%) compared to Maori (47.8%) and Pacific people (49.2%). The five year RSR for prostate cancer was higher in European/Other people (91.3%) than the Maori (74.1%) and Pacific people (81.8%). Figure 49: Five year relative survival rates for lung, bowel and prostate cancer by ethnicity, New Zealand, 2002-2006 1.00 Maori Pacific Other 0.90 Relative survival rate 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Lung Bowel Prostate Figure 50: Five year survival rates of cancers of the ovary, uterus, cervix and breast by ethnicity, New Zealand, 2002-2006 1.00 Maori Pacific Other 0.90 Relative survival rate 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Ovary 75 Uterus Cervix Northern Cancer Network’s Health Needs Assessment - 2009 Breast The five year RSR for cancers of the breast, cervix and uterus were significantly lower for Maori compared to European/Other people. However, the five year RSR for ovarian cancer was higher in Maori than European/Other people. The five year RSR for ovarian and cervical cancer was lowest for Pacific people when compared to Maori and European/Other. 6.5. International comparison of survival of common cancers The following table compares five year survival rates for major cancers in the Northern Region with national and international survival data. Although the time periods are different, they use the same period analysis method and provide a good benchmark for comparison. Five year relative survival for the Northern Region appeared to be comparable to that in Victoria, Australia [16] and the United States[17] for most cancers. The difference in prostate survival may reflect the high prevalence of the Prostate-Specific Antigen (PSA) testing in the United States with active treatment consequently undertaken on numbers of patients who would have survived in any case without intervention. Table 36: Five year relative survival rate (%) for major cancers by Northern Region, New Zealand, Australia (Victoria) and USA Cancer site Northern Region 2002-2006 New Zealand 2002-2006 Victoria (Australia) 2000-2004 USA SEER 1993-1998 Lung 11.1% 8.4% 11% 15.0% Colorectal 60.5% 59.7% 63% 62.2% Breast 84.4% 83.6% 87% 86.4% Cervix 70.6% 72.7% 70% 70.5% Prostate 90.2% 87.5% 84% 98.8% The relative survival for lung, colorectal, breast and prostate cancers was higher in the Northern Region compared to that nationally. However, cervical cancer survival was lower in the Northern Region than that nationally. This could relate to lower cervical screening coverage in the Northern Region, compared to nationally. Colorectal and breast cancer relative survival rates were higher in Victoria than in the Northern Region, while relative survival for prostate cancer was higher in New Zealand, including the Northern Region than in Victoria. 6.6. Key points 76 o The one and five year RSR for all cancers was significantly higher in the Northern Region than all the other regions and New Zealand for the period 2002-2006, o The five year RSR for lung cancer and prostate cancer was significantly higher for the Northern Region than all the other regions and New Zealand for the period 2002-2006, Northern Cancer Network’s Health Needs Assessment - 2009 o The five year RSR for cervical cancer was significantly lower in the Northern Region compared to the Southern Region, o There were no significant differences in one and five year RSR for breast and colorectal cancer between regions, o Maori have lower five year RSR for lung, bowel and prostate cancer nationally than European/Other and Pacific people, o Maori have lower five year RSR nationally for cancers of the breast, cervix and uterus than European/Other people, o The five year RSR nationally for ovarian cancer was higher in Maori people than the European/other people, o The five year RSR nationally for ovarian and cervical cancer was lowest for Pacific people, compared to the other ethnic groups, o The five year RSR for lung and cervical cancers in the Northern Region were comparable to that in Victoria, Australia, o The five year RSR for breast and colorectal cancers were slightly better and that for prostate cancer was worse in Victoria, compared to the Northern Region, o There were no significant differences in the one and five year RSR for lung, bowel, breast, prostate, cervical and uterine cancers in the Northern Region during the period 2002-2006, o Auckland DHB had significantly higher five year RSR for ovarian cancer (55%) than Waitemata DHB (34%) and New Zealand (40%). 77 Northern Cancer Network’s Health Needs Assessment - 2009 7. Chapter Seven: Cancer treatment 7.1. Overview The main methods of treatment for cancer are surgery, chemotherapy and radiotherapy. In New Zealand, six regional oncology centres provide medical oncology, radiation oncology and haematology services. These centres are in Auckland, Hamilton, Palmerston North, Wellington, Christchurch and Dunedin. The Auckland cancer centre serves as the regional centre for the Northern Region. Although radiation treatment is only offered at these six centres, chemotherapy and surgical services are offered in most hospitals. There is lot of interface between public and private sectors in oncology treatment with part of the journey in the private sector, particularly for the investigation phase. A recent study of bowel cancer showed that approximately 25% of colon cancer patients were diagnosed in private and nearly 20% had surgery in the private sector. [18] This section provides the radiotherapy intervention rates and radiotherapy waiting time only. Meaningful data for chemotherapy and surgery is not currently available. In future, the Network, with its tumour stream work should be able to provide meaningful data regarding the primary care and secondary care service interface and time lines from the first specialist appointment to investigations, and treatment for respective tumours. This will provide better information on the regional and ethnic disparities in cancer treatment. 7.2. Radiotherapy Radiotherapy is a critical component of both radical cancer treatment, where the aim is to improve local control of the cancer, and palliative treatment, where the aim is to provide symptom relief in the case of incurable cancer. There is an extensive literature reporting the effectiveness of radiotherapy in improving patient outcomes. [19-21] This is true in both definitive (isolated treatment) and adjuvant (treatment in combination with other modalities, such as delivery after surgery) settings. Of those cured of their cancer it is estimated that radiotherapy contributes to the cure in 40% of cases either alone or in combination with other treatments such as surgery. Table 37: Estimated radiotherapy treatment intervention rates by Northern Region DHBs and New Zealand, 2004/05 – 2006/07 DHB Northland Waitemata Auckland Counties Manukau Northern Region New Zealand 2004/05 27.7% 36.1% 34.4% 31.2% 33.2% Estimated intervention rate 2005/06 25.7% 34.7% 38.2% 34.5% 34.5% 2006/07 26.7% 36.7% 37.8% 37.6% 35.9% 36.4% 35.9% 35.7% Source: Cancer Registry, Personal Health Non Case Weight (PHNCW) and Breast Screen Aotearoa (BSA) 78 Northern Cancer Network’s Health Needs Assessment - 2009 The radiotherapy treatment intervention rate is defined as the proportion of people with cancer who receive at least one course of radiation treatment. Details regarding the method of calculation are available in Appendix 10.3. Based on the recommendations of the National Radiotherapy Advisory Group in England, and applying the model to New Zealand cancer registrations, it was estimated that approximately 45-46% of people diagnosed with cancer need radiotherapy.1 The estimated radiotherapy intervention rate in 2006/07 for the Northern Region had slightly increased over the three years and was approximately 36%. This was similar to the national radiotherapy intervention rate of 35.7%. Among the Northern Region DHBs, Northland had a significantly lower radiation intervention rate (approximately 27%), when compared with the other Northern Region DHBs. All other Northern Region DHBs had slightly higher radiotherapy intervention rates than the national rates (3738% approximately). 7.3. Radiotherapy waiting times Radiotherapy treatment waiting times are well-established as the main indicator used to measure system performance. Radiotherapy treatment waiting time is one of the ten health targets set by the Ministry of Health. The health target in 2007/08 for radiotherapy times was ‘all patients in category A (acute), B (curative) and C (palliative and radical) wait less than eight weeks between the first specialist assessment and the start of radiation oncology treatment’. This has changed for 2008/09 to less than 6 weeks. Category D (combined chemotherapy and radiotherapy) patients are excluded. (Refer to Appendix 10.4 for details on definitions of prioritisation categories for radiation treatment). Figure: Number of patients within radiotherapy waiting time categories (priority A, B & C) in Northern Region, 2003-2008 180 less than 4 160 4--8 >8 140 120 100 80 60 40 20 Ap ri l Au gu st D ec em be r Au gu st D ec em be r Ap ri l Au gu st D ec em be r Ap ri l Au gu st D ec em be r Ap ri l Au gu st D ec em be r -20 Ap ri l Ap ri l Au gu st D ec em be r 0 Source: Ministry of Health, radiotherapy waiting time data 2003-2008 1 Northern Region Radiotherapy Strategic Plan Working Group 79 Northern Cancer Network’s Health Needs Assessment - 2009 In general, the average number of patients (priority A, B and C) waiting for more than 8 weeks for radiotherapy in the Northern Region was less than 10%. However, each year there were monthly fluctuations. 7.4. Key points 8. o For the year 2006/07, the Northern Region had similar radiotherapy intervention rates to national rates, o The radiotherapy intervention rates for Northland were significantly lower than the other Northern Region DHBs, o The radiotherapy waiting time target of less than 8 weeks between the first specialist assessment and the start of radiation treatment was generally met in the Northern Region. Chapter Eight: Conclusions This document commences a formal assessment of the health needs analysis in regards to cancer for the population at a regional level. Key results were presented, interpreted and discussed. The report not only identifies the regional inequalities for the total population but also the disparities between different ethnicities at district and regional levels. Findings from these analyses will inform the Northern Cancer Network Strategic Plan 2009-14. Further, the report will would assist the cancer care stakeholders to identify priorities for their districts or areas. This report can be used as baseline data against which improvements can be measured. It is recognised that there are many other analyses and areas that could be covered in such a report. It is expected that future reports will build on this one. 80 Northern Cancer Network’s Health Needs Assessment - 2009 9. Chapter Nine: References [1] Cancer Control Taskforce. The New Zealand Cancer Control Strategy: Action Plan 2005-2010Wellington: Ministry of Health; 2005. [2] Salmond C, Crampton P, Atkinson J. NZDep2006 Index of Deprivation. Wellington: Department of Public Health, University of Otago; August 2007. [3] National Centre for Classification in Health. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Third Edition. Sydney: National Centre for Classification in Health.; 2002. [4] Ministry of Health. Ethnicity Data Protocols for the Health and Disability Sector. Wellington: Ministry of Health; 2004. [5] Ministry of Health. The New Zealand Cancer Control Strategy. Wellington: Ministry of Health and the New Zealand Cancer Control Trust; 2003. [6] Ministry of Health. Cancer: New Registrations and Deaths 2005. Wellington: Ministry of Health; 2008. [7] National Screening Unit. National Cervical Screening Programme DHB Report. Wellington: Ministry of Health; June 2008. [8] Robinson T, Bullen C, Humphries W, Hornell J, Moyes C. The New Zealand Hepatitis B Screening Programme: screening coverage and prevalence of chronic hepatitis B infection. The New Zealand Medical Journal. March 2005; 118(1211). [9] Robson B, Harris R. Hauora: Maori Standards of Health IV. A study of the years 2000-2005. Wellington: Te Ropu Rangahau Hauora a Eru Pomare; November 2007. [10] Ministry of Health. Asian Health Chart Book 2006. Wellington: Ministry of Health; 2006. [11] Australian Institute of Health and Welfare, Cancer Australia & Australasian Association of Cancer Registries. Cancer survival and prevalence in Australia: cancers diagnosed from 1982 to 2004. Canberra: AIHW; 2008. [12] Robson B, Purdie G, Cormack D. Unequal Impact: Māori and Non-Māori Cancer Statistics 1996–2001. Wellington: Ministry of Health; 2005. [13] Jeffreys M, Stevanovic V, Tobias M, Lewis C, Ellison-Loschmann L, Pearce N, et al. Ethnic Inequalities in Cancer Survival in New Zealand: Linkage Study. Am J Public Health. 2005 May 1, 2005; 95(5):834-7. [14] Haynes M, Smedley B. The Unequal Burden of Cancer: An assessment of NIH research and programs for ethnic minorities and the medically underserved. Washington DC: National Academy Press; 1999. [15] Shavers V, Brown M. Racial and ethnic disparities in the receipt of cancer treatment. Journal of the National Cancer Institute. 2002; 94:334-57. 81 Northern Cancer Network’s Health Needs Assessment - 2009 [16] English D, Farrugia H, Thursfield V, Chang P, Giles G. Cancer Survival Victoria 2007: Estimates of survival in 2004 (and comparisons with earlier periods) Melbourne, Victoria: Victorian Cancer Registry, Cancer Epidemiology Centre, The Cancer Council Victoria; 2007. [17] Brenner H. Long-term survival rates of cancer patients achieved by the end of the 20th century: a period analysis. Lancet. 2002; 360(9340):1131-5. [18] Cunningham R, Sarfati D, Hill S, Dennett E, O'Donnell A. Colon cancer management in New Zealand: 1996-2003. New Zealand Medical Journal. 2009; 122(1294):51-60. [19] Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15 year survival: an overview of the randomised trials. Lancet. 2005; 366:2087-106. [20] Widmark A et al. A randomised trial comparing antiandrogens with or without radiotherapy in the treatment of locally advanced prostate cancer: survival and QOL outcome. Int J Radiat Oncol Biol Phys. 2008; 72(1). [21] Swanson G et al. Update of SWOG 8794: Adjuvant Radiotherapy for pT3 prostate cancer improves metastasis free survival. Int J Radiat Oncol Biol Phys. 2008; 72(1). 82 Northern Cancer Network’s Health Needs Assessment - 2009 10. Appendices 10.1. World Health Organisation Standard Population Age group (years) WHO world population* 0–4 8.86 5–9 8.69 10-14 8.60 15–19 8.47 20–24 8.22 25–29 7.93 30–34 7.61 35–39 7.15 40–44 6.59 45–49 6.04 50–54 5.37 55–59 4.55 60–64 3.72 65–69 2.96 70–74 2.21 75–79 1.52 80–84 0.91 85+ 0.63 Total 100.00 • For the purposes of comparison, the WHO Standard age group 85+ is an aggregate of the age groups 85-89, 90-94, 95-99 and 100+. 10.2. ICD -10 AM codes The following ICD codes are identified and used in the Northern Cancer Network HNA: Code C00 – C14 C15 C16 C17 C18 – C21 C22 – C24 C25 C33 – C34 C40 – C41 C43 C 44 C50 C53 83 Malignant neoplasm Lip, oral cavity and pharynx Oesophagus Stomach Small Intestine Colorectal Liver, biliary tract Pancreas Trachea. Bronchus and lung Bone, joints and articular cartilage Malignant melanoma of skin Other malignant neoplasms of skin Breast Cervix Code C54 – C55 C56 C61 C62 C64 C67 C69 – C72 C73 C81 C82–C85, C96 C91 – C95 D45 – D 47 Malignant neoplasm Uterus Ovary Prostate Testes Kidney, except renal pelvis Bladder Eyes, brain & other parts of CNS Thyroid gland Hodgkin lymphoma Non-Hodgkin lymphoma Leukaemia Chronic myeloproliferative disorders Northern Cancer Network’s Health Needs Assessment - 2009 10.3. Calculation of radiotherapy intervention rate The radiation treatment intervention rate is defined as the proportion of people with cancer who receive at least one course of radiation treatment. The method used for calculating this rate is to compare the relative size of two cohorts: • The number of people who receive radiation treatment in a financial year (e.g., 2004/05) • The number of people with registered cancer in a calendar year (e.g., 2004) We also have to take account of people who are receiving a second course of radiation treatment. Radiation oncologists estimate the ‘re-treatment rate’ to be around 25 percent. We therefore assume that 75% of all those who receive radiation treatment in a given financial year are receiving their first course of radiation. The ‘intervention rate’ is therefore: The total individuals receiving treatment (in a given financial year) x 0.75 / total cancer registrations (in the previous calendar year). ‘Total individuals receiving treatment’ is defined as the number of distinct National Health Index (NHI) numbers appearing under the radiation treatment purchase unit (M5005) in data supplied by DHBs to the Personal Health Non Case Weight (PHNCW) data collection process. Until the 2008/09 year, treatment services for breast cancer patients referred through the Breast Screen Aotearoa (BSA) screening programme have been funded separately by BSA. Because the PHNCW has been used to calculate inter-district flow (IDF) payments between DHBs, data on BSA-funded patients has not been provided to the Ministry of Health. Volume information on BSAfunded treatment has been obtained separately. BSA-funded patients are assumed to have the same average number of attendances as other patients (around 17), and so total volumes are divided by this number to calculate the number of BSA-funded individuals receiving radiation treatment. This number is then added to the number of NHIs found in the PHNCW data. Total cancer registrations by DHB are available directly from the Cancer Registry for the years up to and including 2005. Provisional registration data is not yet available for 2006. In order to obtain a denominator for the 2006/07 treatment data, average actual registrations for the years 2003—05 have been calculated, then increased by the 10year historical growth rate of 1.6% for two years to obtain estimated average registrations for the years 2005—07. The final column under ‘estimated intervention rate’ is therefore more provisional and subject to modification when the 2006 registrations are available 84 Northern Cancer Network’s Health Needs Assessment - 2009 10.4. Radiotherapy treatment booking priorities Priority category A Urgent B Curative Good practice Maximum acceptable Criteria Within 24 hours Patients with rapidly progressive complications of malignancy that require rapid treatment to prevent or minimise severe morbidity or life threat Within 2 weeks Examples Spinal cord compression Superior vena cava obstruction Cord equina compression Major lifethreatening haemorrhage not amenable to surgical intervention Major upper airways or bronchial obstruction with stridor Tumours for which Head and neck radiation cancer treatment usually Bladder cancer results in Carcinoma 20 percent or better oesophagus survival Paediatric at five years and cancer there is High grade Non evidence that delay Hodgkin’s may Lymphoma compromise chance Hodgkin’s of cure Disease Patient fit to have Cervix cancer radical Pre-operative radiation treatment radiation treatment C Palliative Within 4 weeks Radical or adjuvant Prostate cancer Palliativeand treatment radiation Post operative other within 2 weeks treatment where breast cancer radical or sooner there is no Post operative according to clear evidence that endometrial severity of short cancer symptoms delays are likely to Skin cancer affect the Seminoma outcome testis (stage I) Brain tumours D Combined chemotherapy and radiation treatment 85 Start date booked according to treatment schedule Patients having Anal cancer combined Oesophageal radiation treatment cancer and Bladder cancer chemotherapy Rectal cancer where safe, Paediatric effective sequencing cancer of Hodgkin’s treatment modalities disease Northern Cancer Network’s Health Needs Assessment - 2009 is Non-Hodgkin’s required lymphoma Tumours treated Patients in according clinical trials to clinical trial or documented referenced national/international protocols Note When treatment resources do not allow priority C patients to start treatment within four weeks, priorities for A, B and D should not change. Priority C patients should be started as soon as possible but could expect delays longer than the accepted maximum of 4 weeks. 86 Northern Cancer Network’s Health Needs Assessment - 2009 87 Northern Cancer Network’s Health Needs Assessment - 2009