The changing face of cancer care
Cancer care centres in New Zealand are under pressure due to limited resources and the increasing need for their services.
Over the next 15 years it is predicted this demand will increase significantly.1 Despite a decrease in age-standardised
cancer incidence rates, the need for cancer services is increasing due to an ageing population, earlier diagnosis, improved
survival rates and the availability of newer, more targeted chemotherapy medicines. Two-thirds of people diagnosed with
cancer can now expect to live beyond five years, and 80% of people with prostate and breast cancer will be long-term survivors.2 The
result is that more people are living with a diagnosis of cancer and requiring ongoing treatment, surveillance and support.
Medical Oncology National Implementation Plan
To ease the burden on oncology services, and ensure that services are sustainable for the future, a plan has been devised
to set a new national framework for managing cancer treatment and follow-up.3The plan is to be implemented
over the next three to five years.
The plan is separated into three main activities:
- Devise a four-level service centre model, i.e. set up a system where patients can be directed to one of four types
of cancer care service, depending on the complexity of their treatment
- Establish the workforce needs, i.e. determine the requirements for staffing of the cancer service centres, which will
involve oncologists, other clinical and non-clinical roles
- Define a framework for assessing cancer treatment needs, i.e. formulate a consistent approach to directing patients
to the appropriate level of cancer service centre, based on tumour type
Establishing the workforce
In the next 12 months, work will be undertaken on identifying cancer care services that can be devolved to other clinicians
(i.e. non-oncologists). This means defining the scope of practice, training and qualification requirements of the clinicians
involved, as well as establishing support and supervisory systems. It is hoped that these clinical roles will be implemented
A tumour specific approach
The five most common cancers in New Zealand (colorectal, breast, prostate, melanoma and lung) account for 90% of cancer
treatment volumes, and an estimated 70% of oncology treatments are considered routine.3 In order to stratify
cancer treatment from routine to complex, eight tumour types have been identified. The treatment that a patient with cancer
receives, and therefore the place that this treatment is undertaken, will be determined by nationally consistent protocols,
based on tumour type.
Cancer service centres
It is proposed that four levels of cancer care service centres are established, to meet the differing treatment needs
of patients. General Practitioners and other primary care clinicians are most likely to be involved in Level 1 and 2 centres.
Level 1 cancer care service centres will offer non-complex, low-risk, day-based chemotherapy treatment, as well as education
and support for patients and their families/whānau, and follow-up services. In some cases, it is possible that these
centres would be part of an integrated general practice clinic, with General Practitioners and nurses involved in provision
of treatment and follow-up management. Clinicians would receive appropriate post-graduate theoretical and practical training
in order to deliver these services.
Level 2 cancer care service centres will offer all the Level 1 services, plus outpatient clinic care by Senior Medical
Officers and Medical Oncologists. In addition, a complex needs co-ordinator will provide support for primary care clinicians
caring for patients with cancer.
Level 3 and 4 cancer care services centres provide more complex day-treatment and inpatient (hospital) care.
A streamlined referral process
Although not all primary care clinicians will be a part of delivering specific cancer treatments, all will continue
to play a key role in surveillance and detection of cancer, and referral to cancer services.
Improved diagnosis and referral standards will lessen the workload of clinicians providing cancer care. National standards
will be devised to ensure that referrals are appropriate, timely and directed to the correct pathway, and clinicians will
be given guidance on what supporting information and investigations should accompany the referral.
Roles within the referral pathway will be defined, based on treatment needs. The First Specialist Assessment of patients
with cancer categorised as “non-complex” or standard, may potentially be carried out by a General Practitioner or nurse
(with training in oncology). Primary care clinicians may also be involved in counselling, education and pre- and post-clinic
follow-up, e.g. additional investigations and referrals.
Follow-up after cancer treatment
It is anticipated that General Practitioners (with training in oncology) will have a key involvement in follow-up of
patients after cancer treatment, and monitoring for recurrence or other adverse effects of treatment. Protocols will be
established for delivering this care and referral pathways and additional support put in place.
Where to now?
The exact specifications of the Medical Oncology National Implementation Plan will unfold over the next 12 months and
beyond. The Ministry of Health has set aside funding to support the national and regional infrastructure required to establish
and deliver these services. Written communication and face-to-face meetings will take place to discuss and inform key
stakeholders of the progress of the implementation plan.
In the meantime, cancer care services will continue to be delivered throughout New Zealand by the six major cancer networks,
and primary care clinicians should continue to provide cancer detection, referral and follow-up support as required.
For further information see: “Medical oncology implementation plan 2012/13”,
available from: www.health.govt.nz Keyword search: oncology
The role of primary care in the management of people with cancer
The requirements for the care of people with cancer fit well within the strengths of primary care, and have many similarities
with the management of long-term conditions. A systematic review found no difference in patient wellbeing, psychological
morbidity or satisfaction between primary and secondary care follow-up of people with breast cancer.4
Primary care practitioners are well placed to:
- Provide education and psychosocial support to patients and their families/whānau, which may include referral
to community support agencies, e.g. Māori health providers, hospice care, counselling services
- Help to monitor patients’ haematological and biochemical status during chemotherapy
- Manage medicines and common chemotherapy and radiotherapy adverse effects
- Perform surveillance to detect cancer recurrence, both local and metastatic
- Anticipate and manage transitions, e.g. from the curative to palliative phase
What are the specific challenges for primary care?
Continuity of care and effective communication are both critical in establishing a partnership between providers for
cancer management. Care plans must be established to ensure agreed understanding of surveillance programmes for individual
patients, and criteria and pathways for re-entry back into cancer care services when required.
Information technology will play an important role in managing patients with cancer within the practice. Decision support
tools can improve interpretation of cancer markers, and practice based cancer registers can enable pathways of care for
surveillance and follow up.
Disparities in cancer-related health outcomes already exist for Māori and people in lower socioeconomic groups.5,6 There
is evidence that Māori males have a decreased incidence of cancer (all types), yet have increased mortality from
cancer, greater than all other ethnicities in New Zealand.7 It is important that the implementation of a new
framework does not further compound the problem. Although the Medical Oncology National Implementation plan does not make
specific recommendations for reducing disparities, the nationally consistent guidelines for care that will be developed
and implemented have the potential to help to address this problem and ensure that the right level of treatment and follow-up
is available to every patient with cancer. Primary care clinicians have an important role in ensuring that, in particular,
Māori and people in lower socioeconomic groups access cancer care services and that appropriate support is provided
to them and their whānau.