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Aust. J. Rural Health (2015) ••, ••–••
Short Report Radiotherapy: The tyranny of distance Eswaran Waran, MBBS FRACGP FAChPM Territory Palliative Care, Royal Darwin Hospital, Darwin, Northern Territory, Australia
In June 2002 the Baume report (Radiation Oncology Inquiry) was released by the Department of Health and Ageing.1 One of its major recommendations was to improve the availability of radiotherapy in rural and regional Australia. This report played a fundamental role in the establishment of the Alan Walker Cancer Care Centre (AWCCC) in Darwin in March of 2010. This allowed patients in the Top End of Australia to access radiotherapy treatment locally. Prior to this patients requiring radiotherapy had to travel to Adelaide – a 6000-km return trip. The incidence, morbidity and mortality of lung cancer are higher in Indigenous than non-Indigenous Australians,2 and it is widely acknowledged that radiotherapy plays a significant role in the palliative relief of the morbidity of advanced lung cancer. This study examined the use of radiotherapy in Darwin for Indigenous patients with metastatic lung cancer before and after the local availability of radiotherapy.
Participants, methods, and results Ethics approval was granted by the Human Research Ethics committee of the NT Department of Health and Menzies School of Research. Indigenous patients with lung cancer were identified using the Northern Territory cancer registry for the period between 1 January 2002 and 1 December 2012. The inclusion criteria were as follows: Indigenous background, metastatic disease, complete medical records and deceased status. A search of the patient database was undertaken with the following information collected: radiotherapy data (date and site treated) and date of diagnosis of metastatic disease. A total of 73 patients were included in the analysis, with a mean age at diagnosis of 58.4 years. Of these patients, 57 had a diagnosis prior to 20 March 2010 (commenceCorrespondence: Dr Eswaran Waran, Territory Palliative Care, Royal Darwin Hospital, 105 Rocklands Drive, Tiwi, Northern Territory, 0810, Australia. Email: [email protected] Declaration of conflict of interest: No competing financial interests exist. Site of research: Royal Darwin Hospital, 105 Rocklands Drive, TIWI, NT, 0810, Australia. © 2015 National Rural Health Alliance Inc.
ment of radiotherapy in Darwin). A total of 26 patients received radiotherapy. Of these patients, 16 were in the group with a diagnosis prior to 20 March 2010. The radiotherapy utilisation prior and post local availability of radiotherapy were 28.1% and 62.5% respectively (Table 1).
Comment This report demonstrates the improved use of radiotherapy post-local availability of this treatment in Darwin. The role of radiotherapy in the group studied was of a palliative nature. Treatment is aimed at reducing symptoms such as pain and shortness of breath. The improved use since local availability of radiotherapy suggests an improved ability to manage patient symptoms since 20 March 2010. Additionally, radiotherapy being available in Darwin has been associated with a financial benefit to the Northern Territory government. It has been estimated that for each patient not requiring interstate travel approximately $5000 has been saved in transport and accommodation costs (in a personal communication with Mr Kar Giam, practice manager AWCCC on 29 April 2015). Rural and remote Australians have poorer cancer outcomes than their city comrades, and two thirds of Indigenous Australians live outside of its capital cities.2 Poorer outcomes in Indigenous Australians living in rural and remote communities have likely multifactorial aetiologies including delayed and or advanced stage at diagnosis,2 lower socio-economic status,2 poorer treatment3 and remote location.4 Baade et al. showed that in patients with rectal cancer, mortality increased by 6% for every 100 km from a radiotherapy facility.5 Some rural and remote Australians choose to compromise their cancer care rather than travel significant distance.4 Relocation away from family and community has been identified as barriers to effective cancer care in Indigenous Australians.2 The psychological and social morbidity of such displacement was further clarified in a qualitative study by Martin-McDonald et al.6 The initial incentives from the Baume report that led to the AWCCC was boosted by a $560 million investment announced in 2010 for additional regional cancer centres.7 It is hoped that the continuing expansion of the doi: 10.1111/ajr.12215
2 TABLE 1:
E. WARAN
Acknowledgments
Radiotherapy data
Radiotherapy data
Present
Percentage
Had radiotherapy Had radiotherapy to lung Had radiotherapy to bone Had WBRT† Had radiotherapy in last 2 weeks Had radiotherapy with diagnosis before 20 March 2010‡ Had radiotherapy with diagnosis after 20 March 2010‡
26/73 10/26 12/26 11/26 5/73 16/57
35.6 38.5 46.2 42.3 6.8 28.1
10/16
62.5
†All WBRT was for brain metastasis. ‡Radiotherapy became available in the Northern Territory on 20 March 2010. WBRT, whole brain radiotherapy.
regional cancer centre initiative will lead to further improvements in access and support for cancer patients in rural, regional and remote Australia. Future studies could examine changes in the use of curative and palliative radiotherapy since the establishment of the AWCCC. Survival data pre- and post-local availability could be examined for cancers treated locally with a curative intent. With improved use one may expect improved survival.
Conclusion This small study demonstrated the increased use of radiotherapy after the local availability of radiotherapy in a regional centre. The increased funding for radiotherapy since the Baume report of 2002 has been associated with improved access to an essential cancer service.
The author acknowledges the part contribution of Dr Narayan Karanth in the conception and design of this study and would like to thank Mr Kar Giam for providing historical information regarding the Alan Walker Cancer Care Centre.
References 1 Baume P. A Vision for Radiotherapy: Report of the Radiation Oncology Inquiry. Canberra: Commonwealth of Australia Department of Health and Ageing, 2002. 2 Cunningham J, Rumbold AR, Zhang X, Condon JR. Incidence, aetiology, and outcomes of cancer in indigenous peoples in Australia. The Lancet Oncology 2008; 9: 585– 595. 3 Jong KE, Vale PJ, Armstrong BK. Rural inequalities in cancer care and outcome. The Medical Journal of Australia 2005; 182: 13–14. 4 Smith T. A long way from home: access to cancer care for rural Australians. Radiography 2012; 18: 38–42. 5 Baade PD, Dasgupta P, Aitken JF, Turrell G. Distance to the closest radiotherapy facility and survival after a diagnosis of rectal cancer in Queensland. The Medical Journal of Australia 2011; 195: 350–354. 6 Martin-McDonald K, Rogers-Clark C, Hegney D, McCarthy A, Pearce S. Experiences of regional and rural people with cancer being treated with radiotherapy in a metropolitan centre. International Journal of Nursing Practice 2003; 9: 176–182. 7 Australian Government Department of Health and Ageing. 2010. [Cited 8 Jan 2015]. Available from URL: http://www.health.gov.au/internet/publications/publishing .nsf/Content/cancer-policy-booklet~What+the+Government +is+doing+to+tackle+cancer
© 2015 National Rural Health Alliance Inc.
Aust. J. Rural Health (2015) ••, ••–••
Short Report Radiotherapy: The tyranny of distance Eswaran Waran, MBBS FRACGP FAChPM Territory Palliative Care, Royal Darwin Hospital, Darwin, Northern Territory, Australia
In June 2002 the Baume report (Radiation Oncology Inquiry) was released by the Department of Health and Ageing.1 One of its major recommendations was to improve the availability of radiotherapy in rural and regional Australia. This report played a fundamental role in the establishment of the Alan Walker Cancer Care Centre (AWCCC) in Darwin in March of 2010. This allowed patients in the Top End of Australia to access radiotherapy treatment locally. Prior to this patients requiring radiotherapy had to travel to Adelaide – a 6000-km return trip. The incidence, morbidity and mortality of lung cancer are higher in Indigenous than non-Indigenous Australians,2 and it is widely acknowledged that radiotherapy plays a significant role in the palliative relief of the morbidity of advanced lung cancer. This study examined the use of radiotherapy in Darwin for Indigenous patients with metastatic lung cancer before and after the local availability of radiotherapy.
Participants, methods, and results Ethics approval was granted by the Human Research Ethics committee of the NT Department of Health and Menzies School of Research. Indigenous patients with lung cancer were identified using the Northern Territory cancer registry for the period between 1 January 2002 and 1 December 2012. The inclusion criteria were as follows: Indigenous background, metastatic disease, complete medical records and deceased status. A search of the patient database was undertaken with the following information collected: radiotherapy data (date and site treated) and date of diagnosis of metastatic disease. A total of 73 patients were included in the analysis, with a mean age at diagnosis of 58.4 years. Of these patients, 57 had a diagnosis prior to 20 March 2010 (commenceCorrespondence: Dr Eswaran Waran, Territory Palliative Care, Royal Darwin Hospital, 105 Rocklands Drive, Tiwi, Northern Territory, 0810, Australia. Email: [email protected] Declaration of conflict of interest: No competing financial interests exist. Site of research: Royal Darwin Hospital, 105 Rocklands Drive, TIWI, NT, 0810, Australia. © 2015 National Rural Health Alliance Inc.
ment of radiotherapy in Darwin). A total of 26 patients received radiotherapy. Of these patients, 16 were in the group with a diagnosis prior to 20 March 2010. The radiotherapy utilisation prior and post local availability of radiotherapy were 28.1% and 62.5% respectively (Table 1).
Comment This report demonstrates the improved use of radiotherapy post-local availability of this treatment in Darwin. The role of radiotherapy in the group studied was of a palliative nature. Treatment is aimed at reducing symptoms such as pain and shortness of breath. The improved use since local availability of radiotherapy suggests an improved ability to manage patient symptoms since 20 March 2010. Additionally, radiotherapy being available in Darwin has been associated with a financial benefit to the Northern Territory government. It has been estimated that for each patient not requiring interstate travel approximately $5000 has been saved in transport and accommodation costs (in a personal communication with Mr Kar Giam, practice manager AWCCC on 29 April 2015). Rural and remote Australians have poorer cancer outcomes than their city comrades, and two thirds of Indigenous Australians live outside of its capital cities.2 Poorer outcomes in Indigenous Australians living in rural and remote communities have likely multifactorial aetiologies including delayed and or advanced stage at diagnosis,2 lower socio-economic status,2 poorer treatment3 and remote location.4 Baade et al. showed that in patients with rectal cancer, mortality increased by 6% for every 100 km from a radiotherapy facility.5 Some rural and remote Australians choose to compromise their cancer care rather than travel significant distance.4 Relocation away from family and community has been identified as barriers to effective cancer care in Indigenous Australians.2 The psychological and social morbidity of such displacement was further clarified in a qualitative study by Martin-McDonald et al.6 The initial incentives from the Baume report that led to the AWCCC was boosted by a $560 million investment announced in 2010 for additional regional cancer centres.7 It is hoped that the continuing expansion of the doi: 10.1111/ajr.12215
2 TABLE 1:
E. WARAN
Acknowledgments
Radiotherapy data
Radiotherapy data
Present
Percentage
Had radiotherapy Had radiotherapy to lung Had radiotherapy to bone Had WBRT† Had radiotherapy in last 2 weeks Had radiotherapy with diagnosis before 20 March 2010‡ Had radiotherapy with diagnosis after 20 March 2010‡
26/73 10/26 12/26 11/26 5/73 16/57
35.6 38.5 46.2 42.3 6.8 28.1
10/16
62.5
†All WBRT was for brain metastasis. ‡Radiotherapy became available in the Northern Territory on 20 March 2010. WBRT, whole brain radiotherapy.
regional cancer centre initiative will lead to further improvements in access and support for cancer patients in rural, regional and remote Australia. Future studies could examine changes in the use of curative and palliative radiotherapy since the establishment of the AWCCC. Survival data pre- and post-local availability could be examined for cancers treated locally with a curative intent. With improved use one may expect improved survival.
Conclusion This small study demonstrated the increased use of radiotherapy after the local availability of radiotherapy in a regional centre. The increased funding for radiotherapy since the Baume report of 2002 has been associated with improved access to an essential cancer service.
The author acknowledges the part contribution of Dr Narayan Karanth in the conception and design of this study and would like to thank Mr Kar Giam for providing historical information regarding the Alan Walker Cancer Care Centre.
References 1 Baume P. A Vision for Radiotherapy: Report of the Radiation Oncology Inquiry. Canberra: Commonwealth of Australia Department of Health and Ageing, 2002. 2 Cunningham J, Rumbold AR, Zhang X, Condon JR. Incidence, aetiology, and outcomes of cancer in indigenous peoples in Australia. The Lancet Oncology 2008; 9: 585– 595. 3 Jong KE, Vale PJ, Armstrong BK. Rural inequalities in cancer care and outcome. The Medical Journal of Australia 2005; 182: 13–14. 4 Smith T. A long way from home: access to cancer care for rural Australians. Radiography 2012; 18: 38–42. 5 Baade PD, Dasgupta P, Aitken JF, Turrell G. Distance to the closest radiotherapy facility and survival after a diagnosis of rectal cancer in Queensland. The Medical Journal of Australia 2011; 195: 350–354. 6 Martin-McDonald K, Rogers-Clark C, Hegney D, McCarthy A, Pearce S. Experiences of regional and rural people with cancer being treated with radiotherapy in a metropolitan centre. International Journal of Nursing Practice 2003; 9: 176–182. 7 Australian Government Department of Health and Ageing. 2010. [Cited 8 Jan 2015]. Available from URL: http://www.health.gov.au/internet/publications/publishing .nsf/Content/cancer-policy-booklet~What+the+Government +is+doing+to+tackle+cancer
© 2015 National Rural Health Alliance Inc.
