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Aust. J. Rural Health (2015) 23, 2–3

Special Issue – Rural Cancer Editorial There is another gap to narrow Evidence consistently points to worse cancer outcomes for rural Australians. Improved access to diagnostic and treatment services is commonly identified as the solution, yet access to services is only one of a set of complex factors associated with these disparities. While there are great advances being made through the Australian Government’s investment in Regional Cancer Centres, this should not negate an emphasis on understanding all the factors contributing to disparities in outcomes in order to develop system-wide solutions. The social determinants of health are drawn into sharp focus when considering the outcomes for people who live in rural, remote and very remote parts of Australia. An additional challenge is that lifestyle risk factors for cancer are generally higher in these populations, compounding other factors such as lower screening participation rates that also influence health outcomes. The overlap between socio-economic disadvantage, lifestyle risk factors, Aboriginality or being from culturally and linguistically diverse backgrounds and rurality creates a complex milieu of health disadvantage, especially in cancer. The authors of the papers in this edition1,2 explore some of the reasons for disparities experienced by people from the bush and some of the innovative solutions that are being used to overcome these disparities. The significant reliance of our health system on effective primary care is another factor potentially influencing outcomes, as rural Australians often have poorer access to primary care with, on average, lower doctor to patient ratios and sometimes high turnover of staff. Doctors new to the bush also face the challenge of establishing their own referral networks to specialist services without clear guidance on when it is appropriate to refer to local treatment centres and where better outcomes are achieved by travel to a larger centre, such as for rare and complex surgical resections. The health behaviours of some patients and clinicians may be influenced by their underlying beliefs, their expectations or, at times, a pervasive nihilism that influences the way and the timing of interactions with health services. Stronger engagement with primary care requires specialist services and their clinicians to think differently about how they interact with, and provide support for primary care practitioners in isolated settings. This includes ensuring that there is timely documentation of the treatments being offered, the goals of care (cure, life prolongation, palliation) and the particular issues that a © 2015 National Rural Health Alliance Inc.

primary care practitioner should consider, especially if they have to see the patient for an unplanned consultation. The role of primary care practitioners across the cancer pathway from prevention and diagnosis, through treatment, survivorship and palliative care requires new thinking if cancer care is to be successfully delivered closer to home for people in rural Australia. As we build a health system that continues to deliver some of the best cancer outcomes in the world, we will require a more patient-centred approach to service development. This includes decentralising services wherever possible, creating new models of care and ensuring the necessary connectivity between specialist, primary and community services with a greater focus on enabling patient and family self-management. These models will challenge many current models of delivering specialist services. At the same time, if we are to deliver better outcomes, there are specific procedures for some cancers which will continue to require sub-specialist support in larger centres in order to further improve survival. We need to understand what treatment and care can be decentralised and what needs to be centralised in order to get best possible outcomes. However, it is important not to assume rural and remote Australia as always worse off. As Burns et al.3 identify, access to palliative care is better in rural South Australia, and the communities in which these people are dying are providing more supportive, practical care. This issue of the Australian Journal of Rural Health presents a combination of new evidence, synopses of current evidence and working examples within the Australian health system of the emerging models of care that can be scaled up in order to improve systematically access to high-quality services mostly closer to home. The papers4–6 examine how health systems can evolve to better meet the needs of people at risk of, diagnosed with and being treated for cancer in Australia. Innovations such as these will help cancer services to reinvent the delivery of care with the aim of reducing the postcode lottery of cancer outcomes. The health of rural and remote Australians is the responsibility of us all. We trust that this edition of the Australian Journal of Rural Health will help to continue an important dialogue about how better outcomes can be achieved. David C. Currow and Sanchia Aranda Cancer Institute NSW doi: 10.1111/ajr.12174

EDITORIAL

References 1 Diaz A, Whop LJ, Valery PC et al. Cancer outcomes for Aboriginal and Torres Strait Islander Australians in rural and remote areas. The Australian Journal of Rural Health doi: 10.1111/ajr.12174. 2 Chen T, Morrell S, Thomson W et al. Survival from breast, colon, lung, ovarian and rectal cancer by geographical remoteness in New South Wales, Australia, 2000–2008. The Australian Journal of Rural Health doi: 10.1111/ajr.12172. 3 Burns C, Dal Grande E, Tieman J, Abernethy A, Currow D. Who provides care for people dying of cancer? A

© 2015 National Rural Health Alliance Inc.

3 comparison of a rural and metropolitan cohort in a South Australian bereaved population study. The Australian Journal of Rural Health doi: 10.1111/ajr.12168. 4 Platt V, Coleman R, O’Connor K. Improving regional and rural cancer services in Western Australia. The Australian Journal of Rural Health doi: 10.1111/ajr.12171. 5 Murphy C, Sabesan S, Steer C et al. Oncology service initiatives and research in regional Australia. The Australian Journal of Rural Health doi: 10.1111/ajr.12173. 6 Sabesan S. Specialist cancer care through Telehealth models. The Australian Journal of Rural Health doi: 10.1111/ ajr.12170.

There is another gap to narrow.

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