Dr Andrew Penman, Chief Executive Officer, Cancer Council NSW, writes:
Ragg reminds us that equity in health outcomes is a value more promoted in the health service than realised. But there’s more to differences in cancer survival than a headline. He needs to dig deeper to separate wheat from chaff.
First point to make is that not all cancers are the same. Overall cancer rates are made up of those with excellent survival prospects like prostate cancer melanoma, testicular and thyroid cancer and those where survival prosects are truly appalling – like liver cancer, lung, pancreatic and stomach cancer.
The burden of more and less aggressive cancers varies among social groups whether judged by social class, ethnicity and migration status, or location of residence. Some measure of this variation can be found in Cancer Council reports on differences in cancer incidence by migration status and area of residence – indirectly related to socioeconomic status.
It is therefore hasty of Ragg to dismiss lifestyle as a contributor to differences in survival – it plays a big role in determining the cancer you get. But it also has an influence on the treatment you can tolerate. If lung function is poor that a lung resection to cure lung cancer may not be possible and palliation may be the only course. Chronic viral hepatitis may limit chemotherapy options.
Ragg himself makes the point in his report that some improvements in cancer survival are more apparent than real owing to the effect of screening which may be of overall benefit, but for many people may extend the period you live with the disease, while not changing the eventual outcome. So if socioeconomic condition influences participation in screening, as it almost certainly does in prostate cancer for instance, this will be reflected in apparent survival differences.
None of this is to dismiss Ragg’s concern about inequity.
We know for instance that only 35% of people in NSW receive radiotherapy for cancer when evidence tells us that 52% should. Much of this gap is among cancers where radiotherapy is given for curative intent.
We don’t know whether the disadvantaged bear this access burden inequitably and we should. We know that for specific cancers, survival among Aboriginal people is lower than among non-Aboriginal people.
On the other hand the differences in survival between rural and metropolitan population are probably over-stated.
Research that follows the experience of individuals in the health care system is needed if we are to measure the real gap in outcomes and understand where to intervene.