How to improve early breast cancer care in New Zealand

An in-depth study into breast cancer care in New Zealand has suggested four key ways to improve outcomes for patients.

The research was conducted earlier this year by Economist Impact, and sponsored by Merck Sharp & Dohme (New Zealand) Limited (MSD). Released during Breast Cancer Awareness Month, it analyses how New Zealand can improve patient-centred care and build awareness, promote screening, early detection, diagnosis and prognosis, and ensure access to high-quality treatment, including supportive and palliative care.

Emily Tiemann, Health Practice Manager at Economist Impact, says: “Low awareness, late diagnosis, and restricted access to treatment especially for disadvantaged communities has meant that breast cancer outcomes can be poor. However, there are significant opportunities to improve breast cancer care in New Zealand by understanding the patient-centred care pathway for early breast cancer diagnosis and treatment and investigating the unmet needs in the management of breast cancer.”

The four opportunities identified to optimise early breast cancer care and improve outcomes for people living with breast cancer in New Zealand are:

1. Move beyond mortality and focus on quality of life: The outcome measures for breast cancer management should go beyond simply mortality reduction. The target should be to improve quality of life by providing patient-centred care and support.

2. Establish a coalition or alliance of stakeholders: To align the priorities of individuals impacted by breast cancer (patients and carers) and the preferences of the decision-makers, a breast cancer expert coalition or strategic alliance should be established with patient advocates, industry representatives, academia, and relevant healthcare professionals. To ensure patient-centred care, it is crucial to involve the patient.

3. Aspire for world-class care with improved access to innovative treatments: To meet the international standards of breast cancer care, the health system should identify the right outcomes and define tangible key performance indicators (KPIs) and quality performance indicators (QPIs). The aim should be to achieve improved patient-centred care and treatment options and ensure that health budgets are better targeted towards the interventions that would have the biggest effects on patient care and outcomes.

4. Ensure screening programmes are available and are equitable: Since screening programmes play a vital role in early detection, impacting patient outcomes, monitoring and evaluating screening programmes at regular intervals is essential. The screening programme data, alongside important KPIs such as coverage and uptake, can be used to inform policy makers whether the screening programme is delivering the expected benefits or not. Ensuring timely uptake and availability of screening programmes is accessible for Māori and Pacific peoples is key to improving outcomes.

Key findings:

Awareness: Awareness is the first step towards any change. It is critical to promote health literacy to increase participation in preventive care measures such as lifestyle changes and exercise, self-examination of breasts, regular check-ups with GPs, and screening for eligible candidates. Many stakeholders including NGOs, patient advisory groups, and the government are involved in promoting awareness of early breast cancer and associated risk factors such as alcohol consumption and obesity. However, lack of access to information particularly for Māori and Pacific peoples is a big barrier to the optimisation of patient-centred care in New Zealand.

Screening and Diagnosis: New Zealand has a robust national breast cancer screening programme which is responsible for early detection and reduction in mortality. However, the majority of diagnosis is via non-screen routes - GP referral or ED visit. Additionally, inequity in access to screening and diagnosis for Māori and Pacific women and those at high risk or outside the screening age is a big challenge in New Zealand.

Treatment: New Zealand last published guidelines for early breast cancer management in 2009, covering informed decision-making and a multidisciplinary approach to treat cancer. However, the guidelines should be updated to deliver high quality, evidence-based care, improve outcomes, reduce variation, and make good decisions with resources. New Zealand should consider how it equitably prioritises access to modern, innovative medicines for its population.

Survivorship: Continuity of care and psychological support for cancer survivors are important elements of patient centred care. In New Zealand, there is an opportunity for specialist nurses and primary care providers/ GPs to offer continuous support to cancer survivors at the community level. Psychological support, though acknowledged, is identified as an unmet need, which must be addressed.

Workforce: Workforce availability was identified as a challenge across all steps of the patient journey. To optimise patient-centred care, there is a need to develop, retain, and up-skill the health workforce in New Zealand.

Those who took part in the study included Breast Cancer Aotearoa Coalition, the Breast Cancer Foundation New Zealand, plus a number of healthcare experts including surgeons and oncologists. The research is part of an APAC project, which also covers Japan, Thailand, Singapore and South Korea. The New Zealand findings are the first of the five countries to be released.

The facts about breast cancer in New Zealand:

New Zealand is among the countries with the highest prevalence of breast cancer, affecting one in nine women, and more than 600 deaths every year. The incidence rate exceeds the OECD average and is second only to Australia. According to the WHO New Zealand Cancer profile, the total breast cancer cases per year are expected to increase by 31% and reach 4,584 by 2040 from 3,504 in 2018.

Breast cancer is among the leading causes of death in New Zealand with an overall mortality rate of 6.3% and, after lung cancer, it is the most common cause of cancer death for women. Māori women have a 60% higher breast cancer mortality rate than women of European descent in New Zealand.

Breast cancer diagnosed at an early stage, when it is not too large and has not spread, is more likely to be treated successfully than breast cancer diagnosed at an advanced stage. Advanced breast cancer not only creates an urgent health challenge but also impedes the quality of life, and brings significant economic costs for patients, their families and public health systems.

Breast cancer is the second-most expensive cancer (following colorectal cancer), costing $126.7 million (NZD) per year and accounting for 14% of total cancer costs. However, treating patients with early-stage breast cancer is less costly than treating those with advanced (metastatic) disease. Overall, surgery, diagnostic tests, and targeted therapy are the most significant costs. Median costs for Stage 1 are $26,930, rising to $50,388 for Stage IV.

Key quotes:

“The need for improvements in other cancer streams has reduced the level of focus on breast cancer. It shouldn’t be one cancer against the other.”

says Ah-Leen Rayner, CEO of the Breast Cancer Foundation New Zealand

“Breast cancer is overall a very survivable illness across all stages, especially if caught early with screening and self examination. In NZ, we have good access to surgical options including reconstruction and radiotherapy. There is further work needed to improve access to funded medications in some scenarios,” says Dr Katherine Gale, Oncoplastic Breast Surgeon at the North Shore Hospital.

“And it’s much more than just mortality figures. It’s about reducing morbidity from breast cancer, it’s about improving quality of life, facilitating breast conservation wherever possible, and preserving femininity. The outcome measures have gone beyond mortality reduction,” says Adam Stewart, Breast & General Surgeon, National Clinical Lead, BreastScreen Aotearoa.

“If you have early diagnosis, everybody in this country is going to benefit, for example, evidence shows that the 10-year survival drops from 97% for stage 1 to 71% for stage 3 disease,” says Fay Sowerby, Secretary of the Breast Cancer Aotearoa Coalition.

Equity issues must be addressed, particularly the abilities of Māori and Pacific women to access screening services, as well as follow-up care. These under-represented groups should have a voice as decision-makers. “Shifting of the cultural norms that inform design and practice can only improve the quality of the cancer system for all,” says Stephanie Turner, AYA Cancer Network Aotearoa board member and Director, Māori Health at the Health Quality & Safety Commission.

To read the full report, go to Economist Impact Perspectives site.

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