1. Midland Region All Boards Development Days
Midland Cancer Network
I’m Jan Smith, manager Midland Cancer Network. Apologies from Dr Humphrey Pullon clinical director who couldn’t be here today due to scheduled patient clinics.
Presentation today is going to cover:
an overview of the burden of cancer
Midland Cancer Strategy Plan – where are we at 18 months since launch?
Describe who the network is and how we work
Cancer Health Target – how the region is performing
Key achievements 18 months on since launching the Strategy Plan
Some exciting preliminary results of a Midland routes to cancer diagnosis and treatment project
Present high level strategies that provide an opportunity on how to address our key challenges
Lastly I will provide an overview of the bowel screening pathway that is due to start roll out within the region in 2018/19
Then we can have a chance to discuss any queries or questions.
10, 11 April, 2017

2. NZ cancer incidence
NZ Cancer Registrations and Deaths 2012 – just under 22,000 new cancer registrations per annum.
Most common cancers are:
Prostate
Breast
Colorectal
Melanoma
Lung
People aged 65 years and older accounted for nearly 6 out of 10 new cancer cases
Maori have a higher registration rate than non Māori – 26.2% higher
Source: NZ Cancer Registry

3. NZ cancer mortality 1948-2011 Just under 9,000 deaths per annum in NZ
Most common cancer deaths are:
Lung
Colorectal
Breast
Prostate
Pancreatic cancer
People aged 65 years and older accounted for at least 7 out of 10 cancer deaths
Māori have a higher mortality rate 1.7 times the rate of non-Māori
This slide demonstrates that we are changing outcomes of cancer
Source: NZ Cancer Registry

4. NZ cancer survival rates are behind Australia
In addition NZ survival rates lag behind Australia
This difference equates to over 700 extra deaths per year.
Driven by difference at 1-year survival.
Source: NZMJ 19 December 2014, Comparison of cancer survival in New Zealand and Australia, 2006–2010, Phyu S Aye, J Mark Elwood, Vladimir Stevanovic

5. NZ amenable mortality rates 2001-2011
This view indicates mortality rates are reducing but Maori still continue to have a higher mortality rate

6. NZ cancer inequities in treatment and outcomes
Inequalities related to cancer treatment and outcomes are similar to the population disparities demonstrated in previous slides
Maori cancer incidence is 20% higher than non- Maori
Maori cancer mortality is 80% higher than non- Maori
Maori are more likely than non-Maori to have their cancer detected at a later stage of disease spread
Variations in survival rates between DHBs in NZ
Source: Cancer patient survival covering the period 1994–2011 : Ministry of Health, 2015
All adult cancers,

7. Registrations Mortality
Cancer is NZ’s leading cause of death
Midland has over 4,500 new cancers diagnosed each year
Midland has approximately 1700 deaths from cancer each year – this is too high
These maps demonstrate that Midland has a significantly higher incidence rate in Bay of Plenty and Lakes compared to the rest of New Zealand
Of more concern is that ALL Midland DHBs have a significantly higher mortality or deaths from cancer than the rest of New Zealand.
In addition New Zealand is lagging behind our colleagues in Australia – NZ has a higher mortality rate than Australia, especially for women.
New Zealand survival rates are lower than Australia.
This suggests further improvements in recognition, diagnosis and treatment of cancer in New Zealand is possible.
Issues of early management in primary care and time intervals to diagnosis and treatment are important.
So in summary Midland has a BIG challenge to first lift performance to that of other regions within New Zealand as well as striving to achieve similar performance outcomes demonstrated internationally.

8. Vision and strategic objectives
Second Midland Cancer Strategy Plan developed to address the challenges and burden of cancer on our population
Strategic objectives:
To reduce cancer incidence through effective prevention, screening and early detection
Reduce the impact of cancer through equitable access to best practice care
Reduce inequalities with respect to cancer
Improve the experience and outcomes for people with cancer.

9. Midland Cancer Network - Who are we
all stakeholders involved in cancer control
primary, public health, secondary-tertiary
health professionals, planning & funding, service management
non-government organisations
Maori health providers
consumers and carers
network management team
work across organisational and service boundaries
A network is a vehicle that brings all stakeholders together to manage and improve cancer services across the continuum
Primary prevention, screening, diagnosis & treatment, follow-up care, palliative care and last days of life or survivorship.

10. Midland Cancer Network governance
Midland has a number of clinical leads for each tumour or service working group to work on relevant priorities.
All of the clinical chairs sit on the MCN Executive Group which is co-chaired by Humphrey and lead COO – the reason for this is that management is required to help facilitate system and process changes – we need a partnership approach.
This is a very simplified structure linking with national governance. At a national level there is an integrated cancer programme for the DHBs, regional cancer networks and Ministry of Health.
The four networks work together closely and take lead for certain priority areas at a national level.
Midland and Northern networks work closely together based on Midland patient flow areas – such as gynae-oncology
One other unique aspect is the Midland network is we are the lead for the national lung cancer work programme.

11. Faster Cancer Health Target
The new cancer health target started 1 Oct First public reporting for Q2 2014/15 (Oct –Dec 2014) in February 2015
Date of GP referral triaged by hospital consultant.
Patients to receive their first cancer treatment (or other management) within 62 days of being referred with a high suspicion of cancer and a need to be seen within 2 weeks
85% by July 2016, increasing to 90% by June 2017
DHBs also reporting against a 31- day indicator – majority of cancer patients
31 day
Via screening
Diagnosed privately
Patients presenting acutely
Formal referral that is not valid for 62 day

12. Cancer Health Target Cancer Health Target
The FCT Health Target is published quarterly – this is quarter 2 – Midland has made significant improvement
In October 2016 Humphrey presented to the previous All Boards day the majority of the Midland DHBs were in the lower rankings with achievements between 52 – 74%.
Now Midland DHBs 80 – 88%
Midland is the first region as a whole to achieve 85%. BUT caution…
Need to move towards achieving 90%
Last few months we have started to capture mandatory delay codes – such as patient choice, clinical consideration and /or capacity constraints
There is some variability of ranking each quarter but what this demonstrates is that we have a way to go to ensure patients receive their first treatment within 62 days of being referred by a GP when there is a high suspicion of cancer and need to be seen urgently within 2 weeks.
Publishing this target makes us accountable
By lifting our ranking this provides public confidence that we functioning at the top of our game.

13. FCT Midland performance & national average

14. We know targets work
The previous cancer health target shorter waits for cancer treatment health target showed the impact that focusing on a particular part of the pathway can have
This graphs shows for radiation oncology wait times, how over time, consistently met the reduced 4 week timeframe
The difference with the new cancer health target is that it involves multiple services and organisations
The shorter waits for cancer treatment discontinue 30 June This will mean medical oncology and radiation oncology services will need to align with the FCT Health Target

15. 18 months on – some successes to date
Faster Cancer Treatment Health Target
Cancer nurse coordination
BOP full radiation & medical oncology services- 2015
New psychologists and social workers
ProVation in all DHBs
Direct to colonoscopy e-referral
Lakes resident medical oncology service partnering with Waikato regional cancer centre
Supra-regional gynae-oncology MDM and service improvement work programme
National cancer nurse coordination evaluation completed by Litmus demonstrated added value and benefits to patient care – roles will go into DHB baseline in near future.
5 New psychologists and 1.6 new social workers resourced for Midland DHBs.
ProVation is an essential system for endoscopy services and will support DHBs with the roll out of bowel screening.
Direct to colonoscopy e-referral – started implementation – means patients don’t need to attend FSAs prior to colonoscopy – free up resource. Will support DHBs with roll out of bowel screening if a patient has a positive result.
Lakes medical oncology model of service with total visiting service from Waikato RCC not fit for purpose due to growth. Developing a new model of care with a resident medical oncologist supported by Waikato providing visiting specialist services.

16. Routes to cancer diagnosis and treatment project
Aim - achieve of the FCT health target
Understanding routes to diagnosis and treatment for each tumour stream
Identify gaps and issues in service performance
Service improvement opportunities
First project of its kind in NZ
Preliminary findings
The purpose of project is to work towards achievement of the FCT health target by understanding routes to diagnosis and treatment for each tumour stream in each Midland DHB*, through identification of gaps and issues in service performance resulting in prioritisation of service improvement opportunities

17. Emergency Department route to diagnosis
% by Route To Diagnosis - DHB Patients
Tumour Stream
Death Certificate
Emergency
GP Referral
Inpatient Elective
Other Outpatient
Screening
Unknown
Grand Total
Brain / Central nervous system
55.88%
17.65%
20.59%
5.88%
100.00%
Breast
0.34%
4.81%
31.27%
5.15%
43.64%
14.78%
Gynaecological
17.70%
48.67%
12.39%
21.24%
Haematological
1.45%
42.51%
41.06%
0.97%
8.70%
5.31%
Head and neck
15.00%
71.67%
8.33%
5.00%
Lower gastrointestinal
28.57%
48.21%
2.14%
7.50%
13.57%
Lung
55.10%
31.84%
1.63%
8.98%
2.45%
Other
64.71%
25.49%
9.80%
Sarcoma
42.86%
33.33%
23.81%
Skin
10.10%
45.96%
0.51%
7.07%
36.36%
Upper gastrointestinal
55.24%
0.70%
4.20%
3.50%
Urological
20.39%
22.11%
4.18%
33.91%
19.41%
0.20%
28.73%
36.39%
1.51%
13.17%
6.20%
13.80%
The following charts are busy to look at but highlights what is happening to different tumour streams
Since we produced these charts we have audited all patients that entered ED – charts going to be redeveloped based on findings.
Use these charts to demonstrate preliminary findings
Lung and cancer 55% new cancers entry is via ED
Unknown variety of reasons – public care provided privately or private

18. Why does route to diagnosis matter?
% by Route To Diagnosis, Tumour Stream and One Year Mortality
Row Labels
Brain / Central nervous system
Gynaecological
Haematological
Lower gastrointestinal
Lung
Upper gastrointestinal
Emergency
56%
18%
43%
29%
55%
Alive After One Year
26%
75%
66%
69%
GP Referral
49%
41%
48%
32%
36%
67%
98%
85%
87%
60%
44%
Inpatient Elective 0% 1% 2%
50%
83%
100%
Other Outpatient
21%
12% 9% 8% 4%
86%
93%
72%
90%
64%
Screening
Unknown 6% 5%
14% 3%
91%
92%
33%
40%
Grand Total
Lung cancer – only 29% of the patients that came through the ED were alive after 1 year
60% were alive after one year if entry was through GP referral pathway

19. One Year Mortality – a different DHB
% by Route To Diagnosis, Tumour Stream and One Year Mortality
Row Labels
Brain / Central nervous system
Gynaecological
Haematological
Lower gastrointestinal
Lung
Upper gastrointestinal
Emergency
64%
25%
52%
39%
49%
Alive After One Year 0%
40%
48%
74%
24%
29%
GP Referral
18%
45%
27%
46%
50%
78%
83%
79%
13%
Inpatient Elective 1%
100%
Other Outpatient
11%
10%
Screening
Unknown
20% 7% 4% 6%
71%
67%
Grand Total
Lung cancer – only 24% of the patients that came through the ED were alive after 1 year
48% were alive after one year if entry was through GP referral pathway
Haematology had a similar result where 83% were alive after 1 year is entry was through GP referral pathway

20. Areas of challenges & key initiatives moving forward
Access to primary care & secondary interface
Early detection
Achieve Māori equity
Adolescent and young adults with cancer
Faster cancer treatment Health Target
Information systems
Survivorship framework
Bowel screening
Primary and secondary interface We are working with the Waikato PHOs as a starting point to look at the number of GP attendances prior to attending ED. - how do we get people to go to their GP earlier? How do we address the non enrolled population ? – will be an issue with bowel screening
Early detection – need to detect cancer earlier. Lung and bowel cancer are our priority cancers and we are well placed to turn outcomes around. Innovation requires effort and resourcing otherwise we continue with what we have always had. Midland facilitates the national lung cancer programme & currently developing early detection of lung cancer – Midland well place to implement initiatives. Small project in Rotorua several years with Dr Denise Aitken demonstrated shift of patients into stage 1 & 2 = curative treatment, when programme stopped all patients were stage 3 or 4 no patients survived.
Māori equity – delays and issues at every point of the cancer pathway. Key initiative is kia ora e te iwi community based health literacy programme – we average one per DHB p.a. we need to do more, those that attend find valuable and empowers whanau.
AYA – while the outcome for children (0-14 years) with cancer has steadily improved over the last 30 years, with 80% cured. Such survival improvements have not been seen to AYA (12-24years). This age based disparities in cancer outcome appears to be due to a mix of complex factors
Differences in cancer diagnosis
Disparity in access to treatment
Lower enrolment in clinical trials
Poorer treatment compliance.
National AYA Standards of service provision about to be released in next couple of months. Will see centralisation of some tumour streams, which will mean we will need to support these young people and families as they journey through treatment.
FCT – need to continue – its hard, complex and resource intensive. However addressing and sustaining capacity issues is a consistent challenge – cancer growth is greater than population growth – workforce & systems struggle.
IS – knowing who and where our patients are is critical, knowing we are providing the right quality care is important. Our systems aren't integrated. We’ve built a regional FCT database which has helped. We don’t know collect patient staging. We don’t have an MDM management system – just about to start a gap analysis and look at solution options.
People are living longer following cancer treatment. NZ doesn’t have a survivorship model of care. We are partnering with College of cancer nurses, Cancer Society and Central Cancer Network to develop a national framework.

21. Bowel screening overview
$39.3 million over 4 years
People 60–74 years offered test every 2 years
Why? – cancer picked up at earlier stage, most curable with early surgery
Primary test – small faecal sample at home
Bowel screening IT solution –options phase
Patient pathway
NZ has one of the highest rates of bowel cancer in the developed world. Around 3,000 people diagnosed with bowel cancer p.a.
Screening programmes are estimated to reduce mortality in the population by at least 16-22%, and potentially up to 30% after 8-10 years
More than 80% of cancers found through the pilot were those aged years.
17/18 – Hutt, Wairarapa
Counties Manukau and Southern DHBs
With the National Bowel Screening Programme (NBSP) joining the NSU in November, the NBSP and NCSP are working on IT changes to support our current and future programmes.  This work is supported by an IT technology vision, called the Population Health Ecosystem (or PHE) which will provide an integrated IT platform for screening and prevention programmes

22. Bowel screening invite & take the test pathway
Awareness
60-74 years
Choice
Not suitable for screening
Yes
Return completed kit
Re-call in 2 years
Laboratory test
Re-test
NCC will send out invite for people to participate including the faecal immunochemical Test (FIT) kit – this is used to detect unseen blood in bowel motions. Blood in bowel motion doesn’t necessarily mean you have bowel cancer.
The laboratory will undertake the test.
Results of the test will be reported to GP and the national bowel cancer registry.
If a negative result then person will get a letter and be recalled in 2 years.
If positive then offered a diagnostic test by your GP – usually a colonoscopy. If a person has polyps then these usually can be removed during a colonoscopy.
If normal results will be recalled every 2 years and/or if monitoring required go on surveillance.
If required the specialists will manage treatment.
NCC – invitations, manage the register, notification of results, quality and monitoring
GPs arrange referral to colonoscopy; health promotion
DHBs manage colonoscopy, histopathology and treatment services; health promotion
BSRC will support DHBs and NBSP with support, encouraging participation and quality monitoring and reporting
Result
Referral

23. Pathway for positive result
Referral
Investigation
Monitoring required
Normal result
Surveillance
Investigation recall
Treatment
Treatment completed
Adenoma completed

24. Bowel screening roll out in Midland
2018/19 – Waikato DHB (3rd on list) and BSRC
2019/20 – BOP, Tairawhiti, Lakes, Taranaki
DHBs must be able to demonstrate readiness their ability to deliver a safe and effective bowel screening
Midland Bowel Screening Regional Centre design and planning phase
DHBs must be able to demonstrate readiness and their ability to deliver a safe and effective bowel screening service before being able to commence screening.
Pass around kit to have a look.

25. Midland bowel screening challenges v’s pilot
Midland Maori population 26.5%, Pilot 10%
Pilot Maori participation rate
round 1 & % European 63% & 53%
Midland significantly higher number people living in socio-economic deprived areas
Over 3,000 people years unenrolled with GP
Midland greater geographical distance

26. Questions