March 2004, Vol 26, No. 3
Update Article

Cancer screening in Australia

V S P Chan 陳瑞波

HK Pract 2004;26:135-141

Summary

The present cancer screening approach in Australia is described with more detailed discussions about breast, cervix, colorectal, prostate and skin cancers. A one-stop model of health check and the possibility of monetary incentives for patients and their family doctors are suggested, with reference to the present incentive payments system to family doctors for their services and for achieving targets of care in a number of health promotion activities.

摘要

本文描述了目前澳大利亞的癌症篩查方法，並對乳腺、子宮頸、結腸直腸、前列腺和皮膚癌進行了詳細討論。參照現行為家庭醫生所提供服務和達到健康促進活動目標支付獎勵的機制，作者提出了“一站式”健康檢查的模式以及對病人和家庭醫生進行經濟鼓勵 的可能性的建議。

Introduction

The success of a screening programme to reduce mortality and morbidity of cancers depends very much on the medical and health care system which has control of the selection of entities to be screened, decides the interval between screening rounds, identifies target population, pays for the screening process and decides the follow-up systems for people with abnormal results and preferably also pays for the investigations, referrals, and treatments. This paper discusses the present system and updates on future improvements.

The present

In Australia, Medicare which is the government health insurance for the people, pays doctors working in the community e.g. family doctors and specialists, a scheduled consultation fee for most of their services to the population.1 If the doctor bills the government in bulk, the patient needs only to sign a voucher and the payment is made on their behalf by the government. However, many busy family doctors' and specialists' fees are higher than this scheduled fee. This often means that the patients would end up having to pay the fee in cash and then get a rebate from the government equal to the scheduled fee.

A large number of laboratory tests and imaging investigations are also paid by Medicare. If the laboratory investigations are bulk billed by the practice, the patients would again not need to pay: they would just need to sign a voucher. As a result, monetary payment is not a problem for patients to have investigation for a number of cancers in Australia. At present, however, Medicare does not pay for every kind of health screening. The major current population cancer screenings are done only for two cancers, namely breast and cervix. This paper will discuss screening for colorectal, skin and prostate cancers as well.

A.

The screening
 
 
Breast cancer
 
 

The New South Wales government provides free mammogram screening for women between the ages of 50-69 years. This is promoted through the media and the family doctors. The patients can either self-refer or be referred by their family doctors. Once the patient has a free mammogram done, she will receive a reminder to have the mammogram again every two years.

If any suspicious abnormality is detected, the patient would be recalled for ultrasound or further detailed x-ray. The patient's condition and suggested future evaluation would be made known to her family doctor via the telephone. The doctor, not the screening centre, would then arrange the relevant referrals for biopsy and further management.

Although breast self examination (BSE) has been shown to be associated with finding small tumours in their earlier stages before node involvement, it has not been shown to reduce mortality;2,3,4 and so it is neither promoted nor discouraged by the Royal Australian College of General Practitioners.5 It has been recommended that women should be encouraged to know what is normal for their breasts so that they are capable of detecting lumps (without necessarily performing monthly BSE) and consult their doctors for any changes in their breasts to get investigated.2,6

Regular clinical breast examination has not been shown to reduce mortality from breast cancer7 and is not recommended by the College as a routine screening test for patients with average or slightly increased risk.5 It remains an important adjunct to mammogram for the surveillance of women deemed to be of moderate to high risk. General practitioners play a key role in the promotion and provision of information about effective public-health initiatives for the early detection of breast cancer.8
 
 
Cervical cancer
 
 

The screening target population are those between the ages of 18-70, who have had vaginal intercourse and who still maintain an intact cervix. They are advised to have cervical pap smear once every two to three years.5

Although family planning clinics also perform cervical smears for their clients, the majority of smears are performed by family doctors in the community. These doctors often adopt a case finding approach by enquiring from their patients the dates of their last cervical smear and when they are due for their next smear.

Wherever a cervical smear is done in Australia, the laboratory performing the analysis would forward the patient's name, address and the next smear date to a centralised government register. Some patients require earlier follow-up screening due to a current or prior abnormality being noted, while others can have repeat smear once every two to three years. If the name of a patient is not received by the register 3 months after the next due smear date, a reminder will be sent to the patient and the family doctor who did the last smear.

Problems occur when the patient does not inform the Register about a change of address. In this case, the family doctor, on receiving the name from the register, can contact the patient directly. The patient is not required to have the next cervical smear done by the same doctor. Patients can choose any doctor or family planning clinic to have it done.
 
  Colorectal cancer
   
 

Established population screening programme for colorectal cancer is currently not available apart from those carried out in a few small local trials. Opportunistic case finding is recommended for family doctors until the results of various current trails to determine the optimal type of tests are made known.5 Patients between 50 and 80 years of age of average risk are asked to have two-yearly faecal occult blood test.9 However, it is still unclear if five yearly flexible sigmoidoscopy is of any screening benefit.10

Recently, there have been two trials in colorectal cancer screening in Australia, one by opportunistic approach performed by family doctors and one by postal delivery of faecal occult blood test (FOBT) kits.

In the general practice opportunistic screening trial, the patients who presented for any kind of problem to the participating practices were asked to complete a questionnaire which asked about the presence of colorectal symptoms and any family history of colorectal cancer.11 Those who already had symptoms were referred for specialist review. Others were offered a home FOBT kit. The faecal samples were returned either to the general practice or the laboratory. Of 731 patients who completed the questionnaires, 26 were referred for specialist review. For those who were suitable for the trial, 253 (about 1/3) declined, the main reason being old age or the cost of A$28.5 for the test. Payment was required because Medicare would not cover this test if it was for the purpose of population screening. Despite the payment obstacle, an uptake rate of 2/3 was achieved which is equal to the uptake rate of those for free mammogram and cervical smear. These trials showed that a patients' decision on screening can be positively influenced by their family doctors recommendations.

In another trial where FOBT kits were mailed out to patients between 50-70, the patients were asked to collect and send faecal samples to their family doctors or laboratory. The uptake rate was only about one third.12

Patients in the significantly high risk group were asked to have yearly or two-yearly colonoscopies commencing at 25 years of age and to have genetic screening.5 An additional role played by the family doctor is in the identification of this sort of patients through their daily contact. Referral to the appropriate professionals for colonoscopy and genetic screening can then be carried out.
 
 
Skin cancer
 
 
Opportunistic screening by family doctors is adopted for this high ranking Australian cancer. High risk patients are screened annually and the family doctors are alerted for skin lesions with malignant features on examining patients for other reasons.5 Patients are also advised to perform self examination for specific changes that suggest melanoma development.5
 
 
Prostate cancer
 
 

Digital rectal examination (DRE) alone is not recommended as a screening procedure.5 It has a large number of false positive and false negative results. Only 45% of patients who have a palpable nodule have prostate cancer.13 DRE is likely to pick up prostate cancer late in the development compared to performing a Prostate Specific Antigen (PSA) test. PSA however, is not recommended for screening either.5 It has a low positive predictive value. A palpable nodule of cancer may still give a PSA result that is within the normal range. False negativity provides false reassurance. If both PSA and DRE are positive, then the chance of having cancer becomes 60%.14

Significant level of false-positive results may cause unnecessary anxiety and expose patients to the hazards of additional unnecessary invasive investigation like biopsy.15

After the diagnosis is confirmed, therapy itself also poses a problem. Prostate cancer has a very variable natural history. Treatment of screen-detected cancer may fail to save lives as the disease may have already disseminated. On the other hand, the disease may be so indolent that it does not pose a threat to life. The treatments that are available are themselves associated with severe risk and morbidity.15

In the absence of evidence that treatment of PSA screen-detected early prostate cancer results in reduction in mortality, PSA cannot be recommended on a population basis. Trials are needed to identify which group of men, if any, will genuinely benefit from using this test as a screening procedure.

While the current guidelines do not recommend routine screening, there is a place for a case finding approach for selective screening based on the individual's situation and risk factors. Careful pre-test counselling on the limitations of the test and treatments would be important in this situation and for those who request to have the test.15 Guidelines will probably change in the future, as new evidence, tests and treatments are found.
 
 
B.
Reminder system
 
 
More and more family doctors computerise their practice for medical record keeping and practice management. Nearly all software in use has a feature of reminding the doctor which patients are due for cervical smear, blood pressure monitoring, immunisation, blood test for sugar, cholesterol, etc. It can even generate reminders for the patients whom the receptionist fails to contact by phone. The organisations responsible for the present population screening also have their reminding system.
 
 
C.
Cancer registers
 
 
The Cancer Council of New South Wales has a Hereditary Cancer Register to assist management of individuals at high risk of certain kinds of hereditary cancers such as hereditary non-polyposis colorectal cancer syndrome, familial adenomatous polyposis, juvenile polyposis, hyperplastic polyposis syndrome and Peutz-Jeghers Syndrome. After registration, the individuals from these high risk families receive information and screening reminders for the diseases. More and more registers are being established.

The future

In 1999, 11.5% of the Australian population is above 65 years old. Every one person below the age of 65 is looking after 0.13 person above the age of 65. By the year 2026, the percentage will reach 20%, hence each young person will have to look after 0.25 elderly people, nearly doubling the present work load. It is envisaged that the health care system will be unaffordable by then because of the increased chronic diseases and cancers in the elderly.16 Much of these chronic diseases are preventable if action is taken now; and the burden from cancers can be lower if they can be detected in the earlier stages by better screening. A recent expert advisory committee recommended that the present system requires an upgrading in its information technology as well as a need for providing incentives for a structured systematic family doctor prevention and early detection programme of chronic diseases including cancer.17

A possible model, Mature Age Check of Health (MACH), has been suggested and discussed recently in Australia.17 It suggests that there should be a round up of the current discrete episodes of screening into one consultation. This is best done by the family doctors who have background knowledge of their patients. Many of the included procedures can be done by the practice nurse or other ancillary staff e.g. radiographers, laboratory technicians and dieticians with training. The screening can also be performed in purpose-built health check centres headed by family doctors and staffed by ancillary staff.

A. The concept
   
 

People often prefer shopping in an arcade or in a supermarket rather then buying different things from different places at different times. Screening for different diseases by different professionals at different places will be labour intensive, costly and inconvenient for patients, resulting in low up-take rate. It is much more cost-effective to have a one-stop approach for all screenings to be done under one roof.

At present, family doctors are paid for doing an annual health check for patients older than 75 years old (55 for Aboriginals or Torres Strait Islander descent). Items being assessed include the physical, psychological and social functioning and whether preventive health care and training and education should also be offered. It does not include screening of cancers by means of imaging or laboratory tests. Screening of cancers can be incorporated into this sort of annual assessment for elderly patients. Protocols can be written for patients of different age-sex groups or at-risk groups.
 
 
B.
The content
 
 

Items to be checked should have been shown to be cost-effective and acceptable to the patients. There should be evidence of reducing mortality according to the important preventable causes/risk factors for the major proportion of non-injury related death and morbidity in people over the age of 50 years as disability adjusted life years (DALYs).17 Eligible entities include hypertension, hypercholesterolaemia, cervical, breast and skin cancer and diabetes together with primary prevention of cigarette smoking and nutrition based diseases, alcohol abuse, obesity and sedentary lifestyle problems, and early detection of depression.17

Procedures not to be included are those that are invasive or expensive like endoscopy, CT scan, IVP, barium studies. These are classified under further investigations for abnormalities detected during the initial screening procedure.

Substitution or addition of items would be allowed, based on a regular review of evidence of efficacy of prevention and screening and the current DALY burden, e.g. faecal occult blood screening for colorectal cancer, flexible sigmoidoscopy for at risk patients or screening for glaucoma would be added if the feasibility studies now planned justifies this.
 
 
C.
The process
 
 
The consultation can be started with a questionnaire. The examination and tests to be performed depend on the patient's age-sex and at-risk group. An evidence based protocol should be in place for this. If it is not his family doctor who does the health check, any abnormality found is to be forwarded to him/her for further investigation and management. The interval of screening depends on the patient's risk factors and any abnormality detected. Reminder systems are already in place for childhood immunisations, for free mammogram and cervical screening. A similar reminder system can also be used for other cancer screening programmes as well. Because of inconvenience and having a busy lifestyle, many people put off seeing their doctors even when they are sick, not to mention attending screening sessions when they are feeling well. The percentage of patients taking up screening offers depends very much on the cost to the patient in terms of money they have to pay, their time, the inconvenience involved and any distress from the screening procedure. Better health and longer life in the future are too far away to be incentives for most people. The consumers, as well as the professionals, need to be encouraged by more tangible incentives such as a money payment.
 
D.
Incentives
 
 

In Australia, parents of children who have their childhood immunisations done according to schedule by 18 months old are paid A$250 as an incentive for their compliance to the programme (Maternity Immunization Allowance).18 Patients older than 50 years of age can also be awarded for having completed a health check programme.

At present, for each cervical smear done for a patient aged between 20 and 69 inclusive who has not had a cervical smear in the previous 4 years, the family doctor is paid A$35 in addition to the consultation fee. Furthermore, the government recently introduced a Cervical Screening Outcome Payment to be paid to a medical practice (not to the individual doctors in the practice), which has screened 35 percent or more of their female patients aged 20-69 within the last 12 months. In August 2004, the target of female patients screened will increase to 70 percent for the last 24 months. Tables 1 and 2 show the amount of service incentive payments for individual doctors and outcome incentive payments for the practices.1 Incentive payments similar to these can be paid to family doctors who have completed a health check programme for patients of certain age and sex group or at risk group. Whether it is worthwhile for the government to invest in this way is to be assessed by the health economists and pilot trials.


Table 1: Incentive payments for family doctors

Description Amount (A$ per service in addition to normal consultation fee)
Completed a cycle of assessment for diabetes mellitus patient   $40 per patient per year
Completed a plan of monitoring, educating and reviewing asthma patients in at least three consultations   $100 per patient
Completing a plan of assessing, managing and reviewing patients with mental disordersin a number of visits   $150 per patient
One childhood immunisation   $6
Completed childhood immunisation for a child including the one for 18 months old   $18.50 per child
Annual health assessment of elderly patients >75 years old   $130.65 per patient per year
Cervical screening for patients who have not been screened for >4 years   $35 per service


Table 2: Incentive outcome payments for practices

Target of care Amount (A$ paid annually)
20% of diabetes patients in the practice had completed annual assessment programme
(Diabetes outcome payment) 		$20/WPE* of diabetes mellitus
70% of 20-69 years ladies had cervical screening in two years
(Cervical screening outcome payment) 		$2/WPE lady of this age group
>90% of children immunised up-to-date at 6 years old
(Immunisation incentive payment) 		$3.50/WPE of immunised children
*
Patients in Australia can see different doctors at different times. If a patient sees doctor A once and doctor B twice in one year, doctor A has one third WPE and doctor B has two third WPE for the purpose of calculating incentive payments.

Key messages

  1. The success of a screening programme to reduce mortality and morbidity of cancers depends very much on the nature of the medical and health care system.
  2. The population is getting older. It is envisaged that the health care system will be unaffordable because of the increase of chronic diseases and cancers in the elderly.
  3. Population screenings have to be evidence-based in reducing mortality and morbidity.
  4. Based on past-history from repeated contacts, family doctors have a role in the identification of at-risk patients and opportunistic case-finding cancer screening. They are also involved in the promotion and provision of information with regards to effective public-health initiatives and the management of cancers found from screening.
  5. One-stop health check may be more convenient to patients and cost-effective for the government.
  6. Both patients and family doctors need substantial incentives for the implementation of health promotion.

V S P Chan, MFM, MMed(Palliative Care), FRCGP, FAChPM(RACP)
Adjunct Associate Professor of Family Medicine and Palliative Care,
Edith Cowan University, Perth, Australia.

Correspondence to : Dr V S P Chan, 37 John Street, Cabramatta, NSW 2166, Australia.

References
  1. Commonwealth Department of Health and Aging, Australia, Medicare Benefit Schedule Book, November, 2002.
  2. Baxter N, with the Canadian Task Force on Preventive Health Care. Preventive health care 2001 update: Should women be routinely taught breast self-examination to screen for breast cancer? CMA 2001;164:1837-1846.
  3. Thomas DB, Gao DL, Self SG, et al. Randomised trial of breast self-examination in Shanghai: Methodology and Preliminary Results. J Natl Cancer Inst 1997;89:355-365.
  4. Semiglazov VF, Sagaidak VN, Moiseenko VM, et al. Study of the role of breast self-examination in the reduction of mortality from breast cancer: The Russian Federation/World Health Organization Study. Eur J Cancer 1993;29A:2039-2046.
  5. National Preventive and Community Medicine Committee, The Royal Australian College of General Practitioners, Guideline for Preventive Activities in General Practice, updated 5th edition, Special issue of Australian Family Physician, 2002.
  6. UK Trial of Early Detection of Breast Cancer Group. 16 year mortality from breast cancer in the UK trial of early detection of breast cancer. Lance 1999;353:1909-1914.
  7. National Health and Medical Research Council. Preventive interventions in primary health care - cardiovascular disease and cancer. Report of the Assessment of Preventive Activities in the Health Care System Initiative. Canberra: AGPS, 1996. http://www.health.gov.au/nhmrc/publicat/synopses/cp50syn.htm.
  8. Zorbas HM. Breast Cancer Screening, MJA 2003;178:651-652.
  9. Towler BP, Irwig IL, Glasziou P, et al. Screening for colorectal cancer using the faecal occult blood test, Hemoccult. The Cochrane Library, Oxford: Update Software, 2000.
  10. Schoen RE, Pinsky PF, Weissfeld JL, et al. Results of repeat sigmoidoscopy 3 years after a negative examination. JAMA 2003;290:241.
  11. Harnett SJ, Wong SKC, Lackey GW. Opportunistic GP-based bowel cancer screening. Med J Aust 2003;178:92-93.
  12. King J, Fairbrother G, Thompson C, et al. Colorectal cancer screening: optimal compliance with postal faecal occult blood test. Aust N Z J Surg 1992;62:714-719.
  13. Steinberg GD, Carter BS, Beaty TH, et al. The Prostate 1990;17:337-347.
  14. American College of Physicians. Screening for Prostate Cancer. Clinical Guide-lines Part III. Ann Int Med 1997;126:480-484.
  15. Gaze MN, Wilson IM. Handbook of Community Cancer Care, Greenwich Medical Media Ltd, London. 2003.
  16. Commonwealth of Australia 2002. Budget Paper No 5, Intergeneraltional Report 2002-03. Paper prepared by the Department of the Treasury and the Department of Finance and Administration for the Commonwealth Government Budget, Canberra, Australia.
  17. National Cancer Control Initiative, The Primary Care Perspective on Cancer - An Introductory Discussion, National Cancer Control Initiative, 2003, Melbourne, Australia.
  18. Health Insurance Commission, Austrtalia. The Australian Childhood Immunisation Register, at http://www.hic.gov.au/yourhealth/our_services/aacir.htm#payments