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Standing Committee on Health - 29/07/2014 - Skin cancer in Australia

SHUMACK, Professor Stephen, President, The Australasian College of Dermatologists


CHAIR: Welcome. Do you as a witness appearing before the committee have any objection to being recorded by the media during participation in this hearing?

Prof. Shumack : I do not.

CHAIR: Okay. Although the committee does not require you to give evidence under oath, I advise you that these hearings are formal proceedings of the parliament and warrant the same respect as proceedings of the respective houses. The giving of false or misleading evidence is a serious matter and may be regarded as a contempt of the parliament. The evidence given today will be recorded by Hansard and attracts parliamentary privilege. Would you like to make a short opening statement to the committee?

Prof. Shumack : I would like to thank the committee for giving me the opportunity to say a few words and answer some questions regarding the whole issue of delivery of skin cancer treatment in Australia. I would like to say that I am a private dermatologist in private practice. I am also a VMO at Royal North Shore Hospital of Sydney. I am also the medical director of the Skin Cancer Foundation of Australia, which has also put in a submission.

In general I think the delivery of skin cancer diagnosis and treatment in Australia is actually done quite well. We are actually the envy of many places in the world given our coordinated approach to the treatment of skin cancer—that is both diagnosis and treatment—and the breadth of this treatment going across the country. There are very few people in Australia who are not able to access appropriate skin cancer treatment when that is actually necessary.

I thought I would address a couple of issues as per the submission that we put in. The biggest issue is one we feel is most important: public awareness campaigns. Over the last 30 to 40 years there have been a number of public education campaigns that have been undertaken in Australia, starting with the Slip, Slop, Slap campaign and progressing through various campaigns over the eighties, nineties and 2000s. They have been associated with a number of surveys that were undertaken and which have demonstrated the effectiveness of those campaigns. Again that is the envy of the world. People outside Australia are very envious of our ability to modify the general population's behaviour because of those campaigns. We would like to see the establishment of a national registry for non-melanoma skin cancer, particularly BCCs and SCCs, which are the main type of skin cancer and in fact the main type of cancer that is seen in Australia, with probably 400,000 or 500,000 cases being treated per year in Australia alone.

I would like to emphasise that dermatologists are probably the peak trained body as far as the diagnosis and treatment of skin cancer in Australia goes, with our group probably managing about 25 to 30 per cent of patients with skin cancer. I am talking predominantly about non-melanoma skin cancer in Australia to date. We are also quite happy as a group to provide educational services to other medical and allied health groups within Australia to assist in their ability to diagnose and treat skin cancer within this country.

There are a number of dermatological research institutions in Australia, in particular our professorial unit at the University of Sydney and also at the University of Queensland. Part of their major research is looking into aspects of skin cancer, particularly non-melanoma skin cancer. We have heard from the melanoma unit, probably the world recognised institution, just a few moments ago. The predominant aspect of dermatological research is into non-melanoma skin cancer.

One area that could perhaps be looked at from the PBS point of view is the treatment of field areas where doctors in Australia get reimbursed for treating some spots individually. There has been some increasing evidence over the last decade ago that talk about field areas—in other words, a forehead or a scalp—which has had sun over a long period of time. It is an area almost like a fertilised garden for the development of skin cancers, and there are a number of ways now to treat those field areas which are relatively expensive and not subsidised by the PBS or the MBS.

The other area which we think dermatologists have a role to play is in telemedicine, particularly with access for some of our rural colleagues to specialist care. We know from studies that have been undertaken over the last decade or more that telemedicine and particularly teledermatology as a subset of telemedicine is an area where accuracy has been determined. It is a good way of triaging patients relatively quickly without them having to wait for long periods of time because of waiting lists to see either their primary care doctor or a dermatologist.

CHAIR: Thank you. Your submission talked about more manpower being needed. Could you give us an approximate figure of how many more dermatologists you think will be needed in the future?

Prof. Shumack : It is always hard to answer that question. The number of dermatologists per population when I started a number of decades ago was one per 100,000. I think we are now looking at about one per 60,000 as being a reasonable number to have for dermatologists. We currently have 450 dermatologists, but some of those dermatologists work part time. So we would be looking at doubling that number over a period of 10 to 15 years as a way of trying to address the dermatological manpower issues that we have in this country.

CHAIR: How much does it cost to train a single dermatologist, and what is the Commonwealth government's role in funding training positions?

Prof. Shumack : I cannot directly answer that first question. Certainly dermatology registrars are paid as a specialist trainee in a public hospital. That would cost, I would envisage, around $120,000 per year. So you are looking at probably something in the order of half a million dollars, give or take, to train a dermatologist. Basically, this training is undertaken by the state governments. The state governments provide the teaching hospitals, and the teaching hospitals are where the majority of trainee dermatologists in Australia are actually trained. In addition, the federal government has the STP funding, which has been going now for a number of years. I think there are something in the order of 900 STP funded positions throughout Australia, of which dermatology has 29. So a significant number of our positions—29 out of about 120—are funded by the federal government. In addition, a number of private charities set up by dermatologists such as the Skin Cancer Foundation of Australia provide training or funding to train an additional five or six dermatology registrars in Australia per year. So we self-fund a number of dermatologists ourselves.

CHAIR: Do you think that, with the training that GPs do, they do enough in their training period to train them to diagnose skin cancer or do you think they should have more time in their program?

Prof. Shumack : We know internationally and from studies that Australia's GPs or family practitioners are actually quite good at diagnosing and managing skin cancer and precancerous conditions, but they could always be better trained. There is also always a discussion with dermatologists in teaching hospitals and medical schools about allowing more time for us to train medical students. There are a number of programs that have been set in place for undergraduate training. In association with the University of Sydney the college has put together an undergraduate training program that has been wound out to a number of other universities throughout the country. We also, in association with the FRACGP, the college of general practitioners, and the College of Rural and Remote Medicine have a training program looking at upskilling general practitioners in the diagnosis and treatment of a whole manner of skin conditions, particularly skin cancer. So there is room for improvement.

Dr SOUTHCOTT: I have some questions that are really a segue from that. How does the college see the ideal division between general practitioners, perhaps general practitioners with special interest, dermatologists and then the tertiary referral centres like the Melanoma Institute. What do you regard as the ideal, and is that well understood?

Prof. Shumack : I think the ideal situation, at least in Australia, is that most patients are seen, treated, diagnosed and screened in general practice. We know that the majority of general practitioners are actually quite good at doing this. They have had significant experience. It can be improved, but they are actually generally quite good. There are a number of general practitioners with special interests who work either in general practice or in so-called skin cancer clinics, and those general practitioners have even more of an interest in skin cancer type work. So we see the majority of skin cancer patients being treated and appropriately managed as it is at present: in general practice or equivalent.

We see dermatologists as being able to provide an education to that group of general practitioners. We are talking about upskilling, new techniques, new ways of perhaps diagnosing or treating various types of skin cancer. We also see those dermatologists as providing more specialised care. For instance, it might be a bigger basal cell carcinoma than the GP is used to treating. It might be a recurrence. It might be in a difficult area. It might be in a patient who has had multiple skin cancers in the past. But these will be a minority of patients, and we believe the majority of patients can adequately be treated in general practice. We would treat those that are more difficult and require more effort or more knowledge to treat.

Similarly, we see plastic surgeons or surgeons providing that role as well. In fact there is quite a lot of referral between dermatologists and surgeons. There are a number of techniques, in particular Mohs surgery, which we mentioned in the submission and for which there are about 40 Mohs surgeons in Australia. That is a particular type of technique where the skin cancer is cut out. It is looked at immediately under the microscope with frozen sections. If they have not got it all, they go back and take a little bit more. That may go on two or three times—or four or five times—over that day till we are sure that skin cancer has been removed. Those are mostly BCC or SCC. That is either repaired then by the dermatologist or, sometimes, a specialist surgeon—usually a plastic surgeon—for a particular type of repair if necessary

There are some skin cancers, particularly melanoma and some other, non-melanoma skin cancers which are very aggressive, and those are the sorts of skin cancers for which we make use of the specialised institutions such as the melanoma unit of Australia. We send those patients off. We usually have an extremely good relationship with the clinicians associated with organisations such as the melanoma unit. With melanoma, as you heard, most of the thicker melanomas—more than, say, two millimetres in thickness—would be managed in Sydney or New South Wales by the melanoma unit. So we have an easy way of having our patients seen by a specialist group quite quickly.

Dr SOUTHCOTT: I would also like to ask you about international comparison. I think you mentioned in your opening remarks that we are regarded well in this area. Obviously melanoma has had a real focus in Australia because of the high incidence, but do you have some more information about how we benchmark internationally?

Prof. Shumack : Yes. I think the Department of Health submission talks about some of these issues as well. If you look at the number of melanomas per population worldwide, Australia and New Zealand are always neck and neck to win the race for the most. Because of that and because of the public education—we have quite an educated population—if they see something which is large, flat, blackened, irregular and changing over a period of time, they usually go off to their doctor. So we have an educated patient population. We have pretty good primary care physicians and general practitioners. What tends to happen is those patients present early. We have the highest melanoma rate in the world, but we also have the earliest diagnosis rate in the world. In other words, the thickness at the time of diagnosis is the least of any country in the world. Because of that, we therefore have the highest cure rate. If you get a melanoma in Australia, there is more than a 90 per cent chance that you are not going to have any significant problems. The significant mortality rate for melanoma is less than 10 per cent in Australia, and that is because of early diagnosis and early treatment. So we are held in high regard in places like the United States and, particularly, Europe.

Dr SOUTHCOTT: So even a similar country like the United States does not get those sorts of results?

Prof. Shumack : No. The reason they do not is that care in the United States is relatively fragmented. We all know the United States has the best of the best. I don't think anyone will argue that care is spread across the United States in an even way, unlike Australia, where we have really pretty good care and it is spread relatively evenly across the population based areas.

Mr WATTS: You talked about field therapy and I have seen your recommendations suggesting that, while there is this MBS review of best practice, this therapy should be accelerated beyond that. Why do you suggest that it should be prioritised beyond what is going on at the moment? You mentioned earlier that there were significant costs potentially associated with that treatment. What are the returns?

Prof. Shumack : Again, for many years the treatment of solar keratosis, sunspots and skin lesions has been basically by freezing, so we freeze these sunspots and that gets rid of the individual sunspots. But over the last decade or more it has come to be recognised that it is not just the sunspots which are technically precancerous; it is the whole area of skin. If you take the scalp of a bald male aged 55, he has had a fair bit of sun over the years over that whole area. He may actually have half a dozen sunspots which we can freeze off but he may have another couple of dozen incipient sunspots—in other words, cells that are abnormal—that may well produce sunspots over the next year or two. It has now become clear from a number of studies that have been undertaken: if you treat that whole area with a particular agent—and there are a number of agents out there—that you are going to get rid of those preclinical sunspots and that patient will then be required to be seen less often and have less work done. So it may cost a little more at the time, but you may not need to see that patient for another year or two or three rather than seeing that patient every three or four months to have another dozen or so sunspots treated. So we are looking at long-term outcomes and sustained clearance rates of the precancerous and therefore cancerous areas in that particular area.

Evidence is now mounting to support that argument. It has been slow, because you have always got to undertake studies to demonstrate what seems to be relatively obvious to us. It takes time because we have got to follow those patients up for a period of several years to make sure that in fact in a health economic way it is cost-effective to treat those people early rather than late.

Mr WATTS: Because of the lead times involved there isn't a formalised body of evidence saying—

Prof. Shumack : Exactly. There is more evidence available for that. You are quite right: the evidence has been relatively hazy and low level up until the very recent past.

CHAIR: Does that mean field area treatment is not happening, because you didn't have the evidence?

Prof. Shumack : No. In fact, we find that dermatologists are embracing field therapy because of the evidence, the number of talks that are going on in this regard, and it is almost relatively self-evident that this will actually occur. It is a relatively time-consuming and expensive process for the patient—relatively expensive: I am talking $100 or $150; it is not ridiculously expensive. We find in specialist medical practice that it is easier for us to talk to our patients and advise them in this regard. We find that in general practice it is a little more difficult to talk and advise about a relatively expensive procedure or treatment option, so this is being used much more commonly in specialist practice but we believe it would be much better if it were used much more commonly in general practice and therefore we specialists may therefor see fewer patients in this regard.

Mr WATTS: You also raised teledermatology in your recommendations. Could you walk us through a best practice model of how that would work and then give us an indication of how prevalent it is today and how prevalent it should be?

Prof. Shumack : Telemedicine, as you know, has been supported by the MBS schedule over the last few years but that has been what we call real-time telemedicine—in other words, you have a video camera, the patient sitting there. There is usually a person at either end. It has got to be real-time—in other words, the people have got to be sitting there at the same time. It is via moving picture. In dermatology, this is not the model that we really think is appropriate. For us the model is: store-and-forward. We take a picture. We send that picture—

Mr WATTS: Is that a GP or a dermatologist?

Prof. Shumack : The GP will take that picture and send it via some encrypted link. A dermatologist would see it at leisure, which is usually some time that day. We know that the diagnostic accuracy of a photograph is around 80 to 90 per cent, so it is quite accurate. Then usually within 24 hours a response comes back from the dermatologist to the GP. So it is basically assisting the GP, practice nurse, nurse practitioner or some healthcare practitioner about triaging or making a diagnosis as far as what that particular lesion is. We can even do it via magnification. With dermoscopy, which is the way of looking at melanoma where things are magnified by about 10 times, there is a way now where you can take that picture send it off to a central body. Some dermatologist will usually read that and that will come back to the GP or the healthcare practitioner who has sent back the photograph in the first place.

Interestingly, in Queensland they did a pilot study looking at people presenting to Princess Alexandra Hospital and they discovered that the patients waited longer to be seen by a doctor in the emergency department than they did to get the response back from the dermatologist on the photograph that was taken. So it can actually be a rapid way of triaging people and very cheap.

Mr WATTS: So how common is it now?

Prof. Shumack : It is not that common because there are a number of regulatory insurance based issues associated with it and store-and-forward is not rebated at the moment by the MBS. But I know there has been a pilot running with ACRRM, the Australian College of Rural and Remote Medicine, and a number of dermatologists in Queensland over a period of probably six or seven years where it has actually worked quite well. The uptake has been relatively slow or much slower than we expected, and we believe it is probably related to reimbursement issues, particularly on the GP side.

Mr WATTS: So those reimbursement issues are something you think the government ought to be looking at?

Prof. Shumack : Absolutely. Certainly from the sending side that is an important thing to actually look at. We have looked at real-time telemedicine. I know there is an application in looking at store-and-forward telemedicine and we believe that would certainly be a better way, from our point of view, to go.

Mr WATTS: Would the benefits of an increased prevalence of this model of treatment include expanding access to specialty treatment or reducing costs, or both?

Prof. Shumack : Both. Firstly, you would have earlier diagnosis. You would be able to triage patients much more rapidly. The aim basically would be to assist general practitioners or primary-care physicians to undertake appropriate treatment in their own environment. We would envisage a significant minority of patients being required to be triaged to specialty care. It would be a way of assisting, a little like a pathology test, for a general practitioner. 'I am not exactly sure what this is. I will send it off to a dermatologist. I will get an answer back tomorrow that will help me in my management of that particular lesion or that particular rash on that patient.'

Mr WATTS: In principle, it should not be treated any differently to a pathology test? It is the same.

Prof. Shumack : I think that is a good way of looking at it, yes.

CHAIR: Are there any changes in telehealth in regard to dermatology?

Prof. Shumack : There is always the worry about misdiagnosis. One of the things that we would not want to avoid would be to call something more significant than it actually is or in fact say something is benign when it is actually a skin cancer. There have been a number of studies done over the last two decades looking at the accuracy of telemedicine, in particular teledermatology, and we know it is actually quite accurate. So as long as there are people who are undertaking that are aware of the limitations and if they are not able to call something, they call for a real-life consultation, I think most of those dangers about undercalling could be addressed.

CHAIR: Are you aware of the Chemmart pilot program that was run in WA—chemists taking photos with an iPhone magnifier and sending them through to dermatologists?

Prof. Shumack : I am not aware of that program.

CHAIR: What would your thoughts be on a program like that?

Prof. Shumack : One of the things that you need to look at from the point of view of diagnosis is not just a photograph. We would need a brief history. A minimum would be the age of the patient, the sex of the patient, how long it has been there and a provisional diagnosis. They are just four or five points we would need to ensure the greatest accuracy or relevance of a particular diagnosis. I would be a bit hesitant to endorse a program that may not have those sorts of features associated with that.

CHAIR: Would you agree that we might have seen a rise of GP-run skin cancer clinics due to the shortage of dermatologists? Do you think that if we had more dermatologists there would be fewer of those skin clinics?

Prof. Shumack : It is always hard to answer that question. I think there is a shortage of dermatologists, and everybody will recognise that. We could certainly do with more dermatologists out there. But I think many patients who see the skin cancer clinics could probably be just as adequately treated by their own general practitioner. A number of studies have been undertaken looking at the accuracy of diagnosis of so-called skin cancer clinic doctors and general practitioners, and we know that they are about the same. We know in Australia that GPs are actually pretty good. One of the focuses should be upskilling both groups in the diagnosis and management of skin cancer.

CHAIR: Professor Schumacher, thank you for coming in today to assist the committee. I would also like to thank you for your well-researched, comprehensive submission. If you have been asked to provide additional information or feel that you have further information that could assist the inquiry, please forward that to the secretariat by Tuesday, 12 August. If the committee has any further questions, the secretariat will send those to you in writing.

Pr oceedings suspended from 10:26 to 10:44