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Standing Committee on Health
14/04/2014
Skin cancer in Australia

MILLER, Dr Caroline Louise, Director, SAHMRI Population Health, South Australian Health & Medical Research Institute (SAHMRI)

Committee met at 13:00

CHAIR ( Mr Irons ): I declare open this public hearing of the Standing Committee on Health. I ask a committee member to move that the media be allowed to film the proceedings today in accordance with the rules set down for committees, which include not interfering with committee proceedings and not taking footage or still images of the papers or laptop screens of members, committee staff or witnesses. It is so moved by Mr Wyatt.

Welcome, Dr Miller. Thank you for coming today. Do you as a witness appearing before the committee have any objection to being recorded by media during participation in this hearing?

Dr Miller : No.

CHAIR: Do you have any comments on the capacity in which you appear?

Dr Miller : As well as being director of population health research, I am the executive officer for the South Australian Health & Medical Research Institute.

CHAIR: 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. I now invite you to make a short opening statement.

Dr Miller : Thank you for the opportunity to present to the inquiry. SAHMRI welcomes this opportunity. First I would like to tell you a bit about the South Australian Health & Medical Research Institute, because it is new. It is South Australia's first independent health and medical research institute. We were incorporated in 2009. SAHMRI represents a unique collaboration between all of the state's three universities—Adelaide University, Flinders University and the University of South Australia—as well as the government of South Australia.

SAHMRI is a flagship institute for the state and will increase the nation's capacity for cutting-edge research. SAHMRI is building a team of over 600 researchers, who are working towards prevention, better treatments and cures, and solving some of the country's and the globe's most challenging health problems. SAHMRI is located at the centre of what will be a world-class biomedical precinct with state-of-the-art laboratories and equipment adjacent to the site of the new purpose-built Royal Adelaide Hospital. In partnership with SA Health and the three universities, SAHMRI is also leading the development of an academic health-science system designed to produce excellence and alignment in research, teaching and evidence based clinical practice.

SAHMRI's vision is to translate or to transform science into health. By this we mean to accelerate the progress of science into tangible changes in the clinic and in the population to produce health outcomes for the community. SAHMRI is also unique in its commitment to research across the spectrum, from basic science to clinical research and drug development. SAHMRI is also strongly committed to health services research. This is research that improves the effectiveness and efficiency of the health system to deliver better patient outcomes efficiently.

SAHMRI also has a focus on population health and research into the policy and programmatic interventions that will bring about positive changes to the health of the population. I am the director of the SAHMRI population health research group. I lead a team that is investigating the behavioural and policy interventions that best evidence indicates will bring about changes to reduce the impact of cancer as well as other chronic diseases. We undertake significant work in tobacco control as well as in other areas of cancer prevention.

The evidence that I would like to offer is in relation to the prevention of skin cancer. As I am sure you are aware, at least two in three Australians are diagnosed with skin cancer before the age of 70, and every year 1,500 deaths are caused by melanoma and a further 500 from non-melanoma skin cancer. Non-melanoma skin cancer places a high burden on the population, health care and the government, and Australia has the highest rate of non-melanoma skin cancer in the world.

Skin cancer is also the most preventable common cancer, with almost all cases caused by exposure to ultraviolet radiation. UV radiation is a class 1 carcinogen, so it is a known cause of cancer. So great priority should be given to overexposure to UV radiation and its reduction. There are two fundamental ways to go about this: firstly, increasing community awareness of skin cancer prevention and motivating personal behaviour change and, secondly, reducing exposure to UV radiation through structural and other support. It is the combination of strategies to increase community awareness, to motivate behaviour change, coupled with structural and policy change that have brought about the major shifts in behaviour that have been observed in other difficult areas of health, a notable example being tobacco control.

Like many health behaviours, prompted awareness that UV or sun protection is important is high in the community. However, actual protective practices of hat wearing, sunscreen wearing, protective clothing and shade seeking are suboptimal. As you would appreciate, there is a very big difference between knowing what one ought to do to protect one's health and actually doing it. Behaviour is driven by a number of key personal cognitive and affective factors as well as by social norms. The most effective and cost-effective technique to increase community awareness and to motivate behaviour change is investment in quality mass media campaigns. Well-designed, well-executed and adequately resourced mass media campaigns have proven effectiveness in bringing about population-level changes in knowledge, in attitudes and in intentions as well as in behaviour, and the evidence strongly supports this strategy for skin cancer prevention.

Exposure to UV can also be reduced with a range of structural and policy interventions. Several jurisdictions have legislated against solaria, which will reduce one unnecessary source of overexposure. Evidence demonstrates that the presence of formal policy measures results in higher effectiveness in practice. This applies in occupational settings as well as in school settings. Exposure of children and adolescents is important, because the evidence indicates that much of the critical UV exposure occurs during these early years.

Australia has a long history of sun protection policies in schools and in early childhood settings, influencing uniforms, hat wearing and scheduling of outdoor events such as sports days. There is much more that could be done. Greatest progress has been made with younger children, and less progress has been made with adolescents. Outdoor shade provision in schools would provide far greater protection, particularly for adolescents, where hat wearing is far less prevalent. Policy measures which recognise UV exposure as an occupational health and safety risk and adopt measures to mitigate that risk are also worthwhile.

To conclude my statement, I would like to emphasise that there is enormous potential to reduce the health and economic impact of skin cancer through prevention. Investment in evidence based prevention strategies with evaluations to measure their impact has been shown to be very effective and also very efficient. There is a clear opportunity for the Commonwealth government to invest in skin cancer mass media campaigns which raise the importance of avoiding overexposure to UV and also motivate behaviour change. Supporting policies in occupational settings and school settings which provide structural protection from ultraviolet radiation are also very important. Thank you.

CHAIR: Thank you. Do we have any questions from any of my colleagues?

Dr SOUTHCOTT: I understand you have got seven or nine focus areas. Which ones would specifically be looking at cancer in the research focus?

Dr Miller : SAHMRI has seven themes. We have themes dedicated to cancer, heart disease, healthy mothers and babies, nutrition and metabolism, infection and immunity, Indigenous health, and mind and brain. Skin cancer would fall most clearly within the cancer theme and potentially healthy mothers and babies as well. The population health research group that I direct sits across themes, including cancer.

Dr SOUTHCOTT: In your opening remarks you focused a lot on prevention and how we are doing on prevention. What about treatment? We do see some of the newer tyrosine kinase inhibitors offering improved life span but not necessarily improved survival. In the research effort, what treatment are you looking at if someone does have melanoma?

Dr Miller : At the moment, SAHMRI does not have a research effort around melanoma. Our basic science and clinical research in cancer is predominantly liquid tumours, so around leukaemia. As you can appreciate, SAHMRI is a new institution and that is how it has opened. Moving into the solid tumours will be further down the line. SAHMRI is an institute which has been deliberately designed to bring together the state's universities and the hospital, so we do not try to cover every area of science but work in collaboration with people who do. My expertise is in behavioural science, economics and public health so I am not in a position to provide a comment in direct response to that and I apologise for that.

Dr SOUTHCOTT: I understand. On the prevention side, you mentioned we are doing quite well with primary school aged children, not so well with adolescent children. What sorts of things should we be considering for that age group?

Dr Miller : As I indicated, structural measures which provide protection from UV are appropriate. Adolescence, as everyone would appreciate, is a time of change and a time of risk-taking behaviour. That is very functional in maturing but it often means that health behaviours are not the top priority. The elimination of solaria is certainly a helpful measure but I think structural shade provision, which adolescents do use, in the environments that they spend their days in, namely schools, is an important measure. Adolescents' risk-taking behaviour around health is often seen as a reaction against social norms and in some ways it is, but we know very much from the experience that we have in tobacco control that adult role modelling is extremely important in the behaviours people ultimately adopt into adulthood. So socially normalised sun protection is important for adolescents' protection as they move into adulthood—as it is in tobacco control and in other areas of behaviour.

Dr SOUTHCOTT: What do you think the levels of awareness are about UV rating and, specifically, the UV rating of different times of the day as well for people who do have to work outdoors?

Dr Miller : I think the science is there and the applications are there. The information is available. I think the extent to which people use that information is quite poor so, as with lots of health behaviours, well educated people understand what a UV index is, they understand that they can go to an app or they get the information about the times of day when they need to protect themselves and some people will implement that very actively. That is not something that provides a population based solution because a lot of people will protect themselves from heat without an understanding of the difference between heat and UV. On a hot day people will think the UV is high and they need to protect themselves and often they will protect themselves in a way that protects them from the heat or the glare. And on a less hot day in the middle of summer, people will think that UV is low when in fact it is actually not. It is a question of health literacy.

Mr WYATT: I want to go to a couple of interesting questions. One is about the work you are currently doing and the collection that you have. What distinguishes you from all other centres? I have read all the submissions and there are commonalities in everybody's submissions. The other part to this question is: what alliances are you forming and are there distinguishing aspects that each of you are doing research in, as opposed to doing duplicate work?

Dr Miller : SAHMRI as a whole is a deliberate concerted attempt to collaborate across the state. It is uniquely constituted in that all of the universities that are in the state are members of SAHMRI, as is the state government, although we are a company limited by guarantee. That has been done quite deliberately so that within the state people are not competing for research space and duplicating research effort. There is collaboration, which is often not a feature in research. Research can be a very competitive environment.

We are also very deliberately inclusive of the state government so that there is an acceleration in the application of science into practice—in the clinic, but also in health services. Health services is a very underdone area of research. There is a lot known about how better to conduct medical practice that is not implemented on the ground because of what is called 'a translation valley of death' between the scientist and what the scientist knows, and the policy maker and what happens in practice.

That is what happens in terms of SAHMRI. In terms of the population health effort and the other people who are undertaking behavioural science in cancer control around the country, we work as colleagues and collaborators in the work that we do. We do not duplicate the work of other jurisdictions. The Cancer Council is a key partner of the South Australian Health and Medical Research Institute. So the Cancer Council, the state government and SAHMRI form together to pool research dollars and create something called the Beat Cancer Project, which is a deliberate effort to collaborate and not duplicate effort and resources.

Mr WYATT: What work will you be doing in respect of genomics and the types of cancers?

Dr Miller : Genomics is a very large part of the work that is undertaken at SAHMRI. A lot of the scientists that SAHMRI has hired have a very strong background in genomics. Our theme leader, Charles Mullighan is expert in this area. His area of interest and professional work has been in leukaemia, but there are other scientists coming into SAHMRI who work very much in genomics. As I said, I am at the other end of the research spectrum, so it is not my area of expertise, but it is a big part of the research effort at SAHMRI.

Mr WYATT: One of the challenges we will have in Australia is the number of research centres and the level of focus around different cancers and the capacity to sustain the number of scientists who will want to undertake research—hence my question in terms of the Telethon Institute in Western Australia, WAIMR in Western Australia, the Sax Institute, the Baker Institute, the CRC in Darwin and now SAHMRI. There are others, including those in a couple of key neighbouring countries where research is being undertaken on cancer. What plans are there in terms of alliances so that we effectively use the resources that are available under the research funding base?

Dr Miller : As I have indicated, we are very conscious of that. That is why SAHMRI was established and is constituted the way that it is—so that there is a focus on collaboration and non-duplication of effort. We have established at SAHMRI a South Australian Comprehensive Cancer Consortium, as well. It takes what we are doing outside of the walls of research and very much into collaboration with clinicians, in order that the efforts of the state are well coordinated.

We have started working with the Northern Territory. SAHMRI has taken over running of the Northern Territory Cancer Registry, for example. SAHMRI has also already taken over management of the central coordination of the South Australian clinical registry. These are indications, I suppose, of the progress we are starting to make in terms of collaborating with partners locally and also interstate to try to reduce duplication of effort and build critical mass and have a more efficient return for limited research dollars.

Mr WYATT: So how do you see the effectiveness in your relationship with GPs and with hospitals?

Dr Miller : We are in the process of establishing an academic health science system. Academic health science centres are a conscious and deliberate alignment of teaching hospitals and clinical service delivery places, university medical schools and research. The idea is that excellence is key and there is strategic alignment of directions in the three sectors of teaching, clinical service delivery and research.

In terms of what we have done in the state, we have made it an across-state effort. We have also brought in Medicare Locals, as well as local health networks in order that primary care and general practice is part of that effort. We have been working on that with the universities and Health, as well as the Medicare Locals for 12 or 18 months. Cancer is one of the streams. We have different disease streams aligned within that. That is, once again, a deliberate and concerted effort to try to bring the entirety of clinical service delivery and research together to promote excellence, to avoid duplication and to translate into more efficient and better outcomes for the community.

Mr WYATT: Dr Miller, in your view, given the connectivity you have with the universities, do you see the universities responding better in the training of GPs or medical practitioners by having a more significant focus on cancers and skin cancers?

Dr Miller : I do not know that I am in a position to offer an opinion with regard to that. The academic health science system is at its start, so we are setting strategic directions as opposed to implementing. I do not have direct experience with the medical school and their curriculum to be able to give a well informed response, I am sorry.

Mr WYATT: Would you hope, though, to influence—

Dr Miller : Absolutely.

Mr WYATT: I will finish there and allow another colleague to ask some questions.

CHAIR: Dr Miller, thanks for coming in today, as I said before. You mentioned awareness programs during your introductory statement. What a awareness programs have been run in South Australia? Do you know the effects they have had in recent years?

Dr Miller : The sun protection work—the Slip, Slop, Slap work—has been run for several decades around the country, including South Australia. The fact that people know what that is speaks to its success, sustainability and message. That work has involved trying to raise the awareness of the community around the need for sun protection. It has been in place since the 1980s and it has followed through with a focus in schools. I am sure you will have an appreciation that in primary schools it has had a lot of success. Kids are not allowed outside without hats during the terms where UV is high. There has been a lot of traction and a lot of success in that space. There have been some mass media campaign efforts in Australia which have had demonstrated effectiveness. Where they have been well developed based on behavioural science—which is what informs people on making decisions about what they want to do with their behaviour but also on what motivates them to keep those decisions top of mind and to follow through with those behaviours—they are effective. We have had a good example in Australia of a well executed mass media campaign on skin protection in recent years. I was reading some of the other submissions and I think the federal Department of Health has made a submission in relation to its effectiveness.

Most of my experience has been in developing, executing and evaluating tobacco control campaigns. That is another example where behavioural science has been used to inform messages, both to increase people's awareness about the relationship between a behaviour and potential health risks and to take it from the top-of-mind 'Yes, that's bad for me' to something which they feel motivated to do something about and then capable of doing something about, with realistic behaviours that need to be changed tomorrow instead of next month, in six months or next year. Skin cancer is the same, so there are tangible behaviours which need to change in an individual, which flows on into a population. So it is about bringing about that change in a way that is effective and relevant for people, and then that has been shown to flow on to effective behaviour change.

CHAIR: The reason I asked was that I got a little bit excited because I thought there might have been a recent program that had been run in South Australia that might not have been run nationally.

Dr Miller : There is a good campaign, the Dark Side of Tanning campaign, that was developed and has been screened, and that has had demonstrated effectiveness. I think that has been shown federally. It has certainly been shown in South Australia. So that is an example of a well-executed mass media campaign which motivates behaviour change.

CHAIR: The reason I ask—and my colleagues might correct me if I have misunderstood some previous evidence we have had—was that I understood there had not been a federally run program since 2009 and we have not had the national figures on melanoma since 2011. So I just wondered what you were basing your information on, because we have not had that information for quite some time.

Dr Miller : No. As you would appreciate, the latency period on cancer is substantial, so the measures that we would use would be increased awareness, increased motivation to change and then increase in the behaviours that protect against UV, which then will prevent the cancers into the future.

CHAIR: You also mentioned behaviour drives. Does research show any particular items that are thrown up as real behaviour drives for people when they are changing their—

Dr Miller : Yes, health behaviour is changed through concern about the reality of a health risk, so lots of different motivators have been tried to change different types of health behaviour. People think humour is effective and people think talking about money is effective, but in fact it is not. It is actually about making people have a salient sense of a risk that they want to avoid, and it is about the desire to avoid that risk, whether it be genuinely understanding what a skin cancer means—that there is a risk of metastasising and what have you—or other types of risks that are associated with tobacco, for example. So it needs to change people's cognitions—how they think about something and whether they understand that it is a risk or think it is a risk for them—but also their affect—how they feel about it or if they have a sort of visceral response. We know that, if we can increase the extent to which someone either feels like something is likely to happen to them or feels that it would be bad if it happened to them, that is what drives a behaviour change in an individual. So we talk about cognition and affect. What is also important is the extent to which people feel that they can control the behaviour that we are asking them to change; that is called self-efficacy. A third very important variable is social norms. So these things all drive behaviour independently, including the extent to which the people around you and the people who influence you, whether you care to admit that you are influenced by people or not, think that the behaviour you are talking about is acceptable. If you think about where tobacco smoking was three decades ago, we probably would have had ashtrays on the table and everyone would have thought it was normal and completely acceptable.

CHAIR: Ken would still have been lighting up.

Dr Miller : There has been a very marked change in the extent to which people think that that is a normal thing to do, so that changes behaviour. It absolutely has an influence. Quitting is a difficult behaviour. Wearing hats, applying sunscreen and shade seeking are far less difficult behaviours, but the same principles still apply. Making those risks real for people is what we have done in tobacco control. We have given people what we have called a doctor's-eye view of disease, so it is not just, 'Smoking leads to heart disease and lung cancer; it's a lottery that's drawn when I'm 75, and I'll give it a go, because I had an aunt who lived to 90.' It is about helping people understand what they are actually doing to their bodies in the way that a well-informed medical practitioner would, and there are examples of skin cancer campaigns which have done exactly the same.

Dr SOUTHCOTT: On this point, tobacco control, I think, is really the best example of how all of those changes that have been made at different levels of government and through advocacy from health professionals and so on have been extremely effective. How would you compare that with the message on skin cancer and melanoma? Obviously, the message has been around there. To an extent, behaviour has changed. But how does it really compare?

Dr Miller : I think there are good parallels between the behaviours. Certainly, the top-of-mind awareness that UV causes skin cancer is very high. When we ask people in population surveys—and we do—something like 85 or 90 per cent of people will tell you that. You can see the policy change impact in schools. As I said, that has been quite comprehensive. Where there is a policy, the protection for the kids is far greater. Mass media campaigning has, in my view, been underdone in skin cancer preventions. It is about the same application of good behavioural science and a well-executed message which, when tested, actually makes people think, 'Gee, this is something relevant to me; it is something I need to do something about.' That is when you have the flow-on effects. So it is the same principles of increasing genuine understanding of what the issue is in the community, as opposed to a more superficial understanding, and then motivating personal behaviour change, creating an environment which makes it easier for people to make the change. That improves their health and saves dollars for the health system.

CHAIR: One more question. Have you looked at research with regard to cancer-screening programs and how effective they have been, particularly with skin cancer of the older generation now more diagnosed than the younger generation?

Dr Miller : Yes. Screening behaviour is, once again, a combination of an approach-avoid behaviour. You approach screening like you approach going to the dentist because you know it is the right thing to do and you know it is good for your health et cetera, but perhaps you are not sure you want to do it or it costs you money or whatever. That is what pulls you back from the behaviour. So it is about getting the balance right, if you want people to screen.

My understanding of the evidence is that for skin cancer screening there is no evidence to support a population-based screening program. That evidence is tested by establishing how much effort and resources it takes to screen a population and what reduction in, ultimately, morbidity and mortality is brought about as a result of the screening. For a screening program to be effective, it has to have solid enough evidence that screening everybody in a population is worth it to bring about the reductions in morbidity and mortality because of the cost and the other burdens associated with doing it.

CHAIR: How do you get that evidence? Which comes first, the chicken or the egg?

Dr Miller : It is about models. The World Health Organization publish this sort of information. I have not looked at any of that firsthand. But my understanding is that, for skin cancer population-based screening, there is no evidence to warrant a population-based screening program the way there is for other cancers, such as cervix, breast and bowel where there is evidence to support population-based screening.

But that is not to say it is different to an individual's risk. So for a person with fair skin, who has had exposure, it is still a good idea for that individual and for that person's clinician to look at their skin and to monitor the changes in their skin, which is a more personalised clinical approach than a population-based screening approach.

Ms RISHWORTH: I was just going to ask that question. You said you think that behaviour changes have occurred quite significantly in terms of prevention. How would you compare that to individuals checking themselves—in other words, more the early detection route, instead of, 'We're not going down the route of population screening' because that has not been recommended? In terms of people knowing when to go and get something checked, there are no guidelines saying, 'Every two or five years, go and see a doctor.' Where do you think the awareness and the behavioural change is in that space, of actually saying, 'I'm a bit worried about this, I'm going to go to the doctor and get this checked out.' Has that changed as much as the prevention behaviours?

Dr Miller : Yes. I do not have data about the extent to which it has changed. People probably have a low level of understanding about what does and does not need to be checked out. I think the public health messaging around that is for people, if they notice a change, to get it looked at. I think the general population's understanding of what does and does not need to be looked at probably is reasonably low. People do have an understanding that in many cancers picking something up early is better. It is not true universally, but it is true in skin cancer and a number of other cancers. I know that there has been some work around awareness raising in rural communities in South Australia, working with groups at high risk like people in farming and fishing professions, and there has been some work done with women as the gatekeepers of family health to keep an eye on other people's skin. But I do not have data to present to you.

Mr WYATT: We have been successful in having schools have a campaign of 'no hat, no play', and yet those same children an hour after school or on weekends at sporting carnivals, events and even a show that I was at on the weekend had no hats in sight.

Dr Miller : I think that speaks to the point about policy and that, in the absence of policy, it is much harder. In school environments, by and large there is a policy, and the policy is no hat, no play. Compliance is very high and protection is very good; but, if those policies are not in place in other environments run by other groups like sporting groups or what have you, in the absence of policy the behaviour lapses. It also speaks to the point of social norms as well. While we expect children to wear hats, by and large we do not expect adults to wear hats. While primary school children are happy to conform to a behaviour that is specifically for them, adolescents absolutely are not and aspire to adult behaviours—as much as it sometimes seems like they do not—and by and large conform to adult behaviours. Some protective behaviours are quite suboptimal among adults and even parents. So I think there is certainly a role there to try to bring about those sorts of changes through awareness-raising measures, which we have talked about, and also through policy measures in other settings.

Mr WYATT: Have we undertaken any research with regard to whether a campaign other than Slip, Slop, Slap has been successful?

Dr Miller : Yes. As I think I indicated, I was reading through some of the other submissions and looked at the submission of the Australian Department of Health, which talks about when there was a national skin cancer campaign done. They presented evidence that there was effectiveness in terms of increase of awareness and also increase in behaviour change—because awareness is great but, if it does not translate into behaviour change, it has not really achieved its objective. So my understanding is that, yes, there is evidence of that effectiveness.

Mr WYATT: It would be interesting to look at that evidence in the context of sustainability. Often when you have a campaign, people take note of the campaign for a period of time and then it lapses.

Dr Miller : I think that is exactly right. In tobacco control there has been the benefit of sustained intervention, and that sustained intervention has brought about big changes which have lasted. Skin cancer has not had the benefit of that sustained intervention. It has been a shorter-term investment with shorter-term results.

Mr WYATT: Thank you.

CHAIR: Have there been any long-term studies done? I was thinking about how in school they have to have a policy, and maybe legislation is something that would drive that—but you do not want to see that—but, historically, when people wore neck-to-knees to the beach, men wore hats until the early fifties, the ratios of skin cancer diagnosis then compared to now were—we are a lot more open now in wearing virtually nothing on the beach. Have any comparisons of those sorts of behaviour and fashion changes been done?

Dr Miller : Epidemiology is the science that documents that behaviour change, and certainly UV is the driver. When people were top-to-toe on the beach and wearing hats, they were not going to have those exposures which put them at risk. We also know that the exposure that is sustained early in life is critical in terms of future risk. Fashion is absolutely something that, as you have indicated, determines the extent to which people cover up and, therefore, get UV or not UV exposed. People sometimes talk about how, if only we could influence fashion, we could reduce UV exposure. I think that is not something that is ever going to be an effective technique, as much as we might like it to be. So, in the absence of the ability to influence fashion, it is about raising awareness and structural change which protects people, particularly adolescents. Adolescent fashions are certainly not to cover up at the moment, which puts them at risk; so, if there are structures in place during the daylight hours which mean they get the protection, that is going to save those future skin cancers.

Mr WYATT: I want to come back to a question about medical literacy. One of the things that has always fascinated me is that we talk about Australian English but every subject at school has its own English depending on what is taught. In medicine, particularly in the health and allied health areas and amongst GPs and specialists, there is a level of medical literacy that the majority of the public do not understand. They hear the terminology but have no appreciation of what it really means until the treatment becomes intense. Is there any thought about addressing some of that in some of the messages that we give?

Dr Miller : I think that is absolutely right. Health literacy is incredibly important, and we all use language that means something to us and our colleagues but means hardly anything to anybody else. Part of the work that is done to develop public communication is that, in order for it to be effective, it absolutely has to communicate a notion that is something a doctor or a person on the street can understand. Often the lower socioeconomic groups are, unfortunately, the people who carry larger portions of burden, are at greater risk for all sorts of reasons and are under different sorts of pressures; so, for a communication to be effective, that is the first measure of whether it has any chance of being effective. What we try to do is help people to understand in their own language and in a way that speaks to and is relevant to them the issue which is obvious for medical professionals and scientists. So that is absolutely right.

Mr WYATT: The other element to that, then, is the need to explain regimes of treatment and the compliance. I know of numerous people who are prescribed a treatment, talk about the treatment they are having but often say that, because they have to pay costs up front, they wait until payday before they buy whatever medication it is that they need. If they are having chemo and they require something else, they sometimes make the decision to take medication every second day. That is something that also needs to be considered in campaigns that cancer councils and institutes like yours undertake so that the medical literacy and understanding is far better than what it is.

Dr Miller : Yes. I am sure that is exactly right. I am not a clinician, but I worked at the Cancer Council running cancer support and cancer prevention programs for 16 years, so I certainly understand that people are very financially burdened by cancer. Often they are not in a great place when they start. People have to come in from the country to have treatment and have difficulty affording accommodation. Our services can be particularly unfriendly and inappropriate for Aboriginal people, who often present at a much later stage. So I think that is exactly right. I do think it is the responsibility in public health; in order to bring about change, it has to be something that is accessible, relevant and achievable for people wherever they are, and we are not succeeding if we are pretending that people should respond or behave differently than they actually can and do.

Mr WYATT: Thank you.

CHAIR: One last question: in your 16 years with the Cancer Council, what would have been a trigger or initiator of doing an awareness program or advising the government to do an awareness program?

Dr Miller : It is about an opportunity to bring about change in a cost-effective way. It is about where there is a large, preventable burden of disease. Skin cancer is absolutely an example of that. When you see something that has a large burden on the community, there is a solution—in terms of reduction in UV exposure—and there is a cost-effective, efficient and evidence based road to that solution through something like awareness campaigns, that is when we would advocate for that sort of work or do that sort of work ourselves as well to try to help bridge the gap between what cancer councils, people in medical research institutes, doctors and scientists know and what the community understands. You do that through broadcast communication. Certainly you will get a lot further talking to people on the news, Sunrise or something like that than you will publishing in peer reviewed journals, although that is obviously extremely important for the science. You can achieve so much through unpaid media, and coordinated mass media campaigns have been demonstrated to be very effective and very cost effective.

CHAIR: Okay. If there are no other questions, thank you for your evidence and for coming today to assist the committee. If you have been asked to provide additional information, could you please forward it to the secretariat by 28 April? If we have further questions for you, we will send those to you. If we do have further questions, they will come to you in writing from the secretariat. Once again, thank you for coming and giving evidence to the committee.