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Cancer Challenges -

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Norman Swan: Hello, and welcome to this week's Health Report with me, Norman Swan. Today, a radical rethink about asthma treatment and who should get what. Painkillers to prevent cancer, which one is best? Painkillers to treat pain, which is the least useless? And the Australian Institute of Health and Welfare has released the latest statistics on cancer in Australia. Breast cancer is still at the top, bowel cancer next, followed by prostate and melanoma. And counterintuitively, while cancer incidence is rising, when you do have cancer you are less likely to die from it. And hidden in this are some important messages for us all with no cause for complacency. Here to talk about them and also follow up on a story that we had on last week's Health Report on breast density and the risk of breast cancer is the chief executive of the Cancer Council of Australia, Sanchia Aranda. Welcome to the Health Report, Sanchia.

Sanchia Aranda: Hi Norman, how are you?

Norman Swan: All right. Let's start with breast density which can increase the risk of breast cancer by 400%, it may explain about one in three breast cancers in premenopausal women. Last week we had research on which talked about this and showed it might be related to inflammation. But what we discovered as part of that is that the only state in Australia to actually tell women they have dense breasts and be aware of this problem is Breast Screen in Western Australia. And the national policy of Breast Screen Australia is actually not to even record whether a woman has high breast density. What's going on, Sanchia?

Sanchia Aranda: Part of the challenge for the breast screen program is that breast density is actually on a continuum. It includes bright areas within the breast and white areas. It looks as if the white area relates to the masking of diagnosis. So it increases the risk that a woman's breast cancer would not be detected with mammographic screening, whereas the bright area looks like it's the indicator of increased risk. And so part of getting cancer…so part of the challenge for the breast screen program is that we currently don't have the algorithms to actually make those distinctions, and we don't have the capability of them knowing what it is that you're telling a woman. So just telling someone they've got dense breasts is not very helpful, there is no guidance for what you would then do in terms of management. And we desperately need the research that will back up the kinds of information we have about density now.

Norman Swan: So you're in a state of ignorance. In other words, what you're saying is that if a woman's got dense breasts, you don't know what to recommend, you should have ultrasound, you should have MRI, you should have more frequent examinations, so we just won't do anything.

Sanchia Aranda: Well, there's a lot of things that are actually happening. John Hopper in Victoria has done some fantastic work looking at how you use digital mammography to be able to separate out the very bright areas that look as if they are associated with the increased the risk of getting cancer. There are other groups that are looking at how you collaborate really to understand what you should do for diagnosis. And part of the challenge for us in Australia is that the breast screen program has to be about…it's a one-size-fits-all approach, and this is going to take much more tailored advice to women. We know that this very bright area of breast density is probably more important for this very small subset of women than even something like a BRCA1 mutation. So we want to be able to develop breast risk algorithms that can be applied to individual women, the embedding of that within the breast screen program will be very complicated because it is a population-based program. And so we would like to see researchers come together and embed the work in the breast screen program, and for funders to actually see that as a priority.

Norman Swan: Well, it is a priority, isn't it? You compare it to the gene that causes 10 times the risk of breast cancer, but breast density can increase the risk six times, so it's not that far off the breast gene.

Sanchia Aranda: Because you think about breast density on a continuum, it's the very one end of it which is this increased areas of brightness. So it's not a huge volume of women, so it's very similar that breast screen, because it's one-size-fits-all, doesn't lend itself to doing this at a population level. We are going to have to look at how you do risk stratification and model that. And of course from a government perspective you can imagine the anxiety, that if you have a different screening interval, say for very low risk women versus very high risk women, and one of those women gets an interval cancer, if you haven't done the work appropriately then you can cause more problems than you thought you were going to fix.

Norman Swan: Just before we get on to the cancer statistics, isn't it a bit patronising to women thinking that they are better off without this information?

Sanchia Aranda: I certainly wouldn't advocate for that. The problem is we are not at the moment understanding what information we should be given. So when the radiologist is now…in WA they are giving back density information, but there's no indication on that whether this is largely the white areas or the bright areas, so there's no training of radiologists in how to do that at a broader measurement. They use a thing called Cumulus, but in fact that's just a broad measure of breast density. And we don't actually know in WA what people are doing with that. And there's research going on there at the moment looking at what are the women making of this information and what are their GPs making of it because it's coming as static information, not with support for how they would then advise that woman about what's the best approach to manage their breast cancer risk.

Norman Swan: Let's move on to cancer stats which came out just before the weekend, Saturday was World Cancer Day. What are the main messages here from this?

Sanchia Aranda: So from a Cancer Council perspective, three out of the five top cancers in women and four of the top five in men are preventable cancers or cancers that can be diagnosed early in the case of bowel cancer. And so this reinforces the need for us as a community to take charge of our health, stop smoking, eat an appropriate diet, limit our alcohol intake, but also importantly to participate in the national screening programs. 36% of Australians participate in the bowel screening program. It's one of our top five cancers in both sexes, it's also one of the top causes of death. We know that 78% of people rescreen if they get involved in the program in the beginning. So a public awareness campaign around the importance of bowel screening is urgently needed.

Norman Swan: Why is it so low?

Sanchia Aranda: It's probably two factors. One is that when you get that kit in the mail there's a yuk factor in it. But also what the community tell us and some work that has been undertaken in New South Wales is they don't understand really the importance of bowel cancer in our community. They hear lots about prostate cancer, they hear lots about breast cancer, lots about ovarian cancer, and many people minimise or have minimal understanding of the risks that they have for bowel cancer.

Norman Swan: So they don't realise how horrible a rectal cancer can be.

Sanchia Aranda: Absolutely not.

Norman Swan: And there was some evidence and some federal government research that GPs are not necessarily giving the right advice, they don't necessarily believe that the test is worthwhile.

Sanchia Aranda: Certainly from a GP perspective we know that a number of GPs really say to people you are much better off to have a colonoscopy, and yet the immunohistochemical test that is used in the bowel screen program is incredibly sensitive and very accurately able to pick up the early bleeding from polyps. And so it is about a preventive strategy. We've already got a lot of problems with colonoscopies wait times and other things in this country. So participating in the bowel screen program is still the best thing to do.

Norman Swan: And yet here's this cancer report and there's nothing on treatment, there's nothing on the variations in care. And you and I both know that your cancer outcome, once you've got cancer, is highly dependent on which surgeon or cancer specialist you are sent to and, more importantly, which team, and we know almost nothing about what's happening in the private sector, and yet a lot of all this happens in the private sector. Isn't this something we should be getting pretty angry about?

Sanchia Aranda: It's certainly big on our advocacy agenda for the coming period from the Cancer Council. We must start collecting stage treatment and recurrence if we are going to really understand who is missing out in this country. Some work that has been done on New South Wales data shows that the gap between the haves and the have-nots in terms of cancer outcomes is widening. We can't understand that until we can understand variations in treatment and care. So this kind of routinely collected data must be embedded in our system. We have to be able to share data across states and federal jurisdictions. And while there has been positive movement from the Australian government in that regard, we aren't getting enough of that data actually being analysed and informing how we deliver services.

Norman Swan: Sanchia, thank you very much for joining us.

Sanchia Aranda: My pleasure Norman, thank you.

Norman Swan: Sanchia Arandas is chief executive of Cancer Council Australia.