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4.4 The changing cancer landscape
There have been many successes, and there are many remaining challenges, in cancer control. While
the incidence of cancer is rising, the good news is that overall average mortality at the population
level is falling and real improvements in survival are continuing.
These changes in the cancer landscape are not universal, and differ greatly by cancer type and
population group. The overall average is not necessarily indicative or representative of individual
experience, where a diagnosis of cancer is anything but ‘good news’.
The observed rise in overall cancer incidence can be broadly attributed to advancements in early
detection (through organised screening programs and better detection technology), the ageing
population and changes in risk factor exposure. The observed fall in the overall cancer mortality rate
can be mainly attributed to a combination of earlier detection (at a more treatable stage) and more
effective treatments. The number of cancer-related deaths is attributable to changes in risk factor
exposure and the ageing of the population.
The net result of increasing cancer incidence and decreasing overall mortality is more people living
with cancer, that is, higher and gradually increasing prevalence due to increased survival in the
population. Better survival rates for some cancers bring an increasing emphasis on living with, and
after, a cancer diagnosis.
This article examines broadly some features of this changing landscape through:
• describing cancer and the current disease burden
• summarising the historical gains in cancer control
• estimating the future cancer disease burden and discussing emerging issues
• outlining areas where future gains could be made.
What do we know about cancer?
Box 4.1
Defining cancer
Cancer, also called malignancy, is a term for diseases in which abnormal cells divide without
control and can invade nearby tissues.
Cancer cells can also spread to other parts of the body through the blood and lymph systems.
There are several main types of cancer. Carcinoma is a cancer that begins in the skin or in tissues
that line or cover internal organs. Sarcoma is a cancer that begins in bone, cartilage, fat, muscle,
blood vessels, or other connective or supportive tissue. Leukaemia is a cancer that starts in
blood-forming tissue, such as the bone marrow, and causes large numbers of abnormal blood
cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that
begin in the cells of the immune system. Central nervous system cancers are cancers that begin
in the tissues of the brain and spinal cord.
Source: National Cancer Institute 2014.
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Cancer is a major cause of illness in Australia, with more than 116,500 people diagnosed with cancer
in 2010 (excluding non-melanoma skin cancer), and around 43,200 dying from cancer in 2011 (see Box
4.1, Table 4.3). Cancer contributed 16% of the total disease burden in Australasia (Australia and New
Zealand), based on findings from the Global Burden of Disease Study 2010. (For more information on
the burden of disease, see Chapter 4 ’Burden of disease’.)
In 2008–2009, the total health system expenditure in Australia on neoplasms (including cancer
and non-cancerous tumours) was $4,526 million, an increase from $2,894 million in 2000–01, after
adjusting for inflation (AIHW 2013). The majority of health system expenditure on cancer in 2008–09
was on hospital-admitted cancer services (79%), followed by prescription pharmaceuticals (12%) and
out-of-hospital services (9%). Expenditure on national population screening programs was just over
$332 million in 2008–09.
The cancer burden differs by sex, age and population group. These differences are summarised in
Table 4.3.
Table 4.3: Cancer incidence, mortality and survival at a glance
Incidence Mortality Survival
There were 116,580 new
cases of cancer in 2010
(excluding non-melanoma
skin cancer), a rate of 487
per 100,000 people.
There were 43,211 deaths
from cancer in 2011, a rate
of 172 per 100,000 people.
In the period 2006–2010,
5-year relative survival
for all cancers combined
was 66%. That is, people
diagnosed with cancer
had a 66% chance of
surviving at least 5 years
compared with their
counterparts in the
general population.
The incidence of all cancers
combined was 1.4 times as
high among males (585 per
100,000) compared with
females (406 per 100,000).
Mortality from all cancers
combined was 1.6 times
as high among males (219
per 100,000) compared
with females (137 per
100,000).
Females (67%) tended to
experience slightly higher
survival than males (65%)
overall.
Cancer can develop at any
age but around 70% of all
cancers are diagnosed in
people aged 60 and over.
Deaths from cancer are
most common among
older people, with more
than 80% of all deaths from
cancer occurring in people
aged 60 and over.
Survival decreased with
age: from 86% among
people aged 0–39 to 43%
among those aged 80
and over.
continued
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Table 4.3 (continued): Cancer incidence, mortality and survival at a glance
Incidence Mortality Survival
Indigenous Australians
were 1.1 times more
likely to be diagnosed
with cancer in 2004–2008
compared with their non-
Indigenous counterparts.
Indigenous Australians
were 1.5 times more
likely to die from cancer
in 2007–2011 compared
with their non-Indigenous
counterparts.
Indigenous Australians
had lower 5-year relative
survival (40%) in
1999–2007 compared
with their non-Indigenous
counterparts (52%).
People living in areas of
lower socioeconomic status
had a higher incidence of
all cancers combined (490
per 100,000) compared
with people living in
areas of higher relative
socioeconomic status (482
per 100,000), in 2004–2008.
People living in areas of
lower socioeconomic
status had higher mortality
from all cancers combined
(172 per 100,000)
compared with people
living in areas of higher
relative socioeconomic
status (151 per 100,000), in
2006–2010.
People living in areas of
lower socioeconomic
status had lower 5-year
relative survival (63%)
compared with people
living in areas of higher
socioeconomic status
(71%), in 2006–2010.
Incidence rates of all
cancers combined were
higher for Australians living
in Inner regional areas (504
per 100,000) than people
living in Outer regional
(495 per 100,000), Major
cities (480 per 100,000) and
Remote and Very remote
areas (474 per 100,000), in
2004–2008.
Mortality rates for all
cancers combined were
higher for Australians living
in Remote and Very remote
areas (196 per 100,000)
and Outer regional areas
(193 per 100,000) than for
those living in Major cities
(171 per 100,000) and Inner
regional areas (185 per
100,000), in 2006–2010.
Five-year survival from all
cancers combined was
highest among people
living in Major cities (67%)
compared with Inner
regional (66%), Outer
regional (65%) and Remote
and Very remote areas
(63%), in 2006–2010.
For more information, see Chapter 4 ’Cancer in Australia’.
What has changed over time?
In Australia, there are some notable historical trends in cancer incidence, mortality and survival
(Figure 4.4). The trend data presented here reflect the breadth (from first to most recent year) of
available national data: 1982–2010 for incidence, 1968–2011 for mortality and 1982–1986 to
2006–2010 for survival.
The overall cancer incidence rate has on average increased by 0.9% per year between 1982 and 2010
(Figure 4.4). This increase reflects annual rises in the incidence of some of the most commonly diagnosed
cancers such as prostate cancer, breast cancer and melanoma of the skin, as well as some rarer cancers
such as liver and testicular cancers. In contrast, the incidence of some cancers, including lung, bladder
and cervical, fell significantly in that same period. There has been a moderation in the overall trend in
more recent years, with incidence rising by an average of 0.5% per year from 2001 to 2010.
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0
100
200
300
400
500
600
MortalityIncidence
0
10
20
30
40
50
60
70
80
90
100
5-year relative survival
20
10
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20
06
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5-year relative survival (per cent) New cases/deaths per 100,000
20
11
Year
The good news is that despite the overall substantial increase in incidence, overall mortality on average
from all cancers, including the cancers that are the leading causes of death, fell by 0.3% per year
between 1968 and 2011 (Figure 4.4). This fall reflects substantial improvements in survival, thought
to include substantial real gains in survival—that is, delaying death, and not only earlier diagnosis
extending the measured time between diagnosis and death. There has been a gain in the overall trend
in more recent years, with mortality falling by an average of 1.0% per year from 1991 to 2011.
Between 1982–1987 and 2006–2010, 5-year relative survival for all cancers combined rose from 46.9% to
66.1%, a rise of 41% across that period. This trend was observed for most, but not all, cancer types: survival
from bladder, larynx and lip cancers fell, although the change was only significant for bladder cancer.
Changes in cancer incidence, mortality and survival have been shaped by a wide range of factors,
including changes in exposure to the risk factors for cancer, improved primary prevention,
advancements in cancer treatment, and for some cancers, earlier detection through organised
screening programs (bowel, breast and cervical) and opportunistic testing (prostate) (Armstrong 2013).
Notes
1. Deaths registered in 2009 and earlier are based on the final version of cause of death data; deaths registered in 2010
and 2011 are based on revised and preliminary versions, respectively, and are subject to further revision by the ABS.
Data for 2010 have not been adjusted for the additional deaths arising from outstanding registrations of deaths in
Queensland in 2010.
2. Data points for 5-year relative survival refer to the final year in each 5- or 6-year at-risk period: 1982–1987,
1988–1993, 1994–1999, 2000–2005, 2006–2010.
Sources: AIHW Australian Cancer Database 2010; AIHW National Mortality Database; AIHW 2012b.
Incidence (1982–2010), mortality (1982–2011) and 5-year relative survival (1982–1987
to 2006–2010) of all cancers combined, Australia
Figure 4.4
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LEChanges in exposure to risk factorsChanges in exposure to cancer risk factors at the population level can increase or decrease cancer
incidence, which in turn may produce a parallel change in cancer mortality, noting the lag in time
between exposure and the onset of cancer (Armstrong 2013). For most cancers, the causes are not
fully understood; however, some causal factors are well recognised, and include:
• behavioural factors such as tobacco smoking, alcohol, diet, obesity and physical inactivity
• family history, genetic susceptibility and reproductive and hormonal factors
• occupational and environmental exposures (for example, radiation, asbestos, ultraviolet light and
chronic infection)
• medical and iatrogenic factors (AIHW & AACR 2012; IARC 2008; WCRF & AICR 2007).
Selected cancers strongly influenced by changes in exposure to known and quantifiable risk factors in
previous decades include lung and stomach cancers, melanoma of the skin and cervical cancer.
Tobacco smoking is the largest single risk factor for lung cancer in Australia, and is responsible for about
90% of lung cancers in males and 65% in females (AIHW: Ridolfo & Stevenson 2001). Lung cancer
incidence and mortality among males has declined steadily since the 1980s, which is attributed to
the steadily declining rate in daily tobacco smoking: from 58% in 1964 to 16% in 2010. In contrast, for
females, lung cancer incidence and mortality among females continue to rise. This is attributable to a
later turnaround in smoking rates: from a high of 33% in 1976 to 14% in 2010 (AIHW 2012a; OECD 2013).
Ultraviolet radiation is the leading risk factor for melanoma of the skin. In Australia, the incidence
of melanoma of the skin rose between 1982 and 2010—at around 5.0% per year during the 1980s,
moderating to 2.8% per year after that. The initial rapid increase is partly attributable to individual
behaviour and the use of solariums, resulting in increased exposure to solar ultraviolet radiation
(Armstrong & Kricker 2001; Cust et al. 2011). The moderated trend after the 1980s is consistent with
increased awareness of skin cancer and improved sun protective behaviours as a result of extensive
skin cancer prevention programs dating back to the 1970s (AIHW 2012a).
The major causes of stomach cancer are the bacterium Helicobacter pylori, poor nutrition and smoking.
There have been continuous falls in stomach cancer incidence between 1982 and 2010, and stomach
cancer mortality between 1968 and 2011—2% and 3% per year, respectively. The falls are largely
attributable to a decline in the prevalence of H. pylori, and to dietary improvements and the decline in
smoking rates (Armstrong 2013). Further improvements in incidence and mortality are expected as a
result of the continued decreasing trend in daily smoking.
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Chronic infection with the human papillomavirus (HPV) is the cause of around 70–80% of all cervical
cancers (Brotherton 2008). The AIHW and the Victorian Cytology Service recently conducted a study
to evaluate the effectiveness of the HPV vaccine against cervical abnormalities among school-aged
women (Gertig et al. 2013). This study demonstrated that the population-based HPV vaccination
program in Australia is preventing cervical pre-cancer lesions in young women, with a fall in cervical
abnormalities after the program was implemented in 2007 (Gertig et al. 2013). The effect of the
vaccine is expected to increase over time as women vaccinated at age 12–13 become eligible to be
screened in the cervical screening program and enter the age ranges where cancer incidence is more
common. This is an area where gains may also follow for other cancers with a similar viral aetiology
(see Glossary) to cervical cancer.
Early detection through organised screening
Australia has national population screening programs for 3 cancers—breast, cervical and bowel cancer.
BreastScreen Australia was introduced in 1991, the National Cervical Screening Program (NCSP) also
started in 1991, and the National Bowel Cancer Screening Program (NBCSP) was introduced in 2006.
These screening programs aim to reduce illness and death from these cancers through early detection
of cancer and pre-cancerous abnormalities and effective follow-up treatment. Since it was introduced,
BreastScreen Australia has had a major impact in moderating an increasing incidence trend and
in contributing to falling mortality in breast cancer. Similarly, the NCSP has had a major impact in
enhancing decreasing trends for cervical cancer incidence and mortality (Figure 4.5).
The introduction of the BreastScreen Australia program resulted in an initial rapid increase in the
number of breast cancers diagnosed in 1992–1994, followed by a more moderate increasing trend
to 2010, accompanied by a steady decline in breast cancer mortality from 1994 (Figure 4.5A). The
introduction of the NCSP resulted in a rapid decline (from an already decreasing trend) in cervical
cancer incidence from 1991 to 2002, followed by a more stable trend to 2010 and a steady decline in
cervical cancer mortality from 1991 to 2004, followed by a stable trend to 2010 (Figure 4.5B). A similar
effect from the NBCSP is expected for bowel cancer in the longer term.
For more information on cancer screening programs, see Chapter 8 ’Cancer screening in Australia’.
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20
40
60
80
100
120
140
Deaths
New cases
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New cases/deaths per 100,000 females
A. Breast cancer B. Cervical cancer
Year Year
New cases/deaths per 100,000 females
0
2
4
6
8
10
12
14
16
Deaths
New cases
20
10
20
08
20
06
20
04
20
02
20
00
19
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19
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19
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19
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19
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19
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19
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19
84
19
82
Improvements in treatment
Broadly, a variety of improvements in cancer treatments are thought to have led to improvements
in cancer outcomes, particularly decreasing mortality (improved survival). These include: advances
in imaging and technology used to develop and administer treatments; more focused or targeted
therapies; multi-disciplinary approaches to treatment; more options in, and access to, treatment
settings; and clinical trials for patients.
Examples of improvements include:
• the use of platinum-based chemotherapy, credited with the fall in mortality from testicular cancer
(Einhorn 1981)
• multi-disciplinary use of chemotherapy and radiotherapy, effecting a reduction in mortality from
rectal cancer (Philip et al. 1995; Roh et al. 2009; Sauer et al. 2012; Woods et al. 2001)
Notes
1. Deaths registered in 2008 and earlier are based on the final version of cause of death data; deaths registered in
2009 and 2010 are based on revised and preliminary versions, respectively, and are subject to further revision by
the ABS. Data for 2010 have not been adjusted for the additional deaths arising from outstanding registrations of
deaths in Queensland in 2010.
2. The solid vertical line at 1991 indicates the introduction of the national screening programs.
Sources: AIHW Australian Cancer Database 2010; AIHW National Mortality Database.
Incidence and mortality of breast cancer (A) and cervical cancer (B), Australia, 1982–2010
Figure 4.5
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LE• the availability of and participation in clinical trials, a significant factor in reducing mortality from childhood cancers (Stiller et al. 2012)
• the advent of targeted, precision or personalised treatments, such as Hereceptin for HER-2 type
breast cancers, leading to improved survival from that breast cancer sub-type (Romond et al. 2005).
What might the future bring?
Projected incidence and mortality
Extrapolation of historical trend data for all cancer incidence (1982 to 2007) and mortality (1968 to
2010) shows that between 2011 and 2020:
• numbers of new cases and deaths are expected to rise for both males and females
• the incidence rate among females is expected to rise, although the change will not be significant
• the incidence rate among males is not expected to change
• the mortality rate is expected to fall for both males and females (Figure 4.6).
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000 Deaths (number)
New cases (number)
20
20
20
19
20
18
20
17
20
16
20
15
20
14
20
13
20
12
20
11
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Year Year
0
100
200
300
400
500
600
700
800
Deaths (rate)
New cases (rate)
Deaths (number)
New cases (number)
Deaths (rate)
New cases (rate)
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
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11
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200
300
400
500
600
700
800
B. Females
Note: Projected years 2011 to 2020 based on actual data from 1982 to 2007 (incidence) and 1968 to 2010 (mortality).
Sources: AIHW Australian Cancer Database 2010; AIHW National Mortality Database.
Projected cancer incidence and mortality among males (A) and females (B), all cancers
combined, Australia, 2011 to 2020
Figure 4.6
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Based on these projections, in 2020:
• 150,000 people are expected to be diagnosed with cancer, an increase of 29% from 2010
• 50,800 people are expected to die from cancer, an increase of 18% from 2010.
Emerging issues
The combined effect of several factors—increasing incidence, decreasing mortality in some cancers, high
and improving survival for some cancers, earlier diagnosis and detection, and developments in treatment
and management of cancer—is a steady increase in the proportion of the population who have been
diagnosed with cancer. This population is also termed the prevalent or survivorship population.
In 2007, there were around 775,000 Australians alive who had been diagnosed with cancer in the 26
years since incidence data were first collected at a national level (from 1982), accounting for 3.7%
of the total Australian population in that year (AIHW 2012b). It is likely, based on the continuation of
current projected trends in incidence and mortality, that this population will continue to slowly rise
over time, with an accompanying rise in the economic and social burden of cancer.
This will all mean, now and into the future, major changes in the experience of cancer for some
individuals, their families and carers (Hawkins et al. 2010; Quality Health 2013). It also means a challenge
for the health system in responding to these changes, particularly with an ageing population.
These changes and challenges are being seen now in emerging issues such as the survivorship
experience, caring for people with cancer, ageing with cancer, recurrent and multiple primary cancers,
and cancer in the presence of other conditions (comorbidity).
Survivorship experience
Survivorship is increasingly recognised as beginning at diagnosis and continuing long after treatment
ends. It is more than simply not dying from cancer, and focuses on living with, and after, a cancer
diagnosis (Jackson et al. 2013). Cancer survivors often face emotional, physical and financial challenges
as a result of the detection, diagnosis and treatment of cancer. In the longer term, people diagnosed
with cancer:
• may experience enduring physical symptoms following their treatment, such as late effects of
radiation or post-surgical loss of function
• can be at risk of recurrence, that is, the return of the same primary cancer after treatment and after a
period during which cancer cannot be detected
• may be at increased risk of developing other primary cancers due to the effects of treatment (for
example, developing leukaemia after administration of alkylating agents), underlying genetics, and/
or other risk factors for cancer (Youlden & Baade 2011).
These longer-term risks, and the associated stressors and reduced quality of life for cancer survivors
and their family, friends and caregivers, highlight the importance of follow-up health care and of
survivorship as part of the cancer control continuum (Hawkins et al. 2010; Jackson et al. 2013).
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Cancer, caring and ageing
The increasing size of the population who have had cancer also means a corresponding increase in
the number of people caring for someone through cancer diagnosis, treatment and remission, often
into old age. As some cancer treatment and care modalities move away from the acute (hospital)
setting and into outpatient, primary, nurse-led or community care settings, greater support for and
recognition of informal carers of people with cancer will be needed (Access Economics 2010; Cancer
Council Australia & Clinical Oncological Society of Australia 2010). Many cancer support organisations
and groups recognise the importance and growing size of this population, and provide support to
carers, siblings and friends of people with cancer (Cancer Council Victoria 2011). This shift away from the
acute care setting is also apparent in palliative care, with a South Australian study reporting that 70% of
respondents would prefer to die at home than elsewhere, if faced with a terminal illness such as cancer
(Foreman et al. 2006). (For more information on Palliative care, see Chapter 6 ‘Palliative care in Australia’.)
The increasing size of the aged population in Australia is a contributing factor to the projected
increase in the number of new cancer cases and cancer-related deaths to 2020. Ageing, in the context
of survivorship and the increasing prevalence population, also increases the likelihood of:
• recurrent (returning) cancers, as people live longer and into old age after a cancer diagnosis
• the occurrence of multiple primary cancers, with ageing compounding the effect of existing cancer
risk factors (that lead to the first primary cancer)
• cancer as a comorbid chronic disease.
The last of these, cancer and comborbidity, is discussed briefly below.
Cancer and comorbidity
As people survive longer with cancer it will become increasingly important for cancer to be
considered in the context of patients’ other ongoing health conditions. While it is not possible with
current available data to examine the incidence and prevalence of cancer as a comorbid condition, it
is possible to use mortality data to analyse the proportion of Australians who have both cancer and
other conditions recorded as causes of death.
Current monitoring tends to focus on cancer as an underlying cause of death. However, this type of
analysis excludes those deaths where cancer was an associated cause of death, that is, any cause other
than the underlying cause. (For more information on multiple causes of death, see Chapter 3 ‘Multiple
causes of death in Australia’.)
In 2011, cancer was recorded as the underlying cause in 43,221 deaths, accounting for 29% of all
deaths in that year. Cancer was recorded as an associated cause in an additional 6,299 deaths, where
the most common underlying causes were chronic ischaemic heart disease, acute myocardial
infarction or other chronic obstructive pulmonary disease. In total, 49,520 deaths in that year (34%)
included cancer as a cause of death (either underlying or associated).