Oncologists fight tyranny of distance
Only effort and time will redress the dearth of cancer services in rural areas, writes Lynnette Hoffman

11 November 2006

IN just over a year following his diagnosis with oesophageal cancer, Tony Deely and his wife Fran have made eight trips to Melbourne for assessment, surgery and follow up - and more are scheduled.
It's a four-hour drive each way from their home in the Victorian border town of Wodonga, and as owners of a fish and chip shop the Deelys have had to hire two casual staff to cover for their absences.

Along with the additional financial strain that created, there was also the hassle of finding affordable and convenient accommodation in Melbourne each time, not to mention the travel itself.

The experience provided Deely with a taste of the struggles cancer patients in rural areas across the country are facing - but he knows his situation could have been worse.

Unlike many cancer patients in country areas, Deely has been able to access his chemotherapy and radiation treatments at a hospital just minutes away from home.

"I'm extremely lucky I haven't got the stress of travelling long distances all the time - I did radiotherapy every day for six weeks, not including weekends," he says.

Had he had to travel long distances for this treatment, the problems that created would have been immense. "You're only in there for half an hour at a time, so I would have had to find accommodation and find something to do all the rest of the day - and then travelled home on weekends. That would have been catastrophic," Deely says.

And yet it's commonplace for patients in places like Darwin, who have to fly interstate to Adelaide because there is no radiation unit (the government has announced plans to build one). And of course there are thousands of residents in innumerable smaller country towns in every state facing a similar dilemma.

But that sort of disruption only scratches the surface of inequity in quality of care.

A study published in the Medical Journal of Australia shows that people with cancer in regional NSW are 35 per cent more likely to die within five years of diagnosis than patients in cities, and mortality rates increase the further away the patients live. For some cancers, remote patients are up to 300 per cent more likely to die within five years of diagnosis (MJA 2004;180:618-622).

Cancer patients in remote areas are also more likely to be diagnosed later, when their cancer is more advanced and difficult to treat - but the differences in mortality continue even when that fact has been accounted for.

The gaps in services and care are further highlighted in Mapping Rural and Regional Oncology Services, a report released by the Clinical Oncological Society of Australia (COSA) in March that surveyed key staff at Australia's 157 regional hospitals that administer chemotherapy.

Across-the-board service provision is much poorer in rural and remote centres than in the benchmark metropolitan centres. Only one in five of the regional hospitals has a resident oncology service. Access to a visiting service varies widely, to as little as once every six months - and 38 per cent of the regional hospitals are administering chemotherapy without access to any oncologist at all. On top of that, significant numbers of nurses and general practitioners don't have the appropriate training or qualifications, especially in more remote areas. And even in regions with comparatively more resources, few can offer patients access to adequate allied support to deal with psychological problems and other issues they may face, for example.

But an editorial by representatives of COSA and the Cancer Council, published in the Medical Journal of Australia this week, argues that the problem is "not insurmountable" and puts forward recommendations to address the issue (MJA 2006;185(9):479-480).

Chief on the list - to build "regional cancer centres of excellence" which would link to metropolitan centres and provide more multidisciplinary care such as specialised psychologists, dieticians and genetic counselling.

COSA recommends the centres be formed around places where there are already radiation units - half of all cancer patients need radiotherapy and set-up costs are high. No such centres exist, says Craig Underhill, head of COSA's Rural and Regional Oncology Group and the editorial's lead author - but some have come close.

One of those is the centre in the Albury-Wodonga region where Underhill has worked for the past eight years.

Before he arrived there was no resident oncologist. "Locum doctors flew in once a fortnight and saw all the patients on one day," he says. Consequently there were few services and little back-up available if anything went wrong between visits.

Today the region has five resident oncologists, a clinical trials unit and a two-machine radiotherapy service. Patients treated locally have increased from 150 to 750 a year. Chemotherapy day treatments have increased eight-fold, multidisciplinary clinics have been set up, and more than 10 per cent of new patients are participating in a trial.

Underhill says the key to the success is forging links with metropolitan hospitals that can help provide back up staff and resources. "It's not so much a problem of capital as of getting health professionals employed in regional areas," Underhill says.

A survey of medical oncology trainees found they are more likely to work in rural and remote areas if there is at least one other oncologoical specialist there, if locum cover is available so they can attend conferences and workshops, and if they have access to clinical trials - issues Underhill says can be addressed through those links. "Those are things that aren't going to cost a lot of money to fix. People tend to put all this in the too-hard basket, but they are things we can feasibly achieve," Underhill says.

But it won't be without challenges.

John Scarlett, the sole medical oncologist at Latrobe Regional Hospital's Gippsland Cancer Care Centre, can testify to that.

After three years of actively looking he finally managed to recruit a radiation oncologist from New Zealand, who began in July. That means patients no longer have to drive to Melbourne for radiation therapy - but it doesn't cut down on Scarlett's own workload at all, and he says that's a problem many oncologists are facing.

"There are a number of substantial cities with zero or one medical oncologist," Scarlett says. "Bendigo has only an occasional visiting oncologist ... There is a shortage in a number of bigger Queensland towns, it's patchy in NSW - it depends on how remote you go.

"In rural and remote areas there are about a third as many medical oncologists as you'd expect on a population basis. It's a service that's very brittle - if I break a leg, the service ceases in Gippsland. If anything happens the service for that whole corner of the state falls over," he says.

To make matters worse, there is shortage in metropolitan areas as well, so the entire pool of oncologists will need to grow.

Still, Underhill and his colleagues at COSA remain optimistic. They say it will take time and lots of discussion, but if all levels of government and all the stakeholders work together, it can be done.

"We need to convince the government that there is a problem that needs to be fixed, and state and federal governments need to be working very close together to do that," Underhill says. In the meantime he says regions can implement short-term capacity-building such as investing in psychosocial support services and increasing support for distance education, and mentoring programs such as telemedicine in remote areas. "We really just need to make a start because the current situation is unacceptable."