National Cancer Control Plan 2022-2027

Objectives

The Cancer Control Plan seeks to prevent, control and manage cancer’s impact in the Cook Islands, so that people live healthier lives and achieve their aspirations, while providing quality and equitable cancer health-care services.[1]Its overall goal is to reduce cancer-related morbidity, mortality and disability through action across prevention, early detection, diagnosis, treatment, palliative care and health-system strengthening.[2][1][3]

• Reduce the prevalence of priority cancers and cervical precancer by 25% by 2027, increase localised or in-situ cancer presentation by 25% by 2027, and reduce cancer mortality by 25% by 2027.[1]
• Address shared risk factors for cancer and other non-communicable diseases, including overweight and obesity, physical inactivity, alcohol use, smoking and unhealthy diets.[2]
• Support cervical cancer elimination as a public health problem by 2030, including by increasing human papillomavirus vaccination and screening coverage and ensuring treatment for women with invasive disease.[2][3][4]
• Increase early-stage cancer diagnosis, defined as SEER summary stages 0 and 1, and incorporate cancer screening into a national health screening unit.[5]
• Prioritise screening and earlier diagnosis for breast, cervical, prostate, skin and colorectal cancers.[6][7]
• Develop appropriate diagnostic, treatment and palliative-care capacity over 10 to 15 years, guided by an evidence base, situational analysis and treatment roadmap.[7][4]
• Improve cancer information, registration and reporting systems to support planning, advocacy and resource mobilisation.[3][8]
• Promote safer and healthier environments through public health legislation and policy on tobacco, alcohol, diet and conflicts of interest.[9][10]

The plan is underpinned by partnership, participation, cross-sectoral action, accountability, universal health coverage, equity, the right to health, evidence-based practice and protection against conflicts of interest.[1]Its monitoring framework additionally aims to increase public recognition of cancer signs and symptoms, reduce preventable incidence and mortality, strengthen access to diagnosis, treatment and palliative care, and sustain cancer control during public health emergencies.[8][11]

Implementation

Implementation combines integrated service delivery across the health system with national leadership, multisectoral coordination, community partnerships, local service development and overseas referral where advanced care is unavailable.[2][1][8]The Clinical Governance Committee at Rarotonga Hospital is identified as the national cancer leadership structure, while a multisectoral cancer control committee is intended to provide decision-making and intelligence support within Te Marae Ora activity.[2][8]

• Coordinate prevention, screening, diagnosis, treatment and palliative care through Te Marae Ora, the Cook Islands Family Welfare Association and the Cook Islands Breast Cancer Foundation, with formal partner agreements envisaged for cancer control.[1][8]
• Deliver prevention through healthy-lifestyle education, social marketing, food labelling, cancer-awareness campaigns, tobacco and alcohol control, human papillomavirus vaccination outreach and sun-smart campaigns.[3][12]
• Maintain hepatitis B vaccination at birth and provide two-dose human papillomavirus vaccination to girls from nine years of age, with extension to boys planned.[13]
• Establish an organised cervical screening programme by adapting guidance to the Cook Islands context, updating policies and guidelines, and implementing registration, call-back, tracking and reporting pathways.[14][5][6]
• Establish a comprehensive national screening unit with dedicated staff, budget, data management, key performance indicators and responsibility for oversight, monitoring and reporting to the Permanent Secretary.[6][11]
• Provide screening through primary health-care centres and other facilities using relevant breast, cervical, prostate and colorectal screening methods.[7]
• Strengthen diagnosis through appropriate computed tomography use, biomedical technician and engineer training, tele-diagnosis partnerships for pathology and radiology, fast-track protocols, and improved clinical and referral guidance.[7]
• Deliver selected diagnostic and surgical services locally, while sending liquid-based cytology and tissue specimens overseas where required for definitive diagnosis.[14]
• Refer patients requiring advanced treatment to New Zealand, aiming to send diagnosed patients within one month and more rapidly when late presentation requires this.[14]
• Develop community palliative care through awareness, primary health-care worker training in pain management and counselling, caregiver support, essential medicines, support for returning patients and families, and an in-country respite-care facility.[15][4]
• Review the Public Health Act 2004, establish conflict-of-interest registers, update tobacco-control measures, develop an alcohol-control action plan, and implement dietary guidelines and food and nutrition policy.[9][10]

Operational accountability is supported by named leadership roles, including the Directors of Hospital Health Services and Primary Healthcare, the Manager Policy and Planning, the Supervisor Health Information Systems, the Manager Community Nursing and the Health Promotion Manager.[5][6][7][8][11]The Manager Policy and Planning is responsible for the overall monitoring framework, while the plan envisages annual multisectoral committee meetings, quarterly public reporting and four cancer registry reports annually.[8][11]

Monitoring will use surveys, screening and service data, cancer registry information and policy measures to track awareness, risk factors, screening coverage, stage at diagnosis, treatment initiation, palliative pain relief, incidence and mortality.[1][3][11]Data quality improvement includes International Classification of Diseases for Oncology coding, clinician training, better information-source recording, CanReg 5 improvements, standard operating procedures, monitoring of information returned from New Zealand and regular registry outputs.[8]Important data limitations remain: 31% of registry cases have missing data, information sources are not recorded, and patient information may be lost after overseas referral.[15]From 2022, Te Marae Ora required a discharge summary before non-repatriated patients could be considered complete in the information flow.[15]

Monitoring & Evaluation

The plan establishes a monitoring and evaluation framework centred on cancer registration, screening performance, timely diagnosis and treatment, palliative care access, risk-factor policy implementation and population awareness. Responsibility for the overall framework sits with the Manager Policy and Planning, supported by the Supervisor Health Information Systems, Manager Health Promotion, national health screening unit and Clinical Governance Committee at Rarotonga Hospital.[2][8][11]

• Strengthen cancer registry completeness, coding and data management through International Classification of Diseases for Oncology coding, CanReg 5 improvements, standard operating procedures, clinician training, recording of information sources and follow-up of information returned from New Zealand.[8]
• Reduce registry records with unknown items in the International Agency for Research on Cancer minimum data set from a 100% baseline to 20% in 2023 and 5% in 2027, and produce four registry reports annually by the end of 2023.[8][11]
• Monitor cancer occurrence, stage at diagnosis, treatment location, referral patterns and cervical cancer case reporting; registry data for the preceding five years contained 180 records, including 146 malignancies.[13]
• Track screening coverage, follow-up, referral, registration and treatment outcomes, including breast self-examination, cervical screening, human papillomavirus testing, point-of-care treatment, primary healthcare-centre provision and diagnostic turnaround times.[5][6][7]
• Achieve cervical screening coverage of 80% by 2027, human papillomavirus screening coverage of 50% by 2025 and 70% by 2027, treatment following a positive test for 50% of women by 2025 and 90% by 2027, and screening-system registration for 80% of eligible people by 2027.[5][6]
• Increase reported monthly breast self-examination among women aged 40 years and over by 50% by 2027, provide breast, cervical and prostate screening through all primary healthcare centres by 2025, and achieve a five-day diagnostic-result turnaround time by 2023.[5][6][7]
• Measure population awareness through the Cook Islands STEPS survey report 2023 and a knowledge, attitude and practice survey on cancer signs and symptoms, with a statistically significant increase in cancer knowledge sought by 2027.[1][3][11]
• Track priority outcomes including diagnosis at in-situ or localised stage, cancer mortality, priority-cancer incidence, cervical cancer prevalence, cytology positivity, treatment initiation, palliative pain-relief access, obesity, tobacco and alcohol policy responses, and skin-cancer incidence.[3][12][11]
• Target 60% of cancers diagnosed at in-situ or localised stage by 2027, reduce cancer mortality from 17% to 13% by 2027, and reduce the combined incidence of priority cancers by 20% by 2025.[11]
• Maintain cancer testing during public health emergencies and monitor any reduction in testing and delays between first health-facility presentation and recorded incidence.[8][11]
• Report through quarterly public reporting targeted for 2023, annual multisectoral cancer control committee meetings, screening-unit reporting to the Permanent Secretary and the national leadership role of the Clinical Governance Committee.[2][8][11]

Data limitations affect interpretation of baselines: the MedTech-based cancer register has missing data for 31% of cases and does not record information sources, while overseas referral can result in loss of patient information.[15]Available cervical cancer estimates range from 11 to 45 per 100,000 woman-years because diagnoses in New Zealand may not be returned to the Cook Islands registry.[11][16]The plan does not specify a consolidated evaluation methodology or a complete reporting schedule beyond the stated indicators, registry reports and quarterly public-reporting target.[15][8][11]

Costing & Financing

Costing information is limited and primarily concerns overseas referrals, caregiver support and continuity of cancer control during health emergencies. The plan identifies dedicated staffing, data systems, equipment, consumables, training, tele-diagnosis, palliative care support and a dedicated screening-unit budget as resource needs, but does not provide a comprehensive cancer-control budget or financing strategy.[6][7][4]

• Fund overseas cancer referrals, which cost the Cook Islands Government NZ$700,669 for 153 referrals in 2017, equivalent to an average reported referral cost of NZ$4,579 per patient.[14]
• Recognise that reported overseas-referral expenditure excludes treatment costs, although eligible patients have free access to New Zealand’s health-care system for advanced treatment.[14]
• Increase annual caregiver disbursements, using a minimum-wage baseline of NZ$17,680 and target values of NZ$18,720 in 2024 and NZ$19,760 in 2027.[4]
• Allocate an indicative 50k for sustaining cancer control throughout health emergencies; the currency and period are not specified.[3]
• Provide a dedicated budget and single point of responsibility for resourcing the national cancer screening unit, without a stated allocation or funding source.[6]

Cancer control is characterised as under-resourced in the Pacific, with constraints in human and technological capacity and escalating health-system costs associated with non-communicable diseases.[2]The plan does not specify total programme costs, a costing methodology, financing sources, a resource-mobilisation plan, quantified funding gaps or wider economic assumptions.[3][4][8][11][16]