The New Zealand Cancer Control Strategy

Objectives

The New Zealand Cancer Control Strategy establishes the first phase of a comprehensive, co-ordinated national programme to reduce the incidence and impact of cancer and cancer-related inequalities.[1]It frames cancer control as a planned continuum spanning prevention, screening and early detection, diagnosis, treatment, supportive care, rehabilitation, palliative care, research, surveillance and service improvement.[2][3]Its enduring approach is guided by the Treaty of Waitangi, equity, timely and equitable access, quality, sustainability, evidence-based practice, person-centred care, cultural diversity, and consumer and community participation.[1][4]

• Reduce cancer incidence through primary prevention, especially action on tobacco, nutrition, obesity, physical inactivity, alcohol, ultraviolet radiation, infectious disease-related cancers and occupational carcinogens.[5][6][7][8]
• Improve screening and early detection through evidence-based, organised and culturally appropriate programmes, early presentation, familial-risk assessment and surveillance.[5][9][10]
• Ensure timely, evidence-based diagnosis and treatment, including multidisciplinary care, national standards and protocols, appropriate technologies, specialised services where beneficial, and integrated pathways across primary, secondary and tertiary care.[5][11][12]
• Improve quality of life through supportive care, rehabilitation and palliative care that address physical, emotional, social, nutritional, informational, spiritual, cultural and practical needs of people with cancer and their families and whānau.[5][13][14]
• Strengthen service delivery through planning, co-ordination, integration, workforce development, monitoring and evaluation.[5][15][16]
• Improve cancer control through research, surveillance, high-quality data collection, reporting and knowledge translation.[5][17][18]

Equity is a central purpose: the Strategy seeks to reduce avoidable inequalities associated with socioeconomic position, ethnicity, gender and geography, while giving particular priority to Māori health as a Treaty obligation and Government priority.[19][20]It supports a holistic hauora and whānau ora approach, seeks culturally responsive services for Māori and their whānau, and aims to improve access and outcomes for Pacific peoples and other population groups experiencing disparities.[21][22][16]At least 30 percent of future cancer cases are considered preventable through comprehensive action based on current evidence.[23]

The Strategy sets short- to medium-term objectives and broad areas for action over three to five years, while retaining its core purposes and goals as enduring commitments.[4]It also responds to anticipated growth in cancer registrations and deaths associated with population growth and ageing, recognising the resulting pressure on health resources.[24][1]

Implementation

Implementation is intended to translate the Strategy into a subsequent plan that identifies evidence-based priorities, responsible organisations, activities achievable within existing resources, additional resource requirements, and processes for management, monitoring and review.[25][1]Delivery relies on planned, systematic and integrated action by government, non-government organisations, health professionals, providers, communities, consumers, people with cancer and their families and whānau across the full cancer-control continuum.[26][21][3]

• Apply Treaty of Waitangi principles of partnership, participation and protection by involving iwi, hapū, whānau and Māori communities in planning and delivery, safeguarding Māori values and concepts, improving mainstream-service responsiveness, and supporting Māori providers.[21][22]
• Use the Ministry of Health Intervention Framework and Health Equity Assessment Tool to identify inequalities, select intervention points, assess intended and unintended effects, and change planning, funding and service delivery to reduce disparities.[19][27][28]
• Co-ordinate prevention through public health policy, health promotion, primary care, community providers, legislation, taxation, smokefree measures, cessation support, healthy environments and targeted risk-reduction initiatives.[3][6][7]
• Prioritise organised screening over opportunistic screening, linking screening to sustainable diagnosis, treatment and follow-up, and maintain national delivery through the National Cervical Screening Programme and BreastScreen Aotearoa under the Ministry of Health National Screening Unit.[9][3]
• Establish national oversight for screening and familial cancer risk, develop referral guidance and surveillance arrangements, investigate delays in early presentation, and evaluate interventions to address them.[10]
• Develop national and regional standards, guidelines, protocols and minimum data sets; strengthen multidisciplinary teams and clinical trials; and assess new treatments and technologies through continuing evaluation processes.[12]
• Build integrated supportive-care, rehabilitation and palliative-care models with defined leadership, co-ordination between primary care, hospitals, hospices, community and voluntary services, and attention to access barriers, travel needs and culturally appropriate provision.[13][29][14][15]
• Undertake a workforce stocktake and develop a nationally co-ordinated workforce plan covering recruitment, training, retention, palliative-care capacity, Māori and Pacific workforce participation, and culturally responsive practice.[16]

Governance and development were led through partnership between the Ministry of Health and the New Zealand Cancer Control Trust, which was formed by the Cancer Society of New Zealand and the Child Cancer Foundation to facilitate collaboration with the Ministry.[2]The development process involved a Cancer Control Steering Group, a Cancer Control Secretariat, five expert working groups covering prevention, screening and early detection, treatment, support and rehabilitation, and palliative care, as well as international input and public consultation.[5][20][30]District Health Boards have statutory responsibilities to reduce health inequalities, reinforced through Crown Funding Agreements, and are among the key delivery partners.[19]

Research and information systems are intended to support implementation and continuous improvement.[17][31]The approach includes strengthening the New Zealand Cancer Registry within the Ministry of Health, standardising national and ethnicity data, linking clinical, pathology, primary-care and palliative-care information, and analysing cancer stage, treatment, survival, waiting times, geographic variation and ethnic differences in access and outcomes.[18]Monitoring and periodic review should assess whether objectives achieve their intended effects and enable objectives to be added or replaced as evidence develops.[23][4]Specific overall budgets, quantified funding allocations and a comprehensive national indicator or reporting framework are not specified.[1][31]

Monitoring & Evaluation

The Strategy establishes monitoring, evaluation, research and surveillance as core functions for improving cancer control, service quality, equity and accountability across prevention, screening, treatment, supportive care, rehabilitation and palliative care.[5][1][4]It envisages continuous monitoring and periodic review so that objectives can be assessed, amended or replaced as evidence and more effective approaches emerge.[23][4]

• Monitor cancer-control activities and service delivery to assess effectiveness, improve planning, co-ordination and resource integration, and support implementation and outcome decisions.[21][4][15]
• Collect, analyse and report national data on cancer incidence, prevalence, mortality, morbidity, survival, diagnostic methods, stage at diagnosis, treatment received, patterns of care, waiting times and quality of life.[32][17][18]
• Strengthen the New Zealand Cancer Registry, including standardised national data sets, data definitions, database linkages and additional medical and scientific capability for timely analysis and interpretation.[18]
• Standardise and improve ethnicity data to assess inequities in cancer risks, access, treatment effectiveness and outcomes among Māori, Pacific, Asian and other populations.[32][6][18]
• Develop standards, guidelines, protocols and a minimal data set for diagnosis, treatment and care; monitor performance against key measures and evaluate whether recommended standards are achieved.[33][12]
• Maintain routine monitoring and evaluation as quality processes for organised screening, review existing screening recommendations, assess potential programmes, and evaluate interventions intended to reduce delays in early detection.[9][10]
• Monitor tobacco-control programme effectiveness, occupational cancer reporting, adolescent cancer incidence, treatment and outcomes, and workforce requirements affecting service provision.[7][8][34][15]
• Improve accountability of mainstream providers for Māori health outcomes, while involving consumers and communities in assessing needs, setting standards and monitoring services.[27]

Governance mechanisms include proposed national screening oversight, continuing implementation management and review processes, and statutory district health board responsibilities to reduce health inequalities through Crown Funding Agreements.[25][19][10]A comprehensive indicator set, reporting timetable, unified evaluation framework and named accountability body for the whole programme are not specified.[33][12][31]

Costing & Financing

The Strategy is intended to operate within available and relatively scarce resources, using careful priority setting, efficient resource use and planning to identify activities achievable from existing resources and those requiring additional investment.[2][26][25][15]It does not provide an overall budget, costed implementation plan, quantified funding allocation, financing mechanism, funding gap or economic assumptions.[26][31]

• Recognise that rising cancer incidence associated with population growth and ageing will increase pressure on already stretched health resources.[1][24]
• Identify insufficient funding and staff capacity for cancer services as causes of delayed access to essential technologies, including radiation treatment, with some patients travelling to Australia for care.[11]
• Consider funding for inter-regional patient flows, specialised treatment units, and the travel effects on patients, families and whānau.[11]
• Address inequitable travel and accommodation funding for people obtaining specialist care outside their region, including unresolved national adult arrangements and unmet children’s and adolescents’ circumstances.[29]
• Review funding-stream boundaries for disability support services, assess the cost implications of closing supportive-care and rehabilitation gaps, and clarify funding responsibility for survivors’ late effects.[29][35]
• Provide adequate funding and improve systems for integrated care, standards, guidelines, protocols, workforce development, palliative care and service delivery, while avoiding unnecessary duplication.[12][34][15]
• Recognise primary prevention as the most cost-effective form of cancer control and prioritise organised screening over opportunistic screening, which may be resource-intensive and less cost-effective at population level.[6][9]
• Mobilise research support through the Health Research Council, cancer charities and other funders, while increasing support for clinical, public health, epidemiological and other under-investigated research fields.[31]

The Ministry of Health and New Zealand Cancer Control Trust funded strategy development, while the Trust received establishment funding from the Cancer Society of New Zealand and the Child Cancer Foundation in February 2001.[22]No amounts are specified for these sources or for delivery of the Strategy.[22][25]