New Zealand Gynae Cancer Group submission

What is the New Zealand Gynae Cancer Group (NZGCG)

NZGCG is an open-membership national working group composed of New Zealand doctors and nurses looking after women affected by gynaecological cancers. It currently comprises 90 members, who practice in areas of gynaecological cancer surgery, radiation oncology, chemotherapy, nursing care, pathology, radiology, and general gynaecology across urban and rural New Zealand. Members meet twice a year, developing guidelines and promoting education for and from the sector.

Problem statement and 9 recommendations

1.Lack of current “big picture view”

Unlike other countries, New Zealand does not have a National Framework for gynaecological Cancer services [1, 2]. In 2011 a report to the Ministry of Health outlined a plan for improvement in gynaecological cancers services, and this was followed up in 2014 with a subsequent report. Both were written in conjunction with clinicians from the New Zealand Gynae Cancer Group, defining optimal service configuration for treatment of gynaecological cancer [3, 4].

These reports found challenges with “building a sustainable workforce, achieving equitable access to evidence-based services, developing a supportive infrastructure, aligning the funding and purchasing framework with optimal provision, and collecting data on quality and outcomes”[3]. 

In 2023, these challenges remain unchanged with little progress made.  

Furthermore, the number of gynaecological cancers in New Zealand has risen by nearly 40% in just over a decade [5].The number of endometrial cancers, which disproportionately affects Māori and Pacific wāhine, have increased by over 50%, well above the modelled volumes [3, 6]

Recommendation 1: Our group requests an urgent review of the model of care for gynaecological cancer services, with a view to build a sustainable national framework.

2.Gynaecological-oncology workforce sustainability

There is good evidence that centralisation of services and surgery by gynaecological oncologists (G.O) improve survival for women with gynaecological cancer[7, 8]. Gynaecological oncologists are sub-specialty trained gynaecologists, with at least 3 additional years of surgical oncology expertise.

The international benchmark is 3 gynaecological oncologists per million population.  With the current population of over 5 million, New Zealand needs 15 to 16 subspecialists with these skills, and currently has 7, unchanged from the 2011 staffing level [3].  

Loss of trainees and specialist gynaecological oncology workforce to Australia means the national service is critically understaffed and highly vulnerable.  During the past decade, G.O training positions have been available in New Zealand, but trainees have not stayed after graduation, seeking better pay, conditions and infrastructure overseas.  

Consequently, New Zealand has become dependent on international G.O recruitment, though this avenue is constrained by multiple barriers. Compared to other developed countries, New Zealand gynaecological oncology positions offer lower renumeration, require additional training and exams hurdles, do not include public hospital robotic surgery facilities, and offer limited research opportunities. 

Recommendation 2: Our group requests adequate funding to resource and secure a sustainable gynaecological oncology workforce

3. Better access to treatments and tests

a.Radiation treatment

A national shortage of radiation oncologists, especially with expertise in gynaecological cancer treatments, is creating inequity in the provision of services around the country[9]. Facing “increases in cancer number, treatment courses and complexity of treatments”, and unable to recruit, large centres have had to either transfer all their gynaecological cancer patients to other centres or rely on single practitioners[9]. This impairs access for cervical cancer patients to life-saving treatment, with a larger impact on Māori women[10].

Subspeciality fellowship training for gynaecological cancer radiation oncology is not available in New Zealand. Such positions have been created and funding denied, limiting succession planning and perpetuating unmet needs. International recruitment has met the same difficulties as for the gynaecological oncologists (lack of appeal from remuneration, ageing facilities, sparse research opportunities).

Recommendation 3: Our group requests a national review of radiation oncology services to ensure a sustainable future.

b. Chemotherapy treatment

In a recent review of worldwide survival of ovarian cancer, New Zealand performed worse than most countries for epithelial ovarian cancers, but not for non-epithelial cancers, which reflects the limited access to second line chemotherapy compared to other countries[11].

Likewise, a gap between drugs available in New Zealand and Australia has been reported recently [12]. For example, Bevacizumab and Caelyx are widely used drugs in other developed countries for platinum resistant recurrent ovarian cancer. They are not funded in New Zealand for this indication.

Additionally, Bevacizumab is of benefit in recurrent and metastatic cervical cancer, and is not funded in New Zealand for this. Pembrolizumab, a form of immunotherapy, is also not funded for New Zealand women, despite proven benefits to patients with recurrent cervical and endometrial cancer.

Recommendation 4: Our group requests public funding for these drugs to improve the prognosis of women treated with recurrent and advanced gynaecological cancers.

c.Tests

 Testing for germline and somatic BRCA mutations for women affected by epithelial ovarian cancer is not available for all New Zealand women, and needs national funding to provide equal access to PARP inhibitor treatments.

Recommendation 5: Our group requests public funding for germline and somatic BRCA mutations for all women affected by epithelial ovarian cancer.

d. Patient support and navigation roles

Pasifika and Māori supporting initiatives contribute to improvement in patient outcomes, by helping women engage with the health system. A recent survey of more than 2,500 whānau Māori affected by cancer pointed out how, in places, “Māori health services (…) already do this work, but it is not recognised or funded appropriately. In addition, some whānau also recognised that these [navigation roles] are not available to all, ‘so what you receive depends on where you live’”[13].

Recommendation 6: Our group requests better funding and wider distribution of Pasifika and Māori navigation roles.

see next box for 2nd part- and recommendations 7-9

This submission to the Women's Health strategy outlines avenues to tackle inequities and challenges faced by women dealing with Gynaecological cancers in New Zealand and the teams looking after them.

Our working group of frontline clinicians is struggling daily to provide international standards of care. This report suggests structural changes and systems review, which are urgently needed at high level to improve our patients' journeys and outcomes.

We are very appreciative of the opportunity a submission and are looking forward to engage with the relevant authorities to start this work.

NZGCG

2nd part:

4. Access to prevention, screening and data collection

 The rise in endometrial cancer is directly linked to the New Zealand obesity epidemic and disproportionately affects young Pacific women [6, 14]. Addressing the obesity wave in our country would constitute a primary prevention for endometrial cancer. Preventative actions should be led in the childhood and education sectors. Equitable access to bariatric surgery is needed later in life and its current limited funding restricts access and equity for New Zealand women [15]. 

Screening for cervical cancer is the only unfunded screening programme in New Zealand, disproportionately affecting Māori wāhine[16, 17].

Another challenge is the lack of progress in the supporting digital infrastructure. National data collection and outcome reporting has been limited by the lack of national strategy and platforms enabling transfer and extraction of information between hubs. A recent report from Te Aho o Te Kahu, the New Zealand Cancer control Agency, suggested work was underway to develop “a collection of services and tools called CanShare to improve the sharing of cancer information”[18].  

 Recommendation 7: Our group requests full public funding for women to access the cervical cancer screening programme.

Recommendation 8: Our group recommends a larger financial support to obesity prevention and treatment initiatives, such as bariatric surgery.

Recommendation 9: Our group requests the creation of a national gynaecological cancer database with the ability to report on survival as well as quality of life outcomes.

Bibliography

1.            NHS. NHS STANDARD CONTRACT FOR COMPLEX GYNAECOLOGY- SPECIALIST GYNAECOLOGICAL CANCERS 2013  [cited 2023 14/03/2023]; Available from: https://www.england.nhs.uk/wp-content/uploads/2018/08/Cancer-gynaecological.pdf

2.            AustralianGovernment, National Framework for Gynaecological Cancer Control, CancerAustralia, Editor. 2016: https://www.canceraustralia.gov.au/publications-and-resources/cancer-australia-publications/national-framework-gynaecological-cancer-control.

3.            Martin Hefford, N.E. It Takes a Team...Report to the Ministry of Health on a proposed national service improvement plan for gynaecological cancer services. 2011  [cited 2023 14/03/2023]; Available from: https://thehub.swa.govt.nz/assets/documents/40427_it_takes_a_team-_national_plan_for_gynaecological_cancer_services_22_july_2011_0.pdf.

4.            Sapere, Report to the Ministry of Health - National Gynaecological Oncology Service Provision Models 2014. 2014, Sykes P: Available on request.

5.            NewZealandGovernment. New cancer registrations 2020. 2020  [cited 2023 14/03/2023]; Available from: https://www.tewhatuora.govt.nz/our-health-system/data-and-statistics/new-cancer-registrations-2020/.

6.            Bigby, S.M., et al., Increasing incidence of endometrial carcinoma in a high-risk New Zealand community. Australian and New Zealand Journal of Obstetrics and Gynaecology, 2020. 60(2): p. 250-257.

7.            Falzone, L., et al., A multidisciplinary approach remains the best strategy to improve and strengthen the management of ovarian cancer (Review). Int J Oncol, 2021. 59(1).

8.            Woo, Y.L., et al., Centralisation of services for gynaecological cancer. Cochrane Database Syst Rev, 2012. 2012(3): p. Cd007945.

9.            James, M., et al., The changing radiation oncology landscape in New Zealand. J Med Imaging Radiat Oncol, 2022. 66(5): p. 694-700.

10.         Morgan, G.W., et al., 'GAP' in radiotherapy services in Australia and New Zealand in 2009. J Med Imaging Radiat Oncol, 2010. 54(3): p. 287-97.

11.         Matz, M., et al., Worldwide comparison of ovarian cancer survival: Histological group and stage at diagnosis (CONCORD-2). Gynecol Oncol, 2017. 144(2): p. 396-404.

12.         NewZealandGovernment. Mārama ana ki te Āputa: he tātari i te wāteatanga o ngā rongoā mate pukupuku i Aotearoa | Understanding the Gap: an analysis of the availability of cancer medicines in Aotearoa, Te Aho o Te Kahu. 2022; Available from: https://teaho.govt.nz/publications/cancer-medicines.

13.         NewZealandGovernment. Te Aho o Te Kahu, Cancer Control Agency. 2023. Rongohia Te Reo, Whatua He Oranga: The voices of whānau Māori affected by cancer. 2023  [cited 2023 16/03/2023]; Available from: https://teaho.govt.nz/publications/hui-reports.

14.         Scott, O.W., et al., Rapid increase in endometrial cancer incidence and ethnic differences in New Zealand. Cancer Causes Control, 2019. 30(2): p. 121-127.

15.         Norman, K., et al., Barriers to obesity health care from GP and client perspectives in New Zealand general practice: A meta-ethnography review. Obes Rev, 2022. 23(10): p. e13495.

16.         Smith, M.A., et al., Potential for HPV vaccination and primary HPV screening to reduce cervical cancer disparities: Example from New Zealand. Vaccine, 2018. 36(42): p. 6314-6324.

17.         The Lancet, O., Cervical cancer screening and New Zealand's uncomfortable truths. Lancet Oncol, 2021. 22(5): p. 571.

18.         NewZealandGovernment. He Urupare: Responding to the experiences of whānau Māori affected by cancer. 2023; Available from: https://teaho.govt.nz/publications/hui-reports