'Beyond Bricks and Mortar - Building Quality Clinical Cancer Services' Symposium 2011

Travelling to Traralgon: Building High Quality Oncology Services in Regional Victoria - Associate Professor Jeremy Millar

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Director Radiation Oncology, Alfred Health, Head of Brachytherapy Services

Dr Jeremy Millar:

It’s great to be talking after David because I am just reflecting that it’d be good for David perhaps to come down and live in Traralgon and share in multidisciplinary clinics there.

This will eventually come up I hope. I was asked by Abel – and I thank him for his offer to come and talk. Abel asked me about taking a strategic view to what we’re doing with regional cancer centres in provision of radiation oncology services in regional areas in Victoria and today I’d just like to talk about an overview of the problem that we face in regional Victoria and perhaps set the background for a talk that Leigh Smith and Jo Smylie are giving tomorrow about the service we provide down at Traralgon and I’ll provide the helicopter view and give some background to the detail that Jo and Leigh might talk about. So I’m talking about the idea of travelling to Traralgon, and aptly enough Leigh’s talk is about building the road.

The things I’ll talk about will be the exact problem that we face in regional Victoria and then I’ll talk about the service that we’ve helped provide in regional Victorian Gippsland, and perhaps some of the experiences and lessons that we’ve drawn, and then I’ll go on to talk about some of the challenges that we'll face in the next five years.

Now I know that many of the people here will be from out of state, and so I’ll just give some background about the cancer problem in regional Victoria. Victoria has a population of just over 5 million, 25% of that population live outside of the metro area. We’ve got a cancer instance of just under 30,000. It’s been recognised for a long time – there’s been a lot of work done recently but even during the 1970’s and 1980’s it was recognised there were inequalities in outcomes for the care of patients with cancer and this led to a movement that started in the late 1980’s, early 1990’s in Victoria to decentralise cancer services and start to provide cancer services closer to the residence of patients. Previously it had been mostly centralised in Melbourne.

And it led in 1998 to the Victorian Government participating in the single machines unit trial – of single linear accelerators in regional towns and in 2002 machines opened in Ballarat and Bendigo. In 2003 the Victorian Cancer Services Framework was published and accepted by the Victorian Government and this led to the idea of regional integrated cancer services overlaying the framework of the hub-and-spoke model of the radiotherapy centres with five regional integrated cancer services, which you can see on the map there, and the metro cancer service as well, as well as a paediatric integrated cancer service.

So by the early 1990’s we had radiotherapy centres established in many regional towns: Geelong, Ballarat, Bendigo, but not in Gippsland. And Gippsland is a standout – if you look at the figures for mortality from the Victorian Cancer Registry, the figures show that the age standardised rate per 100,000 is the highest in the state: 117 per 100,000, and it goes with a similar thing – it’s not exactly the same, but it’s the five year relative survival rate. These are figures from the Cancer Registry looking at the relative survival rates over the period leading up to 2007, so it’s the period in the early 1990’s, and again it shows that firstly on the left-hand graph there all cancers – Gippsland again has the lowest five-year survival rate: 57%, compared with all of the other regions in Victoria.

And similarly if you break it out through major examples of internal malignancies, you can see it has the worst five-year survival rate in lung cancer, in gastric cancer, and second-worst in prostate cancer. If you’re diagnosed with prostate cancer in Gippsland you’re twice as likely to die of the disease compared with some of the other regional integrated cancer service areas.

So there’s a problem with cancer in Gippsland. It’s important also to note that 5% of the population of Victoria live in Gippsland – it makes an instance of cancer about 1500 a year. The age-standardised rate of cancer in Gippsland is the same as over the state. So it’s not as if people in Gippsland are getting cancer more, it’s just they’re dying from it more frequently. Furthermore the 1500 remember is about two machines’ worth, two linear accelerators worth of patients.
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One thing that we know from the work the department has done is that in the early 2000’s the poor survivals and the higher mortality from cancer in Gippsland wasn’t due to the fact that there was a low-quality radiotherapy service in Gippsland, in fact you can see here from this graph that there were large outflows of patients from Gippsland with cancer to metro services, and so it wasn’t because of the radiotherapy or the cancer services there, patients had to move outside to get care. And that highlights another issue, which is that you can easily calculate from models the numbers of patients who are unnecessarily dying because of the lack, in this case, of radiotherapy services; you could do the same calculations for medical oncology services for example. So we can calculate in the early 2000’s that there are about 250 patients who were not getting radiation treatments. We know that the relative survival benefit from radiotherapy is about 16% from work done by Michael Barton in Westmead, and so that works out to about 40 cases a year and that’s many more than the death rate of road accidents in Gippsland, so you can see that there was a big problem with cancer mortality in Gippsland.

So what do we do about it? We were the last major metro service in Melbourne off the rank for provision of a hub-and-spoke model for NSMU. We came to an arrangement and agreement in 2001 to look after the Traralgon service. The building started in 2004 and we opened in July 2006, treated the first patient. The service has built since then. In 2007/2008 we started multidisciplinary teleconferenced clinics using the ... supported by the GRICS – that’s the regional integrated cancer service people, project officers, and infrastructure. We employed a Registrar down there in 2008, down there full time. By 2009 we had worked with the regional health service to develop a response to the request for expression of interest for the regional cancer service funding – August or September of 2009.

2010 we employed a second radiation oncologist down there. 2008/2009 we made a strong case to Alfred Health that they should be funding a medical oncologist down in Traralgon – there was only one medical oncologist down in Traralgon for the whole state. And by 2010 we were able to recruit and get another medical oncologist down there from Alfred Health working down in Traralgon. We received early 2010 the good news that we had – at least, the regional health service had – $22,000 million of funding for regional health service, and we have purchased and we are right now commissioning a second linear accelerator.

We look forward to opening a multidisciplinary regional cancer centre next year or the year after. And as you’d expect, having looked at that timeline, the numbers of patients we see down there have steadily increased, particularly with the follow-up patients, we see more and more patients every year. These are cancer survivors that we look after down close to their homes in Gippsland, and the numbers of new patients have increased to now around 450 a year.

We see patients from throughout the Gippsland region, Gippsland is quite a large part of the state, and Traralgon is more towards its western end than its eastern end, but we do in fact see patients from all regions of the state. The two pie charts there show you the breakup of the patients that we see and in the other one is the breakup of the population in Gippsland. And apart from the region of Gippsland closest to facilities in Melbourne, we see the same proportion of patients that you’d expect to see from the population basis.

Similarly, you can see that the number of treatments has pretty much steadily increased since we started in 2006. These graphs show superficial radiation treatments and megavoltage radiation treatments. We’ve become saturated at about 420, 450 courses per year. I think RORIC would say that’s the approximate machine capacity and certainly, for reasons I’ll elaborate on later on, it’s very difficult in a town regional centre to run your machines from say seven in the morning to seven at night. We really are constrained by factors other than just having the machines there.

So we’re working down there at a good steady rate, and probably as hard as we can work the machine at the moment. But we’ll see in next year a doubling of this capacity with the new machine.

And going hand in hand with that, this is the graph showing the cover by specialist radiation oncologists to Traralgon showing the radiation oncologists who are based in Traralgon, who are employed in Traralgon, and also the support in the blue bar from radiation oncologists at our centre in metro Melbourne, who are travelling down to Traralgon to provide specialist support. And you can see in recent last year, with the second Traralgon radiation oncologist we’ve been able to slightly decrease the number of times that radiation oncologists travel down to Traralgon, and when you think about it, there and back is about five hours. So for a specialist radiation oncologist to travel down to the specialist clinic in Traralgon – Traralgon is just one of the closest parts of Gippsland – it’s five hours of poor use of time. And if you’re thinking about trying to do a clinic, it means a very long day for radiation oncologists and there’s a shortage of radiation oncologists up in Melbourne so it makes for a lot of tension and a lot of problems in provision of this service.

And what has that all done? Well, the good news is that the cancer registry has now rerun the numbers on the relative survivals over the trailing last five years, and these figures are practically hot off the press, and it shows that across all the different regions in Victoria, there has been an improvement in relative five-year survivals. But the pleasing thing is that of all the improvements, the largest improvement has been down in Gippsland. Now these numbers are very small, it’s hard to say whether these are statistically significant, but it’s heartening for us at least that there appears to be some difference that we might be making.

And as we look forward to what we’re going to do in the future, we will commission a new state-of-the-art linear accelerator with VMAT or RapidArc, and this is state-of-the-art radiation therapy equipment, in fact the RapidArc will probably be commissioned down in Traralgon before we commission in metro Melbourne at our centre, so in some ways the types of radiation technology available in regional Victoria is more advanced and precisely able to be delivered in Melbourne. We’ll commission it in Melbourne after we’ve done it in Traralgon I think.

We’re looking for a third radiation oncologist next year. We’ll have accredited registrar training; registrar at the moment has been unaccredited. We are hoping to invest, and I’ll speak a bit more about this later if I have a chance, in mortality medicine, and we have recently had our first multidisciplinary palliative care clinics in our radiotherapy centre down in Traralgon, after a lot of hard work getting people together.

Palliative care is a big gap in Gippsland, and we’re very pleased to be able to help facilitate a better service to patients down there. In the last few months we’ve commenced lung multidisciplinary clinics down in Traralgon and we’ve been instrumental in now appointing a urology cancer specialist who’s going to travel down to Traralgon we hope to work in our centre to again perform in multidisciplinary clinics, and we’ve recently had talks with upper GI surgeons about doing the same thing, to provide specialist surgical help down in Traralgon.

And of course in the coming years, we hope to be part of a growing high-quality regional cancer centre down at Latrobe Regional Hospital. So it’s all looking very bright.

But it’s not quite so easy in fact. That was all of the good news. All of the superficial gloss. In fact, it’s very, very difficult to run these services, and we’ve had a series of challenges that we’ve faced.

There’s a lot of other problems that come up: we have problems with medical oncology capacity. There’s only one medical oncologist down there so there’s a real problem with waiting times. Although we run a tele-medicine service, it’s a very very inadequate service and it’s difficult to get busy clinicians to use it because it regularly falls over and when it falls over you’ve got to try and find an IT person, and the IT person will be there maybe tomorrow or the next day, and it’s just impossible if you’re trying to run multidisciplinary clinics.

We have tremendous problems with staff retention and recruitment, particularly with, and I’ve told you about radiation oncologists but the same thing is true with radiation therapists and with physicists and we were very lucky that we were able to get the team from the Alfred to go down and support the service down in Traralgon but it did require a lot of travel and a lot of extra time put in by a group of dedicated staff.

There’s quality concerns, and I’ll talk about that in a moment in the next slide. We have problems with organisational structures – we need to interact with both my large Health Service and we have to try and persuade them that Traralgon and cancer provision services down there is a very important thing for them to do, and I come from a hospital which is mainly focused on surgery and trauma, and so cancer is only one of the very small things they do. And there’s a problem with misalignment of priorities that we are very concerned with provision of multidisciplinary cancer care, but it’s difficult to persuade other health services that we rely on that this is as high a priority as we think it is.

I just want to touch on the quality concerns, and this is a problem that I think a lot of regional cancer services are going to face, that – this is just a quote from Lester Peters regarding the TROG 0202 trial. It came out – I later wrote to Lester and challenged him on this, and he made the point that this was not quite the point he was trying to make, but it’s certainly the point that the media and the community take away from comments that many people might make about regional cancer centres – the TROG trial showed that if you didn’t apply protocols properly, then the outcome for radiation treatment would be worse. Now that was associated with treatment in European centres – in small European centres in Eastern Europe those two factors were associated. They didn’t apply the protocols and they were small centres in Europe and so the correlation was in the study that small centres also were associated with worse outcome. But it was really about the application of protocols and people take the wrong message from this, and it’s very easy for people to pick up on this and think that regional cancer centres are not where you’d take your dog. You’d take your dog to metro centres if you want to look after them. So I think it’s a challenge we all face.

Okay, so some quick lessons there about what I think. We need to particularly look after the team of people who are looking after the patients – it’s critical that we recruit and retain people to work in these regional centres. And these are challenges for the future for us. I really see the opportunity of high-quality talented medicine. I think that this is the opportunity we have for improving the quality and efficiency of care that we provide for patients in rural and regional areas.

Also we have to look at institutional arrangements; that we need to look at relationships we have with local stakeholders, both the local primary care doctors down there, the people who work for local health services and the specialists down there, and people don’t recognise, don’t understand the unrecognised costs of providing high-quality cancer services in regional areas. It’s more expensive to provide a high quality of service to a town which is three hours away from a metro Melbourne without a lot of infrastructure that exists in large services.

Now I guess I’ll finish there and thank people, and take questions.
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Norman Swan:

So it is tough getting a multidisciplinary team together in a country town?

Dr Jeremy Millar:

Yes.

Norman Swan:

How have you managed to deal with safety and quality when essentially you’re on your knees begging people to come?

Dr Jeremy Millar:

One of the good things about the hub-and-spoke model that we have is that we are able to overlay the framework that we developed in metro centres to the regional centre, and because of the way in which we now have specialists who work both embedded within the metro centre and the regional centre, they do share time between both sites, it means that people have regular interactions and experience in the metro centre, and they can take it down to the regional centre. So we have quite a close relationship and we have that framework that we developed in metro centres.

Norman Swan:

And research, are able to do any research; is that a way of attracting people?

Dr Jeremy Millar:

I know that from the money that we provide to clinical trials in VCOC to research around the state, there’s not a single cancer trial open in Gippsland. And it’s something that I want to try and change and I think that it’s something that will attract high-quality and talented people to a place like Gippsland, but it’s a real problem down there at the moment.

Norman Swan:

So clinical trials (inaudible) is certainly infrastructure that needs to come…

Dr Jeremy Millar:

Everything.

Norman Swan:

Yes. Could you introduce yourself. It’s okay the microphone will come on when you speak.

Question (Gill Duchesne):

I’m Gill Duchesne, I direct the Department of Radiation Oncology at Peter Mac, and I have to say that I share Jeremy’s tears and grey hairs over having to run a regional centre, but the point I was going to make, it’s almost essential I think to network regional centre with a larger centre in town because it is easier to have the staffing interactions; it is easier to try and get research protocols in place. And very importantly it’s an opportunity to ensure that you can get training out in the regions, and I think we’re going to see a lot of workforce shortages centrally and regionally over the coming decade, and if we can get the training programs going in the regional centres, that at least introduces people to what it’s like to work in those centres and can move forward from there.

Norman Swan:

Thanks very much. What’s the situation with the private sector in Gippsland?

Dr Jeremy Millar:

Well, most of the specialist cancer provision service, apart from radiation oncology, is performed either by private specialists or private specialists who are working as visiting medical officers in regional health services. And so that creates its own difficulties with interaction there and alignment of incentives and the ability to engage with and to work with people.

Norman Swan:

But there’s no private bunker?

Dr Jeremy Millar:

Oh no, no, no.

Question (Mike Poulsen):

Mike Poulsen, I’m involved in two regional cancer centres: one in Toowoomba and one in North Queensland at Cairns, both run by the private sector. I share a lot of Jeremy’s dilemmas, and these are challenging things. I think the key thing for the successful outcome is in the staffing. You know, if you don’t have adequate staff and high-quality staff you can forget about achieving all the rest in terms of quality outcomes.

So you’ve got to look at branding of the institute, and you’ve got to make this an exciting place to work, and attractive to get the staff there, and if you’ve got good quality staff the rest of the things will fall into place. Quality equipment is also important, and that’s one of the incentives of making staff wanting to come to a regional centre. If you’ve got good quality equipment and all the new high-tech gear, that is complementary.

I think one of the other huge challenges we face in the remote areas is that things outside of your own department, all the infrastructure things; good quality radiology, good quality specialists services – I was in Cairns a couple of weeks ago doing a clinic and saw a patient with locally advanced lung cancer and part of our contract is that, it’s mandated that we have to have treatment up and running within 14 days once they’re ready for care. Which is challenging in itself, but when you track this patients’ course, they had their chest X-ray in February of this year – that was the most recent CT scan that we had of the patient. They had their bronchoscopy in April; they had an opinion from a surgeon in Townsville in June…

Norman Swan:

So your 14 days…

Question (Mike Poulsen):

…and radiation treatment in July. And that’s the reality, you know? So you’re behind the eight ball automatically. So there are lots of challenges, and getting the cancer centre component is only part of the story; you’ve got to get all the rest of the bits and pieces in place.

Norman Swan:

So what are you doing about getting that journey more efficiently run?

Question (Mike Poulsen):

Look I mean we’re in our infancy, the department…

Norman Swan:

There’s an epidemic of CT pulmograms being done in Australia, all over the place. It’s buying Mercedes for lots of radiologists. Why can’t it be done in North Queensland?

Question (Mike Poulsen):

Yeah, look, there are bottlenecks. The service in Cairns for instance, there’s not a local radiologist; it’s actually run by a group in Adelaide. So they fly in for three days and they’re gone, so you know, it’s the whole story of attracting specialists to regional centres. So, just sharing some of my…

Norman Swan:

No, thank you for doing that. And we hope to hear more like that. That’s great, thanks for contributing. And Jeremy, thank you very much. Do you want to make a comment?

Dr Jeremy Millar:

No, it's alright thanks.

Norman Swan:

No? Thank you, that was great. Thank you

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