Public Health Bulletin Edition 1, 2004 - SA Health - SA.Gov.au

Public Health
Bulletin
SOUTH AUSTRALIA
Edition 1 /2004
Welcome to the first edition of South
Australia’s Public Health Bulletin. The
aims of the Bulletin are to provide a
vehicle for discussion and debate
about key Public Health activities,
including research, programs and
policies, and to provide information
for health practitioners across the
State. It will include the regular
Communicable Disease Control
Branch Report in addition to health
issues of importance to South
Australia, with the Population Health
approach as a unifying theme. This
first edition focuses on cancer while
future editions will highlight other
health issues.
What is epidemiology
Action Points from the Charter of Paris
Recommendations for Optimising Cancer
Care in Australia
Living with Cancer in Australia
Conference Action Points
6
18
24
26
CANCER: The role of Public Health
Buckett & Hunter, Public Health and the SA
Health Reform Agenda
Luke, Epidemiology & Cancer
Heard, Geographical Mapping
Kirke, Cancer Control in Aust
Clapton, Epidemiological Surveillance
Services
Olver, Of Cancer Registries and Roll-ons
Roder, Ethnicity and racial differences in
cancer differences
Young, Bampton, Cole et al, Screening for
colorectal cancer
Booth, Looking beyond a risk factor approach
to cancer - New challenges for prevention
and health promotion.
Spurr & Herriot, Reducing Cancer Risk
Through Primary Prevention
Miller, Hepatitis C infection in Australia
1
3
7
10
13
16
19
22
25
27
29
Communicable Disease Control Branch report 32
ISSN 1449-485x

PUBLIC HEALTH and the
SA HEALTH REFORM AGENDA
Kevin Buckett
Director Population Health
Department of Health
Miriam Hunter
Senior Consultant
Department of Health
In this first edition of the Public Health Bulletin, it is
worth considering the role of public health in the context
of the Government’s health reform agenda and how it
contributes to the aims of the broader health system.
The way health services are organised and provided
in SA is changing. Along with this there is an evolving
lexicon that describes the health system and its delivery
of services. The intent is to increase the emphasis on
prevention and primary care for the benefit of the health
of the population as a whole. This so called Population
Health approach can be defined as:“an approach to health
that aims to improve the health of the entire population
and to reduce health inequalities among population groups.
In order to reach these objectives, it looks at and acts
upon the broad range of factors and conditions that have
a strong influence on our health”.
The Population Health approach describes a
comprehensive health system which ranges from Public
Health at one end to individual health care at the other.
In this context, “Public Health” activities aim to control
the determinants of disease and reduce public exposure
to risks encountered as part of lifestyle or in the
environment. Thus, the defining features of Public Health
are health protection, illness prevention and health
promotion, all of which are aimed at populations rather
than at individuals. In particular, Public Health focuses on
primary prevention rather than health care and clinical
services. In addressing determinants of disease, Public
Health approaches are often multi-sectorial, involving a
diverse range of players, many from outside the health
system itself. In promoting health and helping to prevent
illness, Public Health initiatives support primary care and
provide cost-effective measures to reduce the burden on
clinical and allied health services.
In April 2002, the Government of South Australia
announced the Generational Health Review (GHR), the
first major review of the health system since the 1970s.
The GHR was challenged to provide a blueprint for
developing the South Australian health system in the 21st
1
Century. In its report 1 , the importance of primary health
care is highlighted as an essential element of a strong
health service, and the GHR recommends a re-orientation
of health services towards prevention, promotion and
early intervention. The overarching conclusion of the GHR
is clear: no change is not an option.
The case for change in the health system is strong,
and the re-emphasis of primary health care is not unique
to South Australia; health systems all over the world are
grappling with similar issues. The driving forces include:
• Changes and projected changes to the population profile
• Increasing evidence of health inequalities, and the
impact of social determinants of health
• Changes in the disease burden and increasing chronic
disease
• Increasing community expectations of care
• Imbalance in the mix and distribution of services
• Fragmentation and duplication of planning, funding and
governance arrangements.
In June 2003, the Government issued First Steps
Forward, 2 its first response to the GHR. With an
overarching aim to achieve improvements in health for
all, it specified three areas for the focus of reform: Better
Governance, Better Systems and Better Services. The
success of this reform agenda will depend on the ability
of the health system to embrace three fundamentals of
health reform: a population health approach, working as
a system, and effective innovation in care.
To achieve this aim, the health system in SA has
embarked on a period of transition. The new pattern and
style of service delivery will rely less on inpatient care,
with greater emphasis on the primary care system,
community-based and home-based services, and greater
effort put towards primary and secondary prevention. A
regional model of health service delivery, recommended
by the GHR, has been adopted and is being implemented.
This represents a major change in how services are to
be delivered in the future.
Even before John Menadue delivered the final GHR
report, the Government had commenced work on its
Primary Health Care Policy, which was launched by the
Minister for Health in September 2003. This describes
Primary Health Care as ‘the first point of contact that a
person has with the health system’. 3 The policy statement
outlines the principles that underpin a Primary Health
Care approach, and identifies the key directions for
implementation.

Given this backdrop, in which health system reform
is directed towards prevention and primary care, with a
population-based approach to health services, what is
the role of Public Health Of necessity, the reform agenda
to date has largely revolved around the delivery of medical
and allied health services. Reform has not yet been
undertaken in Population Health, which deals with
population-wide and community-wide health protection,
primary prevention and health promotion. There is a clear
need to address this aspect of health as the reform
agenda moves forward. A key question is ‘How does
Public Health integrate with and support the broader
health system in conjunction with the reforms commenced
through the GHR and Primary Health Care Policy’
The GHR refers to the need for Public Health reform
under the heading ‘Public and Environmental Health’. This
section describes the importance of state-wide public
health services and policy development: monitoring and
surveillance of injury; communicable and noncommunicable
diseases; health risk assessment and
management; health promotion activities; evaluation of
health promotion and disease prevention strategies. The
case is made for reform in Public and Environmental
Health to support associated reforms in the health system.
pdf format that will be available on the website for the
Department of Health.
Welcome to the first edition of the Public Health
Bulletin.
References
1. Better Choices Better Health: Final Report of the South
Australian Generational Health Review. Adelaide
2. Office of Health Reform. 2003. First steps Forward.
South Australian Health Reform. Adelaide
3. Department of Human Services. 2003. Primary Health
Care Policy Statement 2003 – 2007. Adelaide
This first edition of the Public Health Bulletin provides
an example of how Public Health fits within the broader
health system in relation to one of our national health
priorities – cancer. The papers presented in this issue
range across the health system continuum, from
population-wide health promotion approaches as discussed
by Booth, to clinical analysis and the role of the cancer
registry provided by Clapton and Olver. The power of
system-wide monitoring and surveillance is described by
Heard, and the role of epidemiological analysis in
understanding the incidence and aetiology of cancer by
Luke in ‘Epidemiology and Cancer’ This information
underpins state-wide strategies based on evidence and
need, information and health promotion activities, as well
as assisting regions and clinicians in delivering appropriate
and cost effective treatment and care services for
individuals.
Future editions of the Public Health Bulletin will
continue this thematic approach. The aim is to provide a
forum for discussion and debate around contentious
public policy issues. We will publish scientifically based,
peer-reviewed articles, with evidence of emerging
pathways between determinants of health and underlying
causes of morbidity and mortality. And we will continue
to identify strategies to prevent disease and promote
health and wellbeing.
The Public Health Bulletin will be published periodically
and distributed widely to health practitioners in South
Australia. This and future editions will also be available in
2

Epidemiology and Cancer
Feature article by Colin Luke
Senior Specialist Medical Consultant and Clinical
Epidemiologist
Department of Health
Following dramatic improvements in the control of
infectious diseases during the last century, the attention
of epidemiologists has increasingly turned towards chronic
illnesses. Resulting advances include some of the most
important discoveries in the cause and prevention of
cancer, for example, the causal link between smoking
and lung cancer. Such has been its impact on cancer that
epidemiology now influences the decision-making of
clinicians, experimental researchers, policymakers, and
even the lay public, whose attention is often drawn by
the news media to epidemiological observations and
environmental issues, albeit frequently in an unbalanced
way.
Historical perspective
Epidemiological observations in cancer have a long
and fascinating history. 1 In 1700, the Italian occupational
physician Burnardino Ramazzini observed that breast
cancer was more common amongst nuns than other
women, and attributed his findings to the influence of
celibacy. In 1775, the British surgeon, Percival Pot reported
probably the first description of occupational
carcinogenesis in the form of scrotum cancer among
chimney sweeps. Reports of cancer risks associated with
tobacco in the 18th century included snuff taking and
nasal cancer, reported by Hill in 1761, and pipe smoking
and lip cancer by von Soemmering in 1795. Perhaps the
first modern epidemiological study of cancer was
conducted in 1842 by Rigoni-Stern, who attempted to
quantify the risks of uterine cancer among nuns compared
with other women in the city of Verona; he showed that
the disease was significantly less common in the former
group. Important occupational cancers were also observed
in the 19th century. In 1879, lung cancer, first described
as ‘mediastinal lymphoma’, was found by Harting and
Hesse to be disproportionately common among the metal
miners in Germany; bladder cancer among aniline dye
workers was described by Rehn in 1895. In 1888,
Hutchinson reported the first suggestion of drug-induced
cancer, with an account of skin cancers in patients treated
with an solution containing arsenic.
These historical observations, and many others that
followed, illustrate the importance of clinical observations
as a source of new discoveries in cancer aetiology. 2,3
They also include an early indication of the long-term
3
latent interval in human carcinogenesis: for example,
Percival Pot observed that some of the men with scrotum
cancer had not worked as chimney sweeps since
childhood. Furthermore, such observations show how
some causes could be detected (and diseases prevented)
before specific causal agents and mechanisms were
defined by laboratory investigators. Many decades elapsed
before evidence was available to indicate that agents
such as polycyclic hydrocarbons, radioactive substances,
and aromatic amines explained some of the previously
described findings.
The main contribution of cancer epidemiology is the
detection and quantification of the risks associated with
specific environmental exposures and host factors. 4,5
These associations may lead to causal inferences,
providing the basis for instituting preventive measures.
Epidemiological data supports the concept that
carcinogenesis is a lengthy multistage process that is
affected by a wide variety of factors. Some factors appear
to act early as initiators, others later as promoters, and
still others at both early and late stages. Certain agents
act together to accelerate the carcinogenic process, for
example, tobacco combines synergistically with asbestos
to produce lung cancer, and with alcohol to produce oral
and oesophageal cancers. Furthermore, the process may
be retarded by dietary factors, such as certain
micronutrients that appear to diminish the risk.
The aims of epidemiology are to uncover new
aetiological leads through peculiarities in the distribution
of cancer, to quantify the risks associated with different
exposures (some of which may be protective), promote
insights into the mechanisms of carcinogenesis, and
assess the efficacy of preventive measures. Although
the usual observational methods of epidemiology have
succeeded in identifying many causes of cancer, future
progress may depend to a considerable degree on
innovative strategies that employ laboratory techniques
in epidemiological investigations, especially, for instance,
tumour markers from research of the human genome.
Epidemiological methods are increasingly used to
assess the impact of interventions, both preventive and
therapeutic, on populations or subgroups. Of particular
interest to policy makers and planners is the impact of
early detection and screening programs. Some examples
of these assessments are included in this commentary.
South Australian Cancer Registries
The population-based South Australian Cancer
Registry have been collecting information about all cancers
with the exception of non-melanotic skin cancers since
1977. Primary sources of data include pathology
laboratories, hospitals, treating radiotherapists, and the

Registrar of Births, Deaths and Marriages. Information is
refined through contact with the primary health care
sector and other registries, resulting in near 100%
ascertainment. Furthermore, advances in imaging and
laboratory diagnostic procedures have resulted in more
accurate recording of cancer types; in this post-genomic
period, increasingly specific tumour markers are reported
and these are used to classify cancers.
From the inception of this Registry in 1977 to the
end of the year 2001, 154,075 cases of cancer were
recorded: 46% in females and 54% in males. Of these,
144,120 are described as ‘invasive cancers’, with the
potential to spread both locally and to other organs of
the body. The sex ratio of these invasive cancers is similar
to that of the total. The remainder, 48% females and 52%
males, are known as ‘in situ’ cancers. These are less
likely to spread beyond the tissue of origin but are capable
of local damage, and most are treated. Benign tumours
may grow in size, causing detrimental local pressure
effects, but these do not infiltrate other tissues and so
are not recorded. Similarly, the common skin cancers are
not recorded on the database, as numbers would be
prohibitive and because most are removed by destructive
means, which precludes histological diagnosis.
Data from the SA Cancer Registry is used by a wide
range of health care workers and researchers. Incidence
and prevalence data is frequently sought, to determine
the burden of this disease, to investigate suspected
clusters, and, together with cancer-specific mortality data,
to evaluate the efficacy of screening programs. Information
can guide and monitor health promotion activities. The
long latency period of most cancers, combined with
residential mobility, raises a note of caution: a causal
exposure may have occurred in one location and become
manifest in a future residence.
Hospital-based cancer registries have been developed
to record more detail for specific tumour types. These
collections record additional features including cancer
stage (a measure of tumour spread), cancer grade (a
measure of aggression), a range of tumour markers,
treatments and their outcomes.
the introduction of formal cancer control policies. Although
completely successful treatments for established cancers
are unlikely to be available for some time, there is much
that can be achieved in the areas of prevention and early
detection. Trends in both incidence and mortality are
presented for all cancers in aggregate, together with the
most commonly diagnosed cancers and those responsible
for the majority of deaths in 2001.
Associate Professor David Roder, also from the
Cancer Council, has contributed a paper that describes
incidence and mortality by ethnicity. Such analyses reveal
interesting differences in cancer profiles, depending upon
race and country of birth. Marked differences by race
may be attributed to genetic factors, but most are thought
to be related to life styles and environmental factors. This
contribution suggests that migrants have cancer profiles
similar to their parent countries upon arrival, but these
typically approach those of Australians over time, reflecting
new life styles and environmental exposures. Such studies
provide information about changes in social, behavioural
and environmental factors in relation to cancer risk.
Time Trends
Trends in incidence and mortality for specific cancers
may reflect environmental exposures and behavioural
changes, the efficacy of screening programs, and the
application of new diagnostic techniques. In any such
analysis, it must be noted that increasing age is a major
predictor of the incidence of cancer. If comparisons are
to be made between regions of different demographic
profile, or if examinations of trends over time are of
interest, it is still important to adjust for age. Crude rates
are standardised against a World Standard Population
age profile.
Lung cancer trends provide a challenging example
of the impact of smoking, considered to be the major
causal agent in most lung cancer types.
In this edition of the Public Health Bulletin, Professor
Ian Olver has kindly contributed an article describing the
benefits and limitations of both population-based registry
data and that available from the more specialised
collections located in our major public hospitals. Of
particular interest is his presentation of a recent scenario
concerning cause and effect, a case that most readers
will remember, as it achieved considerable media
exposure.
Elsewhere in this issue, Associate Professor Kerry
Kirke of the Cancer Council of South Australia proposes
4

Figure one shows three-year moving averages for
both incidence and lung cancer-specific mortality; the data
has been adjusted for age to allow meaningful comparisons
.
The incidence of lung cancer reduced by about 25%
in males between 1977-80 and the late 1990s, and a
similar reduction is evident for mortality. By contrast,
females showed an approximate 60% increase in lung
cancer incidence over this period, with the majority of
this increase occurring before 1992. Female lung cancer
mortality shows a 50% increase before 1992, but with
no further increase thereafter.
Smoking is considered to be strongly associated with
squamous and small-cell lesions rather than with
adenocarcinomas. It is likely that the decrease in males
is due to reduced smoking, and this is supported by
Registry data which shows that the ratio of these cell
types fell from 2.4 to 1.5 over this period. By comparison,
there was little change in the ratio of these cell types in
females.
The incidence of diagnosed breast cancer has
increased by nearly 60% from 1977-80 to the present
time, due mostly to increases since the late 1980s that
followed the introduction of population-based
mammography screening. In the 50-69 year-old target
group, the increase was approximately 80%, with a
greater proportion being diagnosed when they were small
and more amenable to treatment.
Implications of this data for anti-smoking campaigns,
especially for women, are apparent. But lung cancer may
also be caused by exposure to asbestos, ionizing radiation
and other occupational carcinogens, and interventions to
limit exposure to these agents should be continued.
Time trends in three significant cancers
It is generally accepted that the application of a
successful cancer screening or early detection program
is followed by a significant reduction in cancer-specific
mortality. Figures 2, 3 and 4 show incidence and mortality
trends for cervical, breast and prostate cancers. Cervical
and breast cancers have been subject to formal screening
programs while prostate has been the subject of much
discussion and debate because of the widespread
application of a blood test (Prostate-specific Antigen)
followed by biopsy.
The incidence of cervical cancer has reduced by
nearly 40% from 1977-80 to the present time. This is
attributed to the detection and early treatment of precursor
lesions.
Cervical cancer-specific mortality rates have decreased
by 60% over the same period. Overall, the percentage
reduction in mortality was greater than the corresponding
reduction in incidence.
This effect is attributable to the application of early
detection methods in the early 1980s, and to the adoption
of formal screening after a series of successful pilot
programs.
Breast cancer-specific mortality rates reduced by
10% for all ages combined over the same period. Overseas
studies have shown that the impact of breast screening
on mortality rates can take several years to become
evident. Near full screening coverage for the SA
community was not achieved until 1991-1992. Within the
last two years 66% of women between 50 – 69 years of
age have been screened. Nonetheless, the agestandardised
mortality rate over the last three years was
20% lower than for the preceding decade in the 50-69
year olds. A smaller reduction of 10% applied to women
over 69 years of age, many of whom would have been
screened at a younger age. There has been no reduction
in mortality for women of less than 50 years of age. A
major challenge is to develop a cost-effective means of
screening these younger women, who tend to have
denser breast tissue. Other forms of imaging are being
investigated, as well as circulating tumour markers.
The incidence of diagnosed prostate cancer has
increased by nearly 95% between 1977-80 and the
present time, peaking in 1993. Most of this increase has
5

een associated with the introduction of Prostate-specific
antigen (PSA) testing, and the subsequent use of
transrectal ultrasonography and biopsy. Because the
prevalence of latent inactive disease is very common,
affecting more than 50% of men over 70 years old, the
increased investigations can lead to a the detection of
large numbers of cancers of uncertain clinical significance.
References:
1.Shimkin MB. Contrary to nature: being an illustrated
commentary on some persons and events of historical
importance in the development of knowledge
concerning … cancer. Washington: United States Dept
of Health, Education and Welfare, Public Health
Service, National Institutes of Health, 1977.
2.Doll R. Part III: 7th Walter Hubert Lecture. Pott and the
prospects for prevention. Br J of Cancer
1975;32(2):263-74.
3.Doll R. The Epidemiology of Cancer. Cancer
1980;45(10):2475-85.
4.Schottenfeld D, Sraumeni JS, eds. Cancer epidemiology
and prevention. 2nd edn. New York: Oxford University
Press, 1996.
5.DeVita VT, Hellman S, Rosenburg SA, eds. Cancer:
principles and practice of oncology. 6th edn.
Philadelphia, Pennsylvania, Lippincott, Williams &
Wilkins, 2001.
Prostate cancer-specific mortality has remained fairly
stable. If this de facto ‘screening’ is beneficial, we would
expect to see a decrease in prostate-specific mortality
after several years. Much research is being conducted to
produce a more specific form of the PSA test, and
randomised clinical trials are underway to determine
whether this ‘screening’ of asymptomatic males provides
a mortality benefit. The lifetime ‘risk’ of being diagnosed
with prostate cancer is about one in ten; the mortality
rate from this cancer is but a fraction of this.
Until the efficacy of such testing is proven, men
should be made aware of the implications of undergoing
a PSA test, including the possibility of radical surgery,
radiotherapy, hormonal therapy and chemotherapy, which
may have significant complications. One strategy is just
as it sounds – ‘Watchful Waiting’.
The challenges associated with the diagnosis of early
stage prostate cancer have had some positive outcomes,
and there is a greater awareness of men’s health in
general. The Collaborative Centre for Prostate Health
works in close association with the Cancer Council of
South Australia, involving Urologists, GPs, Nurses and
the community in developing policies and providing advice
to all parties.
This first issue of the Public Health Bulletin has
focused on cancer, which is actually a group of over 100
recognised diseases. The group is only second to
cardiovascular disease as the major cause of death in
Australians. As our population ages and measures to
control cardiovascular disease improve, cancer in all its
forms is predicted to become our leading cause of death
and morbidity.
What is epidemiology
Colin Luke
Epidemiology is the study of the distribution and
determinants of disease frequency in human populations. It
is based on two fundamental assumptions: firstly, that disease
does not occur at random, and, secondly, that causal and
preventive factors of disease can be identified by investigation
of populations, or subgroups of populations, in different places
or at different times. Its principal objective is to find causes,
so that, ideally, preventive measures may be applied.
Epidemiology contrasts with clinical medicine, in which
the primary concern is the diagnosis and treatment of individual
patients, by focusing on events that necessarily precede the
onset of disease. This approach encompasses all unaffected
persons in a given population as well as the affected members,
which may be useful for comparison purposes. And in this
way, selection factors that may be associated with the
activities of individual clinicians can also be avoided.
Several words are central to the above definition of
epidemiology. The word human differentiates the approach
from laboratory disciplines in cancer research that use animals
and other test systems in their experiments. The study of…
populations stands in contrast to clinical research, which
usually involves investigations at the individual patient or case
series level. The term frequency indicates the orientation of
epidemiology towards quantifying the occurrence of disease
and the risks attributable to various causes. The phrase
distribution and determinants points to two major approaches
in epidemiology. Descriptive studies examine the distribution
of disease frequency in populations, which can be useful in
generating aetiological hypotheses.
Analytical studies test hypotheses of causation by
pursuing differences in the personal characteristics or
exposures among individuals.
6

Geographical Mapping of
Cancer in South Australia
Adrian Heard
Epidemiologist
Department of Health
Background
The main reason for undertaking geographical
mapping of cancer in South Australia is to determine
whether there are any broad geographical trends in cancer
incidence and mortality in this state. Of particular interest
is whether cancer incidence or mortality is determined
more by geographical location or by social and economic
circumstances (SES). The difference in cancer incidence
and mortality between city and country is also of interest.
Geographical mapping of cancer has been carried
out for many years, using Committee for Urban and
Regional Boundaries (CURB) areas, and published in the
‘Epidemiology of Cancer in South Australia’ series. 1
Internationally, mapping is conducted through such
organisations as the National Cancer Institute. 2 This paper
continues that process but uses the updated 1998
statistical local areas (SLAs) of the Bureau of Statistics
as the unit for mapping. 3 The paper also includes analyses
that test for associations between cancer incidence or
mortality and two sets of indicator scores: socio-economic
indicators for areas (SEIFA) 4 and Australian remoteness
indicators for areas (ARIA). 5
Methods
The dots on the maps show relative cancer incidence
and mortality in different parts of the state. The rates
represented in the maps are rates per 100,000 people
per year for the period 1991-2000.
The maps all use age-sex standardised data.
Standardisation is an important component of presenting
cancer information because for many cancers the risk of
diagnosis increases rapidly with age. This process of
standardisation ensures that the different age profiles of
geographical areas do not create bias in the maps.
The unit for each dot shown on the map is a statistical
local area (SLA), using the 1998 designated boundaries.
SLAs generally coincide with council boundaries in rural
South Australia, but there are often multiple SLAs for
each metropolitan council. For each map, 113 SLAs are
shown, together with 4 unincorporated areas. In linking
cancer incidence and mortality to SEIFA and ARIA scores,
7
2001 scores were used. Associations between SEIFA/ARIA
and incidence/ mortality were then estimated using
negative binomial regressions. All analyses were
completed using the Stata statistical package. 6
Using cancer maps
Cancer maps for eleven cancers are available on the
Department of Health website at:
http://www.health.sa.gov.au/pehs/cancer-report-02/cancerreport-2002.pdf
There are a number of problems with mapping cancer
data. Firstly, for some cancers, such as lung cancer, there
is a long latency period between the exposure which
caused the disease and the diagnosis of cancer. This
means that people with lung cancer may move location,
say from a rural area to a regional centre, between
exposure and diagnosis, thus inflating the cancer incidence
rate of the regional centre. Secondly, addresses recorded
in the South Australian Cancer Registry are not always
detailed enough to be accurately assigned into an SLA.
This leads to the loss of about 2% of data, and potentially
inaccurate assignment of a further 5% of data.
Caution needs to be taken in putting too much weight
on individual dots on the maps. The population used to
assign an incidence or death rate varies from over 33,000
in the case of Onkaparinga/Woodcroft in Adelaide’s south
to less than 1,000 in Orroroo/Carrieton in the mid north.
Because a number of rural SLAs and unincorporated
areas have very small populations, the recording of a
small number of a particular type of cancer can lead to
a high incidence rate. A consistent pattern of dots in
geographic groupings (eg. northern Adelaide) enables
more accurate interpretations of the data.
Cancer maps are not necessarily useful in answering
the most frequently asked questions about cancer, such
as ‘why are so many people getting lung cancer in my
suburb’ There are three reasons why cancer maps fail
to answer such questions. Firstly, the questions are on
a micro scale, and often do not take into consideration
the year to year variation of cancer incidence. The cancer
maps use data over a ten-year period and tend to average
out chance variations. Secondly, the units of geographical
area used in the maps are statistical local areas, with
populations generally much larger than a suburb or
neighbourhood. Thirdly, age-sex standardisation of cancer
incidence tends to bring many locally observed high
incidences of cancer back to within a normal range.

Cancer maps are also not particularly useful in
determining a link between environmental hazards and
cancer. This is because environmental hazards may be
very localised and because we still have very few
measurements of carcinogenic exposure in human tissue.
Figure 2 Lung Cancer Mortality Map
On the other hand, cancer maps are powerful tools
for showing how much cancer is avoidable. Clearly, for
instance, people in eastern Adelaide are much less likely
to get lung cancer than their near neighbours in western
Adelaide. Cancer maps also demonstrate how people
who live in high SES areas are more likely to be screened
for preventable cancers than people in low SES areas;
thus higher incidences of these cancers are recorded.
It is well known that more than 50% of all cancers
are accounted for by environmental/behavioural factors.
The large discrepancies between geographical areas in
South Australia for cancer incidence and mortality indicate
that these factors are a major source of variation.
Figure 1 Lung Cancer Incidence Map
Figure 3 Table of associations between cancer
incidence/mortality and SEIFA/ARIA
Results
Figures 1 and 2 show the incidence and mortality of
lung cancer as an exemplar from the available cancer
maps. Figure 3 shows the IRRs and P values for the
association between cancer incidence and mortality for
all cancers with SEIFA and ARIA scores.
Incidences of lung and cervix cancer both decrease
with increasing SES (increasing SEIFA score). For lung
cancer there is a similar relationship for mortality. Northern
8

Adelaide, north western Adelaide and far southern Adelaide
all had high incidence for lung cancer and cervix cancer,
as did the industrialised rural areas of the Iron Triangle
and the Lower South East. The far north and west of the
state with remote and low SES communities also had
high incidence for cervix cancer.
Breast cancer, melanoma and lymphoma had an
increased incidence in high SES groups; but, importantly,
there is no increased mortality among high SES groups
for any of these cancers. While an SES effect was also
evident for colon and prostate cancer incidence, there
was no clear gradient of incidence from low to high SES
groups, and the effect was not significant.
People living in remote areas had an increased
mortality from four cancers: melanoma, prostate, cervix
and leukemia. Stomach cancer incidence was reduced
in remote areas.
Discussion
This paper highlights some important trends, such
as reduced lung and cervix cancer incidence being related
to increasing SES, and increased breast cancer and
melanoma incidence being related to increasing SES. It
has also shown some new trends in relation to increasing
mortality being associated with remote location for a
number of cancers.
While the relationship between lung and cervix cancer
incidence is widely reported in the literature, it is of
interest that, in South Australia, mortality from cervix
cancer is associated with remoteness rather than with
SES. This association may be partly due to Aboriginal
women having high rates of cervix cancer mortality. Lung
cancer is the only cancer for which there is a consistent
and significant SES effect for both incidence and mortality,
confirming the importance of this cancer in low SES
groups.
The lack of an association between stomach cancer
incidence and death and SES is of interest, given the
previous reporting of such an association 7 . Rather, we
have found a declining incidence of stomach cancer with
increasing remoteness. The low population of migrants
outside the metropolitan area may explain this remoteness
effect, as migrants are a high-risk group for stomach
cancer.
The fact that mortality from four cancers is significantly
higher in remote areas than in the metropolitan area is
of concern. This increase in mortality may be due to poor
detection of cancers such as melanoma and cervix cancer,
or due to country people being less likely to undertake
complex or lengthy courses of treatment, such as those
required for prostate cancer and leukemia.
In conclusion, the mapping of cancer incidence and
mortality data provides further refinement in our
knowledge of South Australian cancer epidemiology. The
need to focus health promotion efforts for cervix cancer
on rural, low SES communities is very clear. Also the
fact that people in rural communities are dying from some
cancers at a higher rate than people in metropolitan
communities, may have implications for the provision of
treatment services for these cancers.
References
1. South Australian Cancer Registry. Epidemiology of
cancer in South Australia. Adelaide: South Australian
Cancer Registry, 2001.
2. Devesa SS, Grauman DJ, Blot WJ, Pennello G, Hoover
RN, Fraumeni JF Jr. Atlas of cancer mortality in the
United States, 1950-94. Washington, DC: US Govt Print
Off, 1999; NIH Publ No. 99-4564.
3. Australian Bureau of Statistics: 1998 Australian standard
geographical classification. Canberra: Australian Bureau
of Statistics, 1998.
4. Australian Bureau of Statistics: 2001 census of
population and housing: Socio-economic indicators for
areas. Canberra: Australian Bureau of Statistics, 2002.
5. Australian Bureau of Statistics: 2001 census of
population and housing: Australian remoteness
indicators for areas. Canberra: Australian Bureau of
Statistics, 2002.
6. StataCorp 2003 Stata Statistical Software: Release
8.0. College Station, Texas: Stata Corporation.
7. Howard G, Anderson RT, Russell G et al. Race,
socioeconomic status, and cause-specific mortality.
Ann Epidemiol. 2000; 10: 214-23.
8. Williams J, Clifford C, Hooper J et al. Socioeconomic
status and cancer mortality and incidence in Melbourne.
Eur J Cancer. 1991; 27: 917-21.
Two of the cancers that show an increased incidence
with increasing SES are breast cancer and melanoma,
cancers for which screening and medical detection are
important. This association is widely reported in the literature,
and often is found in other cancers such as colon/rectum
and prostate cancers 8 . Both those latter cancers show a
SES trend which is near significance in this study.
9

Cancer Control in South Australia
A/Prof D Kerry Kirke AM
Manager, Research & Development Unit
The Cancer Council South Australia
The groups of diseases we call cancer are potentially
the most preventable and treatable of all chronic illnesses;
however, the imminent emergence of a panacea is highly
unlikely. Thus it would seem rational to target cancer
control policies towards reducing the impact of cancer
in all population groups in South Australia.
The World Health Organisation has seen fit to publish
a second edition of its National Cancer Control
Programmes: Policies and management guidelines 1 to
help countries make best use of the resources available
in developing their own effective cancer control programs.
Many countries, and some states of Australia, have
developed, or are developing, national and/or regional
cancer control policies and strategies.
Cancer and its treatment cause a great deal of physical
and psychological morbidity, and it has overtaken
cardiovascular disease as the biggest killer of South
Australians. One in three to four South Australians will
be told they have cancer at some point in their lives.
The most recent SA Cancer Registry report 2 provides
2001 data and is the source document for the information
provided in the charts below.
It can be seen that between the diagnostic periods
1977-81 and 1997-01 there was a substantial increase in
age-standardised incidence of cancer: 25% in South
Australian males and 30% in females.
Earlier diagnosis and more effective treatments have
resulted in an 11% decrease in cancer deaths for men
and a 3% decrease for women over that period.
Details of the trends in incidence and mortality for
specific cancer sites are available at the websites of The
Cancer Council SA 3 .
While none would dispute the wisdom of the old
adage that ‘prevention is better than cure’, most advances
in cancer control have been due to earlier detection and
improved treatments. A good example is mammography
screening, and the widespread use of hormonal antineoplastic
agents such as tamoxifen in the treatment of
some breast cancers.
Two exceptions in which prevention has proven
effective are the recognition of tobacco as a potent
carcinogen, with large numbers of adults quitting smoking,
and the identification of precancerous, curable lesions
through cervix screening. Hopefully screening for
colorectal or bowel cancer will find enough precancerous
polyps and curable early cancers to make a difference in
both incidence and mortality.
The non-melanocytic skin cancers, basal cell and
squamous cell carcinomas are so common as not to
require registration; however, together they are the most
common and the most costly cancers in Australia. A
major public health challenge continues to be the
promotion of sun protective behaviours on a population
basis.
10

The commonest cancers (excluding non-melanocytic
skin cancers) and those most frequently causing death
in South Australians are shown in Tables 1 & 2. Again,
the source of this information is the SA Cancer Registry 2 .
What the media reports do not say is that very few
of the reported discoveries are ever incorporated into
routine cancer management practice; those that are take
millions of dollars and many years to get there.
Public health practitioners believe that 50-75% of
cancer mortality is attributable to external, non-genetic
factors. Most of these are related to human behaviours
such as tobacco smoking, overuse of alcohol, improper
diet, lack of physical activity, overexposure to ultraviolet
radiation from sunlight, and sexual activity leading to
certain viral infections. 4,5,6 Modification of such behaviours,
and of the social factors that influence them, is a major
cancer control challenge for public health policy makers.
A cancer control policy, if it were to be comprehensive,
would have to pay more than lip service to consulting
stakeholders. It would need to take account of the
behavioural aspects of prevention and early detection,
the physical, social and psychological dislocations
associated with being referred to and treated at a major
centre, and the post-cancer distress so often requiring
specialised psychological support. 7 It would also need to
promote the clear benefits of integrated multidisciplinary
care, early involvement of palliative care expertise, and
so forth.
Perhaps for the first time nationally, the views of
people affected by cancer have recently been sought, as
well as those of their formal and informal carers. A great
deal of material upon which to base healthy public policy
is now readily available in Australia.
The Charter of Paris against Cancer was launched in
February 2000. This is effectively a bill of rights for people
with cancer and their carers (see box p.18). Among other
things the Charter of Paris established February 4th as
World Cancer Day, providing a stimulus in Australia, at
least for state Cancer Councils and some other agencies,
to embark on wide ranging consultation with regional
communities, health care providers, consumer advocacy
groups and other interested parties. 8
As researchers struggle to understand more and
more about the cellular and molecular biology of cancer,
clinicians, with help from pharmaceutical companies, are
conducting trials of new or different combinations of
drugs, often among patients whose disease no longer
responds to conventional treatment.
Media reports, almost daily, refer to yet another
cancer breakthrough, and it is a popular belief that a
universal remedy for all cancers is just around the corner.
Why would you bother to change your behaviour when,
soon, you’ll just have to swallow a pill
On 4 February 2001, The Cancer Council Australia
acknowledged the Charter of Paris and marked World
Cancer Day with an interfaith event in The Great Hall,
University of Sydney. During that year, under the auspices
of state Cancer Councils, 42 regional seminars were held
across Australia (four in South Australia). The aim was to
discuss The Charter of Paris and to document the views
of people affected by cancer, and those of their formal
and informal carers, about ‘the cancer care system’ and
how it might realistically be improved.
From this process, a large number of issues were
brought together and ‘workshopped’ at a national ‘Living
with Cancer Conference’ in Canberra, on World Cancer
11

Day, 4 February 2002. The report of this conference 9
makes several action points (see box p.26), and cancer
control policy makers would do well to consider these
seriously, since they represent a distillation of the views
of nearly 1000 Australians arising from their personal
experiences of the current cancer care system.
This focus on the rights and legitimate expectations
of users of the cancer care system, exemplified by the
Charter of Paris, led to another major outcome in Australia.
Collaboration between the National Cancer Control
Initiative (NCCI), the Clinical Oncological Society of
Australia (COSA) and The Cancer Council Australia (TCCA)
has produced a report based on the views of consumers,
practioners and representatives of relevant organisations,
published evidence and international reforms. The aim of
the report was to provide Australian and state governments
and policy makers with an agenda and a process for
improving cancer care.
The report ‘Optimising Cancer Care in Australia’ 10
was launched in Sydney on World Cancer Day, 4 Feb
2003; its recommendations and other action items (see
box on p.24) have far reaching implications for health
policy makers. Two other recent national reports which
have relevance to policy development are Priorities for
Action in Cancer Control 2001-2003, 11 and National Cancer
Prevention Policy 2001-2003. 12 It is notable that these
three contemporary documents, despite quite different
consultation processes, make many recommendations
in common.
While some measures of cancer control, such as
survival, suggest that Australia is doing relatively well,
there is a conviction held by people who have been
affected by cancer, and cancer care providers, that the
Australian cancer care system could be and should be
improved substantially.
Could it be time for South Australia to develop its
own cancer control policy After all, cancer is generally
a disease of older people, and the state’s population is
becoming older quite rapidly.
The Cancer Council South Australia’s website 3 offers
downloadable material on many cancer related issues,
and anyone seeking help or information to do with cancer
is encouraged to call the Cancer Helpline, ph 13 11 20.
References
1. World Health Organisation. National cancer control
programmes: policies and management guidelines.
2nd ed. Geneva: WHO, 2002: ISBN 92 4 159023 8.
2. Epidemiology of cancer in South Australia: incidence,
mortality and survival 1977 to 2001. South Australian
Cancer Registry Report, 2003.
3. The Cancer Council South Australia:
www.cancersa.org.au
4. Doll R, Peto R. The causes of cancer. New York: Oxford
University Press, 1981.
5. McGinnis JM, Foege WH. Actual causes of death in
the United States. JAMA 1993; 270: 2207-2215.
6. Harvard report on cancer prevention. Volume 1: Causes
of human cancer. Cancer Causes Survival Control,
1996 (7): 53-559.
7. Little M, Jordens CFC, Paul K, Sayers E-J. Surviving
survival: life after cancer. Marrickville: Choice Books
Publications, 2001.
8. The Charter of Paris against cancer. Copies available
from The Cancer Council Australia, 02 9036 3100.
9. Living with cancer in Australia. Conference report.
The Cancer Council Australia, 2002.
10. National Cancer Control Initiative. Optimising cancer
care in Australia. 2003. Available from:
www.ncci.org.au
11. Priorities for action in cancer control 2001-2003. Cancer
Strategies Group, Commonwealth of Australia, 2001.
ISBN 0 642 50377 X
12. The Cancer Council Australia. National cancer
prevention policy 2001-2003. 2001.
ISBN 0 947 283 68 4. Available from:
www.cancer.org.au/publications
Other reading
The Cancer Council SA. Cancer statistics monograph
series. Available from: www.cancersa.org.au
Little M, Sayers EJ, Paul K et al. On surviving cancer. J
R Soc Med 2000; 93 (10): 501-503.
Cancer in the bush. Conference report 2001. The Cancer
Council Australia.
Appendices (or Boxes)
(i) Action Points from the Charter of Paris against Cancer
(ii) Action Points from the Conference, Living With Cancer
in Australia
(iii) Recommendations from Optimising Cancer Care in
Australia
12

Cancer Epidemiological Surveillance Services
- The South Australian Cancer Registry
Wayne Clapton
Public Health Physician and Medical Director /
Manager
Department of Health
Under the Cancer Regulations, all hospitals, pathology
laboratories and radiotherapy treatment centres in South
Australia are required to report all cases of invasive cancer
(excluding non-melanotic skin cancers) to the SACR.
Many reports are received at the SACR daily. Numbers
of individual pieces of paper and/or electronic reports
received have increased markedly over the last ten years,
as more tests are done, and as people survive longer
(and thus have longer follow-up periods after diagnosis).
INTRODUCTION
This article provides a brief overview of the populationbased
South Australian Cancer Registry (SACR), which
has been in continuous operation since 1977. What follows
is a discussion of what the registry is, what it does, who
uses it and why it is important to have this service in
place.
WHAT IS THE SA CANCER REGISTRY’S MISSION
The SA Cancer Registry aims to provide timely,
accurate population-based cancer epidemiological
surveillance services for the people of South Australia,
the wider Australian nation, and internationally. The
information derived from the SACR contributes to multiple
activities in cancer prevention, cancer control, patient
and carer support, treatment, health services planning,
research and education – all to assist in reducing the
burden of cancer in the community.
WHAT DOES THE SA CANCER REGISTRY DO
Legal underpinning
Legal underpinning is an essential requirement for
Cancer Registry work.
Cancer is a legally mandated notifiable disease under
the South Australian Health Commission (Cancer)
Regulations 1991. Section 42A of the Public and
Environmental Health Act 1987 defines the requirement
to maintain confidentiality, and authorises the exchange
of confidential information to enable the SACR to carry
out its work.
The process of cancer registration
Cancer registration involves the receipt, recording
and continual updating of all cases of invasive cancer
diagnosed in South Australia. Since the SACR started
operations in 1977, it has been an ongoing, ever-increasing
data repository, which provides the most accurate
information possible on cancer incidence (new cases per
year) and mortality (deaths).
It is important to ensure that every case reported is
indeed a recordable invasive cancer. Cancer Registry
officers carefully review all information received to ensure
it is complete and accurate. They skilfully read, interpret
and assess the complex incoming medical data, and
undertake multiple cross-checks, as required, from various
sources such as hospitals, pathology laboratories, medical
practitioners and/or interstate cancer registries. When
the accuracy and completeness of the data have been
determined, they are coded and entered onto the SACR
secure computer database.
This is not the end of the matter for any specific
case, however. As the person with cancer moves through
the processes of diagnosis, treatment and follow-up,
further data are received by the SACR. These new data
are checked against existing information. Sometimes, if
the new material provides a more specific diagnosis,
modifications to existing data may be required.
Sometimes, the new data represents a new primary
cancer for that person. So it must be checked for validity
and accuracy before being entered onto the database.
(Some unfortunate people can have three or four different
primary cancers). Most usually, however, the new data
are concerned with the already-known cancer and thus
the database can be updated with a ‘last contact date’,
which simply indicates that the person was alive at that
time.
Unfortunately, death does occur. The SACR is
authorised to check with the Australian Bureau of Statistics
(ABS) on a monthly basis for death certificates of people
who have died from cancer. Usually, these people are
already known to the SACR; but sometimes, death
certificates are encountered where the cause of death
is specified as cancer; but the case is unknown to the
SACR. In every instance of the latter circumstance, an
investigation is initiated to elicit further information. The
case is not recorded on the SACR until further evidence
of the accuracy of diagnosis is received.
13

It is also important to document the fact of death for
SACR-recorded cases who have died from other causes.
A process of matching the SACR and ABS files detects
these deaths. South Australian cases who have died
interstate are detected from the National Death Index at
the Australian Institute of Health and Welfare.
Further checks are conducted to maximise the
completeness and accuracy of the SACR data. These
include ascertainment checks with hospitals to see if
they know of any cancer cases unknown to the SACR;
authenticating the age of people said to be over 100 years
old; and checking that cases are not duplicated on the
SACR.
There are other activities in the SACR, but the above
outline is sufficient to indicate the complexity of the
process, and to demonstrate the care which is taken to
ensure that the highest possible quality data are available
for analytical tasks.
Through analysis, high quality epidemiological
surveillance statistics are produced. These are posted on
the Internet (see site address below) to enable wide
promulgation of the information so that it can be used in
maximising the health and well-being of the population.
Cancer Registry outputs:
The primary routine outputs of the SACR are accurate
Cancer Incidence and Mortality statistics. Without these
figures, there is no reliable information on the burden of
cancer in the population: such information is basic for
any community.
HOW IS THE SACR INFORMATION USED
SACR information is put to many uses, for example:
• accurately measuring the burden of cancer in South
Australia;
• monitoring trends of cancer incidence and mortality
over time;
• describing the potential associated factors; for example,
age, gender, socio-economic status, occupation, race;
• investigating community concerns about cancer; for
example, perceived cancer clusters;
• pooling South Australian information with that of other
states through the National Cancer Statistics Clearing
House at the Australian Institute of Health and Welfare
in Canberra, in order to derive National figures;
• contributing to world cancer epidemiological monitoring
through the World Health Organisation International
Agency for Research on Cancer (Cancer Incidence in
Five Continents);
• monitoring the effects of health interventions at a
population level; for example, changes in mortality for
population-based screening programs (such as
BreastscreenSA and the SA Cervix Screening Program);
• contributing to external ethically approved descriptive
and aetiological research projects;
• supporting clinical activities in cancer diagnosis,
treatment and management;
• assisting educational activities;
• planning health services;
• providing the evidence for rational policy development.
In addition, various other supplementary analyses of
the data are conducted on a periodic basis and/or as
required. These include:
• survival analyses
• mapping
• prevalence studies
• cluster investigations
• analysis by various data characteristics, such as
o socio-economic status,
o ethnicity,
o tumour histological types.
WHY NOT JUST DO A SURVEY
A method of cancer registration which collects ALL
cases for the State is the only way of determining accurate
cancer incidence and mortality figures. This cannot be
done as accurately with surveys, which sample a target
population rather than enumerating it in total. Sampling
always leads to a certain level of inaccuracy and bias, but
these flaws can be overcome by careful registration
methods.
14
WHO ARE THE SACR STAKEHOLDERS, PARTNERS
AND INFORMATION USERS
Many organisations, stakeholders, partners and
interested parties are involved in and/or are dependent
on SACR activities and outputs. Some examples are: the
general public of South Australia and Australia; other units
and branches of Population Health; politicians; state and
Australian government departments; pathology
laboratories; hospitals and other health care institutions;
screening programs; medical practitioners and their various
organisations; other interstate and overseas cancer
registries and epidemiological surveillance organisations;
non-government organisations (such as the Cancer
Council); educators and educational institutions; and
students, researchers and health services planners.
WHAT ARE SOME ADVANTAGES AND LIMITATIONS
OF THE SACR
The SACR works on the principle of collecting a
minimal dataset quickly and accurately so that timely
epidemiological surveillance information can be provided.
However, it must be remembered that these are
descriptive data only. While they may suggest associations,

these are only suggestions, and it is then the role of
separate, high quality, directed scientific research projects
to explore the field in more detail.
Some overseas cancer registries collect a far more
extensive range of data, including diagnostic information,
cancer stage and grade, detailed treatment data, outcomes
of treatment and recurrence of disease in addition to the
types of data collected at the SACR. While these more
extensive data enable more comprehensive analyses to
be undertaken on clinical factors, far more time is required
for their collection and the timeliness of outputs is reduced
greatly.
However, there is another type of cancer registry
called a Hospital-Based (or Clinical) Cancer Registry
(HBCR). A number of these can be found in major South
Australian teaching hospitals and in one private hospital.
They collect a wide range of diagnostic and clinical
information, of interest to treating clinicians, and more
extensive than that collected by the SACR.
Hence, more information can be made available,
either at the population level or at institution level, even
though it is collected in specialised settings. With proper
safeguards and permissions, it would be possible to link
population-based and hospital-based cancer registries,
and thus have the best of both worlds. Alternatively,
future advances in technology could enable far greater
and far more efficient data collection and analyses than
either of these models has so far achieved.
• Other models of cancer registration exist locally and
around the world; all have inherent advantages and
disadvantages.
FURTHER INFORMATION:
1. Internet website (for SACR reports, time series graphs,
maps): http://www.health.sa.gov.au/pehs/diseasecontrol-stats.htm
2. Dr Wayne Clapton,
Public Health Physician and Medical Director / Manager,
SA Cancer Registry, Ph: 82266362;
E-mail: Wayne.Clapton@health.sa.gov.au
3. Cancer Registry Staff (Ph: 82266158): Maria Cirillo,
Heather Hall, Mary Merdo, Teresa Molik, Maxene
Rosenberg, Christine Scott
4. Jensen OM, Parkin DM, MacLennan R, Muir CS, Skeet
RG, eds. Cancer registration: principles and methods.
Lyon, France: International Agency for Research on
Cancer; 1991. IARC Scientific Publications; No. 95.
CONCLUSIONS:
• Cancer registration is an essential service for accurately
monitoring the burden of cancer in any community
(locally, nationally and internationally) and how this
burden changes over time.
• It is inconceivable that a modern health system would
not have a system of cancer registration in place.
• The South Australian Cancer Registry in the
Epidemiology Branch of the Population Health Group
in the Strategic Planning and Population Health Division
of DH provides this service for South Australia.
• Appropriate legislative underpinning is essential to
enable the process to happen at all.
• Cancer registration is a complex process, requiring
much effort and care, and the participation and
cooperation of a wide range of stakeholders and
partners.
• Accurate incidence and mortality information cannot
be obtained by any other method.
• There are multiple important uses to which cancer
registry information is put, and many users who are
dependent on the information produced by the SACR.
15

Of Cancer Registries and Roll-ons
Ian Olver
Cancer Council Professor of Cancer Care
University of Adelaide
Clinical Director
Royal Adelaide Hospital Cancer Centre
The data from cancer registries tells health service
planners about the incidence of cancer, mortality from
cancer, and the impact of public health programs such
as screening. It also provides clinicians with a tool to help
evaluate the population impact of treatment advances.
The registries are invaluable to the general public, hopefully
assuring them of the quality of local cancer control,
because the outcome data can be compared to
experiences in other states and nations. Also the data
on cancer incidence can constitute an initial step in
investigating concerns about environmental or
occupational health risks.
In Australia the data on cancer incidence has
been collected since 1982. Legislation specified that
incidence data be submitted to the National Cancer
Statistics Clearing House (NCSCH) at the Australian
Institute of Health and Welfare. 1 In the early 1980s, the
South Australian population-based registry was able to
link with death records to provide rates of survival for
each cancer site. 2 Eventually it became possible to link
the cancer registry data of the states and territories with
a National Death Index, which resulted in the first
publication of national survival data spanning the period
from 1983 to 1997. 3
Therefore the minimum data set for population data
collected by Australian registries is: name; sex; date of
birth; diagnosis; cancer site and morphology; how
diagnosed; if multiple primaries; date of death; cause of
death; postcode; country of birth; Indigenous status; and,
if a melanoma, its thickness.
It would clearly be very helpful to have information
on the stages and outcomes of cancers, at least for the
initial treatment, if that were possible. In South Australia,
hospital registries were established in the major hospitals
in 1987 4 . This commenced with a series of special
collections of data on the major tumour types. The
additional data collected included stage, grade and other
prognostic factors, such as tumour markers measured in
the blood, primary treatment, and outcome of the first
treatment. This was somewhat labour intensive, as the
hospital registry staff had to obtain this data from case
notes, other hospital records, and clinicians. The staff of
the population-based registry provided support for the
hospital-based registries, and data could be linked to
provide summaries of ‘survival by stage’ for major cancers;
these were published as annual reports, current to the
preceding year. 4
Clinically, this timely data was extremely useful. For
example the trends in improved breast cancer survival
became apparent early in South Australia, and it could
be postulated that this was due to the prior introduction
of a mammographic screening program. 5 Clinicians could
ask questions about the impact on survival of prognostic
factors such as the effect of a particular pathological
subtype. 6 Cancer Registry data could also be used for
management surveys, for describing treatment patterns
and for quality assurance activities.
It is important to understand the limitations to data
that can be collected by a population-based registry.
Because of the scale of the exercise, the data collected
must be easily available from existing collections; one
accurate source is direct notification from the pathology
services to which tissue is sent and where the diagnosis
of cancer is made. The ability to collect data about the
stage (extent) of a cancer, however, would be more
difficult and costly, since that determination is made
clinically in a variety of settings and is rarely uniformly
documented. More complex still would be the population
collection of data on the outcomes of specific treatments,
since that would involve revisiting a data set multiple
times, and the workload would compound as new cases
were added, requiring increasing staff and resources.
However, rather than having a specific treatment
focus, the population registries have their main focus on
public health, through cancer surveillance, burden of
disease studies and monitoring public health screening
initiatives. Research is epidemiological, often with the
specific aim of determining the aetiology of cancer and
improving prevention, and this often demands large cohort
studies.
16

It is vital that the general public and the media know
how to interpret such data and, particularly, that they are
aware of the limitations of the data. As an example, it is
relatively straightforward to compare the age-adjusted,
stage-related mortality for a cancer between different
states or nations where there is confidence in the data
collections. The next step, trying to determine the possible
causes of any differences, leads to problems. Causes
may be postulated on the basis of associations between
a high death rate and possible aetiological factors, but
separate studies are needed to establish causality.
In the absence of experimental evidence, cancer
cause can be established with observational
epidemiological studies. Cohort studies usually follow a
group of people who have been exposed to a specific
risk factor (or retrospectively are known to have been
exposed) to see how many cancers have developed or
will develop in this group. This is then compared to a
group of unexposed individuals, or at least to the general
population incidence from the registries. A relative risk
of developing cancer in the two groups can then be
calculated. However, cohort studies can require a long
timeframe before there is a result, and they are expensive
to undertake. An alternative is the case-control study.
This identifies a group of patients who have the disease
and a matched group of people who do not and then
ascertains previous exposure to the agent in question.
Population-based registries or hospital records may be
used to identify the cases. The relative risk cannot be
directly calculated in such a study, but the odds ratio
gives a reasonable idea of the relative risk. As with
treatment trials, having more than one study in
epidemiological studies is ideal because collective
evidence of causation is important. 7
An example of the problem of interpreting data on
cancer causation occurred in January 2004 in stories that
appeared in the local newspapers. It was reported that
British scientists had found a link between underarm
deodorant and an increasing rate of breast cancer. The
underlying theme of the stories, as reported, was that
there may be a danger of developing breast cancer for
women who use underarm deodorant and that, as a
precaution, some women should stop this practice. This
caught the imagination of reporters in both the written
and electronic media and resulted in significant media
coverage.
Research into the background of the report revealed
that Dr Darbre had become concerned about the use of
deodorants containing an antibacterial preservative, p-
hydroxybenzoic acid (parabens) and had written a review
article 8 gathering evidence of the potential toxicity of
these products. It was correctly stated that, although
mutations in the genes BRCA1 and BRCA2 and lifetime
exposure to oestrogens were risk factors for developing
breast cancer, other causative factors were unaccounted
for. Parabens had been considered safe to be included
in consumer products but was found to have oestrogenic
properties. Therefore, the potential existed for long-term
low dose exposure to an oestrogenic stimulus with
prolonged use of underarm deodorants containing this
product. Furthermore, Dr Darbre argued, there was a
greater incidence of breast cancers in the upper outer
quadrant of the breast, just the area to which these
cosmetics were applied. Now, parabens had been shown
to be able to stimulate the growth of oestrogen dependent
breast cancer cell lines in laboratory tests, and Dr Darbre’s
team reported that they had been able to measure
parabens in 20 human breast tumours. 9,10
What conclusions can be drawn from this data There
is no doubt that further research was necessary. Greater
patient numbers such as could be collected across a
population would be helpful. We may have to change the
way we think about the toxicology of products to include
such hormone effects as the oestrogenic properties of
parabens. The main conclusion is that more specific
studies such as case control or cohort studies need to
be performed in larger patient groups if we wish to
establish these products as causing breast cancer.
The leap that cannot be taken from this study is that
parabens was the cause of the breast cancers; because
an association does not demonstrate cause without the
support of specific studies such as those described above.
Other factors can account for the observations. For
example, the reason often given for the greater incidence
of breast cancer in the upper outer quadrant of the breast
is simply that there is more breast tissue in that quadrant.
Cancer registries provide cancer incidence and
mortality data. They can also demonstrate associations
between potential risk factors and cancer incidence, but
this does not prove that the factor causes the cancer.
More specific studies are needed, which could also involve
the registries in identifying the cohorts or cases needed.
The public should see the cancer registries as a very
useful tool for quality assurance about cancer control,
and to explore potential aetiological environmental or
occupational health concerns. But they also need to
understand the limitations of the data to avoid jumping
to conclusions with widespread implications that are not
warranted when only the preliminary association has
been reported.
17

References:
1. Australian Institute of Health and Welfare and
Australasian Association of Cancer Registries. Cancer
in Australia 2000. AIHW cat. no. 18. Canberra: Australian
Institute of Health and Welfare, 2003 (Cancer Series
no. 23).
2. Bonett A, Roder D, Esterman A. Determinants of case
survival for cancers of the lung, colon, breast and
cervix in South Australia. Med J Aust 1984; 141: 705-9.
3. Australian Institute of Health and Welfare and
Australasian Association of Cancer Registries. Cancer
survival in Australia. Part 2. Statistical tables. AIHW
cat. no. CAN 14. Canberra: Australian Institute of
Health and Welfare, 2001 (Cancer Series no. 17).
4. South Australian Cancer Registry. Epidemiology of
cancer in South Australia. Incidence, mortality and
survival, 1977 to 1999. Incidence and mortality 1999.
Adelaide: Openbook Publishers, 2000.
5. Gill PG, Farshid G, Luke CG, Roder DM. Detection by
screening mammography is a powerful independent
predictor of survival in women diagnosed with breast
cancer. The Breast 2004 (in press).
6. Davy MLJ, Dodd TJ, Luke CG, Roder DM. Cervical
cancer: effect of glandular cell type on prognosis,
treatment, and survival. Obstetrics & Gynecology
2003; 101: 38-45.
7. Trichopoulos D, Lipworth L, Petridou E, Adami H-O.
Epidemiology of cancer. In: Devita VT, Hellman S,
Rosenberg SA, eds. Cancer principles and practice of
oncology. 5th edn. Philadelphia: Lippincott Raven
Philadelphia, 1997: 231-257.
8. Darbre PD. Underarm cosmetics and breast cancer.
J Appl Toxicol 2003, 23(2): 89-95.
9. Dabre PD, Byfrod JR, Shaw LE, Hall S, Coldman NG,
Pope GS, Sauer MJ. Oestrogenic activity of
benzylparaben. J Appl Toxicol 2003: 23(1): 43-51.
10.Dabre PD, Aljarrah A, Miller WR, Coldham NG, Sauer
MJ, Pope GS. Concentrations of parabens in human
breast tumours. J Appl Toxicol 2004, 24:5-13.
Action Points from the Charter of Paris
Seek political, professional and public commitment to the
principles and practices outlined here in order to prevent
cancer and provide the best possible care for those living
with and dying from this disease.
1. Cancer patients rights are identical to human rights.
2. Cancer is a chronic disease which should not give rise to
discrimination and/or financial hardship.
3. (i) Cancer research needs to be directed at improvements
in cancer care and control in the short term, as well as
basic science.
(ii) Cancer patients should know about and have access
to high quality clinical trials.
4. All members of the community should have access to
good quality cancer prevention, diagnostic, treatment,
palliative and support services which meet up-to-date
guidelines based on the best available evidence.
5. Public policies should be directed at community-wide
application of existing knowledge regarding cancer
prevention, especially in relation to tobacco, diet, infection
control and environmental factors.
6. Early detection initiatives such as proven screening
technologies should be vigorously encouraged, especially
in people at increased risk of cancer.
7. Health care professionals should collaborate with people
affected by cancer to ensure optimal use of resources in
responding to total patient needs, including information
and psychosocial support. Informed patient advocates
should be key strategic partners in improving cancer care
and control.
8. The health care system should concentrate on cancer
care as well as cure, and address issues related to quality
of life including physical, psychological and social function,
as well as managing pain and fatigue.
9. National and regional cancer control strategies should
reflect the needs and resources of local population groups.
10. Targeted outcomes for improved cancer care and control
should be identified, monitored and regularly reported
nationally and regionally, using a set of agreed performance
indicators which go beyond incidence, mortality and case
survival to include quality of life parameters.
18

Ethnic and racial differences in
cancer incidence in South Australia
David Roder
Head Cancer Statistics Unit
Centre for Cancer Control Research
The Cancer Council South Australia
All cancer types
South Australians born overseas had an agestandardised
cancer incidence about 8% lower than that
of the Australian-born during 1977-2000. Among residents
born in Southern Europe and Asia, the incidence was
about 20% and 23% lower, respectively. Additional details
are provided by sex in Figures 1 & 2. Aboriginal and non-
Aboriginal residents had similar incidence rates for all
cancers collectively, although there were differences by
cancer type, some of which are described in this article.
Background
There are marked differences in cancer incidence
around the word. 1, 2 Although genetic factors do
contribute, most differences are attributed to variations
in lifestyle and environmental exposure. 2-4 Broad
inferences can be drawn about the proportion of the
cancer burden that is potentially preventable through
environmental and lifestyle change. For example, cancer
incidence in Africa and Asia, excluding non-melanoma
skin cancers, is generally about half the incidence in
Australia, and so it would appear that at least 50% of
Australian cancers could be preventable. 1
Migrant groups tend to have cancer profiles similar
to those of their parent countries when first they arrive
in adopted homelands, but these profiles typically approach
those of their new countries over time, reflecting lifestyle
adaptations and the effects of local environmental
exposure. 5 Migrant studies have been a rich source of
information about the contributions to cancer risk of
changes in social, behavioural and environmental factors. 5
Data on incidence by ethnicity and race are also
relevant when planning preventive, screening and
treatment services to better address the needs of culturally
diverse groups. Introductory background information is
now provided on ethnic variations in cancer incidence in
South Australia. Further details are available directly from
the Epidemiology Branch (details below), or from the
website of the Department of Health at:
http://www.health.sa.gov.au/pehs/cancer-report-02/cancerreport-2002.pdf
or Cancer Council South Australia, at:
http://www.cancersa.org.au/i-cmspage=1.7.792
Cancers with a higher incidence in the Australian born
Lip cancers and melanomas were generally two to
three times more common in the Australian than in the
overseas born, reflecting lifelong sun exposure. 4 However,
Aboriginal residents were seldom affected, due to the
protective effects of skin colouring. 4, 6 Residents born in
Asia had an incidence almost 90% lower than that of the
Australian born.
Cancers of the mouth, throat and oesophagus had
an incidence about 40% higher in Australian than in
overseas born, with Aboriginal residents showing an
incidence about three to four times higher than other
South Australians. Particularly low incidence figures
applied to residents from Southern Europe. Risk factors
for these cancers include tobacco smoking, high alcohol
intake, and diets deficient in fruit and vegetables. 3, 4, 7, 8
Large-bowel (colon/rectum) cancers had an incidence
almost a quarter higher in Australian than in overseas
born, although Aboriginal residents had a comparatively
low incidence. Risk factors for these cancers include
diets low in vegetables and potentially those high in
processed meat and fat. 3, 4, 7, 8 A lack of exercise and
excess body weight are thought to contribute further
risk. 7 Residents born in Asia and Southern Europe had
an incidence about a third lower than that of the Australian
born.
The incidence of female breast cancer was about
9% higher for Australian than for overseas born, with
particularly low rates applying to residents from Southern
and Eastern Europe (about 30% lower than for the
Australian born). Aboriginal women had an incidence
about half that of their non-Aboriginal counterparts. Earlier
age at time of first full-time pregnancy is a protective
factor for this cancer, and it is likely this would have
contributed to the lower incidence in the Aboriginal
population. 4
19

Prostate cancer had an incidence about a third higher
in Australian than in overseas born, with particularly low
rates occurring in males from Southern Europe and Asia.
The incidence was about 80% lower in Aboriginal than
non-Aboriginal males. Prostate-specific antigen testing
is thought to be less common among Aboriginal residents,
such that more of their lesions would remain undisclosed. 9
The incidence of testicular cancer tended to be higher
(about 20% higher) in Australian than in overseas born
men. Again, very low rates applied for males from Asia
and Southern Europe. The reasons for these variations
are not known, although sedentary lifestyles may be a
risk factor, and, possibly, pre-natal exposure to female
sex hormones. 3, 4, 9
The Australian born had a higher lymphoma incidence
than the overseas born - about 20% higher for non-
Hodgkin’s lymphoma and 40% higher for Hodgkin’s
disease. Aboriginal residents had relatively few cancers
of these types. Lymphomas have been linked to a
malfunctioning immune system, as may result from HIV
or other viral infections, chemotherapy, or medically
induced immunosuppression to avoid rejection of
transplanted organs. 4, 10
Cancers with a higher incidence in the overseas born
The incidence of cancers of the nasopharynx was
about 70% higher in the overseas born than in the
Australian born. Among the Asian born, the incidence
was 9-10 times higher. This may reflect the consumption
from an early age in some parts of Asia of fish, salted
according to local tradition - as practised in Southern and
South Eastern China. 3, 4, 8 There is also a risk association
with Epstein Barr virus infection, which may be causal. 3
The incidence of stomach cancer was approximately
74% higher in the overseas born, with particularly high
rates occurring in residents from Eastern Europe, Germany
and Southern Europe. Aboriginal residents had an
incidence approximately twice as high as other South
Australians. A high salt intake has been implicated,
whereas diets rich in fruit and vegetables are thought to
be protective. 3, 4, 7, 8 Infection with Helicobacter pylori
is an additional risk factor. 3
cancer incidence was almost a third higher in
overseas than in Australian born, with the highest rates
occurring in residents from Northern Europe. Aboriginal
residents had a risk almost 50% higher than other South
Australians. Tobacco smoking is the predominant risk
factor, although contributions from occupational exposures
to asbestos and other carcinogens would also apply. 4
Notably, cancers of the pleura (mesotheliomas) had an
incidence almost 70% higher in the overseas born,
reflecting more common histories of asbestos exposure.4
The incidence of cervical cancer was about twice as
high in women from Germany, and about 40% higher in
those from other Northern European countries, than for
the Australian born. Aboriginal women had a very high
incidence - about four times higher than for non-indigenous
females. Cervical screening can prevent about 90% of
squamous cell carcinomas of the cervix by detecting
precursor lesions for pre-emptive treatment. 4 These
services need to be culturally sensitive if there is to be
a high coverage of the female population.
Other cancers more common in the overseas born
included bladder cancer (about 20% more common),
where tobacco smoking would have contributed, and
possibly past exposure to workplace carcinogens and a
historical use of phenacetin analgesics. 3, 4, 9 The incidence
of thyroid cancer was about twice as high in the Asian
as in the Australian born, probably due to excesses or
deficiencies in dietary iodine. 4
Concluding comments
Cancer rates vary markedly by ethnicity and race.
These epidemiological differences provide aetiological
clues and should be taken into account when planning
culturally appropriate cancer services. The four-fold
incidence of cervical cancer among Aboriginal when
compared with non-Aboriginal women is one of several
elevations that deserve special attention, given the
potential for cervical screening to detect precursor lesions
and resulting interventions to prevent the development
of invasive cancer.
Lung
Liver cancer was almost 50% more common in the
overseas born, with residents from Asia having an
incidence about six times higher than that of the Australian
born. Aboriginal residents also were at very high risk,
with an incidence about seven times higher than for the
non-indigenous population. Risk factors include high levels
of endemic hepatitis B and C infection, and alcoholinduced
cirrhosis. 3, 4, 7
20

References
1. Parkin DM, Whelan SL, Ferlay J, Teppo L, Thomas DB,
eds. Cancer incidence in five continents. Volume VIII.
IARC Scientific Publications No. 155. Lyon: IARC Press,
2002.
2. Stewart BW, Kleihues P, eds. World cancer report.
Lyon: IARC Press, 2003.
3. Adami H-O, Hunter D, Trichopoulos D, eds. Textbook
of cancer epidemiology. Oxford: Oxford University
Press, 2002.
4. Schottenfeld D, Fraumeni JF, eds. Cancer epidemiology
and prevention. 2nd edn. New York: Oxford University
Press, 1996.
5. Thomas DB, Karagas MR. Migrant studies. In:
Schottenfeld D, Fraumeni JF, eds. Cancer epidemiology
and prevention. 2nd edn. New York: Oxford University
Press, 1996: 236-54.
6. The Cancer Council South Australia. Sun-related cancers
of the skin and lip. South Australian cancer statistics.
Monograph No. 2. Adelaide: The Cancer Council South
Australia, 2002.
7. The Cancer Council South Australia. Cancers of the
digestive system. South Australian cancer statistics.
Monograph No. 1. Adelaide: The Cancer Council South
Australia, 2001.
8. World Cancer Research Fund & American Institute for
Cancer Research. Food, nutrition and the prevention
of cancer: a global perspective. Washington DC:
American Institute of Cancer Research, 1997.
9. The Cancer Council South Australia. Cancers of the
prostate, testis, and urological organs. South Australian
cancer statistics. Monograph No. 7. Adelaide: The
Cancer Council South Australia, 2003.
10.The Cancer Council South Australia. Lymphomas,
myelomas and leukaemias. South Australian cancer
statistics. Monograph No. 5. Adelaide: The Cancer
Council South Australia, 2003.
Cancer site:
Males
All sites
Incidence (95% confidence limits)
* Date source: South Australian Cancer Registry.
Figure 1: Annual incidence of cancer in South Australia in 1977-2000 by
country of birth per 100,000 (age-standardised to World Population)*
Cancer site: All sites
Females
Incidence (95% confidence limits)
Contact details for Health Statistics Unit,
Epidemiology Branch
* Data source: South Australian Cancer Registry.
Figure 2: Annual incidence of cancer in South Australia in 1977-2000 by
country of birth per 100,000 (age-standardised to World Population)*
Level 3, 162 Grenfell St,
Adelaide 5000
Ph 8226 6384
FAX 8226 6291
21

Screening for colorectal cancer:
Update on some current research in Adelaide
GP Young 1 , P Bampton 1 , SR Cole 1 J Morcom 2 ,
A Smith 2 , D Turnbull 3 , C Wilson 4 .
1 Flinders University of South Australia,
2 Bowel Health Service, Repatriation General Hospital,
3 Departments of General Practice and Psychology,
University of Adelaide,
4 CSIRO Health Science and Nutrition.
Colorectal cancer (CRC), or bowel cancer, is a
significant health problem in many western countries,
including Australia. While the underlying causes are still
unclear, there is now good evidence that screening is
effective in reducing deaths from CRC, by facilitating the
detection and removal of curable cancers. 1-3 However,
there are many issues still to be resolved before screening
can be implemented in the most effective and appropriate
way in the Australian setting.
There is no simple answer to the question ‘How
should colorectal cancer screening be implemented’
This is because there are different ways of reaching the
target population and different types of screening tests,
each with their own particular advantages or
disadvantages. Within the target population, there are
sub-groups with different levels of risk who ideally require
different approaches to screening. The uncertainties and
complexities of how to implement CRC screening in
Australia can be illustrated by briefly describing some
initiatives and studies being undertaken by a group
affiliated with Flinders University, Adelaide University and
CSIRO. Over the last 5 years this group, based at Flinders
Medical Centre (FMC) and the Repatriation General
Hospital (RGH), Daw Park, and operating as the Bowel
Health Service, has been undertaking research into
screening for CRC. More recently, the group has been
expanded to include behavioural scientists from Adelaide
University and CSIRO.
Options for CRC screening.
There is evidence to support the use of colonoscopy,
flexible sigmoidoscopy and faecal occult blood testing
(FOBT) as possible population screening modalities. Other
methods of detecting colonic lesions include radiological
methods (barium enema or virtual colonoscopy /CT
colonography), digital rectal examination, and DNA based
faecal tests. These methods are either unsuitable as
screening modalities or have not yet been proven as
effective in a population screening setting.
Colonoscopy is regarded as the most sensitive test,
but cost, access, the procedure itself and possible
complications limit its wider use in a screening setting.
However, colonoscopy allows immediate polyp removal
and, if no lesions are found in a person at average risk,
the procedure need not be repeated for 5 years.
Flexible sigmoidoscopy allows the lower bowel to
be examined and is less complicated than colonoscopy.
Flexible sigmoidoscopy can be combined with FOBT to
improve test sensitivity.
FOBTs are effective because they detect blood that
may be derived from cancers and adenomas. Positive
tests identify people who have an increased risk of CRC
and who require follow-up colonoscopy to determine the
source of occult blood. FOBTs are simple, inexpensive
and non-invasive; samples for testing can be collected at
home. But the tests are less sensitive than colonoscopy
and require repeating every 1-2 years.
Chemical (guaiac)-based FOBTs were used in studies
that demonstrated the benefit of screening for reducing
CRC mortality. There are now newer immunochemical
FOBTs (faecal immunochemical tests or FITs) that have
potential advantages, and many of our studies are based
on the use of these new-generation FOBTs. Some of the
key activities of the Bowel Health Service are briefly
described below and help to illustrate some of the
uncertainties that still relate to CRC screening.
Evaluation of new FOBTs
The studies giving evidence that FOBT-based
screening is effective in reducing mortality from CRC
used guaiac-based tests, in which the chemical activity
of haem indicates the presence of haemoglobin in faecal
samples. These guaiac tests require dietary and medication
restrictions to increase specificity and are not specific
for colonic haemoglobin. Newer FITs detect the globin
portion of human haemoglobin; they do not cross-react
with dietary components or medications, and are specific
for colonic blood. We directly compared the performance
of guaiac and immunochemical tests for their ability to
detect cancers (and adenomas). While these studies are
ongoing, preliminary data indicates that immunochemical
tests have the higher sensitivity to cancer and large
adenomas while maintaining test specificity.
22

Screening the above-average risk group
Surveillance is recommended for people with a
significant family or personal history of CRC or colonic
adenomas (polyps). For FMC and RGH patients, this
meant that people were periodically recalled for
surveillance colonoscopy, though an audit revealed that
many patients were not receiving surveillance according
to NHMRC guidelines. 5 The Southern Cooperative Program
for the Prevention of Colorectal Cancer (SCOOP) was
created to provide improved CRC surveillance services
for this above-average risk group on the FMC and RGH
colonoscopy recall databases. Strategies included GP
education, CRC risk assessment, colonoscopy recall and
FOBT screening components.
GP education programs have resulted in greater
awareness about and more appropriate referrals to the
surveillance program. Reassessment of CRC risk levels
has allowed more rational (usually increased) intervals to
be determined, and audits have shown that the new
intervals are now being closely adhered to, thus freeing
up valuable colonoscopy resources.
The NHMRC has recently recommended that FOBTbased
screening should be considered as an additional
surveillance test, in years when colonoscopy is not
performed. 5 We have introduced FOBT screening in this
group and are now well into a 5-year evaluation program.
Results so far indicate that these patients are willing to
participate in screening, and some have been diagnosed
with cancers or adenomas through the screening program.
It is not known whether these lesions developed rapidly,
or whether they were missed at a previous colonoscopy,
but the fact that FOBT-screening does reveal further
neoplasia, and earlier than if only colonoscopy was used,
is clearly of benefit.
Screening the average risk group - population
screening.
One of the biggest challenges to FOBT-based
population screening is simply to get people to complete
the screening test. Without participation there is no
detection, and participation rates in large screening trials
have been typically 30-40%, well below the 70% target
proposed and the goal for other cancer screening
programs. A number of studies are underway that aim
to determine the effect of various program variables on
screening participation rates.
The effect of diet on participation
Client groups were offered a guaiac-based FOBT
(Hemoccult, Beckman-Coulter) which required a modified
diet during sample collection, or an immunochemical test
(FlexSure, Beckman Coulter) which required no dietary
modification. Participation was significantly lower in the
group offered Hemoccult, indicating that dietary restriction
has a strong negative effect on participation. 6
The effect of improved test technology
One FIT that has recently been developed (InSure,
Enterix) incorporates an improved brush (rather than
spatula) sampling process, coupled with a decrease in
the number of faecal samples required, from three to
two. We reasoned that these technological differences
were likely to attract more participants. Three groups of
invitees were offered screening using FOBTs that differed
in their level of technology. We found that the highest
level of participation was obtained in the group offered
an FOBT incorporating technological improvements. 7
The effect of the GP on participation
When considering how to implement screening
programs, options include a centralised screening service
and programs based around general practices. The GP
has a powerful influence on health behaviours, and we
reasoned that screening offers endorsed by a GP might
improve CRC screening rates. People could be screened
either by invitation from the Bowel Health Service, or
through their general practice with two levels of GP
endorsement. Invitations signed by a GP resulted in a
significantly higher level of screening participation (43.5%)
compared to invitations that only indicated practice support
(40.1%), or those received directly from the central Bowel
Health Service (34.0%). 8
Differences between participants and non-participants
Our research trials allowed us to identify groups
of participants and non-participants. We reasoned that
the identification of differences between these groups
could provide insights into key factors associated with
screening behaviour. We developed a specific
questionnaire to survey demographic, behavioural and
psychosocial characteristics, and surveyed the two groups.
We found that non-participants were more likely to find
faecal sampling distasteful, while participants saw more
value in screening and were more likely to attend future
screening. This information can potentially be used to
inform new strategies to overcome barriers to screening
participation.
Development of a flexible sigmoidoscopy service
Flexible sigmoidoscopy is an effective screening
modality for people at average risk of CRC, especially
when performed together with FOBT. To increase
screening options without impacting on colonoscopy
services, the first nurse endoscopist in Australia has been
trained and, in a nurse practitioner role, now undertakes
flexible sigmoidoscopy screening at the Repatriation
General Hospital.
Taken together, these research studies and initiatives
demonstrate the commitment of this group of researchers
and clinicians to the prevention of colorectal cancer
through screening and early detection.
23

Other CRC screening initiatives in Adelaide.
Although not directly linked to our studies, a feasibility
trial of population screening, the Federal Bowel Cancer
Screening Pilot, is currently being conducted in selected
postcodes in Adelaide, Melbourne and Mackay. While
this trial is incomplete, early results indicate that it has
been well received. It is hoped that this feasibility trial
will ultimately lead to the introduction of an Australiawide
population-screening program for prevention of
CRC.
Any questions relating to these research studies can
be directed to the Bowel Health Service, Repatriation
General Hospital on 08 8275 1075. Information about the
SCOOP program can be obtained by calling 08 8204
8902.
References
1. Mandel JS, et al. Reducing mortality from CRC by
screening for fecal occult blood. N Engl J Med
1993;328:1365-71.
2. Hardcastle JD, et al. Randomised controlled trial of
fecal occult blood screening for CRC. Lancet
1996;348:1472-7.
3. Kronborg O, Fenger C, Olsen J, Jorgenson OD,
Sondergaard O. Randomised study of screening for
colorectal cancer with faecal occult blood test. Lancet
1996;348:1467-71.
4. Young GP, St John DJB, Cole SR, et al. Prescreening
evaluation of a brush based faecal immunochemical test
for haemoglobin. J Med Screen 2003;3:123-8.
5. The prevention, early detection and management of
colorectal cancer. Clinical practice guidelines. NHMRC
1999.
6. Cole SR, Young GP. Effect of dietary restriction on
participation in faecal occult blood test screening for
colorectal cancer. Med J Aust 2001;175(4):195-8.
7. Cole SR, Young GP, Esterman A, Cadd B, Morcom J. A
randomised trial of the impact of new faecal haemoglobin
test technologies on population participation in screening
for colorectal cancer. J Med Screen 2003;3:117-22.
8. Cole SR, Young GP, Byrne D, Guy JR, Morcom J.
Participation in screening for colorectal cancer based on
a faecal occult blood test is improved by endorsement
by the primary care practitioner. J Med Screen
2002;9(4):147-52.
Recommendations from optimising cancer care in
Australia
The treatment experience and the quality and length of life
of most people with cancer can be greatly improved if these
recommendations are implemented. The three main themes
predominating in these recommendations are quality, access
and resourcing.
1. Integrated multi-disciplinary care:
• that investigation of the incentives required to foster,
maintain and evaluate integrated multi-disciplinary care
in both the public and private sectors be undertaken.
2. Improving the cancer journey:
• that a national process of quality-driven organisational
reform be implemented to improve ongoing consumer
access to information, palliative and supportive care
throughout the cancer journey.
3. Voluntary accreditation:
• that a system of voluntary accreditation for Australian
cancer care services be developed, broadly modelled
on that of the U.S. Commission on Cancer.
4. Access to clinical trials:
• that the capacity to undertake clinical trials be increased,
including development of a public register of trials.
5. Workforce:
• that the recommendations of the National Strategic
Plan for Radiation Oncology and the Specialist
Haematological and Medical Oncology Workforce in
Australia be implemented urgently and
6. • that the Australian Health Workforce Advisory
Committee consider the entire non-medical cancer
care workforce, especially cancer nurses, radiation
physicists and radiation therapists as a priority.
7. Psycho-oncology:
• that the need for psychologists and/or other
appropriately trained health professionals be brought
to the attention of the Australian Health Ministers
Advisory Council.
8. Radiation oncology:
• that the recommendations of the National Strategic
Plan for Radiation Oncology be implemented.
9. Access to pharmaceuticals:
• that a ministerial working party review and develop
solutions to the problems of access to new and old
cancer drugs.
10. Access to support for travel:
• that there be a review of matters affecting access to
cancer care, including travel to and from treatment
centres.
11. Equity of access:
• that the needs of special populations be the focus of
efforts to narrow gaps in access to and utilisation of
culturally sensitive services.
12. A national taskforce on cancer:
• that a national taskforce be established to drive the
reform process.
There are, in addition, 19 other action items which can be
accessed at: www.ncci.org.au.
24

Looking beyond a risk factor approach to cancer –
New challenges for prevention and health promotion
of Australians perceive cigarette smoking and sun tanning,
respectively, as being of high risk to health. 2 Yet people
do still engage in these activities.
Sue Booth
Senior Project Officer,
Department of Health
Background
It has become apparent in recent years that the
incidence of cancer varies according to gender, social
status and the history of the particular condition. However,
not all cancers occur at a higher prevalence amongst
poorer groups in the population. For example, some
cancers such as breast, ovarian and colon cancers are
more prevalent amongst the rich. 1 Others are more
prevalent amongst the poor (oesophagus, stomach, liver)
and some cancers such as lymphoma, bladder and kidney
show no evidence of socio-economic patterning. 1 This
uneven patterning of cancers between rich and poor begs
the question, what are the broader factors influencing
the behaviours which may predispose an individual to
cancer
In this paper I argue that health promotion efforts
with respect to cancer should go beyond behavioural
responses to become concerned with cancer risk factors,
and should include consideration of the contextual
framework and meaning these behaviours have in people’s
lives. In other words, there is an urgent need to explain
what people do and why. For example, why do people
continue to smoke when they know it is harmful Life
course research and analysis provides a working
knowledge of some of the ‘drivers’ of health-related
behaviours, and attempts to locate them within social
and cultural structures from which meaning can be derived.
Such approaches can complement existing data sources
to inform the development of sensitive, tailored prevention
programs in certain population groups.
Similarly, environmental approaches such as smoke
free-public places may be effective to some degree, but
people may still choose to continue to smoke. The problem
with health promotion based on risk factor data is that
it denies the complex relationships between individuals
and behaviour that is known to be risky to health. This is
not a new cry; indeed, over twenty years ago, Paterson 3
warned of the shortcomings of relying wholly on the
dominant paradigm of risk-factor epidemiology:
By its focus on disease as a problem of incidence,
conceived of as a product of a number of
mechanically related risk factors, epidemiology
denies that the structure of social relationships
in society also has a primary determining role... 3
In short, a more fine-grained approach is needed.
Life course approaches and the role of qualitative data
Life course has been defined as ‘a social construction
derived from the analysis of the interaction between
individual biographies and their socio-cultural contexts
and affected by historical and demographic trends’. 4 The
life course approach explicitly recognises that health
outcomes are a product of individual resiliencies and
vulnerabilities, modified by critical features of family,
childcare, education, healthcare and broader socio-political
environments.
Health related behaviour is a complex interweaving
of biographical, social and cultural threads; however, some
patterning principles are in evidence from a life course
perspective. Such cultural patterning of individual behaviour
and health research in the social sciences can be useful
in structuring the messages and conceptual content of
health promotion activities. 4
Risk-factor epidemiology and behavioural approaches
Traditional behavioural approaches tend to construct
health as the property of individuals; it is therefore
assumed that people can make changes in their lifestyle
to improve their health status. However, it is well known
that simply telling people to stop smoking on the basis
of risk factor epidemiology is ineffective. It seems that
people are aware of the health risks of some forms of
behaviour. For example, a study on environmental health
risk perception shows that approximately 85% and 75%
25

An example of life course research and analysis with
respect to a cancer risk factor
Smoking is a well recognised and preventable
behavioural risk factor for various cancers of the
nasopharynx and respiratory systems. A study on the
daily and life course contexts of smoking 5 sought to
inform the debate on the significance of smoking in
people’s everyday lives. Data are drawn from 54 semistructured
interviews with smokers and ex-smokers about
their experiences and understandings of the place of
smoking in their daily and long-term experience. Two key
themes emerged from the interviews. Firstly, an emphasis
was placed on the ritualised nature of smoking and the
way it is embedded in the daily rhythms of people’s lives
and routines. Secondly, there is a common evolution of
smoking behaviour with respect to life course evolution,
that is, smoking can be seen as a rite of passage from
adolescence to adulthood. An example is the shift from
sharing individual cigarettes with school friends to smoking
serial cigarettes by oneself as a mature adult.
This type of research allows some ‘unpacking’ of
smoking behaviour beyond the physiological/addictive
need to smoke. It highlights that smoking cannot be
treated as an isolated addiction; it has symbolism and
entrenched ritualisation in people’s lives.
Concluding comments:
An examination of some cancer risk factors (eg
smoking, sun protection, or fruit and vegetable
consumption) using the lens of life course research and
analysis can provide valuable insight into the meaning of
certain behaviours in people’s lives. In combination with
risk factor epidemiology and the social determinants of
health, life course work adds to our understanding and
prevention of cancer. Health promotion practitioners and
those designing program interventions should incorporate
findings on life course research into the structure of health
promotion activities.
References
1.IARC Social inequalities and cancer. No 138 Geneva:
World Health Organisation, 1997.
2.Starr G, Langley A, Taylor A. Environmental health risk
perception in Australia. Research report to the
Commonwealth and Aged care. Centre for Population
Studies in Epidemiology. Adelaide: South Australian
Department of Human Services, 2000.
3.Patterson K. Theoretical perspectives in epidemiology:
a critical appraisal. Radical Community Medicine 1981;
Autumn:23-27.
4.Backett KC, Davison C. Life course and lifestyle: the
social and cultural locations of health behaviours. Soc Sci
Med 1995;40(5):629-38.
5.Laurier E, McKie L, Goodwin N. Daily and life course
contexts of smoking. Sociol Health Illn 2000;22(3):289-
309.
Living with cancer in Australia conference action points
1. Coordination of Cancer Care:
• that coordinators of care, with a defined role, career
path, secure funding and access to ongoing training
be placed in referral and regional centres.
2. Education:
• that health-care professional training institutions make
more use of the ‘ideal oncology curriculum’.
• that public education programs reduce discrimination
and stigma associated with cancer.
• that survivorship issues are better understood.
3. Information:
• that the national Cancer Help Line is marketed publicly
and to health professionals, and is quality assured.
4. Infrastructure:
• that practical issues such as travel, appointment times,
accommodation, financial assistance, and carer support
are given adequate attention.
5. Empowerment:
• that information kits at diagnosis, explicit descriptions
of treatment implications, ‘tip’ sheets of questions to
ask, carer involvement and ready access to second
opinions are routinely provided.
6. Support:
• that support services offer proven programs, such as
‘narrative therapy’,and respite and other practical help
is available at community level.
7. Standards:
• that all consumers receive best practice routinely and
a voluntary accreditation system for cancer care services
is developed.
8. Research:
• that access to clinical trials increases and psychosocial,
survivorship and translational research be encouraged.
• that existing programs are evaluated and ‘evidence
based’.
• that consumers’ views are sought and used and
• that ‘quality of life’ in those affected by cancer is
monitored.
9. Early detection and prevention:
• that participation in existing programs and communitywide
application of current knowledge be strongly
encouraged.
26

Reducing Cancer Risk Through
Primary Prevention
Cynthia Spurr
Chief Project Officer, Department of Health
Michele Herriot
Manager Health Promotion Programs,
Department of Health
Over the past 40 years, research has identified primary
prevention approaches that reduce the risk of people
developing many types of cancer. The evidence outlining
the relationship between risk factors and cancer outcome
has been summarized by the National Health Priority
Action Council in the draft National Service Improvement
Framework for Cancer, 1 as follows:
“Reduce smoking: Tobacco smoking causes the following
cancers: lung; oral; nasal cavity and paranasal sinuses;
naso-, oro- and hypopharynx; larynx; oesophagus;
pancreas; stomach; liver; kidney; urinary tract; cervical;
myeloid leukaemia, vulva, penis, bladder, renal parenchyma
and renal pelvis 2-4 . In 2001, 19.5% of Australians (3.07
million Australians) aged 14 years and older smoked daily.
Limit alcohol intake: Alcohol is a causal factor for cancer
of the mouth, pharynx, liver, larynx, oesophagus and
breast cancer in women 2,3 . The Australian Institute of
Health and Welfare (AIHW) has estimated that 12% of
breast cancer may be attributable to alcohol intake. In
2001, 9.9% of people consumed alcohol in a manner that
put them at risk of long-term harm, while 34.4% put
themselves at risk of short-term alcohol-related harm on
at least one drinking occasion 5 .
Increase protection of skin from the sun: Basal cell
carcinoma, squamous cell carcinoma and melanoma are
caused by sun exposure 6 . Sun protection will prevent
approximately 90% of skin cancers. In 1999, between
78-82% of Australian secondary students, aged 12-17
years reported being sunburnt last summer.
Improving diet mainly by increasing the intake of fruit
and vegetables: The expert panel of the World Cancer
Research Fund concluded that inappropriate diets cause
around one-third of all cancer deaths 7 . It recommended
dietary diversity to maximise the likelihood of more
balanced as well as more adequate diets, noting that
there was convincing evidence of dietary protection
against cancer of many sites. The evidence was strongest
and most consistent for diets high in fruits and vegetables.
In 1995 in Australia approximately 44% of males and
34% of females did not consume fruit in the 24 hours
preceding the National Nutrition Survey, and 20% of
males and 17% of females did not consume vegetables 8 .
27
Reduction in rates of overweight and obesity: There
is sufficient evidence for a cancer-preventive effect from
avoidance of weight gain for cancer of the colon, breast
(post-menopausal), endometrium, kidney (renal-cell) and
oesophagus (adenocarcinoma) 9 . For premenopausal breast
cancer, the available evidence suggests a lack of a cancerpreventive
effect. In 2001, an estimated 2.4 million
Australian adults were obese (16% of men and 17% of
women aged 18 years and over). A further 4.9 million
Australian adults were estimated to be overweight but
not obese (42% of men and 25% of women) 10 .
Increased physical activity: There is sufficient evidence
for a cancer-preventive effect of physical activity for cancer
of the colon and breast, limited evidence for a cancerpreventive
effect for cancers of the endometrium and
prostate, and for all other sites the evidence is inadequate 9 .
In 2000, 57% of Australian adults, aged 18-75 years,
were spending sufficient time (ie, at least 150 minutes
of walking, moderate and/or vigorous activity per week)
being physically active for health benefits 11 .
Increased rates of safe sex: Prevention of Human
Papilloma Virus (HPV) infection would prevent cervical
cancer 12 . However, there is inconsistent evidence about
whether condoms can reduce the risk of HPV infection 12 .
Meta-analyses suggest that there is little benefit 13;14 .
However, ongoing randomised trials suggest there may
be some benefit 15 .”
Prevention strategies to address the determinants of
health
It is evident from the above that for some cancers, there
is considerable knowledge about their causes. Given this
evidence, what preventive approaches should be adopted
at the population level to reduce cancer risks The
framework below recognises that the health of individuals
and populations is determined by many factors (e.g.
social, educational, economic, environmental, early years,
genetic, psychosocial factors, health behaviours and the
health system) that may act alone or in conjunction with
each other. It identifies a range of factors that determine
health outcomes and impact on cancer risk. In designing
effective preventive strategies effort needs to be directed
towards different population groups in a range of settings
and incorporating findings from life course research. The
Ottawa Charter for Health Promotion outlines a range of
strategies for effective interventions (see box). Adoption
of a comprehensive range of strategies is essential for
successful outcomes.

Framework for Prevention
Some South Australian examples of cancer prevention
strategies based on this framework are:
• working with Aboriginal populations in remote
communities, the Healthy Ways program is building
leadership and decision making processes with mothers
with babies on the issues of smoking and nutrition.
• the Alcohol Go Easy community education campaign
• promotion of the Alcohol Service Guidelines within the
hospitality industry
• increasing fruit and vegetable consumption by working
collaboratively with health, education and industry to
increase availability, promote adequate quantity and
improve skills for incorporating fruit and vegetables
into daily eating patterns
• developing and implementing food and nutrition
guidelines for schools and pre-schools
• contributing to the development of the SA Physical
Activity Strategy - a whole of government response to
decreasing activity levels
• providing be active community grants to health regions
across the state
• working with Local Government to increase shade in
our communities
• providing high quality sun protective clothing to the
community at competitive prices through Cancer
Council Shops
• Working to reduce smoking prevalence rates amongst
pregnant women (and their partners) in order to improve
the health of new born children.
References
1. National Health Priority Action Council, National Service
Improvement Framework for Cancer, May 2004
2. English D, Holman C, Milne E, et al. The quantification
of drug caused morbidity and mortality in Australia
1995. 1995 edition. Canberra: Commonwealth
Department of Human Services and Health, 1995.
3. Ridolfo B, Stevenson C. The quantification of drugcaused
mortality and morbidity in Australia, 1998.
Canberra: Australian Institute of Health and Welfare,
2001. Drug Statistics series no. 7
28
4. International Agency for Research on Cancer. Tobacco
smoking and involuntary smoking. Lyons: International
Agency for Research on Cancer, 2002.
5. Australian Institute of Health and Welfare. 2001 national
drug strategy household survey: first results. AIHW
cat. no PHE 35. Canberra: Australian Institute of Health
and Welfare, 2002. (Drug Statistics series no. 9)
6. Armstrong B, Kricker A. The epidemiology of solar
radiation and skin cancer. In:Giacomoni P, editor Sun
protection in man. Amsterdam: Elsevier Science,
2001: 151
7. World Cancer Research Fund, American Institute for
Cancer Research. Food nutrition and the prevention
of cancer: a global perspective. Washington: World
Cancer Research Fund and American Institute for
Cancer Research, 1997.
8. Giskes K, Turrell G, Patterson C, Newman B. Socioeconomic
differences in fruit and vegetable
consumption among Australian adolescents and adults.
Public Health Nutrition 2002; 5(5):663-669.
9. International Agency for Research on Cancer. Weight
control and physical activity. Lyons: International
Agency for Research on Cancer, 2002. (Handbooks
of cancer prevention)
10. Australian Institute of Health and Welfare. A growing
problem: trends and patterns in overweight and obesity
among adults in Australia, 1980 to 2000. AIHW cat.
no. AUS 36. Canberra: Australian Institute of Health
and Welfare, 2003.
11. Bauman A, Ford I, Armstrong T. Trends in population
levels of reported physical activity in Australia, 1997,
1999, and 2000. Canberra: Australian Sports
Commission, 2001.
12. Schiffman M, Castle P. Human papillomavirus:
epidemiology and public health. Archives of Pathology
and Laboratory Medicine 2003; 127(8):930-934.
13. Manhart L, Koutsy L. Do condoms prevent genital
HPV infection, external genital warts, or cervical
neoplasia A meta-analysis. Sexually Transmitted
Diseases 2002; 29:725-735.
14. Shepherd J, Weston R, Peersman G, Napuli I.
Interventions for encouraging sexual lifestyles and
behaviours intended to prevent cervical cancer
(Cochrane Review). In:Cochrane Library, editor Oxford:
Update Software, 2004:
15. Bleeker M, Hogewoning C, Voorhorst F, et al. Condom
use promotes regression of human papillomavirusassociated
penile lesions in male sexual partners of
women with cervical intraepithelial neoplasia.
International Journal of Cancer 2003; 107(5):804-810.

Hepatitis C Infection in Australia
– An Ongoing Epidemic
Emma R Miller
Epidemiologist
Department of Health
Infection with the hepatitis C virus (HCV) is one of
the most commonly notified diseases in South Australia.
Since mandatory notification began in 1995, over 12,500
cases have been notified to the State surveillance system
(State Surveillance data, Communicable Disease Control
Branch, Department of Human Services, 2004). Around
20,000 HCV cases are newly notified across Australia
each year (Communicable Diseases Australia, National
Notifiable Diseases Surveillance System, Commonwealth
Department of Health and Ageing, 2004). Infection with
HCV has an extremely high chronicity rate (around 80%
of those infected will fail to clear the virus), 1, 2 which has
contributed to a nationwide prevalence of approximately
1.5% in Australia and in most other developed countries. 3
There are some potentially serious sequelae of HCV
infection, the most serious of which is the association
between long term infection with the virus and
hepatocellular carcinoma (liver cancer). As stated by
Farrell 4 (page 285);
“From a community point of view, the problem of
liver cancer is one of the most important issues that arise
from the hepatitis C epidemic.”
While only a small proportion of those infected will
go on to develop serious health consequences, the sheer
number of Australians now thought to be infected by the
virus, over 200,000 according to recent estimates, 5 has
substantial implications for public health and health service
planning.
Natural history
There are six major strains of the HCV virus (a member
of the flaviviridae family) and over 50 additional subtypes. 6
Moreover, the virus mutates very rapidly to form multiple
quasi species. These are thought to be the chief
mechanism by which the virus evades host immune
systems, resulting in the low rate of viral clearance. 4, 7
The six strains have a differential geographical distribution,
with types 1 to 3 being most common in Australia –
around 55% of cases are thought to be type 1. 8, 9
29
The different genotypes of HCV do not appear to
have a role in severity of disease, or disease outcome,
but are strongly associated with response to treatment.
Currently the only treatment available for chronic infection
is Interferon in combination with Ribavirin. A number of
unpleasant side effects are associated with interferon
therapy, and the treatment course is long. The full
treatment course is six months for HCV other than type
1, and 12 months for type 1. The overall treatment success
(as evidenced by the sustained absence of detectable
viral particles in the blood) is around 55%. Treatment
success is lower in genotype 1, despite the longer duration
of treatment. 10 Whether due to the duration of treatment,
the associated side effects, or the difficulty of ‘selling’ a
fairly aggressive therapy to patients with few apparent
symptoms, treatment uptake remains relatively low in
Australia. 3
Many of the symptoms associated with HCV-infection
tend to be non-specific, if present at all; thus, many
people are not diagnosed until they have been infected
for many years. Disease progression usually occurs over
a relatively long duration of infection, but can result in
very serious health outcomes.
Liver cirrhosis will occur in around 20 percent of
those chronically infected, within approximately 20 years.
Of those with cirrhosis, five to 10 percent will develop
end-stage liver disease or hepatocellular carcinoma (cancer
of the liver) within approximately 40 years of infection. 11,
12 Extrahepatic manifestations (non-liver related
conditions) associated with chronic HCV-infection include
poly sialadenitis (affecting salivary glands and producing
dental problems), cryoglobulinaemia (leading to arthritis
and skin disorders) and membranoproliferative
glomerulonephritis (kidney disease). 1, 13-15
Even in the absence of liver damage or other clinically
measurable signs, many people report various symptoms,
including fatigue, depression and nausea. 16, 17 Studies
have found that health-related quality of life in HCVinfection
is significantly reduced in people with HCVinfection,
irrespective of the stage or grade of their
disease. 18, 19
Epidemiology
There have been approximately 12,500 notifications
of HCV to the State surveillance system since mandatory
notification began in 1995. The majority of new notifications
come from people who may have been infected for a
very long time. The ability to plan preventive strategies
requires that there be some way of identifying those

people who have only recently become infected. Since
very few cases have a noticeable ‘seroconversion’ illness
(jaundice, fever, etc) soon after they are infected, new
infections (or ‘incident’ cases) are generally determined
on the basis of the individual having had a negative test
within 12 months prior to testing positive to HCV
antibodies. Because most people are not serially tested
in this way, the current case definition results in the
majority of new infections remaining unidentified. In
addition, the narrow case definition introduces a bias
which is reflected in the demographics of the cases. For
instance, incidence cases are identified in people who
are more likely to be female and tend to be younger than
other notified cases.
Trends
Chart 1 presents monthly notifications to the South
Australian Surveillance system since January 1998. As
can be seen, while notifications of new infections have
been relatively consistent over time (at roughly, 70
notifications per year), the overall number of notifications
appears to be declining over time.
*All other groups: total incident cases; people identifying as Indigenous;
people 21 years or younger; people over 55 years
Source: Communicable Disease Control Branch, DHS - 2004
It is probable that the decreasing trend observed for
non-Indigenous males aged between 22 and 55 years
represents the gradual ‘mop up’ of cases that have been
infected for many years prior to diagnosis. It is important
to note that the HCV test has only been available for the
last 12 years. Since chronic infection with HCV follows
a very long and (often) symptomless course (as discussed
above), the slow pick up of cases in males of this age is
likely to reflect the slow rates of health service access
known to occur in this group.
Source: Communicable Disease Control Branch, DHS - 2004
Further analysis of the surveillance data reveals that
the decline is mainly occurring in only one specific group
of non-incidence notifications, that is, non-Indigenous
males aged between 22 and 55 years. Since this group
also makes the largest contribution to overall HCV
notification numbers, the decrease in these numbers has
the biggest impact on apparent overall trend. As
demonstrated in Chart 2, non-incidence notifications for
non-Indigenous females of the same age have also
declined, but less steeply and with less impact on overall
trend. No trends have been observed over time for any
other group (Indigenous people, young people, or old
people) when analysed separately or combined (see Chart
2).
Risk factors
Since the introduction in 1990 of the screening of
blood products for HCV, injecting drug use (IDU) has been
recognised as the major risk factor for infection. Chart 3
presents pooled data for all notifications from January
1998 to December 2003. As can be seen, IDU is reported
as the primary risk factor for 60% of all notifications, and
as one amongst other risk factors in a further 12% of
notifications. Household contact with an infected person,
medical procedures, and mother-to-child transmission
are reported in very low numbers. These factors combined
make up less than one percent of notifications over the
five years.
Source: Communicable Disease Control Branch, DHS - 2004
30
Two specific population groups continue to be overrepresented
in the notification data. Firstly, notifications
from people identifying as Indigenous make up
approximately six percent of all notifications, despite
representing less than two percent of the South Australian

population. Over time, there has been little change in the
number of notifications from Indigenous South Australians.
Secondly, history of imprisonment is independently
associated with HCV-infection. 20-22 STD Services advise
that more than 10% of all notifications for HCV in 2002
were received from prisons. Of those notifications
confirmed as new infections (incidence cases), 25% were
notified from South Australian prisons. Prisoners are
clearly over-represented in the surveillance data, since
the overall prison population represents less than one
percent of the total South Australian population. 23
In summary, South Australia is experiencing a
sustained epidemic of HCV infection, for which there is
little evidence of improvement over time for any
demographic group. IDU continues to be the most
common risk factor reported at notification, and some
population groups (such as people in prison and Indigenous
people) are at clear, increased risk for infection. Even
were current and new prevention strategies to begin to
reverse the epidemic, the sheer number of people already
infected with the virus and the slow progression of the
disease will ensure that the incidence of the most serious
health outcome, hepatocellular carcinoma, will continue
to rise for decades more. 4, 24
REFERENCES
1. Hoofnagle JH. Hepatitis C: the clinical spectrum of
disease. Hepatology 1997; 26 (Supplement 1) (3): 15S-
20S.
2. Tillmann HL, Manns MP. Mode of hepatitis C virus
infection, epidemiology and chronicity rate in the
general population and risk groups. Digestive Diseases
and Sciences 1996; 41 (Supplement): 27S-40S.
3. Batey RG. Chronic Hepatitis C, Chapter 4 in Hepatitis
C an update. Australian Family Physician. 2003; 32
(10): 807-11.
4. Farrell GC. Hepatitis C other liver disorders and liver
health. NSW: MacLennan and Petty, 2002.
5. Lowe D, Cotton R. Hepatitis C: a review of Australia’s
response. Canberra: Department of Health and Aged
Care; 1999 January 1999. Report No. 2521.
6. Booth JCL, Brown JL, Thomas HC. The management
of chronic hepatitis C virus infection. Gut 1995; 37:
449-54.
7. Purcell R. The hepatitis C virus: overview. Hepatology
1997; 26 (suppl 1): 11S-14S.
8. Kaba S, Dutta U, Byth K, Crewe EB, Khan MH,
Coverdale SA, et al. Molecular epidemiology of hepatitis
C in Australia. Journal of Gastroenterology &
Hepatology 1998; 13 (9): 914-20.
9. Dore GJ, MacDonald M, Law MG, Kaldor JM.
Epidemiology of hepatitis C virus infection in Australia,
Chapter 1 in Hepatitis C an update. Australian Family
Physician. 2003; 32 (10): 796-8.
10. Jaeckel E, Cornberg M, Wedemeyer H, Santantonio
T, Mayer J, Zankel M, et al. Treatment of acute hepatitis
C with interferon alfa-2b. New England Journal of
Medicine 2001; 345 (20): 1495-7.
11. Isaacson AH, Davis GL, Lau JY. Should we test
hepatitis C virus genotype and viraemia level in patients
with chronic hepatitis C Journal of Viral Hepatitis
1997; 4: 285-92.
12. Sharara AI. Chronic hepatitis C. Southern Medical
Journal 1997; 90: 872-7.
13. Gumber SC, Chopra S. Hepatitis: a multifaceted
disease. Review of extrahepatic manifestations. Annals
of Internal Medicine 1995; 123: 615-20.
14. Hadziyannis SJ. Nonhepatic manifestations and
combined diseases in HCV infection. Digestive
Diseases and Sciences 1996; 41 (Supplement) (12):
63S-74S.
15. Coates EA, Brennan D, Logan RM, Goss AN,
Scopacasa B, Spencer AJ, et al. Hepatitis C infection
and associated oral health problems. Australian Dental
Journal 2000; 45 (2): 108-14.
16. Lee DH, Jamal H, Regenstein FG, Perrillo RP. Morbidity
of chronic hepatitis C as seen in a tertiary care medical
centre. Digestive Diseases and Sciences 1997; 42
(1): 186-91.
17. Wodak A. Aspects of care for the hepatitis C positive
patient. Australian Family Physician 1998; 27 (9): 787-90.
18. Foster GR, Goldin RD, Thomas HC. Chronic hepatitis
C virus infection causes a significant reduction in
quality of life in the absence of cirrhosis. Hepatology
1998; 27: 209-12.
19. Miller ER, Hiller JE, Shaw DR. Quality of life in HCVinfection:
lack of association with ALT levels. Australian
and New Zealand Journal of Public Health 2001; 25:
355-61.
20. Crofts N, Thompson S, Wale E, Hernberger F. Risk
behaviours for blood-borne viruses in a Victorian prison.
Australian and New Zealand Journal of Criminology
1996; 29: 20-8.
21. Dolan K. The epidemiology of hepatitis C infection in
prison populations. In: Commonwealth Department
of Heath and Aged Care, editor. Hepatitis C: Informing
Australia’s National Response. Canberra, 2000; 61-
93.
22. Stark K, Bienzle U, Vonk R, Guggenmoos-Holzmann
I. History of syringe sharing in prison and risk of
hepatitis B virus, hepatitis C virus, and human
immunodeficiency virus infection among injecting
drug users in Berlin. International Journal of
Epidemiology. 1997; 26 (6): 1359-66.
23. ABS. Prisoners in Australia. Canberra, Australian
Bureau of Statistics; 2003. Report No. ABS No.
4517.0.
24. Law MG. Modelling the hepatitis C virus epidemic in
Australia. Hepatitis C Virus Projections Working Group.
Journal of Gastroenterology & Hepatology 1999; 14
(11): 1100-7.
31

Communicable Disease Control Branch
report – 1 january to 31 march 2004
The Communicable Disease Control Branch Bulletin has
been incorporated into a new Public Health Bulletin. We
hope our readers will enjoy the wide range of public
health articles presented in this new Bulletin.
Also in this quarter, a survey of reprocessing activities
within South Australian hospitals was completed with
over 90 responses received from both metropolitan and
country hospitals. This information will be used to assist
in the preparation of a business case for the management
of single use devices in SA.
INFECTION CONTROL SERVICE (ICS)
In this quarter, the following annual or quarterly surveillance
reports were commenced or completed:
• The methicillin-resistant Staphylococcus aureus (MRSA)
annual report for 2002/2003 was completed.
• The antibiotic utilisation annual report for 2003 was
completed.
• The 2003 bacteraemia annual report is in progress.
• The first quarterly surveillance report for 2004 is in
progress.
The ICS held a multi-resistant organism (MRO) Workshop.
At this workshop, 2 years of MRO surveillance in South
Australia (SA) was presented to Infection Control
Practitioners (ICP), microbiologists and interstate guests.
In addition, SA antibiotic utilisation data was presented.
There were presentations from 2 metropolitan hospitals;
one on MRSA isolates and one on a multi-resistant
Acinetobacter outbreak associated with the Bali victims.
Finally there was a presentation from Queensland on
their “Antibiogram” laboratory data collection system.
Following this workshop the ICS is exploring the possibility
of adopting this antibiogram passive surveillance system
in SA.
In this quarter, a statewide survey of respiratory isolation
facilities, including respiratory isolation rooms and staff
personal protective equipment was completed. Individual
reports and recommendations have been directed to
participating Chief Executive Officers and executive staff
from the Department of Health. From this report, hospitals
have developed management plans, in consultation with
ICP’s, Occupational Health and Safety and Engineering
and Maintenance staff. In order to support this action
Department of Health is providing capital works funding
over the next 2 years.
A fit testing workshop has been conducted to assist
hospital staff with gaining the skills necessary to run a
fit testing program for the correct use of N95 masks;
draft guidelines have also been produced to support this
activity.
A gap analysis of infection control resources has been
conducted in conjunction with Country Health. The
information gained from this exercise will be used to
assist in the preparation of a proposal to Country Health
to employ an ICP to assist the ICS to manage country
infection control issues.
The ICS is working with Queensland Health in piloting
its Signal Infection Surveillance Program designed for
smaller hospitals; 5 SA sites are participating in the pilot.
The ICS are currently working with several groups on
other initiatives, including a state hand hygiene project,
formulation of “Guidelines for the Management of
Gastroenteritis in Aged Care” and the revision of the Skin
Penetration and the Hairdressing Guidelines.
SOUTH AUSTRALIAN IMMUNISATION
COORDINATION UNIT (SAICU)
Meningococcal C vaccination programme
Latest figures from the Australian Childhood Immunisation
Register (ACIR) indicate that coverage for children who
turned 1 to 5 years of age during 2003 is 56.6% compared
with the national average of 52.16%.
Since January 2003, children in this age group have been
eligible to receive free Meningococcal C vaccine from
their local doctor or immunisation provider. It must be
remembered, this is a catch-up programme and free
vaccine will only be available for a limited time.
South Australian councils are funded to provide the
Meningococcal C school based vaccination programme.
School students in years 9 to 13 were initially offered free
vaccine in 2003, years 8 to 9 in 2004 and years 1 to 7
over a two-year period commencing in 2004. If students
do not receive the vaccination at school, they can access
free vaccine from local government immunisation clinics.
With the onset of winter and spring, a seasonal increase
in the number of cases of meningococcal disease is
anticipated. Now is a good time to take advantage of the
offer of free vaccine.
32

Fact Sheet : Shigellosis
FACT SHEET : Shigellosis
Shigellosis is a gastrointestinal illness caused by infection
with a bacterium called Shigella. Shigellosis occurs in
people of all ages. However, the illness is particularly
severe in the very young, elderly or malnourished.
What are the symptoms
Typically, the disease is characterised by diarrhoea, fever,
nausea, and vomiting and abdominal cramps. Sometimes
blood or mucus is present in the faeces.
The time between becoming infected and developing
symptoms is 1 to 3 days but may range from 1 to 7 days.
The illness can last anywhere from 4 to 7 days. Mild
infections or infections without symptoms can occur.
How is shigellosis diagnosed
A diagnosis of shigellosis requires the isolation of Shigella
bacteria from a stool specimen or rectal swab. Only your
medical practitioner can order this test.
How long do people remain infectious
People with shigellosis are infectious while symptoms
are present and remain infectious until Shigella bacteria
disappear from the faeces. This usually occurs 4 weeks
after illness. Occasionally, people can shed Shigella in
their faeces for many months.
How is Shigella spread
Shigella bacteria are passed from person to person via
hands or objects contaminated with faeces. The
susceptible person then ingests the faecal matter and
develops shigellosis. Transmission can occur if hands
are not washed correctly after toileting, changing nappies
or after certain kinds of sexual contact.
Food may become contaminated with Shigella from the
hands of infected food handlers. Flies can also carry
Shigella and infect uncovered food items.
Seek medical advice if any of the following symptoms
occur:
Adults
• Signs of dehydration (thirst, lethargy, decreased
urination, dry mouth, feeling faint on standing)
• Fever
• Severe abdominal pain
• Bloody diarrhoea
Children
• Signs of dehydration (thirst, lethargy decreased
urination, dry mouth, sunken eyes)
• Fever
• Abdominal pain
• Bloody diarrhoea
• Any of the above symptoms in a child less than 12
months of age.
How is shigellosis prevented
People with gastrointestinal illness should be excluded
from food handling, childcare, school and work until the
diarrhoea has stopped. They should also use good personal
hygiene. In particular, thorough handwashing with soap
and water should be encouraged after going to the toilet,
changing nappies or exposure to faecal matter.
People with shigellosis should avoid swimming until
diarrhoea has stopped.
For further information on shigellosis please contact your
local medical practitioner or the Communicable Disease
Control Branch.
The Communicable Disease Control Branch can be
contacted on telephone number: 8226 7177, 9am - 5pm
weekdays.
How is shigellosis treated
Many people with mild infections recover without
treatment. For more serious illness, specific antibiotic
therapy will reduce symptoms and control the spread of
infection
Gastrointestinal illness can lead to dehydration, particularly
in the very young or elderly. People with diarrhoea should
be encouraged to drink plenty of fluids. Oral rehydration
solution is highly recommended.
33

Communicable and Notifiable Diseases Activity
Reported from 1 january to 31 march 2004
VACCINE PREVENTABLE DISEASES
VECTORBORNE DISEASES
Dengue fever
In this quarter, there were 3 reports of dengue fever in
people who had travelled to Indonesia or East Timor.
Malaria
Two reports of malaria were received for persons who
had recently returned from a country known for endemic
transmission of malaria.
A report of Plasmodium vivax infection was received for
a 29-year old female who had travelled to Papua New
Guinea. Similarly, a mixed infection of Plasmodium vivax
and Plasmodium falciparum was reported in a 4-year old
child that had holidayed in Papua New Guinea.
Ross River virus
In this quarter, there were 23 reports of Ross River virus
infection. Of these, 14(61%) cases reported interstate
travel in the fortnight prior to the onset of illness. The
remainder of cases reported travelling to various
geographical locations along the River Murray. The last
major outbreak of Ross River virus infections in South
Australia occurred during the summer of 2000-2001.
Health Information
Information on preventing vector borne diseases can be
obtained by visiting our web site:
http://www.health.sa.gov.au/pehs/
ZOONOSES
Hydatid disease
Hydatid disease was reported in a 64-year old male farmer
from rural South Australia. The case was born overseas
and reported a history of various animal contacts including
sheep.
Q fever
There were 4(3 male, 1 female, age range: 30 to 39 years)
reports of Q fever infection. Of these, 3 were residents
of rural South Australia. Cases reported various risk factor
exposures including shooting feral goats, slaughtering
kangaroos and farm exposure to cattle and sheep.
Information for one case is uncertain.
Pertussis
Despite reports of increased pertussis activity in New
South Wales, there has been no increase in the number
of cases of pertussis observed in South Australia.
Influenzae
South Australian influenza surveillance combines
laboratory-confirmed cases reported by the Institute of
Medical and Veterinary Science, with clinical diagnoses
of “influenza-like illness” collected by the Royal College
of General Practitioners members participating in the
Australian Sentinel Practice Network, and Emergency
Departments of the Royal Adelaide Hospital and the
Women’s and Children’s Hospital. (See Figure 1)
In this quarter, 106,376 doses of influenza vaccine were
distributed to vaccine providers. Figure 1 illustrates the
timely distribution of influenza vaccine prior to the onset
of the anticipated influenza season.
An influenza stock take is planned for the third quarter.
SAICU closely monitors the distribution of influenza
vaccine in an attempt to reduce wastage.
Health Information
Information about the influenza vaccination programme
can be obtained by telephoning the South Australian
Immunisation Coordination Unit (08) 82267177.
Invasive pneumococcal disease
In this quarter, there were 41(18 males, 23 females),
laboratory confirmed cases of invasive pneumococcal
disease reported. The median age of cases was 36 years
(age range: 7 months to 93 years).
Eighteen (44%) cases were in children aged less than 5
years. Of these, 2 were identified as Indigenous children
from rural and remote areas of South Australia. No deaths
were reported.
Health Information
Information about the pneumococcal vaccination
programme can be obtained by telephoning the South
Australian Immunisation Coordination Unit (08) 82267177.
Tetanus
There was one case of tetanus reported in an unvaccinated
82-year old female who has sustained an injury while
gardening. The case developed jaw stiffness and
experienced difficulty eating necessitating her admission
to hospital.
34

GASTROINTESTINAL DISEASES
Campylobacter
Campylobacter remains the most commonly reported
notifiable disease in South Australia. In this quarter, 457
notifications were received for residents of metropolitan
Adelaide, rural and remote areas of South Australia. No
outbreaks were detected during this period.
Hepatitis A
In this quarter, there were 6(6 females, age range: 4 to
80 years) sporadic cases of hepatitis A infection reported.
Of these, 2 reported recent overseas travel to Indonesia
and Hong Kong respectively. Risk factor exposures were
not identified for remaining cases.
Shigellosis
There were 31(17 males, 14 females) cases of shigellosis
reported. Of these, Shigella flexneri 2a and Shigella sonnei
biotype g were the most frequently reported species.
Continuing transmission of Shigella flexneri 2a occurred
among rural and remote indigenous communities in South
Australia. In total, 10(4 males and 6 females; age range
1 to 67 years) were reported. Of these, 9 were Indigenous
residents of Coober Pedy, Port Lincoln, Ernabella, Port
Augusta and Port Pirie. (See Figure 2)
In January 2004, the Communicable Disease Control
Branch and local government investigated a cluster of
cases of shigellosis in rural South Australia. In total, 11
persons reported experiencing gastrointestinal illness
between 9 January and 15 February 2004. Of these, 5(1
female, 4 males, age range: 2 to 31 years) provided stool
specimens for routine microbiological testing. All 5
specimens yielded Shigella sonnei biotype g with identical
antibiotic sensitivity patterns.
The apparent index case was a child from Tanzania. This
child and her family were holidaying with a local family.
The onset of gastrointestinal illness in the host family
occurred on 9 January 2004. The following day a second
child from the visiting family experienced similar
symptoms. On 16 January 2004, an adult from the host
family experienced gastrointestinal illness and shigellosis
was diagnosed. Over the following four weeks, children
in a further 3 households were diagnosed with shigellosis.
The median age of laboratory confirmed cases was 4
years. Social network links were established between all
five households via social and child-care settings. Indeed,
parents reported attending social, playgroup and childcare
sessions with symptomatic children.
Salmonella
In this quarter, 143(67 males, 76 females) cases of
salmonellosis were reported. Of these, 42 (29%) cases
were aged less than 5 years of age.
Salmonella Typhimurium phage type 108 (26 cases),
Salmonella Typhimurium phage type 9 (9 cases),
Salmonella Singapore (8 cases) and Salmonella Chester
(7 cases) were the most frequently reported species.
Salmonella Typhimurium phage type 108
In February 2004, the Communicable Disease Control
Branch investigated a cluster of cases of Salmonella
Typhimurium phage type 108. Hypothesis generating
interviews established that cases had consumed cream
filled cakes in the 7 days prior to onset of illness. A trace
back to the point of manufacturer identified a common
bakery located in metropolitan Adelaide.
A case-control study identified a statistically significant
association between illness and consumption of cream
cakes. Microbiological examination of leftover frozen
cream cake purchased from the bakery yielded Salmonella
Typhimurium phage type 108. An environmental
investigation identified several concerns related to general
hygiene and foodhandling. In particular, recommended
procedures for cleaning and sanitising piping bags were
considered inadequate. Immediate intervention strategies
were instituted and no further cases were reported.
(See Figure 3)
Typhoid
Typhoid fever was diagnosed in a 23-year old female who
had travelled to Indonesia and Singapore.
Shiga toxin producing Escherichia coli
In this quarter, there were 4 detections of Shiga-toxin
producing Escherichia coli O157. The age range of cases
(1 male and 3 females) was 22 to 83 years.
All cases were enrolled in a national case-control study
designed to identify risk factors for Shiga-toxin producing
Escherichia coli in Australia.
Immediate intervention strategies were instituted and
the last reported case occurred on 15 February 2004.
35

OUTBREAKS OF VIRAL GASTROENTERITIS
In this quarter, the Communicable Disease Control Branch
investigated 6 outbreaks of gastroenteritis among
residents and staff of aged care and acute care facilities.
In 5 outbreak investigations, Norovirus 2 was identified
as the infecting agent. It is highly probable that Norovirus
2 was circulating in the wider community and was
introduced into these institutions by a visitor or staff
member.
Several possible sources for the illnesses were
investigated. These included, domestic hot water systems,
a home spa, and cooling towers located at various sites
within metropolitan Adelaide and interstate. One
investigation identified a home spa as the most likely
source of one man’s infection.
Continuing outbreaks of viral gastroenteritis have prompted
development of “Guidelines for the management of
gastroenteritis in aged care facilities”.
OTHER DISEASES
Invasive meningococcal disease
In this quarter, 4(2 males, 2 females, age range: 2 months
to 38 years) cases of invasive meningococcal disease
were reported. All were characterised as serogroup B.
There was one death. (See Figure 4)
Legionellosis
Legionella pneumophilia serogroup 1
In this quarter, 3(3 males, age range: 58 to 63 years)
sporadic cases of legionellosis were reported. There was
one death.
36

Figure 2 illustrates the increase
in the number of cases of Shigella
flexneri 2a observed since May
2003.
Figure 4 illustrates the decrease
in the number of cases of
invasive meningococcal
serogroup C in South Australia
since the introduction of the
nationally funded vaccination
programme.
37

Table 1: Notifiable diseases in
South Australia, 1999 to March 2004.
38

Public Health Bulletin South Australia
The Public Health Bulletin South Australia is a publication of
the Department of Health.
Editorial correspondence
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Australia, Health Promotion SA, Department of Health, PO Box 287, Rundle Mall,
ADELAIDE 5000 or email phbsa@health.sa.gov.au or Fax: (08) 8226 6133
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