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Tier 3 - Health system performance

3.04 Early detection and early treatment

Key facts

Why is it important?

Early detection is the discovery of a disease or condition at an early stage of its development or onset, usually before symptoms occur. Early detection may occur through individual patient care or screening programs for targeted populations. Screening is the recognition or diagnosis of an unrecognised disease or condition in the general population by using reliable tests, examinations or other procedures that can be applied rapidly (Zwar & Ackermann 2016). Early treatment is the provision of a treatment regime following as soon as possible after the detection and confirmatory diagnosis of disease. Early detection and treatment programs are most effective when there are systematic approaches to ensuring that assessment and screening occur regularly and at recommended intervals.

Detecting and treating disease early is both more effective and more efficient than treating more advanced disease. For some diseases, early detection and treatment can result in a cure, while for others, it may slow the onset of the disease and reduce the risk of death.

Screening programs need to meet a range of criteria to ensure their efficacy and acceptability to the public. They also need to promote equity of access for all members of the target population, including important subgroups such as Aboriginal and Torres Strait Islander people and people from culturally and linguistically diverse backgrounds (Clinical Principal Committee Standing Committee on Screening 2018).

In Australia, primary health care providers, including Aboriginal and Torres Strait Islander health services and general practitioners (GPs), have a crucial role in detecting and treating disease in its early stages. The World Bank includes selected early detection and management of non-communicable diseases (for example, screening programs) as one of the seven recommended cost‑effective health interventions that can be delivered in the primary health care setting and that play a key role in avoiding adverse health outcomes (Jamison et al. 2017; Jamison et al. 1993).

The Australian Government provides GP health assessments and checks for Indigenous Australians under the Medicare Benefits Schedule (MBS), along with follow-up care and incentive payments for improved chronic disease management and cheaper medicines through the Pharmaceutical Benefits Scheme (PBS). The MBS Item 715 is a general health assessment for Indigenous Australians and is used for detecting a wide range of potential health issues that may need follow-up care such as high blood pressure, high sugar levels, oral health, mental health, sexual health, immunisation status, hearing and vision.

National cancer screening programs are designed to reduce illness and death through early detection of cancer or pre-cancerous abnormalities. National programs for breast and cervical screening were implemented in Australia in the early 1990s. The National Cervical Screening Program (NCSP) currently recommends that asymptomatic women aged 25 to 74 years should have a cervical screening test every five years (DoH 2020a). BreastScreen Australia recommends two-yearly screening for women aged 50–74 (DoH 2020b). The National Bowel Cancer Screening Program (NBCSP) began in 2006, and biennial screening for males and females aged 50 to 74 years is recommended (DoH 2020c).

Findings

What does the data tell us?

Health checks

Health checks through MBS health assessment items for Indigenous Australians aged 55 and over were introduced in 1999, for those aged 15–54 in 2004, and in 2006 for those aged 0–14. In 2009–10, measures to increase take-up of health assessments by those aged 15 and over were introduced.

Between 2009–10 and 2018–19, the number of health assessments through the MBS for Indigenous Australians of all ages significantly increased (by 401%), from 47,283 to 248,841. The rate of MBS health assessments for Indigenous Australians increased by 292% over the years 2009–10 to 2018–19 (from 68 per 1,000 to 297 per 1,000). An unusually large annual increase in health assessments for Indigenous Australians was seen between 2009–10 and 2010–11 (48%) (Table D3.04.3, Figure 3.04.1).

In 2018–19, a total of 81,637 health assessments were undertaken for children aged 0–14, representing 29% of Indigenous children. There were 127,798 health assessments provided for Indigenous Australians aged 15–54 (representing 28% of this population) and 39,406 for those aged 55 and over (representing 40% of this population) (Table D3.04.1).

Figure 3.04.1: Rate of MBS health checks/assessments for Indigenous Australians (MBS item 715), by age group, 2006–07 to 2018–19

This line chart shows that between 2006–07 and 2018–19 the rate (per 1,000) of MBS health checks has increased steadily for all age groups. That is, 28 to 292 per 1,000 for those aged 0–14, 37 to 278 per 1,000 for those aged 15–54 and 70 to 396 per 1,000 for those aged 55 and older.

Source: Tables D3.04.5, D3.04.6, D3.04.7. AIHW analysis of Department of Health Medicare claims data.

For Commonwealth-funded Indigenous primary health care organisations, 37% of Indigenous children 0–4 years (who were regular clients) had received an MBS health assessment in the 12 months prior to December 2018. For eligible adults who were regular clients, 50% of those aged 25–54 had received a health check in the previous 24 months, as had 58% of those aged 55 and over (Table D3.04.25).

Cancer screening

Indigenous Australians are less likely to participate in breast, cervical and bowel population screening programs than non-Indigenous Australians. There are limitations in the data used for calculating the screening participation rates for Indigenous Australians due to under-reporting of Indigenous status.

Breast screening: 38% of Indigenous women aged 50–74 participated in BreastScreen Australia in 2017–2018, compared with 54% of non-Indigenous women.

Cervical screening: 29% of all women aged 25–74 who had a human papillomavirus (HPV) test under the National Cervical Screening Program in 2018 did not state their Indigenous status. This high level of incomplete Indigenous identification in the National Cervical Screening Register makes it challenging to  estimate the cervical screening participation rate by Indigenous women accurately. Work is underway to develop a suitable methodology.

Bowel screening: The estimated participation rate for Indigenous Australians aged 50–74 in the NBCSP was 23% in 2017–2018, compared with 45% for non-Indigenous Australians.

Breast screening

The latest BreastScreen Australia data (2017–2018) showed that after adjusting for differences in the age structure between the two populations, 38% of Indigenous Australian women aged 50–74 had been screened. This was 16 percentage points lower than for non-Indigenous women (54%) (Table D3.04.9).

Breast cancer screening for Indigenous women aged 50–74 varied by remoteness and was lowest in Remote areas (32%) and highest in Inner regional areas (42%) (Table D3.04.30). Screening proportions for Indigenous women aged 50–74 also varied by jurisdiction, with the lowest rate in the Northern Territory (26%) and the highest in Queensland (45%) (Table D3.04.9).

Over the period 1999–2000 to 2017–2018, there was an 18% increase in the proportion of Indigenous women aged 50–69 who were screened for breast cancer (from 31% to 37%), compared with a 15% increase for non-Indigenous women (Table D3.04.12, Figure 3.04.2). From 1 July 2013, the target age group for breast screening in Australia changed from 50–69 to 50–74. Time-series data for the 50–69 age group are presented as a sufficient amount of data are available for long-term trends.

The 2018–19 National Aboriginal and Torres Strait Islander Health Survey (Health Survey) showed that 85% (48,660) of Indigenous women aged 50–69 reported having at least one mammogram (Table D3.04.10).

Figure 3.04.2: Age-standardised participation rates, BreastScreen Australia, women aged 50–69, by Indigenous status, 1999–2000 to 2017–2018

This line chart shows that the proportion of Indigenous women aged 50–69 who participated in breast screening was lower than that for non-Indigenous women of the same age. The Indigenous proportion increased from 31% in 1999–2000 to 37% in 2017–2018, while the proportion of non-Indigenous women increased from 44% to 54% over the same period.

Source: Table D3.04.12. AIHW analysis of BreastScreen Australia data.

Cervical screening

Under the former National Cervical Screening Program (NCSP) (current until 1 December 2017), Pap tests were recommended every two years for most women aged 18–69. Under the renewed NCSP, a cervical screening test (CST)—a human papillomavirus (HPV) test, followed by a cytology test if HPV is found—is recommended every five years for most women aged 25–74.

In 2018, of all Australian women aged 25–74, an estimated 54% had an HPV test under the renewed NCSP. However, the HPV test participation rate for Indigenous women was not available due to the high proportion of participants with Indigenous status not stated on the National Cervical Screening Register (29%) (AIHW 2019a).

Self-reported data from the 2018–19 Health Survey showed that 50% (105,100) of Indigenous women aged 20–69 had a Pap test at least every two years (including women who had a CST from December 2017). Proportions varied by remoteness area, from 41% in Inner regional areas to 57% in Very remote areas (Table D3.04.15, Table D3.04.16, Figure 3.04.3).

Figure 3.04.3: Indigenous women aged 20–69 reporting whether had at least a 2-yearly Pap smear test, by remoteness, 2018–19

This bar chart shows that with the exception of Major cities, the proportion of Indigenous women who had a biannual pap smear increased with remoteness; ranging from 41% in Inner regional areas to 57% for those in Very remote areas. Nationally, the proportion is 50%, similar to the 51% observed for Major cities.

Source: Table D3.04.15. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19.

As of December 2018, Commonwealth-funded Indigenous-specific primary health care organisations reported that 26% (29,140) of regular female clients had a cervical screening in the previous two years, 34% (38,690) in the previous three years and 43% (48,510) in the previous five years (Table D3.04.27). Due to the recent changes to cervical screening, data were collected on clients who had either a Pap test conducted prior to 1 December 2017 or an HPV test conducted from 1 December 2017.

Indigenous female regular clients of the Commonwealth-funded Indigenous-specific primary health care organisations who were screened in the previous five years varied by remoteness, from 36% in Outer regional areas to 52% in Very remote areas. Proportions also varied by jurisdiction from 35% in New South Wales, and the Australian Capital Territory combined, to 56% in the Northern Territory (Table D3.04.27, Table D3.04.28).

National Bowel Cancer Screening Program

The 2018–19 Health Survey showed that 23% of Indigenous males and 20% of Indigenous females aged 50–74 reported having at least one bowel cancer screening test (Table D3.04.17).

In 2018, a total of 1,181,247 Australians participated in the NBCSP; of these, 9,497 identified as Indigenous (0.8%). The participation rate in the NBCSP for Indigenous Australians aged 50–74 was estimated to be 23% in 2017–2018. This compared with an estimated participation rate of 45% for non-Indigenous Australians.

Indigenous participants were more likely to receive a positive (that is, potentially abnormal) test result than non-Indigenous Australians (10% and 7%, respectively). However, Indigenous participants with a positive result had a lower rate of follow-up colonoscopy (48% compared with 66%) and a longer median time between a positive screen and assessment (69 days compared with 51, days respectively) (AIHW 2020) (Table 3.04-1).

Table 3.04-1: Summary of National Bowel Cancer Screening Program screening, results and assessments, people aged 50–74, by Indigenous status, 2018

Number

Indigenous

Non-Indigenous

Screened

9,497

1,150,910

Positive iFOBT result

942

75,677

Diagnostic assessment (colonoscopy)

449

49,919

Rates (%)

Indigenous

Non-Indigenous

iFOBT positivity rate

9.9

6.6

Diagnostic assessment rate

47.7

66.0

Time between positive screen and assessment (days)

Indigenous

Non-Indigenous

iFOBT positivity rate

9.9

6.6

Diagnostic assessment rate

47.7

66.0


Source:
AIHW 2020. National Bowel Cancer Screening Program: monitoring report 2020. 

Other cancer screening

The 2018–19 Health Survey showed that 58% (36,600) of Indigenous males aged 50 and over reported having been tested for prostate cancer at least once (Table D3.04.19). Of Indigenous adults, 7.4% (35,820) had been tested at least once for skin cancer, and 1.5% (7,260) had participated in a lung cancer screening test (Table D3.04.18).

What do research and evaluations tell us?

Participation rates in the NBCSP, BreastScreen Australia and the NCSP appear to be lower for Indigenous Australians than non-Indigenous Australians. Further, the Indigenous mortality rates among each target age cohort is higher for the cancers these programs are trying to prevent (AIHW 2019b, 2019c).

Several preventable cancers occur more commonly and with a lower survival rates for Indigenous than other Australians, indicating that preventive strategies and clinical care are not as effective as they could, and should, be for Indigenous Australians (Clinical Principal Committee Standing Committee on Screening 2018; Condon 2004).

Various studies have investigated the stage of diagnosis and survival rates for cancer for Indigenous Australians. One study in the Northern Territory found that:

  • Indigenous Australians were more likely than non-Indigenous Australians to be diagnosed with advanced disease for cancers of the bowel (colorectal), breast, cervix and non-Hodgkin lymphoma. However, for cancer of the lung, Indigenous Australians were more likely to be diagnosed with localised disease ( i.e., the cancer had not yet spread). This is possibly because many older Indigenous people have regular chest x-rays for the clinical management of chronic respiratory diseases and as part of contact tracing and long-term follow-up by the tuberculosis control program.
  • Indigenous Australians had a lower cancer survival rate than non-Indigenous Australians for all five cancer sites studied. The difference in age-stage-adjusted five-year survival rates was greatest for non-Hodgkin lymphoma (16% for Indigenous Australian compared with non-Indigenous 65%) and least for lung cancer (5% compared with 12%, respectively). With few exceptions, Indigenous Australians had a lower survival rate than non-Indigenous Australians with the same stage at diagnosis for each cancer site.
  • Compared with non-Indigenous Australians diagnosed with the same type of cancer, Indigenous Australians are doubly disadvantaged because they are not only diagnosed later, with more advanced disease, but also have a lower survival rate for every stage at diagnosis (Clinical Principal Committee Standing Committee on Screening 2018; Condon et al. 2005).

A study of 815 Indigenous and 810 non-Indigenous patients diagnosed with cancer in Queensland between 1997 and 2002 found that after adjustment for stage at diagnosis, treatment and comorbidities, non-Indigenous patients had a better survival rate than Indigenous patients. The stage at diagnosis was significantly different, with 47% of Indigenous patients diagnosed with localised cancers compared with 53% of non-Indigenous patients. Comorbidities such as diabetes or chronic renal disease were more common in Indigenous patients. Indigenous patients were less likely to have had treatment for cancer (surgery, chemotherapy or radiotherapy) and waited longer for surgery than non-Indigenous patients (Valery et al. 2006).

One study showed that the major limitation in the bowel cancer-screening program is the low participation rate. Therefore, GPs play a crucial role in the success of screening by facilitating participation in the screening program. The study highlighted that the screening of patients with symptoms is inappropriate. Instead, the study recommended that these patients should be referred for investigation of their symptoms (Parkin et al. 2018).

A recent literature review identified barriers for Indigenous participation in bowel/colorectal cancer-screening programs, some of which appear to be unique to Indigenous people. The review studied the indigenous populations of Canada, New Zealand, Australia and the United States. The review found that indigenous populations have common barriers for screening, such as lack of access to culturally competent health services, discrimination, distrust of Western medicine and distrust of screening tests (D'onise et al. 2020).

Another study examined the delivery of recommended preventive services for Indigenous Australians and investigated the influence of health service and client level factors on adherence to best practice guidelines. The study highlighted that the delivery of recommended preventive care varied widely between different preventive services, with good delivery of most basic measurements but poor follow-up of abnormal findings. The study found that health service characteristics associated with higher quality care were found in the Northern Territory, urban services and centres that serve smaller populations. The study also found that client factors associated with higher quality care included age between 25 and 34 years, being female and more regular attendance. The study provided insights for improving the quality of preventive care for Indigenous Australians and highlighted the benefit of Continuous Quality Improvement processes in identifying and addressing areas for improved service delivery (Bailie C. et al. 2016).

Indigenous Australian women have a higher incidence of cervical cancer and poorer outcomes for breast and cervical cancer than non-Indigenous women. One small study aimed to implement and evaluate strategies to improve the early detection of breast and cervical cancer by GPs. In three sites a female Indigenous worker and female GP developed and implemented local plans aimed to improve service coordination and access, GP knowledge, recall systems, and health promotion. The study found that important factors in project success included collaboration between service providers, community participation in planning and delivery, having an Indigenous health worker to raise awareness among both the women and GPs and a female GP providing a holistic service (Reath & Carey 2008).

A systematic review of cancer studies explored knowledge, attitudes and behaviours towards cancer screening among indigenous people worldwide. Cancer mortality among indigenous people is increasing, but these populations commonly under-use cancer-screening services. The review found that knowledge of and participation in screening was greater for breast cancer than for other cancers. It also found that indigenous people tended to have less knowledge, less favourable attitudes, and a higher propensity to refuse screening than non-Indigenous populations. The review suggested that greater understanding of knowledge, attitudes and behaviours towards cancer screening in diverse indigenous cultures is needed so that culturally appropriate cancer prevention programs can be provided (Kolahdooz et al. 2014).

Implications

Early detection and early treatment through primary health care has significant benefits for those at risk of disease. Identification of Indigenous patients is the first step in providing access to Indigenous-specific health initiatives, including additional MBS and PBS items, and immunisations. Improving the follow-up of abnormal clinical results and access to referral services is also critical to achieving the benefits of health assessments and screening programs (Bailie C. et al. 2016; Bailie J. et al. 2014; Spurling et al. 2009; Whop et al. 2016).

Determining the patient’s risk, providing education, encouraging screening and instituting prompt referrals are essential in reducing bowel/colorectal cancer morbidity and mortality (Parkin et al. 2018). Although Indigenous Australians may have a slightly lower death rate from bowel cancer overall, the death rate for the age group targeted by screening (50–74) is higher. Indigenous Australians also have a lower rate of five-year survival than non-Indigenous Australians. Indigenous Australians are less likely to participate in the bowel cancer-screening program and, of those that are screened, they are more likely to receive a potentially abnormal result and are less likely to have a follow-up colonoscopy. This explains, in part, why Indigenous Australians, when diagnosed, are more likely to have more advanced stages of illness.

More systematic research is required to understand whether the Indigenous participation rates in screening are lower because of less opportunity to screen, less propensity to screen even with the same opportunity or the under-reporting of Indigenous status screening data. A greater understanding of barriers and enablers affecting participation is needed (D'onise et al. 2020).

Given the lower Indigenous participation rates in breast, bowel and cervical cancer-screening programs, better ways of encouraging regular screening are needed (Christou et al. 2010). In the 2014–15 Budget, the Australian Government committed to accelerating the expansion of the National Bowel Cancer Screening Program with the rollout of a biennial bowel screening interval for all Australians aged 50–74 by 2020.

Indigenous Australian women have a higher incidence of cervical cancer and poorer outcomes for breast and cervical cancer than non-Indigenous women. They also appear to be under-screened. Studies have shown that GPs play a critical role in improving early the detection and management of these conditions among Indigenous Australian women. Interventions such as local partnership approaches that improve service collaboration, GP awareness, recall systems and health promotion could assist in improving participation in screening for breast and cervical cancer. Partnerships involving community members planning and implementing evidence-based strategies may also improve the participation of Indigenous Australian women in breast and cervical cancer screening (Reath & Carey 2008).

Cervical screening will remain vital for many decades because the current HPV vaccines are not effective against all types of the virus that cause cervical cancer. A barrier to reporting on the national cervical screening rate for Indigenous women is that Indigenous status information is not collected on pathology forms in all jurisdictions.

Further study is required into factors determining adherence to best practice guidelines and improving the quality of preventive care for Indigenous Australians. Improvement may be achieved by addressing physical, social and cultural barriers to accessing preventive care, and by strengthening systems for the follow-up and completion of preventive health assessments. Possible improvements could also be achieved through health service improvements such as resourcing, team structure and function, and the use of clinical information systems (Bailie C. et al. 2016).

Exploring the experience of Indigenous Australians and their outcomes in relation to cancer incidence, stage of disease at presentation, access to treatment and survival can help illustrate aspects of Indigenous Australians’ access to and interaction with the health system. This provides an opportunity to monitor health system performance for Indigenous Australians in relation to both primary care and specialist services, and the interaction between them (Condon 2004).

The policy context is at Policies and strategies.

References

  • AIHW 2019a. National Cervical Screening Program monitoring report 2019. Cancer series no. 125. Cat. no.132. Canberra: AIHW.
  • AIHW 2019b. National Bowel Cancer Screening Program: monitoring report 2019. Cancer series no. 125. Cat. no. CAN 125. Canberra: AIHW.
  • AIHW 2019c. BreastScreen Australia monitoring report 2019. Canberra: AIHW
  • AIHW 2020. National Bowel Cancer Screening Program: monitoring report 2020. Cancer series no. 128. Cat. no. CAN 133. Canberra.
  • Bailie C, Matthews V, Bailie J, Burgess P, Copley K, Kennedy CM et al. 2016. Determinants and Gaps in Preventive Care Delivery for Indigenous Australians: A Cross-sectional Analysis. Frontiers in public health 4:34.
  • Bailie J, Schierhout GH, Kelaher MA, Laycock AF, Percival NA, O’Donoghue LR et al. 2014. Follow-up of Indigenous-specific health assessments — a socioecological analysis. The Medical Journal of Australia 200:653-7.
  • Christou A, Katzenellenbogen J & Thompson S 2010. Australia's national bowel cancer screening program: does it work for Indigenous Australians? BMC Public Health 10:21.
  • Clinical Principal Committee Standing Committee on Screening 2018. Population based Screening framework. (ed., Health Do). Canberra: Department of Health.
  • Condon JR 2004. Cancer, health services and Indigenous Australians. Department of Health and Ageing.
  • Condon JR, Armstrong BK, Barnes T & Zhao Y 2005. Cancer incidence and survival for Indigenous Australians in the Northern Territory. Australian and New Zealand journal of public health 29:123-8.
  • DoH (Australian Government Department of Health) 2020a. National cervical screening program. Viewed 8/7/2020.
  • DoH 2020b. Breastscreen. Department of Health. Viewed 8/7/2020.
  • DoH 2020c. Bowel cancer screening. Viewed 8/7/2020.
  • D'onise K, Iacobini ET & Canuto KJ 2020. Colorectal cancer screening using faecal occult blood tests for Indigenous adults: A systematic literature review of barriers, enablers and implemented strategies. Preventive Medicine 134:106018.
  • Jamison DT, Gelband H, Horton S, Jha P, Laxminarayan R, Mock CN et al. 2017. Disease Control Priorities, (Volume 9): Improving Health and Reducing Poverty. The World Bank.
  • Jamison DT, Mosley WH, Measham AR & Bobadilla JL 1993. Disease control priorities in developing countries: a summary. The World Bank.
  • Kolahdooz F, Jang SL, Corriveau A, Gotay C, Johnston N & Sharma S 2014. Knowledge, attitudes, and behaviours towards cancer screening in indigenous populations: a systematic review. The Lancet Oncology 15:e504-e16.
  • Parkin CJ, Bell SW & Mirbagheri N 2018. Colorectal cancer screening in Australia. Australian Journal of General Practice 47:859.
  • Reath J & Carey M 2008. Breast and cervical cancer in Indigenous women: overcoming barriers to early detection. Australian Family Physician 37:178.
  • Spurling G, Hayman NE & Cooney AL 2009. Adult health checks for Indigenous Australians: the first year's experience from the Inala Indigenous Health Service. The Medical Journal of Australia 190:562-4.
  • Valery PC, Coory M, Stirling J & Green AC 2006. Cancer diagnosis, treatment, and survival in Indigenous and non-Indigenous Australians: a matched cohort study. The Lancet 367:1842-8.
  • Whop LJ, Baade P, Garvey G, Cunningham J, Brotherton JML, Lokuge K et al. 2016. Cervical Abnormalities Are More Common among Indigenous than Other Australian Women: A Retrospective Record-Linkage Study, 2000–2011. PloS one 11:e0150473.
  • Zwar N & Ackermann E 2016. Guidelines for preventive activities in general practice, 2016, The Royal Australian College of General Practitioners. The Royal Australian College of General Practitioners.

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