Australia and New Zealand's responsibilities in improving oncology services in the Asia-Pacific: A call to action.

AIM: To review the expected increasing demand for cancer services among low and middle-income countries (LMICs) in the Asia-Pacific (APAC), and to describe ways in which Australia and New Zealand (ANZ) can provide support to improve cancer outcomes in our region. METHODS: We first review the current and projected incidence of cancer within the APAC between 2018 and 2040, and the estimated demand for chemotherapy, radiotherapy and surgery. We then explore potential ways in which ANZ can increase regional collaborations to improve cancer outcomes. RESULTS: We identify 6 ways that ANZ can collaborate with LMICs to improve cancer care in the APAC through the ANZ Regional Oncology Collaboration Strategy: Increasing education and institutional collaborations in the APAC region through in-country training, twinning partnerships, observerships and formalised training programs in order to increase cancer care quality and capacity. Promoting and assisting in the establishment and maintenance of population-based cancer registries in LMICs. Increasing research capacity in LMICs through collaboration and promoting high quality global oncology research within ANZ. Engaging and training Australian and New Zealand clinicians in global oncology, increasing awareness of this important career path, and increasing health policy engagement. Increasing web-based endeavours through virtual tumour boards, web-based advocacy platforms and web-based teaching programs. Continuing to leverage for funding through professional bodies, government, industry, not-for-profit organisations and local hospital funds. CONCLUSION: We propose the creation of an Australian and New Zealand Interest Group to provide formalised and sustained collaboration between researchers, clinicians and stakeholders.

Global demand for cancer surgery and an estimate of the optimal surgical and anaesthesia workforce between 2018 and 2040: a population-based modelling study.

BACKGROUND: The growing demand for cancer surgery has placed a global strain on health systems. In-depth analyses of the global demand for cancer surgery and optimal workforce requirements are needed to plan service provision. We estimated the global demand for cancer surgery and the requirements for an optimal surgical and anaesthesia workforce, using benchmarks based on clinical guidelines. METHODS: Using models of benchmark surgical use based on clinical guidelines, we estimated the proportion of cancer cases with an indication for surgery across 183 countries, stratified by income group. These proportions were multiplied by age-adjusted national estimates of new cancer cases using GLOBOCAN 2018 data and then aggregated to obtain the estimated number of surgical procedures required globally. The numbers of cancer surgical procedures in 44 high-income countries were divided by the actual number of surgeons and anaesthetists in the respective countries to calculate cancer procedures per surgeon and anaesthetist ratios. Using the median (IQR) of these ratios as benchmarks, we developed a three-tiered optimal surgical and anaesthesia workforce matrix, and the predictions were extrapolated up to 2040. FINDINGS: Our model estimates that the number of cancer cases globally with an indication for surgery will increase by 5 million procedures (52%) between 2018 (9 065 000) and 2040 (13 821 000). The greatest relative increase in surgical demand will occur in 34 low-income countries, where we also observed the largest gaps in workforce requirements. To match the median benchmark for high-income countries, the surgical workforce in these countries would need to increase by almost four times and the anaesthesia workforce by nearly 5·5 times. The greatest increase in optimal workforce requirements from 2018 to 2040 will occur in low-income countries (from 28 000 surgeons to 58 000 surgeons; 107% increase), followed by lower-middle-income countries (from 166 000 surgeons to 277 000 surgeons; 67% increase). INTERPRETATION: The global demand for cancer surgery and the optimal workforce are predicted to increase over the next two decades and disproportionately affect low-income countries. These estimates provide an appropriate framework for planning the provision of surgical services for cancer worldwide. FUNDING: University of New South Wales Scientia Scholarship and UK Research and Innovation Global Challenges Research Fund.

Evidence-based benchmarks for use of cancer surgery in high-income countries: a population-based analysis.

BACKGROUND: Estimating a population-level benchmark rate for use of surgery in the management of cancer helps to identify treatment gaps, estimate the survival impact of such gaps, and benchmark the workforce and other resources, including budgets, required to meet service needs. A population-based benchmark for use of surgery in high-income settings to inform policy makers and service provision has not been developed but was recommended by the Lancet Oncology Commission on Global Cancer Surgery. We aimed to develop and validate a cancer surgery benchmarking model. METHODS: We examined the latest clinical guidelines from high-income countries (Australia, the UK, the EU, the USA, and Canada) and mapped surgical treatment pathways for 30 malignant cancer sites (19 individual sites and 11 grouped as other cancers) that were notifiable in Australia in 2014, broadly reflecting contemporary high-income models of care. The optimal use of surgery was considered as an indication for surgery where surgery is the treatment of choice for a given clinical scenario. Population-based epidemiological data, such as cancer stage, tumour characteristics, and fitness for surgery, were derived from Australia and other similar high-income settings for 2017. The probabilities across the clinical pathways of each cancer were multiplied and added together to estimate the population-level benchmark rates of cancer surgery, and further validated with the comparisons of observed rates of cancer surgery in the South Western Sydney Local Health District in 2006-12. Univariable and multivariable sensitivity analyses were done to explore uncertainty around model inputs, with mean (95% CI) benchmark surgery rates estimated on the basis of 10 000 Monte Carlo simulations. FINDINGS: Surgical treatment was indicated in 58% (95% CI 57-59) of newly diagnosed patients with cancer in Australia in 2014 at least once during the course of their treatment, but varied by site from 23% (17-27) for prostate cancer to 99% (96-99) for testicular cancer. Observed cancer surgery rates in South Western Sydney were comparable to the benchmarks for most cancers, but were higher for some cancers, such as prostate (absolute increase of 29%) and lower for others, such as lung (-14%). INTERPRETATION: The model provides a new template for high-income and emerging economies to rationally plan and assess their cancer surgery provision. There are differences in modelled versus observed surgery rates for some cancers, requiring more in-depth analysis of the observed differences. FUNDING: University of New South Wales Scientia Scholarship, UK Research and Innovation-Global Challenges Research Fund.

Real-time laboratory surveillance of Dengue antigen(NS1) - Best proposed early warning and response system for Dengue in Sri Lanka? - Results from a pilot study.

Introduction: During the recent past, dengue fever and associated complications have been the most important concern for health policy makers of Sri Lanka. The current notification system has considerable inevitable delays in preventive measures. Objectives: Implementing a laboratory-based real-time antigen (NS1) surveillance system for notification coupled with a rapid preventive response within the Colombo district as a pilot project and compares the notifications with existing national surveillance systems. Methods: An online notification platform was established with a centralized database. Seven main laboratories of the private sector linked with the notification system, where they can create new notifications at the central database, whenever the NS1 test detected as positive. Relevant Medical Officers of Health should update action implemented to complete the response process. A dashboard was designed to visualize each notification and its status with a predefined colour code. Results: Patients from 14 Medical Officer of Health (MOH) areas out of 15 were captured. The immediate preventive response was recorded from the field preventive staff for 90% of the reporting. All most all attended patients have given health advice on awareness, prevention, and source reduction through premise inspection by trained field staff with 24hrs of notification. Conclusions: Salient features of the novel system are notification of antigen-positive patients, the rapidity of notification (real-time) and response, user-friendliness, access to multiple stakeholders simultaneously without data duplication, early involvement of the field staff, the ability to trace the cases using checklists and a color-coding system from a dashboard.

Designing an Optimum Fiscal Policy for Tobacco to Maximise the Tax Revenue, Social Savings and the Net Monetary Benefits in Sri Lanka.

BACKGROUND: Fiscal policy targeting tobacco control is identified as the most effective strategy for rapid control of tobacco use. An optimum fiscal policy to estimate the percentage taxation that will maximise the government tax revenue, social savings and the net monetary benefit has not been empirically designed before in Sri Lanka. METHODS: A model was developed using Microsoft Excel 2016, utilizing up-to-date published evidence on the cigarette sales, current fiscal policy, social cost of tobacco use, consumer response and the price elasticity of cigarettes. Univariate estimates on the expected revenue from tobacco tax, average annual social savings and the net monetary benefit were predicted for different levels of tobacco taxation. A deterministic sensitivity analysis was performed covering all possibilities. The percentage taxation maximizing the government tax revenue and the net monetary benefit were identified. RESULTS: It was estimated that a further 30% tax increase from the 2019 baseline will generate approximately LKR 3544 million per year of additional tax revenue for the government while saving LKR 28 069 million per annum as social savings. A fiscal elevation of 50% will produce identical annual tax revenue to that of 2018, while securing a social saving of more than LKR 47 600 million per annum. The maximum net monetary benefit is achievable at an overnight tax increase of 90% from the baseline, however with a short-term compromise in tax revenue. CONCLUSION: The well-defined thresholds take tobacco taxation advocacy in Sri Lanka a step forward and will assist the government in taking an informed decision on its fiscal policy for cigarettes.

Cost effectiveness of dengue vaccination following pre-vaccination serological screening in Sri Lanka.

OBJECTIVE: This study sets an example of an economic evaluation of a model dengue vaccination strategy for Sri Lanka, following a mandatory pre-vaccination screening strategy. METHODS: A decision analytic Markov model was developed to estimate the cost-effectiveness of a predicted dengue vaccination strategy over a time horizon of 10 years. The cost effectiveness of dengue vaccination strategy for seropositive individuals was estimated in terms of incremental cost effectiveness ratio (ICER) (cost per additional quality adjusted life-year [QALY]). District-specific ICER values and the budget impact for dengue vaccine were estimated with appropriate sensitivity analyses, also taking the variability of the pre-vaccination screening test performance into consideration. RESULTS: The ICER for the predicted vaccination strategy following pre-vaccination screening was 4,382 USD/QALY for Sri Lanka. There was a significant regional variation in vaccine cost effectiveness. The disaggregated regional incidence of dengue and the need to perform pre-vaccination screening affects the cost effectiveness estimates significantly, where a safer version of the vaccine has the potential to become cost saving in high incidence districts. CONCLUSIONS: The cost effectiveness of the predicted dengue vaccination strategy following pre-vaccination screening showed a significant regional variation across the districts of Sri Lanka. District-wise disease incidence and the need for pre-vaccination screening was found to be the most significant factors affecting the cost effectiveness of the vaccine.