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Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Australia's health 2014Understanding health & illness Australia's health system How healthy are we? Some physical and mental conditions can occur across the lifespan among all people, while others occur more frequently among certain age or population groups. The impact of some types of illness can be surprising—for example, mental and behavioural disorders, which are mostly chronic rather than acute, rank only marginally behind cancer, musculoskeletal conditions and cardiovascular disease, in that order, in terms of disease burden in Australasia. This chapter endeavours to highlight the leading causes of ill health in Australia, both physical and mental, and the impact of these illnesses. There has been considerable success in this country in preventing and treating many chronic diseases—for example, through national cancer screening programs that offer better and earlier detection. To ensure a health system is aligned to a country's health challenges, policy makers must be able to compare the effects of different conditions that cause ill-health and premature death.
The most recent global estimates come from the Global Burden of Disease Study 2010, which covered 241 diseases and injuries and 57 risk factors for 187 countries for 1990, 2005 and 2010 (The Lancet 2012). The last national burden of disease analysis that provided estimates for the Australian and Aboriginal and Torres Strait Islander populations was published in 2007, based on 2003 data. What follows is a snapshot of the global study findings for the Australasia region (Australia and New Zealand) published in late 2012.
Non-communicable (largely chronic) diseases accounted for about 85% of the total burden of disease in Australasia in 2010, while injuries accounted for 10%.
The largest contributors to the total burden were cancer (16%), musculoskeletal disorders (15%), cardiovascular diseases (14%) and mental and behavioural disorders (13%).
Musculoskeletal disorders contributed 26% and mental and behavioural disorders 23% of the non-fatal burden in 2010.
Of the risk factors considered by the study, dietary risks (accounting for 11% of the total burden), high body mass index (9%) and smoking (8%) were the leading risk factors. While these risk factors are known to be associated with many diseases, the main conditions affected by these risk factors were cancer, cardiovascular diseases, and diabetes, urogenital, blood and endocrine diseases combined.
A larger fraction of the burden is now caused by ill-health rather than premature death (Figure 4.1). Cancer (ranked 2 in 1990) and musculoskeletal conditions (ranked 3 in 1990) replaced cardiovascular diseases as the leading contributors to the Australasian total disease burden in 2010. Unintentional injuries (other than transport injuries) replaced transport injuries as the largest contributor to injuries. For risk factors, dietary risks and smoking were ranked 1 and 3 respectively in both 1990 and 2010. Ischemic heart disease, lung cancer and stroke were the top 3 contributors to the fatal burden in all countries, while low back pain was the top contributor to the non-fatal burden. As a group, dietary risks was the largest risk factor contributor to overall burden in those countries. The Global Burden of Disease Study 2010 is an important source of information for setting global health priorities.
The global study also included conditions and risk factors not experienced in Australia (for example, cholera), while other conditions and risk factors of policy interest to Australia were not included (for example, mesothelioma).
Chronic diseases are the leading cause of illness, disability and death in Australia, accounting for 90% of all deaths in 2011 (AIHW 2011b).
Many different illnesses and health conditions can be classified under the broad heading of chronic disease. To simplify, chronic disease is often discussed in terms of 4 major disease groups—cardiovascular diseases, cancers, chronic obstructive pulmonary disease (COPD) and diabetes, with 4 common behavioural risk factors—smoking, physical inactivity, poor nutrition and harmful use of alcohol. Long common in Australia and other developed countries, illness and death from chronic disease is now becoming widespread in developing countries, as rising incomes, falling food prices and increasing urbanisation lead to global changes in diet, overweight and physical inactivity (AIHW 2012d; WHO 2011).
Because of its personal, social and economic impact, tackling chronic disease and its causes is the biggest health challenge that Australia faces. Chronic diseases can range from mild conditions such as short- or long-sightedness, dental decay and minor hearing loss, to debilitating arthritis and low back pain, and to life-threatening heart disease and cancers.
These chronic diseases have each been the focus of recent surveillance efforts, because of their significant health effects and costs, and because actions can be taken to prevent them (AIHW 2011b). Table 4.1 gives a further indication as to how widespread these diseases are, with their consequent toll on health, their demands on primary health care and their cost. Leaving aside more common chronic conditions such as short- or long-sightedness and hearing problems, Australian Health Survey data for 2011–12 indicate that almost 15% of the population had arthritis, 13% had back problems, 10% hypertensive disease, 10% asthma and 10% depression. GPs report that the most common chronic diseases or conditions they see are hypertension, diabetes and depression, followed by arthritis and lipid disorders, including high blood cholesterol. However, death rates for some chronic diseases appear to have peaked in Australia (Figure 4.2), particularly for cardiovascular disease and some cancers such as lung cancer.
Deaths registered in 2009 and earlier are based on the final version of cause of death data; deaths registered in 2010 and 2011 are based on revised and preliminary versions, respectively, and are subject to further revision by the ABS.
Since chronic diseases are responsible for the greatest amount of illness and death, it is not surprising that they also cause the greatest burden of disease (Table 4.1). The largest disease groups contributing to the Australasian burden of disease in 2010 were cancer, musculoskeletal disorders, cardiovascular diseases, and mental and behavioural disorders. In addition to the personal and community costs, chronic diseases result in a significant economic burden because of the combined effects of health-care costs and lost productivity from illness and death. This amount is conservative because not all health-care expenditure can be allocated by disease, particularly diseases predominantly managed in primary health care. Although patterns of spending vary by disease group, most health dollars that can be allocated to diseases are spent on admitted patient hospital services, out-of-hospital services, medications, and dental services (see Chapter 2 'How much does Australian spend on health care?' and Figure 2.6). Coronary heart disease has a 40% higher death rate and has demonstrated a lesser rate of decline over time among people living in areas of lowest socioeconomic status compared with those in the highest (AIHW, forthcoming 2014b). The rate of new cases of lung cancer for people living in areas of lowest socioeconomic status was 1.6 times that of people in the highest, which is linked to their higher rates of smoking. People who live in areas of lowest socioeconomic status are also more likely to take part in risky health behaviour, or combinations of behaviours, which can lead to poorer chronic disease outcomes. It is useful to examine how chronic disease occurs across different stages of the life course, because of the strong links between earlier exposures and later health outcomes. Social determinants of health, experienced at different life stages, can also influence the development of chronic diseases, through their effect on biological processes (Lynch & Davey Smith 2005).
Coronary heart disease and COPD are leading examples of strong links between several life course risk factors and processes and the later development of chronic disease (see Table 4.2). The most common chronic diseases or conditions among older Australians are some degree of vision or hearing loss, arthritis or other musculoskeletal problems, and elevated blood pressure or cholesterol levels. Chronic diseases are closely associated with modifiable risk factors such as smoking, physical inactivity, poor nutrition and the harmful use of alcohol. People often have combinations of risk factors, and as their number of risk factors increase, so does the likelihood of developing certain chronic diseases. A group of risk factors, known collectively as the 'metabolic syndrome', greatly increases the risk of type 2 diabetes. The cumulative effect of risk factors magnifies the risk, with earlier and more rapid development of a condition, more complications and recurrence, a greater disease burden, and a greater need for management of the condition (AIHW 2012b). A key focus of the Australian health system therefore is the prevention and better management of chronic disease to improve health outcomes.
There would seem to be great potential in an integrated and coordinated approach to chronic disease care using shared prevention, management and treatment strategies.
If left unchecked, trends in chronic disease risk factors—especially physical inactivity and poor nutrition leading to overweight and obesity—combined with a growing and ageing population will lead to increasing numbers of people living with chronic diseases. The growing chronic disease burden will require effective treatment of multiple chronic conditions and catering to complex health-care needs. The availability of better statistical information on the incidence and prevalence of chronic diseases could benefit future health services planning.
Additional data on comorbidity and treatment—including data on primary care, health service use, medications and whether these are being taken correctly, quality of life, and people's ability to carry out their daily lives—will also help in developing a picture of how chronic diseases affect people in Australia and the effectiveness of strategies. Cancer is a diverse group of several hundred diseases in which some of the body's cells become abnormal and begin to multiply out of control. In 2010, 116,580 new cases of cancer were diagnosed in Australia (excluding basal and squamous cell carcinoma of the skin—the most common types of non-melanoma skin cancer).
The risk of being diagnosed with any cancer before the age of 85 was 1 in 2 for males and 1 in 3 for females. The most commonly diagnosed cancers in 2010 were prostate in males (19,821), bowel (14,860), breast cancer in females (14,181), melanoma of the skin (11,405) and lung (10,296) (Figure 4.3). The number of new cases of cancer diagnosed in Australia is projected to continue to rise over the next decade and is expected to reach 150,000 in 2020. The most common causes of cancer-related death in 2011 were lung (8,114 deaths), bowel (3,999), prostate in males (3,294), breast in females (2,937) and pancreatic (2,416) cancers. In 2006–2010, people diagnosed with cancer had a 66% chance of surviving for at least 5 years compared with their counterparts in the general population (referred to as 5-year survival, see Glossary).
Five-year survival from all cancers increased over time, from 47% in 1982–1987 to 66% in 2006–2010.
The cancers with the largest survival gains were prostate cancer, kidney cancer and non-Hodgkin lymphoma. In 2007, about 1 in 28 living Australians had been diagnosed with cancer at some time in the previous 26 years (referred to as 26-year prevalence, see Glossary). In 2011–12, there were more than 908,700 hospitalisations (see Glossary) for cancer or a cancer-related health service or treatment. There are no national registry data on the stage (severity) of cancer at diagnosis, treatments applied to individual cases of cancer, the frequency of recurrence of cancer after treatment, or the incidence of non-melanoma skin cancers. There have been many successes, and there are many remaining challenges, in cancer control. These changes in the cancer landscape are not universal, and differ greatly by cancer type and population group. The observed rise in overall cancer incidence can be broadly attributed to advancements in early detection (through organised screening programs and better detection technology), the ageing population and changes in risk factor exposure. The net result of increasing cancer incidence and decreasing overall mortality is more people living with cancer, that is, higher and gradually increasing prevalence due to increased survival in the population. Cancer, also called malignancy, is a term for diseases in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread to other parts of the body through the blood and lymph systems. In 2008–2009, the total health system expenditure in Australia on neoplasms (including cancer and non-cancerous tumours) was $4,526 million, an increase from $2,894 million in 2000–01, after adjusting for inflation (AIHW 2013).
There were 116,580 new cases of cancer in 2010 (excluding non-melanoma skin cancer), a rate of 487 per 100,000 people. The incidence of all cancers combined was 1.4 times as high among males (585 per 100,000) compared with females (406 per 100,000). Mortality from all cancers combined was 1.6 times as high among males (219 per 100,000) compared with females (137 per 100,000).
Cancer can develop at any age but around 70% of all cancers are diagnosed in people aged 60 and over. Deaths from cancer are most common among older people, with more than 80% of all deaths from cancer occurring in people aged 60 and over. Survival decreased with age: from 86% among people aged 0–39 to 43% among those aged 80 and over.
Indigenous Australians were 1.1 times more likely to be diagnosed with cancer in 2004–2008 compared with their non- Indigenous counterparts. Indigenous Australians were 1.5 times more likely to die from cancer in 2007–2011 compared with their non-Indigenous counterparts. Indigenous Australians had lower 5-year relative survival (40%) in 1999–2007 compared with their non-Indigenous counterparts (52%).
People living in areas of lower socioeconomic status had a higher incidence of all cancers combined (490 per 100,000) compared with people living in areas of higher relative socioeconomic status (482 per 100,000), in 2004–2008. People living in areas of lower socioeconomic status had higher mortality from all cancers combined (172 per 100,000) compared with people living in areas of higher relative socioeconomic status (151 per 100,000), in 2006–2010. People living in areas of lower socioeconomic status had lower 5-year relative survival (63%) compared with people living in areas of higher socioeconomic status (71%), in 2006–2010. Incidence rates of all cancers combined were higher for Australians living in Inner regional areas (504 per 100,000) than people living in Outer regional (495 per 100,000), Major cities (480 per 100,000) and Remote and Very remote areas (474 per 100,000), in 2004–2008. Mortality rates for all cancers combined were higher for Australians living in Remote and Very remote areas (196 per 100,000) and Outer regional areas (193 per 100,000) than for those living in Major cities (171 per 100,000) and Inner regional areas (185 per 100,000), in 2006–2010.
Five-year survival from all cancers combined was highest among people living in Major cities (67%) compared with Inner regional (66%), Outer regional (65%) and Remote and Very remote areas (63%), in 2006–2010.
In Australia, there are some notable historical trends in cancer incidence, mortality and survival (Figure 4.4). Data points for 5-year relative survival refer to the final year in each 5- or 6-year at-risk period: 1982–1987, 1988–1993, 1994–1999, 2000–2005, 2006–2010. Changes in cancer incidence, mortality and survival have been shaped by a wide range of factors, including changes in exposure to the risk factors for cancer, improved primary prevention, advancements in cancer treatment, and for some cancers, earlier detection through organised screening programs (bowel, breast and cervical) and opportunistic testing (prostate) (Armstrong 2013). Changes in exposure to cancer risk factors at the population level can increase or decrease cancer incidence, which in turn may produce a parallel change in cancer mortality, noting the lag in time between exposure and the onset of cancer (Armstrong 2013). Selected cancers strongly influenced by changes in exposure to known and quantifiable risk factors in previous decades include lung and stomach cancers, melanoma of the skin and cervical cancer.
The major causes of stomach cancer are the bacterium Helicobacter pylori, poor nutrition and smoking.

Chronic infection with the human papillomavirus (HPV ) is the cause of around 70–80% of all cervical cancers (Brotherton 2008).
Australia has national population screening programs for 3 cancers—breast, cervical and bowel cancer.
These screening programs aim to reduce illness and death from these cancers through early detection of cancer and pre-cancerous abnormalities and effective follow-up treatment. The introduction of the BreastScreen Australia program resulted in an initial rapid increase in the number of breast cancers diagnosed in 1992–1994, followed by a more moderate increasing trend to 2010, accompanied by a steady decline in breast cancer mortality from 1994 (Figure 4.5A). For more information on cancer screening programs, see Chapter 8 'Cancer screening in Australia'. Deaths registered in 2008 and earlier are based on the final version of cause of death data; deaths registered in 2009 and 2010 are based on revised and preliminary versions, respectively, and are subject to further revision by the ABS. The solid vertical line at 1991 indicates the introduction of the national screening programs. Broadly, a variety of improvements in cancer treatments are thought to have led to improvements in cancer outcomes, particularly decreasing mortality (improved survival). Note: Projected years 2011 to 2020 based on actual data from 1982 to 2007 (incidence) and 1968 to 2010 (mortality). The combined effect of several factors—increasing incidence, decreasing mortality in some cancers, high and improving survival for some cancers, earlier diagnosis and detection, and developments in treatment and management of cancer—is a steady increase in the proportion of the population who have been diagnosed with cancer. In 2007, there were around 775,000 Australians alive who had been diagnosed with cancer in the 26 years since incidence data were first collected at a national level (from 1982), accounting for 3.7% of the total Australian population in that year (AIHW 2012b). This will all mean, now and into the future, major changes in the experience of cancer for some individuals, their families and carers (Hawkins et al. These changes and challenges are being seen now in emerging issues such as the survivorship experience, caring for people with cancer, ageing with cancer, recurrent and multiple primary cancers, and cancer in the presence of other conditions (comorbidity). Survivorship is increasingly recognised as beginning at diagnosis and continuing long after treatment ends. These longer-term risks, and the associated stressors and reduced quality of life for cancer survivors and their family, friends and caregivers, highlight the importance of follow-up health care and of survivorship as part of the cancer control continuum (Hawkins et al. The increasing size of the population who have had cancer also means a corresponding increase in the number of people caring for someone through cancer diagnosis, treatment and remission, often into old age. The increasing size of the aged population in Australia is a contributing factor to the projected increase in the number of new cancer cases and cancer-related deaths to 2020. As people survive longer with cancer it will become increasingly important for cancer to be considered in the context of patients' other ongoing health conditions. In 2011, cancer was recorded as the underlying cause in 43,221 deaths, accounting for 29% of all deaths in that year. When cancer was recorded as a cause of death (either underlying or associated), it was the underlying cause in 87% of those deaths. Clipping is a handy way to collect and organize the most important slides from a presentation. Having type 2 diabetes greatly increases your risk of having a heart attack or stroke as well as other health complications. Popular Articles 1 Understanding Blood Pressure Readings 2 Sodium and Salt 3 All About Heart Rate (Pulse) 4 What are the Symptoms of High Blood Pressure? This site complies with the HONcode standard for trustworthy health information: verify here. The CDC Arthritis Program recommends self-management education programs and physical activity programs for all people with arthritis.
Health care providers can also help people improve their quality-of-life by referring them to chronic disease self-management education programs that address the effects of arthritis and other chronic conditions.
Learn about CDC recommended intervention programs that are proven to improve the quality of life of people with arthritis. Being physically active is an essential part of preventing and managing many chronic conditions, including arthritis, heart disease, diabetes, and obesity. Health care providers can help people overcome arthritis-specific barriers to physical inactivity by providing appropriate advice and referrals to evidence-based physical activity programs that are designed for adults with arthritis.
Learn about intervention programs, such as self-management education programs and physical activity programs, that are designed to teach people the skills they need to take charge of their conditions and engage in effective, joint-friendly physical activity. Being physically active is an important component of heart disease management, but people with heart disease are less likely to comply with physical activity recommendations than those without heart disease. What are the benefits of increased physical activity for people with heart disease and arthritis?
What are the benefits of increased physical activity for people with diabetes and arthritis?
Adults with both arthritis and diabetes were 30% more likely to be physically inactive than those with diabetes only, even after adjustment for age, sex, and body mass index (BMI). What can people with arthritis and other chronic conditions do to overcome the challenges of both conditions? People with arthritis and other chronic conditions can participate in interventions programs, such as self-management education programs and physical activity programs, that are designed to teach them the skills they need to take charge of their conditions and engage in effective, joint-friendly physical activity. And some types of ill health have a bigger impact on our society than others in terms of healthy years of life lost due to illness or death—often referred to as burden of disease. Chronic diseases, including cancer which is also featured in this chapter, are the leading cause of ill health and death in Australia, and have been for some decades, now that the impact of communicable diseases has diminished through vaccination and other prevention and treatment practices.
But overall, the adverse effects of behavioural and other health risk factors, combined with an ageing population, have led to an increase in their impact on our society. Burden of disease analysis simultaneously compares the non-fatal burden (impact of ill-health) and fatal burden (impact of premature death) of a comprehensive list of diseases and injuries, and quantifies the contribution of various risk factors to the total burden as well as to individual diseases and injuries.
To enable global comparability on such a broad scale, the study needed to introduce innovative methods as well as manage limitations in data availability.
The AIHW is updating these estimates using the 2010 global burden of disease methodology where possible, with some enhancements to better suit the Australian and Indigenous contexts, and using more recent and detailed Australian data.
High body mass index was the second-highest risk factor in 2010, replacing high blood pressure, which was second highest in 1990. However, it does not provide estimates by population groups—in particular the Aboriginal and Torres Strait Islander population—or at a subnational level (for example, by state and territory, remoteness or socioeconomic classification). The advent of chronic diseases follows successes in limiting infection and infant deaths during the late 19th and early 20th century.
They often coexist, share common risk factors and are increasingly being seen as acting together to determine the health status of individuals.
Between them, these 4 disease groups account for three-quarters of all chronic disease deaths. The worldwide chronic disease 'pandemic' was the subject of a high-level United Nations meeting in 2011, which called for a 25% reduction by 2025 in mortality from chronic diseases among people aged between 30 and 70, adopting the slogan '25 by 25' (Beaglehole et al. A growing understanding that many of these diseases arise from similar underlying causes, have similar features, and share a number of prevention, management and treatment strategies, as well as significant and increasing costs, is challenging us to transform the way in which we respond to chronic disease.
They can result from complex causes, which can include a number of different health risk factors. These conditions may never be cured completely, so there is generally a need for long-term management. Analysis of the 2007–08 National Health Survey indicates that one-third of the population (35%, or 7 million people) reported having at least 1 of the following chronic conditions: asthma, type 2 diabetes, coronary heart disease, cerebrovascular disease (largely stroke), arthritis, osteoporosis, COPD, depression or high blood pressure. Since 1980, coronary heart disease (CHD) mortality has declined by 73%, cerebrovascular disease by 69% and all cancers by 17%. Data for 2010 have not been adjusted for the additional deaths arising from outstanding registrations of deaths in Queensland in 2010.
Cardiovascular diseases (coronary heart disease and stroke), dementia and Alzheimer disease, lung cancer and chronic lower respiratory disease including COPD are the most common underlying causes, together being responsible for 40% of all deaths.
The overall burden is measured by the disability-adjusted life year (DALY), which is expressed as the number of years lost due to ill health, disability or early death (see Chapter 4 'Burden of disease'). The 5 leading individual causes of disease burden—heart attack, low back pain, COPD, depression and cerebrovascular disease—accounted for one-quarter of the disease burden. Estimates based on allocated health-care expenditure indicate that the 4 most expensive disease groups are chronic—cardiovascular diseases, oral health, mental disorders, and musculoskeletal—incurring direct health-care costs of $27 billion in 2008–09. Chronic disease costs would also be far greater if non-health sector costs, such as residential care, were included. The large cost, in the order of several billions of dollars, is 1 of the key drivers for more efficient and effective ways to prevent, manage and treat chronic disease. They occur more often among Indigenous Australians, for example, and at a much younger age (AIHW 2010). Survival of people diagnosed with cancer living in the lowest status areas is also lower (AIHW & AACR 2012).
In 2011–12, people living in areas of lowest socioeconomic status were 2.3 times as likely to smoke as those living in the highest (ABS 2013a).
In 2007–08, 350,000 people (2% of the total population) reported having 4 or more concurrent chronic health conditions out of a list comprising asthma, type 2 diabetes, coronary heart disease, cerebrovascular disease, arthritis, osteoporosis, COPD, depression and high blood pressure. Some diseases, such as asthma and type 1 diabetes, usually begin in childhood or adolescence. Often, adult chronic diseases reflect the cumulative influence of prior physical growth, of reproduction, infection, social mobility and changes in behaviour.
Low birthweight babies, for example, are more likely to come from less affluent backgrounds, and low birthweight is associated with increased rates of cardiovascular disease and diabetes later in life. Many of these risk factors can interact with each other as well as with chronic disease development. Around 15% of people in the 0–24 age group reported having either asthma, type 2 diabetes, coronary heart disease, cerebrovascular disease, arthritis, osteoporosis, COPD, depression or high blood pressure, in 2007–08. Yet despite the frequency of chronic disease in later life, two-thirds of older Australians aged 75 and over rate their health as good, very good or excellent. Modifying these can reduce the risk of developing a chronic condition, leading to large health gains in the population through the reduction of illness and rates of death (see Chapter 8 'Prevention for a healthier future').
These behaviours contribute to the development of biomedical risk factors, including overweight and obesity, high blood pressure, and high cholesterol levels, which in turn lead to chronic disease (see Chapter 5 'Biomedical risk factors' and 'Behavioural risk factors' for further details).
For example, males with 5 or more risk factors are 3 times as likely to have COPD as males with 2 or fewer risk factors.
In 2010, 38% of current smokers also consumed alcohol at risky levels, compared with only 12% of people who had never smoked (AIHW, forthcoming 2014a). This risk factor group comprises obesity, impaired fasting blood glucose, raised blood pressure, raised blood triglycerides and reduced HDL cholesterol.
Many common chronic diseases are amenable to preventive measures such as changes in behaviour.
Reducing obesity, for example, may prevent diabetes, hypertension, heart disease, and certain types of cancers. Helping people to make good lifestyle choices at all stages of the life course can help to keep them in good health and prevent illness for as long as possible.
Developing and implementing new and innovative treatment methods—including coordinated care and chronic disease management plans—holds great promise for future disease management (see Chapter 8 'Primary health care in Australia').
Contribution of chronic disease to the gap in adult mortality between Aboriginal and Torres Strait Islander and other Australians.
Multiple causes of death in Australia: an analysis of all natural and selected chronic disease causes of death 1997-2007.
The abnormal cells can invade and damage the tissue around them, and spread to other parts of the body, causing further damage and eventually death. Between 1990 and 2010, the age-standardised incidence rate (see Glossary) for total cancers rose by 16%, from 422 new cases per 100,000 people to 488 per 100,000. This increase in the number of new cases, due primarily to population growth and ageing, is expected to be most evident among older populations.
Between 1991 and 2011, the age-standardised mortality rate for all cancers combined fell by 17%, from 210 deaths per 100,000 people to 172 per 100,000.
Among people who had already survived 5 years past their cancer diagnosis, the chance of surviving for at least another 5 years was 91%. Some of the likely reasons for this include better diagnostic methods, earlier detection and improvements in treatment. The cancers with a decline or no improvement in survival were bladder, larynx, lip and brain cancers, and chronic lymphocytic leukaemia. Chemotherapy sessions accounted for 41% of these hospitalisations, followed by non-melanoma skin cancer (11%). While the incidence of cancer is rising, the good news is that overall average mortality at the population level is falling and real improvements in survival are continuing.
The overall average is not necessarily indicative or representative of individual experience, where a diagnosis of cancer is anything but 'good news'.
The observed fall in the overall cancer mortality rate can be mainly attributed to a combination of earlier detection (at a more treatable stage) and more effective treatments. Better survival rates for some cancers bring an increasing emphasis on living with, and after, a cancer diagnosis. Cancer contributed 16% of the total disease burden in Australasia (Australia and New Zealand), based on findings from the Global Burden of Disease Study 2010. The majority of health system expenditure on cancer in 2008–09 was on hospital-admitted cancer services (79%), followed by prescription pharmaceuticals (12%) and out-of-hospital services (9%). That is, people diagnosed with cancer had a 66% chance of surviving at least 5 years compared with their counterparts in the general population. The trend data presented here reflect the breadth (from first to most recent year) of available national data: 1982–2010 for incidence, 1968–2011 for mortality and 1982–1986 to 2006–2010 for survival.

This increase reflects annual rises in the incidence of some of the most commonly diagnosed cancers such as prostate cancer, breast cancer and melanoma of the skin, as well as some rarer cancers such as liver and testicular cancers. This fall reflects substantial improvements in survival, thought to include substantial real gains in survival—that is, delaying death, and not only earlier diagnosis extending the measured time between diagnosis and death.
This trend was observed for most, but not all, cancer types: survival from bladder, larynx and lip cancers fell, although the change was only significant for bladder cancer.
Lung cancer incidence and mortality among males has declined steadily since the 1980s, which is attributed to the steadily declining rate in daily tobacco smoking: from 58% in 1964 to 16% in 2010. There have been continuous falls in stomach cancer incidence between 1982 and 2010, and stomach cancer mortality between 1968 and 2011—2% and 3% per year, respectively. The AIHW and the Victorian Cytology Service recently conducted a study to evaluate the effectiveness of the HPV vaccine against cervical abnormalities among school-aged women (Gertig et al.
BreastScreen Australia was introduced in 1991, the National Cervical Screening Program (NCSP) also started in 1991, and the National Bowel Cancer Screening Program (NBCSP) was introduced in 2006. Since it was introduced, BreastScreen Australia has had a major impact in moderating an increasing incidence trend and in contributing to falling mortality in breast cancer.
The introduction of the NCSP resulted in a rapid decline (from an already decreasing trend) in cervical cancer incidence from 1991 to 2002, followed by a more stable trend to 2010 and a steady decline in cervical cancer mortality from 1991 to 2004, followed by a stable trend to 2010 (Figure 4.5B). It is likely, based on the continuation of current projected trends in incidence and mortality, that this population will continue to slowly rise over time, with an accompanying rise in the economic and social burden of cancer.
It is more than simply not dying from cancer, and focuses on living with, and after, a cancer diagnosis (Jackson et al.
While it is not possible with current available data to examine the incidence and prevalence of cancer as a comorbid condition, it is possible to use mortality data to analyse the proportion of Australians who have both cancer and other conditions recorded as causes of death. However, this type of analysis excludes those deaths where cancer was an associated cause of death, that is, any cause other than the underlying cause. Cancer was recorded as an associated cause in an additional 6,299 deaths, where the most common underlying causes were chronic ischaemic heart disease, acute myocardial infarction or other chronic obstructive pulmonary disease.
Of these, 35% had only 1 cause recorded (the underlying cause), followed by 23% with 2 causes, 19% with 3 causes and 12% each with 4 and 5 or more causes.
People with other chronic conditions, such as heart disease or diabetes, who also have arthritis. High blood pressure is also associated with heart disease, the most common comorbidity among adults with arthritis (shown in Figure 1). These programs teach people skills to take charge of their conditions and engage in effective, joint-friendly physical activity.
Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation-United States, 2010a€“2012. Increasing physical activity (for example, through aerobic exercise or strength training) can benefit people with heart disease and arthritis. Being physically inactive is an even bigger problem for people with heart disease who also have arthritis (Figure 1). Arthritis as a potential barrier to physical activity among adults with heart disease a€” United States, 2005 and 2007. Being physically inactive is an even bigger problem for people with diabetes who also have arthritis. This means that simply having diabetes and arthritis together increases your likelihood of physical inactivity, regardless of your age, sex, or BMI. Arthritis as a Potential Barrier to Physical Activity Among Adults with Diabetes a€” United States, 2005 and 2007.
Indigenous and subnational breakdowns are key priorities for the current Australian Burden of Disease study. With changing lifestyles and ageing population, chronic diseases have become increasingly common and now cause most of the burden of ill health. There is great potential for integrating prevention and care, and treating selected chronic diseases together, to keep people healthy for as long as possible.
They are a leading cause of disability, and have major impacts on health and welfare services (AIHW 2010). Once present, chronic diseases often persist throughout life, although they are not always the cause of death.
The relative contribution of these causes to total deaths has also changed—for CHD the relative contribution fell from 33% in 1980 to 15% in 2011, and for cerebrovascular disease from 15% to 8%.
When a chronic disease is the underlying cause of death, other chronic diseases, such as cancers of unknown primary site, hypertensive diseases, and coronary heart disease, are common associated causes of death.
A recent international study found that in Australia and New Zealand, chronic diseases together caused 85% of the total burden of disease, a similar figure to chronic diseases accounting for 90% of the burden due to deaths alone (IHME 2013). Two-thirds of the gap in death rates between Aboriginal and Torres Strait Islander and non-Indigenous people is contributed by chronic disease (AHMAC 2012). People living in these same areas of disadvantage were 1.7 times as likely to report having 4 or more risk factors (AIHW 2012b). This proportion increases with age, so that among people aged 65 or older, 8% had 4 or more of these chronic diseases. Others, such as coronary heart disease or cerebrovascular disease, are uncommon before adulthood, although the processes leading to their occurrence begin earlier in life. Adult risk factors for chronic disease also have their own histories; what people do or do not eat in adulthood, for example, is often established much earlier in life. For example, in-utero biological effects, combined with poor nutrition early in life, may affect how particular forms of fat are tolerated later in life.
Seventy per cent of all cardiovascular disease mortality in Australia has been attributed to the combined effects of high blood pressure, high cholesterol and physical inactivity (Begg et al. Females with 5 or more risk factors are 3 times as likely to have had a stroke, and two and a half times as likely to have depression as females with 2 or fewer risk factors (AIHW 2012b).
Daily smoking is also more commonly reported by people with low levels of physical activity.
These changes, together with timely and better medical treatments, are important in improving chronic disease health outcomes. Assessing the risk of cardiovascular disease on the basis of the combined effect of multiple risk factors (absolute cardiovascular disease risk) can lead to better management of modifiable risk factors through lifestyle changes and pharmacological therapy (National Vascular Disease Prevention Alliance 2012).
Despite a decline in cancer deaths and an increase in survival over time, cancer is still the second-most common cause of death in Australia—after cardiovascular diseases.
This was driven by rises in the incidence of prostate, breast and bowel cancers, due largely to improved detection and diagnosis of these cancers. The fall in mortality rates was driven by falls in lung, prostate and bowel cancer death rates among males, and falls in breast and bowel cancer death rates among females. The 26-year prevalence was highest for breast cancer (151,152 women), melanoma of the skin (136,016), prostate cancer (129,978 men) and bowel cancer (105,144).
The number of cancer-related deaths is attributable to changes in risk factor exposure and the ageing of the population.
Carcinoma is a cancer that begins in the skin or in tissues that line or cover internal organs. Expenditure on national population screening programs was just over $332 million in 2008–09.
In contrast, the incidence of some cancers, including lung, bladder and cervical, fell significantly in that same period. There has been a gain in the overall trend in more recent years, with mortality falling by an average of 1.0% per year from 1991 to 2011. In contrast, for females, lung cancer incidence and mortality among females continue to rise. Similarly, the NCSP has had a major impact in enhancing decreasing trends for cervical cancer incidence and mortality (Figure 4.5).
It also means a challenge for the health system in responding to these changes, particularly with an ageing population. Many cancer support organisations and groups recognise the importance and growing size of this population, and provide support to carers, siblings and friends of people with cancer (Cancer Council Victoria 2011). In total, 49,520 deaths in that year (34%) included cancer as a cause of death (either underlying or associated). The proportion of deaths reported as being caused by 3 or more causes rose from 32% in 1997 to 42% in 2011 (Figure 4.7). Arthritis also may directly relate to physical inactivity, which can lead to obesity and other chronic conditions. Physical inactivity is more common in adults who have both arthritis and heart disease compared with people who only have one or neither condition.
Physical inactivity is most common in adults who have both arthritis and diabetes compared with people who only have one or neither condition.
Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation-United States, 2010-2012. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2005.
Notably, mental health-related issues are not a major cause of death, but they do cause significant ill health and disability in the Australian population (see Chapter 4 'Mental health in Australia'). Indigenous people report diabetes at more than 3 times the rate of other Australians, and rates of treatment for end-stage kidney disease are more than 7 times as great. Arthritis and high blood pressure are 2 conditions that commonly occur together among adults. Today's children, who are subject to increased behavioural risks at earlier ages through the consumption of energy-dense foods and poor diet, increased screen time and reduced physical activity, will live longer with risk factors such as obesity (Amschler 2002; Swinburn et al. Observing risk factors and chronic disease development in populations from an early age can provide valuable lessons for future disease management.
Early social disadvantage may interact with affluence in later life to increase coronary heart disease risk. Similarly, around half of people aged 65–74 had to cope with 5 or more chronic diseases, increasing to 70% of those aged 85 and over (AIHW 2012a).
Identifying populations most at risk and monitoring and evaluating preventive interventions are also important (AIHW 2011b).
These strategies all involve better delivery and coordination across the health-care continuum, from health promotion and prevention, to early detection where appropriate, and to primary, secondary and tertiary care. Cancer has a significant impact on individuals, families and the health-care system and has had a prominent policy focus for decades. Sarcoma is a cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. There has been a moderation in the overall trend in more recent years, with incidence rising by an average of 0.5% per year from 2001 to 2010.
This study demonstrated that the population-based HPV vaccination program in Australia is preventing cervical pre-cancer lesions in young women, with a fall in cervical abnormalities after the program was implemented in 2007 (Gertig et al.
Cancer survivors often face emotional, physical and financial challenges as a result of the detection, diagnosis and treatment of cancer.
This shift away from the acute care setting is also apparent in palliative care, with a South Australian study reporting that 70% of respondents would prefer to die at home than elsewhere, if faced with a terminal illness such as cancer (Foreman et al. Despite the falls in death rates and relative contributions to total deaths, the number of people dying from chronic diseases is still large because of Australia's growing and ageing population (see Chapter 6 'Ageing and the health system').
Indigenous people were almost twice as likely as non-Indigenous people to report having asthma. Cholesterol, blood pressure and overweight measures at young ages often persist into adulthood, and can predict the later occurrence of coronary heart disease. GPs and their teams can perform a key role in screening and prevention, and coordinating services (RACGP 2012). Leukaemia is a cancer that starts in blood-forming tissue, such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. The moderated trend after the 1980s is consistent with increased awareness of skin cancer and improved sun protective behaviours as a result of extensive skin cancer prevention programs dating back to the 1970s (AIHW 2012a). Further improvements in incidence and mortality are expected as a result of the continued decreasing trend in daily smoking. Accordingly, rates of hospitalisation and death are higher among Indigenous people (see Chapter 7 'How healthy are Indigenous Australians?'). Having multiple chronic conditions is associated with worse health outcomes, more complex disease management and increased health costs (AIHW 2012b). Based on current knowledge, the future impact of these behavioural risks on individuals, populations and the health system will be significant. Smoking habits acquired in adolescence or early adulthood greatly increase the risk for cardiovascular diseases and COPD in adulthood and old age—along with cancers and many other chronic diseases. Such an approach can strengthen and transform health-care systems, resulting in more effective, efficient, and timely care (Standing Council on Health 2013).
The effect of the vaccine is expected to increase over time as women vaccinated at age 12–13 become eligible to be screened in the cervical screening program and enter the age ranges where cancer incidence is more common.
The age of quitting smoking is also important and a major influence in reducing later COPD, coronary heart disease, and other chronic disease risk. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord. This is an area where gains may also follow for other cancers with a similar viral aetiology (see Glossary) to cervical cancer.

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