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Population‐based cancer control: where is the greatest benefit from proven strategies to ‘Regain’ years of life lost prematurely?

Population‐based cancer control: where is the greatest benefit from proven strategies to ‘Regain’... Objective: To apply a ‘health gain’ Jeanette E. Ward, Jane M.Young Needs Assessment & Health Outcomes Unit, Central Sydney Area Health Service, i and Department of Public Health & Community Medicine, University of Sydney approach to population-based cancer control. Method: We calculated the potential years o life otherwise lost prematurely which f could be ‘regainedthrough implementation o cancer control programs for which Level f I or Level II evidence already exists for population outcomes. Results: More potential years o life lost f (PYLLs)would be ‘regained’by enforcing a ‘smoke-free’Australia than by any other possible scenario based on proven effectiveness. Even achievable scenarios for tobacco control (17% or 20% prevalence) would ‘regain’more PYLL than either mammographic screening according to national policy or faecal occult blood testing (FOBT)o both men and women f over 50 years for colorectal cancer. Conclusions: A s few commentators remain optimistic that more money will be allocated to health, strategic thinking for health gain needs to re-appraise resource allocation for population-basedcancer control in Australia. Implications: We recommend wider debate in response to our finding that, on the basis o best available evidence, the f greatest potential for health gain lies less in cancer screening than fully funded tobacco control. (Aust N Z J Public Heafth1999; 538-40) 23: Paul Jelfs Australian Institute of Health and Welfare n 1994, cancer of all types accounted for the largest number of potential years of life lost (PYLL) across Australia before the age of 75 years (n=253,809), followed by accidents (n=lI8,359) and ischaemic heart disease (n=99,114). Cancer was responsible for one quarter ofall PYLL.’ In the light of increasing international and local interest in the health sector in achieving specified out comes^*' regaining PYLL by avoiding premature cancer deaths through populationbased cancer control represents a key strategy to improve the public’s health. Given the national burden of PYLL due to cancer, there is intrinsic merit in strategic planning for population-based cancer control which is based on evidence, replicable in its development, transparent in its assumptions and designed to achieve health gain. We argue that interventions for which there is Level I (meta-analysis or systematic review of randomised controlled trials) or Level 11 (at least one well-designed randomised control trial) evidence of effectiveness should be considered for implementation before all others4On the basis ofcompelling extant evidence, positive outcomes can be predicted in these cases because of the very assumptions of the scientific paradigm in which the evidence was generated. Only three population-based cancer control interventions meet this rigorous deterministic criterion: tobacco control, mammographic screening and colorectal cancer ~creening.~ The case for tobacco as a carcinogen is well-substantiated. In addition, there is Correspondenceto: evidence from randomised trials of the effectiveness of smoking cessation to reduce mortality risk among previous smokers.6On the basis of published randomised, controlled trials, there also is international consensus that mammographic screening will reduce breast cancer mortality risk among women aged 50 years or over by 24%.l Screening for colorectal cancer using faecal occult blood testing (FOBT) is the only other population-based intervention in cancer control for which there is Level I evidence of effectiveness in reducing site-specific mortality.*To inform strategic planning, can each of these three population-based interventions be ranked on the basis of the PYLL to be regained? Method We first used the latest national cancer statistics for 1996 to ascertain deaths by fiveyear age group for breast and colorectal cancers and those deaths from lung cancer and all cancers attributable to t o b a c ~ o . ~ The relative risk reduction promised by population-based implementation of mammographic screening is 24% (%YO CI 1333%) for women aged 50 to 74 years.’ For colorectal cancer, the most recent metaanalysis of the effectiveness of screening with FOBT concludes there is a relative risk reduction of 17% (95% CI 8-25%).* We then envisaged a future in which these three preventive interventionsfor which compelling evidence of mortality risk reduction exists were applied equitably and effectively. Submitted: July 1998 Revision requested: October 1998 Accepted: July 1999 538 Assoc. Prof. Jeanette Ward, Needs Assessment & Health Outcomes Unit, Locked Bag 8, Newtown, NSW 2042. Fax: (02) 9515 3334;e-mail: jward8 nah.rpa.cs.nsw.gov.au AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO. 5 Brief Report Population-based cancer control strategies Thus, breast cancer deaths would be reduced by 24%, while deaths from colorectal cancer would be reduced by 17%. Deaths from lung cancer alone would be reduced by 80% if Australia was entirely ‘smoke-free’; similarly, deaths from all cancers which have an established attributable risk due to tobacco.I0 We also considered three more realistic scenarios for the future. In one, the prevalence of smoking in Australia would be reduced to 20% (the current target for 2000)“ and, in another, to 17%, as has been achieved in California, where commitment to tobacco control is high.I2However, in recognition of a future in which tobacco control might continue to receive only “paltry and fragmented” funding,I3 we added a scenario in which smoking prevalence was reduced by only 1% from the present rates of 27% for adult men and 23% for adult women to 26% and 22% re~pectively.’~ We calculated the PYLL to be regained by screening with mammography for women and FOBT for men and women as well as for each of the four scenarios for tobacco control (‘smoke free’ Australia; reduction of smoking prevalence to either 20% or 17% and reduction of smoking prevalence by 1%). We assumed that the number of deaths in each five-year age group occurred evenly over the five years to estimate the mean age of death for each group. In other words, the mean age of death for those aged 50-55 years was estimated to be 52.5 years. The difference between the mean age of death and 75 years represented the mean years of life lost for each age group. The number of deaths in each age group multiplied by the mean years of life lost for that group represented the PYLL. The PYLL lost were summed for the age groups recommended for screening. Mammographic screening is recommended for women aged 50-69 years.I5 However, participation in screening can extend to the age of 75 years. Thus, two scenarios were considered: one for avoidable deaths from breast cancer from the ages of 50-69 years only and, the other, from the ages of 50-74 years. As the confidence interval for the relative risk reduction for women aged 40-49 years still includes the value ‘one’, regained Table 1: Comparison of person-years of life lost (PYLL) ‘regained’from cancer as a result of smoking reduction, mammography and faecal occult blood testing. Intervention PYLL ‘regained’ PYLLs were not calculated for younger women on the basis of insufficient evidence.16Colorectal cancer screening has been considered for both men and women aged 50 years and over.8There is insufficient evidence to date on which to base a recommendation for the age at which screening should cease.8 We considered all deaths before age 75 years for this cancer. The PYLL for these age groups were then multiplied by the relative risk reduction conferred by screening to calculate the potential PYLL ‘regained’by each screening program. These calculations were repeated using the upper and lower 95% confidence limits for the relative risk reduction for mammography (13%, 33%) and FOBT (8%, 25%) to estimate a range of PYLL to be ‘regained’ as a result of each screening program. The PYLL due to lung cancer for men and women of all ages were multiplied by the attributable risk of smoking for each sex (84% for men and 77% for women). This gave the total potential PYLL ‘regained’if smoking were completely eliminated.The proportional PYLL ‘regained’ was then calculated for the scenarios reducing adult smoking prevalence to 20%, 17% and by 1YO, and repeated for deaths from all tobacco-caused cancers. Results More PYLLs would be ‘regained’ in a smoke-free Australia than any other possible scenario (Table 1).Applying the 95% confidence limits for the relative risk reduction afforded by each screening program, the range of PYLL ‘regained’would be 1,9604,975 for women aged 50-69 years, 2,058-5,224 for women aged 50-74 years for mammography and, for both men and women aged 50-74 years, 1,890-5,907 for FOBT. Even the most optimistic calculation based on the uppermost 95% CI fails to match the gains to be made from achievable reductions in smoking prevalence to 20% or 17%. Reduction in smoking prevalence by 1% falls short of the PYLL to be regained through either screening program (Table 1). Discussion This approach, which explicitly calculates the PYLL to be regained through implementation of programs in population-based cancer control for which Level I or I1 evidence already exists for health gain, has not been applied explicitly elsewhere.”,”*18 Our approach demonstrates the potential of transparent planning for population-based cancer control which is both evidencebased and outcome-oriented. As few commentators remain optimistic that monies allocated to health will increase,Igwe now face difficult decisions. In population-based cancer control, hnding to launch an effective initiative to reduce smoking prevalence will surpass either breast or colorectal cancer screening as a strategy to ‘regain’ PYLL on the basis of current best evidence. The gains to be made through regaining years of life lost are not yet mirrored in a balanced resource allocation for populationbased cancer control however. For example, approximately $80 million a year is allocated to mammographic screening.20If introduced, a comprehensive biennial FOBT colorectal cancer screening program will consume $426 million over the first two years in Medicare costs alone.* In stark contrast, only $2 million was Reduce smoking 52,018 prevalence to 0% (avoided tobacco-related cancer) Reduce smoking prevalence to: 37,970 (avoided tobacco-related lung cancer) 0% 17% 17,624 (avoided tobacco-related cancer) 12,768 (avoided tobacco-related lung cancer) 17% 20% 11,607 (avoided tobacco-related cancer) 8,359 (avoided tobacco-related lung cancer) 20% FOBT 50-74 wars 4.01 7 (avoided colorectal cancer deaths) Mammography: 3,799 (avoided breast cancer deaths) 50-74 years 3,618 (avoided breast cancer deaths) 50-69 years Reduce smoking prevalence by: 2,013 (avoided tobacco-related cancer) 1Yo 1,475 (avoided tobacco-related lung cancer) 1Yo . ~ Note: Current smokingprevalence of 27% and23% for men and momen respectively 1999 VOL. 23 NO. 5 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Ward,Young and Jelfs Brief Report allocated by the Commonwealth Government in 1998/99 for dedicated tobacco control initiatives.2’While recognising the perceived difficulties in funding public health programs: our calculations pose new principles with which to allocate resources for population-based cancer control. In this instance, our advocacy of programs on the basis of evidence of effectiveness was not tempered by consideration of cost-effectiveness. This position reflects the original tenets of evidence-based health care which emphasised free access to effective care.22 We acknowledge the methodological caveats tempering this first application of a ‘health gain’ approach to population-based cancer control. First, inequity has not been explicitly addressed. The widening health differentials between rich and poor, as well as Indigenous and non-Indigenous Australians is readily apparent in cancer. Our approach did not ‘weight’for the socially desirable reduction in inequity if tobacco-related cancer was differentially reduced in populations bearing the greatest cancer burdens.23 In addition, we acknowledge that the impact of multiple disease mortality risks remains unclear. Further, our estimates of PYLL ‘regained’from reducing smoking prevalence do not adjust for the gradual decline in risk of lung or other tobacco-related cancer occurring after cessation.24Similarly, the effect of duration or amount of smoking on the health benefits of cessation2’ could not be included in this first application of a potential policy model. Time horizons for health gain in cancer screening are in the order of at least a decade from full implementation.Gains from smoking cessation are similarly longterm. On another technical note, our use of mean age of death slightly over-estimates PYLL for each age group, potentially overestimating PYLL ‘regained’ for all interventions. Our calculations for mammographic screening were based on a 70% uptake of screening.’ However, this has not been achieved in Australia.20Similarly, the estimated 17% relative risk reduction from FOBT assumes at least 60% of the population will participate.” Findings from pilot studies do not augur well for high rates of participation by Australians in FOBT screening.” These issues in implementation detract from the overall health gain theoretically possible from screening in our calculations. By focusing on cancer, we have not included the health gains from tobacco control to be achieved in vascular disease, another major cause of PYLL.’ As we selected premature mortality (conventionally calculated as those before the age of 75 years) as the outcome representing health gain, a model which not only addresses equity, but also includes standardised measures of morbidity and quality of life could provide even more compelling arguments for the need to pursue tobacco control before screening initiatives. Thus, there may be promise in the incorporation of morbidity, quality-of-life or disability variables and perhaps cost-effectiveness in future extensions of our evidence-basedapproach. However, any economic perspective ought also make explicit the differential financial effects of policy options in cancer control as attempted recently in an analysis of health and medical research Biotechnology consortia, pharmaceutical companies and others with vested interests may find it difficult to concede the desirability of real population health gain against more immediate outcomes such as company profits and increased demand for clinical services. An evidence-based approach combined with an ecological appraisal of this type could herald a profound paradigm shift in resource allocation in cancer control in the new millenium. Acknowledgments We thank the GPs participating in the RACGP Annual Revision Seminar (Sydney, 1998) who, by requesting an approach to population-based cancer control reflecting health gain, inspired this first step towards a model for evidence-based decision making. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Population‐based cancer control: where is the greatest benefit from proven strategies to ‘Regain’ years of life lost prematurely?

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Publisher
Wiley
Copyright
Copyright © 1999 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1999.tb01314.x
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Abstract

Objective: To apply a ‘health gain’ Jeanette E. Ward, Jane M.Young Needs Assessment & Health Outcomes Unit, Central Sydney Area Health Service, i and Department of Public Health & Community Medicine, University of Sydney approach to population-based cancer control. Method: We calculated the potential years o life otherwise lost prematurely which f could be ‘regainedthrough implementation o cancer control programs for which Level f I or Level II evidence already exists for population outcomes. Results: More potential years o life lost f (PYLLs)would be ‘regained’by enforcing a ‘smoke-free’Australia than by any other possible scenario based on proven effectiveness. Even achievable scenarios for tobacco control (17% or 20% prevalence) would ‘regain’more PYLL than either mammographic screening according to national policy or faecal occult blood testing (FOBT)o both men and women f over 50 years for colorectal cancer. Conclusions: A s few commentators remain optimistic that more money will be allocated to health, strategic thinking for health gain needs to re-appraise resource allocation for population-basedcancer control in Australia. Implications: We recommend wider debate in response to our finding that, on the basis o best available evidence, the f greatest potential for health gain lies less in cancer screening than fully funded tobacco control. (Aust N Z J Public Heafth1999; 538-40) 23: Paul Jelfs Australian Institute of Health and Welfare n 1994, cancer of all types accounted for the largest number of potential years of life lost (PYLL) across Australia before the age of 75 years (n=253,809), followed by accidents (n=lI8,359) and ischaemic heart disease (n=99,114). Cancer was responsible for one quarter ofall PYLL.’ In the light of increasing international and local interest in the health sector in achieving specified out comes^*' regaining PYLL by avoiding premature cancer deaths through populationbased cancer control represents a key strategy to improve the public’s health. Given the national burden of PYLL due to cancer, there is intrinsic merit in strategic planning for population-based cancer control which is based on evidence, replicable in its development, transparent in its assumptions and designed to achieve health gain. We argue that interventions for which there is Level I (meta-analysis or systematic review of randomised controlled trials) or Level 11 (at least one well-designed randomised control trial) evidence of effectiveness should be considered for implementation before all others4On the basis ofcompelling extant evidence, positive outcomes can be predicted in these cases because of the very assumptions of the scientific paradigm in which the evidence was generated. Only three population-based cancer control interventions meet this rigorous deterministic criterion: tobacco control, mammographic screening and colorectal cancer ~creening.~ The case for tobacco as a carcinogen is well-substantiated. In addition, there is Correspondenceto: evidence from randomised trials of the effectiveness of smoking cessation to reduce mortality risk among previous smokers.6On the basis of published randomised, controlled trials, there also is international consensus that mammographic screening will reduce breast cancer mortality risk among women aged 50 years or over by 24%.l Screening for colorectal cancer using faecal occult blood testing (FOBT) is the only other population-based intervention in cancer control for which there is Level I evidence of effectiveness in reducing site-specific mortality.*To inform strategic planning, can each of these three population-based interventions be ranked on the basis of the PYLL to be regained? Method We first used the latest national cancer statistics for 1996 to ascertain deaths by fiveyear age group for breast and colorectal cancers and those deaths from lung cancer and all cancers attributable to t o b a c ~ o . ~ The relative risk reduction promised by population-based implementation of mammographic screening is 24% (%YO CI 1333%) for women aged 50 to 74 years.’ For colorectal cancer, the most recent metaanalysis of the effectiveness of screening with FOBT concludes there is a relative risk reduction of 17% (95% CI 8-25%).* We then envisaged a future in which these three preventive interventionsfor which compelling evidence of mortality risk reduction exists were applied equitably and effectively. Submitted: July 1998 Revision requested: October 1998 Accepted: July 1999 538 Assoc. Prof. Jeanette Ward, Needs Assessment & Health Outcomes Unit, Locked Bag 8, Newtown, NSW 2042. Fax: (02) 9515 3334;e-mail: jward8 nah.rpa.cs.nsw.gov.au AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO. 5 Brief Report Population-based cancer control strategies Thus, breast cancer deaths would be reduced by 24%, while deaths from colorectal cancer would be reduced by 17%. Deaths from lung cancer alone would be reduced by 80% if Australia was entirely ‘smoke-free’; similarly, deaths from all cancers which have an established attributable risk due to tobacco.I0 We also considered three more realistic scenarios for the future. In one, the prevalence of smoking in Australia would be reduced to 20% (the current target for 2000)“ and, in another, to 17%, as has been achieved in California, where commitment to tobacco control is high.I2However, in recognition of a future in which tobacco control might continue to receive only “paltry and fragmented” funding,I3 we added a scenario in which smoking prevalence was reduced by only 1% from the present rates of 27% for adult men and 23% for adult women to 26% and 22% re~pectively.’~ We calculated the PYLL to be regained by screening with mammography for women and FOBT for men and women as well as for each of the four scenarios for tobacco control (‘smoke free’ Australia; reduction of smoking prevalence to either 20% or 17% and reduction of smoking prevalence by 1%). We assumed that the number of deaths in each five-year age group occurred evenly over the five years to estimate the mean age of death for each group. In other words, the mean age of death for those aged 50-55 years was estimated to be 52.5 years. The difference between the mean age of death and 75 years represented the mean years of life lost for each age group. The number of deaths in each age group multiplied by the mean years of life lost for that group represented the PYLL. The PYLL lost were summed for the age groups recommended for screening. Mammographic screening is recommended for women aged 50-69 years.I5 However, participation in screening can extend to the age of 75 years. Thus, two scenarios were considered: one for avoidable deaths from breast cancer from the ages of 50-69 years only and, the other, from the ages of 50-74 years. As the confidence interval for the relative risk reduction for women aged 40-49 years still includes the value ‘one’, regained Table 1: Comparison of person-years of life lost (PYLL) ‘regained’from cancer as a result of smoking reduction, mammography and faecal occult blood testing. Intervention PYLL ‘regained’ PYLLs were not calculated for younger women on the basis of insufficient evidence.16Colorectal cancer screening has been considered for both men and women aged 50 years and over.8There is insufficient evidence to date on which to base a recommendation for the age at which screening should cease.8 We considered all deaths before age 75 years for this cancer. The PYLL for these age groups were then multiplied by the relative risk reduction conferred by screening to calculate the potential PYLL ‘regained’by each screening program. These calculations were repeated using the upper and lower 95% confidence limits for the relative risk reduction for mammography (13%, 33%) and FOBT (8%, 25%) to estimate a range of PYLL to be ‘regained’ as a result of each screening program. The PYLL due to lung cancer for men and women of all ages were multiplied by the attributable risk of smoking for each sex (84% for men and 77% for women). This gave the total potential PYLL ‘regained’if smoking were completely eliminated.The proportional PYLL ‘regained’ was then calculated for the scenarios reducing adult smoking prevalence to 20%, 17% and by 1YO, and repeated for deaths from all tobacco-caused cancers. Results More PYLLs would be ‘regained’ in a smoke-free Australia than any other possible scenario (Table 1).Applying the 95% confidence limits for the relative risk reduction afforded by each screening program, the range of PYLL ‘regained’would be 1,9604,975 for women aged 50-69 years, 2,058-5,224 for women aged 50-74 years for mammography and, for both men and women aged 50-74 years, 1,890-5,907 for FOBT. Even the most optimistic calculation based on the uppermost 95% CI fails to match the gains to be made from achievable reductions in smoking prevalence to 20% or 17%. Reduction in smoking prevalence by 1% falls short of the PYLL to be regained through either screening program (Table 1). Discussion This approach, which explicitly calculates the PYLL to be regained through implementation of programs in population-based cancer control for which Level I or I1 evidence already exists for health gain, has not been applied explicitly elsewhere.”,”*18 Our approach demonstrates the potential of transparent planning for population-based cancer control which is both evidencebased and outcome-oriented. As few commentators remain optimistic that monies allocated to health will increase,Igwe now face difficult decisions. In population-based cancer control, hnding to launch an effective initiative to reduce smoking prevalence will surpass either breast or colorectal cancer screening as a strategy to ‘regain’ PYLL on the basis of current best evidence. The gains to be made through regaining years of life lost are not yet mirrored in a balanced resource allocation for populationbased cancer control however. For example, approximately $80 million a year is allocated to mammographic screening.20If introduced, a comprehensive biennial FOBT colorectal cancer screening program will consume $426 million over the first two years in Medicare costs alone.* In stark contrast, only $2 million was Reduce smoking 52,018 prevalence to 0% (avoided tobacco-related cancer) Reduce smoking prevalence to: 37,970 (avoided tobacco-related lung cancer) 0% 17% 17,624 (avoided tobacco-related cancer) 12,768 (avoided tobacco-related lung cancer) 17% 20% 11,607 (avoided tobacco-related cancer) 8,359 (avoided tobacco-related lung cancer) 20% FOBT 50-74 wars 4.01 7 (avoided colorectal cancer deaths) Mammography: 3,799 (avoided breast cancer deaths) 50-74 years 3,618 (avoided breast cancer deaths) 50-69 years Reduce smoking prevalence by: 2,013 (avoided tobacco-related cancer) 1Yo 1,475 (avoided tobacco-related lung cancer) 1Yo . ~ Note: Current smokingprevalence of 27% and23% for men and momen respectively 1999 VOL. 23 NO. 5 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Ward,Young and Jelfs Brief Report allocated by the Commonwealth Government in 1998/99 for dedicated tobacco control initiatives.2’While recognising the perceived difficulties in funding public health programs: our calculations pose new principles with which to allocate resources for population-based cancer control. In this instance, our advocacy of programs on the basis of evidence of effectiveness was not tempered by consideration of cost-effectiveness. This position reflects the original tenets of evidence-based health care which emphasised free access to effective care.22 We acknowledge the methodological caveats tempering this first application of a ‘health gain’ approach to population-based cancer control. First, inequity has not been explicitly addressed. The widening health differentials between rich and poor, as well as Indigenous and non-Indigenous Australians is readily apparent in cancer. Our approach did not ‘weight’for the socially desirable reduction in inequity if tobacco-related cancer was differentially reduced in populations bearing the greatest cancer burdens.23 In addition, we acknowledge that the impact of multiple disease mortality risks remains unclear. Further, our estimates of PYLL ‘regained’from reducing smoking prevalence do not adjust for the gradual decline in risk of lung or other tobacco-related cancer occurring after cessation.24Similarly, the effect of duration or amount of smoking on the health benefits of cessation2’ could not be included in this first application of a potential policy model. Time horizons for health gain in cancer screening are in the order of at least a decade from full implementation.Gains from smoking cessation are similarly longterm. On another technical note, our use of mean age of death slightly over-estimates PYLL for each age group, potentially overestimating PYLL ‘regained’ for all interventions. Our calculations for mammographic screening were based on a 70% uptake of screening.’ However, this has not been achieved in Australia.20Similarly, the estimated 17% relative risk reduction from FOBT assumes at least 60% of the population will participate.” Findings from pilot studies do not augur well for high rates of participation by Australians in FOBT screening.” These issues in implementation detract from the overall health gain theoretically possible from screening in our calculations. By focusing on cancer, we have not included the health gains from tobacco control to be achieved in vascular disease, another major cause of PYLL.’ As we selected premature mortality (conventionally calculated as those before the age of 75 years) as the outcome representing health gain, a model which not only addresses equity, but also includes standardised measures of morbidity and quality of life could provide even more compelling arguments for the need to pursue tobacco control before screening initiatives. Thus, there may be promise in the incorporation of morbidity, quality-of-life or disability variables and perhaps cost-effectiveness in future extensions of our evidence-basedapproach. However, any economic perspective ought also make explicit the differential financial effects of policy options in cancer control as attempted recently in an analysis of health and medical research Biotechnology consortia, pharmaceutical companies and others with vested interests may find it difficult to concede the desirability of real population health gain against more immediate outcomes such as company profits and increased demand for clinical services. An evidence-based approach combined with an ecological appraisal of this type could herald a profound paradigm shift in resource allocation in cancer control in the new millenium. Acknowledgments We thank the GPs participating in the RACGP Annual Revision Seminar (Sydney, 1998) who, by requesting an approach to population-based cancer control reflecting health gain, inspired this first step towards a model for evidence-based decision making.

Journal

Australian and New Zealand Journal of Public Health – Wiley

Published: Oct 1, 1999

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