National Health Committee
An Overview of
Screening in
New Zealand
March 2015
National Health Committee – An Overview of Screening in New Zealand
National Health Committee (NHC)
The National Health Committee (NHC) is an independent statutory body charged with prioritising new
and existing health technologies and making recommendations to the Minister of Health.
It was reformed in 2011 to establish evaluation systems that would provide the New Zealand people and
the health sector with greater value for money invested in health.
The NHC Executive is the secretariat that supports the Committee. The NHC Executive’s primary
objective is to provide the Committee with sufficient information for it to make decisions regarding
prioritisation and reprioritisation of interventions and services. They do this through a range of evidencebased products chosen according to the nature of the decision required and timeframe within which
decisions need to be made.
The New Zealand Government has asked that all new diagnostic and treatment (non-pharmaceutical)
services, and significant expansions of existing services, are to be referred to the NHC.
In August 2011 the NHC was appointed with new Terms of Reference and a mandate to establish the
capacity to assess new and existing health technologies. Its objectives (under Section 4.2 of its Terms of
Reference – www.nhc.health.govt.nz) include contributing to improved value for money and fiscal
sustainability in the health and disability sector by:
 providing timely advice and recommendations about relative cost-effectiveness based on the best
available evidence;
 providing advice and recommendations which influence the behaviour of decision makers including
clinicians and other health professionals;
 providing advice and recommendations which are reflected in resource allocation at national, regional
and local levels; and
 contributing to tangible reductions in the use of ineffective interventions and improved targeting to
those most likely to benefit.
In order to achieve its objectives under Section 4.2 and to achieve ‘Value for Money’, the NHC has
adopted a framework of four assessment domains – Clinical Safety & Effectiveness; Economic; Societal &
Ethical; and Feasibility of Adoption – in order that assessments cover the range of potential
considerations and that the recommendations made are reasonable.
It is intended that the research questions asked will fall across these domains to ensure that when the
Committee comes to apply its decision-making criteria, it has a balanced range of information available to
it. When the NHC is setting those questions they will have the decision-making criteria in mind.
The 11 decision-making criteria will assist in the determination of the NHC work programme and in the
appraisal and prioritisation of assessments.
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National Health Committee – An Overview of Screening in New Zealand
Contents
1
Introduction
4
2
How screening is organised in New Zealand
5
3
Volumes and costs
6
3.1
6
4
5
National programmes
3.1.1 NCSP
6
3.2
UNHSEIP
6
3.3
NMSP
7
3.4
Antenatal HIV screening
7
3.5
Antenatal screening for Down syndrome and other conditions
7
3.6
Opportunistic screening
8
Emerging technologies and potential programmes
9
4.1
Prostate cancer screening
9
4.2
Colorectal/bowel cancer screening
9
4.3
Modifications to NCSP
10
4.4
Modifications to BSA
10
4.5
Modifications to antenatal and newborn screening
10
4.6
Ultrasound screening for abdominal aortic aneurysms (AAA)
12
4.7
Screening for hepatitis C (HCV)
12
4.8
Screening for rheumatic fever/heart disease
13
4.9
Screening for osteoporosis
13
4.10 Lung cancer screening
14
New Zealand service development and issues
15
References
16
National Health Committee (NHC) and Executive
20
Disclaimer
20
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National Health Committee – An Overview of Screening in New Zealand
1 Introduction
Screening tests asymptomatic individuals (people with no symptoms) for a particular disease or
condition in order to reduce future mortality or morbidity.(1) There are two types of screening:
screening for disease risk (an assessment of the probability that an individual may develop a disease
in the future), and screening for a disease precursor or an early asymptomatic stage of disease that is
amenable to treatment. Delivery of screening services may occur as part of an organised screening
programme (national programmes) or opportunistically during contact with health services.(1) In
contrast to routine clinical practice where a patient seeks help from a service, screening is generally
provider initiated. This results in an ethical requirement for robust evidence that screening is of
benefit whilst ensuring that potential harms are minimised as well as providing informed consent
and equity of access.(2)
This document is intended to provide the National Health Committee (NHC) with an overview of
current and potential screening programmes in New Zealand in order to inform decisions about
whether to undertake further work on screening.
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National Health Committee – An Overview of Screening in New Zealand
2 How screening is organised in New Zealand
National screening programmes are overseen by the National Screening Unit (NSU), Ministry of
Health and include the National Cervical Screening Programme (NCSP), BreastScreen Aotearoa (BSA),
Universal Newborn Hearing Screening and Early Intervention Programme (UNHSEIP), the Newborn
Metabolic Screening Programme (NMSP), the Antenatal HIV (AHIV) Screening Programme and
Antenatal Screening for Down Syndrome and Other Conditions.(3)
Opportunistic screening for chronic diseases, e.g. cardiovascular disease (CVD), diabetes and cancer
are largely driven by primary care and hospital outpatient services.
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National Health Committee – An Overview of Screening in New Zealand
3 Volumes and costs
3.1 National programmes
3.1.1 NCSP
Each year in New Zealand around 1701 women are diagnosed with cancer of the cervix and around
60 women die from cervical cancer.(4) In 2010, cervical cancer accounted for 1.8 per cent of all
female cancer registrations and 1.3 per cent of all deaths from cancer in women. In the three years
ending December 2013, 879,862 women were screened with an overall coverage rate of
77.0 per cent of eligible women aged 25–69 years.(5) The NCSP 2013/14 budget is $40.4 million,
comprising laboratory costs ($16.2 million), colposcopy costs ($9.3 million), regional services
including promotion and coordination, some smear taking and supporting women through screening
($7.0 million), and other associated funding including monitoring, audits, the Register including
invitation and recall, social marketing and programme resources ($7.9 million).2
3.1.2 BSA
Breast cancer is the third most common New Zealand cancer, and most common cancer in women,
accounting for around 2800 new cases and around 650 deaths each year.(4) In the two years ending
February 2014, 495,635 women were screened with an overall coverage rate of 72.5 per cent of
eligible women aged 45–69 years.(6) The BSA 2013/14 budget is $60.0 million, comprising screening
and assessment ($48.3 million), regional recruitment, coordination and support, and supporting
women through screening ($5.6 million), and other associated funding including monitoring, the
rollout and support of a national digital picture archive and communication system, social marketing
and programme resources ($6.1 million).3
3.2 UNHSEIP
Each year approximately 170 New Zealand babies are born with a moderate or severe hearing loss.
In the period April 2012 to December 2012 approximately 83 per cent of babies born across the
country completed newborn hearing screening. This resulted in 672 (1.7 per cent) of babies being
referred for further audiology testing with 42 resulting in a diagnosis of permanent congenital
hearing loss.(7,8) The UNHSEIP 2013/14 budget is $5.3 million, comprising screening costs
($4.4 million) and other associated funding including audits, monitoring and quality improvements
($0.9 million).4
1
180 in 2010
2
Personal communication NSU Group Manager
3
Personal communication NSU Group Manager
4
Personal communication NSU Group Manager
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National Health Committee – An Overview of Screening in New Zealand
3.3 NMSP
The Newborn Metabolic Screening Programme (NMSP) screens for rare but potentially serious
metabolic disorders using a blood sample taken from a baby’s heel at 48 hours of age (the ‘heel prick’
or ‘Guthrie’ test). The NMSP screens for over 20 metabolic disorders, identifies approximately
45 babies a year with a metabolic disorder and has a 2013/14 budget of $2.3 million, mostly
comprising laboratory screening costs.(10) 5
3.4 Antenatal HIV screening
Since 1995 there have been no New Zealand cases where a mother with HIV diagnosed prior to
giving birth has had an infected baby (AIDS Epidemiology Group, 2013). In children born in New
Zealand from 2000 to 2007, where their mother’s HIV status was not recognised during the
pregnancy, 18 have since been diagnosed with HIV. No New Zealand-born children born since 2008
have been diagnosed with HIV infection through mother-to-child transmission. Since 2010, all
pregnant women have been offered HIV screening through the Antenatal HIV Screening Programme.
Between 2011 and 2012, three women were diagnosed with HIV through the programme. In the
period January to June 2013, around 87 per cent of women who had blood tests taken during
pregnancy had an HIV test as part of this.(11, 12) The Antenatal HIV Screening Programme 2013/14
budget is around $1.4 million.6
3.5 Antenatal screening for Down syndrome and other conditions
Antenatal screening for Down syndrome and other conditions has been part of an NSU quality
improvement programme since 2007. Risk results for Trisomy 13, 18 and 21 are provided along with
information on other rare genetic conditions. Two screening options are currently available:
 First Trimester Combined Screening combines the result of serum markers (pregnancy associated
protein A (PaPP-A) and beta-human chorionic gonadotrophin (β-hcg)) and a nuchal translucency
ultrasound scan, along with other information (e.g. age and weight), to calculate a risk result
 Second Trimester Maternal Serum Screening – this option combines the results from serum
markers (β-hcg, alfa-fetoprotein (AFP) unconjugated oestriol (uE3) and inhibin A) with other
information to calculate a risk result.
Further diagnostic testing is offered in the case of increased chance results. In 2012 over 47,000
pregnant women chose to participate in either first or second trimester screening. Approximately
2 per cent of women received an increased chance(13, 14) result. The 2013/14 budget for antenatal
screening for Down syndrome and other conditions is around $4.6 million.7
5
Personal communication NSU Group Manager
6
Personal communication NSU Group Manager
7
Personal communication NSU Group Manager
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National Health Committee – An Overview of Screening in New Zealand
3.6 Opportunistic screening
3.6.1 CVD risk assessment and diabetes checks
The current DHB-based health target, ‘More Heart and Diabetes Checks’, includes a diabetes test as
part of an overall CVD risk assessment, i.e. history including risk factors examination including blood
pressure and serum lipid profiling. Coverage targets were set at 60 per cent by July 2012 and
75 per cent by July 2013. While there has been an overall trend of increasing CVD risk assessment
over time (at the end of the last quarter of 2012/13 the national assessment rate was 67 per cent),
there was considerable variability between DHBs (from 32 per cent to 81 per cent) and only four
DHBs met the 75 per cent target. Overall performance was better in eligible Pacific populations but
worst for Māori compared to other ethnic groups. For the 1.4 million New Zealanders currently
undiagnosed with IHD, best practice screening at five-year intervals including cost of clinical
encounter is approximately $10.50 per person per annum, or $14.7 million.(15-17)
3.6.2 National clinical genetic health services
Genetic Health Service New Zealand (GHSNZ) delivers services from three hubs (Auckland,
Wellington and Christchurch) and 17 outreach clinics. GHSNZ provides information and education,
risk assessment and clinical management, diagnosis and laboratory testing for a wide variety of
inherited and/or congenital conditions. The national price for clinical genetic testing is $608.76 for
the 2011/12 year with the modal price for 2012/13 year being $582.63.(18)
3.6.3 Pre-implantation genetic screening
Of the 62,540 women who gave birth in New Zealand in 2009, approximately 2 per cent received
some form of assisted reproductive technologies (ART) treatment. Of 5606 ART treatment cycles
reported in 2009, 27.6 per cent resulted in a clinical pregnancy and 21.2 per cent in a live delivery
(1270 liveborn babies, 961 singletons). Pre-implantation genetic diagnosis (PGD) is a procedure in
which cells from the embryo are removed and analysed for chromosomal disorders or genetic
diseases before embryo transfer. In 2009, PGD was performed in 34 cycles, representing 0.7 per cent
of cycles in which embryos were created (31 out of 2906 fresh cycles) or thawed (4 out of 1869 thaw
cycles).(19)
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National Health Committee – An Overview of Screening in New Zealand
4 Emerging technologies and potential programmes
4.1 Prostate cancer screening
Prostate cancer is the most common male New Zealand cancer (around 3000 men each year) and the
third most common cause of male cancer death (around 600 each year).(4) Māori men are about
25 per cent less likely to be diagnosed than non-Māori men but are more than twice as likely to die
from prostate cancer.(20) Each year approximately 40 per cent of men over 50 years of age have a
PSA test. The PSA test, however, is not highly sensitive for prostate cancer; not all men with prostate
cancer have a raised PSA and not all men with a raised PSA have prostate cancer.(21) Reliance on PSA
testing alone therefore poses risks of both under-diagnosis and harm caused by unnecessary
treatment. A 2011 Health Committee report did not support the establishment of a national
prostate screening programme but recommended the establishment of a prostate cancer awareness
and quality improvement programme (AQIP).(22) The Ministry of Health is rolling out this prostate
AQIP to be funded at $4.3 million over four years.(23)
4.2 Colorectal/bowel cancer screening
Colorectal cancer (cancers of the colon and rectum, also called bowel cancer) is the second most
common cancer and cause of cancer deaths in New Zealand. Each year more than 28008 people are
diagnosed and more than 1200 die from the disease.(4) A four-year $24 million Waitemata DHB area
bowel screening pilot commenced in 2011 to gather information about demand and capacity in order
to determine whether a bowel screening programme should be rolled out nationally. The pilot offers
bi-annual screening to 50–74-year-olds using an at-home kit where a bowel motion sample is
collected and then posted for laboratory FOBTi testing which, if positive, is followed up with the offer
of a diagnostic colonoscopy. In the first year of the pilot around 29,500 screening kits were returned,
a 54 per cent participation rate with around 2200 people offered a diagnostic colonoscopy and
cancer was detected in 60 people. Most eligible participants (86 per cent) were offered a diagnostic
colonoscopy within 10 weeks of a positive test. The pilot is also detecting many non-cancerous
polyps which require removal and future regular colonoscopy surveillance. No decision will be made
on implementing a national programme until all monitoring and evaluation data from the pilot has
been analysed. The cost of a national bowel screening programme for people aged 50–74 years has
been estimated at $60 million a year, with additional costs to establish a supporting information
system.(24, 25)
8
2988 in 2010
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National Health Committee – An Overview of Screening in New Zealand
4.3 Modifications to NCSP
In New Zealand HPV immunisation of 12–13-year-old girls commenced in 2009, with a catch-up
available for up to 20-year-olds. HPV immunisation confers some protection against cervical cancer
related to HPV, approximately 70 per cent of cervical cancer and 90 per cent of genital warts is
related to HPV. Cervical screening is less sensitive in women immunised against HPV, hence
internationally the implementation of HPV immunisation programmes is driving a change from
cytology screening to HPV testing as the primary cervical screening test. The Ministry of Health is
contributing to an Australian pilot initiative which is looking at a time and motion laboratory study
for HPV testing as the primary cervical screening test.(26) Approval is being sought to commence
policy development work to consider whether the NCSP should be changed to introduce HPV testing
as the primary screening test.
4.4 Modifications to BSA
A 2012 NSU literature review on the evidence for routine age extension for breast cancer screening
for women over 70 found no new consistent high-quality scientific evidence about the benefits of
such screening. Internationally some breast screening programmes are extending their upper age
range into the 70s; however the evidence and international changes are being monitored in New
Zealand at this time.(27) In addition the NSU is currently revising its position statement on the
benefits and harms of BSA. A Cochrane Collaboration systematic review found that breast cancer
mortality was an unreliable outcome that was biased in favour of screening.(28) However this
Cochrane study did not adequately account for reduction in morbidity resulting from national breast
screening programmes(29) or that the perception of ‘harm’ from the perspective of the Cochrane
review may not be seen as a harm by women screened as emerging in the qualitative literature.9
Digital breast tomosynthesis (DBT) is a technology for breast imaging in the early stages of testing
and clinical use which may be able to improve diagnostic accuracy in the early detection of breast
cancer. Further evidence is required, e.g. completion of two major trials (Malmo 2014 and Oslo
2015), before the consideration of any widespread implementation of DBT in routine screening
practice.
4.5 Modifications to antenatal and newborn screening
4.5.1 Gestational diabetes mellitus
GDM is defined as ‘carbohydrate intolerance resulting in elevated blood sugar of variable severity
with onset or first recognition during pregnancy’ by the World Health Organization(30) and is inclusive
of those women with previously undiagnosed diabetes. A presentation at the 2013 New Zealand
Society for the Study of Diabetes Conference indicated that the number of pregnancies associated
with gestational diabetes had increased from 1.3 per cent in 2001 to 2 per cent in 2006 and to
4.9 per cent in 2012, an average annual increase of 13.9 per cent.(31) In 2012 there was wide
9
Personal communication BSA programme NSU
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National Health Committee – An Overview of Screening in New Zealand
variation in total GDM rates between DHBs with even greater variation between ethnic groups.
The Ministry of Health has commissioned a national clinical guideline for the screening, diagnosis and
management of gestational diabetes in New Zealand. The draft guideline recommends universal
antenatal blood screening before 20 weeks gestation using HbA1c testing followed by oral glucose
testing at 24 to 28 weeks for women not previously diagnosed with diabetes.(32)
4.5.2 Pre-implantation genetic diagnosis
There is emerging capability and capacity for embryonic genome sequencing in the IVF space with a
view to screening for a wide range of genetic diseases and risk factors.(33)
4.5.3 Screening for pre-eclampsia
Antenatal placental growth factor screening for pre-eclampsia, a potentially life-threatening disease
of pregnancy characterised by hypertension, oedema and proteinuria is under consideration in
Australia. The prevalence of pre-eclampsia in the New Zealand general population is around
3–5 per cent of pregnancies and disproportionately affects Māori. The clinical utility of screening for
pre-eclampsia is unclear as the standard treatment is induced or medical delivery.(34)
4.5.4 Severe combined immunodeficiency syndrome (SCID)
SCID is a genetic disorder with an incidence of between 1 in 50,000–100,000 live births affecting the
production of T cells critical to the immune response to infectious diseases. USA pilot studies to
diagnose SCID in newborns utilising polymerase chain reaction (PCR) are under way.(35) The NSU is in
the process of seeking a feasibility and cost effectiveness analysis.
4.5.5 Lysosomal storage diseases (LSDs)
LSDs are inherited metabolic disorders of variable severity that affect cellular organelles (lysosomes)
resulting in organ deposition of waste materials afflicting approximately 460 New Zealanders.10 LSDs
may be screened for by enzyme assay or genetic mutation analysis.(35) LSD screening has been
referred to the NSU. However, diagnostic criteria across LSDs are unclear and not all can be treated.
NSU maintains a watching brief.
4.5.6 Pulse oximetry screening for critical congenital heart disease (CCHD)
Up to 25 per cent of babies with severe forms of congenital heart disease are discharged postdelivery from hospital undiagnosed. Polynesians and Māori have disproportionately high rates of
CHDs.(36) The incidence of severe congenital heart disease requiring expert cardiology care is 2.5–3.0
per 1000 live births.(37) Pulse oximetry measures blood oxygen levels by measuring the absorbance
of light utilising a non-invasive sensor placed on a thin part of the body (e.g. finger, ear or foot).
A 2012 systematic review of pulse oximetry screening (POxS) for CCHD in newborn babies found it to
be highly specific, moderately sensitive and meet the criteria for universal screening.(38)
10
NHC analysis May 2012 of National Minimum Dataset (NMDS – 30 June 2011), Mental Health Information
National Collection (MHINC 2001–2008), Programme for the Integration of Mental Health Data (PRIMHD
2008+), National Needs Assessment and Service Coordination Information System (SOCRATES), Client
Claims Processing System (CCPS – Disability Support Services payments).
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National Health Committee – An Overview of Screening in New Zealand
Pulse oximetry is commonplace in clinical settings and relatively cheap. The NSU has received
enquiries about, and maintains a watching brief on, POxS screening.
4.6 Ultrasound screening for abdominal aortic aneurysms (AAA)
AAAs is a localised ballooning of the abdominal aorta, by more than 3 cm of its normal diameter with
smoking as a key risk factor at some point in their lifetime (over 90 per cent of AAA sufferers) and in
men. The larger the aneurysm the greater the risk of rupture(39) with a commensurate mortality rate
of up to 90 per cent. Using single encounter abdominal ultrasound and taking into account mortality
associated with case treatment, benefits outweigh risks for defined groups of men, but are more
contentious for women due to lower prevalence.(40) The impact of a New Zealand AAA screening
programme on the New Zealand health system would include a 2–3 times increase in operative
repairs required (currently around 263 per annum) and an ongoing requirement for radiological
surveillance of individuals with AAAs less than 5.5 cm (potentially around 90 per cent of AAAs
detected).(39) NSAC considered that the question of AAA screening requires counterfactual modelling
to balance benefits of lives saved (given the very high mortality of ruptured AAA) versus programme
cost for the New Zealand population.
4.7 Screening for hepatitis C (HCV)
HCV is a chronic viral infection that, via cirrhosis, may lead to liver failure and/or cancer. There is no
vaccine for hepatitis C. Of 50,000 New Zealanders with HCV infection, approximately 20 per cent
have been diagnosed and 5 per cent have accessed drug treatment. All patients treated by a
hepatitis C treatment service require regular monitoring during and after treatment. Without
treatment, between 5–15 per cent of those with HCV will develop cirrhosis and 3 per cent will
develop liver cancer. Forty percent of those with cirrhosis will be referred for liver transplantation.
It has been estimated that HCV-related deaths and transplants will triple by 2030.(41)
The Hepatitis Foundation of New Zealand (HepFNZ) has been supported to provide an
implementation plan for a potential three-year programme to promote the targeted testing of
specific ‘at-risk’ groups. This programme would encourage early HCV diagnosis and treatment
options for at-risk groups. The case detection component of the HepFNZ programme includes the
development of educational resources to risk stratified groups that will support better case
management.(42)
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National Health Committee – An Overview of Screening in New Zealand
4.8 Screening for rheumatic fever/heart disease
Rheumatic fever is a consequence of the autoimmune response to throat infection by Streptococcus
pyogenes, with a New Zealand rate of approximately 15 cases/100,000 children aged 5–15 years of
age, comparable to that of a third world country. The longer term management of rheumatic
valvular disease often requires invasive cardiac intervention. It is not possible to screen for the
disease ‘rheumatic fever’. Echocardiography has been trialled for detecting asymptomatic rheumatic
valvular disease; there is however no clear evidence that this is effective.(43) The Ministry of Health is
rolling out a programme to reduce the risk of developing rheumatic fever and ensuring best practice
management. This includes a communications campaign to raise awareness of sore throats and
rheumatic fever among vulnerable communities and health professionals with a view to offering a
package of housing-related interventions (Auckland region), symptomatic school-based throat
swabbing services in the 10 DHB areas with the highest incidence of rheumatic fever, providing
access to rapid sore throat management in areas where there are large numbers of cases
(particularly where there are no school-based services) and improving the management of sore
throats in high-risk children across the country. Programme progress is monitored by the
‘Government’s Better Public Services target for rheumatic fever’ to reduce the incidence rate to
1.4 cases per 100,000 people by June 2017.(44)
4.9 Screening for osteoporosis
Osteoporosis is a skeletal disease characterised by low bone density and disruption of bone
architecture with an associated increased risk of fracture (particularly fractures of the hip and
vertebra). As the number of older New Zealanders increases, their quality of life will decrease and
there will be an increase in premature mortality and demand on health systems attributable to
osteoporosis. The total cost of osteoporosis in New Zealand in 2007 was estimated to be greater
than $1.5 billion with an estimate of a 30 per cent increase in expenditure by 2020.(45) As
recommended by ‘Osteoporosis New Zealand’, Best Practice Advocacy Centre New Zealand
recommends that bone densitometry (dual energy X-ray absorbitometry – DEXA) only be undertaken
when the result of this testing will have an impact on clinical decision making and therefore
treatment.(46) There is unresolved international debate as to whether all women 65 years of age
should be screened for osteoporosis.(47) The Burden of Osteoporosis in New Zealand: 2007–2020
study recommended publicly funded DEXA scans for women over 50 with low trauma fractures
supported by awareness campaigns to increase public and health professional awareness.(45)
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National Health Committee – An Overview of Screening in New Zealand
4.10 Lung cancer screening
Each year 1600 New Zealanders die from lung cancer, representing 19 per cent of all cancer deaths
and is therefore the leading cause of New Zealand cancer deaths.(4) Tobacco smoking causes up to
90 per cent of lung cancer cases. Tobacco control and smoking cessation are therefore the single
most effective and cost effective lung cancer preventative interventions.(48) Recommendations of the
Northern Cancer Network endorsed research, “Identification of barriers to the early diagnosis of
people with lung cancer and description of best practice solutions”, could be regarded as
recommendations for opportunistic screening and may benefit from regional and/or national service
improvement programmes. Recommendations include improved health literacy; increasing primary
care awareness of lung cancer, its risk factors and the benefits of early treatment; routine recording
of smoking status with appropriate follow-up; improved GP utilisation of chest X-rays; appropriate
follow-up of patients with ongoing symptoms, abnormal results and did not attends (DNAs) and to
improve access to timely outpatient CT scans for suspected lung cancer.(49) The five-year survival of
surgical tumour resection for local disease at up to 70 per cent compares to 15 per cent for those
with locally advanced disease and to 3 per cent if metastases are present at the time of diagnosis.
Early diagnosis, combined with timely appropriate cancer care, therefore has the potential to
improve lung cancer survival outcomes.
Screening with a yearly low-dose CT scan has demonstrated decreased mortality in a randomised
trial of patients with increased risk due to smoking.(50) However a 2010 meta-analysis noted that for
every 1000 asymptomatic smokers screened, nine curable Stage 1 lung cancers would be detected,
while 235 “false positive” nodules would be found and four thoracotomies would also be performed
to determine if a screened positive lesion was benign.(51) Better risk stratification of smokers, which
may include spirometry, presence of emphysema on CT, family history and genetic susceptibility,
may result in a reduction in the current high false positive radiological screening rates. Many
screening studies have also failed to evaluate whether smokers would be willing to participate in
screening outside of the context of research.(52)
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National Health Committee – An Overview of Screening in New Zealand
5 New Zealand service development and issues
Maintaining a watching brief on emerging screening technologies and extensions and/ or
modifications to existing screening programmes may remain of interest to the NHC. These include
the place of NCSP HPV primary screening,(26) age extension for BSA,(27) the roll-out of the prostate
cancer awareness and quality improvement programme,(23) the outcome of the colorectal/bowel
cancer screening pilot,(24) publication of the final New Zealand national guideline to GDM screening
(UoA, 2013) and roll-out of the HepFNZ hepatitis C early detection programmes.(42) The National
Maternity Monitoring Group has recommended that the Ministry of Health and the maternity sector
develop a clinical guideline for the diagnosis and treatment of hypertension and pre-eclampsia in
pregnancy.11
Conversations within the New Zealand screening community indicate little interest in disinvestment
in currently existing screening initiatives. Interest has been expressed in screening for postnatal
depression, melanoma and alcohol abuse, but in particular in ultrasound based screening for AAA.(53)
The essential features of a quality national screening system include a central agency to lead and
co-ordinate the screening pathway, clinical leadership, infrastructure and systems for programme,
management, continuous quality management monitoring and improvement.(1) A screening
programme displaying these characteristics ‘lifts the screening game’ for the programme concerned.
The challenge to national screening programmes is to maintain this quality by working more closely
with the wider health sector in a time of fiscal constraint.
The commensurate challenge for opportunistic screening is to ‘lift the screening game’ without
incurring the financial costs that national programmes require.
Quality initiatives might be undertaken for primary care driven opportunistic chronic disease
screening. Many screening programmes are underperforming for Māori , Pacific, Asian and
economically deprived populations.(54) Unless carefully planned, health interventions tend to
increase inequalities. The NHC executive may see itself as mitigator of health changes affecting
vulnerable groups. Work is currently under way by DHBs and the Ministry of Health to reduce wait
times, including:(55)
 DHBs now reporting through the Colonoscopy Diagnostic Wait Time Indicator through the
electives work programme
 publication of National Referral Criteria for Direct Access Colonoscopy, which will provide
consistency in access and waiting times for patients referred for colonoscopy
 a National Endoscopy Quality Improvement Programme, now rolled out to all 20 DHBs, will lead
to improvements in quality and efficiency of colonoscopy services over time
 Health Workforce New Zealand are looking into options to increase workforce capacity.
11
Personal communication Principal Advisor Maternity Ministry of Health
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National Health Committee – An Overview of Screening in New Zealand
References
1.
Ministry of Health. Screening [cited 27 June 2014]. Available from:
http://www.health.govt.nz/our-work/preventative-health-wellness/screening
2.
Hale M. Essential Components of Organised Screening Programmes (Unpublished). Wellington:
National Screening Unit, 2012.
3.
National Health Committee. Screening to Improve Health in New Zealand: Criteria to Assess
Screening Programmes. Wellington: National Health Committee, 2003.
4.
Ministry of Health. Cancer: New Registrations and Deaths 2010. Wellington: Ministry of Health,
2013.
5.
National Screening Unit. National Cervical Screening Program monthly coverage data [cited
27 June 2014]. Available from: http://www.nsu.govt.nz/health-professionals/4949.aspx.
6.
National Screening Unit. BreastScreening Aoteoroa: Internal Report 2014 (in publication).
Wellington: National Screening Unit, 2014.
7.
National Screening Unit. Reports into quality improvements for the Universal Newborn Hearing
Screening Programme [cited 27 June 2014]. Available from: http://www.nsu.govt.nz/healthprofessionals/4627.aspx.
8.
National Screening Unit. Universal Newborn Hearing Screening Programme 2013 [cited
16 February 2014]. Available from: http://www.nsu.govt.nz/current-nsu-programmes/3735.aspx.
9.
National Screening Unit. Newborn Metabolic Screening Programme: Ministry of Health; 2014
[cited 27 June 2014]. Available from: http://www.nsu.govt.nz/current-nsu-programmes/newbornmetabolic-screening.aspx.
10.
National Screening Unit. Newborn Metabolic Screening Programme (NMSP) Annual Report 2011.
Unpublished Report. Ministry of Health, 2013.
11.
AIDS Epidemiological Group. AIDS Epidemiological Group. AIDS – New Zealand. Dunedin:
University of Otago; 2013.
12.
National Screening Unit. Māori Monitoring and Equity Group Report on Antenatal HIV Screening
Programme. Unpublished Report. Ministry of Health, 2013. [cited 27 June 2014]. Available from:
http://www.nsu.govt.nz/health-professionals/2427.aspx
13.
National Screening Unit. Antenatal Screening for Down Syndrome and Other Conditions (DSCO)
Summary Report January–December 2011. Unpublished Report. Ministry of Health, 2013. [cited
16 February 2014].Available from: http://www.nsu.govt.nz/current-nsu-programmes/antenatalscreening.aspx
14.
National Screening Unit. Antenatal Screening for Down Syndrome and Other Conditions 2013
[cited 16 February 2014]. Available from: http://www.nsu.govt.nz/current-nsuprogrammes/antenatal-screening.aspx.
15.
Ministry of Health. Health Targets: More Heart and Diabetes Checks 2013 [cited 17 September
2014]. Available from: http://www.health.govt.nz/new-zealand-health-system/healthtargets/about-health-targets/health-targets-more-heart-and-diabetes-checks.
Page 16
National Health Committee – An Overview of Screening in New Zealand
16.
Ministry of Health. Diabetes 2013. Available from: http://www.health.govt.nz/yourhealth/conditions-and-treatments/diseases-andillnesses/diabetes?mega=Your%20health&title=Diabetes,.
17.
Ministry of Heatlh. How Is My DHB Performing? – 2012/13 2013 [cited 17 September 2013].
Available from: http://www.health.govt.nz/new-zealand-health-system/health-targets/how-mydhb-performing/how-my-dhb-performing-2012-13.
18.
Genetic Health Service NZ. Genetic Health Service NZ – Central Hub: Health Point information
matters; 2014 [cited 17 February 2014]. Available from:
http://www.healthpoint.co.nz/specialists/genetics/genetic-health-service-nz-central-hub/.
19.
ACART. Assisted Reproductive Technology in New Zealand 2009. Wellington: Advisory Committee
on Assisted Reproductive Technology, 2013.
20.
Prostate Cancer Taskforce. Diagnosis and Management of Prostate Cancer in New Zealand Men:
Recommendations from the Prostate Cancer Taskforce. Wellington: Ministry of Health, 2013.
21.
New Zealand Guidelines Group. Population-Based Screening for Prostate Cancer and Testing of
Asymptomatic Men in New Zealand. New Zealand Guidelines Group, Wellington, April 2004.
Wellington: New Zealand Guidelines Group, 2004.
22.
Health Select Committee. Health Select Committee. Inquiry into Early Detection and Treatment of
Prostate Cancer. Wellington: Parliament of New Zealand, 2011.
23.
Ryall T. $4.3m Prostate Cancer Campaign to Save Lives [cited 30 July 2013]. Available from:
http://www.beehive.govt.nz/release/43m-prostate-cancer-campaign-save-lives,.
24.
Ministry of Health. Bowel Screening Pilot January to December 2012 Results 2013 [cited 30 July
2013]. Available from: http://www.health.govt.nz/our-work/diseases-and-conditions/cancerprogramme/bowel-cancer-programme/bowel-screening-pilot/bowel-screening-pilot-results/bowelscreening-pilot-january-december-2012-results.
25.
Ministry of Heatlh. About Bowel Screening 2013. [cited 17 September 2013] Available from:
http://www.health.govt.nz/our-work/diseases-and-conditions/cancer-programme/bowel-cancerprogramme/about-bowel-screening,.
26.
National Screening Unit. Understanding HPV, HPV Testing, Cervical Cancer and the HPV Vaccine
2014 [cited 17 February 2014]. Available from: http://www.nsu.govt.nz/current-nsuprogrammes/2480.aspx.
27.
National Screening Unit. Review of the Latest Literature on Extending the Age Range for Women
Eligible for National Breast Screening Programmes. Internal Memo. 2013.
28.
Gotzsche PC, Jorgensen KJ. Screening for Breast Cancer with Mammography. Cochrane Database
Syst Rev. 2013;6:CD001877. doi: 10.1002/14651858.CD001877.pub5.
29.
Royal Australasian College of Surgeons. Early and Locally Advanced Breast Cancer Diagnosed in
New Zealand Patients in 2011. Annual Report 2011 Prepared for Ministry of Health, New Zealand
by the Australasian Safety and Efficacy Register of New Interventional Procedures – Royal
Australasian College of Surgeons. Adelaide: Royal Australasian College of Surgeons, 2013.
30.
World Health Organization. Definition, Diagnosis and Classification of Diabetes Mellitus 5161 and
Its Complications. Report of a WHO Consultation. Part 1: Diagnosis and Classification of Diabetes
Mellitus. 1999. Geneva: World Health Organization, 1999.
Page 17
National Health Committee – An Overview of Screening in New Zealand
31.
Drury P, Jo E. Increasing Incidence of Diabetes in Pregnancy in New Zealand. Report from the
Nzssd and National Diabetes Services Improvement Group. Wellington: Ministry of Health, 2013.
32.
Uniservices TUOA. Uniservices, the University of Auckland. Screening, Diagnosis and Management
of Gestational Diabetes in New Zealand: A Clinical Practice Guideline: Draft Version. Auckland:
Uniservices, The University of Auckland, 2013.
33.
Geddes L. First Baby Born after Full Genetic Screening of Embryos. New Scientist.
2013;219(2925):8-9.
34.
Health Policy Advisory Committee on Technology. Technology Brief: Antenatal Placental Growth
Factor Screening for Pre‐Eclampsia, August 2013. In Publication. 2013. Available from:
http://www.health.qld.gov.au/healthpact.
35.
Longo D, Fauci A, Kasper D, Hause S, Jameson J, Loscalzo J. Harrison’s Principles of Internal
Medicine. 18th ed 2011.
36.
Borman B, Veale A, Findlay J. Major Birth Defects in New Zealand: Prevalence and Patterns.
Patient Management. 1987.
37.
Hoffman S, Kaplan S. The Incidence of Congenital Heart Disease. Journal of the American College
of Cardiology. 2002;39(12):1890-900.
38.
Thangaratinam S, Brown K, Zamora J, Khan KS, Ewer AK. Pulse Oximetry Screening for Critical
Congenital Heart Defects in Asymptomatic Newborn Babies: A Systematic Review and MetaAnalysis. Lancet. 2012;379(9835):2459-64. doi: 10.1016/S0140-6736(12)60107-X.
39.
National Screening Advisory Committee. Should Abdominal Aortic Aneurysm Screening Be
Implemented in New Zealand? Key Issues and Recommendations. Draft Advice. 2011.
40.
Nair N, Shaw C, Sarfati D, Stanley J. Abdominal Aortic Aneurysm Disease in New Zealand:
Epidemiology and Burden between 2002 and 2006. NZ Med J. 2012;125(1350):10-20.
41.
Ministry of Health. Strategic Directions for Hepatitis C: Improving Access to, and Uptake of
Hepatitis C Treatment Services. Wellington: Ministry of Health, 2008.
42.
Ministry of Health. Hepatitis C. Work in Progress for Improving Hepatitis Treatment Services in
New Zealand. 2011 [cited 4 October 2011]. Available from: http://www.health.govt.nz/ourwork/diseases-and-conditions/hepatitis-c.
43.
New Zealand Guidelines Group. New Zealand Primary Care Handbook Wellington: New Zealand
Guidelines Group, Wellington; 2012 [cited 13 September 2013]. Available from:
http://www.health.govt.nz/publication/new-zealand-primary-care-handbook-2012.
44.
Ministry of Health. Rheumatic Fever 2014 [cited 18 February 2014]. Available from:
http://www.health.govt.nz/our-work/diseases-and-conditions/rheumatic-fever.
45.
School of Population Health. The Burden of Osteoporosis in New Zealand: 2007–2020. Prepared
for Osteoporosis New Zealand Inc. University of Auckland 2007. Available from:
http://www.iofbonehealth.org/sites/default/files/PDFs/white_paper_new_zealand_2007.pdf.
46.
Best Practice Advocacy Centre New Zealand. Prevention of Osteoporosis 2008 [cited 11 October
2013]. Available from:
http://www.bpac.org.nz/magazine/2008/october/docs/bpj17_bones_pages_6-32.pdf, .
47.
Up to Date. Screening for Osteoporosis 2013 [cited 11 October 2013]. Available from:
http://www.uptodate.com/contents/screening-for-osteoporosis:
Page 18
National Health Committee – An Overview of Screening in New Zealand
48.
Up to Date. Patient Information: Lung Cancer Prevention and Screening (Beyond the Basics) [cited
7 October 2013]. Available from: http://www.uptodate.com/contents/lung-cancer-preventionand-screening-beyond-the-basics.
49.
Northern Cancer Network. Summary of the Recommendations from the HRC_DHBnz funded
project: “Identification of Barriers to the Early Diagnosis of People with Lung Cancer and
Description of Best Practice Solutions.” 2012 [cited 4 October 2013]. Available from:
http://www.northerncancernetwork.org.nz/Research/tabid/110/language/en-NZ/Default.aspx.
50.
Neugut AI, Accordino MK, ACP Journal Club. Review: CT Screening for Lung Cancer Reduced
Mortality in 1 Large Trial but Not in 2 Smaller Trials. Ann Intern Med. 2012;157(6):JC3-6. doi:
10.7326/0003-4819-157-6-201209180-02006.
51.
Gopal M, Abdullah SE, Grady JJ, Goodwin JS. Screening for Lung Cancer with Low-Dose Computed
Tomography: A Systematic Review and Meta-Analysis of the Baseline Findings of Randomised
Controlled Trials. J Thorac Oncol. 2010;5(8):1233-9. doi: 10.1097/JTO.0b013e3181e0b977.
52.
Best Practice Advocacy Centre New Zealand. Lung Cancer in New Zealand: Overcoming Barriers.
Best Practice Journal. 2012;48:3-5.
53.
Committee NSA. National Screening Advisory Committee 2012 [cited 18 February 2014]. Available
from: http://www.nsac.health.govt.nz/.
54.
National Screening Unit. The NZ Health Sector 2013. Available from:
http://www.nsu.govt.nz/about/781.aspx.
55.
Ministry of Health. Targeting Shorter Waits for Cancer Treatment. Wellington: Ministry of Health;
2011. Available from: http://www.health.govt.nz/publication/targeting-shorter-waits-cancertreatment.
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National Health Committee – An Overview of Screening in New Zealand
National Health Committee (NHC) and Executive
The National Health Committee (NHC) is an independent statutory body which provides advice to the
New Zealand Minister of Health. It was reformed in 2011 to establish evaluation systems that would
provide the New Zealand people and health sector with greater value for the money invested in
health. The NHC Executive are the secretariat that supports the Committee. The NHC Executive’s
primary objective is to provide the Committee with sufficient information for them to make
recommendations regarding prioritisation and reprioritisation of interventions. They do this through
a range of evidence-based reports tailored to the nature of the decision required and timeframe
within which decisions need to be made.
Citation: National Health Committee. 2015. An Overview of Screening in New Zealand.
Wellington: National Health Committee.
Published in March 2015 by the National Health Committee
PO Box 5013, Wellington, New Zealand
ISBN 978-0-478-42862-9 (online)
HP 5951
This document is available on the National Health Committee’s website:
http://www.nhc.health.govt.nz/
Disclaimer
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