Meet the Solutionists, with Mark Scott

Humans are constantly getting better at fighting cancer. Our understanding of the suite of diseases is more robust, our technology is more advanced, and our public health systems are more efficient. But cancer epidemiologist Professor Karen Canfell says Australia will still see more and more incidences of cancer over time.

But Australia’s also on track to become the first country to eliminate cervical cancer, the fourth-most common cancer in women. Karen says that our fight against cervical cancer can teach us how to beat other diseases, too. Crucially, it can also teach us how to help our closest neighbours: cervical cancer is low on Australia’s list of most deadly cancers, and yet it’s at the top of the list in Papua New Guinea.

Karen explains why Australia’s leading the world in this space, and how that gives us a responsibility and opportunity to help improve public health worldwide. 

Mark Scott  00:01

This podcast is recorded at the University of Sydney's Camperdown campus on the land of the Gadigal people of the Eora Nation. They have been discovering and sharing knowledge here for 10s of 1000s of years. I pay my respects to elders past and present, and extend that respect to all Aboriginal and Torres Strait Islander people.

Renee B  00:27

The first sign for me was identified with my partner. I bled during intercourse, and it was the colour of the blood that was very sinister that alerted me to the fact that there was something obviously catastrophically wrong. I was 38. When I went to the gynaecologist to have a colposcopy, which is internal biopsies. I was hoping for the best, and it was when the gynaecologist said to me, just as she was finishing taking biopsies, “just say a little prayer”. That's when my heart plummeted. I'm Renee, and I am a cervical cancer survivor.

Mark Scott  01:34

Every year roughly 350,000 women around the world die from cervical cancer, according to the World Health Organisation. The vast majority of them don't have to. Cervical cancer, the fourth most common cancer for women, is one of the few cancers we can actually prevent. We have a vaccine, we have a screening programme, and we have a clear road map for elimination. And Australia is on track to become the first country in the world to do just that. But that in itself raises some interesting questions. What happens to the hundreds of thousands of women dying every year in other countries, including those right on our doorstep, and how can what's working in Australia be transferred to other parts of the world? This is The Solutionists. I'm Mark Scott. Professor Karen Canfell is a cancer epidemiologist at the University of Sydney, a Companion of the Order of Australia, and one of the architects of Australia's path towards being the first country to eliminate cervical cancer. She now leads EPICC, a $35 million programme, taking that playbook to the Indo-Pacific. So, Karen, you're a cancer epidemiologist, you're a Director of the Cancer Elimination Collaboration. You know, cancer better than almost anyone in the country. Can you give us a view on where we are today in the fight against cancer? So many families are still affected by it. It seems to be more prevalent than ever, but technology is giving us great breakthroughs as well. Where are we today?

Karen Canfell  03:19

So, I think there's many dimensions to what's put in this bucket of cancer. I mean, I think the first thing to say is that cancer is actually more than 100 different diseases, it's not one disease, and that increases, of course, the complexity. And I think we see a very, very different picture of cancer in high-income countries like Australia than we do in emerging economies and low and middle income countries. So in Australia, for example, we have seen substantial reductions in both incidence and mortality over the last few decades, and increased survival, which is fantastic news. But there's still a long way to go. There's still projected to be an increase by about a third in the number of cancer deaths over the next 20 years or so, and that's partly because of the growth and ageing of our population.

Mark Scott  04:11

So, is that in Australia or global?

Karen Canfell  04:14

In Australia, in Australia.

Mark Scott  04:14

So we're going to see increasing cancer cases in Australia?

Karen Canfell  04:18

We're going to see an increasing number of cancer cases in Australia, absolutely, because our population is growing and ageing. And then alongside of that, there's other emerging issues. For example, you might have heard about what's called early onset cancer, which is an increasing incidence of cancer in young people in Australia, particularly cancers like bowel and breast cancers. So, there is, there's a very mixed picture. There's certainly been some incredible progression, but there's also going to be, I think, an increasing challenge to our society in supporting all of the people that will continue to be diagnosed with cancer, to understanding it, to preventing it, to detecting it, to, to treating it. And I think that has to be a focus for the next few decades.

Mark Scott  05:04

So we know more about cancer than ever before, and we know how to treat it better than ever before, but in a sense, incidents might still be kind of, moving away from us.

Karen Canfell  05:14

Well, I think what we're seeing in a country like Australia, we're seeing the rates of cancer actually tracking down overall, which is really good news. So, when you think about the actual rates, what's happening in people of different ages, that is tracking down, and that's due to progression across what we call the cancer control spectrum prevention, screening early detection, and treatment. Across the spectrum, there's been progression and improvements. But, at the same time our population demographics are changing, so as the population grows and as it ages, that means that cancer cases and deaths will actually increase.

Mark Scott  05:52

There's a sense that cancer treatment is expensive, high tech more expensive. Is it true to say that we'll be treating more cancer cases, and is it getting more expensive to treat cancer cases, given the technology that's available now?

Karen Canfell  06:10

Yes. Look, I think it's really important that even in a country like Australia, we think beyond the treatment paradigm. Because, and we'll get to what an elimination framework is for cancer, in a bit more detail, but the fundamental is we act across the cancer control spectrum. So where we can prevent cancer, we prevent it. Where we can screen for it, we screen for it. Where we can detect it early, we detect it early. And then if all else fails, we need to treat it. And from a societal perspective, by far, far the best bang for buck is prevention, screening, and early detection. So, as we think about facing the challenges of the next few decades in Australia, it's really important that we build on those major public health success stories that we've had in tobacco control, in HPV vaccination, and in the screening programmes in Australia, because those are really saving hundreds of thousands of lives, in fact, and will continue to do so over that period.

Mark Scott  07:10

So, cervical cancer is a great case study of that. For those who aren't familiar, what is cervical cancer? How does it start, and where exactly?

Karen Canfell  07:18

So, cervical cancer is cancer of the cervix, it starts with an HPV infection. By the way, most HPV infections don't result in cervical cancer, but the cervix is the neck of the womb. So it's an area that's vulnerable to infection, often acquired at a younger age, certainly in the pre-vaccination era, and then it's a relatively slow growing disease where the HPV virus transforms in some cases and moves into a precancerous state, and then eventually in some women, into invasive cervical cancer.

Mark Scott  07:57

So, how's the virus acquired?

Karen Canfell  07:59

So, the virus is sexually transmitted, and so, and by the way, that's been one reason for stigmatisation of cervical cancer. So, in the pre-vaccination era, it is a very, very common virus. In fact, there's HPVs all over us, there's also skin HPVs. There's more than 100 different types, and they've lived with humans, they've co-evolved with human populations for millennia, but the anogenital types are sexually transmitted. And a few of those types, it's about eight of those types in fact, have been implicated in cervical cancer. And in some women, an infection inquired often fairly early in life, often fairly soon after the initiation of sexual activity, can over time develop into a pre-cancer and then into an invasive cervical cancer. But again, the critical insight is that this whole cycle can be totally disrupted, either by vaccinating to stop this whole cycle starting, or by screening to detect that precancer, and then treating that precancer before it develops.

Mark Scott  09:06

Part of the challenge of cervical cancer is that in early stages it doesn't throw off symptoms.

Karen Canfell  09:13

Yes, that's part of the challenge, and that's actually the challenge for many cancers. I think the important thing about cervical cancer is that it has defined precancerous stages. And there are other cancers that have these precancerous stages, including bowel cancer. And why that's important is that if you can screen for that and treat that precancerous disease, you can actually prevent cancer developing in the first place, so it's not just about what we call down staging or detecting at an early stage, it's actually about preventing cancer from actually happening.

Renee B  09:49

I remember this really vividly, ‘cause it's like your world spins on its axis. And I had just left my partner’s, and I was driving down the highway. I had a couple of hours drive ahead of me, and the phone rang, and it was a gynaecologist. And she identified straight away that I was driving, and she said, "Can you pull over?”. And I pulled over, and she said, "It's cancer, sweetie”. At that point, it felt like everything moved pretty quickly, and I felt like I had a solid plan. I felt like going in to have my lymph nodes checked, and having a, even though I was petrified of having a radical hysterectomy, because there's just, there's nothing pleasant about that at all. But when I got into hospital, they actually come and stopped my bed from being wheeled out of the room, and they said “We've just got your results from your lymph nodes, and two of them have tested positive. So we've removed them”, and they said “Your radical hysterectomy is now cancelled, and we are now going to send you on to the Peter MacCallum Cancer Centre in Melbourne for chemotherapy, radiation, and brachytherapy”.

Mark Scott  11:08

So, so tell us about the approach. How you attack cervical cancer, and how you focus on prevention.

Karen Canfell  11:15

So cervical cancer has had a longstanding history of being a cancer that has been a screenable cancer, if you like. And so Pap smear programmes have been established for many decades, and in Australia that was in 1991. And so we did have a very successful Pap smear programme going for several decades here that reduced rates of cervical cancer by about a half over time. And then in the early 2000s there was this great disruptor, which is the emergence of the HPV vaccine. And Australia was the first country in the world to introduce it into a publicly funded vaccination programme, and that happened in 2007. And so what we had then was an effective screening programme in women, and then a effective vaccination programme, starting, which is most effective when given to young pre-adolescents or adolescents. And I think that's really set the scene for what we've seen over the last 20 years since then, which is this increasing investment in our public health systems towards actually using vaccination and screening, tailoring them to each other, optimising them in the context of effective treatment. So we've seen a bunch of improvements since then. We saw the introduction of the National HPV Vaccination Program in 2007 but then we saw it extended to boys in 2013.

Mark Scott  12:46

Why boys?

Karen Canfell  12:48

So HPV actually causes cancers at a number of sites in both men and women, of the anogenital tract and also the head and neck. So the first target for vaccination is young girls, because that's where 90% of HPV related cancers reside. But then for countries that can afford it, and where it's cost-effective, and where the vaccine price has come to the right point, vaccination of boys is also recommended. So, Australia again was one of the first countries in the world to do that. And then in 2017 we then had another major change, which was moving from Pap smear based screening, which kind of worked, but had reached its limits, and it required screening every two years. And then we moved to five yearly HPV molecular testing, which is the current programme in women. So we now have, we were one of the first two countries in the world to do that in 2017. And then we moved from there to actually be the first country to introduce what's called universal access to self collection, which means a woman no longer has to have a pelvic examination, which has been a major barrier, particularly for certain cultural groups. And a woman can now self-collect her own sample, under the supervision of a primary care practitioner. And that has really also been a, a major game changer.

Mark Scott  14:12

A game changer in terms of number of people who are willing to do it? Quality of the test?

Karen Canfell  14:16

Yeah, so the big, you know, the gateway to that was a really important analysis in 2018 which showed that for HPV testing, a woman taking her own sample will give you equivalent sensitivity to a practitioner sample. So that opens up a lot of choice, and gives women control over how they want to do the exam. And that really has helped, I think, in promoting different ways of access in different communities, co-designing what works for them. And so it's been a game changer, I think, for access, and we're seeing that play out now. In the most recent statistics, actually, about half of the women in Australia that are having cervical screening are choosing to self-collect. And what's really exciting about that is that proportion is higher in groups that were previously not well served, that were previously not accessing screenings, so we've really seen this turnaround.

Mark Scott  15:11

I appreciate that great research on the human papillomavirus and the vaccine took place in Australia, but it's very interesting to hear you talk about Australia's global leadership around this entire treatment, not just in early days. Why has Australia been at the forefront of this cancer research more than others?

Karen Canfell  15:31

There's several elements. There's obviously been the leadership of Professor Ian Frazer and his co-inventor Jian Zhou in the vaccine space. And I think what's really important to note is that Ian also took a stance in the public health space as well, and that was influential in terms of Australia being an early adopter of the vaccine. But I think since then there's been this, just this investment in the public health systems that I've described, which is not about one big change, it's about incremental improvements to both vaccination and screening. So, Australia, you know, has become this exemplar of what's possible. When our team, which is now at the Cancer Elimination Collaboration in the School of Public Health here at Sydney, were thinking about this back in the about 2017, 2018. We did some modelling of what the possibilities would be for cervical cancer incidents dropping, and that's when we basically put a timeline to it. We said that Australia could eliminate cervical cancer according to the definition, which was subsequently adopted by around 2035 and that it was on track to be the first country in the world to do it. And it was through this combination of both vaccination and screening, but again in context of very good treatment access when it's needed.

Mark Scott  17:02

Let's go to the region. Let's take a 35 year old woman in PNG. How will her experience likely to be different to an Australian woman in the preventative steps taken to stop cervical cancer?

Karen Canfell  17:16

Yeah, well, that's a really profound comparison, because of course PNG is, is just over the water, it's so close geographically to Australia. And yet currently rates of cervical cancer mortality are 12 times the rate that they are in Australia, 12 times. And in countries like PNG, and in fact in many low and middle income countries, this is number one or two cause of cancer death in women. So when we think about the global picture of cervical cancer, on average it's number four, but when we talk about a country like PNG, it's really there. It is something that when we talk to our colleagues in PNG, so many people, everyone has a mother, a sister, a friend that's been impacted. It's part of society because it is incredibly common, cancer.

Mark Scott  18:07

Can you explain why? If it's globally number four, why in a country like PNG would it be that much higher, that much more prevalent again? Is it the fact that it doesn't, you know, throw off symptoms that are obvious earlier?

Karen Canfell  18:22

The biggest differentiator between rates between countries is historical access to cervical screening.

Mark Scott  18:29

Right.

Karen Canfell  18:29

So, in Australia, last time I looked at the statistics, it was number 13 of our cancers. It's right down there, because we've been,

Mark Scott  18:37

Screening.

Karen Canfell  18:37

Screening for decades. 

Mark Scott  18:38

Yep.

Karen Canfell  18:39

In a country like PNG, there hasn't been screening, and that's what, of course, we're looking to change through the programmatic work that we're doing. But that is the challenge, because if I come back to the big picture here. As you said in your introduction, this is a cancer that literally no woman should be dying from. We know how to prevent it, in adolescence. We know how to screen for it. We know how to treat precancer. And even if women do have cancer, there is really good outcomes if it's early stage cancer, and it can be treated. So, no woman should be dying of cervical cancer, and that's what our programmatic work is all about.

Mark Scott  19:15

And what are the constraints you're dealing with there? Is it cost of rollout, is it skilled workforce and capability on the ground? What are you, when you get out into the field and assess the challenges, what, what comes into focus for you?

Karen Canfell  19:30

Yeah, all of the above. Look, I think what we have found, though, is that you know the thing that isn't missing now, the thing that elimination, the initiative of cervical cancer elimination has really promoted is political will. So what we do find is this incredible momentum and resolution, and local leaders who are really taking this on in countries. And so in terms of those challenges in systems of training workforce, upskilling, establishing the infrastructure, and so on. That's very much part of the support that EPICC can provide. So we draw on dozens of multidisciplinary experts to help in that establishment phase for countries. But the biggest thing for us now is thinking about the longer term barriers and sustainability. And it's very easy to use that word, sustainability, and it's used in development a lot. But in this space, it's really about how do we make sure this is embedded in health systems, that there's a permanently skilled and trained workforce able to deliver it, and then how do we make sure that this is financed appropriately. And so one of the things that we're now doing in EPICC is we're transitioning from being sort of purely implementation on the ground focused, to very much thinking at the core, how do we support countries to get affordable HPV tests? How do we bring more HPV tests to market? How do we coordinate procurement? How do we think about demand? And how do we really build those long-term financing, blended financing platforms that will help countries embed this and be doing it for decades? Because it will need to be done for decades.

Mark Scott  21:11

Just explain to me about kind of viruses and, and, and disease, the way you approach it, this. Before the recent, you know, uncertainty around vaccines, there was a sense that we had eliminated polio. It was no longer a contagion, so therefore it was gone. When you talk about eliminating cervical cancer, are you talking about a process that says we can reduce its incidence greatly, but will always be needing to reduce its insulins greatly. It doesn't disappear, we just know how to stop it in its tracks.

Karen Canfell  21:47

Yeah, I think you've put your finger on the crucial point. So, elimination of a cancer is a completely new concept. And it is, as you've noted, this idea of elimination is actually borrowed from the world of infectious diseases. So, when we come back to what elimination means, it's a very defined kind of threshold. The evidence base for this is articulated in the WHO strategy for the acceleration of the elimination of cervical cancer, which was released in 2020. But the idea is that elimination of a cancer, and this is, this is often confused, is not the same as eradication of the HPV virus. Eradication of the HPV virus may happen, but it will be decades and decades and decades away. What we're talking about is elimination of a cancer, so that it is, cervical cancer is reduced to such a low level that it is controlled, fully controlled as a public health problem. And so what we have jointly done, I think, is the global community have defined this threshold. Technically, it's four per 100,000 women per annum in a country, which means that there's a very low number of women being diagnosed with cervical cancer. But as you just identified, Mark, this doesn't mean this is one and done. We can't just do this and then walk away. We have to keep controlling cervical cancer, we have to keep screening, we have to keep vaccinating, we have to keep treating. And this has to be embedded and sustained in systems for decades.

Mark Scott  23:23

When you travel in the region and you compare the advanced, you know, the sophistication of the treatment programmes rolled out here, compared to what you're seeing there, and the challenges you face on the ground. How much do you get a sense of almost burden and responsibility that Australia should carry for this around the region? And, and when it comes to Australia's reputation in the region, what kind of opportunity does this work create?

Karen Canfell  23:49

I, I think it's a huge burden and a huge responsibility. If you travel in the region, or if you understand what's going on in countries, not only in the Indo-Pacific, but in Sub-Saharan Africa and elsewhere, it's an absolute tragedy. And you know, I think it cannot be said enough that hundreds of thousands of women are dying. Often without dignity in conditions of stigmatisation, often by their communities, often even without palliative care or even basic pain relief. So this is completely avoidable, and I think there's a huge burden and a huge responsibility. I think the opportunity with our work and with EPICC, and I often try and articulate this, because I, one of the challenges that I get is, isn't this a vertical? And by that people mean, where you go in and you intervene on a single disease, but you're not really changing or transforming health systems more broadly, and I think that's actually not right. I think that with cervical cancer elimination, what we're actually trying to do is kind of use this as a way forward to increase access to global services that are relevant to women, and to men actually, through oncology services, so radiotherapy, surgery, palliative care, and so on. And also to think about increased, building out for early detection, so thinking about breast cancer screening, as well as well, breast cancer early detection, as well as cervical screening. And then all those touch points with reproductive health, and also with HIV services, because women with HIV are at higher risk. So, I think this is not about just dealing with a single disease. If we're going to be successful, we have to embed these services, and then they will provide a platform to increase access for people in low and middle income countries to all of these critical services.

Mark Scott  25:45

Tell me about the teams that you're taking in and working with, as part of this EPICC programme. What capabilities and skills do they need, and, and, and what's the range of expertise that's required to scale a programme like this?

Karen Canfell  25:59

I want to acknowledge, first of all, the leaders in countries, we've got incredible leadership in the countries in which we work. But what EPICC, is, is essentially a way to, for those countries to call on whatever technical support or technical assistance they need to meet them where they're at. So, we do have a tiered support framework. So we can help a country from everything, from well, I'm, you know, thinking about how do I prioritise cervical cancer elimination? How do I plan for it, how do I build the investment case, how do I convince the government this is important to do? So we can help in that planning policy space, and that's often a really important place to start. And in fact we do that for many more countries where we're on the ground, because actually helping countries plan well to think about where are you going to establish your screening sites? How much is it going to cost? How am I going to finance it? What's the plan? How often am I going to screen? How do I build the linkages to care? And so on and so forth. Those are really, really critical starting points for countries. And then at the next tier we will help with demonstration projects on the ground, getting screening going. Then at the next tier after that, subnational expansion, and then in some countries, some small Pacific Island countries, we're now talking about national coverage of elimination. In terms of the partners and the people involved, we have experts here from many, it's a consortium. So there are many, many different participating institutions. We have the National Centre for Immunisation Research and Surveillance, who can help on vaccine issues, anything to do with barriers to vaccination, planning roll out of programmes. We have partners that can help with designing screening programmes. Our team at the University of Sydney helps with the policy and planning, costing exercises, and we also have a lot of work that we do in the cancer treatment space. So, in fact, our, most of our team are actually in Fiji as we speak, running a major palliative care workshop for the region. 

Mark Scott  28:01

Right.

Karen Canfell  28:01

So we're doing everything across the spectrum, and we call EPICC end to end for that reason. It's not about picking off a piece of siloed activity, it's actually trying to strengthen the health systems across the board.

Renee B  28:18

The biggest gift that we can give to ourself as girls, as women, is what I believe is a sexual health contract. And I think that we greatly fail ourselves in this part, but we need to know the health of anybody that we're intimate in, and we need to protect that with ourselves. We need to not have shame about getting tested to know that who we do have an intimate relationship with does have a healthy, clean sexual record as well. That's the best gift we can give to ourselves as women for our sexual health.

Mark Scott  28:59

Strikes me, talking to you today, but in previous conversations we've had as well. You’re, you're kind of thrilled by the opportunity, but burdened,

Karen Canfell  29:11

Yes.

Mark Scott  29:12

By the responsibility. How has this work changed you?

Karen Canfell  29:15

Oh gosh. I, I think you've summed it up well. Thrilled by the opportunity, absolutely burdened, and I've said this before, but literally it keeps you up at night, and it should keep us up at night that we have to make this work. The trust and the faith that we've had from country leaders, from our funders, from the university, I think we do take very, very seriously. So, how has it changed me? I'm a cancer epidemiologist, so I've worked in what we were talking about earlier, some of the, the progressions in Australia, modelling the impact of the HPV transition, in screening. And then supporting WHO, and we, to support WHO with the elimination planning we did, very, very high level modelling, global modelling of the impact and the number of lives that can be saved by this very, very exciting, you know, 62 million lives over a century. But I think it's been for me, how EPICC has changed me has been really connecting that very high level conceptual, if you like, fairly abstract work. It's necessary to put quantities on how many lives will be saved with the people on the ground, and to meet the individuals that we're working with, and to understand their lives and their challenges. And so, so for me and for many of our team, it's just brought us much closer, I think, to people in countries. 

Mark Scott  30:43

So you put faces to the numbers.

Karen Canfell  30:45

Absolutely.

Mark Scott  30:46

And that the weight of responsibility flows from that.

Karen Canfell  30:48

Yeah absolutely. Yes.

Mark Scott  30:53

That's Professor Karen Canfell, epidemiologist and NHMRC Leadership Fellow from the University of Sydney. You also heard from Renee, who we thank for generously sharing her experience. If you're interested in public health, you'll love our episode with Professor Melody Ding, who studies loneliness.

Melody Ding  31:16

From the policy point of view, the interventions are more likely to be at the structural level. For example, creating public open spaces, the so-called third place where people can go hang out with each other to increase the level of incidental interactions among each other. So that is addressing more of social isolation side of the problem.

Mark Scott  31:38

You can listen to that episode of The Solutionists right now, and make sure you're following the show, so you don't miss an episode. The Solutionists is a podcast from the University of Sydney, produced by Deadset Studios.

The Solutionists is a podcast from the University of Sydney, produced by Deadset Studios. Keep up to date with The Solutionists by following @sydney_uni on Facebook and Instagram, and @sydney.edu.au on Bluesky.

This episode was produced by Liam Riordan with sound design by Jeremy Wilmot. Supervising producer is Sarah Dabro. Executive editors are Kellie Riordan, Sladjana Rstic, and Mark Scott. Strategist is Ann Chesterman.

This podcast was recorded on the land of the Gadigal people of the Eora nation. For thousands of years, across innumerable generations, knowledge has been taught, shared and exchanged here. We pay respect to elders past and present and extend that respect to all Aboriginal and Torres Strait Islander people.