What will our political parties do for breast cancer?

Until breast cancer is eradicated, saving and extending women’s lives requires early detection, quick diagnosis and optimal treatment. In our public health system, this requires political leadership, investment and action – both what can happen now, what needs to be explored and getting NZ ready for future medical and technological advancements. It is our government that decides who gets free mammograms, that can unlock and harness innovation in public health, that drive standardised and timely diagnoses and treatment, that can prioritise those most at risk, and ensure everyone has the free treatment they need, when they need it and where they need it.

We asked about these areas – in context of what is happening internationally, latest and emerging innovation, who is most at risk of getting breast cancer or dying from it, and a public health system that is short on staff, under pressure, and in the midst of reform. The questions we asked are all interrelated and part of a multifaceted approach to tackling breast cancer during the next term of government. During that term, 10,000 more women will be diagnosed and nearly 2000 will die, on top of the 25,000 undergoing treatment and the 50,000 who have recovered. These numbers show how important it is – breast cancer is a society issue, a women’s issue and something that impacts us all.

Other than Te Pāti Māori who sadly didn’t reply, all six of the main parties responded to our recent version - Act, Greens, Labour, National, NZ First and The Opportunities Party.

We sought tick-box answers for all questions, requiring explanations for only some of them.

• Where we only sought tick-box answers, we accepted the answer and recorded it as is.
• Where we also sought an explanation, we assessed it against the ‘yes’ or ‘no’ – if it didn’t align, we downgraded the ‘yes’ to a ‘partly’. We have included those explanations and our commentary below.
• We analysed what they said overall.

BCFNZ is encouraged by the commitments to drive change – we received a lot of ‘yes’ responses - even if some explanations were light on detail, did not go far enough, weren’t telling us what they would do specifically, or the manifestos were silent.

• The big win? All parties committed to raising the screening age to 74, with National, Labour and NZ First including it in their manifestos. While it's not the first time it's been an election promise, it's the first time all parties agree and it’s in our two major parties’ manifestos. We will hold them to this.

• All parties will increase Pharmac’s budget to address NZ’s woeful access to medicines, with only NZ First indicating it will fund breast cancer drugs. Labour and National don’t support reforming Pharmac meaning the core problems won’t be solved.

• All parties show a piecemeal or compartmentalised approach to the recommendations, despite them being interrelated e.g. raising the free mammogram age to 74 but nothing of substance for innovation to increase workforce or system capacity, a commitment to targets but no methods to identify and prioritise women most at risk, increasing Pharmac’s budget but won’t necessarily invest in genomic testing to limit the extent of treatments overall through a more targeted approach.

• The explanations often reinforced how behind the parties are in understanding, exploring or using innovation, and what we need from our leaders to drive change in this area, particularly given innovation is a key part of improving outcomes, reducing costs, increasing productivity and addressing workforce shortages – all of which our political parties say they want. While we appreciate any work advancing innovation and the willingness to explore things further if elected, it is clear NZ is still lagging in this area – we need a culture and practice that welcomes innovation and research, pilots it and ultimately embeds it in our public system.

Our biggest takeaways?

• They’re willing. We (all) need to do more work to show what is possible, why and how it will unlock the very things our women need, and the parties say they want.
• That even knowing our public health system has limited resources and stretched capacity, there’s a lack of prioritising women we know are most at risk or using innovation to be more targeted, increase capacity and improve productivity.
• That the extent of what will happen over the next three years may rely on coalition negotiations.
• That none of NZ’s main political parties have a multifaceted, multiyear outcomes (or people) driven plan to tackle cancer, let alone breast cancer.

This is something we’d like to change.

Free mammograms for women aged 70-74

We have a win: cross-party support for raising the free mammogram age to 74 with it being included in National’s, Labour’s and NZ First’s health manifestos! This is on top of the early show of support for Dr Reti’s Private Member’s Bill to extend the screening age to 74 tabled in August. We expect it to be rolled out next year given the bipartisan support but won’t rest it until it happens.

Early detection is key to saving lives, minimising treatment and reducing the down-stream impact on the health system. Evidence shows the benefit of screening women aged 70-74[i], yet BreastScreen Aotearoa’s screening programme stops at age 69. This is why we’ve been campaigning so hard to change that for the last seven years.

Free screening for high-risk women aged 40-44 similar to the bowel screening programme

There are two ways to detect breast cancer: via a mammogram or after being referred to a specialist after spotting a symptom, usually by a GP. BreastScreen Aotearoa’s screening programme currently provides free mammograms to women aged 45 to 69. For women aged 40 to 45 years, evidence shows that women benefit from regular mammograms from age 40[ii], that Māori and Pacific Island women have higher rates of breast cancer than Pākehā at 17%, 21% and 11% respectively, and that Māori and Pacific Island are more likely to die if cancer is detected by spotting a symptom - when it is detected via a mammogram, survival is the same for Pākehā women[iii]. 

Given this and the pressures on the workforce, we want the next Government to prioritise introducing a new risk-based screening programme for women aged 40-44 like the bowel screening programme. This would include women with genetic risks and all Māori and Pacific Island women. We gave our parties the option of introducing screening for all women aged 40-44 as well.

Greens, NZ First and TOP all committed to lowering the screening age to 40 either via the risk-based approach (TOP) or for all women of that age (Greens and NZ First) with NZ First using an ‘opt-in’ approach. Act was silent, and Labour and National said no, meaning that any progress in this area may come down to a coalition agreement. Their response reinforces inequitable access by not prioritising women most at risk in context of a stretched system. Not doing so continues the status quo – later diagnoses requiring more expensive and resource intensive treatments, and ultimately unnecessary deaths.

Enable and invest in the use of AI in breast screening

BreastScreen Aotearoa’s programme entitles all women aged 45-69 - and hopefully soon 70-74! - to a free mammogram every two years. This mammogram is conducted by a mammographer/MIT and ‘read’ by two different radiologists. This is time and resource intensive, with a growing shortage of these roles, both here and overseas (See BreastScreen Aotearoa’s Workforce Development Strategy 2022-2032). The Scottish and Victorian (Australian) health systems are currently researching and piloting how artificial intelligence can be used to make mammogram readings less resource intensive and faster at scale (see this 1 News article too). We want NZ to do the same – explore using AI to ensure BreastScreen Aotearoa’s programme can meet demand.

Despite political parties confirming their focus on addressing workforce shortages and increasing productivity, none of the answers showed an intent to drive innovative solutions as part of this. The responses were too high level, implied it was a long way off, lacked detail and/or misunderstood how AI is a workforce solution. The workforce solutions outlined are generally focused on training (which takes years), retention and recruitment, including from overseas (which may be difficult given this is a global issue). This is at odds with BreastScreen Aotearoa’s Workforce Development Strategy 2022–2032 specifically stating that “traditional methods of determining workforce shortages tend to assume that the structure of the workforce is set, and don’t consider…..how innovation and developing technologies may change work practices” and that “the constraints on labour supply in New Zealand, and globally, will necessitate a much great focus on improving the performance and productivity of the available workforce” (pg. 25). AI’s potential is even referenced in this report, but seemingly as a ‘future focused’ initiative.

We don’t agree with this compartmentalised, ‘one-day’ approach and consider it integral that our parties explore innovation alongside other methods. Our concern is that if NZ does not drive innovative solutions at the same time and use them to shape the workforce (e.g. qualifications, training, practice) in the same way that is happening overseas or in private practice, NZ will not keep pace internationally, won’t be able to recruit and will need to invest more to catch up. As noted in The New Zealand Health Strategy, professions are evolving or need to, and our health system needs to harness innovation and create a learning culture to improve productivity and efficiency (See Priorities 3 and 4). So, we are disappointed there were no clear “yes” responses with details on how they will do this.

Enable and invest in the use of genomic testing

Genomic testing is a tool to establish risk, be more targeted in early detection initiatives and treatment, and improve our understanding of breast cancer to ultimately advance solutions. Genomic testing can help identify if a treatment will be effective or not, including chemo and radiation, stopping people getting unnecessary treatments. Which is why we asked our political parties if they would invest in genomic testing for women with breast cancer to help make sure they receive the most effective treatment, and to build NZ’s understanding and capability in genomic testing for cancer in general. Their responses show a willingness to explore it further, which is great, but we are not sure the extent they will drive this.

Establish a fast-track system for high-risk women, including all Māori and Pacific Island women, to be seen at diagnostic centre appointment within two weeks

For the same reasons we proposed a risk-based screening programme for Māori and Pacific women (see above), we want all Māori and Pacific women to be fast-tracked to a diagnostic centre appointment within two weeks of reporting a symptom to their GP. This would apply to Māori and Pacific women of all ages to address the fact that they are currently experiencing the worst breast cancer outcomes and given the higher proportion of women being diagnosed under 45 years. This is a ‘right now’ solution to overcome the barriers and inequities Māori and Pacific women face, particularly given how well evidenced it is that Māori and Pacific women are more likely to have cancer and face delays[iv]. Timeliness is critical - delays of more than 12 weeks can lead to worst outcomes[v].

The responses were disappointing, with only the Greens and TOP saying yes, and our two major parties saying no. This – and not wanting to establish a high-risk screening programme for 40-44 – is nonsensical in light of the evidence and status quo: with limited resources and stretched workforce, wouldn’t you prioritise those most at risk? It’s akin to the triage system that happens in the emergency department, where those with the biggest need are seen first.

Reform Pharmac and fund it to provide more breast cancer treatments

Pharmac decides what breast cancer treatments our women can access for free – if it’s not funded, either they pay for it privately or they go without, which can affect their survival. Pharmac’s decision making processes are slow and lack transparency, do not keep pace with medical advancements and the treatments provided fall well behind comparable OECD countries (See 2021 Pharmac Review). Addressing this is a decision for the future government – Cabinet sets its budget, its model is determined by law and the Minister of Health oversees its operations.

There are 14 highly-effective breast cancer treatments that are needed in NZ and available overseas, including Keytruda, Trodelvy and T-Dxd (Enhertu). These treatments are a priority and will make the biggest difference to women with breast cancer today. As such, we intentionally asked each party whether they would fund Pharmac to provide these treatments, how much they would increase Pharmac’s budget overall and whether they will actually reform it.

Only NZ First indicated a commitment to fund Pharmac to provide breast cancer drugs, although it was silent on exactly which ones. They all committed to increasing Pharmac's budget, with NZ First wanting to replace its operating model, Greens ensuring all the 2021 Review recommendations are implemented and TOP committing to reform it (see also Te Pāti Māori’s health manifesto for its proposed approach). It remains to be seen what breast cancer treatments will be provided and when.

See below for more detailed responses from each party.

Te Aho o Te Kahu, the Cancer Control Agency, in consultation with a National Breast Cancer Working Group which includes BCFNZ, is currently developing Breast Cancer Quality Performance Indicators (QPIs) – or measures to drive timely diagnosis and treatment for all. It is the role of the government to establish targets and to use them to monitor what is happening, hold the public health system to account and drive improvements.

We asked if the parties will adopt and use these targets. While all parties said ‘yes’ in principle, the majority noted that they couldn’t commit to any until they are finalised – while we understand this, we expect the next government to implement targets, either Te Aho o Te Kahu’s QPIs or a version that improves on them. Since receiving the response below, National released a new manifesto to ‘bring back (health) targets’, with one relating to cancer - 85% of cancer patients receive management within 31 days of decision to treat. Likewise, we would need to see all targets and how they are defined to be able to assess them.

We asked each party what their priority for women’s health will be if elected. We did not include this on the scorecard – we wanted to know where their focus lies and how intentionally they will be in regard to women’s health, including breast cancer.

These are their responses.

[i] Nickson et al. Breast cancer screening of women aged 70–74 years: results from a natural experiment across Australia, Breast Cancer Res Treat (2014); Population screening and intensity of screening are associated with reduced breast cancer mortality: evidence of efficacy of mammography screening in Australia; Roder, D et al. Breast Cancer Res Treat (2008) 108:409–416; Breast Cancer Screening Beyond 70 Years Old; Henry Kwok, BSA Counties Manukau; 2015.

[ii] Breast Cancer Foundation NZ (2022). 30,000 voices: Informing a better future for breast cancer in Aotearoa New Zealand. Breast Cancer Foundation NZ

[iii] Seneviratne S, et al, 2015. Impact of mammographic screening on ethnic and socioeconomic inequities in breast cancer stage at diagnosis and survival. BMC Public Health 15: 46.

[iv] Breast Cancer Foundation NZ (2022). 30,000 voices: Informing a better future for breast cancer in Aotearoa New Zealand. Breast Cancer Foundation NZ.

[v] Hanna, T.P., et al., Mortality due to cancer treatment delay: systematic review and meta-analysis. BMJ, 2020. 371: p. m 4087