Surviving lung cancer in Aotearoa New Zealand could depend on whether you can access a GP – raising questions about equity in the country’s health system.
Our new research examines the outcomes for patients who are diagnosed with lung cancer through their GP versus those who are diagnosed at the emergency department (ED).
Examining 2,400 lung cancer diagnoses in Waikato between 2011 and 2021, we found those who are diagnosed with lung cancer after ED visits tended to have later-stage disease and poorer outcomes compared to those diagnosed after a GP referral.
We also found diagnosis after ED attendance was 27% higher for Māori than non-Māori and 22% higher for men than women.
These results raise important questions about health inequity in New Zealand and highlight the need to ensure everyone is able to access an early cancer diagnosis.
Limited access to everyday health care
Currently half of all general practices have closed their books to new patients, leaving 290,000 patients unenrolled and reliant on emergency departments for their health care.
Some 80% of practices have closed their books to new patients at some point since 2019.
For those who are enrolled in a practice, the wait times for appointments are often such that the only option is to go to the ED for help.
This is especially true in rural areas where the hospital can become the default route to diagnosis.
Lung cancer is New Zealand’s single biggest cause of cancer deaths, with over 1,800 per year. Some 80% of those who are diagnosed with lung cancer present with advanced disease and very poor prospects of survival.
It’s also the cancer with the largest equity gap. The mortality rate for Māori with lung cancer is three to four times that of people of European descent.
While much of this disparity is due to differences in the rates of smoking among ethnic groups, there is also evidence delays in diagnosis and poorer access to surgery are also major influences on survival rates.
Identifying lung cancer
Lung cancer usually starts in the tissue lining the airways and symptoms can initially be relatively minor – some shortness of breath during exercise, a niggly cough or sharp pains while breathing.
Patients with these sorts of symptoms usually go to a GP to check whether this is something that needs further investigation.
But if someone cannot get an appointment, or does not recognise the symptoms as serious, then they are likely to delay taking action.
Advanced symptoms of lung cancer include coughing up blood or having lumps in the neck due to lymphatic spread of the cancer. People with these alarming symptoms tend to go to the hospital for treatment.
Our study confirms earlier findings that those diagnosed through the emergency department are:
- more likely to have advanced disease
- more likely to have a more aggressive type of cancer (called small cell cancer), and
- have substantially poorer likelihoods of survival.
The median survival for those who never went to the ED was 13.6 months, while the median survival for those with one ED visit was just three months.
That said, attending an emergency department has some advantages. These include being seen by a doctor within a few hours, immediate access to x-rays and, in our major hospitals, access to the definitive diagnostic tool for a lung cancer – a computed tomography (CT) machine.
Our study found 25% of cases went to the ED two or more times in the two weeks before their diagnosis. This was especially true for those going to one of the Waikato rural hospitals, where a second or third visit was more likely before being diagnosed.
Barriers to care
It is clear New Zealand still has several barriers to primary care. This has lead to an over-reliance on emergency departments for diagnosing cancer, despite the long-running faster cancer treatment targets.
The situation is unlikely to improve. Access to GPs is getting worse, in part due to increasing fees.
Māori and Pacific patients with lung cancer were less likely than other ethnic groups to have been enrolled with a primary health organisation when they were diagnosed. They were also less likely to have visited a GP in the three months prior to diagnosis.
Making it easier to see a GP
Making general practice care more accessible is the most effective way of addressing the inequities in our lung cancer statistics.
Currently, New Zealand has only 74 GPs per 100,000 people, compared to 110 in Australia.
It is clear we need to substantially increase the number of GPs. This is a long-term project but needs to be a strategic goal for the health sector.
In the meantime, we need to make primary care more accessible by increasing patient subsidies and reducing the direct patient costs to see a doctor. At the same time, we need to better equip GPs with access to diagnostic facilities, including in our rural hospitals.
