A Global Perspective: Overcoming Challenges in Rural Oncology in Australia

In honor of the inaugural international panel at the Association of Cancer Care Centers’ (ACCC) 41st National Oncology Conference, ACCCBuzz spoke with Christopher Steer, MBBS, FRACP, medical oncologist, Albury Wodonga Regional Cancer Centre (AWRCC), associate professor, University of New South Wales, adjunct professor, John Richards Centre for Rural Ageing Research, La Trobe University, to gain further insight into his experience collaborating with academic centers and the unique challenges he faces as an oncologist practicing in a rural community.

ACCCBuzz: Please tell us about your background.

Dr. Steer: I was born in the Albury region. I studied medicine at the University of Melbourne and then undertook medical oncology training at various hospitals in Melbourne. After completing formal medical oncology training (in Australia that entails gaining Fellowship of the Royal Australasian College of Physicians) I worked as a clinical research fellow at Guy’s and St. Thomas’ hospitals in London for 3 years. I returned to Albury 21 years ago.

I work at Albury Wodonga Regional Cancer Centre, which is a standalone adult cancer centre collocated with a regional public hospital. Our catchment is around 250,000 to 300,000 people. The closest large metropolitan centre is the city of Melbourne 325 kilometers away, so patients must travel for specialist surgery and complex haematology. We run tumour boards in the common cancers and specialty surgeons from the city dial in, as they are considered part of the team. We dial in to the multidisciplinary teams in the city for patients with melanoma, gynaecological, and central nervous system tumours.

ACCCBuzz: Why did you choose to practice oncology, and what inspires you about caring for patients with cancer?

Dr. Steer: I chose oncology because of the patients. Yes, it is a field of medicine with exciting science and innovative treatment opportunities, but it was the patients that sealed it for me.

I knew early on that I was not going to be a surgeon and felt more of a calling to be a specialist physician rather than a general practitioner or a family doctor. Speaking with patients and developing an ongoing professional therapeutic relationship was important to me. The physician training programme has enabled me to develop my skills and bring them home to practice in the region where I grew up. The experience of working on the oncology unit at the Royal Melbourne Hospital in my residency years was formative. I knew at that time that these were the patients I wished to care for and have been comfortable with that decision ever since.

People sometimes wonder how oncologists do what we do: “It must be so depressing.” It is anything but, though it depends on your goals. We know we can’t cure everyone, but improving a patient’s quality of life and ensuring they are well cared for during the end of their life can be just as rewarding.

ACCCBuzz: What are the specific challenges of providing cancer care in rural areas, and how have you overcome them?

Dr. Steer: The delivery of cancer care in a rural area does have its challenges, however, I think we need to remember that the patients are essentially the same as those in the cities. I would argue that in some cases, we even deliver better care than metro centres. Due to the nature of our private practice delivering care to all patients in the region, our model of care entails a continuous relationship with an oncologist. Some models of care in large, metropolitan hospital outpatient services are based on patients potentially seeing different doctors at each visit. I have found that sometimes we can deliver more personalised, individualised care in comparison to a large metropolitan service, where patients sometimes get lost in the system. Rural care can also be more timely and closer to home.

Distance is often cited as a challenge, but I find that our patients are willing to travel if they need to. The need to travel to the city (and the difficulty of this) does sometimes dictate treatment choices, but not as often as we may think. Some instances that force patients to move to the city include the need for complex or prolonged care, participation in a clinical trial that is not offered in the region, or the need for specialised therapies such as CAR T-cell therapy for haematological conditions. However, the availability of radiation oncology centres in the region has significantly improved accessibility to this important treatment modality, as the need to travel to the city for radiation was very challenging for some patients.

The lack of supportive services—such as allied health, interventional radiology, and specialist histopathology—is challenging. It can take days to get immunohistochemistry reports and that can be frustrating. We can access PET, MRI, and CT within days of a request, but it currently takes 2 weeks to get the imaging formally reported.

But as a clinician, being part of the local community is a benefit rather than a burden, and should be embraced rather than avoided. Being a rural generalist is rewarding, but increasingly difficult. The increased susbspecialisation and complexity of cancer care is very challenging to negotiate, as is delivering world-class care for all patients in a diverse, general oncology practice. Keeping up to date on the latest treatments and toxicity management requires substantial effort as well. As a rural generalist, you must have a network of subspecialty experts and advisers who can offer advice.

ACCCBuzz: How do you collaborate with academic institutions to enhance cancer care and research in rural settings?

Dr. Steer: I am an academic at 2 local universities: associate professor at University of New South Wales and adjunct professor at La Trobe University, as part of the John Richards Centre for Rural Ageing Research. I have developed an interest in the care of older adults with cancer with a focus on supportive care, a result of my clinical research fellowship at Guy’s hospital in London.

Initially, this topic came from research projects that enabled engagement with the global geriatric oncology community. Even 20 years ago it was clear that the care of older adults needed to be addressed and improved, and population demographics (the aging of the population and the increase in cancer incidence in older adults) have only increased the scale of the problem since then. Conducting research in older adults, specifically, is a way to improve the evidence base in this priority area and provides an opportunity for the introduction of geriatric oncology principles into general cancer care. I believe that that you cannot run an oncology practice without offering clinical research to your patients. The work we are doing in the field of geriatric oncology enables original clinical research in our region that, in turn, really can change practice.

While our clinical trials unit runs a wide range of studies, it is the collaboration with the universities that brings opportunities to do our own research. One of the most interesting research projects has been what I call Geriatric Assessment in the Instagram Era—studying the incorporation of patient-derived photographs in the geriatric assessment process. We learnt that this is a novel way to deliver age-friendly patient-centred care. The use of photographs helped the clinician determine what matters most to the patient—a key aim of age-friendly care. These research collaborations have enabled improvements in care delivery, such as the implementation of geriatric assessment in our region as part of an enhanced supportive care programme.

I also supervise PhD students and undergraduate research projects. These opportunities serve to enhance the research culture in the organisation, because at the most basic level, we are conducting clinical research projects that are designed to improve care of our patients. In addition, we are fostering and normalising the culture of research in the clinic and teaching a new generation the methodology of clinical research. Clinical research is a core component of cancer care, but this needs to be recognised and nurtured. Furthermore, having the opportunity to disseminate your findings and improve the evidence base leads to the enhancement of care in other regions—both nationally and internationally.

I cannot overstate the role of the community in this care delivery. The community fills gaps that the government health service does not. In the AWRCC, our community organisation runs the wellness centre, engages volunteers, provides transportation services, directly employs the clinical psychologist, and funds exercise classes.

We also gain some research funding from community fundraising. The cancer centre has a trust fund that raises money for services not funded by the government, like the psycho-oncology service. But this is more than fundraising—the active engagement of the community humanises the cancer centre. This community engagement is a win-win situation: everybody benefits, and the community members who donate feel they are contributing to the care of patients with cancer in the region—because they are!

Read more content from the inaugural international panel in the  Day 3 NOC ACCCBuzz Blog.

Rachel Radwan is an Editorial Coordinator for the Association of Cancer Care Centers.