Exciting times in gastroenterology and hepatology

OUR Prime Minister Malcolm Turnbull once remarked that “there has never been a more exciting time to be an Australian”. In 2018, one can confidently qualify that further to say: “There has never been a more exciting time to be an Australian gastroenterologist and hepatologist!”

We bask in an era of breathtaking research and development, rapidly evolving diagnostic tools, technological advancements in imaging and endoscopy, and have at our helm a remarkable array of life-changing therapies. However, inherent to those innovations lie our challenges.

Our challenges lie in enabling equitable access to the highest quality, research- and evidence-based gastroenterological care to all affected communities in Australia, and in ensuring that the prevention of gastrointestinal, liver-related diseases and cancers are not a mere afterthought, but prime and foremost in our practice.

While the focus of care historically has been centred in our major metropolitan cities for many legitimate reasons, paradoxically, Australians who live closer to our geographical centre continue to linger in the penumbra of basic entitlements to what we perceive as “good” health. Our national statistics are staggering: 70% of Australians living in outer regional and remote areas are overweight or obese, and 70% do not participate in exercise and, not surprisingly, experience significantly higher rates of type 2 diabetes compared with those who live in cities. Our Indigenous communities are especially more susceptible to poor health.

How do these disparities in overall and metabolic health translate to gastrointestinal and liver disease? It is well recognised that obesity and diabetes are associated with cardio-, cerebro-, reno- and peripheral vascular complications. However, it is still greatly underappreciated that individuals with obesity or diabetes are at significantly heightened risk of several digestive tract cancers, including bowel, gastric, oesophageal and pancreatic cancers; and that obesity and type 2 diabetes can interact with other risk factors for liver disease, such as chronic viral hepatitis infection or excessive alcohol, to further exacerbate hepatocellular carcinoma or primary liver cancer risk by ten- up to 100-fold.

While the uptake of the National Bowel Cancer Screening Program is near-comparable between rural regional Australia (42%) and the major cities (39%), it is cold cause for comfort. Of those participants, people who live in remote areas have higher screening positive faecal occult blood test rates than city dwellers (10% v 8%), but enjoy lower rates of further diagnostic follow-up or colonoscopy (54%) compared with their fellow Australians who live in cities (73%). Those who live in rural Australia also experience longer waiting times between positive screen and assessment. As for liver cancer, there are no specific data on hepatocellular carcinoma and cirrhosis rates in Australia by the Australian Institute of Health and Welfare or the Australian Bureau of Statistics’ National Health Survey. Ignorance here is certainly not bliss.

The Gastroenterological Society of Australia (GESA), our nation’s peak body in gastroenterology and hepatology, plays a critical role in shaping the future of how patients living with gastrointestinal and liver disease are cared for and how we, as a profession, can lead in, guide and champion safe, effective and appropriate screening, prevention and treatment of such diseases and related cancers. Our newly elected Board of Directors, GESA’s council, has just commenced and, while we serve a brief 2-year term, we have a clear and collective vision that extends across the next decade.

The prevention and early detection of all gastrointestinal tract cancers, including liver cancer, are among our key and most pressing priorities, as well as the advancement of knowledge and increased awareness of what constitutes good, basic gastrointestinal and liver health – not just among professional colleagues but for all Australians.

To do so, GESA is exploring new partnerships with other medical disciplines and with not-for-profit health advocacy and support groups, for example Diabetes Australia, in campaigning for increased understanding of gastrointestinal and liver cancer risk factors and what simple, accessible, effective and positive preventive steps we can all take in reducing those risks in our major cities and in the bush.

Rather than seeking more funds (for now) from an already stretched federal health budget, GESA has been working collaboratively and constructively with the Commonwealth’s Department of Health towards better rationalisation, improved allocation and more efficient use of federal health dollars in the detection, treatment and research into gastrointestinal tract and liver diseases and their related cancers. Our energies so far have been focused on proactively advising and guiding the federal government and nationally funded bodies for the improvement of safety and quality in healthcare delivery, such as the Australian Commission on Safety and Quality in Health Care, in the appropriate utilisation of endoscopic procedures and in ensuring optimal care of patients who undergo colonoscopy. The new Colonoscopy Clinical Standard will be launched later in 2018.

Quality and safety go “hand in hand” with training. Here, GESA will continue to provide dedicated and committed input into our profession’s educational initiatives, tailored across all abilities from the novice to the more established physician or surgeon (such as in endoscopy “Train the Trainer” workshops). To ensure maintenance of optimal clinical standards in colonoscopy after qualification or certification, GESA in conjunction with the Department of Health have established a Colonoscopy Recertification Program, which our professional society and the government enthusiastically promulgate and encourage all health practitioners who perform colonoscopies in Australia to participate in.

Last but not least, it must be emphasised that the practice of cutting-edge and evidence-based gastroenterology and hepatology is critically underpinned by active research and development. GESA strongly promotes and supports the research initiatives of our trainees and professional colleagues by way of scholarships, fellowships, travel, seed and bridge project grants – GESA members have started to generously contribute to a new philanthropic fund to further grow our society’s research endeavors and to invest in our young trainees.

The long term sustainability of clinician-investigators and basic scientists is threatened by our current savage climate of external competitive funding and a shrinking pool of early to mid-career researchers. Australia’s gastroenterology and hepatology clinical and research workforce, their distribution, their supply and demand, and future training implications will increasingly matter. Discussions in these areas, while still in embryonic phase, have begun with the Commonwealth Department of Health.

The road ahead? Fast forward to 2028, overheard on The Bush Telegraph:

“That is correct, madam. Our colonoscopy waiting list for a positive bowel screening test is only 2 weeks and if you need a liver clinic review, it is just as quick. However, our gut and liver health improvement programs are booked out … but good news, with extra funding from the federal government, we are opening up more slots next week! Yes, this is for patients from the city and the country. We now have three full-time gastroenterologists who can provide specialist care at your closest regional centre. Yep, no extended travel needed to the Big Smoke, just a day return-trip for your assessment and management.”

Ah, yes, another typical day in Gastro-Utopia.

Narci Teoh is a Professor of Medicine and clinician-researcher at the Australian National University and the Canberra Hospital. She is a gastroenterologist and hepatologist with experience in managing patients with digestive tract disorders and hepatocellular carcinoma, and is active in translational research. She is the current President of GESA.

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