Breast cancer diagnosis, patterns of care and burden of disease in Queensland, Australia (1998-2004): does being Indigenous make a difference?

Utilising the CREATE quality appraisal tool to analyse Aboriginal and Torres Strait Islander peoples' involvement and reporting of cancer research in Australia

OBJECTIVE

We aimed to evaluate Aboriginal and Torres Strait Islander involvement in research focusing on cancer experiences using an Aboriginal and Torres Strait Islander quality appraisal tool (the QAT).

METHODS

We conducted a systematic review of the peer-reviewed literature on Aboriginal and Torres Strait Islander peoples' experiences associated with cancer, recently published elsewhere. We then appraised articles for the inclusion of Aboriginal and Torres Strait Islander-led research, community consultation, and involvement.

RESULTS

91 articles were appraised. A lack of Aboriginal and Torres Strait Islander-led research and consultation was reported in the majority of articles, only 10 (11%) demonstrated success across seven (50%) or more questions of the QAT.

CONCLUSIONS

This review underscores the need for anti-racist research and publication practices that actively engage Aboriginal and Torres Strait Islander peoples and researchers. This approach is vital to enhance cancer outcomes within these communities.

IMPLICATIONS FOR PUBLIC HEALTH

To advance and prioritise appropriate involvement of Aboriginal and Torres Strait Islander peoples in cancer research, the onus must be on 'systems owners,' including academic journals and institutions, to require and report genuine engagement as standard practice. Researchers will produce higher-calibre research with a strengths-based focus, advancing the cause of equitable research.

"Everyone needs a Deb": what Australian indigenous women say about breast cancer screening and treatment services

BACKGROUND

Breast cancer continues to be the second most diagnosed cancer overall and the most diagnosed cancer for women in Australia. While mortality rates overall have declined in recent years, Indigenous women continue to be diagnosed at more marginal rates (0.9 times) and are more likely to die (1.2 times). The literature provides a myriad of reasons for this; however, the voices of Indigenous women are largely absent. This study sets out to understand what is happening from the perspectives of Australian Indigenous women with a view to charting culturally safer pathways that improve participation in screening and treatment by Indigenous women.

METHODS

This co-design study was conducted using semi-structured, in-depth interviews and focus group discussions. Recruitment of study participants was via snowball sampling. Participants were subsequently consented into the study through the Aboriginal Health Service and the research team. Interviews were audio recorded and transcribed verbatim, and data coded in NVivo12 using inductive thematic analysis.

RESULTS

A total of 21 Indigenous women and 14 health service providers were interviewed predominantly from the same regional/rural area in NSW, with a small proportion from other states in Australia. Six major themes were identified: Access, Awareness, Community and Family, Lack of control, Negative feelings and associations and Role of services.

CONCLUSION

To improve access and participation of Indigenous women and ultimately improve mortality rates, breast cancer services must explicitly address cultural and community needs.

Factors associated with cancer survival disparities among Aboriginal and Torres Strait Islander peoples compared with other Australians: A systematic review

Background

While cancer survival among Aboriginal and Torres Strait Islander peoples has improved over time, they continue to experience poorer cancer survival than other Australians. Key drivers of these disparities are not well understood. This systematic review aimed to summarise existing evidence on Aboriginal and Torres Strait Islander cancer survival disparities and identify influential factors and potential solutions.

Methods

In accordance with PRISMA guidelines, multiple databases were systematically searched for English language peer-reviewed articles on cancer survival by Aboriginal and Torres Strait Islander status published from 1/1/2008 to 4/05/2022. Observational studies presenting adjusted survival measures in relation to potential causal factors for disparities were included. Articles were screened independently by two authors. Included studies were critically assessed using Joanna Briggs Institute tools.

Results

Thirty population-based and predominantly state-level studies were included. A consistent pattern of poorer unadjusted cancer survival for Aboriginal and Torres Strait Islander peoples was evident. Studies varied widely in the covariates adjusted for including a combination of socio-demographics, cancer stage, comorbidities, and treatment. Potential contributions of these factors varied by cancer type. For lung and female breast cancer, adjusting for treatment and comorbidities reduced the survival disparity, which, while still elevated was no longer statistically significant. This pattern was also evident for cervical cancer after adjustment for stage and treatment. However, most studies for all cancers combined, or colorectal cancer, reported that unexplained survival disparities remained after adjusting for various combinations of covariates.

Conclusions

While some of the poorer survival faced by Aboriginal and Torres Strait Islander cancer patients can be explained, substantial disparities likely to be related to Aboriginal determinants, remain. It is imperative that future research consider innovative study designs and strength-based approaches to better understand cancer survival for Aboriginal and Torres Strait Islander peoples and to inform evidence-based action.

Improving breast cancer outcomes for Aboriginal women: a mixed-methods study protocol

INTRODUCTION

Breast cancer is the most commonly diagnosed cancer affecting Australian women, and the second highest cause of cancer death in Australian women. While the incidence of breast cancer is lower in Aboriginal women than non-Aboriginal women, the mortality rate for Aboriginal women is higher, with Aboriginal women 1.2 times more likely to die from the disease. In New South Wales, Aboriginal women are 69% more likely to die from their breast cancer than non-Aboriginal women.Co-design is a research method recognised to enhance collaboration between those doing the research and those impacted by the research; which when used with Aboriginal communities, ensures research and services are relevant, culturally competent and empowers communities as co-researchers. We report the development of a new protocol using co-design methods to improve breast cancer outcomes for Aboriginal women.

METHODS AND ANALYSIS

Through a Community Mapping Project in 2018, we co-designed an iterative quantitative and qualitative study consisting of five phases. In Phase 1, we will establish a governance framework. In Phase 2, we will provide information to community members regarding the modified parts of the screening, diagnosis, treatment and follow-up processes and invite them to partake. In Phase 3, the research team will collect data on the outcomes of the modified processes and the outcomes for the women who have and have not participated. The data shall be analysed quantitatively and thematically in Phase 4 with Aboriginal community representatives and reported back to community. Lastly, in Phase 5, we evaluate the co-design process and adapt our protocol for use in partnership with other communities.

ETHICS AND DISSEMINATION

This study has ethics approval of the Aboriginal Health and Medical Research Council ref:1525/19. The findings will be published in the literature, presented at conferences and short summaries will be issued via social media.

Quantifying the hospital and emergency department costs for women diagnosed with breast cancer in Queensland

PURPOSE

With increasing rates of cancer survival due to advances in screening and treatment options, the costs of breast cancer diagnoses are attracting interest. However, limited research has explored the costs to the Australian healthcare system associated with breast cancer. We aimed to describe the cost to hospital funders for hospital episodes and emergency department (ED) presentations for Queensland women with breast cancer, and whether costs varied by demographic characteristics.

METHODS

We used a linked administrative dataset, CancerCostMod, limited to all breast cancer diagnoses aged 18 years or over in Queensland between July 2011 and June 2015 (n = 13,285). Each record was linked to Queensland Health Admitted Patient Data Collection and Emergency Department Information Systems records between July 2011 and June 2018. The cost of hospital episodes and ED presentations were determined, with mean costs per patient modelled using generalised linear models with a gamma distribution and log link function.

RESULTS

The total cost to the Queensland healthcare system from hospital episodes for female breast cancer was AUD$309 million and AUD$12.6 million for ED presentations during the first 3 years following diagnosis. High levels of costs and service use were identified in the first 6 months following diagnosis. Some significant differences in cost of hospital and ED episodes were identified based on demographic characteristics, with Indigenous women and those from lower socioeconomic backgrounds having higher costs.

CONCLUSION

Hospitalisation costs for breast cancer in Queensland exert a high burden on the healthcare system. Costs are higher for women during the first 6 months from diagnosis and for Indigenous women, as well as those with underlying comorbidities and lower socioeconomic position.

Surgical Services for Breast Cancer Patients in Australia, is There a Gap for Aboriginal and/or Torres Strait Islander Women?

BACKGROUND

Breast cancer is the most commonly diagnosed cancer in Aboriginal and/or Torres Strait Islander women. When compared to other Australians, Aboriginal and/or Torres Strait Islander women have a higher breast cancer mortality rate. This systematic literature review examined disparities in breast cancer surgical access and outcomes for Aboriginal and/or Torres Strait Islander women.

METHODS

This systematic literature review, following the PRISMA guidelines, compared measures of breast cancer surgical care for Aboriginal and/or Torres Strait Islander people and other Australians.

RESULTS

The 13 included studies were largely state-based retrospective reviews of data collected prior to the year 2012. Eight studies reported more advanced breast cancer presentation among Aboriginal and/or Torres Strait Islander women. Despite the increased distance to a multidisciplinary, specialist team, there were no disparities in seeing a surgeon, or in the time from diagnosis to surgical treatment. Two studies reported disparities in the receipt of surgery and two reported no variations. Three studies reported disparities in the receipt of mastectomy versus breast conserving surgery, whilst four studies reported no variations. No studies examined postoperative surgical outcomes.

CONCLUSIONS

Aboriginal and/or Torres Strait Islander women present with more advanced breast cancer. There may be disparities in the receipt of surgery and the type of surgery. However, the metrics tested were not related to optimal care guidelines, and the databases utilised contain limited data on individual factors contributing to surgical care decisions. It is therefore difficult to determine whether the reported differences in the receipt of surgical care reflect disparate or appropriate care.

What Is the Evidence Globally for Culturally Safe Strategies to Improve Breast Cancer Outcomes for Indigenous Women in High Income Countries? A Systematic Review

The aim was to systematically assess the evidence on whether cultural safety affects breast cancer outcomes with regards to care for Indigenous women in high income countries. We conducted a systematic review in accordance with PRISMA guidelines of peer-reviewed articles in Medline, EMBASE, CINAHL, Scopus, Web of Science, Proquest Sociology and Informit Rural health database and Indigenous collection databases. Key inclusion criteria were: adult female patients with breast cancer; high income country setting; outcome measure, including screening, diagnosis, treatment and follow up care. A total of 15 were selected. We developed a Community Engagement assessment tool in consultation with aboriginal researchers, based on the National Health and Medical Research Councils' community engagement guidelines, against which studies were appraised. This novel element allowed us to evaluate the literature from a new and highly relevant perspective. Thematic analysis of all 15 studies was also undertaken. Despite limited literature there are evidence-based strategies that are likely to improve outcomes for Indigenous women with breast cancer in high income countries and indicate that culture makes a positive difference. It is also clear that strong Indigenous community leadership and governance at all stages of the research including design is an imperative for feasibility.

Comparing cancer incidence, stage at diagnosis and outcomes of First Nations and all other Manitobans: a retrospective analysis

Background

Globally, epidemiological evidence suggests cancer incidence and outcomes among Indigenous peoples are a growing concern. Although historically cancer among First Nations (FN) peoples in Canada was relatively unknown, recent epidemiological evidence reveals a widening of cancer related disparities. However evidence at the population level is limited. The aim of this study was to explore cancer incidence, stage at diagnosis, and outcomes among status FN peoples in comparison with all other Manitobans (AOM).

Methods

All cancers diagnosed between April 1, 2004 and March 31, 2011 were linked with the Indian Registry System and five provincial healthcare databases to compare differences in characteristics, cancer incidence, and stage at diagnosis and mortality of the FN and AOM cohorts. Cox proportional hazard regression models were used to examine mortality.

Results

The FN cohort was significantly younger, with higher comorbidities than AOM. A higher proportion of FN people were diagnosed with cancer at stages III (18.7% vs. 15.4%) and IV (22.4% vs. 19.9%). Cancer incidence was significantly lower in the FN cohort, however, there were no significant differences between the two cohorts after adjusting for age, sex, income and area of residence. No significant trends in cancer incidence were identified in either cohort over time. Mortality was generally higher in the FN cohort.

Conclusions

Despite similar cancer incidence, FN peoples in Manitoba experience poorer survival. The underlying causes of these disparities are not yet understood, particularly in relation to the impact of colonization and other determinants of health.

Cancer treatment and the risk of cancer death among Aboriginal and non-Aboriginal South Australians: analysis of a matched cohort study

BACKGROUND

Aboriginal and Torres Strait Islander Australians have poorer cancer outcomes than other Australians. Comparatively little is known of the type and amount of cancer treatment provided to Aboriginal and Torres Strait Islander people and the consequences for cancer survival. This study quantifies the influence of surgical, systemic and radiotherapy treatment on risk of cancer death among matched cohorts of cancer cases and, the comparative exposure of cohorts to these treatments.

METHODS

Cancers registered among Aboriginal South Australians in 1990-2010 (N = 777) were matched with randomly selected non-Indigenous cases by sex, birth and diagnostic year, and primary site, then linked to administrative cancer treatment for the period from 2 months before to 13 months after diagnosis. Competing risk regression summarised associations of Indigenous status, geographic remoteness, comorbidities, cancer stage and treatment exposure with risk of cancer death.

RESULTS

Fewer Aboriginal cases had localised disease at diagnosis (37.2% versus 50.2%) and they were less likely to: experience hospitalisation with cancer diagnosis, unadjusted odds ratio (UOR) = 0.76; 95%CI = 0.59-0.98; have surgery UOR = 0.65; 95%CI = 0.53-0.80; systemic therapies UOR = 0.64; 95%CI = 0.52-0.78; or radiotherapy, UOR = 0.76; 95%CI = 0.63-0.94. Localised disease carried lower risk of cancer death compared to advanced cases receiving surgery or systemic therapies, SHR = 0.34; 95%CI = 0.25-0.47 and SHR = 0.35; 95%CI = 0.25-0.48. Advanced disease and no treatment carried higher risk of cancer death, SHR = 1.82; 95%CI = 1.26-2.63.

CONCLUSION

The effects of treatment did not differ between Aboriginal and non-Indigenous cohorts. However, comparatively less exposure to surgical and systemic treatments among Aboriginal cancer cases further complicated the disadvantages associated with geographic remoteness, advanced stage of disease and co-morbid conditions at diagnosis and add to disparities in cancer death. System level responses to improving access, utilisation and quality of effective treatments are needed to improve survival after cancer diagnosis.

Disparities in breast screening, stage at diagnosis, cancer treatment and the subsequent risk of cancer death: a retrospective, matched cohort of aboriginal and non-aboriginal women with breast cancer

Background

Australia’s Aboriginal and Torres Strait Islander women have poorer survival and twice the disease burden from breast cancer compared to other Australian women. These disparities are influenced, but not fully explained, by more diagnoses at later stages. Incorporating breast screening, hospital and out of hospital treatment and cancer registry records into a person-linked data system can improve our understanding of breast cancer outcomes. We focussed one such system on a population-based cohort of Aboriginal women in South Australia diagnosed with breast cancer and a matched cohort of non-Aboriginal women with breast cancer. We quantify Aboriginal and non-Aboriginal women’s contact with publicly funded screening mammograms; quantify exposure to a selection of cancer treatment modalities; then assess the relationship between screening, treatment and the subsequent risk of breast cancer death.

Methods

Breast cancers registered among Aboriginal women in South Australia in 1990–2010 (N = 77) were matched with a random selection of non-Aboriginal women by birth and diagnostic year, then linked to screening records, and treatment 2 months before and 13 months after diagnosis. Competing risk regression summarised associations of Aboriginality, breast screening, cancer stage and treatment with risk of breast cancer death.

Results

Aboriginal women were less likely to have breast screening (OR = 0.37, 95%CIs 0.19–0.73); systemic therapies (OR = 0.49, 95%CIs 0.24–0.97); and, surgical intervention (OR = 0.35, 95%CIs 0.15–0.83). Where surgery occurred, mastectomy was more common among Aboriginal women (OR = 2.58, 1.22–5.46). Each of these factors influenced the risk of cancer death, reported as sub-hazard ratios (SHR). Regional spread disease (SHR = 34.23 95%CIs 6.76–13.40) and distant spread (SHR = 49.67 95%CIs 6.79–363.51) carried more risk than localised disease (Reference SHR = 1). Breast screening reduced the risk (SHR = 0.07 95%CIs 0.01–0.83). So too did receipt of systemic therapy (SHR = 0.06 95%CIs 0.01–0.41) and surgical treatments (SHR = 0.17 95%CIs 0.04–0.74). In the presence of adjustment for these factors, Aboriginality did not further explain the risk of breast cancer death.

Conclusion

Under-exposure to screening and treatment of Aboriginal women with breast cancers in South Australia contributed to excess cancer deaths. Improved access, utilisation and quality of effective treatments is needed to improve survival after breast cancer diagnosis.

Factors influencing breast cancer outcomes in Australia: A systematic review

PURPOSE

This systematic review evaluates factors influencing breast cancer outcomes for women treated in Australia, facilitating the exploration of disparities in breast cancer outcomes for certain groups of women in Australia.

METHOD

A systematic literature search was performed using MEDLINE and Scopus focusing on breast cancer in Australia with outcome measures being breast cancer survival and recurrence with no restrictions on date. Risk of bias was assessed using Cairns Assessment Scale for Observational studies of Risk factors (CASOR).

RESULTS

Fifteen quantitative studies were included: two were high quality, 11 were intermediate quality, and two were low quality. Traditional risk factors such as invasive tumour type, larger size, higher grade and stage, lymph node involvement and absence of hormone receptors were found to be associated with breast cancer mortality. Being younger (<40 years old) and older (>70 years old), having more comorbidities, being of lower socioeconomic status, identifying as Aboriginal or Torres Strait Islander, living in more rural areas or having a mastectomy were factors found to be associated with poorer breast cancer outcomes.

CONCLUSION

Despite the heterogeneity of the studies, this review identified significant risk factors for breast cancer mortality and recurrence. The use of this data would be most useful in developing evidence-based interventions and in optimising patient care through creation of a prediction model.

PROSPERO REGISTRATION

CRD42017072857.

Understanding the effects of socioeconomic status along the breast cancer continuum in Australian women: a systematic review of evidence

Background

Globally, the provision of equitable outcomes for women with breast cancer is a priority for governments. However, there is growing evidence that a socioeconomic status (SES) gradient exists in outcomes across the breast cancer continuum – namely incidence, diagnosis, treatment, survival and mortality. This systematic review describes this evidence and, because of the importance of place in defining SES, findings are limited to the Australian experience.

Methods

An on-line search of PubMed and the Web of Science identified 44 studies published since 1995 which examined the influence of SES along the continuum. The critique of studies included the study design, the types and scales of SES variable measured, and the results in terms of direction and significance of the relationships found. To aid in the interpretation of results, the findings were discussed in the context of a systems dynamic feedback diagram.

Results

We found 67 findings which reported 107 relationships between SES within outcomes along the continuum. Results suggest no differences in the participation in screening by SES. Higher incidence was reported in women with higher SES whereas a negative association was reported between SES and diagnosis. Associations with treatment choice were specific to the treatment choice undertaken. Some evidence was found towards greater survival for women with higher SES, however, the evidence for a SES relationship with mortality was less conclusive.

Conclusions

In a universal health system such as that in Australia, evidence of an SES gradient exists, however, the strength and direction of this relationship varies along the continuum. This is a complex relationship and the heterogeneity in study design, the SES indicator selected and its representative scale further complicates our understanding of its influence. More complex multilevel studies are needed to better understand these relationships, the interactions between predictors and to reduce biases introduced by methodological issues.

Routine screening of Indigenous cancer patients' unmet support needs: a qualitative study of patient and clinician attitudes

Background

Indigenous Australians have poorer cancer outcomes in terms of incidence mortality and survival compared with non-Indigenous Australians. The factors contributing to this disparity are complex. Identifying and addressing the psychosocial factors and support needs of Indigenous cancer patients may help reduce this disparity. The Supportive Care Needs Assessment Tool for Indigenous People (SCNAT-IP) is a validated 26-item questionnaire developed to assess their unmet supportive care needs. This qualitative study reports on patient and clinician attitudes towards feasibility and acceptability of SCNAT-IP in routine care.

Methods

Forty-four in-depth semi-structured interviews were conducted with 10 clinical staff and 34 Indigenous cancer patients with heterogeneous tumours. Participants were recruited from four geographically diverse Australian cancer clinics. Transcripts were imported into qualitative analysis software (NVivo 10 Software), coded and thematic analysis performed.

Results

Indigenous patients (mean age 54.4 years) found the SCNAT-IP beneficial and easy to understand and they felt valued and heard. Clinical staff reported multiple benefits of using the SCNAT-IP. They particularly appreciated its comprehensive and systematic nature as well as the associated opportunities for early intervention. Some staff described improvements in team communication, while both staff and patients reported that new referrals to support services were directly triggered by completion of the SCNAT-IP. There were also inter-cultural benefits, with a positive and bi-directional exchange of information and cultural knowledge reported when using the SCNAT-IP. Although staff identified some potential barriers to using the SCNAT-IP, including the time required, the response format and comprehension difficulties amongst some participants with low English fluency, these were outweighed by the benefits. Some areas for scaled improvement were also identified by staff.

Conclusions

Staff and patients found the SCNAT-IP to be an acceptable tool and supported universal screening for Indigenous cancer patients. The SCNAT-IP has the potential to help reduce the inequalities in cancer care experienced by Indigenous Australians by identifying and subsequently addressing their unmet support needs. Further research is needed to explore the validity of the SCNAT-IP for Indigenous people from other nations.