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

Prevalence of surgery in Indigenous people with cancer: a systematic review and meta-analysis

Background

As cancer incidence increases globally, so does the prevalence of cancer among Indigenous peoples. Indigenous peoples face significant barriers to healthcare, including access to and uptake of surgery. To date, the synthesis of access to and uptake of surgery for Indigenous peoples living with cancer has not yet been reported.

Methods

We conducted a systematic literature review and meta-analysis of access to and uptake of surgery for Indigenous peoples in Canada, Australia, New Zealand, and the United States. Five databases were searched to identify studies of Indigenous adults with cancer and those who received surgery. The Joanna Briggs Institute critical appraisal tools were used to assess the quality and inclusion of articles. Random effect meta-analyses were conducted to estimate the pooled prevalence of surgery in Indigenous people with cancer.

Findings

Of the 52 studies in the systematic review, 38 were included in the meta-analysis. The pooled prevalence of surgery in Indigenous people with cancer was 56.2% (95% confidence interval (CI): 45.4-66.7%), including 42.8% (95% CI: 36.3-49.5%) in the Native Hawaiian population, 44.5% (95% CI: 38.7-50.3%) in the Inuit and 51.5% (95%CI: 36.8-65.9%) in Aboriginal and Torres Strait Islander people. Overall, Indigenous people received marginally less cancer surgery than non-Indigenous people (3%, 95% CI: 0-6%). Indigenous people were 15% (95% CI: 6-23%) less likely to receive surgery than non-Indigenous people for respiratory cancers. Remoteness, travel distance, financial barriers, and long waiting times to receive surgery were factors cited as contributing to lower access to surgery for Indigenous people compared to non-Indigenous people.

Interpretation

Efforts to improve access and use of cancer services and surgery for Indigenous peoples should be multilevel to address individual factors, health services and systems, and structural barriers. These determinants need to be addressed to expedite optimal care for Indigenous peoples, especially those living in outer metropolitan areas.

Funding

The Research Alliance for Urban Goori Health (RAUGH) funded this project. GG was funded by an NHMRC Investigator Grant (#1176651).

Outcomes of Revascularization for Peripheral Artery Disease in Aboriginal and Torres Strait Islander Peoples and Non-Indigenous Australians

BACKGROUND

Australia's Aboriginal and Torres Strait Islander Peoples are at high risk of peripheral arterial disease (PAD), but outcomes of revascularization are unknown. Revascularization outcomes were compared among Aboriginal and Torres Strait Islander and non-Indigenous Australians.

METHODS

A retrospective cohort study was conducted of patients who underwent lower limb revascularization between January 2015 and July 2023. PAD severity was defined using the Rutherford classification and angiographic scoring systems (ANGIO score, Global Limb Anatomic Staging System [GLASS], Trans-Atlantic Inter-Society Consensus). The primary outcome was major adverse limb events (MALE), that is, major amputation or repeat revascularization. The secondary outcomes were major adverse cardiovascular events (MACE), major amputation, and repeat revascularization alone.

RESULTS

A total of 504 patients were included. Fifty-seven (11.3%) were Aboriginal and Torres Strait Islander People, who were more likely to present with chronic limb-threatening ischemia (74% vs. 65%; P = 0.01) and have infrapopliteal disease (GLASS: odds ratio [OR] 1.93, 95% confidence interval 1.15-3.24; P = 0.013; ANGIO score: OR 1.97, 1.18-3.29; P = 0.01) compared to non-Indigenous Australians. Risk of MALE (rate ratio [RR] 1.39; 0.91-2.13; P = 0.126) and repeat revascularization (RR 1.18, 0.74-1.88; P = 0.493) were similar, but Aboriginal and Torres Strait Islander People had a higher risk of major amputation (RR 3.35; 1.66-6.75; P = 0.001) and MACE (RR 1.88, 1.17-3.03; P = 0.009) than non-Indigenous participants. Adjusted analyses suggested the increased risk of major amputation was due to Aboriginal and Torres Strait Islander People presenting with more severe PAD and tissue loss compared to non-Indigenous patients.

CONCLUSION

Aboriginal and Torres Strait Islander Peoples present with more severe PAD and have greater risk of major amputation. Culturally appropriate programs are needed to raise awareness and promote secondary prevention.

Disparities in Breast Cancer Treatment and Reconstruction Among Native Hawaiian and Pacific Islander Women: Systematic Review and Meta-Analysis

BACKGROUND

Native Hawaiian and Pacific Islander (NHPI) women experience significant disparities in breast cancer treatment and outcomes, including lower rates of postmastectomy reconstruction, higher refusal rates of radiation therapy, and delays in surgical care. These disparities contribute to poorer survival and increased complications compared to other racial/ethnic groups. This systematic review and meta-analysis aim to quantify these disparities and assess their impact on breast cancer outcomes in NHPI women.

METHODS

A comprehensive search of PubMed, Scopus, and Embase databases was conducted to identify studies reporting on breast cancer surgery, reconstruction, radiation therapy refusal, and surgical delays for NHPI women. Thirteen studies, encompassing a total of 5 546 918 patients, were included, and meta-analyses were performed to pool odds ratios (OR) and hazard ratios (HR) for key outcomes using random-effects models. Heterogeneity was assessed using I² statistics. Thematic analysis was also conducted to explore cultural and structural factors influencing treatment disparities.

RESULTS

NHPI women had significantly lower odds of receiving postmastectomy reconstruction compared to non-Hispanic White women (pooled OR = 2.02, 95% confidence interval [CI]: 1.96-2.08, I² = 99%). Delays in surgical care were more frequent, with NHPI women being 4.51 times more likely to experience delays (OR = 4.51, 95% CI: 3.82-5.32, I² = 99%). Radiation therapy refusal was notably higher, with a pooled hazard ratio of 3.28 (95% CI: 2.99-3.58, I² = 77%) indicating that NHPI women who refused radiation therapy had more than three times the risk of mortality compared to those who accepted it. Thematic analysis revealed that geographic isolation, limited access to specialized care, and cultural perceptions surrounding cancer treatments, including fear of radiation due to historical trauma, contributed significantly to treatment disparities.

CONCLUSIONS

Native Hawaiian and Pacific Islander women face considerable barriers to receiving equitable breast cancer treatment and reconstruction, resulting in worse outcomes compared to other racial/ethnic groups. Efforts to address these disparities must focus on improving access to care, reducing treatment delays, and implementing culturally sensitive interventions. Targeted policies and healthcare system improvements, especially in geographically isolated areas, are critical to improving survival and treatment outcomes for NHPI women.