Lung cancer treatment and mortality for Aboriginal people in New South Wales, Australia: results from a population-based record linkage study and medical record audit

Background

The aim of this study was to compare surgical treatment received by Aboriginal and non-Aboriginal people with non-small cell lung cancer (NSCLC) in New South Wales (NSW), Australia and to examine whether patient and disease characteristics are associated with any disparities found. An additional objective was to describe the adjuvant treatments received by Aboriginal people diagnosed with NSCLC in NSW. Finally, we compared the risk of death from NSCLC for Aboriginal and non-Aboriginal people.

Methods

We used logistic regression and competing risks regression to analyse population-based cancer registry records for people diagnosed with NSCLC in NSW, 2001–2007, linked to hospital inpatient episodes and deaths. We also analysed treatment patterns from a medical record audit for 170 Aboriginal people diagnosed with NSCLC in NSW, 2000–2010.

Results

Of 20,154 people diagnosed with primary lung cancer, 341 (1.7 %) were Aboriginal. Larger proportions of Aboriginal people were younger, female, living outside major cities or in areas of greater socioeconomic disadvantage, smoking at the time of diagnosis and had comorbidities. Although Aboriginal people were, on average, younger at diagnosis with non-metastatic NSCLC than non-Aboriginal people, only 30.8 % of Aboriginal people received surgery, compared with 39.5 % of non-Aboriginal people. Further, Aboriginal people who were not receiving surgery, at the time of diagnosis, were more likely to be younger, live in major cities and have no comorbidities. The observed risk of death from NSCLC 5 years after diagnosis was higher for 266 Aboriginal people (83.3 % 95 % CI 77.5–87.7) than for 15,491 non-Aboriginal people (77.6 % 95 % CI 76.9–78.3) and the adjusted subhazard ratio was 1.32 (95 % CI 1.14–1.52). From the medical record audit, 29 % of Aboriginal people with NSCLC had potentially curative treatment, 45 % had palliative radiotherapy/chemotherapy and 26 % had no active treatment.

Conclusions

There are disparities in NSCLC surgical treatment and mortality for Aboriginal people compared with non-Aboriginal people in NSW. It is imperative that Aboriginal people are offered active lung cancer treatment, particularly those who are younger and without comorbidities and are therefore most likely to benefit, and are provided with assistance to access it if required.

Comparing colorectal cancer treatment and survival for Aboriginal and non-Aboriginal people in New South Wales

OBJECTIVES

Our aim was to compare surgical treatment rates and survival rates for Aboriginal and non-Aboriginal people in New South Wales with colorectal cancer, and to describe the medical treatment received by a sample of Aboriginal people with colorectal cancer.

DESIGN, SETTING AND PARTICIPANTS

All people diagnosed with colorectal cancer in NSW during 2001-2007 were identified and their cancer registry records linked to hospital admissions data and death records. A medical records audit of a sample of Aboriginal people diagnosed with colorectal cancer during 2000-2011 was also conducted.

MAIN OUTCOME MEASURES

Cause-specific survival, odds of surgical treatment, and the proportions of people receiving adjuvant treatments.

RESULTS

Of 29 777 eligible colorectal cancer cases, 278 (0.9%) involved Aboriginal people. Similar proportions of Aboriginal (76%) and non-Aboriginal (79%) people had undergone surgical treatment. Colorectal cancer-specific survival was similar for Aboriginal and non-Aboriginal people up to 18 months after diagnosis, but 5 years post-diagnosis the risk of death for Aboriginal people who had had surgical treatment was 68% higher than for non-Aboriginal people (adjusted hazards ratio, 1.68; 95% CI, 1.32-2.09). Of 145 Aboriginal people with colorectal cancer identified by the medical records audit, 117 (81%) had undergone surgery, and 56 (48%) had also received adjuvant chemotherapy and/or radiotherapy.

CONCLUSIONS

Aboriginal people with colorectal cancer had poorer survival rates than non-Aboriginal people, although rates of surgical treatment, complications and follow-up colonoscopy were similar. More work is needed to identify and understand why outcomes for Aboriginal people with colorectal cancer are different from those of other New South Wales residents.

Are Aboriginal people more likely to be diagnosed with more advanced cancer?

OBJECTIVE

To determine whether Aboriginal people in New South Wales were diagnosed with more advanced cancer than non-Aboriginal people.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional study of cancer cases, excluding lymphohaematopoietic cancers and cancers of unknown primary site, diagnosed in NSW in 2001-2007.

MAIN OUTCOME MEASURE

Spread of disease at time of cancer diagnosis.

RESULTS

Overall, 40.3% of 2039 cancers in Aboriginal people and 46.6% of 191 954 cancers in non-Aboriginal people were localised at diagnosis. After adjusting for age, sex, year of diagnosis, area of residence and socioeconomic status, Aboriginal people had significantly higher risks of regional or distant spread for head and neck cancer, relative to localised spread, than non-Aboriginal people (regional: adjusted relative risk ratio [RRR], 1.89; 95% CI, 1.21-2.98; distant: adjusted RRR, 3.40; 95% CI, 1.85-6.05; P < 0.001). For breast, cervical and prostate cancers and melanoma, the risks of regional or distant spread were higher for Aboriginal people, but these differences were not statistically significant. For lung, colorectal, upper gastrointestinal tract, other gynaecological, and eye, brain and central nervous system cancers, the risks of regional, distant and unknown spread of cancer were similar for Aboriginal and non-Aboriginal people.

CONCLUSION

Aboriginal people were more likely than non-Aboriginal people to be diagnosed with more advanced cancer for only a few cancer types, most notably head and neck cancers. Differences in spread of disease at diagnosis are unlikely to explain much of the survival differences observed across a wide range of cancers between Aboriginal and non-Aboriginal people in NSW.

Mortality associated with primary hyperparathyroidism

561 patients with primary hyperparathyroidism were followed between 1961 and 1994. Relative survival was compared to that of the Australian population studied during the same time interval. Mortality was significantly greater in the hyperparathyroid population (P<0.001). Mortality was not greater in the patients with serum calcium levels >3.00 mmol/L compared to those with a serum calcium levels <3.00 mmol/L. 113 patients did not have parathyroid surgery. Their relative survival was not significantly different from those who had surgery but their mean serum calcium and parathyroid hormone (PTH) levels were significantly lower than those who had surgery. A re-analysis of the 453 patients followed between 1972 and 2011 was carried out and a 20-year survival analysis made of those diagnosed between 1972 and 1981 and those diagnosed between 1982 and 1991. The latter group had significantly worse relative mortality than the former group (P<0.001) but was significantly older at the time of diagnosis (56.94 ± 14.83 vs 52.01 ± 13.58, P<0.001). The serum calcium and serum PTH levels were not significantly different between these two groups.

Prostate cancer mortality outcomes and patterns of primary treatment for Aboriginal men in New South Wales, Australia

OBJECTIVE

To compare prostate cancer mortality for Aboriginal and non-Aboriginal men and to describe prostate cancer treatments received by Aboriginal men.

PATIENTS AND METHODS

We analysed cancer registry records for all men diagnosed with prostate cancer in New South Wales (NSW) in 2001-2007 linked to hospital inpatient episodes and deaths. More detailed information on androgen-deprivation therapy and radiotherapy was obtained from medical records for 87 NSW Aboriginal men diagnosed in 2000-2011. The main outcomes were primary treatment for, and death from, prostate cancer. Analysis included Cox proportional hazards regression and logistic regression.

RESULTS

There were 259 Aboriginal men among 35,214 prostate cancer cases diagnosed in 2001-2007. Age and spread of disease at diagnosis were similar for Aboriginal and non-Aboriginal men. Prostate cancer mortality 5 years after diagnosis was higher for Aboriginal men (17.5%, 95% confidence interval (CI) 12.4-23.3) than non-Aboriginal men (11.4%, 95% CI 11.0-11.8). Aboriginal men were 49% more likely to die from prostate cancer (hazard ratio 1.49, 95% CI 1.07-1.99) after adjusting for differences in demographic factors, stage at diagnosis, health access and comorbidities. Aboriginal men were less likely to have a prostatectomy for localised or regional cancer than non-Aboriginal men (adjusted odds ratio 0.60, 95% CI 0.40-0.91). Of 87 Aboriginal men with full staging and treatment information, 60% were diagnosed with localised disease. Of these, 38% had a prostatectomy (± radiotherapy), 29% had radiotherapy only and 33% had neither.

CONCLUSION

More research is required to explain differences in treatment and mortality for Aboriginal men with prostate cancer compared with non-Aboriginal men. In the meantime, ongoing monitoring and efforts are needed to ensure Aboriginal men have equitable access to best care.

Increasing rates of surgical treatment and preventing comorbidities may increase breast cancer survival for Aboriginal women

Background

Lower breast cancer survival has been reported for Australian Aboriginal women compared to non-Aboriginal women, however the reasons for this disparity have not been fully explored. We compared the surgical treatment and survival of Aboriginal and non-Aboriginal women diagnosed with breast cancer in New South Wales (NSW), Australia.

Methods

We analysed NSW cancer registry records of breast cancers diagnosed in 2001–2007, linked to hospital inpatient episodes and deaths. We used unconditional logistic regression to compare the odds of Aboriginal and non-Aboriginal women receiving surgical treatment. Breast cancer-specific survival was examined using cumulative mortality curves and Cox proportional hazards regression models.

Results

Of the 27 850 eligible women, 288 (1.03%) identified as Aboriginal. The Aboriginal women were younger and more likely to have advanced spread of disease when diagnosed than non-Aboriginal women. Aboriginal women were less likely than non-Aboriginal women to receive surgical treatment (odds ratio 0.59, 95% confidence interval (CI) 0.42-0.86). The five-year crude breast cancer-specific mortality was 6.1% higher for Aboriginal women (17.7%, 95% CI 12.9-23.2) compared with non-Aboriginal women (11.6%, 95% CI 11.2-12.0). After accounting for differences in age at diagnosis, year of diagnosis, spread of disease and surgical treatment received the risk of death from breast cancer was 39% higher in Aboriginal women (HR 1.39, 95% CI 1.01-1.86). Finally after also accounting for differences in comorbidities, socioeconomic disadvantage and place of residence the hazard ratio was reduced to 1.30 (95% CI 0.94-1.75).

Conclusion

Preventing comorbidities and increasing rates of surgical treatment may increase breast cancer survival for NSW Aboriginal women.

Age, health, and education determine supportive care needs of men younger than 70 years with prostate cancer

PURPOSE

It is important to meet the supportive care needs of cancer patients to ensure their satisfaction with their care. A population-wide sample of men younger than 70 years and newly diagnosed with prostate cancer was surveyed to determine their unmet needs in five domains and the factors predicting them.

PATIENTS AND METHODS

Eligible men were younger than 70 years and residents in New South Wales, Australia, with newly diagnosed histopathologically confirmed prostate cancer. Sixty-seven percent of eligible men diagnosed between October 2000 and October 2001 participated. Demographic, treatment, and self-reported health data were collected. Information on cancer stage, grade, and prostate-specific antigen was obtained from medical records. Logistic regression analyses determined patient and treatment variables that predicted higher unmet needs.

RESULTS

More than half (54%) of men with prostate cancer expressed some level of unmet psychological need, and 47% expressed unmet sexuality needs. Nearly one fourth expressed a moderate or high level of unmet need with respect to changes in sexuality. Sexuality needs were independently predicted by being younger, having had a secondary school education only, having had surgery, and being married, living as married, or divorced. Uncertainty about the future was also an important area of unmet need.

CONCLUSION

Attention should be given to sexual and psychological needs in the early months after diagnosis or treatment of prostate cancer, particularly in younger men, those with less education, and those having surgery. Research into better ways of meeting these needs will enable us to meet them with as much rigor as we meet clinical treatment needs.

Cancer mortality in Aboriginal people in New South Wales, Australia, 1994-2002

OBJECTIVE

To describe, for the first time, mortality from cancer for Aboriginal residents of New South Wales (NSW).

METHODS

These are the results of a descriptive study of cancer deaths from the NSW Central Cancer Registry for 1994 to 2002. Standardised mortality ratios were calculated with Poisson confidence intervals to compare the relative rates in the Indigenous and non-Indigenous populations.

RESULTS

The overall standardised mortality rates were 66% higher for males and 59% higher for females for Aboriginal people compared with non-Indigenous people. Mortality from lung cancer was 50% and 100% higher than for NSW non-Indigenous males and females respectively. The high mortality rate from cervical cancer in Aboriginal females is contrary to the trends in the general population since the introduction of free population-based screening.

CONCLUSIONS

For the first time, data are available for cancer mortality for Aboriginal people in NSW. Mortality for all cancers combined was higher than that of the non-Indigenous population. This suggests that a combination of later diagnoses and perhaps poorer treatment outcomes as well as being diagnosed with poorer prognosis cancers is occurring in Aboriginal people of NSW.

IMPLICATIONS

It was possible to increase the rate of identification in a population register using routinely collected data, but the completeness and accuracy of Indigenous status should, and can, be improved in all notifying data collections. Public health planners in NSW can now begin to address the issues of prevention, treatment and palliation of cancer in Aboriginal people with local, rather than imputed, evidence.

The extent and nature of food promotion directed to children in Australian supermarkets

The aim of this study was to describe the nature and amount of sales promotion use on food packaging in selected Australian supermarkets, specifically those directed at children through the use of premium offers, such as giveaways and competitions, and cartoon and movie character promotions. The study also examined the promotion of healthy versus unhealthy foods. Nine supermarkets located across the metropolitan area of Sydney, Australia were surveyed to assess the extent and nature of food promotion directed at children. The number and types of promotions were measured within seven food categories: sweet biscuits, snack foods, confectionery, chips/savoury snacks, cereals, dairy snacks and ice cream. Any foods that utilized promotional tactics were categorized as either healthy or unhealthy, according to set criteria. The study found that within the seven food categories between 9 and 35% of food products used promotional tactics. The use of television, movie celebrities and cartoon characters for promotion was most common, making up 75% of all promotions. Giveaways accounted for 13% of all promotions. When used, giveaways were commonly used in conjunction with another promotional method. Data from this study also confirmed that 82% of all food promotions were for unhealthy foods and only 18% were used to promote healthy foods. However, for dairy snacks and ice cream the majority of promotions, 99 and 65%, respectively, were healthier choices. This was the first study to describe the extent and nature of food promotions used in supermarkets. The promotion of unhealthy foods in supermarkets is common and is one of the many factors contributing to today's obesity promoting environment. Further research is required to determine the impact of food promotions on children's dietary intake, and to determine the most effective ways to restrict the promotion of unhealthy foods.

How much food advertising is there on Australian television?

The purpose of this study was to conduct a comprehensive content analysis of television food advertising and provide data on current levels of food advertising in Australia. All three commercial stations available on free-to-air Australian television were concurrently videotaped between 7 a.m. and 9 p.m. on two weekdays and both weekend days in four locations across Australia to provide a total of 645 h for analysis. Each advertisement was categorized as 'non-food ad', 'healthy/core food ad' or 'unhealthy/non-core food ad' according to set criteria. Thirty-one percent of the advertisements analyzed were for food. Eighty-one percent of the food advertisements identified were for unhealthy/non-core foods. When comparing the results of this study with previous research, it was found that the number of unhealthy advertisements screened per hour had not changed over the past few years. On weekdays, the number of advertisements increased throughout the day to peak at more than five advertisements per hour in the 6 p.m. to 9 p.m. time slot. The early morning time slot on Saturday was the most concentrated period for advertising unhealthy/non-core food with more than six advertisements screened per hour. The regional areas screened a significantly lower level of unhealthy/non-core food advertisements (19.5%) compared with the metropolitan areas (29.5%). Fast food and takeaway was the most advertised food category, followed by chocolate and confectionery. A total 194 breaches of the Children's Television Standards were identified according to our interpretation of the standard. It is well recognized that childhood obesity is a worldwide problem. The heavy marketing of energy-dense, nutrient-poor foods influences food choices and contributes to the incidence of overweight and obesity in children. Despite the recognition of this growing problem, little has been done to ensure children are protected against the use of large volumes of unhealthy/non-core food advertising.

Interval breast cancers in New South Wales, Australia, and comparisons with trials and other mammographic screening programmes

OBJECTIVE

To present information on 1st year interval breast cancer from the New South Wales mammographic screening programme and to compare with published results from trials and services.

SETTING

New South Wales data were derived from a population based biennial mammographic screening programme, which achieved statewide coverage in 1995. Women aged 50-69 years screened during 1995-7 were included.

METHODS

Bilateral two view mammography with reading by two radiologists is used for biennial screening examinations. Interval cancers were detected by the screening programme and by linkage with the statewide cancer registry. In situ carcinoma was excluded. Incidence of interval cancer was estimated as a proportion of the expected underlying incidence of breast cancer. Comparative data were derived from the published literature and meta-analyses were performed.

RESULTS

Although randomised trials of screening have a proportional incidence by meta-analysis of 19% (95% confidence interval (95% CI) 12% to 25%), service studies yield a proportional incidence by meta-analysis of 27% (95% CI 25% to 30%), and more than half report proportional incidences greater than 25%. In the New South Wales mammographic screening programme the proportional incidence of interval breast cancer was 33% (95% CI 29% to 38%) for ages 50-59 years, 28% (95% CI 24% to 32%) for ages 60-69 years, and 31% (95% CI 28% to 34%) for ages 50-69 years combined. Proportional incidence in the New South Wales programme for ages 50-69 years was not significantly different from the rate for service studies by meta-analysis.

CONCLUSIONS

Effectiveness of mammographic screening for reducing mortality from breast cancer needs to be examined relative to rates of interval cancer from actual service situations as trials may concentrate resources and expertise in ways which may be less replicable in routine delivery of the service.

Observations on the effect of abolishing analgesic abuse and reducing smoking on cancers of the kidney and bladder in New South Wales, Australia, 1972-1995

OBJECTIVES

We have assessed the effect on the rates of cancers of the kidney and bladder of measures undertaken by the government in 1979-1983 to limit smoking and analgesic abuse in New South Wales (NSW). Sale of phenacetin-containing analgesics, previously available without restriction and regularly taken by 11-13% of women and 4-9% of men in NSW, was prohibited from 1979. The prevalence of current smokers among adult Australian men had fallen from 72% in 1945 to 43% in 1980 and to 28% in 1992. In women the corresponding figures were 26%, 31% and 24%.

METHODS

Incidence and mortality data from the New South Wales Central Cancer Registry for the period 1972 to 1995 were analyzed, by sex and age, for trends over time. Relative survival was calculated for cases diagnosed in the period 1980-94 and followed until the end of 1996.

RESULTS

Significant trends evident from these data were: throughout the period of review a rising incidence of, and to a lesser extent mortality from, renal parenchymal cancer for which relative survival has steadily improved; falling mortality from bladder cancer throughout the period of review, but more rapid after 1985; a reversal of the earlier increasing incidence of, and mortality from, cancer of the renal pelvis; and relative survival for bladder and renal pelvic cancers which was worse in women than men. Changes in registration practice in 1985 and 1993 introduced artifacts into the trends in incidence of bladder cancer.

CONCLUSIONS

Improvements in the trends of incidence and mortality of cancers of the renal pelvis and bladder in the mid-1980s are interpreted, in the light of registration and clinical practice, to indicate a beneficial effect of regulations which virtually abolished analgesic abuse and, less certainly, a contribution from measures restricting smoking, in New South Wales. However, renal parenchymal cancer continues to increase, although there has been some apparent benefit of earlier detection.