Measuring cancer in indigenous populations

Indigenous access to clinical services along the lung cancer treatment pathway: a review of current evidence

BACKGROUND

Lung cancer is a deadly cancer. Early diagnosis and access to timely treatment are essential to maximizing the likelihood of survival. Indigenous peoples experience enduring disparities in lung cancer survival, and disparities in access to and through lung cancer services is one of the important drivers of these disparities. In this manuscript, we aimed to examine the current evidence on disparities in Indigenous access to services along the lung cancer treatment pathway.

METHODS

A narrative literature review was conducted for all manuscripts and reports published up until July 20, 2022, using Medline, Scopus, Embase, and Web of Science. Following the identification of eligible literature, full-text versions were scanned for relevance for inclusion in this review, and relevant information was extracted. After scanning 1,459 documents for inclusion, our final review included 36 manuscripts and reports that included information on lung cancer service access for Indigenous peoples relative to non-Indigenous peoples. These documents included data from Aotearoa New Zealand, Australia, Canada, and the USA (including Hawai'i).

RESULTS

Our review found evidence of disparities in access to, and the journey through, lung cancer care for Indigenous peoples. Disparities were most obvious in access to early detection and surgery, with inconsistent evidence regarding other components of the pathway.

CONCLUSION

These observations are made amid relatively scant data in a global sense, highlighting the need for improved data collection and monitoring of cancer care and outcomes for Indigenous peoples worldwide. Access to early detection and guideline-concordant treatment are essential to addressing enduring disparities in cancer survival experienced by Indigenous peoples globally.

Seroprevalence of Treponema pallidum infection in Brazilian indigenous people: a cross-sectional study

Indigenous communities in Brazil have a complex epidemiological profile, which increases their chances of contracting sexually transmitted diseases. However, limited data is available on Treponema pallidum infections in this population. We investigated the seroprevalence and risk factors associated with T. pallidum infection in an indigenous population of Dourados, Mato Grosso do Sul. Blood samples were collected from September 2017 to March 2020, and the participants were interviewed to obtain comprehensive data on demography and sexual behavior. Serological tests were performed to detect T. pallidum infection. Besides conducting descriptive analysis, we performed Chi-squared tests and determined the bivariate odds ratio. The data were also analyzed using logistic regression. Among the 2190 invited individuals, 1927 (88%) were included in this study. The seroprevalence of T. pallidum infection was 2.91%. The results of a multivariate analysis showed that individuals who were 30-39 years old, with up to 4 years of school education, living in households without piped water, with a history of genital lesions, multiple sexual partners, and having a history of STIs had the highest seroprevalence of T. pallidum. This study showed that behavioral, social, and economic factors play an important role in the transmission of T. pallidum within the indigenous population. Thus, targeted intervention, including imparting education in the native language, mass testing initiatives, and implementing public policies to improve socioeconomic indicators, is needed to reduce the cases of syphilis in this community.

Pan-Canadian Survey of Radiation Oncology Professional Involvement in Global Oncology Initiatives in Low- and Middle-Income Countries

PURPOSE

Canadian radiation oncology professionals have a strong history of involvement in global oncology initiatives worldwide. This pan-Canadian survey-based study was conducted to determine the current level of engagement of Canadian radiation oncologists (ROs) and medical physicists (MPs) in global oncology initiatives and broaden the development of these activities.

MATERIALS AND METHODS

This was a cross-sectional study. The survey was designed to characterize current levels of engagement of Canadian ROs and MPs in global oncology initiatives. The survey was open from March 2019 to April 2020. It was disseminated to all Canadian Association of Radiation Oncology and Canadian Organization of Medical Physicists members with two subsequent email reminders.

RESULTS

Survey responses were received from 40 (93%) of the 43 Canadian cancer treatment centers that offer radiotherapy. At least one RO responded at 34 centers (79%) and one MP from 34 centers (79%) with some overlap. A response was received from a total of 93 participants, 47 ROs and 46 MPs. Of all survey participants, 58% reported some experience with global oncology. Nineteen percent of the participants surveyed were currently directly involved in short- or long-term projects, more than half of which have opportunity for additional staff involvement. The projects spanned 26 countries in South America, Africa, and Asia. Quality improvement and capacity building accounted for 27% and 20% of initiatives, respectively. The most common area of engagement was in direct treatment care, accounting for 56% of the projects.

CONCLUSION

This study demonstrates the landscape of involvement of Canadian ROs and MPs in global oncology initiatives. The study also highlights areas of opportunity for broadening international participation and collaboration as it relates to global oncology for Canadian radiation oncology professionals.

Patients' and carers' priorities for cancer research in Aotearoa/New Zealand

BACKGROUND

Discrepancies have been reported between what is being researched, and what patients/families deem important to be investigated. Our aim was to understand research priorities for those who live with cancer in Aotearoa/New Zealand, with emphasis on Māori.

METHODS

Adult outpatients with cancer and their whānau/family completed a survey (demographics, selecting keywords, free-text comments) at Christchurch hospital. Quantitative and qualitative data were evaluated using standard statistical and thematic analyses, respectively.

RESULTS

We recruited 205 participants, including both tūroro/patients (n = 129) and their whānau/family/carer (n = 76). Partnership with Māori health workers enabled greater recruitment of Māori participants (19%), compared to the proportion of Māori in Canterbury (9%). Cancer research was seen as a priority by 96% of participants. Priorities were similar between Māori and non-Māori participants, with the keywords 'Cancer screening', 'Quality of Life' and 'Development of new drugs' chosen most often. Free-text analysis identified three themes; 'Genetics and Prevention', 'Early Detection and Treatment', and 'Service Delivery', with some differences by ethnicity.

CONCLUSIONS

Cancer research is a high priority for those living with cancer. In addition, participants want researchers to listen to their immediate and practical needs. These findings may inform future cancer research in Aotearoa.

MāORI TERMS AND TRANSLATION

Aotearoa (New Zealand) he aha ō whakaaro (what are your thoughts) hui (gathering) mate pukupuku (cancer) mokopuna (descendent) Ōtautahi (Christchurch) rongoā (traditional healing) tāne (male) te reo (Māori language) Te Whatu Ora (weaving of wellness, Health New Zealand) tikanga (methods, customary practices) tūroro (patients) (alternative terms used: whānau affected by cancer or tangata whaiora (person seeking health)) wahine (female) Waitaha (Canterbury) whakapapa (genealogy) whānau ((extended) family, based on whakapapa, here also carer).

Cancer statistics for American Indian and Alaska Native individuals, 2022: Including increasing disparities in early onset colorectal cancer

American Indian and Alaska Native (AIAN) individuals are diverse culturally and geographically but share a high prevalence of chronic illness, largely because of obstacles to high-quality health care. The authors comprehensively examined cancer incidence and mortality among non-Hispanic AIAN individuals, compared with non-Hispanic White individuals for context, using population-based data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries. Overall cancer rates among AIAN individuals were 2% higher than among White individuals for incidence (2014 through 2018, confined to Purchased/Referred Care Delivery Area counties to reduce racial misclassification) but 18% higher for mortality (2015 through 2019). However, disparities varied widely by cancer type and geographic region. For example, breast and prostate cancer mortality rates are 8% and 31% higher, respectively, in AIAN individuals than in White individuals despite lower incidence and the availability of early detection tests for these cancers. The burden among AIAN individuals is highest for infection-related cancers (liver, stomach, and cervix), for kidney cancer, and for colorectal cancer among indigenous Alaskans (91.3 vs. 35.5 cases per 100,000 for White Alaskans), who have the highest rates in the world. Steep increases for early onset colorectal cancer, from 18.8 cases per 100,000 Native Alaskans aged 20-49 years during 1998 through 2002 to 34.8 cases per 100,000 during 2014 through 2018, exacerbated this disparity. Death rates for infection-related cancers (liver, stomach, and cervix), as well as kidney cancer, were approximately two-fold higher among AIAN individuals compared with White individuals. These findings highlight the need for more effective strategies to reduce the prevalence of chronic oncogenic infections and improve access to high-quality cancer screening and treatment for AIAN individuals. Mitigating the disparate burden will require expanded financial support of tribal health care as well as increased collaboration and engagement with this marginalized population.

Sâkipakâwin: Assessing Indigenous Cancer Supports in Saskatchewan Using a Strength-Based Approach

Given that the health care system for Indigenous people tends to be complex, fragmented, and multi-jurisdictional, their cancer experiences may be especially difficult. This needs assessment study examined system-level barriers and community strengths regarding cancer care experiences of Indigenous people in Saskatchewan. Guided by an advisory committee including Indigenous patient and family partners, we conducted key informant interviews with senior Saskatchewan health care administrators and Indigenous leaders to identify supports and barriers. A sharing circle with patients, survivors, and family members was used to gather cancer journey experiences from Indigenous communities from northern Saskatchewan. Analyses were presented to the committee for recommendations. Key informants identified cancer support barriers including access to care, coordination of care, a lack of culturally relevant health care provision, and education. Sharing circle participants discussed strengths and protective factors such as kinship, connection to culture, and spirituality. Indigenous patient navigation, inter-organization collaboration, and community relationship building were recommended to ameliorate barriers and bolster strengths. Recognizing barriers to access, coordination, culturally relevant health care provision, and education can further champion community strengths and protective factors and frame effective cancer care strategies and equitable cancer care for Indigenous people in Saskatchewan.

Métis Peoples and Cancer: A Scoping Review of Literature, Programs, Policies and Educational Material in Canada

Much of the existing Indigenous cancer research focuses on First Nation populations or reports on pan-Indigenous data that include First Nations, Métis, and Inuit metrics together, which fails to capture the distinct lived realities, experiences of colonialism, and culture of each Indigenous group. The purpose of this scoping review was to summarize existing knowledge on cancer among Métis peoples in Canada, offering direction to researchers, institutions, and policymakers for future actions that enhance Métis-specific cancer surveillance and cancer care. We searched Embase, Medline, iPortal, and Proquest Theses and Dissertations databases, Google Scholar and Google, alongside ten websites relevant to cancer and Métis peoples. Two reviewers gathered 571 records. After screening, 77 records were included. Data show that Métis peoples experience higher behavioral risk factors, lower screening participation, higher cancer incidence for some cancers, and higher mortality rates compared to the non-Indigenous population. Existing research is piece-meal and researchers emphasize that there is inadequate Métis-specific cancer data. There is a need for targeted, Peoples-specific cancer control interventions to reduce these health inequities and a coordinated, Peoples-specific approach to cancer research. These efforts must involve collaboration among Métis Nations and organizations, provincial governments and agencies, researchers, and policymakers.

Cancer care disparities among Australian and Aotearoa New Zealand Indigenous peoples

PURPOSE OF REVIEW

Persistent and significant inequalities for Indigenous people with cancer around the globe exist, arising from colonial settlement of Indigenous land with profound social, economic and cultural impacts. We summarize recent publications concerning cancer disparities affecting Australian Aboriginal and Torres Strait Islander Peoples and Aotearoa New Zealand Māori Peoples.

RECENT FINDINGS

Cancer-free survival and overall survival statistics testify to the urgent need to 'close the gap'. For Indigenous peoples in Australia and New Zealand, disparity persists along the cancer care pathway, from increased risk factors to lower screening access, health resource utilization and survivorship care. Recent publications highlight multimorbidity as contributing to poor cancer outcomes in Indigenous populations. The implementation of tailored Optimal Care Pathways is described, as is the validation of tailored tools capturing the perspectives of Indigenous persons. Finally, the importance of Indigenous-led research is emphasized.

SUMMARY

Cancer-specific outcomes in Indigenous people of Australia and New Zealand remain poor with many widening disparities compared to non-indigenous populations. A growing body of epidemiological, health service and clinical research is documenting both the problems and potential solutions. Further work is needed in both broad health policies and the workforce, in building cultural competence to optimize individual care encounters.

Issues postopératoires chez les Autochtones au Canada: revue systématique

Contexte:

Il existe d’importantes iniquités en matière de santé chez les populations autochtones au Canada. La faible densité de la population canadienne et les populations en région éloignée posent un problème particulier à l’accès et à l’utilisation des soins chirurgicaux. Aucune synthèse des données sur les issues chirurgicales chez les Autochtones au Canada n’avait été publiée jusqu’à maintenant.

Méthodes:

Nous avons interrogé 4 bases de données pour recenser les études comparant les issues chirurgicales et les taux d’utilisation chez les adultes des Premières Nations, inuits et métis et chez les adultes non autochtones au Canada. Des évaluateurs indépendants ont réalisé toutes les étapes en parallèle. L’issue primaire était la mortalité; les issues secondaires comprenaient le taux d’utilisation des chirurgies, les complications et la durée du séjour à l’hôpital. Nous avons effectué une méta-analyse pour l’issue primaire à l’aide d’un modèle à effets aléatoires. Nous avons évalué les risques de biais à l’aide de l’outil ROBINS-I.

Résultats:

Vingt-huit études ont été analysées, pour un total de 1 976 258 participants (10,2 % d’Autochtones). Aucune étude ne portait précisément sur les populations inuites et métisses. Quatre études portant sur 7 cohortes ont fourni des données corrigées sur la mortalité pour 7135 participants (5,2 % d’Autochtones); les Autochtones présentaient un risque de décès après une intervention chirurgicale 30 % plus élevé que les patients non autochtones (rapport de risque combiné 1,30; IC à 95 % 1,09–1,54; I² = 81 %). Les complications étaient aussi plus fréquentes chez le premier groupe, notamment les infections (RC corrigé 1,63; IC à 95 % 1,13–2,34) et les pneumonies (RC 2,24; IC à 95 % 1,58–3,19). Les taux de différentes interventions chirurgicales étaient plus faibles, notamment pour les transplantations rénales, les arthroplasties, les chirurgies cardiaques et les accouchements par césarienne.

Interprétation:

Les données disponibles sur les issues postopératoires et le taux d’utilisation de la chirurgie chez les Autochtones au Canada sont limitées et de faible qualité. Elles suggèrent que les Autochtones ont de plus hauts taux de décès et d’issues négatives postchirurgicales et qu’ils font face à des obstacles dans l’accès aux interventions chirurgicales. Ces conclusions indiquent qu’il y a un besoin de réévaluer en profondeur les soins chirurgicaux prodigués aux Autochtones au Canada pour leur assurer un accès équitable et améliorer les issues.

Numéro d’enregistrement du protocole:

PROSPERO-CRD42018098757.

Creating a Canadian Indigenous Research Network Against Cancer to Address Indigenous Cancer Disparities

PURPOSE

In Canada, Indigenous peoples’ cancer rates have increased, but cancer screening rates tend to be lower. When coupled with poor cancer prognosis, treatment barriers, and inaccessible health care, Indigenous patients with cancer experience many unmet needs. Further complicating their journey is a multijurisdictional system that complicates cancer control services, treatments, patient supports, and cancer surveillance. To address these issues, the Canadian Indigenous Research Network Against Cancer (CIRNAC) was developed. This article describes the forerunners and consultative process that created the network and the consensus model developed to ground this network with, by, and for Indigenous peoples.

METHODS

A consultative workshop was held to (1) establish and increase network membership, (2) enhance partnerships with Indigenous communities and other researchers, and (3) develop an Indigenous-led research program, new funding, and related initiatives.

RESULTS

Participants viewed the CIRNAC as a reflective parallel network led by Indigenous peoples that would identify research priorities within Canada, assess how these priorities align with Indigenous patients’ cancer care and research needs, and cross-check to see if these priorities align with each other. The network would also advocate for Indigenous elders/knowledge holders and community grassroot processes to drive research and training, thus demonstrating the power of the community voice and lived experience in research. In addition, the network would foster research partnerships to investigate alternative Indigenous models for cancer prevention, care, treatment, and support.

CONCLUSION

The CIRNAC evolved as a viable vehicle to address cancer with, for, and by Indigenous peoples. The network is guided by a preamble, a set of aims, and an inclusion engagement circle model. It is evolving through major world initiatives, with the aim of formally becoming an internationally linked national network.

Psychosocial Aspects of Delivering Cancer Care to Indigenous People: An Overview

Globally, a growing body of evidence has reported significant disparities in cancer outcomes between indigenous and nonindigenous people. Although some effort is being made to address these disparities, relatively little attention has been directed toward identifying and focusing on the psychosocial aspects of cancer care for indigenous patients, which are critical components in improving cancer care and outcomes. The purpose of this article is to describe the results of a scoping review of the psychosocial aspects of cancer care for indigenous people. We highlight considerations in undertaking research in this field with indigenous people and the implications for clinical practice.

Reflection on modern methods: statistical, policy and ethical implications of using age-standardized health indicators to quantify inequities

Methods for calculating health indicators profoundly influence understanding of and action on population health and inequities. Age-standardization can be useful and is commonly applied to account for differences in age structures when comparing health indicators across groups. Age-standardized rates have well-acknowledged limitations, including that they are relative indices for comparison, and not accurate measures of actual rates where the age structures of groups diverge. This paper explores these limitations, and demonstrates alternative approaches through a case study quantifying mortality rates within the Aboriginal and Torres Strait Islander (Indigenous) population of Australia and inequities compared with the non-Indigenous population, over 2001–16. Applying the Australian Standard Population, the Aboriginal and Torres Strait Islander age-standardized mortality rate was more than double the crude mortality rate in 2001 and 2016, inflated through high weighting of older age groups. Despite divergent population age structures, age-standardized mortality rates remain a key policy metric for measuring progress in reducing Indigenous-non-Indigenous inequities in Australia. Focusing on outcomes age-standardized to the total population can obscure inequities, and denies Aboriginal and Torres Strait Islander peoples and communities valid, actionable information about their health and well-being. Age-specific statistics convey the true magnitude of health risks and highlight high-risk subgroups. When requiring standardization, standardizing to a population-specific standard (here, an Indigenous standard) generates metrics centred around and reflective of reality for the population of focus, supporting communities’ self-determination to identify priorities and informing resource allocation and service delivery. The principles outlined here apply across populations, including Indigenous and other populations internationally.

Postoperative outcomes for Indigenous Peoples in Canada: a systematic review

Background:

Substantial health inequities exist for Indigenous Peoples in Canada. The remote and distributed population of Canada presents unique challenges for access to and use of surgery. To date, the surgical outcome data for Indigenous Peoples in Canada have not been synthesized.

Methods:

We searched 4 databases to identify studies comparing surgical outcomes and utilization rates of adults of First Nations, Inuit or Métis identity with non-Indigenous people in Canada. Independent reviewers completed all stages in duplicate. Our primary outcome was mortality; secondary outcomes included utilization rates of surgical procedures, complications and hospital length of stay. We performed meta-analysis of the primary outcome using random effects models. We assessed risk of bias using the ROBINS-I tool.

Results:

Twenty-eight studies were reviewed involving 1 976 258 participants (10.2% Indigenous). No studies specifically addressed Inuit or Métis populations. Four studies, including 7 cohorts, contributed adjusted mortality data for 7135 participants (5.2% Indigenous); Indigenous Peoples had a 30% higher rate of death after surgery than non-Indigenous patients (pooled hazard ratio 1.30, 95% CI 1.09–1.54; I² = 81%). Complications were also higher for Indigenous Peoples, including infectious complications (adjusted OR 1.63, 95% CI 1.13–2.34) and pneumonia (OR 2.24, 95% CI 1.58–3.19). Rates of various surgical procedures were lower, including rates of renal transplant, joint replacement, cardiac surgery and cesarean delivery.

Interpretation:

The currently available data on postoperative outcomes and surgery utilization rates for Indigenous Peoples in Canada are limited and of poor quality. Available data suggest that Indigenous Peoples have higher rates of death and adverse events after surgery, while also encountering barriers accessing surgical procedures. These findings suggest a need for substantial re-evaluation of surgical care for Indigenous Peoples in Canada to ensure equitable access and to improve outcomes.

Protocol registration:

PROSPERO-CRD42018098757

Sociodemographic characteristics of women with invasive cervical cancer in British Columbia, 2004-2013: a descriptive study

BACKGROUND

Although cancer screening has led to reductions in the incidence of invasive cervical cancer (ICC) across Canada, benefits of prevention efforts are not equitably distributed. This study investigated the sociodemographic characteristics of women with ICC in British Columbia compared with the general female population in the province.

METHODS

In this descriptive study, data of individuals 18 years and older diagnosed with ICC between 2004 and 2013 were obtained from the BC Cancer Registry. Self-reported sociodemographic characteristics were derived from standardized health assessment forms (HAFs) completed upon admission in the BC Cancer Registry. Standardized ratios (SRs) were derived by dividing observed and age-adjusted expected counts by ethnicity or race, language, and marital, smoking and urban-rural status. Differences between observed and expected counts were tested using χ² goodness-of-fit tests. General population data were derived from the 2006 Census, 2011 National Household Survey and 2011/12 Canadian Community Health Survey.

RESULTS

Of 1705 total cases of ICC, 1315 were referred to BC Cancer (77.1%). Of those who were referred, 1215 (92.4%) completed HAFs. Among Indigenous women, more cases were observed (n = 85) than expected (n = 39; SR 2.16, 95% confidence interval [CI] 2.15-2.18). Among visible minorities, observed cases (n = 320) were higher than expected (n = 253; 95% CI 1.26-1.26). Elevated SRs were observed among women who self-identified as Korean (SR 1.78, 95% CI 1.76-1.80), Japanese (SR 1.77, 95% CI 1.74-1.79) and Filipino (SR 1.60, 95% CI 1.58-1.62); lower SRs were observed among South Asian women (SR 0.63, 95% CI 0.62-0.63). Elevated SRs were observed among current smokers (SR 1.34, 95% CI 1.33-1.34) and women living in rural-hub (SR 1.29, 95% CI 1.28-1.31) and rural or remote (SR 2.62, 95% CI 2.61-2.64) areas; the SR was lower among married women (SR 0.90, 95% CI 0.90-0.90).

INTERPRETATION

Women who self-identified as visible minorities, Indigenous, current smokers, nonmarried and from rural areas were overrepresented among women with ICC. Efforts are needed to address inequities to ensure all women benefit from cervical cancer prevention.

Achieving cervical cancer elimination among Indigenous women

Achieving the World Health Organisation (WHO) cervical cancer elimination target of fewer than four new cases per 100,000 woman-years requires scaling up HPV vaccination of girls, cervical screening, and pre-cancer and cancer treatment. We reviewed data from four high-income colonised countries (Australia, Canada, Aotearoa New Zealand (NZ), and the United States (US)) to identify how each is currently performing compared to the cervical cancer incidence elimination and triple-intervention targets, nationally and in Indigenous women. We also summarise barriers and enablers to meeting targets for Indigenous women. To achieve elimination, cervical cancer incidence must be reduced by 74% in Indigenous women in Australia, and 63% in Maori women in NZ; data were not published in sufficient detail to compare incidence in Indigenous women in Canada or the US to the WHO target. Only Australia meets the vaccination coverage target, but uptake appears comparatively equitable within Australia, NZ and the US, whereas there appears to be a substantial gap in Canada. Screening coverage is lower for Indigenous women in all four countries though the differential varies by country. Currently, only Australia universally offers HPV-based screening. Data on pre-cancer and cancer treatment were limited in all countries. Large inequities in cervical cancer currently exist for Indigenous peoples in Australia, Canada, New Zealand and the US, and elimination is not on track for all women in these countries. Current data gaps hinder improvements. These countries must urgently address their systemic failure to care and provide health care for Indigenous women.

Stomach Cancer Incidence and Mortality Trends among Circumpolar Nations

BACKGROUND

Stomach cancer incidence and mortality rates are declining across circumpolar nations, but the burden may not be distributed equally across subpopulations, including Indigenous peoples. Our objective was to examine stomach cancer incidence and mortality trends across circumpolar populations.

METHODS

Cancer incidence and mortality data from 1999-2016 were obtained from the Canadian Cancer Registry, Canadian Vital Statistics, CDC WONDER, NORDCAN, Northwestern Russian cancer registries, and National Cancer Reports. The direct method was used to calculate 10-year rolling age-standardized incidence and mortality rates to the world (WHO 2000-2025) and 2011 Canadian standard populations. Standardized incidence rate ratios (SRR) were calculated. Data were stratified by sex, year, and region. U.S. data were broken down by race [White; American Indian/Alaska Native (AIAN)]. Race data were not available from non-U.S. cancer registries.

RESULTS

Most populations showed declining incidence and mortality rates over time. Incidence rates among Greenland males and females, Alaska AIAN males and females, and Northern Canadian both sexes were elevated compared with regional counterparts and remained stable. The largest male SRR was observed among Alaska AIAN versus Alaska Whites [SRR = 3.82; 95% confidence interval (95% CI), 2.71-5.37]. The largest female SRR was observed among Alaska AIAN versus Alaska Whites (SRR = 4.10; 95% CI, 2.62-6.43).

CONCLUSIONS

Despite stomach cancer incidence and mortality rates declining overall, some northern and Indigenous populations experience elevated and stable incidence and mortality rates.

IMPACT

There is a need to address disparities observed among circumpolar subpopulations. Given similarities in incidence, mortality, and risk factor prevalence across circumpolar regions, addressing disparities could benefit from coordinated international action.

[Profile of antineoplastic medication among indigenous people treated in the Brazilian Unified National Health System]

Brazil has an estimated 900,000 indigenous people (0.4% of the country's population), belonging to more than 300 different ethnic groups. However, information is scarce on cancer epidemiology and the antineoplastic drugs used in treatment of these individuals. The study's objectives are to identify the antineoplastic drugs used and to describe the profile of use of these drugs in the indigenous population treated in Brazil, as well as to describe the patients' epidemiological profile. An ecological study was performed involving outpatient chemotherapy care from January 2014 to December 2018 throughout Brazil. The data source was the Outpatient Information System of the Brazilian Health Informatics Department, considering only Authorizations for High-Complexity Chemotherapy Procedures. We identified 2,425 authorizations for chemotherapy procedures for treatment of indigenous patients. Of these, 2,292 authorizations for a total of 210 individuals were analyzed. We found an increase in the number of authorizations and of indigenous persons receiving chemotherapy over the period, with a higher concentration of individuals living in and receiving treatment in the South of Brazil, plus a wide diversity in the types of diagnosed tumors (n = 63) and of treatment regimen used during the treatment (n = 107). The current study provided a new overview of the epidemiological profile of indigenous patients receiving chemotherapy in the Brazilian Unified National Health System. The findings help fill a current knowledge gap on indigenous people's health in Brazil.

Association between known risk factors and colorectal cancer risk in Indigenous people participating in the Ontario Familial Colon Cancer Registry

Introduction

Colorectal cancer is one of the most common cancers in Ontario and imposes a high burden on many Indigenous populations. There are two aims for this short communication: ■ Highlight colorectal risk factor findings from a population-based case-control study■ Highlight trends and challenges of colorectal cancer research in Indigenous populations in Ontario.

Methods

Prevalences of cigarette smoking, obesity, fruit and vegetable consumption, and family history of colorectal cancer were estimated using the Indigenous identifier in the Ontario Familial Colon Cancer Registry for 1999-2007 and then compared for cases and controls using age-adjusted odds ratios (ors) with 95% confidence intervals (cis).

Results

The registry search identified 66 Indigenous cases and 23 Indigenous controls. Cigarette smoking (or: 1.88; 95% ci: 0.63 to 5.60) and obesity (or: 2.16; 95% ci: 0.72 to 6.46) were higher in cases, but not statistically significantly so.

Conclusions

Findings were consistent with previous literature describing Indigenous populations. A small sample size and poor Indigenous identification questions make it challenging to comprehensively understand cancer risk factors and burden in Indigenous populations.

Colorectal cancer screening using faecal occult blood tests for Indigenous adults: A systematic literature review of barriers, enablers and implemented strategies

OBJECTIVE

Colorectal cancer (CRC) screening using a Faecal Occult Blood Test (FOBT) is a well-established population intervention to reduce mortality and morbidity of CRC. As Indigenous people are not fully benefiting from the screening programs, a greater understanding of barriers and enablers affecting participation is needed.

METHODS

Searches were carried out in PubMed, Embase, Sociological Abstracts, Scopus, CINAHL, and selected websites. Both qualitative and quantitative studies related to Indigenous populations of Canada, New Zealand, Australia and the United States of America were assessed for quality and data related to FOBT were extracted and synthetised.

RESULTS

A total of 375 publications were identified and screened against the inclusion/exclusion criteria. Thirty-four studies were included in the review. The barriers for participation in CRC screening included the lack of culturally competent health service access, particularly access to Indigenous health service providers. Medical discrimination, long-standing distrust in Western medicine and/or health staff and screening tests were all identified as barriers for Indigenous people. There were a small number of promising interventions to improve participation, which could be considered on a broader scale to increase overall participation by Indigenous people in CRC screening.

CONCLUSIONS

The review identified barriers and possible enablers for Indigenous participation in the CRC screening program, some which appear to be unique to Indigenous people. Further intervention studies conducted in partnership with Indigenous communities are needed to improve participation.

Collection and Reporting of Indigenous Status Information in Cancer Registries Around the World

PURPOSE

Worldwide, Indigenous people often have disproportionally worse health and lower life expectancy than their non-Indigenous counterparts. Despite the impact of cancer on life expectancy, little is known about the burden of cancer for Indigenous people primarily because of the paucity of data. We investigated the collection and reporting of Indigenous status information among a global sample of population-based cancer registries (PBCRs).

PARTICIPANTS AND METHODS

An online survey was e-mailed to eligible registries using set inclusion criteria. Respondents were asked questions on the collection, reporting, and quality assessment of Indigenous status in their registers.

RESULTS

Eighty-three PBCRs from 25 countries were included. Of these, 66% reported that their registry collected Indigenous status data, although the quality of this variable had been assessed in less than half in terms of completeness (38%) and accuracy (47%). Two thirds of PBCRs who collected Indigenous status data (67%), from nine of 25 countries responded that cancer statistics for Indigenous people were reported using registry data. Key barriers to the collection of Indigenous status information included the lack of data collection at the point of care (79%), lack of transfer of Indigenous status to the cancer registry (46%), inadequate information systems (43%), and legislative limitations (32%). Important variations existed among world regions, although the lack of Indigenous status data collection at the point of care was commonly reported across all regions.

CONCLUSION

High-quality data collection is lacking for Indigenous peoples in many countries. To ensure the design and implementation of cancer control activities required to reduce disparities for Indigenous populations, health information systems, including cancer registries, need to be strengthened, and this must be done in dialogue with Indigenous leaders.

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.

The US Census and the People's Health: Public Health Engagement From Enslavement and "Indians Not Taxed" to Census Tracts and Health Equity (1790-2018)

Public health professionals have long played a vital-albeit underappreciated-role in shaping, not simply using, US Census data, so as to provide the factual evidence required for good governance and health equity. Since its advent in 1790, the US Census has constituted a key political instrument, given the novel mandate of the US Constitution to allocate political representation via a national decennial census. US Census approaches to categorizing and enumerating people and places have profound implications for every branch and level of government and the resources and representation accorded across and within US states. Using a health equity lens to consider how public health has featured in each generation's political battles waged over and with census data, this essay considers three illustrations of public health's engagement with the enduring ramifications of three foundational elements of the US Census: its treatment of slavery, Indigenous populations, and the politics of place. This history underscores how public health has major stakes in the values and vision for governance that produces and uses census data.

Selecting lung cancer screenees using risk prediction models-where do we go from here

The National Lung Screening Trial (NLST) demonstrated that low dose computed tomography (LDCT) screening could reduce lung cancer mortality by 20% in high-risk individuals. The United States Preventive Services Task Force (USPSTF) and Centers for Medicare and Medicaid Services (CMS) approved lung cancer screening. The NLST, USPSTF and CMS define high risk as smoking ≥30 pack-years, smoking within the past 15 years, and being ages 55-74, 55-80 or 55-77. Retrospective studies demonstrated selection using model-estimated risk is superior to NLST-like criteria: higher sensitivity and positive predictive value (PPV), more deaths averted and higher cost-effectiveness. Projects are underway that may additionally support use of risk to determine eligibility. Firstly, the International Lung Screen Trial (ILST) is prospectively enrolling 4,000 individuals for screening if individuals have PLCOm2012 model risk ≥1.5% or are USPSTF+ve. Six-year follow-up will allow comparisons. Interim results support the risk approach. Secondly, Cancer Care Ontario started the Lung Cancer Screening Pilot for People at High Risk in order to find optimal design for province-wide programmatic screening. They are enrolling 3,000 individuals to screening based on PLCOm2012 risk ≥2%. Some hesitation to recommend screening selection based on model risk comes from the observation that selected individuals are older, have more comorbidities, are expected to have fewer life years and quality-adjusted life years (QALY) and are more likely to die from competing causes. We show that 25.6% of NLST eligible smokers are at low risk (6-year lung cancer incidence proportion =0.008). This group will not benefit from screening but has lower age, fewer comorbidities and fewer competing causes of death. When they are excluded from the NLST+ve group, age, comorbidity count and competing causes of death are similar to those in the PLCOm2012+ve group. In some jurisdictions, model-based lung cancer screening selection needs to take into consideration the elevated risk in blacks and indigenous peoples.