Cancer survival in New Zealand: Ethnic, social and geographical inequalities

Ethnic differences in time to surgery for women with early stage breast cancer in Aotearoa/New Zealand: a population-based study

Background

This study evaluates whether there are ethnic differences in time to surgery in women with early-stage (1-3a) breast cancer in four NZ urban regions between 2000 and 2020 pre- and post- Faster Cancer Treatment (FCT) implementation, which was introduced to address inequities in cancer outcomes.

Methods

This retrospective analysis used Te Rēhita Mate Ūtaetae (Breast Cancer Foundation National Register), a prospectively maintained database of breast cancers from 2000 to 2020. Women with stage 3b, 3c, metastatic or bilateral cancers were excluded. Logistic regression models evaluated ethnic differences in time to surgery (≤31/>31 days as per FCT plan) with sequential adjustment for potential contributing factors (demographic, mode of diagnosis, tumour, treatment facility type and treatment). Subgroup analyses by pre- and post-FCT implementation date were undertaken.

Findings

Of the 16,365 women included, 74.1% were NZ European (NZE), 10.2% were Māori, 6.1% were Pacific, and 9.2% were Asian. Wāhine Māori (Māori women) and Pacific women were more likely to experience delays in surgery >31 days, compared to NZE (maximally adjusted OR: 1.18; 95% CI:1.05, 1.33 and OR:1.42; 95% CI:1.22, 1.65, respectively)-deprivation and treatment facility type contributed most to this. Wāhine Māori experienced delay in the public system only. The associations did not differ between the pre- and post- FCT periods.

Interpretation

Ethnic inequities exist with respect to time to surgery for women with early-stage breast cancer and these differences persist after FCT implementation.

Funding

LB is supported by the Richard Stewart scholarship, the Royal Australasian College of Surgeons and Oxford Population Health.

Ethnic inequities in use of breast conserving surgery and radiation therapy in Aotearoa/New Zealand: which factors contribute?

PURPOSE

Aotearoa/New Zealand (NZ) faces ethnic inequities with respect to breast cancer survival and treatment. This study establishes if there are ethnic differences in (i) type of surgery and (ii) receipt of radiotherapy (RT) following breast conserving surgery (BCS), among women with early-stage breast cancer in NZ.

METHODS

This analysis used Te Rēhita Mata Ūtaetae (Breast Cancer Foundation National Register), a prospectively maintained database of breast cancers from 2000 to 2020. Logistic regression models evaluated ethnic differences in type of surgery (mastectomy or BCS) and receipt of RT with sequential adjustment for potential contributing factors. Subgroup analyses by treatment facility type were undertaken.

RESULTS

Of the 16,228 women included, 74% were NZ European (NZE), 10.3% were Māori, 9.4% were Asian and 6.2% were Pacific. Over one-third of women with BCS-eligible tumours received mastectomy. Asian women were more likely to receive mastectomy than NZE (OR 1.62; 95% CI 1.39, 1.90) as were wāhine Māori in the public system (OR 1.21; 95% CI 1.02, 1.44) but not in the private system (OR 0.78; 95% CI 0.51, 1.21). In women undergoing BCS, compared to NZE, Pacific women overall and wāhine Māori in the private system were, respectively, 36 and 38% less likely to receive RT (respective OR 0.64; 95% CI 0.50, 0.83 and 0.62; 95% CI 0.39, 0.98).

CONCLUSION

A significant proportion of women with early-stage breast cancer underwent mastectomy and significant ethnic inequities exist. Recently developed NZ Quality Performance Indicators strongly encourage breast conservation and should facilitate more standardized and equitable surgical management of early-stage breast cancer.

Association between travel distance and face-to-face consultations with general practitioners before an incident acute myocardial infarction: a nationwide register-based spatial epidemiological study

OBJECTIVES

This study examined the association between travel distance to the general practitioner's (GP) office and no face-to-face GP consultation within 1 year before an incident acute myocardial infarction (AMI).

DESIGN

A prospective cohort study using multilevel spatial logistic regression analysis of nationwide register data.

SETTING

Nationwide study including contacts to GPs in Denmark prior to an incident AMI in 2005-2017.

PARTICIPANTS

121 232 adults (≥30 years) with incident AMI were included in the study.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The primary outcome was odds of not having a face-to-face GP consultation within 1 year before an incident AMI.

RESULTS

In total, 13 108 (10.8%) of the 121 232 individuals with incident AMI had no face-to-face consultation with the GP within 1 year before the AMI. Population density modified the association between travel distance and no face-to-face GP consultation. Increased odds of no face-to-face GP consultation was observed for medium (25th-75th percentile/1123-5449 m) and long (>75th percentile/5449 m) compared with short travel distance (<25th percentile/1123 m) among individuals living in small cities (OR (95% credible intervals) of 1.19 (1.10 to 1.29) and 1.19 (1.06 to 1.33), respectively) and rural areas (1.46 (1.26 to 1.68) and 1.48 (1.29 to 1.68), respectively). No association was observed for individuals living in large cities and the capital.

CONCLUSIONS

Travel distance above approximately 1 km was significantly associated with no face-to-face GP consultation before an incident AMI among individuals living in small cities and rural areas. The structure of the healthcare system should consider the importance of geographical distance between citizens and the GP in remote areas.

Differences in the referral process from general practice to resident specialists in gynaecology depending on density of specialists and patients' socioeconomic status

BACKGROUND

There are significant differences in the densities of resident specialists in gynaecology (RSGs) in various regions of Denmark. It is unclear whether this disparity affects gynaecological patients' experience of the referral process and whether it differs in terms of their socioeconomic status (SES).

OBJECTIVE

To examine gynaecological patients' experiences of the referral process to an RSG concerning RSG density and patients' SES.

DESIGN

Cross-sectional questionnaire and registry-based study.

SETTING

In Denmark, general practitioners (GPs) serve as gatekeepers of secondary care and are responsible for referrals to resident specialists as well as inpatient and outpatient hospital care.

SUBJECTS

A total of 2917 patients who consulted an RSG participated in this study.

MAIN OUTCOME MEASUREMENTS

Patients' experiences of referral to an RSG, waiting times, involvement, and how they experienced the referral process.

RESULTS

Patients who lived in the highest density RSG region were referred to an RSG more promptly after the onset of symptoms, had to visit their GP less frequently to obtain a referral to the RSG, and rarely received a gynaecological examination by their GP compared with those living in regions with lower RSG densities. Moreover, their waiting times were shorter, and more often, the patients themselves proposed to be referred to an RSG. The findings show that RSG density had a greater impact on women's experiences than SES.

CONCLUSION

To allow equal access to specialist care, RSG density must be equal across all regions in the country.

Is survival rate lower after breast cancer in deprived women according to disease stage?

BACKGROUND

Socioeconomic deprivation has been associated with lower breast cancer (BC) survival, but the influence of stage at diagnosis on this association merits further study. Our aim was to investigate this association using the Loire-Atlantique/Vendee Cancer Registry (France).

METHODS

Twelve-thousand seven-hundred thirty-eight women living in the area covered by the registry and diagnosed with invasive breast carcinoma between 2008 and 2015 were included in the study. They were censored at maximal 6 years. Deprivation was measured by the French European Deprivation Index. Excess hazard and net survival were estimated for deprivation level, stage and age at diagnosis using a flexible excess mortality hazard model.

RESULTS

After adjustment by stage, women living in the most deprived areas had a borderline non-significant higher excess mortality hazard (+25% (95% CI: -3%; +62%)) compared to those living in the least deprived areas. Stage-adjusted 5-year net survival differed significantly between these two subgroups (respectively, 88.2% (95% CI:85.2%-90.5%) and 92.5% (95% CI:90.6%-93.9%)).

CONCLUSION

BC survival remained lower in deprived areas in France, despite universal access to cancer care. Intensification of prevention measures could help to reduce advanced BC, responsible for the majority of deaths from BC. A better understanding of remaining social disparities is crucial to implement specific interventions.

Danish general practitioners as gatekeepers for gynaecological patients in regions with different density of resident specialists in gynaecology: in which situations and to whom do they refer? A cross-sectional study

BACKGROUND

There are large differences in the density of Resident Specialists in Gynaecology (RSG) in the various regions of Denmark. It is unknown if this inequality affects the General Practitioner (GP) referral patterns of gynaecological patients.

OBJECTIVE

To investigate the GP referral patterns of gynaecological patients to the RSG or to the Hospital/Outpatient Clinic (HOC) in specific situations according to the regional density of RSGs. Moreover, to examine whether GPs prefer to refer to the HOC or to the RSG, or whether they were treated by the GP depending on the density of RSGs, specifically, in six benign gynaecological diagnoses.

DESIGN

A cross-sectional questionnaire survey.

SETTING

In Denmark, GPs serve as gatekeepers to secondary care, being responsible for referrals to resident specialists and in- and outpatient hospital care.

SUBJECTS

Five hundred Danish GPs were randomly selected and invited to take part in the questionnaire study. Main outcome measurements: Referral patterns: Own treatment, RSG, or HOC.

RESULTS

GPs prefer to refer their gynaecologic patients to RSGs rather than to HOCs. In addition, the study shows the higher the density of RSGs, the more gynaecological patients are referred to the RSG. This also applies to the six diagnoses examined.

CONCLUSION

To allow patients' equal access to specialist care, the density of RSGs must be equal all over the country.

The dynamic impacts of environmental-health and MDR-TB diseases and their influence on environmental sustainability at Chinese hospitals

The purpose of this study is to identify at what extent multidrug-resistant tuberculosis (MDR-TB) diseases effect on environmental health issues in selected provinces of Chinese hospitals. In survival analysis approach, this study employs the Cox proportional hazard model (CPM) to incorporate the duration of event, probability of occurrence of an event, and the issue of right censoring. An advantage of using CPM is that one does not need to specify the distribution of baseline hazard H₀ (t) as it considers a common value for all units in population. The results indicate that male and travel expenditures have negative association with the duration of cure. Furthermore, the medical expenditures and the spatial characteristic of time expenditure have positive association with the duration of cure of MDR-TB patients. The inconsistent behavior of males in taking medicines as compared to females and males is also more prone to tuberculosis (TB).

Rural vs urban inequalities in stage at diagnosis for lung cancer

OBJECTIVES

Early diagnosis of lung cancer increases the chance of survival. The aim of this study was to measure the relationship between geographic residence in Saskatchewan and stage of lung cancer at the time of diagnosis.

MATERIALS AND METHODS

Retrospective cohort analysis of 2,972 patients with a primary diagnosis of either non-small cell cancer (NSCLC) or small cell lung cancer (SCLC) between 2007 and 2012 was performed. Incidence proportion of early and advanced stage cancer, and relative risk of being diagnosed with advanced-stage lung cancer relative to early-stage was calculated.

RESULTS

Compared to urban Saskatchewan, rural Saskatchewan lung cancer patients had a higher relative risk of advanced stage NSCLC (relative risk [RR] = 1.11, 95% confidence interval [CI]: 1.01-1.22). Rural Saskatchewan was further subdivided into north and south. The relative risk of advanced stage NSCLC in rural north Saskatchewan compared to urban Saskatchewan was even greater (RR = 1.17, 95% CI: 1.03-1.31). Although not statistically significant, there was a trend for a higher incidence of advanced stage SCLC in rural and rural north vs urban Saskatchewan (RR = 1.16, 95% CI: 0.95-1.43 and RR = 1.22; 95% CI: 0.94-1.58, respectively). There was a higher incidence proportion of advanced stage NSCLC in rural areas relative to urban (31.6-34.4 vs 29.5 per 10,000 people).

CONCLUSION

Patients living in rural Saskatchewan have higher incidence proportion of and were more likely to present with advanced stage NSCLC in comparison to urban Saskatchewan patients at time of diagnosis. This inequality was even greater in rural north Saskatchewan.

Developing the geographic classification for health, a rural-urban classification for New Zealand health research and policy: A research protocol

INTRODUCTION

Rural-urban health inequities, exacerbated by deprivation and ethnicity, have been clearly described in the international literature. To date, the same inequities have not been as clearly demonstrated in Aotearoa New Zealand despite the lower socioeconomic status and higher proportion of Māori living in rural towns. This is ascribed by many health practitioners, academics and other informed stakeholders to be the result of the definitions of 'rural' used to produce statistics.

AIMS

To outline a protocol to produce a 'fit-for-health purpose' rural-urban classification for analysing national health data. The classification will be designed to determine the magnitude of health inequities that have been obscured by use of inappropriate rural-urban taxonomies.

METHODS

This protocol paper outlines our proposed mixed-methods approach to developing a novel Geographic Classification for Health. In phase 1, an agreed set of community attributes will be used to modify the new Statistics New Zealand Urban Accessibility Classification into a more appropriate classification of rurality for health contexts. The Geographic Classification for Health will then be further developed in an iterative process with stakeholders including rural health researchers and members of the National Rural Health Advisory Group, who have a comprehensive 'on the ground' understanding of Aotearoa New Zealand's rural communities and their attendant health services. This protocol also proposes validating the Geographic Classification for Health using general practice enrolment data. In phase 2, the resulting Geographic Classification for Health will be applied to routinely collected data from the Ministry of Health. This will enable current levels of rural-urban inequity in health service access and outcomes to be accurately assessed and give an indication of the extent to which older classifications were masking inequities.

The association of low socioeconomic status with advanced stage thyroid cancer

Objectives

This study investigates the link between low socioeconomic status (SES) and advanced thyroid cancer at the time of detection. It also assesses the socioeconomic variables that may potentially affect the stage of thyroid cancer at presentation.

Methods

This retrospective cohort study was conducted on patients with thyroid cancer between January 2016 and April 2020. The data were collected using the patients' medical records from the hospital information system (BESTcare) and through interview-based surveys. To assess the factors predicting the stage of advanced thyroid cancer, socioeconomic status (SES) predictors like area of residency, educational level, income, and marital status were collected.

Results

A total of 220 patients with thyroid cancer were included in this study. Male patients (p = 0.025), older than 55 years (p < 0.001), living in rural areas (p = 0.002), with low educational level (p = 0.021) were found to be significantly associated with advanced-stage thyroid cancer at presentation. Multivariate analysis showed that gender (men) and age (above 55 years) were significant predictors of advanced stage thyroid cancer. However, no association between income and the stage of thyroid cancer has been found in this study.

Conclusion

This study has shown that even in a country like KSA with a strong government-funded healthcare system, health disparity among people battling thyroid cancer exists. Our study has found that SES factors have a significant impact on the stage of thyroid cancer at the time of presentation, whereas the economic status of the patients had no impact on the stage of thyroid cancer. Furthermore, patients in lower SES groups were diagnosed with more advanced stages at presentation.

Factors Explaining Socio-Economic Inequalities in Survival from Colon Cancer: A Causal Mediation Analysis

BACKGROUND

Socio-economic inequalities in colon cancer survival exist in high-income countries, but the reasons are unclear. We assessed the mediating effects of stage at diagnosis, comorbidities, and treatment (surgery and intravenous chemotherapy) on survival from colon cancer.

METHODS

We identified 2,203 people aged 15 to 79 years with first primary colon cancer diagnosed in Victoria, Australia, between 2008 and 2011. Colon cancer cases were identified through the Victorian Cancer Registry (VCR), and clinical information was obtained from hospital records. Deaths till December 31, 2016 (n = 807), were identified from Victorian and national death registries. Socio-economic disadvantage was based on residential address at diagnosis. For stage III disease, we decomposed its total effect into direct and indirect effects using interventional mediation analysis.

RESULTS

Socio-economic inequalities in colon cancer survival were not explained by stage and were greater for men than women. For men with stage III disease, there were 161 [95% confidence interval (CI), 67-256] additional deaths per 1,000 cases in the 5 years following diagnosis for the most disadvantaged compared with the least disadvantaged. The indirect effects through comorbidities and intravenous chemotherapy explained 6 (95% CI, -10-21) and 15 (95% CI, -14-44) per 1,000 of these additional deaths, respectively. Surgery did not explain the observed gap in survival.

CONCLUSIONS

Disadvantaged men have lower survival from stage III colon cancer that is only modestly explained by having comorbidities or not receiving chemotherapy after surgery.

IMPACT

Future studies should investigate the potential mediating role of factors occurring beyond the first year following diagnosis, such as compliance with surveillance for recurrence and supportive care services.

A cohort study analyzing the impact of socioeconomic and spatial characteristics alongside treatment regimens on the environmental-health outcomes of the MDR-TB treatment in Pakistan

This study identifies and analyzes a number of factors that correlate with the environmental-health outcome of multi-drug resistance tuberculosis (MDR-TB) treatment in Pakistan. Survival analysis is carried out by applying the multivariable Cox Proportional Hazard model on secondary data of 369 patients registered at three main MDR-TB sites in Pakistan during 2012-2017. Results show that there is no difference in survival of patients between the two treatment arms, hospital and ambulatory care. Male gender and travel expenditure are found to be negatively associated with the environmental-health outcome, whereas spatial characteristic of time expenditure is positively related to it supporting distance bias approach. Medical expenditure is also positively related to the environmental-health outcome. The study concludes that availability of affordable and accessible health services, better environmental conditions, and ambulatory care based on WHO recommendation as well as health education along with social protection schemes should be ensured by the government to improve environmental-health outcome in the resource-scarce setting in Pakistan.

The Epidemiology of Myeloproliferative Neoplasms in New Zealand between 2010 and 2017: Insights from the New Zealand Cancer Registry

BACKGROUND

There is a paucity of data on ethnic disparities in patients with the classical Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs): polycythaemia vera (PV), essential thrombocythaemia (ET) and primary myelofibrosis (PMF).

METHODS

This study analysed the demographic data for PV, ET and PMF collected by the New Zealand Cancer Registry (NZCR) between 2010 and 2017.

RESULTS

We found that the NZCR capture rates were lower than average international incidence rates for PV and ET, but higher for PMF (0.76, 0.99 and 0.82 per 100,000, respectively). PV patients were older and had worse outcomes than expected, which suggests these patients were reported to the registry at an advanced stage of their disease. Polynesian patients with all MPN subtypes, PV, ET and PMF, were younger than their European counterparts both at the time of diagnosis and death (p < 0.001). Male gender was an independent risk factor for mortality from PV and PMF (hazard ratios (HR) of 1.43 and 1.81, respectively; p < 0.05), and Māori ethnicity was an independent risk factor for mortality from PMF (HR: 2.94; p = 0.006).

CONCLUSIONS

New Zealand Polynesian patients may have increased genetic predisposition to MPN, thus we advocate for modern genetic testing in this ethnic group to identify the cause. Further work is also required to identify modifiable risk factors for mortality in MPN, in particular those associated with male gender and Māori ethnicity; the results may benefit all patients with MPN.

Prostate cancer outcomes disparities: Population survival analysis in an ethnically diverse nation

BACKGROUND

Prostate cancer represents a significant health burden on New Zealand men. There are increasing concerns regarding inequities in prostate cancer morbidity and mortality among the different ethnic groups in New Zealand. This study aims to assess ethnic differences in survival outcomes among men newly diagnosed with prostate cancer.

MATERIALS AND METHODS

The analyzed cohort included 42,563 men, 40 years or older, diagnosed with prostate cancer from January 1st, 2000 to January 1st, 2016. Overall and cancer-specific survivals were estimated for the main ethnic groups in New Zealand namely: Māori (indigenous), Pacific, Asian, and European. Hazard ratio (HR) of death from prostate cancer was calculated with Fine-Gray competing risk regression, while adjusting for age, socioeconomic deprivation, year of cancer diagnosis, residential status, presence of urology service, and cancer grade at diagnosis.

RESULTS

Among all ethnic groups, Māori participants consistently had worst survival outcomes. At 15-year follow-up, the overall cumulative survival probabilities were 39.8%, 43.6%, 63.3%, and 46.5%, for Māori, Pacific, Asian and European men, respectively. In the same order, cancer-specific survivals were 62.7%, 64.3%, 79.8% and 72.0%. Māori men had 43% higher risk of dying from prostate cancer when compared to Europeans. This persisted following adjustments in the multivariable model (adjusted HR = 1.44, [95% CI: 1.29-1.61], P< 0.001). Conversely, differences in sociodemographic and cancer characteristics between Pacific and European men could explain the higher mortality risk in the former group (adjusted HR = 1.00, [95% CI: 0.84-1.19], P= 0.990).

CONCLUSIONS

Significant ethnic disparities in prostate cancer survival outcomes are currently present in New Zealand. Several explanations have been proposed to account for this observation including differences in comorbidities, healthcare access and cancer grade at diagnosis.

Culture of prevention and early disease detection of cancer in Russia

This study analyzed the early cancer detection in Russia. Using data from the Russian Ministry of Health from 2005 to 2016, this study aims to evaluate relationships between the number of patients diagnosed with I-II stage of cancer with the number of preventive visits, screening tests, and expedited access to specialists. The results of de-trending time-series model indicate that the number of specialists in outpatient facilities and the number of patients' preventive visits positively affect the number of patients diagnosed with cancer for the first time and the number of patients diagnosed with I-II degree cancer. The Russian Federation's experience suggests that early detection of cancer can be achieved by increasing the number of early cancer screening facilities, providing free screening, and moderating geographical and time constraints that prevent people of different geographic and socio-economic backgrounds from being screened. Another strategy includes dispelling myths associated with cancer screening, fostering outreach and patient education, and assuring availability and timely referrals to specialists and laboratory work.

Socioeconomic Status and Melanoma in Canada: A Systematic Review

As melanoma is one of the leading cancers in average years of life lost per death from disease, screening and early diagnosis are imperative to decrease morbidity and mortality. Socioeconomic status (SES) has been shown to be associated with melanoma incidence. However, it is unclear if this association holds true in universal healthcare systems where screening, diagnostic, and treatment services are available to all patients. The objective of this systematic review was to evaluate the evidence on the association of SES and melanoma incidence in Canada. A comprehensive search of PubMed and EMBASE yielded 7 studies reporting on melanoma incidence or outcomes with respect to SES in Canada. High SES was associated with increased melanoma incidence across all studies, which encompassed all Canadian provinces, and time periods spanning from 1979 to 2012. Studies also reported an increasing incidence of melanoma over time. There were substantial discrepancies in melanoma incidence across Canadian provinces, after controlling for SES and demographic characteristics. Populations of lower SES and living within certain healthcare regions had increased risks of advanced melanoma at diagnosis. This review highlights the potential for inequities in access to care even within a universal healthcare system. Future research is needed to characterize specific risk factors within different patient groups and within the universal health system context in order to implement targeted strategies to lower melanoma incidence, morbidity, and mortality.

Methodology for building a geographical accessibility health index throughout metropolitan France

Spatial accessibility to health services is a key factor in terms of public health. Even though some tools are available, establishing accessibility criteria applicable from one geographic scale to another remains difficult. Therefore, we propose a method for creating a health accessibility index applicable on a large geographic scale, based on a methodology that overcomes the limitations of political-administrative divisions and which allows a multi-scalar approach to be implemented. The index highlights, on a national scale, areas of cumulative health disadvantages. This index of accessibility to health care combines accessibility and availability and can be adapted to many geographical scales. As accessibility can be understood in various dimensions, a score could be calculated for various fields such as education and culture. The index can help policymakers to identify under-endowed areas and find optimal locations. In terms of public health, it may be used to understand the mechanisms underlying geographic health disparities.

Geographical Variations in Prostate Cancer Outcomes: A Systematic Review of International Evidence

Background: Previous reviews of geographical disparities in the prostate cancer continuum from diagnosis to mortality have identified a consistent pattern of poorer outcomes with increasing residential disadvantage and for rural residents. However, there are no contemporary, systematic reviews summarizing the latest available evidence. Our objective was to systematically review the published international evidence for geographical variations in prostate cancer indicators by residential rurality and disadvantage.

Methods: Systematic searches of peer-reviewed articles in English published from 1/1/1998 to 30/06/2018 using PubMed, EMBASE, CINAHL, and Informit databases. Inclusion criteria were: population was adult prostate cancer patients; outcome measure was PSA testing, prostate cancer incidence, stage at diagnosis, access to and use of services, survival, and prostate cancer mortality with quantitative results by residential rurality and/or disadvantage. Studies were critically appraised using a modified Newcastle-Ottawa Scale.

Results: Overall 169 studies met the inclusion criteria. Around 50% were assessed as high quality and 50% moderate. Men from disadvantaged areas had consistently lower prostate-specific antigen (PSA) testing and prostate cancer incidence, poorer survival, more advanced disease and a trend toward higher mortality. Although less consistent, predominant patterns by rurality were lower PSA testing, prostate cancer incidence and survival, but higher stage disease and mortality among rural men. Both geographical measures were associated with variations in access and use of prostate cancer-related services for low to high risk disease.

Conclusions: This review found substantial evidence that prostate cancer indicators varied by residential location across diverse populations and geographies. While wide variations in study design limited comparisons across studies, our review indicated that internationally, men living in disadvantaged areas, and to a lesser extent more rural areas, face a greater prostate cancer burden. This review highlights the need for a better understanding of the complex social, environmental, and behavioral reasons for these variations, recognizing that, while important, geographical access is not the only issue. Implementing research strategies to help identify these processes and to better understand the central role of disadvantage to variations in health outcome are crucial to inform the development of evidence-based targeted interventions.

Continuous Rural-Urban Coding for Cancer Disparity Studies: Is It Appropriate for Statistical Analysis?

Background: The dichotomization or categorization of rural-urban codes, as nominal variables, is a prevailing paradigm in cancer disparity studies. The paradigm represents continuous rural-urban transition as discrete groups, which results in a loss of ordering information and landscape continuum, and thus may contribute to mixed findings in the literature. Few studies have examined the validity of using rural-urban codes as continuous variables in the same analysis. Methods: We geocoded cancer cases in north central Florida between 2005 and 2010 collected by Florida Cancer Data System. Using a linear hierarchical model, we regressed the occurrence of late stage cancer (including breast, colorectal, hematological, lung, and prostate cancer) on the rural-urban codes as continuous variables. To validate, the results were compared to those from using a truly continuous rurality data of the same study region. Results: In term of associations with late-stage cancer risk, the regression analysis showed that the use of rural-urban codes as continuous variables produces consistent outcomes with those from the truly continuous rurality for all types of cancer. Particularly, the rural-urban codes at the census tract level yield the closest estimation and are recommended to use when the continuous rurality data is not available. Conclusions: Methodologically, it is valid to treat rural-urban codes directly as continuous variables in cancer studies, in addition to converting them into categories. This proposed continuous-variable method offers researchers more flexibility in their choice of analytic methods and preserves the information in the ordering. It can better inform how cancer risk varies, degree by degree, over a finer spectrum of rural-urban landscape.

Socioeconomic environment and disparities in cancer survival for 19 solid tumor sites: An analysis of the French Network of Cancer Registries (FRANCIM) data

Social inequalities are concerning along the cancer continuum. In France, social gradient in health is particularly marked but little is known about social gradient in cancer survival. We aimed to investigate the influence of socioeconomic environment on cancer survival, for all cancers reported in the French Network of Cancer Registries. We analyzed 189,657 solid tumors diagnosed between 2006 and 2009, recorded in 18 registries. The European Deprivation Index (EDI), an ecological index measuring relative poverty in small geographic areas, assessed social environment. The EDI was categorized into quintiles of the national distribution. One- and five-year age-standardized net survival (ASNS) were estimated for each solid tumor site and deprivation quintile, among men and among women. We found that 5-year ASNS was lower among patients living in the most deprived areas compared to those living in the least deprived ones for 14/16 cancers among men and 16/18 cancers among women. The extent of cancer survival disparities according to deprivation varied substantially across the cancer sites. The reduction in ASNS between the least and the most deprived quintile reached 34% for liver cancer among men and 59% for bile duct cancer among women. For pancreas, stomach and esophagus cancer (among men), and ovary and stomach cancer (among women), deprivation gaps were larger at 1-year than 5-year survival. In conclusion, survival was worse in the most deprived areas for almost all cancers. Our results from population-based cancer registries data highlight the need for implementing actions to reduce social inequalities in cancer survival in France.

Cancer diagnostic delays and travel distance to health services: A nationwide cohort study in Denmark

BACKGROUND

This study aims to investigate the association between distance to health services and intervals in the cancer diagnostic pathway, and explore whether the diagnostic difficulty of the cancer influences this association.

METHOD

A nationwide cohort study was conducted based on data from both questionnaires and registries. Danish cancer patients diagnosed in 2005-2016 and their general practitioner (GP) were included if enrolled in the Danish Cancer in Primary Care (CaP) cohort (n = 37,872). The CaP cohorts provided data on intervals assessed by patients and GPs. The Geographical Information System (GIS) was used to calculate travel distances from the residence of the patient to their GP surgery and to the hospital of diagnosis.

RESULTS

Longer travel distance to the hospital of diagnosis was associated with longer diagnostic interval. This association was strongest in the period before the implementation of Cancer Patient Pathways (CPP) in 2010. Patients with a cancer categorised as ´hard to diagnose´ contributed mostly to the association. Longer travel distance to the GP was associated with shorter patient interval and primary care interval for patients diagnosed with cancer types ´intermediate to diagnose´.

CONCLUSION

Travel distance to cancer diagnostic health care services was associated with interval length in the diagnostic pathway. This association was less pronounced in the period after introducing CPPs and also strongly depending of the underlying cancer type and symptomatology.

Socioeconomic Differences and Lung Cancer Survival-Systematic Review and Meta-Analysis

Background: The impact of socioeconomic differences on cancer survival has been investigated for several cancer types showing lower cancer survival in patients from lower socioeconomic groups. However, little is known about the relation between the strength of association and the level of adjustment and level of aggregation of the socioeconomic status measure. Here, we conduct the first systematic review and meta-analysis on the association of individual and area-based measures of socioeconomic status with lung cancer survival.

Methods: In accordance with PRISMA guidelines, we searched for studies on socioeconomic differences in lung cancer survival in four electronic databases. A study was included if it reported a measure of survival in relation to education, income, occupation, or composite measures (indices). If possible, meta-analyses were conducted for studies reporting on individual and area-based socioeconomic measures.

Results: We included 94 studies in the review, of which 23 measured socioeconomic status on an individual level and 71 on an area-based level. Seventeen studies were eligible to be included in the meta-analyses. The meta-analyses revealed a poorer prognosis for patients with low individual income (pooled hazard ratio: 1.13, 95 % confidence interval: 1.08–1.19, reference: high income), but not for individual education. Group comparisons for hazard ratios of area-based studies indicated a poorer prognosis for lower socioeconomic groups, irrespective of the socioeconomic measure. In most studies, reported 1-, 3-, and 5-year survival rates across socioeconomic status groups showed decreasing rates with decreasing socioeconomic status for both individual and area-based measures. We cannot confirm a consistent relationship between level of aggregation and effect size, however, comparability across studies was hampered by heterogeneous reporting of socioeconomic status and survival measures. Only eight studies considered smoking status in the analysis.

Conclusions: Our findings suggest a weak positive association between individual income and lung cancer survival. Studies reporting on socioeconomic differences in lung cancer survival should consider including smoking status of the patients in their analysis and to stratify by relevant prognostic factors to further explore the reasons for socioeconomic differences. A common definition for socioeconomic status measures is desirable to further enhance comparisons between nations and across different levels of aggregation.

Mapping rural-urban disparities in late-stage cancer with high-resolution rurality index and GWR

Effects of urban/rural residence on late-stage cancer have long been explored, but remained controversial. Spatial granularity of rural definition, temporal change of rurality, and local variability of such effects may contribute to inconsistent findings, but they have not been fully addressed. We proposed a spatially resolved and temporally comparable rurality index and a geographically weighted regression approach to re-examine this question. Taking Florida as an example, our analyses show that rural effects on late-stage cancer vary dramatically over locations (600-m cells). The odds ratios range from 0.9 to 1.10, and imply that one degree of rurality can increase/decrease local risk of late-stage cancer by up to 10%. Our study is an early attempt to explore local effects of rurality on cancer at a fine spatial scale, and reveals interesting patterns hidden by global multi-level analysis. The new framework and findings can better inform precision interventions to mitigate cancer disparities.

Cancer Mortality in Córdoba, Argentina, 1986–2006: An Age-Period-Cohort Analysis

Aims and background

Cancer is the second main cause of death in Argentina, surpassed only by cardiovascular disease. However, analytical approaches isolating some of the known effects, such as age at death, period of death and birth cohort, have never been performed in cancer mortality studies in Argentina. The aim of this study was to analyze cancer mortality trends in a representative region of the country, the Córdoba province (1986–2006).

Methods and study design

Overall age-standardized (world population) mortality rates for cancer (all sites) were computed by a direct method. Joinpoint regression was fitted to the age-standardized mortality rates for both sexes to provide estimated and 95% confidence intervals of the annual percentage changes. The effects of age (15 age groups), period of death (1986–90, 1991–95, 1996–00 or 2001–06), and birth cohort (18 overlapping 10-year birth cohorts) covariates on mortality rates were estimated using a sequentially fitted Poisson regression model.

Results

During the study period, 102,737 people died of cancer in Córdoba, with the age-standardized mortality rates decreasing from 139.3 to 118.7/100,000 person-years. Although this reduction was more noticeable in men, the joinpoint regression model showed a significant change of the age-standardized mortality rates after 1996 in both sexes. Age-period-cohort analysis suggested that the cancer mortality trends may be linked with a strong age effect and a moderate or mild period and cohort effect, related to sex and place of residence.

Conclusions

Based on the observed cohort effect, it maybe argued that there has been a lower exposure level to some risk factors, such as diet and other environmental factors, in Cordoba over the last decades.

Ethnic disparities in breast cancer survival in New Zealand: which factors contribute?

Background

New Zealand has major ethnic disparities in breast cancer survival with Māori (indigenous people) and Pacific women (immigrants or descended from immigrants from Pacific Islands) faring much worse than other ethnic groups. This paper identified underlying factors and assessed their relative contribution to this risk differential.

Methods

This study involved all women who were diagnosed with primary invasive breast cancer in two health regions, covering about 40% of the national population, between January 2000 and June 2014. Māori and Pacific patients were compared with other ethnic groups in terms of demographics, mode of diagnosis, disease factors and treatment factors. Cox regression modelling was performed with stepwise adjustments, and hazards of excess mortality from breast cancer for Māori and Pacific patients were assessed.

Results

Of the 13,657 patients who were included in this analysis, 1281 (9.4%) were Māori, and 897 (6.6%) were Pacific women. Compared to other ethnic groups, they were younger, more likely to reside in deprived neighbourhoods and to have co-morbidities, and less likely to be diagnosed through screening and with early stage cancer, to be treated in a private care facility, to receive timely cancer treatment, and to receive breast conserving surgery. They had a higher risk of excess mortality from breast cancer (age and year of diagnosis adjusted hazard ratio: 1.76; 95% CI: 1.51–2.04 for Māori and 1.97; 95% CI: 1.67–2.32 for Pacific women), of which 75% and 99% respectively were explained by baseline differences. The most important contributor was late stage at diagnosis. Other contributors included neighbourhood deprivation, mode of diagnosis, type of health care facility where primary cancer treatment was undertaken and type of loco-regional therapy.

Conclusions

Late diagnosis, deprivation and differential access to and quality of cancer care services were the key contributors to ethnic disparities in breast cancer survival in New Zealand. Our findings underscore the need for a greater equity focus along the breast cancer care pathway, with an emphasis on improving access to early diagnosis for Māori and Pacific women.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3797-0) contains supplementary material, which is available to authorized users.

The relationship between ethnicity, social deprivation and late presentation of colorectal cancer

INTRODUCTION

Tumour staging at time of presentation is an important factor in determining survival in colorectal cancer. The aim of this paper is to investigate the relationship between ethnicity and deprivation in late (Stage IV) presentation of colorectal cancer.

METHODS

Data from the Thames Cancer Registry comprising 77,057 colorectal cancer patients between the years 2000 and 2012 were analysed.

RESULTS

A total of 17,348 patients were identified with complete data, of which 53.9% were male. Patients from a Black Afro/Caribbean background were diagnosed with CRC at a much younger age than the White British group (median age 67 compared with 72, p<0.001). In multiple regression, ethnicity, deprivation and age were positive predictors of presenting with advanced tumour stage at time of diagnosis. Black patients were more likely to present with Stage IV tumours than white patients (OR 1.37, 95% CI 1.18-1.59, p<0.001). Social deprivation was also a predictor of Stage IV cancer presentation, with the most deprived group (Quintile 5) 1.26 times more likely to be diagnosed with Stage IV cancer compared with the most affluent group (CI 1.13-1.40, p<0.001). Sub-group analyses demonstrated that Black & Affluent patients were still at greater risk of Stage IV CRC than their White & Affluent counterparts (OR 1.24, 95% CI 1.11-1.45, p=0.023). Patients with rectal cancer were less likely to present with Stage IV CRC (OR 0.66, 95% CI 0.61-0.71, p<0.001).

CONCLUSION

Racial and age related disparities exist in tumour presentation in the United Kingdom. Patients from black and socially deprived backgrounds as well as the elderly are more likely to present with advanced tumours at time of diagnosis.

The Effects of Residential Segregation and Neighborhood Characteristics on Surgery and Survival in Patients with Early-Stage Non-Small Cell Lung Cancer

BACKGROUND

Although the negative effects of lower socioeconomic status on non-small cell lung cancer (NSCLC) treatment and survival have been widely studied, the impact of residential segregation on prognosis and the receipt of treatment has yet to be determined.

METHODS

This is a retrospective, cohort study of NSCLC patients in Georgia (2000-2009; n = 8,322) using data from the Georgia Comprehensive Cancer Registry. The effects of segregation, economic deprivation, and combined segregation/deprivation on the odds of receiving surgery were examined in separate multilevel models. To determine the association for the exposures of interest on the risk of death for different racial groups, separate multilevel survival models were conducted for black and white patients.

RESULTS

Living in areas with the highest [AOR = 0.35, 95% confidence interval (CI), 0.19-0.64] and second highest (AOR = 0.37, 95% CI, 0.20-0.68) levels of segregation was associated with decreased odds of receipt of surgery. Black patients living in areas with high residential segregation and high economic deprivation were 31% (95% CI, 1.04-1.66) more likely to die, even after surgery was controlled for. For white patients, economic deprivation was associated with decreased odds of surgery but not survival. Segregation had no effect.

CONCLUSION

Our findings suggest how black and white individuals experience segregation and area-level poverty is likely different leading to differences in adverse health outcomes.

IMPACT

Identifying neighborhood characteristics impacting health outcomes within different racial groups could help reduce health disparities across racial groups by implementing targeted policies and interventions. Cancer Epidemiol Biomarkers Prev; 25(5); 750-8. ©2016 AACR.

Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review

OBJECTIVES

To investigate whether there is an association between differences in travel time/travel distance to healthcare services and patients' health outcomes and assimilate the methodologies used to measure this.

DESIGN

Systematic Review. We searched MEDLINE, Embase, Web of Science, Transport database, HMIC and EBM Reviews for studies up to 7 September 2016. Studies were excluded that included children (including maternity), emergency medical travel or countries classed as being in the global south.

SETTINGS

A wide range of settings within primary and secondary care (these were not restricted in the search).

RESULTS

108 studies met the inclusion criteria. The results were mixed. 77% of the included studies identified evidence of a distance decay association, whereby patients living further away from healthcare facilities they needed to attend had worse health outcomes (eg, survival rates, length of stay in hospital and non-attendance at follow-up) than those who lived closer. 6 of the studies identified the reverse (a distance bias effect) whereby patients living at a greater distance had better health outcomes. The remaining 19 studies found no relationship. There was a large variation in the data available to the studies on the patients' geographical locations and the healthcare facilities attended, and the methods used to calculate travel times and distances were not consistent across studies.

CONCLUSIONS

The review observed that a relationship between travelling further and having worse health outcomes cannot be ruled out and should be considered within the healthcare services location debate.

Inequalities in socioeconomic status and race and the odds of undergoing a mammogram in Brazil

Background

Access to mammograms, in common with other diagnostic procedures, is strongly conditioned by socioeconomic disparities. Which aspects of inequality affect the odds of undergoing a mammogram, and whether they are the same in different localities, are relevant issues related to the success of health policies.

Methods

This study analyzed data from the 2008 PNAD - Brazilian National Household Sample Survey (11.607 million women 40 years of age or older), on having had at least one mammogram over life for women 40 years of age or older in each of Brazil’s nine Metropolitan Regions (MR), according to socioeconomic position. The effects of income, schooling, health insurance and race in the different regions were investigated using multivariate logistical regression for each region individually, and for all MRs combined. The age-adjusted odds of a woman having had a mammogram according to race and stratified by two income strata (and two schooling strata) were also analyzed.

Results

Having a higher income increases four to seven times a woman’s odds of having had at least one mammogram in all MRs except Curitiba. For schooling, the gradient, though less steep, is favorable to women with more years of study. Having health insurance increases two to three times the odds in all MRs. Multivariate analysis did not show differences due to race (except for the Fortaleza MR), but the stratified analysis by income and schooling shows effects of race in most MRs, with greater differences for women with higher socioeconomic status.

Conclusions

This study confirms that income and schooling, as well as having health insurance, are still important determinants of inequality in health service use in Brazil. Additionally, race also contributes to the odds of having had a mammogram. The point is not to isolate the effect of each factor, but to evaluate how their interrelations may exacerbate differences, generating patterns of cumulative adversity, a theme that is still little explored in Brazil. This is much more important when we consider that race has only recently started be included in analyses of health outcomes in Brazil.

A critical review of methods for assessing cancer survival disparities in indigenous population

PURPOSE

An increasing cancer burden among indigenous populations has led to a growing literature about survival disparities between indigenous and nonindigenous persons. We aim to describe and appraise methods used to measure cancer survival in indigenous persons in the United States, Canada, Australia, and New Zealand.

METHODS

We searched Medline, Web of Science, and EMBASE for articles published between 1990 and 2015 that estimated survival in populations indigenous to one of these four countries. We gathered information about data sources, analytical methods, and the extent to which threats to validity were discussed.

RESULTS

The search retrieved 83 articles. The most common approach to survival analysis was cause-specific survival (n = 49). Thirty-eight articles measured all-cause survival and 11 measured excess mortality attributable to cancer (relative survival). Three sources of information bias common to all studies (ethnic misclassification, incomplete case ascertainment, and incomplete death ascertainment) were acknowledged in a minority of articles.

CONCLUSIONS

The methodological considerations we present here are shared with studies of cancer survival across other subpopulations. We urge future researchers on this and related topics to clearly describe their data sources, to justify analytic choices, and to fully discuss the potential impact of those choices on the results and interpretation.

Ethnic Inequalities in Rectal Cancer Care in a Universal Access Healthcare System: A Nationwide Register-Based Study

BACKGROUND

Ethnic inequalities in colorectal cancer care were reported previously in the United States. Studies specifically reporting on ethnic inequalities in rectal cancer care are limited.

OBJECTIVE

This study aimed to explore potential ethnic inequalities in rectal cancer care in the Netherlands.

DESIGN

This was a nationwide, population-based observational study.

SETTINGS

The study linked data of the Netherlands Cancer Registry with the Dutch population registry and the Social Statistics Database of Statistics Netherlands. Data were analyzed using stepwise multivariable logistic regression models.

PATIENTS

All of the patients diagnosed with rectal carcinoma in 2003-2011 in the Netherlands (N = 27,159) were included.

MAIN OUTCOME MEASURES

We analyzed 2 rectal cancer treatment indicators (preoperative radiotherapy and sphincter-sparing surgery) and 2 indicators of short-term outcome of rectal cancer surgery (anastomotic leakage and 30-day postoperative mortality).

RESULTS

Patients of Western non-Dutch and non-Western origin with rectal cancer were significantly younger and had a higher tumor stage than ethnic Dutch patients. Considering preoperative radiotherapy, anastomotic leakage, and 30-day postoperative mortality, no ethnic inequalities were detected. After adjustment for age, sex, disease characteristics, and socioeconomic status, Western non-Dutch and non-Western patients were significantly more likely to receive sphincter-sparing surgery than ethnic Dutch patients (OR = 1.27 (95% CI, 1.04-1.55) and OR = 1.57 (95% CI, 1.02-2.42)).

LIMITATIONS

This study was limited by the relatively low numbers of non-Dutch patients with rectal cancer.

CONCLUSIONS

Non-Dutch ethnic origin was associated with a higher rate of sphincter-sparing surgery. The absence of ethnic inequalities in preoperative radiotherapy, anastomotic leakage, and 30-day postoperative mortality suggests that ethnic minority patients have similar chances of optimal rectal cancer care outcomes as Dutch patients.

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.

Differences in Breast Cancer Survival between Public and Private Care in New Zealand: Which Factors Contribute?

Background

Patients who received private health care appear to have better survival from breast cancer compared to those who received public care. This study investigated if this applied to New Zealand women and identified factors that could explain such disparities.

Methods

This study involved all women who were diagnosed with primary breast cancer in two health regions in New Zealand, covering about 40% of the national population, between June 2000 and May 2013. Patients who received public care for primary treatment, mostly surgical treatment, were compared with those who received private care in terms of demographics, mode of presentation, disease factors, comorbidity index and treatment factors. Cox regression modelling was performed with stepwise adjustments, and hazards of breast cancer specific mortality associated with the type of health care received was assessed.

Results

Of the 14,468 patients, 8,916 (61.6%) received public care. Compared to patients treated in private care facilities, they were older, more likely to be Māori, Pacifika or Asian and to reside in deprived neighbourhoods and rural areas, and less likely to be diagnosed with early staged cancer and to receive timely cancer treatments. They had a higher risk of mortality from breast cancer (hazard ratio: 1.95; 95% CI: 1.75, 2.17), of which 80% (95% CI: 63%, 100%) was explained by baseline differences, particularly related to ethnicity, stage at diagnosis and type of loco-regional therapy. After controlling for these demographic, disease and treatment factors, the risk of mortality was still 14% higher in the public sector patients.

Conclusions

Ethnicity, stage at diagnosis and type of loco-regional therapy were the three key contributors to survival disparities between patients treated in public and private health care facilities in New Zealand. The findings underscore the need for more efforts to improve the quality, timeliness and equitability of public cancer care services.

Increasing Disadvantages in Cancer Survival in New Zealand Compared to Australia, between 2000-05 and 2006-10

New Zealand has lower cancer survival compared to its neighbour Australia. If this were due to long established differences between the two patient populations, it might be expected to be either constant in time, or decreasing, as improving health services deals with inequities. In this study we compared trends in relative cancer survival ratios in New Zealand and Australia between 2000-05 and 2006-10, using data from the New Zealand Cancer Registry and the Australian Institute for Health and Welfare. Over this period, Australia showed significant improvements (6.0% in men, 3.0% in women) in overall 5-year cancer survival, with substantial increases in survival from major cancer sites such as lung, bowel, prostate, and breast cancers. New Zealand had only a 1.8% increase in cancer survival in men and 1.3% in women, with non-significant changes in survival from lung and bowel cancers, although there were increases in survival from prostate and breast cancers. For all cancers combined, and for lung and bowel cancer, the improvements in survival and the greater improvements in Australia were mainly in 1-year survival, suggesting factors related to diagnosis and presentation. For breast cancer, the improvements were similar in each country and seen in survival after the first year. The findings underscore the need to accelerate the efforts to improve early diagnosis and optimum treatment for New Zealand cancer patients to catch up with the progress in Australia.

Barriers to and delays in accessing breast cancer care among New Zealand women: disparities by ethnicity

BACKGROUND

Unequal access to health care contributes to disparities in cancer outcomes. We examined the ethnic disparity in barriers to accessing primary and specialist health care experienced by New Zealand women with breast cancer.

METHODS

Women diagnosed with a primary invasive breast cancer between 2005 and 2007 were eligible. There were 1,799 respondents, n = 302 Māori (the indigenous population of NZ), n = 70 Pacific and n = 1,427 non-Māori/non-Pacific women. Participants completed a questionnaire listing 12 barriers grouped into three domains for analysis: personal; practical; and health care process factors, and reported the number of days between seeing a primary and a specialist care provider. Chi-squared, Fisher exact tests and logistic regression were used to assess uni- and multivariable differences in prevalence between ethnic groupings.

RESULTS

The prevalence of reporting three or more barriers was 18% among Pacific, 10% among Māori and 3% among non-Māori/non-Pacific women (P <0.001). The most commonly reported barriers were fear (Māori women) and cost (Pacific and non-Māori/non-Pacific women). Ethnic differences in reported barriers were not explained by deprivation or diabetes prevalence. Women with diabetes reported a two-fold higher risk of experiencing barriers to care compared to those without diabetes (odds ratio [OR]: 2.06, 95%CI 1.20 to 3.57). Māori and Pacific women were more likely to face delays (median 14 days) in seeing a specialist than non-Māori/non-Pacific women (median 7 days); these differences were not explained by the reported barriers.

CONCLUSIONS

Patterns of reported barriers to care differed according to ethnicity and were not explained by deprivation, or presence of co-morbidity. Māori and Pacific women are more likely to experience barriers to breast cancer care compared to non- Māori/non-Pacific women. We identified two key barriers affecting care for Māori and Pacific women; (a) delays in follow-up, and (b) the impact of co-morbid conditions. Future New Zealand work needs to focus attention on health care process factors and improving the interface between primary and secondary care to ensure quality health care is realised for all women with breast cancer.

Socioeconomic inequalities in prostate cancer survival: A review of the evidence and explanatory factors

Although survival rates after prostate cancer diagnosis have improved in the past two decades, survival analyses regarding the socioeconomic status (SES) suggest inequalities indicating worse prognosis for lower SES groups. An overview of the current literature is lacking and moreover, there is an ongoing discussion about the underlying causes but evidence is comparatively sparse. Several patient, disease and health care related factors are discussed to have an important impact on disparities in survival. Therefore, a systematic review was conducted to sum up the current evidence of survival inequalities and the contribution of different potential explanatory factors among prostate cancer patients. The PubMed database was screened for relevant articles published between January 2005 and September 2014 revealing 330 potentially eligible publications. After systematic review process, 46 papers met the inclusion criteria and were included in the review. About 75% of the studies indicate a significant association between low SES and worse survival among prostate cancer patients in the fully adjusted model. Overall, hazard ratios (low versus high SES) range from 1.02 to 3.57. A decrease of inequalities over the years was not identified. 8 studies examined the impact of explanatory factors on the association between SES and survival by progressive adjustment indicating mediating effects of comorbidity, stage at diagnosis and treatment modalities. Eventually, an apparent majority of the obtained studies indicates lower survival among patients with lower SES. The few studies that intend to explain inequalities found out instructive results regarding different contributing factors but evidence is still insufficient.

Breast cancer biology and ethnic disparities in breast cancer mortality in new zealand: a cohort study

Introduction

Indigenous Māori women have a 60% higher breast cancer mortality rate compared with European women in New Zealand. We investigated differences in cancer biological characteristics and their impact on breast cancer mortality disparity between Māori and NZ European women.

Materials and Methods

Data on 2849 women with primary invasive breast cancers diagnosed between 1999 and 2012 were extracted from the Waikato Breast Cancer Register. Differences in distribution of cancer biological characteristics between Māori and NZ European women were explored adjusting for age and socioeconomic deprivation in logistic regression models. Impacts of socioeconomic deprivation, stage and cancer biological characteristics on breast cancer mortality disparity between Māori and NZ European women were explored in Cox regression models.

Results

Compared with NZ European women (n=2304), Māori women (n=429) had significantly higher rates of advanced and higher grade cancers. Māori women also had non-significantly higher rates of ER/PR negative and HER-2 positive breast cancers. Higher odds of advanced stage and higher grade remained significant for Māori after adjusting for age and deprivation. Māori women had almost a 100% higher age and deprivation adjusted breast cancer mortality hazard compared with NZ European women (HR=1.98, 1.55-2.54). Advanced stage and lower proportion of screen detected cancer in Māori explained a greater portion of the excess breast cancer mortality (HR reduction from 1.98 to 1.38), while the additional contribution through biological differences were minimal (HR reduction from 1.38 to 1.35).

Conclusions

More advanced cancer stage at diagnosis has the greatest impact while differences in biological characteristics appear to be a minor contributor for inequities in breast cancer mortality between Māori and NZ European women. Strategies aimed at reducing breast cancer mortality in Māori should focus on earlier diagnosis, which will likely have a greater impact on reducing breast cancer mortality inequity between Māori and NZ European women.

Treatment modalities for Māori and New Zealand European men with localised prostate cancer

OBJECTIVES

To examine diagnostic and treatment pathways for Māori (the indigenous people of New Zealand [NZ]) and NZ European men with prostate cancer in order to identify causes of higher mortality rates for Māori men.

METHODS

All Māori men (150) diagnosed with prostate cancer in the Midland Cancer Network region between 2007 and 2010 were identified from the NZ Cancer Registry and frequency age-matched with three randomly sampled NZ European men. Clinical records of these men were searched for information on clinical stage at diagnosis, comorbidities, and type of treatment for localised disease.

RESULTS

The final cohort included 136 Māori and 400 NZ European men, of whom 97 Māori and 311 NZ European were diagnosed with localised prostate cancer. Māori men were twice as likely to be diagnosed with distant metastases compared with NZ European men (19.1 vs 9.8 %). Māori men with localised disease were less likely to be treated with radical prostatectomy compared with NZ European men [RR 0.66 (95 % CI 0.48, 0.90)]. Multivariate regression analysis adjusted for age, D'Amico risk strata, comorbidities, and socioeconomic deprivation showed that Māori men were more likely to be managed expectantly [RR 1.74 (95 % CI 1.06, 2.57)].

CONCLUSION

Differences between Māori and NZ European men observed in the management of localised prostate cancer cannot be readily explained by patient characteristics, such as comorbidities or risk assessment at diagnosis. Poorer outcomes for Māori men may not only be related to later stage at diagnosis but differences in treatment modalities may also be a factor.

The influence of geographical access to health care and material deprivation on colorectal cancer survival: evidence from France and England

This article investigates the influence of distance to health care and material deprivation on cancer survival for patients diagnosed with a colorectal cancer between 1997 and 2004 in France and England. This population-based study included all cases of colorectal cancer diagnosed between 1997 and 2004 in 3 cancer registries in France and 1 cancer registry in England (N=40,613). After adjustment for material deprivation, travel times in England were no longer significantly associated with survival. In France patients living between 20 and 90min from the nearest cancer unit tended to have a poorer survival, although this was not statistically significant. In England, the better prognosis observed for remote patients can be explained by associations with material deprivation; distance to health services alone did not affect survival whilst material deprivation level had a major influence, with lower survival for patients living in deprived areas. Increases in travel times to health services in France were associated with poorer survival rates. The pattern of this influence seems to follow an inverse U distribution, i.e. maximal for average travel times.