Waiting times and treatment following cancer diagnosis: comparison between immigrants and the Norwegian host population

Breast cancer-specific survival among immigrants and non-immigrants invited to BreastScreen Norway

Introduction

We have previously shown that immigrants have lower attendance in BreastScreen Norway than non-immigrants and that non-Western immigrants have lower incidence of breast cancer, but more advanced disease.

Purpose

To compare breast cancer-specific survival for immigrants versus non-immigrants diagnosed with screen-detected or symptomatic breast cancer.

Material and methods

We analyzed data from 28,320 women aged 50-69 diagnosed with breast cancer after being invited to BreastScreen Norway. We divided women into three groups; non-immigrants, immigrants from Western countries and immigrants from non-Western countries. We stratified our analyses according to detection mode (screen-detected breast cancer, interval cancer and cancer detected outside screening), and used cox regression to model the association between immigrants/non-immigrants and time to breast cancer death.

Results

Among screen-detected breast cancers, 28.7% were histologic grade 3 among immigrants from non-Western countries compared to 21.3% among non-immigrants. Interval cancers and cancers detected outside screening had larger tumor diameter and a higher percentage were histologic grade 3 and lymph node positive among immigrants from non-Western countries compared to non-immigrants. Hazard ratio (95% confidence interval) adjusted for age and year of diagnosis for time to breast cancer death compared to non-immigrants was 0.70 (0.39-1.27) for immigrants from Western countries and 0.52 (0.23-1.17) for immigrants from non-Western countries.

Conclusion

Despite more advanced histopathological tumor characteristics among immigrants from non-Western countries compared to non-immigrants, we did not observe statistically significant differences in breast-cancer specific survival between the two groups. Keeping in mind the low number of breast cancer deaths and possible overestimation of survival among immigrants, this might imply that equity in outcome can be achieved through adequate follow-up and treatment despite inequal access.

Impact of Prostate Cancer in Eastern Europe and Approaches to Treatment and Policy

Prostate cancer is among the most prevalent cancer globally and within Eastern Europe, where there are also higher levels of mortality compared with Western Europe. Cancer control plans exist in most countries in the region. Attention should be given to devising and implementing optimal screening initiatives. Our review has identified that a lack of resources and health system dysfunctions hamper progress in ameliorating the burden of prostate cancer. Regional cooperation is needed as well as drawing on guidelines and findings from elsewhere. Health institutions must also know the latest developments and set up systems that allow swift adoption.

Identification of an oncological clinical pathway through questionnaires to health professionals

BACKGROUND

Clinical Pathways in Oncology can benefit patients using organized interventions to standardize and increase care efficiency. Healthcare systems should have tools to identify their oncological clinical pathways for a better institutional organization to reduce mortality rates and contain costs without compromising quality. Our objective is to determine the regional Oncology Clinical Pathway from a first basic hypothesis using questionnaires directed to healthcare professionals considered key deciders within the Pathway.

METHODS

Study design consisted of data analysis of two structured region-wide questionnaires; built using available literature on Oncology Clinical Pathways, in a Portuguese Healthcare context and pre-tested in a focus group of key deciders (Physicians and nurses with management functions) from which a design was created. Queries analyzed the patients: tumor staging at service arrival; time intervals on tumor suspicion/diagnosis confirmation and diagnosis/first treatment; referral pathway; diagnostic networks and patient Follow-up. One questionnaire was sent to key deciders directly involved with Oncology patients at a Regional Hospital. 15 physicians and 18 nurses of this sample answered the questionnaire (approx. response rate = 67%). Another questionnaire sent to healthcare professionals in Primary Healthcare Centers yielded response rate 19.2%, N = 29 physicians and 46 nurses. Finally, we performed a descriptive analysis and a Cronbach Alpha reliability analysis.

RESULTS

Our findings reveal: different appreciations of tumor staging at arrival in Primary Healthcare Centers and Regional Hospitals (the latter receiving more metastatic cases); approximately 4 weeks between tumor suspicion-diagnostic and divided opinions regarding diagnostic-treatment time intervals. Primary Healthcare Centers depend on private laboratories for diagnostics confirmation, while the Hospitals resolve this locally. Referral pathways indicate almost half of the patients being sent from primary healthcare centers to National Reference Hospitals instead of a Regional Hospital. Patient follow-up is developed throughout the institutions, however, is more established at Regional Hospitals. As patients advance through the Oncology Clinical Pathway and toward treatment stages the number of healthcare professionals involved reduce.

CONCLUSION

Our questionnaires enable us to understand the real pathway between the different institutions involved and the main entry points of the patients into the Oncology Clinical Pathway.

Early screening outcomes among non-immigrants and immigrants targeted by BreastScreen Norway, 2010-2019

AIMS

This study aimed to analyse results on early screening outcomes, including recall and cancer rates, and histopathological tumour characteristics among non-immigrants and immigrants invited to BreastScreen Norway.

METHODS

We included information about 2, 763,230 invitations and 2,087,222 screening examinations from 805,543 women aged 50-69 years who were invited to BreastScreen Norway between 2010 and 2019. Women were stratified into three groups based on their birth country: non-immigrants, immigrants born in Western countries and immigrants born in non-Western countries. Age-adjusted regression models were used to analyse early screening outcomes. A random intercept effect was included in models where women underwent several screening examinations.

RESULTS

The overall attendance was 77.5% for non-immigrants, 68% for immigrants from Western countries and 51.5% for immigrants from non-Western countries. The rate of screen-detected cancers was 5.9/1000 screening examinations for non-immigrants, 6.3/1000 for immigrants from Western countries and 5.1/1000 for immigrants from non-Western countries. Adjusted for age, the rate did not differ statistically between the groups (p=0.091). The interval cancer rate was 1.7/1000 screening examinations for non-immigrants, 2.4/1000 for immigrants from Western countries and 1.6/1000 for non-Western countries (p<0.001). Histological grade was less favourable for screen-detected cancers, and subtype was less favourable for interval cancers among immigrants from non-Western countries versus non-immigrants.

CONCLUSIONS

There were no differences in age-adjusted rate of screen-detected cancer among non-immigrants and immigrants from Western countries or non-Western countries among women attending BreastScreen Norway between 2010 and 2019. Small but clinically relevant differences in histopathological tumour characteristics were observed between the three groups.

Primary Care Continuity and Wait Times to Receiving Breast Cancer Chemotherapy: A Population-Based Retrospective Cohort Study Using CanIMPACT Data

(1) Background: Wait times to chemotherapy are associated with morbidity and mortality in breast cancer patients; however, it is unclear how primary care physician (PCP) continuity impacts these wait times, or whether this association is different in immigrants, who experience cancer care inequities. We assessed the association between PCP continuity and the contact-to-chemotherapy interval (wait time from when a patient first presents to healthcare to the first day of receiving breast cancer chemotherapy), with a specific look at the immigrant population. (2) Methods: Population-based, retrospective cohort study of women who were diagnosed with stage I–III breast cancer in Ontario who received surgery and adjuvant chemotherapy. We used quantile regression at the median and 90th percentile to quantify the effect of PCP continuity on the contact-to-chemotherapy interval, performing a separate analysis on the immigrant population. (3) Results: Among 12,781 breast cancer patients, including 1706 immigrants, the median contact-to-chemotherapy interval (126 days) was 3.21 days shorter (95% confidence interval (CI) 0.47–5.96) in symptom-detected patients with low PCP continuity, 10.68 days shorter (95% CI 5.36–16.00) in symptom-detected patients with no baseline PCP visits and 17.43 days longer (95% CI 0.90–34.76) in screen-detected immigrants with low PCP continuity compared to the same groups with high PCP continuity. (4) Conclusions: Higher PCP continuity was not associated with a change in the contact-to-chemotherapy interval for most of our study population, but was associated with a marginally longer interval in our symptom-detected population and a shorter contact-to-chemotherapy interval in screen-detected immigrants. This highlights the importance of PCP continuity among immigrants with positive screening results. Additionally, having no PCP visits at baseline was associated with a shorter contact-to-chemotherapy interval in symptom-detected patients.

The power of empirical data; lessons from the clinical registry initiatives in Scandinavian cancer care

BACKGROUND

In Scandinavia, there is a strong tradition for research and quality monitoring based on registry data. In Denmark, Norway and Sweden, 63 clinical registries collect data on disease characteristics, treatment and outcome of various cancer diagnoses and groups based on process-related and outcome-related variables.

AIM

We describe the cancer-related clinical registries, compare organizational structures and quality indicators and provide examples of how these registries have been used to monitor clinical performance, develop prediction models, assess outcome and provide quality benchmarks. Further, we define unmet needs such as inclusion of patient-reported outcome variables, harmonization of variables and barriers for data sharing.

RESULTS AND CONCLUSIONS

The clinical registry framework provides an empirical basis for evidence-based development of high-quality and equitable cancer care. The registries can be used to follow implementation of new treatment principles and monitor patterns of care across geographical areas and patient groups. At the same time, the lessons learnt suggest that further developments and coordination are needed to utilize the full potential of the registry initiative in cancer care.