Variations in outcomes for Indigenous women with breast cancer in Australia: A systematic review

Improving Breast Cancer Outcomes for Indigenous Women in Australia

In Australia, the incidence rate of breast cancer is lower in Indigenous* women than non-Indigenous women; however, the mortality rate is higher, with Indigenous women 1.2 times more likely to die from the disease. This paper provides practical and achievable solutions to improve health outcomes for Indigenous women with breast cancer in Australia. This research employed the Context-Mechanism-Outcome (CMO) framework to reveal potential mechanisms and contextual factors that influence breast cancer outcomes for Indigenous women, stratified into multiple levels, namely, micro (interpersonal), meso (systemic) and macro (policy) levels. The CMO framework allowed us to interpret evidence regarding Indigenous women and breast cancer and provides nine practical ways to improve health outcomes and survival rates.

Cancer Screening Services: What Do Indigenous Communities Want? A Systematic Review

PURPOSE

Indigenous communities experience worse cancer outcomes compared with the general population partly because of lower cancer screening access. One-size-fits-all screening programs are unsuitable for reaching Indigenous communities. In this review, we summarize available evidence on the perspectives of these communities; with a view to informing the improvement of cancer screening services to achieve equitable access.

METHODS

We undertook a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using the databases MEDLINE, Scopus, PubMed, and Google Scholar. The search terms used were "Indigenous community or Indigenous communities," "cancer screening," and "facilitators, enablers, desires, or needs." Qualitative studies published up to the August 30, 2022 investigating the perspectives of Indigenous communities on factors encouraging screening participation were included in the study. The included studies were reviewed and analyzed inductively by two independent reviewers, and key themes regarding indigenous access to cancer screening were then extracted.

RESULTS

A total of 204 unique articles were identified from the search. The title and abstracts of these studies were screened, and 164 were excluded on the basis of the exclusion and inclusion criteria. The full texts of the remaining 40 studies were examined and 18 were included in the review. Four key themes were identified pertaining to culturally tailored education and information dissemination, community involvement, positive relationships with health care providers, and individual empowerment and autonomy.

CONCLUSION

Improvements, on the basis of the key themes identified from this review, must be made at all levels of the health care system to achieve equitable screening participation in Indigenous communities. However, we recommend an investigation into the perspectives of the local Indigenous communities before the initiation of cancer screening programs.

Does breast cancer policy meet the needs of Aboriginal and Torres Strait Islander women in Australia? a review

OBJECTIVE

To evaluate if existing Australian public policy related to screening, diagnosis, treatment and follow up care for breast cancer addresses the needs of and outcomes for Indigenous¹ women?

METHODS

This review of policy employed a modified Delphi method via an online panel of experts (n = 13), who were purposively recruited according to experience and expertise. A series of online meetings and online surveys were used for data collection. The aims of the study were to: Identify all existing and current breast cancer policy in Australia;  Analyse the extent to which consideration of Indigenous peoples is included in the development, design and implementation of the policy; and Identify policy gaps and make recommendations as to how they could be addressed. The policies were evaluated using 'A Guide to Evaluation under the Indigenous Evaluation Strategy, 2020'.

RESULTS

A list of current breast cancer policies (n = 7) was agreed and analysed. Five draft recommendations to improve breast cancer outcomes for Indigenous women were developed and refined by the panel.

CONCLUSIONS

Current breast cancer policy in Australia does not address the needs of Indigenous women and requires change to improve outcomes.

"Everyone needs a Deb": what Australian indigenous women say about breast cancer screening and treatment services

BACKGROUND

Breast cancer continues to be the second most diagnosed cancer overall and the most diagnosed cancer for women in Australia. While mortality rates overall have declined in recent years, Indigenous women continue to be diagnosed at more marginal rates (0.9 times) and are more likely to die (1.2 times). The literature provides a myriad of reasons for this; however, the voices of Indigenous women are largely absent. This study sets out to understand what is happening from the perspectives of Australian Indigenous women with a view to charting culturally safer pathways that improve participation in screening and treatment by Indigenous women.

METHODS

This co-design study was conducted using semi-structured, in-depth interviews and focus group discussions. Recruitment of study participants was via snowball sampling. Participants were subsequently consented into the study through the Aboriginal Health Service and the research team. Interviews were audio recorded and transcribed verbatim, and data coded in NVivo12 using inductive thematic analysis.

RESULTS

A total of 21 Indigenous women and 14 health service providers were interviewed predominantly from the same regional/rural area in NSW, with a small proportion from other states in Australia. Six major themes were identified: Access, Awareness, Community and Family, Lack of control, Negative feelings and associations and Role of services.

CONCLUSION

To improve access and participation of Indigenous women and ultimately improve mortality rates, breast cancer services must explicitly address cultural and community needs.

Factors associated with cancer survival disparities among Aboriginal and Torres Strait Islander peoples compared with other Australians: A systematic review

Background

While cancer survival among Aboriginal and Torres Strait Islander peoples has improved over time, they continue to experience poorer cancer survival than other Australians. Key drivers of these disparities are not well understood. This systematic review aimed to summarise existing evidence on Aboriginal and Torres Strait Islander cancer survival disparities and identify influential factors and potential solutions.

Methods

In accordance with PRISMA guidelines, multiple databases were systematically searched for English language peer-reviewed articles on cancer survival by Aboriginal and Torres Strait Islander status published from 1/1/2008 to 4/05/2022. Observational studies presenting adjusted survival measures in relation to potential causal factors for disparities were included. Articles were screened independently by two authors. Included studies were critically assessed using Joanna Briggs Institute tools.

Results

Thirty population-based and predominantly state-level studies were included. A consistent pattern of poorer unadjusted cancer survival for Aboriginal and Torres Strait Islander peoples was evident. Studies varied widely in the covariates adjusted for including a combination of socio-demographics, cancer stage, comorbidities, and treatment. Potential contributions of these factors varied by cancer type. For lung and female breast cancer, adjusting for treatment and comorbidities reduced the survival disparity, which, while still elevated was no longer statistically significant. This pattern was also evident for cervical cancer after adjustment for stage and treatment. However, most studies for all cancers combined, or colorectal cancer, reported that unexplained survival disparities remained after adjusting for various combinations of covariates.

Conclusions

While some of the poorer survival faced by Aboriginal and Torres Strait Islander cancer patients can be explained, substantial disparities likely to be related to Aboriginal determinants, remain. It is imperative that future research consider innovative study designs and strength-based approaches to better understand cancer survival for Aboriginal and Torres Strait Islander peoples and to inform evidence-based action.

Quantifying the number of deaths among Aboriginal and Torres Strait Islander cancer patients that could be avoided by removing survival inequalities, Australia 2005–2016

Background

While Aboriginal and Torres Strait Islander peoples have poorer cancer survival than other Australians, absolute measures of survival disparities are lacking. This study quantified crude probabilities of deaths from cancer and other causes and estimated the number of avoidable deaths for Aboriginal and Torres Strait Islanders if these survival disparities were removed.

Methods

Flexible parametric relative survival models were used to estimate reported measures for a population-based cohort of 709,239 Australians (12,830 Aboriginal and Torres Strait Islander peoples), 2005–2016.

Results

Among Aboriginal and Torres Strait Islander peoples, the 5-year crude probability of cancer death was 0.44, while it was 0.07 for other causes of death. These probabilities were 0.07 and 0.03 higher than among other Australians, respectively. Magnitude of these disparities varied by cancer type and ranged for cancer deaths from <0.05 for pancreatic, prostate and uterine cancers to 0.20 for cervical and head and neck cancers. Values for disparity in other causes of death were generally lower. Among an average cohort of Aboriginal and Torres Strait Islander peoples diagnosed per year over the most recent five-year diagnosis period (2012–2016, n = 1,269), approximately 133 deaths within 5 years of diagnosis were potentially avoidable if they had the same overall survival as other Australians, with 94 of these deaths due to cancer. The total number of avoided deaths over the entire study period (2005–2016) was 1,348, with 947 of these deaths due to cancer.

Conclusions

Study findings suggest the need to reduce the prevalence of risk factors prevalence, increase screening participation, and improve early detection, diagnosis and treatment rates to achieve more equitable outcomes for a range of cancer types. Reported measures provide unique insights into the impact of a cancer diagnosis among Aboriginal and Torres Strait Islander peoples from a different perspective to standard relative survival measures.

Quantifying Differences in Remaining Life Expectancy after Cancer Diagnosis, Aboriginal and Torres Strait Islanders, and Other Australians, 2005-2016

BACKGROUND

This study quantified differences in remaining life expectancy (RLE) among Aboriginal and Torres Strait Islander and other Australian patients with cancer. We assessed how much of this disparity was due to differences in cancer and noncancer mortality and calculated the population gain in life years for Aboriginal and Torres Strait Islanders cancer diagnoses if the cancer survival disparities were removed.

METHODS

Flexible parametric relative survival models were used to estimate RLE by Aboriginal and Torres Strait Islander status for a population-based cohort of 709,239 persons (12,830 Aboriginal and Torres Strait Islanders), 2005 to 2016.

RESULTS

For all cancers combined, the average disparity in RLE was 8.0 years between Aboriginal and Torres Strait Islanders (12.0 years) and other Australians (20.0 years). The magnitude of this disparity varied by cancer type, being >10 years for cervical cancer versus <2 years for lung and pancreatic cancers. For all cancers combined, around 26% of this disparity was due to differences in cancer mortality and 74% due to noncancer mortality. Among 1,342 Aboriginal and Torres Strait Islanders diagnosed with cancer in 2015 an estimated 2,818 life years would be gained if cancer survival disparities were removed.

CONCLUSIONS

A cancer diagnosis exacerbates the existing disparities in RLE among Aboriginal and Torres Strait Islanders. Addressing them will require consideration of both cancer-related factors and those contributing to noncancer mortality.

IMPACT

Reported survival-based measures provided additional insights into the overall impact of cancer over a lifetime horizon among Aboriginal and Torres Strait Islander peoples.

Improving breast cancer outcomes for Aboriginal women: a mixed-methods study protocol

INTRODUCTION

Breast cancer is the most commonly diagnosed cancer affecting Australian women, and the second highest cause of cancer death in Australian women. While the incidence of breast cancer is lower in Aboriginal women than non-Aboriginal women, the mortality rate for Aboriginal women is higher, with Aboriginal women 1.2 times more likely to die from the disease. In New South Wales, Aboriginal women are 69% more likely to die from their breast cancer than non-Aboriginal women.Co-design is a research method recognised to enhance collaboration between those doing the research and those impacted by the research; which when used with Aboriginal communities, ensures research and services are relevant, culturally competent and empowers communities as co-researchers. We report the development of a new protocol using co-design methods to improve breast cancer outcomes for Aboriginal women.

METHODS AND ANALYSIS

Through a Community Mapping Project in 2018, we co-designed an iterative quantitative and qualitative study consisting of five phases. In Phase 1, we will establish a governance framework. In Phase 2, we will provide information to community members regarding the modified parts of the screening, diagnosis, treatment and follow-up processes and invite them to partake. In Phase 3, the research team will collect data on the outcomes of the modified processes and the outcomes for the women who have and have not participated. The data shall be analysed quantitatively and thematically in Phase 4 with Aboriginal community representatives and reported back to community. Lastly, in Phase 5, we evaluate the co-design process and adapt our protocol for use in partnership with other communities.

ETHICS AND DISSEMINATION

This study has ethics approval of the Aboriginal Health and Medical Research Council ref:1525/19. The findings will be published in the literature, presented at conferences and short summaries will be issued via social media.

Quantifying the hospital and emergency department costs for women diagnosed with breast cancer in Queensland

PURPOSE

With increasing rates of cancer survival due to advances in screening and treatment options, the costs of breast cancer diagnoses are attracting interest. However, limited research has explored the costs to the Australian healthcare system associated with breast cancer. We aimed to describe the cost to hospital funders for hospital episodes and emergency department (ED) presentations for Queensland women with breast cancer, and whether costs varied by demographic characteristics.

METHODS

We used a linked administrative dataset, CancerCostMod, limited to all breast cancer diagnoses aged 18 years or over in Queensland between July 2011 and June 2015 (n = 13,285). Each record was linked to Queensland Health Admitted Patient Data Collection and Emergency Department Information Systems records between July 2011 and June 2018. The cost of hospital episodes and ED presentations were determined, with mean costs per patient modelled using generalised linear models with a gamma distribution and log link function.

RESULTS

The total cost to the Queensland healthcare system from hospital episodes for female breast cancer was AUD$309 million and AUD$12.6 million for ED presentations during the first 3 years following diagnosis. High levels of costs and service use were identified in the first 6 months following diagnosis. Some significant differences in cost of hospital and ED episodes were identified based on demographic characteristics, with Indigenous women and those from lower socioeconomic backgrounds having higher costs.

CONCLUSION

Hospitalisation costs for breast cancer in Queensland exert a high burden on the healthcare system. Costs are higher for women during the first 6 months from diagnosis and for Indigenous women, as well as those with underlying comorbidities and lower socioeconomic position.

An exploration of the sociodemographic and health conditions associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults

Objective

To identify sociodemographic factors and health conditions associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults. Participants were recruited via investigator networks and an online panel provider with an established nationwide panel of Aboriginal and Torres Strait Islander adults. Those interested were invited to complete a survey that included an assessment of wellbeing using a visual analogue scale. Data was collected from October–November 2019 and August–September 2020. Exploratory analyses were conducted to ascertain factors associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults.

Results

Having more than enough money to last until next pay day, full-time employment, completion of grade 12, having a partner, and living with others were significantly associated with higher wellbeing among Aboriginal and Torres Strait Islander adults. A self-reported history of depression, anxiety, other mental health conditions, heart disease, or disability were associated with lower self-rated wellbeing scores. Our findings indicate a need for further investigation among these socioeconomic and patient groups to identify how to improve and support the wellbeing of Aboriginal and Torres Strait Islander adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05794-3.

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

BACKGROUND

Breast cancer is the most commonly diagnosed cancer in Aboriginal and/or Torres Strait Islander women. When compared to other Australians, Aboriginal and/or Torres Strait Islander women have a higher breast cancer mortality rate. This systematic literature review examined disparities in breast cancer surgical access and outcomes for Aboriginal and/or Torres Strait Islander women.

METHODS

This systematic literature review, following the PRISMA guidelines, compared measures of breast cancer surgical care for Aboriginal and/or Torres Strait Islander people and other Australians.

RESULTS

The 13 included studies were largely state-based retrospective reviews of data collected prior to the year 2012. Eight studies reported more advanced breast cancer presentation among Aboriginal and/or Torres Strait Islander women. Despite the increased distance to a multidisciplinary, specialist team, there were no disparities in seeing a surgeon, or in the time from diagnosis to surgical treatment. Two studies reported disparities in the receipt of surgery and two reported no variations. Three studies reported disparities in the receipt of mastectomy versus breast conserving surgery, whilst four studies reported no variations. No studies examined postoperative surgical outcomes.

CONCLUSIONS

Aboriginal and/or Torres Strait Islander women present with more advanced breast cancer. There may be disparities in the receipt of surgery and the type of surgery. However, the metrics tested were not related to optimal care guidelines, and the databases utilised contain limited data on individual factors contributing to surgical care decisions. It is therefore difficult to determine whether the reported differences in the receipt of surgical care reflect disparate or appropriate care.

What Is the Evidence Globally for Culturally Safe Strategies to Improve Breast Cancer Outcomes for Indigenous Women in High Income Countries? A Systematic Review

The aim was to systematically assess the evidence on whether cultural safety affects breast cancer outcomes with regards to care for Indigenous women in high income countries. We conducted a systematic review in accordance with PRISMA guidelines of peer-reviewed articles in Medline, EMBASE, CINAHL, Scopus, Web of Science, Proquest Sociology and Informit Rural health database and Indigenous collection databases. Key inclusion criteria were: adult female patients with breast cancer; high income country setting; outcome measure, including screening, diagnosis, treatment and follow up care. A total of 15 were selected. We developed a Community Engagement assessment tool in consultation with aboriginal researchers, based on the National Health and Medical Research Councils' community engagement guidelines, against which studies were appraised. This novel element allowed us to evaluate the literature from a new and highly relevant perspective. Thematic analysis of all 15 studies was also undertaken. Despite limited literature there are evidence-based strategies that are likely to improve outcomes for Indigenous women with breast cancer in high income countries and indicate that culture makes a positive difference. It is also clear that strong Indigenous community leadership and governance at all stages of the research including design is an imperative for feasibility.

Do histopathological features of breast cancer in Australian Indigenous women explain the survival disparity? A two decade long study in the Northern Territory

AIMS

In the Northern Territory (NT) of Australia, Indigenous women have a lower incidence of breast cancer, but a higher mortality than Non-indigenous women. The aim of this study was to describe and compare breast cancer pathological features related to stage and biological aggression between the two groups.

METHODS

Subjects were identified by extract from the NT Cancer Registry in two separate cohorts, cohort 1 (1991-2000) and cohort 2 (2001-2010). Data from cohort 1 included age, stage, tumor grade and estrogen receptor status (ER) and treatment completion. Additional pathological variables including tumor size, HER2 status, lymphovascular invasion and derived tumor phenotype were available for cohort 2. Bivariate P values for categoric variables were calculated using Fisher's exact tests.  The Wilcoxon rank-sum test was used to compare cohort 2. Logistic regression was used to calculate odds ratios.

RESULTS

There were 359 (44 indigenous) eligible women in cohort 1 and 526 (100 indigenous) for cohort 2. In cohort 1, in both cohorts, indigenous women were more likely to present at an advanced stage, but there was no difference in ER status or tumor grade. When derived phenotypes were compared, indigenous women were less likely to have better prognosis luminal A tumors, and more likely to have HER2-enriched tumors.

CONCLUSION

This two decade long comparison of the pathological features of breast cancer between indigenous and nonindigenous women of the NT has confirmed that Indigenous women not only present at a later stage than NI women but are also afflicted by poorer prognosis tumors, particularly HER2 enriched.

Emerging cancer incidence, mortality, hospitalisation and associated burden among Australian cancer patients, 1982 - 2014: an incidence-based approach in terms of trends, determinants and inequality

OBJECTIVE

Cancer is a leading killer worldwide, including Australia. Cancer diagnosis leads to a substantial burden on the individual, their family and society. The main aim of this study is to understand the trends, determinants and inequalities associated with cancer incidence, hospitalisation, mortality and its burden over the period 1982 to 2014 in Australia.

SETTINGS

The study was conducted in Australia.

STUDY DESIGN

An incidence-based study design was used.

METHODS

Data came from the publicly accessible Australian Institute of Health and Welfare database. This contained 2 784 148 registered cancer cases over the study period for all types of cancer. Erreygers' concentration index was used to examine the magnitude of socioeconomic inequality with regards to cancer outcomes. Furthermore, a generalised linear model was constructed to identify the influential factors on the overall burden of cancer.

RESULTS

The results showed that cancer incidence (annual average percentage change, AAPC=1.33%), hospitalisation (AAPC=1.27%), cancer-related mortality (AAPC=0.76%) and burden of cancer (AAPC=0.84%) all increased significantly over the period. The same-day (AAPC=1.35%) and overnight (AAPC=1.19%) hospitalisation rates also showed an increasing trend. Further, the ratio (least-most advantaged economic resources ratio, LMR of mortality (M) and LMR of incidence (I)) was especially high for cervix (M/I=1.802), prostate (M/I=1.514), melanoma (M/I=1.325), non-Hodgkin's lymphoma (M/I=1.325) and breast (M/I=1.318), suggesting that survival inequality was most pronounced for these cancers. Socioeconomically disadvantaged people were more likely to bear an increasing cancer burden in terms of incidence, mortality and death.

CONCLUSIONS

Significant differences in the burden of cancer persist across socioeconomic strata in Australia. Policymakers should therefore introduce appropriate cancer policies to provide universal cancer care, which could reduce this burden by ensuring curable and preventive cancer care services are made available to all people.

Breast screening attendance of Aboriginal and Torres Strait Islander women in the Northern Territory of Australia

OBJECTIVE

To compare breast screening attendances of Indigenous and non-Indigenous women.

METHODS

A total of 4,093 BreastScreen cases were used including 857 self-identified Indigenous women. Chi-squared analysis compared data between Indigenous and non-Indigenous women. Logistic regression was used for groupings based on visits-to-screening frequency. Odds ratios and 95% confidence intervals were calculated for associations with low attendance.

RESULTS

Indigenous women were younger and had fewer visits to screening compared with non-Indigenous women. Non-English speaking was mainly associated with fewer visits for Indigenous women only (OR 1.9, 95%CI 1.3-2.9). Living remotely was associated with fewer visits for non-Indigenous women only (OR 1.3, 95%CI 1.1-1.5). Shared predictors were younger age (OR 12.3, 95%CI 8.1-18.8; and OR 11.5, 95%CI 9.6-13.7, respectively) and having no family history of breast cancer (OR 2.1, 95%CI 1.3-3.3; and OR 1.8, 95%CI 1.5-2.1, respectively).

CONCLUSIONS

Factors associated with fewer visits to screening were similar for both groups of women, except for language which was significant only for Indigenous women, and remoteness which was significant only for non-Indigenous women. Implications for public health: Health communication in Indigenous languages may be key in encouraging participation and retaining Indigenous women in BreastScreen; improving access for remote-living non-Indigenous women should also be addressed.

Disparities in breast screening, stage at diagnosis, cancer treatment and the subsequent risk of cancer death: a retrospective, matched cohort of aboriginal and non-aboriginal women with breast cancer

Background

Australia’s Aboriginal and Torres Strait Islander women have poorer survival and twice the disease burden from breast cancer compared to other Australian women. These disparities are influenced, but not fully explained, by more diagnoses at later stages. Incorporating breast screening, hospital and out of hospital treatment and cancer registry records into a person-linked data system can improve our understanding of breast cancer outcomes. We focussed one such system on a population-based cohort of Aboriginal women in South Australia diagnosed with breast cancer and a matched cohort of non-Aboriginal women with breast cancer. We quantify Aboriginal and non-Aboriginal women’s contact with publicly funded screening mammograms; quantify exposure to a selection of cancer treatment modalities; then assess the relationship between screening, treatment and the subsequent risk of breast cancer death.

Methods

Breast cancers registered among Aboriginal women in South Australia in 1990–2010 (N = 77) were matched with a random selection of non-Aboriginal women by birth and diagnostic year, then linked to screening records, and treatment 2 months before and 13 months after diagnosis. Competing risk regression summarised associations of Aboriginality, breast screening, cancer stage and treatment with risk of breast cancer death.

Results

Aboriginal women were less likely to have breast screening (OR = 0.37, 95%CIs 0.19–0.73); systemic therapies (OR = 0.49, 95%CIs 0.24–0.97); and, surgical intervention (OR = 0.35, 95%CIs 0.15–0.83). Where surgery occurred, mastectomy was more common among Aboriginal women (OR = 2.58, 1.22–5.46). Each of these factors influenced the risk of cancer death, reported as sub-hazard ratios (SHR). Regional spread disease (SHR = 34.23 95%CIs 6.76–13.40) and distant spread (SHR = 49.67 95%CIs 6.79–363.51) carried more risk than localised disease (Reference SHR = 1). Breast screening reduced the risk (SHR = 0.07 95%CIs 0.01–0.83). So too did receipt of systemic therapy (SHR = 0.06 95%CIs 0.01–0.41) and surgical treatments (SHR = 0.17 95%CIs 0.04–0.74). In the presence of adjustment for these factors, Aboriginality did not further explain the risk of breast cancer death.

Conclusion

Under-exposure to screening and treatment of Aboriginal women with breast cancers in South Australia contributed to excess cancer deaths. Improved access, utilisation and quality of effective treatments is needed to improve survival after breast cancer diagnosis.

Factors influencing breast cancer outcomes in Australia: A systematic review

PURPOSE

This systematic review evaluates factors influencing breast cancer outcomes for women treated in Australia, facilitating the exploration of disparities in breast cancer outcomes for certain groups of women in Australia.

METHOD

A systematic literature search was performed using MEDLINE and Scopus focusing on breast cancer in Australia with outcome measures being breast cancer survival and recurrence with no restrictions on date. Risk of bias was assessed using Cairns Assessment Scale for Observational studies of Risk factors (CASOR).

RESULTS

Fifteen quantitative studies were included: two were high quality, 11 were intermediate quality, and two were low quality. Traditional risk factors such as invasive tumour type, larger size, higher grade and stage, lymph node involvement and absence of hormone receptors were found to be associated with breast cancer mortality. Being younger (<40 years old) and older (>70 years old), having more comorbidities, being of lower socioeconomic status, identifying as Aboriginal or Torres Strait Islander, living in more rural areas or having a mastectomy were factors found to be associated with poorer breast cancer outcomes.

CONCLUSION

Despite the heterogeneity of the studies, this review identified significant risk factors for breast cancer mortality and recurrence. The use of this data would be most useful in developing evidence-based interventions and in optimising patient care through creation of a prediction model.

PROSPERO REGISTRATION

CRD42017072857.

Variations in outcomes by residential location for women with breast cancer: a systematic review

OBJECTIVES

To systematically assess the evidence for variations in outcomes at each step along the breast cancer continuum of care for Australian women by residential location.

DESIGN

Systematic review.

METHODS

Systematic searches of peer-reviewed articles in English published from 1 January 1990 to 24 November 2017 using PubMed, EMBASE, CINAHL and Informit databases. Inclusion criteria were: population was adult female patients with breast cancer; Australian setting; outcome measure was survival, patient or tumour characteristics, screening rates or frequencies, clinical management, patterns of initial care or post-treatment follow-up with analysis by residential location or studies involving non-metropolitan women only. Included studies were critically appraised using a modified Newcastle-Ottawa Scale.

RESULTS

Seventy-four quantitative studies met the inclusion criteria. Around 59% were considered high quality, 34% moderate and 7% low. No eligible studies examining treatment choices or post-treatment follow-up were identified. Non-metropolitan women consistently had poorer survival, with most of this differential being attributed to more advanced disease at diagnosis, treatment-related factors and socioeconomic disadvantage. Compared with metropolitan women, non-metropolitan women were more likely to live in disadvantaged areas and had differing clinical management and patterns of care. However, findings regarding geographical variations in tumour characteristics or diagnostic outcomes were inconsistent.

CONCLUSIONS

A general pattern of poorer survival and variations in clinical management for Australian female patients with breast cancer from non-metropolitan areas was evident. However, the wide variability in data sources, measures, study quality, time periods and geographical classification made direct comparisons across studies challenging. The review highlighted the need to promote standardisation of geographical classifications and increased comparability of data systems. It also identified key gaps in the existing literature including a lack of studies on advanced breast cancer, geographical variations in treatment choices from the perspective of patients and post-treatment follow-up.

Psychological distress among Indigenous Australian cancer survivors

PURPOSE

The purpose of this study is to identify the level of and factors associated with distress in 155 Indigenous Australian cancer survivors approximately 6 months post-diagnosis.

METHODS

The distress thermometer (DT) was used to assess clinically significant distress (defined as having a DT score ≥ 4). Logistic regression was used to identify sociodemographic and clinical factors associated with clinically significant distress.

RESULTS

The mean distress score was 2.7 (SD 2.9), with about one in three Indigenous cancer survivors reporting clinically significant distress (35%; n = 54). After adjusting for age and sex, clinically significant distress was more likely among those who were separated/divorced/widowed than those who were married (odds ratio (OR) = 2.99, 95% confidence intervals (95% CI) 1.21-7.35, p = 0.017) and less likely among those residing in remote areas than those in major cities (OR = 0.23, 95% CI 0.08-0.71, p = 0.001) and in those receiving non-surgical treatment only compared with surgery only (OR = 0.24, 95% CI 0.08-0.68, p = 0.008).

CONCLUSIONS

Despite increased screening for distress in cancer care, this is, to our knowledge, the first published assessment of distress among Indigenous Australian cancer survivors. The characteristics of Indigenous cancer survivors associated with greater likelihood of clinically significant distress indicate at-risk subgroups who would benefit from screening and early intervention. Further research is required to identify the specific aetiologies of distress. Our findings indicate a need to identify psychological distress and for survivorship care to include culturally sensitive and tailored psychological support for Indigenous cancer survivors.