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

Towards precision cancer medicine for Aboriginal and Torres Strait Islander cancer health equity

Delivering cancer control at scale for Aboriginal and Torres Strait Islander communities is a national priority that requires Aboriginal and Torres Strait Islander leadership and codesign, as well as significant involvement of the Aboriginal community-controlled health sector. The unique genomic variation observed among Aboriginal and Torres Strait Islander peoples may have implications for standard and precision medicine. Yet, Aboriginal and Torres Strait Islander peoples are absent from, or under-represented within, human reference genome resources, genomic studies, cancer studies, cancer cell lines, patient-derived xenografts and cancer clinical trials. Genomics-guided precision cancer medicine offers an opportunity to reduce cancer health disparities experienced by Aboriginal and Torres Strait Islander peoples through personalising prevention, diagnosis, treatment and long term management. Here, we describe what is required to ensure that Aboriginal and Torres Strait Islander peoples can receive the benefits of precision cancer medicine. Equity of access to care, an Aboriginal and Torres Strait Islander cancer workforce, and appropriate genome reference resources are important for safe and effective cancer medicine. Building Indigenous data sovereignty principles and Aboriginal and Torres Strait Islander governance into research is required to protect Aboriginal and Torres Strait Islander rights and collective interests. Aboriginal and Torres Strait Islander community engagement should be undertaken to develop an understanding of the unique cultural and ethical considerations for precision cancer research. Local and national genomic health research guidelines are needed to define a consensus best practice in genomics research with Aboriginal and Torres Strait Islander peoples.

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.

"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.

Consensus views on an advanced breast cancer education curriculum for cancer nurses: A Delphi study

BACKGROUND

Specialist nursing care is a core indicator of quality care for people living with advanced breast cancer. However, access to and quality of nurse education programmes in advanced breast cancer is variable.

OBJECTIVES

This study aims to define the topics for inclusion in an international curriculum for an advanced breast cancer education programme.

METHODS

A modified four-round Delphi study was undertaken with experts by profession and experience in advanced breast cancer. Thirty-four topics related to advanced breast cancer and six online teaching and learning methods were pre-selected following a systematic review. Between September 2021 and March 2022, the expert panel determined the importance of topics for inclusion in the education programme. Consensus was defined by at least 80 % agreement on the highest three points on a 9-point Likert scale.

RESULTS

A total of 31 experts participated in rounds 1-3 of this study, and 156 experts by profession and experience participated in an additional fourth round, including people living with advanced breast cancer (n = 72, 46 %), healthcare professionals (n = 46, 29 %), family members or caregivers of a person diagnosed with advanced breast cancer (n = 30, 19 %) and advocacy professionals working in the area of advanced breast cancer (n = 8, 5 %). In round 4, 36 topics and five of six learning methods reached consensus.

CONCLUSIONS

The results of this study provide a framework to develop education programmes in advanced breast cancer, defining the essential elements of curriculum content for such programmes. The results highlight the need for advanced breast cancer education programmes to use multiple teaching and learning methods to promote nurses' understanding of person-centred supportive care and the physical, psychosocial and spiritual issues experienced by people living with advanced breast cancer.

Our relationships, our values, our culture - Aboriginal young men's perspectives about sex, relationships and gender stereotypes in Australia

Studies of Aboriginal young people have often followed a deficit approach depicting them as 'risky' and in need of help. In contrast, this study took a strengths-based approach and focussed on what Aboriginal young people value, how they stay safe and how their culture impacts their lives. 16 Aboriginal men aged 16 to 24 years were interviewed in Sydney, Australia. We examined Aboriginal young men's perspectives about relationships, sex and gender. Interviews were conducted by young Aboriginal men in 2019 and 2020. Overall, four features of positive sexual and romantic relationships were discussed: (1) love, connection and support; (2) enjoyment and fun; (3) responsibility, safety and consent; and 4) honesty, respect and trust. Additionally, three topics related to gender roles: (1) becoming a man; (2) sex as a masculine achievement; and (3) inequality and gender stereotypes. Our study suggests that Aboriginal young men are exploring sexual and romantic relationships, and although they value enjoyment and fun, they are aware of broader issues such as consent and respect. The young men acknowledged gender stereotypes faced by young women. Our results could be used by future school safe sex education programmes to better meet the needs of Aboriginal young men.

Practical, epistemic and normative implications of algorithmic bias in healthcare artificial intelligence: a qualitative study of multidisciplinary expert perspectives

BACKGROUND

There is a growing concern about artificial intelligence (AI) applications in healthcare that can disadvantage already under-represented and marginalised groups (eg, based on gender or race).

OBJECTIVES

Our objectives are to canvas the range of strategies stakeholders endorse in attempting to mitigate algorithmic bias, and to consider the ethical question of responsibility for algorithmic bias.

METHODOLOGY

The study involves in-depth, semistructured interviews with healthcare workers, screening programme managers, consumer health representatives, regulators, data scientists and developers.

RESULTS

Findings reveal considerable divergent views on three key issues. First, views on whether bias is a problem in healthcare AI varied, with most participants agreeing bias is a problem (which we call the bias-critical view), a small number believing the opposite (the bias-denial view), and some arguing that the benefits of AI outweigh any harms or wrongs arising from the bias problem (the bias-apologist view). Second, there was a disagreement on the strategies to mitigate bias, and who is responsible for such strategies. Finally, there were divergent views on whether to include or exclude sociocultural identifiers (eg, race, ethnicity or gender-diverse identities) in the development of AI as a way to mitigate bias.

CONCLUSION/SIGNIFICANCE

Based on the views of participants, we set out responses that stakeholders might pursue, including greater interdisciplinary collaboration, tailored stakeholder engagement activities, empirical studies to understand algorithmic bias and strategies to modify dominant approaches in AI development such as the use of participatory methods, and increased diversity and inclusion in research teams and research participant recruitment and selection.

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.

COL11A1 serves as a biomarker for poor prognosis and correlates with immune infiltration in breast cancer

Breast cancer is the malignant tumor with the highest incidence rate at present, and its incidence rate ranks first in the female population. COL11A1 is an important component of collagen XI and is considered to play an important role in a variety of connective tissue diseases. Recent studies have shown that COL11A1 is associated with the occurrence and development of many kinds of malignant tumors. However, its prognostic value in breast cancer and its correlation with immune cell infiltration in tumor tissue are not clear. In this paper, we reveal the prognostic value of COL11A1 in breast cancer and its tumor immune-related function through in-depth bioinformatics analysis. The expression of COL11A1 is abnormally upregulated in breast cancer and is significantly related to the poor prognosis of breast cancer. In the analysis of the clinical characteristics of the patients, we found that the expression level of COLL11A1 was closely related to lymph node metastasis, PAM50 (Prediction Analysis of Microarray 50) expression, clinical stage and so on. Gene Ontology (GO) and Kyoto Encyclopedia of Gene and Genome (KEGG) all suggest that COL11A1 is related to tumor immunity. Further study found that the COL11A1 expression was significantly correlated with the degree of immune infiltration and the expression of a variety of immune cell markers in tumor tissue. More importantly, COL11A1 can affect the prognosis of breast cancer patients by participating in the regulation of tumor immune infiltration. Therefore, we believe that COL11A1 is a very potential target for diagnosis and treatment of breast cancer.

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.

Occurrence and timely management of problems requiring prompt intervention among Indigenous compared with non-Indigenous Australian palliative care patients: a multijurisdictional cohort study

OBJECTIVES

Anticipation and prompt relief of symptoms among patients with a life-limiting illness is a core element of palliative care. Indigenous Australians commonly encounter cultural barriers in healthcare that may impair outcomes. The Palliative Care Outcomes Collaboration collects patient care data for the purposes of continuous quality improvement and benchmarking, with each recorded care episode divided into phases that reflect a patient's condition. We aimed to investigate differences between Indigenous and non-Indigenous patients in the occurrence and duration of 'unstable' phases (which indicate unanticipated deterioration in a patient's condition or circumstances), and determine attainment of the relevant benchmark (resolution of unstable phases in ≤3 days in 90% of cases) for both groups.

DESIGN

Cohort study.

SETTING

Australia-wide hospital-based and community-based specialist palliative care (1 January 2010 to 30 June 2015).

PARTICIPANTS

139 556 (1502 Indigenous and 138 054 non-Indigenous) adult patients.

OUTCOME MEASURES

Indigenous and non-Indigenous patients were compared on (1) the risk of a phase being categorised as unstable, (2) the duration of unstable phases, and (3) the risk of unstable phases being prolonged (>3 days). Crude and adjusted estimates were produced from three-level robust Poisson regression and complementary log-log discrete time survival models.

RESULTS

Unstable phases occurred with similar frequency overall among Indigenous and non-Indigenous patients (adjusted relative risks 1.06; 95% CI 1.00 to 1.11; not significant after correction for multiple comparisons). The duration and risk of prolongation of unstable phases were similar in both patient groups, with no significant differences evident among subgroups. The benchmark was not met for either Indigenous or non-Indigenous patients (unstable phase duration >3 days in 24.3% vs 25.5%; p=0.398).

CONCLUSIONS

Despite well-documented shortcomings of healthcare for Indigenous Australians, there is no clear evidence of greater occurrence or prolongation of unanticipated problems among Indigenous patients accessing specialist palliative care services in hospital or the community.

Choosing Wisely in radiation therapy for breast cancer: Time lag in adoption of hypofractionated radiation therapy in Victoria

INTRODUCTION

To evaluate the adoption of hypofractionated radiotherapy (HFRT) for breast cancer (BC) in Victoria, Australia.

METHODS

This is a population-based cohort of women with BC who had breast RT as captured in the Victorian Radiotherapy Minimum Data Set between 2012 and 2017. We defined HFRT as < 25 fractions of RT. The pattern of HFRT use over time was evaluated with the Cochrane-Armitage test for trend. Factors associated with HFRT were identified using multivariable logistic regression.

RESULTS

12,717 women were included in the study. Overall, 6,653 (52%) patients had HFRT. HFRT use increased from 35% in 2012 to 66% in 2017 (P-trend < 0.001). Older women were more likely to have HFRT (74% for women aged ≥ 70 years vs. 27% for women aged < 50 years; P < 0.001). Women who had nodal irradiation were less likely to have HFRT compared with those who did not (13% vs. 57%; P < 0.001). HFRT use was more common in public than private institutions (57% vs. 46%, P < 0.001), and in metropolitan than regional centres (54% vs. 46%, P < 0.001). In multivariable analyses, the progressive increase in HFRT use over time was independent of other covariates - women treated in 2017 were 7.3 times (95% CI = 6.3-8.6, P < 0.001) more likely to be treated with HFRT than in 2012. Age at RT, nodal irradiation, area of residence and institutional type and locations were all independently associated with HFRT use.

CONCLUSION

This large Australian contemporary population-based study demonstrates increasing use of HFRT for BC. However, large sociodemographic and institutional provider-related variations in practice still exist.

DNAJB4 identified as a potential breast cancer marker: evidence from bioinformatics analysis and basic experiments

Background

Breast cancer (BC) is the leading cause of tumor-related death in women worldwide, but its pathogenesis is not clear. The efficient screening of new therapeutic targets for BC through bioinformatics and biological experimental techniques has become a hot topic in BC research.

Methods

The bioinformatics method was used to analyze the gene chips and obtain the hub genes, playing an important role in the development of BC. The biological processes (BP) involved in the hub genes were analyzed by Bingo, and the impact of each hub gene on disease-free survival (DFS) and overall survival (OS) in BC patients was evaluated in the Kaplan-Meier Plotter database. The expression of DNAJB4, the hub gene with the greatest degree and having an effect on the prognosis of BC patients, was detected in BC cell lines and clinicopathological specimens. And DNAJB4 was selected for further biological experiments and clinical prognosis verification.

Results

Ten hub genes including DNAJB4, the greatest degree genes, were found by bioinformatics analysis of BC gene chips. DNAJB4 expressions in both BC cell lines and clinicopathological specimens were detected and the results showed that DNAJB4 was significantly down-regulated in BC cell lines and tissues. After interfering with the expression of DNAJB4, it was found that the invasion and migration ability of MDA-MB-231 cell line was significantly enhanced in vitro. The clinical survival data of BC patients showed that patients with high DNAJB4 expression had longer DFS.

Conclusions

DNAJB4 may be a tumor suppressor gene in BC as it could regulate invasion and migration of BC cells and its expression level is related to the prognosis of BC patients. Nevertheless, further researches are still necessary to verify its role in BC so as to provide evidences for clinical guidance regarding diagnosis and treatment.

Access to Palliative Care Services and Clinical Outcomes of Patients With Solid Malignancy-Associated Myelophthisis in a Resource-Limited Setting

BACKGROUND

Myelophthisis (MPT) has been associated with a dreadful prognosis. Patients' access to palliative care (PC) and factors influencing its clinical outcomes are poorly described. Our aim was to analyze the impact of patient- and disease-specific characteristics on survival of patients with MPT and describe their use of PC in a resource-limited setting.

METHODS

Retrospective study including patients with solid tumor MPT, diagnosed between 1996 and 2018.

RESULTS

Seventy patients (median 58 years) were included. 58% were synchronously diagnosed with MPT at time of primary tumor diagnosis. Most common oncologic diagnoses were prostate (25.7%), gastrointestinal (20%), and breast (18.6%) neoplasms. Median overall survival (OS) was 1.9 months. Primaries other than prostate, breast, and lung (HR 1.37, 95% CI 1.15 - 1.8; p = 0.02) and transfusion requirements (HR 2.8, 95% CI 1.01 - 7.9; p = 0.04) were independently associated with decreased OS. Administration of multiple systemic therapeutic interventions (HR 0.15, 95% CI 0.06 - 0.39; p = 0.01) was the sole factor improving OS. Assessment by PC was pursued in 51.4% of patients. The median number of consults per patient was two, with no difference in assessment rate or consult number across different primaries (P = 0.96). Four cases of palliative sedation were reported, all performed by the primary care team.

CONCLUSION

MPT is highly heterogeneous and risk stratification to optimize the use of therapeutic interventions in unison with palliative interventions is needed to maximize efforts toward improving patient quality of life. There is an alarming need of PC services in the multidisciplinary management of patients within developing regions.

Cancer treatment and the risk of cancer death among Aboriginal and non-Aboriginal South Australians: analysis of a matched cohort study

BACKGROUND

Aboriginal and Torres Strait Islander Australians have poorer cancer outcomes than other Australians. Comparatively little is known of the type and amount of cancer treatment provided to Aboriginal and Torres Strait Islander people and the consequences for cancer survival. This study quantifies the influence of surgical, systemic and radiotherapy treatment on risk of cancer death among matched cohorts of cancer cases and, the comparative exposure of cohorts to these treatments.

METHODS

Cancers registered among Aboriginal South Australians in 1990-2010 (N = 777) were matched with randomly selected non-Indigenous cases by sex, birth and diagnostic year, and primary site, then linked to administrative cancer treatment for the period from 2 months before to 13 months after diagnosis. Competing risk regression summarised associations of Indigenous status, geographic remoteness, comorbidities, cancer stage and treatment exposure with risk of cancer death.

RESULTS

Fewer Aboriginal cases had localised disease at diagnosis (37.2% versus 50.2%) and they were less likely to: experience hospitalisation with cancer diagnosis, unadjusted odds ratio (UOR) = 0.76; 95%CI = 0.59-0.98; have surgery UOR = 0.65; 95%CI = 0.53-0.80; systemic therapies UOR = 0.64; 95%CI = 0.52-0.78; or radiotherapy, UOR = 0.76; 95%CI = 0.63-0.94. Localised disease carried lower risk of cancer death compared to advanced cases receiving surgery or systemic therapies, SHR = 0.34; 95%CI = 0.25-0.47 and SHR = 0.35; 95%CI = 0.25-0.48. Advanced disease and no treatment carried higher risk of cancer death, SHR = 1.82; 95%CI = 1.26-2.63.

CONCLUSION

The effects of treatment did not differ between Aboriginal and non-Indigenous cohorts. However, comparatively less exposure to surgical and systemic treatments among Aboriginal cancer cases further complicated the disadvantages associated with geographic remoteness, advanced stage of disease and co-morbid conditions at diagnosis and add to disparities in cancer death. System level responses to improving access, utilisation and quality of effective treatments are needed to improve survival after cancer diagnosis.