Disparities in cancer care in australia and the pacific

Age-specific differences in cervical cancer screening rates in women using mental health services in New South Wales, Australia

OBJECTIVE

Women living with mental health conditions have lower cervical cancer screening rates and higher mortality. More evidence is needed to target health system improvement efforts. We describe overall and age-specific cervical cancer screening rates in mental health service users in New South Wales.

METHODS

Cervical cancer screening registers were linked to New South Wales hospital and community mental health service data. Two-year cervical screening rates were calculated for New South Wales mental health service users aged 20-69 years (n = 114,022) and other New South Wales women (n = 2,110,127). Rate ratios were compared for strata of age, socio-economic disadvantage and rural location, and overall rates compared after direct standardisation.

RESULTS

Only 40.3% of mental health service users participated in screening, compared with 54.3% of other New South Wales women (incidence rate ratio = 0.74, 95% confidence interval = [0.74, 0.75]). Differences in age, social disadvantage or rural location did not explain screening gaps. Screening rates were highest in mental health service users aged <35 years (incidence rate ratios between 0.90 and 0.95), but only 15% of mental health service users aged >65 years participated in screening (incidence rate ratio = 0.27, 95% confidence interval = [0.24, 0.29]).

CONCLUSION

Women who use mental health services are less likely to participate in cervical cancer screening. Rates diverged from population rates in service users aged ⩾35 years and were very low for women aged >65 years. Intervention is needed to bridge these gaps. New screening approaches such as self-testing may assist.

Current landscape of cancer survivorship research in Australia

AIM

Response to the substantial and long-term impacts that a cancer diagnosis and treatment has on the growing population of cancer survivors, requires priority-driven, impactful research. This study aimed to map Australian cancer survivorship research activities to identify gaps and opportunities for improvement and compare activities against identified survivorship research priorities.

METHODS

An online survey was completed by Australian researchers regarding their cancer survivorship research, and the barriers they identified to conducting such research. Current research activity was compared to recently established Australian survivorship research priorities.

RESULTS

Overall, 178 participants completed the online survey. The majority of the research undertaken utilized survey or qualitative designs and focused on breast cancer, adult populations, and those in early survivorship (<5 years post-treatment). Barriers to conducting survivorship research included funding, collaboration and networking, mentoring, and time constraints. There was moderate alignment with existing research priorities. Investigating models of care and health service delivery were the most frequently researched priorities. Research priorities that were less commonly investigated included patient navigation, patient-reported outcomes, multimorbidity, fear of cancer recurrence, and economic issues.

CONCLUSION

This study provides the first snapshot of Australian survivorship research activity. Comparison to established priorities demonstrates health services research is receiving attention and highlights areas for potential pursuits, such as rare cancers or multimorbidity. Findings indicate the need for improved funding and infrastructure to support researchers in advancing the survivorship research agenda.

Treatment patterns and out-of-hospital healthcare resource utilisation by patients with advanced cancer living with pain: An analysis from the Stop Cancer PAIN trial

BACKGROUND

About 70% of patients with advanced cancer experience pain. Few studies have investigated the use of healthcare in this population and the relationship between pain intensity and costs.

METHODS

Adults with advanced cancer and scored worst pain ≥ 2/10 on a numeric rating scale (NRS) were recruited from 6 Australian oncology/palliative care outpatient services to the Stop Cancer PAIN trial (08/15-06/19). Out-of-hospital, publicly funded services, prescriptions and costs were estimated for the three months before pain screening. Descriptive statistics summarize the clinico-demographic variables, health services and costs, treatments and pain scores. Relationships with costs were explored using Spearman correlations, Mann-Whitney U and Kruskal-Wallis tests, and a gamma log-link generalized linear model.

RESULTS

Overall, 212 participants had median worst pain scores of five (inter-quartile range 4). The most frequently prescribed medications were opioids (60.1%) and peptic ulcer/gastro-oesophageal reflux disease (GORD) drugs (51.6%). The total average healthcare cost in the three months before the census date was A$6,742 (95% CI $5,637, $7,847), approximately $27,000 annually. Men had higher mean healthcare costs than women, adjusting for age, cancer type and pain levels (men $7,872, women $4,493, p<0.01) and higher expenditure on prescriptions (men $5,559, women $2,034, p<0.01).

CONCLUSIONS

In this population with pain and cancer, there was no clear relationship between healthcare costs and pain severity. These treatment patterns requiring further exploration including the prevalence of peptic ulcer/GORD drugs, and lipid lowering agents and the higher healthcare costs for men.

TRIAL REGISTRATION

ACTRN12615000064505. World Health Organisation unique trial number U1111-1164-4649. Registered 23 January 2015.

Development of an Australia and New Zealand Lung Cancer Clinical Quality Registry: a protocol paper

INTRODUCTION

Lung cancer is the leading cause of cancer mortality, comprising the largest national cancer disease burden in Australia and New Zealand. Regional reports identify substantial evidence-practice gaps, unwarranted variation from best practice, and variation in processes and outcomes of care between treating centres. The Australia and New Zealand Lung Cancer Registry (ANZLCR) will be developed as a Clinical Quality Registry to monitor the safety, quality and effectiveness of lung cancer care in Australia and New Zealand.

METHODS AND ANALYSIS

Patient participants will include all adults >18 years of age with a new diagnosis of non-small-cell lung cancer (NSCLC), SCLC, thymoma or mesothelioma. The ANZLCR will register confirmed diagnoses using opt-out consent. Data will address key patient, disease, management processes and outcomes reported as clinical quality indicators. Electronic data collection facilitated by local data collectors and local, state and federal data linkage will enhance completeness and accuracy. Data will be stored and maintained in a secure web-based data platform overseen by registry management. Central governance with binational representation from consumers, patients and carers, governance, administration, health department, health policy bodies, university research and healthcare workers will provide project oversight.

ETHICS AND DISSEMINATION

The ANZLCR has received national ethics approval under the National Mutual Acceptance scheme. Data will be routinely reported to participating sites describing performance against measures of agreed best practice and nationally to stakeholders including federal, state and territory departments of health. Local, regional and (bi)national benchmarks, augmented with online dashboard indicator reporting will enable local targeting of quality improvement efforts.

Factors Associated with Low Screening Participation and Late Presentation of Cancer amongst Women in the Pacific Island Countries and Territories: A Systematic Review

Background and Objective:

In most Pacific Island Countries and Territories (PICTs), cancer patients commonly present at very late stages and by the time the disease is diagnosed, it is often too late for treatment. This review examines the evidence on factors associated with low cancer screening participation and late presentation of cancer among women of the PICTs.

Materials and Methods:

Medline, PubMed, ProQuest and The Cumulative Index to Nursing and Allied Health Literature were searched to identify relevant studies for this review. Terms of medical subject headings was performed in combination with other key words such as “screening”, “delay”, “determinants”, “awareness”.

Results:

Eleven studies met the inclusion criteria of this review. Six factors were identified from these studies: resources and facilities, trust in the health care system, culture and tradition, modesty, awareness and socioeconomic status.

Conclusion:

Due to several barriers and factors, women in the PICTs are hindered from accessing cancer screening practices and often present late with cancer symptoms leading to advanced stage diagnosis. The findings of this study provide a foundation for future studies that could focus more in-depth to explain how these factors contribute to the presentation of cancer in late stages.

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.

Cancer Mortality in the US-Affiliated Pacific Islands, 2008-2013

Cancer-related mortality in the US-Affiliated Pacific Island (USAPI) jurisdictions is unknown. This is the first ever reporting of cancer-related mortality in the USAPI using cancer registry data. The individual USAPI jurisdictions collected incident cancer data and submitted it to the Pacific Regional Central Cancer Registry (PRCCR). All cases reported to PRCCR (n = 3,118) with vital status of dead (n = 1,323) during 2008-2013 were examined. Cause of death was coded based on clinical information provided in the cancer registry. Incidencebased mortality (IBM) rates were calculated using SEER*Stat software and age adjusted to the US standard population. Total cancer IBM rates among males were highest in Palau (151.5 per 100,000), Republic of the Marshall Islands (RMI, 142.0), and Guam (133.2); rates were lowest in American Samoa (21.7), the Commonwealth of the Northern Mariana Islands (CNMI, 22.7), and the Federated States of Micronesia (FSM, 28.9). Total cancer IBM rates among females were highest in RMI (120.3 per 100,000), Palau (107.7), and Guam (72.2); rates were lowest in CNMI (19.0), FSM (23.2), and American Samoa (42.8). The median time from cancer diagnosis to death was 8-28 days in the Freely Associated States and 102-128 days in the Flag Territories. IBM rates were higher among individuals in USAPI jurisdictions than among Asian/ Pacific Islanders in Hawai'i for many cancers preventable through vaccination, smoking cessation, overweight and obesity prevention, and cancer screening. Geographic remoteness, underreporting, delay in reporting, and challenges with accurate death registration and certification led to lower IBM rates for some jurisdictions. These mortality data can help prioritize evidence-based interventions to reduce cancer-related deaths through risk factor reduction, early detection, and improved quality of life after a cancer diagnosis through palliative care.

Perspectives of Aboriginal women on participation in mammographic screening: a step towards improving services

Background

Early detection of breast cancer using screening mammography provides an opportunity for treatment which can lead to significantly improved outcomes. Despite considerable efforts having been made, the rate at which Aboriginal and Torres Strait Islander (hereafter respectfully referred to as Aboriginal) women in Western Australia participate in BreastScreen WA’s screening mammogram program remains below that for the overall female population of Western Australia. This study aimed to examine perspectives on breast screening amongst Aboriginal women in Western Australia. We explored the factors which impact on participation in breast screening and sought to identify potential initiatives to address lower participation in screening.

Methods

Semi-structured interviews, focus group discussions and yarning sessions were conducted with a total of 65 research participants. They were all Aboriginal and comprised consumers and health professionals from locations across the state.

Results

Our findings show that research participants generally were willing to have a mammogram. Key reasons given were having a genetic predisposition to breast cancer and a perception of investing in health for the sake of the next generation, as well as personal well-being. Barriers identified included lack of education about or understanding of screening, inadequacies in cultural appropriateness in the screening program, cultural beliefs around cancer in general and breast cancer in particular, and competing health and life priorities. However, many enablers were identified which can serve as potential strategies to assuage fear and increase screening uptake. These included increased education delivered by respected Aboriginal women, culturally appropriate promotion and the provision of care and support from other women in the community.

Conclusion

The higher participation rates for Aboriginal women in Western Australia than are found for Aboriginal women nationally demonstrate the success of the strategies put in place by BreastScreen WA. These efforts must be supported and existing policies and practices enhanced to address the limitations in the existing program. Only by implementing and evaluating such initiatives and making breast screening programs more accessible to Aboriginal women can the current disparity between the screening participation rates of Aboriginal and non-Aboriginal women be reduced.

Cancer control-A global perspective

Disparities in cancer control exist in low- and middle-income countries (LMICs). Many countries do not have cancer registries to record incidence, mortality and prevalence and are reliant on Globocan estimates of their cancer burden. Poorer cancer control within and between countries occurs in those living remotely from urban centres, those in a low socioeconomic group and some ethnic groups who have lifestyle and belief systems which impact on cancer control. High-income countries generally have population screening programmes for cervix, breast and bowel cancer. However, simpler forms of screening for cancer of the cervix like visual inspection with acetic acid have been shown to be feasible in developing nations. The widespread use of vaccines to prevent cancer has been achieved with the Hepatitis B vaccine but the human papilloma virus vaccine to prevent cancer of the cervix is largely only available in high-income countries. Access to and training of oncological surgeons in LMICs is limited, while 70% of patients in these countries cannot access radiotherapy. The World Health Organization has developed a list of essential medicines although access remains poor in LMICs. The United Nations has set targets for the control of non-communicable diseases to improve global cancer control.

Equivalence of outcomes for rural and metropolitan patients with metastatic colorectal cancer in South Australia

OBJECTIVE

To compare the management and outcome of rural and metropolitan patients with metastatic colorectal cancer (mCRC) in South Australia.

DESIGN, SETTING AND PATIENTS

Retrospective cohort study of patients with mCRC submitted to the South Australian mCRC registry between 2 February 2006 and a cut-off date of 28 May 2012.

MAIN OUTCOME MEASURES

Differences in oncological and surgical management and overall survival (calculated using the Kaplan-Meier method) between city and rural patients.

RESULTS

Of 2289 patients, 624 (27.3%) were rural. There was a higher proportion of male patients in the rural cohort, but other patient characteristics did not significantly differ between the cohorts. Equivalent rates of chemotherapy administration between city and rural patients were observed across each line of treatment (first line: 56.0% v 58.3%, P = 0.32; second line: 23.3% v 22.5%, P = 0.78; and third line: 10.1% v 9.3%, P = 0.69). A higher proportion of city patients received combination chemotherapy in the first-line setting (67.4% v 59.9%; P = 0.01). When an oxaliplatin combination was prescribed, oral capecitabine was used more frequently in rural patients (22.9% v 8.4%; P < 0.001). No significant difference was seen in rates of hepatic resection or other non-chemotherapy treatments between cohorts. Median overall survival was equivalent between city and rural patients (14.6 v 14.9 months, P = 0.18).

CONCLUSION

Patterns of chemotherapy and surgical management of rural patients with mCRC in SA are equivalent to their metropolitan counterparts and lead to comparable overall survival. The centralised model of oncological care in SA may ensure rural patients gain access to optimal care.

Overview of hepatitis B prevalence, prevention, and management in the Pacific Islands and Territories

There are over 500-750 000 deaths per year because of hepatitis B virus (HBV)-related cirrhosis and liver cancer worldwide and the World Health Organization Western Pacific Region has some of the highest endemic levels of HBV in the world, particularly within China, South East Asia and Pacific Island Countries and Territories (PICT). The PICT have unique ethnic diversity and a very high prevalence of smoking and metabolic syndrome, both important risk factors for liver fibrosis and liver cancer. However, in contrast to many Asian countries, there is little published data on HBV prevalence and related liver disease burden in PICT. In this review, the available published literature and World Health Organization data for HBV prevalence and related liver disease and liver cancer burden in PICT is outlined, and unmet needs for improving HBV prevention and control in the region are highlighted.

Health service utilization by indigenous cancer patients in Queensland: a descriptive study

INTRODUCTION

Indigenous Australians experience more aggressive cancers and higher cancer mortality rates than other Australians. Cancer patients undergoing treatment are likely to access health services (e.g. social worker, cancer helpline, pain management services). To date Indigenous cancer patients' use of these services is limited. This paper describes the use of health services by Indigenous cancer patients.

METHODS

Indigenous cancer patients receiving treatment were recruited at four major Queensland public hospitals (Royal Brisbane Women's Hospital, Princess Alexandra, Cairns Base Hospital and Townsville Hospital). Participants were invited to complete a structured questionnaire during a face-to-face interview which sought information about their use of community and allied health services.

RESULTS

Of the 157 patients interviewed most were women (54.1%), of Aboriginal descent (73.9%), lived outer regional areas (40.1%) and had a mean age of 52.2 years. The most frequent cancer types were breast cancer (22.3%), blood related (14.0%), lung (12.1%) and gastroenterological (10.8%). More than half of the participants reported using at least one of the 'Indigenous Health Worker/Services' (76.4%), 'Allied Health Workers/Services' (72.6%) and 'Information Sources' (70.7%). Younger participants 19-39 years were more likely to use information sources (81.0%) than older participants who more commonly used community services (48.8%). The cancer patients used a median of three health services groups while receiving cancer treatment.

CONCLUSIONS

Indigenous cancer patients used a range of health services whilst receiving treatment. Indigenous Health Workers/Services and Allied Health Workers/Services were the most commonly used services. However, there is a need for further systematic investigation into the health service utilization by Indigenous cancer patients.

Slow progress in cancer care disparities: HIPAA, PPACA, and CHEWBACCA... but we're still not there!

The way forward in solving disparities in cancer care in the U.S. is examined.