The uneven playing field: Inequi3es in cancer care and outcomes in New Zealand

Transcription

1 The uneven playing field: Inequi3es in cancer care and outcomes in New Zealand

2 Māori: Indigenous New Zealanders British colonisation Māori now 15% NZ pop Health inequalities

3 All cancers, incidence and mortality per 100,000 by Rate deprivation per 100,000 decile for Maori both Non-Maori sexes, age-standardised Māori Non-Maori 250 Incidence Rate 1per 100, NZDep deciles NZ DEP2001 decile Māori Non-Māori Māori Non-Maori 120 Mortality Richer NZDep deciles NZDep2001 decile (1=least deprived, 10=most deprived) Poorer

4 Survival rates are improving over 3me Excess mortality rate has been reducing by 27% each 10 years since early 1990 s for those diagnosed with colorectal cancer Soeberg M, Blakely T, Sarfati D et al (2012). Cancer Trends: Trends in Survival by Ethnic and Socioeconomic Group, New Zealand Wellington: University of Otago and Ministry of Health.

5 Not all good news (inequi3es) Soeberg M, Blakely T, Sarfati D et al (2012). Cancer Trends: Trends in Survival by Ethnic and Socioeconomic Group, New Zealand Wellington: University of Otago and Ministry of Health.

6 Why ethnic inequi3es in cancer survival? More aggressive/ advanced tumours? Pa3ent comorbidity? Health care quality and/or access?

7 Ethnic inequi3es in colon cancer survival 40% Excess mortality risk (Maori/non-Maori) 30% 20% 10% Comorbidity and treatment/health service factors each accounted for a third of the survival difference. 0% Unadjusted Demographics + Disease factors + Patient factors Risk adjustments + Treatment + Health service access Hill S, Sarfa3 D et al. Cancer. 2010: 116;

8 Ethnic inequi3es in colon cancer survival Percentage of cohort (stage III) Referred to oncologist Reviewed by oncologist Offered adjuvant chemo Received adjuvant chemo Started within 8 weeks 10 0 Māori non-māori Hill S, Sarfa3 D, et al J Epidemiol Comm Health 2010: 64;

9 Not just colon cancer è Māori were four,mes less likely to receive cura,ve rather than pallia,ve an,cancer treatment for nonmetasta,c disease compared with Europeans è even a;er adjus,ng for age, gender, NZDep, CCI [comorbidity], tumor type, stage and pa,ent declining management. Stevens W, Stevens G et al. Ethnic differences in the management of lung cancer in NZ. J Thoracic Oncol 2008.

10 Liver and stomach cancers

11 Liver cancer Age- standardised incidence rates per 100,000: Males 25+ yr Māori Pacific Euro Blakely T, et al. (2010) Cancer Trends: Trends in Incidence by Ethnic and Socioeconomic Group, New Zealand Wellington

12 (%) No Risk Factors Age standardised percentage of liver cancer pa,ents with viral hepa,,s (95% CI) Hepa33s B Hepa33s C Hepa,,s status Unknown Maori Non- Maori Chamberlain J. Sarfa3 D et al. Incidence and management of hepatocellular carcinoma among Maori and non- Maori New Zealanders, Aust NZ J Public Health 2013).

13 Stomach cancer ge- standardised incidence rates per 100,000: Males 25+ yr Māori Pacific Euro Blakely T, et al. (2010) Cancer Trends: Trends in Incidence by Ethnic and Socioeconomic Group, New Zealand Wellington

14 Es3mated seroprevalence of H Pylori by birth cohort and ethnicity in New Zealand 100% 90% 80% 70% 60% 50% 40% 30% Pacific Māori European 20% 10% 0% Birth Cohort McDonald A, Sarfa3 D, Baker M, Blakely T Trends in Helicobacter pylori infec,on among Māori, Pacific and European birth cohorts in New Zealand. Paper under review

15 Methods Hospital note review of 780 pa3ents diagnosed rectal, 189 liver, 335 stomach final cohorts Equal number Māori and non- Māori Detailed data on pa3ent, tumour and treatment factors Small sample sizes, so most results should be considered indica3ve only

16 Characteris3cs at diagnosis Liver Stomach (n=189) (n=335) % male 80% 62% Age at presenta3on Māori 59y 60y Non Māori 65y 70y Stage 3-4 at diagnosis Māori 67% 62% Non Māori 65% 69%

17 Chamberlain J. Sarfa3 D et al. Incidence and management of hepatocellular carcinoma among Maori and non- Maori New Zealanders (ANZJPH 2013). Liver cancer: Treatment Only one in five pa3ents underwent defini3ve surgery Two- thirds (64%) were referred immediately to pallia3ve care No (detectable) difference between Māori and non- Māori pa3ents

18 Stomach cancer Treatment: Some things looked similar Stage and Grade Wai3ng 3mes through the pathway % receiving Cura3ve surgery for stage I III pa3ents % receiving Chemo pre/post opera3ve for stage I III pa3ents BUT. other things looked different Signal V, Sarfa3 D, et al. Indigenous inequi3es in the presenta3on and management of stomach cancer in New Zealand: a country with universal health care coverage. Gastric Cancer (in press).

19 Stomach tumour site (age sex adjusted) % cases Proximal Distal 10 0 Māori Non- Māori

20 Māori less likely to: Have specialist upper GI surgeon (38% vs 79%, p<0.01) Have surgery in a main centre (43% vs 83%, p<0.01) This remained when stra3fied by surgery type Signal V, Sarfa3 D, et al. Indigenous inequi3es in the presenta3on and management of stomach cancer in New Zealand: a country with universal health care coverage. Gastric Cancer (in press).

21 Chamberlain J. Sarfa3 D et al. Incidence and management of hepatocellular carcinoma among Maori and non- Maori New Zealanders (ANZJPH 2013). Liver cancer: Survival Poor survival Mortality hazard ra3o for Maori compared with non- Maori, adjusted for age, sex and stage = 1.36 ( )

22 Stomach cancer: Survival Poor survival Mortality hazard ra3o for Maori compared with non- Maori, adjusted for age, sex and stage = 1.21 ( ) Signal V, Sarfa3 D, et al. Indigenous inequi3es in the presenta3on and management of stomach cancer in New Zealand: a country with universal health care coverage. Gastric Cancer (in press).

23 Liver and stomach cancers Major driver of incidence is infec3ous disease Hep B/C H Pylori Both associated with depriva3on esp high levels of housing overcrowding Both tend to present late and have poor prognosis

24 Take home messages Inequity in cancer outcomes occur at every stage of the process: Distribu3on of determinants of health Access to resources, depriva3on, overcrowding Access to health care Including screening and immunisa3on Primary care Processes within health care

25 Where to from here? Primary preven3on Screening Minimum treatment standards Data availability