A community based intervention for rural Maori at risk of lung cancer

Transcription

1 A community based intervention for rural Maori at risk of lung cancer Ross Lawrenson, Jacquie Kidd, Chunhuan Lao, Rawiri Keenan, Anna Rolleston, Brendan Hokowhitu, Denise Aitken, Janice Wong

2 Background 2000 New Zealanders are diagnosed with lung cancer each year. Lung cancer is the leading cause of cancer deaths in NZ with 1650 deaths per year. Māori have 2-3 times the incidence of lung cancer compared to NZ European. Much of the reason for the poor outcomes in lung cancer is that it is typically diagnosed at a late stage.

3 Role of General Practice Prevention Diagnosis Supportive care after diagnosis Ongoing monitoring Palliative care

4 Incidence of Lung Cancer vs Death Rate (per 100,000) in NZ

5 Incidence of Lung Cancer vs Death Rate (per 100,000) in NZ

6 Incidence of Lung Cancer (per 100,000) Māori vs NZ

7 Lung Cancer Deaths (per 100,000) for all NZ vs Māori

8 Male cancer mortality rates ( ), by site, 25+ years

9 Female cancer mortality rates ( ), by site, 25+ years

10 Prevention In 2015/16 the target was that 90% of PHO enrolled patients who smoke have been offered help to quit smoking by a health care practitioner in the last 15 months.

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12 Early diagnosis Localised lung cancer can be cured if found early enough. In the US lobectomy for early stage lung cancer showed an 80% cure rate. Does screening for lung cancer work?

13 Screening The National Lung Screening Trial (NLST) was conducted to determine whether screening with low-dose CT could reduce mortality from lung cancer. Enrolled 53,454 persons at high risk. Participants were randomly assigned to undergo three annual screenings with either low-dose CT or single-view PA chest radiography. There were 247 deaths from lung cancer per 100,000 personyears in the low-dose CT group and 309 deaths per 100,000 person-years in the radiography group, representing a relative reduction in mortality from lung cancer with low-dose CT screening of 20.0% (95% CI, 6.8 to 26.7; P = 0.004). N Engl J Med August 4; 365(5):

14 Screening CT 7049 positive tests, 5089 procedures, 270 new cases X-ray 2348 positive tests, 1414 procedures, 136 new cases

15 Queensland study The Queensland Lung Cancer Screening Study is an ongoing, prospective observational study of screening by LDCT at a single tertiary institution. Healthy volunteers at high risk of lung cancer (age years; smoking history 30 pack years, current or quit within 15 years; forced expiratory volume in 1s >50% predicted) are recruited from the general public through newspaper advertisement and press release. Participants receive a LDCT scan of the chest at baseline, year 1 and year 2 using a multidetector helical computed tomography scanner and are followed up for a total of 5 years.

16 Screening Detection in blood of autoantibodies to tumour antigens as a case-finding method in lung cancer using the EarlyCDT -Lung Test (ECLS): study protocol for a randomized controlled trial

17 Screening The Waikato Medical Research Foundation has just given Dr Tim Edwards of University of Waikato $30,000 dollars to kick off the research. He and his team are training pet dogs, including his own dog Tui, to sniff breath and saliva samples from the Waikato District Health board's respiratory clinic.

18 Early diagnosis Over a third of lung cancer patients present directly to ED as the first presentation, without evidence of a GP referral. Late diagnosis can be due to a variety of factors including patient factors, system factors and the characteristics of the cancer. The Model of Pathways to Treatment recognises four key intervals to treatment: symptom appraisal, the help-seeking interval, diagnostic interval and pre-treatment interval.

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20 Early diagnosis Many Māori live in rural areas where GP shortages and a lack of continuity of care mean poorer access. It maybe for Māori there are also cultural barriers.

21 HDC Report The Health & Disability Commissioner (HDC) noted in their report on Delayed Diagnosis of Cancer in Primary Care that issues around a lung cancer diagnosis was one of the commonest causes of complaint. Reasons for delay by GPs included the presence of comorbidities drawing focus away from the lung cancer diagnosis, and inappropriate reliance on a test. Thus a negative chest X-ray is likely to reassure a GP that lung cancer is not present whereas it is not uncommon on CT to discover cancer that was not apparent on X-ray.

22 HRC 17/438 Improving early access to lung cancer diagnosis for Māori and Rural Communities R Lawrenson, B Hokowhitu, J Kidd, R Keenan, C Lao, J Wong, L Chepulis, S Cassim, D Aitken, A Rolleston, M Firth

23 Design This study will take a kaupapa Māori approach. A key emphasis is on the relationship between the research team and the community. This means that community engagement prior to the research, communication throughout the project and ongoing dissemination and discussions after the project ends are prioritised. The framework enables each process and mechanism within the intervention to be viewed in isolation as well as in its entirety.

24 Community involvement We will identify six rural localities (approx. size 15,000) with the highest number/incidence of Māori patients with lung cancer. We will undertake the co-design of a community based intervention to be trialled in three study populations vs three control populations. The framework for the intervention will be informed by the findings of the qualitative studies. Following this research the intervention will be tailored, implemented and evaluated.

25 Symptoms include: a persistent, worsening cough coughing up excessive phlegm with blood chest pain with coughing or breathing recurring chest infections.

26 Outcomes Improve stage at diagnosis Improve surgical treatment rates Improve survival

27 Data Cleaned Midland Register from 2011 to 2015 (this is ongoing) Data from NZStats Cancer Registry data for Midland Cancer Network 2011 to 2015 Mortality data

28 Midland Lung cancer registry Number of lung cancer cases registered in the MLCR and the NZCR Dataset Year of diagnosis Total ( ) MLCR (375) 1629 NZCR Combined* Dataset DHB Bay of Plenty Lakes Tairawhiti Waikato Total ( ) MLCR NZCR Combined*

29 Type of lung cancer in combined dataset Cell type Number Percentage NSCLC % Small Cell % Mesothelioma % NSCLC-other % Malignant Carcinoid % Other 9 0.5% Unknown (485) Total 1745(2230) 100%

30 Ethnicity and lung cancer by DHB: in combined dataset Ethnicity Bay of Plenty Lakes Tairawhiti Waikato Total N % N % N % N % N % Māori % % 85 58% % % Pacific 5 1% 1 0% 0% 19 2% 25 1% Others % % 61 42% % % Total

31 Ethnicity by stage: in combined dataset Stage Māori Pacific Others Total N % N % N % N % % 1 4% % % % 0% 72 5% 103 5% % 4 17% % % 2 or % 1 4% 28 2% 39 2% % 18 75% % % Unknown 73 12% 1 4% % % Total

32 Surgery by ethnicity: in MLCR 176/1629 (10.8% received surgery) Surgery type Māori Pacific Others Total N % N % N % N % Lobectomy 42 8% 1 5% 96 9% 139 9% Pneumonectomy % 9 1% Segmentectomy % 1 0% Sternotomy 2 0% 0 1 0% 3 0% Wedge resection 6 1% % 27 2% No surgery % 18 95% % % Total

33 All-cause survival by ethnicity: in the 2138 lung cancer case in NZCR Follow-up time All-cause survival Māori Non-Māori P-value (chi-square test) 6 months 54.3% 50.6% year 34.8% 36.0% 2 years 16.0% 21.6% 5 years 5.0% 11.9%

34 Urban rural differences Midland Region Main Urban Areas Hamilton is divided into three urban zones: Hamilton Urban Zone Cambridge Urban Zone: includes Leamington Te Awamutu Urban Zone: includes Kihikihi Tauranga: Omokoroa to Papamoa Beach; and Mount Maunganui to Tauriko and Pyes Pa Rotorua: Ngongotaha to Owhata Gisborne: Makaraka to Okitu

35 Urban Rural differences Subgroups Main urban Others P-value (Chi-square test) Age group (years) < % % % % % % % % % % Gender Female % % Male % %

36 Urban Rural differences Ethnicity Asian % 7 0.9% European % % Māori % % Pacific % % Others 5 0.4% 0 0.0% Unknown 3 2 Smoking status Current smoker % % Ex-smoker % % Never smoked % % Unknown

37 Urban rural differences -stage Cancer stage % % % % % % % % Unknown Cell type NSCLC % % NSCLC-other % % Small cell % % Malignant Carcinoid 4 0.4% 1 0.1% Others % 5 0.7% Unknown

38 Urban rural differences - surgery Surgery 0.90 Had surgery % % No surgery % % Unknown

39 Survival Kaplan-Meier all-cause survival curve for main urban patients and others Log rank test p-value=0.102

40 Ongoing monitoring and palliative care Many lung cancer patients are discharged back to their GP for ongoing care Can be post surgery with requirements to follow up Many will be offered palliative care from the outset.

41 Questions What are the barriers to early diagnosis of lung cancer? What are the barriers for Maori? What can be done to improve early diagnosis?

42 Summary Focus is on improving outcomes from lung cancer through earlier diagnosis Use mixed methods with initial focus on Māori Lung cancer register is a key tool to help measure outcomes need intermediate outcome measures Look to Midland Lung Cancer Work Group for guidance as project progresses