CANCER IN NSW ABORIGINAL PEOPLES. Incidence, mortality and survival September 2012

Transcription

1 CANCER IN NSW ABORIGINAL PEOPLES Incidence, mortality and survival September 2012

2 CANCER IN NSW ABORIGINAL PEOPLES Contents Tables 1 Figures 2 Message from the Chief Cancer Officer 4 Executive summary 5 Introduction 6 Results 7 Cancer incidence by Aboriginal status 7 Incidence of major cancers from multiple imputation 8 Mortality from major cancers 21 Age-specific incidence and mortality from major cancers 30 All cancers 30 Major cancers 31 Degree of spread by Aboriginal status for major cancers 34 Survival by Aboriginal status and major cancer type 49 All cancers 50 Survival by major cancers 51 Methods 65 Cancer Registration in NSW 65 Sources of Aboriginal and/or Torres Strait Islander Status recording in the CCR 66 Missing data 67 Complete case analysis 67 Multiple imputation (MI) 68 Comparison of analyses with and without multiple imputation 71 Age standardisation 72 Survival analysis 72 Conclusions 73 Appendix 74 Appendix 1: Cancer incidence and mortality to the world population 74 Appendix 2: Glossary 83 Appendix 3: Abbreviations 84 Appendix 4: References 85 National Library of Australia Cataloguing in Publication data: Cancer in NSW Aboriginal peoples: incidence, mortality and survival SHPN (CI) ISBN Key words: Cancer, Aboriginal, New South Wales, Australia. Suggested citation: Cancer in NSW Aboriginal peoples: incidence, mortality and survival Sydney: Cancer Institute NSW, Cancer Institute NSW PO Box 41 Alexandria NSW 1435 Telephone (02) Facsimile (02) information@cancerinstitute.org.au Homepage Copyright Cancer Institute NSW This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the Cancer Institute NSW.

3 INCIDENCE, MORTALITY AND SURVIVAL Tables Table 1: Cancer incidence in Aboriginal males NSW, Table 2: Cancer incidence in non-aboriginal males, NSW, Table 3: Cancer incidence in Aboriginal females, NSW, Table 4: Cancer incidence in non-aboriginal females, NSW, Table 5: Cancer incidence in Aboriginal persons, NSW, Table 6: Cancer incidence in non-aboriginal persons, NSW, Table 7: Standardised incidence ratios of major cancers from multiple imputation, Aboriginal people compared to NSW, Table 8: Cancer mortality in Aboriginal and Non-Aboriginal males, NSW, Table 9: Cancer mortality in Aboriginal and Non-Aboriginal females, NSW, Table 10: Cancer mortality in Aboriginal and Non-Aboriginal persons, NSW, Table 11: Standardised mortality ratios, Aboriginal peoples compared to NSW, Table 12: Age-standardised incidence rates by degree of spread at diagnosis, males, NSW, Table 13: Age-standardised incidence rates by degree of spread at diagnosis, females, NSW, Table 14: Age-standardised mortality rates by degree of spread at diagnosis, males, NSW, Table 15: Age-standardised mortality rates by degree of spread at diagnosis, females, NSW, Table 16: Standardised incidence ratios by degree of spread, Aboriginal people compared to NSW, Table 17: Standardised mortality ratios by degree of spread, Aboriginal people compared to NSW, Table 18: Percentage surviving all cancers, by Aboriginal status and years since diagnosis 50 Table 19: Percentage surviving head and neck cancer, by Aboriginal status and years since diagnosis 51 Table 20: Percentage surviving oesophageal cancer, by Aboriginal status and years since diagnosis 52 Table 21: Percentage surviving stomach cancer, by Aboriginal status and years since diagnosis 53 Table 22: Percentage surviving large bowel cancer, by Aboriginal status and years since diagnosis 54 Table 23: Percentage surviving liver cancer, by Aboriginal status and years since diagnosis 55 Table 24: Percentage surviving pancreatic cancer, by Aboriginal status and years since diagnosis 56 Table 25: Percentage surviving lung cancer, by Aboriginal status and years since diagnosis 57 Table 26: Percentage surviving melanoma, by Aboriginal status and years since diagnosis 58 Table 27: Percentage surviving breast cancer, by Aboriginal status and years since diagnosis 59 Table 28: Percentage surviving cervical cancer, by Aboriginal status and years since diagnosis 60 Table 29: Percentage surviving uterine cancer, by Aboriginal status and years since diagnosis 61 Table 30: Percentage surviving ovarian cancer, by Aboriginal status and years since diagnosis 62 Table 31: Percentage of surviving prostate cancer, by Aboriginal status and years since diagnosis 63 Table 32: Percentage of surviving kidney cancer, by Aboriginal status and years since diagnosis 64 Table 33: Predictors used in multiple imputation model 69 Table 34: Odds-ratio estimates from logistic regression modelling of covariates used to inform imputation of Aboriginal status 70 Table 35: Comparison of estimated incidence from complete case and multiple imputation approaches, NSW female breast cancer, Table A1: Cancer incidence in Aboriginal males NSW, Table A2: Cancer incidence in Non-Aboriginal males NSW, Table A3: Cancer incidence in Aboriginal females NSW, Table A4: Cancer incidence in Non-Aboriginal females NSW, Table A5: Cancer incidence in Aboriginal persons NSW, Table A6: Cancer incidence in Non-Aboriginal persons NSW, Table A7: Cancer mortality in Aboriginal and Non-Aboriginal males NSW, Table A8: Cancer mortality in Aboriginal and Non-Aboriginal females NSW, Table A9: Cancer mortality in Aboriginal and Non-Aboriginal persons NSW,

4 CANCER IN NSW ABORIGINAL PEOPLES Figures Figure 1: Age-standardised incidence rates for all cancers, by multiple imputation (MI) and complete case analysis, Aboriginal and non-aboriginal people, NSW, Figure 2: Multiple imputation estimates of incidence of common cancers, Aboriginal and non-aboriginal males, NSW, Figure 3: Multiple imputation estimates of incidence of common cancers, Aboriginal and non-aboriginal females, NSW, Figure 4: Multiple imputation estimates of incidence of common cancers, Aboriginal and non-aboriginal persons, NSW, Figure 5: Standardised incidence ratios of major cancers from multiple imputation, Aboriginal male compared to NSW, Figure 6: Standardised incidence ratios of major cancers from multiple imputation, Aboriginal female compared to NSW, Figure 7: Standardised incidence ratios of major cancers from multiple imputation, Aboriginal people compared to NSW, Figure 8: Directly age-standardised mortality rates, all cancers, Aboriginal and non-aboriginal people, males and females, NSW, Figure 9: Directly age-standardised mortality rates for common cancers in Aboriginal and non-aboriginal males, NSW, Figure 10: Directly age-standardised mortality rates for common cancers in Aboriginal and non-aboriginal females, NSW, Figure 11: Directly age-standardised mortality rates for common cancers in Aboriginal and non-aboriginal persons, NSW, Figure 12: Standardised mortality ratios, Aboriginal male compared to NSW, Figure 13: Standardised mortality ratios, Aboriginal female compared to NSW, Figure 14: Standardised mortality ratios, Aboriginal people compared to NSW, Figure 15: Age-specific incidence and mortality rates for all cancers, NSW, Figure 16: Age-specific incidence and mortality rates for large bowel cancer, NSW, Figure 17: Age-specific incidence and mortality rates for lung cancer, NSW, Figure 18: Age-specific incidence and mortality rates for melanoma, NSW, Figure 19: Age-specific incidence and mortality rates for breast cancer, NSW, Figure 20: Age-specific incidence and mortality rates for cervical cancer, NSW, Figure 21: Age-specific incidence and mortality rates for prostate cancer, NSW, Figure 22: Age-standardised all-cancer incidence rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 23: Age-standardised all-cancer mortality rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 24: Age-standardised stomach cancer incidence rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 25: Age-standardised stomach cancer mortality rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 26: Age-standardised large bowel cancer incidence rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 27: Age-standardised large bowel cancer mortality rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 28: Age-standardised lung cancer incidence rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 29: Age-standardised lung cancer mortality rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 30: Age-standardised melanoma incidence rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 31: Age-standardised melanoma mortality rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 32: Age-standardised breast cancer incidence rates by Aboriginal status and degree of spread at diagnosis, NSW,

5 INCIDENCE, MORTALITY AND SURVIVAL Figure 33: Age-standardised breast cancer mortality rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 34: Age-standardised cervical cancer incidence rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 35: Age-standardised cervical cancer mortality rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 51: Kaplan-Meier survival curve for prostate cancer by Aboriginal status, Males, NSW, Figure 52: Kaplan-Meier survival curve for kidney cancer by Aboriginal status, NSW, Figure 53: Comparison of estimated incidence from complete case and multiple imputation approaches, NSW female breast cancer, Figure 36: Age-standardised prostate cancer incidence rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 37: Age-standardised prostate cancer mortality rates by Aboriginal status and degree of spread at diagnosis, NSW, Figure 38: Kaplan-Meier survival curve for all cancers by Aboriginal status, NSW, Figure 39: Kaplan-Meier survival curve for head and neck cancer by Aboriginal status, NSW, Figure 40: Kaplan-Meier survival curve for oesophageal cancer by Aboriginal status, NSW, Figure 41: Kaplan-Meier survival curve for stomach cancer by Aboriginal status, NSW, Figure 42: Kaplan-Meier survival curve for large bowel cancer by Aboriginal status, NSW, Figure 43: Kaplan-Meier survival curve for liver cancer by Aboriginal status, NSW, Figure 44: Kaplan-Meier survival curve for pancreatic cancer by Aboriginal status, NSW, Figure 45: Kaplan-Meier survival curve for lung cancer by Aboriginal status, NSW, Figure 46: MI Kaplan-Meier survival curve for melanoma by Aboriginal status, NSW, Figure 47: Kaplan-Meier survival curve for female breast cancer by Aboriginal status, NSW, Figure 48: MI Kaplan-Meier survival curve for cervical cancer by Aboriginal status, NSW, Figure 49: MI Kaplan-Meier survival curve for uterine cancer by Aboriginal status, NSW, Figure 50: MI Kaplan-Meier survival curve for ovarian cancer by Aboriginal status, Females, NSW,

6 CANCER IN NSW ABORIGINAL PEOPLES Message from the Chief Cancer Officer The health issues experienced by Aboriginal peoples are well documented and include: 12 per cent of the total burden of disease and injury from smoking in Australia; lower rates of access to acute care investigations and procedures; and lower likelihood of being treated for and surviving cancer. * The high rates of disease and poorer survival from cancer shows us that our priority is to improve the responsiveness of the health system and close the gaps for Aboriginal people with cancer, their carers and their communities. That s why improving cancer care and survival in Aboriginal communities across NSW is a key feature of the NSW Cancer Plan and we are already looking at new programs and initiatives that will help to reduce the gap in cancer outcomes in the years ahead. To be able to improve these outcomes, we need to know more about the impact of cancer on Aboriginal communities. Historically, we haven t had an accurate reading about cancer in these communities. As a result, the Cancer Institute NSW is working on improving our data recording in NSW through the Central Cancer Registry. We are now also starting to see more people identify as Aboriginal which, combined with improvements to our Registry, is providing more robust data and a clearer picture of their health outcomes. From our statistics, we ve found that much of the excess cancer incidence and mortality in Aboriginal peoples is the result of higher incidence of lung, and head and neck cancers in men and women; stomach and kidney cancers in men; and uterine and cervical cancer in women. Clearly, as most of these cancers are preventable, targeted programs potentially can mean better outcomes for Aboriginal peoples at risk of, and with, cancer. Our collaboration with Aboriginal peak bodies, stakeholders and patients in setting the goals for the Cancer Plan has been an eye-opening experience and has presented an insight into the history, the conflict and triumphs of Aboriginal peoples in Australia. We have also identified some of the language; resources and tools we can use to more effectively reach Aboriginal peoples and ultimately improve their health outcomes into the future. David Currow Chief Cancer Officer and CEO Cancer Institute NSW * outcomes.pdf 4

7 INCIDENCE, MORTALITY AND SURVIVAL Executive summary It is essential to have accurate and complete collection and recording of health information on Aboriginal and Torres Strait Islander people if we are to make informed decisions about future service provision. Historically, health information about Aboriginal peoples, including cancer statistics, has been limited due to under-recording of Aboriginal status in administrative health data collections. Over the past decade or so, a range of initiatives have been undertaken to improve the recording of Aboriginal status and much of this work has now flowed on to cancer statistics. Mortality data from 1994 onwards is considered of sufficient quality to use as recorded by the NSW Central Cancer Registry (CCR). However, in order to analyse cancer incidence and survival, and minimise recording bias in NSW Aboriginal peoples, we used multiple imputation methods for cancer diagnosed from 1999 onwards (see the Methods section in Appendix 1 for more information). This has resulted in an extra 146 and 140 cancer cases in Aboriginal men and women respectively over After imputation for unstated Aboriginal status, Aboriginal peoples were found to have 7 per cent higher incidence of cancer than for NSW overall (9 per cent higher in men, 6 per cent higher in women), which was statistically significant. Specific cancers with significantly higher incidence rates in both Aboriginal men and women include head and neck, lung and bronchus, oesophagus and liver. Men also had significantly higher rates of cancer of the stomach, pancreas and unknown primary. Women had significantly higher rates of cervical cancer. All-cancer mortality was also statistically significantly higher in Aboriginal peoples than for NSW overall, with excess cancer mortality estimated to be 69 per cent overall (68% in males, 73% in females). The differential between excess incidence and mortality indicates lower survival in Aboriginal peoples diagnosed with cancer. Significantly higher male and female Aboriginal cancer mortality was found for lung, head and neck, oesophagus, stomach, liver, pancreas, and kidney. Aboriginal men also had significantly higher mortality from bowel, prostate, and unknown primary. In Aboriginal women, excess mortality occurred from breast, cervical and uterine cancers. Outcomes for Aboriginal men with prostate cancer are particularly poor: despite significantly lower incidence of prostate cancer than NSW overall, Aboriginal men have 86 per cent higher mortality from prostate cancer. Stage of disease at diagnosis is a major prognostic indicator for cancer outcomes, and differences in degree of spread (the modified CCR staging) at diagnosis between Aboriginal and non-aboriginal people explain some of the differences in cancer mortality and survival. Overall, Aboriginal peoples have lower incidence rates of localised cancer; and in men this difference is significant. Correspondingly, they have higher rates of regional and distant cancers. Aboriginal peoples also have higher mortality across each degree of spread category despite having lower incidence of localised cancer, they have higher mortality from localised cancer. These mortality differentials are reflected in five-year cancer survival for Aboriginal peoples of 53 per cent, compared to 65 per cent for non-aboriginal people. Five-year survival for Aboriginal men and women is 49 per cent and 57 per cent respectively, compared to 64 per cent and 67 per cent in non-aboriginal men and women. 5

8 CANCER IN NSW ABORIGINAL PEOPLES Introduction The collection and recording of accurate and complete registration details about all patients and clients receiving publicly provided health services in NSW is vital for making informed decisions about services provided for the population, including Aboriginal and Torres Strait Islander peoples. Historically, statistics on Aboriginal Australians have been limited across a range of health issues due to poor identification of Aboriginal people in the various health and health-related administrative data collections. The reasons are complex and include lack of awareness and training of staff; staff reluctance to ask the question; refusal to answer the question; staff perceptions about Aboriginal people not wanting to disclose their status; perceived lack of privacy when answering the question; minimal checking and validating of the data and follow up of missing information; inadequate data management systems; and a mistrust of health services. 1 This issue also applies to cancer statistics, which in the past have been limited because of under-reporting of Aboriginal status in cancer registrations; Aboriginal people diagnosed with cancer are registered, but many of them are not identified as Aboriginal in cancer recording. In the past the cancer registers of the Northern Territory, Western Australia and South Australia have been viewed as having Aboriginal status of sufficient quality to allow publication of Aboriginal cancer incidence and mortality breakdowns, but this has not been the case for cancer registries in other jurisdictions. 2, 3 Thus, despite considerable detailed knowledge on cancer epidemiology in the NSW population and the broader Australian population, information on cancer in Aboriginal and Torres Strait Islander people is limited. In the interests of ensuring that information on the health status of Aboriginal Australians is accurately reported and enables more informed decisions about the planning and delivery of health services, a range of initiatives were undertaken in NSW to assess data quality and improve Aboriginal status recording in administrative health data collections. In the mid-1990s, NSW Health undertook an assessment of collection of Aboriginal status when patients presented to a NSW public hospital or other health care facility. As a result, staff were trained extensively and guidelines were developed to improve the recording of Aboriginal status at NSW Healthcare facilities. 4 The asking of, and recording of, Aboriginal status is mandatory for the NSW Health data collection systems. Adherence to the NSW Health 2005 policy (a re-issue of a 2002 Policy) on identifying Aboriginal status is mandatory in all facilities and Health Networks. This policy is being reviewed and new projects aimed at improving Aboriginal identification are being planned for implementation in 2011, 2012 and 2013 as part of the National Partnership Agreement Closing the Gap in Indigenous Health Outcomes. 5 A 2007 survey undertaken by NSW Health of nearly 3,000 admitted patients in 20 hospitals drawn from metropolitan, inner regional, outer regional and remote locations of NSW found that admitted patient data were 89 per cent correct in relation to Aboriginality, ranging from 82 per cent in metropolitan hospitals to 100 per cent in remote hospitals. This survey was repeated in 2010, and preliminary figures show a result similar to the 2007 survey. (NSW Health, personal communication Dr Kerry Chant). As a large proportion of notifications for cancer come from the NSW hospital system, the effects of these activities would be expected to flow through to cancer statistics in Aboriginal people. The Cancer Institute NSW has therefore undertaken an assessment of data quality in the NSW Central Cancer Registry to determine which data on Aboriginal people with cancer are now of sufficient quality to report on. This project has been undertaken in two parts: the first report describes the quality and completeness of the Aboriginal status variable in the NSW Central Cancer Registry, and describes which subsets of the data are suitable for analysis by this variable. Potential biases are discussed as well as methods to minimise them. This second report presents estimates of incidence and mortality of cancer in the NSW Aboriginal population, based on an imputation approach to assigning Aboriginal status to records in which Aboriginal status is unknown. As a final note, the Aboriginal population, both Aboriginal and Torres Strait Islander People, are referred to in this report as Aboriginal in recognition of the fact that Aboriginal people are the original inhabitants of NSW. Consequently, identification of Aboriginal people attending NSW hospitals improved significantly and hospital statistics are now considered of sufficient quality to report by Aboriginal status. 6

9 INCIDENCE, MORTALITY AND SURVIVAL Results Cancer incidence by Aboriginal status For , 146 extra cases of cancer were assigned as Aboriginal by multiple imputation in men and 140 extra cases in women. The total number of cancer cases (excluding non-melanoma skin cancer) estimated by multiple imputation for in Aboriginal men was 1,347, and in Aboriginal females was estimated to be 1,257. Mean annual incidence of all cancers was estimated by multiple imputation to be 660 per 100,000 compared to 569 per 100,000 in non-aboriginal men (Figure 1, Table 1) The mean annual incidence rate for Aboriginal women was estimated as 462 per 100,000 person years, compared to 396 per 100,000 in non-aboriginal women. For both men and women, these incidence rate differences are statistically significant. An Aboriginal man was estimated as having a one in 2.6 risk of a cancer diagnosis from birth to age 75 years, compared to 2.8 in non-aboriginal men. In Aboriginal women, the risk of cancer was estimated to be 3.5 compared to 3.8 in non-aboriginal women. Mean annual cancer incidence for all Aboriginal peoples was estimated to be 545 per 100,000 compared to 472 per 100,000 in non-aboriginal people (Tables 5 & 6). As expected, the non-imputed estimates for each subgroup were lower, but relative differences were similar, as indicated by Aboriginal : non-aboriginal incidence ratios of 1.15 and 1.20 from imputed and nonimputed estimates respectively. Figure 1: Age-standardised incidence rates for all cancers, by multiple imputation (MI) and complete case analysis, Aboriginal and non-aboriginal people, NSW, * MI_males MI_females MI_persons Males Females Persons MI_Males MI_Females MI_Persons Males Females Persons Aboriginal people Non-Aboriginal non-aboriginal people * Directly standardised to the Australian 2001 population 7

10 CANCER IN NSW ABORIGINAL PEOPLES Incidence of major cancers from multiple imputation Aboriginal men During Aboriginal men had significantly lower incidence of melanoma (34 per 100,000 person years) and nonsignificantly lower incidence of prostate cancer (145 per 100,000), non-hodgkin s lymphoma (17 per 100,000) and brain cancer (5.5 per 100,000) than non-aboriginal men (Figure 2; Table 1). These represented standardised incidence ratios (SIR) of 0.4, 0.8, 1.0 and 0.7, respectively (compared to NSW overall, Figure 5, Table 7). Cancers with significantly higher incidence in Aboriginal than non-aboriginal men were: head and neck (38 per 100,000; SIR=2.0), lung and bronchus (111 per 100,000; SIR=1.9) and stomach (26 per 100,000; SIR=1.8). Aboriginal men had non-significantly higher incidence of most other cancers including oesophageal, liver, gall bladder, pancreas, kidney, bladder and cancer of unknown primary (30 per 100,000), mesothelioma (7 per 100,000; SIR=1.5), kidney (24 per 100,000; SIR=1.4), and leukaemia (24 per 100,000; SIR=1.4) (Figure 5). Most other cancers in Aboriginal peoples either had similar incidence rates to non-aboriginal people or incident numbers were too small to judge with certainty the extent or direction of any differences. Aboriginal women Aboriginal women had significantly lower incidence rates of melanoma of the skin (20 per 100,000; SIR=0.5) and thyroid cancer (7 per 100,000; SIR=0.5) than non-aboriginal women (Figures 3 & 4; Tables 3 & 7). Non-Hodgkin s lymphoma (11 per 100,000; SIR=0.7) was borderline significantly lower, but the estimate for breast cancer, expected to be somewhat lower, was very similar to that for non-aboriginal women (116 per 100,000 compared to 113 per 100,000). Significantly higher cancer incidence occurred for cancer of the head and neck (13 per 100,000; SIR=2.0), cervix (19 per 100,000; SIR=2.4) and lung and bronchus (69 per 100,000; SIR=2.4). Liver cancer was borderline significantly higher (6 per 100,000; SIR=2.2), with incidence of most remaining cancers non-significantly higher than in non-aboriginal women. Lung cancer incidence in female Aboriginal people exceeded that in non-aboriginal men (cf. Table 2). Aboriginal peoples For Aboriginal peoples overall, the lower incidence rates of non-hodgkin s lymphoma in males and females becomes statistically significant, and the incidence of stomach, oesophageal, liver, pancreatic and kidney cancers is significantly higher than for non-aboriginal people. (Table 5 cf. Table 6). Prostate cancer is the most commonly diagnosed cancer in Aboriginal men (as in non-aboriginal men), followed by lung cancer, unlike non-aboriginal men where the second most common is large bowel cancer (Figure 2). In women, the pattern is similar: breast cancer is the most common in both Aboriginal and non-aboriginal people, but lung cancer is the next most common in Aboriginal women, while large bowel cancer is the next most common in non-aboriginal women (Figure 3). Lung cancer is the most commonly diagnosed cancer in Aboriginal peoples overall, followed by large bowel, breast and prostate (Figure 4). In summary, all-cancer incidence in Aboriginal peoples is 7 per cent higher than for NSW overall (statistically significant), but is double or more for Aboriginal women compared to all NSW women for cancers of the cervix, lung, liver, head and neck and oesophagus, despite female all-cancer incidence being 6 per cent higher than NSW (Table 7; Figures 5 & 6). In Aboriginal men, incidence is 70 per cent or higher than all NSW males for cancers of the head and neck, lung, stomach and oesophagus, with 9 per cent higher all-cancer incidence. 8

11 INCIDENCE, MORTALITY AND SURVIVAL Figure 2: Multiple imputation estimates of incidence of common cancers, Aboriginal and non-aboriginal males, NSW, * Per Prostate Lung Large bowel Head & neck Melanoma of skin Aboriginal males Unknown primary Stomach Kidney non-aboriginal Non-Aboriginal males All leukaemias Non-Hodgkin's lymphoma * Directly standardised to the Australian 2001 population Figure 3: Multiple imputation estimates of incidence of common cancers, Aboriginal and non-aboriginal females, NSW, * Breast Lung Large bowel Uterus Melanoma of skin Cervix Unknown primary Pancreas Head & neck Kidney Ovary Per 100,000 Aboriginal females Non-Aboriginal non-aboriginal females * Directly standardised to the Australian 2001 population 9

12 CANCER IN NSW ABORIGINAL PEOPLES Figure 4: Multiple imputation estimates of incidence of common cancers, Aboriginal and non-aboriginal persons, NSW, * Lung Large bowel Breast Prostate Melanoma of skin Head & neck Unknown primary Kidney All leukaemias Aboriginal persons Non-Aboriginal non-aboriginal persons Stomach Non-Hodgkin's lymphoma * Directly standardised to the Australian 2001 population 10

13 INCIDENCE, MORTALITY AND SURVIVAL Table 1: Cancer incidence in Aboriginal males NSW, (a) Cancer site Complete case method Missing (%) Cases ASR (b) 95%CI Risk to age 75 1 in Multiple imputation method Cases ASR (b) 95%CI Risk to age 75 1 in Head & neck ( ) ( ) 34 Oesophagus ( ) ( ) 86 Stomach ( ) ( ) 54 Large bowel ( ) ( ) 17 Liver ( ) ( ) 81 Gallbladder ( ) ( ) 393 Pancreas ( ) ( ) 87 Lung ( ) ( ) 12 Melanoma of skin ( ) ( ) 48 Mesothelioma ( ) ( ) 211 Prostate ( ) ( ) 10 Kidney ( ) ( ) 60 Bladder ( ) ( ) 105 Brain ( ) ( ) 262 Non-Hodgkin's lymphoma ( ) ( ) 62 Multiple myeloma ( ) ( ) 130 All leukaemias ( ) ( ) 70 Unknown primary ( ) ( ) 47 Myelodysplasia ( ) ( ) 118 All cancers (c) 1, ( ) , ( ) 2.6 (a) (b) (c) Directly standardised to the Australian 2001 population. Australian standardised rate (ASR) per 100,000 males. All cancers include C00-C96, D45-D47 and exclude non-melanoma skin cancer. 11

14 CANCER IN NSW ABORIGINAL PEOPLES Table 2: Cancer incidence in non-aboriginal males, NSW, (a) Cancer site Complete case Method Missing Cases ASR (b) 95%CI Risk to (%) age 75 1 in Multiple Imputation Method Cases ASR (b) 95%CI Risk to age 75 1 in Head & neck 5, ( ) , ( ) 59 Oesophagus 2, ( ) , ( ) 174 Stomach 3, ( ) , ( ) 107 Large bowel 20, ( ) , ( ) 17 Liver 2, ( ) , ( ) 172 Gallbladder ( ) ( ) 532 Pancreas 3, ( ) , ( ) 124 Lung 16, ( ) , ( ) 23 Melanoma of skin 10, ( ) , ( ) 23 Mesothelioma 1, ( ) , ( ) 276 Prostate 35, ( ) , ( ) 8 Kidney 4, ( ) , ( ) 73 Bladder 4, ( ) , ( ) 87 Brain 2, ( ) , ( ) 150 Non-Hodgkin s lymphoma 5, ( ) , ( ) 60 Multiple myeloma 2, ( ) , ( ) 180 All leukaemias 4, ( ) , ( ) 83 Unknown primary 5, ( ) , ( ) 77 Myelodysplasia 2, ( ) , ( ) 157 All cancers (c) 140, ( ) , ( ) 2.8 (a) (b) (c) Directly standardised to the Australian 2001 population. Australian standardised rate (ASR) per 100,000 males. All cancers include C00-C96, D45-D47 and exclude non-melanoma skin cancer. 12

15 INCIDENCE, MORTALITY AND SURVIVAL Table 3: Cancer incidence in Aboriginal females, NSW, (a) Cancer site Complete case Method Cases ASR (b) 95%CI Risk to age 75 1 in Missing (%) Multiple Imputation Method Cases ASR (b) 95%CI Risk to age 75 1 in Head & neck ( ) ( ) 81 Oesophagus ( ) ( ) 207 Stomach ( ) ( ) 173 Large bowel ( ) ( ) 29 Liver ( ) ( ) 213 Pancreas ( ) ( ) 119 Lung ( ) ( ) 19 Melanoma of the skin ( ) ( ) 74 Breast ( ) ( ) 12 Cervix ( ) ( ) 69 Uterus ( ) ( ) 65 Ovary ( ) ( ) 109 Kidney ( ) ( ) 105 Brain ( ) ( ) 174 Thyroid ( ) ( ) 173 Non-Hodgkin s lymphoma ( ) ( ) 96 All leukaemias ( ) ( ) 203 Unknown primary ( ) ( ) 73 Myelodysplasia ( ) ( ) 272 All cancers (c) 1, ( ) , ( ) 3.5 (a) (b) (c) Directly standardised to the Australian 2001 population. Australian standardised rate (ASR) per 100,000 females. All cancers include C00-C96, D45-D47 and exclude non-melanoma skin cancer. 13

16 CANCER IN NSW ABORIGINAL PEOPLES Table 4: Cancer incidence in non-aboriginal females, NSW, (a) Cancer site Complete case Method Missing Cases ASR (b) 95%CI Risk to (%) age 75 1 in Multiple Imputation Method Cases ASR (b) 95%CI Risk to age 75 1 in Head & neck 1, ( ) , ( ) 193 Oesophagus 1, ( ) , ( ) 521 Stomach 1, ( ) , ( ) 253 Large bowel 16, ( ) , ( ) 26 Liver ( ) ( ) 533 Pancreas 3,153 9 ( ) , ( ) 166 Lung 9, ( ) , ( ) 44 Melanoma of the skin 6, ( ) , ( ) 34 Breast 31, ( ) , ( ) 11 Cervix 1, ( ) , ( ) 186 Uterus 4, ( ) , ( ) 77 Ovary 3, ( ) , ( ) 112 Kidney 2, ( ) , ( ) 140 Brain 1, ( ) , ( ) 235 Thyroid 3, ( ) , ( ) 107 Non-Hodgkin s lymphoma 4, ( ) , ( ) 87 All leukaemias 3, ( ) , ( ) 142 Unknown primary 5, ( ) , ( ) 101 Myelodysplasia 2, ( ) , ( ) 249 All cancers (c) 113, ( ) , ( ) 3.8 (a) (b) (c) Directly standardised to the Australian 2001 population. Australian standardised rate (ASR) per 100,000 females. All cancers include C00-C96, D45-D47 and exclude non-melanoma skin cancer. 14

17 INCIDENCE, MORTALITY AND SURVIVAL Table 5: Cancer incidence in Aboriginal persons, NSW, (a) Cancer site Complete case Method Missing (%) Multiple Imputation Method Cases ASR (b) 95%CI Risk to age 75 1 in Cases ASR (b) 95%CI Risk to age 75 1 in Head & neck ( ) ( ) 48 Oesophagus 41 9 ( ) ( ) 125 Stomach ( ) ( ) 86 Large bowel ( ) ( ) 22 Liver ( ) ( ) 122 Pancreas ( ) ( ) 102 Lung ( ) ( ) 15 Melanoma of the skin ( ) ( ) 59 Breast ( ) ( ) 22 Cervix ( ) ( ) 130 Uterus ( ) ( ) 123 Prostate ( ) ( ) 21 Kidney ( ) ( ) 78 Bladder ( ) ( ) 158 Non-Hodgkin s lymphoma ( ) ( ) 76 Multiple myeloma ( ) ( ) 192 All leukaemias ( ) ( ) 108 Unknown primary ( ) ( ) 58 Myelodysplasia ( ) ( ) 170 All cancers (c) 2, ( ) , ( ) 3.0 (a) (b) (c) Directly standardised to the Australian 2001 population. Australian standardised rate (ASR) per 100,000 persons. All cancers include C00-C96, D45-D47 and exclude non-melanoma skin cancer. 15

18 CANCER IN NSW ABORIGINAL PEOPLES Table 6: Cancer incidence in non-aboriginal persons, NSW, (a) Cancer site Complete case Method Missing Cases ASR (b) 95%CI Risk to (%) age 75 1 in Multiple Imputation Method Cases ASR (b) 95%CI Risk to age 75 1 in Head & neck 7, ( ) , ( ) 92 Oesophagus 3, ( ) , ( ) 264 Stomach 5, ( ) , ( ) 152 Large bowel 36, ( ) , ( ) 21 Liver 3, ( ) , ( ) 262 Pancreas 6, ( ) , ( ) 142 Lung 25, ( ) , ( ) 30 Melanoma of the skin 16, ( ) , ( ) 27 Breast 31, ( ) , ( ) 21 Cervix 1, ( ) , ( ) 368 Uterus 4, ( ) , ( ) 151 Prostate 35, ( ) , ( ) 16 Kidney 7, ( ) , ( ) 97 Bladder 6, ( ) , ( ) 138 Non-Hodgkin s lymphoma 10, ( ) , ( ) 71 Multiple myeloma 3, ( ) , ( ) 221 All leukaemias 7, ( ) , ( ) 105 Unknown primary 11, ( ) , ( ) 88 Myelodysplasia 5, ( ) , ( ) 194 All cancers (c) 254, ( ) , ( ) 3.2 (a) (b) (c) Directly standardised to the Australian 2001 population. Australian standardised rate (ASR) per 100,000 persons. All cancers include C00-C96, D45-D47 and exclude non-melanoma skin cancer. 16

19 INCIDENCE, MORTALITY AND SURVIVAL Figure 5: Standardised incidence ratios of major cancers from multiple imputation, Aboriginal male compared to NSW, Head and neck Head & neck Oesophagus Oesophagus Stomach Stomach Large bowel Large bowel Liver Liver Pancreas Pancreas Lung Lung Melanoma of skin Melanoma of skin Prostate Prostate Kidney Kidney Thyroid Thyroid Non-Hodgkin s Non-Hodgkin's lymphoma lymphoma All leukaemas All leukaemias Unknown primary Unknown primary All cancers All cancers Standardised incidence ratio Standardised incidence ratio Figure 6: Standardised incidence ratios of major cancers from multiple imputation, Aboriginal female compared to NSW, Head and neck Head & neck Oesophagus Oesophagus Stomach Stomach Large bowel Large bowel Liver Liver Pancreas Pancreas Lung Lung Melanoma of Melanoma skin of skin Breast Breast Cervix Cervix Uterus Uterus Ovary Ovary Kidney Kidney Thyroid Thyroid Non-Hodgkin s Non-Hodgkin's lymphoma lymphoma All leukaemas All leukaemias Unknown primary Unknown primary All cancers All cancers Standardised Standardised incidence incidence ratio ratio 17

20 CANCER IN NSW ABORIGINAL PEOPLES Figure 7: Standardised incidence ratios of major cancers from multiple imputation, Aboriginal people compared to NSW, Head and neck Head & neck Oesophagus Oesophagus Stomach Stomach Large bowel Large bowel Liver Liver Pancreas Pancreas Lung Lung Melanoma of Melanoma skin of skin Breast Breast Cervix Cervix Uterus Uterus Ovary Ovary Prostate Prostate Testis Testis Kidney Kidney Thyroid Thyroid Non-Hodgkin's lymphoma Non-Hodgkin s lymphoma All leukaemias All leukaemas Unknown primary Unknown primary All cancers All cancers standardised incidence ratio Standardised incidence ratio 18

21 INCIDENCE, MORTALITY AND SURVIVAL Table 7: Standardised incidence ratios of major cancers from multiple imputation, Aboriginal people compared to NSW, Cancer site SIR (a) 95%CI SIR (a) 95%CI SIR (a) 95%CI Head & neck 2.00 ( ) 2.05 ( ) 2.01 ( ) Oesophagus 1.91 ( ) 1.85 ( ) 2.16 ( ) Stomach 1.65 ( ) 1.85 ( ) 1.35 ( ) Large bowel 1.00 ( ) 1.06 ( ) 0.95 ( ) Liver 1.79 ( ) 1.67 ( ) 2.21 ( ) Pancreas 1.50 ( ) 1.53 ( ) 1.49 ( ) Lung 2.10 ( ) 1.93 ( ) 2.43 ( ) Melanoma of skin 0.45 ( ) 0.44 ( ) 0.47 ( ) Mesothelioma 1.13 ( ) 1.32 ( ) 0.51 ( ) Breast 0.97 ( ) 0.94 ( ) Cervix 2.51 ( ) 2.43 ( ) Uterus 1.20 ( ) 1.16 ( ) Ovary 1.14 ( ) 1.11 ( ) Prostate 0.79 ( ) 0.82 ( ) Kidney 1.30 ( ) 1.31 ( ) 1.33 ( ) Bladder 1.01 ( ) 1.07 ( ) 0.91 ( ) Brain 0.88 ( ) 0.74 ( ) 1.08 ( ) Thyroid 0.58 ( ) 0.69 ( ) 0.54 ( ) Non-Hodgkin s lymphoma 0.86 ( ) 0.95 ( ) 0.76 ( ) Multiple myeloma 1.07 ( ) 1.24 ( ) 0.87 ( ) All leukaemias 0.98 ( ) 1.06 ( ) 0.89 ( ) Unknown primary 1.46 ( ) 1.63 ( ) 1.29 ( ) Myelodysplasia 1.27 ( ) 1.50 ( ) 1.00 ( ) All cancers (b) 1.07 ( ) 1.09 ( ) 1.06 ( ) (a) (b) Standardised incidence ratio (SIR) in Aboriginal people compared to total NSW population. All cancers include C00-C96, D45-D47 and exclude non-melanoma skin cancer. 19

22 CANCER IN NSW ABORIGINAL PEOPLES Cancer mortality by Aboriginal status During , 1,229 Aboriginal peoples were recorded as dying from cancer, 657 men and 572 women. Mean annual all-cancer mortality (excluding non-melanoma skin cancers) in NSW Aboriginal people was estimated to be 66 per cent higher than in non-aboriginal people (295 versus 178 per 100,000 persons) (Table 10; Figure 8). The standardised mortality ratio (SMR, with respect to all NSW) was 1.7 (Table 11; Figure 14). The 70 per cent excess cancer mortality in Aboriginal peoples compared to NSW is considerably higher than the excess of cancer incidence (7%), signifying lower survival in Aboriginal peoples when they are diagnosed with cancer. Aboriginal male cancer mortality was 373 per 100,000 (Table 8; Figure 8, SMR=1.7) and in women was 240 per 100,000 (Table 9; Figure 8, SMR=1.7). The Aboriginal female cancer mortality rate exceeded that of non-aboriginal males. The cumulated risk of dying from cancer over 0-75 years in Aboriginal males is 1 in 4.7 compared to 7.5 for non-aboriginal males; in females the corresponding risks are 1 in 6.5 versus 1 in Figure 8: Directly age-standardised mortality rates, all cancers, Aboriginal and non-aboriginal people, males and females, NSW, * Males Females Females Persons Aboriginal people people Non-Aboriginal non-aboriginal people people * Directly standardised to the Australian 2001 population 20

23 INCIDENCE, MORTALITY AND SURVIVAL Mortality from major cancers Lung cancer is the leading cause of cancer-related mortality in Aboriginal men and women. It is also the leading cause of cancer death in non-aboriginal men, but not in non-aboriginal women, where breast cancer is the leading cause of cancer death (Figures 9 & 10). Lung cancer mortality in Aboriginal men (91 per 100,000), is 1.9 times that of non-aboriginal men (Table 8), and the SMR is 2.0 (Table 11; Figure 12). In Aboriginal women, lung cancer mortality (58 per 100,000) is 2.7 times that of non-aboriginal women. As with lung cancer incidence, the lung cancer mortality rate in Aboriginal women exceeded that in non-aboriginal men. Aboriginal men also had significantly higher mortality from head and neck, prostate, stomach, oesophageal and unknown primary cancer than non-aboriginal men (Figure 9). Despite lower incidence of prostate cancer (Figure 2; Tables 1 & 2), prostate cancer mortality (57 per 100,000) is 85 per cent higher in Aboriginal than in non-aboriginal men (Table 8). Other major cancers with significantly higher mortality, and showing similar patterns of higher mortality than incidence ratios (compared to NSW overall), are: head and neck (SMR=3.2 vs. SIR=2.0), oesophagus (SMR=2.3 vs. SIR=1.9), large bowel (SMR=1.4 vs. SIR=1.1) leukaemia (SMR=1.4 vs. SIR=1.1), kidney (SMR=1.7 vs. SIR=1.3), and cancer of unknown primary (SMR=1.9 vs. SIR=1.6). These differences are borne out in lower survival from these cancers in Aboriginal men (see the survival section of this report). Aboriginal women have significantly higher mortality from cancer of the lung and bronchus, breast, pancreas, cervix, head and neck, and kidney than non-aboriginal women (Figure 10, Table 9). Lung cancer is the leading cause of cancer mortality in Aboriginal women, followed by breast and large bowel cancer (Figure 10). In non-aboriginal women, the leading cancer cause of death is from breast cancer, followed by lung and large bowel. The picture of mortality relative to incidence is similar to men for major cancers. Despite similar breast cancer incidence to non-aboriginal women, mortality from breast cancer in Aboriginal women is 50 per cent higher than for NSW (SMR=1.5 vs. SIR=1.0); 374 per cent higher from cervical cancer compared to 140 per cent higher incidence (SMR=4.7 vs. SIR=2.4); 221 per cent higher from cancer of the head and neck compared to 100 per cent higher incidence (SMR=3.2 vs. SIR=2.0); 105 per cent higher from uterine cancer compared to 20 per cent higher incidence (SMR=2.1 vs. SIR=1.2); 136 per cent higher from kidney cancer compared to 30 per cent higher incidence (SMR=2.4 vs. SIR=1.3); 98 per cent higher mortality from stomach cancer despite 35 per cent higher incidence (SMR=2.0 vs. SIR=1.4); and 82 higher from pancreatic cancer despite 50 per cent higher incidence (SMR=1.8 vs. SIR=1.5). In summary, Aboriginal peoples not only have significantly higher incidence of most major cancers, they also have higher mortality, such that it exceeds that expected from the higher background level of cancer incidence. That is, survival is lower in Aboriginal peoples when diagnosed with most major cancers than in non-aboriginal people. 21

24 CANCER IN NSW ABORIGINAL PEOPLES Figure 9: Directly age-standardised mortality rates for common cancers in Aboriginal and non-aboriginal males, NSW, * Lung Prostate Large bowel Unknown primary Stomach Head & neck Pancreas All leukaemias Oesophagus Kidney Aboriginal males Non-Aboriginal males * Directly standardised to the Australian 2001 population Figure 10: Directly age-standardised mortality rates for common cancers in Aboriginal and non-aboriginal females, NSW, * Pper 100, Lung Breast Large bowel Pancreas Unknown primary Cervix Ovary Stomach Kidney Head & neck Aboriginal females Non-Aboriginal females * Directly standardised to the Australian 2001 population 22

25 INCIDENCE, MORTALITY AND SURVIVAL Figure 11: Directly age-standardised mortality rates for common cancers in Aboriginal and non-aboriginal persons, NSW, * Lung Large bowel Prostate Breast Unknown primary Pancreas Stomach Head & neck All leukaemias Kidney Aboriginal persons Non-Aboriginal persons * Directly standardised to the Australian 2001 population 23

26 CANCER IN NSW ABORIGINAL PEOPLES Table 8: Cancer mortality in Aboriginal and Non-Aboriginal males, NSW, (a) Cancer sites Aboriginal Deaths ASR (b) 95%CI Risk to age 75 1 in Non-Aboriginal M:I Deaths ASR (b) 95%CI Risk to Ratio (c) age 75 1 in Head & neck ( ) , ( ) Oesophagus ( ) , ( ) Stomach ( ) , ( ) Large bowel ( ) , ( ) Liver ( ) , ( ) Pancreas ( ) , ( ) Lung ( ) , ( ) Melanoma of skin ( ) , ( ) Prostate ( ) , ( ) Kidney ( ) , ( ) Bladder ( ) , ( ) Brain ( ) , ( ) Non-Hodgkin s lymphoma M:I Ratio (c) ( ) , ( ) All leukaemias ( ) , ( ) Unknown primary ( ) , ( ) All cancers (d) ( ) , ( ) (a) (b) (c) (d) Directly standardised to the Australian 2001 population. males. M:I Ratio - Mortality rate versus Multiple Imputation incidence rate All cancers include C00-C96, D45-D47 and exclude non-melanoma skin cancer. 24