Lung cancer treatment and mortality for Aboriginal people in New South Wales, Australia: results from a population-based record linkage study and medical record audit.

BACKGROUND: The aim of this study was to compare surgical treatment received by Aboriginal and non-Aboriginal people with non-small cell lung cancer (NSCLC) in New South Wales (NSW), Australia and to examine whether patient and disease characteristics are associated with any disparities found. An additional objective was to describe the adjuvant treatments received by Aboriginal people diagnosed with NSCLC in NSW. Finally, we compared the risk of death from NSCLC for Aboriginal and non-Aboriginal people. METHODS: We used logistic regression and competing risks regression to analyse population-based cancer registry records for people diagnosed with NSCLC in NSW, 2001-2007, linked to hospital inpatient episodes and deaths. We also analysed treatment patterns from a medical record audit for 170 Aboriginal people diagnosed with NSCLC in NSW, 2000-2010. RESULTS: Of 20,154 people diagnosed with primary lung cancer, 341 (1.7%) were Aboriginal. Larger proportions of Aboriginal people were younger, female, living outside major cities or in areas of greater socioeconomic disadvantage, smoking at the time of diagnosis and had comorbidities. Although Aboriginal people were, on average, younger at diagnosis with non-metastatic NSCLC than non-Aboriginal people, only 30.8% of Aboriginal people received surgery, compared with 39.5% of non-Aboriginal people. Further, Aboriginal people who were not receiving surgery, at the time of diagnosis, were more likely to be younger, live in major cities and have no comorbidities. The observed risk of death from NSCLC 5 years after diagnosis was higher for 266 Aboriginal people (83.3% 95% CI 77.5-87.7) than for 15,491 non-Aboriginal people (77.6% 95% CI 76.9-78.3) and the adjusted subhazard ratio was 1.32 (95% CI 1.14-1.52). From the medical record audit, 29% of Aboriginal people with NSCLC had potentially curative treatment, 45% had palliative radiotherapy/chemotherapy and 26% had no active treatment. CONCLUSIONS: There are disparities in NSCLC surgical treatment and mortality for Aboriginal people compared with non-Aboriginal people in NSW. It is imperative that Aboriginal people are offered active lung cancer treatment, particularly those who are younger and without comorbidities and are therefore most likely to benefit, and are provided with assistance to access it if required.

Comparing colorectal cancer treatment and survival for Aboriginal and non-Aboriginal people in New South Wales.

OBJECTIVES: Our aim was to compare surgical treatment rates and survival rates for Aboriginal and non-Aboriginal people in New South Wales with colorectal cancer, and to describe the medical treatment received by a sample of Aboriginal people with colorectal cancer. DESIGN, SETTING AND PARTICIPANTS: All people diagnosed with colorectal cancer in NSW during 2001-2007 were identified and their cancer registry records linked to hospital admissions data and death records. A medical records audit of a sample of Aboriginal people diagnosed with colorectal cancer during 2000-2011 was also conducted. MAIN OUTCOME MEASURES: Cause-specific survival, odds of surgical treatment, and the proportions of people receiving adjuvant treatments. RESULTS: Of 29 777 eligible colorectal cancer cases, 278 (0.9%) involved Aboriginal people. Similar proportions of Aboriginal (76%) and non-Aboriginal (79%) people had undergone surgical treatment. Colorectal cancer-specific survival was similar for Aboriginal and non-Aboriginal people up to 18 months after diagnosis, but 5 years post-diagnosis the risk of death for Aboriginal people who had had surgical treatment was 68% higher than for non-Aboriginal people (adjusted hazards ratio, 1.68; 95% CI, 1.32-2.09). Of 145 Aboriginal people with colorectal cancer identified by the medical records audit, 117 (81%) had undergone surgery, and 56 (48%) had also received adjuvant chemotherapy and/or radiotherapy. CONCLUSIONS: Aboriginal people with colorectal cancer had poorer survival rates than non-Aboriginal people, although rates of surgical treatment, complications and follow-up colonoscopy were similar. More work is needed to identify and understand why outcomes for Aboriginal people with colorectal cancer are different from those of other New South Wales residents.

Prostate cancer mortality outcomes and patterns of primary treatment for Aboriginal men in New South Wales, Australia.

OBJECTIVE: To compare prostate cancer mortality for Aboriginal and non-Aboriginal men and to describe prostate cancer treatments received by Aboriginal men. PATIENTS AND METHODS: We analysed cancer registry records for all men diagnosed with prostate cancer in New South Wales (NSW) in 2001-2007 linked to hospital inpatient episodes and deaths. More detailed information on androgen-deprivation therapy and radiotherapy was obtained from medical records for 87 NSW Aboriginal men diagnosed in 2000-2011. The main outcomes were primary treatment for, and death from, prostate cancer. Analysis included Cox proportional hazards regression and logistic regression. RESULTS: There were 259 Aboriginal men among 35,214 prostate cancer cases diagnosed in 2001-2007. Age and spread of disease at diagnosis were similar for Aboriginal and non-Aboriginal men. Prostate cancer mortality 5 years after diagnosis was higher for Aboriginal men (17.5%, 95% confidence interval (CI) 12.4-23.3) than non-Aboriginal men (11.4%, 95% CI 11.0-11.8). Aboriginal men were 49% more likely to die from prostate cancer (hazard ratio 1.49, 95% CI 1.07-1.99) after adjusting for differences in demographic factors, stage at diagnosis, health access and comorbidities. Aboriginal men were less likely to have a prostatectomy for localised or regional cancer than non-Aboriginal men (adjusted odds ratio 0.60, 95% CI 0.40-0.91). Of 87 Aboriginal men with full staging and treatment information, 60% were diagnosed with localised disease. Of these, 38% had a prostatectomy (± radiotherapy), 29% had radiotherapy only and 33% had neither. CONCLUSION: More research is required to explain differences in treatment and mortality for Aboriginal men with prostate cancer compared with non-Aboriginal men. In the meantime, ongoing monitoring and efforts are needed to ensure Aboriginal men have equitable access to best care.

Are Aboriginal people more likely to be diagnosed with more advanced cancer?

OBJECTIVE: To determine whether Aboriginal people in New South Wales were diagnosed with more advanced cancer than non-Aboriginal people. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional study of cancer cases, excluding lymphohaematopoietic cancers and cancers of unknown primary site, diagnosed in NSW in 2001-2007. MAIN OUTCOME MEASURE: Spread of disease at time of cancer diagnosis. RESULTS: Overall, 40.3% of 2039 cancers in Aboriginal people and 46.6% of 191 954 cancers in non-Aboriginal people were localised at diagnosis. After adjusting for age, sex, year of diagnosis, area of residence and socioeconomic status, Aboriginal people had significantly higher risks of regional or distant spread for head and neck cancer, relative to localised spread, than non-Aboriginal people (regional: adjusted relative risk ratio [RRR], 1.89; 95% CI, 1.21-2.98; distant: adjusted RRR, 3.40; 95% CI, 1.85-6.05; P < 0.001). For breast, cervical and prostate cancers and melanoma, the risks of regional or distant spread were higher for Aboriginal people, but these differences were not statistically significant. For lung, colorectal, upper gastrointestinal tract, other gynaecological, and eye, brain and central nervous system cancers, the risks of regional, distant and unknown spread of cancer were similar for Aboriginal and non-Aboriginal people. CONCLUSION: Aboriginal people were more likely than non-Aboriginal people to be diagnosed with more advanced cancer for only a few cancer types, most notably head and neck cancers. Differences in spread of disease at diagnosis are unlikely to explain much of the survival differences observed across a wide range of cancers between Aboriginal and non-Aboriginal people in NSW.

Increasing rates of surgical treatment and preventing comorbidities may increase breast cancer survival for Aboriginal women.

BACKGROUND: Lower breast cancer survival has been reported for Australian Aboriginal women compared to non-Aboriginal women, however the reasons for this disparity have not been fully explored. We compared the surgical treatment and survival of Aboriginal and non-Aboriginal women diagnosed with breast cancer in New South Wales (NSW), Australia. METHODS: We analysed NSW cancer registry records of breast cancers diagnosed in 2001-2007, linked to hospital inpatient episodes and deaths. We used unconditional logistic regression to compare the odds of Aboriginal and non-Aboriginal women receiving surgical treatment. Breast cancer-specific survival was examined using cumulative mortality curves and Cox proportional hazards regression models. RESULTS: Of the 27 850 eligible women, 288 (1.03%) identified as Aboriginal. The Aboriginal women were younger and more likely to have advanced spread of disease when diagnosed than non-Aboriginal women. Aboriginal women were less likely than non-Aboriginal women to receive surgical treatment (odds ratio 0.59, 95% confidence interval (CI) 0.42-0.86). The five-year crude breast cancer-specific mortality was 6.1% higher for Aboriginal women (17.7%, 95% CI 12.9-23.2) compared with non-Aboriginal women (11.6%, 95% CI 11.2-12.0). After accounting for differences in age at diagnosis, year of diagnosis, spread of disease and surgical treatment received the risk of death from breast cancer was 39% higher in Aboriginal women (HR 1.39, 95% CI 1.01-1.86). Finally after also accounting for differences in comorbidities, socioeconomic disadvantage and place of residence the hazard ratio was reduced to 1.30 (95% CI 0.94-1.75). CONCLUSION: Preventing comorbidities and increasing rates of surgical treatment may increase breast cancer survival for NSW Aboriginal women.

Validity of registry data: agreement between cancer records in an end-stage kidney disease registry (voluntary reporting) and a cancer register (statutory reporting).

AIMS: End-stage kidney disease registries inform outcomes and policy. Data quality is crucial but difficult to measure objectively. We assessed agreement between incident cancer reported to the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) and to the Central Cancer Registry (CCR) in New South Wales. METHODS: ANZDATA records were linked to CCR using probabilistic matching. We calculated agreement between registries for patients with > or =1 cancers, all cancers and site-specific cancer using the kappa statistic (kappa). We investigated cases where records disagreed and compared estimates of cancer risk based either on ANZDATA or on CCR using standardized incidence ratios (indirect standardization by age, sex and calendar year). RESULTS: From 1980 to 2001, 9453 residents had dialysis or transplantation. ANZDATA recorded 867 cancers in 779 (8.2%) registrants; CCR 867 cancers in 788 (8.3%). ANZDATA recorded 170 patients with cancer that CCR did not, CCR recorded 179 patients that ANZDATA did not (kappa = 0.76). ANZDATA had sensitivity 77.3% (confidence interval (CI) 74.2-80.2), specificity 98.1% (CI 97.7-98.3) if CCR records were regarded as the reference standard. Agreement was similar for diagnoses while receiving dialysis (kappa = 0.78) or after transplantation (kappa = 0.79), but varied by cancer type. Agreement was poorest for melanoma (kappa = 0.61) and myeloma (kappa = 0.47) and highest for lymphoma (kappa = 0.80), leukaemia (kappa = 0.86) and breast cancer (kappa = 0.85). Artefact accounted for 20.8% of the non-concordance but error and misclassification did occur in both registries. Estimates of cancer risk based on ANZDATA or CCR records did not differ in any important way. CONCLUSION: Agreement of cancer records between both registries was high and differences largely explicable. It is likely that both ANZDATA and CCR have some inaccuracies, for reasons that are now more explicit, with themes similar to those likely to be experienced by other registries.

Cancer mortality in Aboriginal people in New South Wales, Australia, 1994-2002.

OBJECTIVE: To describe, for the first time, mortality from cancer for Aboriginal residents of New South Wales (NSW). METHODS: These are the results of a descriptive study of cancer deaths from the NSW Central Cancer Registry for 1994 to 2002. Standardised mortality ratios were calculated with Poisson confidence intervals to compare the relative rates in the Indigenous and non-Indigenous populations. RESULTS: The overall standardised mortality rates were 66% higher for males and 59% higher for females for Aboriginal people compared with non-Indigenous people. Mortality from lung cancer was 50% and 100% higher than for NSW non-Indigenous males and females respectively. The high mortality rate from cervical cancer in Aboriginal females is contrary to the trends in the general population since the introduction of free population-based screening. CONCLUSIONS: For the first time, data are available for cancer mortality for Aboriginal people in NSW. Mortality for all cancers combined was higher than that of the non-Indigenous population. This suggests that a combination of later diagnoses and perhaps poorer treatment outcomes as well as being diagnosed with poorer prognosis cancers is occurring in Aboriginal people of NSW. IMPLICATIONS: It was possible to increase the rate of identification in a population register using routinely collected data, but the completeness and accuracy of Indigenous status should, and can, be improved in all notifying data collections. Public health planners in NSW can now begin to address the issues of prevention, treatment and palliation of cancer in Aboriginal people with local, rather than imputed, evidence.

Cancer incidence and mortality in people aged less than 75 years: changes in Australia over the period 1987-2007.

BACKGROUND: Australia has one of the highest rates of cancer incidence worldwide and, despite improving survival, cancer continues to be a major public health problem. Our aim was to provide simple summary measures of changes in cancer mortality and incidence in Australia so that progress and areas for improvement in cancer control can be identified. METHODS: We used national data on cancer deaths and newly registered cancer cases and compared expected and observed numbers of deaths and cases diagnosed in 2007. The expected numbers were obtained by applying 1987 age-sex specific rates (average of 1986-1988) directly to the 2007 population. The observed numbers of deaths and incident cases were calculated for 2007 (average of 2006-2008). We limited the analyses to people aged less than 75 years. RESULTS: There was a 28% fall in cancer mortality (7827 fewer deaths in 2007 vs. 1987) and a 21% increase in new cancer diagnoses (13,012 more diagnosed cases in 2007). The greatest reductions in deaths were for cancers of the lung in males (-2259), bowel (-1797), breast (-773) and stomach (-577). Other notable falls were for cancers of the prostate (-295), cervix (-242) and non-Hodgkin lymphoma (-240). Only small or no changes occurred in mortality for cancers of the lung (female only), pancreas, brain and related, oesophagus and thyroid, with an increase in liver cancer (267). Cancer types that showed the greatest increase in incident cases were cancers of the prostate (10,245), breast (2736), other cancers (1353), melanoma (1138) and thyroid (1107), while falls were seen for cancers of the lung (-1705), bladder (-1110) and unknown primary (-904). CONCLUSIONS: The reduction in mortality indicates that prevention strategies, improvements in cancer treatment, and screening programmes have made significant contributions to cancer control in Australia since 1987. The rise in incidence is partly due to diagnoses being brought forward by technological improvements and increased coverage of screening and early diagnostic testing.

Prostate cancer and prostate-specific antigen testing in New South Wales.

OBJECTIVE: To describe trends in prostate-specific antigen (PSA) testing, prostate cancer incidence and mortality in New South Wales. DESIGN AND SETTING: Descriptive analysis using routinely collected data of observed trends in PSA testing from 1989 to 2006, and prostate cancer cases and deaths from 1972 to 2005 in NSW. MAIN OUTCOME MEASURES: Age-standardised and age-specific rates and joinpoint regression to identify changes in trends; projected trends observed before the introduction of PSA testing to quantify its impact on incidence and mortality rates. RESULTS: The number of PSA tests per year more than doubled between 1994 and 2006. Age-standardised incidence of prostate cancer peaked in 1994, fell by 10.0% per year to 1998 and then increased by 4.9% per year from 2001 to 2005. An estimated 19 602 (43%) more men than expected from preceding trends were diagnosed with prostate cancer between 1989 and 2005 after PSA testing was introduced. The incidence of recorded advanced prostate cancer at diagnosis fell from 13.0 per 100,000 men in 1987-1991 to 7.0 per 100,000 men in 2002-2005. The age-standardised mortality from prostate cancer increased by 3.6% per year between 1984 and 1990 and then fell by 2.0% per year to 2005. CONCLUSIONS: There was a sustained increase in prostate cancer incidence in NSW after PSA testing was introduced. While falls in the incidence of advanced disease at diagnosis and mortality from prostate cancer after 1993 are consistent with a benefit from PSA testing, other explanations cannot be excluded.

Preventing primary liver cancer: how well are we faring towards a national hepatitis B strategy?

Worldwide, over 80% of primary liver cancers are attributable to chronic infection with hepatitis B or C virus. Over the past two decades, primary liver cancer incidence rates have been consistently rising in Australia. In New South Wales, the standardised incidence ratios for primary liver cancer in males born in Vietnam, Hong Kong and Macau, Korea, Indonesia and China and in females born in Vietnam and China are 6-12 times those in Australian-born populations. The incidence of liver cancer is likely to continue to increase unless a coordinated approach to disease control can be developed. Effective programs for chronic hepatitis B management need to link prevention, treatment and care, and enhance opportunities for research and surveillance activities. The evidence that suppression of hepatitis B virus replication could limit disease progression needs to inform the development of a public health response. Lessons learned in the development of the National Hepatitis C Strategy and the experience of international hepatitis B control programs need to inform this process.

Gaps in optimal care for lung cancer.

PURPOSE: Lung cancer is the leading cause of cancer death in Australia, but little is known about how Australian patients with this disease are managed. METHODS: Lung cancer patients diagnosed from November 1, 2001 to December 31, 2002 were identified through the population-based New South Wales Central Cancer Registry. Information was collected on diagnosis, staging, referrals, and treatment. Cross-tabulations and logistic regression examined factors related to not receiving cancer-specific therapy. RESULTS: There were 2931 potentially eligible patients registered by the Central Cancer Registry and completed questionnaires were obtained for 1812 patients (62%); median age 71 years and 66% men. The pathology was non-small cell in 71%, small cell in 15% and not confirmed in 13% of patients. Eleven percent of patients did not see a lung cancer specialist and 33% received no cancer-specific therapy after initial diagnosis. Treatment utilization rates were 17% for surgery, 39% for radiotherapy, and 30% for chemotherapy. Factors significantly associated with having no cancer-specific therapy included female gender, older age, weight loss, poorer performance status, advanced or unknown disease stage, and consultation with a low patient volume lung cancer specialist or a non-lung cancer specialist. The median survival was 172 days and 2-year crude survival was 17%. CONCLUSIONS: Treatment patterns were in broad concordance with present national guidelines. Nevertheless, a significant proportion of lung cancer patients did not receive cancer-specific therapy. Treatment decisions should be multidisciplinary and decision-makers should include experienced lung cancer specialists.

Age, health, and education determine supportive care needs of men younger than 70 years with prostate cancer.

PURPOSE: It is important to meet the supportive care needs of cancer patients to ensure their satisfaction with their care. A population-wide sample of men younger than 70 years and newly diagnosed with prostate cancer was surveyed to determine their unmet needs in five domains and the factors predicting them. PATIENTS AND METHODS: Eligible men were younger than 70 years and residents in New South Wales, Australia, with newly diagnosed histopathologically confirmed prostate cancer. Sixty-seven percent of eligible men diagnosed between October 2000 and October 2001 participated. Demographic, treatment, and self-reported health data were collected. Information on cancer stage, grade, and prostate-specific antigen was obtained from medical records. Logistic regression analyses determined patient and treatment variables that predicted higher unmet needs. RESULTS: More than half (54%) of men with prostate cancer expressed some level of unmet psychological need, and 47% expressed unmet sexuality needs. Nearly one fourth expressed a moderate or high level of unmet need with respect to changes in sexuality. Sexuality needs were independently predicted by being younger, having had a secondary school education only, having had surgery, and being married, living as married, or divorced. Uncertainty about the future was also an important area of unmet need. CONCLUSION: Attention should be given to sexual and psychological needs in the early months after diagnosis or treatment of prostate cancer, particularly in younger men, those with less education, and those having surgery. Research into better ways of meeting these needs will enable us to meet them with as much rigor as we meet clinical treatment needs.

How much food advertising is there on Australian television?

The purpose of this study was to conduct a comprehensive content analysis of television food advertising and provide data on current levels of food advertising in Australia. All three commercial stations available on free-to-air Australian television were concurrently videotaped between 7 a.m. and 9 p.m. on two weekdays and both weekend days in four locations across Australia to provide a total of 645 h for analysis. Each advertisement was categorized as 'non-food ad', 'healthy/core food ad' or 'unhealthy/non-core food ad' according to set criteria. Thirty-one percent of the advertisements analyzed were for food. Eighty-one percent of the food advertisements identified were for unhealthy/non-core foods. When comparing the results of this study with previous research, it was found that the number of unhealthy advertisements screened per hour had not changed over the past few years. On weekdays, the number of advertisements increased throughout the day to peak at more than five advertisements per hour in the 6 p.m. to 9 p.m. time slot. The early morning time slot on Saturday was the most concentrated period for advertising unhealthy/non-core food with more than six advertisements screened per hour. The regional areas screened a significantly lower level of unhealthy/non-core food advertisements (19.5%) compared with the metropolitan areas (29.5%). Fast food and takeaway was the most advertised food category, followed by chocolate and confectionery. A total 194 breaches of the Children's Television Standards were identified according to our interpretation of the standard. It is well recognized that childhood obesity is a worldwide problem. The heavy marketing of energy-dense, nutrient-poor foods influences food choices and contributes to the incidence of overweight and obesity in children. Despite the recognition of this growing problem, little has been done to ensure children are protected against the use of large volumes of unhealthy/non-core food advertising.

The extent and nature of food promotion directed to children in Australian supermarkets.

The aim of this study was to describe the nature and amount of sales promotion use on food packaging in selected Australian supermarkets, specifically those directed at children through the use of premium offers, such as giveaways and competitions, and cartoon and movie character promotions. The study also examined the promotion of healthy versus unhealthy foods. Nine supermarkets located across the metropolitan area of Sydney, Australia were surveyed to assess the extent and nature of food promotion directed at children. The number and types of promotions were measured within seven food categories: sweet biscuits, snack foods, confectionery, chips/savoury snacks, cereals, dairy snacks and ice cream. Any foods that utilized promotional tactics were categorized as either healthy or unhealthy, according to set criteria. The study found that within the seven food categories between 9 and 35% of food products used promotional tactics. The use of television, movie celebrities and cartoon characters for promotion was most common, making up 75% of all promotions. Giveaways accounted for 13% of all promotions. When used, giveaways were commonly used in conjunction with another promotional method. Data from this study also confirmed that 82% of all food promotions were for unhealthy foods and only 18% were used to promote healthy foods. However, for dairy snacks and ice cream the majority of promotions, 99 and 65%, respectively, were healthier choices. This was the first study to describe the extent and nature of food promotions used in supermarkets. The promotion of unhealthy foods in supermarkets is common and is one of the many factors contributing to today's obesity promoting environment. Further research is required to determine the impact of food promotions on children's dietary intake, and to determine the most effective ways to restrict the promotion of unhealthy foods.