Ethnic inequities in use of breast conserving surgery and radiation therapy in Aotearoa/New Zealand: which factors contribute?

PURPOSE: Aotearoa/New Zealand (NZ) faces ethnic inequities with respect to breast cancer survival and treatment. This study establishes if there are ethnic differences in (i) type of surgery and (ii) receipt of radiotherapy (RT) following breast conserving surgery (BCS), among women with early-stage breast cancer in NZ. METHODS: This analysis used Te Rehita Mata Utaetae (Breast Cancer Foundation National Register), a prospectively maintained database of breast cancers from 2000 to 2020. Logistic regression models evaluated ethnic differences in type of surgery (mastectomy or BCS) and receipt of RT with sequential adjustment for potential contributing factors. Subgroup analyses by treatment facility type were undertaken. RESULTS: Of the 16,228 women included, 74% were NZ European (NZE), 10.3% were Maori, 9.4% were Asian and 6.2% were Pacific. Over one-third of women with BCS-eligible tumours received mastectomy. Asian women were more likely to receive mastectomy than NZE (OR 1.62; 95% CI 1.39, 1.90) as were wahine Maori in the public system (OR 1.21; 95% CI 1.02, 1.44) but not in the private system (OR 0.78; 95% CI 0.51, 1.21). In women undergoing BCS, compared to NZE, Pacific women overall and wahine Maori in the private system were, respectively, 36 and 38% less likely to receive RT (respective OR 0.64; 95% CI 0.50, 0.83 and 0.62; 95% CI 0.39, 0.98). CONCLUSION: A significant proportion of women with early-stage breast cancer underwent mastectomy and significant ethnic inequities exist. Recently developed NZ Quality Performance Indicators strongly encourage breast conservation and should facilitate more standardized and equitable surgical management of early-stage breast cancer.

Treatment patterns in patients with systemic lupus erythematosus in New Zealand.

OBJECTIVES: This study aims to explore the treatment pattern of systemic lupus erythematosus (SLE) in Aotearoa/New Zealand. METHODS: SLE patients were linked to the pharmaceutical dispensing data. The use of publicly funded anti-malarials, immunomodulators, biologics, glucocorticoids and bisphosphonates were compared by gender, ethnicity, age group, socioeconomic status and year of SLE identification. Adherence to hydroxychloroquine was examined using the medication possession ratio (MPR), with a MPR of ≥0.8 considered as high adherence. RESULTS: Of the 2631 SLE patients, 73.8% used hydroxychloroquine, 64.1% used immunomodulators/biologics and 68.0% used 5 mg or more prednisone daily for at least 90 days. Women were more likely to use hydroxychloroquine than men. Asian patients had a different treatment pattern than other ethnic groups, and Maori were less likely to use hydroxychloroquine. The proportions of patients using different treatments decreased with age. Of the patients using hydroxychloroquine, 54.5% had high adherence. For patients over 40 years old and on long term prednisone, 47.3% had bisphosphonates and this figure was 17.8% for patients under the age of 40 years old. Patients with better socioeconomic status had a higher probability of using bisphosphonates than patients with lower socioeconomic status. CONCLUSIONS: Adherence to hydroxychloroquine in these patients varied and was lower in men and in Maori. Prednisone is commonly prescribed and used long term. Half of those over the age of 40 years old co-administered bisphosphonate. Further research is needed to identify the reasons for these discrepancies on SLE treatments by gender, ethnicity, age and socioeconomic status.

Equity of travel to access surgery and radiation therapy for lung cancer in New Zealand.

PURPOSE: Centralisation of lung cancer treatment can improve outcomes, but may result in differential access to care for those who do not reside within treatment centres. METHODS: We used national-level cancer registration and health care access data and used Geographic Information Systems (GIS) methods to determine the distance and time to access first relevant surgery and first radiation therapy among all New Zealanders diagnosed with lung cancer (2007-2019; N = 27,869), and compared these outcomes between ethnic groups. We also explored the likelihood of being treated at a high-, medium-, or low-volume hospital. Analysis involved both descriptive and adjusted logistic regression modelling. RESULTS: We found that Maori tend to need to travel further (with longer travel times) to access both surgery (median travel distance: Maori 57 km, European 34 km) and radiation therapy (Maori 75 km, European 35 km) than Europeans. Maori have greater odds of living more than 200 km away from both surgery (adjusted odds ratio [aOR] 1.83, 95% CI 1.49-2.25) and radiation therapy (aOR 1.41, 95% CI 1.25-1.60). CONCLUSIONS: Centralisation of care may often improve treatment outcomes, but it also makes accessing treatment even more difficult for populations who are more likely to live rurally and in deprivation, such as Maori.

Ethnic differences in the characteristics of patients with newly diagnosed lung cancer in the Te Manawa Taki region of New Zealand.

BACKGROUND: Maori have three times the mortality from lung cancer compared with non-Maori. The Te Manawa Taki region has a population of 900 000, of whom 30% are Maori. We have little understanding of the factors associated with developing and diagnosing lung cancer and ethnic differences in these characteristics. AIMS: To explore the differences in the incidence and characteristics of patients with newly diagnosed lung cancer between Maori and non-Maori. METHODS: Patients were identified from the regional register. Incidence rates were calculated based on population data from the 2013 and 2018 censuses. The patient and tumour characteristics of Maori and non-Maori were compared. The analysis used Χ2 tests and logistic models for categorical variables and Student t tests for continuous variables. RESULTS: A total of 4933 patients were included, with 1575 Maori and 3358 non-Maori. The age-standardised incidence of Maori (236 per 100 000) was 3.3 times higher than that of non-Maori. Maori were 1.3 times more likely to have an advanced stage of disease and 1.97 times more likely to have small cell lung cancer. Maori were more likely to have comorbidities, chronic obstructive pulmonary disease, cardiovascular disease and diabetes. They also had higher levels of social deprivation and tended to be younger, female and current smokers. CONCLUSIONS: The findings point to the need to address barriers to early diagnosis and the need for system change including the need to introduce a lung cancer screening focussing on Maori. There is also the need for preventive programmes to address comorbidities that impact lung cancer outcomes as well as a continued emphasis on creating a smoke-free New Zealand.

Prevalence and outcomes of end-stage kidney disease in patients with systemic lupus erythematous: a population-based study.

This study aims to examine the prevalence and outcomes of end-stage kidney disease (ESKD) among systemic lupus erythematosus (SLE) patients. SLE patients identified from the national administrative datasets were linked to the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) to identify the ESKD cases. Period prevalence of ESKD among SLE patients was calculated. The risk of developing ESKD by ethnicity was explored with Cox Proportional Hazards model. The adjusted hazard ratio (HR) of all-cause mortality for Maori, Pacific, Asian compared to European/others was estimated. Of the 2837 SLE patients, 210 (7.4%) developed ESKD. The average period prevalence of ESKD among SLE patients was 5.7%. Men had twice the prevalence rate of ESKD than women (10.0% vs 5.2%). Maori and Pacific had higher prevalence rate than Asian and European/others (9.4%, 9.8% vs 4.4% and 3.8%). The adjusted HR of developing ESKD for men compared to women was 3.37 (95% CI 1.62-7.02). The adjusted HR of developing ESKD for Maori and Pacific compared to European/others was 4.63 (95% CI 1.61-13.29) and 4.66 (95% CI 1.67-13.00), respectively. Compared to European/others, Maori had an HR of 2.17 (95% CI 1.18-4.00) for all-cause mortality. SLE patients had a high prevalence rate of ESKD. Men, Maori, and Pacific patients with SLE were more likely to develop ESKD. Maori patients with ESKD had poorer survival than other patients. Interventions are needed to reduce the risk of ESKD and to improve the survival of ESKD patients for the disadvantaged groups.

Treatment Patterns for End-Stage Kidney Failure in Patients With Systemic Lupus Erythematous.

BACKGROUND: This study aims to examine the treatment patterns of end-stage kidney disease (ESKD) among SLE patients and to compare the outcome of hemodialysis (HD) and peritoneal dialysis (PD). METHODS: SLE patients identified from the national administration dataset in 2005-2021 were linked to the Australia and New Zealand Dialysis and Transplant Registry to identify ESKD cases. The adjusted odds ratio of having PD instead of HD as the first treatment for ESKD for Asian, Maori, and Pacific compared with European/others was estimated with the logistic regression model. The adjusted hazards ratio of all-cause mortality for patients having PD first compared with HD first was calculated. RESULTS: Two hundred ten ESKD patients with SLE were identified. Two thirds (137/210) of the ESKD patients had HD as the first treatment, and one third (68, 32.4%) had PD first. Around 60% of Asian patients had PD as the first treatment, compared with 30% in other ethnic groups. The adjusted odds ratio of having PD as the first treatment for Asian patients compared with European/others was 3.00 (95% confidence interval, 1.16-7.73). The adjusted hazards ratio of all-cause mortality for patients in the PD group compared with the HD group was 0.60 (95% confidence interval, 0.37-0.97). CONCLUSIONS: Asian patients with ESKD were more likely to have PD as the first treatment. The optimal dialysis type for ESKD patients with SLE might be different from ESKD patients caused by other diseases. ESKD patients with SLE receiving PD first had superior outcomes than patients receiving HD first.

Post-diagnostic statin use and breast cancer-specific mortality: a population-based cohort study.

PURPOSE: Statins are the most widely prescribed cholesterol lowering medications and have been associated with both improved and unchanged breast cancer outcomes in previous studies. This study examines the association between the post-diagnostic use of statins and breast cancer outcomes (death and recurrence) in a large, representative sample of New Zealand (NZ) women with breast cancer. METHODS: Women diagnosed with a first primary breast cancer between 2007 and 2016 were identified from four population-based regional NZ breast cancer registries and linked to national pharmaceutical data, hospital discharges, and death records. Cox proportional hazard models were used to estimate the hazard of breast cancer-specific death (BCD) associated with any post-diagnostic statin use. RESULTS: Of the 14,976 women included in analyses, 27% used a statin after diagnosis and the median follow up time was 4.51 years. Statin use (vs non-use) was associated with a statistically significant decreased risk of BCD (adjusted hazard ratio: 0.74; 0.63-0.86). The association was attenuated when considering a subgroup of 'new' statin users (HR: 0.91; 0.69-1.19), however other analyses revealed that the protective effect of statins was more pronounced in estrogen receptor positive patients (HR: 0.77; 0.63-0.94), postmenopausal women (HR: 0.74; 0.63-0.88), and in women with advanced stage disease (HR: 0.65; 0.49-0.84). CONCLUSION: In this study, statin use was associated with a statistically significant decreased risk of breast cancer death, with subgroup analyses revealing a more protective effect in ER+ patients, postmenopausal women, and in women with advanced stage disease. Further research is warranted to determine if these associations are replicated in other clinical settings.

Impact of diabetes on surgery and radiotherapy for breast cancer.

PURPOSES: This study aims to examine whether diabetes has an impact on the use of surgery and adjuvant radiotherapy in treating women with localised breast cancer. METHODS: Women diagnosed with stage I-III breast cancer between 2005 and 2020 were identified from Te Rehita Mate Utaetae-Breast Cancer Foundation New Zealand National Register, with diabetes status determined using New Zealand's Virtual Diabetes Register. The cancer treatments examined included breast conserving surgery (BCS), mastectomy, breast reconstruction after mastectomy, and adjuvant radiotherapy after BCS. Logistic regression modelling was used to estimate the adjusted odds ratio (OR) and 95% confidence interval (95% CI) of having cancer treatment and treatment delay (> 31 days) for patients with diabetes at the time of cancer diagnosis compared to patients without diabetes. RESULTS: We identified 25,557 women diagnosed with stage I-III breast cancer in 2005-2020, including 2906 (11.4%) with diabetes. After adjustment for other factors, there was no significant difference overall in risk of women with diabetes having no surgery (OR 1.12, 95% CI 0.94-1.33), although for patients with stage I disease not having surgery was more likely (OR 1.45, 95% CI 1.05-2.00) in the diabetes group. Patients with diabetes were more likely to have their surgery delayed (adjusted OR of 1.16, 95% CI 1.05-1.27) and less likely to have reconstruction after mastectomy compared to the non-diabetes group-adjusted OR 0.54 (95% CI 0.35-0.84) for stage I cancer, 0.50 (95% CI 0.34-0.75) for stage II and 0.48 (95% CI 0.24-1.00) for stage III cancer. CONCLUSIONS: Diabetes is associated with a lower likelihood of receiving surgery and a greater delay to surgery. Women with diabetes are also less likely to have breast reconstruction after mastectomy. These differences need to be taken in to account when considering factors that may impact on the outcomes of women with diabetes especially for Maori, Pacific and Asian women.

Association of diabetes and breast cancer characteristics at diagnosis.

PURPOSE: This study aims to examine the association of diabetes and breast cancer characteristics at diagnosis in Aotearoa/New Zealand. METHODS: Patients diagnosed with invasive breast cancer between 2005 and 2020 were identified from the National Breast Cancer Register. Logistic regression modeling was used to estimate the adjusted odds ratio (OR) of having stage III-IV cancer and the OR of having stage IV cancer for women with diabetes compared to those without diabetes. The adjusted OR of having screen-detected breast cancers for patients aged 45-69 years with diabetes compared to patients without diabetes was estimated. RESULTS: 26,968 women were diagnosed with breast cancer, with 3,137 (11.6%) patients having diabetes at the time of cancer diagnosis. The probability of co-occurrence of diabetes and breast cancer increased with time. Maori, Pacific and Asian women were more likely to have diabetes than European/Others. The probability of having diabetes also increased with age. For patients with diabetes, the probability of being diagnosed with stage III-IV cancer and stage IV cancer was higher than for patients without diabetes (OR 1.14, 95% CI 1.03-1.27; and 1.17, 95% CI 1.00-1.38). Women aged 45-69 years with diabetes were more likely to have screen-detected cancer than those without diabetes (OR 1.13, 95% CI 1.02-1.26). CONCLUSIONS: The co-occurrence of diabetes and breast cancer is becoming more common. Overall there is a small but significant adverse impact of having advanced disease for women with diabetes that is found at the time of breast cancer diagnosis, and this may contribute to other inequities that occur in the treatment pathway that may impact on patient outcomes.

Mortality and causes of death in systemic lupus erythematosus in New Zealand: A population-based study.

OBJECTIVES: This study aims to assess the mortality of systemic lupus erythematosus (SLE) patients and examine whether there are variations by subgroup. METHODS: SLE patients from 2005-2021 were identified from the national administrative datasets. The underlying causes of death were examined. Standardised mortality ratio (SMR) was estimated to compare the relative rate of observed deaths in SLE patients to expected deaths in the general population. The hazard ratios (HR) and 95% confidence intervals (CI) of all-cause mortality and SLE specific mortality by ethnicity were estimated after adjustment for age using a Cox proportional hazards model. RESULTS: Of the 2,802 patients included for analysis, 699 (24.9%) died with 209 (29.9%) SLE deaths. The age-standardised mortality rate of SLE was 0.29 per 100 000 for women and 0.05 for men. The mean age at death was 65.3 ± 17.1 years. Younger patients were more likely to have SLE as the underlying cause of death, from 78.9% for those under 20 years old to 18.7% for those aged 70-79 years. Compared with the general population, SLE patients were four times more likely to die (SMR: 4.0; 95% CI: 3.7-4.3). Young patients had higher SMRs than older patients. Maori had worse all-cause mortality (HR: 1.72; 95% CI: 1.10-2.67) and SLE specific mortality (HR: 2.60; 95% CI: 1.29-5.24) than others. CONCLUSIONS: The outcomes of SLE in New Zealand were still very poor compared with the general population. Maori with SLE had worse survival than others. Further research is needed to identify the reasons to this disparity.

Incidence and prevalence of systemic lupus erythematosus in New Zealand from the national administrative datasets.

OBJECTIVES: This study aims to provide updated data on the incidence and prevalence of systemic lupus erythematosus (SLE) in New Zealand and to examine the difference between ethnic groups. METHODS: We identified the SLE cases from the national administrative datasets. The date of first identification of SLE was the earliest date of a related inpatient event or the earliest date of a related outpatient event. The crude incidence and prevalence of SLE in 2010-2021 were estimated by gender, age group and ethnicity. The WHO (World Health Organization) age-standardised rate (ASR) of incidence and prevalence of SLE was calculated, after stratifying the cases by ethnicity and gender. RESULTS: The average ASR of incidence and prevalence of SLE in 2010-2021 was 2.1 and 42.1 per 100,000 people in New Zealand. The average ASR of incidence for women was 3.4 per 100,000 for women and 0.6 for men. It was highest for Pacific women (9.8), followed by Asian women (5.3) and Maori women (3.6), and was lowest for Europeans/Others (2.1). The average ASR of prevalence was 65.2 per 100,000 for women and 8.5 for men. It was highest for Pacific women (176.2), followed by Maori women (83.7) and Asian women (72.2), and was lowest for Europeans/Others (48.5). The ASR of prevalence of SLE has been increasing slightly over time: from 60.2 in 2010 to 66.1 per 100,000 in 2021 for women and from 7.6 in 2010 to 8.8 per 100,000 in 2021 for men. CONCLUSION: The incidence and prevalence of SLE in New Zealand were comparable to the rates in European countries. Pacific people had the highest incidence and prevalence of SLE, more than three times the rates for Europeans/others. The high incidence of SLE in Maori and Asian people also has implications for the future as these populations increase as a proportion to the total population.

Inequities in COVID-19 Omicron infections and hospitalisations for Maori and Pacific people in Te Manawa Taki Midland region, New Zealand.

COVID-19 impacts population health equity. While mRNA vaccines protect against serious illness and death, little New Zealand (NZ) data exist about the impact of Omicron - and the effectiveness of vaccination - on different population groups. We aim to examine the impact of Omicron on Maori, Pacific, and Other ethnicities and how this interacts with age and vaccination status in the Te Manawa Taki Midland region of NZ. Daily COVID-19 infection and hospitalisation rates (1 February 2022 to 29 June 2022) were calculated for Maori, Pacific, and Other ethnicities for six age bands. A multivariate logistic regression model quantified the effects of ethnicity, age, and vaccination on hospitalisation rates. Per-capita Omicron cases were highest and occurred earliest among Pacific (9 per 1,000) and Maori (5 per 1,000) people and were highest among 12-24-year-olds (7 per 1,000). Hospitalisation was significantly more likely for Maori people (odds ratio (OR) = 2.03), Pacific people (OR = 1.75), over 75-year-olds (OR = 39.22), and unvaccinated people (OR = 4.64). Length of hospitalisation is strongly related to age. COVID-19 vaccination reduces hospitalisations for older individuals and Maori and Pacific populations. Omicron inequitably impacted Maori and Pacific people through higher per-capita infection and hospitalisation rates. Older people are more likely to be hospitalised and for longer.

Barriers to obesity health care in general practice from rural Waikato GP perspectives: A qualitative study.

OBJECTIVE: Over 34% of New Zealand (NZ) adults are classed as obese, which reduces quality of life for many individuals. Those living in rural areas, high-deprivation communities, and indigenous Maori populations are more likely to experience obesity and related co-morbidities than other cohorts. General practice is positioned as most suitable to deliver effective weight management health care; however, little is understood about the rural general practitioner (GP) experience in NZ, despite having the majority of patients at high risk of developing obesity. The aim of this study was to investigate rural GP perspectives on barriers to delivering weight management. DESIGN: Qualitative descriptive design guided by Braun and Clarke (2006) using semi-structured interviews and analysed using deductive reflexive thematic approach. SETTING: Rural Waikato general practice which has significant rural, Maori and high-deprivation communities. PARTICIPANTS: Six rural Waikato GPs. RESULTS: Three significant themes were identified: communication barriers, rural health care barriers, and social and cultural barriers. GPs reported not wanting to jeopardise the doctor-patient relationship by discussing weight. GPs felt unsupported by the health system through lack of rurally appropriate obesity intervention options, funding and resources. The unique rural lifestyle and health needs were reportedly not understood at the wider health system level, making the role of a rural GP working in high-deprivation communities more difficult. Additional barriers to delivering effective weight management included factors outside the clinical practice such as obesity stigma, an obesogenic environment and sociocultural factors shaping rural patients' lives. CONCLUSION: Rural GPs have a lack of weight management referral options that are considered effective for their patients, as the options available reportedly do not cater for their patients' unique rural health needs. GPs position addressing the individualised and complex weight management health issue as challenging. Navigating stigma, wider sociocultural issues, and limited intervention options were difficult and found to be questionable to achieve in a short 15-min consult. There is a need for rural health support in the form of funding, staff (indigenous and non-indigenous), and rurally feasible resources to improve health outcomes and reduce inequity. Effective primary care weight management strategies need to be appropriate for high-deprivation rural communities, including tailored, affordable and reliable interventions that GPs can offer patients if future weight management efforts are to be successful in this space.

Post-diagnostic beta blocker use and breast cancer-specific mortality: a population-based cohort study.

PURPOSE: Beta blockers (BB) have been associated with improved, worsened, or unchanged breast cancer outcomes in previous studies. This study examines the association between the post-diagnostic use of BBs and death from breast cancer in a large, representative sample of New Zealand (NZ) women with breast cancer. METHODS: Women diagnosed with a first primary breast cancer between 2007 and 2016 were identified from four population-based regional NZ breast cancer registries and linked to national pharmaceutical data, hospital discharges, and death records. The median follow-up time was 4.51 years. Cox proportional hazard models were used to estimate the hazard of breast cancer-specific death (BCD) associated with any post-diagnostic BB use. RESULTS: Of the 14,976 women included in analyses, 21% used a BB after diagnosis. BB use (vs non-use) was associated with a small and nonstatistically significant increased risk of BCD (adjusted hazard ratio: 1.11; 95% CI 0.95-1.29). A statistically significant increased risk confined to short-term use (0-3 months) was seen (HR = 1.40; 1.14-1.73), and this risk steadily decreased with increasing duration of use and became a statistically significant protective effect at 3 + years of use (HR = 0.55; 0.34-0.88). CONCLUSION: Our findings suggest that any increased risk associated with BB use may be driven by risk in the initial few months of use. Long-term BB use may be associated with a reduction in BCD.

Patient-reported diagnostic intervals to colorectal cancer diagnosis in the Midland region of New Zealand: a prospective cohort study.

BACKGROUND AND OBJECTIVES: New Zealand (NZ) has high rates of colorectal cancer (CRC) but low rates of early detection. The majority of CRC is diagnosed through general practice, where lengthy diagnostic intervals are common. We investigated factors contributing to diagnostic delay in a cohort of patients newly diagnosed with CRC. METHODS: Patients were recruited from the Midland region and interviewed about their diagnostic experience using a questionnaire based on a modified Model of Pathways to Treatment framework and SYMPTOM questionnaire. Descriptive statistics were used to describe the population characteristics. Chi-square analysis and logistic regression were used to analyse factors influencing diagnostic intervals. RESULTS: Data from 176 patients were analysed, of which 65 (36.9%) experienced a general practitioner (GP) diagnostic interval of >120 days and 96 (54.5%) experienced a total diagnostic interval (TDI) > 120 days. Patients reporting rectal bleeding were less likely to experience a long TDI (odds ratio [OR] 0.34, 95% confidence interval [CI]: 0.14-0.78) and appraisal/help-seeking interval (OR, 0.19, 95% CI: 0.06-0.59). Patients <60 were more likely to report a longer appraisal/help-seeking interval (OR, 3.32, 95% CI: 1.17-9.46). Female (OR, 2.19, 95% CI: 1.08-4.44) and Maori patients (OR, 3.18, 95% CI: 1.04-9.78) were more likely to experience a long GP diagnostic interval. CONCLUSION: NZ patients with CRC can experience long diagnostic intervals, attributed to patient and health system factors. Young patients, Maori, females, and patients experiencing change of bowel habit may be at particular risk. We need to increase symptom awareness of CRC for patients and GPs. Concentrated efforts are needed to ensure equity for Maori in access to screening, diagnostics, and treatment.

New Zealand has high rates of colorectal cancer but low rates of early detection. We interviewed newly diagnosed patients about their diagnostic experience to identify factors influencing time to diagnosis. More than half of patients experienced a long diagnostic interval. Young patients, Maori, females, and patients experiencing changes of bowel habit may be at particular risk for long intervals. With the diagnostic difficulty of colorectal cancer (CRC), we need to increase CRC symptom awareness for patients and general practitioners.

Prevalence of gestational diabetes in the Waikato region of New Zealand.

Gestational diabetes mellitus (GDM) during pregnancy is associated with health complications for both mother and infant, but patient numbers in the Waikato District Health Board region of New Zealand have not been well characterised. This study reviewed the full 2018 cohort of Waikato District Health Board hospital births (n = 4970) to report on GDM prevalence by ethnicity and age. The overall prevalence of GDM was 5.7% and is more likely to affect Asian, Pacific and Maori women as well as those of advanced maternal age.

Metastatic relapse of stage I-III breast cancer in New Zealand.

PURPOSE: This study aims to investigate the factors that influence the risk of metastatic relapse in women presenting with stage I-III breast cancer in New Zealand. METHODS: The study included women diagnosed with stage I-III breast cancer. Cumulative incidence of distant metastatic relapse was examined with the Kaplan-Meier method by cancer stage and subtype. Cox proportional hazards models were used to estimate the adjusted hazard ratio of developing recurrent metastatic breast cancer by cancer stage and biomarker subtype after adjustment for other factors. RESULTS: A total of 17,543 eligible women were identified. The 5-year cumulative incidence of metastatic recurrence was 3.7% for stage I, 13.3% for stage II and 30.9% for stage III disease. The adjusted hazard ratios (HR) of stage II and stage III breast cancer developing metastatic disease were 2.07 and 4.82 compared to stage I. The adjusted risk of distant metastatic relapse was highest for luminal B HER2- cancers (adjusted HR: 1.59 compared to luminal A disease). Higher grade cancers were associated with a higher risk of metastases. After adjustment, women aged 60-69 years and Asian women had the lowest risk of distant metastatic relapse. CONCLUSIONS: The prognosis of women with locally invasive breast cancer differs greatly with the chance of developing metastatic disease depending on the stage of disease at diagnosis and the subtype. Grade of disease at diagnosis was also important. Maori or Pacific ethnicity did not influence the risk of developing metastatic disease, although Asian women seemed less likely to develop metastases.

Ha Ora: secondary care barriers and enablers to early diagnosis of lung cancer for Maori communities.

BACKGROUND: Lung Cancer is the leading cause of cancer deaths in Aotearoa New Zealand. Maori communities in particular have higher incidence and mortality rates from Lung Cancer. Diagnosis of lung cancer at an early stage can allow for curative treatment. This project aimed to document the barriers to early diagnosis and treatment of lung cancer in secondary care for Maori communities. METHODS: This project used a kaupapa Maori approach. Nine community hui (focus groups) and nine primary healthcare provider hui were carried out in five rural localities in the Midland region. Community hui included cancer patients, whanau (families), and other community members. Healthcare provider hui comprised staff members at the local primary healthcare centre, including General Practitioners and nurses. Hui data were thematically analysed. RESULTS: Barriers and enablers to early diagnosis of lung cancer were categorised into two broad themes: Specialist services and treatment, and whanau journey. The barriers and enablers that participants experienced in specialist services and treatment related to access to care, engagement with specialists, communication with specialist services and cultural values and respect, whereas barriers and enablers relating to the whanau journey focused on agency and the impact on whanau. CONCLUSIONS: The study highlighted the need to improve communication within and across healthcare services, the importance of understanding the cultural needs of patients and whanau and a health system strategy that meets these needs. Findings also demonstrated the resilience of Maori and the active efforts of whanau as carers to foster health literacy in future generations.

Outcomes from colonoscopy following referral from New Zealand general practice: a retrospective analysis.

BACKGROUND: New Zealand has high rates of colorectal cancer (CRC) but poor outcomes. Most patients with CRC are diagnosed following referral from general practice, where a general practitioner (GP) assesses symptoms according to national guidelines. All referred patients are then re-prioritised by the hospital system. The first objective of this study was to identify what proportion of patients referred by general practice to surgical/gastroenterology at Waikato District Health Board (DHB) had a colonoscopy. The second objective was to determine what proportion of these referrals have an underlying CRC and the factors associated with the likelihood of this diagnosis. METHODS: This study is a retrospective analysis of e-referral data for patients aged 30-70+ who were referred from 75 general practices to general surgery, gastroenterology or direct to colonoscopy at Waikato DHB, 01 January 2015-31 December 2017. Primary and secondary outcome measures included the proportion and characteristics of patients who were having colonoscopy, and of those, who were diagnosed with CRC. Data were analysed using chi square and logistic regression. RESULTS: 6718/20648 (32.5%) patients had a colonoscopy and 372 (5.5%) of these were diagnosed with CRC. The probability of having CRC following a colonoscopy increased with age (p value < 0.001). Females (p value < 0.001), non-Maori (p value < 0.001), and patients with a high suspicion of cancer (HSCan) label originating from their GP were more likely to have a colonoscopy, while the odds ratio of Maori having a colonoscopy was 0.66 (95% CI 0.60-0.73). The odds ratio of a CRC diagnosis following colonoscopy was 1.67 (95% CI 1.35-2.07) for men compared to women, and 2.34 (95% CI 1.70-3.22) for those with a GP HSCan label. Of the 585 patients referred with a GP HSCan, 423 (72.3%) were reprioritised by the hospital and 55 patients had their diagnosis unnecessarily delayed. CONCLUSIONS: If a GP refers a patient with an HSCan, and the patient receives a colonoscopy, then the likelihood of having CRC is almost 15.0%. This would suggest that these patients should be routinely prioritised without further triage by the hospital. Further research is needed to understand why Maori are less likely to receive a colonoscopy following referral from general practice.

Indigenous perspectives on breaking bad news: ethical considerations for healthcare providers.

Most healthcare providers (HCPs) work from ethical principles based on a Western model of practice that may not adhere to the cultural values intrinsic to Indigenous peoples. Breaking bad news (BBN) is an important topic of ethical concern in health research. While much has been documented on BBN globally, the ethical implications of receiving bad news, from an Indigenous patient perspective in particular, is an area that requires further inquiry. This article discusses the experiences of Maori (Indigenous peoples of New Zealand) lung cancer patients and their families, in order to investigate the ethical implications of receiving bad news. Data collection occurred through 23 semistructured interviews and nine focus groups with Maori lung cancer patients and their families in four districts in the Midland Region of New Zealand: Waikato, Bay of Plenty, Lakes and Tairawhiti. The findings of this study were categorised into two key themes: communication and context. Avenues for best practice include understanding the centrality of the HCP-patient relationship and family ties in the healthcare journey, and providing patients with the full range of viable treatment options including hope, clear advice and guidance when the situation calls for it. Overall, the findings of this study hold implications for providing culturally safe and humanistic cancer care when BBN to Maori and Indigenous patients.