A longitudinal linkage study of occupation and ischaemic heart disease in the general and Maori populations of New Zealand.

OBJECTIVES: Occupation is a poorly characterised risk factor for cardiovascular disease (CVD) with females and indigenous populations under-represented in most research. This study assessed associations between occupation and ischaemic heart disease (IHD) in males and females of the general and Maori (indigenous people of NZ) populations of New Zealand (NZ). METHODS: Two surveys of the NZ adult population (NZ Workforce Survey (NZWS); 2004-2006; n = 3003) and of the Maori population (NZWS Maori; 2009-2010; n = 2107) with detailed occupational histories were linked with routinely collected health data and followed-up until December 2018. Cox regression was used to calculate hazard ratios (HR) for IHD and "ever-worked" in any of the nine major occupational groups or 17 industries. Analyses were controlled for age, deprivation and smoking, and stratified by sex and survey. RESULTS: 'Plant/machine operators and assemblers' and 'elementary occupations' were positively associated with IHD in female Maori (HR 2.2, 95%CI 1.2-4.1 and HR 2.0, 1.1-3.8, respectively) and among NZWS males who had been employed as 'plant/machine operators and assemblers' for 10+ years (HR 1.7, 1.2-2.8). Working in the 'manufacturing' industry was also associated with IHD in NZWS females (HR 1.9, 1.1-3.7), whilst inverse associations were observed for 'technicians and associate professionals' (HR 0.5, 0.3-0.8) in NZWS males. For 'clerks', a positive association was found for NZWS males (HR 1.8, 1.2-2.7), whilst an inverse association was observed for Maori females (HR 0.4, 0.2-0.8). CONCLUSION: Associations with IHD differed significantly across occupational groups and were not consistent across males and females or for Maori and the general population, even within the same occupational groups, suggesting that current knowledge regarding the association between occupation and IHD may not be generalisable across different population groups.

Ischaemic Heart Disease and Occupational Exposures: A Longitudinal Linkage Study in the General and Maori Populations of New Zealand.

OBJECTIVES: This study assessed associations between occupational exposures and ischaemic heart disease (IHD) for males and females in the general and Maori populations (indigenous people of New Zealand). METHODS: Two surveys of the general adult [New Zealand Workforce Survey (NZWS); 2004-2006; n = 3003] and Maori population (Maori NZWS; 2009-2010; n = 2107), with information on occupational exposures, were linked with administrative health data and followed-up until December 2018. Cox proportional hazards regression (adjusted for age, deprivation, and smoking) was used to assess associations between organizational factors, stress, and dust, chemical and physical exposures, and IHD. RESULTS: Dust [hazard ratio (HR) 1.6, 95%CI 1.1-2.4], smoke or fumes (HR 1.5, 1.0-2.3), and oils and solvents (HR 1.5, 1.0-2.3) were associated with IHD in NZWS males. A high frequency of awkward or tiring hand positions was associated with IHD in both males and females of the NZWS (HRs 1.8, 1.1-2.8 and 2.4, 1.1-5.0, respectively). Repetitive tasks and working at very high speed were associated with IHD among NZWS females (HRs 3.4, 1.1-10.4 and 2.6, 1.2-5.5, respectively). Maori NZWS females working with vibrating tools and those exposed to a high frequency of loud noise were more likely to experience IHD (HRs 2.3, 1.1-4.8 and 2.1, 1.0-4.4, respectively). Exposure to multiple dust and chemical factors was associated with IHD in the NZWS males, as was exposure to multiple physical factors in males and females of the NZWS. CONCLUSIONS: Exposures associated with an elevated IHD risk included dust, smoke or fumes, oils and solvents, awkward grip or hand movements, carrying out repetitive tasks, working at very high speed, loud noise, and working with tools that vibrate. Results were not consistently observed for males and females and between the general and Maori populations.

Germline CDH1 mutations are a significant contributor to the high frequency of early-onset diffuse gastric cancer cases in New Zealand Maori.

New Zealand Maori have a considerably higher incidence of gastric cancer compared to non-Maori, and are one of the few populations worldwide with a higher prevalence of diffuse-type disease. Pathogenic germline CDH1 mutations are causative of hereditary diffuse gastric cancer, a cancer predisposition syndrome primarily characterised by an extreme lifetime risk of developing diffuse gastric cancer. Pathogenic CDH1 mutations are well described in Maori families in New Zealand. However, the contribution of these mutations to the high incidence of gastric cancer is unknown. We have used next-generation sequencing, Sanger sequencing, and Multiplex Ligation-dependent Probe Amplification to examine germline CDH1 in an unselected series of 94 Maori gastric cancer patients and 200 healthy matched controls. Overall, 18% of all cases, 34% of cases diagnosed with diffuse-type gastric cancer, and 67% of cases diagnosed aged less than 45 years carried pathogenic CDH1 mutations. After adjusting for the effect of screening known HDGC families, we estimate that 6% of all advanced gastric cancers and 13% of all advanced diffuse-type gastric cancers would carry germline CDH1 mutations. Our results demonstrate that germline CDH1 mutations are a significant contributor to the high frequency of diffuse gastric cancer in New Zealand Maori.

Inequities in exposure to occupational risk factors between Maori and non-Maori workers in Aotearoa New Zealand.

BACKGROUND: Health inequities between indigenous and non-indigenous people are well documented. However, the contribution of differential exposure to risk factors in the occupational environment remains unclear. This study assessed differences in the prevalence of self-reported exposure to disease risk factors, including dust and chemicals, physical factors and organisational factors, between Maori and non-Maori workers in New Zealand. METHODS: Potential participants were sampled from the New Zealand electoral rolls and invited to take part in a telephone interview, which included questions about current workplace exposures. Logistic regression, accounting for differences in age, socioeconomic status and occupational distribution between Maori and non-Maori, was used to assess differences in exposures. RESULTS: In total, 2344 Maori and 2710 non-Maori participants were included in the analyses. Maori had greater exposure to occupational risk factors than non-Maori. For dust and chemical exposures, the main differences related to Maori working in occupations where these exposures are more common. However, even within the same job, Maori were more likely to be exposed to physical factors such as heavy lifting and loud noise, and organisational factors such as carrying out repetitive tasks and working to tight deadlines compared with non-Maori. CONCLUSIONS: This is one of the first studies internationally to compare occupational risk factors between indigenous and non-indigenous people. These findings suggest that the contribution of the occupational environment to health inequities between Maori and non-Maori has been underestimated and that work tasks may be unequally distributed according to ethnicity.

Risk of stomach cancer in Aotearoa/New Zealand: A Maori population based case-control study.

Maori, the indigenous people of New Zealand, experience disproportionate rates of stomach cancer, compared to non-Maori. The overall aim of the study was to better understand the reasons for the considerable excess of stomach cancer in Maori and to identify priorities for prevention. Maori stomach cancer cases from the New Zealand Cancer Registry between 1 February 2009 and 31 October 2013 and Maori controls, randomly selected from the New Zealand electoral roll were matched by 5-year age bands to cases. Logistic regression was used to estimate odd ratios (OR) and 95% confidence intervals (CI) between exposures and stomach cancer risk. Post-stratification weighting of controls was used to account for differential non-response by deprivation category. The study comprised 165 cases and 480 controls. Nearly half (47.9%) of cases were of the diffuse subtype. There were differences in the distribution of risk factors between cases and controls. Of interest were the strong relationships seen with increased stomach risk and having >2 people sharing a bedroom in childhood (OR 3.30, 95%CI 1.95-5.59), testing for H pylori (OR 12.17, 95%CI 6.15-24.08), being an ex-smoker (OR 2.26, 95%CI 1.44-3.54) and exposure to environmental tobacco smoke in adulthood (OR 3.29, 95%CI 1.94-5.59). Some results were attenuated following post-stratification weighting. This is the first national study of stomach cancer in any indigenous population and the first Maori-only population-based study of stomach cancer undertaken in New Zealand. We emphasize caution in interpreting the findings given the possibility of selection bias. Population-level strategies to reduce the incidence of stomach cancer in Maori include expanding measures to screen and treat those infected with H pylori and a continued policy focus on reducing tobacco consumption and uptake.

A Comparison of Midwife-Led and Medical-Led Models of Care and Their Relationship to Adverse Fetal and Neonatal Outcomes: A Retrospective Cohort Study in New Zealand.

BACKGROUND: Internationally, a typical model of maternity care is a medically led system with varying levels of midwifery input. New Zealand has a midwife-led model of care, and there are movements in other countries to adopt such a system. There is a paucity of systemic evaluation that formally investigates safety-related outcomes in relationship to midwife-led care within an entire maternity service. The main objective of this study was to compare major adverse perinatal outcomes between midwife-led and medical-led maternity care in New Zealand. METHODS AND FINDINGS: This was a population-based retrospective cohort study. Participants were mother/baby pairs for all 244,047 singleton, term deliveries occurring between 1 January 2008 and 31 December 2012 in New Zealand in which no major fetal, neonatal, chromosomal or metabolic abnormality was identified and the mother was first registered with a midwife, obstetrician, or general practitioner as lead maternity carer. Main outcome measures were low Apgar score at five min, intrauterine hypoxia, birth-related asphyxia, neonatal encephalopathy, small for gestational age (as a negative control), and mortality outcomes (perinatal related mortality, stillbirth, and neonatal mortality). Logistic regression models were fitted, with crude and adjusted odds ratios (ORs) generated for each outcome for midwife-led versus medical-led care (based on lead maternity carer at first registration) with 95% confidence intervals. Fully adjusted models included age, ethnicity, deprivation, trimester of registration, parity, smoking, body mass index (BMI), and pre-existing diabetes and/or hypertension in the model. Of the 244,047 pregnancies included in the study, 223,385 (91.5%) were first registered with a midwife lead maternity carer, and 20,662 (8.5%) with a medical lead maternity carer. Adjusted ORs showed that medical-led births were associated with lower odds of an Apgar score of less than seven at 5 min (OR 0.52; 95% confidence interval 0.43-0.64), intrauterine hypoxia (OR 0.79; 0.62-1.02), birth-related asphyxia (OR 0.45; 0.32-0.62), and neonatal encephalopathy (OR 0.61; 0.38-0.97). No association was found between lead carer at first registration and being small for gestational age (SGA), which was included as a negative control (OR 1.00; 0.95-1.05). It was not possible to definitively determine whether one model of care was associated with fewer infant deaths, with ORs for the medical-led model compared with the midwife-led model being 0.80 (0.54-1.19) for perinatal related mortality, 0.86 (0.55-1.34) for stillbirth, and 0.62 (0.25-1.53) for neonatal mortality. Major limitations were related to the use of routine data in which some variables lacked detail; for example, we were unable to differentiate the midwife-led group into those who had received medical input during pregnancy and those who had not. CONCLUSIONS: There is an unexplained excess of adverse events in midwife-led deliveries in New Zealand where midwives practice autonomously. The findings are of concern and demonstrate a need for further research that specifically investigates the reasons for the apparent excess of adverse outcomes in mothers with midwife-led care. These findings should be interpreted in the context of New Zealand's internationally comparable birth outcomes and in the context of research that supports the many benefits of midwife-led care, such as greater patient satisfaction and lower intervention rates.

Understanding Pasifika youth and the obesogenic environment, Auckland and Wellington, New Zealand.

AIM: In New Zealand, the burden of obesity is greatest among Pacific people, especially in children and adolescents. We investigated the factors of the obesogenic environment that were indigenous to Pasifika youths' social-cultural context, their food purchasing behaviours, and associated anthropometric measures. METHODS: An exploratory study of 30 Pasifika youth aged 16-24 years in Wellington and Auckland, New Zealand. RESULTS: A large proportion of the participants were obese (mean body mass index: 31.0kg/m2; waistto-hip ratio: 0.84; waist-to-height ratio: 0.6), suggesting that the future health and wellbeing trajectory of the studied Pasifika youth is poor. Purchasing behaviours of food and snacks over a 7-day period provided meaningful insights that could be a useful future research tool to examine the role of their physical environment on food access and availability. CONCLUSIONS: From this exploratory study, we highlight the following: (i) the future health trajectory of Pasifika youth is poor. Developing the youths' healthy lifestyle knowledge may lend itself to developing culturally relevant intervention programmes; (ii) identifying the enablers and barriers within the Pasifika ontext of an obesogenic environment can provide very useful information; (iii) use of spatial analysis using purchased food receipts adds to the current knowledge base of obesity-related research, although this was an exploratory investigation. We need to address these highlights if we are to reverse the trend of obesity for this population.

The role and potential of community-based cancer care for Maori in Aotearoa/New Zealand.

AIM: To investigate the contribution to cancer care and prevention by Maori health provider organisations (MHPs) in Aotearoa/New Zealand. METHODS: A nationwide postal survey of all MHPs (n=253) was undertaken in 2011. The response rate was 55%. RESULTS: We found that MHPs are delivering a wide range of programmes including cancer prevention services focussed on health promotion, advocacy, information and support. MHPs identified financial hardship, transport difficulties, and lack of information as the greatest barriers to cancer care. Culturally safe care by mainstream providers would improve cancer service provision overall. The importance of trust and long-term relationships, with a focus on families rather than individual-based care, was highlighted. CONCLUSION: These findings could lead to substantial improvements in quality of life for Maori cancer patients. This is the first study to show how indigenous health providers contribute to cancer care and prevention in Aotearoa/New Zealand.

Cancer incidence in indigenous people in Australia, New Zealand, Canada, and the USA: a comparative population-based study.

INTRODUCTION: Indigenous people have disproportionally worse health and lower life expectancy than their non-indigenous counterparts in high-income countries. Cancer data for indigenous people are scarce and incidence has not previously been collectively reported in Australia, New Zealand, Canada, and the USA. We aimed to investigate and compare, for the first time, the cancer burden in indigenous populations in these countries. METHODS: We derived incidence data from population-based cancer registries in three states of Australia (Queensland, Western Australia, and the Northern Territory), New Zealand, the province of Alberta in Canada, and the Contract Health Service Delivery Areas of the USA. Summary rates for First Nations and Inuit in Alberta, Canada, were provided directly by Alberta Health Services. We compared age-standardised rates by registry, sex, cancer site, and ethnicity for all incident cancer cases, excluding non-melanoma skin cancers, diagnosed between 2002 and 2006. Standardised rate ratios (SRRs) and 95% CIs were computed to compare the indigenous and non-indigenous populations of each jurisdiction, except for the Alaska Native population, which was compared with the white population from the USA. FINDINGS: We included 24 815 cases of cancer in indigenous people and 5 685 264 in non-indigenous people from all jurisdictions, not including Alberta, Canada. The overall cancer burden in indigenous populations was substantially lower in the USA except in Alaska, similar or slightly lower in Australia and Canada, and higher in New Zealand compared with their non-indigenous counterparts. Among the most commonly occurring cancers in indigenous men were lung, prostate, and colorectal cancer. In most jurisdictions, breast cancer was the most common cancer in women followed by lung and colorectal cancer. The incidence of lung cancer was higher in indigenous men in all Australian regions, in Alberta, and in US Alaska Natives than in their non-indigenous counterparts. For breast cancer, rates in women were lower in all indigenous populations except in New Zealand (SRR 1·23, CI 95% 1·16-1·32) and Alaska (1·14, 1·01-1·30). Incidence of cervical cancer was higher in indigenous women than in non-indigenous women in most jurisdictions, although the difference was not always statistically significant. INTERPRETATION: There are clear differences in the scale and profile of cancer in indigenous and non-indigenous populations in Australia, New Zealand, Canada, and the USA. Our findings highlight the need for much-improved, targeted programmes of screening, vaccination, and smoking cessation, among other prevention strategies. Governments and researchers need to work in partnership with indigenous communities to improve cancer surveillance in all jurisdictions and facilitate access to cancer data. FUNDING: International Agency for Research on Cancer-Australia Fellowship.

Exploring Maori cancer patients', their families', community and hospice views of hospice care.

BACKGROUND: Despite poor cancer survival statistics, Maori do not readily access hospice services. This study aims to explore how hospice services respond to Maori by investigating the different influences and interactions between three perspectives of hospice care. METHOD: The authors conducted a Maori-centred, cross-sectional qualitative study by undertaking semi-structured interviews with hospice patients and whanau (families) (n=8), hospice representatives (n=4), and representatives from three Maori health provider organisations (n=5). CONCLUSIONS: The study found that negative perceptions of hospice are being changed by hospices' relationships with other organisations and positive stories from whanau. Involvement from whanau, continuity of care and after-hours care with a greater Maori workforce and a further emphasis on culturally safe care are critical for this work to gain momentum. Findings can be of use to further develop quality of care indicators that reflect the perspectives of patients and whanau, and those who provide their care.

Barriers to and delays in accessing breast cancer care among New Zealand women: disparities by ethnicity.

BACKGROUND: Unequal access to health care contributes to disparities in cancer outcomes. We examined the ethnic disparity in barriers to accessing primary and specialist health care experienced by New Zealand women with breast cancer. METHODS: Women diagnosed with a primary invasive breast cancer between 2005 and 2007 were eligible. There were 1,799 respondents, n = 302 Maori (the indigenous population of NZ), n = 70 Pacific and n = 1,427 non-Maori/non-Pacific women. Participants completed a questionnaire listing 12 barriers grouped into three domains for analysis: personal; practical; and health care process factors, and reported the number of days between seeing a primary and a specialist care provider. Chi-squared, Fisher exact tests and logistic regression were used to assess uni- and multivariable differences in prevalence between ethnic groupings. RESULTS: The prevalence of reporting three or more barriers was 18% among Pacific, 10% among Maori and 3% among non-Maori/non-Pacific women (P <0.001). The most commonly reported barriers were fear (Maori women) and cost (Pacific and non-Maori/non-Pacific women). Ethnic differences in reported barriers were not explained by deprivation or diabetes prevalence. Women with diabetes reported a two-fold higher risk of experiencing barriers to care compared to those without diabetes (odds ratio [OR]: 2.06, 95%CI 1.20 to 3.57). Maori and Pacific women were more likely to face delays (median 14 days) in seeing a specialist than non-Maori/non-Pacific women (median 7 days); these differences were not explained by the reported barriers. CONCLUSIONS: Patterns of reported barriers to care differed according to ethnicity and were not explained by deprivation, or presence of co-morbidity. Maori and Pacific women are more likely to experience barriers to breast cancer care compared to non- Maori/non-Pacific women. We identified two key barriers affecting care for Maori and Pacific women; (a) delays in follow-up, and (b) the impact of co-morbid conditions. Future New Zealand work needs to focus attention on health care process factors and improving the interface between primary and secondary care to ensure quality health care is realised for all women with breast cancer.

Indigenous inequities in the presentation and management of stomach cancer in New Zealand: a country with universal health care coverage.

BACKGROUND: Maori in New Zealand have markedly higher incidence and poorer survival from stomach cancer than non-Maori. We investigated the presentation, management and survival of stomach cancer in a cohort of newly diagnosed Maori and non-Maori patients. METHODS: A clinical notes review of all Maori from the North Island diagnosed between 2006 and 2008, and a random equivalent sample of non-Maori, was conducted (final cohort n = 335). Patient characteristics, tumour characteristics, receipt and timing of treatment and cancer-specific survival were compared. RESULTS: Compared to non-Maori, Maori patients had a younger average age at diagnosis, higher prevalence of congestive heart failure and renal disease, and were more likely to be diagnosed with distal disease (43 % Maori, 26 % non-Maori, p = 0.004). Stage and grade distributions were similar between ethnic groups. Two-thirds (66 %) of stage I-III patients had definitive surgery, with similar rates for Maori (71 %) and non-Maori (68 %). Maori were less likely to have surgery performed by a specialist upper gastrointestinal surgeon (38 % Maori, 79 % non-Maori, p < 0.01) and less likely to be treated in a main centre (44 % Maori, 87 % non-Maori, p < 0.01). After adjusting for age, sex, stage, tumour site and comorbidity, Maori had nonsignificant 27 % poorer survival (hazard ratio 1.27, 95 % CI 0.96-1.68). CONCLUSIONS: There was evidence of differential presentation and access to specialised surgical services, as well as differential survival, for Maori stomach cancer patients compared to non-Maori. These findings support the development of the national stomach cancer treatment standards and highlight the need for an equity focus within these guidelines.

Cancer care decision making in multidisciplinary meetings.

Little research has been undertaken on the actual decision-making processes in cancer care multidisciplinary meetings (MDMs). This article was based on a qualitative observational study of two regional cancer treatment centers in New Zealand. We audiorecorded 10 meetings in which 106 patient cases were discussed. Members of the meetings categorized cases in varying ways, drew on a range of sources of authority, expressed different value positions, and utilized a variety of strategies to justify their actions. An important dimension of authority was encountered authority-the authority a clinician has because of meeting the patient. The MDM chairperson can play an important role in making explicit the sources of authority being drawn on and the value positions of members to provide more clarity to the decision-making process. Attending to issues of process, authority, and values in MDMs has the potential to improve cancer care decision making and ultimately, health outcomes.

Analyzing historical trends in breast cancer biomarker expression: a feasibility study (1947-2009).

BACKGROUND/OBJECTIVES: Determining long-term trends in tumor biomarker expression is essential for understanding aspects of tumor biology amenable to change. Limiting the availability of such data, currently used assays for biomarkers are relatively new. For example, assays for the estrogen receptor (ER), which are the oldest, extend back only to the 1970s. METHODS: To extend scant knowledge about the feasibility of obtaining long-term data on tumor biomarkers, we randomly selected 60 breast cancer cases (10 per decade) diagnosed between 1947-2009 among women members of the Kaiser Permanente Northern California health plan to obtain and analyze their formalin-fixed paraffin-embedded (FFPE) tumor specimens. For each tumor specimen, we created duplicate tissue microarrays for analysis. RESULTS: We located tumor blocks and pathology reports for 50 of the 60 cases (83%), from which we randomly sampled 5 cases per decade for biomarker analysis (n = 30). All 30 cases displayed excellent morphology and exhibited biomarkers compatible with histologic type and grade. Test-retest reliability was also excellent: 100% for ER; 97% for human epidermal growth factor receptor 2 and epidermal growth factor receptor; 93% for progesterone receptor and cytokeratin 5/6; and 90% for Ki67 and molecular phenotype; the kappa statistic was excellent (>0.9) for 4 of the 7 biomarkers, strong (0.6-0.8) for 2, and fair for only 1 (owing to low prevalence). CONCLUSIONS: These results indicate immunostaining for biomarkers commonly used to evaluate breast cancer biology and assign surrogate molecular phenotypes can reliably be employed on archival FFPE specimens up to 60 years old.

Healthy lifestyle and risk of breast cancer for indigenous and non-indigenous women in New Zealand: a case control study.

BACKGROUND: The reasons for the increasing breast cancer incidence in indigenous Maori compared to non-Maori New Zealand women are unknown. The aim of this study was to assess the association of an index of combined healthy lifestyle behaviours with the risk of breast cancer in Maori and non-Maori women. METHODS: A population-based case-control study was conducted, including breast cancer cases registered in New Zealand from 2005-2007. Controls were matched by ethnicity and 5-year age bands. A healthy lifestyle index score (HLIS) was generated for 1093 cases and 2118 controls, based on public health and cancer prevention recommendations. The HLIS was constructed from eleven factors (limiting red meat, cream, and cheese; consuming more white meat, fish, fruit and vegetables; lower alcohol consumption; not smoking; higher exercise levels; lower body mass index; and longer cumulative duration of breastfeeding). Equal weight was given to each factor. Logistic regression was used to estimate the associations between breast cancer and the HLIS for each ethnic group stratified by menopausal status. RESULTS: Among Maori, the mean HLIS was 5.00 (range 1-9); among non-Maori the mean was 5.43 (range 1.5-10.5). There was little evidence of an association between the HLIS and breast cancer for non-Maori women. Among postmenopausal Maori, those in the top HLIS tertile had a significantly lower odds of breast cancer (Odds Ratio 0.47, 95% confidence interval 0.23-0.94) compared to those in the bottom tertile. CONCLUSION: These findings suggest that healthy lifestyle recommendations could be important for reducing breast cancer risk in postmenopausal Maori women.

The burden of stomach cancer in indigenous populations: a systematic review and global assessment.

OBJECTIVE: Stomach cancer is a leading cause of cancer death, especially in developing countries. Incidence has been associated with poverty and is also reported to disproportionately affect indigenous peoples, many of whom live in poor socioeconomic circumstances and experience lower standards of health. In this comprehensive assessment, we explore the burden of stomach cancer among indigenous peoples globally. DESIGN: The literature was searched systematically for studies on stomach cancer incidence, mortality and survival in indigenous populations, including Indigenous Australians, Maori in New Zealand, indigenous peoples from the circumpolar region, native Americans and Alaska natives in the USA, and the Mapuche peoples in Chile. Data from the New Zealand Health Information Service and the Surveillance Epidemiology and End Results (SEER) Program were used to estimate trends in incidence. RESULTS: Elevated rates of stomach cancer incidence and mortality were found in almost all indigenous peoples relative to corresponding non-indigenous populations in the same regions or countries. This was particularly evident among Inuit residing in the circumpolar region (standardised incidence ratios (SIR) males: 3.9, females: 3.6) and in Maori (SIR males: 2.2, females: 3.2). Increasing trends in incidence were found for some groups. CONCLUSIONS: We found a higher burden of stomach cancer in indigenous populations globally, and rising incidence in some indigenous groups, in stark contrast to the decreasing global trends. This is of major public health concern requiring close surveillance and further research of potential risk factors. Given evidence that improving nutrition and housing sanitation, and Helicobacter pylori eradication programmes could reduce stomach cancer rates, policies which address these initiatives could reduce inequalities in stomach cancer burden for indigenous peoples.

'It's whanaungatanga and all that kind of stuff': Maori cancer patients' experiences of health services.

INTRODUCTION: There are unacceptable ethnic differences in cancer survival in Aotearoa/New Zealand. For people with cancer, quality of life and survival are shaped by access to care, but research on Maori access to, and through, cancer care is limited. Internationally, research has shown that primary care plays an important role in providing patient-centred, holistic care and information throughout the cancer care journey. Additionally, Maori health providers provide practical support and facilitate access to all levels of health care. Here we describe the cancer journeys of Maori patients and whanau and identify factors that may facilitate or inhibit access to and through cancer care services. METHODS: Twelve Maori patients affected by cancer and their whanau (family) in the lower North Island took part in face-to-face semi-structured interviews exploring their experiences of cancer screening, diagnosis, treatment, survival and palliative care. FINDINGS: Three key areas were identified that impacted upon the cancer care journey: the experience of support; continuity of care; and the impact of financial and geographic determinants. CONCLUSION: Primary care plays a key role in support and continuity of care across the cancer journey. Alongside interpersonal rapport, a long-term relationship with a primary health provider facilitated a more positive experience of the cancer care journey, suggesting that patients with a 'medical home' are happier with their care and report less problems with coordination between services. Positive, longstanding relationships with general practitioners and Maori health providers assisted patients and whanau with the provision and understanding of information, alongside practical support.

Age and ethnic differences in volumetric breast density in new zealand women: a cross-sectional study.

Breast cancer incidence differs by ethnicity in New Zealand (NZ) with Maori (the indigenous people) women having the highest rates followed by Pakeha (people primarily of British/European descent), Pacific and Asian women, who experience the lowest rates. The reasons for these differences are unclear. Breast density, an important risk factor for breast cancer, has not previously been studied here. We used an automated system, Volpara™, to measure breast density volume from the medio-lateral oblique view of digital mammograms, by age (≤50 years and >50 years) and ethnicity (Pakeha/Maori/Pacific/Asian) using routine data from the national screening programme: age; x-ray system and mammography details for 3,091 Pakeha, 716 Maori, 170 Pacific and 662 Asian (total n = 4,239) women. Linear regression of the natural logarithm of absolute and percent density values was used, back-transformed and expressed as the ratio of the geometric means. Covariates were age, x-ray system and, for absolute density, the natural log of the volume of non-dense tissue (a proxy for body mass index). Median age for Pakeha women was 55 years; Maori 53 years; and Pacific and Asian women, 52 years. Compared to Pakeha women (reference), Maori had higher absolute volumetric density (1.09; 95% confidence interval [95% CI] 1.03-1.15) which remained following adjustment (1.06; 95% CI 1.01-1.12) and was stronger for older compared to younger Maori women. Asian women had the greatest risk of high percentage breast density (1.35; 95% CI 1.27-1.43) while Pacific women in both the ≤50 and >50 year age groups (0.78; 95% CI 0.66-0.92 and 0.81; 95% CI 0.71-0.93 respectively) had the lowest percentage breast density compared to Pakeha. As well as expected age differences, we found differential patterns of breast density by ethnicity consistent with ethnic differences seen in breast cancer risk. Breast density may be a contributing factor to NZ's well-known, but poorly explained, inequalities in breast cancer incidence.

Cigarette smoking and risk of breast cancer in a New Zealand multi-ethnic case-control study.

BACKGROUND: The association between breast cancer and tobacco smoke is currently unclear. The aim of this study was to assess the effect of smoking behaviours on the risk of breast cancer among three ethnic groups of New Zealand women. METHODS: A population-based case-control study was conducted including breast cancer cases registered on the New Zealand Cancer Registry between 2005 and 2007. Controls were matched by ethnicity and 5-year age-group. Logistic regression was used to estimate the association between breast cancer and smoking at different time points across the lifecourse, for each ethnic group. Estimated odds ratios (OR) were adjusted for established risk factors. RESULTS: The study comprised 1,799 cases (302 Maori, 70 Pacific, 1,427 non-Maori/non-Pacific) and 2,540 controls (746 Maori, 191 Pacific, 1,603 non-Maori/non-Pacific). There was no clear association between smoking and breast cancer for non-Maori/non-Pacific women, although non-Maori/non-Pacific ex-smokers had statistically significant increased risk of breast cancer when smoking duration was 20 years or more, and this remained significant in the fully adjusted model (OR 1.31, 95% CI 1.03 to 1.66). Maori showed more consistent increased risk of breast cancer with increasing duration among current smokers (<20 years OR 1.61, 95% CI 0.55 to 4.74; 20+ years OR 2.03, 95% CI 1.29 to 3.22). There was a clear pattern of shorter duration since smoking cessation being associated with increased likelihood of breast cancer, and this was apparent for all ethnic groups. CONCLUSION: There was no clear pattern for cigarette smoking and breast cancer incidence in non-Maori/non-Pacific women, but increased risks were observed for Maori and Pacific women. These findings suggest that lowering the prevalence of smoking, especially among Maori and Pacific women, could be important for reducing breast cancer incidence.