Examining the impact of COVID-19 on Maori:non-Maori health inequities in Aotearoa, New Zealand: an observational study protocol.

INTRODUCTION: The COVID-19 pandemic has had both direct and indirect impacts on the health of populations worldwide. While racial/ethnic health inequities in COVID-19 infection are now well known (and ongoing), knowledge about the impact of COVID-19 pandemic management on non-COVID-19-related outcomes for Indigenous peoples is less well understood. This article presents the study protocol for the Health Research Council of New Zealand funded project 'Ma te Mohio ka Marama: Impact of COVID-19 on Maori:non-Maori inequities'. The study aims to explore changes in access to healthcare, quality of healthcare and health outcomes for Maori, the Indigenous peoples of Aotearoa New Zealand (NZ) and non-Maori during the COVID-19 outbreak period across NZ. METHODS AND ANALYSIS: This observational study is framed within a Kaupapa Maori research positioning that includes Kaupapa Maori epidemiology. National datasets will be used to report on access to healthcare, quality of healthcare and health outcomes between Maori and non-Maori during the COVID-19 pandemic in NZ. Study periods are defined as (a) prepandemic period (2015-2019), (b) first pandemic year without COVID-19 vaccines (2020) and (c) pandemic period with COVID-19 vaccines (2021 onwards). Regional and national differences between Maori and non-Maori will be explored in two phases focused on identified health priority areas for NZ including (1) mortality, cancer, long-term conditions, first 1000 days, mental health and (2) rheumatic fever. ETHICS AND DISSEMINATION: This study has ethical approval from the Auckland Health Research Ethics Committee (AHREC AH26253). An advisory group will work with the project team to disseminate the findings of this project via project-specific meetings, peer-reviewed publications and a project-specific website. The overall intention of the project is to highlight areas requiring health policy and practice interventions to address Indigenous inequities in health resulting from COVID-19 pandemic management (both historical and in the future).

Evolving swabbing practices for COVID-19 in a New Zealand emergency department during the early stages of an emerging pandemic.

OBJECTIVE: To review if tests for suspected COVID-19 were performed according to the Ministry of Health (MoH) case definitions, identify patterns associated with testing outside of the case definition, and discuss the potential impacts on hospital services. METHODS: This was a retrospective audit of patients presenting to the Wellington Hospital ED between 24 March 2020 and 27 April 2020 who were swabbed for COVID-19 in ED. Swabs were audited against the March 15th and April 8th MoH COVID-19 case definitions. RESULTS: Five hundred and thirty-six COVID-19 swabs for 518 patients were taken during the study period. There was poor alignment of testing with the March 15th case definition, with only 11.6% of the 164 swabs taken during this period meeting the case definition. Of the 145 swabs that did not meet the case definition, the majority (n = 119, 82.1%) met symptom criteria only. Alignment of testing with the wider April 8th case definition was much higher with 88.2% meeting criteria. Factors associated with being swabbed despite not meeting the case definitions included fever >38°, a diagnosis of cancer, subsequent hospital admission, and for the March case definition only 'contact with a traveller'. CONCLUSION: There were associations found between testing outside of criteria and specific variables potentially perceived as high-risk. Poor alignment of testing with case definitions can impact hospital services through the (mis)use of limited laboratory testing capacity and implications for resource management. Improved communication and feedback between clinicians and policymakers may improve case definition implementation in a clinical setting.

Regional variation in post-operative mortality in New Zealand.

BACKGROUND: There is a growing body of evidence that access to best practice perioperative care varies within our population. In this study, we use national-level data to begin to address gaps in our understanding of regional variation in post-operative outcomes within New Zealand. METHODS: Using National Collections data, we examined all inpatient procedures in New Zealand public hospitals between 2005 and 2017 (859 171 acute, 2 276 986 elective/waiting list), and identified deaths within 30 days. We calculated crude and adjusted rates per 100 procedures for the 20 district health boards (DHBs), both for the total population and stratified by ethnicity (Maori/European). Odds ratios comparing the risk of post-operative mortality between Maori and European patients were calculated using crude and adjusted Poisson regression models. RESULTS: We observed regional variations in post-operative mortality outcomes. Maori, compared to European, patients experienced higher post-operative mortality rates in several DHBs, with a trend to higher mortality in almost all DHBs. Regional variation in patterns of age, procedure, deprivation and comorbidity (in particular) largely drives regional variation in post-operative mortality, although variation persists in some regions even after adjusting for these factors. Inequitable outcomes for Maori also persist in several regions despite adjustment for multiple factors, particularly in the elective setting. CONCLUSIONS: The persistence of variation and ethnic disparities in spite of adjustment for confounding and mediating factors suggests that multiple regions require additional resource and support to improve outcomes. Efforts to reduce variation and improve outcomes for patients will require both central planning and monitoring, as well as region-specific intervention.

The Impact of Transport on Population Health and Health Equity for Maori in Aotearoa New Zealand: A Prospective Burden of Disease Study.

BACKGROUND: The land transport system influences health via a range of pathways. This study aimed to quantify the amount and distribution of health loss caused by the current land transport system in Aotearoa New Zealand (NZ) through the pathways of road injury, air pollution and physical inactivity. METHODS: We used an existing multi-state life table model to estimate the long-term health impacts (in health-adjusted life years (HALYs)) and changes in health system costs of removing road injury and transport related air pollution and increasing physical activity to recommended levels through active transport. Health equity implications were estimated using relative changes in HALYs and life expectancy for Maori and non-Maori. RESULTS: If the NZ resident population alive in 2011 was exposed to no further air pollution from transport, had no road traffic injuries and achieved at least the recommended weekly amount of physical activity through walking and cycling from 2011 onwards, 1.28 (95% UI: 1.11-1.5) million HALYs would be gained and $7.7 (95% UI: 10.2 to 5.6) billion (2011 NZ Dollars) would be saved from the health system over the lifetime of this cohort. Maori would likely gain more healthy years per capita than non-Maori, which would translate to small but important reductions (2-3%) in the present gaps in life expectancy. CONCLUSION: The current transport system in NZ, like many other car-dominated transport systems, has substantial negative impacts on health, at a similar level to the effects of tobacco and obesity. Transport contributes to health inequity, as Maori bear greater shares of the negative health impacts. Creating a healthier transport system would bring substantial benefits for health, society and the economy.

Anaesthetic choice for hip or knee arthroplasty in New Zealand: Risk of postoperative death and variations in use.

Anaesthetic choice for large joint surgery can impact postoperative outcomes, including mortality. The extent to which the impact of anaesthetic choice on postoperative mortality varies within patient populations and the extent to which anaesthetic choice is changing over time remain under-explored both internationally and in the diverse New Zealand context. In a national study of 199,211 hip and knee replacement procedures conducted between 2005 and 2017, we compared postoperative mortality among those receiving general, regional or general plus regional anaesthesia. Focusing on unilateral (n=86,467) and partial (n=13,889) hip replacements, we assessed whether some groups within the population are more likely to receive general, regional or general plus regional anaesthesia than others, and whether mortality risk varies depending on anaesthetic choice. We also examined temporal changes in anaesthetic choice over time. Those receiving regional alone or general plus regional for unilateral hip replacement appeared at increased risk of 30-day mortality compared to general anaesthesia alone, even after adjusting for differences in terms of age, ethnicity, deprivation, rurality, comorbidity, American Society of Anesthesiologists physical status score and admission type (e.g. general plus regional: adjusted hazard ratio (adj. HR)=1.94, 95% confidence intervals (CI) 1.32 to 2.84). By contrast, we observed lower 30-day mortality among those receiving regional anaesthesia alone compared to general alone for partial hip replacement (adj. HR=0.86, 95% CI 0.75 to 0.97). The latter observation contrasts with declining temporal trends in the use of regional anaesthesia alone for partial hip replacement procedures. However, we recognise that postoperative mortality is one perioperative factor that drives anaesthetic choice.

Disparities in post-operative mortality between Maori and non-Indigenous ethnic groups in New Zealand.

AIM: To describe disparities in post-operative mortality experienced by Indigenous Maori compared to non-Indigenous New Zealanders. METHODS: We completed a national study of all those undergoing a surgical procedure between 2005 and 2017 in New Zealand. We examined 30-day and 90-day post-operative mortality for all surgical specialties and by common procedures. We compared age-standardised rates between ethnic groups (Maori, Pacific, Asian, European, MELAA/Other) and calculated hazard ratios (HRs) using Cox proportional hazards regression modelling adjusted for age, sex, deprivation, rurality, comorbidity, ASA score, anaesthetic type, procedure risk and procedure specialty. RESULTS: From nearly 3.9 million surgical procedures (876,976 acute, 2,990,726 elective/waiting list), we observed ethnic disparities in post-operative mortality across procedures, with the largest disparities occurring between Maori and Europeans. Maori had higher rates of 30- and 90-day post-operative mortality across most broad procedure categories, with the disparity between Maori and Europeans strongest for elective/waiting list procedures (eg, elective/waiting list musculoskeletal procedures, 30-day mortality: adj. HR 1.93, 95% CI 1.56-2.39). CONCLUSIONS: The disparities we observed are likely driven by a combination of healthcare system, process and clinical team factors, and we have presented the key mechanisms within these factors.

Bowel cancer screening age range for Maori: what is all the fuss about?

The current New Zealand Bowel Screening Programme (BSP) is inequitable. At present, just over half of bowel cancers in Maori present before the age of 60 years (58% in females and 52% in males), whereas just under a third of bowel cancers in non-Maori are diagnosed before the same age (27% in females and 29% in males). The argument for extending the bowel screening age range down to 50 years for Maori is extremely simple-in comparison to non-Maori, a greater percentage of bowel cancers in Maori occur before the age of 60 years (when screening starts). Commencing the BSP at 50 years of age for Maori with high coverage will help fix this inequity. In this paper we review the current epidemiology of colorectal cancer with respect to the age range extension for Maori.

Postoperative mortality in New Zealand following general anaesthetic: demographic patterns and temporal trends.

OBJECTIVES: In this manuscript, we describe broad trends in postoperative mortality in New Zealand (a country with universal healthcare) for acute and elective/waiting list procedures conducted between 2005 and 2017. DESIGN, PARTICIPANTS AND SETTING: We use high-quality national-level hospitalisation data to compare the risk of postoperative mortality between demographic subgroups after adjusting for key patient-level confounders and mediators. We also present temporal trends and consider how rates in postoperative death following acute and elective/waiting list procedures have changed over this time period. RESULTS AND CONCLUSION: A total of 1 836 683 unique patients accounted for 3 117 374 admissions in which a procedure was performed under general anaesthetic over the study period. We observed an overall 30-day mortality rate of 0.5 per 100 procedures and a 90-day mortality rate of 0.9 per 100. For acute procedures, we observed a 30-day mortality rate of 1.6 per 100, compared with 0.2 per 100 for elective/waiting list procedures. In terms of procedure specialty, respiratory and cardiovascular procedures had the highest rate of 30-day mortality (age-standardised rate, acute procedures: 3-6 per 100; elective/waiting list: 0.7-1 per 100). As in other contexts, we observed that the likelihood of postoperative death was not proportionally distributed within our population: older patients, Maori patients, those living in areas with higher deprivation and those with comorbidity were at increased risk of postoperative death, even after adjusting for all available factors that might explain differences between these groups. Increasing procedure risk (measured using the Johns Hopkins Surgical Risk Classification System) was also associated with an increased risk of postoperative death. Encouragingly, it appears that risk of postoperative mortality has declined over the past decade, possibly reflecting improvements in perioperative quality of care; however, this decline did not occur equally across procedure specialties.

Impact of low-dose CT screening for lung cancer on ethnic health inequities in New Zealand: a cost-effectiveness analysis.

OBJECTIVE: There are large inequities in the lung cancer burden for the Indigenous Maori population of New Zealand. We model the potential lifetime health gains, equity impacts and cost-effectiveness of a national low-dose CT (LDCT) screening programme for lung cancer in smokers aged 55-74 years with a 30 pack-year history, and for formers smokers who have quit within the last 15 years. DESIGN: A Markov macrosimulation model estimated: health benefits (health-adjusted life-years (HALYs)), costs and cost-effectiveness of biennial LDCT screening. Input parameters came from literature and NZ-linked health datasets. SETTING: New Zealand. PARTICIPANTS: Population aged 55-74 years in 2011. INTERVENTIONS: Biennial LDCT screening for lung cancer compared with usual care. OUTCOME MEASURES: Incremental cost-effectiveness ratios were calculated using the average difference in costs and HALYs between the screened and the unscreened populations. Equity analyses included substituting non-Maori values for Maori values of background morbidity, mortality and stage-specific survival. Changes in inequities in lung cancer survival and 'health-adjusted life expectancy' (HALE) were measured. RESULTS: LDCT screening in NZ is likely to be cost-effective for the total population: NZ$34 400 per HALY gained (95% uncertainty interval NZ$27 500 to NZ$42 900) and for Maori separately (using a threshold of gross domestic product per capita NZ$45 000). Health gains per capita for Maori females were twice that for non-Maori females and 25% greater for Maori males compared with non-Maori males. LDCT screening will narrow absolute inequities in HALE and lung cancer mortality for Maori, but will slightly increase relative inequities in mortality from lung cancer (compared with non-Maori) due to differential stage-specific survival. CONCLUSION: A national biennial LDCT lung cancer screening programme in New Zealand is likely to be cost-effective, will improve total population health and reduce health inequities for Maori. Attention must be paid to addressing ethnic inequities in stage-specific lung cancer survival.

Disparities in Cancer-Specific Survival Between Maori and Non-Maori New Zealanders, 2007-2016.

PURPOSE: While cancer survival is improving across most developed nations, those improvements are not shared equally within their population. Using high-quality national data, we have reviewed the extent to which cancer survival inequities are persisting for indigenous Maori compared with non-Maori New Zealanders and the extent to which these disparities are driven by deprivation, comorbidity, and stage of disease. METHODS: Incident cases of cancer (2007-2016) were extracted from the New Zealand Cancer Registry and linked to mortality and hospitalization data. Descriptive, Kaplan-Meier, and Cox regression methods were used to compare survival outcomes between Maori and non-Maori. RESULTS: Maori continue to have poorer survival than non-Maori for 23 of the 24 most common causes of Maori cancer death, with the extent of this disparity ranging from 12% to 156%. The magnitude of these disparities varies according to deprivation, comorbidity, and stage. Of note, there was a tendency for survival disparities to be largest among those with no comorbidity. CONCLUSION: Maori continue to experience substantial cancer survival inequities. These observations are in keeping with reports from previous decades, which suggest that these disparities persist despite heightened attention. Reduction of the cancer burden on Maori and achievement of equitable survival outcomes require us to prevent cancer for Maori where we can, diagnose Maori patients early when we cannot, and once diagnosed, deliver equitable care to Maori patients at each step along the treatment path.

Postoperative Mortality of Indigenous Populations Compared With Nonindigenous Populations: A Systematic Review.

Importance: A range of factors have been identified as possible contributors to racial/ethnic differences in postoperative mortality that are also likely to hold true for indigenous populations. Yet despite its severity as an outcome, death in the period following a surgical procedure is underresearched for indigenous populations. Objective: To describe postoperative mortality experiences for minority indigenous populations compared with numerically dominant nonindigenous populations and examine the factors that drive any differences observed. Evidence Review: This review was conducted according to PRIMSA guidelines and registered on PROSPERO. Articles were identified through searches of the Embase, Ovid MEDLINE, Scopus, and Cumulative Index to Nursing and Allied Health Literature databases, with manual review of references and gray literature searches conducted. Eligible articles included those that reported associations between ethnicity/indigeneity and mortality up to 90 days following surgery and published in English between January 1, 1990, and March 26, 2019. Data on the study design, setting, participants (including indigeneity), and results were extracted. A modified Newcastle-Ottawa Quality Assessment Scale was used to determine study quality. Findings: A total of 442 abstracts were screened, 92 articles were reviewed in full text, and 21 articles (from 20 studies) and 7 reports underwent data extraction. All included studies were cohort studies (3 prospective and the remainder retrospective) investigating a wide range of surgical procedures in the US, Australia, or New Zealand. Seven studies were from single facilities, while the remainder used data from national databases. Sample sizes ranged, with indigenous sample sizes ranging from 20 to 3052 patients and a number of studies reporting less than 10 indigenous deaths. The postoperative mortality experience for minority indigenous populations compared with the nonindigenous populations was mixed. There was evidence from several studies that indigenous populations may be more likely to die following cardiac procedures. However, the available evidence has overall poor study quality, with methods to identify the indigenous populations being a major limitation of most of the studies. Conclusions and Relevance: Postoperative mortality experiences for indigenous populations should not be interpreted in isolation from the broader context of inequities across the health care pathway and must take into account the quality of data used for indigenous identification.

Testicular Cancer in New Zealand (TCNZ) study: protocol for a national case-control study.

Testicular cancer (TC) is by far the most common cancer to affect young men; however, the exposures that cause this disease are still poorly understood. Our own research has shown that Maori men have the highest rates of this disease in New Zealand-a puzzling observation, since internationally TC is most commonly a disease of men of European ancestry. These trends provide us with a unique opportunity: to learn more about the currently unknown exposures that cause TC, and to explain why Maori have the highest rates of this disease in New Zealand. Using epidemiology and genetics, our experienced research team will conduct a nationwide study which aims to answer these internationally important questions. AIM OF STUDY: The overall aim of the current national case-control study is to identify the key exposures in the development of TC in New Zealand, and explore which factors might explain the difference in the incidence of TC between Maori and non-Maori. METHODS AND ANALYSIS: Outside of our own investigations into cryptorchidism, we still do not know which exposures are driving the significant incidence disparity between ethnic groups in NZ. The aim of the proposed research is to use a population-based case-control study to identify the key exposures in the development of TC in New Zealand. We will recruit 410 TC cases and 410 controls, and collect (1) environmental exposure data, via interview and (2) genetic information, via genome-wide genotyping. ETHICS AND DISSEMINATION: Ethical approval for this study was sought and received from the New Zealand Ministry of Health's Health and Disability Ethics Committee (reference # 17/NTA/248). Following a careful data interpretation process, we will disseminate the findings of this study to a wide and varied audience ranging from general academia, community groups and clinical settings, as well as to the participants themselves.

A review of cervical cancer occurrences in New Zealand 2008-2012.

BACKGROUND: A review of the screening histories of women/wahine diagnosed with cervical cancer was undertaken to assess where the screening pathway can be improved. METHODS: Women diagnosed with confirmed or possible cervical cancer during 1 January 2008-31 December 2012 were identified from the National Cancer Registry (NCR) records. Screening histories for these women were obtained from the National Cervical Screening Programme (NCSP) Register along with pathology and cytology reports and staging information. Women aged 25-69 years with confirmed cervical cancer underwent a review of their screening history. Cervical cancer incidence rates were calculated using Statistics New Zealand mid-year population estimates. RESULTS: Seven hundred and seventy-two confirmed diagnoses of cervical cancer were made during 2008-2012 for an incidence rate of 6.9 per 100,000 women per year. Only 13% of 644 women aged 25-69 years had regular cervical cancer screening according to New Zealand guidelines and this proportion was lower among Maori and Pacific people and those living in deprived areas. However, 37% of women had had a screen in the preceding three-year screening interval, excluding screens undertaken within six months of histological diagnosis. In addition, a significant number developed cancer following an abnormal screen. CONCLUSION: Ongoing efforts are required to improve uptake of regular cervical screening particularly for Maori and socio-economically disadvantaged women/wahine. Further investigation of incident cervical cancers using population-linked data, slide reviews of screens reported as negative and more clinical information is needed to facilitate clinical pathway review to determine the contributing factors that lead to the development of cervical cancer following normal and abnormal screening tests.

APE2 promotes DNA damage response pathway from a single-strand break.

As the most common type of DNA damage, DNA single-strand breaks (SSBs) are primarily repaired by the SSB repair mechanism. If not repaired properly or promptly, unrepaired SSBs lead to genome stability and have been implicated in cancer and neurodegenerative diseases. However, it remains unknown how unrepaired SSBs are recognized by DNA damage response (DDR) pathway, largely because of the lack of a feasible experimental system. Here, we demonstrate evidence showing that an ATR-dependent checkpoint signaling is activated by a defined plasmid-based site-specific SSB structure in Xenopus HSS (high-speed supernatant) system. Notably, the distinct SSB signaling requires APE2 and canonical checkpoint proteins, including ATR, ATRIP, TopBP1, Rad9 and Claspin. Importantly, the SSB-induced ATR DDR is essential for SSB repair. We and others show that APE2 interacts with PCNA via its PIP box and preferentially interacts with ssDNA via its C-terminus Zf-GRF domain, a conserved motif found in >100 proteins involved in DNA/RNA metabolism. Here, we identify a novel mode of APE2-PCNA interaction via APE2 Zf-GRF and PCNA C-terminus. Mechanistically, the APE2 Zf-GRF-PCNA interaction facilitates 3'-5' SSB end resection, checkpoint protein complex assembly, and SSB-induced DDR pathway. Together, we propose that APE2 promotes ATR-Chk1 DDR pathway from a single-strand break.

Colorectal Cancer Screening: How Health Gains and Cost-Effectiveness Vary by Ethnic Group, the Impact on Health Inequalities, and the Optimal Age Range to Screen.

Background: Screening programs consistently underserve indigenous populations despite a higher overall burden of cancer. In this study, we explore the likely health gains and cost-effectiveness of a national colorectal cancer screening program for the indigenous Maori population of New Zealand (NZ).Methods: A Markov model estimated: health benefits (quality-adjusted life-year; QALY), costs, and cost-effectiveness of biennial immunochemical fecal occult blood testing (FOBTi) of 50- to 74-year-olds from 2011. Input parameters came from literature reviews, the NZ Bowel Screening Programme Pilot, and NZ linked health datasets. Equity analyses substituted non-Maori values for Maori values of background (noncolorectal cancer) morbidity and mortality, colorectal cancer survival and incidence, screening coverage, and stage-specific survival. We measured the change in "quality-adjusted life expectancy" (QALE) as a result of the intervention.Results: Based upon a threshold of GDP per capita (NZ$45,000), colorectal cancer screening in NZ using FOBTi is cost-effective: NZ$2,930 (US$1,970) per QALY gained [95% uncertainty interval: cost saving to $6,850 (US$4,610)]. Modeled health gains per capita for Maori were less than for non-Maori: half for 50- to 54-year-olds (0.031 QALYs per person for Maori vs. 0.058 for non-Maori), and a fifth (0.003 c.f. 0.016) for 70- to 74-year-olds and ethnic inequalities in QALE increased with colorectal cancer screening.Conclusions: Colorectal cancer screening in NZ using FOBTi is likely to be cost-effective but risks increasing inequalities in health for Maori.Impact: To avoid or mitigate the generation of further health inequalities, attention should be given to underserved population groups when planning and implementing screening programs. Cancer Epidemiol Biomarkers Prev; 26(9); 1391-400. ©2017 AACR.

A screening program to test and treat for Helicobacter pylori infection: Cost-utility analysis by age, sex and ethnicity.

BACKGROUND: The World Health Organization recommends all countries consider screening for H. pylori to prevent gastric cancer. We therefore aimed to estimate the cost-effectiveness of a H. pylori serology-based screening program in New Zealand, a country that includes population groups with relatively high gastric cancer rates. METHODS: A Markov model was developed using life-tables and morbidity data from a national burden of disease study. The modelled screening program reduced the incidence of non-cardia gastric cancer attributable to H. pylori, if infection was identified by serology screening, and for the population expected to be reached by the screening program. A health system perspective was taken and detailed individual-level costing data was used. RESULTS: For adults aged 25-69 years old, nation-wide screening for H. pylori was found to have an incremental cost of US$196 million (95% uncertainty interval [95% UI]: $182-$211 million) with health gains of 14,200 QALYs (95% UI: 5,100-26,300). Cost per QALY gained was US$16,500 ($7,600-$38,400) in the total population and 17% (6%-29%) of future gastric cancer cases could be averted with lifetime follow-up. A targeted screening program for Maori only (indigenous population), was more cost-effective at US$8,000 ($3,800-$18,500) per QALY. CONCLUSIONS: This modeling study found that H. pylori screening was likely to be cost-effective in this high-income country, particularly for the indigenous population. While further research is needed to help clarify the precise benefits, costs and adverse effects of such screening programs, there seems a reasonable case for policy-makers to give pilot programs consideration, particularly for any population groups with relatively elevated rates of gastric cancer.

Correction: Health, Health Inequality, and Cost Impacts of Annual Increases in Tobacco Tax: Multistate Life Table Modeling in New Zealand.

[This corrects the article DOI: 10.1371/journal.pmed.1001856.].

Ethnic inequalities in cancer incidence and mortality: census-linked cohort studies with 87 million years of person-time follow-up.

BACKGROUND: Cancer makes up a large and increasing proportion of excess mortality for indigenous, marginalised and socioeconomically deprived populations, and much of this inequality is preventable. This study aimed to determine which cancers give rise to changing ethnic inequalities over time. METHODS: New Zealand census data from 1981, 1986, 1991, 1996, 2001, and 2006, were all probabilistically linked to three to five subsequent years of mortality (68 million person-years) and cancer registrations (87 million person years) and weighted for linkage bias. Age-standardised rate differences (SRDs) for Maori (indigenous) and Pacific peoples, each compared to European/Other, were decomposed by cancer type. RESULTS: The absolute size and percentage of the cancer contribution to excess mortality increased from 1981-86 to 2006-11 in Maori males (SRD 72.5 to 102.0 per 100,000) and females (SRD 72.2 to 109.4), and Pacific females (SRD -9.8 to 42.2) each compared to European/Other. Specifically, excess mortality (SRDs) increased for breast cancer in Maori females (linear trend p < 0.01) and prostate (p < 0.01) and colorectal cancers (p < 0.01) in Maori males. The incidence gap (SRDs) increased for breast (Maori and Pacific females p < 0.01), endometrial (Pacific females p < 0.01) and liver cancers (Maori males p = 0.04), and for cervical cancer it decreased (Maori females p = 0.03). The colorectal cancer incidence gap which formerly favoured Maori, decreased for Maori males and females (p < 0.01). The greatest contributors to absolute inequalities (SRDs) in mortality in 2006-11 were lung cancer (Maori males 50 %, Maori females 44 %, Pacific males 81 %), breast cancer (Maori females 18 %, Pacific females 23 %) and stomach cancers (Maori males 9 %, Pacific males 16 %, Pacific females 20 %). The top contributors to the ethnic gap in cancer incidence were lung, breast, stomach, endometrial and liver cancer. CONCLUSIONS: A transition is occurring in what diseases contribute to inequalities. The increasing excess incidence and mortality rates in several obesity- and health care access-related cancers provide a sentinel warning of the emerging drivers of ethnic inequalities. Action to further address inequalities in cancer burden needs to be multi-pronged with attention to enhanced control of tobacco, obesity, and carcinogenic infectious agents, and focus on addressing access to effective screening and quality health care.

Screening for colorectal cancer: spoiled for choice?

There are many different potential screening strategies for colorectal cancer (CRC) that vary both in the likely magnitude of their benefits on CRC mortality and their impact on health services. Many approaches to CRC screening are cost-effective, but there is substantial uncertainty about the optimal approach. Decision models using Markov or microsimulation modelling that compare the cost-effectiveness of different screening strategies are useful in this regard. We have reviewed recent decision models that compare the cost-effectiveness of one-off flexible sigmoidoscopy screening with immunochemical faecal occult blood (FIT) based screening. Models consistently show that any population-based screening is cost-effective compared with no screening, and that FIT-based screening is more effective than one-off sigmoidoscopy screening. The combination of one-off sigmoidoscopy with FIT is more effective in saving lives than either modality alone, but has the greatest impact on health service resources. The recent decision to proceed with biennial FIT-based screening is consistent with current evidence.

Economic evaluation of single-fraction versus multiple-fraction palliative radiotherapy for painful bone metastases in breast, lung and prostate cancer.

INTRODUCTION: Single- and multiple-fraction external beam radiotherapy (SFX-EBRT and MFX-EBRT) are palliative treatment options for localized metastatic bone pain. MFX is the preferred choice in many developed countries. Evidence shows little difference in how effectively SFX and MFX reduce pain. However, SFX is associated with higher retreatment and (in one meta-analysis) pathological fracture rates. MFX is, however, more time-consuming and expensive. We estimated the cost-effectiveness of SFX versus MFX for metastatic bone pain in breast, prostate and lung cancer in New Zealand. METHODS: We constructed a Markov microsimulation model to estimate health gain (in quality-adjusted life-years or QALYs), health system costs (in real 2011 NZ dollars) and cost-effectiveness. The model was populated using effect estimates from randomized controlled trials and other studies, and New Zealand cancer and cost data. Disability weights from the 2010 Global Burden of Disease study were used in estimating QALYs. RESULTS: Across all three cancers, QALY gains were similar for SFX compared to MFX, and per patient costs were less for SFX than MFX, with a difference of NZ$1469 (95% uncertainty interval $1112 to $1886) for lung cancer, $1316 ($810 to $1854) for prostate cancer and $1344 ($855 to $1846) for breast cancer. Accordingly, from a cost-effectiveness perspective, SFX was the preferable treatment option. Various sensitivity analyses did not overturn the clear preference for SFX. CONCLUSION: For all three cancers, SFX was clearly more cost-effective than MFX. This adds to the case for desisting from offering MFX to patients with metastatic bone pain, from a cost-effectiveness angle.