Association between pre-existing cardiometabolic comorbidities and the pathological profiles of breast cancer at initial diagnosis: a cross sectional study.

The presence of comorbidities has been associated with later stages of breast cancer diagnosis. It is unclear whether biological mechanisms are partly responsible. We examined the association between the presence of pre-existing comorbidities and tumour profile at initial diagnosis with breast cancer. Data for the present analysis were derived from a prior inception cohort study comprising 2,501 multiethnic women, newly diagnosed with breast cancer between 2015 and 2017 in four hospitals across Klang Valley. At the inception of the cohort, medical and drug histories, height, weight and blood pressure were recorded. Blood samples were taken to measure serum lipid and glucose. Modified Charlson Comorbidity Index (CCI) was calculated using data extracted from medical records. The association of CCI as well as specific comorbidities, with pathological breast cancer profile was analysed. Higher comorbidity burden, namely cardiometabolic conditions were associated with unfavourable pathological features including larger tumours, involvement of >9 axillary lymph nodes, distant metastasis and human epidermal growth factor receptor 2 overexpression. These associations remained largely significant following multivariable analyses. Specifically, diabetes mellitus was independently associated with high nodal metastasis burden. Low level of high-density lipoprotein was associated with larger tumours (>5 cm), and distant metastasis. Evidence from this study seems to support the hypothesis that the later stages of breast cancer diagnosis in women with (cardiometabolic) comorbidities may be partially explained by underlying pathophysiological events.

Driving quality improvement through better data: The story of New Zealand's radiation oncology collection.

Aotearoa/New Zealand is one of the first nations in the world to develop a comprehensive, high-quality collection of radiation therapy data (the Radiation Oncology Collection, ROC) that is able to report on treatment delivery by health region, patient demographics and service provider. This has been guided by radiation therapy leaders, who have been instrumental in overseeing the establishment of clear and robust data definitions, a centralised database and outputs delivered via an online tool. In this paper, we detail the development of the ROC, provide examples of variation in practice identified from the ROC and how these changed over time, then consider the ramifications of the ROC in the wider context of cancer care quality improvement. In addition to a review of relevant literature, primary data were sourced from the ROC on radiation therapy provided nationally in New Zealand between 2017 and 2020. The total intervention rate, number of fractions and doses are reported for select cancers by way of examples of national variation in practice. Results from the ROC have highlighted areas of treatment variation and have prompted increased uptake of hypofractionation for curative prostate and breast cancer treatment and for palliation of bone metastases. Future development of the ROC will increase its use for quality improvement and ultimately link to a real time cancer services database.

Cancer and diabetes co-occurrence: A national study with 44 million person-years of follow-up.

The number of new cases of cancer is increasing each year, and rates of diabetes mellitus are also increasing dramatically over time. It is not an unusual occurrence for an individual to have both cancer and diabetes at the same time, given they are both individually common, and that one condition can increase the risk of the other. In this manuscript, we use national-level diabetes (Virtual Diabetes Register) and cancer (New Zealand Cancer Registry) data on nearly five million individuals over 44 million person-years of follow-up to examine the occurrence of cancer amongst a national prevalent cohort of patients with diabetes. We completed this analysis separately by cancer for the 24 most commonly diagnosed cancers in Aotearoa New Zealand, and then compared the occurrence of cancer among those with diabetes to those without diabetes. We found that the rate of cancer was highest amongst those with diabetes for 21 of the 24 most common cancers diagnosed over our study period, with excess risk among those with diabetes ranging between 11% (non-Hodgkin's lymphoma) and 236% (liver cancer). The cancers with the greatest difference in incidence between those with diabetes and those without diabetes tended to be within the endocrine or gastrointestinal system, and/or had a strong relationship with obesity. However, in an absolute sense, due to the volume of breast, colorectal and lung cancers, prevention of the more modest excess cancer risk among those with diabetes (16%, 22% and 48%, respectively) would lead to a substantial overall reduction in the total burden of cancer in the population. Our findings reinforce the fact that diabetes prevention activities are also cancer prevention activities, and must therefore be prioritised and resourced in tandem.

Understanding disparities in post-operative mortality for Indigenous patients.

There is an urgent need for high-quality evidence regarding post-operative mortality among Indigenous peoples. Our group recently published a national audit of 4,000,000 procedures conducted between 2005-2017, which identified considerable disparities in post-operative mortality between Indigenous Maori and non-Indigenous New Zealanders. Understanding the primary drivers of these disparities-for Maori, but likely also other Indigenous populations worldwide-requires us to consider the multiple levels at which these drivers might arise. To that end, in this paper we breakdown these drivers in detail, conceptualising these drivers as operating in layers with each factor leading to the next. These layers include structural factors, care system factors, care process factors, care team factors and patient factors. Each of these factors are presented within a framework that can be used to begin to understand them - with a view to rousing action and inspiring intervention to address inequities in post-operative outcomes experienced by Indigenous peoples.

Te Aho o Te Kahu: weaving equity into national-level cancer control.

The purpose of this manuscript was to consider how mainstream health organisations can develop structures, processes, and functions to address inequity, using the New Zealand Cancer Control Agency (Te Aho o Te Kahu) as an example. In New Zealand (Aotearoa), as in other countries, inequities in cancer incidence and outcomes exist between population groups, including for indigenous populations. Despite much discussion regarding the need to address racial inequities, often the proposed solutions are at operational or programmatic levels, and disadvantaged communities are unable to have much of a say in the system design and service delivery of these solutions. The establishment of a dedicated cancer control agency has created a unique opportunity to centralise principles and approaches to achieving equity within the core functions of the agency, and enabled a new method of approaching cancer control with the aim of achieving equity for the most disadvantaged populations. Using a framework based on the founding agreement between New Zealand's Indigenous Maori people and the British Government (Te Tiriti o Waitangi), we consider how health system organisations can develop structures, processes, and functions to achieve equity, and summarise how this new agency has been shaped to achieve these objectives for Maori people in particular, including the innovative and equity-first approach to organisational structure and focus. Within this framework, we highlight the key equity-focused work programmes, initiatives, and other actions taken since the inception of the agency. Finally, we discuss the ongoing equity-related challenges the agency faces, as well as the current and future opportunities for achieving equity in health outcomes.

Equity of travel required to access first definitive surgery for liver or stomach cancer in New Zealand.

In New Zealand, there are known disparities between the Indigenous Maori and the majority non-Indigenous European populations in access to cancer treatment, with resulting disparities in cancer survival. There is international evidence of ethnic disparities in the distance travelled to access cancer treatment; and as such, the aim of this paper was to examine the distance and time travelled to access surgical care between Maori and European liver and stomach cancer patients. We used national-level data and Geographic Information Systems (GIS) analysis to describe the distance travelled by patients to receive their first primary surgery for liver or stomach cancer, as well as the estimated time to travel this distance by road, and the surgical volume of hospitals performing these procedures. All cases of liver (ICD-10-AM 3rd edition code: C22) and stomach (C16) cancer that occurred in New Zealand (2007-2019) were drawn from the New Zealand Cancer Registry (liver cancer: 866 Maori, 2,460 European; stomach cancer: 953 Maori, 3,192 European), and linked to national inpatient hospitalisation records to examine access to surgery. We found that Maori on average travel 120km for liver cancer surgery, compared to around 60km for Europeans, while a substantial minority of both Maori and European liver cancer patients must travel more than 200km for their first primary liver surgery, and this situation appears worse for Maori (36% vs 29%; adj. OR 1.48, 95% CI 1.09-2.01). No such disparities were observed for stomach cancer. This contrast between cancers is likely driven by the centralisation of liver cancer surgery relative to stomach cancer. In order to support Maori to access liver cancer care, we recommend that additional support is provided to Maori patients (including prospective financial support), and that efforts are made to remotely provide those clinical services that can be decentralised.

Using national data to model the New Zealand radiation oncology workforce.

INTRODUCTION: Demand for radiation therapy is expected to increase over time. In Aotearoa/New Zealand, the radiation oncology workforce experiences high numbers of clinical hours but an intervention rate that is lower than in comparable countries, suggesting unmet treatment need. Accurate models on the supply and demand for radiation oncologists (ROs) are needed to ensure adequate staffing levels. METHODS: We developed a demand model that predicted the future number of ROs required, using national data from the Radiation Oncology Collection (ROC) and a survey of ROs. Radiation therapy intervention and retreatment rates (IR/RTRs), and benign and non-cancer conditions being treated, were derived from the ROC and applied to Census population projections. Survey data provided definitions of treatment by complexity, time spent in different activities and time available for work. Results were linked to radiation oncology workforce forecasts from a supply model developed by the Ministry of Health. RESULTS: The demand model showed that 85 ROs would be needed in 2031, if current IR/RTRs were maintained, an increase from 68 in 2021. The supply model predicted a decrease in ROs over time, leaving a significant shortfall. Model parameters could be modified to assess the impact of workforce or practice changes; more ROs would be needed if average working hours reduced or IR/RTRs increased. CONCLUSION: Workforce models based on robust data collections are an important tool for workforce planning. The RO demand model presented here combines detailed information on treatment and work activities to provide credible estimates that can be used to inform actions on training, recruitment and retention.

The impact of COVID-19 on lung cancer detection, diagnosis and treatment for Maori in Aotearoa New Zealand.

AIM: The purpose of this article is to examine disparities in the impact of the COVID-19 pandemic on access to lung cancer diagnosis and access to clinical services between Maori and non-Maori. METHODS: Using national-level data, we examined age-standardised lung cancer registrations, diagnostic procedures (bronchoscopy) and lung surgeries separately by ethnic group for the years 2018-2020, as well as patterns of stage of diagnosis. RESULTS: We found a trend toward a reduction in rates of lung cancer registration in Maori (but not non-Maori/non-Pacific) New Zealanders in 2020 compared to 2018 and 2019, but no apparent shift in the distribution of stage at diagnosis. We found a trend toward a reduction in rates of bronchoscopy for both Maori and non-Maori/non-Pacific patients, with the largest reduction observed for Maori. Rates of lung cancer surgery appeared to have reduced for Maori patients, although this was based on a small number of procedures. CONCLUSIONS: We observed disparities between Maori and non-Maori/non-Pacific patients in lung cancer registration and bronchoscopy as a result of the COVID-19 pandemic.

Where Are We Dying? Ethnic Differences in Place of Death Among New Zealanders Dying of Cancer.

PURPOSE: Around a third of people with cancer will die outside of their preferred place of death, with substantial variation occurring between and within countries in terms of place of death. Here, we examine place of death within the New Zealand cancer context, with specific focus on differences between Indigenous Maori and other ethnic groups. METHODS: Using national-level data, we identified all those who died in New Zealand between 2007 and 2018 of cancer (N = 107,373), stratified by ethnicity and cancer type, and linked these patients to national health and mortality records. We then described the crude and age-standardized proportions of cancer deaths by location separately by ethnic group, and conducted logistic regression to compare odds of death within a given location between ethnic groups. RESULTS: After adjusting for age, sex, and deprivation, we found that Maori people with cancer are more likely to die in a private residence than Europeans (46% v 26%; odds ratio [OR] 2.45; 95% CI, 2.36 to 2.55), and also somewhat more likely to die in hospital (27% v 23%; OR 1.26; 95% CI, 1.21 to 1.32). Commensurately, Maori are less likely to die in either hospice inpatient unit (14% v 27%; OR 0.48; 95% CI, 0.45 to 0.51) or residential care (12% v 30%; OR 0.56; 95% CI, 0.52 to 0.59). Pacific patients generally follow the same pattern as Maori patients. These findings were largely repeated across cancer types, with some variation in the magnitude not overall pattern. CONCLUSION: It remains unclear whether these differences reflect differences in preferences for place of death between ethnic groups, or whether they reflect differences in access to appropriate supportive care. Further research is required to examine these differences in greater detail.

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.

Equity of timely access to liver and stomach cancer surgery for Indigenous patients in New Zealand: a national cohort study.

OBJECTIVES: When combined, liver and stomach cancers are second only to lung cancer as the most common causes of cancer death for the indigenous Maori population of New Zealand-with Maori also experiencing substantial disparities in the likelihood of survival once diagnosed with these cancers. Since a key driver of this disparity in survival could be access to surgical treatment, we have used national-level data to examine surgical procedures performed on Maori patients with liver and stomach cancers and compared the likelihood and timing of access with the majority European population. DESIGN, PARTICIPANTS AND SETTING: We examined all cases of liver and stomach cancers diagnosed during 2007-2019 on the New Zealand Cancer Registry (liver cancer: 866 Maori, 2460 European; stomach cancer: 953 Maori, 3192 European) and linked these cases to all inpatient hospitalisations that occurred over this time to identify curative and palliative surgical procedures. As well as descriptive analysis, we compared the likelihood of access to a given procedure between Maori and Europeans, stratified by cancer and adjusted for confounding and mediating factors. Finally, we compared the timing of access to a given procedure between ethnic groups. RESULTS AND CONCLUSIONS: We found that (a) access to liver transplant for Maori is lower than for Europeans; (b) Maori with stomach cancer appear more likely to require the type of palliation consistent with gastric outlet obstruction; and (c) differential timing of first stomach cancer surgery between Maori and European patients. However, we may also be cautiously encouraged by the fact that differences in overall access to curative surgical treatment were either marginal (liver) or absent (stomach).

Global patterns in testicular cancer incidence and mortality in 2020.

With 74 500 new cases worldwide in 2020, testicular cancer ranks as the 20th leading cancer type, but is the most common cancer in young men of European ancestry. While testicular cancer incidence has been rising in many populations, mortality trends, at least those in high-income settings, have been in decline since the 1970s following the introduction of platinum-based chemotherapy. To examine current incidence and mortality patterns, we extracted the new cases of, and deaths from cancers of the testis from the GLOBOCAN 2020 database. In 2020, testicular cancer was the most common cancer in men aged 15 to 44 in 62 countries worldwide. Incidence rates were highest in West-, North- and South-Europe and Oceania (age-standardised rate, ASR ≥7/100 000), followed by North America (5.6/100 000 and lowest (<2/100 000) in Asia and Africa. The mortality rates were highest in Central and South America (0.84 and 0.54 per 100 000, respectively), followed by Eastern and Southern Europe, and Western and Southern Africa. The lowest mortality rates were in Northern Europe, Northern Africa and Eastern Asia (0.16, 0.14, 0.9 per 100 000, respectively). At the country level, incidence rates varied over 100-fold, from 10/100 000 in Norway, Slovenia, Denmark and Germany to ≤0.10/100 000 in Gambia, Guinea, Liberia, Lesotho. Mortality rates were highest in Fiji, Argentina and Mexico. Our results indicate a higher mortality burden in countries undergoing economic transitions and reinforce the need for more equitable access to testicular cancer diagnosis and treatment globally.

Patient volume and clinical outcome after pancreatic cancer resection: A contemporary systematic review and meta-analysis.

BACKGROUND: Pancreatic cancer remains a highly fatal disease with a 5-year overall survival of less than 10%. In seeking to improve clinical outcomes, there is ongoing debate about the weight that should be given to patient volume in centralization models. The aim of this systematic review is to examine the relationship between patient volume and clinical outcome after pancreatic resection for cancer in the contemporary literature. METHODS: The Google Scholar, PubMed, and Cochrane Library databases were systematically searched from February 2015 until June 2021 for articles reporting patient volume and outcomes after pancreatic cancer resection. RESULTS: There were 46 eligible studies over a 6-year period comprising 526,344 patients. The median defined annual patient volume thresholds varied: low-volume 0 (range 0-9), medium-volume 9 (range 3-29), high-volume 19 (range 9-97), and very-high-volume 28 (range 17-60) patients. The latter 2 were associated with a significantly lower 30-day mortality (P < .001), 90-day mortality (P < .001), overall postoperative morbidity (P = .005), failure to rescue rate (P = .006), and R0 resection rate (P = .008) compared with very-low/low-volume hospitals. Centralization was associated with lower 30-day mortality in 3 out of 5 studies, while postoperative morbidity was similar in 4 out of 4 studies. Median survival was longer in patients traveling greater distance for pancreatic resection in 2 out of 3 studies. Median and 5-year survival did not differ between urban and rural settings. CONCLUSION: The contemporary literature confirms a strong relationship between patient volume and clinical outcome for pancreatic cancer resection despite expected bias toward more complex surgery in high-volume centers. These outcomes include lower mortality, morbidity, failure-to-rescue, and positive resection margin rates.

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.

National Study of Pain Medicine Access Among Maori and Non-Maori Patients With Lung Cancer in New Zealand.

PURPOSE: Pain is among the most common and consequential symptoms of cancer, particularly in the context of lung cancer. Maori have extremely high rates of lung cancer, and there is evidence that Maori patients with lung cancer are less likely to receive curative treatment and more likely to receive palliative treatment and to wait longer for their treatment than non-Maori New Zealanders. The extent to which Maori patients with lung cancer are also less likely to have access to pain medicines as part of their supportive care remains unclear. METHODS: Using national-level Cancer Registry and linked health records, we describe access to subsidized pain medicines among patients with lung cancer diagnosed over the decade spanning 2007-2016 and compare access between Maori and non-Maori patients. Descriptive and logistic regression methods were used to compare access between ethnic groups. RESULTS: We observed that the majority of patients with lung cancer are accessing some form of pain medicine and there do not appear to be strong differences between Maori and non-Maori in terms of overall access or the type of pain medicine dispensed. However, Maori patients appeared more likely than non-Maori to first access pain medicines within 2 weeks before their death and commensurately less likely to access them more than 24 weeks before death. CONCLUSION: Given the plausibility that there are differences in first access to pain medicines (particularly opioid medicines) among Maori approaching end of life, further investigation of the factors contributing to this disparity is required.

Maintaining cancer services during the COVID-19 pandemic: the Aotearoa New Zealand experience.

COVID-19 caused significant disruption to cancer services around the world. The health system in Aotearoa New Zealand has fared better than many other regions, with the country being successful, so far, in avoiding sustained community transmission. However, there was a significant initial disruption to services across the cancer continuum, resulting in a decrease in the number of new diagnoses of cancer in March and April 2020. Te Aho o Te Kahu, Aotearoa New Zealand's national Cancer Control Agency, coordinated a nationwide response to minimise the impact of COVID-19 on people with cancer. The response, outlined in this paper, included rapid clinical governance, a strong equity focus, development of national clinical guidance, utilising new ways of delivering care, identifying and addressing systems issues and close monitoring and reporting of the impact on cancer services. Diagnostic procedures and new cancer registrations increased in the months following the national lockdown, and the cumulative number of cancer registrations in 2020 surpassed the number of registrations in 2019 by the end of September. Cancer treatment services - surgery, medical oncology, radiation oncology and haematology - continued during the national COVID-19 lockdown in March and April 2020 and continued to be delivered at pre-COVID-19 volumes in the months since. We are cautiously optimistic that, in general, the COVID-19 pandemic does not appear to have increased inequities in cancer diagnosis and treatment for Maori in Aotearoa New Zealand.

Age disparities in lung cancer survival in New Zealand: The role of patient and clinical factors.

OBJECTIVE: Age is an important prognostic factor for lung cancer. However, no studies have investigated the age difference in lung cancer survival per se. We, therefore, described the role of patient-related and clinical factors on the age pattern in lung cancer excess mortality hazard by stage at diagnosis in New Zealand. MATERIALS AND METHODS: We extracted 22 487 new lung cancer cases aged 50-99 (median age = 71, 47.1 % females) diagnosed between 1 January 2006 and 31 July 2017 from the New Zealand population-based cancer registry and followed up to December 2019. We modelled the effect of age at diagnosis, sex, ethnicity, deprivation, comorbidity, and emergency presentation on the excess mortality hazard by stage at diagnosis, and we derived corresponding lung cancer net survival. RESULTS: The age difference in net survival was particularly marked for localised and regional lung cancers, with a sharp decline in survival from the age of 70. No identified factors influenced age disparities in patients with localised cancer. However, for other stages, females had a greater difference in survival between middle-age and older-age than males. Comorbidity and emergency presentation played a minor role. Ethnicity and deprivation did not influence age disparities in lung cancer survival. CONCLUSION: Sex and stage at diagnosis were the most important factors of age disparities in lung cancer survival in New Zealand.

Silver linings: a qualitative study of desirable changes to cancer care during the COVID-19 pandemic.

INTRODUCTION: Public health emergencies and crises such as the current COVID-19 pandemic can accelerate innovation and place renewed focus on the value of health interventions. Capturing important lessons learnt, both positive and negative, is vital. We aimed to document the perceived positive changes (silver linings) in cancer care that emerged during the COVID-19 pandemic and identify challenges that may limit their long-term adoption. METHODS: This study employed a qualitative design. Semi-structured interviews (n = 20) were conducted with key opinion leaders from 14 countries. The participants were predominantly members of the International COVID-19 and Cancer Taskforce, who convened in March 2020 to address delivery of cancer care in the context of the pandemic. The Framework Method was employed to analyse the positive changes of the pandemic with corresponding challenges to their maintenance post-pandemic. RESULTS: Ten themes of positive changes were identified which included: value in cancer care, digital communication, convenience, inclusivity and cooperation, decentralisation of cancer care, acceleration of policy change, human interactions, hygiene practices, health awareness and promotion and systems improvement. Impediments to the scale-up of these positive changes included resource disparities and variation in legal frameworks across regions. Barriers were largely attributed to behaviours and attitudes of stakeholders. CONCLUSION: The COVID-19 pandemic has led to important value-based innovations and changes for better cancer care across different health systems. The challenges to maintaining/implementing these changes vary by setting. Efforts are needed to implement improved elements of care that evolved during the pandemic.