Human papillomavirus self-testing among unscreened and under-screened Maori, Pasifika and Asian women in Aotearoa New Zealand: A preference survey among responders and interviews with clinical-trial nonresponders.

INTRODUCTION: Maori, Pasifika and Asian women are less likely to attend cervical screening and Maori and Pasifika women are more likely to be diagnosed with later-stage cervical cancer than other women in Aotearoa New Zealand. This study-with under-screened women taking part in a randomized-controlled trial comparing self-testing and standard screening-explored the acceptability of a human papillomavirus (HPV) self-test kit and the preferred method for receiving it. METHODS: Maori, Pasifika and Asian women (N= 376) completed a cross-sectional postal questionnaire. Twenty-six women who had not accepted the trial invitation were interviewed to understand their reasons for nonparticipation. RESULTS: Most women found the self-test kit easy and convenient to use and reported that they did not find it painful, uncomfortable or embarrassing. This was reflected in the preference for a self-test over a future smear test on the same grounds. Most women preferred to receive the kit by mail and take the test themselves, rather than having it done by a doctor or nurse. There was a range of preferences relating to how to return the kit. Phone calls with nonresponders revealed that, although most had received the test kit, the reasons for not choosing to be involved included not wanting to, being too busy or forgetting. CONCLUSION: HPV self-testing was acceptable for Maori, Pasifika and Asian women in Aotearoa New Zealand. HPV self-testing has considerable potential to reduce the inequities in the current screening programme and should be made available with appropriate delivery options as soon as possible. PATIENT OR PUBLIC CONTRIBUTION: This study explored the acceptability of HPV self-testing and their preferences for engaging with it among Maori, Pasifika and Asian women. Thus, women from these underserved communities were the participants and focus of this study.

Pasifika women's knowledge and perceptions of cervical-cancer screening and the implementation of self-testing in Aotearoa New Zealand: A qualitative study.

Background: In Aotearoa New Zealand, Pasifika women have a higher rate of cervical cancer incidence and mortality than European/Other women and a lower screening rate. Despite actions to reduce the barriers, there has been little change in screening coverage for Pasifika women since 2007. Novel strategies are therefore required. Persistent cervical infection with oncogenic human papillomavirus (HPV) causes virtually all cervical cancers and HPV testing will be implemented in Aotearoa in 2023, with women being able to choose to self-test. We undertook a qualitative focus group (FG) study with Pasifika women to explore their perspectives on the barriers to, and facilitators of, HPV self-testing and how best to implement this in Aotearoa. Methods: A trained female Pasifika Research Assistant facilitated participant recruitment and the FGs. Eligible participants self-identified as Pasifika, were aged 30-69 years, in the Wellington area, who had never been screened or who were overdue (≥5 years) for cervical-cancer screening. Recruitment was predominantly through Pasifika key-informant networks and in collaboration with Pasifika primary care providers. Participants were offered face-to-face FGs but, due to occasional Covid-19 restrictions and personal preferences, FGs via Zoom were also used. The FGs were audio-recorded and transcribed verbatim. The FG transcripts were thematically analysed. Findings: Seven FGs were conducted with 24 participants. We identified five main themes around barriers and potential facilitators of HPV self-testing in Pasifika women: 1) perceptions and knowledge of cervical-cancer screening; 2) challenges to engaging in organised cervical screening; 3) perceptions of self-testing for HPV and challenges women face when deciding to self-test; 4) enthusiasm for an HPV self-test; and 5) information and communication. Knowledge about cervical cancer and screening varied considerably among participants, with some never having heard about cervical-cancer screening. The main challenges that were raised were personal privacy and confidentiality and time management. There was consensus around the need for adequate, consistent, and accurate accessible information to boost the confidence of women undertaking self-testing. In general, the participants were eager for self-testing to be made available soon. This was accompanied by the need for the promotion and implementation of self-testing to include a collective/community approach consistent with Pasifika worldviews. Interpretation: Although participants were enthusiastic about HPV self-testing, multi-level and interacting barriers exist to participation by Pasifika women in HPV self-testing. Implementation of self-testing in Aotearoa New Zealand should be accompanied by clear information about the entire process, using culturally appropriate tailored educational campaigns in different Pasifika languages. Funding: The study was supported by the Collaboration for Cancer Research Aotearoa New Zealand (CCR).

Acceptability of human papillomavirus (HPV) self-sampling among never- and under-screened Indigenous and other minority women: a randomised three-arm community trial in Aotearoa New Zealand.

BACKGROUND: Internationally, self-sampling for human papillomavirus (HPV) has been shown to increase participation in cervical-cancer screening. In Aotearoa New Zealand, there are long-standing ethnic inequalities in cervical-cancer screening, incidence, and mortality, particularly for indigenous Maori women, as well as Pacific and Asian women. METHODS: We invited never- and markedly under-screened (≥5 years overdue) 30-69-year-old Maori, Pacific, and Asian women to participate in an open-label, three-arm, community-based, randomised controlled trial, with a nested sub-study. We aimed to assess whether two specific invitation methods for self-sampling improved screening participation over usual care among the least medically served populations. Women were individually randomised 3:3:1 to: clinic-based self-sampling (CLINIC - invited to take a self-sample at their usual general practice); home-based self-sampling (HOME - mailed a kit and invited to take a self-sample at home); and usual care (USUAL - invited to attend a clinic for collection of a standard cytology sample). Neither participants nor research staff could be blinded to the intervention. In a subset of general practices, women who did not participate within three months of invitation were opportunistically invited to take a self-sample, either next time they attended a clinic or by mail. FINDINGS: We randomised 3,553 women: 1,574 to CLINIC, 1,467 to HOME, and 512 to USUAL. Participation was highest in HOME (14.6% among Maori, 8.8% among Pacific, and 18.5% among Asian) with CLINIC (7.0%, 5.3% and 6.9%, respectively) and USUAL (2.0%, 1.7% and 4.5%, respectively) being lower. In fully adjusted models, participation was statistically significantly more likely in HOME than USUAL: Maori OR=9.7, (95%CI 3.0-31.5); Pacific OR=6.0 (1.8-19.5); and Asian OR=5.1 (2.4-10.9). There were no adverse outcomes reported. After three months, 2,780 non-responding women were invited to participate in a non-randomised, opportunistic, follow-on substudy. After 6 months,192 (6.9%) additional women had taken a self-sample. INTERPRETATION: Using recruitment methods that mimic usual practice, we provide critical evidence that self-sampling increases screening among the groups of women (never and under-screened) who experience the most barriers in Aotearoa New Zealand, although the absolute level of participation through this population approach was modest. Follow-up for most women was routine but a small proportion required intensive support. TRIAL REGISTRATION: ANZCTR Identifier: ACTRN12618000367246 (date registered 12/3/2018) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371741&isReview=true; UTN: U1111-1189-0531. FUNDING: Health Research Council of New Zealand (HRC 16/405). PROTOCOL: http://publichealth.massey.ac.nz/assets/Uploads/Study-protocol-V2.1Self-sampling-for-HPV-screening-a-community-trial.pdf.

Social impacts and costs of schizophrenia: a national cohort study using New Zealand linked administrative data.

AIM: To identify a national population of individuals living with schizophrenia in New Zealand, and to examine health, social support, justice, economic outcomes and estimated government costs compared to a matched comparison group. METHODS: Data were sourced from the Integrated Data Infrastructure. Individuals with a schizophrenia diagnosis in public hospital discharge or specialist secondary mental health service data, aged 18 to 64 and living in New Zealand were included in the schizophrenia population. Propensity score matching was used to select a comparison group of individuals without schizophrenia from the New Zealand resident population and compare outcomes and costs. RESULTS: In 2015 there were 18,096 people living with schizophrenia in New Zealand, a prevalence of 6.7 per 1,000 people. Compared to the matched comparison population, individuals with schizophrenia had higher hospitalisation rates for mental (OR=52.80) and physical (OR=1.18) health conditions. They were more likely to receive social welfare benefits (OR=17.64), less likely to be employed (OR=0.11) and had lower income ($26,226 lower). Per-person government costs were higher for the schizophrenia group across all domains, particularly health ($14,847 higher) and social support ($11,823 higher). CONCLUSION: Schizophrenia is associated with a range of adverse health, social and economic outcomes and considerably higher government costs compared to the general population.

Associations of Occupational Exposures to Electric Shocks and Extremely Low-Frequency Magnetic Fields With Motor Neurone Disease.

In a New Zealand population-based case-control study we assessed associations with occupational exposure to electric shocks, extremely low-frequency magnetic fields (ELF-MF) and motor neurone disease using job-exposure matrices to assess exposure. Participants were recruited between 2013 and 2016. Associations with ever/never, duration, and cumulative exposure were assessed using logistic regression adjusted for age, sex, ethnicity, socioeconomic status, education, smoking, alcohol consumption, sports, head or spine injury, and solvents, and was mutually adjusted for the other exposure. All analyses were repeated stratified by sex. An elevated risk was observed for having ever worked in a job with potential for electric shocks (odds ratio (OR) = 1.35, 95% confidence interval (CI): 0.98, 1.86), with the strongest association for the highest level of exposure (OR = 2.01, 95% CI: 1.31, 3.09). Analysis by duration suggested a nonlinear association: Risk was increased for both short duration (<3 years; OR = 4.69, 95% CI: 2.25, 9.77) and long duration (>24 years; OR = 1.88; 95% CI: 1.05, 3.36) in a job with high level of electric shock exposure, with less pronounced associations for intermediate durations. No association with ELF-MF was found. Our findings provide support for an association between occupational exposure to electric shocks and motor neurone disease but did not show associations with exposure to work-related ELF-MF.

An estimate of limited duration cancer prevalence in New Zealand using 'big' data.

AIMS: Increases in cancer survival may increase cancer prevalence and demand for healthcare. We aimed to estimate cancer prevalence in the New Zealand population. METHODS: We used national linked health, social and census datasets from the Stats NZ Integrated Data Infrastructure to identify the number of New Zealand residents who had at least one cancer diagnosis in New Zealand. We included all primary cancers recorded on the New Zealand Cancer Registry from January 1995 to June 2013, and used the 2013 census for demographic and socioeconomic data. RESULTS: On 30 June 2013, 140,600 of 4,438,900 (3.2%) New Zealand residents had been diagnosed with cancer in the last 18.5 years. In ≥15 year olds, the age-standardised prevalence of cancer diagnosed 0 to ≤1 year, and >1 to ≤5 years, prior to 30 June 2013 was 0.4% and 1.1% in men and 0.3% and 0.9% in women, respectively. Over the 18.5-year period prevalence was greatest in the oldest ages, European/Other, highest qualified, highest income, least deprived, ex-smokers, and Canterbury, Bay of Plenty and Nelson/Marlborough District Health Boards (age-standardised). CONCLUSIONS: Groups with the highest survival and the greatest access to healthcare had the highest cancer prevalences.

Correction to: Comparison of two invitation-based methods for human papillomavirus (HPV) self-sampling with usual care among un- and under-screened Maori, Pacific and Asian women: study protocol for a randomised controlled community trial to examine the effect of self-sampling on participation in cervical-cancer screening.

Following publication of the original article [1], the authors reported an error in the authorship list associated with the paper. Georgina McPherson has therefore been added.

Comparison of two invitation-based methods for human papillomavirus (HPV) self-sampling with usual care among un- and under-screened Maori, Pacific and Asian women: study protocol for a randomised controlled community trial to examine the effect of self-sampling on participation in cervical-cancer screening.

BACKGROUND: Maori, Pacific and Asian women in New Zealand have lower cervical-cancer screening rates than European women, and there are persistent inequities in cervical cancer outcomes for Maori and Pacific women. Innovative ways to address access barriers are required. New Zealand is transitioning to screening with human papillomavirus (HPV) DNA testing, which could allow women themselves, rather than a clinician, to take the sample. Internationally, self-sampling has been found to increase screening participation rates. The aim of this open-label community-based randomised controlled trial is to investigate whether self-sampling increases screening participation among un- and under-screened Maori, Pacific and Asian women in New Zealand. METHODS/DESIGN: We aim to invite at least 3550 un- or under-screened (≥5 years overdue) Maori, Pacific and Asian women (1050, 1250, 1250 respectively), aged 30-69 years, for screening. The three study arms are: usual care in which women are invited to attend a clinic for a standard clinician-collected cytology test; clinic-based self-sampling in which women are invited to take a self-sample at their usual general practice; and mail-out self-sampling in which women are mailed a kit and invited to take a self-sample at home. Women will be randomised 3:3:1 to the clinic and mail-out self-sampling groups, and usual care. There is also a nested sub-study in which non-responding women in all allocation groups, when they subsequently present to the clinic for other reasons, are offered clinic or home-kit self-sampling. The primary outcome will be the proportion of women who participate (by taking a self-sample or cytology test). DISCUSSION: This trial is the first to evaluate the effectiveness of mailed self-sampling in New Zealand and will be one of the first internationally to evaluate the effectiveness of opportunistic in-clinic invitations for self-sampling. The trial will provide robust evidence on the impact on participation proportions from different invitation approaches for HPV self-sampling in New Zealand un- and under-screened Maori, Pacific and Asian women. TRIAL REGISTRATION: ANZCTR Identifier: ACTRN12618000367246 (date registered 12/3/2018) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371741&isReview=true; UTN: U1111-1189-0531.

Can cost-effectiveness results be combined into a coherent league table? Case study from one high-income country.

BACKGROUND: Doubts exist around the value of compiling league tables for cost-effectiveness results for health interventions, primarily due to methods differences. We aimed to determine if a reasonably coherent league table could be compiled using published studies for one high-income country: New Zealand (NZ). METHODS: Literature searches were conducted to identify NZ-relevant studies published in the peer-reviewed journal literature between 1 January 2010 and 8 October 2017. Only studies with the following metrics were included: cost per quality-adjusted life-year or disability-adjusted life-year or life-year (QALY/DALY/LY). Key study features were abstracted and a summary league table produced which classified the studies in terms of cost-effectiveness. RESULTS: A total of 21 cost-effectiveness studies which met the inclusion criteria were identified. There were some large methodological differences between the studies, particularly in the time horizon (1 year to lifetime) but also discount rates (range 0 to 10%). Nevertheless, we were able to group the incremental cost-effectiveness ratios (ICERs) into general categories of being reported as cost-saving (19%), cost-effective (71%), and not cost-effective (10%). The median ICER (adjusted to 2017 NZ$) was ~ $5000 per QALY/DALY/LY (~US$3500). However, for some interventions, there is high uncertainty around the intervention effectiveness and declining adherence over time. CONCLUSIONS: It seemed possible to produce a reasonably coherent league table for the ICER values from different studies (within broad groupings) in this high-income country. Most interventions were cost-effective and a fifth were cost-saving. Nevertheless, study methodologies did vary widely and researchers need to pay more attention to using standardised methods that allow their results to be included in future league tables.

Acceptability of human papillomavirus self-sampling for cervical-cancer screening in under-screened Maori and Pasifika women: a pilot study.

AIM: To assess whether self-sampling for cervical-cancer screening is acceptable to New Zealand women. METHODS: Maori, Pacific and Asian un- or under-screened women aged 30-69 years were asked to: 1) examine three self-sampling devices; 2) complete a questionnaire on demographics and experiences with the devices; and 3) take a self-sample. Samples were tested 'off-label' using the cobas® 4800 human papillomavirus (HPV) test (Roche Diagnostics NZ). RESULTS: Thirty-one Pacific, 12 Maori, nine Asian and four women of other ethnicities participated (mean age, 39.5 years). Before trying any devices, 78% indicated a preference to self-sample, compared to 22% who preferred a physician-collected sample (PCS). After trying a device (HerSwab™, 91%; Delphi Screener™, 14%; cobas Swab, 13%; 12.5% used >1 device), fewer women (66%) preferred to self-sample next time, fewer (16%) preferred a PCS, while 18% expressed no preference. One of 32 samples with valid results (35 were tested) was positive for HPV 'other' oncogenic types. CONCLUSIONS: This was the first New Zealand study to invite women, including Maori women, to take a self-sample for cervical-cancer screening. The pilot study suggests that un- and under-screened women generally find self-sampling acceptable and all sample types are suitable for use with the cobas HPV test.

Occupation and motor neuron disease: a New Zealand case-control study.

OBJECTIVES: To assess associations between occupation and motor neuron disease (MND). METHODS: We conducted a population-based case-control study with cases (n=321) recruited through the New Zealand Motor Neurone Disease Association and hospital discharge data. Controls (n=605) were recruited from the Electoral Roll. Information on personal and demographic details, lifestyle factors and a full occupational history was collected using questionnaires and interviews. Associations with ever/never employed and employment duration were estimated using logistic regression stratified by sex and adjusted for age, ethnicity, socioeconomic deprivation, education and smoking. RESULTS: Elevated risks were observed for field crop and vegetable growers (OR 2.93, 95% CI 1.10 to 7.77); fruit growers (OR 2.03, 95% CI 1.09 to 3.78); gardeners and nursery growers (OR 1.96, 95% CI 1.01 to 3.82); crop and livestock producers (OR 3.61, 95% CI 1.44 to 9.02); fishery workers, hunters and trappers (OR 5.62, 95% CI 1.27 to 24.97); builders (OR 2.90, 95% CI 1.41 to 5.96); electricians (OR 3.61, 95% CI 1.34 to 9.74); caregivers (OR 2.65, 95% CI 1.04 to 6.79); forecourt attendants (OR 8.31, 95% CI 1.79 to 38.54); plant and machine operators and assemblers (OR 1.42, 95% CI 1.01 to 2.01); telecommunications technicians (OR 4.2, 95% CI 1.20 to 14.64); and draughting technicians (OR 3.02, 95% CI 1.07 to 8.53). Industries with increased risks were agriculture (particularly horticulture and fruit growing), construction, non-residential care services, motor vehicle retailing, and sport and recreation. Positive associations between employment duration and MND were shown for the occupations fruit growers, gardeners and nursery growers, and crop and livestock producers, and for the horticulture and fruit growing industry. CONCLUSIONS: This study suggests associations between MND and occupations in agriculture and several other occupations.

Prevalence of HPV infection and other risk factors in a Fijian population.

BACKGROUND: Cancer is among the leading contributors to morbidity and mortality in the Pacific, but the magnitude of the problem and the potential for prevention have not been comprehensively studied. Over the past decade, cervical cancer has been the most common cancer among women in Fiji with an age standardised cervical cancer incidence rate of 51 per 100,000. This rate is among the highest in the South Pacific region and in the world. This high cervical cancer incidence rate is likely linked to the low cervical screening rate, but it points also to the possibility of a high burden of human papillomavirus (HPV) infection. METHODS: We conducted a population-based survey in Fiji to provide information on human papillomavirus (HPV) prevalence, and the distribution of individual HPV types in a Fijian health-sub-district. We included 1,261 women aged between 16 and 64 years. A general primer GP5+/6+ mediatedpolymerase chain reaction (PCR) assay was used for HPV testing of 44 HPV types. RESULTS: The crude HPV prevalence in 1,244 women with an adequate HPV sample was 24.0% (95% confidence interval (CI), 21.7-26.4%) and the corresponding age standardised prevalence was 25.5% (95% CI, 23.1-28.1%). The prevalence of high-risk HPV types was 13.6% (95% CI, 11.8-15.6%). Among 1,192 women with adequate cytological results, 13 (1.1%) showed cervical abnormalities, the majority of which were high-grade intraepithelial lesions or worse. HPV prevalence declined from 35.8% in women aged <25 years to 18.6% in those aged 55-64 years of age. After adjustment, the only variables significantly associated with HPV-positivity were age (ranging from odds ratio (OR) 0.57 (95% CI, 0.36-0.89) for 25-34 year-old-women to OR 0.43 (95% CI, 0.20-0.89) for 55-64 year-old-women) and 'husband's extramarital sexual relationships' (OR 1.69; 95% CI, 1.17-2.34). CONCLUSION: These findings on HPV provide key information for future policy decisions on the most appropriate methods of cervical cancer prevention in Fiji and in the Pacific region.

Which factors account for the ethnic inequalities in stage at diagnosis and cervical cancer survival in New Zealand?

OBJECTIVE: There are substantial ethnic inequalities in stage at diagnosis and cervical cancer survival in New Zealand. We assessed what proportions of these differences were due to screening history (for the analyses of late stage diagnosis), stage at diagnosis (for the analyses of survival), comorbid conditions (for the analyses of survival), and travel time to the nearest General Practitioner and cancer centre. METHODS: The study involved 1594 cervical cancer cases registered during 1994-2005. We used G-computation to assess the validity of the estimates obtained by standard logistic regression methods. RESULTS: Maori women had a higher risk of late stage diagnosis compared with 'Other' (mainly European) women (odds ratio (OR) = 2.71; 95% confidence interval 1.98, 3.72); this decreased only slightly (OR 2.39; 1.72, 3.30) after adjustment for screening history, and travel time to the nearest General Practitioner and cancer centre. In contrast, the (non-significantly) elevated risk in Pacific women (1.39; 0.76, 2.54) disappeared almost completely when adjusted for the same factors (1.06; 0.57, 1.96). The hazard ratio of mortality for cervical cancer for Maori women was 2.10 (1.61, 2.73) and decreased to 1.45 (1.10, 1.92) after adjustment for stage at diagnosis, comorbid conditions, and travel time to the nearest General Practitioner and cancer centre; the corresponding estimates for Pacific women were 1.96 (1.23, 3.13) and 1.55 (0.93, 2.57). The G-computation analyses gave similar findings. CONCLUSIONS: The excess relative risk of late stage diagnosis in Maori women remains largely unexplained, while more than half of the excess relative risk of mortality in Maori and Pacific women is explained by differences in stage at diagnosis and comorbid conditions.

Does comorbidity explain the ethnic inequalities in cervical cancer survival in New Zealand? A retrospective cohort study.

BACKGROUND: There are large ethnic differences in cervical cancer survival in New Zealand that are only partly explained by stage at diagnosis. We investigated the association of comorbidity with cervical cancer survival, and whether comorbidity accounted for the previously observed ethnic differences in survival. METHODS: The study involved 1,594 cervical cancer cases registered during 1994-2005. Comorbidity was measured using hospital events data and was classified using the Elixhauser instrument; effects on survival of individual comorbid conditions from the Elixhauser instrument were also assessed. Cox regression was used to estimate adjusted cervical cancer mortality hazard ratios (HRs). RESULTS: Comorbidity during the year before diagnosis was associated with cervical cancer-specific survival: those with an Elixhauser count of ≥3 (compared with a count of zero) had a HR of 2.17 (1.32-3.56). The HR per unit of Elixhauser count was 1.25 (1.11-1.40). However, adjustment for the Elixhauser instrument made no difference to the mortality HRs for Maori and Asian women (compared to 'Other' women), and made only a trivial difference to that for Pacific women. In contrast, concurrent adjustment for 12 individual comorbid conditions from the Elixhauser instrument reduced the Maori HR from 1.56 (1.19-2.05) to 1.44 (1.09-1.89), i.e. a reduction in the excess risk of 21%; and reduced the Pacific HR from 1.95 (1.21-3.13) to 1.62 (0.98-2.68), i.e. a reduction in the excess risk of 35%. CONCLUSIONS: Comorbidity is associated with cervical cancer-specific survival in New Zealand, but accounts for only a moderate proportion of the ethnic differences in survival.

Does screening history explain the ethnic differences in stage at diagnosis of cervical cancer in New Zealand?

BACKGROUND: There are ethnic disparities in cervical cancer survival in New Zealand. The objectives of this study were to assess the associations of screening history, ethnicity, socio-economic status (SES) and rural residence with stage at diagnosis in women diagnosed with cervical cancer in New Zealand during 1994-2005. METHODS: The 2323 cases were categorized as 'ever screened' if they had had at least one smear prior to 6 months before diagnosis, and as 'regular screening' if they had had no more than 36 months between any two smears in the period 6-114 months before diagnosis. Logistic regression was used to estimate the associations of screening history, ethnicity, SES and urban/rural residence with stage at diagnosis. RESULTS: The percentages 'ever screened' were 43.3% overall, 24.8% in Pacific, 30.5% in Asian, 40.6% in Maori and 46.1% in 'Other' women. The corresponding estimates for 'regular screening' were 14.0, 5.7, 7.8, 12.5 and 15.3%. Women with 'regular screening' had a lower risk of late stage diagnosis [odds ratio (OR) 0.16, 95% confidence interval (CI) 0.10-0.26], and the effect was greater for squamous cell carcinoma (OR 0.12, 95% CI 0.07-0.23) than for adenocarcinoma (OR 0.32, 95% CI 0.13-0.82). The increased risk of late-stage diagnosis (OR 2.72, 95% CI 1.99-3.72) in Maori (compared with 'Other') women decreased only slightly when adjusted for screening history (OR 2.45, 95% CI 1.77-3.39). CONCLUSIONS: Over half of cases had not been 'ever screened'. Regular screening substantially lowered the risk of being diagnosed at a late stage. However, screening history does not appear to explain the ethnic differences in stage at diagnosis.

Demographic differences in stage at diagnosis and cervical cancer survival in New Zealand, 1994-2005.

OBJECTIVE: To investigate ethnic, socioeconomic, and urban/rural differences in stage at diagnosis and cervical cancer survival in New Zealand. METHODS: The study involved 1594 cervical cancer cases registered during 1994-2005. Cox regression was used to estimate adjusted cervical cancer mortality hazard ratios (HRs). RESULTS: Maori and Pacific women had higher death rates than Other (predominantly European) women, with age and year of diagnosis adjusted HRs of 2.15 (95% CI 1.68-2.75) and 1.98 (95% CI 1.25-3.13), respectively, whereas Asian women had a lower (nonstatistically significant) risk (0.81, 95% CI 0.47-1.42). Adjustment for stage reduced the HR in Maori to 1.62 (95% CI 1.25-2.09), but there was little change for Pacific or Asian women. These patterns varied over time: for cases diagnosed during 1994-1997, the HR for Maori women was 2.34 (95% CI 1.68-3.27), which reduced to 1.83 (95% CI 1.29-2.60) when adjusted for stage; for cases diagnosed during 2002-2005, the corresponding estimates were 1.54 (95% CI 0.75-3.13) and 0.90 (95% CI 0.43-1.89). Socioeconomic status and urban/rural residence had only marginal effects. CONCLUSIONS: There were major ethnic differences in cervical cancer survival in New Zealand that were only partly explained by stage at diagnosis. These patterns varied over time, with postdiagnostic factors playing an important role in the high Maori mortality rates in the 1990s, but in more recent years, the excess mortality in Maori women appeared to be almost entirely due to stage at diagnosis, indicating that ethnic differences in access to and uptake of screening and treatment of premalignant lesions may have been playing a major role.

A New Zealand linkage study examining the associations between A1C concentration and mortality.

OBJECTIVE: To examine associations between A1C concentration and mortality in a New Zealand population. RESEARCH DESIGN AND METHODS: During a Hepatitis Foundation screening campaign for hepatitis B (1999-2001), participants were offered A1C testing. The participants were anonymously linked to the national mortality collection to 31 December 2004. Hazard ratios (HRs) and 95% CIs adjusted for age, ethnicity, smoking, and sex were estimated using Cox regression. RESULTS: There were 47,904 participants (71% Mâori, 12% Pacific, 5% Asian, and 12% other). A1C measurements were categorized as <4.0% (n = 142), 4.0 to <5.0% (reference category; n = 12,867), 5.0 to <6.0% (n = 30,222), 6.0 to <7.0% (n = 2,669), and >or=7.0% (n = 1,596); there were also 408 participants with a previous diabetes diagnosis. During the follow-up period, 815 individuals died. In those without a prior diabetes diagnosis, there were steadily increasing HRs from the A1C reference category to the highest category (>or=7.0%; HR 2.36 [95% CI 1.72-3.25]). As well as all-cause mortality, A1C was associated with mortality from diseases of the circulatory system; endocrine, nutritional, metabolic, and immunity disorders; and other and unknown causes. Mortality was also elevated in those with a prior diabetes diagnosis (5.19 [3.67-7.35]), but this was only partially explained by their elevated A1C levels. CONCLUSIONS: This is the largest study to date of A1C levels and subsequent mortality risk. It confirms previous findings that A1C levels are strongly associated with subsequent mortality in both men and women without a prior diabetes diagnosis.