Emergency presentation prior to lung cancer diagnosis: A national-level examination of disparities and survival outcomes.

OBJECTIVES: A recent multinational investigation of emergency presentation within 30 days of cancer diagnosis, conducted within the International Cancer Benchmarking Programme (ICBP), observed that New Zealand had the highest rate of emergency presentation prior to lung cancer diagnosis compared to other similar countries. Here we use national-level health data to further investigate these trends, focussing on ethnic disparities in emergency presentation prior to lung cancer diagnosis. We have also compared survival outcomes between those who had an emergency presentation in the preceding 30 days to those who did not. MATERIALS AND METHODS: Our study included all lung cancer registrations between 2007 and 2019 on the New Zealand Cancer Registry (N = 27,869), linked to national hospitalisation and primary healthcare data. We used descriptive (crude and age-standardised proportions) and logistic regression (crude and adjusted odds ratios) analyses to examine primary care access prior to cancer diagnosis, emergency hospitalisation up to and including 30 days prior to diagnosis, and one-year mortality post-diagnosis, both for the total population and between ethnicities. Regression models adjusted for age, sex, deprivation, rurality, comorbidity, tumour type and stage. RESULTS: We found stark disparities by ethnic group, with 62% of Pacific peoples and 54% of Maori having an emergency presentation within 30 days prior to diagnosis, compared to 47% of Europeans. These disparities remained after adjusting for multiple covariates including comorbidity and deprivation (adj. OR: Maori 1.21, 95% CI 1.13-1.30; Pacific 1.50, 95% CI 1.31-1.71). Emergency presentation was associated with substantially poorer survival outcomes across ethnic groups (e.g. 1-year mortality for Maori: no emergency presentation 50%, emergency presentation 79%; adj. OR 2.40, 95% CI 2.10-2.74). CONCLUSIONS: These observations reinforce the need for improvements in the early detection of lung cancer, particularly for Maori and Pacific populations, with a view to preventing diagnosis of these cancers in an emergency setting.

A kia ora, a wave and a smile: an urban marae-led response to COVID-19, a case study in manaakitanga.

BACKGROUND: When COVID-19 emerged, there were well-founded fears that Maori (indigenous peoples of Aotearoa (New Zealand)) would be disproportionately affected, both in terms of morbidity and mortality from COVID-19 itself and through the impact of lock-down measures. A key way in which Kokiri (a Maori health provider) responded was through the establishment of a pataka kai (foodbank) that also provided a gateway to assess need and deliver other support services to whanau (in this case, client). Maori values were integral to this approach, with manaakitanga (kindness or providing care for others) at the heart of Kokiri's actions. We sought to identify how Kokiri operated under the mantle of manaakitanga, during Aotearoa's 2020 nationwide COVID-19 lockdown and to assess the impact of their contributions on Maori whanau. METHODS: We used qualitative methods underpinned by Maori research methodology. Twenty-six whanau interviews and two focus groups were held, one with eight kaimahi (workers) and the other with seven rangatahi (youth) kaimahi. Data was gathered between June and October 2020 (soon after the 2020 lockdown restrictions were lifted), thematically analysed and interpreted using a Maori worldview. RESULTS: Three key themes were identified that aligned to the values framework that forms the practice model that Kokiri kaimahi work within. Kaitiakitanga, whanau and manaakitanga are also long-standing Maori world values. We identified that kaitiakitanga (protecting) and manaakitanga (with kindness) - with whanau at the centre of all decisions and service delivery - worked as a protective mechanism to provide much needed support within the community Kokiri serves. CONCLUSIONS: Maori health providers are well placed to respond effectively in a public-health crisis when resourced appropriately and trusted to deliver. We propose a number of recommendations based on the insights generated from the researchers, kaimahi, and whanau. These are that: Maori be included in pandemic planning and decision-making, Maori-led initiatives and organisations be valued and adequately resourced, and strong communities with strong networks be built during non-crisis times.

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.

Patterns of age disparities in colon and lung cancer survival: a systematic narrative literature review.

OBJECTIVES: To identify patterns of age disparities in cancer survival, using colon and lung cancer as exemplars. DESIGN: Systematic review of the literature. DATA SOURCES: We searched Embase, MEDLINE, Scopus and Web of Science through 18 December 2020. ELIGIBILITY CRITERIA: We retained all original articles published in English including patients with colon or lung cancer. Eligible studies were required to be population-based, report survival across several age groups (of which at least one was over the age of 65) and at least one other characteristic (eg, sex, treatment). DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted data and assessed the quality of included studies against selected evaluation domains from the QUIPS tool, and items concerning statistical reporting. We evaluated age disparities using the absolute difference in survival or mortality rates between the middle-aged group and the oldest age group, or by describing survival curves. RESULTS: Out of 3047 references, we retained 59 studies (20 for colon, 34 for lung and 5 for both sites). Regardless of the cancer site, the included studies were highly heterogeneous and often of poor quality. The magnitude of age disparities in survival varied greatly by sex, ethnicity, socioeconomic status, stage at diagnosis, cancer site, and morphology, the number of nodes examined and treatment strategy. Although results were inconsistent for most characteristics, we consistently observed greater age disparities for women with lung cancer compared with men. Also, age disparities increased with more advanced stages for colon cancer and decreased with more advanced stages for lung cancer. CONCLUSIONS: Although age is one of the most important prognostic factors in cancer survival, age disparities in colon and lung cancer survival have so far been understudied in population-based research. Further studies are needed to better understand age disparities in colon and lung cancer survival. PROSPERO REGISTRATION NUMBER: CRD42020151402.

A Mobile- and Web-Based Health Intervention Program for Diabetes and Prediabetes Self-Management (BetaMe/Melon): Process Evaluation Following a Randomized Controlled Trial.

BACKGROUND: Technology-assisted self-management programs are increasingly recommended to patients with long-term conditions such as diabetes. However, there are a number of personal and external factors that affect patients' abilities to engage with and effectively utilize such programs. A randomized controlled trial of a multi-modal online program for diabetes self-management (BetaMe/Melon) was conducted in a primary care setting, and a process evaluation was completed at the end of the study period. OBJECTIVE: This process evaluation aimed to examine the utilization patterns of BetaMe/Melon, identify which components participants found most (and least) useful, and identify areas of future improvement. METHODS: Process evaluation data were collected for intervention arm participants from 3 sources: (1) the mobile/web platform (to identify key usage patterns over the 16-week core program), (2) an online questionnaire completed during the final study assessment, and (3) interviews conducted with a subset of participants following the study period. Participants were classified as "actively engaged" if any usage data was recorded for the participant (in any week), and patterns were reported by age, gender, ethnicity, and diabetes/prediabetes status. The online questionnaire asked participants about the usefulness of the program and whether they would recommend BetaMe/Melon to others according to a 5-point Likert Scale. Of 23 invited participants, 18 participated in a digitally recorded, semistructured telephone interview. Interview data were thematically analyzed. RESULTS: Out of the 215 participants, 198 (92%) received an initial health coaching session, and 160 (74%) were actively engaged with the program at some point during the 16-week core program. Engagement varied by demographic, with women, younger participants, and ethnic majority populations having higher rates of engagement. Usage steadily declined from 50% at Week 0 to 23% at Week 15. Participants ranked component usefulness as education resources (63.7%), health coaches (59.2%), goal tracking (48.8%), and online peer support (42.1%). Although 53% agreed that the program was easy to use, 64% would recommend the program to others. Interview participants found BetaMe/Melon useful overall, with most identifying beneficial outcomes such as increased knowledge, behavioral changes, and weight loss. Barriers to engagement were program functionality, internet connectivity, incomplete delivery of all program components, and participant motivation. Participants suggested a range of improvements to the BetaMe/Melon program. CONCLUSIONS: The program was generally well received by participants; active engagement was initially high, although it declined steadily. Maintaining participant engagement over time, individualizing programs, and addressing technical barriers are important to maximize potential health benefits from online diabetes self-management programs. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12617000549325; https://tinyurl.com/y622b27q.

Impact of a comprehensive digital health programme on HbA1c and weight after 12 months for people with diabetes and prediabetes: a randomised controlled trial.

AIMS/HYPOTHESIS: The aim of this RCT was to evaluate the effectiveness of a digital health programme (BetaMe/Melon) vs usual care in improving the control of type 2 diabetes and prediabetes in a primary care population. METHODS: We conducted a randomised parallel-group two-arm single-blinded superiority trial in the primary care setting in two regions of New Zealand. Eligible participants were identified through Primary Health Organisations and participating practices. Eligibility criteria were as follows: age 18-75 years, HbA1c 41-70 mmol/mol (5.9-8.6%), not taking insulin, and daily access to the internet. BetaMe/Melon is a 12 month mobile-device and web-based programme with four components: health coaching; evidence-based resources; peer support; and goal tracking. Participants were randomised into the intervention or control arm (1:1 allocation) based upon baseline HbA1c (prediabetes or diabetes range), stratified by practice and ethnicity. Research nurses and the study biostatistician were blind to study arm. Primary outcomes of the study were changes in HbA1c and weight at 12 months, using an intention-to-treat analysis. RESULTS: Four hundred and twenty-nine individuals were recruited between 20 June 2017 and 11 May 2018 (n = 215 intervention arm, n = 214 control arm), most of whom were included in analyses of co-primary outcomes (n = 210/215, 97.7% and n = 213/214, 99.5%). HbA1c levels at 12 months did not differ between study arms: mean difference was -0.9 mmol/mol (95% CI -2.9, 1.1) (-0.1% [95% CI -0.3, 0.1]) for the diabetes group and was 0.0 mmol/mol (95% CI -0.9, 0.9) (0.0% [95% CI -0.1, 0.1]) for the prediabetes group. Weight reduced slightly at 12 months for participants in both study arms, with no difference between arms (mean difference -0.4 kg [95% CI -1.3, 0.5]). CONCLUSIONS/INTERPRETATION: This study did not demonstrate clinical effectiveness for this particular programme. Given their high costs, technology-assisted self-management programmes need to be individually assessed for their effectiveness in improving clinical outcomes for people with diabetes. TRIAL REGISTRATION: www.anzctr.org.au ACTRN12617000549325 (universal trial number U1111-1189-9094) FUNDING: This study was funded by the Health Research Council of New Zealand, the Ministry of Health New Zealand and the Healthier Lives National Science Challenge. Graphical abstract.

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.

Improving management of comorbidity in patients with colorectal cancer using comprehensive medical assessment: a pilot study.

BACKGROUND: Screening for and active management of comorbidity soon after cancer diagnosis shows promise in altering cancer treatment and outcomes for comorbid patients. Prior to a large multi-centre study, piloting of the intervention (comprehensive medical assessment) was undertaken to investigate the feasibility of the comorbidity screening tools and proposed outcome measures, and the feasibility, acceptability and potential effect of the intervention. METHODS: In this pilot intervention study, 72 patients of all ages (36 observation/36 intervention) with newly diagnosed or recently relapsed colorectal adenocarcinoma were enrolled and underwent comorbidity screening and risk stratification. Intervention patients meeting pre-specified comorbidity criteria were referred for intervention, a comprehensive medical assessment carried out by geriatricians. Each intervention was individually tailored but included assessment and management of comorbidity, polypharmacy, mental health particularly depression, functional status and psychosocial issues. Recruitment and referral to intervention were tracked, verbal and written feedback were gathered from staff, and semi-structured telephone interviews were conducted with 13 patients to assess screening tool and intervention feasibility and acceptability. Interviews were transcribed and analysed thematically. Patients were followed for 6-12 months after recruitment to assess feasibility of proposed outcome measures (chemotherapy uptake and completion rates, grade 3-5 treatment toxicity, attendance at hospital emergency clinic, and unplanned hospitalisations) and descriptive data on outcomes collated. RESULTS: Of the 29 intervention patients eligible for the intervention, 21 received it with feedback indicating that the intervention was acceptable. Those in the intervention group were less likely to be on 3+ medications, to have been admitted to hospital in previous 12 months, or to have limitations in daily activities. Collection of data to measure proposed outcomes was feasible with 55% (6/11) of intervention patients completing chemotherapy as planned compared to none (of 14) of the control group. No differences were seen in other outcome measures. Overall the study was feasible with modification, but the intervention was difficult to integrate into clinical pathways. CONCLUSIONS: This study generated valuable results that will be used to guide modification of the study and its approaches prior to progressing to a larger-scale study. TRIAL REGISTRATION: Retrospective, 26 August 2019, ACTRN12619001192178.

Dairy Consumption and Risk of Testicular Cancer: A Systematic Review.

Dairy consumption has been studied extensively in terms of its relationship with testicular cancer (TC), yet this relationship remains unclear. In this systematic review, we aimed to answer whether TC development is associated with (a) high amounts of dairy product consumption, (b) the type of dairy product consumed, (c) increasing levels of dairy product consumption, and (d) dairy consumption during certain periods during the lifecourse. Following a systematic review of the literature, eight studies (all case-control studies) were included in our review. The included studies varied in terms of the dairy product(s) investigated (milk, cheese, cream, butter, and yoghurt) as well as the type of exposure to dairy consumption (e.g., high vs. low exposure, dose-response, and timing during lifecourse). We found that there was no strong evidence that high levels of dairy consumption are associated with risk of TC, conflicting evidence of a dose-response relationship, inconsistent evidence on whether certain types of dairy are more strongly associated with TC than others, and conflicting evidence that exposure during certain life-course periods affects TC risk more than other periods. There is no consistent evidence to support the premise that dairy product consumption is associated with the risk of TC development.

BetaMe: impact of a comprehensive digital health programme on HbA1c and weight at 12 months for people with diabetes and pre-diabetes: study protocol for a randomised controlled trial.

BACKGROUND: Long-term conditions (LTCs) are the biggest contributor to health loss in New Zealand. The economic cost and burden on the health system is substantial and growing. Self-management strategies offer a potential way to reduce the pressure on health services. This study evaluates a comprehensive self-management programme (the BetaMe programme) delivered by mobile and web-based technologies for people with Type 2 diabetes (T2DM) and pre-diabetes. The primary aim of this study is to evaluate the effectiveness of the BetaMe programme versus usual care among primary care populations in improving the control of T2DM and pre-diabetes, as measured by change in HbA1c and weight over 12 months. METHODS: Participants will be recruited through two primary healthcare organisations and a Maori healthcare provider in New Zealand (n = 430). Eligible participants will be 18 to 75 years old, with T2DM or pre-diabetes, with an HbA1c of 41-70 mmol/mol up to 2 years prior to study commencement. Eligible participants who consent to participate will be individually randomised to the control arm (usual care) or intervention arm (usual care and BetaMe). The programme consists of a 16-week core followed by a maintenance period of 36 weeks. It incorporates (1) individualised health coaching, (2) goal setting and tracking, (3) peer support in an online forum and (4) educational resources and behaviour-change tools. The primary outcome measures are change in HbA1c and weight at 12 months. Secondary outcomes are changes in waist circumference, blood pressure, patient activation and diabetes-specific behaviours. All outcomes will be assessed at 4 and 12 months for the total study population and for Maori and Pacific participants specifically. All primary analyses will be based on intention-to-treat. Primary analysis will use linear mixed models comparing mean outcome levels adjusted for initial baseline characteristics at 12 months. DISCUSSION: This is a randomised controlled trial of a comprehensive self-management intervention for people with diabetes and pre-diabetes. If effective, this programme would allow healthcare providers to deliver an intervention that is person-centred and supports the self-care of people with T2DM, pre-diabetes and potentially other LTCs. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ID: ACTRN12617000549325 . Registered on 19 April 2017.

Physical activity and risk of testicular cancer: a systematic review.

BACKGROUND: Physical activity has been implicated as a risk factor in the development of testicular cancer (TC), but the relationship remains controversial. This systematic review pooled available evidence regarding this association. METHODS: Using Boolean search terms and following PRISMA guidelines, we examined the risk of TC across three categories of exposure: intensity (i.e. comparison of risk between those previously exposed to high, moderate and low levels of physical activity); dose-response (i.e. whether risk of TC increases or decreases with increasing exposure to physical activity); and the role of timing of physical activity (i.e. during early childhood or adolescence). RESULTS: Thirteen studies (11 case-control studies, 2 cohort studies) were included in the review. While some studies have reported a strong protective effect of high levels of physical activity on risk of TC, others have reported either no relationship or a weak direct association; and while a dose-response relationship has been identified across several studies, this relationship has been observed in both directions. Similarly conflicting results exist in terms of individual types of activity and the lifecourse timing of the physical activity. Reasons for this inconsistency may include the absence of any association, heterogeneous assessment of physical activity, misclassification bias and difference in sample sizes. CONCLUSIONS: On balance, there is presently no strong evidence of an association between physical activity and risk of subsequent TC. This review highlights key areas for future investigation that may clarify any association between physical activity and risk of testicular cancer.

Risk factors for cryptorchidism.

Undescended testis - known as cryptorchidism - is one of the most common congenital abnormalities observed in boys, and is one of the few known risk factors for testicular cancer. The key factors that contribute to the occurrence of cryptorchidism remain elusive. Testicular descent is thought to occur during two hormonally-controlled phases in fetal development - between 8-15 weeks (the first phase of decent) and 25-35 weeks gestation (the second phase of descent); the failure of a testis to descend permanently is probably caused by disruptions to one or both of these phases, but the causes and mechanisms of such disruptions are still unclear. A broad range of putative risk factors have been evaluated in relation to the development of cryptorchidism but their plausibility is still in question. Consistent evidence of an association with cryptorchidism exists for only a few factors, and in those cases in which evidence seems unequivocal the factor is likely to be a surrogate for the true causal exposure. The relative importance of each risk factor could vary considerably between mother-son pairs depending on an array of genetic, maternal, placental and fetal factors - all of which could vary between regions. Thus, the role of causative factors in aetiology of cryptorchidism requires further research.

Analgesia use during pregnancy and risk of cryptorchidism: a systematic review and meta-analysis.

STUDY QUESTION: Are boys who are born to mothers who use analgesics during pregnancy at increased risk of cryptorchidism compared to those born to mothers who do not take analgesia? SUMMARY ANSWER: In this systematic review and meta-analysis of 10 published studies, we observed only weak evidence of an association between analgesia use during pregnancy and risk of cryptorchidism in the son. WHAT IS KNOWN ALREADY: Concentrations of analgesia relevant to human exposure have been implicated as causing endocrine disturbances in the developing foetal testis. However, when viewed collectively there appears to be conflicting evidence regarding an association between maternal use of analgesics and development of cryptorchidism. STUDY DESIGN, SIZE, DURATION: A systematic review and meta-analysis of studies on analgesia use during pregnancy and risk of cryptorchidism was performed. The search terms used were (analges* OR paracetamol OR acetaminophen) AND (cryptorchidism OR cryptorchism OR undescended test* OR non-descended test* OR non descended test*) for the databases Ovid Medline, Embase, Scopus and Web of Science. The search included all published articles up until 23 May 2016 and no limits were set in terms of language. PARTICIPANTS/MATERIALS, SETTING, METHODS: Abstracts were screened by one reviewer to remove irrelevant studies, with a 10% random sample of these verified by a second reviewer. The full text of all remaining papers was assessed by two reviewers. Abstracts included in the final analysis were studies which reported associations between the exposure (analgesia) and the outcome (cryptorchidism). Studies were only included if data were provided from which summary associations (odds ratios (ORs) or relative risks) and their 95% CIs could be calculated, or if summary associations were provided by the authors themselves. For each included study, two reviewers independently extracted study meta-data in line with PRISMA recommendations. We assessed study quality and potential for bias using the criteria outlined in the Newcastle-Ottawa Quality Assessment Scale, but did not determine a quality score. Two reviewers independently assessed study quality against these criteria. MAIN RESULTS AND THE ROLE OF CHANCE: After screening 350 manuscripts, 10 were included in our review (5 case-control studies, 5 cohort studies). We observed weak evidence of an association between ever use of analgesia and risk of cryptorchidism (pooled crude OR: 1.11, 95% CI: 1.00-1.23), with case-control studies revealing a marginally stronger association (1.23, 95% CI: 0.85-1.78) than cohort studies (1.09, 95% CI: 0.97-1.22). We observed weak evidence of a dose-response relationship between increasing weeks of analgesia exposure and risk of cryptorchidism, as well as weak evidence of an effect of timing on analgesia exposure and risk of cryptorchidism. Assessment of study quality via the Newcastle-Ottawa criteria revealed little (if any) evidence of substantial bias that may have meaningfully affected a given study's results. LIMITATIONS, REASONS FOR CAUTION: While confounding does not appear to be important, misclassification of the exposure is possibly an important source of measurement error in this context. The systematic review is open to reporting bias. Owing to scant data, no meta-analyses for two key questions (relating to dose-response and timing of exposure) could be performed. Medications were grouped based on their common effect and this offers little insight into the relation between specific types of analgesia and cryptorchidism. Finally, there are limitations in assuming that analgesia use reported by mothers is synonymous with actual intrauterine exposure. WIDER IMPLICATIONS OF THE FINDINGS: The ubiquity of analgesia use during pregnancy makes this exposure particularly important from a population health perspective. About 9 of the 10 studies were conducted in Europe or USA, limiting generalizability of our observations. While the observations from our systematic review and meta-analysis suggest that analgesia use during pregnancy is not strongly associated with cryptorchidism development in the son, they also highlight the need for further detailed assessments of this relationship. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by the Health Research Council of New Zealand (reference #: 14/052). The authors have no conflict of interest to declare. REGISTRATION NUMBER: CRD42016041414.

Quality Improvement: Indigenous Influence in Oral Health Policy, Process, and Practice.

A Quality Improvement Group for Maori oral health providers [Indigenous New Zealand oral health services] has been an effective and necessary mechanism for engaging Indigenous oral health expertise in decision-making for Indigenous oral health policy and sector developments to reduce oral health inequalities and improve Indigenous oral health outcomes.

Quality Improvement: Indigenous Influence in Oral Health Policy, Process, and Practice.

A Quality Improvement Group for Maori oral health providers [Indigenous New Zealand oral health services] has been an effective and necessary mechanism for engaging Indigenous oral health expertise in decision-making for Indigenous oral health policy and sector developments to reduce oral health inequalities and improve Indigenous oral health outcomes.

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

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

Ethnicity and rectal cancer management in New Zealand.

AIM: Research shows survival disparities between Maori and non-Maori colon cancer patients, with comorbidity and cancer care being major contributing factors. We studied rectal cancer management and survival in a cohort of Maori and non-Maori patients with a newly diagnosed rectal cancer. METHODS: 194 Maori and non-Maori patients diagnosed with rectal cancer between 2006 and 2008 were identified from the New Zealand Cancer Registry. Medical records were reviewed and patients compared on presentation, patient and tumour characteristics, and receipt and timing of treatment. Cox regression models were fitted to compare cancer-specific survival. RESULTS: Compared to non-Maori patients, Maori patients were younger (mean age at diagnosis 63.5 and 69.2 for Maori and Non-Maori respectively; p<0.001) and had higher prevalence of comorbidity. Stage, grade and tumour size distributions were similar. Almost all stage I-III patients (97%) underwent definitive surgery, with no difference between Maori and non-Maori. Maori patients waited longer for referral to medical oncologists (40 days vs. 33 days; p=0.03). Results suggested Maori patients with stage IV disease may be less likely than non-Maori to be referred to palliative care (13% vs. 40%; p=0.07). The hazard ratio for cancer-specific death for Maori compared with non-Maori patients was 1.24 (95% CI 0.65-2.35). CONCLUSION: The findings suggest both similarities and some differences in treatment and outcomes between Maori and non-Maori rectal cancer patients, but firm conclusions are limited by small sample size.