Disparities in gynaecological cancer

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Disparities in gynaecological cancer

• Red lights green lights
• Cancer Society, June 2007

Dr Beverley Lawton Womens Health Research
Centre University of Otago, Wellington
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Red lights Green lights
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The Cancer Control Strategy

• To reduce the incidence and impact of cancer
• To reduce inequalities with respect to cancer

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Disparities / Inequalities

• Maori versus non-Maori
• Economic
• Rural versus urban
• Education
• Language
• Other ethnicities

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Cancer disparities

• Overall, Maori are 18 more likely to be
  diagnosed with cancer than non-Maori
• Nearly twice as likely as non-Maori to die from
  cancer
• Cancer-specific survival is lower for Maori than
  non-Maori for most types of cancer

Cormack et al 2005 Access to Cancer services for
Maori
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Cancer mortality

• The age-standardised Maori cancer mortality rate
  127.9 per 100,000, nearly twice that of non-Maori
  at 66.3 per 100,000

Cormack et al 2005 Access to Cancer services for
Maori
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Female leading cancer deaths 1996-2001

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Cancer control continuum
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Cervical cancer

• Greater incidence compared with non-Maori
  (Relative risk 2.27)
• Greater mortality compared with non-Maori
  (Relative risk 4.85)

Robson, Unequal impact Maori and non-Maori
Cancer statistics 1996-2001
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Cervical cancer
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HPV vaccine

• Without universal access this will increase
  disparities - those who can afford will vaccinate
  
• QALYs are great
• What happens if we vaccinate in schools?
• Is this universal access?
• Standardised care?
• Compulsion?

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HPV vaccine

• Vaccination rates in school children
• Consultation and ownership are priorities to
  reduce disparities

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Polio vaccination coverage for Year 7 Maori and
non-Maori in one DHB region (2005)

• Year 7 includes 11-12 year olds

Source Loring B, Masters thesis, Unpublished
data 2007
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Uterine Cancer

• Greater incidence compared with non-Maori
  (Relative risk 1.61)
• Greater mortality compared with non-Maori
  (Relative risk 2.28)

Robson, Unequal impact Maori and non-Maori
Cancer statistics 1996-2001
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Uterine Cancer
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Likely differences

• Referral process
• Definitive diagnostic procedures
• Staging procedures
• Optimal treatment
• Management of cancer

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Common themes
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Alignment of activities

• Public health education
• Legislation
• Social will
• Medical will
• Community buy-in

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Applying a template

• Universal access
• Standardised care
• Element of compulsion

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Dental disparities

• Poor oral health is an important negative
  public health outcome
• Substantial ethnic disparities exist
• Universal access to care does not remove
  disparities1
• Standard of care is relevant

1. Ismail JADA 2001132295-303
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Military oral health care system

• Dental Disparities disappear
• Universal access
• Standard care
• Element of compulsion

Hyman JADA,Vol.137March 2006
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Mammography

• Poor rates of success
• Process to improve universal access
• ChCh area

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Cervical screening Gisborne

• Active involvement of the screening unit with
  community and primary care

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Racism

• We treat patients differently
• Recent work strongly suggests racism plays a part
  in disparities
• Maori are less likely to be offered cardiac
  procedures
• Do we do the same thing to all our patients?
  clearly not

Harris et al, Lancet 2006 (367), Blakely et al
Lancet 2006(368)
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Clinical Pathway

• Waitemata DHB
• Culturally appropriate models to maximise care
  co-ordination
• Concept of community navigators
• Secondary care level systems advocate
• Midcentral DHB
• Maori Cancer Co-ordinator service
• Workshops to demystify cancer.

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Applying a template

• Universal access
• Standardised care
• Element of compulsion
• Elimination/awareness of racism

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Achieving Behavioural Change
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Applying a template

• Universal access
• Standardised care
• Element of compulsion
• Elimination/awareness of racism

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The Future

• The challenge is to look at our services
• Apply the template
• Universal access
• Standardised care
• Element of compulsion
• Elimination/awareness of racism
• To promote existing and future green lights

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Kia ora Thank you
Dr Bev Lawton www.otago.ac.nz/whrc
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Cancer registrations 1996-2001, number and
age-standardised rates ratios for Mäori and
non-Mäori
(ranked by Maori incidence)