Sociocultural influences on healthcare inequalities among Australian Indigenous breast cancer patients

17P - Distance related outcome in indigenous and non-indigenous breast cancer women of Western Australia

115 Background: Indigenous women with breast cancer have substantially higher mortality then non-Indigenous women. They are more likely to live in more remote communities with potential delays to presentation, investigation and diagnosis as well as slower access to cancer treatment facilities, potentially impacting survival. Here we explore by evaluating the diagnosis of de-novo metastasis and any association of remoteness, highlighting the geographic and possibly early access to treatment. Methods: A cohort of patients was retrospectively selected comprising age- and remoteness matched Indigenous and non-Indigenous women in a 1:1 ratio from the Western Australian Cancer Registry. Further data were collected from medical records and results systems. Remoteness was defined by the ARIA system. In addition, the distance from the nearest treatment center was calculated. The survival analysis was performed by Indigenous status and remoteness. Results: The final cohort comprised 250 Indigenous and 261 non–Indigenous women. Of the total, 7.6% (19/250) and 7.7% (20/261) were identified to have de-novo metastasis. At 10 years of follow up, most de-novo metastatic patients in both groups were from remote communities, distributed as 10.1, 9.1, 7.8, 8.7 and 5.0 % in metropolitan, inner regional, outer regional, remote and very remote areas respectively. In Indigenous group with de-novo metastasis the average distance of patient from treatment center was 1720km for vs 1018 km in Non-Indigenous patient with a p-value of 0.03. In non-metastasis cohort, Indigenous patient has 1065 km v 1241 km in non-indigenous group. Considering outcomes for those developing metastatic disease, median survivals after metastatic diagnosis were shorter for Indigenous patients, 21 v 33 months, p = 0.03. Conclusions: Indigenous women in WA with metastatic breast cancer have inferior survival outcomes from diagnosis of metastases relative to non-Indigenous peers. Most de-novo metastatic patients were from remote locations in both cohorts but no relation between remoteness and de-novo metastasis, identified to be impacting survival. Future studies are needed to better elucidate if any geographical, health care disparities and improve on treatment related outcomes. It is suggested to derive targeted policies to improve survival outcome of all Indigenous cancer patients, particularly those residing in remote areas.

In Australia, incidence of breast cancer is lower but mortality risk is substantially higher in Indigenous relative to non-Indigenous women. Substantial detriment has been found to remain even after compensating for social class and stage of disease with risk of dying still being more than double. At almost one million square miles many patients in Western Australia have to travel for several days for single cycles of treatment in the capital Perth. Indigenous patients on average live in significantly more remote locations than non-Indigenous patients. We have also identified greater incidences of higher risk breast cancer sub-types in the Indigenous population including luminal B and HER2-enriched cancers which require more frequent and longer IV treatment schedules. Research is entirely lacking on systemic treatment disparities in adjuvant and metastatic settings, differences in follow-up and secondary screening protocols by Indigenous status in Australia. Here we set out to define patterns of offered, accepted, and completed treatment with a view to addressing service gaps for disadvantaged populations. An initial cohort of 100 patients comprising 1:1 matched Indigenous and non-Indigenous patients from across WA was obtained from the WA Cancer Registry. Registry data was supplemented with data from the Death Registry, individual medical records from hospitals and family practitioners, state results systems and pharmacy records. Initial surgery performed, radiotherapy delivered and rates of offering, accepting, commencing and completing chemotherapy, HER2-targeted and endocrine therapy were collated by sub-type and stage. Here initial results on treatment of early disease are presented. At the time of writing, data for 37 Indigenous and 33 non-Indigenous breast cancer patients are available. 46% of the cohort are deceased with a median follow-up of 13.2 years. 10-year survival was higher for patients in the metro area than regional or remote patients (79 v 58%, p=0.03) and for non-Indigenous relative to Indigenous patients (84 v 53%, p=0.003). Considering treatment pattern by Indigenous status, no significant differences were observed. Proportionally more Indigenous patients underwent mastectomy relative to conservative surgery (44 v 29 %), a difference observed across tumour sizes. Rate of axillary clearance relative to lymph node (LN) biopsy was similar (48 v 44%) but interestingly was numerically higher for Indigenous women where LNs were involved (99 v 88%). Post-operative radiotherapy was delivered in cases of conservative surgery or locally advanced disease in 87 and 93% of Indigenous and non-Indigenous cases with 9 and 7% of patients declining radiotherapy. For chemotherapy similar proportions of Indigenous and non-Indigenous patients declined offered adjuvant treatment (17 v 19%). Once commenced chemotherapy was completed in similar proportions (89 v 92%). 96% of both groups with estrogen receptor positive tumours were offered adjuvant endocrine therapy. However, the rate of declining or stopping endocrine therapy was numerically higher in Indigenous women (33 v 16%, p=0.12). To conclude, in this small cohort outcomes were significantly inferior, both for Indigenous women and for women living in regional and remote areas. Rates of delivery of local and adjuvant systemic therapy were similar. Rates of offering endocrine treatment were not different but a trend to lower acceptance or compliance with endocrine treatment was seen in Indigenous women that could potentially be addressed by improved patient information, expanded follow-up and toxicity management. Citation Format: Andrew David Redfern, Azim Khan, Lisa J Spalding, Hilary Martin. Breast cancer treatment patterns and outcomes for Australian women by indigenous status and remoteness of residence [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-10-16.

Cervical cancer in Indigenous women: The case of Australia

Indigenous peoples in countries with similar colonial histories have disproportionate burdens of disease compared with non-Indigenous peoples. We aimed to systematically identify and collate studies describing the prevalence of pre-existing diabetes and gestational diabetes, and compare the prevalence of these conditions between Indigenous and non-Indigenous pregnant women in Australia, Canada, New Zealand, and the USA. For this systematic review and meta-analysis, an information specialist did a comprehensive search of eight databases (Ovid MEDLINE, Ovid Embase, Ovid Global Health, CINAHL [EBSCO], Scopus, ProQuest Dissertations and Theses Global, PROSPERO, and the Wiley Cochrane Library) in June, 2019, for studies published between inception and June 25, 2019, without restrictions on language, publication type, or year of publication. Database searches were supplemented by grey literature searches of the Bielefield Academic Search Engine and Google Scholar, and the reference lists of relevant articles were also manually searched. We included observational epidemiological studies comparing the prevalence of pre-existing diabetes or gestational diabetes in Indigenous and non-Indigenous pregnant women in Australia, Canada, New Zealand, and the USA. Two independent reviewers assessed study eligibility and risk of bias. We used a standardised data extraction form to collect information from the published reports of eligible studies, and, if needed, we contacted authors for further information. We did a Mantel-Haenszel random-effects meta-analysis to obtain the pooled unadjusted prevalence odds ratios (PORs) of pre-existing diabetes and gestational diabetes in Indigenous women compared with non-Indigenous women. We stratified meta-analyses by country and type of diabetes. The study is registered with PROSPERO, number CRD42018095971. Our search identified 1348 studies, of which 43 studies with 32 952 441 participants from Australia, Canada, New Zealand, and the USA were included in the systematic review, and 39 of these studies were included in the meta-analysis. 40 of the included studies used a cohort design. Pre-existing diabetes was more prevalent in Indigenous women than in non-Indigenous women, with pooled PORs ranging from 1·81 (95% CI 1·53-2·13) for women in the USA to 3·63 (2·35-5·62) for women in Australia. Similarly, gestational diabetes was more prevalent in Indigenous women than in non-Indigenous women, with PORs ranging from 1·42 (1·24-1·63) for women in Australia to 2·04 (1·46-2·84) for women in Canada. Risk of bias was low in 37·2% of studies, unclear in 34·8% of studies, and high in 27·9% of studies. Heterogeneity between studies was predominantly high (I2=97-100%), with one exception of moderate heterogeneity (I2=48%); however, the magnitude and direction of the PORs from individual studies indicated an association between pre-existing diabetes or gestational diabetes and indigeneity among pregnant women. The prevalence of pre-existing diabetes and gestational diabetes was higher in Indigenous pregnant women than in non-Indigenous pregnant women in four countries (Australia, Canada, New Zealand and the USA) with similar histories of colonialism. These findings have implications for prenatal care services and the monitoring of Indigenous women in industrialised countries. Canadian Institute of Health Research and the Women's and Children's Health Research Institute.

There is a disparity in health outcomes between indigenous and nonindigenous Australians, with higher chronic disease burden and shorter life expectancy in this minority population. Although rates of breast cancer among indigenous women are lower than nonindigenous women, they face a higher breast cancer-associated mortality, which may not entirely be explained by socio-economic disadvantage. This retrospective cohort study investigated previously described pathologic prognostic factors in indigenous Australians in the Northern Territory. Data analyzed confirmed that indigenous women were more likely to have poorer prognostic disease features, including ER/PR negative and human epidermal growth factor receptor 2 amplified tumors, larger tumors, and higher stage disease. These pathologic features portend to a poor prognosis, raising the possibility these factors contribute to the disparity in health outcomes between indigenous and nonindigenous women with breast cancer, in addition to known socio-economic factors.

BackgroundThere is a disparity in the burden of gynaecological cancer for Indigenous women compared with non-Indigenous women in Australia. Understanding how Indigenous women currently experience gynaecological cancer care services and factors that impact on their engagement with care is critical. This study explored Indigenous Australian women’s experience of gynaecological cancer care at a major metropolitan hospital in Queensland.MethodsIndigenous women receiving care at a major metropolitan Queensland hospital for investigation or diagnosis of gynaecological cancer were invited to participate in a larger longitudinal study exploring women’s experiences of gynaecological cancer care. This component was an in-depth, qualitative interview exploring the women’s experiences of hospital care at approximately three-month post initial referral. A peer-approach was used to interview women. Hospital-based care providers involved in the care of Indigenous gynaecological cancer patients were invited to be interviewed. Interviews were transcribed and thematically analysed using an interpretative phenomenological approach enabling a multi-layered, contextualised understanding of the patients' experience and their interaction with tertiary cancer services.ResultsEight Indigenous patients and 18 care providers were interviewed. Analysis of all interviews revealed four broad issues affecting Indigenous patients’ early experiences of care: (1) navigating the system, impacted by timely diagnosis, access to support services and follow up; (2) communication and decision-making, patients’ decision-making, efficacy of doctor-patient communication, and patients’ knowledge about cancer; (3) coping with treatment demands, was impacted by emotional stress, access to services and support by hospital staff; and (4) feeling welcome and safe in the hospital, impacted by patients’ relationship with care providers and their access to culturally-safe services. The combination of factors impacting these women’s’ experience of gynaecological care commonly left these women at breaking point, often with limited access to information, resources or support.ConclusionsOur findings revealed that experiences of cancer care for Indigenous women are overlain by challenges associated with late referral, misdiagnosis, miscommunication, lack of information, logistics in accessing treatment and services and system cultural insensitivities. Our findings offer insights that can inform cancer care provision to more effectively support Indigenous women accessing gynaecological cancer services.

We compared patterns of care, comorbidity, disability-adjusted life-years (DALYs) and survival in Indigenous and non-Indigenous women with breast cancer in Queensland, Australia (1998-2004). A cohort study of Indigenous (n=110) and non-Indigenous women (n=105), frequency matched on age and remoteness. We used Pearson's Chi-squared analysis to compare proportions, hazard models to assess survival differences and calculated disability-adjusted life years (DALYs). Indigenous women were more likely to be socially disadvantaged (43 vs. 20%, p<0.01) have comorbidity (42 vs. 18% p<0.01), and have regional spread or distant metastasis (metastasis, 51 vs. 36%, p=0.02) than non-Indigenous women; there was no difference in treatment patterns. More Indigenous women died in the follow-up period (p=0.01). DALY's were 469 and 665 per 100,000 for Indigenous and non-Indigenous women, respectively, with a larger proportion of the burden attributed to premature death among the former (63 vs. 59%). Indigenous women with breast cancer received comparable treatment to their non-Indigenous counterparts. The higher proportion of DALYs related to early death in Indigenous women suggests higher fatality with breast cancer in this group. Later stage at diagnosis and higher comorbidity presence among Indigenous women reinforce the need for early detection and improved management of co-existing disease.

Indigenous women in Mesoamerica experience disproportionately high maternal mortality rates and are less likely to have institutional deliveries. Identifying correlates of institutional delivery, and satisfaction with institutional deliveries, may help improve facility utilization and health outcomes in this population. We used baseline surveys from the Salud Mesoamérica Initiative to analyze data from 10,895 indigenous and non-indigenous women in Guatemala and Mexico (Chiapas State) and indigenous women in Panama. We created multivariable Poisson regression models for indigenous (Guatemala, Mexico, Panama) and non-indigenous (Guatemala, Mexico) women to identify correlates of institutional delivery and satisfaction. Compared to their non-indigenous peers, indigenous women were substantially less likely to have an institutional delivery (15.2% vs. 41.5% in Guatemala (P<0.001), 29.1% vs. 73.9% in Mexico (P<0.001), and 70.3% among indigenous Panamanian women). Indigenous women who had at least one antenatal care visit were more than 90% more likely to have an institutional delivery (adjusted risk ratio (aRR) = 1.94, 95% confidence interval (CI): 1.44–2.61), compared to those who had no visits. Indigenous women who were advised to give birth in a health facility (aRR = 1.46, 95% CI: 1.18–1.81), primiparous (aRR = 1.44, 95% CI: 1.24–1.68), informed that she should have a Caesarean section (aRR = 1.41, 95% CI: 1.21–1.63), and had a secondary or higher level of education (aRR = 1.36, 95% CI: 1.04–1.79) also had substantially higher likelihoods of institutional delivery. Satisfaction among indigenous women was associated with being able to be accompanied by a community health worker (aRR = 1.15, 95% CI: 1.05–1.26) and facility staff speaking an indigenous language (aRR = 1.10, 95% CI: 1.02–1.19). Additional effort should be exerted to increase utilization of birthing facilities by indigenous and poor women in the region. Improving access to antenatal care and opportunities for higher-level education may increase institutional delivery rates, and providing culturally adapted services may improve satisfaction.

Evidence on long-term trends in gestational diabetes mellitus (GDM) prevalence in Australia is lacking. To assess and compare trends in GDM prevalence among Indigenous and non-Indigenous Australian women. Analysis of crude and age-adjusted GDM prevalence over time by Indigenous status and age, using routinely collected midwives data from Australian states and territories on mothers giving birth from 1990 to 2009. Despite considerable data variation, particularly in 1990-1999, and likely underestimation of GDM prevalence, crude and age-adjusted GDM prevalences were higher in Indigenous than non-Indigenous women at all time-points (4.7% vs 3.1% in 1990-1999; 5.1% vs 4.5% in 2000-2009, P<0.0001). Data variability precluded quantitative assessment of trends and changes in prevalence ratios before 2000. From 2000 to 2009, GDM prevalence increased significantly among Indigenous women by a mean 2.6% annually (Ptrend <0.0001), and non-Indigenous women by 3.2% annually (Ptrend <0.0001), with no significant trend in the age-adjusted Indigenous/non-Indigenous prevalence ratios (PR) (P=0.34). GDM prevalence increased significantly with age (P<0.0001), although the increase with age was significantly greater among Indigenous women (PR 5.34 (4.94-5.77), ≥35 vs <25years) compared to non-Indigenous women (PR 3.72 (3.64-3.81), ≥35 vs <25years), Pinteraction <0.0001. Bearing data quality concerns in mind, GDM prevalence is increasing rapidly among Australian women, more than doubling in non-Indigenous women between 1990 and 2009. Prevalence is consistently higher in Indigenous versus non-Indigenous women, with statistically consistent differences between the groups in recent years. The marked increase in prevalence with age highlights an important period for prevention, particularly for Indigenous women.

Introduction: The modified Glasgow prognostic score (mGPS) is known to be useful in prognostication of multiple cancers. The mGPS, which integrates albumin and C-reactive protein, could assist as a possible prognostic marker in breast cancer. Indigenous women have inferior breast cancer survival to non-Indigenous women and may also have a differing inflammatory environment. Here, we examine the utility and impact of baseline mGPS on survival outcomes in women with metastatic breast cancer by Indigenous status. Methods: We retrospectively collected data from the Western Australian Cancer Registry and electronic records for patients diagnosed with breast cancer between 2001 and 2016 with confirmed metastatic disease. Overall survival (OS) were measured from the date of diagnosis until death. mGPS comprised scores of one point given for CRP &amp;gt; 10 mg/L and/or albumin &amp;lt; 3.5 g/dL, therefore having a value of 0 to 2. Results: Of 152 patients with metastatic breast cancer, 89 patients had all relevant data available and were included with a median follow up of 120 months. The median age was 55.3 years. Baseline mGPS was 0 in 46.6 %, 1 in 34.8 % and 2 in 18.6 %. Median OS across Indigenous and non-Indigenous patients combined was significantly worse moving from the mGPS-0 group through mGPS-1 to mGPS 2, 50.0 v 30.0 v 8.0 months respectively (p&amp;lt;0.0001). Looking at the groups separately, both cohorts separately demonstrated inferior median OS in mGPS-2 compared to mGPS-1 patients, 9 v 32 months (p=0.02) for Indigenous patients, and 2.0 vs 25.0 months for non_Indigenous patients (p=0.001). The correlation between mGPS and the neutrophil-to-lymphocyte ratio (NLR) was weak with a Pearson correlation R-value of 0.184 (p=0.085) Conclusion: The study shows that the mGPS is an independent prognostic factor in advanced-stage disease. A higher baseline mGPS score was associated with worse survival in Indigenous and non-Indigenous patients. A larger prospective study is needed to validate the results, inclusive of assessing links between mGPS and OS in different breast cancer sub-types. Citation Format: Azim Khan, Hilary Martin, Lisa Spalding, Andrew Redfern. The impact of baseline modified glasgow prognostic score (mGPS) on survival outcomes in in indigenous and non-indigenous patients with advanced breast cancer patients of Western Australia [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS6-58.

Breast cancer is the third leading cause of cancer deaths in Aboriginal women after cervical and lung cancer. A retrospective 5-year surgical audit comparing breast cancer in indigenous and non-indigenous women in Far North Queensland was undertaken. The mean age at diagnosis was similar for indigenous (54.0 years) and non-indigenous (55.4 years) women. Indigenous women presented with slightly larger tumours (mean 32.2 mm vs 23 mm; P = 0.07). More indigenous women had involved lymph nodes (P = 0.03). Despite larger tumour size, indigenous women were considered suitable for breast conservation surgery at a rate similar to the non-indigenous population. Indigenous women present with more advanced breast cancer in Far North Queensland despite similar detection rates among the screened indigenous and non-indigenous population. Indigenous women received similar rates of breast conservation surgery. Differences in mortality rates will require further study.

Aboriginal and Torres Strait Islander women have a higher mortality rate due to gynecologic cancer compared with non-Indigenous women. For cervical cancer, Australian Indigenous women are less likely to survive 5 years following diagnoses than non-Indigenous women. This study investigates the factors associated with gynecologic cancer treatment and survival among Queensland indigenous and non-Indigenous women. Australian Indigenous women diagnosed with uterine, cervical, ovarian, or other gynecologic cancers during 1998-2004 in the public hospital system were included. They were frequency matched on age (±5 years), residential remoteness, and cancer type to a random sample of non-Indigenous women. One- and 5-year cancer-specific survival was examined according to Indigenous status using Cox proportional hazards regression. Indigenous women (n = 137) compared with non-Indigenous women (n = 120) were less likely to be diagnosed with localized disease (49% vs 65%, P = 0.02) and had more comorbidities (52% vs 21%, P < 0.001). Indigenous women were less likely to receive any cancer treatment compared with non-Indigenous women (91% vs 98%, P = 0.01), although when excluding those with metastatic cancer, there was no significant difference in uptake of treatment (95% vs 91%, respectively, P = 0.31). Among those who did undergo treatment, there was no difference in time to treatment (median difference 0.5 days, P = 0.98). Gynecologic cancer-specific survival differences between Indigenous and non-Indigenous women were most prominent in the first year following diagnosis (hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.06-3.38) and were no longer significant 5 years after diagnosis (HR, 1.47 [95% CI, 0.97-2.25]). For cervical cancer, crude 1-year survival was poorer for Indigenous women compared with non-Indigenous women (HR, 2.46 [95% CI, 1.03-5.90]), but was no different when adjusted for stage and treatment of cancer (HR, 1.00 [95% CI, 0.45-2.24]). Improving the early diagnosis of cervical cancer in Indigenous women may increase cancer-specific survival in the year following diagnosis.

e12529 Background: Indigenous women with breast cancer (BrCa) have markedly higher mortality and are more likely to be diagnosed with more advanced disease compared with non-indigenous women. However, it is unknown if Indigenous older adults receive same lines of treatment as non-indigenous older adults with breast cancer. Methods: We retrospectively examined data from WA cancer registry from 2001 to 2016 with BrCa by Indigenous status. Indigenous were considered older adults aged above 55 years and non-indigenous aged above 65 years. Cases with confirmed breast cancer, where chemotherapy was indicated in adjuvant and metastatic setting were included for analysis. Overall survival was compared between treatment arms of indigenous and non-indigenous cohort using log-rank analysis and demonstrated by Kaplan Meier curve. Chi-square was employed as well. Results: At time of writing, results were available for 75 indigenous and non-indigenous older adults identified for analysis from cohort of 315 older adults. 79% Indigenous received treatment in adjuvant setting, 14% was not offered and 7% declined adjuvant treatment compared to 89% non-indigenous patients received adjuvant chemotherapy, 7% were not offered and 4% declined therapy. In first line metastatic setting, only 65% older indigenous group received chemotherapy compared to 76% non-indigenous patients. In second line, only 48% patients received treatment compared to 61% non-indigenous patients. In third line, 23% indigenous women received chemotherapy compared to 51% non-indigenous women with significant p-value 0.012. The rate of decline was higher in indigenous cohort. Kaplan meier curve of 10-year survival analysis favors the Non-Indigenous group. The difference between groups was 55 vs 68%. When comparing groups, the median survival of Indigenous group was 79 months and mean survival of Non-Indigenous cohort was 97 months. Log-rank testing p value 0.0025. Conclusions: In this study, indigenous patients have shown reduced survival outcomes and with drop in lines of treatment in the course of disease, highlighting a potential area to address and improve survival outcomes, along with addressing barriers that lead to treatment disparity in older adults.

This paper focuses on a series of cookbooks published by Indigenous Australian groups. These cookbooks are typically produced with government funding, and are developed by nutritionists, dieticians, and health workers in consultation with local communities. They are designed to teach Indigenous Australians to cook healthy, nutritious, low-cost meals. In this paper, Fredericks and Anderson identify the value of these cookbooks as low-cost, public health interventions. However, they note that their value as health interventions has not been tested. Fredericks and Anderson question the value of these cookbooks within the broader context of the health disadvantage faced by Indigenous Australians. They argue that the cookbooks are developed from a Western perspective of health and nutrition that fails to recognise the value of traditional Indigenous foodways. They suggest that incorporating more Indigenous food knowledge and food-related traditions into cookbooks may be one way of improving health among Indigenous peoples and revitalising Indigenous knowledge.