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How we can overcome cancer inequality in New Zealand

Fighting inequities: Dr Nina Scott. Photo/Supplied

Māori are 20% more likely than non-Māori to get cancer, and nearly twice as likely to die from it, and addressing disparities in incidence and care will be a key focus of cancer strategy into the future.

Public health physician Dr Nina Scott, chair of Hei Āhuru Mōwai, the national Māori cancer leadership group, says inequities exist at almost every step of the cancer-care pathway. Overall, Māori are diagnosed late, referred late, seen late and offered and receive treatment late and receive lower-quality treatment. She says Hei Āhuru Mōwai is working with leaders in the cancer sector to eliminate these differences.

When she started out in the sector as a palliative-care doctor and then public-health registrar, Scott says, “a lot of people didn’t believe there were cancer inequities. There was blatant racism at multiple levels and we had to fight to get the Māori cancer equity issue on the table. We had some evidence of unequal outcomes, but people weren’t sure why they existed or what to do about them or even whether they were important. Now, we are all on board and know they are unfair and unjust and the result of health-system issues that need to be – and can be – resolved. It’s been an amazing turnaround.”

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She says good data is crucial and inequities tend to disappear when they are well monitored. One area that has had investment in intensive equity monitoring is breast cancer treatment. Māori women with screening-detected breast cancer have the same chance of survival as non-Māori women. “Now we just need to do the same for women who get breast cancer diagnosed outside of screening – where Māori women have to wait longer to get treatment and have a 30% lower chance of survival.”

Targets are a must for equity monitoring, says Scott. Cancer patients can now be excluded from being counted under the 62-days-to-first-treatment target if they have other conditions that may affect their care. “That’s made some of the inequities disappear because Māori are more likely to have these other clinical conditions. Hiding inequities is not a solution.”

The last National Government stymied efforts to tackle the equity gap, she says. In 2016, the Ministry of Health disestablished Te Kete Hauora (the national Māori policy team), which was making progress on Māori cancer data. “That’s institutionalised racism at its best.”

Scott has been pushing for more discussion on the equity gap caused by the bowel cancer screening programme that is being rolled out nationally after modelling that showed life-expectancy gains were 2.5 times higher for non-Māori. Research suggests two things would redress that inequity: dropping the recommended entry age of screening by 10 years for Māori (to 50) and increasing Māori participation rates to a target of 78% from the present 60%.

In July, the Ministry of Health rejected those recommendations, saying it would review the parameters once the programme was fully implemented. Scott says the ministry has since agreed to have experts review the evidence to ensure equity for Māori and non-Māori.

Professor Diana Sarfati. Photo/Supplied

Waikato/Bay of Plenty Cancer Society chief executive Shelley Campbell says a conference in Wellington this month is the first time the whole cancer sector will have come together to plan ahead. “We can’t keep designing cancer-care or screening programmes and then think later about how we are going to make them work for Māori or be more culturally appropriate. That approach just doesn’t work. It doesn’t happen by chance. Tackling inequality takes really great focus, leadership and persistence – we’re not going to crack this in a year or two years. We need strong Māori voices from the top determining priorities and what we fund.”

Tobacco, obesity and chronic infections are the three main drivers of inequality in cancer incidence in Māori, says University of Otago, Wellington, cancer epidemiologist and researcher Professor Diana Sarfati. Although the significance of smoking and obesity is well understood, the important role of infection is not. Māori and Pasifika have four to six times higher rates of stomach cancer than Europeans. Most of the difference results from their higher incidence of a type of cancer that’s caused by infection with Helicobacter pylori that usually occurs in childhood. H pylori infection is associated with poverty and overcrowding. Type 2 diabetes is more common among Māori and Pasifika people, but if they also get cancer, they’re less likely to be treated for cancer, and if they are treated, their response might be worse if their diabetes isn’t well controlled.

Sarfati says the health system “doesn’t work quite as well for Māori at any point. At each step, they will do slightly worse, and though the difference isn’t great, the cumulative effect of it not working adds up.” She says there is still debate about whether it would be a good or bad thing to have a separate cancer strategy focusing on Māori. “I’m slightly on the fence, but I think having a very strong equity focus within a main strategy is where I would probably land.”

Although outcomes are measured according to ethnicity, the data doesn’t give a good indication of what needs to be done differently. “In general, we need to be focusing on prevention and that’s so boring no one wants to hear it. Everyone agrees prevention is better than cure, but no one ever mortgages their house to go to Mexico for a miracle prevention for cancer.”

This article was first published in the January 26, 2019 issue of the New Zealand Listener.