The findings from the PIPER Project, the country’s largest-ever study comparing survival from colorectal cancer for different population groups in New Zealand, were published last week in the New Zealand Medical Journal.

Of the almost 5000 patients studied, the five-year risk of death from bowel cancer was highest in Pacific patients (59 per cent), followed by Māori (47 per cent), then non-Māori (38 per cent).

Māori and Pacific patients are more likely to present as an emergency for their first diagnosis, and have a more advanced stage at presentation.

Of all patients with colorectal cancer, 31 per cent of patients presented directly to the emergency department (ED). Māori patients were the most likely to present to ED (45 per cent) followed by Pacific (35 per cent) than non-Māori non-Pacific (30 per cent). This is likely to reflect inequities in access to primary care and barriers to early diagnosis.

The study, funded by the Health Research Council and the Ministry of Health, is extremely important for working towards combating New Zealand’s high rate of deaths by bowel cancer, says the Consultant Medical Oncologist on the study Dr Christopher Jackson.

“We looked specifically at the poorer outcomes for Pacific Island Māori and were able to unpick why Māori and Pacific Island are diagnosed at a later point and more often in the emergency department. We looked at symptoms not being picked up, and what’s happening at the pre-hospital stage. We have a lot of work to do to get higher rates of bowel cancer picked up earlier on in Māori and Pacific Island patients.”

Previous research had also shown that Māori may have experienced inequities in the care pathway from when their cancer was diagnosed, but our research found that the poorer outcome for Māori was largely explained by their being diagnosed at a later point when the cancer is more advanced, treatment more risky, and more difficult. Piper report researchers said that more research is needed to understand the survival rates of Pacific people.

The Hutt Valley and Wairarapa District Health Boards (DHBs) began free bowel screening in July 2017 and Waitemata transitioned from a pilot programme to the national programme in January of this year. Southern DHB is about to begin their programme. Other DHBs will follow in stages with all DHBs around the country expecting to be offering bowel screening by the end of 2021.

Once the programme is fully rolled out, bowel screening will be offered every two years to people aged 60 to 74 who are eligible for publicly funded health care. Once fully implemented it is expected to detect 500–700 cancers a year.

Dr Jackson explains that the screening programme must be accessible to all.

“The screening programme will need to be structured, targeted and promoted in an appropriate way to both Māori and Pacific Island communities. How to do that is a question for the Ministry but if Pepsi and Coke can market their products effectively to their markets it is possible for a sophisticated screening programme to identify and target who they need to as well.”

Dr Melissa McLeod (Ngāi Tahu) is a public health physician and senior research fellow working at Te Rōpū Rangahau Hauora a Eru Pōmare at the University of Otago. She was lead author on a paper released last year that modelled a nationwide colorectal cancer (CRC) screening programme for New Zealand.

She says the CRC screening programme will improve Māori health by preventing some cancers (by removing pre-cancerous lesions) and by diagnosing CRC earlier when there are better rates of survival. Another benefit of the CRC screening programme for Māori, she says, is a clear pathway of care that will be closely monitored to ensure Māori are able to access appropriate and timely treatment for colorectal cancer.

However, she explains, the screening for bowel cancer programme is also problematic for Maori.

“The national colorectal cancer screening programme is likely to increase inequalities in health for Māori for two key reasons. Māori are less likely to get colorectal cancer than non-Māori, so there are fewer cancers for the screening programme to pick up and, screening programmes in New Zealand routinely achieve lower levels of coverage for the Māori population.”

She echoes Dr Jackson’s sentiments by saying that to ensure Māori get as much benefit as possible from the screening programme, “every effort must be made to get high rates of screening coverage for Māori “.

The Piper study found that care experienced post-diagnosis had improved for all groups, said Dr Jackson.

“We’re getting better. Just more slowly than I would like.”

Further study is already underway and is looking at what are the barriers to primary care experienced by different New Zealanders.

The findings of that study are sure to be of interest to Dr McLeod.

“Māori are more likely to present to ED than non-Māori non-Pacific [nMnP]. This indicates a serious issue with access to primary care service for Māori in New Zealand.”

Health Central also spoke to Rachel Afeaki from Bowel Cancer New Zealand about the PIPER study.

Are the findings of the study a surprise?

Yes – Pacific patients had the worst outcomes, with a five-year cumulative incidence of death from CRC of 59 per cent, and a risk two-fold higher than that for nMnP”. What is the current health system doing to address this and how can we as a Pacific and Māori community mitigate these statistics?

The inequality between Pacific and non-Pacific and non-Māori – is not surprising but I believe more is being done through effective community leadership to address such disparity between the two groups.  My experience is CRC is an ‘unknown’ to our Pacific communities.

If we look at the 60+ age group, this group would represent a migrant population and growing up in the Pacific Islands as a young person – cancer of any sort was unfamiliar.

What do you think of the findings? 

The findings have been provided for a medical audience. I look forward to Bowel Cancer New Zealand working with our Pacific and Māori bowel cancer ambassadors to better articulate key messages to our respective communities.

This research provides further endorsement for more in-depth research to be conducted for both Māori and Pacific regarding CRC, and key findings concerning post diagnosis care, addressing ‘ethnic culture and values’ and its relevance to Pacific wellbeing in general.

The findings need to be further shared across all key media platforms targeting Māori and Pacific networks – a summary of key findings and recommendations going forward.”

What does Bowel Cancer New Zealand think needs to be done to encourage more of our Māori and Pacific Islanders to get a check-up?

Increase awareness via Pacific and Māori appropriate messaging to all of its communities both in rural and urban areas.

Push for national screening to occur across all 20 DHBs – namely locations where the Māori and Pacific population is significant.

Bowel cancer is already including Māori and Pacific stories across its key campaigns to ensure the messages are getting out to its respective communities. What the health sector needs to realise and understand is the need to demystify all cancers for Māori and Pacific communities. We are likely to present CRC symptoms at a much younger age, hence the need to lower the age for Pacific and Māori across the BC national screening programme to as young as 50 years old.

Do you think the Pacific Island and Māori communities are not being communicated to as well as other groups about the importance of being tested?

Yes, but with only four DHBs (I am aware of Southern coming into play soon) on board the Waitemata and Hutt DHB will need to ensure they do their best to raise the awareness of when, how and why, one should engage with the programme.

It’s great to see where the programme is being rolled out where ethnic-specific culturally-appropriate information is provided via pamphlets. The need to target churches and maraes is another effective platform to increase awareness with Māori and Pacific.

Is it tiring for our Pacific Island communities to always be hearing negative health statistics, on top of experiencing the inequities themselves?

 What is tiring, is that the statistic continues to show itself up year after year, indicating nothing is being done to address what research is telling us. The positive is what we do with the research and how we turn it around.

What we are seeing is an emergence of Pacific and Māori community leaders, health practitioners and survivors beginning to go out and speak to in their communities, begin to mobilise communities to work more collaboratively health, education, churches and maraes to raise the awareness and better mitigate adverse outcomes.

What is needed is appropriate funding to tap into Māori and Pacific communities to drive key messages regarding key cancers and to recognise symptoms, how to talk to your GP and what measures are required to keep healthy.

Bowel Cancer New Zealand is working on its diversity to ensure more effective engagement with its Māori and Pacific communities.

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