Cancer in indigenous populations: challenges and responses

There are significant challenges for cancer control in indigenous populations in both developed and under developed countries. The decision to develop a themed section on cancer in indigenous populations is underpinned by our desire at EJCC to facilitate international dialogue so that we can understand the nature of these challenges, and to identify ways in which researchers, governments, service providers and others are responding to these challenges. Through the sharing of knowledge and experience, we hope that this themed issue will facilitate ways in which we can work together towards reducing the inequities in cancer outcomes that are so evident within indigenous communities throughout the world. In our experience as editors, we are regularly reminded of the differences in preferences for use of the term indigenous (including whether to capitalise indigenous), as well as other terms applied to identify members of an indigenous culture or cultures (e.g. Aboriginal and/or Torres Strait Islander). Thus, within this themed section, we have not attempted to edit terms applied by authors. We also trust that authors have in good faith applied terms that are consistent with the way in which cultures they work with prefer to be identified. Cancer is ubiquitous and occurs throughout the world, in developed and underdeveloped countries. A focus on cancer in underdeveloped countries will feature in a later themed section, scheduled for publication November, 2016. Here we present a collection of papers from Australia, New Zealand and Canada. These countries are described as highly developed; for example, they are ranked in the top eight countries with regard to key indices including life-expectancy, education and income (Moore et al. 2015). Despite these impressive rankings, indigenous people living in these countries experience poor health, including a high incidence of cancers with low rates of survival, and for which are potentially preventable through infection reduction and/or lifestyle change (Moore et al. 2015). As documented in a previous article published in EJCC (see Miller et al. 2012), indigenous peoples in these regions experience significantly poorer cancer outcomes than their non-indigenous counterparts. Disparities in access and outcome are relevant across the cancer continuum, and where data are available for comparison, disparities in mortality rates among indigenous populations compared with non-indigenous populations, are reported for cancers of the cervix, breast, gallbladder, lip and oropharynx, liver, lung, prostate and stomach (Miller et al. 2012). In many of these regions, these disparities are large. For example, in Australia, Aboriginal and Torres Strait Islanders experience a 30% higher mortality rate from cancer, compared with non-Indigenous Australians (Zorbas & Elston 2016). Until recently, data were relatively sparse with regard to enabling comparisons in overall cancer burden in indigenous populations in high-income countries such as Australia, the United States of America (US), Canada and New Zealand. A recent paper published in Lancet Oncology (Moore et al. 2015) suggests that among indigenous populations there is an overall lower burden of cancer in the US, similar or lower levels in Australia and Canada (Alberta, Canada), with the highest level of cancer burden indicated for New Zealand. While there are several differences in cancer incidence and patterns of cancer across these regions, generally the most commonly occurring cancers among indigenous populations in these regions include lung cancer (among men) and breast cancer (among women). However, there is a lower incidence of breast cancer among indigenous populations compared with non-indigenous populations in Alaska and New Zealand. In Canada, there is a higher incidence of colorectal cancer, and in the US, a higher incidence of prostate cancer (Moore et al. 2015). Moore et al. (2015, p. 1489) suggest that the poorer outcomes reported for indigenous populations ‘… highlight the common legacy of colonisation and its resultant political, social, environmental, and economic effects on the health of indigenous people’. Authors contributing to this themed issue also acknowledge the ongoing impact of colonisation, as well as social disadvantage and marginalisation on the health and social and emotional wellbeing of indigenous populations (Brown et al. 2016). A history of exposure to racism continues to impact negatively on the health of indigenous people, with papers in this issue continuing to highlight significant inequities in cancer outcomes for indigenous people in New Zealand (Robson & Ellison-Loschmann 2016), Canada (Beben & Muirhead 2016) and Australia (Zorbas & Elston 2016). The ability of health systems to adapt and deliver care in alignment with the needs and preferences of indigenous people continues to be a barrier (Meiklejohn et al. 2016) so does the potential to alienate patients and their families though poor communication (Brown et al. 2016; Zorbas & Elston 2016). Smoking underpins the high rates of lung and head and neck cancers. Thus, Knott et al.'s (2016) exploratory study generates a range of hypotheses regarding potential differences in the determinants of smoking that may exist among Indigenous men and women in Australia. Importantly, the study identifies a range of novel motivators for quitting among Indigenous men (e.g. sport, children) and women (e.g. body image, concern for others). While there remain significant challenges in improving cancer control outcomes for indigenous patients and families affected by cancer, there are examples reported herein whereby governments and researchers are working together with indigenous people to bring about change. Brown et al. (2016) provide an example of an approach in Australia whereby Aboriginal communities are working with policy makers, health service providers and researchers to drive change in the way data are collected and utilised. A specific focus of the CanDAD project is to drive change at the health system and service delivery levels via the integration of quantitative (registry data) and qualitative data (narratives) using methods including mapping as well as data-linkage. Zorbas and Elston (2016) report on an Australian government initiative involving the development of a Framework which identifies key priorities for improving cancer outcomes for Indigenous Australians. The Framework, developed in partnership with Menzies School of Health Research, identifies key priorities which include a focus on ensuring health services are adaptable and culturally safe. Authors suggest, for example, that the approach taken by Cancer Australia may provide the impetus for other countries to develop an approach to the development of specific priorities for indigenous populations. The papers presented here are not exhaustive of the initiatives aimed at improving cancer outcomes for indigenous populations throughout the world. There are many initiatives such as those involving grass roots advocacy in which survivors aim to both engage their communities in activities involving prevention, while also facilitating system level change. We hope in the future to publish updates of such work, and encourage others who are reading this themed section, to share their knowledge and experiences with our readers.

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