Breast cancer management in Australian rural indigenous women: trends and challenges

INTRODUCTION

Several studies have reported the disparities in cancer survival and overall outcomes between rural, regional and urban Australia.^1,2 The cancer patients residing in rural areas have a 7% higher mortality when compared to their counterparts in urban centres.³ Approximately a third of Australia’s population reside in regional and remote areas.² Despite of several advances in the multidisciplinary management of breast cancer, women with breast cancer in rural and regional Australia face several challenges. The survival rates for women with breast cancer in Australia have significantly improved in the few decades, however studies shows that survival in indigenous and Torres Strait islander women diagnosed with breast cancer is lower than the non-indigenous population.^1-4 The causes for this inequality are complex and not fully understood.

Breast cancer trends in indigenous women

In Australia breast cancer is the most common cancer affecting women and accounts for approximately 27% of all cancers in women. It is reported that 30% of women diagnosed with breast cancer live outside metropolitan cities.¹ Among the indigenous and Torres Strait islander women breast cancer accounts for 25% of all cancer diagnosis.^5,6 In the year 2016 alone it is estimated that there will be more than 8000 new cases of invasive breast cancer diagnosed in Australian women aged 50-69. It is also estimated that around 1000 women women aged 50-69 will die from breast cancer which is equivalent to 40 deaths per 100,000 women.^7,8 This causes significant mortality and makes breast cancer the second-most common cause of cancer related mortality in Australian women.⁸

It is interesting to know that the incidence of breast cancer is lower in indigenous women than for non-indigenous women (214 versus 278 new cases per 100,000 women aged 50-69).^5,6 Despite of the lower incidence rates among the indigenous women, the mortality from breast cancer is similar in both groups.⁶ Breast Screen Australia plays an important role in the diagnosis and management of breast cancer in Australia and it is reported that the participation in the screening program is lower in the rural and remote areas when compared to the urban centres (46.9% versus 52.2%).^1,5,6

It is reported that in 2013-2014 only 36.5% indigenous women participated in Breast Screen when compared to 53.8% of non-Indigenous Australian women.⁹ Despite of increase in overall breast screening participation in the last 10 years, it has been shown that indigenous women have always had lower participation rates when compared to non-indigenous women.⁵

Current challenges for the indigenous women in rural and regional Australia

Approximately 44% of indigenous Australians reside in regional areas and 22% live in remote areas. It is reported that the indigenous Australians living in rural and remote areas have poorer access to health services and have poorer health outcomes when compared to their non-indigenous counterparts residing in metropolitan and urban areas. Due to their isolation from major urban cancer centres, the indigenous women living in the rural and regional Australia face several challenges.^1-6,10-13

There is good evidence that the multidisciplinary care for breast cancer provides the best overall outcome.¹ Medical and health facilities, specialist cancer services and allied health support are usually concentrated in the urban and metropolitan areas, which makes it harder for the indigenous women living in the rural and remote areas to access those comprehensive breast cancer management services.^1-3,10

Also often for several indigenous women it is not easy to travel to metropolitan or urban centres for their treatment and follow-up. This can cause unnecessary financial burden. This is a significant concern for a majority of indigenous women who have inadequate financial resources for travelling. For most women it is also difficult or in fact impossible to maintain employment whilst receiving lengthy treatment.^4-6

It has been shown that indigenous women lack awareness about breast cancer, screening, self-examination, and management.^1,6 A higher proportion of indigenous women have other comorbidities and chronic illnesses such as diabetes mellitus and renal disease. This can make it difficult for them to travel to specialist breast cancer centres. Also low numbers of culturally sensitive and appropriate specialist health facilities can lead to delayed diagnosis, non-compliance and suboptimal treatment. Participation in breast screen can be lower due to poor education and awareness, poverty, discrimination and lack of culturally appropriate health facilities. These findings have been reported by the closing the gap-screening program in Queensland, Australia.^5,6,8,11

Lack of support groups and services in rural and remote areas can also lead to poor overall management of the indigenous women with breast cancer.¹ Good communication between the health professionals and the patients lead to better patient satisfaction and successful overall patient care. Poor communication between the medical and allied health practitioners can lead to inadequate care, which can lead to higher morbidity and mortality amongst indigenous women.^2-4

DISCUSSION

Breast cancer management is dynamic and we are making substantial progress. New and advanced diagnostic tools and molecular markers have significantly improved the diagnosis, risk assessment and management of the breast cancer. Despite of these clinical advances indigenous women in rural and remote areas of Australia still face significant number of challenges and barriers to receive optimal treatment.^1,3,5 Breast cancer screening rates amongst the indigenous women have improved in the last decade. Despite of the isolation associated with the regional and rural residents the results of the Australian federal and state government run programs aiming to close the gap between the disparities between the indigenous and non-indigenous Australian women in rural and regional areas are encouraging.⁵

It is therefore vital to have a culturally sensitive and accessible treatment program in the regional and rural centres. All Australian residents should have an equal and fair access to their treatment. Breast cancer patients in rural and regional areas should not have to leave their social and emotional support off their loved ones and families to access specialist and allied health services for the management of their breast cancer. They should not have to face the additional burden of travel, accommodation and other expenses associated to access their treatment. Government should have adequate allied health and support services available to the patient’s rural and regional areas and this should not be any different to the services offered to their urban counterparts.^1,4,6

State and federal government health departments should ensure adequate resources are available to provide a multidisciplinary approach to the management of breast cancer for all indigenous women in the rural areas. Outreach clinics for the specialist and allied health professional to visit can improve the management of breast cancer. Tele-oncology involving use of teleconference technology for patients to communicate remotely with the health professionals can overcome some of the challenges of access to health professionals in the rural and remote areas.^14,15 It is also vital that the health professionals are trained to use culturally sensitive and effective communication strategies as this will enhance doctor-patient relationship and trust and will improve patient compliance and overall patient outcomes.^3,4,15

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

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