Cancer Screening and Diagnosis for Immigrant Canadians: Disparities and Potential Solutions Aisha K. Lofters MD PhD CCFP
What We Will Cover Today • What do we know about cancer screening disparities for immigrant Canadians in Ontario? • What do we know about disparities in cancer diagnosis for immigrant Canadians? • What are barriers to screening for immigrants Canadians? • What can we do about this all?
Disparities in Cancer Screening • 2013-2015 = 61% eligible Ontario women up- to-date on cervical cancer screening • 2014-2015 = 65% of eligible Ontario women up-to-date on breast cancer screening • 2015 = 50% of eligible Ontario adults overdue for colorectal cancer screening
• Who are the people not being screened? • How can we use data to answer this question?
Who Isn’t Being Screened? • Population-level administrative databases • Health card data, Immigration Refugee & Citizenship Canada data, primary care physician data • Data available for everyone with status in Ontario
Who Isn’t Being Screened for Cervical Cancer? 2.9 million women • 2.1 million <50 yrs of age • 800K 50+ yrs of age • 2006-2008 • Who had at least one Pap test?
Who Isn’t Being Screened? Younger women
Who Isn’t Being Screened? Younger women
Who Isn’t Being Screened? Younger women
Who Isn’t Being Screened? Older women
Who Isn’t Being Screened? Older women
Who Isn’t Being Screened? • Did you notice the income gradient?
Who Isn’t Being Screened? Younger women
Who Isn’t Being Screened? Older women
Who Isn’t Being Screened? Best-case vs. worst-case scenario : Of the younger Canadian-born women living in the highest-income neighbourhoods and in a patient enrolment model: 79.0% Of the older South Asian women living in the lowest- income neighbourhoods and not in a patient enrolment model: 21.9%
Who Isn’t Being Screened for Breast Cancer? 1.4 million women • 2010-2012 • Who had at least one mammogram?
Who Isn’t Being Screened? Mammography 100 90 80 70 60 50 % up-to-date 40 30 20 10 0 Caribbean East Asia Eastern Middle East South Asia Sub-Saharan US, Australia Western Long-term and Latin and Pacific Europe and and North Africa and New Europe residents America Central Asia Africa Zealand
Who Isn’t Being Screened? Mammography 100 90 80 70 60 50 % up-to-date 40 30 20 10 0 Caribbean East Asia Eastern Middle East South Asia Sub-Saharan US, Australia Western Long-term and Latin and Pacific Europe and and North Africa and New Europe residents America Central Asia Africa Zealand
Who Isn’t Being Screened for Colorectal Cancer? • 182K immigrants aged 60-74 • 2005-2015 • Who was overdue for colorectal cancer screening?
Who Isn’t Being Screened? • 182K immigrants aged 60-74 • 2005-2015 • Who was overdue for colorectal cancer screening?
Who Isn’t Being Screened? % overdue for CRC screening
Who Isn’t Being Screened? % overdue for CRC screening
Let’s Go A Little Deeper… • Looked at all immigrant women eligible for Pap tests • 2012-2015 • Classified into regions of birth • Within regions, classified countries as Muslim-majority vs. not • 761K women
Let’s Go A Little Deeper… 70 % overdue 60 for screening 50 40 Muslim majority Non-Nuslim majority 30 20 10 0 East Asia & Pacific Eastern Europe & Middle East & North South Asia Sub-Saharan Africa Central Asia Africa
Let’s Go A Little Deeper… 70 % overdue 60 for screening 50 40 Muslim majority Non-Nuslim majority 30 20 10 0 East Asia & Pacific Eastern Europe & Middle East & North South Asia Sub-Saharan Africa Central Asia Africa
Let’s Go A Little Deeper… 70 % overdue 60 for screening 50 40 Muslim majority Non-Nuslim majority 30 20 10 0 East Asia & Pacific Eastern Europe & Middle East & North South Asia Sub-Saharan Africa Central Asia Africa
Let’s Go A Little Deeper… 70 % overdue 60 for screening 50 40 Muslim majority Non-Nuslim majority 30 20 10 0 East Asia & Pacific Eastern Europe & Middle East & North South Asia Sub-Saharan Africa Central Asia Africa
Let’s Review… • Immigrant Canadians have lower uptake of cancer screening • Variation between different immigrant groups • Variation WITHIN immigrant groups • South Asian immigrants particularly at risk of under-screening for all three • Somali women particularly at risk for cervical cancer screening
• But what if immigrants (including South Asian immigrants) are less at risk of cancer?
Incidence of Cancer Among Immigrants US, NZ and Australia 0.27 Age-standardized Sub-Saharan Africa 0.24 incidence rates, per 1000 females, South Asia 0.14 colorectal cancer, 2004-2014 Middle East and North Africa 0.31 Latin America and the Caribbean 0.32 Europe and Central Asia 0.51 East Asia and Pacific 0.37 Long-term resident 0.57 0.00 0.10 0.20 0.30 0.40 0.50 0.60
Incidence of Cancer Among Immigrants US, NZ and Australia 0.27 Age-standardized Sub-Saharan Africa 0.24 incidence rates, per 1000 females, South Asia 0.14 colorectal cancer, 2004-2014 Middle East and North Africa 0.31 Latin America and the Caribbean 0.32 Europe and Central Asia 0.51 East Asia and Pacific 0.37 Long-term resident 0.57 0.00 0.10 0.20 0.30 0.40 0.50 0.60
Incidence of Cancer Among Immigrants US, NZ and Australia 0.34 Age-standardized Sub-Saharan Africa 0.41 incidence rates, per 1000 males, South Asia 0.18 colorectal cancer, 2004-2014 Middle East and North Africa 0.38 Latin America and the Caribbean 0.30 Europe and Central Asia 0.65 East Asia and Pacific 0.44 Long-term resident 0.72 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80
Incidence of Cancer Among Immigrants US, NZ and Australia 0.34 Age-standardized Sub-Saharan Africa 0.41 incidence rates, per 1000 males, South Asia 0.18 colorectal cancer, 2004-2014 Middle East and North Africa 0.38 Latin America and the Caribbean 0.30 Europe and Central Asia 0.65 East Asia and Pacific 0.44 Long-term resident 0.72 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80
Incidence of Cancer Among Immigrants Age- US, NZ and Australia 1.30 standardized incidence Sub-Saharan Africa 1.14 rates, per 1000 women, for South Asia 1.00 breast cancer, 2004-2014 Middle East and North Africa 1.49 Latin America and the Caribbean 1.09 Europe and Central Asia 1.35 East Asia and Pacific 1.07 Long-term resident 1.61 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80
Incidence of Cancer Among Immigrants Age- US, NZ and Australia 1.30 standardized incidence Sub-Saharan Africa 1.14 rates, per 1000 women, for South Asia 1.00 breast cancer, 2004-2014 Middle East and North Africa 1.49 Latin America and the Caribbean 1.09 Europe and Central Asia 1.35 East Asia and Pacific 1.07 Long-term resident 1.61 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80
Incidence of Cancer Among Immigrants • We are seeing a healthy immigrant effect • How does that change over time?
Incidence of Cancer Among Immigrants • Regression analysis among immigrants only • Controlled for age, income, and place of birth • The risk of colorectal and breast cancer increased for each additional 5 years that immigrants lived in Canada • Length of stay had the greatest effect on risk of breast cancer where risk increased 7% for each additional 5years in Canada (p<0.0001)
Stage at Diagnosis for Immigrants • Women diagnosed with cervical cancer in Ontario, 2010-2014 • 2508 women, 345 immigrants (13.7%) • Matched immigrants to non-immigrants based on age and census tract • 4:1 match = 1380 non-immigrant women retained
Stage at Diagnosis for Immigrants • 13.7% of women with cervical cancer foreign- born < ~25% of women in Ontario foreign-born
Stage at Diagnosis for Immigrants • 13.7% of women with cervical cancer foreign- born < ~25% of women in Ontario foreign-born Immigrant Long-term resident Stage I 34.2% 33.5% Stage I 12.4% 10.2% Stage III 9.8% 11.8% Stage IV 6.7% 7.7% No stage available 36.8% 36.7%
Stage at Diagnosis for Immigrants Region of Origin Early Stage Late Stage Africa 5.1% 1.0% Caribbean 7.6% 6.0% East Asia 39% 31% Hispanic America 9.3% 8.0% Middle East 4.2% 4.0% South Asia 4.2% 22.0% Western Europe/USA 30.5% 28.0%
Stage at Diagnosis for Immigrants Region of Origin Early Stage Late Stage Africa 5.1% 1.0% Caribbean 7.6% 6.0% East Asia 39% 31% Hispanic America 9.3% 8.0% Middle East 4.2% 4.0% South Asia 4.2% 22.0% Western Europe/USA 30.5% 28.0%
Stage of Diagnosis for Immigrants • CanIMPACT = Canadian Team to Improve Community-Based Cancer Care along the Continuum • A multi-province multi-method program of research aimed at improving integration and coordination of breast cancer care along the cancer care continuum
Stage of Diagnosis for Immigrants • 46,952 Ontario women diagnosed with breast cancer in 2007-2011 • 11.7% immigrants
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