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    Epidemiological studies of cervical cancer survival in New Zealand : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Epidemiology at Massey University, Wellington Campus, New Zealand
    (Massey University, 2011) Brewer, Naomi
    In this thesis I describe a series of studies of the stage at diagnosis and subsequent survival of women registered with cervical cancer in New Zealand during the period 1994 to 2005, and the factors that may contribute to the demographic differences that were found in both stage at diagnosis and survival. The studies involved all of the cervical cancer cases registered on the New Zealand Cancer Registry between 1994 and 2005. The cases were linked to the National Mortality Collection (for mortality data), the National Cervical Screening Programme- Register (for screening history), and the hospital events on the National Minimum Dataset (for information on comorbid conditions). The studies assessed what proportions of the ethnic differences in late stage diagnosis (after adjustment for socioeconomic position) were due to various factors such as screening history and urban/rural residency, and what proportions of the ethnic differences in survival (after adjustment for socio-economic position) were due to various factors including stage at diagnosis, comorbid conditions, and travel time and distance to the nearest General Practitioner and cancer centre. Māori and Pacific women had a higher risk of late stage diagnosis compared with ‘Other’ (predominantly European) women. Screening history did not entirely explain the increased risk in Māori women, but did explain that in Pacific women. More than half of the women with cervical cancer had not been screened, while those that had been ‘regularly’ screened had a considerably lower risk of a late stage diagnosis. Stage at diagnosis accounted for some but not all of the ethnic differences in survival. Comorbidity explained a moderate proportion of the ethnic differences in survival, while travel time may account for a small proportion of the ethnic differences in stage at diagnosis, and to a lesser extent mortality, particularly for Pacific women. The higher risk of late stage diagnosis in Māori women remains largely unexplained, whereas in Pacific women it is almost entirely due to differences in screening history and travel time. More than one-half of the higher risk of mortality in Māori and Pacific women is explained by differences in stage at diagnosis and comorbid conditions.
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    Survival disparities in indigenous and non-indigenous New Zealanders with colon cancer: The role of patient comorbidity, treatment and health service factors
    (BMJ Publishing Group Ltd, 2010) Hill S; Sarfati D; Blakely T; Robson B; Purdie G; Chen J; Dennett E; Cormack D; Cunningham R; Dew K; McCreanor T; Kawachi I
    Background Ethnic disparities in cancer survival have been documented in many populations and cancer types. The causes of these inequalities are not well understood but may include disease and patient characteristics, treatment differences and health service factors. Survival was compared in a cohort of Maori (Indigenous) and non-Maori New Zealanders with colon cancer, and the contribution of demographics, disease characteristics, patient comorbidity, treatment and healthcare factors to survival disparities was assessed. Methods Maori patients diagnosed as having colon cancer between 1996 and 2003 were identified from the New Zealand Cancer Registry and compared with a randomly selected sample of non-Maori patients. Clinical and outcome data were obtained from medical records, pathology reports and the national mortality database. Cancer-specific survival was examined using Kaplan�Meier survival curves and Cox hazards modelling with multivariable adjustment. Results 301 Maori and 328 non-Maori patients with colon cancer were compared. Maori had a significantly poorer cancer survival than non-Maori (hazard ratio (HR)=1.33, 95% CI 1.03 to 1.71) that was not explained by demographic or disease characteristics. The most important factors contributing to poorer survival in Maori were patient comorbidity and markers of healthcare access, each of which accounted for around a third of the survival disparity. The final model accounted for almost all the survival disparity between Maori and non-Maori patients (HR=1.07, 95% CI 0.77 to 1.47).