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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?

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SLIDE 1

Cancer Screening and Diagnosis for Immigrant Canadians: Disparities and Potential Solutions

Aisha K. Lofters MD PhD CCFP

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SLIDE 2

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?
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SLIDE 3

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

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SLIDE 4
  • Who are the people not being screened?
  • How can we use data to answer this question?
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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

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SLIDE 6

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?
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SLIDE 7

Who Isn’t Being Screened?

Younger women

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SLIDE 8

Who Isn’t Being Screened?

Younger women

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SLIDE 9

Who Isn’t Being Screened?

Younger women

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SLIDE 10

Who Isn’t Being Screened?

Older women

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SLIDE 11

Who Isn’t Being Screened?

Older women

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SLIDE 12

Who Isn’t Being Screened?

  • Did you notice the income gradient?
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Who Isn’t Being Screened?

Younger women

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Who Isn’t Being Screened?

Older women

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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%

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Who Isn’t Being Screened for Breast Cancer?

1.4 million women

  • 2010-2012
  • Who had at least one mammogram?
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Who Isn’t Being Screened?

10 20 30 40 50 60 70 80 90 100 Caribbean and Latin America East Asia and Pacific Eastern Europe and Central Asia Middle East and North Africa South Asia Sub-Saharan Africa US, Australia and New Zealand Western Europe Long-term residents

Mammography

% up-to-date

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SLIDE 18

Who Isn’t Being Screened?

10 20 30 40 50 60 70 80 90 100 Caribbean and Latin America East Asia and Pacific Eastern Europe and Central Asia Middle East and North Africa South Asia Sub-Saharan Africa US, Australia and New Zealand Western Europe Long-term residents

Mammography

% up-to-date

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SLIDE 19

Who Isn’t Being Screened for Colorectal Cancer?

  • 182K immigrants aged 60-74
  • 2005-2015
  • Who was overdue for colorectal cancer

screening?

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SLIDE 20

Who Isn’t Being Screened?

  • 182K immigrants aged 60-74
  • 2005-2015
  • Who was overdue for colorectal cancer

screening?

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SLIDE 21

Who Isn’t Being Screened?

% overdue for CRC screening

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SLIDE 22

Who Isn’t Being Screened?

% overdue for CRC screening

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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
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Let’s Go A Little Deeper…

10 20 30 40 50 60 70 East Asia & Pacific Eastern Europe & Central Asia Middle East & North Africa South Asia Sub-Saharan Africa Muslim majority Non-Nuslim majority

% overdue for screening

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SLIDE 25

Let’s Go A Little Deeper…

10 20 30 40 50 60 70 East Asia & Pacific Eastern Europe & Central Asia Middle East & North Africa South Asia Sub-Saharan Africa Muslim majority Non-Nuslim majority

% overdue for screening

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SLIDE 26

Let’s Go A Little Deeper…

10 20 30 40 50 60 70 East Asia & Pacific Eastern Europe & Central Asia Middle East & North Africa South Asia Sub-Saharan Africa Muslim majority Non-Nuslim majority

% overdue for screening

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SLIDE 27

Let’s Go A Little Deeper…

10 20 30 40 50 60 70 East Asia & Pacific Eastern Europe & Central Asia Middle East & North Africa South Asia Sub-Saharan Africa Muslim majority Non-Nuslim majority

% overdue for screening

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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

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SLIDE 29
  • But what if immigrants (including South Asian

immigrants) are less at risk of cancer?

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Incidence of Cancer Among Immigrants

0.57 0.37 0.51 0.32 0.31 0.14 0.24 0.27 0.00 0.10 0.20 0.30 0.40 0.50 0.60 Long-term resident East Asia and Pacific Europe and Central Asia Latin America and the Caribbean Middle East and North Africa South Asia Sub-Saharan Africa US, NZ and Australia

Age-standardized incidence rates, per 1000 females, colorectal cancer, 2004-2014

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Incidence of Cancer Among Immigrants

0.57 0.37 0.51 0.32 0.31 0.14 0.24 0.27 0.00 0.10 0.20 0.30 0.40 0.50 0.60 Long-term resident East Asia and Pacific Europe and Central Asia Latin America and the Caribbean Middle East and North Africa South Asia Sub-Saharan Africa US, NZ and Australia

Age-standardized incidence rates, per 1000 females, colorectal cancer, 2004-2014

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Incidence of Cancer Among Immigrants

0.72 0.44 0.65 0.30 0.38 0.18 0.41 0.34 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 Long-term resident East Asia and Pacific Europe and Central Asia Latin America and the Caribbean Middle East and North Africa South Asia Sub-Saharan Africa US, NZ and Australia

Age-standardized incidence rates, per 1000 males, colorectal cancer, 2004-2014

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Incidence of Cancer Among Immigrants

0.72 0.44 0.65 0.30 0.38 0.18 0.41 0.34 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 Long-term resident East Asia and Pacific Europe and Central Asia Latin America and the Caribbean Middle East and North Africa South Asia Sub-Saharan Africa US, NZ and Australia

Age-standardized incidence rates, per 1000 males, colorectal cancer, 2004-2014

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Incidence of Cancer Among Immigrants

1.61 1.07 1.35 1.09 1.49 1.00 1.14 1.30 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 Long-term resident East Asia and Pacific Europe and Central Asia Latin America and the Caribbean Middle East and North Africa South Asia Sub-Saharan Africa US, NZ and Australia

Age- standardized incidence rates, per 1000 women, for breast cancer, 2004-2014

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Incidence of Cancer Among Immigrants

1.61 1.07 1.35 1.09 1.49 1.00 1.14 1.30 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 Long-term resident East Asia and Pacific Europe and Central Asia Latin America and the Caribbean Middle East and North Africa South Asia Sub-Saharan Africa US, NZ and Australia

Age- standardized incidence rates, per 1000 women, for breast cancer, 2004-2014

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Incidence of Cancer Among Immigrants

  • We are seeing a healthy immigrant effect
  • How does that change over time?
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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)

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SLIDE 38

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
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SLIDE 39

Stage at Diagnosis for Immigrants

  • 13.7% of women with cervical cancer foreign-

born < ~25% of women in Ontario foreign-born

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SLIDE 40

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%

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SLIDE 41

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%

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SLIDE 42

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%

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SLIDE 43

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

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SLIDE 44

Stage of Diagnosis for Immigrants

  • 46,952 Ontario women diagnosed with breast

cancer in 2007-2011

  • 11.7% immigrants
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Stage of Diagnosis for Immigrants

Adjusted relative risk East Asia & Pacific 1.05 Eastern Europe & Central Asia 0.94 Latin America & Caribbean 0.93 Middle East & North Africa 1.01 South Asia 0.93 Sub-Saharan Africa 0.99 US/New Zealand/Australia 0.98 Western Europe 1.01 Long-term residents (reference) 1.0 Risk of early versus late stage breast cancer

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SLIDE 46

Screen-Detected Breast Cancers

Adjusted relative risk East Asia & Pacific 0.86 Eastern Europe & Central Asia 0.89 Latin America & Caribbean 0.80 Middle East & North Africa 1.00 South Asia 0.80 Sub-Saharan Africa 0.94 US/New Zealand/Australia 1.00 Western Europe 1.09 Long-term residents (reference) 1.0 Risk of screen- detected versus symptom- detected breast cancer

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SLIDE 47

Let’s Review…

  • Immigrant Canadians have lower incidence of

cancer than Canadian-born BUT diminishes with time

  • Variation in cancer incidence for different

immigrant groups

  • Variation in stage of diagnosis for different

immigrant groups

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SLIDE 48

Let’s Review…

  • Eastern Europeans = lowest CRC screening,

highest CRC incidence among immigrants

  • South Asian women = lowest cervical cancer

screening, later stage of cancer diagnosis

  • South Asian women = lowest breast cancer

screening, less screen-detected; even though low incidence, later stage at diagnosis

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SLIDE 49

Let’s Review…

  • Women from Latin America & Caribbean = high

breast cancer screening rates, but still more likely to be symptom-detected, later stage of diagnosis

  • Women from East Asia & Pacific = less likely to

be screen-detected but earlier stage of diagnosis

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SLIDE 50
  • Can we start talking about what we DO about

all of this?

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Solutions Barriers

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Barriers to Cancer Screening – Concept Mapping

  • 1. Brainstorm responses to a focal question
  • 2. Sort the responses into conceptually similar

groups

  • 3. Rate the responses using specific questions
  • 4. Analyze the data collected
  • 5. Verify and refine the summary of the analysis

with the community

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Barriers to Cancer Screening – Concept Mapping with South Asian community

  • Patients’ beliefs, fears, and lack of social support
  • Limited knowledge among patients
  • Cost
  • Ethno-cultural discordance with the health system
  • Limited knowledge among health care providers
  • Materials and delivery of education programs
  • Health system
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Levels of Barriers

  • Individual-Level
  • Patients’ beliefs, fears, and lack of social support
  • Limited knowledge among patients
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Levels of Solutions – Individual Level

  • Targeted and tailored education campaigns
  • Increase supports for screening e.g. patient

navigation

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Levels of Solutions – Individual Level

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Levels of Solutions – Individual Level

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SLIDE 58

Levels of Solutions – Individual Level

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SLIDE 59

Levels of Solutions – Individual Level

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Levels of Solutions – Individual Level

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Levels of Barriers

  • Provider-Level
  • Ethno-cultural discordance with the health system
  • Limited knowledge among health care providers
  • Materials and delivery of education programs
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SLIDE 62

Levels of Solutions – Provider Level

  • Changing how providers reach out to patients

about cancer screening

  • Taking ethnicity and culture of patients into

account

  • Providing tailored materials
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SLIDE 63

Levels of Solutions – Provider Level

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SLIDE 64

Levels of Solutions – Provider Level

Phone calls Materials in waiting room 1:1 conversations

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Levels of Barriers

  • System/Policy-Level
  • Cost
  • Ethno-cultural discordance with the health system
  • Materials and delivery of education programs
  • Health system
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Levels of Solutions – System/Policy Level

  • Making screening more accessible in creative

ways

  • Tailored materials and approaches
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Levels of Solutions – System/Policy Level

Group mammograms

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SLIDE 68

Levels of Solutions – System/Policy Level

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Levels of Solutions – System/Policy Level

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Levels of Solutions – System/Policy Level

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SLIDE 71

A Word on Privilege…

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Barriers to Cancer Screening

  • Patients’ beliefs, fears, and lack of social support
  • Limited knowledge among patients
  • Cost
  • Ethno-cultural discordance with the health system
  • Limited knowledge among health care providers
  • Materials and delivery of education programs
  • Health system
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SLIDE 73

Facilitators of Cancer Screening

  • Patients’ beliefs, fears, and lack of social support
  • Limited knowledge among patients
  • Cost
  • Ethno-cultural discordance with the health system
  • Limited knowledge among health care providers
  • Materials and delivery of education programs
  • Health system
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SLIDE 74

Facilitators of Cancer Screening

  • Social networks normalize screening
  • Limited knowledge among patients
  • Cost
  • Ethno-cultural discordance with the health system
  • Limited knowledge among health care providers
  • Materials and delivery of education programs
  • Health system
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SLIDE 75

Facilitators of Cancer Screening

  • Social networks normalize screening
  • Knowing about screening tests
  • Cost
  • Ethno-cultural discordance with the health system
  • Limited knowledge among health care providers
  • Materials and delivery of education programs
  • Health system
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SLIDE 76

Facilitators of Cancer Screening

  • Social networks normalize screening
  • Knowing about screening tests
  • Being able to afford transportation, childcare, time off,

etc.

  • Ethno-cultural discordance with the health system
  • Limited knowledge among health care providers
  • Materials and delivery of education programs
  • Health system
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SLIDE 77

Facilitators of Cancer Screening

  • Social networks normalize screening
  • Knowing about screening tests
  • Being able to afford transportation, childcare, time off,

etc.

  • Ethno-cultural concordance with the health system
  • Limited knowledge among health care providers
  • Materials and delivery of education programs
  • Health system
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SLIDE 78

Facilitators of Cancer Screening

  • Social networks normalize screening
  • Knowing about screening tests
  • Being able to afford transportation, childcare, time off,

etc.

  • Ethno-cultural concordance with the health system
  • Having health care providers that offer screening
  • Materials and delivery of education programs
  • Health system
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SLIDE 79

Facilitators of Cancer Screening

  • Social networks normalize screening
  • Knowing about screening tests
  • Being able to afford transportation, childcare, time off,

etc.

  • Ethno-cultural concordance with the health system
  • Having health care providers that offer screening
  • Education programs are targeted to you
  • Health system
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SLIDE 80

Facilitators of Cancer Screening

  • Social networks normalize screening
  • Knowing about screening tests
  • Being able to afford transportation, childcare, time off,

etc.

  • Ethno-cultural concordance with the health system
  • Having health care providers that offer screening
  • Education programs are targeted to you
  • Health system is targeted to you
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SLIDE 81

Key Take-Home Messages

  • Disparities in cancer screening and diagnosis

for immigrant Canadians

  • Different factors can interact and be synergistic

to affect those disparities

  • Incredible amount of diversity within our

immigrant communities

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SLIDE 82

Key Take-Home Messages

  • Solutions need to align to barriers to screening

& diagnosis in order to be meaningful

  • Solutions need to be multi-faceted and multi-

level

  • We need sustainable and sustained solutions!
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SLIDE 83

Key Take-Home Messages

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SLIDE 84

Acknowledgements

  • Health Equity Research Collaborative
  • CanIMPACT Study Team
  • Institute for Clinical Evaluative Sciences
  • Li Ka Shing Knowledge Institute
  • University of Toronto Department of Family &

Community Medicine

  • Trainees: Cindy Shen, Jennifer Shuldiner
  • All co-authors
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SLIDE 85

References

  • http://www.csqi.on.ca/by_patient_journey/screening/cervical_screening_participation/
  • Lofters A, Hwang S, Moineddin R, Glazier RH. Cervical cancer screening among urban

immigrants by region of origin: a population-based cohort study. Prev Med. 2010; 51(6): 509- 16.

  • Lofters AK, Vahabi M, Kim E, Ellison L, Graves E, Glazier RH. Cervical cancer screening

among women from Muslim-majority countries in Ontario, Canada. Cancer Epidemiol Biomarkers Prev. Sep 2017. https://doi.org/10.1158/1055-9965.EPI-17-0323.

  • Vahabi M, Lofters A, Kim E, Wong JP, Ellison L, Graves E, Glazier RH. Breast cancer

screening utilization among women from Muslim majority countries in Ontario, Canada. Prev

  • Med. Sep 2017. https://doi.org/10.1016/j.ypmed.2017.09.008.
  • Lofters AK, Vahabi M, Prakash V, Banerjee L, Bansal P, Goel S, Dunn S. Lay health educators

within primary care practices to improve cancer screening uptake for South Asian patients: Challenges in Quality improvement. Patient Prefer Adherence. 2017; 11: 495-503.

  • Dunn SF, Lofters AK, Ginsburg OM, Meaney CA, Ahmad F, Moravac MC, Nguyen CTJ, Arisz
  • AM. Cervical and breast cancer screening after CARES: A community program for immigrant

and marginalized women. Am J Prev Med. 13 Jan 2017. DOI: 10.1016/j.amepre.2016.11.023.

  • Lofters A, Moineddin R, Hwang SW, Glazier RH. Low rates of cervical cancer screening

among urban immigrants: a population-based study in Ontario, Canada. Med Care. 2010; 48(7): 611-

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SLIDE 86

References

  • Voruganti RT, Moineddin R, Jembere N, Elit L, Grunfeld E, Lofters AK. Comparing cervical

cancer stage of diagnosis at presentation in immigrant women and long-term residents: a retrospective cohort study. CMAJ Open August 12, 2016; 4 (3): E424-E430.

  • Vahabi M, Lofters A, Kumar M, Glazier R. Breast cancer screening disparities among

immigrant women by world region of origin: A population-based study in Ontario, Canada. Cancer Med 2016 Apr. DOI: 10.1002/cam4.700.

  • Vahabi M, Lofters AK, Kumar M, Glazier RH. Breast cancer screening disparities among urban

immigrants: A population-based study in Ontario, Canada. BMC Public Health 2015; 15:679. DOI 10.1186/s12889-015-2050-5.

  • Lobb R, Pinto A, Lofters A. Using concept mapping in the knowledge-to-action process to

compare stakeholder opinions on barriers to use of cancer screening among South Asians. Implementation Science 2013; 8:37.

  • Lofters A, Moineddin R, Hwang SW, Glazier RH. Predictors of low cervical cancer screening

among immigrant women in Ontario, Canada. BMC Women's Health. 2011; 11: 20 (27 May 2011).

  • Lofters A, Shankardass K, Kirst M, Quinonez C. Sociodemographic data collection in Ontario

healthcare settings: An examination of public opinions. Med Care. 2011 Feb; 49(2): 193-9.

  • Lofters A, Hwang S, Moineddin R, Glazier RH. Cervical cancer screening among urban

immigrants by region of origin: a population-based cohort study. Prev Med. 2010; 51(6): 509- 16.