If there’s one thing the pandemic has made clear, it’s that there are serious inequities in many facets of society, not least of all in health care. “There are a lot of disparities in health care, and cancer care is no different,” says Dr. Craig Earle, CEO of the Canadian Partnership Against Cancer (CPAC). “We need to increase equitable access and close gaps in who gets care. But gaps aren’t just in care; they’re also in the results of treatment.”
The pandemic caused a number of negative effects specific to cancer care. Many screening programs for breast, cervical and colorectal cancer were paused in the first wave, resulting in missed opportunities to diagnose cancer early, when it is highly treatable. “Delaying diagnosis and treatment can lead to worse outcomes,” says Earle. “And all of these effects are magnified for patients who are underserved, who have been the hardest hit by the pandemic. If you can’t take time off work or don’t have the means to travel to see a doctor, this greatly affects your health care.”
In 2020, CPAC modelling projected that a six-month interruption in screening could result in an additional 400 individuals dying from breast cancer and 770 individuals dying from colorectal cancer. The cancellation of cancer surgeries because of COVID-19, pandemic restrictions limiting access to doctors’ offices and emergency departments, and patient hesitancy because of fear of COVID-19 exposure all add to the delay in diagnoses and treatment of cancer.
All of these disruptions in service and COVID-19 restrictions add to longstanding inequities in access to screening and cancer care. Populations frequently underserved by the cancer system – Indigenous peoples, people with lower incomes, new immigrants, 2SLGBTQ+ and people living in rural and remote areas – continue to be disproportionately affected.
That’s why it is critical to take an equity-first approach to cancer care and outcomes. Groups that are underserved tend to experience more barriers in accessing health services, particularly culturally appropriate services. Racism, cost and location can also be barriers to spaces such as gyms, recreational facilities and green spaces that support good health. “While we have witnessed overall improvements in cancer care, experience and outcomes, not all people are benefiting equally from these advances,” says Earle.
To collectively achieve equitable access, experience and outcomes, and eliminate barriers to high-quality, culturally safe care for all, there needs to be a focus on systemically excluded communities and the barriers they face.
CPAC is committed to taking action to provide access to quality cancer care for all people in Canada. “We need to put equity considerations first in the design of programs,” says Earle, who points to how new health programs are often initiated in urban centres to serve more people, but this often further heightens disparities.
There are many barriers to care – our history of trauma from colonization, not feeling welcome in medical settings, racism in health care, to name a few. Working with our partners like CPAC and Nova Scotia Health and our communities to build meaningful relationships ensures that we facilitate cancer care and prevention that reflect Mi’kmaw values. This will contribute to long-term, sustainable Mi’kmaq wellness, vitality and survivorship.— Kara Paul, Director of the health branch, Union of Nova Scotia Mi’kmaq
“If you look at when new diagnostic imaging technologies were introduced, high-income and more advantaged people tended to access them first,” he explains. “This often resulted in widening the disparities in access and disadvantaging those with the greatest need or who are most vulnerable.”
That’s why CPAC recommends taking steps to achieve equity when bringing in new health-care services by working with and building partnerships with groups that represent and work with underserved groups. ”We work with all the provinces and territories to develop and learn from different models of care,” says Earle. “We support those in the jurisdictions and health authorities in forming new partnerships and moving things forward.”
Partnerships in action
One example is the implementation of organized lung cancer screening programs for those at high risk – a key priority of the 2019-2029 Canadian Strategy for Cancer Control. CPAC is providing an initial $5-million to accelerate the development of these programs in various communities. CPAC’s recent report on lung cancer and equity found alarming differences in access to lung cancer care – as well as outcomes – among some populations. For example, people with lower income are nearly twice as likely to be diagnosed with lung cancer as those with higher income and are less likely to survive.
“We’re supporting partners to plan and develop lung cancer screening programs for those at high risk, such as First Nations, Inuit and Métis communities and underserved communities, where there are high smoking and lung cancer rates,” says Earle. “This may not be the easiest way to set up a program, but we’re trying to set it up so the people who are most at risk have easiest access.”
The Saskatchewan Cancer Agency (SCA) is working with First Nation and Métis stakeholders to understand how cancer affects their communities and how services can be made relevant and accessible. “For screening programs to be effective and accessible, we need to work alongside community leaders, patients and families,” says Kevin Wilson, vice-president, population health, quality and research. “How we build trust while delivering a plan with those who are experts in their own experience will fundamentally affect our success in reaching those who would benefit most from screening and prevention efforts.”
Similarly, the Mi’kmaw Cancer Care Strategy takes a community approach to increasing knowledge with the 13 Mi’kmaw communities in Nova Scotia through the Union of Nova Scotia Mi’kmaq. “Our team goes into communities to teach cancer 101, including cancer care and screening, but it also gives us a chance to really learn about the communities’ needs,” says Kara Paul, director of the health branch for the union. “That is what informs the work we do. It’s really a two-way learning relationship.
“In our communities, many people look at cancer as a death sentence,” says Paul. “We are hoping to change that perception and that reality, and move cancer to a chronic disease. That requires a systematic view shift and investments from partners to ensure that work is being done on the ground.”
Paul points to the many factors that have affected Indigenous peoples’ access to health care. “There are many barriers to care – our history of trauma from colonization, not feeling welcome in medical settings, racism in health care, to name a few. Working with our partners like CPAC and Nova Scotia Health and our communities to build meaningful relationships ensures that we facilitate cancer care and prevention that reflect Mi’kmaw values. This will contribute to long-term, sustainable Mi’kmaq wellness, vitality and survivorship.”
Closing care gaps
The goal of these collective efforts is to change the course of cancer for all people living in Canada. “By setting up from the very start to achieve equity, we see new types of outcomes,” says Earle. “It’s not just about how many patients take part but which patients. We need to evaluate using different metrics to understand how we are closing these care gaps. That also means capturing data that wasn’t typically collected, such as race, gender and income. The need for this kind of focused effort has never been greater.”
For more information, visit partnershipagainstcancer.ca.
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