Amanda J. Sheppard

Cancer survival among First Nations people of Ontario, Canada (1968-2007).

We aimed to compare cancer survival in Ontario First Nations people to that in other Ontarians for five major cancer types: colorectal, lung, cervix, breast and prostate. A list of registered or “Status” Indians in Ontario was used to create a cohort of over 140,000 Ontario First Nations people. Cancers diagnosed in cohort members between 1968 and 2001 were identified from the Ontario Cancer Registry, with follow‐up for death until December 31st, 2007. Flexible parametric modeling of the hazard function was used to compare the survival experience of the cohort to that of other Ontarians. We considered changes in survival from the first half of the time period (1968–1991) to the second half (1992–2001). For other Ontarians, survival had improved over time for every cancer site. For the First Nations cohort, survival improved only for breast and prostate cancers; it either declined or remained unchanged for the other cancers. For cancers diagnosed in 1992 or later, all‐cause and cause‐specific survival was significantly poorer for First Nations people diagnosed with breast, prostate, cervical, colorectal (male and female) and male lung cancers as compared to their non‐First Nations peers. For female lung cancer, First Nations women appeared to have poorer survival; however, the result was not statistically significant. Ontarios First Nations population experiences poorer cancer survival when compared to other Ontarians and strategies to reduce these inequalities must be developed and implemented.

Stage at Diagnosis and Comorbidity Influence Breast Cancer Survival in First Nations Women in Ontario, Canada

Background: Indigenous populations in Canada and abroad have poorer survival after a breast cancer diagnosis compared with their geographic counterparts; however, the influence of many demographic, personal, tumor, and treatment factors has not been examined to describe this disparity according to stage at diagnosis. Methods: A case–case design was employed to compare First Nations (FN) women (n = 287) to a frequency-matched random sample of non-FN women (n = 671) diagnosed with breast cancer within the Ontario Cancer Registry. Women were matched on period of diagnosis (1995–1999 and 2000–2004), age at diagnosis (<50 vs. ≥50), and Regional Cancer Centre (RCC). Stage and other factors were collected from medical charts at the RCCs. Survival was compared using an adjusted Cox proportional hazards model and stratified by stage at diagnosis (I, II, and III–IV). Determinants of survival in FN women stratified by stage at diagnosis were also modeled. Results: Survival was more than three times poorer for FN women diagnosed at stage I than for non-FN women (HR = 3.10, 95% CI = 1.39–6.88). The risk of death after a stage I breast cancer diagnosis was about five times higher among FN women with a comorbidity other than diabetes (HR = 4.65, 95% CI = 1.39–15.53) and was more than five times greater for women with diabetes (HR = 5.49, 95% CI = 1.69–17.90) than for those without a comorbidity. Conclusions: Having a preexisting comorbidity was the most important factor in explaining the observed survival disparity among FN women. Impact: Improving the general health status of FN women could increase their survival after an early-stage breast cancer diagnosis. Cancer Epidemiol Biomarkers Prev; 20(10); 2160–7. ©2011 AACR.

Favourable prognostic factors of subsequent screen-detected breast cancers among women aged 50-69.

Most studies reporting more favourable biological features of screen-detected breast cancers compared with symptomatic or interval cancers include initial or prevalent screens and therefore may not indicate the real benefit of screening on breast cancer mortality. We conducted case–case comparisons within a cohort of eligible women (N=771 715) who were aged 50–69 between 1 January 1995 and 31 December 2003. A randomly selected sample of breast cancers (N=1848) diagnosed among these women were compared by detection method. Tumour characteristics of interval cancers (N=362) diagnosed after 6–24 months of a negative screen or symptomatic breast cancers (N=491) were compared with subsequent screen-detected breast cancers diagnosed within 6 months of a positive screen (N=995) using polytomous logistic regression. Tumours were evaluated for clinical presentation, histology and expression of hormone receptors. Women with symptomatic detected [odds ratio (OR)=7.48, 95% confidence interval (CI)=5.38–10.38] and interval cancers (OR=2.20, 95% CI=1.56–3.10) were more often diagnosed at stage III–IV versus I than women with rescreen-detected cancers. After adjusting for tumour size, women with symptomatic cancers had tumours of higher grade (OR=1.50, 95% CI=1.05–2.15) and mitotic score (OR=1.69, 95% CI=1.15–2.49) and women with interval cancers had tumours of higher mitotic score (OR=1.52, 95% CI=1.01–2.28) compared with women diagnosed at screening. Subsequent screen-detected cancers are not only detected at an earlier stage but are also less aggressive, leading to a better prognosis. As long-term mortality reduction for breast screening may depend on subsequent screens, our study indicates that mammography screening can be effective in women aged 50–69.

Comparison of black-white disparities in preterm birth between Canada and the United States

Background: A higher risk of preterm birth among black women than among white women is well established in the United States. We compared differences in preterm birth between non-Hispanic black and white women in Canada and the US, hypothesizing that disparities would be less extreme in Canada given the different historical experiences of black populations and Canada’s universal health care system. Methods: Using data on singleton live births in Canada and the US for 2004–2006, we estimated crude and adjusted risk ratios and risk differences in preterm birth (< 37 wk) and very preterm birth (< 32 wk) among non-Hispanic black versus non-Hispanic white women in each country. Adjusted models for the US were standardized to the covariate distribution of the Canadian cohort. Results: In Canada, 8.9% and 5.9% of infants born to black and white mothers, respectively, were preterm; the corresponding figures in the US were 12.7% and 8.0%. Crude risk ratios for preterm birth among black women relative to white women were 1.49 (95% confidence interval [CI] 1.32 to 1.66) in Canada and 1.57 (95% CI 1.56 to 1.58) in the US (p value for heterogeneity [pH] = 0.3). The crude risk differences for preterm birth were 2.94 (95% CI 1.91 to 3.96) in Canada and 4.63 (95% CI 4.56 to 4.70) in the US (pH = 0.003). Adjusted risk ratios for preterm birth (pH = 0.1) were slightly higher in Canada than in the US, whereas adjusted risk differences were similar in both countries. Similar patterns were observed for racial disparities in very preterm birth. Interpretation: Relative disparities in preterm birth and very preterm birth between non-Hispanic black and white women were similar in magnitude in Canada and the US. Absolute disparities were smaller in Canada, which reflects a lower overall risk of preterm birth in Canada than in the US in both black and white populations.

A decade of research in Inuit children, youth, and maternal health in Canada: areas of concentrations and scarcities

Inuit Canadians are on average about 20 years younger and have a 10-year lower life expectancy than other Canadians. While there have been improvements in Inuit health status over time, significant health disparities still remain. This paper will review the peer-reviewed literature related to Inuit child, youth, and maternal health between 2000 and 2010, investigate which thematic areas were examined, and determine what proportion of the research is related to each group. Establishing areas of research concentrations and scarcities may help direct future research where it is needed. We followed a systematic literature review and employed peer-reviewed research literature on child, youth, and maternal health which were selected from 3 sources, MEDLINE, CINAHL, and the Circumpolar Health Bibliographic Database. The resulting references were read, and summarized according to population group and thematic area. The thematic areas that emerged by frequency were: infectious disease; environment/environmental exposures; nutrition; birth outcomes; tobacco; chronic disease; health care; policy, human resources; interventions/programming; social determinants of health; mental health and wellbeing; genetics; injury; and dental health. The 72 papers that met the inclusion criteria were not mutually exclusive with respect to group studied. Fifty-nine papers (82%) concerned child health, 24 papers (33%) youth health, and 58 papers (81%) maternal health. The review documented high incidences of illness and significant public health problems; however, in the context of these issues, opportunities to develop research that could directly enhance health outcomes are explored.Inuit Canadians are on average about 20 years younger and have a 10-year lower life expectancy than other Canadians. While there have been improvements in Inuit health status over time, significant health disparities still remain. This paper will review the peer-reviewed literature related to Inuit child, youth, and maternal health between 2000 and 2010, investigate which thematic areas were examined, and determine what proportion of the research is related to each group. Establishing areas of research concentrations and scarcities may help direct future research where it is needed. We followed a systematic literature review and employed peer-reviewed research literature on child, youth, and maternal health which were selected from 3 sources, MEDLINE, CINAHL, and the Circumpolar Health Bibliographic Database. The resulting references were read, and summarized according to population group and thematic area. The thematic areas that emerged by frequency were: infectious disease; environment/environmental exposures; nutrition; birth outcomes; tobacco; chronic disease; health care; policy, human resources; interventions/programming; social determinants of health; mental health and wellbeing; genetics; injury; and dental health. The 72 papers that met the inclusion criteria were not mutually exclusive with respect to group studied. Fifty-nine papers (82%) concerned child health, 24 papers (33%) youth health, and 58 papers (81%) maternal health. The review documented high incidences of illness and significant public health problems; however, in the context of these issues, opportunities to develop research that could directly enhance health outcomes are explored.Inuit Canadians are on average about 20 years younger and have a 10-year lower life expectancy than other Canadians. While there have been improvements in Inuit health status over time, significant health disparities still remain. This paper will review the peer-reviewed literature related to Inuit child, youth, and maternal health between 2000 and 2010, investigate which thematic areas were examined, and determine what proportion of the research is related to each group. Establishing areas of research concentrations and scarcities may help direct future research where it is needed. We followed a systematic literature review and employed peer-reviewed research literature on child, youth, and maternal health which were selected from 3 sources, MEDLINE, CINAHL, and the Circumpolar Health Bibliographic Database. The resulting references were read, and summarized according to population group and thematic area. The thematic areas that emerged by frequency were: infectious disease; environment/environmental exposures; nutrition; birth outcomes; tobacco; chronic disease; health care; policy, human resources; interventions/programming; social determinants of health; mental health and wellbeing; genetics; injury; and dental health. The 72 papers that met the inclusion criteria were not mutually exclusive with respect to group studied. Fifty-nine papers (82%) concerned child health, 24 papers (33%) youth health, and 58 papers (81%) maternal health. The review documented high incidences of illness and significant public health problems; however, in the context of these issues, opportunities to develop research that could directly enhance health outcomes are explored.

Are residents of downtown Toronto influenced by their urban neighbourhoods? Using concept mapping to examine neighbourhood characteristics and their perceived impact on self-rated mental well-being

BackgroundThere is ample evidence that residential neighbourhoods can influence mental well-being (MWB), with most studies relying on census or similar data to characterize communities. Few studies have actively investigated local residents’ perceptions.MethodsConcept mapping was conducted with residents from five Toronto neighbourhoods representing low income and non-low income socio-economic groups. These residents participated in small groups and attended two sessions per neighbourhood. The first session (brainstorming) generated neighbourhood characteristics that residents felt influenced their MWB. A few weeks later, participants returned to sort these neighbourhood characteristics and rate their relative importance in affecting residents’ ‘good’ and ‘poor’ MWB. The data from the sorting and rating groups were analyzed to generate conceptual maps of neighbourhood characteristics that influence MWB.ResultsWhile agreement existed on factors influencing poor MWB (regardless of neighbourhood, income, gender and age), perceptions related to factors affecting good MWB were more varied. For example, women were more likely to rank physical beauty of their neighbourhood and range of services available as more important to good MWB, while men were more likely to cite free access to computers/internet and neighbourhood reputation as important. Low-income residents emphasized aesthetic attributes and public transportation as important to good MWB, while non-low-income residents rated crime, negative neighbourhood environment and social concerns as more important contributors to good MWB.ConclusionThese findings contribute to the emerging literature on neighbourhoods and MWB, and inform urban planning in a Canadian context.

Paternal education and adverse birth outcomes in Canada

Background Research on predictors of adverse birth outcomes has focused on maternal characteristics. Much less is known about the role of paternal factors. Paternal education is an important socioeconomic marker that may predict birth outcomes over and above maternal socioeconomic indicators. Methods Using data from the 2006 Canadian Birth-Census Cohort, we estimated the associations between paternal education and preterm birth, small-for-gestational-age (SGA) birth, stillbirth and infant mortality in Canada, controlling for maternal characteristics. Binomial regression was used to estimate risk ratios and risk differences for adverse birth outcomes associated with paternal education, after controlling for maternal education, age, marital status, parity, ethnicity and nativity. Results A total of 131 285 singleton births were included in the present study. Comparing the lowest to the highest paternal education category, adjusted risk ratios (95% CIs) were 1.22 (1.10 to 1.35) for preterm birth, 1.13 (1.03 to 1.23) for SGA birth, 1.92 (1.28 to 2.86) for stillbirth and 1.67 (1.01 to 2.75) for infant mortality. Consistent patterns of associations were observed for absolute risk differences. Conclusions Our study suggests that low paternal education increases the risk of adverse birth outcomes, and especially of fetal and infant mortality, independently from maternal characteristics.

Adverse birth outcomes and infant mortality according to registered First Nations status and First Nations community residence across Canada

ObjectiveStudies of perinatal health outcomes in Canadian First Nations populations have largely focused on limited geographical areas and have been unable to examine outcomes by registered status and community residence. In this study, we compare rates of adverse birth outcomes among First Nations individuals living within vs. outside of First Nations communities and those with vs. without registered status.MethodsData included 13,506 singleton pregnancies from the 2006 Canadian Birth-Census Cohort. Outcomes examined included preterm birth (PTB), small- and large-for-gestational-age birth (SGA, LGA), stillbirth, overall infant mortality, and neonatal and postneonatal mortality. Risk ratios (RRs) were estimated with adjustment for maternal age, education, parity, and paternal education.ResultsMothers living in First Nations communities and those with status had elevated adjusted risks of LGA (RR for First Nations community residence = 1.22, 95% CI = 1.09–1.35; RR for status = 1.50, 95% CI = 1.16–1.93). Rates of SGA were significantly lower among mothers with status (adjusted RR = 0.62, 95% CI = 0.44–0.86). Rates of PTB did not vary substantially by residence or by status. Adjusted differences in fatal outcomes could not be estimated, owing to small cell sizes. However, mothers living in First Nations communities had higher crude rates of infant mortality (10.9 vs. 7.7 per 1000), particularly for neonatal mortality (6.1 vs. 2.9).ConclusionFuture investigations should explore risk factors, including food security and access to health care services, that may explain disparities in SGA and LGA by status and residence within First Nations populations.RésuméObjectifLes études examinant les issues de santé périnatale des populations canadiennes des Premières Nations examinent, pour la plupart d’entre elles, des étendues géographiques limitées. De plus, ces études n’ont pas pu examiner les issues de santé périnatale selon la statut (statut d’Indien inscrit), ni selon la résidence dans les communautés des Premières Nations. Dans cette étude, notre objectif est d’examiner la prévalence des diverses issues néonatales selon la résidence dans une communauté des Premières Nations ainsi que selon le statut.Méthodes13 506 grossesses simples de la cohorte canadienne de naissance du Recensement de 2006 ont été examinées. Les complications néonatales étudiées comprenaient la naissance prématurée, le nouveau-né avec un petit ou un grand poids pour l’âge gestationnel (PAG, GAG), la mortinaissance, la mortalité infantile totale ainsi que la mortalité néonatale et post-néonatale. Les données ont été examinées selon la résidence dans une communauté des Premières Nations ou non et selon l’obtention ou non de statut. Les risques relatifs (RR) ont été estimés avec l’ajustement pour l’âge maternel, le niveau de scolarité de la mère, la parité et le niveau de scolarité du père.RésultatsLes mères habitant dans une communauté des Premières Nations ainsi que celles qui avaient de statut avaient un risque ajusté élevé de nouveau-né GAG (RR pour la résidence dans une communauté des Premières Nations = 1,22, IC de 95 % : 1,09, 1,35; RR pour le statut = 1,50, IC de 95 % : 1,16, 1,93). La prévalence de nouveau-nés PAG était significativement plus basse chez les mères ayant du statut (RR ajusté = 0,62, IC de 95 % : 0,44, 0,86) comparativement à celles n’ayant pas de statut. La prévalence des naissances prématurées n’a pas significativement varié selon la résidence, ni selon le statut. Les différences ajustées pour les issues fatales n’ont pas pu être estimées en raison de la taille de l’échantillon. Cependant, les mères qui habitaient dans une communauté des Premières Nations avaient un taux brut de mortalité infantile plus élevé (10,9 par 1 000, c. 7,7 par 1000), particulièrement pour la mortalité néonatale (6,1 c. 2,9), comparativement à celles n’habitant pas dans une communauté des Premières Nations.ConclusionDe futures études sont nécessaires afin d’examiner les facteurs, tel que la sécurité alimentaire et l’accès aux services de santé, pouvant expliquer les différences de prévalence de nouveau-nés PAG et GAG selon le statut et la résidence au sein des populations des Premières Nations.

New President of the International Arctic Science Committee

A stage I breast cancer diagnosis was morethan five times higher among FN womenwith a comorbidity at diagnosis (HR=5.39,95% CI=1.94-14.96). These findings areactionable and can be used to improve theprognosis of FN women with breast cancer.It is likely that the same or similar factorsare largely responsible for the survivaldisadvantage observed among Ontario FNpeople for most other major cancers. Keywords: breast cancer, indigenous, diagnosis,survival, First Nations