Health equity and Māori cancer care

Cancer is the leading cause of death in Aotearoa / New Zealand. The number of those affected by cancer is forecast to increase by 50% in the next 15 years, primarily driven by a growing and ageing population. Our survival rates from cancer lag behind those of Australia, Canada and Scandinavian countries, and are not improving at the same rate as elsewhere. Even more telling is that our outcomes for cancer vary within New Zealand.

Our Indigenous and most marginalised fare worse, with Māori and Pacific people having higher rates of preventable cancers, worse survival and higher death rates than other New Zealanders.

Increasingly, regional variations in care and outcome are being reported. At the same time, the costs of cancer care are escalating beyond our capacity to afford them. Drivers include the rising number of people with cancer, increasing age and comorbidity of patients, technology and new drugs, increasing specialisation, and increasing awareness of and demand for supportive care. The pace of change in cancer management, particularly new drugs and technology, presents major challenges for our systems and services.

The management of cancer is uniquely complex, impacting on every aspect of our healthcare services, and so any solution must have a whole-of-system focus. Of course, many of the challenges we must face in relation to cancer care and control are not unique to us in New Zealand, and there is much to be learned by looking abroad (D Sarfati et al., 2019)

In this series of presentations, cancer leaders, clinicians, researchers and Māori health experts discuss a range of issues that will help inform and guide your interactions with Māori families and whānau.

The Central Cancer Network (CCN) leads the Regional Cancer Work Program across 7 District Health Boards (Midcentral, Capital and Coast, Hutt Valley, Wairarapa, Whanganui, Hawkes Bay and Taranaki) aiming to reduce the incidence, impact and inequities in Cancer across the continuum of care and enabler areas from prevention to palliation. In the Central Region Māori are 20% more likely to get cancer and twice as likely to die from it. CCN is committed to working together with Māori to improve cancer outcomes, and to help achieve this completed a Regional Cancer Deep Dive during 2019-2020 in partnership with a wide range of stakeholders that included the following activities:

• 7 Māori Cancer Community Hui (Aug-Oct 2019)
• 4 Māori Cancer Stakeholder Hui (Nov-Dec 2019)
• 4 Māori Cancer Deep Dive Reports (Jan-Jun 2020)

Over 1,000 people attended the Community Hui and 240 stakeholders attended the Stakeholder Hui. More detailed information on the Deep Dive and the Final Reports can be found here. Included below is a selection of presentations from the Deep Dive relevant to primary and community care.

System and leadership

Fletcher Beazley, Regional Cancer Manager and Leader of the Regional Cancer Deep Dive sets the scene. Topics covered include:

• equity in cancer care
• accelerating Māori health gain
• empowering whānau through community action
• Kaupapa Māori and Rongoā Māori approaches.

Fletcher Beazley (BHSc, BA(SocSci), MMgt(Hon), MA(Mātauranga Māori)) identifies as Ngāti Mahuta, Ngāti Rehua and Ngāti Maraeariki. Fletcher has over 20 years experience leading teams in the health sector having worked as a Regional Health Equity Manager, Health of Older People Manager, Primary and Community Care Manager, Mental Health and Disability Manager and has recently been appointed as the Whānau Centred Care Manager at the NZ Cancer Control Agency.

Te Tiriti o Waitangi (The Treaty of Waitangi)

Stephanie Turner presents on the importance of Te Tiriti o Waitangi in improving Māori cancer outcomes and that Te Tiriti should underpin and drive the work we do in the health sector. Topics covered include:

• Kawanatanga (partnering and strategic decision making)
• Tino Rangatiratanga (Māori determining)
• Oritetanga (equity)
• Wairuatanga (holistic care).

Stephanie Turner (MA(Hon) in Art Therapy)) identifies as Ngāti Raukawa Ki te Tonga, Ngāti Toa Rangatira and Te Arawa. Stephanie is a Senior Leader in Māori Health having worked as a General Manager of Māori Health at Wairarapa and Midcentral DHBs for 15 years, as an Advisor to the Central Cancer Network Māori Cancer Projects, Member of National Māori Cancer Leadership Group (Hei Āhuru Mōwai) and is currently the Director of Māori health outcomes at the Health Quality Safety Commission (HQSC).

Whānau centred care

Henare Kani presents on the importance of whānau centred care to improving Māori cancer outcomes across the whole continuum of care. Topics covered include:

• whānau centred care
• access and quality of care
• supportive care
• survivorship and palliative care.

Henare Kani (Dip.Māori Art and Design) is a Senior Kaumātua and identifies as Ngāti Kahungunu and Rangitāne. Henare has a lifetime of experience working with Whānau Māori in the health and development sectors and as a leader of his people. He currently holds several roles as Kaihutū at Te Manawa Museum, Te Hauangi at the Cancer Society and Kaumātua of the Central Cancer Network. Henare led the Cultural and Tikanga Aspects of the entire Deep Dive investigation and was an essential part of the team during the design and delivery of all hui, Henare is also a cancer survivor.

Supportive care

Dr Monica Koia presents on some of the themes coming out of the Māori community hui across the supportive care section of the pathway. Topics covered include:

• whānau centred care
• mproving access and quality of care
• building trust and creating a supportive environment
• increasing the Māori workforce.

Dr Monica Koia (BBS, PGDip Bus, MMGT, PhD) whakapapa to Ruawaipu, Ngāti Porou, Ngāti Kahungunu, Te Arawa and Ngāti Raukawa ki te Tonga. Monica is a Māori health consumer, whānau caregiver and researcher based at Massey University (Office of the DVC Māori). She completed her PhD that investigated the roles of Māori Cancer Navigators in the MidCentral region and has also been involved in other cancer research such as culturally appropriate end of life care for Māori and Epidermal Growth Factor Receptor testing for Māori patients with advanced non-small-cell lung cancer. Monica was an integral part of the Deep Dive, contributing to analysing the information collected by CCN from the 7 community and 4 stakeholder hui, including being part of the team that wrote the feedback report.

Diagnosis and treatment

Lisa Te Paiho presents on themes coming out of the Māori community hui across the Diagnosis and Treatment section of the pathway. Topics covered include:

• shared decision making
• whānau centred care
• more Māori treatment options
• cultural competency.

Lisa Te Paiho is a Māori Cancer Clinician and identifies as Te Aitanga a Mahaki, she is trained in radiotherapy and currently works as the Cancer Equity Lead for Midcentral District Health Board. Lisa was an integral part of the Deep Dive, giving presentations at both the community hui and stakeholder hui, running focus groups with Whānau Māori and contributing to the event planning.

Rongoā (Traditional Māori Healing)

Hemaima Wiremu presents on the importance of Rongoā (traditional Māori healing) as a holistic approach that has the potential to enhance Māori health outcomes in partnership with the existing cancer workforce. Topics covered include:

• Māori wellness
• Rongoā (traditional Māori healing)
• Whānau centred care
• Wairuatanga (spirituality).

Hemaima Wiremu is a Traditional Māori Healer with over 30 years of experience supporting whānau Māori. Hemaima and her team from the Rongoā Collective of the A.R.T Confederation work across the Capital Coast, Hutt Valley and Midcentral DHB Areas providing Rongoā Māori services in primary care through the local PHO. Hemaima and other Rongoā experts supported the Māori Community and Stakeholder hui by exposing participants to Rongoā Māori such as Kawakawa and other Rakau (herbs), Mirimiri (massage) and Karakia (prayer).

Comorbidities

Dr Virginia Signal representing the Otago University C3 research team presents on the importance of comorbidities to cancer care. Topics covered include:

• Māori cancer inequities
• effect of comorbidity on treatment
• effect of comorbidity on survival
• possible solutions.

Dr Virginia Signal is a trained Oncology Nurse and Research Fellow with the Cancer and Chronic Conditions (C3) research group (Te Rōpū Rangahau mō te Mate Pukupuku me ngā Mate Mau Tonu) based at the Otago University Department of Public Health. The (C3) group is a collaborative group of researchers working at the interface between public health, health services research, and clinical medicine. Their work includes a range of projects aimed at reducing the impact of cancer and chronic conditions on population health and health inequalities through policy and health system change.

Māori research

Dr Mellissa Cragg presents on conducting meaningful research with whānau Māori. Topics covered include:

• Māori worldview
• ethics and Tikanga
• accountability and availability
• Māori leadership and involvement.

Dr Mellissa Cragg (BA(Māori and History), BA(Hon), PhD) completed her Doctorate in Māori Studies at Massey University under the supervision of Sir Mason Durie. Melissa is a Principal Consultant at Karake Consultancy and has worked in a wide variety of roles including at Nelson Malborough and Whanganui DHB’s, Westcoast PHO and Massey University

Peer group discussion points

Redistribution of existing health funding, resources and focus is essential to achieve health equity in cancer.

• How could your organisation redistribute its focus and resources to help achieve equity?
• Fletcher proposed a shift in focus from mainly cancer treatment to more on cancer prevention. Identify some areas in your practice that you could implement to shift into this new paradigm of practicing. 

The Treaty of Waitangi should underpin and drive the work of the health sector.

• How could you ensure that your Māori patients are part of the decision making in how they receive primary and community care?
• How could you improve your relationships with other primary and community care providers both Māori and non- Māori to ensure better outcomes for Māori patients?

Working with whānau is essential with Māori patients across the continuum of care. This could include including whānau in decision making, care planning and consultations.

• What are you currently doing in your practice to ensure that your care is whānau centred?
• What could you do to ensure that the care you provide is more whānau centred?

Building relationships of trust and a friendly environment for Māori patients is essential to improving the access and quality of cancer care across the continuum.

• What things are you currently doing to ensure that the environment of your practice helps Māori patients feel welcome and supported? What more could you do?

• Monica identified that Māori patients regularly experience difficulties navigating the health system across the continuum of care and that Cancer Nurse Co-ordinators and Whānau Ora Navigators help. What could you do to ensure that your patients are better supported to navigate the system throughout the cancer journey from prevention to palliation?

Māori wellness is holistic and requires treatment options that recognise Māori worldviews which includes Rongoā.

• Are there any Rongoā (traditional Māori healing) organisations are you able to send referrals to at the moment?
• How could you or your organisation include more Rongoā (traditional Māori healing) options to support the primary and community care that you provide?

Patients with comorbidities are less likely to receive cancer treatment, however there is evidence that those that do have better survival.

• How do you currently manage patients with both cancer and comorbidities?
• What more could you do to improve outcomes for patients with both cancer and co-morbidities?