Tēnā koutou, tēnā koutou, tēnā koutou, tēnā tātou katoa. So I just wanted to start by acknowledging the indigenous people from this area, the organisers of this symposium, and everyone who's gathered here today. I thought that I'd start by talking a little bit briefly about where things are at with lung cancer screening in Aotearoa, New Zealand, and I lead a programme of research. We started in 2018 with a cost-effectiveness analysis, some focus groups and survey work with Māori communities, we've now finished an invitation trial, we're working on assessing the PLCO to ensure that it accurately predicts Māori risk, and we've received some funding for four new programmes. There's also a national planning process underway, which involves the development of a business case to go to Treasury to see if we can get some funding. In reality, I don't think that a national screening programme informed by our research programme will be in place, I'd like to say three years, but more likely five. So the first thing in terms of equity for lung cancer screening for Māori is to know your epidemiology and then apply it. So the incidence of lung cancer in my community is over three times that of non-Māori people. The mortality rate for Māori women is over four times that for non-Māori women, and for Māori men it's over three times that of non-Māori men. And lung cancer is the second biggest contributor to the difference in life expectancy. It accounts for about 0.8 of a year of the just over seven year gap for men, and 1.1 year of the 6.7 year gap for women. So if we can implement lung cancer screening equitably, then we will make a significant impact in Māori lives. Unfortunately, none of the current national screening programmes are equitable. So we know, this data says, that we must not have an inequitable lung cancer screening programme. We need to design it so that it works for Māori, because otherwise these dreadful inequities will be worse. The second element of epidemiology that we need to think about, worldwide we have an age-based criteria for starting lung cancer screening. This is a lung cancer incidence for Māori men and women, and non-Māori men and women, the Māori in the blue bars. And you can see that the incidence of lung cancer climbs at a much younger age for Māori. And so if we just use an age cut-off, then Māori do not have the same opportunity to benefit from the screening programme. So we could address this by either saying, OK, and in this case, it's a rate of 200 per 100,000 people. That would mean that we would start lung cancer screening for Māori at age 55, and for non-Māori at 70. So use the epidemiology to ensure and inform your programme, so that you start screening programmes at an age that everyone has the same opportunity to benefit from them. Another way you could make that decision is using the cumulative percentage of diagnosed cancers by age. And again, you can see, again, you might make an arbitrary decision and say, OK, we'll start lung cancer screening when 40% of lung cancers have already been diagnosed. And that's the horizontal line. And that would suggest that for Māori, who are the blue lines, you would start screening at about just under 60, or say 60 for ease, whereas for non-Māori, you would do that at 65. Designing the pathway. We know in New Zealand, our current national screening programmes are inequitable. And that is because the pathways were designed to suit everyone and suit the majority. And that means not Māori. And so we really need to co-design a pathway with those that are most at need of the programme. And we need to understand and address the barriers and facilitators to access and address those. And in our research programme, we are systematically looking at all of those things. Our programme has been informed by a group called Te Hā Kotahi, which is our community advisory group. These people were initially participants in our focus groups and survey work. And they really wanted to support the ongoing work. So we developed our advisory group. They've been intimately involved in the identification of our future research projects, all our resources, and giving feedback on all our processes. We've recently been funded to start doing some work in the central North Island, in a region called the Manawatu. And that we've done. So our current work invitation trial compared general practice versus central hub based invitation mechanism for potentially eligible people. Central hub was more effective than primary care. But we're actually going to need both. And we'll have a central hub, I think, and a primary care mechanism. And in fact, any way in is going to be the right way in to lung cancer screening. And we are testing a number of different strategies in our current risk prediction project, where we're using vouchers. So people who are risk assessed are given five vouchers that have some information about lung cancer screening, an 0800 number, and a QR code. And that's been surprisingly popular as a way of people finding out about lung cancer screening and being risk assessed. In the Manawatu, we are working with Maori organizations in the area to co-design different methods of identifying potentially eligible Maori and inviting them. And the role that these Maori organizations want to play in invitation, risk assessment, shared decision making, and in supporting people through the CT scan and results process. We're just starting that. We're very excited. And then Te Hononga is the Maori cancer workers in the region, in the Manawatu. And they will be our advisory group alongside some other community members. And those two groups, the Te Hononga, the community members, as well as the three Maori organizations we're working with, will be the designers of the pathway there. A very important barrier to participation in lung cancer screening in our focus group and survey work, and I'm sure internationally, is stigma. And 32%, a third of our survey participants said they're worried about health workers judging them because they have been a smoker. And they went on to say that that would stop them participating in the project. And so our team are very clear that we cannot stigmatize people. You know, I like to say, love the person, hate the product. Love the person, hate the tobacco companies. But aroha ki te tangata, love for the person. And it's very important that people don't feel stigmatized. In New Zealand, a relatively recently published, 2020 published, systematic review of two decades of qualitative research about Maori experience in the New Zealand public health system. That's both hospitals and general practices. And found this. And so people are aware when our implicit biases and negative stereotypes affect the way we engage with people and the way we deliver services to them. It's not that we are personally racist, it's that we are caught out by our implicit biases. And in New Zealand, medical practitioners are expected to be culturally safe and to examine ourselves what our stereotypes and biases might be and how they affect the care that we provide to people. So this is my last slide with recommendations. Know and use the epidemiology, co-design, be culturally safe and non-discriminatory, have brave conversations and self-reflections, and use implementation science to implement, monitor, and refine your program. Kia ora.

lung cancer screening

Māori health equity

Aotearoa New Zealand

culturally safe healthcare

implementation science