Emma Espiner talks to Dr Maxine Ronald, the only wahine Māori consultant breast cancer surgeon in the world, about inequities in breast cancer outcomes for Māori.
We were sitting in the clinic room, waiting for the last patient of the day. When she came in I recognised the Māori woman who had received a double mastectomy two weeks earlier. She had come a long way to see us. Women who live in rural areas can travel for hours to make doctors’ appointments. In my experience, they rarely complain after all that, even if their appointments get delayed. I feel ashamed when I think of how I start fidgeting if I have to wait more than 10 minutes for my GP at their inner city Auckland practice.
This woman came in to have her wounds checked, and she smiled up at the two of us standing over her on the examination table with our gloves and sterile tools. She repeated something she’d said to us before her operation “It’s so nice to see your beautiful Māori faces.”
There are few things that drive home the privilege of your role as a medical student than being present when someone is told they have cancer. Our supervising clinicians ask for permission for our presence, but it’s always a shockingly personal encounter to be there for. The human condition is laid bare in a way that few other clinical encounters match. The tableau is usually a triangle, medical student at the awkward apex, clinician at the desk swivelled away from the computer to face the newly diagnosed and their whānau. Sometimes the person comes alone.
For a while last year I spent my weekdays in Whangārei. Early each Monday, before my family were awake, I’d set off, guiding our shabby black station wagon north through the roadworks and heavy trucks on State Highway 1. On Friday afternoons I’d do the reverse trip, arriving home in time to put my daughter to bed. I left my family behind so I could take up a rare opportunity – six weeks with the only wahine Māori consultant breast surgeon in the world.
There’s not a lot of autonomy to be had in the medical school curriculum. This makes sense; the public will be pleased to know their future medical workforce isn’t randomly choosing what to learn and what to ignore. At the University of Auckland we get just two opportunities to focus on an area of interest – six weeks in fifth year and eight to ten weeks in sixth year. With only a very small number of Māori specialists in any discipline, my opportunities to be mentored by a Māori clinician were almost non-existent if I relied on chance placements alone.
Why does this matter? We know that rates of breast cancer for Māori women are 1.4 times that of non-Māori women. We are 1.5 times more likely to die from breast cancer compared to non-Māori. We understand that inequities in the provision of screening and cancer services unfairly disadvantage Māori women whose breast cancers are identified at a later stage of disease, leading to poorer prognoses compared to non-Māori. In this context, I wanted to see how a Māori breast surgeon practised. We know that the diversification of the medical workforce is a critical step towards health equity, but what does this look like on the frontlines?
It looks like a quietly reassuring, authoritative presence in a role where few of us are seen. It looks like doing the hard, often boring and frustrating work behind the scenes. It looks like influencing others simply by existing. It looks like Dr Maxine Ronald, general and oncoplastic breast surgeon at Whangārei Hospital, chair of the Indigenous Health Committee for the Royal Australasian College of Surgeons, member of the Perioperative Mortality Review Committee of the HQSC, Hei Āhuru Mowai (Māori Cancer Leadership Group), the Northern Regional and Northland Equity Governance Groups, and Te Rōpū Whakakaupapa Urutā.
As a student I’ve worked with plenty of non-Māori breast surgeons, specialist breast cancer nurses and oncologists as well, and they’ve all been deeply committed to equity and patient care. So why are we still more likely to fail Māori women compared with non-Māori women? The evidence shows how the individual factors affecting Māori women’s access to care are cumulative, and this is why each step in the process requires scrutiny using an equity lens.
“I know that, at our DHB, once Māori women access the breast screening service, outcomes are comparable to non-Māori – this is why so much of our attention has been focused on getting women into screening. The quality of the outcomes once women are in the screening programme shows us how important it is to remove any barriers to access.”
Research into access for Māori highlights practical barriers like limited transport, financial barriers and lack of childcare. The evidence for the importance of culturally appropriate care is growing, as is the evidence of the harm caused by previous bad experiences in the health system – either to individuals themselves, or to their whānau. As Māori move through the layers of the health system, from primary care through to hospital services, as disease severity increases, the barriers compound one another.
The true story of Māori inequities in access to healthcare in New Zealand is therefore best illustrated through the disparities between women identified through breast cancer screening, and those who come with a lump, or other symptoms of breast cancer.
“Māori who are identified through breast cancer screening do much better than Māori who present with symptoms. This is also true for non-Māori, but we do worse. To me this shows that when the system is allowed to passively do what it is designed to do, it will always default to work for the group it was meant to serve,” she says.
“This tells the complete story of Māori access to healthcare in New Zealand because it captures the many points at which we experience barriers, and demonstrates the need to counter all those many barriers by intervening at every junction.”
It’s a difficult paradox to unpack. You would assume that the person who is symptomatic, and therefore potentially has more advanced disease than someone who is just turning up for screening (the goal of screening being to investigate asymptomatic women to detect cancer earlier, and ideally catch it at a much earlier stage) would warrant being directed to urgent assessment and treatment. But that’s not what we are seeing.
It’s a tragic irony that the rigour and success of the screening programme makes the inequities in symptomatic breast cancer treatment more obvious. It also demonstrates the levers available when certain outcomes are prioritised. Breast cancer screening is centralised through the National Screening Unit, and the targets are strictly mandated and apply nationwide.
Emily Writes’ interview with Dr Monica Saini explains the role of mammograms in screening. Here is the broader process that screening mammography fits into: Women are first invited for a mammogram as part of the free breast cancer screening programme for women aged 45 to 60. If the mammogram shows something of concern, women are recalled and have to be seen within two weeks. There is a comprehensive work up including radiology, pathology and a meeting with a surgeon – all of which takes place on the same day. Results must be returned within seven days, and a treatment plan agreed upon once the results are available. Treatment should have commenced within four weeks of results being shared with the patient. Penalties apply for DHBs who do not meet these targets. Dr Ronald says this comprehensive, wraparound service with strict targets is a big part of what makes the screening programme so successful.
The cohesion and consistency of this approach are not reflected in the symptomatic pathway to cancer diagnosis. If a woman finds a lump, or experiences pain or nipple discharge, she has to go to her GP who can initiate investigations or refer to secondary care, often necessitating multiple appointments and no coordinated system to ensure timely and best-practice treatment. Compared with the collaborative approach of the multi-disciplinary teams involved in breast cancer screening, the pathway to treatment for women experiencing symptoms of breast cancer leaves much to be desired, according to Dr Ronald.
“We have a chronic shortage of general practitioners in Northland, which definitely contributes to inequities and there doesn’t seem to be any meaningful movement on this, so the rural-urban divide continues to grow,” Dr Ronald tells me.
“General practitioners are such important partners for those of us who work in other parts of cancer care; we can’t see patients with cancer outside of screening programmes unless they come through their GP or present to ED. But with the shortages up here, GP appointments can be really difficult to get, and that’s without accounting for all the access problems that we know Māori experience at higher rates than non-Māori. Even once a GP has seen a woman with suspected breast cancer, she then has to navigate this horribly fragmented system.”
What are the solutions? Better coordinated IT systems, including utilisation of the Breast Cancer Foundation National Register (which the Northland DHB joined in June), as well as improvements in resourcing for cancer care, especially in rural areas. Pro-equity approaches are also a must, according to Dr Ronald.
“I think that clinicians should just have a high index of suspicion if any Māori woman presents with breast cancer symptoms. We don’t have to wait for system change, we’re all capable of looking at the evidence and just deciding to do the best thing for our patients,” she says.
“Sometimes that means working outside of the strict confines of our jobs to do what is needed rather than the bare minimum. If we do that as well as advocating for change – not the least, increasing availability of services especially in our rural communities, and making sure those services are culturally safe – then we can feel confident that we’re doing our best to advocate for our patients who need us the most.”