Why is it important?:Early detection is the discovery of a disease or condition at an early stage of its development or onset, usually prior to the development of symptoms. Early detection may occur for individual patients, where clinically indicated, or for all members of a population through screening programs. In Australia, primary health care providers, including Aboriginal and Torres Strait Islander health services, and GPs, are a key element in early detection and early treatment programs. Early detection and treatment programs are most effective when there are systematic approaches to ensuring assessment and screening occurs regularly, at recommended intervals.
Breast, bowel and cervical cancer screening programs are designed to detect cancer early (breast and bowel cancer) or prevent its occurrence in the first place (bowel and cervical cancer). National programs for breast and cervical screening were implemented in Australia in the early 1990s, and have resulted in reductions in mortality for these cancers. The national program for bowel cancer screening was first implemented in 2006. From available data, almost 80% of the bowel cancers detected and removed as a result of the program were in the earliest two (out of four) stages of cancer spread.
Participation by Indigenous Australians in BreastScreen (the national breast screening program), the National Cervical Screening Program, and the National Bowel Cancer Screening Program (NBCSP) is at a lower rate than non-Indigenous participation (AIHW 2010c; Reath et al. 2008; Cancer Australia 2012). A recent analysis of the NBCSP suggests that factors contributing to this disparity include enrolment via Medicare records, thus disadvantaging those who are not registered; distribution of screening kits by post, disadvantaging those without a fixed address; the nature of the test; cultural perceptions of cancer; and lack of information about bowel cancer and screening (Christou et al. 2010).
Findings:Health assessments for Indigenous Australians aged 55 years and over were introduced in 1999 and for those aged 15–54 years in 2004. In 2009–10 new measures to increase the take up of health assessments for those aged 15 years and over were introduced as part of the National Partnership Agreement in Closing the Gap in Indigenous Health Outcomes. Trend analysis shows a statistically significant increase in health assessments for those aged 15 years and over between July 2009 and December 2011 with more than a doubling of the rate.
MBS items for health assessments for Indigenous children aged 0–14 years were introduced in 2006. During 2010–11, 22,415 health assessments were undertaken, representing around 11% of children in the target group. There was also a statistically significant increase in these health assessments since 1 July 2009. Note: between July 2007 and June 2009, approximately 10,000 additional Child Health Checks were provided or funded as part of the Northern Territory Emergency Response which were not captured in the Medicare dataset.
There were 38,331 health assessments provided in 2010–11 for Indigenous Australians aged 15–54 years and 10,623 for those aged 55 years and over. The proportion of the Indigenous population aged 55 years and over receiving health assessments (21%) was lower than the proportion of all Australians aged 75 years and older receiving health assessments (27%).
In 2008–09 an estimated 37% of Indigenous women aged 50–69 years participated in screening for breast cancer compared with 56% for other Australian women. Rates were highest for Indigenous women in Qld (49%) and lowest in the NT (24%). In 2004–05, 58% of Aboriginal and Torres Strait Islander women aged 18 years and over reported having a regular Pap smear test. This compares with an estimated 61% of all Australian women aged 20–69 years who were recorded in the national cervical screening register in 2004–05 (AIHW 2008b), and 59% in 2009–10 (AIHW 2011d). Indigenous women aged 18 years and over living in remote areas were more likely to report having a regular Pap smear test than those in major cities (65% and 54% respectively). Rates were highest in the NT (72%) and lowest in WA and NSW (52%).
In the period 1 July 2008 to 30 June 2011, 806,480 Australians participated in the NBCSP. Of these, 4,825 (0.6%) identified as Indigenous. Participants recorded as Indigenous were more likely to receive a positive (i.e., potentially abnormal) test result than those recorded as non-Indigenous (11% and 8%, respectively). Of the people with positive results, primary health care practitioner follow-up visits were reported for 52% of the Indigenous group, compared with 55% of the non-Indigenous group, which is not a statistically significant difference. However, there was a statistically significant difference in the proportions of Indigenous and non-Indigenous Australians who had a colonoscopy follow-up following positive results (58% compared with 72%) (AIHW 2012d).
Most Aboriginal and Torres Strait Islander primary health care services provide early detection and early intervention services. In 2010–11, these services reported providing regular well persons’ checks (75%), and screening for diabetes (80%), cervical cancer (76%), sexually transmissible diseases (71%), hearing problems (71%), eye disease (70%), cardiovascular disease (68%) and renal disease (56%). Since 2001–02, the largest increase in screening has been for cardiovascular disease, followed by well persons’ checks.Top of Page
Implications:Early detection and early treatment through primary health care has significant benefits for those at risk of disease. Identification of Indigenous patients is the first step in providing access to Aboriginal and Torres Strait Islander-specific health initiatives, including the additional MBS, PBS and immunisation programs available.
A large study in the US found that American adults received ‘recommended care’ in the detection and treatment of disease 55% of the time in 1999–2000 while an Australian study found that 57% of adults received appropriate care in 2009–10. This dropped to 47% for preventative care (including alcohol consumption and screening for cancers) (Runciman et al. 2012). An Australian study in Aboriginal Community Controlled Health Organisations found that the proportion of patients who had not been screened within the recommend guidelines was 27% for cholesterol, 24% for diabetes, 40% for blood pressure, 47% for cervical cancer and 54% for breast cancer (Stewart et al. 2012).
The National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes includes a range of initiatives to improve early detection and management of chronic diseases. Early indications from the Medicare data show significant increases in the number of health assessments provided to Indigenous Australians since the introduction of this initiative. The Practice Incentives Program—Indigenous Health Incentive is being implemented to support health services to provide better health care, including early detection and treatment of chronic disease. As at 30 April 2012, more than 2,900 general practices and Indigenous health services had signed on to the initiative. Around 40,000 patients were registered in 2011.
There is evidence that population based programs such as the National Bowel Screening Program need to develop better ways of ensuring vulnerable minorities, particularly Aboriginal and Torres Strait Islander peoples, are encouraged to participate (Christou et al. 2010) and that screening occurs more regularly. To help improve the availability of screening in regional and remote Indigenous communities, the National Bowel Cancer Screening Program worked with state and territory governments to trial and evaluate alternative service delivery models for the program between 2008 and 2011, including providing kits opportunistically to individuals during Well Person’s Health Checks or visits to local health clinics. A rise in Indigenous participation rates was achieved in the states and territories that participated in the pilots.
Screening through Pap smears will remain vital for many decades, as the current HPV vaccines are not effective against all types of the virus that cause cervical cancer. A barrier to reporting on cervical screening is that pathology request forms do not currently include provision for Indigenous status to be recorded in all jurisdictions.Top of Page
Figure 152—Rate per 1,000 persons receiving Medicare Benefits Schedule Health Assessments, by age group, Indigenous Australians, January–March 2006 to October–December 2011
Source: AIHW analysis of Medicare Australia dataTop of page
Figure 153—Rate per 1,000 persons receiving Medicare Benefits Schedule Health Assessments, Aboriginal and Torres Strait Islander peoples aged 55 years and over, all Australians aged 75 years and over, 2010–11
Source: Medicare Financing & Analysis Branch, DoHATop of page
Figure 154—Participation rates for BreastScreen Australia, women aged 40 years and over, by Indigenous status and state/territory, 2008–09
Source: AIHW analysis of BreastScreen Australia dataTop of Page