Kia ora  
He uri ahau o Te Tai Tokerau.  
Nō Ngā Puhi, Ngāti Wai, Ngāti Hine, Te Kapotai ōku iwi. 
Ko Maxine Ronald toku ingoa. 

My name is Maxine Ronald, I’m from Northland, and I am a general surgeon and breast surgeon in Whangārei.  

Some of the things we know about breast cancer for Māori and for Pasifika women is that overall, Māori women in particular tend to have a higher incidence of breast cancer and also tend to die more from breast cancer than non-Māori women. And what we see in the breast screening population is the incidence of breast cancer in that age group, that 45- to 69-year-old age group, is about 45% higher for Māori than for non-Māori. But access to screening, or engagement with screening, for Māori has always been much lower. 

We know from research that’s been done a few years ago that if Māori women are diagnosed with breast cancer through the breast screening programme, they have the same outcomes as non-Māori for breast cancer, in terms of five-year mortality. So, it’s critical that Māori women have access to screening, and screening that’s provided in a culturally safe and culturally appropriate way. 

Despite introduction of the faster cancer times in the public health system, Māori and Pasifika are still less likely to receive surgery in a timely manner and have delays in accessing their operations compared to non-Māori, and that’s just in one example. 

If you are diagnosed with a symptomatic breast cancer, where you detect a breast lump, the pathway into getting treatment for that is much more difficult and extended compared to the breast screening programme. Because you need to first of all recognise there’s a breast lump and understand the significance of that, and then be able to see a GP to be referred to the hospital. 

We know accessing GP’s is a big problem at the moment. Primary health care is swamped and there’s not enough GPs, so often it can take people weeks and weeks, if not months to see a GP. Then that referral needs to be triaged and there’s also some inbuilt biases that can occur in the triage system, or it can be difficult to interpret what’s coming through in the referral, so people may not be triaged as urgently as they should be. Then there’s the whole access issue to the system and progressing through the system. 

I’m grateful for the Māori Breast Cancer Research Leadership Fellowship, which is supported by Hei Āhuru Mōwai, Breast Cancer Foundation NZ and Breast Cancer Cure. It gives us the opportunity to spend some time to dive deep into some of these issues because, as a clinician, that’s something that I’m very acutely aware of, seeing people who are diagnosed in the breast screening pathway and through the symptomatic pathway within the same clinical space, as it’s sometimes quite difficult to reconcile. That’s an area that I’m interested in looking at, and that we are currently incorporating into a wider Health Research Council grant programme to try and dive a bit deeper into that. 

I’m hoping this will fill one part of the overall puzzle, or the overall kind of issue that surrounds breast cancer inequities for Māori. Because there are lots of people who are doing, or already have done, really amazing stuff in the community in that pre-diagnostic space. I think what I can bring is more knowledge and connections within the clinical space. But I’m definitely very mindful that we can’t all operate in silos, we need to be connecting across all these different areas. 

One specific area I want to look at with the fellowship is looking at the symptomatic pathway and diving deep into where those points of delays may occur along that pathway. Understanding what whānau Māori experiences of what being in that part of the system is like for them, and then looking at a feasibility study to investigate what it would be like if we invested resources into symptomatic pathways, so they have the same kind of structure and framework as the breast screening pathway. 

There’s the pre-diagnosis space, the diagnostic and investigation space, the treatment and then the survival space. It’s critical that we link all of those spaces up together. 

The evidence seems to be so strong around equitable outcomes for wāhine Māori diagnosed through the screening programme and really, that needs to be the key focus of any mahi, any efforts that are put into addressing breast cancer inequalities for Māori women. But that’s not going to happen overnight and there will still always be people who are diagnosed through the symptomatic pathway. Arguably, people diagnosed through a symptomatic pathway have a later stage of disease than those who are diagnosed through the screening programme. So, I think what it will do is hopefully improve the equity of access to investigations and treatment, and obviously overall, we want to see equity of outcome as well. 

Ultimately at the core of it, it’s just unfair. There’s no reason why Māori inherently should die more from any cancer, and in breast cancer in particular. It’s not a foregone conclusion that we should do worse from breast cancer than non-Māori. 

We need to be good Treaty partners, trying to work hard to ensure that everybody gets the access to the treatment they need in order to have the same outcomes as everybody else. 

Having been diagnosed with breast cancer myself, I think I have a greater appreciation of what that whole breast cancer journey is like for women. I was very fortunate in my breast cancer journey that I had private health insurance, I knew people who were in this specialty, and I understood the information that was being given to me. I appreciate that for a lot of people who don’t have that, that’s a huge privilege I had, as well as being able to access top-line treatment that wasn't available through the publicly funded health system. 

What I want for everybody, and particularly for wāhine Māori and Pasifika because they already have worse outcomes, is to have that same privilege that I had. I think that it’s important that we’re constantly critiquing ourselves and trying to improve the care that we’re providing for women in Aotearoa with breast cancer. We can only do that through innovation and through research, and a lot of that’s restricted in the public health system. So, we’re reliant on generous sponsorship from benefactors who believe that, like many of us, we shouldn’t necessarily have to die from breast cancer. We live in such an amazing time at the moment, with access to incredible technology, medication, and treatment. We should be optimising that and making sure that we’re making the best of all these opportunities.  

There’s always hope, and breast cancer is largely very treatable. I think that’s a really important message to convey to people – that yes, this is a tough diagnosis, but we can get through this, and most people will do really well. The key is early detection, and then making sure that once you are on that treatment pathway that you don’t have any barriers that are unnecessary to stop you from having an optimal outcome.