Māori and Pacifika patients are far less likely to get their breast reconstructed after losing them to cancer than European women, a new study has revealed.
The research - conducted by Royal Australasian College of Surgeons Fellows - reviewed data from all patients diagnosed with breast cancer in 2017 at Counties Manukau District Health Board.
It showed major ethnic inequalities in South Auckland patients who underwent a government-funded post-mastectomy breast reconstruction (PMBR) surgery.
One of the researchers, Dr Michelle Locke, said it was alarming minority groups were missing out of the surgery because it could make a huge difference to their quality of life and happiness after battling cancer.
"[The surgery] helps them regain their confidence, helps them overcome the emotional challenges and physical changes ... there's lot of really good research that women flourish after breast reconstruction."
The study found that of the 365 patients diagnosed with cancer at the DHB during 2017, 177 underwent a mastectomy - which is a surgery to remove all tissue from a breast as a way to treat or prevent cancer.
Of that, only 26 patients had PMBR - 20 were European, one was Māori, five were Asian and none were Pacifika.
Locke - who is a plastic and reconstructive surgeon at Middlemore Hospital - said it was likely to be similar, if not worse, at other DHBs across the country.
"It's all part of the postcode lottery within our health system," she said.
"It's very disappointing first of all that there were low rates of people getting reconstructions overall and then to see that reconstructions are disproportionately European patients and a shockingly low number of Māori and no Pacifika women in this particular cohort."
New Zealand's new cancer boss Diana Sarfati echoed these concerns, saying it again highlighted inequities in New Zealand's cancer care system and reinforced the need for Te Aho o Te Kahu, Cancer Control Agency, which she heads.
"Te Aho o Te Kahu recognises this inequity and acknowledges there is much work to be done to address it. Te Aho o Te Kahu was formed to ensure that everyone in New Zealand has access to world-class cancer care, no matter who they are or where they live."
Why are there racial inequalities?
Locke said there were many reasons for the inequalities between ethnicities including high rates of smoking and obesity among Māori and Pacifika.
In order to get a PMBR, patients need to meet certain eligibility criteria, which differ slightly at each DHB.
At Counties Manukau DHB, patients need to have a body mass index (BMI) of under 35 and should not have smoked for at least six weeks before the surgery.
Locke said this was because smoking and obesity were associated with higher complication rates during and after surgery, including delays in wound healing and infections.
The study found smoking rates among the cohort were highest among Māori (38 per cent) and Pacifika (17 per cent).
As a result, only 34 per cent of Maori and 31 per cent of Pacifika women undergoing a mastectomy meet the eligibility criteria for PMBR.
That's compared to 73 per cent of European women and 100 per cent of Asian patients.
"One of the drivers for this study was to look at whether our criteria is preventing Māori and Pacifika women from breast reconstruction," Locke said.
She said other reasons for the inequalities could be the cost of taking time of work to recovery from the surgery, access to treatment, communication and cultural barriers.
What needs to change?
When asked what needed to change Locke said:
• Smoking rates are far to high, there needs to be a focus to reduce those rates.
• More support is needed for patients who need to travel, have children to look after and need take time off work to recover.
• More information about breast reconstruction is needed in breast clinics and we will look at make our breast reconstruction nurse more available in the clinics.
She said the DHB was committed to try to improve these low rates.
"I'd love to see the rates of patients getting reconstructions doubled, especially among Māori and Pacifika, to bring us more in line with America-US levels."
A Counties Manukau DHB spokesperson said the findings were no surprise given the higher prevalence of smoking and obesity in our population that this does impact on their ability to be eligible for some interventions.
"It is important to note that this study looks at one year, in one DHB and caution should be exercised in drawing conclusions from such a sample to other DHBs or services.
"We take from this study confirmation that advancing programmes that increase access to smoking cessation and interventions and wider health system efforts to address obesity for vulnerable populations are still critically important to provide in our healthcare system."
"Counties Manukau Health already has a wide range of service offers that target Māori and Pacific as part of the Living Smokefree programme and other primary care based initiatives such as Green Prescription (GRx) programmes which support increased physical activity for our population."
The spokesperson said the DHB also supported the conclusions from the study that suggest reviewing BMI criteria but will that response to clinical experts as this has significant implications for surgical provision.
"We are very pleased with this study and acknowledge the work of our specialist clinicians as adding to the body of knowledge on how inequities can arise in our healthcare system and, importantly, what we can do about it."
Sarfati said: "As a new independent agency we are currently building our relationships with DHBs so we can monitor, advise and support them in improving cancer outcomes, especially for Māori and Pacific people and other priority populations.
"Our Covid advice to DHBs was equity-focused and well received, with analysis showing existing inequities in cancer care did not increase over lockdown. We are confident we can continue to build on this.
"Te Aho o Te Kahu Equity Director's role is to ensure equity is central to all Agency work and they lead a dedicated equity-focused team. We also have an Equity Project Manager in each of the four regional hubs. This has us well placed to address specific regional and systemic barriers to equity in cancer care."
Auckland mum Samantha Lafaialii says she woke up from her breast reconstruction surgery smiling.
"That sums up reconstruction for me," she said.
The 47-year-old was diagnosed with non-invasive breast cancer in February last year.
She was advised to get a mastectomy to remove her right breast to prevent the cancer from growing.
"It was quite sobering, I was really scared. I don't have much of a breast cancer history in my family so it came as a shock," she said.
"I got over the mastectomy quite quickly because it was my breast or my life. It was an easy decision to make because I have a little girl."
Though the operation kept being talked about as a cure, Lafaialii said she couldn't help but think of it as a disfiguring surgery.
"I was blessed in the chest with e-cup boobs and thinking about having a bare chest was very sobering."
Her doctor told her about the option of getting a reconstruction but when she heard about the BMI criteria she freaked out.
"I'm a build Samoan, I got my BMI tested and the doctor said it could be a defining factor for getting the reconstruction surgery but he recommended me for it.
"I went straight to the chemist and bought boxes and boxes of optislim and went on a low-calorie diet.
"Looking back it probably wasn't the best plan but I dropped a couple of kgs and when I saw the plastics team didn't even mention it, they said I was fine but they asked me about 12 times if I smoked to which I said no."
Lafaialii said the smoking disqualification was huge for people and felt like there wasn't enough awareness in the Pacifika and Māori community.
"I've had colleagues who weren't even offered reconstruction or were told it was an instant no when they started to explore it.
"I do wonder how well understood it is between Pacifika women and Māori women."
The 10-hour surgery included a skin-sparing mastectomy which meant most of the skin over her breast was left intact and only the tissue, nipple and areola are removed.
Then, surgeons took fat from her tummy and put it into her right breast and then took a patch of skin from her tummy to cover it.
She had to take three months off work to recovery but said it was the best decision she ever made.
"I'm just lucky I was able to get it when so many miss out."