A new breast cancer centre opened at Sunnybrook Health Sciences Centre last week, becoming the largest of its kind in Canada. The Louise Temerty Breast Cancer Centre adopts the integrative model of housing the whole spectrum of breast cancer care under one roof, including direct access to screening, rapid assessments and diagnosis, and tailored treatment options. The Centre features expanded areas for specialized clinics, integrated breast imaging research, and clinical trials.
The opening of this new facility comes at an important time: Ontario’s Ministry of Health and Long-Term Care has a focus on chronic disease prevention; and in Canada, breast cancer is the most frequently diagnosed cancer in women – at 26% – and ranks second in women’s mortality at 14%. Undoubtedly, this new breast cancer centre will help many individuals and families impacted by breast cancer, and its more integrated approach is to be welcomed. At the same time, it is always important to look at such innovations through an equity lens: how can we ensure that the benefits of these new approaches are accessible to all women?
Applying an equity lens to the Centre services would mean considering:
- ensuring that care is available in many languages and that professional interpretation is an integral part of the Centre’s service mix
- ensuring that all staff are trained and supported in cultural competence
- analyzing whether there are pressures and barriers in women’s wider lives that will affect their treatment experience and outcomes. For example, could the high costs of transportation and parking be an added source of anxiety and barrier to patients and their families? Could limited child care be a problem? While these would seem to be beyond the hospital’s control, each of these examples could be addressed as part of comprehensive care: e.g. subsidized transportation, child care on site, social work support to surface such concerns and plans on how to mitigate them
- evaluating the impact of these new and different treatment approaches. The equity lens here is collecting sufficient disaggregated race, ethno-cultural background, immigration history, income, and social conditions data to be able to assess if there are any inequitable outcome and access differences
The Centre could also look beyond the hospital walls, especially to consider the conditions to which women are returning to after treatment:
- how will poor housing and inadequate living conditions faced by lower income women affect their recovery?
- how will the cost of medications be a barrier for those without benefits plans?
Again, while these examples are definitely beyond the hospitals’ immediate sphere, they do illustrate how patients’ social and living conditions need to be taken into account in discharge planning and follow-up support. Some hospitals have developed innovative partnerships to address these wider determinants of health issues. Also, they show how equity has to be built into the full continuum of care: e.g. if there is to be home-based nursing or other care, then this needs to take account of patient’s language and culture needs
And looking even further up-stream to what happens before women get to treatment in the new centre, the social determinants of health play an influential role in creating barriers to initial breast cancer screening. Research shows that those with lower levels of income and education are at particular risk, and that these determinants are intensified by cultural beliefs and access issues, such as geographic location, access to health providers, and language barriers. For example, a 2004 spatial and epidemiologic study of mammography use in Toronto found that mammography rates were lowest in areas with low income and high immigration. Universal approaches to breast screening promotion may be inappropriate, as those who uptake the information are usually those who already have the background knowledge of the benefits of screening. Therefore, targeted actions are necessary for more equitable screening rates of breast cancer. Peer health ambassador type programs, in which people from particular ethno-cultural or other social groupings are trained and supported to provide system navigation, health promotion and other support, have shown promise in this regard.
Furthermore, Bowen et al. note that even when the initial screening process is completed, many of the same barriers listed above continue to exist for low-income women that influence the course of treatment after abnormal results. The structural and cultural barriers they face are often compounded with the emotional distress of the news and the potential need to remain as the family caretaker and remain employed due to the need to access medical insurance offered by the employer and other financial reasons.
To ensure more equitable breast cancer screening, actions that could be taken include:
- distributing breast cancer screening information in different languages at physicians’ office and health centres, as well as other public spaces such as community centres, public libraries, and places of worship
- providing cultural competency training for physicians to allow for better understanding and communication with patients
- offering mobile screening units that provide services in hard-to-reach communities, such as done in Alberta
- delivering educational programs that inform participants about the benefits of, and ways to overcome barriers to screening
This is not meant as a critique of the new Sunnybrook Centre: it is to be hoped that its planners have been considering these equity and wider population health issues. I’ve tried to illustrate how we can concretely consider equity as we plan innovative new approaches and work towards the province’s goal of excellent care for all. The Ministry of Health and Long-Term Care has developed a tool that can be used in this equity-driven planning: so one starting point can be to always apply Health Equity Impact Assessment to all such innovations and new programs.