Cancer disparities in Southeast Asia: intersectionality and a call to action.

Southeast Asia has a population of over 680 million people—approximately half the population of India and twice the population of the United States—and is a region marked by rich and complex histories and cultures, dynamic growth, and unique and evolving health challenges.1 Despite the momentum of economic development, health inequalities persist. These inequities have been aggravated since the COVID-19 pandemic, which pushed millions further into poverty, possibly exacerbating health disparities, especially among populations who suffer vulnerabilities.2 Particularly salient are the challenges associated with providing adequate care for people with cancer, a leading cause of morbidity and mortality in the region.1,2 Cancer incidence and mortality in the region are projected to rise in the coming decades, given population growth and rapidly changing socioeconomic and geopolitical factors, as well as a host of interrelated and dynamic environmental, behavioral, and occupational risk factors.1, 2, 3 Large epidemiologic studies have demonstrated differences among Southeast Asian countries in terms of cancer incidence and mortality.3 Epidemiologic patterns can be attributed to variations in complex risk factors, access to screening and cancer care, and likely genetic predisposition.1, 2, 3 However, these differences also underscore that within each country exist richly diverse populations that experience disparities in cancer risk, screening, care access, outcomes, and survivorship in ways that require further examination. We draw attention to disparities in cancer in Southeast Asian countries. We highlight the need to study cancer disparities affecting minoritised groups in Southeast Asia—not only along lines of race/ethnicity, but also people minoritised along lines of sex/gender, socioeconomic status, religion, geography, and others. We highlight the intersectionality of elements of an individual's identity. Intersectionality, developed by critical race theorist Professor Kimberlé Crenshaw in 1989, is an analytic framework borne out of Black American feminist scholarship, that examines how a person's sociopolitical identities lead to disparate balances of privilege and discrimination.4 An intersectional approach would demonstrate that an individual or a community does not only experience economic poverty as the sole barrier to improved health; such an approach would examine how other identities such as religion or immigration status affect access to care. These different social determinants of health are not mutually exclusive; their interrelationships are complex, with consequences for health.5 We leverage the intersectional approach, which parallels the inherently syncretic cultures and histories of Southeast Asian nations, and explore how these identities impact access to cancer care. Meaningful cancer research focusing on peoples of Southeast Asia could present many opportunities for intervention and improvement

BHPR research: qualitative1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis

Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck”). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?”). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it ... he said that hasn't worked as good as he'd wanted to ... but the pain has gone”). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about”). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interes

New genetic loci link adipose and insulin biology to body fat distribution.

Body fat distribution is a heritable trait and a well-established predictor of adverse metabolic outcomes, independent of overall adiposity. To increase our understanding of the genetic basis of body fat distribution and its molecular links to cardiometabolic traits, here we conduct genome-wide association meta-analyses of traits related to waist and hip circumferences in up to 224,459 individuals. We identify 49 loci (33 new) associated with waist-to-hip ratio adjusted for body mass index (BMI), and an additional 19 loci newly associated with related waist and hip circumference measures (P < 5 × 10(-8)). In total, 20 of the 49 waist-to-hip ratio adjusted for BMI loci show significant sexual dimorphism, 19 of which display a stronger effect in women. The identified loci were enriched for genes expressed in adipose tissue and for putative regulatory elements in adipocytes. Pathway analyses implicated adipogenesis, angiogenesis, transcriptional regulation and insulin resistance as processes affecting fat distribution, providing insight into potential pathophysiological mechanisms

Disparities in Access to Cancer Diagnostics in ASEAN Member Countries

Diagnostics, including laboratory tests, medical and nuclear imaging, and molecular testing, are essential in the diagnosis and management of cancer to optimize clinical outcomes. With the continuous rise in cancer mortality and morbidity in the Association of Southeast Asian Nations (ASEAN), there exists a critical need to evaluate the accessibility of cancer diagnostics in the region so as to direct multifaceted interventions that will address regional inequities and inadequacies in cancer care. This paper identifies existing gaps in service delivery, health workforce, health information systems, leadership and governance, and financing and how these contribute to disparities in access to cancer diagnostics in ASEAN member countries. Intersectoral health policies that will strengthen coordinated laboratory services, upscale infrastructure development, encourage health workforce production, and enable proper appropriation of funding are necessary to effectively reduce the regional cancer burden

Disparities in access to cancer diagnostics in ASEAN member countries

Diagnostics, including laboratory tests, medical and nuclear imaging, and molecular testing, are essential in the diagnosis and management of cancer to optimize clinical outcomes. With the continuous rise in cancer mortality and morbidity in the Association of Southeast Asian Nations (ASEAN), there exists a critical need to evaluate the accessibility of cancer diagnostics in the region so as to direct multifaceted interventions that will address regional inequities and inadequacies in cancer care. This paper identifies existing gaps in service delivery, health workforce, health information systems, leadership and governance, and financing and how these contribute to disparities in access to cancer diagnostics in ASEAN member countries. Intersectoral health policies that will strengthen coordinated laboratory services, upscale infrastructure development, encourage health workforce production, and enable proper appropriation of funding are necessary to effectively reduce the regional cancer burden

Palliative and Supportive Care in the Philippines: Systems, Barriers, and Steps Forward

Although integral to alleviating serious health-related suffering, global palliative care remains systemically and culturally inaccessible to many patients living in low- and middle-income countries. In the Philippines, a lower-middle income country in Southeast Asia of over 110 million people, up to 75% of patients with cancer suffer from inadequate pain relief. We reviewed factors that preclude access to basic palliative care services in the Philippines. PubMed and Google Scholar were searched thoroughly; search terms included but were not limited to “palliative care,” “supportive care,” “end-of-life care,” and “Philippines.” We found that a limited palliative care workforce, high out-of-pocket healthcare costs, and low opioid availability all hinder access to palliative care in the archipelago. Religious fatalism, strong family-orientedness, and physician reluctance to refer to palliative care providers represent contributory sociocultural factors. Efforts to improve palliative care accessibility in the country must address health systems barriers while encouraging clinicians to discuss end-of-life options in a timely manner that integrates patients’ unique individual, familial, and spiritual values. Research is needed to elucidate how Filipinos—and other global populations—view end-of-life, and how palliative care strategies can be individualised accordingly

Leveraging national and global political determinants of health to promote equity in cancer care

Health and politics are deeply intertwined. In the context of national and global cancer care delivery, political forces -the political determinants of health-influence every level of the cancer care continuum. We explore the "three-i" framework-which structures the upstream political forces that impact policy choices in the context of actors' interests, ideas, and institutions-to examine how political determinants of health underlie cancer disparities. Interests are "the agendas of societal groups, elected officials, civil servants, researchers, and policy entrepreneurs." Ideas manifest in "knowledge or beliefs about what is (eg, research knowledge), views about what ought to be (eg, values), or combinations of the two." And institutions are "the rules of the game." We provide examples from around the world. Political interests have helped to fuel the establishment of cancer centers in India and have galvanized the 2022 Cancer Moonshot in the United States. The politics of ideas underlie global disparities in cancer clinical trials, that is, in the distribution of epistemic power. Ideas also influence which interventions are tested in costly trials. Lastly, historical institutions have helped to perpetuate disparities related to racist and colonialist legacies. Current institutions have also been leveraged to improve access for those in greatest need, as exemplified by the experience in Rwanda. In providing these global examples, we demonstrate how interests, ideas, and institutions influence access to cancer care, across the breadth of the cancer continuum. We argue that these forces can be leveraged to promote cancer care equity nationally and globally