FormalPara Key Points

  • Cultural safety, legislation, and Indigenous collaboration lead to quality care.

  • Cultural safety must be embedded throughout the cancer-care journey.

  • Equity in research can drive improved access, care, and outcomes.

There are multiple avenues for approaching the goal of improving the cancer-care journey of an Indigenous person and their family. This care should be culturally safe, multidisciplinary, and equitably delivered, allowing optimal access to the full spectrum of diagnostic tools, procedures, and treatments. It should be adapted to innovative research findings specific to Indigenous cancer care, with increasing numbers of Indigenous researchers, healthcare providers, and leaders in these spaces. These principles are relevant on a global scale, including within Canada.

Culturally Safe Cancer Care: From Aspiration to Legislation

While cancer prevention and screening are critical, once diagnosed there is a need to focus on culturally safe and equitable cancer care specific to Indigenous individuals and families on this path. This dialogue has expanded over the years—from these concepts being seen as aspirational and compassionate to being expected and vital. In Canada, this recognition includes obligations documented in Truth and Reconciliation Calls to Action [1], and the province of British Columbia’s (BC) In Plain Sight Report on Indigenous-Specific Racism and Discrimination in BC Health Care [2]. Challenges faced by Indigenous peoples in healthcare and witnessed across the cancer-care spectrum are not unique to Canada, as efforts to enshrine the right to “the highest attainable standard of physical and mental health” are well documented in the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) [3]. Notable is the subsequent legislation of these UNDRIP promises in the BC DRIP Act [4], enabling ongoing implementation of BC’s inaugural Indigenous-specific cancer strategy [5] and the expected increased scope and impact of subsequent strategies and growing partnerships. Partnerships with Indigenous communities, leadership, and healthcare organizations are necessary for creating tools and legislation to optimize cancer care for Indigenous individuals. This includes sharing experiences internationally to demonstrate how Indigenous self-determination, data governance, access to care, and the research driving it all contribute to the goal of improved outcomes and wellness on one’s cancer journey.

The Cancer-Care Spectrum: Equity and Optimizing the Journey

The cancer-care journey can be smooth and predictable, but for many it can be frightening and sub-optimal. Unfortunately, as in most healthcare cases, the experiences of Indigenous people tend to fall into the latter category [2]. Policies implemented through colonization and Western biomedical models have led to systemic anti-Indigenous stereotyping and racism within healthcare. This has created culturally unsafe environments along the entire cancer-care spectrum, from prevention and screening, diagnosis and treatment, to palliative care and survivorship.

Cancer is complex, and optimal care requires a multidisciplinary approach to treatment. Cancer surgeons are often the first specialists that patients meet, either upon symptom presentation, during a diagnostic biopsy, or for surgical resection for treatment and staging. Surgeons may disclose a cancer diagnosis to patients and families, but healthcare professionals (HCPs) often lack the training to do so in a culturally safe and appropriate manner. Following surgery, a patient may see a medical oncologist for systemic drug treatments (e.g., chemotherapy) and/or a radiation oncologist for radiation treatment. Medical oncologists increasingly rely on genomic testing to guide treatment decisions. Unfortunately, such testing may be less relevant to Indigenous peoples who were excluded from the study populations used to derive treatment options or guidelines. Radiation treatment has a unique challenge of geographic accessibility, as radiotherapy centers are typically situated in larger cities, given the infrastructure and human resources required [6], meaning patients often travel long distances to access a center. Discussions around end of life, including the decision to stop treatment, are critical to ensure patients’ wishes are respected and to preserve quality of life and dignity. These discussions must be in culturally safe environments with supportive resources, but both are often absent.

Across all healthcare professions, there is a significant lack of Indigenous HCPs. Despite this challenge, every point of care is an opportunity for cancer HCPs to embed humility and cultural safety into their practice. Healthcare delivery is supported and led by a wide range of HCPs, including nurses, social workers, dieticians, pharmacists, and Indigenous patient navigators. This interdisciplinary space optimizes care, especially when the full range of perspectives, expertise, and resources are available and discussed with patients and their advocates. In Canada, there are programs and initiatives that aim to increase the presence of Indigenous trainees, researchers, and faculty in healthcare programs and Indigenous leadership in postsecondary institutions, research funding agencies, and cancer-care centers. In addition to having Indigenous peoples in these roles, all HCPs must learn how to provide culturally safe healthcare and commit to doing so in concert with other professional competencies. The University of BC has mandatory cultural safety and humility training for most first-year HCP students, including those studying medicine [7].

Knowledge Development Via Research and Capacity

Evidence-based cancer care in Canada is not based on research conducted with Indigenous communities. Cancer research is typically conducted in metropolitan regions affiliated with postsecondary academic institutions and tertiary cancer-care centers (clustered along the southern border in BC and Canada). Given the Canadian population demographics, Indigenous peoples are often based in rural, remote, and/or northern populations—that is, those least likely to have access to tertiary cancer care or research opportunities. This is especially true regarding clinical trials and oncogenomic research towards precision medicine. Without Indigenous participation, the challenges of generalizing research results to Indigenous individuals seeking cancer care continue to grow, including the expanding “genomic divide” when care is not taken to address inequities in access to genomic research as it evolves [8, 9]. Indigenous-led construction and governance of population-specific entities such as biobanks as research platforms [9] and background-variant libraries [10] as diagnostic tools are two examples emerging in Canada. While contemporary health and healthcare delivery are increasingly indexed to predictive, preventive, and participatory models, these require a shift towards considering the physical, emotional, mental, spiritual, and social facets of healthcare and wellbeing through culturally safe healing approaches [11, 12].

Just as cancer treatment inequities must be addressed, inequities in access to—and inclusion in—research that increases cancer knowledge must also be considered. While global examples show that Indigenous leadership in biobanks can lead to increased access to oncogenomic research, similar efforts must focus on participation and options in clinical trials, health-services research, and health-policy development and evaluation. Once again, with increased Indigenous expertise in these arenas and the contribution of passionate Indigenous individuals to determining solutions, this can be addressed nationally and internationally. Capacity building within healthcare and research must continue as a focus to provide potential solutions and optimize current (or create alternative) models of cancer-care delivery. These efforts must be led by Indigenous peoples, for Indigenous peoples—now a common, well-understood expectation.

Moving Forward

With official published reports, strategies, legislation, and policy developments, we are deepening our understanding of where we are at and where we must go regarding cancer care and Indigenous peoples in Canada. Cancer care is improving, and the provision of culturally safe care is an acknowledged goal in many facets of our healthcare system. Cancer research lags, but it is moving in a similar direction, with national and provincial research funding bodies, postsecondary institutions, and publishers recognizing the need to address inequities in their own fields. Access to culturally relevant, respectful, and safe cancer research and care involves increasing the number of Indigenous scholars, physicians, and leaders across all fields, allowing evidence-based care, providing precision medicine when possible, and considering innovative solutions to improve the cancer-care journey and ultimate outcomes for Indigenous peoples.