Poor access to appropriate cancer diagnosis and care means that Australian prison inmates with cancer are at significantly increased risk of poor outcomes including death compared with the general population, a study has concluded.

At the same time, the AMA has repeated longstanding calls for governments to lift the “appalling” ban on prison inmates accessing Medicare and PBS services.

Delayed diagnosis and nonattendance at clinic appointments due to prison transport problems were key reasons why incarcerated Australians suffered from substandard cancer care, according to researchers led by Victorian oncologist Dr Genni Newnham.

With a growing and ageing prison population, tailored interventions are urgently required to improve the provision of timely, comprehensive cancer care, the researchers say.

The largest study of cancer in this population, the research involved a retrospective review of all Victorian prisoners with malignancy treated at St Vincent’s Hospital Melbourne from 2002 to 2017.

Over the 15 years, 191 prisoners with 200 cancers were identified, almost one-third of whom had incurable disease at diagnosis.

Indeed, 77% were symptomatic at the time of diagnosis, with only 12% diagnosed incidentally and 8% through routine follow-up, reported the researchers in Internal Medicine Journal (link here).

There were significant trends of increasing age and numbers of cancer diagnoses over the 15-year period, they noted.

In the first five years, there were 31 cancer diagnoses with a median age of 45, whereas in the final five years of the study, there were 101 cancer diagnoses and a median age of 55.

“This indicates our prison population is ageing and experiencing worse health outcomes,” said Dr Newnham, a medical oncologist at St Vincent’s Hospital, Melbourne.

“Our study showed that over time, cancer diagnoses in the prison population has increased rapidly. And wait times for prisoners to see a specialist were up to 30 weeks. It’s a problem that’s only getting worse.”

“We are seeing more and more prisoners with cancer who are in the over the age of 55, too – meaning there’s an ageing prison population with cancer and who are not getting access to the care they need.”

Adherence to Optimal Care Pathways (OCPs) was as low as 30% for some cancer types, indicating poor delivery of care in those cases, the researchers added.

“Our data demonstrates that our patients’ cancer was predominately exposure-related and diagnoses were often delayed, making management difficult and adding to the challenges of providing optimal care,” they said.

Barriers to receiving care

“Nonattendance was a huge issue for incarcerated patients, and although personal choice played a role in missed appointments, hospital practice and transport often impacted patients’ ability to make their appointments.”

Barriers included transport and travel, as well as personal safety concerns, with all prisoners requiring treatment having to go through a single, high-security prison in Melbourne before attending hospital regardless of their usual classification.

“Additionally, prisoners often refuse to attend medical appointments at SVHM even when transport is available,” the researchers said.

“This may relate to poor health literacy and a lack of understanding of the importance of medical treatment. It is possible that there are human barriers to communication with prisoners that may impact their engagement in medical care.”

“Treatment refusal may also relate to competing priorities, as prisoners will often prioritise court appearances over medical appointments. Finally, several prisoners in this cohort, particularly those from the lower-security or protections prisons, reported personal safety concerns at Port Philip Prison. They were not necessarily refusing medical care but the process required to access it.”

Solutions were likely to be multifaceted but should include more use of telemedicine as a starting point, the researchers recommended.

Beyond that, delivery of care beyond hospital wards also warranted investigation, enabling some treatments and tests to be delivered within or close to the prisons, they said.

“Regardless of what additional approaches may be used, improved shared understanding and communication between the health and justice systems is essential to enable more efficient use of available resources so that the cancer outcomes of this vulnerable group are improved,” they concluded.

Inmates denied Medicare and PBS services

Meanwhile the AMA has agains called on the federal government to remove “unfair” rules that prevent people in custodial settings from accessing Medicare and medicines subsidised by the Pharmaceutical Benefits Scheme (PBS).

AMA President Professor Steve Robson said health services in custodial settings must be of equivalent professional, ethical and technical standards to the wider Australian community.

“It is appalling and an affront to Australia’s human rights status that prisoners in this country aren’t allowed to receive the same quality of healthcare as the wider community,” Professor Robson said.

“Because of legislation dating back to 1973, people in custodial settings are not able to receive treatment under the country’s universal health insurance scheme, Medicare, nor are they allowed to receive medicines subsidised by the PBS,” he noted.

The legislation was designed to avoid duplication of services, with state and territory governments funding prison-based health services. However, as an AMA submission to the PBAC notes, this exclusion has led to significant health treatment disparities for Australian prisoners.

The AMA said people in prison with complex medical conditions that require high-cost drugs currently have their treatment determined by state justice health departments, while everyone else in the community has access to the PBS.

“The AMA is pleased PBAC has acknowledged barriers preventing people in custody from accessing PBS medicines, and we look forward to the PBAC meeting in March when the committee will provide an update on the advice received from jurisdictions and various submissions,” said Professor Robson.