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Commentry 

Improving First Nations Cancer Journeys: 

Current Policy Perspectives and 

Approaches in British Columbia, Canada 
Nadine R. Caron2,3, Kevin Linn1; John J. Spinelli2,3, Harmony Johnson1*;  

1. First Nations Health Authority, Vancouver, BC, Canada 
2. BC Cancer, Vancouver, BC, Canada 
3. University of British Columbia, Vancouver, BC, Canada 

*Corresponding author email: harmony.johnson@fnha.ca 

ABSTRACT 
Processes of reconciliation in Canada have created a new climate for discussions about systemic racism 

and a lack of cultural safety and humility as a root cause of health outcome disparities for First Nations 

people. In British Columbia, efforts to improve First Nations cancer outcomes and experiences are now 

formalized through an Indigenous Cancer Strategy that incorporates BC First Nations perspectives on 

health and wellness. In partnership with the unique First Nations health governance structure in the 

province, health system and community partners are leveraging the current climate for change to 

improve First Nations cancer journeys, and are leading the way to improving culturally safe health services 

for all British Columbians. 

KEYWORDS: First Nations, Indigenous, Aboriginal, cancer, disparities, cultural safety, cultural humility 

  

Citation: Caron N et al (2018) Improving First Nations cancer journeys: current policy perspectives and 

approaches in British Columbia, Canada. Cancer Health Disparities  2:e1-e8. doi:10.9777/chd.2018.10012 

 

 

 

 

 

 

 

 

 

 

 



 
 
 
 
 

 

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First Nations in British Columbia (BC), Canada have 

enjoyed a rich history of health and wellness since 

time immemorial. This health and wellness was 

intentionally disrupted through processes of 

colonialism implemented by governments and other 

institutions, including policies of forcible 

displacement of people from family and community, 

culture and ceremony, language and land. The 

resulting loss and subsequent trauma from these 

policies continue to negatively impact many First 

Nations people in their interaction with Western 

institutions, including the healthcare system. 

Colonialism continues to manifest itself in structural 

barriers for First Nations people in achieving 

equitable access to health and wellness resources 

and services, including those that relate to cancer 

control. Canada is a country in the midst of facing 

this history of colonialism and its continuing impact 

on the health and wellness of Indigenous people. In 

2015, the Truth and Reconciliation Commission (TRC) 

of Canada documented the history of Canadian 

federal government policy that resulted in Aboriginal 

children being taken from their families and placed in 

Indian Residential Schools. In the TRC’s report, it was 

concluded that Indian Residential Schools amounted 

to cultural genocide. As part of the reconciliation 

process, ninety four ‘Calls to Action’ were presented 

by the TRC to redress the harms inflicted through 

various policies of colonialism, including calls related 

specifically to health and health service delivery (TRC, 

2015). In this era of Truth and Reconciliation in 

Canada, there is increasing acknowledgement of the 

ongoing systemic racism and bias against First 

Nations people that is unacceptable. In this context, it 

is recognized that First Nations people have a right 

to access health and cancer care services that are 

free of discrimination and that address unique 

community and individual needs. However, health 

services in BC, including cancer care, were never 

designed with an understanding of First Nations’ 

definitions of health and wellness, nor of colonialism 

and its impact on First Nations people. A transparent 

recognition of the need for cultural safety as part of 

quality improvement in health services is required, 

and there is now a unique and unprecedented 

system-wide movement underway to achieve this in 

BC.  

The First Nations Perspective on Health and Wellness 

in Figure 1 presents a visual depiction of BC First 

Nations’ philosophy and definition of health and 

well-being, which recognizes the health and wellness 

of individuals as consisting and being an outcome of 

many interrelated internal and external factors (First 

Nations Health Authority [FNHA], nd-a). This 

Perspective was developed based on guidance 

provided by BC First Nations and founded in 

traditional teachings. The centre circle represents 

individual human beings, recognizing that wellness 

starts with individuals. The second circle illustrates the 

importance of mental, emotional, spiritual and 

physical facets of a healthy, well and balanced life. 

The third circle represents the overarching values 

that support wellness, including: respect, wisdom, 

responsibility, and relationships. The fourth circle 

depicts the people that surround us and the places 

from which we come: Nations, family, community 

and land. And the fifth circle depicts the social, 

cultural, economic and environmental determinants 

of our health and well-being. Recognizing all 

components of the circle and the interconnectedness 

of the physical, emotional, spiritual and mental 

dimensions and determinants of First Nations health 

and wellbeing is a starting point towards improving 

quality and addressing disparities in cancer care 



 
 
 
 
 

 

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between First Nations and non-First Nations people in the province. 

 

Figure 1. First Nations Perspective on Health and Wellness 

This Perspective is a visual depiction of First Nations peoples’ collective philosophy that the mind, heart, 

body and spirit are all connected and are supported by internal and external factors including culture, 

relationships, and responsibility, and are shaped by family, community, the land and broader 

environmental, social and economic factors (FNHA, nd-a). 

A recent study of incidence and survival rates 

between First Nations and non-First Nations 

people living in BC between 1993 and 2010 

highlighted disparities in cancer incidence and 

outcomes (Mcgahan et al., 2017). Data from this 

study, the first of its kind, demonstrated that First 

Nations people in BC were more likely to be 

diagnosed with colorectal (men and women) and 

cervical cancers while enduring the same incidence 

rates of breast cancer, which was the most 

commonly diagnosed cancer in First Nations and 

non-First Nations women, as indicated in Table 1. 

Colorectal cancer was the second most commonly 

diagnosed cancer in First Nations men and 

women, and cervical cancer was the fourth most 

common among First Nations women. Study 

findings also showed lower survival rates in 10 out 

of the 12 cancer sites examined in First Nations 

men and 10 out of 15 cancer sites examined in First 

Nations women, including lower survival rates for 

colorectal (men and women), breast and cervical 

cancers as indicated in Table 2. Lower cancer 

survival rates can be caused by a combination of 

differences in access to or utilization of primary 



 
 
 
 
 

 

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care, screening programs (and subsequent impact 

on stage of cancers at time of diagnosis), and/or 

high quality, timely, appropriate and effective 

cancer treatment, to name a few. While this study 

was a key step in understanding the quality of 

cancer care from an equity perspective, it needs to 

be acknowledged that First Nations health goals 

and targets should not be solely defined by 

comparisons with the health status of non-First 

Nations people. 

 

Table 1: Incidence Counts, Age-Standardized Incidence Rates and Standardized Rate Ratios (SRRs) by 

disease site for each sex, in First Nations (FN) and non-FN populations 1993-2010. 

 Incidence Age-Standardized Incidence Rate (95% CI) SRR (95% CI) 

 FN Non-FN FN Non-FN  

Females  

 Breast 767 45,478 224.0 ( 207 - 241) 240.0 ( 238 - 243) 0.93 (0.87 - 1.01) 

 Cervical 134 2,810 33.1 (27.0 - 39.3) 17.2 (16.6 - 17.9) 1.92 (1.49 - 2.48) 

 Colorectal 292 18,226 92.9 (81.5 - 104) 76.4 (75.1 - 77.6) 1.22 (1.06 - 1.39) 

Males  

 Colorectal 366 21,834 154 ( 137 - 171) 111 ( 109 - 113) 1.39 (1.22 - 1.58) 

Note: Adapted by permission from Mcgahan et al: Springer International Publishing. Cancer Causes & 

Control. Cancer in First Nations people living in British Columbia, Canada: an analysis of incidence and 

survival from 1993 to 2010. Copyright Springer International Publishing AG 2017 

Table 2: Observed 1-year and 5-year cause-specific survival and age-adjusted cause-specific hazard ratio 

(95% CI) by disease site in First Nations (FN) and non-FN populations, 1993-2010. 

 FN 

Incidence 

1-year age-standardized cause-

specific survival 

5-year age-standardized cause-

specific survival 

Age-

Standardized 

HR (95% CI) 

  FN Non-FN FN Non-FN  

Females       

Breast 
767 0.97 (0.95-0.98) 0.96 (0.96-0.97) 0.83 (0.80-0.86) 0.85 (0.85-

0.86) 

1.14 (0.96-1.35) 

Cervical 
134 0.89 (0.82-0.93) 0.89 (0.88-0.90) 0.73 (0.64-0.80) 0.73 (0.71-

0.75) 

1.19 (0.84-1.67) 

Colorectal 
292 0.82 (0.77-0.86) 0.78 (0.78-0.79) 0.57 (0.50-0.63) 0.57 (0.56-

0.57) 

1.16 (0.97-1.39) 

Males       

Colorectal 
366 0.78 (0.73-0.82) 0.81 (0.81-0.82) 0.51 (0.45-0.57) 0.57 (0.56-

0.57) 

1.30 (1.12-1.52) 

Note: Adapted by permission from Mcgahan et al: Springer International Publishing. Cancer Causes & 

Control. Cancer in First Nations people living in British Columbia, Canada: an analysis of incidence and 

survival from 1993 to 2010. Copyright Springer International Publishing AG 2017

Understanding BC’s cancer care system is 

important when interpreting these statistics. 

Cancer care services in BC were designed and are 

delivered by a diverse matrix of health system 

partners. For example, there are six regional BC 

Cancer centres in the province that provide all 

radiation therapy treatments, over 50% of 

chemotherapy treatments, specialized imaging 



 
 
 
 
 

 

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services (such as PET scans and breast MRI), and a 

range of patient assessments, follow-up and 

supportive cancer care services. Other important 

cancer care services, such as surgery, diagnostics 

and palliative care, as well as some local delivery 

of chemotherapy treatments, are planned and 

provided by regional health authorities. For the 

province’s population-based colon, breast and 

cervical cancer screening programs, a partnership 

framework is followed with BC Cancer overseeing 

the provincial approach, primary care providers 

identifying eligible patients for screening, and 

regional health authorities and community 

(private) imaging clinics and laboratories delivering 

the screening tests. As with many health services in 

BC, participation in these screening programs 

requires access to a primary care provider. This is 

concerning, as in addition to the cancer outcome 

disparities noted earlier, it has also been found 

that First Nations people are less likely than non-

First Nations people to be attached to a primary 

care physician (FNHA, nd-b). BC also has a publicly 

funded vaccination program against the Human 

Papilloma Virus (HPV), which includes free 

vaccinations for all boys and girls as part of a 

school-age child vaccination schedule. 

Considering this complexity in service delivery, full 

engagement and coordination amongst BC 

Cancer, regional health authority, and primary care 

partners is needed to improve the quality of 

cancer care services in the province.  

For First Nations people, families and communities, 

there is an additional level of complexity and 

planning required for health service delivery, as 

the federal government has a constitutional 

responsibility for First Nations in Canada while the 

provinces are constitutionally responsible for 

health services (Health Canada, 2014). This mix of 

federal and provincial responsibility for First 

Nations has created a lack of jurisdictional clarity 

that results in barriers for First Nations people in 

accessing healthcare (Indigenous Services Canada, 

2018; Lavoie, J. G., 2013). There are concerns that 

these barriers to accessing healthcare also extend 

to receiving vital cancer care services in the 

province. Since 2006, a significant shift has been 

underway in BC to resolve these jurisdictional 

barriers and recognize the need to meaningfully 

involve First Nations in decision-making when it 

comes to health service planning. A unique First 

Nations health governance structure in BC, which 

includes the First Nations Health Authority (FNHA), 

has been established. FNHA is the first population-

based health authority in the province and 

amongst the largest First Nations public service 

organizations in Canada (Gallagher, Mendez, & 

Kehoe, 2015). It works to drive quality 

improvement in service delivery for First Nations 

and all British Columbians by promoting 

partnerships, collaborations, and innovation with 

provincial and regional health authorities. FNHA is 

responsible for the design and delivery of First 

Nations health programs and services that were 

formerly handled by the federal government in BC, 

and is involved in decision-making within the 

larger provincial health system related to 

prioritization, planning, service coordination, and 

accountability monitoring. As a result, and in the 

context of reconciliation, addressing disparities in 

First Nations care and outcomes is now being built 

into key processes of health service planning and 

quality improvement efforts in the province.  

One of the quality improvement priorities being 

championed by FNHA and health system partners 

has been a system-wide movement on 

embedding cultural safety and humility within 

health services. FNHA’s Policy Statement on 

Cultural Safety and Humility provides a vision for 



 
 
 
 
 

 

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this work (FNHA, nd-e). In reflection of this vision, 

cultural safety is an outcome based on respectful 

engagement that recognizes and strives to 

address power imbalances inherent in the 

healthcare system. It results in an environment free 

of racism and discrimination, where people feel 

safe when receiving care. Cultural humility is a 

process of self-reflection for healthcare providers 

to understand personal and systemic biases, and 

to develop and maintain respectful processes and 

relationships based on mutual trust. When 

healthcare professionals engage with First Nations 

people from a place of cultural humility, they are 

helping to create a safer healthcare environment 

where individuals and families experience respect. 

This puts power in the hands of clients to define 

what culturally safe care looks and feels like, and 

requires training of healthcare providers to be 

lifelong learners and self-interrogators to 

understand how their culture and society impacts 

their practice. By improving cultural safety in 

health services, First Nations people will be more 

likely to access care when needed; increased 

access and utilization of healthcare services will 

inevitably result in improved health outcomes.  

To operationalize cultural safety and humility as a 

health system priority, key provincial and regional 

health partners have signed Declarations of 

Commitment to advance cultural safety and 

humility and are undertaking associated action 

planning and implementation work. Health system 

partners include all BC regional and provincial 

health authorities (FNHA, nd-c) and all twenty-

three BC Health Regulators (provincial regulatory 

colleges of health professions; FNHA, nd-d). Work 

is also underway with universities and education 

providers in the province to support the education 

needs of students studying in the health and social 

sciences; thereby supporting improvements in 

cultural safety on many fronts and for the long 

term. As per the TRC’s ‘Calls to Action’ #23 and 

#24, cultural safety and humility has now become 

necessary and expected (TRC, 2015). These 

essential concepts are no longer considered 

progressive or optional. In a country as diverse as 

Canada, this is seen as progress not just for 

Indigenous people, but for all Canadians. 

The issue of cultural safety and humility is now also 

firmly embedded in provincial cancer care quality 

improvement efforts through a first-of-its-kind 

Indigenous Cancer Strategy released in 2017 

(FNHA, Métis Nation British Columbia, BC 

Association of Aboriginal Friendship Centres, and 

BC Cancer, nd). Embodying a culturally safe 

philosophy throughout its development, the 

strategy took a “best of both worlds” approach, 

blending Western models of strategy development 

with a deep commitment to Indigenous decision-

making and community engagement. In the 

context of reconciliation, the strategy posits that 

the disparities in cancer outcomes are at least 

partially attributable to processes of colonialism, 

intergenerational trauma and a lack of cultural 

safety in the healthcare system, particularly as it 

relates to primary care and tertiary cancer 

treatment services. Therefore, the Indigenous 

Cancer Strategy aims to improve Indigenous 

cancer journeys by implementing actions that 

promote cultural safety and humility along all steps 

of the cancer journey, from prevention through to 

survivorship and end-of-life. Examples include: 

 Completing relevant data linkages to identify 

First Nations HPV vaccination rates, cancer 

screening (colon, cervical and breast cancer) 

program participation rates, and updating First 

Nations cancer incidence (including stage at 

diagnosis) and survival rates to evaluate the 



 
 
 
 
 

 

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performance of the cancer control system for 

First Nations people in order to direct solutions 

for improvement specific to such findings.   

 Promoting client and community awareness 

and engagement in cancer prevention 

(environment, commercial tobacco, physical 

activity, healthy eating and HPV vaccination) 

and screening programs (colon, cervical and 

breast cancer); 

 Supporting health system partners to improve 

quality of service across the cancer care 

spectrum through applying a lens of cultural 

safety and humility to their values and 

attitudes, structures and policies, system 

performance frameworks, and staff training 

and development; and, 

 Connecting First Nations people, families and 

communities impacted by cancer to build an 

empowered First Nations cancer survivorship 

network to provide peer-support and further 

identify and guide First Nations cancer quality 

improvement priorities. 

The development and now implementation of an 

Indigenous Cancer Strategy in BC is an essential 

approach to strategically improving First Nations 

cancer journeys in the province. The processes of 

reconciliation in Canada have created a new 

climate for discussions about systemic racism, and 

highlighted the lack of cultural safety as a root 

cause of health outcome disparities for First 

Nations and the need for greater First Nations 

decision-making. In BC, one of these processes of 

reconciliation is the establishment of a First 

Nations health governance structure that works in 

partnership with federal and provincial 

governments in the design and delivery of health 

services accessed by First Nations people. Through 

this process, efforts have been initiated to support 

quality improvement in health services through 

cultural safety and humility. These broad priorities 

and processes are being focused specifically to 

improve cancer care and associated outcomes for 

First Nations people. Through the development of 

an Indigenous Cancer Strategy, FNHA and health 

system partners are now leveraging the current 

climate for change and reconciliation to improve 

cancer outcomes and experiences for First Nations 

people, families and communities, and are leading 

the way of improving culturally safe health services 

for all British Columbians. 

Acknowledgements 

The authors would like to acknowledge the 

contribution of the late Preston Guno who was 

instrumental in the development of the BC 

Indigenous Cancer Strategy. 

Conflict of interest 
The authors declare that no competing or conflict of 

interests exist. The funders had no role in study 

design, writing of the manuscript, or decision to 

publish. 

Authors’ contributions 
All authors contributed equally to this manuscript.  

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