








































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Genitourinary malignancy, Indigenous health, 
cancer, Canadian First Nations, urology

None declared. Received on July 7, 2022 
Accepted on July 22, 2023 
This article has been peer reviewed.

Soc Int Urol J. 2023;4(2):85–87

DOI: 10.48083/ZDVM7715

Genitourinary Malignancy in Canadian 
Indigenous Populations

Jonathan Suderman, Peter C. Black

Department of Urologic Sciences, University of British Columbia, Vancouver, Canada

Sowing the Seeds of Health Care Disparity
Universal access to health care is a foundational principle in Canadian health care as set out by the Canada Health 
Act. As with many Indigenous groups around the world, Canadian Indigenous communities (First Nations, Métis, 
and Inuit) have faced disparities in health care. The cause of these disparities is multifactorial.

In Canada, the Indian Act of 1876 enacted many colonial laws aimed at eliminating Indigenous culture and assim-
ilating Indigenous people into a European-based Canadian society. This permitted the development of residential 
schools and allowed Indigenous populations to be moved onto reserve lands. In 1895 the Indian Act was amended to 
make any Indigenous festival, dance, or ceremony illegal, despite these acts playing a fundamental role in the healing 
practices of many Indigenous people. These policies have led to a long history of mistrust between Indigenous popu-
lations and the Canadian government. With government-funded health care and generations of negative experiences 
associated with Canadian western health care, many disparities have arisen that limit Indigenous health outcomes 
and access to health care services.

Genitourinary Malignancy in Canadian Indigenous Peoples
Cancer is among the leading causes of death in Indigenous people[1]. Canadian Indigenous people have a higher 
incidence of several cancers, including colorectal and kidney cancer, and a lower incidence of others, including 
prostate, breast, and bladder cancer[2,3]. With several genitourinary cancers, the 5-year survival rate is worse in 
Indigenous people than in their non-Indigenous peers[4].

A paucity of data exists regarding genitourinary malignancies in Canadian Indigenous populations. A Health 
Report published in 2021 looking at the incidence and mortality of cancer in First Nations people in Ontario between 
1991 and 2010 provides the best estimate of cancer burden in Canadian Indigenous populations[5].

Kidney Cancer
An elevated incidence of kidney cancer has been reported in First Nations females living in British Columbia[2], 
and males and females living on reserves or northern cities in Quebec[6]. In the Ontario cohort, kidney cancer was 
the fifth most diagnosed cancer in First Nations people, yet only the 12th most common in the general population. 
Kidney cancer was identified as having significantly higher relative risk in First Nations males and females in all 
age groups compared with the rest of the population. Kidney cancer rates in First Nations females also increased 
over time relative to other females in Ontario. This may relate to a higher prevalence of risk factors (eg, smoking and 
obesity) within these populations[7]. Mortality rates from kidney cancer were significantly elevated in all ages.

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Prostate Cancer
In the Ontario study, prostate cancer rates were 
unchanged in First Nations males from 1991 to 2010, 
despite an increased incidence in males in the general 
population[5], suggesting that First Nations populations 
did not follow the worldwide trend of overdiagnosis 
associated with widespread implementation of PSA 
screening during the early 1990s. This may reflect access 
to and utilization of cancer screening protocols. This 
discrepancy was confirmed in the First Nations Regional 
Health Survey (2009) that showed that only 23.4% of 
First Nations men over 18 have ever had a screening 
digital rectal examination or serum PSA test[8]. The 
national estimates suggest that 35% to 75% of males 
over 50 years of age have had at least one PSA test. 
This number seems profound but may be biased by the 
discrepant age ranges included in both populations[9].

Prostate cancer incidence was significantly lower in 
First Nations males compared to the general popula-
tion[5], yet Withrow et al. showed a significant excess 
mortality rate ratio (EMRR) between 1992 and 2000 
in Canadian First Nations men with prostate cancer 
(EMRR 2.76; 95% CI 1.81 to 4.21)[4]. Concurrently, pros-
tate cancer rates were found to be lower in the Quebec 
reservation cohort[6].

Other Genitourinary Malignancies
First Nations males had significantly lower rates of 
bladder cancer compared with the general population 
(rate ratio of 0.47 [95% CI 0.36 to 0.61]). The trend in 
First Nations females was similar but less pronounced 
(rate ratio of 0.73 [95% CI 0.50 to 1.01]). Rates of testis 
cancer did not differ significantly from the rates in the 
general population (rate ratio of 0.76 [95% CI 0.57 to 
1.00]), and rates of penile malignancy were not reported 
in the Ontario study results[5].

Putting the Numbers into Context
Differences have been shown in cancer rates and 
outcomes between Canadian First Nations people 
and the general population. While biological factors 
and variable exposure to risk factors are important, 

social determinants of health are likely most critical. 
These include historical trauma, poor access to health 
care, poor education, marginalization, and lower 
socioeconomic status[5].

Jamal et al. suggested working towards “equitable 
access to a conducively built environment, affordable 
healthy foods, and a culturally safe and respectful health 
system” for Indigenous people to help address discrep-
ant medical experiences related to cancer diagnosis 
and treatment[5]. This sense of safety may be especially 
important relating to genitourinary cancers, as many 
clinical scenarios can include sensitive or uncomfortable 
examinations such as cystoscopy, genital examination, 
or digital rectal examinations.

Education and screening programs have yielded 
promising results in other body systems. Lung and 
cervical cancer rates have fallen, which may be related 
to programs to reduce smoking and encourage cervi-
cal cancer screening in First Nations communities[7]. 
Similar programs may be beneficial for genitourinary 
malignancies.

The Canadian health care system divides responsibil-
ities between federal, provincial, and territorial govern-
ments. The federal government has taken steps to work 
alongside Indigenous populations, instituting indepen-
dent programming such as Indigenous Services Canada, 
which provides independent funding and health care 
services to First Nations, Inuit, and Métis communi-
ties. Multiple policies also exist at the provincial level, 
where legislation “recognizes the values and role of 
Indigenous groups in the planning and delivery of 
health services in their communities.” Some provinces 
have supported Indigenous-led organizations to oversee 
delivery of health care in a culturally safe and appropri-
ate fashion[10].

Finally, Canadian medical schools now set aside 
designated seats for students with Indigenous heritage. 
This is an excellent step towards encouraging Indigenous 
representation within the Canadian medical community 
and bridging the gap between traditional and modern 
healing practices.

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References

1. Tjepkema M, Wilkins R, Senécal S, Guimond É, Penney C. Mortality 
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study. Health Rep.2009;20(4):31-51. PMID: 20108604

2. McGahan CE, Linn K, Guno P, Johnson H, Coldman AJ, Spinelli JJ, et 
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3. Mazereeuw MV, Withrow DR, Diane Nishri E, Tjepkema M, Marrett 
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5. Jamal S, Jones C, Walker J, Mazereeuw M, Sheppard AJ, Henry D, 
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6. Louchini R, Beaupre M. Cancer incidence and mortality among 
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8. First Nations Information Governance Centre. First Nations Regional 
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9. Canadian Partnership Against Cancer, Screening Action Group. PSA 
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10. Government of Canada. Indigenous health care in Canada. Published 
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https://www.partnershipagainstcancer.ca/topics/prostate-cancer-screening-trials/
https://www.partnershipagainstcancer.ca/topics/prostate-cancer-screening-trials/
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https://www.sac-isc.gc.ca/eng/1626810177053/1626810219482
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