Effect of community population size on breast cancer screening, stage distribution, treatment use and outcomes

Current Challenges and Disparities in the Delivery of Equitable Breast Cancer Care in Canada

Recent exciting advances in the diagnosis and management of breast cancer have improved outcomes for Canadians diagnosed and living with breast cancer. However, the reach of this progress has been uneven; disparities in accessing care across Canada are increasingly being recognized and are at risk of broadening. Members of racial minority groups, economically disadvantaged individuals, or those who live in rural or remote communities have consistently been shown to experience greater challenges in accessing 'state of the art' cancer care. The Canadian context also presents unique challenges-vast geography and provincial jurisdiction of the delivery of cancer care and drug funding create significant interprovincial differences in the patient experience. In this commentary, we review the core concepts of health equity, barriers to equitable delivery of breast cancer care, populations at risk, and recommendations for the advancement of health equity in the Canadian cancer system.

Barriers to Screening At-risk Populations in Canada

Cancer screening is invaluable for early detection of disease, including for breast and lung cancer. Through early detection, cancer treatment can be commenced prior to the development of advanced stage disease, significantly reducing morbidity and mortality. However, eligible patients may face barriers when accessing screening services, and some groups may be more disproportionately affected than others. This review aims to describe some of the most prominent barriers that at-risk populations may face when accessing image-based cancer screening services in Canada. Characterizing these barriers would be helpful in determining the best strategies to increase uptake to these screening services and, consequently, improve health equity.

Small area disease mapping of cancer incidence in British Columbia using Bayesian spatial models and the smallareamapp R Package

INTRODUCTION

There is an increasing interest in small area analyses in cancer surveillance; however, technical capacity is limited and accessible analytical approaches remain to be determined. This study demonstrates an accessible approach for small area cancer risk estimation using Bayesian hierarchical models and data visualization through the smallareamapp R package.

MATERIALS AND METHODS

Incident lung (N = 26,448), female breast (N = 28,466), cervical (N = 1,478), and colorectal (N = 25,457) cancers diagnosed among British Columbia (BC) residents between 2011 and 2018 were obtained from the BC Cancer Registry. Indirect age-standardization was used to derive age-adjusted expected counts and standardized incidence ratios (SIRs) relative to provincial rates. Moran's I was used to assess the strength and direction of spatial autocorrelation. A modified Besag, York and Mollie model (BYM2) was used for model incidence counts to calculate posterior median relative risks (RR) by Community Health Service Areas (CHSA; N = 218), adjusting for spatial dependencies. Integrated Nested Laplace Approximation (INLA) was used for Bayesian model implementation. Areas with exceedance probabilities (above a threshold RR = 1.1) greater or equal to 80% were considered to have an elevated risk. The posterior median and 95% credible intervals (CrI) for the spatially structured effect were reported. Predictive posterior checks were conducted through predictive integral transformation values and observed versus fitted values.

RESULTS

The proportion of variance in the RR explained by a spatial effect ranged from 4.4% (male colorectal) to 19.2% (female breast). Lung cancer showed the greatest number of CHSAs with elevated risk (Nwomen = 50/218, Nmen = 44/218), representing 2357 total excess cases. The largest lung cancer RRs were 1.67 (95% CrI = 1.06-2.50; exceedance probability = 96%; cases = 13) among women and 2.49 (95% CrI = 2.14-2.88; exceedance probability = 100%; cases = 174) among men. Areas with small population sizes and extreme SIRs were generally smoothed towards the null (RR = 1.0).

DISCUSSION

We present a ready-to-use approach for small area cancer risk estimation and disease mapping using BYM2 and exceedance probabilities. We developed the smallareamapp R package, which provides a user-friendly interface through an R-Shiny application, for epidemiologists and surveillance experts to examine geographic variation in risk. These methods and tools can be used to estimate risk, generate hypotheses, and examine ecologic associations while adjusting for spatial dependency.

Ninety-day mortality after radiotherapy for head and neck cancer: A population-based comparison between rural and urban patients

BACKGROUND

This study assesses whether 90-day mortality differs between patients living in rural and urban areas, as lower access to supportive care services in rural areas could result in higher mortality.

METHODS

All patients with head and neck cancer (HNC) treated between 1998 and 2014 with radiotherapy in British Columbia were included. Patients were divided into rurality areas according to the Modified Statistics Canada (mSC) definition, which classifies a population <30 000 as rural and ≥30 000 as urban.

RESULTS

Five thousand five hundred and fifty-four patients were included in this study, of which 68% lived in urban centers. The 90-day mortality for rural versus urban patients were 3.0% and 3.9% (p = 0.09), respectively. Univariate and multivariate analyses showed no association with 90-day mortality and rurality.

CONCLUSION

After controlling for potentially confounding factors, we did not find a significant association between 90-day mortality and rurality in patients who were treated with radiotherapy for HNC in British Columbia.

Nurse Navigators' Views on Patient and System Factors Associated with Navigation Needs among Women with Breast Cancer

Coordinating breast cancer treatment is a complex task that can overwhelm patients and their support networks. Though the Cancer Patient Navigator (CPN) program in Nova Scotia (NS) provides professional assistance to patients, certain groups of patients may still face barriers to accessing its services. Employing interviews and a modified Delphi approach with CPN participants, this study sought to identify factors associated with the need for navigation to help better target CPN program referrals among breast cancer patients. Six CPNs were recruited directly through the CPN program manager for interviews and surveys. The CPNs identified 27 different factors, which were divided into 4 categories: sociodemographic, psychological, clinical and health systems. While these patient factors (particularly sociodemographic) are not directly modifiable, awareness of their association with the need for navigation could be used to better target patients with a high need for navigation for referral to CPN services.

Beyond Universal Health Care: Barriers to Breast Cancer Screening Participation in Canada

PURPOSE

Despite well-established preventive screening guidelines for breast cancer, screening rates do not meet targets in both the United States and Canada. Although access to preventive care is an important factor toward participation, breast cancer screening rates in Canada vary despite a universal health care system. The objective of this study is to understand features within the Canadian population that potentiate screening disparities through a systematic review of the literature.

METHODS

A search of MEDLINE and Embase was performed to identify relevant studies published from 2005 onward. Titles and abstracts were screened, followed by full-text screening. Inclusion criteria were defined as studies reporting on disparities in image-based screening for breast cancer.

RESULTS

Three hundred twenty-four studies were retrieved, from which 29 studies were selected on the basis of the predetermined inclusion criteria. Population groups identified at risk for low image-based screening participation included those of low socioeconomic status, individuals with comorbidities, new immigrants and refugees, those in remote geographic locations, individuals with intellectual or developmental disabilities, and ethnocultural minorities. Barriers to image-based screening can be improved by targeting measures specific to these at-risk groups at the individual, organization, and policy levels.

CONCLUSIONS

Multiple at-risk population groups exist for preventive cancer screening within a universal health care system. By understanding specific characteristics within these vulnerable populations, effective intervention strategies can be established to improve breast cancer preventive care.

Provincial development of a patient-reported outcome initiative to guide patient care, quality improvement, and research

The BC Cancer Agency Radiotherapy (RT) program started the Prospective Outcomes and Support Initiative (POSI) at all six centres to utilize patient-reported outcomes for immediate clinical care, quality improvement, and research. Patient-reported outcomes were collected at time of computed tomography simulation via tablet and 2 to 4 weeks post-RT via either tablet or over the phone by a registered nurse. From 2013 to 2016, patients were approached on 20,150 attempts by POSI for patients treated with RT for bone metastases (52%), brain metastases (11%), lung cancer (17%), gynecological cancer (16%), head and neck cancer (2%), and other pilots (2%). The accrual rate for all encounters was 85% (n = 17,101), with the accrual rate varying between the lowest and the highest accruing centre from 78% to 89% ( P < .001) and varying by tumour site ( P < .001). Using the POSI database, we have performed research and quality improvement initiatives that have changed practice.

Environmental market factors associated with electronic health record adoption among cancer hospitals

BACKGROUND

Although recent literature has explored the relationship between various environmental market characteristics and the adoption of electronic health records (EHRs) among general, acute care hospitals, no such research currently exists for specialty hospitals, including those providing cancer care.

PURPOSE

The aim of the study was to examine the relationship between market characteristics and the adoption of EHRs among Commission on Cancer (CoC)-accredited hospitals.

METHODS/APPROACH

Secondary data on EHR adoption combined with hospital and environmental market characteristics were analyzed using logistic regression. Using the resource dependence theory, we examined how measures of munificence, complexity, and dynamism are related to the adoption of EHRs among CoC-accredited hospitals and, separately, hospitals not CoC-accredited.

FINDINGS

In a sample of 2,670 hospitals, 141 (0.05%) were academic-based CoC-accredited hospitals and 562 (21%) were community-based CoC-accredited hospitals. Measures of munificence such as cancer incidence rates (OR = 0.99, CI [0.99, 1.00], p = .020) and percentage population aged 65+ (OR = 0.99, CI [0.99, 1.00], p = .001) were negatively associated with basic EHR adoption, whereas urban location was positively associated with comprehensive EHR adoption (OR = 3.07, CI [0.89, 10.61], p = .076) for community-based CoC-accredited hospitals. Measures of complexity such as hospitals in areas with less competition were less likely to adopt a basic EHR (OR = 0.33, CI [0.19, 0.96], p = .005), whereas Medicare Managed Care penetration was positively associated with comprehensive EHR adoption (OR = 1.02, CI [1.00, 1.05], p = .070) among community-based CoC-accredited hospitals. Lastly, dynamism, measured as population change, was negatively associated with the adoption of comprehensive EHRs (OR = 0.99, CI [0.99, 1.00], p = .070) among academic-based CoC-accredited hospitals.

PRACTICE IMPLICATIONS

A greater understanding of the environment's relationship to health information technology adoption in cancer hospitals will help stakeholders in these institutions make informed strategic decisions about information technology investments guided by their facilities' respective environmental factors. The results of this study may also be useful to hospital chief information officers and chief executive officers seeking to either improve their quality of care or achieve and maintain accreditation in providing cancer care.

Geographic Distribution and Survival Outcomes for Rural Patients With Cancer Treated in Clinical Trials

IMPORTANCE

Studies showing that patients with cancer from rural areas have worse outcomes than their urban counterparts have relied on cancer population data and did not account for differences in access to care. Clinical trial patients receive protocol-directed care by design, so large clinical trial databases are ideal for examining the impact of rural vs urban residency on outcomes.

OBJECTIVE

To compare the geographic distribution and survival outcomes for rural vs urban patients with cancer treated in clinical trials.

DESIGN, SETTING, AND PARTICIPANTS

In this comparative effectiveness retrospective cohort analysis, 36 995 patients from all 50 states enrolled in 44 phase 3 and phase 2/3 SWOG (formerly the Southwest Oncology Group) treatment trials from January 1, 1986, to December 31, 2012, were examined. Seventeen different cancer-specific analysis cohorts were constructed. Data through January 30, 2018, were analyzed.

MAIN OUTCOMES AND MEASURES

Rural vs urban residency was defined using the Rural-Urban Continuum Codes developed by the US Department of Agriculture. Multivariate Cox regression was used to estimate the association of residency with overall survival, progression-free survival, and cancer-specific survival, controlling for major disease-specific prognostic factors and demographic variables and stratifying by study. Different definitions of rurality were examined. The distribution of rural vs urban patients by geographic region was described.

RESULTS

Overall, 27.7% of patients were 65 years or older (range across 17 cohort analyses, 7.8%-74.5%), 40.3% were female in the non-sex-specific analyses (range across 17 cohort analyses, 28.1%-45.9%), and 10.8% were black (range across 17 cohort analyses, 1.9%-22.4%). Overall, 19.4% of patients (7184 of 36 995) were from rural locations. Rural patients were more likely to be aged 65 years or older (rural, 30.7% aged ≥65 years vs urban, 27.0% aged ≥65 years; difference, 3.7%; 95% CI, 2.5%-4.9%; P < .001), were less likely to be black (rural, 5.4% vs urban, 12.1%; difference, 6.7%; 95% CI, 6.1%-7.3%; P < .001), were similar with respect to sex (rural, 40.4% female vs urban, 39.7% female; difference, 0.6%; 95% CI, -1.4% to 2.6%; P = .53), and were well represented within major US geographic regions (West, Midwest, South, and Northeast). Clinical prognostic factors were similar. In multivariable regression, rural patients with adjuvant-stage estrogen receptor-negative and progesterone receptor-negative breast cancer had worse overall survival (hazard ratio, 1.27; 95% CI, 1.06-1.51; P = .008) and cancer-specific survival (hazard ratio, 1.26; 95% CI, 1.04-1.52; P = .02). No other statistically significant differences for overall, progression-free, or cancer-specific survival were found. Results were consistent regardless of the definition of rurality.

CONCLUSIONS AND RELEVANCE

Rural and urban patients with uniform access to cancer care through participation in a SWOG clinical trial had similar outcomes. This finding suggests that improving access to uniform treatment strategies for patients with cancer may help resolve the disparity in cancer outcomes between rural and urban patients.

Cancer mortality in Yukon 1999-2013: elevated mortality rates and a unique cancer profile

Background: Although cancer is the leading cause of death in Canada, cancer in the North has been incompletely described.

Objective: To determine cancer mortality rates in the Yukon Territory, compare them with Canadian rates, and identify major causes of cancer mortality.

Design: The Yukon Vital Statistics Registry provided all cancer deaths for Yukon residents between 1999-2013. Age-standardised mortality rates (ASMRs) were calculated using direct standardisation and compared with Canadian rates. Standardised mortality ratios (SMRs) were calculated using indirect standardisation relative to age-specific rates from Canada, British Columbia (BC), and three sub-provincial BC administrative health regions : Interior Health (IH), Northern Health (NH) and Vancouver Coastal Health (VCH). Trends in smoothed ASMRs were examined with graphical methods.

Results: Yukon’s all-cancer ASMRs were elevated compared with national and provincial rates for the entire period. Disparities were greatest compared with the urban VCH: prostate (SMR_VCH=246.3, 95% CI 140.9–351.6), female lung (SMR_VCH=221.2, 95% CI 154.3–288.1), female breast (SMR_VCH=169.0 95% CI, 101.4–236.7), and total colorectal (SMR_VCH=149.3, 95% CI 101.8–196.8) cancers were significantly elevated. Total stomach cancer mortality was significantly elevated compared with all comparators.

Conclusions: Yukon cancer mortality rates were elevated compared with national, provincial, urban, and southern-rural jurisdictions. More research is required to elucidate these differences.

Management of stage II and III rectal cancer in British Columbia: Is there a rural-urban difference?

BACKGROUND

This study assessed management of patients with locally advanced rectal cancer from rural, small and large local health authorities (LHA) in British Columbia (BC), Canada.

METHODS

We analyzed patients from 2004-2009 using a prospective database. Patients were defined as living in rural, small or large LHA using Statistics Canada definitions. Differences in treatments and outcomes were analyzed using chi-squared and log-rank tests, respectively.

RESULTS

Among 1964 patients, 13% lived in rural, 22% in small, and 66% in large LHAs. There were no differences in rates of abdominoperineal resections in rural (33%), small (39%) and large (35%) areas (p = 0.30). The proportion of patients who received radiotherapy (86-88%, p = 0.80) and adjuvant chemotherapy (56-57%, p = 0.89) were similar. There was no difference in 5-year disease-free survival (84-86%, p = 0.98) or overall survival (57-59%, p = 0.99).

CONCLUSIONS

The management and outcome of locally advanced rectal cancer patients seems to be comparable for rural and non-rural BC.

Breast cancer survival by molecular subtype: a population-based analysis of cancer registry data

BACKGROUND

The relation between breast cancer molecular subtype and survival has been studied in several jurisdictions, but limited information is available for Ontario. The aim of this study was to determine breast cancer survival by molecular subtype and to assess the effect on survival of selected demographic and tumour-based characteristics.

METHODS

We extracted 29 833 breast cancer cases (in 26 538 girls and women aged ≥ 15 yr) diagnosed between 2010 and 2012 from the Ontario Cancer Registry. Cancers were categorized into 4 molecular subtypes: 1) luminal A (estrogen-receptor-positive and/or progesterone-receptor-positive [ER+ and/or PR+] and negative for human epidermal growth factor receptor 2 [HER2-]), 2) luminal B (ER+ and/or PR+/HER2+), 3) HER2-enriched (ER- and PR-/HER2+) and 4) triple-negative (ER- and PR-/HER2-). We estimated associations with predictor variables (age, stage at diagnosis, histologic type, comorbidity and place of residence [urban or rural]) using a multivariate Cox proportional hazards model. Likelihood ratio testing was used to evaluate differences in risk of death.

RESULTS

Luminal A was the most commonly diagnosed subtype (59.0%) and had the greatest survival, whereas triple-negative had the poorest survival. For all subtypes, a dose-response effect was observed between the hazard of death and age and stage at diagnosis, with the greatest effect found for the HER2-enriched subtype (age: hazard ratio [HR] 7.87 [95% confidence interval (CI) 3.68-11.81]; stage at diagnosis: HR 37.71 [95% CI 34.64-41.27]). Moderate comorbidity (Charlson Comorbidity Index score 1 or 2) was associated with increased risk of death for triple-negative cancers (HR 2.42 [95% CI 1.36-4.31]), and severe comorbidity (Charlson Comorbidity Index score ≥ 3) increased the risk for all molecular subtypes.

INTERPRETATION

The results indicate the importance of including molecular subtype, along with age, stage at diagnosis and comorbidity, in assessing breast cancer survival. They highlight the need to address outcomes related to hormone-receptor-negative cancers, for which survival lags behind that for hormone-receptor-positive cancers.

Geographic variation in the intended choice of adjuvant treatments for women diagnosed with screen-detected breast cancer in Queensland

Background

Although early diagnosis and improved treatment can reduce breast cancer mortality, there still appears to be a geographic differential in patient outcomes. This study aims to determine and quantify spatial inequalities in intended adjuvant (radio-, chemo- and hormonal) therapy usage among women with screen-detected breast cancer in Queensland, Australia.

Methods

Linked population-based datasets from BreastScreen Queensland and the Queensland Cancer Registry during 1997−2008 for women aged 40−89 years were used. We adopted a Bayesian shared spatial component model to evaluate the relative intended use of each adjuvant therapy across 478 areas as well as common spatial patterns between treatments.

Results

Women living closer to a cancer treatment facility were more likely to intend to use adjuvant therapy. This was particularly marked for radiotherapy when travel time to the closest radiation facility was 4 + h (OR =0.41, 95 % CrI: [0.23, 0.74]) compared to <1 h. The shared spatial effect increased towards the centres with concentrations of radiotherapy facilities, in north-east (Townsville) and south-east (Brisbane) regions of Queensland. Moreover, the presence of residual shared spatial effects indicates that there are other unmeasured geographical barriers influencing women’s treatment choices.

Conclusions

This highlights the need to identify the additional barriers that impact on treatment intentions among women diagnosed with screen-detected breast cancer, particularly for those women living further away from cancer treatment centers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2527-2) contains supplementary material, which is available to authorized users.

Disparity in Breast Cancer Late Stage at Diagnosis in Missouri: Does Rural Versus Urban Residence Matter?

INTRODUCTION

Despite the fact that black women have a lower incidence of breast cancer compared to white women, black women experience higher death rates than any other group. We examined the stage of breast cancer presentation by race and geographic region using population-based breast cancer incidence in all 115 counties in the state of Missouri.

METHODS

We used 2003-2008 breast cancer incidence data from Missouri Cancer Registry and Research Center. County of residence was categorized as urban or rural using the rural-urban continuum code. We computed the conditional proportion of stage at diagnosis by race and metropolitan status and also used Pearson's chi-squared test with Yates' continuity correction to determine statistical significance of association.

RESULTS

Results of the study indicate that a greater proportion of black women (38.8 %) compared to white women (30.2 %) were diagnosed with more advanced breast metastasis. Our results further suggest that stage at diagnosis depended on county of residence or metropolitan status (p = .04). Women living in non-metropolitan counties were slightly more likely to have late-stage breast cancer than their metropolitan counterparts (32.0 vs 30.7 %). Overall, black women had 1.5-fold increased odds of late-stage breast cancer diagnosis compared to their white counterparts (OR = 1.50; 95 % CI, 1.39, 1.63; p < 0.0001). While the odds of late diagnosis among women living in non-metropolitan or rural counties was over 11 % higher compared with their metropolitan or urban counterpart.

CONCLUSION

The current study corroborates previous findings that the risk of late-stage breast cancer diagnosis was higher among women residing in non-metropolitan rural counties.

Effect of vaginal self-sampling on cervical cancer screening rates: a community-based study in Newfoundland

Background

Cervical cancer is highly preventable and treatable if detected early through regular screening. Women in the Canadian province of Newfoundland & Labrador have relatively low rates of cervical cancer screening, with rates of around 40 % between 2007 and 2009. Persistent infection with oncogenic human papillomavirus (HPV) is a necessary cause for the development of cervical cancer, and HPV testing, including self-sampling, has been suggested as an alternative method of cervical cancer screening that may alleviate some barriers to screening. Our objective was to determine whether offering self-collected HPV testing screening increased cervical cancer screening rates in rural communities.

Methods

During the 2-year study, three community-based cohorts were assigned to receive either i) a cervical cancer education campaign with the option of HPV testing; ii) an educational campaign alone; iii) or no intervention. Self-collection kits were offered to eligible women at family medicine clinics and community centres, and participants were surveyed to determine their acceptance of the HPV self-collection kit. Paired proportions testing for before-after studies was used to determine differences in screening rates from baseline, and Chi Square analysis of three dimensional 2 × 2 × 2 tables compared the change between communities.

Results

Cervical cancer screening increased by 15.2 % (p < 0.001) to 67.4 % in the community where self-collection was available, versus a 2.9 % increase (p = 0.07) in the community that received educational campaigns and 8.5 % in the community with no intervention (p = 0.193). The difference in change in rates was statistically significant between communities A and B (p < 0.001) but not between communities A and C (p = 0.193). The response rate was low, with only 9.5 % (168/1760) of eligible women opting to self-collect for HPV testing. Of the women who completed self-collection, 15.5 % (26) had not had a Pap smear in the last 3 years, and 88.7 % reported that they were somewhat or very satisfied with self-collection.

Conclusions

Offering self-collected HPV testing increased the cervical cancer screening rate in a rural NL community. Women who completed self-collection had generally positive feelings about the experience. Offering HPV self-collection may increase screening compliance, particularly among women who do not present for routine Pap smears.

Availability and outcomes of radiotherapy in Central Poland during the 2005-2012 period - an observational study

BACKGROUND

Using a cross-database integrative approach, we performed an epidemiological analysis in a representative region of central Poland to evaluate the availability of radiotherapy (RTx) and overall survival of adult patients undergoing RTx for cancer.

METHODS

Epidemiological data on cancer incidence in the 2005-2012 period were obtained from the Nationwide Cancer Registry. Using data from the Ministry of Internal Affairs, we collected survival information of all patients treated in the only centre providing RTx for a region inhabited by approximately 2.6 million people.

RESULTS

After filtering out individuals on the basis of exclusion criteria, the final dataset covered 17,736 patients. Availability of RTx increased marginally, from 23.5% (2005) to 24.4% (2011, R = 0.39, p = 0.38), with the highest values noted in patients with cervical (78.5%), prostate (70.6%) and breast cancer (62.7%). However, due to the decreasing population of the region, we noted increasing disparity in the likelihood of receiving RTx depending on the patient's area of residence, with rural areas becoming progressively more neglected. The best prognosis was noted among patients with breast or prostate cancer with 5-year OS rates reaching 81.2% and 83.3%, respectively. Multivariate analysis controlling for type of diagnosis and patient age showed a time-dependent improvement in outcomes (HR(95% CI): 0.96(0.94-0.98); p < 0.0001).

CONCLUSIONS

Availability of RTx in Poland is still below that reported by developed European centres. Survival of patients undergoing radical RTx has gradually improved, although it is still below that of leading RTx departments, potentially due to delayed diagnosis or organisational barriers, necessitating further investigations.

Effect of place of residence and treatment on survival outcomes in patients with diffuse large B-cell lymphoma in British Columbia

BACKGROUND

We examined the relationship between location of residence at the time of diagnosis of diffuse large B-cell lymphoma (DLBCL) and health outcomes in a geographically large Canadian province with publicly funded, universally available medical care.

PATIENTS AND METHODS

The British Columbia Cancer Registry was used to identify all patients 18-80 years of age diagnosed with DLBCL between January 2003 and December 2008. Home and treatment center postal codes were used to determine urban versus rural status and driving distance to access treatment.

RESULTS

We identified 1,357 patients. The median age was 64 years (range: 18-80 years), 59% were male, 50% were stage III/IV, 84% received chemotherapy with curative intent, and 32% received radiotherapy. There were 186 (14%) who resided in rural areas, 141 (10%) in small urban areas, 183 (14%) in medium urban areas, and 847 (62%) in large urban areas. Patient and treatment characteristics were similar regardless of location. Five-year overall survival (OS) was 62% for patients in rural areas, 44% in small urban areas, 53% in medium urban areas, and 60% in large urban areas (p = .018). In multivariate analysis, there was no difference in OS between rural and large urban area patients (hazard ratio [HR]: 1.0; 95% confidence interval [CI]: 0.7-1.4), although patients in small urban areas (HR: 1.4; 95% CI: 1.0-2.0) and medium urban areas (HR: 1.4; 95% CI: 1.0-1.9) had worse OS than those in large urban areas.

CONCLUSION

Place of residence at diagnosis is associated with survival of patients with DLBCL in British Columbia, Canada. Rural patients have similar survival to those in large urban areas, whereas patients living in small and medium urban areas experience worse outcomes.

Access to medical and supportive care for rural and remote cancer survivors in northern British Columbia

BACKGROUND

Rural cancer survivors (RCS) potentially have unique medical and supportive care experiences when they return to their communities posttreatment because of the availability and accessibility of health services. However, there is a limited understanding of cancer survivorship in rural communities.

PURPOSE

The purpose of this study is to describe RCS experiences accessing medical and supportive care postcancer treatment.

METHODS

Interviews and focus groups were conducted with 52 RCS residing in northern British Columbia, Canada. The data were analyzed using qualitative content analysis methods.

RESULTS

General Population RCS and First Nations RCS experienced challenges accessing timely medical care close to home, resulting in unmet medical needs. Emotional support services were rarely available, and, if they did exist, were difficult to access or not tailored to cancer survivors. Travel and distance were barriers to medical and psychological support and services, not only in terms of the cost of travel, but also the toll this took on family members. Many of the RCS lacked access to trusted and useful information. Financial assistance, for follow-up care and rehabilitation services, was rarely available, as was appropriate employment assistance.

CONCLUSION

Medical and supportive care can be inaccessible, unavailable, and unaffordable for cancer survivors living in rural northern communities.

Disparities in breast cancer stage at diagnosis in urban and rural adult women: a systematic review and meta-analysis

PURPOSE

Survival from breast cancer is dependent on stage at diagnosis and some evidence suggests that rural women are more likely than urban women to be diagnosed with advanced stage disease. This systematic review and meta-analysis compared the stage of breast cancer at diagnosis between women residing in urban and rural areas.

METHODS

PubMed (1951-2012), EMBASE (1966-2012), CINAHL (1982-2012), RURAL (1966-2012), and Sociological abstracts (1952-2012) were systematically searched in November 2012 for relevant peer reviewed studies. Studies on adult women were included if they reported quantitative comparisons of rural and urban differences in staging of breast cancer at diagnosis.

RESULTS

Twenty-four studies were included in the systematic review and 21 studies had sufficient information for inclusion in the meta-analysis (N = 879,660). Evidence indicated that patients residing in rural areas were more likely to be diagnosed with more advanced breast cancer. Using a random effects model, the results of the meta-analysis showed that rural breast cancer patients had 1.19 higher odds (95% confidence interval, 1.12-1.27) of late stage breast cancer compared with urban breast cancer patients.

CONCLUSIONS

Rural women were more likely than urban women to be diagnosed at a later stage. Preventive measures may need to target the rural population.

Stage, treatment and outcomes for patients with breast cancer in British Columbia in 2002: a population-based cohort study

BACKGROUND

There are very few long-term Canadian data on breast cancer outcomes by stage. We described the stage, treatment and outcomes of breast cancer at a population level for patients in British Columbia.

METHODS

This population-based cohort study included almost all patients with incident breast cancer registered in 2002 (about 97.6% registry case completeness). For these patients, information on stage, primary local surgery, radiotherapy, chemotherapy, hormone therapy and survival outcome (based on registry date and cause-of-death data) were available. We calculated Kaplan-Meier curves for breast cancer-specific survival and overall survival by stage and analyzed prognostic and treatment factors with a multivariable Cox model.

RESULTS

The 2927 incident cases of breast cancer identified in 2002 had the following distribution by stage: stage 0 (in situ), 424 (14%); stage I, 1118 (38%); stage II, 938 (32%); stage III, 233 (8%); stage IV, 123 (4%); unknown, 91 (3%). The distribution of patients' ages was < 40 years, 127 (4%); 40-49, 538 (18%); 50-59, 719 (25%); 60-69, 660 (23%); 70-79, 583 (20%); ≥ 80, 300 (10%). Within the first year after diagnosis, radiotherapy was provided to 1649 patients (56%), chemotherapy to 928 (32%) and hormone therapy to 1664 (57%). Ten-year breast cancer-specific survival rates by stage were > 99% for stage 0, 95% for stage I, 81% for stage II, 55% for stage III and 4% for stage IV. Ten-year overall survival rates were 89% for stage 0, 81% for stage I, 68% for stage II, 43% for stage III and 2% for stage IV.

INTERPRETATION

This analysis provides a Canadian benchmark for treatment rates and 10-year outcomes by stage for all incident cases of breast cancer in a single province. Outcomes in British Columbia compared well with published rates for the United States and Europe.

Relationships between family physicians' referral for palliative radiotherapy, knowledge of indications for radiotherapy, and prior training: a survey of rural and urban family physicians

BACKGROUND

The primary objective of this research was to assess the relationship between FPs' knowledge of palliative radiotherapy (RT) and referral for palliative RT.

METHODS

1001 surveys were sent to FPs who work in urban, suburban, and rural practices. Respondents were tested on their knowledge of palliative radiotherapy effectiveness and asked to report their self-assessed knowledge.

RESULTS

The response rate was 33%. FPs mean score testing their knowledge of palliative radiotherapy effectiveness was 68% (SD = 26%). The majority of FPs correctly identified that painful bone metastases (91%), airway obstruction (77%), painful local disease (85%), brain metastases (76%) and spinal cord compression (79%) can be effectively treated with RT, though few were aware that hemoptysis (42%) and hematuria (31%) can be effectively treated. There was a linear relationship between increasing involvement in palliative care and both self-assessed (p < 0.001) and tested (p = 0.02) knowledge. FPs had higher mean knowledge scores if they received post-MD training in palliative care (12% higher; p < 0.001) or radiotherapy (15% higher; p = 0.002). There was a strong relationship between FPs referral for palliative radiotherapy and both self-assessed knowledge (p < 0.001) and tested knowledge (p = 0.01).

CONCLUSIONS

Self-assessed and tested knowledge of palliative RT is positively associated with referral for palliative RT. Since palliative RT is underutilized, further research is needed to assess whether family physician educational interventions improve palliative RT referrals. The current study suggests that studies could target family physicians already in practice, with educational interventions focusing on hemostatic and other less commonly known indications for palliative RT.