Rural–Urban Disparities in Time to Diagnosis and Treatment for Colorectal and Breast Cancer

Socioeconomic disparities and health literacy: Unraveling the impact on diagnostic and cancer care in Uruguay

BACKGROUND

Disparities in the timely diagnosis and care of cancer patients, particularly concerning geographical, racial/ethnic, and economic factors, remain a global health challenge. This study explores the multifaceted interplay between socioeconomic status, health literacy, and specific patient perceptions regarding care access and treatment options that impact cancer care in Uruguay.

METHODS

Using the Cancer Health Literacy Test, Spanish Version (CHLT-30-DKspa), and a highly comprehensive questionnaire, we dissected the factors influencing the pathway to diagnosis and route of cancer care. This was done to identify delays by analyzing diverse socioeconomic and sex subgroups across multiple healthcare settings.

RESULTS

Patients with lower income took longer to get an appointment after showing symptoms (p = 0.02) and longer to get a diagnosis after having an appointment (p = 0.037). Race/ethnicity also had a significant impact on the length of time from symptoms to first appointment (p =0.019), whereas employment status had a significant impact on patients being susceptible to diagnostic delays beyond the advocated 14-day window (p = 0.02). Higher educational levels were positively associated with increased cancer health literacy scores (p = 0.043), revealing the potential to mitigate delays through health literacy-boosting initiatives. Women had significantly higher self-reported symptom duration before seeking an intervention (p = 0.022). We also found many other significant factors effecting treatment delays and cancer health literacy.

CONCLUSIONS

While affirming the global pertinence of socioeconomic- and literacy-focused interventions in enhancing cancer care, the findings underscore a complex, gendered, and perceptually influenced healthcare navigation journey. The results highlight the urgent necessity for strategically crafted, globally relevant interventions that transcend equitable access to integrate literacy, gender sensitivity, and patient-perception alignments in pursuit of optimized global cancer care outcomes.

Multi-Institutional Study of Referral Patterns for Gynecologic Oncology Consultation

PURPOSE

Evaluation by a gynecologic oncologist (GO) is associated with improved clinical outcomes for patients with gynecologic cancers, yet little is known about health care factors that influence patients' referrals to GO.

METHODS

Medical records of 50 consecutive new patients seen in GO clinics at each of six referral centers across the United States were reviewed. Patient and disease characteristics were collected along with referral indication, evaluation and referral dates, diagnostic procedures, provider specialties, and zone improvement plan (ZIP) code of up to three referring providers per patient. The primary outcome was interval between first evaluation and referral. Univariate associations were evaluated with Chi-square and Wilcoxon rank-sum tests and multivariable associations with negative binomial regression models. Secondary outcome was prolonged time to GO referral, defined as greater than the 75th percentile. Logistic regression was used for multivariable modeling.

RESULTS

Three hundred patient records were analyzed. The median time from first health care encounter to referral was 15 days (IQR, 5-43). The mean distance from residence to GO was 39.8 miles (standard deviation, 53.8). Seventy-one percent of GO referrals were initiated by obstetrician-gynecologists, 9% by family physicians, and 6% internists. Presentation-to-referral interval was 76% shorter for patients evaluated by an emergency medicine clinician (exp(Beta), 0.24; 95% CI, 0.11 to 0.53; P < .001). Public insurance was associated with 1.47 times longer time to referral compared with private insurance (exp(Beta), 1.47; 95% CI, 1.05 to 2.04; P = .001). Residents of nonmetropolitan ZIP codes were less likely to have prolonged time to referral (odds ratio [OR], 0.288; P = .017). Distance from residence to GO (per 10 miles) increased the likelihood of prolonged time to referral (OR, 1.10; P = .010).

CONCLUSION

Interventions are needed to improve recognition and referral of patients for gynecologic oncology evaluation. Community outreach and engagement with obstetrician-gynecologists should be prioritized to improve times to referral.

Estimating the Impact of Rurality in Disparities in Cancer Mortality

PURPOSE

Estimation of the independent effect of rurality on cancer mortality requires causal inference methodology and consideration of area-level socioeconomic status and rural designations.

METHODS

Using SEER data, we identified key incident cancers diagnosed between 2000 and 2016 at age ≥20 years (N = 3,788,273), examining a 20% random sample (n = 757,655). Standardized competing risk and survival models estimated the association between rural residence, defined by Rural-Urban Continuum Codes, and cancer-specific and all-cause mortality, controlling for age at cancer diagnosis, sex, race/ethnicity, year of diagnosis, and Area Deprivation Index (ADI). We estimated the attributable fraction (AF) of rurality and high ADI (ADI > median) to the probability of mortality. Finally, we examined county measurement issues contributing to mortality rates discordant from hypothesized rates.

RESULTS

The 5-year standardized failure probability for cancer mortality for rural patients was 33.9% versus 31.56% for urban. The AF for rural residence was 1.04% at year 1 (0.89% by year 5), the highest among local stage disease (Y1 2.1% to Y5 1.9%). The AF for high ADI was 3.33% in Y1 (2.87% in Y5), while the joint effect of rural residence and high ADI was 4.28% in Y1 (3.71% in Y5). Twenty-two percent of urban counties and 30% of rural were discordant. Among discordant urban counties, 30% were only considered urban because of adjacency to metro area. High ADI was associated with urban discordance and low ADI with rural discordance.

CONCLUSION

Rural residence independently contributes to cancer mortality. The rural impact is the greatest among those with localized disease and in high deprivation areas. Rural-urban county designations may mask high-need urban counties, limiting eligibility to state and federal resources dedicated to rural areas.

The impact of a regionally based translational cancer research collaborative in Australia using the FAIT methodology

BACKGROUND

Translating research, achieving impact, and assessing impact are important aspirations for all research collaboratives but can prove challenging. The Hunter Cancer Research Alliance (HCRA) was funded from 2014 to 2021 to enhance capacity and productivity in cancer research in a regional centre in Australia. This study aimed to assess the impact and benefit of the HCRA to help inform future research investments of this type.

METHOD

The Framework to Assess the Impact from Translational health research (FAIT) was selected as the preferred methodology. FAIT incorporates three validated methodologies for assessing impact: 1) Modified Payback; 2) Economic Analysis; and 3) Narrative overview and case studies. All three FAIT methods are underpinned by a Program Logic Model. Data were collected from HCRA and the University of Newcastle administrative records, directly from HCRA members, and website searches.

RESULTS

In addition to advancing knowledge and providing capacity building support to members via grants, fellowships, scholarships, training, events and targeted translation support, key impacts of HCRA-member research teams included: (i) the establishment of a regional biobank that has distributed over 13,600 samples and became largely self-sustaining; (ii) conservatively leveraging $43.8 M (s.a.$20.5 M - $160.5 M) in funding and support from the initial $9.7 M investment; (iii) contributing to clinical practice guidelines and securing a patent for identification of stem cells for endometrial cell regeneration; (iv) shifting the treatment paradigm for all tumour types that rely on nerve cell innervation, (v) development and implementation of the world's first real-time patient treatment verification system (Watchdog); (vi) inventing the effective 'EAT' psychological intervention to improve nutrition and outcomes in people experiencing radiotherapy for head and neck cancer; (vi) developing effective interventions to reduce smoking rates among priority groups, currently being rolled out to disadvantaged populations in NSW; and (vii) establishing a Consumer Advisory Panel and Consumer Engagement Committee to increase consumer involvement in research.

CONCLUSION

Using FAIT methodology, we have demonstrated the significant impact and downstream benefits that can be achieved by the provision of infrastructure-type funding to regional and rural research collaboratives to help address inequities in research activity and health outcomes and demonstrates a positive return on investment.

Development of the Rural Perception Scale (RPS-18)

BACKGROUND

People living in rural areas often experience limited access to health resources, slow knowledge diffusion, and geographical isolation, and tend to be at higher risk for poor physical and mental health outcomes compared with nonrural populations. It is unclear, yet, how the concept of "rural" shapes observed differences from nonrural populations. We aim to develop a psychometrically sound scale to assess key dimensions that constitute individual-level perceived rurality.

METHODS

We first conducted a broad literature review to identify a priori concepts related to rurality and adapted survey items measuring relevant constructs, such as loneliness, attitudes toward people living in rural areas, and perceived social membership. We used these conceptual constructs and measures to develop a survey questionnaire focused on rural perceptions. We recruit residents in 3 rural states: Kentucky, New Hampshire, and Vermont. Using the explorative factor analysis and second-order measurement model in the structural equation model framework, we developed a rural perception scale consisting of 18 items.

RESULTS

We recruited 1,384 participants (n = 686 from KY; n = 698 from NH/VT) using Amazon Mechanical Turk (n = 897, 64.8%) and social media paid ads (n = 487, 35.2%). The average age of participants was 41 years old (SD = 15); 54.7% of respondents had less than college graduate education, and 94.2% reported their race as non-Hispanic White. Majority of the participants were from Rural Urban Commuting Area (RUCA)-designated urban areas (n = 798, 57.7%), followed by RUCA-designated large rural areas (257, 18.6%), RUCA-designated rural areas (n = 174, 12.6%) and RUCA-designated isolated areas (n = 133, 9.6%). Our final model revealed 4 latent constructs: "belonging" (Cronbach's α = 0.896), "attitudes toward rural life" (Cronbach's α = 0.807), "loneliness" (Cronbach's α = 0.898), and "community social ties to people in their community" (Cronbach's α = 0.846).

CONCLUSIONS

We identified 4 subfactors of the umbrella concept of rurality that explain how people in rural regions may perceive being in rural environments and having rural lifestyles.

Evaluating Social Determinants of Health Related to Cancer Survivorship and Quality of Care

BACKGROUND

Social determinants of health posit that negative outcomes are influenced by individuals living in underserved and underresourced neighborhoods.

OBJECTIVE

This study examines a cancer diagnosis, race/ethnicity, age, geographic location (residence), education, and social economic status factors at disease onset and treatment.

METHODS

A multivariable PO regression analysis was run for quality of care at testing or diagnosis, and quality of care at treatment and the quality of received care compared with another person.

RESULTS

Participants are representative of the Southern Community Cohort Study (SCCS) of adults diagnosed with breast (n = 263), prostate (n = 195), lung (n = 46), colorectal (n = 105), or other cancers (n = 526). This study includes cancer survivors who completed the SCCS Baseline and Cancer Navigation Surveys in urban (73.13%) and rural (26.87%) areas. White participants reported a higher quality of received care for testing or diagnosis and care for treatment compared with Black participants. Participants with high school or equivalent education (odds ratio, 1.662; 95% confidence interval, 1.172-2.356; P = .0044) or some college or junior college education (odds ratio, 1.970; 95% confidence interval, 1.348-2.879; P = .0005) were more likely to report a better level of quality of received care for treatment.

CONCLUSIONS

The SCCS represents individuals who are historically underrepresented in cancer research. The results of this study will have broad implications across diverse communities to reduce disparities and inform models of care.

IMPLICATIONS FOR PRACTICE

Nurses are positioned to evaluate the quality of population health and design and lead interventions that will benefit underserved and underresourced communities.

Exploring Demographic Differences and Outcomes in Early-Onset Colorectal Cancer

PURPOSE

Early-onset colorectal cancer (EOCRC), defined as CRC diagnosed before age 50 years, has increased significantly worldwide. The majority of EOCRCs do not appear to be driven by genetic factors and may be influenced by environmental factors. We hypothesized that sociodemographic disparities exist in EOCRC. The purpose was of the study was to examine the geographic disparities in patients with EOCRC.

METHODS

We retrospectively examined the SEER database from 1976 to 2016 to examine the geographic disparities in EOCRC. A total of 73,378 patients with EOCRC were included in the analysis. We performed univariate and multivariable analyses to evaluate overall survival (OS) and disease-specific survival (DSS). Sociodemographic factors, including the location of residence (metropolitan areas [MA] or rural areas [RA]), sex, race, insurance status, and marital status, were included in the statistical analysis.

RESULTS

The incidence and mortality rates were consistently higher in RA versus MA during the study period. Multivariable analysis showed that patients living in RA had worse OS (hazard ratio [HR], 1.14; P < .01) and DSS (HR, 1.15; P < .001) compared with those living in MA. Similarly, non-Hispanic Black ethnicity and uninsured patients had significantly worse survival when compared with non-Hispanic White and insured patients, respectively. Married status showed better survival outcomes.

CONCLUSION

Patients with EOCRC living in RA have worse outcomes. Understanding the mechanisms behind such socioeconomic disparities is important so that future studies can reduce these disparities.

Evaluating geographical disparities on clinical outcomes following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Rural Australians typically encounter disparities in healthcare access leading to adverse health outcomes, delayed diagnosis and reduced quality of life (QoL) parameters. These disparities may be exacerbated in advanced malignancies, where treatment is only available at highly specialised centres with appropriate multidisciplinary expertise. Thus, this study aims to determine the association between patient residence on oncological, surgical and QoL outcomes following cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC).

METHODS

A retrospective analysis was conducted on consecutive patients undergoing CRS and HIPEC at Royal Prince Alfred Hospital from January 2017 to March 2022. On the basis of their postcode of residence, patients were stratified into metropolitan and regional groups. Data encompassing demographics, oncological, surgical and QoL outcomes were compared. Statistical analysis included chi-square test, t-tests and Kaplan-Meier survival curves.

RESULTS

Among the 317 patients, 228 (72%) were categorised as metropolitan and 89 (28%) as regional. Metropolitan patients presented higher rates of recurrence (61.8% versus 40.0%, p = 0.014) and shorter overall mean survival [3.8 years (95% CI: 3.44-4.09) versus 4.2 years (95% CI: 3.76-4.63), p = 0.019] compared with regional patients. No other statistically significant differences were observed in oncological, surgical and QoL outcomes.

CONCLUSIONS

Most oncological, surgical and QoL parameters did not differ by geographical location of patients undergoing CRS and HIPEC for peritoneal malignancies at a high-volume quaternary referral centre. Observed differences in recurrence and survival may be attributed to the selective nature of surgical referrals and variable follow-up patterns. Future research should focus on characterising referral pathways and its influence on post-operative outcomes.

Socioeconomic Disparities in Surgical Care for Congenital Hand Differences

BACKGROUND

The purpose of this study was to evaluate the influence of socioeconomic factors on access to congenital hand surgery care, hospital admission charges, and analyze these geographic trends across regions of the country.

METHODS

Retrospective cohort study was conducted of congenital hand surgery performed in the United States from 2010 through 2020 using the Pediatric Health Information System. Multivariate regression was used to analyze the impact of socioeconomic factors.

RESULTS

During the study interval, 5531 pediatric patients underwent corrective surgery for congenital hand differences, including syndactyly repair (n = 2439), polydactyly repair (n = 2826), and pollicization (n = 266). Patients underwent surgery at significantly earlier age when treated at above-median case volume hospitals (P < .001). Patients with above-median income (P < .001), non-white race (P < .001), commercial insurance (P < .001), living in an urban community (P < .001), and not living in an underserved area (P < .001) were more likely to be treated at high-volume hospitals. Nearly half of patients chose to seek care at a distant hospital rather than the one locally available (49.5%, n = 1172). Of those choosing a distant hospital, most patients chose a higher-volume facility (80.9%, n = 948 of 1172). On multivariate regression, white patients were significantly more likely to choose a more distant, higher-volume hospital (P < .001).

CONCLUSIONS

Socioeconomic and geographic factors significantly contribute to disparate access to congenital hand surgery across the country. Patients with higher socioeconomic status are more likely to be treated at high-volume hospitals. Treatment at hospitals with higher case volume is associated with earlier age at surgery and decreased hospital admission charges.

Rural versus urban commuting patients with stage III colon cancer: is there a difference in treatment and outcome?

BACKGROUND

To evaluate if there are differences in outcomes for patients with stage III colon cancer in those from urban vs. rural commuting areas.

METHODS

Data were evaluated on patients diagnosed with stage III colon cancer between 2012 and2018 from the Louisiana Tumor Registry. Patients were classified into rural and urban groups. Data on overall survival, time from diagnosis to surgery and time from surgery to chemotherapy, and sociodemographic factors (including race, age, and poverty level) were recorded.

RESULTS

Of 2652 patients identified, 2159 were urban (81.4%) and 493 rural (18.6%). No age difference between rural and urban patients (p = 0.56). Stage IIIB accounted for 66.7%, followed by IIIC (21.6%) and IIIA (11%), with a significant difference between rural and urban patients based on stage (p = 0.02). There was no difference in the extent of surgery (p = 0.34) or tumor size (p = 0.72) between urban and rural settings. No difference in undergoing chemotherapy (p = 0.12). There was a statistically significant difference in receiving timely treatment for hospital volume (p < 0.0001) and poverty level (p < 0.0001), but no difference in time from diagnosis to surgery (p = 0.48), and time from surgery to chemotherapy (p = 0.27). Non-Hispanic Blacks were less likely to receive timely treatment when compared with non-Hispanic Whites for both surgery and adjuvant chemotherapy, (aHR 0.91, 95% CI 0.83-0.99) and (aHR 0.86, 95% CI 0.77-0.97), respectively. There was no difference in Kaplan-Meier overall survival curves comparing rural vs. urban patients (p = 0.77).

CONCLUSIONS

There was no statistical difference in overall survival, time to surgery, and time to adjuvant chemotherapy between rural and urban patients with Stage III colon cancer.

Cancer Survivors Living in Rural Settings: A Qualitative Exploration of Concerns, Positive Experiences and Suggestions for Improvements in Survivorship Care

In Canada, the number of cancer survivors continues to increase. It is important to understand what continues to present difficulties after the completion of treatment from their perspectives. Various factors may present barriers to accessing help for the challenges they experience following treatment. Living rurally may be one such factor. This study was undertaken to explore the major challenges, positive experiences and suggestions for improvement in survivorship care from rural-dwelling Canadian cancer survivors one to three years following treatment. A qualitative descriptive analysis was conducted on written responses to open-ended questions from a national cross-sectional survey. A total of 4646 individuals living in rural areas responded to the survey. Fifty percent (2327) were male, and 2296 (49.4%) were female; 69 respondents were 18 to 29 years (1.5%); 1638 (35.3%) were 30 to 64 years; and 2926 (63.0%) were 65 years or older. The most frequently identified major challenges (n = 5448) were reduced physical capacity and the effects of treatment. Positive experiences included family and friend support and positive self-care practices. The suggestions for improvements focused on the need for better communication and information about self-care, side effect management, and programs and services, with more programs available locally for practical and emotional support.

Association of Rural Residence and Receipt of Guideline-Concordant Care for Locoregional Colon Cancer

BACKGROUND

Incidence and mortality rates of colon cancer (CC) are higher in rural populations. This study aimed to determine whether rural residence is associated with differences in guideline-concordant care for patients with locoregional CC.

METHODS

Patients with stages I-III CC from 2006 to 2016 were identified in the National Cancer Database. Guideline-concordant care (GCC) was defined as resection with negative margins, adequate nodal harvest, and receipt of adjuvant chemotherapy for patients with high-risk stage II or III disease. Multivariable logistic regression (MVR) was performed to evaluate the association between rural residence and the odds of receiving GCC. Effect modification was evaluated using a two-way interaction for rurality by insurance status.

RESULTS

Of 320,719 identified patients, 6191 (2%) were rural. The rural patients had lower income and lower educational status than the urban patients and were more often Medicare-insured (p < 0.001). The rural patients traveled farther (44.5 vs. 7.5 miles; p < 0.001), although time to surgery was similar (8 vs. 9 days). The two cohorts had similar resection rates (98.8% vs. 98.0%), margin positivity (5.4% vs. 4.8%), adequate lymphadenectomy (80.9% vs. 83.0%), adjuvant chemotherapy (stage III: 69.2% vs. 68.7%), and receipt of GCC (66.5% vs. 68.3%). In the MVR, the odds of receiving GCC did not differ between the rural and urban patients (odds ratio, 0.99; 95% confidence interval, 0.94-1.05%). Insurance status did not differentially influence the receipt of GCC by the rural versus the urban patients (interaction: p = 0.83).

CONCLUSIONS

Rural and urban patients with locoregional CC are equally likely to receive GCC, suggesting that differences in cancer care delivery may not explain rural-urban disparities.

The effect of physician density on colorectal cancer stage at diagnosis: causal inference methods for spatial data applied on regional-level data

BACKGROUND

The early detection of colorectal cancer (CRC) through regular screening decreases its incidence and mortality rates and improves survival rates. Norway has an extremely high percentage of CRC cases diagnosed at late stages, with large variations across municipalities and hospital catchment areas. This study examined whether the availability of physicians related to CRC primary diagnosis and preoperative investigations, or physician density, contributes to the observed geographical differences in late-stage incidence rates.

METHOD

Municipality-level data on CRC stage at diagnosis were obtained from the Cancer Registry of Norway for the period 2012-2020. Physician density was calculated as the number of physicians related to CRC investigations, general practitioners (GPs) and specialists per 10,000 people, using physician counts per municipality and hospital areas from Statistics Norway. The relationship was examined using a novel causal inference method for spatial data-neighbourhood adjustment method via spatial smoothing (NA approach)-which allowed for studying the region-level effect of physician supply on CRC outcome by using spatially referenced data and still providing causal relationships.

RESULTS

According to the NA approach, an increase in one general practitioner per 10,000 people will result in a 3.6% (CI -0.064 to -0.008) decrease in late-stage CRC rates. For specialists, there was no evidence of a significant correlation with late-stage CRC distribution, while for both groups, GPs and specialists combined, an increase of 1 physician per 10,000 people would be equal to an average decrease in late-stage incidence rates by 2.79% (CI -0.055 to -0.001).

CONCLUSION

The study confirmed previous findings that an increase in GP supply will significantly improve CRC outcomes. In contrast to previous research, this study identified the importance of accessibility to both groups of physicians-GPs and specialists. If GPs encounter insufficient workforces in hospitals and long delays in colonoscopy scheduling, they will less often recommend colonoscopy examinations to patients. This study also highlighted the efficiency of the novel methodology for spatially referenced data, which allowed us to study the effect of physician density on cancer outcomes within a causal inference framework.

Physical activity and cognitive function: A comparison of rural and urban breast cancer survivors

PURPOSE

Increasing evidence suggests rural breast cancer survivors (BCS) may experience greater burden in symptoms known to be associated with cancer-associated cognitive decline (CACD). Yet, little is known about CACD in rural BCS. This study (1) examined differences in cognitive function, moderate-to-vigorous physical activity (MVPA), and other CACD correlates and (2) tested the effects of MVPA on cognitive function in rural versus urban BCS.

METHODS

Rural and urban BCS (N = 80), matched on age, education, and time since diagnosis from a larger study, completed cognitive tasks assessing processing speed (Trails-B, Mazes, Task-Switch) and working memory (spatial working memory) and questionnaires assessing subjective memory impairment (SMI), MVPA, and CACD correlates (i.e., sleep quality, fatigue, anxiety/depression). Some participants (n = 62) wore an accelerometer to objectively estimate MVPA. Multiple linear regression and multivariate analysis of covariance were used to test study aims.

RESULTS

Rural BCS (n = 40, M = 61.1±8.4 years-old) performed significantly slower on Trails-B (p<0.01) compared with urban BCS (n = 40, M = 61.0±8.2 years-old) and engaged in less objectively-estimated daily MVPA (mean difference = 13.83±4.73 minutes; p = 0.01). No significant differences in SMI, self-reported MVPA, or CACD correlates were observed (all p>0.28). Regression models did not reveal a significant interaction between MVPA and cognitive performance (all p>0.1); however, estimated marginal means models indicated that the effect of MVPA on processing speed was evident only among rural BCS (Trails-B, p = 0.04; Mazes, p = 0.03).

CONCLUSIONS

Findings suggest rural BCS may suffer greater CACD and engage in less MVPA. Additional research is warranted to further examine CACD and more effectively promote MVPA in rural BCS.

Cancer histotypes and trends in Azare, Northeast Nigeria: impact of diagnostic support disparity in data reporting

Background

Definitive, affordable, and timely diagnosis of cancer is key to providing data for surveillance and control programmes. Care disparities have been shown to contribute to poorer survival, especially in resource-constrained populations. Here, we describe the profile of histologically diagnosed cancers in our hospital and highlight the possible effects of inadequate diagnostic support on data reporting.

Methods

We designed a retrospective cross-sectional descriptive study to review histopathology reports archived at the Department of Pathology of our hospital spanning from January 2011 to December 2022. Cases diagnosed as cancer were retrieved and classified by systems, organs and histology types alongside the patient's age and gender. The trend in the volume of pathology requests and the corresponding malignant diagnosis yield over the period was also documented. Data generated were analyzed statistically using appropriate statistics and presented as proportions and means, with the level of statistical significance set at p < 0.05.

Results

There were 488 cancers out of 3,237 histopathology requests received within the study period. Of these 316 (64.7%) were females. Overall mean age was 48.8 ± 18.6 years with a peak age at the sixth decade, females being significantly younger (46.1 versus 53.5 years; p < 0.001). The top five cancers were breast (22.7%), cervical (12.7%), prostate (11.7%), skin (10.7%) and colorectal cancers (8%). Among females, breast, cervical and ovarian cancers predominated, whereas prostate, skin and colorectal cancers, were commonest among males in decreasing order. Paediatric malignancies accounted for 3.7% of all the cases, most being small round blue cell tumours. The volume of pathology requests rose remarkably from 95 cases in 2014 to 625 cases in 2022 with a corresponding increase in cancer case diagnoses.

Conclusion

Cancer subtypes and ranking in this study are similar to those from urban populations in Nigeria and Africa, despite the low number of cases recorded. Efforts to reduce the disease burden are warranted.

Use of a Novel Network-Based Linchpin Score to Characterize Accessibility to the Oncology Physician Workforce in the United States

Importance

Physician headcounts provide useful information about the cancer care delivery workforce; however, efforts to track the oncology workforce would benefit from new measures that capture how essential a physician is for meeting the multidisciplinary cancer care needs of the region. Physicians are considered linchpins when fewer of their peers are connected to other physicians of the same specialty as the focal physician. Because they are locally unique for their specialty, these physicians' networks may be particularly vulnerable to their removal from the network (eg, through relocation or retirement).

Objective

To examine a novel network-based physician linchpin score within nationwide cancer patient-sharing networks and explore variation in network vulnerability across hospital referral regions (HRRs).

Design, Setting, and Participants

This cross-sectional study analyzed fee-for-service Medicare claims and included Medicare beneficiaries with an incident diagnosis of breast, colorectal, or lung cancer from 2016 to 2018 and their treating physicians. Data were analyzed from March 2022 to October 2022.

Exposures

Physician characteristics assessed were specialty, rurality, and Census region. HRR variables assessed include sociodemographic and socioeconomic characteristics and use of cancer services.

Main Outcomes and Measures

Oncologist linchpin score, which examined the extent to which a physician's peers were connected to other physicians of the same specialty as the focal physician. Network vulnerability, which distinguished HRRs with more linchpin oncologists than expected based on oncologist density. χ2 and Fisher exact tests were used to examine relationships between oncologist characteristics and linchpin score. Spearman rank correlation coefficient (ρ) was used to measure the strength and direction of relationships between HRR network vulnerability, oncologist density, population sociodemographic and socioeconomic characteristics, and cancer service use.

Results

The study cohort comprised 308 714 patients with breast, colorectal, or lung cancer. The study cohort of 308 714 patients included 161 206 (52.2%) patients with breast cancer, 76 604 (24.8%) patients with colorectal cancer, and 70 904 (23.0%) patients with lung cancer. In our sample, 272 425 patients (88%) were White, and 238 603 patients (77%) lived in metropolitan areas. The cancer patient-sharing network included 7221 medical oncologists and 3573 radiation oncologists. HRRs with more vulnerable networks for medical oncology had a higher percentage of beneficiaries eligible for Medicaid (ρ, 0.19; 95% CI, 0.08 to 0.29). HRRs with more vulnerable networks for radiation oncology had a higher percentage of beneficiaries living in poverty (ρ, 0.17; 95% CI, 0.06 to 0.27), and a higher percentage of beneficiaries eligible for Medicaid (ρ, 0.21; 95% CI, 0.09 to 0.31), and lower rates of cohort patients receiving radiation therapy (ρ, -0.18; 95% CI, -0.28 to -0.06; P = .003). The was no association between network vulnerability for medical oncology and percent of cohort patients receiving chemotherapy (ρ, -0.03; 95% CI, -0.15 to 0.08).

Conclusions and Relevance

This study found that patient-sharing network vulnerability was associated with poverty and lower rates of radiation therapy. Health policy strategies for addressing network vulnerability may improve access to interdisciplinary care and reduce treatment disparities.

Population-based study on coverage and healthcare processes for cancer during implementation of national healthcare insurance in Indonesia

Background

A national healthcare insurance has been implemented in Indonesia since 2014. Although cancer care currently represents a smaller part of the healthcare support, the demographic development will lead to a rapid growth of the population within age groups at cancer risk. This requires strategic and developmental planning of cancer care resources. Based on data of the national healthcare insurance, current cancer care processes and their determinants were evaluated.

Methods

Nationwide reimbursement data as well as demographic, economic and healthcare infrastructure data were used for the study. Poor and underserved population was stratified according to the national classification system. Availability of healthcare resources was evaluated at provincial level. Cancer care usage was analysed applying descriptive and multivariate statistical approaches (regression, cluster analysis, tree classification).

Findings

Cancer care was provided in primary care (PHC) for 2.6/1000 and advanced care (AHC) for 4.8/1000 participants within the family-based membership structure. Regression analysis revealed human resource availability in rural/remote areas a determinant for cancer PHC. Cancer care in AHC was determined by PHC provided by general practitioners (GP), availability of AHC infrastructure (Class A & B hospital beds) and treatment migration between provinces. Tree classification confirmed predominant roles of GP, AHC infrastructure and referral between cancer care provider levels.

Interpretation

Cancer care will gain much higher importance for the Indonesian healthcare system within the next decade. Infrastructure, human resources, and process development should avoid rising overload of cancer care delivery by targeting reduction of treatment migration (availability of GPs in rural/remote provinces), improvement of referral systems (effective clinical selection processes and back-referral) and AHC cancer care structures (regional distribution of Class A & B hospitals).

Funding

This project was supported by grants from Centre for Research, Publication, and Community Development Muhammadiyah University of Yogyakarta (SW, ID), and data provision by BPJS Indonesia.

The association between sociodemographic factors and time to diagnosis for colorectal cancer in northern Sweden

OBJECTIVES

This study examined whether sociodemographic factors, including distance to hospital, were associated with differences in the diagnostic interval and the treatment interval for colorectal cancer in northern Sweden.

METHODS

Data were retrieved from the Swedish cancer register on patients (n = 446) diagnosed in three northern regions during 2017-2018, then linked to data from Statistics Sweden and medical records. Also, Google maps was used to map the distance between patients' place of residence and nearest hospital. The different time intervals were analysed using Mann-Whitney U-test and Cox regression.

RESULTS

Differences in time to diagnosis were found between groups for income and distance to hospital, favouring those with higher income and shorter distance. The unadjusted regression analysis showed higher income to be associated with more rapid diagnosis (HR 1.004, CI 1.001-1.007). This association remained in the fully adjusted model for income (HR 1.004, CI 1.000-1.008), but not for distance. No differences between sociodemographic groups were found in the treatment interval.

CONCLUSION

Higher income and shorter distance to hospital were in the unadjusted models associated with shorter time to diagnosis for patients with CRC in northern Sweden. The association remained for income when adjusting for other variables even though the difference was small.

A qualitative exploration of the facilitators and barriers to early diagnosis and treatment of head and neck cancer: Perceptions of patients and carers

OBJECTIVE

The objective of this study to explore experiences of patients and carers of the pathway to diagnosis and treatment of head and neck cancer (HNC), focusing on differences based on remoteness of residence.

METHODS

Patients ≥6 months post-treatment completion, and their carers, were recruited. Semi-structured interviews, guided by the Model of Pathways to Treatment as the theoretical framework, were conducted to examine pathways to treatment of HNC and facilitators and barriers to early diagnosis and treatment. Thematic analysis with an iterative and data-driven approach was used to identify themes.

RESULTS

A total of 39 patients and 17 carers participated in the interviews. Facilitators of timely diagnosis and treatment included a sense of urgency from health care professionals (HCPs), advocacy by the HCP or carers, and leveraging social capital. Distance to services, financial costs, and a perceived lack of emotional investment by HCPs arose as barriers to timely diagnosis and treatment. Participants were often able to rationalise that not all delays were negative, depending causes and expected impact on cancer management.

CONCLUSION

The findings highlight the complex nature of factors facilitating and impeding early HNC diagnosis and treatment that may be targeted in interventions to support patients and meet important benchmarks for high-quality cancer care.

Disparities in Treatment Satisfaction and Supportive Care Receipt for Young Adult Oncology Patients on the Basis of Residential Location

PURPOSE:

Adolescent and young adult oncology programs are critical but exist primarily in academic centers, prompting potential disparities in care on the basis of patient residence. We studied the impact of residential location on supportive care receipt and treatment satisfaction in young adults (YAs) with cancer age 19-39 years treated at the University of Wisconsin Carbone Cancer Center (UWCCC).

METHODS:

YA patients with cancer age 19-39 years seen at UWCCC from March 30, 2019, to March 29, 2020, were sent a survey assessing supportive care receipt and satisfaction. Survey results were compared with retrospective chart review of YAs seen at UWCCC between April 1, 2011, and April 1, 2021. Data were categorized on the basis of residential location using distance from UWCCC and 2013 Rural-Urban Continuum Code (RUCC).

RESULTS:

Survey results were obtained for 145 YAs, including 29 from nonmetro RUCC (20.0%) and 81 living > 20 miles from UWCCC (55.9%). YAs from nonmetro locations had lower satisfaction with available treatments (79.3% v 91.4%, P = .005), and distant YAs living > 20 miles from UWCCC more frequently identified location as a barrier to supportive care receipt (35.6% v 15.8%, P = .02). Metro YAs more frequently listed fertility consultations as unavailable (38.0% v 16.0%, P = .04) in the survey despite chart review data showing higher rates of sexual health assessments (48.2% v 20.4%, P = .002) and fertility visits (29.6% v 18.5%, P = .18).

CONCLUSION:

We identified differences in both supportive care receipt and treatment satisfaction on the basis of residential location. These findings support the need for measures to successfully meet treatment and supportive care needs regardless of residential location.

Optimization of a Quality Improvement Tool for Cancer Diagnosis in Primary Care: Qualitative Study

Background

The most common route to a diagnosis of cancer is through primary care. Delays in diagnosing cancer occur when an opportunity to make a timely diagnosis is missed and is evidenced by patients visiting the general practitioner (GP) on multiple occasions before referral to a specialist. Tools that minimize prolonged diagnostic intervals and reduce missed opportunities to investigate patients for cancer are therefore a priority.

Objective

This study aims to explore the usefulness and feasibility of a novel quality improvement (QI) tool in which algorithms flag abnormal test results that may be indicative of undiagnosed cancer. This study allows for the optimization of the cancer recommendations before testing the efficacy in a randomized controlled trial.

Methods

GPs, practice nurses, practice managers, and consumers were recruited to participate in individual interviews or focus groups. Participants were purposively sampled as part of a pilot and feasibility study, in which primary care practices were receiving recommendations relating to the follow-up of abnormal test results for prostate-specific antigen, thrombocytosis, and iron-deficiency anemia. The Clinical Performance Feedback Intervention Theory (CP-FIT) was applied to the analysis using a thematic approach.

Results

A total of 17 interviews and 3 focus groups (n=18) were completed. Participant themes were mapped to CP-FIT across the constructs of context, recipient, and feedback variables. The key facilitators to use were alignment with workflow, recognized need, the perceived importance of the clinical topic, and the GPs’ perception that the recommendations were within their control. Barriers to use included competing priorities, usability and complexity of the recommendations, and knowledge of the clinical topic. There was consistency between consumer and practitioner perspectives, reporting language concerns associated with the word cancer, the need for more patient-facing resources, and time constraints of the consultation to address patients’ worries.

Conclusions

There was a recognized need for the QI tool to support the diagnosis of cancer in primary care, but barriers were identified that hindered the usability and actionability of the recommendations in practice. In response, the tool has been refined and is currently being evaluated as part of a randomized controlled trial. Successful and effective implementation of this QI tool could support the detection of patients at risk of undiagnosed cancer in primary care and assist in preventing unnecessary delays.

Medical treatment decision-making in rural cancer patients: A qualitative systematic review and meta-synthesis

OBJECTIVE

Rural cancer patients have unique care needs which may impact upon treatment decision-making. Our aim was to conduct a qualitative systematic review and meta-synthesis to understand their perspectives and experiences of making treatment decisions.

METHODS

A systematic search of MEDLINE, PsycINFO, CINAHL and RURAL was conducted for qualitative studies in rural cancer patients regarding treatment decision-making. Articles were screened for relevance, and data from the included articles were extracted and analysed using meta-thematic synthesis.

RESULTS

Twelve studies were included, with 4 themes and 9 subthemes identified. Many studies reported patients were not given a choice regarding their treatment. Choice, if given, was influenced by personal factors such as finances, proximity to social supports, convenience, and their personal values. Patients were also influenced by the opinions of others and cultural norms. Finally, it was reported that patients made choices in the context of seeking the best possible medical care and the patient-clinician relationship.

CONCLUSIONS

In the rural context, there are universal and unique factors that influence the treatment decisions of cancer patients.

PRACTICAL IMPLICATIONS

Our findings are an important consideration for clinicians when engaging in shared decision-making, as well as for policymakers, to understand and accommodate the unique rural perspective.

Rural-Urban Disparities in Cancer Outcomes: Opportunities for Future Research

Cancer care disparities among rural populations are increasingly documented and may be worsening, likely because of the impact of rurality on access to state-of-the-art cancer prevention, diagnosis, and treatment services, as well as higher rates of risk factors such as smoking and obesity. In 2018, the American Society of Clinical Oncology undertook an initiative to understand and address factors contributing to rural cancer care disparities. A key pillar of this initiative was to identify knowledge gaps and promote the research needed to understand the magnitude of difference in outcomes in rural vs nonrural settings, the drivers of those differences, and interventions to address them. The purpose of this review is to describe continued knowledge gaps and areas of priority research to address them. We conducted a comprehensive literature review by searching the PubMed (Medline), Embase, Web of Science, and Cochrane Library databases for studies published in English between 1971 and 2021 and restricted to primary reports from populations in the United States and abstracted data to synthesize current evidence and identify continued gaps in knowledge. Our review identified continuing gaps in the literature regarding the underlying causes of rural-urban disparities in cancer outcomes. Rapid advances in cancer care will worsen existing disparities in outcomes for rural patients without directed effort to understand and address barriers to high-quality care in these areas. Research should be prioritized to address ongoing knowledge gaps about the drivers of rurality-based disparities and preventative and corrective interventions.

Unsupervised learning methods for efficient geographic clustering and identification of disease disparities with applications to county-level colorectal cancer incidence in California

Many public health policymaking questions involve data subsets representing application-specific attributes and geographic location. We develop and evaluate standard and tailored techniques for clustering via unsupervised learning (UL) algorithms on such amalgamated (dual-domain) data sets. The aim of the associated algorithms is to identify geographically efficient clusters that also maximize the number of statistically significant differences in disease incidence and demographic variables across top clusters. Two standard UL approaches, k means with k++ initialization (k++) and the standard self-organizing map (SSOM), are considered along with a new, tailored version of the SOM (TSOM). The TSOM algorithm involves optimization of a customized objective function with terms promoting individual geographic cluster cohesion while also maximizing the number of differences across clusters, and two hyper-parameters controlling the relative weighting of geographic and attribute subspaces in a non-Euclidean distance measure within the clustering problem. The performance of these three techniques (k++, SSOM, TSOM) is compared and evaluated in the context of a data set for colorectal cancer incidence in the state of California, at the level of individual counties. Clusters are visualized via chloropleth maps and ordered graphs are also used to illustrate disparities in disease incidence among four identity groups. While all three approaches performed well, the TSOM identified the largest number of disease and demographic disparities while also yielding more geographically efficient top clusters. Techniques presented in this study are relevant to applications including the delivery of health care resources and identifying disparities among identity groups, and to questions involving coordination between county- and state-level policymakers.

Are deprivation-specific cancer survival patterns similar according to individual-based and area-based measures? A cohort study of patients diagnosed with five malignancies in England and Wales, 2008-2016

OBJECTIVE

To investigate if measured inequalities in cancer survival differ when using individual-based ('person') compared with area-based ('place') measures of deprivation for three socioeconomic dimensions: income, deprivation and occupation.

DESIGN

Cohort study.

SETTING

Data from the Office for National Statistics Longitudinal Study of England and Wales, UK, linked to the National Cancer Registration Database.

PARTICIPANTS

Patients diagnosed with cancers of the colorectum, breast, prostate, bladder or with non-Hodgkin's lymphoma during the period 2008-2016.

PRIMARY AND SECONDARY OUTCOME MEASURES

Differentials in net survival between groups defined by individual wage, occupation and education compared with those obtained from corresponding area-level metrics using the English and Welsh Indices of Multiple Deprivation.

RESULTS

Survival was negatively associated with area-based deprivation irrespective of the type analysed, although a trend from least to most deprived was not always observed. Socioeconomic differences were present according to individually-measured socioeconomic groups although there was an absence of a consistent 'gradient' in survival. The magnitude of differentials was similar for area-based and individually-derived measures of deprivation, which was unexpected.

CONCLUSION

These unique data suggest that the socioeconomic influence of 'person' is different to that of 'place' with respect to cancer outcomes. This has implications for health policy aimed at reducing inequalities. Further research could consider the separate and additional influence of area-based deprivation over individual-level characteristics (contextual effects) as well as investigate the geographic, socioeconomic and healthcare-related characteristics of areas with poor outcomes in order to inform policy intervention.

Urban–Rural Disparities in the Lung Cancer Surgical Treatment Pathway: The Paradox of a Rich, Small Region

Introduction

Rural populations in large countries often receive delayed or less effective diagnosis and treatment for lung cancer. Differences are related to population-based factors such as lower pro capita income or increased risk factors or to differences in access to facilities. Switzerland is a small, rich country with peculiar geographic and urban characteristics.

We explored the relationship between lung cancer diagnostic–surgical pathway and urban–rural residency in our region.

Methods

We retrospectively analyzed the medical records of 280 consecutive patients treated for primary non-small cell lung cancer at our institution (2017–2021). This is a regional tertiary center for diagnosis and treatment, and data were extracted from a prospectively collected clinical database. We included anatomical lung resection. Collected variables included patients and surgical characteristics, risk factors, comorbidities, histology and staging, symptoms (vs. incidental diagnosis), general practitioner (GP) involvement, health insurance, and suspected test-treatment interval. The exposure was rurality, defined by the 2009 rural–urban residency classification from the Department of Land.

Results

A total of 150 patients (54%) lived in rural areas. Rural patients had a higher rate of smoking history (93% vs. 82%; p = 0.007). Symptomatic vs. incidental diagnosis did not differ as well as previous cancer rate, insurance, and pathological staging. In rural patients, there was a greater burden of comorbidities (mean Charlson Comorbidity Index Age-Adjusted 5.3 in rural population vs. 4.8 in urban population, p = 0.05), and GP was more involved in the diagnostic pathway (51% vs. 39%, p = 0.04). The interval between the first suspected test and treatment was significantly shorter (56 vs. 66.5 days, p = 0.03). Multiple linear regression with backward elimination was run. These variables statistically predicted the time from the first suspected test and surgical treatment [F(3, 270), p < .05, R² = 0.24]: rurality (p = 0.04), GP involvement (p = 0.04), and presence of lung cancer-related symptoms (p = 0.02).

Conclusions

In our territory with inhomogeneous population distribution and geographic barriers, residency has an impact on the lung cancer pathway. It seems paradoxical that rural patients had a shorter route. The more constant involvement of GP might explain this finding, having suggested more tests for high-risk patients in the absence of symptoms or follow-ups. This did not change the staging of surgical patients, but it might be essential for the organization of an effective lung cancer screening program.

Colorectal Cancer Screening in Castilla La Mancha, Spain: The Influence of Social, Economic, Demographic and Geographic Factors

Colorectal cancer (CRC) is a health problem with a significant social impact, accounting for 700,000 deaths a year globally. CRC survival rates are increasing as a result of early detection and improvements in society and labor conditions. Differences in CRC have been found depending on place of residence (urban or rural), socioeconomic situation and unemployment, although studies in this regard are limited. The aims of the present study were to determine whether differences exist in diagnostic delay according to place of residence, to analyze the association between socioeconomic level and colonoscopy results and to evaluate CRC risk according to place of residence, income level and unemployment. Retrospective, descriptive and observational study based on colonoscopies performed between May 2015 and November 2018, analyzing relationships between colonoscopy findings of a population screening program and various socioeconomic and demographic variables included in the study (sex, age, place of residence, average annual income, unemployment rate, etc.), and determining any association between such factors and related increases in adenocarcinoma risk. A total of 1422 patients were included in the study. The difference in participation according to sex was greater in rural population (63,4% men/36,6% women in rural areas, 58% men/42% women in urban areas). The mean delayed diagnosis was 59,26 days in both groups. Adenocarcinoma risk was 1.216 times higher in rural population. High-grade dysplasic lesions and adenocarcinoma were more common in municipalities with income < 9000€. However, advanced stage adenocarcinoma was higher in municipalities with income > 9000€. Adenocarcinoma risk was 1,088 times higher in municipalities with an unemployment rate of > 10%. Living in rural areas is not a barrier to access to health care, with no disadvantages identified regarding diagnosis and treatment, thanks to public health policies and the large number of small municipalities near the referral hospital in Cuenca.

Disparities in quality of life, social distress and employment outcomes in Australian cancer survivors

PURPOSE

To examine how socio-demographic, comorbidities and information needs influence quality of life (QoL) outcomes of survivors of breast, colorectal, or prostate cancer, non-Hodgkin lymphoma or melanoma.

METHODS

Cross-sectional postal survey with eligible participants identified through a population-based cancer registry. QoL outcomes were assessed by EQ-5D-5L, social difficulties index (SDI) and, for those employed at diagnosis, current employment. Regression analyses explored associations between outcome variables and cancer type, age, time since diagnosis, residential location, socio-economic disadvantage, comorbidities and unmet information needs. Mediation analyses examined whether comorbidities and information needs explained relationships between outcome variables and socio-economic disadvantage.

RESULTS

2115 survivors participated. Mean EQ-5D-5L scores (mean = 0.84) were similar to population averages and SDI scores were low for the entire sample (mean = 3.80). In multivariate analyses, being aged over 80, greater socio-economic disadvantage, comorbidities and unmet information needs decreased EQ-5D-5L scores. Higher SDI scores were associated with socio-economic disadvantage, comorbidities and unmet information needs. Not being employed was associated with being aged over 50, more comorbidities and socio-economic disadvantage. Comorbidities but not information needs partially mediated the impact of socio-economic disadvantage on EQ-5D-5L and SDI accounting for 17% and 14% of the total effect of socio-economic disadvantage respectively. Neither comorbidities nor information needs mediated the association between socio-economic disadvantage and employment outcomes.

CONCLUSIONS

To improve quality of life, survivorship care should be better tailored to address the needs of individuals given their overall health and impact of comorbidities, their age and type of cancer and not simply time since diagnosis.

Influence of Race, Insurance, and Rurality on Equity of Breast Cancer Care

BACKGROUND

Considerable gaps in knowledge remain regarding the intersectionality between race, insurance status, rurality, and community-level socioeconomic status that contribute in concert to disparities in breast cancer care delivery.

METHODS

Women age 18-64 y old with either private, Medicaid, or no insurance coverage and a diagnosis of breast cancer from the North Carolina Central Cancer Registry (2010-2015) were identified and reviewed. Logistic regression models examined the impact of race, insurance status, rurality, and the Social Deprivation Index (SDI) on advanced stage disease at diagnosis (III, IV) and receipt of cancer directed surgery (CDS). Models tested two-way interactions between race, insurance status, rurality, and SDI.

RESULTS

Of the study population (n = 23,529), 14.6% were diagnosed with advanced stage disease (III, IV), and 97.1% of women with non-metastatic breast cancer (n = 22,438) received cancer directed surgery (CDS). Twenty percent of women were non-Hispanic Black (NHB), 3.0% Hispanic, 10.9% Medicaid insured, 5.9% uninsured, 20.0% of women resided in rural areas, and 20.0% resided in communities of the highest quartile SDI. NHB race, Medicaid or uninsured status, and residence in rural or socially deprived areas were associated with advanced stage breast cancer at diagnosis. NHB and Medicaid or uninsured women were significantly less likely to receive CDS. There were no statistically significant interactions found influencing stage at diagnosis or receipt of cancer directed surgery.

CONCLUSIONS

In a heterogeneous population across the state of North Carolina, non-Hispanic Black race, Medicaid or uninsured status, and residence in rural or high social deprivation communities are independently associated with advanced stage breast cancer at diagnosis, while non-Hispanic Black race and Medicaid or uninsured status are associated with lower odds to receive cancer directed surgery.

Predictors of At-Home Death for Cancer Patients in Rural Clinics in Japan

BACKGROUND

The prediction of at-home deaths has become an important topic in rural areas of Japan with an advanced aging society. However, there are no well-established predictors to explain how these factors influence intention. This study aims to investigate the possible predictors of at-home death for cancer patients in rural clinics in Japan.

METHODS

This is a nationwide cross-sectional survey. A self-administered questionnaire was sent to 493 rural clinics in Japan. The main outcome was the realization of at-home deaths for cancer patients.

RESULTS

Among the 264 clinics (54%) that responded to the survey, there were 194 clinics with the realization of at-home death. The use of a clinical pathway (adjusted odds ratio 4.19; 95% confidence interval 1.57-11.19) and the provision of organized palliative care (adjusted odds ratio 19.16; 95% confidence interval 7.56-48.52) were associated with the prediction of at-home death, irrespective of island geography or the number of doctors and nurses.

CONCLUSIONS

Having a clinical pathway and systematizing palliative care could be important to determine the possibility of at-home deaths for cancer patients in rural clinics in Japan.

Disparities in Cancer Screening: The Role of County-Level Metropolitan Status and Racial Residential Segregation

Mortality from cervical and colorectal cancers can be reduced through routine screening, which can often be accessed through primary care. However, uptake of screening in the US remains suboptimal, with disparities observed across geographic characteristics, such as metropolitan status or level of racial residential segregation. Little is known about the interaction of metropolitan status and segregation in their relationship with cancer screening. We conducted a quantitative survey of 474 women aged 45-65 in central Pennsylvania. The survey collected county-level characteristics and participant-level demographics, beliefs, cancer screening barriers, and cervical and colorectal cancer screening. We used bivariate and multivariable logistic regression to analyze relationships between metropolitan status and segregation with screening. For cervical cancer screening, 82.8% of participants were up-to-date, which did not differ by county type in the final analysis. Higher healthcare trust, higher cancer fatalism, and reporting cost as a barrier were associated with cervical cancer screening. For colorectal cancer screening, 55.4% of participants were up-to-date, which differed by county type. In metropolitan counties, segregation was not associated with colorectal cancer screening, but in non-metropolitan counties, segregation was associated with greater colorectal cancer screening. The relationship between metropolitan status and being up-to-date with colorectal, but not cervical, cancer screening varied by segregation. Other important beliefs and barriers to screening varied by county type. This research can guide future cancer screening interventions in primary care settings in underserved communities.

Reliance on Self-Medication Increase Delays in Diagnosis and Management of GI Cancers: Results From Nepal

PURPOSE

Patients with GI cancers in Nepal often present with advanced disease and poor outcomes. The purpose of the study was to determine the time to presentation, diagnosis, and treatment of GI cancer and the baseline factors that may be associated with delays.

PATIENTS AND METHODS

An institutional review board–approved study was performed in Kathmandu, Nepal, from July 2018 to June 2019. Patients with newly diagnosed GI cancers were asked to fill out a standardized questionnaire. Baseline factors such as residence, literacy, and use of self-medication were recorded. Patients were asked to report the time from first symptom to presentation, time from primary care visit to pathologic diagnosis, and time from diagnosis to surgery and/or treatment. Baseline factors were analyzed using 2-tailed t tests (Prism 8.0; GraphPad, La Jolla, CA) to determine whether any factors were associated with longer time delays in these 3 intervals.

RESULTS

The cohort comprised of 104 patients with a median age of 53.5 years (range, 22-77 years); 61.5% were men, 46.2% had upper GI cancers, and 83.7% presented with stage III or IV disease. The median time to presentation was 150 days, time to diagnosis was 220 days, and time to treatment was 50 days. There was no statistically significant difference in time intervals between upper and lower GI cancers. Use of self-medication (88.5%) was the only factor associated with longer time intervals to presentation, diagnosis, and treatment.

CONCLUSION

Patients in Nepal have long time intervals to presentation, diagnosis, and treatment of GI cancer. Self-medication led to longer delays. Reasons for self-medication and other potential barriers will be explored in future studies in the hopes of improving outcomes.

A comparison of liver MRI and contrast enhanced CT as standard workup before treatment for rectal cancer in usual care - a Retrospective Study

BACKGROUND

The liver is the most common site for rectal cancer metastases. Recommended standard pre-treatment workup has involved computed tomography (CT) for abdominal metastases. However, few hospitals have replaced this with magnetic resonance imaging (MRI).

INTRODUCTION

The aim of this study was to compare MRI with CT as an index examination of the liver in the pre-treatment workup in usual care. The primary endpoint was the need for supplementary liver investigations.

METHOD

Consecutive patients from two hospitals during 2013-2015 were identified in the Regional Swedish Colorectal Cancer Register and included in this retrospective study. Hospital records and radiology reports were reviewed. Inconclusive reports were re-evaluated by two radiologists.

RESULT

A total of 320 patients were included, and 293 were available for analysis. Some 175 and 118 patients had undergone CT and MRI, respectively, as their index pretreatment liver examination. Thirty-four (19.4%) in the CT group and 6 (5.1%) patients in the MRI group underwent supplementary liver investigation due to inconclusive index examination (RR 3.82, 95% CI: 1.66;8.81, p=0.0017). Median time (q1;q3) from index examination to start of treatment was 50 (36;68) days in the CT group and 34 (27;45) days in the MRI group.

CONCLUSION

This retrospective study of two modalities within usual care found that MRI of the liver as index radiological workup before treatment for rectal cancer was associated with fewer supplementary liver investigations and a shorter time to start treatment. Based on these findings, a prospective trial should be undertaken before implementing MRI as a standard.

Impact of Race, Ethnicity, and Socioeconomic Status over Time on the Long-term Survival of Adolescent and Young Adult Hodgkin Lymphoma Survivors

BACKGROUND

Although there are growing numbers of adolescent and young adult (AYA) Hodgkin lymphoma (HL) survivors, long-term overall survival (OS) patterns and disparities in this population are underreported. The aim of the current study was to assess the impact of race/ethnicity, socioeconomic status (SES), rurality, diagnosis age, sex, and HL stage over time on long-term survival in AYA HL survivors.

METHODS

The authors used the Surveillance, Epidemiology, and End Results (SEER) registry to identify survivors of HL diagnosed as AYAs (ages 15-39 years) between the years 1980 and 2009 and who were alive 5 years after diagnosis. An accelerated failure time model was used to estimate survival over time and compare survival between groups.

RESULTS

There were 15,899 5-year survivors of AYA HL identified, with a median follow-up of 14.4 years and range up to 33.9 years from diagnosis. Non-Hispanic black survivors had inferior survival compared with non-Hispanic white survivors [survival time ratio (STR): 0.71, P = 0.002]. Male survivors, older age at diagnosis, those diagnosed at higher stages, and those living in areas of higher SES deprivation had unfavorable long-term survival. There was no evidence of racial or sex-based survival disparities changing over time.

CONCLUSIONS

Racial, SES, and sex-based disparities persist well into survivorship among AYA HL survivors.

IMPACT

Disparities in long-term survival among AYA HL survivors show no evidence of improving over time. Studies investigating specific factors associated with survival disparities are needed to identify opportunities for intervention.

Examining the Effect of Travel Distance to Pediatric Cancer Centers and Rurality on Survival and Treatment Experiences: A Systematic Review

Accessing pediatric cancer treatment remains problematic for rural families or those living at increased distances from specialized centers. Rural adult cancer patients or those living far removed from treatment may present with later stage disease, receive different treatments than their closer counterparts, and experience worsened survival. While the financial and psychosocial strain of increased travel is well documented, effects of travel distance on similar outcomes for pediatric cancer patients remain ill-defined. We conducted a systematic review to synthesize literature examining the effect of travel distance and/or rurality (as a proxy for distance) on pediatric cancer treatment experiences and survival outcomes. Included studies examined travel distance to specialized centers or rural status for patients above 21 years of age. Studies were excluded if they focused on financial or quality of life outcomes. We analyzed 24 studies covering myriad malignancies and outcomes, including location of care, clinical trial participation, and likelihood of receiving specialized treatments such as stem cell transplants or proton beam therapy. Most were retrospective, and 9 were conducted outside the United States. While some studies suggest rural patients may experience worsened survival and those traveling furthest may experience shorter hospitalization times/rates, the available evidence does not uniformly assert negative effects of increased distance.

Physical, emotional, and practical concerns, help-seeking and unmet needs of rural and urban dwelling adult cancer survivors

PURPOSE

This study explores the influence of residency location on the experiences of cancer survivors. The influence of where individuals live during cancer screening, diagnosis, and treatment has been described in various countries. However, understanding the context of residency on experiences during survivorship has received less attention.

METHODS

A survey was designed to assess experiences of cancer survivors transitioning to follow-up care. Descriptive statistics were used to contrast physical, emotional, and practical concerns, help-seeking, and unmet needs of rural and urban dwelling respondents. Difference in proportions of greater than 5% were considered clinically meaningful.

RESULTS

In total, 13,319 respondents completed the survey of which 4646 met the criteria for rural dwelling (e.g., living in villages or towns with 10,000 or less residents or on an acreage, ranch, or farm). Proportions of respondents in rural and urban groups were similar in terms of level of concerns. Differences were observed for help seeking regarding return to work and for difficulty in obtaining help regarding taking care of children and other family members, changes in relationships with family, friends and co-workers, and getting to and from appointments. Unmet needs existed across all domains and were similar in both groups. A larger proportion of rural dwelling respondents experienced unmet needs regarding return to work.

CONCLUSIONS

[implications]: High proportions of cancer survivors experienced concerns following cancer treatment. However, rural dwelling survivors were more challenged in obtaining help for selected concerns. Implications exist for development of community-based support services in rural settings.

Effect of rurality and socioeconomic deprivation on presentation stage and long-term outcomes in patients undergoing surgery for colorectal cancer

BACKGROUND

Geographical remoteness and socioeconomic status (SES) are important factors affecting presentation stage and survival for colorectal cancer. A series of patients from a single institution in northern New South Wales was studied to determine if rural isolation or SES affected presentation and survival in patients undergoing resection.

METHODS

Consecutive colorectal cancer resections performed at Lismore Base Hospital from 2011 to 2019 were identified. Patient residential addresses were categorized by the Modified Monash Model (MMM), an Australian Government definition of rural isolation, and Socioeconomic Index for Areas (SEIFA) quintiles, an Australian Bureau of Statistics index of socioeconomic deprivation. Univariate and Cox regression survival analysis was performed on data from histopathology and clinical notes matched with survival data.

RESULTS

A total of 405 patients were included in MMM categories 3 (n = 207, 51.1%), 4 (n = 69, 17%) and 5 (n = 129, 31.9) corresponding to large, medium and small rural towns. MMM 3 was associated with emergency cases (25.6% versus 18.7%, P < 0.001), nodal disease (44.4% versus 38.4%, P = 0.018) and T3/4 tumours (82.1% versus 73.7%, P < 0.001) compared with isolated patients without difference in 5-year survival (P = 0.370). Disadvantaged SEIFA quintiles 1/2 demonstrated increased poor differentiation (23.0% versus 15.4%, P < 0.001) and vascular invasion (15.8% versus 9.1%, P < 0.001) with reduced 5-year survival (57.0% versus 70.4%, P = 0.039). Independent predictors of survival included age, emergency cases, group stage, lymphatic invasion and low lymph node yield.

CONCLUSION

A 'rural reversal' may be present for patients in northern New South Wales; however, SES and established clinicopathological factors are the strongest predictors of survival in our population.

Navigating a Path to Equity in Cancer Care: The Role of Patient Navigation

Notable barriers exist in the delivery of equitable care for all patients with cancers. Social determinants of health at distal, intermediate, and proximal levels impact cancer care. Patient navigation is a patient-centered intervention that functions across these overlapping determinants to increase access to cancer services throughout the cancer care continuum. There is a need to standardize patient navigation training while remaining responsive to local contexts of care and a need to implement patient navigation programs with a health equity lens to address cancer care inequities.

A Comparison of CT Manifestations between Coronavirus Disease 2019 (COVID-19) and Other Types of Viral Pneumonia

BACKGROUND

Though imaging manifestations of COVID-19 and other types of viral pneumonia are similar, their clinical treatment methods differ. Accurate, non-invasive diagnostic methods using CT imaging can help developing an optimal therapeutic regimen for both conditions.

OBJECTIVES

To compare the initial CT imaging features in COVID-19 with those in other types of viral pneumonia.

METHODS

Clinical and imaging data of 51 patients with COVID-19 and 69 with other types of viral pneumonia were retrospectively studied. All significant imaging features (Youden index >0.3) were included for constituting the combined criteria for COVID-19 diagnosis, composed of two or more imaging features with a parallel model. McNemar's chi-square test or Fisher's exact test was used to compare the validity indices (sensitivity and specificity) among various criteria.

RESULTS

Ground glass opacities (GGO) dominated density, peripheral distribution, unilateral lung, clear margin of lesion, rounded morphology, long axis parallel to the pleura, vascular thickening, and crazy-paving pattern were more common in COVID-19 (p <0.05). Consolidation-dominated density, both central and peripheral distribution, bilateral lung, indistinct margin of lesion, tree-in-bud pattern, mediastinal or hilar lymphadenectasis, pleural effusion, and pleural thickening were more common in other types of viral pneumonia (p < 0.05). GGO-dominated density or long axis parallel to the pleura (with the highest sensitivity), and GGO-dominated density or long axis parallel to the pleura or vascular thickening (with the highest specificity) are good combined criteria of COVID-19.

CONCLUSION

The initial CT imaging features are helpful for differential diagnosis between COVID-19 and other types of viral pneumonia.

Rural disparities in surgical care from gynecologic oncologists among Midwestern ovarian cancer patients

OBJECTIVE

Up to one-third of women with ovarian cancer in the United States do not receive surgical care from a gynecologic oncologist specialist despite guideline recommendations. We aim to investigate the impact of rurality on receiving surgical care from a specialist, referral to a specialist, and specialist surgery after referral, and the consequences of specialist care.

METHODS

We utilized a retrospective cohort created through an extension of standard cancer surveillance in three Midwestern states. Multivariable adjusted logistic regression was utilized to assess gynecologic oncologist treatment of women 18-89 years old, who were diagnosed with primary, histologically confirmed, malignant ovarian cancer in 2010-2012 in Kansas, Missouri and Iowa by rurality.

RESULTS

Rural women were significantly less likely to receive surgical care from a gynecologic oncologist specialist (adjusted odds ratio (OR) 0.37, 95% confidence interval (CI) 0.24-0.58) and referral to a specialist (OR 0.37, 95% CI 0.23-0.59) compared to urban women. There was no significant difference in specialist surgery after a referral (OR 0.56, 95% CI 0.26-1.20). Rural women treated surgically by a gynecologic oncologist versus non-specialist were more likely to receive cytoreduction and more complete tumor removal to ≤1 cm.

CONCLUSION

There is a large rural-urban difference in receipt of ovarian cancer surgery from a gynecologic oncologist specialist (versus a non-specialist). Disparities in referral rates contribute to the rural-urban difference. Further research will help define the causes of referral disparities, as well as promising strategies to address them.

Health service inequalities during the COVID-19 pandemic among elderly people living in large urban and non-urban areas in Florida, USA

OBJECTIVE

Health inequalities were often exacerbated during the emerging epidemic. This study examined urban and non-urban inequalities in health services among COVID-19 patients aged 65 years or above in Florida, USA, from 2 March to 27 May 2020.

METHODS

A retrospective time series analysis was conducted using individual patient records. Multivariable Poisson's and logistic models were used to calculate adjusted incidence of COVID-19 and the associated rates of emergency department visits, hospitalizations, and deaths.

RESULTS

As of 27 May 2020, there were 13,659 elderly COVID-19 patients (people aged 65 years or above) in Florida and 14.9% of them died. Elderly people living in small metropolitan areas might be less likely to be confirmed with COVID-19 infection than those living in large metropolitan areas. The emergency department visit and hospitalization rates decreased significantly across metropolitan statuses for both men and women. Those patients living in small metropolitan or rural areas were less likely to be hospitalized than those living in large metropolitan areas (35% and 34% vs 41%). Elderly women aged 75 years or above living in rural areas had 113% higher adjusted incidence of COVID-19 than those living in large metropolitan areas, and the rates of hospitalizations were lower compared with those counterparts living in large metropolitan areas (29% vs 46%; odds ratio: 0.37 (0.25-0.54), p < 0.001).

CONCLUSION

For elderly people living in Florida, USA, those living in small metropolitan or rural areas were less likely to receive adequate health care than those living in large or medium metropolitan areas during the COVID-19 pandemic.

Designing Policy Solutions to Build a Healthier Rural America

Disparities exist in the health, livelihood, and opportunities for the 46-60 million people living in America's rural communities. Rural communities across the United States need a new energy and focus concentrated around health and health care that allows for the designing capturing, and spreading of existing and new innovations. This paper aims to provide a framework for policy solutions to build a healthier rural America describing both the current state of rural health policy and the policies and practices in states that could be used as a national model for positive change.

Comparing Pathways to Diagnosis and Treatment for Rural and Urban Patients With Colorectal or Breast Cancer: A Qualitative Study

PURPOSE

Colorectal cancer patients living in rural areas have poorer outcomes than urban counterparts, but such disparities are not found for breast cancer. Although time to care may contribute to rural-urban disparities, few studies examine patient experiences to understand how and why delays may occur. We compared rural and urban patient experiences of pathways to colorectal or breast cancer diagnosis and treatment in Victoria, Australia.

METHODS

Semistructured telephone interviews were conducted with 43 patients (49% colorectal; 60% rural, median 7 months postdiagnosis). A framework analysis was applied using the Model of Pathways to Treatment.

FINDINGS

Rural and urban patients expressed similar attitudes and reasons for prolonged symptom appraisal and help-seeking triggers. However, some rural patients reported long waiting times to see a Primary Care Practitioner (PCP) and perceived greater gatekeeping to diagnostic services. Patient perceptions of the urgency of PCP referral could impact behavior, such as waiting longer to book appointments. Colorectal cancer patients reported more variable types of symptoms, interpretation, and coping strategies, as well as diverse presentation routes and reduced sense of urgency, compared to breast cancer patients. Waiting time for colonoscopy could be long, particularly in the public health system, but mammograms were quickly arranged.

CONCLUSIONS

Pathway variation was more evident by cancer type than residential location. However, access to primary care and diagnostic services for rural patients with colorectal cancer may be important policy targets. Future research should investigate the impact of diagnostic service accessibility on PCP referral behavior to further understand rural-urban disparities.

Concordance between Optimal Care Pathways and colorectal cancer care: Identifying opportunities to improve quality and reduce disparities

RATIONALE, AIMS, AND OBJECTIVES

Care pathway policies for cancer aim to reduce variation and improve the quality of patient care, and there is increasing evidence that adherence to such pathways is associated with improved survival and lower health care costs. Australia is implementing Optimal Care Pathways (OCPs) for several cancers, including colorectal cancer, but studies evaluating how well care conforms to OCP recommendations are rare. This study examined concordance between OCP recommendations and colorectal cancer care prior to policy rollout and disparities for vulnerable populations.

METHOD

Cross-sectional survey (2012-2014) of cancer registry-identified colorectal cancer patients aged ≥40 approached within 6 months of diagnosis (n = 433), their general practitioner (GP, n = 290), and specialist (n = 144) in Victoria, Australia. We measured concordance with 10 OCP recommendations and variation by geography, socio-economic, and health insurance status using age- and sex-adjusted logistic regression models.

RESULTS

Use of recommended GP investigations varied from 66% for colonoscopy to 13% for digital rectal exam. Recommended waiting times to receive a colonoscopy, see a specialist after referral, and begin adjuvant chemotherapy were exceeded for around a third of patients. Twenty-eight percent of specialists reported a pretreatment multidisciplinary meeting. Most patients received surgery in a hospital with an intensive care unit (92%) and chemotherapy for high risk disease (84%). In general, care was similar across sociodemographic groups. However, receipt of GP investigations tended to be higher and waiting times longer for rural, low socio-economic, and non-privately insured patients. For example, receiving a colonoscopy within 4 weeks was significantly less likely for rural (51%) than urban (78%) patients (odds ratio = 0.30; 95% confidence interval, 0.11-0.79).

CONCLUSION

Prior to implementation, a significant proportion of colorectal cancer patients received care that did not meet OCP recommendations. Low concordance and inequities for rural and disadvantaged populations highlight components of the pathway to target during policy implementation.

Return on Investment of Free Colorectal Cancer Screening Tests in a Primarily Rural Uninsured or Underinsured Population in Northeast Texas

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer in the USA. Its economic impact is extensive, and preventive screening services are warranted to help prevent it.

OBJECTIVE

We sought to examine the return on investment, in terms of reduced costs attributed to cancer prevention, of a CRC screening outreach program providing education and screening in a primarily rural region targeting the uninsured and underinsured.

METHODS

The expenditures of the Northeast Texas CRC screening program were calculated for the years of 2016 and 2017. Prices ($US) were adjusted for inflation and converted to year 2017 values. The costs saved were calculated using the estimated costs of CRC care present in the literature.

RESULTS

For fiscal years 2016 and 2017, the program provided an average return of $US1.46-2.06 for every tax dollar spent. Estimated cost avoidance was $US165,080 per avoided case and estimated cost avoidance of $US245,601 among early-stage cancer cases detected, resulting in potential savings ranging from $US3,893,676 to $US4,837,923.

CONCLUSION

A CRC outreach program providing education and screening operating in less densely populated regions yields a positive return on investment.

Reconceptualising Rural Cancer Inequalities: Time for a New Research Agenda

Evidence has shown for over 20 years that patients residing in rural areas face poorer outcomes for cancer. The inequalities in survival that rural cancer patients face are observed throughout the developed world, yet this issue remains under-examined and unexplained. There is evidence to suggest that rural patients are more likely to be diagnosed as a result of an emergency presentation and that rural patients may take longer to seek help for symptoms. However, research to date has been predominantly epidemiological, providing us with an understanding of what is occurring in these populations, yet failing to explain why. In this paper we outline the problems inherent in current research approaches to rural cancer inequalities, namely how ‘cancer symptoms’ are conceived of and examined, and the propensity towards a reductionist approach to rural environments and populations, which fails to account for their heterogeneity. We advocate for a revised rural cancer inequalities research agenda, built upon in-depth, community-based examinations of rural patients’ experiences across the cancer pathway, which takes into account both the micro and macro factors which exert influence on these experiences, in order to develop meaningful interventions to improve cancer outcomes for rural populations.

Influence of remoteness of residence on timeliness of diagnosis and treatment of oral cavity and oropharynx cancer: A retrospective cohort study

INTRODUCTION

Geographic disparities in head and neck cancer (HNC) outcomes in Australia may be mediated by timeliness of diagnosis and treatment. This retrospective cohort study examines geographic variations in survival and time intervals leading up to treatment for HNC at two tertiary referral centres in New South Wales.

METHODS

Eligible patients were NSW residents aged ≥18 years, diagnosed with primary oropharynx or oral cavity squamous cell carcinoma (SCC) between 01 July 2008 and 30 June 2013, and treated with curative intent. Main outcomes were times from diagnosis to treatment and from surgery to post-operative radiotherapy and overall survival. Differences based on remoteness of residence (regional/remote or metropolitan) were assessed.

RESULTS

A total of 224 patients were eligible. Median time from symptom onset to treatment was longer for regional/remote patients with oropharynx SCC (4.7 vs. 3.8 months, P = 0.044) and oral cavity SCC (6.4 vs. 3.3 months, P = 0.003). Median time from diagnosis to treatment was longer for regional/remote patients with oropharyngeal SCC (47 days vs. 36 days, P = 0.003). Time from surgery to adjuvant radiotherapy was longer among regional/remote patients with oral cavity SCC (66 vs. 42 days, P = 0.001). Overall survival did not differ based on remoteness.

CONCLUSION

Regional/remote HNC patients experienced longer times to diagnosis and treatment, and regardless of remoteness of residence, fewer than half of patients were treated within guideline recommended timeframes. Despite this non-adherence to guidelines, there were no differences in survival outcomes among this cohort. However, the impact of not meeting guidelines on patient outcomes other than survival warrants further investigation.