Is Access to Care Associated With Stage at Presentation and Survival for Melanoma Patients?

Rural Melanoma Patients Have Less Surgery and Higher Melanoma-Specific Mortality

BACKGROUND

Melanoma causes most skin cancer-related deaths, and disparities in mortality persist. Rural communities, compared to urban, face higher levels of poverty and more barriers to care, leading to higher stage at presentation and shorter survival in melanoma. To further evaluate these disparities, we sought to assess the association between rurality and melanoma cause-specific mortality and receipt of recommended surgery in a national cohort.

METHODS

Patients with primary non-ocular, cutaneous melanoma from the SEER database, 2000-2017, were included. Outcomes included melanoma-specific survival and receipt of recommended surgery. Rurality was based on Rural-Urban Continuum Codes. Variables included age, sex, race, ethnicity, income, and stage. Multivariate regression models assessed the effect of rurality on survival and receipt of recommended surgery.

RESULTS

103,606 patients diagnosed with non-ocular cutaneous primary melanoma met criteria during this period. 93.3% (n = 96620) were in urban areas and 6.7% (n = 6986) were in rural areas. On multivariate regression controlling for age, sex, race, ethnicity, and stage patients living in a rural area were less likely to receive recommended surgery (aOR .52, 95% CI: .29-.90, P = .02) and had increased hazard of melanoma-specific mortality (aHR 1.19, 95% CI: 1.02-1.40, P = .03) even after additionally controlling for surgery receipt.

CONCLUSION

Using a large national cohort, our study found that rural patients were less likely to receive recommended surgery and had shorter melanoma cause-specific survival. Our findings highlight the importance of access to cancer care in rural areas and how this ultimately effects survival for these patients.

Association of Patient Proximity to Dermatologic Care With Melanoma Stage at Diagnosis and Outcome

This cohort study evaluates the association of proximity to dermatologic clinicians with stage at diagnosis and cancer-specific survival among adults with cutaneous melanoma in Iowa.

Dermatology Workforce in the United States - Part 1: Overview, Transformations, and Implications

The dermatology workforce continues to evolve to meet the growing and diversified demands of the United States population. Part 1 of this continuing medical education (CME) series is designed to provide an overview of the dermatology workforce as well as delineate the motivators and socio-economic implications of significant workforce transformations which are impacting dermatologic health care. Part 2 of the series will consider the impact of workforce challenges on patient outcomes and discuss potential actions that may help to optimize workforce organization and care delivery.

Restructuring Skin Cancer Care in Ontario: A Provincial Plan

There is a global rise in skin cancer incidence, resulting in an increase in patient care needs and healthcare costs. To optimize health care planning, costs, and patient care, Ontario Health developed a provincial skin cancer plan to streamline the quality of care. We conducted a systematic review and a grey literature search to evaluate the definitions and management of skin cancer within other jurisdictions, as well as a provincial survey of skin cancer care practices, to identify care gaps. The systematic review did not identify any published comprehensive skin cancer management plans. The grey literature search revealed skin cancer plans in isolated regions of the United Kingdom (U.K.), National Institute for Health and Care Excellence (NICE) guidelines for skin cancer quality indicators and regional skin cancer biopsy clinics, and wait time guidelines in Australia and the U.K. With the input of the Ontario Cancer Advisory Committee (CAC), unique definitions for complex and non-complex skin cancers and the appropriate cancer services were created. A provincial survey of skin cancer care yielded 44 responses and demonstrated gaps in biopsy access. A skin cancer pathway map was created and a recommendation was made for regional skin cancer biopsy clinics. We have created unique definitions for complex and non-complex skin cancer and a skin cancer pathways map, which will allow for the implementation of both process and performance metrics to address identified gaps in care.

Impact of rurality on melanoma diagnosis in Utah

Aim

To analyze trends in Utah melanoma diagnosis and study the impact of rurality.

Patients & methods

State-wide melanoma incidence was calculated using Surveillance, Epidemiology, and End Results data (2005-2013). A subset of 5199 patients treated in an integrated healthcare system was further stratified for urban or rural residence.

Results

Early-stage tumors accounted for most of the increase in melanoma incidence over time. Age-adjusted melanoma incidence rate was higher in rural counties (46.7 vs 39.4). Anatomic site and stage did not differ between rural and urban patients. Rural patients were more commonly diagnosed by a local primary care provider.

Conclusion

Rurality had an impact on melanoma diagnosis in the specialty and location of the diagnosing provider.

Disparities in surgical management of endometrial cancers in a public healthcare system: A question of equity

OBJECTIVE

Timely surgery has been shown to impact outcome in endometrial cancer patients. Social determinants of health (SDH) are associated with adverse cancer outcomes. We sought to evaluate the association of SDH with surgical treatment indicators in endometrial cancer patients in a public healthcare system.

METHODS

Endometrial cancer patients in Ontario, Canada, diagnosed between 2009 and 2017 were identified, and clinical, social and demographic variables were extracted from administrative databases. Validated community marginalization scores that include material deprivation, residential instability and ethnic concentration were used for stratification. Surgical treatment features were compared across marginalization quintiles using chi-square, Fischer exact or Wilcoxon rank sum tests as appropriate. Predictors of timely surgical treatment were evaluated with logistic regression.

RESULTS

20228 patients were identified of whom 14,423 had primary hysterectomy for a preoperative diagnosis of endometrial cancer. Fewer patients in marginalized communities received surgery (89% vs. 93%, p < 0.001). Surgical delay was longer among marginalized patients and 78% had surgery within 12 weeks compared to 84% of those least marginalized (p < 0.0001). Other quality indicators of surgical treatment were not negatively associated with marginalization. On multivariable analysis adjusted for patient and disease factors, marginalization was independently associated with increased odds of delayed surgery (OR = 0.94/quintile, CI 0.91-0.97, p < 0.001).

CONCLUSIONS

Social marginalization is associated with decreased likelihood of having surgery and with delayed surgery among endometrial cancer patients in Ontario. This may be mediated by delayed presentation and real or perceived barriers to access. Reducing surgical wait times among marginalized cancer patients is an important deliverable in public healthcare.

The impact of demographics, socioeconomics, and health care access on melanoma outcomes

Disparities in melanoma care exist in the United States. Disparities in provider type, patient demographics, place of residence, insurance status, socioeconomic status, race/ethnicity, and age impact melanoma outcomes. Melanomas detected by dermatologists are thinner, at an earlier stage, and have better survival outcomes compared with detection by primary care providers or patients. Lower socioeconomic status, race/ethnicity, and place of residence are associated with decreased access to or use of dermatologists, or both, and more advanced melanomas at diagnosis. Additionally, uninsured and publicly insured individuals are more likely to present with late-stage melanomas, resulting in worse outcomes. This review provides a comprehensive overview of how structural and patient-level characteristics influence melanoma outcomes in order to inform clinical care and health care policy as it relates to addressing gaps in melanoma care.