For patients with breast cancer, geographic and social disparities are independent determinants of access to specialized surgeons. A eleven-year population-based multilevel analysis

Are National Breast and Cervical Cancer Early Detection Program Recipients Providing Services in Counties Heavily Burdened by Breast and Cervical Cancer?

INTRODUCTION

Alignment of National Breast and Cervical Cancer Early Detection Program (NBCCEDP) clinical services with the spatial distribution of breast and cervical cancer burden is essential to maximizing programmatic impact and addressing cancer disparities. This study identified spatial clustering of breast and cervical cancer burden scores and assessed whether and to what extent NBCCEDP clinical services were associated with clusters for the 5-year period, 2015-2019.

METHODS

We examined burden scores for spatial clustering using Local Indicators of Spatial Association (LISA) tests in GeoDA. We then used t-tests to compare the NBCCEDP 5-year average percentage of eligible women served clinical breast and cervical cancer services between hotspot (high burden) and coolspot clusters.

RESULTS

There was statistically significant spatial clustering in the pattern of breast and cervical cancer burden scores across counties, with hotspot clusters mostly observed in the Southern region, Idaho and Nevada. For both breast and cervical cancer, higher percentages of eligible women received breast and cervical cancer clinical services in coolspot clusters compared to hotspot clusters during each year from 2015-2019.

CONCLUSION

NBCCEDP clinical services can help reduce breast and cervical cancer burden. Yet, during 2015-2019, increased service delivery was not aligned with the spatial distribution of counties with greater breast and cervical cancer burdens. NBCCEDP recipients may improve their impact on breast and cervical cancer burden by prioritizing and consistently increasing service delivery in cancer burden hotspot clusters if they have not already maximized their resources in these areas.

Spatial patterns and the associated factors for breast cancer hospitalization in the rural population of Fujian Province, China

BACKGROUND

Despite the known increasing incidence of breast cancer in China, evidence on the spatial pattern of hospitalization for breast cancer is scarce. This study aimed to describe the disparity of breast cancer hospitalization in the rural population of Southeast China and to explore the impacts of socioeconomic factors and heavy metal pollution in soil.

METHODS

This study was conducted using the New Rural Cooperative Medical Scheme (NRCMS) claims data covering 20.9 million rural residents from 73 counties in Southeast China during 2015-2016. The associations between breast cancer hospitalization and socioeconomic factors and soil heavy metal pollutants were evaluated with quasi-Poisson regression models and geographically weighted Poisson regressions (GWPR).

RESULTS

The annual hospitalization rate for breast cancer was 101.40/100,000 in the studied area and the rate varied across different counties. Overall, hospitalization for breast cancer was associated with road density (β = 0.43, P = 0.02), urbanization (β = 0.02, P = 0.002) and soil cadmium (Cd) pollution (β = 0.01, P = 0.02). In the GWPR model, a stronger spatial association of Cd, road density and breast cancer hospitalization was found in the northeast regions of the study area while breast cancer hospitalization was mainly related to urbanization in the western regions.

CONCLUSIONS

Soil Cd pollution, road density, and urbanization were associated with breast cancer hospitalization in different regions. Findings in this study might provide valuable information for healthcare policies and intervention strategies for breast cancer.

No Geographical Inequalities in Survival for Sarcoma Patients in France: A Reference Networks' Outcome?

Simple Summary

As patients with rare cancers face specific problems, reference networks have been developed in several European countries and then at the European level to improve their management. In some cases, the specialized centers belonging to reference networks provide remote services (specialized diagnosis review, discussion in the Multidisciplinary Tumour Board, etc.) to increase access to these services. Using data from the national sarcoma reference network implemented in France (NETSARC+), the IGéAS research program assesses the potential of its organization to address the geographical inequalities in cancer management. We analyze the individual, clinical, and geographical determinants of the overall survival of sarcoma patients in France. We found no association between the overall survival of sarcoma patients and variables measuring their social deprivation, remoteness from reference centers, and geographical context. Following previous results from the research program, this study suggests that reference network organization should be considered to reduce cancer inequalities.

Abstract

The national reference network NETSARC+ provides remote access to specialized diagnosis and the Multidisciplinary Tumour Board (MTB) to improve the management and survival of sarcoma patients in France. The IGéAS research program aims to assess the potential of this innovative organization to address geographical inequalities in cancer management. Using the IGéAS cohort built from the nationwide NETSARC+ database, the individual, clinical, and geographical determinants of the 3-year overall survival of sarcoma patients in France were analyzed. The survival analysis was focused on patients diagnosed in 2013 (n = 2281) to ensure sufficient hindsight to collect patient follow-up. Our study included patients with bone (16.8%), soft-tissue (69%), and visceral (14.2%) sarcomas, with a median age of 61.8 years. The overall survival was not associated with geographical variables after adjustment for individual and clinical factors. The lower survival in precarious population districts [HR 1.23, 95% CI 1.02 to 1.48] in comparison to wealthy metropolitan areas (HR = 1) found in univariable analysis was due to the worst clinical presentation at diagnosis of patients. The place of residence had no impact on sarcoma patients’ survival, in the context of the national organization driven by the reference network. Following previous findings, this suggests the ability of this organization to go through geographical barriers usually impeding the optimal management of cancer patients.

Association between Neighborhood Social Deprivation and Stage at Diagnosis among Breast Cancer Patients in South Carolina

The purpose of this study was to examine the association between neighborhood social deprivation and individual-level characteristics on breast cancer staging in African American and white breast cancer patients. We established a retrospective cohort of patients with breast cancer diagnosed from 1996 to 2015 using the South Carolina Central Cancer Registry. We abstracted sociodemographic and clinical variables from the registry and linked these data to a county-level composite that captured neighborhood social conditions-the social deprivation index (SDI). Data were analyzed using chi-square tests, Student's t-test, and multivariable ordinal regression analysis to evaluate associations. The study sample included 52,803 female patients with breast cancer. Results from the multivariable ordinal regression model demonstrate that higher SDI (OR = 1.06, 95% CI: 1.02-1.10), African American race (OR = 1.35, 95% CI: 1.29-1.41), and being unmarried (OR = 1.17, 95% CI: 1.13-1.22) were associated with a distant stage at diagnosis. Higher tumor grade, younger age, and more recent year of diagnosis were also associated with distant-stage diagnosis. As a proxy for neighborhood context, the SDI can be used by cancer registries and related population-based studies to identify geographic areas that could be prioritized for cancer prevention and control efforts.

Determinants of the access to remote specialised services provided by national sarcoma reference centres

Background

Spatial inequalities in cancer management have been evidenced by studies reporting lower quality of care or/and lower survival for patients living in remote or socially deprived areas. NETSARC+ is a national reference network implemented to improve the outcome of sarcoma patients in France since 2010, providing remote access to specialized diagnosis and Multidisciplinary Tumour Board (MTB). The IGéAS research program aims to assess the potential of this innovative organization, with remote management of cancers including rare tumours, to go through geographical barriers usually impeding the optimal management of cancer patients.

Methods

Using the nationwide NETSARC+ databases, the individual, clinical and geographical determinants of the access to sarcoma-specialized diagnosis and MTB were analysed. The IGéAS cohort (n = 20,590) includes all patients living in France with first sarcoma diagnosis between 2011 and 2014. Early access was defined as specialised review performed before 30 days of sampling and as first sarcoma MTB discussion performed before the first surgery.

Results

Some clinical populations are at highest risk of initial management without access to sarcoma specialized services, such as patients with non-GIST visceral sarcoma for diagnosis [OR 1.96, 95% CI 1.78 to 2.15] and MTB discussion [OR 3.56, 95% CI 3.16 to 4.01]. Social deprivation of the municipality is not associated with early access on NETSARC+ remote services. The quintile of patients furthest away from reference centres have lower chances of early access to specialized diagnosis [OR 1.18, 95% CI 1.06 to 1.31] and MTB discussion [OR 1.24, 95% CI 1.10 to 1.40] but this influence of the distance is slight in comparison with clinical factors and previous studies on the access to cancer-specialized facilities.

Conclusions

In the context of national organization driven by reference network, distance to reference centres slightly alters the early access to sarcoma specialized services and social deprivation has no impact on it. The reference networks’ organization, designed to improve the access to specialized services and the quality of cancer management, can be considered as an interesting device to reduce social and spatial inequalities in cancer management. The potential of this organization must be confirmed by further studies, including survival analysis.

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.

Access denied: The relationship between patient insurance status and access to high-volume hospitals

BACKGROUND

Underinsured patients face significant barriers in accessing high-quality care. Evidence of whether access to high-volume surgical care is mediated by disparities in health insurance coverage remains wanting.

METHODS

The authors used the National Cancer Data Base to identify all adult patients who had a confirmed diagnosis of breast, prostate, lung, or colorectal cancer during 2004 through 2016. The odds of receiving surgical care at a high-volume hospital were estimated according to the type of insurance using multivariable logistic regression analyses for each malignancy. Then, the interactions between study period and insurance status were assessed.

RESULTS

In total, 1,279,738 patients were included in the study. Of these, patients with breast cancer who were insured by Medicare (odds ratio [OR], 0.75; P < .001), Medicaid (OR, 0.55; P < .001), or uninsured (OR, 0.50; P < .001); patients with prostate cancer who were insured by Medicare (OR, 0.87; P = .003), Medicaid (OR, 0.58; P = .001), or uninsured (OR, 0.36; P < .001); and patients with lung cancer who were insured by Medicare (OR, 0.84; P = .020), Medicaid (OR, 0.74; P = .001), or uninsured (OR, 0.48; P < .001) were less likely to receive surgical care at high-volume hospitals compared with patients who had private insurance. For patients with colorectal cancer, the effect of insurance differed by study period, and improved since 2011. For those on Medicaid, the odds of receiving care at a high-volume hospital were 0.51 during 2004 through 2007 and 0.99 during 2014 through 2016 (P for interaction = .001); for uninsured patients, the odds were 0.45 during 2004 through 2007 and 1.19 during 2014 through 2016 (P for interaction < .001) compared with patients who had private insurance.

CONCLUSIONS

Uninsured, Medicare-insured, and Medicaid-insured patients are less likely to receive surgical care at high-volume hospitals. For uninsured and Medicaid-insured patients with colorectal cancer, the odds of receiving care at high-volume hospitals have improved since implementation of the Patient Protection and Affordable Care Act of 2010.

The effect of socioeconomic status on age at diagnosis and overall survival in patients with intracranial meningioma

BACKGROUND

Intracranial meningiomas are the most common primary tumors of the central nervous system. How socioeconomic status (SES) impacts treatment access and outcomes for brain tumor subtypes is an emerging area of research. Few studies have examined the relationship between SES and meningioma survival and management with reference to relevant clinical factors, including age at diagnosis. We studied the independent effects of SES on receiving surgery and survival probability in patients with intracranial meningioma.

METHODS

54,282 patients diagnosed with intracranial meningioma between 2003 and 2012 from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute database were included. Patient SES was divided into tertiles. Patient age groups included 'older' (>65, the median patient age) and 'younger'. Multivariable linear regression and Cox proportional hazards model were used with SAS v9.4. Results were adjusted for race, sex, and tumor grade. Kaplan-Meier survival curves were constructed according to SES tertiles and age groups.

RESULTS

Meningioma prevalence increased with higher SES tertile. Higher SES tertile was also associated with younger age at diagnosis (OR = 0.890, p < 0.05), an increased likelihood of undergoing gross total resection (GTR) (OR = 1.112, p < 0.05), and a trend toward greater 5-year survival probability (HR = 1.773, p = 0.0531). Survival probability correlated with younger age at diagnosis (HR = 2.597, p < 0.001), but not with GTR receipt.

CONCLUSION

The findings from this national longitudinal study on patients with meningioma suggest that SES affects age at diagnosis and treatment access for intracranial meningiomas patients. Further studies are required to understand and address the mechanisms underlying these disparities.

Mapping mammography in Arkansas: Locating areas with poor spatial access to breast cancer screening using optimization models and geographic information systems

Introduction:

Arkansans have some of the worst breast cancer mortality to incidence ratios in the United States (5th for Blacks, 4th for Whites, 7th overall). Screening mammography allows for early detection and significant reductions in mortality, yet not all women have access to these life-saving services. Utilization in Arkansas is well below the national average, and the number of FDA-approved screening facilities has decreased by 38% since 2001. Spatial accessibility plays an important role in whether women receive screenings.

Methods:

We use constrained optimization models within a geographic information system (GIS) to probabilistically allocate women to nearby screening facilities, accounting for facility capacity and patient travel time. We examine accessibility results by rurality derived from rural–urban commuting area (RUCA) codes.

Results:

Under most models, screening capacity is insufficient to meet theoretical demand given travel constraints. Approximately 80% of Arkansan women live within 30 minutes of a screening facility, most of which are located in urban and suburban areas. The majority of unallocated demand was in Small towns and Rural areas.

Conclusions:

Geographic disparities in screening mammography accessibility exist across Arkansas, but women living in Rural areas have particularly poor spatial access. Mobile mammography clinics can remove patient travel time constraints to help meet rural demand. More broadly, optimization models and GIS can be applied to many studies of healthcare accessibility in rural populations.

Intraoperative Radiotherapy for Breast Cancer Treatment in a Rural Community

BACKGROUND

Access to health care poses particular challenges for patients living in rural communities. Intraoperative radiotherapy (IORT) offers a treatment alternative to traditional whole-breast radiation therapy (WBRT) for select patients. This study aimed to analyze the use of IORT for patients undergoing breast-conserving surgery at an academic institution located in a rural state.

METHODS

A retrospective review analyzed all patients at a single institution with a diagnosis of ductal carcinoma in situ (DCIS) or invasive breast cancer from April 2012 to January 2017 who were undergoing breast-conserving surgery with either IORT or WBRT. Student's t test or Fisher's exact test was used to make statistical comparisons.

RESULTS

Patients undergoing IORT (n = 117) were significantly older than patients treated with WBRT (n = 191) (65.6 vs 58.6 years; p < 0.001) and had smaller tumors on both preoperative imaging (1.04 vs 1.66 cm; p < 0.05) and final pathology (0.99 vs 1.48 cm; p < 0.05). Patients receiving IORT lived farther from the treating facility than patients treated with WBRT (67.2 vs 30.8 miles; p < 0.05). To account for biases created in the IORT selection criteria, subgroup analysis was performed for women receiving WBRT who fulfilled IORT selection criteria, and distance traveled remained significant (67.2 vs 31.4 miles; p < 0.05). Neither recurrence nor survival differed between the IORT and WBRT groups. Medicare reimbursement for IORT was approximately 50% more than for WBRT.

CONCLUSIONS

For women from rural communities, IORT appears to be an attractive option because these women tend to be older and to live farther from the treatment facility.

Variations in outcomes by residential location for women with breast cancer: a systematic review

OBJECTIVES

To systematically assess the evidence for variations in outcomes at each step along the breast cancer continuum of care for Australian women by residential location.

DESIGN

Systematic review.

METHODS

Systematic searches of peer-reviewed articles in English published from 1 January 1990 to 24 November 2017 using PubMed, EMBASE, CINAHL and Informit databases. Inclusion criteria were: population was adult female patients with breast cancer; Australian setting; outcome measure was survival, patient or tumour characteristics, screening rates or frequencies, clinical management, patterns of initial care or post-treatment follow-up with analysis by residential location or studies involving non-metropolitan women only. Included studies were critically appraised using a modified Newcastle-Ottawa Scale.

RESULTS

Seventy-four quantitative studies met the inclusion criteria. Around 59% were considered high quality, 34% moderate and 7% low. No eligible studies examining treatment choices or post-treatment follow-up were identified. Non-metropolitan women consistently had poorer survival, with most of this differential being attributed to more advanced disease at diagnosis, treatment-related factors and socioeconomic disadvantage. Compared with metropolitan women, non-metropolitan women were more likely to live in disadvantaged areas and had differing clinical management and patterns of care. However, findings regarding geographical variations in tumour characteristics or diagnostic outcomes were inconsistent.

CONCLUSIONS

A general pattern of poorer survival and variations in clinical management for Australian female patients with breast cancer from non-metropolitan areas was evident. However, the wide variability in data sources, measures, study quality, time periods and geographical classification made direct comparisons across studies challenging. The review highlighted the need to promote standardisation of geographical classifications and increased comparability of data systems. It also identified key gaps in the existing literature including a lack of studies on advanced breast cancer, geographical variations in treatment choices from the perspective of patients and post-treatment follow-up.

Quality Of Breast Cancer Care In The US Territories: Insights From Medicare

The quality of breast cancer care among Medicare beneficiaries in the US territories-where federal spending for health care is lower than in the continental US-is unknown. We compared female Medicare beneficiaries who were residents of the US territories and had surgical treatment for breast cancer in 2008-14 to those in the continental US in terms of receipt of recommended breast cancer care (diagnostic needle biopsy and adjuvant radiation therapy [RT] following breast-conserving surgery) and the timeliness (time from needle biopsy to surgery and from surgery to adjuvant RT) of that care. Residents of the US territories were less likely to receive recommended care (24 percent lower odds of receiving diagnostic needle biopsy and 34 percent lower odds of receiving adjuvant RT) and to receive timely care (45 percent lower odds of receiving surgery and 82 percent lower odds of receiving adjuvant RT, both within three months). Further research is needed to identify barriers to the provision of adequate and timely breast cancer care in this unique population.

Developing a Return to Work Intervention for Breast Cancer Survivors with the Intervention Mapping Protocol: Challenges and Opportunities of the Needs Assessment

Return to work (RTW) is an important step for breast cancer survivors (BCSs). However, they face many barriers that affect particularly women with low socioeconomic status (SES). Health care, workplace, and insurance actors lack knowledge and collaborate poorly. No intervention to date has proven effective to reduce social disparities in employment after breast cancer. The intervention mapping (IM) protocol is being used in France to develop, implement, and evaluate an intervention to facilitate and sustain RTW after breast cancer [FAciliter et Soutenir le retour au TRAvail après un Cancer du Sein (FASTRACS) project]. The research question of this study was to elicit the needs for RTW after breast cancer from various stakeholders' point of view. The aim of this study was to describe the process and the preliminary results of the needs assessment of the FASTRACS project. Different methods were followed to (a) establish and work with a planning group and (b) conduct a needs assessment to create a logic model of the problem. A planning group was organized to gather the stakeholders with the research team. A review of the literature and indicators was conducted to identify the magnitude of the problem and the factors influencing RTW. A qualitative inquiry was conducted with 12 focus groups and 48 individual semi-structured interviews to explore the needs and experience of the stakeholders. The results of these tasks were the proposition of a charter of partnership to structure the participative process, a review of the scientific evidence and indicators, and the description by the stakeholders of their needs and experience. Many stakeholders disagreed with the concept of "early intervention." They advocated for a better support of BCSs during their RTW, emphasized as a process. Anticipation, intersectoral collaboration, and workplace accommodation were mentioned to fit the needs of the BCS and their environment. A logic model of the problem was elaborated from these data. The ability of the model to consider specific characteristics of women with low SES is discussed, with a view to developing the FASTRACS intervention through the next steps of the IM protocol.

Understanding the effects of socioeconomic status along the breast cancer continuum in Australian women: a systematic review of evidence

Background

Globally, the provision of equitable outcomes for women with breast cancer is a priority for governments. However, there is growing evidence that a socioeconomic status (SES) gradient exists in outcomes across the breast cancer continuum – namely incidence, diagnosis, treatment, survival and mortality. This systematic review describes this evidence and, because of the importance of place in defining SES, findings are limited to the Australian experience.

Methods

An on-line search of PubMed and the Web of Science identified 44 studies published since 1995 which examined the influence of SES along the continuum. The critique of studies included the study design, the types and scales of SES variable measured, and the results in terms of direction and significance of the relationships found. To aid in the interpretation of results, the findings were discussed in the context of a systems dynamic feedback diagram.

Results

We found 67 findings which reported 107 relationships between SES within outcomes along the continuum. Results suggest no differences in the participation in screening by SES. Higher incidence was reported in women with higher SES whereas a negative association was reported between SES and diagnosis. Associations with treatment choice were specific to the treatment choice undertaken. Some evidence was found towards greater survival for women with higher SES, however, the evidence for a SES relationship with mortality was less conclusive.

Conclusions

In a universal health system such as that in Australia, evidence of an SES gradient exists, however, the strength and direction of this relationship varies along the continuum. This is a complex relationship and the heterogeneity in study design, the SES indicator selected and its representative scale further complicates our understanding of its influence. More complex multilevel studies are needed to better understand these relationships, the interactions between predictors and to reduce biases introduced by methodological issues.

[On overview of social inequalities in health in France]

Health is dependent on the living conditions and the socioeconomic environment of populations. The healthcare system tends to underestimate these aspects and thereby maintain, and even aggravate, the resulting social inequalities in health. It is essential that this situation is improved by adopting a global and interdisciplinary vision of healthcare and its social determinants.

Impact of geographic accessibility on utilization of the annual health check-ups by income level in Japan: A multilevel analysis

Although both geographic accessibility and socioeconomic status have been indicated as being important factors for the utilization of health care services, their combined effect has not been evaluated. The aim of this study was to reveal whether an income-dependent difference in the impact of geographic accessibility on the utilization of government-led annual health check-ups exists. Existing data collected and provided by Chiba City Hall were employed and analyzed as a retrospective cohort study. The subjects were 166,966 beneficiaries of National Health Insurance in Chiba City, Japan, aged 40 to 74 years. Of all subjects, 54,748 (32.8%) had an annual health check-up in fiscal year 2012. As an optimal index of geographic accessibility has not been established, five measures were calculated: travel time to the nearest health care facility, density of health care facilities (number facilities within a 30-min walking distance from the district of residence), and three indices based on the two-step floating catchment area method. Three-level logistic regression modeling with random intercepts for household and district of residence was performed. Of the five measures, density of health care facilities was the most compatible according to Akaike's information criterion. Both low density and low income were associated with decreased utilization of the health check-ups. Furthermore, a linear relationship was observed between the density of facilities and utilization of the health check-ups in all income groups and its slope was significantly steeper among subjects with an equivalent income of 0.00 yen than among those with equivalent income of 1.01-2.00 million yen (p = 0.028) or 2.01 million yen or more (p = 0.040). This result indicated that subjects with lower incomes were more susceptible to the effects of geographic accessibility than were those with higher incomes. Thus, better geographic accessibility could increase the health check-up utilization and also decrease the income-related disparity of utilization.

[The human and economic burden of cancer in France in 2014, based on the Sniiram national database]

INTRODUCTION

The national health insurance information system (Sniiram) can be used to estimate the national medical and economic burden of cancer. This study reports the annual rates, characteristics and expenditure of people reimbursed for cancer.

METHODS

Among 57 million general health scheme beneficiaries (86% of the French population), people managed for cancer were identified using algorithms based on hospital diagnoses and full refund for long-term cancer. The reimbursed costs (euros) related to the cancer, paid off by the health insurance, were estimated.

RESULTS

In 2014, 2.491 million people (4.4%) covered by the general health scheme had a cancer managed (men 1.1 million, 5.1%; women 1.3 million, 4.9%). The annual (2012-2014) average growth rate of patients was 0.8%. The spending related to the cancer was 13.5 billion: 5 billion for primary health care (drugs 2.3 billion), 7.5 billion for the hospital (drugs 1.3 billions) and 900 million for sick leave and invalidity pensions. Spending annual average growth rate (2012-2014) was 4% (drugs 2%). The rates of patients and the relative spending were 1.8% and 2.5 billion for the breast cancer (women), 1.5% and 1.0 billion for prostate cancer, 0.9% and 1.5 billion for the colon cancer, and 0.19% and 1.3 billion for lung cancer.

DISCUSSION

Cancers establish one of the first groups of chronic diseases pathologies in terms of patients and spending. If the numbers of patients remain stables, the spending increases, mainly for medicines.

Geographical Inequalities in Surgical Treatment for Localized Female Breast Cancer, Queensland, Australia 1997-2011: Improvements over Time but Inequalities Remain

The uptake of breast conserving surgery (BCS) for early stage breast cancer varies by where women live. We investigate whether these geographical patterns have changed over time using population-based data linkage between cancer registry records and hospital inpatient episodes. The study cohort consisted of 11,631 women aged 20 years and over diagnosed with a single primary invasive localised breast cancer between 1997 and 2011 in Queensland, Australia who underwent either BCS (n = 9223, 79%) or mastectomy (n = 2408, 21%). After adjustment for socio-demographic and clinical factors, compared to women living in very high accessibility areas, women in high (Odds Ratio (OR) 0.58 (95% confidence intervals (CI) 0.49, 0.69)), low (OR 0.47 (0.41, 0.54)) and very low (OR 0.44 (0.34, 0.56)) accessibility areas had lower odds of having BCS, while  the odds for women from middle (OR 0.81 (0.69, 0.94)) and most disadvantaged (OR 0.87 (0.71, 0.98)) areas was significantly lower than women living in affluent areas. The association between accessibility and the type of surgery reduced over time (interaction p = 0.028) but not for area disadvantage (interaction p = 0.209). In making informed decisions about surgical treatment, it is crucial that any geographical-related barriers to implementing their preferred treatment are minimised.

Socioeconomic status does not affect prognosis in patients with glioblastoma multiforme

Background:

Glioblastoma multiforme (GBM) is an aggressive malignancy, but there is marked heterogeneity in survival time. Health care disparities have demonstrated significance in oncologic outcomes but have not been clearly examined in this patient population. We investigated the role of sociodemographic variables in the prognosis of adult patients diagnosed with GBM.

Methods:

This retrospective analysis included patients with a histologically confirmed diagnosis of GBM, who underwent resection or biopsy at a single institution from 2000 to 2014. Socioeconomic status (SES) was determined by household income according to the US Census zip code tabulation areas and the US national poverty level. Multivariate Cox proportional hazards analysis calculated effects on patient survival.

Results:

Thirty percent of 218 subjects were of low SES, 57% mid, and 13% high. Low SES patients tended to be male (62%), Caucasian (92%), unmarried (91%), have dependents (100%), and limited to high school education (55%). SES did not predict insurance or employment status. SES was associated with marital status and number of cohabitants (P < 0.0001) but not clinical trial enrollment. Multivariate analysis demonstrated no relationship between SES and survival. Shorter prognosis was associated with history of military service (hazard ratio [HR] 2.06, P = 0.0125), elderly patients (HR 1.70, P = 0.0158), and multifocal disease (HR 1.75, P = 0.0119). Longer prognosis was associated with gross total resection (HR 0.49, P = 0.0009), radiation therapy (HR 0.12, P < 0.0001), and temozolomide (HR 0.28, P < 0.0001).

Conclusions:

SES alone does not predict prognosis in patients with newly diagnosed GBM. Sociodemographic variables such as old age, military service record, and insurance type may have a prognostication role.

Urban-rural disparity of breast cancer and socioeconomic risk factors in China

Breast cancer is one of the most commonly diagnosed cancers worldwide. The primary aim of this work is the study of breast cancer disparity among Chinese women in urban vs. rural regions and its associations with socioeconomic factors. Data on breast cancer incidence were obtained from the Chinese cancer registry annual report (2005–2009). The ten socioeconomic factors considered in this study were obtained from the national population 2000 census and the Chinese city/county statistical yearbooks. Student’s T test was used to assess disparities of female breast cancer and socioeconomic factors in urban vs. rural regions. Pearson correlation and ordinary least squares (OLS) models were employed to analyze the relationships between socioeconomic factors and cancer incidence. It was found that the breast cancer incidence was significantly higher in urban than in rural regions. Moreover, in urban regions, breast cancer incidence remained relatively stable, whereas in rural regions it displayed an annual percentage change (APC) of 8.55. Among the various socioeconomic factors considered, breast cancer incidence exhibited higher positive correlations with population density, percentage of non-agriculture population, and second industry output. On the other hand, the incidence was negatively correlated with the percentage of population employed in primary industry. Overall, it was observed that higher socioeconomic status would lead to a higher breast cancer incidence in China. When studying breast cancer etiology, special attention should be paid to environmental pollutants, especially endocrine disruptors produced during industrial activities. Lastly, the present work’s findings strongly recommend giving high priority to the development of a systematic nationwide breast cancer screening program for women in China; with sufficient participation, mammography screening can considerably reduce mortality among women.

Rates of Neoadjuvant Chemotherapy and Oncoplastic Surgery for Breast Cancer Surgery: A French National Survey

BACKGROUND

The current retrospective study was intended to obtain up-to-date and comprehensive data on surgical practice for breast cancer throughout France, including neoadjuvant chemotherapy (NAC) and the more recent surgical techniques of oncoplastic surgery (OPS).

METHODS

In June 2011, e-mail surveys were sent to 33 nationally renowned breast cancer surgeons from French public or private hospitals. The questionnaire focused on all the new cases of breast cancer treated in 2010. It included questions regarding surgical practices, with special emphases on NAC and OPS and other surgical characteristics.

RESULTS

The overall response rate for the survey was 72.7 %. The total number of breast cancer cases from the survey was 13,762, which constitutes 26.2 % of the total incidence in 2010. Breast-conserving surgery (BCS) was performed for 71.0 % of the patients, and the results were similar throughout the types of practices. Of these patients, 13.9 % received OPS, either upfront or after NAC. Mastectomy was performed for 29.0 % of the patients, which is consistent with French official numbers. Among all patients, 16.3 % underwent surgery after NAC.

CONCLUSION

To the authors' knowledge, there are no publications of national figures on NAC or OPS rates to date. They are convinced that this study offers real-life surgical care information on a large population and covers France's breast cancer surgical landscape. Mastectomy rates in France remain stable and consistent with those in other European countries. However, additional large-scale retrospective studies are required to confirm these figures and further explore NAC and OPS rates as well as surgical practice characteristics.

Individual, Area, and Provider Characteristics Associated With Care Received for Stages I to III Breast Cancer in a Multistate Region of Appalachia

PURPOSE

We describe individual, area, and provider characteristics associated with care patterns for early-stage breast cancer in Appalachian counties of Kentucky, North Carolina, Ohio, and Pennsylvania.

METHODS

Cases of stages I to III breast cancer from 2006 to 2008 were linked to Medicare claims occurring within 1 year of diagnosis. Rates of guideline-concordant endocrine therapy (n = 1,429), chemotherapy (n = 1,480), and radiation therapy (RT) after breast-conserving surgery were studied; RT was studied in women age ≥ 70 years with stage I estrogen receptor (ER) -positive/progesterone receptor (PR) -positive cancer, for whom RT was optional (n = 1,108), and in all others, for whom RT was guideline concordant (n = 1,422). Univariable and multivariable analyses were performed. Independent variables included age, race, county-level economic status, state, surgeon graduation year and volume, comorbidity, diagnosis year, Medicaid/Medicare dual status, histology, tumor size, tumor sequence, positive lymph nodes, ER/PR status, stage, trastuzumab use, and surgery type.

RESULTS

Population mean age was 74 years; 97% were white. For endocrine therapy, chemotherapy, and RT, guideline concordance was 76%, 48%, and 83%, respectively. Where it was optional, 77% received RT. Guideline-concordant endocrine therapy was lower in North Carolina versus Pennsylvania (odds ratio [OR], 0.60; 95% CI, 0.41 to 0.88) and higher if surgeon graduated between 1984 and 1988 versus ≥ 1989 (OR, 1.58; 95% CI, 1.06 to 2.34). Guideline-concordant chemotherapy varied significantly by state, county-level economic status, and surgeon volume. In guideline-concordant RT, lower surgeon volume (v highest) predicted RT use (OR, 1.63; 95% CI, 1.61 to 2.36). In optional RT, North Carolina residence (v Pennsylvania; OR, 0.29; 95% CI, 0.17 to 0.48) and counties with higher economic status (OR, 0.61; 95% CI, 0.40 to 0.94) predicated RT omission.

CONCLUSION

Notable variation in care by geographic and surgical provider characteristics provides targets for further research in underserved areas.

Research in cancer care disparities in countries with universal healthcare: mapping the field and its conceptual contours

The paper reviews published studies focused on disparities in receipt of cancer treatments and supportive care services in countries where cancer care is free at the point of access. We map these studies in terms of the equity stratifiers they examined, the countries in which they took place, and the care settings and cancer populations they investigated. Based on this map, we reflect on patterns of scholarly attention to equity and disparity in cancer care. We then consider conceptual challenges and opportunities in the field, including how treatment disparities are defined, how equity stratifiers are defined and conceptualized and how disparities are explained, with special attention to the challenge of psychosocial explanations.

The association of hospital spending intensity and cancer outcomes: a population-based study in an Asian country

BACKGROUND

Different results are reported for the relationship between regional variation in medical spending and disease prognosis for acute illness and for cancer. Our objective was to investigate the association between hospital medical care spending intensity and mortality rates in cancer patients.

METHODS

A total of 80,597 patients with incident cancer diagnosed in 2002 were identified from the National Health Insurance Research Database of Taiwan, Republic of China. The Cox proportional hazards model was used to compare the 5-year survival rates of patients treated at hospitals with different spending intensities after adjusting for possible confounding and risk factors.

RESULTS

After adjustment for patient characteristics, treatment modality, and hospital volume, an association was found between lower hospital spending intensity and poorer survival rates. The 5-year survival rate expressed by hazard ratios was 1.36 (95% confidence interval [CI]: 1.30-1.43, p < .001) for colorectal cancer, 1.18 (95% CI: 1.08-1.29, p < .001) for lung cancer, 1.13 (95% CI: 1.05-1.22, p = .002) for hepatoma, 1.16 (95% CI: 1.07-1.26, p < .001) for breast cancer, and 1.23 (95% CI: 1.10-1.39, p = .001) for prostate cancer.

CONCLUSION

Our preliminary findings indicate that higher hospital spending intensity was associated with lower mortality rates in patients being treated for lung cancer, breast cancer, colorectal cancer, prostate cancer, hepatoma, or head and neck cancer. The cancer stages were unavailable in this series, and more research linked with the primary data may be necessary to clearly address this issue.

Surgeon and breast unit volume-outcome relationships in breast cancer surgery and treatment

OBJECTIVES

To determine whether surgeon case volume and Unit case volume affected specific recognized key performance indicators (KPIs) of breast cancer surgical management.

BACKGROUND

An increasing body of evidence suggests that a higher standard of cancer care, demonstrated by improved outcomes, is provided in high-volume units or by high-volume surgeons. The volume-outcome relationship pertaining to screen-detected breast cancers has yet to be thoroughly established and remains a pertinent issue in view of the debate surrounding breast cancer screening.

METHODS

The study population comprised all women with a new screen diagnosed breast cancer between 2004-2005 and 2009-2010. Surgeons' mean annual patient volumes were calculated and grouped as very low (<5), low (5-15), medium (16-49), or high volume (>50). The effect of breast screening unit volume was also evaluated. Statistical analyses were performed using Minitab V16.0 software (State College, PA) and R V2.13.0.

RESULTS

There were 81,416 patients aged 61 (±6.8) years treated by 682 surgeons across 82 units. There were 209 very low-, 126 low-, 295 medium-, and 51 high-volume surgeons. The proportion of patients managed by very low-, low-, medium-, and high-volume surgeons was 1.2%, 6.9%, 65.5%, and 25.7%, respectively. Patients managed by high-volume surgeons were more likely to have breast-conserving surgery (BCS) than those managed by low-volume surgeons (P < 0.001). There was a higher proportion of sentinel lymph node biopsies (SLNB) performed by high-volume surgeons in invasive cancers (P = 0.005). High-volume units performed more BCS and SLNB than low-volume units (P < 0.001 and P < 0.001, respectively).

CONCLUSIONS

Even in a setting with established quality control measures (KPIs) surgeon and unit volume have potent influences on initial patient management and treatment.

The association of socioeconomic status and access to low-volume service providers in breast cancer

Background

No large-scale study has explored the combined effect of patients’ individual and neighborhood socioeconomic status (SES) on their access to a low-volume provider for breast cancer surgery. The purpose of this study was to explore under a nationwide universal health insurance system whether breast cancer patients from a lower individual and neighborhood SES are disproportionately receiving breast cancer surgery from low-volume providers.

Methods

5,750 patients who underwent breast cancer surgery in 2006 were identified from the Taiwan National Health Insurance Research Database. The Cox proportional hazards model was used to compare the access to a low-volume provider between the different individual and neighborhood SES groups after adjusting for possible confounding and risk factors. Hosmer-Lemeshow goodness-of-fit statistic was used to determine how well the model fit the data.

Results

Univariate analysis data shows that patients in disadvantaged neighborhood were more likely to receive breast cancer surgery at low-volume hospitals; and lower-SES patients were more likely to receive surgery from low-volume surgeons. In multivariate analysis, after adjusting for patient characteristics, the odds ratios of moderate- and low-SES patients in disadvantaged neighborhood receiving surgery at low-volume hospitals was 1.47 (95% confidence interval=1.19-1.81) and 1.31 (95% confidence interval=1.05-1.64) respectively compared with high-SES patients in advantaged neighborhood. Moderate- and low-SES patients from either advantaged or disadvantaged neighborhood had an odds ratios ranging from 1.51 to 1.80 (p<0.001) to receiving surgery from low-volume surgeons. In Hosmer-Lemeshow goodness-of-fit test, p>0.05 that shows the model has a good fit.

Conclusions

In this population-based cross-sectional study, even under a nationwide universal health insurance system, disparities in access to healthcare existed. Breast cancer patients from a lower individual and neighborhood SES are more likely to receive breast cancer surgery from low-volume providers. The authorities and public health policies should keep focusing on these vulnerable groups.

The impact of comorbidity on cancer survival: a review

Background

A number of studies have shown poorer survival among cancer patients with comorbidity. Several mechanisms may underlie this finding. In this review we summarize the current literature on the association between patient comorbidity and cancer prognosis. Prognostic factors examined include tumor biology, diagnosis, treatment, clinical quality, and adherence.

Methods

All English-language articles published during 2002–2012 on the association between comorbidity and survival among patients with colon cancer, breast cancer, and lung cancer were identified from PubMed, MEDLINE and Embase. Titles and abstracts were reviewed to identify eligible studies and their main results were then extracted.

Results

Our search yielded more than 2,500 articles related to comorbidity and cancer, but few investigated the prognostic impact of comorbidity as a primary aim. Most studies found that cancer patients with comorbidity had poorer survival than those without comorbidity, with 5-year mortality hazard ratios ranging from 1.1 to 5.8. Few studies examined the influence of specific chronic conditions. In general, comorbidity does not appear to be associated with more aggressive types of cancer or other differences in tumor biology. Presence of specific severe comorbidities or psychiatric disorders were found to be associated with delayed cancer diagnosis in some studies, while chronic diseases requiring regular medical visits were associated with earlier cancer detection in others. Another finding was that patients with comorbidity do not receive standard cancer treatments such as surgery, chemotherapy, and radiation therapy as often as patients without comorbidity, and their chance of completing a course of cancer treatment is lower. Postoperative complications and mortality are higher in patients with comorbidity. It is unclear from the literature whether the apparent undertreatment reflects appropriate consideration of greater toxicity risk, poorer clinical quality, patient preferences, or poor adherence among patients with comorbidity.

Conclusion

Despite increasing recognition of the importance of comorbid illnesses among cancer patients, major challenges remain. Both treatment effectiveness and compliance appear compromised among cancer patients with comorbidity. Data on clinical quality is limited.

Health disparities around the world: perspectives from the 2012 Principles and Practice of Cancer Prevention and Control course at the National Cancer Institute

INTRODUCTION

The National Cancer Institute Principles and Practice of Cancer Prevention and Control course is a 4-week course encompassing a variety of cancer prevention and control topics that is open to attendees from medical, academic, government, and related institutions around the world. Themes related to the challenges health disparities present to cancer prevention efforts and potential solutions to these issues emerged from facilitated group discussions among the 2012 course participants.

MATERIALS AND METHODS

Small-group discussion sessions with participants (n = 85 from 33 different countries) and facilitators (n = 9) were held once per week throughout the 4-week course. Facilitators prepared open-ended questions related to course topics. Participants provided responses reflecting their opinions of topics on the basis of experiences in their countries. A thematic analysis was conducted to explore themes emerging from the discussion groups.

RESULTS

The varied influences of health disparities on cancer prevention efforts among > 30 countries represented prominent themes across discussion groups. Participants discussed the interplay of individual characteristics, including knowledge and culture, interpersonal relationships such as family structure and gender roles, community and organizational factors such as unequal access to health care and access to treatment, and national-level factors including policy and government structure.

CONCLUSION

The ideas and solutions presented here are from a geographically and professionally diverse group of individuals. The collective discussion highlighted the pervasiveness of health disparities across all areas represented by course participants and suggested that disparities are the largest impediment to achieving cancer prevention goals.

Hospital and surgeon caseload are associated with risk of re-operation following breast-conserving surgery

Breast-conserving surgery (BCS) is increasingly used for breast cancer treatment. One of the disadvantages of BCS is the risk of re-operation, associated with additional costs to the woman, health service and society. Hospital and surgeon caseload have been associated with better outcomes in breast cancer. Whether these are related to re-operation rates is not clear. In women who underwent BCS initially, we aimed to quantify re-operation rates and identify the factors related to the risk of undergoing subsequent (i) re-operation and (ii) total mastectomy (TM). From the National Cancer Registry Ireland, we identified women diagnosed with a first invasive breast cancer during 2002-2008, and who initially had BCS. Poisson regression with robust error variance was used to identify factors significantly associated with (i) re-operation (vs no re-operation) or (ii) re-operation by TM (vs re-operation by BCS). 16,551 women were diagnosed with invasive breast cancer and 8,318 underwent initial BCS. Of these, 17 % had one or more subsequent re-operations and, of these, 62 % had TM. Surgeon and hospital volume significantly predicted subsequent re-operation after adjustment for socio-demographic and clinical variables. Women having surgery in lower-volume hospitals by low-volume surgeons significantly increased the risk of re-operation [incidence rate ratio (IRR) = 1.56; 95 % CI 1.33-1.83] compared to those operated in higher-volume hospitals by a higher-volume surgeon. Risk of subsequent TM was increased by 22 % (95 % CI 1.10-1.35) and 21 % (95 % CI 1.09-1.33), if women were operated by a lower or intermediate-volume surgeon. The fact that factors related to healthcare organisation/service provision are associated with re-operations suggests that it may be possible to reduce the overall re-operation rate. The high frequency of subsequent TM raises questions about strategies for selecting women for initial BCS. Our results may inform the development of information strategies to help ensure that women are aware of risks of re-operation following BCS and hence, make appropriate treatment choices.