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

Beyond the urban-rural divide: Exploring spatial variations in breast cancer outcomes in Queensland, Australia

BACKGROUND

Breast cancer is the most commonly diagnosed cancer among women worldwide. While previous studies have reported urban and rural differences in breast cancer outcomes, the level of heterogeneity within these broad regions is currently unknown.

METHODS

Population-level data from Queensland Cancer Register including 58,679 women aged at least 20 years who were diagnosed with breast cancer in Queensland, Australia, 2000-2019 were linked to BreastScreen Queensland and Queensland Hospital Admitted Patients Data Collection to estimate five breast cancer outcomes: incidence, proportion of localised disease and screen-detected cases (via public-funded program), surgical rates, and 5-year survival. Bayesian spatial models were used to smooth outcomes across 512-517 small areas in Queensland.

RESULTS

The incidence of breast cancer was not proportionally distributed, with urban regions having higher rates. Less than half (47 %) of women were diagnosed with localised disease, 91 % had surgery, with five-year relative survival of 92 %. There was no evidence of geographic variation in the proportion of localised disease, surgical rates, or survival over Queensland. Publicly-funded screening detected 38 % of cases, with lower proportion of screen-detected cases observed in Queensland's urbanised south-east corner.

CONCLUSION

Although the disparities in health outcomes faced by Australians living in rural areas have received increased attention, this study found limited evidence for spatial variation in breast cancer outcomes along the continuum of care across Queensland. These results suggest the detection and management practices for breast cancer may provide an achievable benchmark for other cancer types in reducing the geographical disparity in cancer outcomes.

Influence of geographic access and socioeconomic characteristics on breast cancer outcomes: A systematic review

Socio-economic and geographical inequalities in breast cancer mortality have been widely described in European countries and the United States. To investigate the combined effects of geographic access and socio-economic characteristics on breast cancer outcomes, a systematic review was conducted exploring the relationships between: (i) geographic access to healthcare facilities (oncology services, mammography screening), defined as travel time and/or travel distance; (ii) breast cancer-related outcomes (mammography screening, stage of cancer at diagnosis, type of treatment and rate of mortality); (iii) socioeconomic status (SES) at individuals and residential context levels. In total, n = 25 studies (29 relationships tested) were included in our systematic review. The four main results are: The statistical significance of the relationship between geographic access and breast cancer-related outcomes is heterogeneous: 15 were identified as significant and 14 as non-significant. Women with better geographic access to healthcare facilities had a statistically significant fewer mastectomy (n = 4/6) than women with poorer geographic access. The relationship with the stage of the cancer is more balanced (n = 8/17) and the relationship with cancer screening rate is not observed (n = 1/4). The type of measures of geographic access (distance, time or geographical capacity) does not seem to have any influence on the results. For example, studies which compared two different measures (travel distance and travel time) of geographic access obtained similar results. The relationship between SES characteristics and breast cancer-related outcomes is significant for several variables: at individual level, age and health insurance status; at contextual level, poverty rate and deprivation index. Of the 25 papers included in the review, the large majority (n = 24) tested the independent effect of geographic access. Only one study explored the combined effect of geographic access to breast cancer facilities and SES characteristics by developing stratified models.

Trends in surgery and adjuvant treatment for early-stage breast cancer: a population-based study in Queensland, Australia

PURPOSE

Our aim was to describe variations in the treatment of early-stage breast cancer and to examine factors associated with disease-specific survival (DSS).

METHODS

The study used linked data for 24,190 women with a T1 (≤ 20 mm) breast cancer who underwent surgery from 2005 to 2019. Multivariate logistic regression was used to model predictors of receiving breast-conserving surgery (BCS) compared to mastectomy and a multinomial model was used to examine factors associated with type(s) of treatment received.

RESULTS

Overall, 70.3% had BCS, with a reduced likelihood of BCS observed for younger women (p < 0.001), rural residence, (p < 0.001), socioeconomic disadvantage (p = 0.004), higher tumour grade (p < 0.001) and surgery in a public versus private hospital (p < 0.001). Compared to women who received BCS and radiation therapy (RT), those having mastectomy alone or mastectomy plus RT were more likely to be younger (p < 0.001), live in a rural area (p < 0.001), have higher-grade tumours (p < 0.001) and positive lymph nodes (p < 0.001). Overall 5-year survival was 95.3% and breast cancer-specific survival was 98.3%. Highest survival was observed for women having BCS and RT and lowest for those having mastectomy and RT (p < 0.001).

CONCLUSION

Our results indicate some variation in the management of early-stage breast cancer. Lower rates of BCS were observed for rural and disadvantaged women and for those treated in a public or low-volume hospital. Whilst survival was high for this cohort, differences in tumour biology likely explain the differences in survival according to treatment type.

Surgical and radiotherapy patterns of care in the management of breast cancer in NSW and ACT Australia

INTRODUCTION

This study aims to report on the surgical and radiotherapy patterns of breast cancer care in New South Wales (NSW) and Australian Capital Territory (ACT) in Australia, to identify factors that impact on utilisation of evidence-based treatment and to report on the overall survival (OS) rate and the influencing factors on OS.

METHODS

Cancer registry data linked to hospital records for all patients with breast cancer diagnosis in NSW and ACT between 2009 and 2014 were used to calculate rates of breast conserving surgery (BCS), mastectomy, sentinel lymph node biopsy (SLNB), axillary lymph node dissection (ALND) and radiotherapy. Multivariate analysis used to identify factors that led to variations in care. 5-year OS was calculated and cox regression model assessed factors that influenced survival.

RESULTS

Data for 30,337 patients were analysed. BCS and mastectomy rates were 64% and 36%, respectively. The SLNB, ALND and ALND after SLNB rates were 61.5%, 32.1% and 6.4%, respectively. Radiotherapy was utilised in 63%. Younger age, socio-economic disadvantage, longer distance to a radiotherapy facility and overseas place of birth were factors that predicted for increased rates of mastectomy and ALND. Radiotherapy was more likely to be utilised in later years of diagnosis, patients between 40-69 years old, and those who lived in major cities and closer to a radiotherapy facility. 5-year OS was 80.5%. Older patients, the socioeconomically disadvantaged and those advanced tumours had worse survival.

CONCLUSION

Variations in breast cancer care continue to exist in certain patient groups that we identified. Targeted strategic planning and further research to identify other drivers of existing disparities remain a priority.

Quantifying the hospital and emergency department costs for women diagnosed with breast cancer in Queensland

PURPOSE

With increasing rates of cancer survival due to advances in screening and treatment options, the costs of breast cancer diagnoses are attracting interest. However, limited research has explored the costs to the Australian healthcare system associated with breast cancer. We aimed to describe the cost to hospital funders for hospital episodes and emergency department (ED) presentations for Queensland women with breast cancer, and whether costs varied by demographic characteristics.

METHODS

We used a linked administrative dataset, CancerCostMod, limited to all breast cancer diagnoses aged 18 years or over in Queensland between July 2011 and June 2015 (n = 13,285). Each record was linked to Queensland Health Admitted Patient Data Collection and Emergency Department Information Systems records between July 2011 and June 2018. The cost of hospital episodes and ED presentations were determined, with mean costs per patient modelled using generalised linear models with a gamma distribution and log link function.

RESULTS

The total cost to the Queensland healthcare system from hospital episodes for female breast cancer was AUD$309 million and AUD$12.6 million for ED presentations during the first 3 years following diagnosis. High levels of costs and service use were identified in the first 6 months following diagnosis. Some significant differences in cost of hospital and ED episodes were identified based on demographic characteristics, with Indigenous women and those from lower socioeconomic backgrounds having higher costs.

CONCLUSION

Hospitalisation costs for breast cancer in Queensland exert a high burden on the healthcare system. Costs are higher for women during the first 6 months from diagnosis and for Indigenous women, as well as those with underlying comorbidities and lower socioeconomic position.

Beliefs and perceptions about breast cancer among the people living in rural and less privileged areas in Sindh, Pakistan

Purpose

Globally, women suffer from a lack of knowledge about breast cancer (BC), its symptoms and treatment. The purpose of this paper is to examine how people living in rural and less developed areas in Pakistan perceive BC. The study investigates the level of knowledge about BC in rural communities and analyses how the prevalent perceptions and beliefs impact women's lives and delay the diagnosis.

Design/methodology/approach

This study is based on 42 in-depth interviews with the women who have undergone BC treatment during the past five years. The participants were interviewed were the residents of the northern Sindh, southern Pakistan.

Findings

Findings show that BC was perceived as a contagious disease transmitted through touching or being physically close to the patient. Some women were abandoned by their husbands because of this perception. Faith in fatalism and the perception that BC is an incurable disease were common in communities with low socio-economic status. This is likely to affect the prevention and early detection of BC.

Originality/value

The study shows a strong co-relation of awareness with the prevalent perceptions regarding BC. Therefore, we recommend promoting health literacy and introducing culturally specific interventions in remote communities to enhance their understanding of the available treatment and help remove misconceptions about BC.

Impact of area-level socioeconomic status and accessibility to treatment on life expectancy after a cancer diagnosis in Queensland, Australia

AIMS

This study quantifies geographic inequities in loss of life expectancy (LOLE) by area-level socioeconomic status (SES) and accessibility to treatment.

METHODS

Analysis was conducted using a population-based cancer-registry cohort (n = 371,570) of Queensland (Australia) residents aged 50-89 years, diagnosed between 1997-2016. Flexible parametric survival models were used to estimate LOLE by area-level SES and accessibility for all invasive cancers and the five leading cancers. The gain in life years that could be achieved if all cancer patients experienced the same relative survival as those in the least disadvantaged-high accessibility category was estimated for the 2016 cohort.

RESULTS

For all invasive cancers, men living in the most disadvantaged areas lost 34 % of life expectancy due to their cancer diagnosis, while those from the least disadvantaged areas lost 25 %. The corresponding percentages for women were 33 % and 23 %. Accessibility had a lower impact on LOLE than SES, with patients from low accessibility areas losing 0-4 % more life expectancy than those from high accessibility areas. For cancer patients diagnosed in 2016 (n = 24,423), an estimated 101,387 life years will be lost. This would be reduced by 19 % if all patients experienced the same relative survival as those from the least disadvantaged-high accessibility areas.

CONCLUSION

The impact of a cancer diagnosis on remaining life expectancy varies by geographical area. Establishing reasons why area disadvantage impacts on life expectancy is crucial to inform subsequent interventions that could increase the life expectancy of cancer patients from more disadvantaged areas.

Factors associated with being diagnosed with high severity of breast cancer: a population-based study in Queensland, Australia

PURPOSE

This study explores factors that are associated with the severity of breast cancer (BC) at diagnosis.

METHODS

Interviews were conducted among women (n = 3326) aged 20-79 diagnosed with BC between 2011 and 2013 in Queensland, Australia. High-severity cancers were defined as either Stage II-IV, Grade 3, or having negative hormone receptors at diagnosis. Logistic regression models were used to estimate odds ratios (ORs) of high severity BC for variables relating to screening, lifestyle, reproductive habits, family history, socioeconomic status, and area disadvantage.

RESULTS

Symptom-detected women had greater odds (OR 3.38, 2.86-4.00) of being diagnosed with high-severity cancer than screen-detected women. Women who did not have regular mammograms had greater odds (OR 1.78, 1.40-2.28) of being diagnosed with high-severity cancer than those who had mammograms biennially. This trend was significant in both screen-detected and symptom-detected women. Screen-detected women who were non-smokers (OR 1.77, 1.16-2.71), postmenopausal (OR 2.01, 1.42-2.84), or employed (OR 1.46, 1.15-1.85) had greater odds of being diagnosed with high-severity cancer than those who were current smokers, premenopausal, or unemployed. Symptom-detected women being overweight (OR 1.67, 1.31-2.14), postmenopausal (OR 2.01, 1.43-2.82), had hormone replacement therapy (HRT) < 2 years (OR 1.60, 1.02-2.51) had greater odds of being diagnosed with high-severity cancer than those of healthy weight, premenopausal, had HRT > 10 years.

CONCLUSION

Screen-detected women and women who had mammograms biennially had lower odds of being diagnosed with high-severity breast cancer, which highlighted the benefit of regular breast cancer screening. Women in subgroups who are more likely to have more severe cancers should be particularly encouraged to participate in regular mammography screening.

Sleep Quality and Fatigue among Breast Cancer Patients Undergoing Chemotherapy

Background: Breast cancer survivors make up a growing population facing treatment that poses long - standing adverse effects including chemotherapy- related sleep disorders and fatigue. There is limited knowledge of patients' lived experiences of chemotherapy- induced sleep disorders and fatigue. The aim of this study was to explore sleep quality and fatigue among breast cancer patients undergoing chemotherapy. Materials and Methods: One hundred fifteen patients were included in this census-based cross-sectional study. Data were collected through the Pittsburgh Sleep Quality Index and Brief Fatigue Inventory four days after the chemotherapy session. Statistical analysis was carried out using SPSS software version 13 and P<0.05 was considered statistically significant in all tests. Results: The mean hours of sleep were 5.6±1.83 in the range of 2 to 10 hours. The mean score of fatigue of participants was 5.59±1.67. Based on the cutting point, 57.4%, 20.9%, and 21.7% of participants had a moderate (4-6.9), mild (0.1-3.9), and severe (7-9.9) level of fatigue, respectively. The mean score of sleep quality among the participants was equal to 14.06±3.06, with a maximum and minimum of 7 and 21. The results of Spearman correlation coefficient showed that there is a significant relationship between fatigue and quality of sleep )0.210). Conclusion: Although the study findings revealed that patients with breast cancer undergoing chemotherapy experience different degrees of sleep disorders and fatigue, there is a need for more detailed studies to improve the quality of sleep and reduce fatigue in these patients due to the little attention paid to this issue in the medical field.

Factors influencing breast cancer outcomes in Australia: A systematic review

PURPOSE

This systematic review evaluates factors influencing breast cancer outcomes for women treated in Australia, facilitating the exploration of disparities in breast cancer outcomes for certain groups of women in Australia.

METHOD

A systematic literature search was performed using MEDLINE and Scopus focusing on breast cancer in Australia with outcome measures being breast cancer survival and recurrence with no restrictions on date. Risk of bias was assessed using Cairns Assessment Scale for Observational studies of Risk factors (CASOR).

RESULTS

Fifteen quantitative studies were included: two were high quality, 11 were intermediate quality, and two were low quality. Traditional risk factors such as invasive tumour type, larger size, higher grade and stage, lymph node involvement and absence of hormone receptors were found to be associated with breast cancer mortality. Being younger (<40 years old) and older (>70 years old), having more comorbidities, being of lower socioeconomic status, identifying as Aboriginal or Torres Strait Islander, living in more rural areas or having a mastectomy were factors found to be associated with poorer breast cancer outcomes.

CONCLUSION

Despite the heterogeneity of the studies, this review identified significant risk factors for breast cancer mortality and recurrence. The use of this data would be most useful in developing evidence-based interventions and in optimising patient care through creation of a prediction model.

PROSPERO REGISTRATION

CRD42017072857.

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.

Reoperation after breast-conserving surgery for cancer in Australia: statewide cohort study of linked hospital data

OBJECTIVES

To investigate between-hospital variation in the probability of reoperation within 90 days of initial breast-conserving surgery (BCS), and the contribution of health system-level and other factors.

DESIGN

Population-based, retrospective cohort study.

SETTING

New South Wales (NSW), Australia.

PARTICIPANTS

Linked administrative hospitalisation data were used to define a cohort of adult women undergoing initial BCS for breast cancer in NSW between 1 July 2002 and 31 December 2013.

PRIMARY OUTCOME MEASURES

Multilevel, cross-classified models with patients clustered within hospitals and residential areas were used to examine factors associated with any reoperation, and either re-excision or mastectomy, within 90 days.

RESULTS

Of 34 458 women undergoing BCS, 29.1% underwent reoperation within 90 days, half of which were mastectomies. Overall, the probability of reoperation decreased slightly over time. However, there were divergent patterns by reoperation type; the probability of re-excision increased alongside a concomitant decrease in the probability of mastectomy. Significant between-hospital variation was observed. Non-metropolitan location and surgery at low-volume hospitals were associated with a higher overall probability of reoperation, and of mastectomy specifically, after accounting for patient-level factors, calendar year and area-level socioeconomic status. The magnitude of association with geographical location and surgical volume decreased over time.

CONCLUSIONS

Reoperation rates within 90 days of BCS varied significantly between hospitals. For women undergoing mastectomy after BCS, this represents a dramatic change in clinical course. Multilevel modelling suggests unwarranted clinical variation may be an issue, likely due to disparities in access to multidisciplinary breast cancer care and preoperative diagnostic procedures. However, the observed reduction in disparities over time is encouraging and indicates that guidelines and policy initiatives have the potential to improve regional breast cancer care.

Variations in outcomes for Indigenous women with breast cancer in Australia: A systematic review

This systematic review examines variations in outcomes along the breast cancer continuum for Australian women by Indigenous status. Multiple databases were systematically searched for peer-reviewed articles published from 1 January 1990 to 1 March 2015 focussing on adult female breast cancer patients in Australia and assessing survival, patient and tumour characteristics, diagnosis and treatment by Indigenous status. Sixteen quantitative studies were included with 12 rated high, 3 moderate and 1 as low quality. No eligible studies on referral, treatment choices, completion or follow-up were retrieved. Indigenous women had poorer survival most likely reflecting geographical isolation, advanced disease, patterns of care, comorbidities and disadvantage. They were also more likely to be diagnosed when younger, have advanced disease or comorbidities, reside in disadvantaged or remote areas, and less likely to undergo mammographic screening or surgery. Despite wide heterogeneity across studies, an overall pattern of poorer survival for Indigenous women and variations along the breast cancer continuum of care was evident. The predominance of state-specific studies and small numbers of included Indigenous women made forming a national perspective difficult. The review highlighted the need to improve Indigenous identification in cancer registries and administrative databases and identified key gaps notably the lack of qualitative studies in current literature.

Geographical differences in risk of advanced breast cancer: Limited evidence for reductions over time, Queensland, Australia 1997-2014

BACKGROUND

Reducing geographical inequalities in breast cancer stage remains a key focus of public health policy. We explored whether patterns of advanced breast cancer by residential accessibility and disadvantage in Queensland, Australia, have changed over time.

METHODS

Population-based cancer registry study of 38,706 women aged at least 30 years diagnosed with a first primary invasive breast cancer of known stage between 1997 and 2014. Multilevel logistic regression was used to examine temporal changes in associations of area-level factors with odds of advanced disease after adjustment for individual-level factors.

RESULTS

Overall 19,401 (50%) women had advanced breast cancer. Women from the most disadvantaged areas had higher adjusted odds (OR = 1.23 [95%CI 1.13, 1.32]) of advanced disease than those from least disadvantaged areas, with no evidence this association had changed over time (interaction p = 0.197). Living in less accessible areas independently increased the adjusted odds (OR = 1.18 [1.09, 1.28]) of advanced disease, with some evidence that the geographical inequality had reduced over time (p = 0.045). Sensitivity analyses for un-staged cases showed that the original associations remained, regardless of assumptions made about the true stage distribution.

CONCLUSIONS

Both geographical and residential socioeconomic inequalities in advanced stage diagnoses persist, potentially reflecting barriers in accessing diagnostic services. Given the role of screening mammography in early detection of breast cancer, the lack of population-based data on private screening limits our ability to determine overall participation rates by residential characteristics. Without such data, the efficacy of strategies to reduce inequalities in breast cancer stage will remain compromised.