Breast cancer management: a rural perspective

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.

The influence of socio-economic and locational disadvantage on survival after a diagnosis of lung or breast cancer in Western Australia

Objectives

The effects of demographic, locational and socio-economic disadvantage, and the influence of private health care on five-year mortality rates in patients with lung cancer or after breast cancer surgery in Western Australia were examined.

Methods

The Western Australian Record Linkage Project was used to extract all hospital morbidity, cancer and death records of all people with lung or breast cancer in Western Australia from 1982 to 1996. Mortality rate ratios after a diagnosis of lung cancer or breast cancer surgery were estimated using Cox regression. Two sets of analyses were carried out: demographically adjusted from 1982 to 1996; and demographically and disadvantage adjusted from 1992 to 1996.

Results

Overall, 87.7% of lung cancer and 17.8% of breast cancer patients were deceased by five years. Lung and breast cancer patients treated in rural hospitals had higher mortality rates (1992-1996: relative risk (RR) 1.24, 95% confidence interval (CI) 1.07-1.44, and RR 1.20, 95% CI 0.92-1.56, respectively; 1982-1996: RR 1.20, 95% CI 1.11- 1.30, and RR 1.19, 95% CI 1.06-1.33, respectively), whereas location of residence had little effect. Lung and breast cancer patients treated in private hospitals had lower mortality (1992-1996: RR 0.85, 95% CI 0.76-0.95, and RR 0.90, 95% CI 0.77-1.05, respectively; 1982-1996: RR 0.91, 95% CI 0.84-0.97, and RR 0.92, 95% CI 0.85-0.99, respectively), although insurance status was not a factor. Women with breast cancer had significantly worse survival in the more socio-economically disadvantaged groups (1992-1996: RR 1.41 to 1.26; 1982-1996: RR 1.45 to 1.29).

Conclusions

Survival was poorer in patients treated in the public hospital system, but the possession of private health insurance was not predictive of better outcomes. People treated in rural hospitals had worse survival, whereas location of residence was not an independent factor. Women in more socio-economically advantaged groups who underwent breast cancer surgery had improved survival.

Identifying clinical and support service resources and network practices for cancer patients and survivors in southern Puerto Rico

OBJECTIVE

The objectives of this study were to identify cancer-related health care services and to explore the presence of inter-organizational interactions among clinical and support oncology services in southern Puerto Rico.

METHODS

From January through July of 2010, a survey was completed by 54 health care organizations offering clinical, supportive, or both services to cancer patients/survivors (CPS) in southern PR. Survey data were compiled and descriptive analyses performed using the software Statistical Package for a Social Science (SPSS), version 18.0.

RESULTS

The distribution of the primary services provided by the participating organizations was the following: 26 had clinical services, 16 had support services, and 12 offered a combination of clinical and support services. Only 24 % of the surveyed organizations offered their services exclusively to patients diagnosed with cancer. In terms of referral practices, 61 % of the responses were for medical specialists, 43 % were for mental health services, and 37 % were referrals for primary care services. The most common reason for interacting (n = 27) was to provide a given patient both a referral and information.

CONCLUSION

Findings suggest gaps in both the availability of oncology services and the delivery of integrated health care. Lack of communication among clinical and support organizations (for cancer patients, specifically) could negatively impact the quality of the services that they offer. Further network analysis studies are needed to confirm these gaps. Until systemic, structural changes occur, more efforts are needed to facilitate communication and collaboration among these kinds of organization.

Reaching further with online education? The development of an effective online program in palliative oncology

Patients in rural and remote Australia have less access to specialist oncology services and rely more on local health professionals for provision of cancer care. We have developed a 7.5-h online educational program on palliative oncology for health professionals focused on the needs of rural providers. There were 501 active (enrolled) users and 268 ad hoc (non-enrolled) users, with 90 completing evaluation. Eighty-two (91%) indicated that their learning needs were partially or entirely met. Sixty-five (75%) respondents planned to review or change their practice as a result. The online program is effective in meeting learning needs of Australian health providers, reaching high numbers with high acceptability.

The breast cancer experience of rural women: a literature review

This report is a review of studies that focus on rural breast cancer survivorship. It includes a total of 14 studies using large databases and 27 other studies using qualitative and quantitative methods. In our review of this literature, we identified four broad themes, including access to treatment and treatment type, medical providers and health information, psychosocial adjustment and coping, and social support and psychological support services. We review the findings of the rural breast cancer survivorship studies within each of these broad themes. A few of the findings of the review include that rural and urban women receive different primary treatments for breast cancer, that rural women may have greater difficulty negotiating their traditional gender roles during and after treatment, that rural women desire greater health-related information about their breast cancer, and that rural women have less access to mental health therapy. The review discusses the implications of these findings as well as the weakness in the literature.

Surgical service centralisation in Australia versus choice and quality of life for rural patients

High patient volume for both hospitals and surgeons is an important determinant of operative mortality and outcome for complex and infrequently performed operations. The 13% of Australia's population who live in rural and remote areas often choose to have surgery close to home and support networks despite the potentially higher operative mortality and morbidity. Rural patients should be able to make an informed choice about having their surgery locally. Rural and metropolitan surgeons should discuss and reach mutual agreement on where each patient is best treated. A balance must be struck between quality of services that can be provided locally and geographic convenience.

Unequal access to breast-conserving surgery in Western Australia 1982-2000

BACKGROUND

The purpose of the present study was to examine the effects of demographic, locational and social disadvantage and the possession of private health insurance in Western Australia on the likelihood of women with breast cancer receiving breast-conserving surgery rather than mastectomy.

METHODS

The WA Record Linkage Project was used to extract all hospital morbidity, cancer and death records of women with breast cancer in Western Australia from 1982 to 2000 inclusive. Comparisons between those receiving breast-conserving surgery and mastectomy were made after adjustment for covariates in logistic regression.

RESULTS

Younger women, especially those aged less than 60 years, and those with less comorbidity were more likely to receive breast-conserving surgery (BCS). In lower socio-economic groups, women were less likely to receive BCS (OR 0.73; 95% CI 0.60-0.90). Women resident in rural areas tended to receive less BCS than those from metropolitan areas (OR 0.84; 95% CI 0.55-1.29). Women treated in a rural hospital had a reduced likelihood of BCS (OR 0.74; 95% CI 0.61-0.89). Treatment in a private hospital reduced the likelihood of BCS (OR 0.70; 95% CI 0.54-0.90), while women with private health insurance were much more likely to receive BCS (OR 1.39; 95% CI 1.08-1.79).

CONCLUSION

Several factors were found to affect the likelihood of women with breast cancer receiving breast-conserving surgery, in particular, women from disadvantaged backgrounds were significantly less likely to receive breast-conserving surgery than those from more privileged groups.

Multidisciplinary care for women with early breast cancer in the Australian context: what does it mean?

For women with early breast cancer, multidisciplinary care has the potential to reduce mortality, improve quality of life and reduce healthcare costs. In Australia, the diversity of healthcare delivery settings and types of care means that a single model of multidisciplinary care may not be appropriate. The "Principles of multidisciplinary care" were developed to provide a flexible framework for the provision of multidisciplinary care in Australia. The Principles emphasise five key elements: the team, communication, access to the full range of therapies, standards of care and involvement of the woman. This flexible, principle-based approach to multidisciplinary care is unique. The Principles have the potential to be applied to other cancers and other chronic diseases.

Maintaining surgical standards beyond the city in Australia

Many Australians, by choice or necessity, live and work in rural Australia. In the past broadly trained general surgeons and appropriately trained general practitioner (GP) surgeons provided much of the surgical management. Recently very few rural GPs have been trained in surgery and there is a shortage of specialist surgeons in many rural parts of Australia. Outreach surgery can assist in the provision of some surgical services but it is not as effective as an on-site surgical presence. The challenge for the Royal Australasian College of Surgeons Rural Surgical Training Programme is to provide an ongoing supply of well-trained surgeons in general surgery and the other specialties to provide adequate surgical services to rural Australians. This will be best achieved by having adequate numbers of surgeons resident in rural areas with appropriate outreach specialist services, and training and support of the procedural GPs in the smaller centres.

Attitudes to evidence-based practice in urology: results of a survey

BACKGROUND

The advantages of promoting evidence-based care through implementation of clinical guidelines are well established. Clinical practice guidelines have been developed for lower urinary tract symptoms (LUTS) and prostate cancer screening. Aspects of the delivery of care by urologists or specialist registrars relevant to the guidelines were assessed.

METHODS

A questionnaire was distributed at the 1999 meeting of the Urological Society of Australasia, which was attended by 187 Australasian and 33 foreign delegates. Questions addressed access to resources for evidence-based medicine; perceived need; preferred sources of information; and then presented four clinical scenarios. These were: (i) treatment recommendations in early stage prostate cancer; (ii) the same scenario if the respondent was the patient; (iii) treatment recommendations after radical prostatectomy when there was a positive resection margin; and (iv) clinical investigations for mild to moderate LUTS.

RESULTS

Of 220 possible responses, 132 were received, a response rate of 60%. Urologists overwhelmingly (100%) endorsed the need for access to evidence-based reviews, although 28% claimed such access was non-existent to poor. Clinical guidelines were the preferred source of evidence-based information. For early stage prostate cancer in a 55-year-old man, radical prostatectomy was recommended by 93.2% of respondents, but this dropped to 83% when the respondent was the patient (P < 0.05), and a wider range of treatments was recommended. Pelvic radiotherapy and hormone therapy were equally recommended for biochemical progression following radical prostatectomy where there was a positive surgical margin. Investigations for LUTS included serum prostate-specific antigen (PSA) testing (78.0%) and voided flow studies (77.3%).

CONCLUSIONS

Urologists express a need for evidence-based practice resources, in particular clinical guidelines. Nevertheless their clinical approach is not necessarily consistent with existing guidelines, particularly for LUTS. An alteration in the recommendation when the respondent is the patient of interest and endorses the recommendation that patients with prostate cancer should be involved in treatment decisions.

Systematic review of cancer treatment programmes in remote and rural areas

In an attempt to ensure high quality cancer treatment for all patients in the UK, care is being centralized in specialist centres and units. For patients in outlying areas, however, access problems may adversely affect treatment. In an attempt to assess alternative methods of delivering cancer care, this paper reviews published evidence about programmes that have set out to provide oncology services in remote and rural areas in order to identify evidence of effectiveness and problems. Keyword and textword searches of on-line databases (MEDLINE, EMBASE, HEALTHSTAR and CINAHL) from 1978 to 1997 and manual searches of references were conducted. Fifteen papers reported evaluations of oncology outreach programmes, tele-oncology programmes and rural hospital initiatives. All studies were small and only two were controlled, so evidence was suggestive rather than conclusive. There were some indications that shared outreach care was safe and could make specialist care more accessible to outlying patients. Tele-oncology, by which some consultations are conducted using televideo, may be an acceptable adjunct. Larger and more methodologically robust studies are justified and should be conducted.