A systematic review of inequalities in psychosocial outcomes for women with breast cancer according to residential location and Indigenous status in Australia

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

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

Supportive care needs and psychosocial outcomes of rural versus urban women with breast cancer

OBJECTIVE

To identify whether supportive care needs vary according to remoteness and area-level socio-economic status (SES) and to identify the combinations of socio-demographic, area-level and health factors that are associated with poorer quality of life, psychological distress and severity of unmet supportive care needs METHODS: Cross sectional data was collected from women with a breast cancer diagnosis (n=2,635) in Queensland, Australia, through a telephone survey including socio-demographic, health, psychosocial and supportive care needs measures. Hierarchical regression and cluster analyses were applied to assess the predictors of unmet need and psychosocial outcomes and to identify socio-demographic and health status profiles of women, comparing their level of unmet needs and psychosocial outcomes.

RESULTS

Women living in outer regional areas reported the highest severity of unmet need in the patient care domain. Greater unmet need for health systems and information and patient care was also evident for those in moderately and most disadvantaged areas. Three clusters were identified reflecting (1) older women with poorer health and lower education (19%); (2) younger educated women with better health and private insurance (61%); and (3) physically active women with localised cancer who had completed treatment (20%). Poorer outcomes were evident in the first two of these clusters.

CONCLUSIONS

This better understanding of the combinations of characteristics associated with poorer psychosocial outcomes and higher unmet need can be used to identify women with higher supportive care needs early and to target interventions. This article is protected by copyright. All rights reserved.

The relationship between hope levels and unmet needs of caregivers of advanced cancer patients†

AIM

The effects in cultural and health provisions can lead to different unmet support needs. Hope is seen as an important support, a supportive power, and an efficient coping strategy for cancer caregivers. The purpose of this study in Turkish society is to determine supportive care needs of caregivers of cancer patients, to determine the hope levels of those caring for cancer patients and foresee how variables and hope can trigger needs.

METHODS

To identify the unmet needs and hope levels of caregivers of advanced cancer patients in Turkish society. Data were collected using the Supportive Care Needs of Caregivers Scale and Herth Hope Index.

RESULTS

More than half of the advanced cancer caregivers (56.51%) reported unmet care needs. Their unmet needs and hope levels were above average. Regression analysis showed the total score for hope was related to health care and information needs, work-social needs.

CONCLUSION

Hope was related to health care and information needs and work-social needs. Oncology nurses should focus on the unmet needs of caregivers, taking into account their cultural differences in order to raise their hopes.

Quality of Life in the First Year of Cancer Diagnosis among Aboriginal and Non-Aboriginal People Living in Regional and Remote Areas of Australia

Little is known of the quality of life (QoL) of cancer patients in the Northern Territory (NT) of Australia, where healthcare delivery is geographically challenged. This exploratory study describes QoL among Aboriginal and non-Aboriginal cancer patients in the NT, in the first year of diagnosis. Participants were recruited from the only cancer care centre in the NT and completed the Assessment of Quality-of-Life questionnaire (AQoL-4D). The results were descriptively analysed. The participants' (n = 63; mean age 58.8 years) mean AQoL utility score was 0.72 (SD 0.26); patients scored lowest in the relationships and mental health dimensions of the questionnaire (mean 0.89, SD 0.19, and 0.89, SD 0.17, respectively). Participants living in remote and very remote areas (46%) reported higher QoL scores, compared with participants in the outer regional capital city of the NT in the overall (mean 0.76, SD 0.22 and 0.78, SD 0.20 vs. 0.67, SD 0.29, respectively), and mental health dimensions (mean 0.92, SD 0.09 and mean 0.94, SD 0.06 vs. 0.85, SD 0.22, respectively). The findings were suggestive of clinically meaningful differences across socioeconomic groups, cancer and treatment types, and comorbidity status. Mean QoL scores were consistent with previous reports in other Australian cancer cohorts. The findings suggest a need to support cancer patients' mental health and relationships during the diagnosis and treatment phase of their cancer journey.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The mediating role of unmet needs in the relationship between displacement and psychological adjustment: A study of cancer survivors from a Portuguese island region

PURPOSE

The present study aims to explore whether the association between previous displacement to mainland Portugal to perform cancer therapy and current psychological adaptation is mediated by cancer survivors' unmet needs in terms of their emotional experience, financial concerns, access and continuity of care, and relations with others.

METHOD

This cross-sectional study included a sample of 173 cancer survivors from the Azores archipelago (Portugal) recruited from a local oncological health unit. Participants completed a sociodemographic and clinical questionnaire and self-report measures assessing their unmet needs and psychological adaptation. Two parallel multiple mediation models were tested.

RESULTS

Azorean cancer survivors live with unmet needs, especially emotional needs (M = 16.68, SD = 10.78). Displacement was indirectly associated with both anxious (indirect effect = 0.58, SE = 0.27, 95% Bias Corrected and accelerated Confidence Interval = [0.05, 1.15]) and depressive symptomatology (indirect effect = 0.36, SE = 0.17, 95% Bias Corrected and accelerated Confidence Interval = [0.03, 0.84]) through unmet emotional needs.

CONCLUSION

Previous displacements seem to play an important role in the way cancer survivors adapt to survivorship by contributing to higher levels of unmet emotional needs. These findings can provide a scientific and clinical contribution to other isolated or island regions in the world where survivors face similar constraints.

Coping with fear of cancer recurrence among ovarian cancer survivors living in small urban and rural settings: A qualitative descriptive study

PURPOSE

Fear of cancer recurrence (FCR) is a paramount concern among ovarian cancer survivors. Evidence shows that cancer survivors living in regional or rural areas have higher psychological morbidity; however, no known studies have explored how ovarian cancer survivors living in small urban and rural areas cope with FCR.

METHODS

In this qualitative descriptive study, a semi-structured questioning process was developed in accordance with Carver et al.'s conceptualization of coping. Focus groups or 1:1 telephone interviews were used to collect data from a convenience sample of ovarian cancer survivors. Participants completed a demographic form and the Fear of Cancer Recurrence Inventory, and clinical information was extracted from hospital charts.

RESULTS

The average age of participants (n = 15) was 62.8 years (Range 51-76 years) and the average time since diagnosis was 2.7 years (Range 1-19 years). Most women had elevated levels of FCR. Five themes for coping were expressed by all women: 1) health care provider support; 2) knowing, trusting, and prioritizing self; 3) finding what works; 4) uniqueness and belonging; and 5) redirecting thoughts and actions. One additional theme was expressed by most women (n = 11): 6) preparing for the future.

CONCLUSION

Fear of cancer recurrence was a concern for most ovarian cancer survivors who used a variety of ways to cope. Results can be used to guide nurses' discussions with post-treatment ovarian cancer survivors or be used to inform refinement and development of resources to assist ovarian cancer survivors living in small urban and rural settings to cope with FCR.

Development of the Australian Cancer Atlas: spatial modelling, visualisation, and reporting of estimates

BACKGROUND

It is well known that the burden caused by cancer can vary geographically, which may relate to differences in health, economics or lifestyle. However, to date, there was no comprehensive picture of how the cancer burden, measured by cancer incidence and survival, varied by small geographical area across Australia.

METHODS

The Atlas consists of 2148 Statistical Areas level 2 across Australia defined by the Australian Statistical Geography Standard which provide the best compromise between small population and small area. Cancer burden was estimated for males, females, and persons separately, with 50 unique sex-specific (males, females, all persons) cancer types analysed. Incidence and relative survival were modelled with Bayesian spatial models using the Leroux prior which was carefully selected to provide adequate spatial smoothing while reflecting genuine geographic variation. Markov Chain Monte Carlo estimation was used because it facilitates quantifying the uncertainty of the posterior estimates numerically and visually.

RESULTS

The results of the statistical model and visualisation development were published through the release of the Australian Cancer Atlas ( https://atlas.cancer.org.au ) in September, 2018. The Australian Cancer Atlas provides the first freely available, digital, interactive picture of cancer incidence and survival at the small geographical level across Australia with a focus on incorporating uncertainty, while also providing the tools necessary for accurate estimation and appropriate interpretation and decision making.

CONCLUSIONS

The success of the Atlas will be measured by how widely it is used by key stakeholders to guide research and inform decision making. It is hoped that the Atlas and the methodology behind it motivates new research opportunities that lead to improvements in our understanding of the geographical patterns of cancer burden, possible causes or risk factors, and the reasons for differences in variation between cancer types, both within Australia and globally. Future versions of the Atlas are planned to include new data sources to include indicators such as cancer screening and treatment, and extensions to the statistical methods to incorporate changes in geographical patterns over time.

Geographic variations in stage at diagnosis and survival for colorectal cancer in Australia: A systematic review

INTRODUCTION

Australia has one of the highest incidence rates of colorectal cancer (CRC) in the world. Residents in rural areas of Australia experience disadvantage in health care and outcomes. This review investigates whether patients with CRC in rural areas demonstrate poorer survival and more advanced stages of disease at diagnosis.

METHODS

Systematic review of peer-reviewed articles and grey literature. Studies were included if they provided data on survival or stage of disease at diagnosis across multiple geographical locations; focused on CRC patients; and were conducted in Australia.

RESULTS

Twenty-six articles met inclusion criteria. Twenty-three studies examined survival, while five studies investigated stage at diagnosis. The evidence suggests that non-metropolitan patients are less likely to survive CRC for five years compared to patients living in metropolitan areas, yet there was limited evidence to suggest geographical disparity in stage of diagnosis.

CONCLUSIONS

While five-year survival disparities are apparent, these patterns appear to vary as a function of specific region and health jurisdiction, cancer type and year/s of data collection. Future research should examine current data using consistent and robust methods of reporting survival and classifying geographical location. The impact of population-level screening programmes on survival and stage at diagnosis also needs to be thoroughly explored.

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.

Evaluation of a Breastfeeding App in Rural Australia: Prospective Cohort Study

BACKGROUND

New mothers often need support to establish and maintain breastfeeding, and rural women may find it difficult to access breastfeeding resources locally. There are many smartphone applications for breastfeeding mothers; however, very few have been developed by health professionals. We evaluated a smartphone application, Breastfeeding Solutions, developed by U.S. IBCLC Nancy Mohrbacher. Research aims: The aims were (a) to explore usability of the application among rural Australian breastfeeding women and (b) to describe participants' infant feeding outcomes compared with the general population.

METHODS

A prospective longitudinal self-report survey design was used. Data were collected via online questionnaires at baseline and at 3 and 6 months from a convenience sample of new mothers. The setting was southwest Victoria, Australia, from 2016 to 2017. Descriptive statistics were used to answer research aims.

RESULTS

Of the initial 46 participants who received the app, 63% ( n = 29) completed surveys at 3 and 6 months. Usability was assessed at 3 months: 93.5% of participants (29 of 31) rated the application favorably, whereas 96.8% (30 of 31) found the application helpful and 87.1% (27 of 31) would recommend it to other mothers. At the 6-month survey, 79% of participants ( n = 23) were breastfeeding; 10% ( n = 3) had stopped breastfeeding during the first 3 months. The local breastfeeding rate at 6 months was approximately 50% according to routinely collected data; however, we cannot infer that the application was responsible for the difference.

CONCLUSION

The smartphone application was acceptable to breastfeeding women in an Australian rural setting. Further evaluation using a user-centered design could improve rural postpartum women's access to reliable, evidence-based information.

Development and validation of a search filter to identify equity-focused studies: reducing the number needed to screen

Background

Health inequalities, worse health associated with social and economic disadvantage, are reported by a minority of research articles. Locating these studies when conducting an equity-focused systematic review is challenging due to a deficit in standardised terminology, indexing, and lack of validated search filters. Current reporting guidelines recommend not applying filters, meaning that increased resources are needed at the screening stage.

Methods

We aimed to design and test search filters to locate studies that reported outcomes by a social determinant of health. We developed and expanded a ‘specific terms strategy’ using keywords and subject headings compiled from recent systematic reviews that applied an equity filter. A ‘non-specific strategy’ was compiled from phrases used to describe equity analyses that were reported in titles and abstracts, and related subject headings. Gold standard evaluation and validation sets were compiled. The filters were developed in MEDLINE, adapted for Embase and tested in both. We set a target of 0.90 sensitivity (95% CI; 0.84, 0.94) in retrieving 150 gold standard validation papers. We noted the reduction in the number needed to screen in a proposed equity-focused systematic review and the proportion of equity-focused reviews we assessed in the project that applied an equity filter to their search strategy.

Results

The specific terms strategy filtered out 93-95% of all records, and retrieved a validation set of articles with a sensitivity of 0.84 in MEDLINE (0.77, 0.89), and 0.87 (0.81, 0.92) in Embase. When combined (Boolean ‘OR’) with the non-specific strategy sensitivity was 0.92 (0.86, 0.96) in MEDLINE (Embase 0.94; 0.89, 0.97). The number needed to screen was reduced by 77% by applying the specific terms strategy, and by 59.7% (MEDLINE) and 63.5% (Embase) by applying the combined strategy. Eighty-one per cent of systematic reviews filtered studies by equity.

Conclusions

A combined approach of using specific and non-specific terms is recommended if systematic reviewers wish to filter studies for reporting outcomes by social determinants. Future research should concentrate on the indexing standardisation for equity studies and further development and testing of both specific and non-specific terms for accurate study retrieval.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0567-x) contains supplementary material, which is available to authorized users.

Geographical Variations in the Clinical Management of Colorectal Cancer in Australia: A Systematic Review

Background

In Australia, cancer survival is significantly lower in non-metropolitan compared to metropolitan areas. Our objective was to evaluate the evidence on geographical variations in the clinical management and treatment of colorectal cancer (CRC).

Methods

A systematic review of published and gray literature was conducted. Five databases (CINAHL, PubMed, Embase, ProQuest, and Informit) were searched for articles published in English from 1990 to 2018. Studies were included if they assessed differences in clinical management according to geographical location; focused on CRC patients; and were conducted in Australia. Included studies were critically appraised using a modified Newcastle–Ottawa Scale. PRISMA systematic review reporting methods were applied.

Results

17 articles met inclusion criteria. All were of high (53%) or moderate (47%) quality. The evidence available may suggest that patients in non-metropolitan areas are more likely to experience delays in surgery and are less likely to receive chemotherapy for stage III colon cancer and adjuvant radiotherapy for rectal cancer.

Conclusion

The present review found limited information on clinical management across geographic regions in Australia and the synthesis highlights significant issues both for data collection and reporting at the population level, and for future research in the area of geographic variation. Where geographical disparities exist, these may be due to a combination of patient and system factors reflective of location. It is recommended that population-level data regarding clinical management of CRC be routinely collected to better understand geographical variations and inform future guidelines and policy.

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.

A systematic review of geographical differences in management and outcomes for colorectal cancer in Australia

BACKGROUND

Australia and New Zealand have the highest incidence of colorectal cancer (CRC) in the world, presenting considerable health, economic, and societal burden. Over a third of the Australian population live in regional areas and research has shown they experience a range of health disadvantages that result in a higher disease burden and lower life expectancy. The extent to which geographical disparities exist in CRC management and outcomes has not been systematically explored. The present review aims to identify the nature of geographical disparities in CRC survival, clinical management, and psychosocial outcomes.

METHODS

The review followed PRISMA guidelines and searches were undertaken using seven databases covering articles between 1 January 1990 and 20 April 2016 in an Australian setting. Inclusion criteria stipulated studies had to be peer-reviewed, in English, reporting data from Australia on CRC patients and relevant to one of fourteen questions examining geographical variations in a) survival outcomes, b) patient and cancer characteristics, c) diagnostic and treatment characteristics and d) psychosocial and quality of life outcomes.

RESULTS

Thirty-eight quantitative, two qualitative, and three mixed-methods studies met review criteria. Twenty-seven studies were of high quality, sixteen studies were of moderate quality, and no studies were found to be low quality. Individuals with CRC living in regional, rural, and remote areas of Australia showed poorer survival and experienced less optimal clinical management. However, this effect is likely moderated by a range of other factors (e.g., SES, age, gender) and did appear to vary linearly with increasing distance from metropolitan centres. No studies examined differences in use of stoma, or support with stomas, by geographic location.

CONCLUSIONS

Overall, despite evidence of disparity in CRC survival and clinical management across geographic locations, the evidence was limited and at times inconsistent. Further, access to treatment and services may not be the main driver of disparities, with individual patient characteristics and type of region also playing an important role. A better understanding of factors driving ongoing and significant geographical disparities in cancer related outcomes is required to inform the development of effective interventions to improve the health and welfare of regional Australians.