Spatial inequalities in colorectal and breast cancer survival: premature deaths and associated factors

Socioeconomic inequalities of 3-year survival in formal employees with colorectal cancer between 2012 and 2019 in Colombia

BACKGROUND

Colorectal cancer is a high-burden disease that requires comprehensive multidisciplinary management. In Colombia, despite a healthcare system covering 97% of the population, socioeconomic disparities persist. Lower income levels are associated with decreased survival, potentially due to delays in diagnosis or treatment and a higher probability of advanced staging at diagnosis, These inequities persist even among relatively advantaged populations, such as formal employee who are assumed to have fewer barriers to accessing healthcare services compared to informal workers.

OBJECTIVE

This study aimed to assess the association monthly minimum wages (MMW) as a measure of socioeconomic status in three-year survival among formal employees diagnosed with colorectal cancer in Colombia from 2012 to 2019.

METHODS

A retrospective cohort study was conducted using administrative databases that included healthcare and mortality records. Formal employees newly diagnosed with colorectal cancer were identified through diagnostic and oncological procedure codes and were followed for three years from the date of diagnosis or until death. The exposure variable was the legal monthly minimum wage (MMW) at the time of diagnosis, used as a proxy for socioeconomic status, while the outcome variable was three-year survival. Patients were stratified into quartiles based on their MMW. The three-year mortality proportion was calculated for each quartile. To assess survival differences, Cox proportional hazards regression models were applied to estimate adjusted hazard ratios (HRs). Socioeconomic gradients in survival were quantified using the Relative Index of Inequality (RII) and the Slope Index of Inequality (SII).

RESULTS

The cohort included 1,913 formal employees (mean age: 49.9 years), with 660 deaths (34.5%) recorded over the follow-up period. Patients in the lowest MMW quartile experienced the highest three-year mortality (39.5%) compared to those in the highest quartile (30.7%). After adjusting for confounders, individuals in the highest quartile had a 25% lower risk of death than those in the lowest quartile (aHR: 0.74; 95% CI: 0.59-0.92). The RII indicated a 50% higher risk of death in the lowest income group (RII: 1.50; 95% CI: 1.13-1.99), while the SII revealed an absolute difference of 0.16 deaths per 1,000 individuals (p=0.01).

CONCLUSION

Significant income-based disparities in colorectal cancer survival were observed among formal employees in Colombia despite the theoretically equitable healthcare system. These findings underscore the persistent influence of socioeconomic factors on health outcomes, even within populations assumed to have better access to care.

The hospitalisation risk of chronic circulatory and respiratory diseases associated with coal mining in the general population in Queensland, Australia

Queensland is the main coal mining state in Australia where populations in coal mining areas have been historically exposed to coal mining emissions. Although a higher risk of chronic circulatory and respiratory diseases has been associated with coal mining globally, few studies have investigated these associations in the Queensland general population. This study estimates the association of coal production with hospitalisations for chronic circulatory and respiratory diseases in Queensland considering spatial and temporal variations during 1997-2014. An ecological analysis used a Bayesian hierarchical spatiotemporal model to estimate the association of coal production with standardised rates of each, chronic circulatory and respiratory diseases, adjusting for sociodemographic factors and considering the spatial structure of Queensland's statistical areas (SA2) in the 18-year period. Two specifications; with and without a space-time interaction effect were compared using the integrated nested Laplace approximation -INLA approach. The posterior mean of the best fit model was used to map the spatial, temporal and spatiotemporal trends of risk. The analysis considered 2,831,121 hospitalisation records. Coal mining was associated with a 4 % (2.4-5.5) higher risk of hospitalisation for chronic respiratory diseases in the model with a space-time interaction effect which had the best fit. An emerging higher risk of either chronic circulatory and respiratory diseases was identified in eastern areas and some coal-mining areas in central and southeast Queensland. There were important disparities in the spatiotemporal trend of risk between coal -and non-coal mining areas for each, chronic circulatory and respiratory diseases. Coal mining is associated with an increased risk of chronic respiratory diseases in the Queensland general population. Bayesian spatiotemporal analyses are robust methods to identify environmental determinants of morbidity in exposed populations. This methodology helps identifying at-risk populations which can be useful to support decision-making in health. Future research is required to investigate the causality links between coal mining and these diseases.

Socio-economic factors related to premature death from colorectal cancer in Santiago de Chile, 2014-2018: a cross-sectional study

OBJECTIVES

In Chile, colorectal cancer (CRC) is the fourth cause of death by cancer. Few studies have evaluated the role of contextual and individual socio-economic variables associated with premature death by CRC (<70 years). We analyzed the association between socio-economic factors (at individual and contextual levels) and premature death from CRC in Santiago de Chile.

STUDY DESIGN

This was a cross-sectional study.

METHODS

We analyzed deaths from CRC between 2014 and 2018 using data published by the Ministry of Health. Individual predictors were sex, marital status, and educational level. Contextual variable included the Social Priority Index (SPI) of the commune where the deceased lived. The association was assessed through multilevel logistic regression models.

RESULTS

During the period, 4762 deaths occurred (51.7% women); 39.3% were premature. At the individual level, male sex (odds ratio [OR] 1.36; 95% confidence interval [CI] 1.20-1.53) and single marital status (OR 1.45; 95% CI 1.24-1.68) were associated with premature death from CRC. Primary or lower education was a protective factor (OR 0.53; 95% CI 0.47-0.60). At the contextual level, communes with a higher SPI were three times more at risk than those with a lower SPI (OR 3.13; 95% CI 2.15-4.57).

CONCLUSIONS

This study showed that individual and contextual socio-economic variables are related to premature death from CRC. Residing in communes with greater socio-economic vulnerability was associated with greater risk. To reduce this gap, it is urgent to design and implement structural policies to reduce social inequities and improve access to health care.

The application of spatial measures to analyse health service accessibility in Australia: a systematic review and recommendations for future practice

BACKGROUND

Australia's inequitable distribution of health services is well documented. Spatial access relates to the geographic limitations affecting the availability and accessibility of healthcare practitioners and services. Issues associated with spatial access are often influenced by Australia's vast landmass, challenging environments, uneven population concentration, and sparsely distributed populations in rural and remote areas. Measuring access contributes to a broader understanding of the performance of health systems, particularly in rural/remote areas. This systematic review synthesises the evidence identifying what spatial measures and geographic classifications are used and how they are applied in the Australian peer-reviewed literature.

METHODS

A systematic search of peer-reviewed literature published between 2002 and 2022 was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Search terms were derived from three major topics, including: [1] Australian population; [2] spatial analysis of health service accessibility; and [3] objective physical access measures.

RESULTS

Database searches retrieved 1,381 unique records. Records were screened for eligibility, resulting in 82 articles for inclusion. Most articles analysed access to primary health services (n = 50; 61%), followed by specialist care (n = 17; 21%), hospital services (n = 12; 15%), and health promotion and prevention (n = 3; 4%). The geographic scope of the 82 articles included national (n = 33; 40%), state (n = 27; 33%), metropolitan (n = 18; 22%), and specified regional / rural /remote area (n = 4; 5%). Most articles used distance-based physical access measures, including travel time (n = 30; 37%) and travel distance along a road network (n = 21; 26%), and Euclidean distance (n = 24; 29%).

CONCLUSION

This review is the first comprehensive systematic review to synthesise the evidence on how spatial measures have been applied to measure health service accessibility in the Australian context over the past two decades. Objective and transparent access measures that are fit for purpose are imperative to address persistent health inequities and inform equitable resource distribution and evidence-based policymaking.

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

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.

Spatial variation and disparity in female breast cancer relative survival in the United States

BACKGROUND

Breast cancer is the most common cancer among women in the United States. However, data on spatial disparities in survival for breast cancer are limited in the country. This study estimated 5-year relative survival (RS) of female breast cancer and examined the spatial variations across the contiguous United States.

METHODS

Women newly diagnosed with breast cancer in 2003-2010 in the United States were identified from the National Cancer Database and followed up through 2016. The crude 5-year RS at the county level was estimated and adjusted for patients' key sociodemographic and clinical factors. To account for spatial effects, the RS estimates were smoothed using the Bayesian spatial survival model. A local spatial autocorrelation analysis with the Getis-Ord Gi* statistics was applied to identify geographic clusters of low or high RS.

RESULTS

Clusters of low RS were identified in more than 15 states covering 671 counties, mostly in the southeast and southwest regions, including Georgia, Alabama, Mississippi, Louisiana, Arkansas, Oklahoma, and Texas. Approximately 30% of these clusters can be explained by patients' characteristics: Race, insurance, and stage at diagnosis appeared to be the major attributable factors.

CONCLUSIONS

Significant spatial disparity in female breast cancer survival was found, with low RS clusters identified in Georgia, Alabama, Mississippi, Louisiana, Arkansas, Oklahoma, and Texas. Policies and interventions that focus on serving Black women, improvements in insurance coverage, and early detection in these areas could potentially mitigate the spatial disparities.

An egalitarian society? Widening inequalities in premature mortality from non-communicable diseases in Australia, 2006-16

BACKGROUND

The recent slowdown in life expectancy increase in Australia has occurred concurrently with widening socioeconomic and geographical inequalities in all-cause mortality risk. We analysed whether, and to what extent, mortality inequalities among specific non-communicable diseases (NCDs) in Australia at ages 35-74 years widened during 2006-16.

METHODS

Registered deaths that occurred during 2006-16 in Australia were analysed. Inequalities were measured by area socioeconomic quintile [ranging from Q1 (lowest) to Q5 (highest)] and remoteness (major cities, inner regional, outer regional/remote/very remote). Age-standardized death rates (ASDR) for 35-74 years were calculated and smoothed over time.

RESULTS

NCD mortality inequalities by area socioeconomic quintile widened; the ratio of Q1 to Q5 ASDR for males increased from 1.96 [95% confidence interval (CI) 1.91-2.01] in 2011 to 2.08 (2.03-2.13) in 2016, and for females from 1.78 (1.73-1.84) to 1.96 (1.90-2.02). Moreover, Q1 NCD ASDRs did not clearly decline from 2011 to 2016. CVD mortality inequalities were wider than for all NCDs. There were particularly large increases in smoking-related mortality inequalities. In 2016, mortality inequalities were especially high for chronic respiratory diseases, alcohol-related causes and diabetes. NCD mortality rates outside major cities were higher than within major cities, and these differences widened during 2006-16. Higher mortality rates in inner regional areas than in major cities were explained by socioeconomic factors.

CONCLUSIONS

Widening of inequalities in premature mortality rates is a major public health issue in Australia in the context of slowing mortality decline. Inequalities are partly explained by major risk factors for CVDs and NCDs: being overweight or obese, lack of exercise, poor diet and smoking. There is a need for urgent policy responses that consider socioeconomic disadvantage.

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.

Transportation as a barrier to colorectal cancer care

BACKGROUND

Transportation barriers limit access to cancer care services and contribute to suboptimal clinical outcomes. Our objectives were to describe the frequency of Veterans reporting and the factors associated with transportation barriers to or from colorectal cancer (CRC) care visits.

METHODS

Between November 2015 and September 2016, Veterans with incident stage I, II, or III CRC completed a mailed survey to assess perceived barriers to recommended care. Participants who reported difficulty with transportation to or from CRC care appointments were categorized as experiencing transportation barriers. We assessed pairwise correlations between transportation barriers, transportation-related factors (e.g., mode of travel), and chaotic lifestyle (e.g., predictability of schedules), and used logistic regression to examine the association between the reporting of transportation difficulties, distance traveled to the nearest Veterans Affairs (VA) facility, and life chaos.

RESULTS

Of the 115 Veterans included in this analysis, 18% reported experiencing transportation barriers. Distance to the VA was not strongly correlated with the reporting of transportation barriers (Spearman's ρ = 0.12, p = 0.19), but chaotic lifestyle was both positively and significantly correlated with experiencing transportation barriers (Spearman's ρ = 0.22, p = 0.02). Results from the logistic regression model modestly supported the findings from the pairwise correlations, but were not statistically significant.

CONCLUSIONS

Transportation is an important barrier to or from CRC care visits, especially among Veterans who experience greater life chaos. Identifying Veterans who experience chaotic lifestyles would allow for timely engagement in behavioral interventions (e.g., organizational skills training) and with support services (e.g., patient navigation).

Breast cancer treatment and survival differences in women in remote and socioeconomically disadvantaged areas, as demonstrated by linked data from New South Wales (NSW), Australia

INTRODUCTION

Reducing variations in cancer treatment and survival is a key aim of the NSW Cancer Plan. Variations in breast cancer treatment and survival in NSW by remoteness and socioeconomic status of residence were investigated to determine benchmarks. Reducing variations in cancer treatment and survival is a key aim of the NSW Cancer Plan. Variations in breast cancer treatment and survival in NSW by remoteness and socioeconomic status of residence were investigated to determine benchmarks.

METHODS

A retrospective cohort study used linked data for invasive breast cancers, diagnosed in May 2002 to December 2015 from the NSW Cancer Registry, with corresponding inpatient, and medical and pharmaceutical insurance data. Associations between treatment modalities, area socioeconomic status and residential remoteness were explored using logistic regression. Predictors of breast cancer survival were investigated using Kaplan-Meier product-limit estimates and multivariate competing risk regression.

RESULTS

Results indicated a high 5-year disease-specific survival in NSW of 90%. Crude survival was equivalent by residential remoteness and marginally lower in lower socioeconomic areas. Competing risk regression showed equivalent outcomes by area socioeconomic status, except for the least disadvantaged quintile, which showed a higher survival. Higher sub-hazard ratios for death occurred for women with breast cancer aged 70 + years, and more advanced stage. Adjusted analyses indicated more advanced stage in lower socioeconomic areas, with less breast reconstruction and radiotherapy, and marginally less hormone therapy for women from these areas. Conversely, among these women who had breast conserving surgery, there was higher use of chemotherapy. Remoteness of residence was associated in adjusted analyses with less radiotherapy and less immediate breast reconstruction. In these short term data, remoteness of residence was not associated with lower survival.

CONCLUSION

This study provides benchmarks for monitoring future variations in treatment and survival.

Beyond the map: evidencing the spatial dimension of health inequalities

Background

Spatial inequalities in health result from different exposures to health risk factors according to the features of geographical contexts, in terms of physical environment, social deprivation, and health care accessibility. Using a common geographical referential, which combines indices measuring these contextual features, could improve the comparability of studies and the understanding of the spatial dimension of health inequalities.

Methods

We developed the Geographical Classification for Health studies (GeoClasH) to distinguish French municipalities according to their ability to influence health outcomes. Ten contextual scores measuring physical and social environment as well as spatial accessibility of health care have been computed and combined to classify French municipalities through a K-means clustering. Age-standardized mortality rates according to the clusters of this classification have been calculated to assess its effectiveness.

Results

Significant lower mortality rates compared to the mainland France population were found in the Wealthy Metropolitan Areas (SMR = 0.868, 95% CI 0.863–0.873) and in the Residential Outskirts (SMR = 0.971, 95% CI 0.964–0.978), while significant excess mortality were found for Precarious Population Districts (SMR = 1.037, 95% CI 1.035–1.039), Agricultural and Industrial Plains (SMR = 1.066, 95% CI 1.063–1.070) and Rural Margins (SMR = 1.042, 95% CI 1.037–1.047).

Conclusions

Our results evidence the comprehensive contribution of the geographical context in the constitution of health inequalities. To our knowledge, GeoClasH is the first nationwide classification that combines social, environmental and health care access scores at the municipality scale. It can therefore be used as a proxy to assess the geographical context of the individuals in public health studies.

The geographic distribution of the US pediatric dermatologist workforce: A national cross-sectional study

BACKGROUND /OBJECTIVES

Although 82% of pediatricians report that their patients have difficulty accessing pediatric dermatologists, the regions with greatest need for the specialty are not well-defined. We aimed to determine the geographic distribution of pediatric dermatologists relative to the number of children and pediatric generalists.

METHODS

We performed a cross-sectional study of all US board-certified pediatric dermatologists, generalists (defined as pediatricians and family medicine physicians), and children in 2020. Data were obtained from the Society for Pediatric Dermatology, American Board of Pediatrics, Centers for Medicare and Medicaid, and US Census Bureau. Number of children, pediatric dermatologists, and pediatric generalists were tabulated in each county and state, and the distributions of pediatric dermatologists and generalists relative to the population of children were quantified with the Gini coefficient.

RESULTS

Of 317 pediatric dermatologists, 243 (76.7%) were women and 311 (98.1%) worked in a metropolitan county. A pediatric dermatologist was present in 41/50 (82%) states and 142/3228 (4.4%) counties. Not a single pediatric dermatologist was found in 54/92 (58.7%) counties with 100 000-199 999 children, 15/53 (28.3%) counties with 200 000-499 999 children, and 4/13 (30.8%) counties with ≥500 000 children. The Gini coefficient for the state-level distribution of pediatric dermatologists relative to population of children was 0.488 compared to 0.132 for that of pediatric generalists.

CONCLUSION

There is a maldistribution of pediatric dermatologists, resulting in children with unmet dermatologic needs in nine states and 96 heavily populated counties. These results can inform initiatives to recruit pediatric dermatologists and to expand telehealth access to specific high-density areas.

Socio-economic inequalities on cancer mortality in nine European areas: The effect of the last economic recession

BACKGROUND

The effect of inequalities aggravated by economic recessions in the mortality rates of certain diseases has been previously described. In this study, we analyzed the relationship between socio-economic deprivation and cancer mortality. We focused on lung, colon, prostate, and breast cancers in nine European urban areas over three periods: two before (2000-2003 and 2004-2008) and one after (2009-2014) the onset of the 2008 financial crisis.

METHODS

This is an ecological study of trends. The units of analysis were small areas within nine European urban areas. We used a composite deprivation index as a socio-economic indicator. As a mortality indicator, we used the smoothed standardized mortality ratio, calculated using the hierarchical Bayesian model proposed by Besag, York and Mollié. To analyze the evolution of socio-economic inequalities, we fitted an ecological regression model that included the socio-economic indicator, the period of time, and the interaction between these terms.

RESULTS

In men, socio-economic inequalities in all-cancer and lung cancer mortality were observed in most of the cities studied, but did not increase after the onset of the economic crisis. In women, only two cities (Stockholm and London) showed socio-economic inequalities in all-cancer and lung cancer mortality; there was also no increase in inequalities.

CONCLUSIONS

Our results did not validate our hypothesis that inequalities increase in times of crisis. However, they emphasize the importance of socio-economic measurements for understanding mortality inequalities, and can be used to inform prevention strategies and help plan local health programs aimed at reducing health inequalities.

A Review of Models Used for Investigating Barriers to Healthcare Access in Australia

Understanding barriers to healthcare access is a multifaceted challenge, which is often highly diverse depending on location and the prevalent surroundings. The barriers can range from transport accessibility to socio-economic conditions, ethnicity and various patient characteristics. Australia has one of the best healthcare systems in the world; however, there are several concerns surrounding its accessibility, primarily due to the vast geographical area it encompasses. This review study is an attempt to understand the various modeling approaches used by researchers to analyze diverse barriers related to specific disease types and the various areal distributions in the country. In terms of barriers, the most affected people are those living in rural and remote parts, and the situation is even worse for indigenous people. These models have mostly focused on the use of statistical models and spatial modeling. The review reveals that most of the focus has been on cancer-related studies and understanding accessibility among the rural and urban population. Future work should focus on further categorizing the population based on indigeneity, migration status and the use of advanced computational models. This article should not be considered an exhaustive review of every aspect as each section deserves a separate review of its own. However, it highlights all the key points, covered under several facets which can be used by researchers and policymakers to understand the current limitations and the steps that need to be taken to improve health accessibility.

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.

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.

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.

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.

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.

A flexible parametric approach to examining spatial variation in relative survival

Most of the few published models used to obtain small-area estimates of relative survival are based on a generalized linear model with piecewise constant hazards under a Bayesian formulation. Limitations of these models include the need to artificially split the time scale, restricted ability to include continuous covariates, and limited predictive capacity. Here, an alternative Bayesian approach is proposed: a spatial flexible parametric relative survival model. This overcomes previous limitations by combining the benefits of flexible parametric models: the smooth, well-fitting baseline hazard functions and predictive ability, with the Bayesian benefits of robust and reliable small-area estimates. Both spatially structured and unstructured frailty components are included. Spatial smoothing is conducted using the intrinsic conditional autoregressive prior. The model was applied to breast, colorectal, and lung cancer data from the Queensland Cancer Registry across 478 geographical areas. Advantages of this approach include the ease of including more realistic complexity, the feasibility of using individual-level input data, and the capacity to conduct overall, cause-specific, and relative survival analysis within the same framework. Spatial flexible parametric survival models have great potential for exploring small-area survival inequalities, and we hope to stimulate further use of these models within wider contexts. Copyright © 2016 John Wiley & Sons, Ltd.

The impact of geographic unit of analysis on socioeconomic inequalities in cancer survival and distant summary stage - a population-based study

OBJECTIVE

When using area-level disadvantage measures, size of geographic unit can have major effects on recorded socioeconomic cancer disparities. This study examined the extent of changes in recorded socioeconomic inequalities in cancer survival and distant stage when the measure of socioeconomic disadvantage was based on smaller Census Collection Districts (CDs) instead of Statistical Local Areas (SLAs).

METHODS

Population-based New South Wales Cancer Registry data were used to identify cases diagnosed with primary invasive cancer in 2000-2008 (n=264,236). Logistic regression and competing risk regression modelling were performed to examine socioeconomic differences in odds of distant stage and hazard of cancer death for all sites combined and separately for breast, prostate, colorectal and lung cancers.

RESULTS

For all sites collectively, associations between socioeconomic disadvantage and cancer survival and distant stage were stronger when the CD-based socioeconomic disadvantage measure was used compared with the SLA-based measure. The CD-based measure showed a more consistent socioeconomic gradient with a linear upward trend of risk of cancer death/distant stage with increasing socioeconomic disadvantage. Site-specific analyses provided similar findings for the risk of death but less consistent results for the likelihood of distant stage.

CONCLUSIONS

The use of socioeconomic disadvantage measure based on the smallest available spatial unit should be encouraged in the future. Implications for public health: Disadvantage measures based on small spatial units can more accurately identify socioeconomic cancer disparities to inform priority settings in service planning.

Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review

OBJECTIVES

To investigate whether there is an association between differences in travel time/travel distance to healthcare services and patients' health outcomes and assimilate the methodologies used to measure this.

DESIGN

Systematic Review. We searched MEDLINE, Embase, Web of Science, Transport database, HMIC and EBM Reviews for studies up to 7 September 2016. Studies were excluded that included children (including maternity), emergency medical travel or countries classed as being in the global south.

SETTINGS

A wide range of settings within primary and secondary care (these were not restricted in the search).

RESULTS

108 studies met the inclusion criteria. The results were mixed. 77% of the included studies identified evidence of a distance decay association, whereby patients living further away from healthcare facilities they needed to attend had worse health outcomes (eg, survival rates, length of stay in hospital and non-attendance at follow-up) than those who lived closer. 6 of the studies identified the reverse (a distance bias effect) whereby patients living at a greater distance had better health outcomes. The remaining 19 studies found no relationship. There was a large variation in the data available to the studies on the patients' geographical locations and the healthcare facilities attended, and the methods used to calculate travel times and distances were not consistent across studies.

CONCLUSIONS

The review observed that a relationship between travelling further and having worse health outcomes cannot be ruled out and should be considered within the healthcare services location debate.

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.

New spatially continuous indices of redlining and racial bias in mortgage lending: links to survival after breast cancer diagnosis and implications for health disparities research

Racial health disparities continue to be a serious problem in the United States and have been linked to contextual factors, including racial segregation. In some cases, including breast cancer survival, racial disparities appear to be worsening. Using the Home Mortgage Disclosure Act (HMDA) database, we extend current spatial analysis methodology to derive new, spatially continuous indices of (1) racial bias in mortgage lending and (2) redlining. We then examine spatial patterns of these indices and the association between these new measures and breast cancer survival among Black/African American women in the Milwaukee, Wisconsin metropolitan area. These new measures can be used to examine relationships between mortgage discrimination and patterns of disease throughout the United States.

Spatially Varying Coefficient Inequalities: Evaluating How the Impact of Patient Characteristics on Breast Cancer Survival Varies by Location

An increasing number of studies have identified spatial differences in breast cancer survival. However little is known about whether the structure and dynamics of this spatial inequality are consistent across a region. This study aims to evaluate the spatially varying nature of predictors of spatial inequality in relative survival for women diagnosed with breast cancer across Queensland, Australia. All Queensland women aged less than 90 years diagnosed with invasive breast cancer from 1997 to 2007 and followed up to the end of 2008 were extracted from linked Queensland Cancer Registry and BreastScreen Queensland data. Bayesian relative survival models were fitted using various model structures (a spatial regression model, a varying coefficient model and a finite mixture of regressions model) to evaluate the relative excess risk of breast cancer, with the use of Markov chain Monte Carlo computation. The spatially varying coefficient models revealed that some covariate effects may not be constant across the geographic regions of the study. The overall spatial patterns showed lower survival among women living in more remote areas, and higher survival among the urbanised south-east corner. Notwithstanding this, the spatial survival pattern for younger women contrasted with that for older women as well as single women. This complex spatial interplay may be indicative of different factors impacting on survival patterns for these women.

Comparing multilevel and Bayesian spatial random effects survival models to assess geographical inequalities in colorectal cancer survival: a case study

BACKGROUND

Multilevel and spatial models are being increasingly used to obtain substantive information on area-level inequalities in cancer survival. Multilevel models assume independent geographical areas, whereas spatial models explicitly incorporate geographical correlation, often via a conditional autoregressive prior. However the relative merits of these methods for large population-based studies have not been explored. Using a case-study approach, we report on the implications of using multilevel and spatial survival models to study geographical inequalities in all-cause survival.

METHODS

Multilevel discrete-time and Bayesian spatial survival models were used to study geographical inequalities in all-cause survival for a population-based colorectal cancer cohort of 22,727 cases aged 20-84 years diagnosed during 1997-2007 from Queensland, Australia.

RESULTS

Both approaches were viable on this large dataset, and produced similar estimates of the fixed effects. After adding area-level covariates, the between-area variability in survival using multilevel discrete-time models was no longer significant. Spatial inequalities in survival were also markedly reduced after adjusting for aggregated area-level covariates. Only the multilevel approach however, provided an estimation of the contribution of geographical variation to the total variation in survival between individual patients.

CONCLUSIONS

With little difference observed between the two approaches in the estimation of fixed effects, multilevel models should be favored if there is a clear hierarchical data structure and measuring the independent impact of individual- and area-level effects on survival differences is of primary interest. Bayesian spatial analyses may be preferred if spatial correlation between areas is important and if the priority is to assess small-area variations in survival and map spatial patterns. Both approaches can be readily fitted to geographically enabled survival data from international settings.

Distance from treating hospital and colorectal cancer survivors' quality of life: a gendered analysis

PURPOSE

Distance from residence to hospital has been associated with clinical outcomes for colorectal cancer patients. However, little is known about the association of remoteness with quality of life (QoL) for colorectal cancer survivors. We examined the relationship between distance from hospital and colorectal cancer survivors' QoL, with a specific focus on gender.

METHODS

Colorectal cancer survivors in Ireland who were more than 6-months postdiagnosis completed the European Organization for Research and Treatment of Cancer QLQ-C30, measuring global health status (GHS) and physical, role, cognitive, social, and emotional functioning. Bootstrap linear regression was used to evaluate the association between remoteness and QoL scales, controlling for demographic and clinical variables. Separate models were generated for the full sample, for women, and for men.

RESULTS

The final analytical sample was 496 colorectal cancer survivors; 186 women and 310 men. Living remote from the treating hospital was associated with lower physical functioning (coefficient -4.38 [95 % confidence interval -8.13, -0.91]) and role functioning (coeff. -7.78 [-12.64, -2.66]) among all colorectal cancer survivors. In the separate gender models, remoteness was significantly associated with lower physical (coeff. -7.00 [-13.47, -1.49]) and role functioning (coeff. -11.50 [-19.66, -2.65]) for women, but not for men. Remoteness had a significant negative relationship to GHS (coeff. -4.31 [-8.46, -0.27]) for men.

CONCLUSIONS

Aspects of QoL are lower among colorectal cancer survivors who live far from their treating hospital. There are gender differences in how remoteness is related to QoL domains. The results of this study suggest that policy makers, service providers, and health care professionals should consider the specific QoL needs of remote colorectal cancer survivors, and be attuned to and prepared to address the differing needs of men and women.

Geographic variation in prostate cancer survival in New South Wales

OBJECTIVES

To determine whether the previously reported urban-rural differential in prostate cancer survival remains after adjusting for demographic and clinical factors, and to investigate temporal trends in this differential.

DESIGN, SETTING AND PARTICIPANTS

Retrospective population-based survival analysis of 68 686 men diagnosed with prostate cancer from January 1982 to December 2007 in New South Wales.

MAIN OUTCOME MEASURES

Survival rate and relative excess risk (RER) of death over 10 years of follow-up in relation to geographic remoteness after adjusting for other prognostic factors.

RESULTS

Overall, 10-year survival increased during the study period, increasing from 57.5% in 1992-1996 and 75.7% in 1997-2001 to 83.7% in 2002-2007. The increasing trends were also observed across categories of geographic remoteness and socioeconomic status. Urban-rural differentials were significant (P < 0.001) after adjusting for five important prognostic factors, with men living outside major cities having higher risk of death from prostate cancer (RER, 1.18 and 1.32 for inner regional and rural areas, respectively). Socioeconomic status was also a significant factor (P < 0.001) for prostate cancer mortality, with the risk of dying being 34% to 40% higher for men living in socioeconomically disadvantaged areas than those living in least disadvantaged areas. There was no evidence that this inequality is reducing over time, particularly for men living in inner regional areas.

CONCLUSIONS

Despite the increasing awareness of urban-rural differentials in cancer outcomes, little progress has been made. Appropriately detailed data, including details of tumour characteristics, treatment and comorbid conditions, to help understand why these inequalities exist are required urgently so interventions and policy changes can be guided by appropriate evidence.

Quality of life in urban and rural settings: a study of head and neck cancer survivors

OBJECTIVE

Urban-rural variation in cancer incidence, treatment, and clinical outcomes has been well researched. With the growing numbers and longer lifespan of cancer survivors, quality of life (QOL) is now a critical issue. The present study investigates the QOL of head and neck cancer (HNC) survivors in Ireland, paying special attention to urban and rural variation.

METHODS

From the population-based National Cancer Registry Ireland, we identified 991 survivors of HNC (ICD10 C00-C14, C32), who were at least eight months post-diagnosis, and invited them to complete a postal survey. We used self-reported data and information from the Registry to create a composite variable classifying respondents' current area of residence as "urban" or "rural." Respondents self-reported QOL using the Functional Assessment for Cancer Therapy with Head and Neck module (FACT-HN). We used bootstrap linear regression to control for confounding variables, while estimating the association of urban and rural residence to FACT-HN domain scores.

RESULTS

We obtained survey and Registry data from 583 HNC survivors. Controlling for demographic and clinical variables, rural survivors reported higher physical (coefficient 1.27, bias-corrected and accelerated 95% confidence interval 0.54, 2.43), emotional (coef. 0.99, 95% CI 0.21, 2.02), and HNC-specific (coef. 1.55, 95% CI 0.32, 3.54) QOL than their urban counterparts. Social and functional QOL did not differ significantly.

CONCLUSIONS

These findings add to growing evidence of important differences in life experiences of cancers survivors in urban and rural settings. Results such as these will allow health professionals, policy makers and service providers to better serve these populations.

Geographic remoteness, area-level socioeconomic disadvantage and inequalities in colorectal cancer survival in Queensland: a multilevel analysis

Background

To explore the impact of geographical remoteness and area-level socioeconomic disadvantage on colorectal cancer (CRC) survival.

Methods

Multilevel logistic regression and Markov chain Monte Carlo simulations were used to analyze geographical variations in five-year all-cause and CRC-specific survival across 478 regions in Queensland Australia for 22,727 CRC cases aged 20–84 years diagnosed from 1997–2007.

Results

Area-level disadvantage and geographic remoteness were independently associated with CRC survival. After full multivariate adjustment (both levels), patients from remote (odds Ratio [OR]: 1.24, 95%CrI: 1.07-1.42) and more disadvantaged quintiles (OR = 1.12, 1.15, 1.20, 1.23 for Quintiles 4, 3, 2 and 1 respectively) had lower CRC-specific survival than major cities and least disadvantaged areas. Similar associations were found for all-cause survival. Area disadvantage accounted for a substantial amount of the all-cause variation between areas.

Conclusions

We have demonstrated that the area-level inequalities in survival of colorectal cancer patients cannot be explained by the measured individual-level characteristics of the patients or their cancer and remain after adjusting for cancer stage. Further research is urgently needed to clarify the factors that underlie the survival differences, including the importance of geographical differences in clinical management of CRC.