Social and geographic disparities in access to reference care site for patients with colorectal cancer in France

Cancer Treatment Closer to the Patient Reduces Travel Burden, Time Toxicity, and Improves Patient Satisfaction, Results of 546 Consecutive Patients in a Northern Italian District

Background and Objectives: The distance to cancer facilities may cause disparities by creating barriers to oncologic diagnosis and treatment, and travel burden may cause time and financial toxicity. Materials and Methods: To relieve travel burden, a program to deliver oncologic treatment closer to the patient was initiated in the district of Piacenza (Northern Italy) several years ago. The oncologic activities are performed by oncologists and by nurses who travel from the oncologic ward of the city hospital to territorial centres to provide cancer patient management. This model is called Territorial Oncology Care (TOC): patients are managed near their home, in three territorial hospitals and in a health centre, named "Casa della Salute" (CDS). A retrospective study was performed and the records of patients with cancer managed in the TOC program were analysed. The primary endpoints were the km and time saved, the secondary endpoints: reduction of caregiver need for transport and patient satisfaction. Results: 546 cancer patients managed in the TOC program from 2 January 2021 to 30 June 2022 were included in this study. Primary endpoints: median km to reach the city hospital: 26 (range 11-79 km) median time: 44 min (range 32-116); median km to reach the territorial clinicians in the TOC program: 7 (range 1-35 km), median time: 16 minutes (range 6-54), p < 0.001. Secondary endpoints: 64.8% of patients who needed a caregiver for the city hospital could travel alone in the TOC program and 99.63% of patients were satisfied. Conclusions: The results of this retrospective study highlight the possibility of treating cancer patients near their residence, reducing travel burden and saving time.

Cancer Survival and Travel Time to Nearest Reference Care Center for 10 Cancer Sites: An Analysis of 21 French Cancer Registries

BACKGROUND

The impact of several non-clinical factors on cancer survival is poorly understood. The aim of this study was to investigate the influence of travel time to the nearest referral center on survival of patients with cancer.

PATIENTS AND METHODS

The study used data from the French Network of Cancer Registries that combines all the French population-based cancer registries. For this study, we included the 10 most common solid invasive cancer sites in France between 1 January 2013 and 31 December 2015, representing 160,634 cases. Net survival was measured and estimated using flexible parametric survival models. Flexible excess mortality modelling was performed to investigate the association between travel time to the nearest referral center and patient survival. To allow the most flexible effects, restricted cubic splines were used to investigate the influence of travel times to the nearest cancer center on excess hazard ratio.

RESULTS

Among the 1-year and 5-year net survival results, lower survival was observed for patients residing farthest from the referral center for half of the included cancer types. The remoteness gap in survival was estimated to be up to 10% at 5 years for skin melanoma in men and 7% for lung cancer in women. The pattern of the effect of travel time was highly different according to tumor type, being either linear, reverse U-shape, non-significant, or better for more remote patients. For some sites restricted cubic splines of the effect of travel time on excess mortality were observed with a higher excess risk ratio as travel time increased.

CONCLUSIONS

For numerous cancer sites, our results reveal geographical inequalities, with remote patients experiencing a worse prognosis, aside from the notable exception of prostate cancer. Future studies should evaluate the remoteness gap in more detail with more explanatory factors.

Associations between measures of pediatric human resources and the under-five mortality rate: a nationwide study in China in 2014

BACKGROUND

To quantify the associations between the under-five mortality rate (U5MR) and measures of pediatric human resources, including pediatricians per thousand children (PPTC) and the geographical distribution of pediatricians.

METHODS

We analyzed data from a national survey in 2015-2016 in 2636 counties, accounting for 31 mainland provinces of China. We evaluated the associations between measures of pediatric human resources and the risk of a high U5MR (≥ 18 deaths per 1000 live births) using logistic regression and restricted cubic spline regression models with adjustments for potential confounders. PPTC and pediatricians per 10,000 km2 were categorized into quartiles. The highest quartiles were used as reference.

RESULTS

The median values of PPTC and pediatricians per 10,000 km2 were 0.35 (0.20-0.70) and 150 (50-500), respectively. Compared to the counties with the highest PPTC (≥ 0.7), those with the lowest PPTC (< 0.2) had a 52% higher risk of a high U5MR, with an L-shaped relationship. An inverted J-shaped relationship was found that the risk of a high U5MR was 3.74 [95% confidence interval (CI) 2.55-5.48], 3.07 (95% CI 2.11-4.47), and 2.25 times (95% CI 1.52-3.31) higher in counties with < 50, 50-149, and 150-499 pediatricians per 10,000 km2, respectively, than in counties with ≥ 500 physicians per 10,000 km2. The joint association analyses show a stronger association with the risk of a high U5MR in geographical pediatrician density than PPTC.

CONCLUSION

Both population and geographical pediatrician density should be considered when planning child health care services, even in areas with high numbers of PPTC.

Colonoscopy resource availability and its association with the colorectal cancer diagnostic interval: A population-based cross-sectional study

BACKGROUND

Colonoscopy is a key resource used to diagnose colorectal cancer (CRC). This study evaluated the relationship between colonoscopy availability and the length of the CRC diagnostic interval.

METHODS

This is a cross-sectional study of CRC patients diagnosed in Ontario, Canada, in 2008-2012. We used administrative health data to characterise colonoscopist density, private colonoscopy clinic access, distance to the closest colonoscopist and the diagnostic interval, defined as the time from patients' first cancer-related healthcare encounter to their cancer diagnosis date. We used multivariable quantile regression to evaluate the association between colonoscopy availability and the diagnostic interval, modelling the median and 90th percentile.

RESULTS

The median diagnostic interval was 84 days (90th percentile 323 days). The diagnostic interval was longer in patients residing in areas with lower colonoscopists density or private clinic access (adjusted median difference = 9 and 19 days, respectively), with evidence of effect modification by symptom status. Increased distance to a colonoscopist was associated with a longer diagnostic interval in asymptomatic patients, but a shorter diagnostic interval in symptomatic patients (adjusted median difference = 29 and -25 days, respectively).

CONCLUSIONS

This study demonstrated that reduced colonoscopy resource availability is associated with longer diagnostic intervals for CRC patients.

Influence of social deprivation and remoteness on the likelihood of sphincter amputation for rectal cancer: a high-resolution population-based study

BACKGROUND

Medical care in rectal cancer is subject to social inequality. According to the last French guidelines, a 1-cm distal margin below the lower pole of the rectal tumor is now considered sufficient. This extends the limits of the current sphincter preservation gold standard. Like for other innovative technics, the dissemination of such technics is often subject to social and geographical inequalities. The objective was to analyze whether sphincter preservation in rectal cancer is subject to social or geographical inequality.

METHODS

The odds of sphincter preservation was modeled by logistic regression among the 1453 patients in the Calvados digestive cancer registry between 1 January 1997 and 31 December 2015 by examining some of the variables that could influence it: social inequalities and geographical remoteness, sex, age, and stage.

RESULTS

A total of 69.4% of the population received sphincter preservation. Patients in the more deprived quintiles had a significantly higher probability of having sphincter amputation (odds ratio (OR) = 1.469 (1.046-2.064)). This result was no longer significant after adjustment on stage and travel time. There was a dose-effect pattern of geographical remoteness on likelihood of sphincter preservation with a progressive increase in OR between patients living the nearest and the furthest from the reference center (p-trend = 0.0178).

CONCLUSION

This study shows that the probability of receiving sphincter preservation is influenced by the social environment and strongly influenced by remoteness. Although management guidelines have had a huge impact on the rates of sphincter preservation, they have not reduced the influence of the social and geographical environment on sphincter preservation.

Colorectal Cancer Screening in African American HOPE VI Public Housing Residents

This study explores whether colorectal cancer screening outreach via home visits and follow-up calls is effective among public housing African American residents. It reports on the proportion of returned Fecal Immunochemical Test kits, on the characteristics of study participants, and on their primary reasons for returning the kit. By conducting home visits and follow-up calls, our colorectal cancer-screening outreach resulted in a higher Fecal Immunochemical Test kit return rate than anticipated. Findings suggest that a more personalized outreach approach can yield higher colorectal cancer-screening rates among urban minority populations, which are at higher risk to be diagnosed with late-stage colorectal cancer.

Totally implanted venous access-associated adverse events in oncology: Results from a prospective 1-year surveillance programme

INTRODUCTION

During the last decade, most studies on totally implanted venous access-associated adverse events (TIVA-AE) were conducted retrospectively and/or were based on a limited sample size. The aim of our survey was two-fold: to estimate the incidence of TIVA-AE and to identify risk factors in patients with cancer.

METHODS

Data from our routine surveillance of TIVA-AE were collected prospectively between October 2009 and January 2011 in two oncology referral centers in Northern France. The open cohort under surveillance during the same time period was reconstituted retrospectively using data from the hospital information systems. Incidences of first TIVA-AE per 1000 TIVA-days were calculated. Risk factors were identified using multivariate logistic regressions.

RESULTS

We included 2286 cancer patients, corresponding to 582,347 TIVA-days. Among the 133 first TIVA-AE observed (incidence 0.23 per 1000 TIVA-days [0.19-0.27]), there were 50 infectious AE (incidence 0.09 [0.06-0.11]) and 83 non-infectious AE (incidence 0.14 [0.11-0.17]). Compared to non-metastatic solid cancers, metastatic cancers (aOR=2.3 [0.9-6.0]), and hematologic malignancies (aOR=3.2 [1.1-8.8]) tended to be associated with a higher risk of infectious TIVA-AE (P=0.087). Solid cancer type was associated with non-infectious TIVA-AE (P=0.030), especially digestive cancers.

DISCUSSION

We report accurate estimations of TIVA-AE incidences in one of the largest populations among previously published studies. As in previous studies, metastatic cancers and hematologic malignancies tended to be associated with a higher risk of infectious TIVA-AE. Further studies are warranted to confirm the effect of digestive cancers.

Small-area geographic and socioeconomic inequalities in colorectal tumour detection in France

The aim of this study was to assess the impact of area deprivation and primary care facilities on colorectal adenoma detection and on colorectal cancer (CRC) incidence in a French well-defined population before mass screening implementation. The study population included all patients aged 20 years or more living in Côte d'Or (France) with either colorectal adenoma or invasive CRC first diagnosed between 1995 and 2002 and who were identified from the Burgundy Digestive Cancer Registry and the Côte d'Or Polyp Registry. Area deprivation was assessed using the European deprivation index on the basis of the smallest French area available (Ilots Regroupés pour l'Information Statistique). Healthcare access was assessed using medical density of general practitioners (GPs) and road distance to the nearest GP and gastroenterologist. Bayesian regression analyses were used to estimate influential covariates on adenoma detection and CRC incidence rates. The results were expressed as relative risks (RRs) with their 95% credibility interval. In total, 5399 patients were diagnosed with at least one colorectal adenoma and 2125 with invasive incident CRC during the study period. Remoteness from GP [RR=0.71 (0.61-0.83)] and area deprivation [RR=0.98 (0.96-1.00)] independently reduced the probability of adenoma detection. CRC incidence was only slightly affected by GP medical density [RR=1.05 (1.01-1.08)] without any area deprivation effect [RR=0.99 (0.96-1.02)]. Distance to gastroenterologist had no impact on the rates of adenoma detection or CRC incidence. This study highlighted the prominent role of access to GPs in the detection of both colorectal adenomas and overall cancers. Deprivation had an impact only on adenoma detection.

Diagnosis of cancer as an emergency: a critical review of current evidence

Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumour, patient and health-care factors, often in combination. Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. In this Review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this under-researched aspect of cancer diagnosis.

Measuring inequality in physician distributions using spatially adjusted Gini coefficients

Objective

To measure inequality in physician distributions using Gini coefficient and spatially adjusted Gini coefficients.

Design

Measurements were based on the distribution of physician data from the Taiwan National Health Insurance Research Database (NHIRD) and population data from the Ministry of the Interior in Taiwan.

Settings

The distribution of population and physicians in Taiwan from 2001 to 2010.

Participants

This study considered 35 000 physicians who are registered in Taiwan.

Main Outcome Measures

To calculate the Gini coefficient and spatially adjusted Gini coefficients in Taiwan from 2001 to 2010.

Results

The Gini coefficient for each year, from 2001 to 2010, ranged from 0.5128 to 0.4692, while the spatially adjusted Gini coefficients based on travel time and travel distance ranged, respectively, from 0.4324 to 0.4066 and from 0.4408 to 0.4178. We found that, in each year, irrespective of the type of spatial adjustment, the spatially adjusted Gini coefficient was smaller than the Gini coefficient itself. Our empirical findings support that the Gini coefficient may overestimate the maldistribution of physicians.

Conclusions

Our simulations demonstrate that increasing the number of physicians in medium-sized cities (such as capitals of counties or provinces), and/or improving the transportation time between medium-sized cities and rural areas, could be feasible solutions to mitigate the problem of geographical maldistribution of physicians.

Patterns of colorectal cancer care in Europe, Australia, and New Zealand

Colorectal cancer is the second most common cancer in women and the third most common in men worldwide. In this study, we used MEDLINE to conduct a systematic review of existing literature published in English between 2000 and 2010 on patterns of colorectal cancer care. Specifically, this review examined 66 studies conducted in Europe, Australia, and New Zealand to assess patterns of initial care, post-diagnostic surveillance, and end-of-life care for colorectal cancer. The majority of studies in this review reported rates of initial care, and limited research examined either post-diagnostic surveillance or end-of-life care for colorectal cancer. Older colorectal cancer patients and individuals with comorbidities generally received less surgery, chemotherapy, or radiotherapy. Patients with lower socioeconomic status were less likely to receive treatment, and variations in patterns of care were observed by patient demographic and clinical characteristics, geographical location, and hospital setting. However, there was wide variability in data collection and measures, health-care systems, patient populations, and population representativeness, making direct comparisons challenging. Future research and policy efforts should emphasize increased comparability of data systems, promote data standardization, and encourage collaboration between and within European cancer registries and administrative databases.

The effect of provider density on lung cancer survival among blacks and whites in the United States

INTRODUCTION

Lung cancer mortality rates may vary with access to specialty providers and local resources. We sought to examine the effect of access to care, using density of lung cancer care providers, on lung cancer mortality among blacks and whites in the United States.

METHODS

We examined U.S. county-level data for age-adjusted lung cancer mortality rates from 2003 to 2007. Our primary independent variable was per capita number of thoracic oncologic providers, adjusting for county-level smoking rates, socioeconomic status, and other geographic factors. Data were obtained from 2009 Area Resource File, National Center for Health Statistics, and the County Health Rankings Project.

RESULTS

Providers of lung cancer care were unevenly distributed among the U.S. counties. For example, 41.4% of the U.S. population reside in counties with less than four thoracic surgeons per 100,000 people, 23.4% in counties with 4 to 15 surgeons per 100,000 people, and 35.3% in counties with more than 15 surgeons per 100,000 people. Geographically, 4.3% of whites compared with 11.2% of blacks lived in high lung cancer mortality zones. Lung cancer mortality did not vary by density of thoracic surgeons or oncology services; however, higher primary care provider density was associated with lung cancer mortality reduction of 4.1 per 100,000 for whites.

CONCLUSION

Variation in provider density for thoracic oncology in the United States was not associated with a difference in lung cancer mortality. Lower mortality associated with higher primary care provider density suggests that equitable access to primary care may lead to reduced cancer disparities.

The impact of Japan's 2004 postgraduate training program on intra-prefectural distribution of pediatricians in Japan

Objective

Inequity in physician distribution poses a challenge to many health systems. In Japan, a new postgraduate training program for all new medical graduates was introduced in 2004, and researchers have argued that this program has increased inequalities in physician distribution. We examined the trends in the geographic distribution of pediatricians as well as all physicians from 1996 to 2010 to identify the impact of the launch of the new training program.

Methods

The Gini coefficient was calculated using municipalities as the study unit within each prefecture to assess whether there were significant changes in the intra-prefectural distribution of all physicians and pediatricians before and after the launch of the new training program. The effect of the new program was quantified by estimating the difference in the slope in the time trend of the Gini coefficients before and after 2004 using a linear change-point regression design. We categorized 47 prefectures in Japan into two groups: 1) predominantly urban and 2) others by the definition from OECD to conduct stratified analyses by urban-rural status.

Results

The trends in physician distribution worsened after 2004 for all physicians (p value<.0001) and pediatricians (p value = 0.0057). For all physicians, the trends worsened after 2004 both in predominantly urban prefectures (p value = 0.0012) and others (p value<0.0001), whereas, for pediatricians, the distribution worsened in others (p value = 0.0343), but not in predominantly urban prefectures (p value = 0.0584).

Conclusion

The intra-prefectural distribution of physicians worsened after the launch of the new training program, which may reflect the impact of the new postgraduate program. In pediatrics, changes in the Gini trend differed significantly before and after the launch of the new training program in others, but not in predominantly urban prefectures. Further observation is needed to explore how this difference in trends affects the health status of the child population.

Risk assessment before allogeneic hematopoietic cell transplantation for older adults with acute myeloid leukemia

Acute myeloid leukemia (AML) most commonly affects patients older than 60 years. Outcomes of treatment of older AML patients have been poor. The advent of reduced-intensity conditioning (RIC) regimens made allogeneic hematopoietic cell transplantation (HCT) an available treatment option with curative intent for older AML patients. Because older patients are often excluded from clinical trials, little is known about the stratification of their risks before allogeneic HCT. While recent studies of RIC and allogeneic HCT have shown little impact of age on outcomes, other variables such as the recipient health status and the AML disease status and chromosomal aberrations have proven to be of prognostic significance. Here, the authors review recent studies of allogeneic HCT for older patients with AML with detailed evaluation of risk factors for relapse as well as non-relapse mortality. The authors have integrated the currently available information on transplant risks into a five-category risk-benefit system that could aid in the decision-making in this patient population.

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

Background

It has been shown in several studies that survival in cancer patients who were operated on by a high-volume surgeon was better. Why then do all patients not benefit from treatment by these experienced surgeons? The aim of our work was to study the hypothesis that in breast cancer, geographical isolation and the socio-economic level have an impact on the likelihood of being treated by a specialized breast-cancer surgeon.

Methods

All cases of primary invasive breast cancer diagnosed in the Côte d’Or from 1998 to 2008 were included. Individual clinical data and distance to the nearest reference care centre were collected. The Townsend Index of each residence area was calculated. A Log Rank test and a Cox model were used for survival analysis, and a multilevel logistic regression model was used to determine predictive factors of being treated or not by a specialized breast cancer surgeon.

Results

Among our 3928 patients, the ten-year survival of the 2931 (74.6 %) patients operated on by a high-volume breast cancer surgeon was significantly better (LogRank p < 0.001), independently of age at diagnosis, the presence of at least one comorbidity, circumstances of diagnosis (screening or not) and TNM status (Cox HR = 0.81 [0.67-0.98]; p = 0.027). In multivariate logistic regression analysis, patients who lived 20 to 35 minutes, and more than 35 minutes away from the nearest reference care centre were less likely to be operated on by a specialized surgeon than were patients living less than 10 minutes away (OR = 0.56 [0.43; 0.73] and 0.38 [0.29; 0.50], respectively). This was also the case for patients living in rural areas compared with those living in urban areas (OR = 0.68 [0.53; 0.87]), and for patients living in the two most deprived areas (OR = 0.69 [0.48; 0.97] and 0.61 [0.44; 0.85] respectively) compared with those who lived in the most affluent area.

Conclusions

A disadvantageous socio-economic environment, a rural lifestyle and living far from large specialized treatment centres were significant independent predictors of not gaining access to surgeons specialized in breast cancer. Not being treated by a specialist surgeon implies a less favourable outcome in terms of survival.

Volume of surgical activity and lymph node evaluation for patients with colorectal cancer in France

BACKGROUND

The correct examination of lymph nodes is decisive for tumour classification into stage 2 and stage 3. The aim of this specialised population-based study was to investigate the influence of clinical factors and volume of surgical activity on lymph node assessment in France for patients diagnosed with localised colorectal cancer.

METHODS

From 1997 to 2004, French digestive cancer registries recorded a total of 4197 cases of colorectal cancer. The volume of surgical activity was appreciated by the annual number of digestive surgery admissions in 2004. The probability of having at least 12 lymph nodes examined after surgical resection was analysed using a multilevel logistic regression model.

RESULTS

Only 1900 patients had more than 12 lymph nodes examined (45.2%). The percentage of patients with at least 12 lymph nodes examined after tumour resection is directly associated with the volume of surgical activity within care centres for patients diagnosed between 1997 and 2000. This association was no longer significant during the second period study (2001-2004).

CONCLUSION(S)

This population-based study reports that only 55% of colorectal patients have a sufficient number of lymph nodes examined. This insufficient number of examined lymph nodes could be considered as a potential prospect for increasing treatment quality in cancer patients in France.

Evaluation of resource allocation and supply-demand balance in clinical practice with high-cost technologies

RATIONALE, AIMS AND OBJECTIVES

Japan has one of the highest numbers of high-cost medical devices installed relative to its population. While evaluations of the distribution of these devices traditionally involve simple population-based assessments, an indicator that includes the demand of these devices would more accurately reflect the situation. The purpose of this study was to develop an indicator of the supply-demand balance of such devices, using examples of magnetic resonance imaging scanners (MRI) and extracorporeal shockwave lithotripters (ESWL), and to investigate the relationship between this indicator, personnel distribution statuses and operating statuses at the prefectural level.

METHODS

Using data from nation-wide surveys and claims data from 16 hospitals, we developed an indicator based on the ratio of the supplied number of device units to the number of device units in demand for MRI and ESWL. The latter value was based on patient volume and utilization proportion. Correlation analyses were conducted between the supply-demand balances of these devices, personal distribution and operating statuses.

RESULTS

Comparisons between our indicator and conventional population-based indicators revealed that 15% and 30% of prefectures were at risk of underestimating the availability of MRI and ESWL, respectively. The numbers of specialist personnel/device units showed significant, negative correlations with our indicators in both devices.

CONCLUSIONS

Utilization-based analyses of health care resource placement and utilization status provide a more accurate indication than simple population-based assessments, and can assist decision makers in reviewing gaps between health policy and management. Such an indicator therefore has the potential to be a tool in helping to improve the efficiency of the allocation and placement of such devices.

The impact of geographic proximity to transplant center on outcomes after allogeneic hematopoietic stem cell transplantation

Patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) need access to specialized care. We hypothesized that access to the transplant center after HSCT may be challenging for patients living in geographically distant areas, and that this would have an adverse effect on their outcome. We analyzed 1912 adult patients who underwent allogeneic HSCT at the Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC) between 1996 and 2009 and who resided within 6 hours driving time of the institution. Driving time from primary residence to DF/BWCC based on zipcode was determined using geographic information systems. The median driving time (range) to DF/BWCC was 72 (2-358) minutes. When patients were stratified by driving time quartile, overall survival (OS) after HSCT was similar in the first year but worse after 1 year in patients in the top quartile (≥ 160 minutes driving time). In a landmark analysis of the 909 patients alive and free of disease at 1 year, 5-year OS was 76% and 65% for patients in the first (≤ 40 minutes) and fourth (≥ 160 minutes) quartiles, respectively (P = .027). This was confirmed in a multivariable analysis. The difference appeared to be mostly because of an increase in nonrelapse mortality. The number of visits to the transplant center between day 100 and 365 after HSCT declined significantly with increasing driving time to the transplant center, which was independently associated with worse survival. Long driving time to the transplant center is associated with worse OS in patients alive and disease-free 1 year after HSCT, independently of other patient-, disease-, and HSCT-related variables. This may be in part related to the lower frequency of post-HSCT visits in patients living farther away.

Mapping oncology services in regional and rural Australia

OBJECTIVE

To map clinical oncology services in regional and rural Australia.

DESIGN AND SETTING

A self-administered survey was sent to 161 regional hospitals administering chemotherapy (RHAC) in Australia. RHAC were categorised by state, Hospital Peer Group and the Australian Standard Geographical Classification (ASGC) Remoteness Areas classification.

MAIN OUTCOME MEASURE(S)

Survey data provided percentage and aggregate figures about availability of medical, radiation and surgical oncologists, chemotherapy nurses, breast cancer nurses, palliative care physicians and allied health professionals according to remoteness and state. Chemotherapy prescribing practices, adherence to occupational health and safety guidelines and availability of multidisciplinary clinics were also explored.

RESULTS

A 98% survey completion rate was achieved. Significant deficiencies in service provision were identified in RHAC. Only 21% of RHAC reported a resident medical oncology service, 7% had a radiation oncology unit, and 6% had a resident surgical oncologist. Only 24% of RHAC reported a dedicated palliative care specialist and 39% identified a dedicated oncology counselling service. Other issues included administration of chemotherapy by nurses outside a recognised facility or by nurses without recognised oncology training, limited availability of funded breast care nurses and lack of multidisciplinary clinics.

CONCLUSION

Survey data highlight marked cancer service deficiencies in rural and regional Australia. It is not unreasonable to conclude that these deficiencies might contribute to poorer outcomes for cancer patients living in these areas. The results suggest the need for short- and long-term measures to improve access to best-practice cancer services for patients living in regional, rural and remote areas of Australia.

Access to care, socioeconomic deprivation and colon cancer survival

BACKGROUND

The influence of socioeconomic environment on cancer survival has been established in numerous studies in the EU and the US, prognosis being constantly poorer for the most underprivileged patients.

AIM

To investigate the influence of distance to care centre and deprivation on colon cancer survival, using a multilevel Cox model and taking into account cancer stage at diagnosis and treatment modalities.

METHODS

The study population comprised all cases of colon cancer diagnosed between 1997 and 2000 in two French areas covered by specialized cancer registries (n = 2066).

RESULTS

Road distance to the nearest reference care centre was associated with poorer prognosis even after adjustment for stage at diagnosis (P for trend = 0.01). Subgroups analysis showed that this association was maximal for patients with advanced cancer [RR = 1.27 (1.04-1.51); P for trend = 0.015] for whom access to chemotherapy varying according to distance explained the major part of geographic inequalities in survival.

CONCLUSIONS

The major effect of distance from reference care centre on survival suggests that current regional health planning does not guarantee equity in cancer management. Improvement in access to adjuvant therapy, especially for patients with advanced cancers, seems crucial for reducing geographic disparities in colon cancer survival.

Accessibility as a major determinant of radiotherapy underutilization: A population based study

BACKGROUND AND PURPOSE

A survey was conducted of radiotherapy (RT) resources and utilization in a northwestern Italian Region in order to assess geographical variations in radiotherapy utilization rates, and the effects of infrastructure supply on accessibility.

MATERIALS AND METHODS

The survey was conducted by analysing standardized utilization rates based on administrative records. The data were analysed at both Regional and Local Health Unit (LHU) level.

RESULTS

Wide variation was found among LHUs RT utilization rates--the sex- and age-standardized rates varied from 1.8/1000 inhabitants to more than 3/1000 inhabitants. Patients resident in LHUs with no RT service showed a lower probability of accessing RT (standardized rate ratio (SRR), 0.82; 95%IC, 0.80-0.85). The utilization rate decreased in relation to the distance between a patient's residence and the nearest RT service; the reduction was greater for patients > or =70 years of age.

CONCLUSION

The wide geographic variation implies lack of equity in access to services. Utilization levels decreased significantly with increasing distance from the nearest RT service, distance being a barrier to access particularly for older persons. The heterogeneous distribution of services on the Regional territory seems a relevant explanation of differences in utilization rates.

Social determinants of access to reference care centres for patients with colorectal cancer – A multilevel analysis

BACKGROUND

Although social disparities in survival for patients with cancer are documented in an increasing number of papers, knowledge on the underlying mechanisms concerning screening, diagnosis, treatment or follow-up, is relatively poor. Our study was aimed at investigating the social determinants of access to reference cancer care centres for surgery for colorectal cancer in France.

METHODS

Retrospective analysis was conducted on population-based data from a specialised cancer registry (County of Calvados, France). The population consisted of 5156 patients with surgical treatment for colorectal cancer recorded between January 1st 1981 and December 31st 2000.

RESULTS

The probability of being cared for in a reference care centre was 1.3-fold lower for people living in a deprived district (mean income < 15000 euros) and 3-fold lower for people living in a district where more than 7% of houses were devoid of bath and shower in comparison with districts where this rate was under 2%. After adjustment for distance from reference care centre, the probability of being cared for in a reference care centre was still over one third lower for people living in a district with more than 7% of houses devoid of bath and shower. Social disparities in management of patients with colorectal cancer have increased in the last decade. The reduction of access to reference care with distance was stronger in elderly patients.

CONCLUSIONS

There is a social and geographical determination of type of treatment centre for care management of colorectal cancer in France. Special attention needs to be paid to the high quality of care management in non-specialised care centres in order to avoid an increased social gradient in cancer mortality in France.

Socioeconomic and geographic determinants of survival of patients with digestive cancer in France

Using a multilevel Cox model, the association between socioeconomic and geographical aggregate variables and survival was investigated in 81 268 patients with digestive tract cancer diagnosed in the years 1980-1997 and registered in 12 registries in the French Network of Cancer Registries. This association differed according to cancer site: it was clear for colon (relative risk (RR)=1.10 (1.04-1.16), 1.10 (1.04-1.16) and 1.14 (1.05-1.23), respectively, for distances to nearest reference cancer care centre between 10 and 30, 30 and 50 and more than 90 km, in comparison with distance of less than 10 km; P-trend=0.003) and rectal cancer (RR=1.09 (1.03-1.15), RR=1.08 (1.02-1.14) and RR=1.12 (1.05-1.19), respectively, for distances between 10 and 30 km, 30 and 50 km and 50 and 70 km, P-trend=0.024) (n=28 010 and n=18 080, respectively) but was not significant for gall bladder and biliary tract cancer (n=2893) or small intestine cancer (n=1038). Even though the influence of socioeconomic status on prognosis is modest compared to clinical prognostic factors such as histology or stage at diagnosis, socioeconomic deprivation and distance to nearest cancer centre need to be considered as potential survival predictors in digestive tract cancer.