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

The provision of general surgery in rural Australia: a narrative review

Rural surgery is most commonly provided by general surgeons to the 29% of people (7 million) living in rural Australia. The provision of rural general surgery to enable equitable and safe surgical care for rural Australians is a multifaceted issue concerning recruitment, training, retention, surgical procedures and surgical outcomes. Sustaining the rural general surgical workforce will be dependent upon growing an increased number of resident rural general surgeons, as well as changed models of care, with a need for ongoing review to track the outcomes of these changes. To increase recruitment, rural general surgical training must improve to be less stressful for trainees and to be incorporated alongside a rural-facing generalist curriculum. Rural general surgical outcomes (excluding some oncology conditions) achieve comparable results to metropolitan centres. Access to, and outcomes of, surgical oncology services continues to be inequitable for rural Australians and should be a major focus for improved service delivery.

Regional access to a centralized extracorporeal membrane oxygenation (ECMO) service in Victoria, Australia

Introduction

Victoria, Australia provides a centralised state ECMO service, supported by ambulance retrieval. Equity of access to this service has not been previously described.

Objective

Describe the characteristics of ECMO recipients and quantify geographical and socioeconomic influence on access.

Design

Retrospective observational study with spatial mapping.

Participants and setting

Adult (≥18 years) ECMO recipients from July 2016-June 2022. Data from administrative Victorian Admissions Episodes Database analysed in conjunction with Australian Urban Research Infrastructure Network population data and choropleth mapping. Presumed ECMO modes were inferred from cardiopulmonary bypass and pre-hospital cardiac arrest codes. Spatial autoregressive models including Moran's test used for spatial lag testing.

Outcomes

Demographics and outcomes of ECMO recipients; ECMO incidence by patient residence (Statistical-Area Level 2, SA-2) and Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD); and ECMO utilisation adjusted for patient factors and linear distance from the central ECMO referral site.

Results

631 adults received ECMO over 6 years, after exclusion of paediatric (n = 242), duplicate (n = 135), and interstate or incomplete (n = 72) records. Mean age was 51.8 years, and 68.8 % were male. Overall ECMO incidence was 3.00 ± 3.95 per 105 population. 135 (21.4 %) were presumed VA-ECMO, 59 (9.3 %) presumed ECPR, and 437 (69.3 %) presumed VV-ECMO. Spatial lag was non-significant after adjusting for patient characteristics. Distance from the central referral site (dy/dx = 0.19, 95% CI -0.41-0.04, p = 0.105) and IRSAD score (dy/dx = 0.17, 95% CI -0.19-0.53, p = 0.359) did not predict ECMO utilisation.

Conclusion

Victorian ECMO incidence rates were low. We did not find evidence of inequity of access to ECMO irrespective of regional area or socioeconomic status.

A prognostic survival model for women diagnosed with invasive breast cancer in Queensland, Australia

PURPOSE

Prognostic models can help inform patients on the future course of their cancer and assist the decision making of clinicians and patients in respect to management and treatment of the cancer. In contrast to previous studies considering survival following treatment, this study aimed to develop a prognostic model to quantify breast cancer-specific survival at the time of diagnosis.

METHODS

A large (n = 3323), population-based prospective cohort of women were diagnosed with invasive breast cancer in Queensland, Australia between 2010 and 2013, and followed up to December 2018. Data were collected through a validated semi-structured telephone interview and a self-administered questionnaire, along with data linkage to the Queensland Cancer Register and additional extraction from medical records. Flexible parametric survival models, with multiple imputation to deal with missing data, were used.

RESULTS

Key factors identified as being predictive of poorer survival included more advanced stage at diagnosis, higher tumour grade, "triple negative" breast cancers, and being symptom-detected rather than screen detected. The Harrell's C-statistic for the final predictive model was 0.84 (95% CI 0.82, 0.87), while the area under the ROC curve for 5-year mortality was 0.87. The final model explained about 36% of the variation in survival, with stage at diagnosis alone explaining 26% of the variation.

CONCLUSIONS

In addition to confirming the prognostic importance of stage, grade and clinical subtype, these results highlighted the independent survival benefit of breast cancers diagnosed through screening, although lead and length time bias should be considered. Understanding what additional factors contribute to the substantial unexplained variation in survival outcomes remains an important objective.

Treatment and outcomes of unresectable and metastatic pancreatic cancer treated in public and private Australian hospitals

BACKGROUND

Prior studies have reported for several cancer types that treatment in the private sector is associated with improved survival outcomes. Data for patients with locally advanced unresectable and metastatic pancreatic ductal adenocarcinoma (PDAC) have not previously been reported.

METHODS

Analysis of patients from January 2016 to June 2020 registered to a multicentre prospective cancer database. Baseline demographic and clinicopathologic characteristics were compared. The Kaplan-Meier method was used to compare overall survival (OS). Multivariate Cox and logistic regression analyses were used to determine predictors of mortality and first-line chemotherapy treatment, respectively.

RESULTS

Of 822 patients, 22.5% received private care. Private patients were older (median 71.5 vs. 68.9 years, p ≤ .05), had better performance status (ECOG 0 to 1: 82.2 vs. 73.5%, p = .05) and more likely to reside in an area with high socioeconomic advantage (67.0 vs. 19.6%, p ≤ .01). Private patients were more likely to receive first-line chemotherapy (69.7 vs. 54.2%, p ≤ .01) with logistic regression demonstrating private care (OR: 1.87, 95% CI: 1.20 to 2.97) as an independent predictor of receiving chemotherapy. Private patients had prolonged survival (median OS: 9.2 vs. 6.9 months, HR 1.2, p = .05). Receiving first-line chemotherapy was an independent predictor of mortality, but private care was not.

CONCLUSIONS

Care in the private system is associated with improved OS, with higher uptake of first-line chemotherapy appearing to be the main contributor. Given the discrepancy, further studies are needed to determine what factors are driving this difference.

Factors influencing breast cancer outcomes in Australia: A systematic review

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

PROSPERO REGISTRATION

CRD42017072857.

Socioeconomic Differences and Lung Cancer Survival-Systematic Review and Meta-Analysis

Background: The impact of socioeconomic differences on cancer survival has been investigated for several cancer types showing lower cancer survival in patients from lower socioeconomic groups. However, little is known about the relation between the strength of association and the level of adjustment and level of aggregation of the socioeconomic status measure. Here, we conduct the first systematic review and meta-analysis on the association of individual and area-based measures of socioeconomic status with lung cancer survival.

Methods: In accordance with PRISMA guidelines, we searched for studies on socioeconomic differences in lung cancer survival in four electronic databases. A study was included if it reported a measure of survival in relation to education, income, occupation, or composite measures (indices). If possible, meta-analyses were conducted for studies reporting on individual and area-based socioeconomic measures.

Results: We included 94 studies in the review, of which 23 measured socioeconomic status on an individual level and 71 on an area-based level. Seventeen studies were eligible to be included in the meta-analyses. The meta-analyses revealed a poorer prognosis for patients with low individual income (pooled hazard ratio: 1.13, 95 % confidence interval: 1.08–1.19, reference: high income), but not for individual education. Group comparisons for hazard ratios of area-based studies indicated a poorer prognosis for lower socioeconomic groups, irrespective of the socioeconomic measure. In most studies, reported 1-, 3-, and 5-year survival rates across socioeconomic status groups showed decreasing rates with decreasing socioeconomic status for both individual and area-based measures. We cannot confirm a consistent relationship between level of aggregation and effect size, however, comparability across studies was hampered by heterogeneous reporting of socioeconomic status and survival measures. Only eight studies considered smoking status in the analysis.

Conclusions: Our findings suggest a weak positive association between individual income and lung cancer survival. Studies reporting on socioeconomic differences in lung cancer survival should consider including smoking status of the patients in their analysis and to stratify by relevant prognostic factors to further explore the reasons for socioeconomic differences. A common definition for socioeconomic status measures is desirable to further enhance comparisons between nations and across different levels of aggregation.

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.

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.

Socio-economic status and survival from breast cancer for young, Australian, urban women

OBJECTIVE

To estimate the association between measures of socio-economic status (SES) and breast cancer (BC) survival for young, urban Australian women.

METHODS

We used a population-based sample of 1,029 women followed prospectively for a median of 7.9 years. SES was defined by education and area of residence. Hazard ratios (HRs) associated with SES measures were estimated for (i) distant recurrence (DR) and (ii) all-cause mortality as end-points.

RESULTS

HRs for area of residence were not significantly different from unity, with or without adjustment for age at diagnosis and education level. The univariable HR estimate of DR for women with university education compared with women with incomplete high school education was 1.51 (95% CI = 1.08 - 2.13, p = 0.02), which reduced to 1.20 (95% CI = 0.85 - 1.72, p = 0.3) after adjusting for age at diagnosis and area of residence. Adjusting for prognostic factors differentially distributed across SES groups did not substantially alter the association between survival and SES.

CONCLUSIONS

Among young, urban Australian women there is no association between SES and BC survival.

IMPLICATIONS

This lack of estimates of association may be partly attributed to universal access to adequate breast cancer care in urban areas.

Cancer survival and excess mortality estimates among adolescents and young adults in Western Australia, 1982-2004: a population-based study

BACKGROUND

Data are limited on cancer outcomes in adolescents and young adults.

METHODS

Based on data from the Western Australian Data Linkage System, this study modelled survival and excess mortality in all adolescents and young adults aged 15-39 years in Western Australia who had a diagnosis of cancer in the period 1982-2004. Relative survival and excess all-cause mortality for all cancers combined and for principal tumour subgroups were estimated, using the Ederer II method and generalised linear Poisson modelling, respectively.

RESULTS

A cancer diagnosis in adolescents and young adults conferred substantial survival decrement. However, overall outcomes improved over calendar period (excess mortality hazard ratio [HR], latest versus earliest diagnostic period: 0.52, trend p<0.0001). Case fatality varied according to age group (HR, oldest versus youngest: 1.38, trend p<0.0001), sex (HR, female versus male: 0.66, 95% confidence interval [CI] 0.62-0.71), ethnicity (HR, Aboriginal versus others: 1.47, CI 1.23-1.76), geographical area (HR, rural/remote versus urban: 1.13, CI 1.04-1.23) and residential socioeconomic status (HR, lowest versus highest quartile: 1.14, trend p<0.05). Tumour subgroups differed substantially in frequency according to age group and sex, and were critical outcome determinants.

CONCLUSIONS

Marked progressive calendar-time improvement in overall outcomes was evident. Further research is required to disentangle the contributions of tumour biology and health service factors to outcome disparities between ethno-demographic, geographic and socioeconomic subgroups of adolescents and young adults with cancer.

Developing a sustainable model of rural cancer care: the Western Australian Cancer Network project

PROBLEM

Cancer-related mortality is higher in rural areas than in urban centres. One of the contributing factors is limited access to treatment options in rural areas.

DESIGN

An evaluation of the effectiveness of the Western Australian Cancer Network (CanNET WA) pilot project was undertaken using qualitative methods and document analysis.

SETTING

CanNET WA was established in the Great Southern region of Western Australia.

KEY MEASURES FOR IMPROVEMENT

Three measures were assessed: impact of the CanNET WA on consumers, care providers and changes to systems and processes.

STRATEGIES FOR CHANGE

CanNET WA comprised a number of initiatives that together led to an improvement in cancer care. These included a multidisciplinary cancer team, improved access to visiting medical specialists, formal links with tertiary cancer centres, increased primary health involvement in cancer care and increased education regarding cancer care for local health care providers.

EFFECTS OF CHANGE

Changes in the three key outcome measures were reported. Consumers had greater choice of treatment options and had more involvement in decision making. Health professionals reported improvements in care coordination and in peer support related to the new multidisciplinary cancer care team, and improved links with tertiary cancer centres in Perth. Systemic changes included mapping of referral pathways and tumour-specific care pathways.

LESSONS LEARNT

  CanNET WA has demonstrated the need for coordinated cancer care for rural people that offers care locally whenever possible. The success of the project paved the way for the rollout of the CanNET WA concept into other regional areas of Western Australia.

Increased mortality among Hispanic testis cancer patients independent of neighborhood socioeconomic status: a SEER study

Testis cancer-specific survival (CSS) varies by Hispanic ethnicity. Our goal was to assess whether neighborhood socioeconomic status (SES) accounts for elevated testis CSS among Hispanic patients. We queried the Surveillance, Epidemiology, and End Results (SEER) database for Hispanic (HW) and Non-Hispanic white (NHW) patients. Multivariate Cox regression analyses evaluated Hispanic ethnicity's impact on tCSS while adjusting for neighborhood socioeconomic status (education and income levels). HWs constituted 14.3% of the 26,258 patients in the cohort. Neighborhood SES factors such as county income (P < 0.001) and education level (P < 0.001) were significant predictors of testis cancer-specific survival (tCSS). Controlling for SES and other variables, Hispanic ethnicity remained a significant predictor of tCSS. Compared to NHWs, HWs experienced a 41% greater cancer-specific mortality (HR: 1.406, 95% CI: 1.178-1.678, P < 0.001). The mechanism underlying the increased testis cancer mortality experienced by Hispanic patients remains unknown.

A multilevel analysis on the relationship between neighbourhood poverty and public hospital utilization: is the high Indigenous morbidity avoidable?

BACKGROUND

The estimated life expectancy at birth for Indigenous Australians is 10-11 years less than the general Australian population. The mean family income for Indigenous people is also significantly lower than for non-Indigenous people. In this paper we examine poverty or socioeconomic disadvantage as an explanation for the Indigenous health gap in hospital morbidity in Australia.

METHODS

We utilised a cross-sectional and ecological design using the Northern Territory public hospitalisation data from 1 July 2004 to 30 June 2008 and socio-economic indexes for areas (SEIFA) from the 2006 census. Multilevel logistic regression models were used to estimate odds ratios and confidence intervals. Both total and potentially avoidable hospitalisations were investigated.

RESULTS

This study indicated that lifting SEIFA scores for family income and education/occupation by two quintile categories for low socio-economic Indigenous groups was sufficient to overcome the excess hospital utilisation among the Indigenous population compared with the non-Indigenous population. The results support a reframing of the Indigenous health gap as being a consequence of poverty and not simplistically of ethnicity.

CONCLUSIONS

Socio-economic disadvantage is a likely explanation for a substantial proportion of the hospital morbidity gap between Indigenous and non-Indigenous populations. Efforts to improve Indigenous health outcomes should recognise poverty as an underlying determinant of the health gap.

Preliminary evaluation of psychoeducational support interventions on quality of life in rural breast cancer survivors after primary treatment

Although most cancer survivors are at risk for being lost in the transition from treatment to survivorship, rural breast cancer survivors face special challenges that might place them at particular risk. This small-scale preliminary study had 2 specific aims: (aim 1) establish the feasibility of rural breast cancer survivors participation in a longitudinal quality of life (QOL) intervention trial and (aim 2) determine the effects of the Breast Cancer Education Intervention (BCEI) on overall QOL. Fifty-three rural breast cancer survivors were randomized to either an experimental (n = 27) or a wait-control arm (n = 26). Participants in the experimental arm received the BCEI consisting of 3 face-to-face education and support sessions and 2 face-to-face and 3 telephone follow-up sessions, along with supplemental written and audiotape materials over a 6-month period. Breast Cancer Education Intervention modules and interventions are organized within a QOL framework. To address the possible effects of attention, wait-control participants received 3 face-to-face sessions and 3 telephone sessions during the first 6 months of participation in the study, but not the BCEI intervention. Research questions addressing aim 1 were as follows: (a) can rural breast cancer survivors be recruited into a longitudinal intervention trial, and (b) can their participation be retained. Research questions for aim 2 were as follows: (a) do participants who received the BCEI show improvement in overall QOL, and (b) is the QOL improvement sustained over time. Data were analyzed using repeated-measures general linear mixed models. Results demonstrated the ability to recruit and retain 53 rural breast cancer survivors, that the experimental arm showed improvement in overall QOL (P = .013), and that there were significant differences in overall QOL between the experimental and wait-control groups at both months 3 and 6. Thus, it appears that at least some rural breast cancer survivors can and will participate in a larger trial and will maintain their participation and that those that do participate experience significant QOL benefit.

Does Center Volume Correlate with Survival from Breast Cancer?

With its high incidence and long history of patient advocacy, breast cancer has generated the most concern about the quality of its care and the volume-outcome relationship. In breast cancer surgery, the risk of perioperative morbidity or mortality is low, but surgery is only one single piece in the mosaic of multidisciplinary care that eventually determines survival. Only a limited number of articles is available investigating the relationship between case volume of physicians and hospitals and specialization of surgeons and survival. In summary, there is evidence to support the hypothesis that specialization, research interest, and caseload of physicians and hospitals is positively correlated with providing state-of-the-art care and with survival. However, it is less clear what impact might be attributed to the surgical routine gained with increasing number of procedures compared to the deeper insight into the biology of breast cancer that comes with specialization in oncology and the weight of the multidisciplinary setting that is more easily established and maintained with a higher caseload.

Lung cancer: an exploration of patient and general practitioner perspectives on the realities of care in rural Western Australia

OBJECTIVE

This study investigates if the pattern of diagnostic testing for suspected lung cancer, stage at diagnosis, patterns of specialist referral and treatment options offered to people in rural Western Australia are similar to those in the metropolitan area. It then explores the barriers to quality care in rural areas as perceived by GPs and patients.

METHODS

There was a review of GP records to obtain clinical and referral information and an in-depth interview with patients and GPs concerning their perspectives of the quality of care.

RESULTS/DISCUSSION

We selected age and sex-matched samples of 22 rural and 21 metropolitan patients. Rural patients had more symptoms and took longer to consult their GPs, leading to later diagnosis and fewer treatment options. They experienced longer waits for specialist consultation and underwent less diagnostic testing. The GPs always referred lung cancer patients to a specialist, usually a respiratory physician. Teaching hospitals were preferred because of their comprehensive facilities and multidisciplinary teams. Rural GPs reported distance, time and availability of appointments as barriers; they also raised concerns about late confirmation of diagnosis. Rural and metropolitan patients were equally satisfied with their quality of care, but rural patients desired more information and better communication between hospital and GPs. Facilities for rural patients at some metropolitan hospitals were criticised. In conclusion, rural patients received a different care pattern from metropolitan patients and they and their GPs raised concerns about the equity and quality of lung cancer care.

Assessing the impact of socio-economic status on cancer survival in New South Wales, Australia 1996-2001

OBJECTIVE

To assess the impact of socio-economic status (SES) on cancer survival in the state of New South Wales (NSW), Australia.

METHODS

Patients diagnosed with one of 13 major cancers during 1992-2000 in NSW were followed-up to the end of 2001. The effect of SES on survival was estimated for each individual cancer and all 13 cancers combined using multivariable modeling. The numbers of lives that could be extended if all people had the same level of excess risk of death due to cancer as patients in the highest SES areas were also estimated.

RESULTS

There were highly statistically significant variations in survival across SES groups for four cancers: stomach, liver, lung, and breast and all 13 cancers combined. Variation remained highly significant after adjusting for disease stage. Patients in lower SES areas had 10-20% higher excess risk than those in the highest SES areas. In total, there were 3,346 lives potentially extendable beyond 5 years; the highest number was for lung cancer (756).

CONCLUSION

The significantly worse survival in lower SES areas from cancers of the stomach, liver, lung, and breast may be due to poorer access to high-quality cancer care. Estimates of the number of lives potentially extendable by improving cancer survival in lower SES areas suggest that priority should be given to improving lung cancer care in lower SES areas in NSW, Australia.

Social inequalities in the incidence and case fatality of cancers of the lung, the stomach, the bowels, and the breast

OBJECTIVE

In order to examine health inequalities in terms of incidences and case fatalities in a German health insurance population. Lung cancer, stomach cancer, intestinal carcinoma, and breast cancer were considered. Social differentiation was depicted by income and occupational position in order to examine which one is more strongly associated with incidence and case fatality.

METHODS

Analyses were performed using data from a statutory health insurance (n = 170,848). Incomes were divided into quintiles, and subjects were grouped according to occupational status.

RESULTS

For lung cancer incidence a gradient between the highest and the lowest 20% of the income distribution emerged. The relative risk of the lowest category was RR = 7.03, for occupational position the figure was RR = 6.98. For stomach cancer the relative risks were RR = 5.33 for income and RR = 7.11 for occupational position. For intestinal carcinoma only income was significantly related with incidence (RR = 4.37 for the lowest 20% of the income distribution), and for breast cancer incidence no social inequalities were found. For case fatality increased relative risks emerged for lung cancer, but only for income.

CONCLUSIONS

Income and occupational position were associated with cancer incidence with the exception of breast cancer. Apart from lung cancer, case fatalities were unrelated to measures of social differentiation.

Emotional toil: psychosocial care in rural settings for patients with cancer

AIM

This paper is a report of a study to identify experienced rural nurses' perceptions of key issues related to the provision of effective psychosocial care for people with cancer in rural settings.

BACKGROUND

A cancer diagnosis has a major impact on psychological and emotional wellbeing, and psychosocial support provided by nurses is an integral part of ensuring that people with cancer have positive outcomes. Although, ideally, people with cancer should be managed in specialist settings, significant numbers are cared for in rural areas.

METHODS

Using a qualitative descriptive approach, three focus groups were conducted in 2005 with 19 nurses in three hospitals in rural Victoria, Australia.

FINDINGS

Participants indicated that a key issue in providing psychosocial care to patients with cancer in the rural setting was their own 'emotional toil'. This Global Theme encapsulated three Organizing Themes- task vs. care, dual relationships and supportive networks--reflective of the unique nature of the rural environment. Nurses in rural Australia are multi-skilled generalists and they provide care to patients with cancer without necessarily having specialist knowledge or skill. The fatigue and emotional exhaustion that the nurses described often has a major impact on their own well-being.

CONCLUSION

In the rural context, it is proposed that clinical supervision may be an important strategy to support clinicians who face emotional exhaustion as part of their cancer nursing role.

Insurance and quality of life in men with prostate cancer: data from the Cancer of the Prostate Strategic Urological Research Endeavor

OBJECTIVE

To evaluate the effect of medical insurance coverage on health-related quality of life (HRQoL) outcomes in men newly diagnosed with prostate cancer, as insurance status has been shown to be related to clinical presentation, and types of treatments received for localized prostate cancer, but the relationship of insurance and QoL has not been explored sufficiently.

PATIENTS AND METHODS

Data from the Cancer of the Prostate Strategic Urological Research Endeavor (CaPSURE), a national longitudinal database registry of men with prostate cancer, were used for this study. Men who were newly diagnosed at entry to CaPSURE and completed one questionnaire before treatment, and one or more afterwards, were included. Insurance groups specific to age distribution of the study population were assessed, i.e. Medicare, preferred provider organizations (PPOs), health maintenance organizations (HMOs), fee for service (FFS), and the Veterans Administration (VA) for the younger group, and Medicare only, Medicare plus supplement (+S), and HMO/PPO for the older group. Associations between patients' clinical and sociodemographic characteristics and insurance status were evaluated by chi-square and analysis of variance. Relationships between insurance status and HRQoL outcomes over time were evaluated by multivariate mixed model.

RESULTS

Of 2258 men who met the study criteria, 1259 were younger and 999 were older than 65 years. More than half of the younger patients belonged to an HMO or PPO (42.2% and 32.5%, respectively), with the remainder distributed between Medicare, FFS and VA. In the older group most men belonged to Medicare only and the Medicare +S groups (22.4% and 58.8%, respectively). There was greater variation in clinical risk categories at presentation by insurance groups in the younger group. In the multivariate analysis, insurance status was significantly associated with changes in most HRQoL outcomes over time in the younger group, while in the older patients the effect of insurance diminished. Men in the VA and Medicare systems had lower scores at baseline and a steeper decline in Physical Function, Role Physical, Role Emotional, Social Function, Bodily Pain, Vitality, and General Health domains over time, controlling for type of initial treatment received, timing of HRQoL assessment, number of comorbidities, clinical risk at presentation, and income.

CONCLUSION

Insurance was independently related to changes in a wide range of HRQoL outcomes in men aged <65 years treated for prostate cancer. With the latest advances in early diagnosis and treatment of prostate cancer, clinicians and researchers should be aware of the specific groups of patients who are more vulnerable to the adverse effects of treatment and subsequent decline in functioning. The present findings could provide important tools for understanding the process of recovery after treatment for prostate cancer, and identifying needs for specific services.

Area disadvantage, individual socio-economic position, and premature cancer mortality in Australia 1998 to 2000: a multilevel analysis

OBJECTIVE

To examine associations between area and individual socio-economic characteristics and premature cancer mortality using multilevel analysis.

METHODS

We modeled cancer mortality among 25-64-year-old men and women (n = 16,340) between 1998 and 2000 in Australia. Socio-economic characteristics of Statistical Local Areas (n = 1,317) were measured using an Index of Relative Socio-economic Disadvantage (quintiles), and individual socio-economic position was measured by occupation (professionals, white and blue collar).

RESULTS

After adjustment for within-area variation in age and occupation, the probability of premature cancer mortality was highest in the most disadvantaged areas for all-cancer mortality for men (RR 1.48 95% CI 1.35-1.63) and women (RR 1.30 95% CI 1.18-1.43) and for lung cancer mortality for men (1.91 95% CI 1.63-2.25) and women (1.51 95% CI 1.04-2.18). Men in blue collar occupations had a higher rate of cancer mortality (RR 1.57 95% CI 1.50-1.65) and lung cancer mortality (RR 2.31 95 % CI 2.09-2.56), whereas men in white collar occupations had a lower all-cancer mortality rate (RR 0.78 95% CI 0.72-0.85). Compared with professionals, women in white collar occupations had an all-cancer mortality rate that was lower (RR 0.85 95% CI 0.80-0.90). When deaths from breast cancer were excluded, women in blue collar occupations had a significantly higher all-cancer mortality rate than professionals (RR 1.12 95% CI 1.02-1.22).

CONCLUSIONS

Area disadvantage and individual socio-economic position were independently associated with premature cancer mortality, suggesting that interventions to reduce inequalities should focus on places and people.

Prostate cancer outcomes among older men: insurance status comparisons results from CaPSURE database

With growing number of older adults in the United States and complexity of issues related to Medicare and other insurances more research is needed to evaluate an effectiveness of the different insurance types in prevention, screening and treatment of cancer. With prostate cancer being highly prevalent disease in older men, the importance of appropriate treatment and favorable outcomes is imperative. In this study we examine whether prostate cancer outcomes, such as risk category at diagnosis, treatment and survival differ in relationship to insurance status in older patients in CaPSURE. Data were abstracted from CaPSURE, a longitudinal observational database of 13 124 men with prostate cancer. Men were selected for the study if they were older than 65 years old at diagnosis, newly diagnosed between 1995 and 2005 at entry to CaPSURE with localized disease and received radical prostatectomy (RP), external beam radiation (EBRT), brachytherapy (BT), hormonal therapy or expectant management (EM). Insurance status was summarized by eight categories: Medicare only, Medicare+supplement, Medicare+HMO, Medicare+PPO, Medicare+FFS, health maintenance organization (HMO), preferred provider organization (PPO) and Veteran's Administration (VA). A total of 2983 men met the inclusion criteria. Odds ratios (OR) for the likelihood of receiving each type of therapy compared to RP by insurance status and likelihood of presenting with high-risk classification at diagnosis were derived using multinomial logistic regression, adjusting for clinical and demographic characteristics. Difference in survival between insurance groups was evaluated by Cox's multivariate regression. Multivariate analysis demonstrated a strong association between initial treatment and insurance status. Compared to Medicare patients, men in the CaPSURE database treated at HMO, PPO and VA systems were more likely to receive BT than RP (OR, 1.71-1.92) and less likely to receive this treatment if they were in Medicare+FFS and Medicare+PPO (OR, 0.18-0.38). Hormonal treatment demonstrated similar pattern, however OR did not reached statistical significance for HMO and PPO. Use of EM was much more predominant for patients in VA system (OR, 4.74; 95% CI, 1.94-11.55). Use of EBRT was significantly associated with type of insurance. Men with VA, Medicare+FFS and Medicare+PPO insurance were less likely to receive this treatment compared to RP. Survival and clinical risk at diagnosis was associated with insurance status in univariate analysis but this association diminished after adjusting for possible covariates. This study provides important information on relationship between insurance status and several outcomes in patients with prostate cancer. Even after controlling for important clinical and sociodemographic factors we found marked differences in prostate cancer treatment according to type of insurance. Future explorations of associations between health care delivery system, cancer care and outcomes are needed.

Surgery of non-small cell lung cancer in the elderly

PURPOSE OF REVIEW

The aim of this review is to analyze recent evidence for optimal treatment of elderly patients with non-small cell lung cancer, focusing on surgery, and possibly to foresee the future strategies to apply in these patients.

RECENT FINDINGS

Surgery in elderly patients affected by non-small cell lung cancer is safe and feasible when careful preoperative respiratory and cardiac studies have been carried out and the disease has been properly staged. The surgical treatment is not to be denied in elderly patients due to age per se, but when a major contraindication to surgery has been recognized. Long term survival for elderly patients with early stage lung cancer treated by anatomical pulmonary resection is comparable to the survival rate of younger patients. Pneumonectomy, extended surgical procedure or preoperative induction chemotherapy are major risk factors for an increased postoperative morbidity and mortality rate. When co-morbidities are present or a patient is 80 years or older, there is evidence that a non-anatomical resection can be performed without affecting long-term results.

SUMMARY

Due to the aging of the general population, elderly patients will become a large percentage of the cases of non-small cell lung cancer to be treated. Implementing preoperative cardiologic studies and redefining selective respiratory criteria specifically could dramatically improve results.

Methods for dealing with discrepant records in linked population health datasets: a cross-sectional study

BACKGROUND

Linked population health data are increasingly used in epidemiological studies. If data items are reported on more than one dataset, data linkage can reduce the under-ascertainment associated with many population health datasets. However, this raises the possibility of discrepant case reports from different datasets.

METHODS

We examined the effect of four methods of classifying discrepant reports from different population health datasets on the estimated prevalence of hypertensive disorders of pregnancy and on the adjusted odds ratios (aOR) for known risk factors. Data were obtained from linked, validated, birth and hospital data for women who gave birth in a New South Wales hospital (Australia) 2000-2002.

RESULTS

Among 250,173 women with linked data, 238,412 (95.3%) women had perfect agreement on the occurrence of hypertension, 1577 (0.6%) had imperfect agreement; 9369 (3.7%) had hypertension reported in only one dataset (under-reporting) and 815 (0.3%) had conflicting types of hypertension. Using only perfect agreement between birth and discharge data resulted in the lowest prevalence rates (0.3% chronic, 5.1% pregnancy hypertension), while including all reports resulted in the highest prevalence rates (1.1 % chronic, 8.7% pregnancy hypertension). The higher prevalence rates were generally consistent with international reports. In contrast, perfect agreement gave the highest aOR (95% confidence interval) for known risk factors: risk of chronic hypertension for maternal age > or =40 years was 4.0 (2.9, 5.3) and the risk of pregnancy hypertension for multiple birth was 2.8 (2.5, 3.2).

CONCLUSION

The method chosen for classifying discrepant case reports should vary depending on the study question; all reports should be used as part of calculating the range of prevalence estimates, but perfect matches may be best suited to risk factor analyses. These findings are likely to be applicable to the linkage of any specialised health services datasets to population data that include information on diagnoses or procedures.

The effects of socioeconomic status, accessibility to services and patient type on hospital use in Western Australia: a retrospective cohort study of patients with homogenous health status

Background

This study aimed to investigate groups of patients with a relatively homogenous health status to evaluate the degree to which use of the Australian hospital system is affected by socio-economic status, locational accessibility to services and patient payment classification.

Method

Records of all deaths occurring in Western Australia from 1997 to 2000 inclusive were extracted from the WA mortality register and linked to records from the hospital morbidity data system (HMDS) via the WA Data Linkage System. Adjusted incidence rate ratios of hospitalisation in the last, second and third years prior to death were modelled separately for five underlying causes of death.

Results

The independent effects of socioeconomic status on hospital utilisation differed markedly across cause of death. Locational accessibility was generally not an independent predictor of utilisation except in those dying from ischaemic heart disease and lung cancer. Private patient status did not globally affect utilisation across all causes of death, but was associated with significantly decreased utilisation three years prior to death for those who died of colorectal, lung or breast cancer, and increased utilisation in the last year of life in those who died of colorectal cancer or cerebrovascular disease.

Conclusion

It appears that the Australian hospital system may not be equitable since equal need did not equate to equal utilisation. Further it would appear that horizontal equity, as measured by equal utilisation for equal need, varies by disease. This implies that a 'one-size-fits-all' approach to further improvements in equity may be over simplistic. Thus initiatives beyond Medicare should be devised and evaluated in relation to specific areas of service provision.

Health related migration: evidence of reduced “urban-drift”

The aim of this study was to determine if the onset of serious disease triggers a different intra-state migratory response from patterns observed in the healthy population. The analysis was carried out using linked administrative data. The onset of serious disease triggered a reduction in the rate of endocentric migration in remote and rural populations. Urban drift occurred only in people with mental illness in rural locations. Rural and remote communities appear to suffer from an unhealthy selection force, with persons unable to migrate centrally to access services due to the onset of the physical illness they require treatment for.

Unlimited Access to Care: Effect on Racial Disparity and Prognostic Factors in Lung Cancer

STUDY OBJECTIVE

Evaluate the prognostic factors influencing lung cancer survival under a universal health care system and determine if access to care eliminates clinical outcome disparity.

DESIGN

Retrospective case series review.

BACKGROUND

Lung cancer survival is worse in men and in African Americans, thought to be related to poor general health in men and limited access to heath care in African Americans. The Military Health Care System, with unlimited access to care, provides an excellent setting for evaluating gender and racial disparities in lung cancer survival.

METHODS

Lung cancers diagnosed at Walter Reed Army Medical Center, from 1990 to 2000, were evaluated by chart review for age, gender, race, smoking history, cancer history, histology, stage, and completeness of resection.

RESULTS

Seven hundred thirteen Caucasians and 173 African Americans, 2:1 male predominance, had a 22% 5-year survival. Cox model analysis showed that male gender [hazard ratio (HR, 1.31) 95% confidence interval (95% CI), 1.02-1.68], advanced-stage disease (stage III: HR, 2.58; 95% CI, 1.57-4.26/stage IV: HR, 4.20; 95% CI, 2.51-7.41), and incomplete resection (HR, 4.06; 95% CI, 2.75-5.99) were predictors of poor outcome; whereas bronchoalveolar carcinoma features (HR, 0.35; 95% CI, 0.23-0.52) and smoking cessation >7 years (HR, 0.70; 95% CI, 0.49-0.99) were predictors of favorable outcome. No ethnic differences in survival were observed.

CONCLUSIONS

No racial disparities in survival when access to medical care is universal. Male gender, incomplete resection, and advanced stage are significant predictors of poor outcome in lung cancer.

Improving the evidence base for promoting quality and equity of surgical care using population-based linkage of administrative health records

This paper highlights the uses of population-based linkage of administrative health records to improve the quality, safety, and equity of surgical care. The primary focus of the paper is on the transfer of this type of research into policy and practice. In the modern era of evidence-based medicine, it is essential that not only is new evidence incorporated into clinical practice, but that the implementation and associated costs are monitored; this requires the setting of appropriate benchmarking criteria. Furthermore, it is imperative that all members of the population receive optimal health care and people are not discriminated against because of socio-economic, locational, or racial factors. The use of data linkage can assist with examining these aspects of health care and this paper provides real-life examples such as costs and adverse events from laparoscopic cholecystectomy, event monitoring for post-operative venous thrombosis, and inequalities in cancer care. The influence of these studies on clinical practice and policy is also discussed. Furthermore, this paper discusses the strengths and weaknesses of data linkage research and how to avoid pitfalls. Health researchers, clinicians, and policy-makers will find the discussion of these issues useful in their everyday practice.