Primary and secondary care management of women with early breast cancer from affluent and deprived areas: retrospective review of hospital and general practice records

Analysis

We analysed the data using SPSS software. Associations between treatment options and whether women lived in affluent or deprived areas were examined by χ²tests. The relations of time to treatment and consultation frequency to deprivation were analysed by Mann-Whitney tests.

Access to care

Time between the date of the general practice consultationand the date on the referral letter did not differ between women living in affluent and deprived areas (affluent: median 1 day, interquartile range 0 to 2.7; deprived: median 0 day, 0 to 4; Z=−0.34, P=0.74). Only four women received private care. The time between the date of the referral letter and the first clinic visit was one day shorter in women from affluent areas (table 2). There was, however, no significant difference between the groups in the time from clinic visit to surgery or in number of days spent in hospital at the time of original surgery.

Treatment

There were no differences in the type of breast surgery between women living in affluent and deprived areas (table 3). However, more women living in deprived areas had axillary sampling rather than axillary clearance. No significant differences were detected between women living in affluent and deprived areas with respect to radiotherapy, chemotherapy, or endocrine therapy (table 3).

Follow up

The number of hospital clinic visits was not significantly different between women living in affluent and deprived areas (mean (SD) number of visits 7.63 (2.76) for women from affluent areas and 7.98 (3.14) for women from deprived areas, t=1.10, P=0.27) in the first two years after diagnosis. The proportion of women requiring extra clinic appointments before the scheduled appointments did not differ between the groups. Although the numbers are small, significantly more patients from deprived areas failed to attend appointments (6 (4%) v25 (12%), χ²=5.65, P=0.017).

Most women had consulted their general practitioner in the year before diagnosis, but there was no difference between those living in affluent and deprived areas (92 (86%) v 141 (88%), χ²=0.26, P=0.61). In the 12 months after diagnosis, all women consulted more often than before diagnosis, but women living in deprived areas consulted more frequently than women living in affluent areas (table 4). The frequency of consultations in the second year after diagnosis was still greater than before diagnosis, with women in deprived areas continuing to consult more often than women in affluent areas. This difference was particularly striking in women who consulted more than once a month. During the first year after diagnosis, 31 (29%) women living in affluent areas consulted their general practitioner more than once a month, compared with 67 (41%) women living in deprived areas (χ²=4.49, df=1, P=0.034). In the second year after diagnosis, 17 (16%) women living in affluent areas were continuing to consult more frequently than once a month compared with 41 (27%) women living in deprived areas (χ²=4.44, df=1, P=0.035).

In the first two years after the end of initial treatment, there was no difference in hospital admissions for problems related to breast cancer between women from affluent and deprived areas (number admitted once or more: 13 (10%) v34 (16%), χ²=2.62, df=1, P=0.106). However, women from affluent areas were less likely to be admitted than women from deprived areas (13 (10%) v51 (24%), χ²=11.1, df=1, P=0.001) for problems unrelated to breast cancer.

Access to care

The largest component of delay between noticing symptoms and attendance at hospital clinic has been suggested to be patient delay.14 Although we are unable to comment on any delay before consultation in primary care, there was no significant delay in referral after presentation to general practitioners. The significant difference in the number of days between referral and clinic visit probably occurred because the hospital where many of the patients from affluent areas were seen had two clinics for new patients each week, whereas the other four hospitals had one clinic a week. In any case, the difference was not clinically important and did not cause a delay in surgery.

The numbers of days spent in hospital at the time of surgery were also similar. A study in south east England found that more women from deprived areas are admitted as emergencies and that more women from affluent areas are admitted as day cases.15 Information on emergency admissions is not available from our study, but the women from affluent areas did not have a shorter stay than those from deprived areas. Our data do not support the suggestion by Pollock and Vickers that “primary care is failing patients from deprived areas.” 15

Treatment

We found no difference in the hospital management of women living in affluent areas and deprived areas in terms of type of breast surgery performed or whether they received radiotherapy, chemotherapy, or endocrine therapy. These results suggest that socioeconomic status was not a factor in these decisions.

We did, however, find a difference between the two groups with respect to axillary surgery. Closer inspection of the data shows that although axillary clearance was the operation of choice throughout the city, in one hospital almost half of axillary procedures were described as sampling (clearance 31 (52%), sampling 29 (48%)). This hospital saw women only from deprived areas, thus confounding the results. Since this study the variation has been eliminated, with more than 90% of women with breast cancer having axillary clearance (H Burns, personal communication, 1999) in keeping with recommendations in several recent clinical guidelines.16^–18

Follow up

We found no differences between women living in affluent and deprived areas in terms of the total number of times seen at clinic. Although the numbers are small, more patients from deprived areas seemed to fail to attend appointments. This may relate to ease of access to hospital rather than lack of concern about follow up.

Analysis of the number of hospital admissions in the two years after diagnosis of breast cancer showed that admissions to hospital for conditions unconnected with breast cancer were more common in women living in deprived areas than among women from affluent areas. Consultations in primary care in the two years after diagnosis were greater for all women than before diagnosis, but were greatest for women living in deprived areas. Both the greater admission rate to hospital for conditions unrelated to breast cancer and the higher consultation rate in general practice may be an indication of greater comorbidity in women from deprived areas. This may explain the poorer survival figures that have been reported for all causes.19

Conclusion

The only differences in the management of women from affluent and deprived areas identified in this study could be explained by differences in hospital policy or were unlikely to have any significant impact on outcome. The NHS (in Glasgow, at least) seems to deliver health care equitably to women with breast cancer. The poorer survival of women from deprived areas with breast cancer may not be due to their breast cancer or its management but to other factors which result in deprived women (and also men) having a reduced life expectancy compared with affluent groups.19 In particular, the relation of comorbidity and deprivation requires further investigation.