Rural–urban differences in the presentation, management and survival of breast cancer in Western Australia

doi:10.1016/j.breast.2006.04.001

The Breast

Volume 15, Issue 6, December 2006, Pages 769-776

https://doi.org/10.1016/j.breast.2006.04.001 Get rights and content

Summary

From all women diagnosed with invasive breast cancer in 1999 in Western Australia, rural and urban women were compared with regard to mode of detection, tumour characteristics at presentation, diagnostic investigations, treatment and survival. Women from rural areas with breast cancer ( $n = 206$ , 23%) were less likely to have open biopsy with frozen section ( $P < 0.001$ ), breast-conserving surgery ( $P < 0.001$ ), adjuvant radiotherapy ( $P = 0.004$ ) and hormonal therapy ( $P = 0.03$ ), and were less likely to be treated by a high caseload breast cancer surgeon ( $P < 0.001$ ). Adjusting for age and tumour characteristics, rural women had an increased likelihood of death within 5 years of breast cancer diagnosis (HR 1.62, 95% CI 1.10–2.38). This difference was not significant after adjustment for treatment factors (HR 1.36, 95% CI 0.90–2.04).

Introduction

People living in rural areas have less access to health care and facilities, and incur higher costs, compared with their urban counterparts.¹ Recent studies have indicated that rural women diagnosed with breast cancer have a later stage of cancer at diagnosis,2, 3 undergo fewer diagnostic investigations,⁴ are less likely to have breast-conserving surgery5, 6 and radiotherapy,⁷ and are less likely to be treated by a high caseload surgeon⁸ than women living in urban areas. Research has shown mixed results regarding the likelihood of rural women undergoing mammographic screening compared with urban women.9, 10 Australian statistics show similar mortality rates for breast cancer in urban and rural areas.1, 11

Approximately 30% of Western Australia's (WA's) population lives in rural or remote areas. All breast cancer screening, diagnostic and treatment services are available in the capital city, Perth. Some of these services are also available in regional centres, and mobile mammography units provide screening in rural and remote areas.

This study used data from all women diagnosed with breast cancer in WA in 1999 to investigate whether differences exist between women living in urban and rural areas in the presentation, investigation, primary treatment and 5-year survival from breast cancer.

Section snippets

Methods

The methods for this study have been described previously12, 13 and are briefly summarised here.

Results

There were 1025 women diagnosed with invasive breast cancer in 1999 and notified to the WA Cancer Registry. Of these 899 (88%) were included in the analysis. Cases were excluded if the tumour was not an incident tumour but had recurred in 1999, if the tumour was secondary from somewhere other than the breast or if the tumour was not confirmed histologically. Some eligible women were not included because the woman's doctor refused to permit access to medical records following changes to the

Discussion

In this study, we found no significant differences in the characteristics of tumours at presentation between urban and rural women with breast cancer. This contradicts previous research, which has suggested that breast cancers in rural women are diagnosed at a later stage than those in women from urban areas.2, 3 Our finding may reflect the continuing development of mammographic services in WA in the intervening decade. But it also means that differences in the investigation and management of

Conclusions

Despite similarities in mode of presentation and tumour characteristics, women with breast cancer from rural WA experience a poorer survival outcome than their urban counterparts. This survival difference seems to be largely due to variations in treatment and surgeon caseload between rural and urban cases. From the data to hand, we cannot tell whether these disparities arise from inadequate information among rural patients and practitioners, the tyrannies of distance, or incomplete availability

References (21)

M. Siahpush et al.
Sociodemographic variations in breast cancer screening behaviour among Australian women: results from the 1995 National Health Survey
Prev Med
(2002)
D.M. Ingram et al.
Surgical caseload and outcomes for women with invasive breast cancer treated in Western Australia
Breast
(2005)
C. Davis et al.
Needs assessment of rural and remote women travelling to the city for breast cancer treatment
Aust N Z J Public Health
(1998)
K. Strong et al.
Health in rural and remote Australia
(1998)
D.J. Hill et al.
Changes in the investigation and management of primary operable breast cancer in Victoria
Med J Aust
(1994)
J.M. Liff et al.
Rural–urban differences in stage at diagnosis: possible relationship to cancer screening
Cancer
(1991)
A.J. Spillane et al.
Australia's breast conserving surgery workload is changing: comparison of a metropolitan and a rural hospital
Aust N Z J Surg
(1999)
P.S. Craft et al.
Surgical management of breast cancer in Australian women in 1993: analysis of Medicare statistics
Med J Aust
(1997)
S.E. Hall et al.
Unequal access to breast-conserving surgery in Western Australia 1982–2000
Aust N Z J Surg
(2004)
A.B. Nattinger et al.
Relationship of distance from a radiotherapy facility and initial breast cancer treatment
J Natl Cancer Inst
(2001)

There are more references available in the full text version of this article.

Cited by (72)

Impact of geography on Scottish cancer diagnoses in primary care: Results from a national cancer diagnosis audit
2020, Cancer Epidemiology
A recent meta-analysis of global research found cancer patients living in rural locations are 5% less likely to survive than their urban counterparts, a survival disadvantage that has never been satisfactorily explained.
[1] To describe and compare primary-care involvement in the diagnosis of cancer between rural and urban patients in Scotland. [2] To compare the length of key diagnostic pathway intervals between rural and urban cancer patients in Scotland.
Participating GPs in the Scottish National Cancer Audit of cancer diagnosis (2017) collected data from primary-care medical records on the diagnostic pathway of patients diagnosed in 2014. Residential postcodes designated the patients as rural or urban dwellers. Key cancer diagnostic pathway intervals (primary, diagnostic, secondary, and treatment) were compared using binary logistic regression. Descriptive analysis included comparison of patient characteristics, and routes to diagnosis.
73 Scottish general practices provided data on 1,905 cancer diagnoses. Rural patients did not have higher odds of prolonged diagnostic intervals compared to urban patients but were significantly more likely to have had a cancer alarm feature at presentation and three or more primary-care consultations prior to referral. Rural GPs were significantly more likely to perceive an avoidable delay in their patient’s diagnostic pathway.
There was no evidence that rural patients were more likely to be subject to prolonged cancer diagnostic delays than urban patients. Rural patients may experience primary care differently in the lead-up to a cancer diagnosis. The effect on outcome is probably negligible, but further research is required to confirm this.
Adherence to Needed Adjuvant Therapy Could Decrease Recurrence Rates for Rural Patients With Early Breast Cancer
2016, Clinical Breast Cancer
The purpose of this study was to evaluate the differences in stage upon diagnosis, adherence to adjuvant treatment, and recurrence between rural and urban patients with early breast cancer.
This retrospective study included 3640 patients with primary breast cancer recruited from 2000 to 2009. Patients who developed recurrence or metastasis were verified by adequate diagnostic imaging modalities and pathology. The χ² test was used to compare groups with respect to variables (recurrence and clinicopathologic features). A multivariable Cox proportional hazard regression model was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for breast cancer recurrence risk.
Compared with tumors in urban patients, those in rural patients showed higher histologic grade, larger size, more lymphatic metastasis, and higher Ki-67 index; therapy adherence was strongly associated with recurrence in both. Compared with urban patients, the female rural patients had a higher recurrence rate. However, no significant difference in recurrence rates was observed between urban and rural patients following guideline adherence.
The results of our study suggest that the later stage upon diagnosis and nonadherence to treatment contribute toward worse breast cancer outcomes among rural patients with breast cancer. Adherence to needed adjuvant therapy could decrease recurrence rates for rural patients with early breast cancer.
Examining Determinants of Radiotherapy Access: Do Cost and Radiotherapy Inconvenience Affect Uptake of Breast-conserving Treatment for Early Breast Cancer?
2015, Clinical Oncology
Radiotherapy utilisation is likely affected by multiple factors pertaining to radiotherapy access. Radiotherapy is an integral component of breast-conserving treatment (BCT) for early breast cancer. We aimed to determine if stepwise improvements in radiotherapy access in regional Australia affected the uptake of BCT and thus radiotherapy.
Breast cancer operations in the Central Coast of New South Wales between January 2010 and March 2014 for T1-2N0-1M0 invasive or in situ (≤5 cm) disease in female patients eligible for BCT were examined. BCT uptake was calculated for three 1 year periods: period 1 (local radiotherapy available at cost to user or out of area radiotherapy with travel cost and inconvenience); period 2 (as per period 1 + publicly funded transport and radiotherapy at out of area facilities at no cost to user); period 3 (as per period 1 + publicly funded local radiotherapy at no cost to user).
In total, 574 cases met eligibility criteria. BCT declined with increasing distance to publicly funded radiotherapy (P = 0.035). BCT rates for periods 1, 2 and 3 were 63% (113/180), 61% (105/173) and 71% (156/221). There were no statistically significant differences in BCT between periods 1 and 2 in the whole cohort or within age, histology or tumour size subgroups. Overall, there was a 9% increase in BCT in the whole cohort in period 3 compared with periods 1 and 2 (P = 0.031). This increase was statistically significant for women over 70 years (19% increase, P = 0.034), for women with ductal carcinoma in situ (25% increase, P = 0.013) and for women with primary tumours that were ≤10 mm (21% increase, P = 0.016).
Improving the affordability of radiotherapy through publicly funded transport and radiotherapy at out of area facilities did not improve BCT uptake in a region where radiotherapy was locally available, albeit at cost to the user. Improving both affordability and convenience through the provision of local publicly funded radiotherapy increased BCT uptake. Service availability and affordability have long been recognised as important determinants of radiotherapy access. Our findings suggest that inconvenience may also influence radiotherapy utilisation.
The contribution of prognostic factors to socio-demographic inequalities in breast cancer survival in Victoria, Australia
2023, Cancer Medicine
Evaluating the quality and safety of the BreastScreen remote radiology assessment model of service delivery in Australia
2023, Journal of Telemedicine and Telecare
Trends in surgery and adjuvant treatment for early-stage breast cancer: a population-based study in Queensland, Australia
2022, Breast Cancer Research and Treatment

View all citing articles on Scopus

View full text

ORIGINAL ARTICLERural–urban differences in the presentation, management and survival of breast cancer in Western Australia

Summary

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Prev Med

Breast

Aust N Z J Public Health

Health in rural and remote Australia

Changes in the investigation and management of primary operable breast cancer in Victoria

Med J Aust

Rural–urban differences in stage at diagnosis: possible relationship to cancer screening

Cancer

Australia's breast conserving surgery workload is changing: comparison of a metropolitan and a rural hospital

Aust N Z J Surg

Surgical management of breast cancer in Australian women in 1993: analysis of Medicare statistics

Med J Aust

Unequal access to breast-conserving surgery in Western Australia 1982–2000

Aust N Z J Surg

Relationship of distance from a radiotherapy facility and initial breast cancer treatment

J Natl Cancer Inst

ORIGINAL ARTICLE
Rural–urban differences in the presentation, management and survival of breast cancer in Western Australia