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Canadian Journal of Public Health

, Volume 103, Issue 1, pp 46–52 | Cite as

Effect of Community Population Size on Breast Cancer Screening, Stage Distribution, Treatment Use and Outcomes

  • Robert A. OlsonEmail author
  • Alan Nichol
  • Nadine R. Caron
  • Ivo A. Olivotto
  • Caroline Speers
  • Stephen Chia
  • Ashley Davidson
  • Andy Coldman
  • Chris Bajdik
  • Scott Tyldesley
Quantitative Research
  • 1 Downloads

Abstract

Objective

Residents of rural communities have decreased access to cancer screening and treatments compared to urban residents, though use of resources and patient outcomes have not been assessed with a comprehensive population-based analysis. The objectives of this study were to investigate whether breast cancer screening and treatments were utilized less frequently in rural BC and whether this translated into differences in outcomes.

Methods

All patients diagnosed with breast cancer in British Columbia (BC) during 2002 were identified from the Cancer Registry and linked to the Screening Mammography database. Patient demographics, pathology, stage, treatments, mammography use and death data were abstracted. Patients were categorized as residing in large, small and rural local health authorities (LHAs) using Canadian census information. Use of resources and outcomes were compared across these LHA size categories. We hypothesized that mastectomy rates (instead of breast-conserving surgery) would be higher in rural areas, since breast conservation is standardly accompanied by adjuvant radiotherapy, which has limited availability in rural BC. In contrast we hypothesized that cancer screening and systemic therapy use would be similar, as they are more widely dispersed across BC. Exploratory analyses were performed to assess whether disparities in screening and treatment utilization translated into differences in survival.

Results

2,869 breast cancer patients were included in our study. Patients from rural communities presented with more advanced disease (p=0.01). On multivariable analysis, patients from rural, compared to urban, LHAs were less likely to be screening mammography attendees (OR=0.62; p<0.001). Women from rural communities were less likely to undergo breast-conserving surgery (multivariable OR=0.47; p<0.001). There was no significant difference in use of chemotherapy (p=0.54) or hormonal therapy (p=0.36). The 5-year breast cancer-specific survival for large, small and rural LHAs was 90%, 88% and 86%, respectively (p=0.08), while overall survival was 84%, 81% and 77%, respectively (p=0.01). On multivariable analysis with 7.4 years of median follow-up, neither breast cancer-specific survival (HR=1.16; 0.76–1.76; p=0.49) nor overall survival (HR=1.25; 0.92-1.70; p=0.16) was significantly worse for patients from rural compared to large LHAs.

Conclusion

There was a significant difference in screening mammography use, stage distribution and loco-regional treatments use by population size of LHA. After controlling for differences in patient and tumour factors by LHA, survival was not significantly different.

Keywords

Breast cancer mammography breast conserving surgery mastectomy rural hormonal therapy chemotherapy 

Résumé

Objectifs

Comparativement aux résidents des zones urbaines, les résidents des communautés rurales ont moins accès au dépistage et aux traitements du cancer, mais l’on n’a pas encore évalué l’utilisation des ressources par les patients, ni les résultats sanitaires de ces patients, à l’aide d’analyses populationnelles globales. Notre étude visait à déterminer si le dépistage et les traitements du cancer du sein étaient utilisés moins souvent dans les régions rurales de la Colombie-Britannique (C.-B.), et si cela se traduisait par des résultats différents.

Méthode

Nous avons répertorié toutes les personnes ayant reçu un diagnostic de cancer du sein en C.-B. en 2002 en consultant le Registre du cancer, et nous avons lié ces données à celles de la base de données des mammographies de dépistage. Nous en avons extrait les données démographiques, la pathologie, le stade, les traitements, le recours à la mammographie et les données de mortalité des patientes. À l’aide des données du Recensement du Canada, nous avons classé les patientes selon leur lieu de résidence (leur autorité sanitaire locale [ASL]: petite, grande ou rurale), puis comparé l’utilisation des ressources et les résultats sanitaires pour chaque catégorie d’ASL. Nous avons supposé que les taux de mastectomie (par opposition à la chirurgie mammaire conservatrice) seraient supérieurs dans les régions rurales, la conservation du sein étant normalement accompagnée par la radiothérapie adjuvante, laquelle est peu disponible dans les zones rurales de la province. Par contre, nous avons supposé que les taux d’utilisation du dépistage du cancer et des traitements systémiques seraient semblables, car ces services sont disponibles dans toute la province. Nous avons effectué des analyses exploratoires pour déterminer si les disparités dans l’utilisation du dépistage et des traitements se traduisaient par des écarts dans la survie.

Résultats

Notre étude a porté sur 2 869 femmes atteintes de cancer du sein. Les patientes des communautés rurales se sont présentées avec des cancers à un stade plus avancé (p=0,01). Après analyse multivariée, les patientes provenant des ASL rurales, et non urbaines, étaient moins susceptibles d’avoir subi une mammographie de dépistage (RC=0,62; p<0,001). Les femmes des communautés rurales étaient moins susceptibles d’avoir subi une chirurgie mammaire conservatrice (RC multivarié=0,47; p<0,001). Il n’y avait aucun écart significatif dans l’utilisation de la chimiothérapie (p=0,54) ou de l’hormonothérapie (p=0,36). Les taux de survie propres au cancer du sein après cinq ans étaient de 90% dans les grandes ASL, de 88% dans les petites ASL et de 86% dans les ASL rurales (p=0,08), tandis que les taux de survie globaux étaient de 84%, 81% et 77%, respectivement (p=0,01). Après analyse multivariée avec une médiane de 7,4 années de suivi, ni la survie propre au cancer du sein (coefficient de danger [CD]=1,16; 0,76–1,76; p=0,49), ni la survie globale (CD=1,25; 0,92–1,70; p=0,16) n’étaient significativement inférieures chez les patientes des ASL rurales comparativement à celles des grandes ASL.

Conclusion

On observe des écarts significatifs dans le recours aux mammographies de dépistage, la distribution selon le stade de cancer et l’utilisation locale-régionale des traitements en fonction de la taille de la population de l’ASL. Compte tenu des écarts par ASL dans les facteurs liés aux patientes et aux tumeurs, la survie n’était pas significativement différente.

Mots clés

cancer du sein mammographie chirurgie mammaire conservatrice mastectomie rural hormonothérapie chimiothérapie 

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References

  1. 1.
    Olivotto IA, Mates D, Kan L, Fung J, Samant R, Burhenne LJ. Prognosis, treat-ment, and recurrence of breast cancer for women attending or not attending the screening mammography program of British Columbia. Breast Cancer Res Treat 1999;54(1):73–81.PubMedCrossRefGoogle Scholar
  2. 2.
    Maxwell CJ, Bancej CM, Snider J. Predictors of mammography use among Canadian women aged 50–69: Findings from the 1996/97 National Population Health Survey. CMAJ 2001;164(3):329–34.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Shields M, Wilkins K. An update on mammography use in Canada. Health Rep 2009;20(3):7–19.PubMedGoogle Scholar
  4. 4.
    Samet JM, Hunt WC, Farrow DC. Determinants of receiving breast-conserving surgery: The surveillance, epidemiology, and end results program, 1983–1986. Cancer 1994;73(9):2344–51.PubMedCrossRefGoogle Scholar
  5. 5.
    Nattinger AB, Gottlieb MS, Veum J, Yahnke D, Goodwin JS. Geographic vari-ation in the use of breast-conserving treatment for breast cancer. N Engl J Med 1992;326(17):1102–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Hall SE, Holman CDJ, Hendrie DV, Spilsbury K. Unequal access to breast-conserving surgery in Western Australia 1982–2000. ANZ J Surg 2004;74(6):413–19.PubMedCrossRefGoogle Scholar
  7. 7.
    Barton M. Radiotherapy utilization in New South Wales from 1996 to 1998. Australas Radiol 2000;44(3):308–14.PubMedCrossRefGoogle Scholar
  8. 8.
    Iscoe NA, Goel V, Wu K, Fehringer G, Holowaty EJ, Naylor CD. Variation in breast cancer surgery in Ontario. CMAJ 1994;150(3):345–52.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Mackillop WJ, Groome PA, Zhang-Solomons J, Zhou Y, Feldman-Stewart D, Paszat L, et al. Does a centralized radiotherapy system provide adequate access to care? J Clin Oncol 1997;15(3):1261–71.PubMedCrossRefGoogle Scholar
  10. 10.
    Tyldesley S, McGahan C. Utilisation of radiotherapy in rural and urban areas in British Columbia compared with evidence-based estimates of radiotherapy needs for patients with breast, prostate and lung cancer. Clin Oncol 2010;22(7):526–32.CrossRefGoogle Scholar
  11. 11.
    Goel V, Olivotto I, Hislop TG, Sawka C, Coldman A, Holowaty EJ. Patterns of initial management of node-negative breast cancer in two Canadian provinces. British Columbia/Ontario Working Group. CMAJ 1997;156(1):25–35.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Schroen AT, Brenin DR, Kelly MD, Knaus WA, Slingluff CL, Jr. Impact of patient distance to radiation therapy on mastectomy use in early-stage breast cancer patients. J Clin Oncol 2005;23(28):7074–80.PubMedCrossRefGoogle Scholar
  13. 13.
    Postal code conversion file (PCCF): Product main page [homepage on the Internet]. Available at: https://doi.org/www.statcan.gc.ca/bsolc/olc-cel/olc-cel?catno=92F0153GIE&lang=eng (Accessed May 18, 2011).
  14. 14.
    British Columbia Automobile Association website [homepage on the Internet]. Available at: https://doi.org/www.bcaa.com (Accessed May 18, 2011).
  15. 15.
    Black PE. Manhattan distance. In: Black PE (Ed.), Dictionary of Algorithms and Data Structures [online]. US National Institute of Standards and Technology, 2006. Available at: https://doi.org/www.nist.gov/dads/HTML/manhattanDistance.html (Accessed May 18, 2011).Google Scholar
  16. 16.
    Jacobs LK, Kelley KA, Rosson GD, Detrani ME, Chang DC. Disparities in urban and rural mastectomy populations: The effects of patient- and county-level factors on likelihood of receipt of mastectomy. Ann Surg Oncol 2008;15(10):2644–52.PubMedCrossRefGoogle Scholar
  17. 17.
    Nystrom L, Andersson I, Bjurstam N, Frisell J, Nordenskjold B, Rutqvist LE. Long-term effects of mammography screening: Updated overview of the Swedish randomised trials. Lancet 2002;359(9310):909–19.PubMedCrossRefGoogle Scholar
  18. 18.
    Kalager M, Zelen M, Langmark F, Adami H. Effect of screening mammography on breast-cancer mortality in Norway. N Engl J Med 2010;363(13):1203–10.PubMedCrossRefGoogle Scholar
  19. 19.
    Swedish Organised Service Screening Evaluation Group. Effect of mammo-graphic service screening on stage at presentation of breast cancers in Sweden. Cancer 2007;109(11):2205–12.CrossRefGoogle Scholar
  20. 20.
    Sheppard AJ, Chiarelli AM, Marrett LD, Mirea L, Nishri ED, Trudeau ME, et al. Detection of later stage breast cancer in First Nations women in Ontario, Canada. Can J Public Health 2010;101(1):101–5.PubMedGoogle Scholar
  21. 21.
    Gilchrist KW, Gould VE, Hirschl S, Imbriglia JE, Patchefsky AS, Penner DW, et al. Interobserver variation in the identification of breast carcinoma in intra-mammary lymphatics. Hum Pathol 1982;13(2):170–72.PubMedCrossRefGoogle Scholar
  22. 22.
    Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002;347(16):1227–32.PubMedCrossRefGoogle Scholar
  23. 23.
    Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002;347(16):1233–41.PubMedCrossRefGoogle Scholar
  24. 24.
    Poggi MM, Danforth DN, Sciuto LC, Smith SL, Steinberg SM, Liewehr DJ, et al. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: The National Cancer Institute Randomized Trial. Cancer 2003;98(4):697–702.PubMedCrossRefGoogle Scholar
  25. 25.
    Blichert-Toft M, Nielsen M, Düring M, Møller S, Rank F, Overgaard M, et al. Long-term results of breast conserving surgery vs. mastectomy for early stage invasive breast cancer: 20-year follow-up of the Danish randomized DBCG-82TM protocol. Acta Oncol 2008;47(4):672–81.PubMedCrossRefGoogle Scholar
  26. 26.
    Clarke M, Collins R, Darby S, Davies C, Elphinstone P, Evans E, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: An overview of the randomised trials. Lancet 2005;366(9503):2087–106.PubMedCrossRefGoogle Scholar
  27. 27.
    Hawley ST, Griggs JJ, Hamilton AS, Graff JJ, Janz NK, Morrow M, et al. Deci-sion involvement and receipt of mastectomy among racially and ethnically diverse breast cancer patients. J Natl Cancer Inst 2009;101(19):1337–47.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Polacek GN, Ramos MC, Ferrer RL. Breast cancer disparities and decision-making among U.S. women. Patient Educ Couns 2007;65(2):158–65.PubMedCrossRefGoogle Scholar
  29. 29.
    Whelan T, Levine M, Gafni A, Sanders K, Willan A, Mirsky D, et al. Mastec-tomy or lumpectomy? Helping women make informed choices. J Clin Oncol 1999;17(6):1727–35.PubMedCrossRefGoogle Scholar
  30. 30.
    Hokanson P, Seshadri R, Miller KD. Underutilization of breast-conserving ther-apy in a predominantly rural population: Need for improved surgeon and public education. Clin Breast Cancer 2000;1(1):72–76.PubMedCrossRefGoogle Scholar
  31. 31.
    Morrow M, Jagsi R, Alderman AK, Griggs JJ, Hawley ST, Hamilton AS, et al. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. JAMA 2009;302(14):1551–56.PubMedPubMedCentralCrossRefGoogle Scholar
  32. 32.
    Sawka C, Olivotto I, Coldman A, Goel V, Holowaty E, Hislop TG. The associ-ation between population-based treatment guidelines and adjuvant therapy for node-negative breast cancer. British Columbia/Ontario Working Group. Br J Cancer 1997;75(10):1534–42.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© The Canadian Public Health Association 2012

Authors and Affiliations

  • Robert A. Olson
    • 1
    • 2
    • 3
    • 4
    • 8
    Email author
  • Alan Nichol
    • 2
    • 3
  • Nadine R. Caron
    • 3
    • 4
    • 5
    • 6
  • Ivo A. Olivotto
    • 2
    • 3
  • Caroline Speers
    • 2
  • Stephen Chia
    • 2
    • 3
  • Ashley Davidson
    • 3
    • 7
  • Andy Coldman
    • 2
    • 3
  • Chris Bajdik
    • 2
    • 3
  • Scott Tyldesley
    • 2
    • 3
  1. 1.BC Cancer AgencyCentre for the NorthPrince GeorgeCanada
  2. 2.BC Cancer AgencyVancouver CentreVancouverCanada
  3. 3.University of British ColumbiaVancouverCanada
  4. 4.University of Northern British ColumbiaPrince GeorgeCanada
  5. 5.University Hospital of Northern British ColumbiaPrince GeorgeCanada
  6. 6.Johns Hopkins Bloomberg School of Public HealthBaltimoreCanada
  7. 7.BC Cancer AgencyFraser Valley CentreSurreyCanada
  8. 8.VancouverCanada

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