BC Cancer Agency, Centre for the North, Prince George, BC.
Can J Public Health. 2012 Jan-Feb;103(1):46-52. doi: 10.1007/BF03404068.
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.
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.
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.
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.
与城市居民相比，农村社区的居民获得癌症筛查和治疗的机会减少，尽管尚未通过全面的基于人群的分析来评估资源利用和患者结局。本研究的目的是调查在不列颠哥伦比亚省（BC），农村地区的乳腺癌筛查和治疗是否利用不足，以及这是否导致结局存在差异。
从癌症登记处和筛查乳房 X 线照片数据库中确定了 2002 年在不列颠哥伦比亚省诊断患有乳腺癌的所有患者。提取患者的人口统计学、病理学、分期、治疗、乳房 X 线照片使用和死亡数据。使用加拿大人口普查信息将患者分为居住在大型、小型和农村地方卫生当局（LHA）的患者。比较这些 LHA 规模类别之间的资源利用和结局。我们假设，由于乳房保护通常伴随着辅助放疗，而放疗在农村 BC 中可用性有限，因此农村地区的乳房切除术（而不是乳房保留手术）的比例会更高。相比之下，我们假设癌症筛查和系统治疗的使用情况会相似，因为它们在 BC 中更广泛地分布。进行了探索性分析，以评估筛查和治疗利用方面的差异是否转化为生存差异。
我们的研究纳入了 2869 名乳腺癌患者。来自农村社区的患者表现出更晚期的疾病（p=0.01）。多变量分析显示，与城市相比，来自农村 LHA 的患者接受筛查乳房 X 线照片检查的可能性较小（OR=0.62；p<0.001）。来自农村社区的女性较少接受乳房保留手术（多变量 OR=0.47；p<0.001）。化疗（p=0.54）和激素治疗（p=0.36）的使用无显著差异。大、小和农村 LHA 的 5 年乳腺癌特异性生存率分别为 90%、88%和 86%（p=0.08），而总生存率分别为 84%、81%和 77%（p=0.01）。在中位随访 7.4 年的多变量分析中，来自农村 LHA 的患者的乳腺癌特异性生存率（HR=1.16；0.76-1.76；p=0.49）和总生存率（HR=1.25；0.92-1.70；p=0.16）均未显著差于大 LHA 的患者。
LHA 人口规模不同，筛查乳房 X 线照片使用率、分期分布和局部区域治疗使用率存在显著差异。在按 LHA 调整患者和肿瘤因素的差异后，生存率无显著差异。
