Institute of Applied Health Science, University of Aberdeen, Aberdeen.
Centre for Population Health Sciences, University of Edinburgh, Edinburgh.
Br J Gen Pract. 2018 Aug;68(673):e566-e575. doi: 10.3399/bjgp18X697901. Epub 2018 Jun 18.
Those living in rural areas have poorer cancer outcomes, but current evidence on how rurality impacts melanoma care and survival is contradictory.
To investigate the impact of rurality on setting of melanoma excision and mortality in a whole-nation cohort.
Analysis of linked routine healthcare data comprising every individual in Scotland diagnosed with melanoma, January 2005-December 2013, in primary and secondary care.
Multivariate binary logistic regression was used to explore the relationship between rurality and setting of melanoma excision; Cox proportional hazards regression between rurality and mortality was used, with adjustments for key confounders.
In total 9519 patients were included (54.3% [ = 5167] female, mean age 60.2 years [SD 17.5]). Of melanomas where setting of excision was known, 90.3% ( = 8598) were in secondary care and 8.1% ( = 771) in primary care. Odds of primary care excision increased with increasing rurality/remoteness. Compared with those in urban areas, those in the most remote rural locations had almost twice the odds of melanoma excision in primary care (adjusted odds ratio [aOR] 1.92; 95% confidence interval [CI] = 1.33 to 2.77). No significant association was found between urban or rural residency and all-cause mortality. Melanoma-specific mortality was significantly lower in individuals residing in accessible small towns than in large urban areas (adjusted hazards ratio [HR] 0.53; 95% CI = 0.33 to 0.87) with no trend towards poorer survival with increasing rurality.
Patients in Scottish rural locations were more likely to have a melanoma excised in primary care. However, those in rural areas did not have significantly increased mortality from melanoma. Together these findings suggest that current UK melanoma management guidelines could be revised to be more realistic by recognising the role of primary care in the prompt diagnosis and treatment of those in rural locations.
农村地区的癌症患者预后较差，但目前关于农村地区对黑色素瘤治疗和生存的影响的证据相互矛盾。
在全国范围内的队列研究中，调查农村地区对黑色素瘤切除术和死亡率的影响。
分析了 2005 年 1 月至 2013 年 12 月期间苏格兰所有在初级和二级保健中诊断为黑色素瘤的个体的相关常规医疗保健数据。
使用多元二项逻辑回归来探讨农村地区与黑色素瘤切除术设置之间的关系；使用 Cox 比例风险回归来探讨农村地区与死亡率之间的关系，并对关键混杂因素进行了调整。
共纳入 9519 例患者（54.3%[=5167]为女性，平均年龄为 60.2 岁[标准差 17.5]）。在已知切除部位的黑色素瘤中，90.3%（=8598）在二级保健中，8.1%（=771）在初级保健中。初级保健切除的可能性随着农村地区/偏远程度的增加而增加。与城市地区相比，最偏远农村地区的黑色素瘤在初级保健中切除的几率几乎增加了两倍（调整后的优势比[aOR]1.92；95%置信区间[CI]为 1.33 至 2.77）。城市或农村居住与全因死亡率之间无显著相关性。与居住在可及的小镇的人相比，居住在大城市的人的黑色素瘤特异性死亡率显著降低（调整后的危险比[HR]0.53；95%置信区间[CI]为 0.33 至 0.87），而且随着农村地区的发展，生存率没有下降的趋势。
苏格兰农村地区的患者更有可能在初级保健中切除黑色素瘤。然而，农村地区的黑色素瘤死亡率并没有显著增加。这些发现表明，目前的英国黑色素瘤管理指南可以通过认识到初级保健在快速诊断和治疗农村地区患者方面的作用而进行修订，使其更加切合实际。
