The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, United States of America.
Department of Health Policy and Management, University of North Carolina at Chapel Hill, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States of America.
Gynecol Oncol. 2019 Jan;152(1):112-118. doi: 10.1016/j.ygyno.2018.11.010. Epub 2018 Nov 12.
Urban-rural health disparities are often attributed to the longer distances rural patients travel to receive care. However, a recent study suggests that distance to care may affect urban and rural cancer patients differentially. We examined whether this urban-rural paradox exists among patients with cervical cancer.
We identified individuals diagnosed with cervical cancer from 2004 to 2013 using a statewide cancer registry linked to multi-payer, insurance claims. Our primary outcome was receipt of guideline-concordant care: surgery for stages IA1-IB1; external beam radiation therapy (EBRT), concomitant chemotherapy, and brachytherapy for stages IB2-IVA. We estimated risk ratios (RR) using modified Poisson regressions, stratified by urban/rural location, to examine the association between distance to nearest facility and receipt of treatment.
62% of 999 cervical cancer patients received guideline-concordant care. The association between distance and receipt of care differed by type of treatment. In urban areas, cancer patients who lived ≥15 miles from the nearest surgical facility were less likely to receive primary surgical management compared to those <5 miles from the nearest surgical facility (RR: 0.77, 95% CI: 0.60-0.98). In rural areas, patients living ≥15 miles from the nearest brachytherapy facility were more likely to receive treatment compared to those <5 miles from the nearest brachytherapy facility (RR: 1.71, 95% CI: 1.14-2.58). Distance was not associated with the receipt of chemotherapy or EBRT.
Among cervical cancer patients, there is evidence supporting the urban-rural paradox, i.e., geographic distance to cancer care facilities is not consistently associated with treatment receipt in expected or consistent ways. Healthcare systems must consider the diverse and differential barriers encountered by urban and rural residents to improve access to high quality cancer care.
城乡卫生差异通常归因于农村患者接受医疗的距离较长。然而，最近的一项研究表明，距离医疗保健可能会对城市和农村癌症患者产生不同的影响。我们研究了这种城乡悖论是否存在于宫颈癌患者中。
我们使用全州癌症登记处与多付款人保险索赔相关联，从 2004 年至 2013 年确定了宫颈癌患者。我们的主要结局是接受指南一致的治疗：IA1-IB1 期手术；IB2-IVA 期外照射放疗（EBRT）、同期化疗和近距离放疗。我们使用修正泊松回归，根据城乡位置进行分层，估计风险比（RR），以检查距离最近的医疗机构与接受治疗之间的关联。
62%的 999 名宫颈癌患者接受了指南一致的治疗。距离与治疗接受之间的关联因治疗类型而异。在城市地区，距离最近的手术设施≥15 英里的癌症患者接受主要手术治疗的可能性低于距离最近的手术设施<5 英里的患者（RR：0.77，95%CI：0.60-0.98）。在农村地区，距离最近的近距离放疗设施≥15 英里的患者比距离最近的近距离放疗设施<5 英里的患者更有可能接受治疗（RR：1.71，95%CI：1.14-2.58）。距离与接受化疗或 EBRT 无关。
在宫颈癌患者中，有证据支持城乡悖论，即到癌症治疗设施的地理距离并不总是以预期或一致的方式与治疗接受相关。医疗保健系统必须考虑城市和农村居民遇到的不同和差异化的障碍，以改善获得高质量癌症护理的机会。
