Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, WHO, Lyon, France.
Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium; Population and Health Impact Surveillance Group, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya; Centre for Health Informatics, Computing and Statistics, Lancaster Medical School, Lancaster University, Lancaster, UK.
Lancet Glob Health. 2024 Jul;12(7):e1111-e1119. doi: 10.1016/S2214-109X(24)00138-4. Epub 2024 May 21.
There is an urgent need to improve breast cancer survival in sub-Saharan Africa. Geospatial barriers delay diagnosis and treatment, but their effect on survival in these settings is not well understood. We examined geospatial disparities in 4-year survival in the African Breast Cancer-Disparities in Outcomes cohort.
In this prospective cohort study, women (aged ≥18 years) newly diagnosed with breast cancer were recruited from eight hospitals in Namibia, Nigeria, South Africa, Uganda, and Zambia. They reported sociodemographic information in interviewer-administered questionnaires, and their clinical and treatment data were collected from medical records. Vital status was ascertained by contacting participants or their next of kin every 3 months. The primary outcome was all-cause mortality in relation to rural versus urban residence, straight-line distance, and modelled travel time to hospital, analysed using restricted mean survival time, Cox proportional hazards, and flexible parametric survival models.
2228 women with breast cancer were recruited between Sept 8, 2014, and Dec 31, 2017. 127 were excluded from analysis (58 had potentially recurrent cancer, had previously received treatment, or had no follow-up; 14 from minority ethnic groups with small sample sizes; and 55 with missing geocoded home addresses). Among the 2101 women included in analysis, 928 (44%) lived in a rural area. 1042 patients had died within 4 years of diagnosis; 4-year survival was 39% (95% CI 36-42) in women in rural areas versus 49% (46-52) in urban areas (unadjusted hazard ratio [HR] 1·24 [95% CI 1·09-1·40]). Among the 734 women living more than 1 h from the hospital, the crude 4-year survival was 37% (95% CI 32-42) in women in rural areas versus 54% (46-62) in women in urban areas (HR 1·35 [95% CI 1·07-1·71] after adjustment for age, stage, and treatment status). Among women in rural areas, mortality rates increased with distance (adjusted HR per 50 km 1·04, 1·01-1·07) and travel time (adjusted HR per h 1·06, 1·02-1·10). Among women with early-stage breast cancer receiving treatment, women in rural areas had a strong survival disadvantage (overall HR 1·54, 1·14-2·07 adjusted for age and stage; >1 h distance adjusted HR 2·14, 1·21-3·78).
Geospatial barriers reduce survival of patients with breast cancer in sub-Saharan Africa. Specific attention is needed to support patients with early-stage breast cancer living in rural areas far from cancer treatment facilities.
US National Institutes of Health (National Cancer Institute), Susan G Komen for the Cure, and the International Agency for Research on Cancer.
迫切需要提高撒哈拉以南非洲的乳腺癌生存率。地理空间障碍会延迟诊断和治疗，但它们对这些环境中生存的影响尚不清楚。我们研究了在非洲乳腺癌-结局差异中，4 年生存率的地理空间差异。
在这项前瞻性队列研究中，从纳米比亚、尼日利亚、南非、乌干达和赞比亚的 8 家医院招募了新诊断为乳腺癌的女性（年龄≥18 岁）。她们在采访者管理的问卷中报告了社会人口统计学信息，并从病历中收集了她们的临床和治疗数据。每 3 个月通过联系参与者或其近亲来确定生存状态。主要结局是全因死亡率与城乡居住、直线距离和到医院的模拟旅行时间的关系，使用受限平均生存时间、Cox 比例风险和灵活参数生存模型进行分析。
2014 年 9 月 8 日至 2017 年 12 月 31 日期间，共招募了 2228 名乳腺癌患者。其中 127 人因潜在的复发性癌症、已接受过治疗或无随访而被排除在分析之外（58 人）；14 人因少数民族群体样本量小而被排除（14 人）；55 人因缺少地理编码的家庭住址而被排除（55 人）。在 2101 名纳入分析的女性中，928 人（44%）居住在农村地区。1042 名患者在诊断后 4 年内死亡；农村地区患者的 4 年生存率为 39%（95%CI 36-42），而城市地区患者的 4 年生存率为 49%（46-52）（未调整的危险比[HR]1.24[95%CI 1.09-1.40]）。在 734 名居住距离医院 1 小时以上的女性中，农村地区患者的粗 4 年生存率为 37%（95%CI 32-42），而城市地区患者的 4 年生存率为 54%（46-62）（年龄、分期和治疗状态调整后的 HR 1.35[95%CI 1.07-1.71]）。在农村地区的女性中，死亡率随着距离（调整后的 HR 每 50 公里 1.04，1.01-1.07）和旅行时间（调整后的 HR 每小时 1.06，1.02-1.10）而增加。在接受治疗的早期乳腺癌女性中，农村地区的女性生存劣势明显（总体 HR 1.54，1.14-2.07，调整年龄和分期；距离>1 小时的调整 HR 2.14，1.21-3.78）。
地理空间障碍降低了撒哈拉以南非洲乳腺癌患者的生存率。需要特别关注支持居住在远离癌症治疗设施的农村地区的早期乳腺癌患者。
美国国立卫生研究院（国家癌症研究所）、Susan G Komen for the Cure 和国际癌症研究机构。
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