Do rural cancer patients present later than those in the city?
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1 Do rural cancer patients present later than those in the city? Dr Katie Hoff ( M.B.B.S.) Acknowledgements: Prof. J. Emery, V. Gray, D. Howting September 2011
2 BACKGROUND Cancer is a leading causes of death in Australia In 2009 cancer accounted for 29.8% of all registered deaths (Australian Bureau Statistics - Most common cancers in Australia (excluding nonmelanoma skin cancer) are prostate, colorectal, breast, melanoma and lung cancer. ( Mortality statistics from Australian Bureau of statistics 2009 Colorectal cancer 7 th leading cause Prostate 11 th leading cause Breast 12 th leading cause
3 Growing evidence that delays in cancer presentation result in poorer outcomes! Influence of delay on survival in patients with breast cancer: a systematic review (Lancet 1999) Time to diagnosis and mortality in colorectal cancer: a cohort study in primary care (British Journal of cancer 2011)
4 Well established rural cancer patients in Australia have worse outcomes Rural patients with cancer have 20-30% greater mortality than metropolitan patients Rural Patients are less likely to receive Radiotherapy or hormonal treatment in breast cancer Radical surgery for colorectal cancer Radical prostatectomy Poorer outcomes for Aboriginal patients Inequalities in rural health care: differences in surgical intervention between metropolitan and rural WA. (2005) Colorectal cancer surgical care and survival: do private health insurance, socioeconomic and local status make a difference?(2005) Prostate cancer: socioeconomic, geographic and private health insurance effects on care and survival. (2005)
5 Assumption that Differences in rural and metropolitan outcomes are thought to be related to access and treatment options
6 It is unknown how much of this is due to late presentation Or how much time to diagnosis matters?
7 Part of a larger study. - Improving Rural Cancer Outcomes Project - Breast, Colorectal, Lung, Prostate Great Southern, Mid-west, Wheatbelt, Goldfields and South-west regions of WA and Perth Metropolitan Area Over 5 years 850 patient for each cohort Funded by Cancer Council, NH&MRC & Department of Health WA
8 Measuring components of delay to diagnosis and treatment MODEL OF PATIENT PATHWAYS TO TREATMENT FM Walter, A Webster, S Scott, J Emery in press Journal of Health Service Research and Policy Adapted from original by Richard Neil
9 Surveys looking at Appraisal Interval + Help-seeking interval
10
11 Recruitment Process Nurse Cancer co-ordinators Multi-discipline Meetings Consultants
12 Number of Patients recruited Number of Patients Total Breast Cancer Colorectal Cancer Lung Cancer Prostate Cancer Rural Metropolitan
13 Symptom Appraisal Interval - Rural Data - Screen detected results removed and 3 breast and 2 prostate outliers removed
14 Symptom Appraisal Interval - Rural Data -
15 Symptom Appraisal Interval - Rural - Valid N Median (Days) Min. (Days) Max. (Days) Breast Symptom Appraisal Delay Colorectal Lung Prostate
16 Symptom Appraisal Interval - Metropolitan Data -
17 Comparison of Symptom Appraisal Interval - Rural - - Metropolitan -
18 Symptom Appraisal Interval - Metropolitan - Valid N Median (Days) Min. (Days) Max. (Days) Breast Symptom Appraisal Delay Colorectal Lung Prostate
19 Symptom appraisal and Help Seeking - Themes in Pilot Study Interviews - Competing priorities Significant life events Holidays Seasonal demands Work or family demands Alternative explanations Work pressure Age getting older Physical and mental stress Tired Previous experience of similar symptoms previous benign cause Co-morbidities
20 Symptom appraisal and Help Seeking - Themes in Pilot Study Interviews - Fear Fear of mammogram Fear of rectal exam Stoic Hero bloke don t go to the doctor Downplay of severity Adjust lifestyle to suit symptoms Beliefs about cancer Assumption that there needs to be pain to react, severe pain as a prompt Temporal nature Intermittent symptoms
21 N&um=1&hl=en&client=firefox-a&sa=N&rls=org.mozilla:en-
22 Future Understand if there are differences in symptom appraisal analysis between rural and metropolitan patients Compare how components of delay differ between each of the four cancers studied (breast, colorectal, lung and prostate) More questionnaires to be collected Interventions to improve symptom appraisal analysis time
23 INTERVENTION - Community symptom awareness campaign in parts of regional Western Australia -
24 For each of the four cancers
25 QUESTIONS
26 References (Slide 2) - Delays in cancer presentation affects outcome - Influence of delay on survival in patients with breast cancer: a systematic review (Lancet 1999) Time to diagnosis and mortality in colorectal cancer: a cohort study in primary care (British Journal of cancer 2011) The influence on survival of delay in the presentation and treatment of symptomatic breast cancer (1999 British Journal of Cancer) Retrospective study of reasons for improved survival in patients with breast cancer in East Anglia: earlier diagnosis or better treatment (BMJ 1997) Trends in breast cancer incidence, survival, and mortality (Lancet 2000 A short diagnostic delay is more important for rectal than for colonic cancer (European Journal of Surgery 1997) Delays in managing lung cancer (Thorax 2004) Impact on delay on diagnosis and treatment of primary lung cancer. Radical prostatectomy versus watchful waiting in early prostate cancer (New England Journal of medicine 2002) Urban rural differences in prostate cancer outcomes in Australia: What has changed? (MJA 2011)
27 References (Slide 4) - Poorer outcomes in rural compared with metropolitan patients - 1) The influence of socio-economic and location disadvantage on survival after a diagnosis of lung or breast cancer in Western Australia (2004) 2) Unequal access to breast-conserving surgery in Western Australia (2004) 3) The influence of socio-economic and local disadvantage on patterns of surgical care for lung cancer in Western Australia (2004) 4) Colorectal cancer surgical care and survival: do private health insurance, socioeconomic and local status make a difference? (2005) 5) Prostate cancer: socioeconomic, geographic and private health insurance effects on care and survival. (2005) 6) Lung cancer: an exploration of patient and general practitioner perspectives on the realities of care in rural Western Australia. (2008) 7) Inequalities in rural health care: differences in surgical intervention between metropolitan and rural Western Australia. (2005) 8) Mapping Rural and Regional Oncology Services in Australia ( 2006) clinical oncology society of Australia
28 Other results Getting to see a General Practitioner is not generally a problems Christmas effect Other masking symptoms / false reassurance Indigenous, communication breakdowns Lung and breast have good access to investigation and treatment and short waiting lists Colorectal and prostate have long delays to see specialist, get prostate biopsy and receive treatment
29 Other interventions GP education around diagnostic and referral pathways Aims to make GP more aware of referral pathways and new referral pathways Streamlining diagnosis fast track diagnosis One stop prostate clinic
30
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