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Quality of life in urban and rural settings: A study of head and neck cancer survivors
Oral Oncology xxx (2014) xxx–xxx
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Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology
Quality of life in urban and rural settings: A study of head and neck cancer survivors Audrey Alforque Thomas a,⇑, Aileen Timmons b, Michal Molcho c, Alison Pearce b, Pamela Gallagher d, Phyllis Butow e, Eleanor O’Sullivan f, Rachael Gooberman-Hill g, Ciaran O’Neill h, Linda Sharp b a
Health Promotion Research Centre, Aras na Coiribe, National University of Ireland, Galway, Ireland National Cancer Registry Ireland, Building 6800, Cork Airport Business Park, Kinsale Road, Cork, Ireland National University of Ireland, School of Health Sciences, Galway, Ireland d School of Nursing and Human Sciences, Dublin City University, Glasnevin, Dublin 9, Ireland e Centre for Medical Psychology & Evidence-based Decision-making, University of Sydney, Australia f Cork University Dental School and Hospital, Wilton, Co. Cork, Ireland g School of Clinical Sciences, University of Bristol, Southmead Hospital BS10 5NB, United Kingdom h School of Business and Economics, National University of Ireland, Galway, Ireland b c
a r t i c l e
i n f o
Article history: Received 12 December 2013 Received in revised form 12 February 2014 Accepted 23 March 2014 Available online xxxx Keywords: Head and neck cancer Survivorship Rural health Urban Quality of life Ireland
s u m m a r y Objective: Urban–rural variation in cancer incidence, treatment, and clinical outcomes has been well researched. With the growing numbers and longer lifespan of cancer survivors, quality of life (QOL) is now a critical issue. The present study investigates the QOL of head and neck cancer (HNC) survivors in Ireland, paying special attention to urban and rural variation. Methods: From the population-based National Cancer Registry Ireland, we identified 991 survivors of HNC (ICD10 C00-C14, C32), who were at least eight months post-diagnosis, and invited them to complete a postal survey. We used self-reported data and information from the Registry to create a composite variable classifying respondents’ current area of residence as ‘‘urban’’ or ‘‘rural.’’ Respondents self-reported QOL using the Functional Assessment for Cancer Therapy with Head and Neck module (FACT-HN). We used bootstrap linear regression to control for confounding variables, while estimating the association of urban and rural residence to FACT-HN domain scores. Results: We obtained survey and Registry data from 583 HNC survivors. Controlling for demographic and clinical variables, rural survivors reported higher physical (coefficient 1.27, bias-corrected and accelerated 95% confidence interval 0.54, 2.43), emotional (coef. 0.99, 95% CI 0.21, 2.02), and HNC-specific (coef. 1.55, 95% CI 0.32, 3.54) QOL than their urban counterparts. Social and functional QOL did not differ significantly. Conclusions: These findings add to growing evidence of important differences in life experiences of cancers survivors in urban and rural settings. Results such as these will allow health professionals, policy makers and service providers to better serve these populations. Ó 2014 Elsevier Ltd. All rights reserved.
Introduction Cancer incidence has been rising while cancer-related mortality has been decreasing, resulting in growing numbers of cancer survivors [1–3]. While researchers have explored urban–rural variations in the clinical aspects of cancer, survivors’ quality of life (QOL) has remained an ancillary focus. The large body of cancer research on ⇑ Corresponding author. Address: Health Promotion Research Centre, Aras na Coiribe, National University of Ireland, Galway, Ireland. Tel.: +353 (0)91 494181; fax: +353 (0)91 494547. E-mail address: [email protected] (A.A. Thomas).
urban and rural differences has mainly focused on incidence [4–6], diagnosis [7–10], treatment [11,12], and survival [13–16]. There is an emerging need for further research about urban–rural variation in cancer survivors’ life experiences after the completion of treatment. From the time urbanism was first studied, social scientists postulated the negative effect of the city on psychosocial wellbeing [17,18]. Following from this tradition, recent studies on the general population find a rural advantage in terms of physical and mental health [19–22]. However, extant research on cancer survivors suggests that living in a rural area is associated with poorer psychosocial wellbeing [23]. It has been suggested that the cost
http://dx.doi.org/10.1016/j.oraloncology.2014.03.007 1368-8375/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Thomas AA et al. Quality of life in urban and rural settings: A study of head and neck cancer survivors. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.03.007
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A.A. Thomas et al. / Oral Oncology xxx (2014) xxx–xxx
and time involved in traveling to hospitals to attend appointments with healthcare professionals may preclude some rural cancer survivors from receiving services, thereby resulting in poorer QOL. Specifically, mental health has been shown to be poorer for rural breast, hematologic, and colorectal survivors [24]. QOL, both health-related and breast cancer-specific, has also been shown to be poorer for rural than urban survivors [25,26]. Most of this work has been conducted in the United States and Australia, with an emerging literature in Canada and Scotland. Understanding the unique aspects of rural cancer survivorship is especially pertinent in Ireland, which is unique among more economically developed countries in that a significant portion of its population (37%) lives in rural areas [27]. In the United States, Australia, the United Kingdom, and Canada, less than one-fifth the population lives in rural areas [27]. A further limitation of the existing evidence base around QOL is that the majority of studies focus on survivors of the most common cancers – breast, colorectal, and prostate cancer. Less is known about the post-treatment life experiences of survivors with less common, but potentially more burdensome, cancers. Survivors of head and neck cancer (HNC) are an important group to consider because the treatment and the cancer itself may have immense and long-lasting effects on the everyday lives of survivors [28]. Research indicates that pain [29], compromised nutritional status, and weight loss [30,31] are common issues among HNC survivors. Radiotherapy, a standard and important treatment for HNC, may cause short-term issues such as taste loss, as well as irreversible side effects such as difficulty swallowing [32]. Studies show that HNC survivors’ QOL can be adversely affected by pain [33,34], compromised nutritional status [35–37], and eating problems [38]. Although there is growing interest in HNC survivors’ QOL, little attention has been paid to urban–rural variation. Investigating this is important because potential support services, including speech therapists, dieticians, and dentists, may not be locally available for rural HNC survivors. The present study aimed to extend the existing evidence base by identifying the magnitude and significance of differences in various QOL domains for urban versus rural HNC survivors in Ireland. Patients and methods Participants and procedures In April 2012, we identified individuals eligible for the study from the National Cancer Registry Ireland, which aims to record all incident primary cancers of people usually resident in the Republic of Ireland. Eligibility criteria were: (1) 18 years or older at the time of diagnosis, (2) a stage I–III head and neck cancer (ICD 10 C00-C14, C32), (3) at least eight months post-diagnosis, and (4) treated in one or more of 14 hospitals throughout Ireland, which included all of the major treating centers for HNC. The treating consultant of each survivor confirmed that the individual was alive, was aware they had cancer, had completed treatment, was considered disease-free, and that there was no medical or other reason why it would be inappropriate to contact the potential participant about the study. We posted surveys with explanatory letters, information sheets, and consent forms to 991 eligible individuals. The research ethics committee for each of the participating hospitals approved the study. Measures The outcome variables for this analysis were derived from the Functional Assessment of Cancer Therapy (FACT-G), a QOL measure validated for use in different countries [39,40] and with rural
populations [41]. We used the component on concerns specific to HNC survivors (FACT-HN), which is also validated and widely used [42]. This instrument measures five domains: physical, social/family, emotional, functional, and HNC-specific. Participants were asked to rate 39 QOL statements as they applied in the 7 days prior to taking the survey. The domain scores were calculated in SPSS version 20.0, using a scoring program from the organization that produced FACT-HN [43]. Respondents must have answered at least half of the questions in a domain to be included in the subscale score for that domain. A higher domain score indicates higher QOL. In their research on Irish geographical areas and health outcomes, Teljeur and Kelley [44] encourage the use of multiple measures to classify rural and urban. We therefore created a composite variable using three component variables to categorize survivors as ‘‘urban’’ or ‘‘rural.’’ For the composite measure, if a participant was classified as ‘‘rural’’ for at least two of these three component variables, then we classified them as ‘‘rural’’ for the composite measure. The first component variable, self-reported area where the participant was living at the time of the survey, was a measure of settlement size. In keeping with the Irish Census Office definition of rural [45], we coded responses ‘‘Dublin city/ county,’’ ‘‘City other than Dublin,’’ and ‘‘Town (1500+)’’ as ‘‘urban.’’ We coded ‘‘Village’’ and ‘‘Open country’’ as ‘‘rural.’’ The second component variable was distance from the participant’s current residence to the hospital of his/her treating consultant, which we obtained from the Registry. The last tertile of distance (P49.88 km) was classified as ‘‘rural,’’ while ‘‘<49.88 km’’ was classified as ‘‘urban.’’ The third component variable was population density of the area in which the survivor lived at the time of the survey, based on 2006 census small-area population figures. In this variable, we considered ‘‘<1 person per hectare’’ as ‘‘rural,’’ and ‘‘P1 person per hectare’’ as ‘‘urban.’’ This classification has been used in Ireland in previous studies [46,47]. We obtained data on gender, age at the time of the survey, cancer site, chemotherapy, radiotherapy, surgery, and stage at diagnosis from the National Cancer Registry Ireland. We used participants’ survey responses as the source of information on marital status, education level, whether the respondents’ cancer had returned or spread, and whether the individual had a medical card at the time of diagnosis. In Ireland, a medical card entitles the holder to free or substantially-subsidized health care. Having a medical card is a proxy for income since eligibility for a medical card is means-tested. Eligibility is less stringent for people over 70, but still means-tested. Statistical analysis We compared respondents and non-respondents on demographic and clinical variables. Then we examined urban–rural variation on those variables within respondents using chi-square tests. We used the non-parametric Wilcoxon–Mann–Whitney test to determine if there was a difference between urban and rural participants’ age at survey. The FACT domain scores were skewed, so we conducted tests of significant group differences (rural versus urban) using Wilcoxon–Mann–Whitney tests. We developed bootstrap linear regression models to investigate associations between the composite urban–rural variable and each FACT domain, controlling for demographic and clinical characteristics. We used bias-corrected and accelerated confidence intervals to determine significance (at the p < 0.05 level), which account for the skewness of the scores. We conducted a sensitivity analysis in which we re-ran the regression models using each of the component urban–rural variables, and compared the results to those obtained for the composite variable. Due to the small number of respondents with lip cancer (n = 7), we excluded them from the regression analyses.
Please cite this article in press as: Thomas AA et al. Quality of life in urban and rural settings: A study of head and neck cancer survivors. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.03.007
A.A. Thomas et al. / Oral Oncology xxx (2014) xxx–xxx
Following methods of researchers working on unmet support needs of cancer survivors [48,49], we examined urban–rural differences on each FACT question. For each item, we coded the two responses indicating the lowest scores as ‘‘low score’’; all other response were considered not to indicate a low score. For example, a low score for the item ‘‘My mouth is dry,’’ were the responses, ‘‘Quite a bit’’ or ‘‘Very much.’’ However, for the item, ‘‘I feel close to my friends’’ the responses, ‘‘A little bit,’’ or ‘‘Not at all’’ indicated a low score. We calculated the percentage of respondents with a low score for each item, and compared urban and rural survivors on each item using chi-square tests. We performed all statistical analyses using Stata, version 12.1. Results Study sample
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were more concerned with their relationships with their friends than rural dwellers: the two items about friends, ‘‘I get support from my friends’’ (v2 (df) = 4.11(1), p = 0.043) and ‘‘I feel close my friends’’ (v2 (df) = 4.81(1), p = 0.028) showed significantly lower scores for urban versus rural survivors. In addition, urban dwellers reported lower scores on the item, ‘‘I am able to eat as much food as I want’’ (v2 (df) = 4.03(1), p = 0.045). FACT domain scores Table 3 summarizes the statistics for the FACT domains for the entire sample and by urban and rural residence. Rural cancer survivors reported better emotional (Wilcoxon–Mann–Whitney z-score = 2.80, p = 0.005), functional (z-score = 2.38, p = 0.018), and HNC-specific (z-score = 2.06, p = 0.039) QOL than their urban counterparts. Physical and social domain scores did not significantly differ for rural versus urban respondents.
Of the 991 individuals invited to participate, 583 survivors (58.8% response rate) returned completed surveys. There were no statistically significant differences between responders and nonresponders in terms of gender, cancer site, stage at diagnosis, or time since diagnosis. However, the proportion of people older than 65 years old was lower in the respondent group (26.6%) than in the non-respondent group (35.5%, p-value = 0.012). Two-thirds of the respondents were men (n = 392, 67.2%). About half of the respondents had a medical card (n = 272, 48.1%). Mean age at survey completion was 63.0 years (SD = 11.4; range = 28–92 years). Most of the respondents were married or cohabiting (n = 413, 71.5%). Approximately one-fifth of the respondents reported completing third level or post-graduate education (n = 121, 21.4%). The site of the primary tumor was: lip (n = 7, 1.2%), mouth (n = 242, 41.5%), salivary glands (n = 44, 7.6%), pharynx (n = 112, 19.2%), and larynx (n = 178, 30.5%). The majority of respondents reported no tumor progression or recurrence by the time of survey completion (n = 516, 93.8%). A previous study of long-term HNC survivors shows no relationship between QOL and treatment-related factors [50], and, in this study, no statistically significant differences were found between urban and rural survivors in terms of stage at diagnosis and treatment (data not shown), so these variables were not included in the model. On the basis of the composite variable, 37% (n = 214) of the participants were ‘‘rural’’ and 63% (n = 361) were ‘‘urban.’’ No statistically significant differences emerged between rural and urban respondents on demographic and clinical variables (Table 1), with the exception of a higher proportion of rural participants who were married/cohabiting as compared with urban participants (p = 0.049).
Table 4 shows the results of five separate bootstrap linear regression models used to determine factors associated with each of the domain scores. For emotional and HNC-specific QOL, the lower scores for urban subjects seen in the bivariate analyses held even when controlling for demographic and clinical variables. In addition, the regression analysis showed significantly lower scores for urban survivors in the physical domain. However, functional QOL was no longer significantly associated with living in a rural area. The sensitivity analysis showed that the regression coefficients of the component variables used to measure ‘‘urban’’ and ‘‘rural’’ were broadly similar to the coefficients for the composite variable. The magnitude of the effects were slightly different, but the overall associations were consistent across these variables (data not shown). As for other factors associated with QOL, female respondents had significantly higher social but lower emotional domain scores. Possession of a medical card at the time of diagnosis had a significant negative relationship with all domains except social QOL. Being married or cohabiting was significantly positively associated with social and functional domains. Respondents with higher levels of education had higher physical and HNC-specific, but lower social domain scores. Increasing age was significantly associated with higher physical and emotional scores. In terms of clinical variables, for survivors whose cancer had returned or spread showed a significant negative association with physical, emotional, and HNC-specific QOL. Compared to respondents with larynx cancer, those with pharynx cancer reported lower scores in physical and HNC-specific QOL.
Individual QOL items
Discussion
HNC-specific concerns dominated the top QOL issues for survivors. Over one-third of respondents had problems with dry mouth (n = 200, 38.0%) or with the quality and strength of their voice (n = 182, 35.0%). Approximately one-quarter also had trouble swallowing naturally and easily (n = 150, 28.3%) and with the amount they could eat (n = 125, 23.9%). Lack of energy also emerged as an important issue (n = 150, 28.4%). A large proportion of those who answered the sexual question reported a low score (n = 103, 42.0%). Differences in QOL issues emerged between urban and rural survivors (Table 2). For each item on which there was a statistically significant difference, urban dwellers had a lower score. Urban survivors more often had lower scores on the item ‘‘My work (including at home) is fulfilling’’ (v2 (df) = 7.28(1), p = 0.007). They
Important differences in QOL between urban and rural cancer survivors emerged from this study. Controlling for demographic and clinical variables, HNC survivors in rural Ireland are more likely to report higher physical, emotional, and HNC-specific QOL than those living in urban areas. These findings are consonant with studies on the general population [19–21], including in the Irish context [51], that suggest a rural advantage in terms of psychosocial wellbeing. However, the findings run counter to previous QOL research on cancer survivors, which points to a rural disadvantage [23–26]. More rural respondents were married or cohabiting compared to urban respondents, which could contribute to the higher emotional, functional, and HNC-specific scores in the bivariate analysis. Being married or cohabiting was positively associated
Factors associated with FACT domain scores
Please cite this article in press as: Thomas AA et al. Quality of life in urban and rural settings: A study of head and neck cancer survivors. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.03.007
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A.A. Thomas et al. / Oral Oncology xxx (2014) xxx–xxx
Table 1 Demographic and clinical characteristics of urban and rural head and neck cancer survivors.a Demographics
a b c d
Urban (n = 361)
Rural (n = 214)
p-Value
n
%
n
%
Sexb Female Male
117 244
32.4 67.6
71 143
33.2 66.8
Medical card at diagnosisc Yes No
171 179
48.9 51.1
95 112
45.9 54.1
Marital statusc With a partner Not with a partner Age at surveyb – mean (SD)
246 112 62.7 (11.5)
68.7 31.3
162 50 63.4 (11.4)
76.4 23.6
Highest level of education completedc Primary or secondary Third level or post-graduate
272 79
77.5 22.5
165 42
79.7 20.3
Cancer returned or spreadc Yes No
17 322
5.0 95.0
17 187
8.33 91.7
Cancer siteb,d Larynx Lip Mouth Pharynx Salivary glands
104 4 166 66 21
28.8 1.1 46.0 18.3 5.8
72 2 74 45 21
33.6 0.9 34.6 21.0 9.8
0.850
0.499
0.049
0.361 0.539
0.122
0.069
Based on 575 respondents. We could not categorize 8 respondents due to missing data. National cancer registry data. Self-reported. ICD 10 C00-C14, C32.
Table 2 FACT items on which urban and rural cancer survivors have significantly different scores, number and percent of those who are experiencing a problem with each item. Item (Domain)
Urban
My work (including at home) is fulfilling (functional) I am able to eat as much food as I want (HNC-specific) I get support from my friends (social) I feel close to my friends (social) I am content with the quality of my life right now (functional) I am able to enjoy life (functional) I feel close to my partner (or the person who is my main support) (social) I have pain (physical) I have pain in my mouth, throat, or neck (HNC-specific) I feel sad (emotional) I am forced to spend time in bed (physical) I have nausea (physical) I feel ill (physical) a b
Rural
n
%
n
%
86 88 85 81 63 54 50 50 45 38 34 24 20
27.7 26.8 26.2 24.4 19.1 16.4 16.0 15.8 13.7 12.8 10.5 7.5 6.2
32 36 34 31 24 16 15 14 14 10 8 5 4
17.1 19.0 18.3 16.2 12.4 8.3 8.4 7.6 7.3 5.9 4.3 2.8 2.2
chi-square statistic
p-Value
7.28 4.03 4.11 4.81 3.89 6.85 5.79 7.03 4.92 5.46 6.10 4.82 4.25
0.007b 0.045a 0.043a 0.028a 0.049a 0.009b 0.016a 0.008b 0.026a 0.019a 0.013a 0.028a 0.039a
Significant at p < 0.05. Significant at p < 0.01.
Table 3 Urban and rural head and neck cancer survivors’ median and interquartile range for FACT domain scores.
Physical domain Social domain Emotional domain Functional domain Head and neck specific domain a
All respondents
Urban
Rural
Urban–rural comparison
Median
Interquartile range
n
Median
Interquartile range
n
Median
Interquartile range
25.0 21.0 20.0 21.0 30.0
20.0–28.0 16.8–25.7 17.0–23.0 15.2–26.0 22.2–35.0
327 332 302 329 333
25.0 21.0 20.0 20.0 29.0
19.0–28.0 16.3–25.7 17.0–23.0 15.0–25.0 22.0–35.0
189 189 173 195 194
25.0 22.2 21.0 22.0 31.0
21.0–28.0 18.0–25.7 19.0–23.0 16.0–26.6 23.0–35.6
z-Scorea
p-Value
1.84 1.36 2.80 2.38 2.06
0.066 0.173 0.005⁄⁄ 0.018⁄ 0.039⁄
Test statistic for Wilcoxon–Mann–Whitney.
with the social and functional domains in the multivariate analysis. These results were in accordance with a study of cancer survivors in the rural United States, which found that divorce had a negative effect on wellbeing [52].
The extant literature suggests that people living in rural areas are more stoic about their health [53–56]. In our study, significantly fewer rural survivors reported problems with pain or being able to eat as much as they like. Moreover, controlling for
Please cite this article in press as: Thomas AA et al. Quality of life in urban and rural settings: A study of head and neck cancer survivors. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.03.007
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A.A. Thomas et al. / Oral Oncology xxx (2014) xxx–xxx Table 4 Bootstrap linear regression coefficients with bias-corrected and accelerated confidence intervals for FACT domain scores. Physical
Social BCA 95% CI
Coef
Lower
Upper
Emotional BCA 95% CI
Coef
Lower
Upper
Functional
BCA 95% CI Coef
Lower
Upper
Head and neck
BCA 95% CI Coef
Lower
Upper
BCA 95% CI Coef
Lower
Upper
1.27
0.54
2.43a
0.89
0.18
2.32
0.99
0.21
2.02a
1.41
0.10
2.79
1.55
0.32
3.54a
0.22
1.00
1.50
1.64
0.12
2.62a
1.15
1.96
0.17a
0.56
0.94
1.82
0.91
0.59
2.83
1.78
2.85
0.23a
0.79
2.11
0.24
1.63
2.50
0.62a
2.44
3.70
0.98a
2.24
3.87
0.82a
0.42
0.71
2.17
2.36
0.96
3.78a
0.18
0.79
0.66
1.76
0.38
3.42a
1.10
0.56
2.96
1.96
0.77
3.08a
1.51
3.46
0.32a
0.61
0.23
1.67
0.69
1.17
2.23
2.62
0.84
4.63a
Age at survey (continuous)
0.10
0.06
0.14a
0.03
0.03
0.08
0.07
0.03
0.12a
0.04
0.01
0.11
0.04
0.01
0.11
Cancer returned or spread Yes No (reference)
3.77
6.10
1.67a
0.44
1.60
2.24
1.93
4.15
0.21a
2.22
5.29
0.08
4.34
7.30
1.74a
Cancer type Salivary glands Mouth Pharynx Larynx (reference)
0.54 0.60 2.09
1.25 1.13 3.61
2.47 1.46 0.63a
0.85 0.85 0.93
0.21 0.21 2.79
2.34 2.34 0.61
1.22 0.37 0.29
0.17 0.84 1.42
2.71 1.20 1.26
1.65 1.38 1.00
1.31 0.12 2.54
4.08 3.01 1.68
0.96 0.96 5.38
2.64 2.64 7.72
1.07 1.07 3.50a
Rural Urban (reference) Female Male (reference) Medical card Yes No (reference) Married or cohabiting Not married/cohabiting (reference) Highest education Third level Primary or secondary (reference)
Coef, coefficient; BCA, bias-corrected and accelerated; CI, confidence interval. a Significant at p < 0.05.
confounding variables, rural survivors had higher scores in the domains of physical and HNC-specific QOL. Another way that the urban and rural communities may differ is in their network structures. Voluntary relationships (e.g. friendships) may be important to urban dwellers because the heterogeneity and critical mass of people in cities allows urban dwellers to associate based on common interests [57–60]. This would account for the finding that significantly more urban cancer survivors were concerned about feeling close to and receiving support from their friends. Despite these differences, urban and rural cancer survivors share many of the same QOL issues. Issues already documented in the literature were affirmed in this study: compromised vocal quality, problems with eating, and lack of energy. An issue brought to light in this study and not prominent in the previous literature on QOL of HNC survivors, is the importance of satisfaction with sex life. While there are some methodological issues to consider regarding missing data on sex questions [61–63], those who answered this question overwhelmingly voiced their dissatisfaction with their sex life. Possible explanations are suggested in by theories about urban– rural differences in health. The Biophilia Hypothesis, the idea that green space is therapeutic [19,20], would explain why rural cancer survivors have higher scores in the emotional domain than urban cancer survivors. The Drifter Hypothesis, the tendency for ill people to move to urban center, in part for access to specialized medical care [21], would account for the higher physical and HNC-specific QOL in rural areas. The way rural and urban are measured imply different explanations for the relationship to QOL. For example, using distance to an urban center as a measure implies that the influence of the city is related to how closely one resides to that city. Categorizing areas based on population density could suggest that green space is an important factor. A composite variable, such as the one used in this study, gives a holistic measure of urbanicity and rurality. Rather than privileging one type of measurement over another, a composite variable attempts to capture idea of urban
and rural. In this way, a composite variable is more relevant to the norms and culture of each area. Having said this, it was noteworthy that in our sensitivity analysis, in which we examined associations between each of the component variables and QOL domains, the results were broadly similar to those we obtained with the composite variable. Possession of a medical card at the time of diagnosis, which was used as a proxy for low income, was negatively related to all QOL domains except social. Low-income survivors may not be able to pay for or take time off of work for physical therapy or counseling services after cancer treatment. Previous studies have demonstrated that low income and QOL are negatively related in the general population [64,65] and within cancer survivors [66]. The findings of this study are consonant with and add to the existing literature. Several limitations to our study should be noted. People older than 70 were under-represented in the study sample, which would likely affect the results. The present study and previous research have found that increasing age was positively associated with wellbeing [25,67]. The study was cross-sectional, so we could not assess changes over time, investigate determinants of QOL, or establish causal relationships. It is well established that weight loss and compromised nutritional status are issues for HNC survivors [30,31,36] and the analysis of individual QOL items shows that significantly more urban survivors have a problem with being able to eat as much food as they want. However, these factors were not explored fully in the analysis. Information about nutritional support in urban compared to rural areas could be conducted to determine what services are needed. In conclusion, this study explores the increasingly relevant topic of urban and rural variation in QOL with an under-researched group, HNC survivors. Future qualitative studies could explore social networks and behavioral norms around health in both urban and rural areas. In the meantime, policy makers and service providers may need to consider services that better address the physical, emotional, and HNC-specific needs of urban cancer survivors in Ireland.
Please cite this article in press as: Thomas AA et al. Quality of life in urban and rural settings: A study of head and neck cancer survivors. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.03.007
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Role of the funding sources The SuN study data collection was supported by a Health Research Board Project Grant (HRA/2009/262).This analysis was supported by Health Research Board Interdisciplinary Capacity Enhancement Award (ICE/2012/09). Conflict of interest statement None declared. Acknowledgements The SuN study was supported by a Health Research Board Project Grant (HRA/2009/262).This analysis was supported by Health Research Board Interdisciplinary Capacity Enhancement Award (ICE/2012/09). We thank Eamonn O’Leary at the National Cancer Registry Ireland for statistical advice. Geographic information system support was provided by Neil McCluskey and Sandra Deady at the National Cancer Registry Ireland. Finally, we are grateful to the tumor registration officers and data team at the National Cancer Registry Ireland who collected and processed the details of the patients with head and neck cancer who formed the study population. References [1] Malvezzi M, Bertuccio P, Levi F, et al. European cancer mortality predictions for the year 2013. Ann Oncol 2013;24:792–800. http://dx.doi.org/10.1093/ annonc/mdt010. [2] Siegel R, DeSantis C, Virgo K, et al. Cancer treatment and survivorship statistics, 2012. CA Cancer J Clin 2012;62:220–41. http://dx.doi.org/10.3322/caac.21149. [3] Maddams J, Utley M, Møller H. Projections of cancer prevalence in the United Kingdom, 2010–2040. Br J Cancer 2012;107:1195–202. http://dx.doi.org/ 10.1038/bjc.2012.366. [4] Rushton G, Peleg I, Banerjee A, et al. Analyzing geographic patterns of disease incidence: rates of late-stage colorectal cancer in Iowa. J Med Syst 2004;28:223–36. [5] Carsin AE, Sharp L, Comber H. Geographical, urban/rural and socioeconomic variations in nonmelanoma skin cancer incidence: a population-based study in Ireland. Br J Dermatol 2011;164:822–9. [6] Baade PD, Youlden DR, Coory MD, et al. Urban-rural differences in prostate cancer outcomes in Australia: what has changed. Med J Aust 2011;194:293–6. [7] Campbell NC, Elliott AM, Sharp L, et al. Rural and urban differences in stage at diagnosis of colorectal and lung cancers. Br J Cancer 2001;84:910–4. [8] Liff JM, Chow W-H, Greenberg RS. Rural–urban differences in stage at diagnosis Possible relationship to cancer screening. Cancer 1991;67:1454–9. [9] Baade PD, Dasgupta P, Aitken J, et al. Geographic remoteness and risk of advanced colorectal cancer at diagnosis in Queensland: a multilevel study. Br J Cancer 2011;105:1039–41. [10] Parikh-Patel A, Bates JH, Campleman S. Colorectal cancer stage at diagnosis by socioeconomic and urban/rural status in California, 1988–2000. Cancer 2006;107:1189–95. [11] Coory MD, Baade PD. Urban–rural differences in prostate cancer mortality, radical prostatectomy and prostate-specific antigen testing in Australia. Med J Aust 2005;182:112–5. [12] Campbell NC, Elliott AM, Sharp L, et al. Impact of deprivation and rural residence on treatment of colorectal and lung cancer. Br J Cancer 2002;87:585–90. [13] Singh GK, Williams SD, Siahpush M, et al. Socioeconomic, rural–urban, and racial inequalities in US cancer mortality: Part I – All cancers and lung cancer and Part II – Colorectal, prostate, breast, and cervical cancers. J Cancer Epidemiol 2012;2011:27. [14] Dasgupta P, Baade PD, Aitken JF, et al. Multilevel determinants of breast cancer survival: association with geographic remoteness and area-level socioeconomic disadvantage. Breast Cancer Res Treat 2012;132:701–10. [15] Campbell NC, Elliott AM, Sharp L, et al. Rural factors and survival from cancer: analysis of Scottish cancer registrations. Br J Cancer 2000;82:1863–6. [16] Cramb SM, Mengersen KL, Turrell G, et al. Spatial inequalities in colorectal and breast cancer survival: premature deaths and associated factors. Health Place 2012;18:1412–21. [17] Milgram S. The experience of living in cities. Science 1970;167:1461–8. [18] Wirth L. Urbanism as a way of life. Am J Sociol 1938;44:1–24. http:// dx.doi.org/10.2307/2768119. [19] Verheij RA, Maas J, Groenewegen PP. Urban–rural health differences and the availability of green space. Eur Urban Reg Stud 2008;15:307–16.
[20] Van den Berg AE, Maas J, Verheij RA, et al. Green space as a buffer between stressful life events and health. Soc Sci Med 2010;70:1203–10. http:// dx.doi.org/10.1016/j.socscimed.2010.01.002. [21] Lankila T, Näyhä S, Rautio A, et al. Health and well-being of movers in rural and urban areas – A grid-based analysis of northern Finland birth cohort 1966. Soc Sci Med 2013;76:169–78. http://dx.doi.org/10.1016/j.socscimed.2012.10.021. [22] Dhingra SS, Strine TW, Holt JB, et al. Rural–urban variations in psychological distress: findings from the behavioral risk factor surveillance system, 2007. Int J Public Health 2009;54:16–22. http://dx.doi.org/10.1007/s00038-009-0002-5. [23] Butow PN, Phillips F, Schweder J, et al. Psychosocial well-being and supportive care needs of cancer patients living in urban and rural/regional areas: a systematic review. Support Care Cancer 2012;20:1–22. [24] Burris JL, Andrykowski M. Disparities in mental health between rural and nonrural cancer survivors: a preliminary study. Psychooncology 2010;19:637–45. http://dx.doi.org/10.1002/pon.1600. [25] DiSipio T, Hayes SC, Newman B, et al. Does quality of life among breast cancer survivors one year after diagnosis differ depending on urban and non-urban residence? A comparative study. Health Qual Life Outcomes 2010;8:1–10. http://dx.doi.org/10.1186/1477-7525-8-3. [26] Reid-Arndt SA, Cox CR. Does rurality affect quality of life following treatment for breast cancer? J Rural Health 2010;26:402–5. [27] The World Bank. Data: Rural population (% of total population). Data. 2013.. [28] Mehanna Hm, Morton Rp. Patients’ views on the utility of quality of life questionnaires in head and neck cancer: a randomised trial. Clin Otolaryngol 2006;31:310–6. <10.1111/j.1749-4486.2006.01256.x>. [29] Macfarlane TV, Wirth T, Ranasinghe S, et al. Head and neck cancer pain: systematic review of prevalence and associated factors. J Oral Maxillofac Res 2012;3:e1. [30] Platek ME, Myrick E, McCloskey SA, et al. Pretreatment weight status and weight loss among head and neck cancer patients receiving definitive concurrent chemoradiation therapy: implications for nutrition integrated treatment pathways. Support Care Cancer 2013;21:2825–33. http:// dx.doi.org/10.1007/s00520-013-1861-0. [31] Larsson M, Hedelin B, Johansson I, et al. Eating problems and weight loss for patients with head and neck cancer: a chart review from diagnosis until one year after treatment. Cancer Nurs 2005;28:425–35. [32] Vissink A, Jansma J, Spijkervet FKL, et al. Oral sequelae of head and neck radiotherapy. Crit Rev Oral Biol Med 2003;14:199–212. http://dx.doi.org/ 10.1177/154411130301400305. [33] List MA, Mumby P, Haraf D, et al. Performance and quality of life outcome in patients completing concomitant chemoradiotherapy protocols for head and neck cancer. Qual Life Res 1997;6:274–84. http://dx.doi.org/10.1023/ A:1026419023481. [34] Fischer DJ, Villines D, Kim YO, et al. Anxiety, depression, and pain: differences by primary cancer. Support Care Cancer 2009;18:801–10. http://dx.doi.org/ 10.1007/s00520-009-0712-5. [35] Ravasco P, Monteiro-Grillo I, Vidal PM, et al. Cancer: disease and nutrition are key determinants of patients? quality of life. Support Care Cancer 2004;12:246–52. http://dx.doi.org/10.1007/s00520-003-0568-z. [36] Couch M, Lai V, Cannon T, et al. Cancer cachexia syndrome in head and neck cancer patients: Part I. Diagnosis, impact on quality of life and survival, and treatment. Head Neck 2007;29:401–11. http://dx.doi.org/10.1002/hed.20447. [37] Capuano G, Gentile PC, Bianciardi F, et al. Prevalence and influence of malnutrition on quality of life and performance status in patients with locally advanced head and neck cancer before treatment. Support Care Cancer 2009;18:433–7. http://dx.doi.org/10.1007/s00520-009-0681-8. [38] Spielman AI. Chemosensory function and dysfunction. Crit Rev Oral Biol Med 1998;9:267–91. http://dx.doi.org/10.1177/10454411980090030201. [39] Fumimoto H, Kobayashi K, Chang C-H, et al. Cross-cultural validation of an international questionnaire, the general measure of the functional assessment of cancer therapy scale (FACT-G), for Japanese. Qual Life Res 2001;10:701–9. http://dx.doi.org/10.1023/A:1013851216181. [40] Dapueto J, Francolino C, Servente L, et al. Evaluation of the functional assessment of cancer therapy-general (FACT-G) Spanish version 4 in South America: classic psychometric and item response theory analyses. Health Qual Life Outcomes 2003;1:32. [41] Winstead-Fry P, Schultz A. Psychometric analysis of the functional assessment of cancer therapy-general (FACT-G) scale in a rural sample. Cancer 1997;79:2446–52. http://dx.doi.org/10.1002/(SICI)10970142(19970615)79:12<2446::AID-CNCR23>3.0.CO;2-Q. [42] List MA, D’Antonio LL, Cella DF, et al. The performance status scale for head and neck cancer patients and the functional assessment of cancer therapyhead and neck scale: A study of utility and validity. Cancer 1996;77:2294–301. http://dx.doi.org/10.1002/(SICI)1097-0142(19960601)77:11<2294::AIDCNCR17>3.0.CO;2-S. [43] FACIT. Functional Assessment of Chronic Illness Therapy (FACIT) Questionnaires. . [44] Teljeur C, Kelly A. An urban–rural classification for health services research in Ireland. Ir Geogr 2008;41:295–311. http://dx.doi.org/10.1080/ 00750770802506972. [45] Ireland, Central Statistics Office. This is Ireland: highlights from Census 2011, part 1. Dublin: Stationery Office; 2012. [46] National Cancer Registry, Northern Ireland Cancer Registry. All-Ireland Cancer Atlas 1995–2007. 2011. .
Please cite this article in press as: Thomas AA et al. Quality of life in urban and rural settings: A study of head and neck cancer survivors. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.03.007
A.A. Thomas et al. / Oral Oncology xxx (2014) xxx–xxx [47] Sharp L, Donnelly D, Hegarty A, et al. Risk of several cancers is higher in urban areas after adjusting for socioeconomic status, Results from a two-country population-based study of 18 common cancers. J Urban Health 2014:1–16. http://dx.doi.org/10.1007/s11524-013-9846-3. [48] Hall A, Campbell HS, Sanson-Fisher R, et al. Unmet needs of Australian and Canadian haematological cancer survivors: a cross-sectional international comparative study. Psychooncology 2013;22:2032–8. http://dx.doi.org/ 10.1002/pon.3247. [49] Campbell HS, Sanson-Fisher R, Turner D, et al. Psychometric properties of cancer survivors’ unmet needs survey. Support Care Cancer 2011;19:221–30. http://dx.doi.org/10.1007/s00520-009-0806-0. [50] Mehanna Hm, Morton Rp. Deterioration in quality-of-life of late (10-year) survivors of head and neck cancer. Clin Otolaryngol 2006;31:204–11. <10.1111/j.1749-4486.2006.01188.x>. [51] Van Lente E, Barry MM, Molcho M, et al. Measuring population mental health and social well-being. Int J Public Health 2012;57:421–30. http://dx.doi.org/ 10.1007/s00038-011-0317-x. [52] Schultz AA, Winstead-Fry P. Predictors of quality of life in rural patients with cancer. Cancer Nurs 2001;24:12–9. [53] Kroneman M, Verheij R, Tacken M, et al. Urban–rural health differences: primary care data and self reported data render different results. Health Place 2010;16:893–902. [54] Larson SL, Fleishman JA. Rural–urban differences in usual source of care and ambulatory service use: analyses of national data using urban influence codes. Med Care 2003;41:III65–74. http://dx.doi.org/10.2307/376769. [55] Weinert C, Long KA. Understanding the health care needs of rural families. Fam Relations 1987;36:450–5. [56] Judd F, Jackson H, Komiti A, et al. Help-seeking by rural residents for mental health problems: the importance of agrarian values. Aust N Z J Psychiatry 2006;40:769–76. http://dx.doi.org/10.1111/j.1440-1614.2006.01882.x. [57] White KJC, Guest AM. Community lost or transformed? urbanization and social ties. City Community 2003;2:239–59. http://dx.doi.org/10.1111/15406040.00053.
7
[58] Finke Roger, Guest Avery M, Stark Rodney. Mobilizing local religious markets: Religious pluralism in the Empire State, 1855–1865. Am Sociol Rev 1996;61:203–18. [59] Fischer CS. The subcultural theory of urbanism: a twentieth-year assessment. Am J Sociol 1995;101:543–77. http://dx.doi.org/10.2307/2781994. [60] Fischer CS. Toward a subcultural theory of urbanism. Am J Sociol 1975;80:1319–41. http://dx.doi.org/10.2307/2777297. [61] Bell ML, Butow PN, Goldstein D. Informatively missing quality of life and unmet needs sex data for immigrant and Anglo-Australian cancer patients and survivors. Qual Life Res;:1–4.. [62] Cheung YB, Daniel R, Ng GY. Response and non-response to a quality-of-life question on sexual life: a case study of the simple mean imputation method. Qual Life Res 2006;15:1493–501. [63] Fayers PM, Curran D, Machin D. Incomplete quality of life data in randomized trials: missing items. Stat Med 1998;17:679–96. http://dx.doi.org/10.1002/ (SICI)1097-0258(19980315/15)17:5/7<679::AID-SIM814>3.0.CO;2-X. [64] Burström K, Johannesson M, Diderichsen F. Health-related quality of life by disease and socio-economic group in the general population in Sweden. Health Policy 2001;55:51–69. [65] Lahana E, Pappa E, Niakas D. The impact of ethnicity, place of residence and socioeconomic status on health-related quality of life: results from a Greek health survey. Int J Public Health 2010;55:391–400. http://dx.doi.org/10.1007/ s00038-010-0171-2. [66] Movsas B, Scott C, Watkins-Bruner D. Pretreatment factors significantly influence quality of life in cancer patients: a radiation therapy oncology group (RTOG) analysis. Int J Radiat Oncol Biol Phys 2006;65:830–5. http:// dx.doi.org/10.1016/j.ijrobp.2006.01.004. [67] Bloom JR, Petersen DM, Kang SH. Multi-dimensional quality of life among long-term (5+ years) adult cancer survivors. Psychooncology 2007;16: 691–706. http://dx.doi.org/10.1002/pon.1208.
Please cite this article in press as: Thomas AA et al. Quality of life in urban and rural settings: A study of head and neck cancer survivors. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.03.007
Contents lists available at ScienceDirect
Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology
Quality of life in urban and rural settings: A study of head and neck cancer survivors Audrey Alforque Thomas a,⇑, Aileen Timmons b, Michal Molcho c, Alison Pearce b, Pamela Gallagher d, Phyllis Butow e, Eleanor O’Sullivan f, Rachael Gooberman-Hill g, Ciaran O’Neill h, Linda Sharp b a
Health Promotion Research Centre, Aras na Coiribe, National University of Ireland, Galway, Ireland National Cancer Registry Ireland, Building 6800, Cork Airport Business Park, Kinsale Road, Cork, Ireland National University of Ireland, School of Health Sciences, Galway, Ireland d School of Nursing and Human Sciences, Dublin City University, Glasnevin, Dublin 9, Ireland e Centre for Medical Psychology & Evidence-based Decision-making, University of Sydney, Australia f Cork University Dental School and Hospital, Wilton, Co. Cork, Ireland g School of Clinical Sciences, University of Bristol, Southmead Hospital BS10 5NB, United Kingdom h School of Business and Economics, National University of Ireland, Galway, Ireland b c
a r t i c l e
i n f o
Article history: Received 12 December 2013 Received in revised form 12 February 2014 Accepted 23 March 2014 Available online xxxx Keywords: Head and neck cancer Survivorship Rural health Urban Quality of life Ireland
s u m m a r y Objective: Urban–rural variation in cancer incidence, treatment, and clinical outcomes has been well researched. With the growing numbers and longer lifespan of cancer survivors, quality of life (QOL) is now a critical issue. The present study investigates the QOL of head and neck cancer (HNC) survivors in Ireland, paying special attention to urban and rural variation. Methods: From the population-based National Cancer Registry Ireland, we identified 991 survivors of HNC (ICD10 C00-C14, C32), who were at least eight months post-diagnosis, and invited them to complete a postal survey. We used self-reported data and information from the Registry to create a composite variable classifying respondents’ current area of residence as ‘‘urban’’ or ‘‘rural.’’ Respondents self-reported QOL using the Functional Assessment for Cancer Therapy with Head and Neck module (FACT-HN). We used bootstrap linear regression to control for confounding variables, while estimating the association of urban and rural residence to FACT-HN domain scores. Results: We obtained survey and Registry data from 583 HNC survivors. Controlling for demographic and clinical variables, rural survivors reported higher physical (coefficient 1.27, bias-corrected and accelerated 95% confidence interval 0.54, 2.43), emotional (coef. 0.99, 95% CI 0.21, 2.02), and HNC-specific (coef. 1.55, 95% CI 0.32, 3.54) QOL than their urban counterparts. Social and functional QOL did not differ significantly. Conclusions: These findings add to growing evidence of important differences in life experiences of cancers survivors in urban and rural settings. Results such as these will allow health professionals, policy makers and service providers to better serve these populations. Ó 2014 Elsevier Ltd. All rights reserved.
Introduction Cancer incidence has been rising while cancer-related mortality has been decreasing, resulting in growing numbers of cancer survivors [1–3]. While researchers have explored urban–rural variations in the clinical aspects of cancer, survivors’ quality of life (QOL) has remained an ancillary focus. The large body of cancer research on ⇑ Corresponding author. Address: Health Promotion Research Centre, Aras na Coiribe, National University of Ireland, Galway, Ireland. Tel.: +353 (0)91 494181; fax: +353 (0)91 494547. E-mail address: [email protected] (A.A. Thomas).
urban and rural differences has mainly focused on incidence [4–6], diagnosis [7–10], treatment [11,12], and survival [13–16]. There is an emerging need for further research about urban–rural variation in cancer survivors’ life experiences after the completion of treatment. From the time urbanism was first studied, social scientists postulated the negative effect of the city on psychosocial wellbeing [17,18]. Following from this tradition, recent studies on the general population find a rural advantage in terms of physical and mental health [19–22]. However, extant research on cancer survivors suggests that living in a rural area is associated with poorer psychosocial wellbeing [23]. It has been suggested that the cost
http://dx.doi.org/10.1016/j.oraloncology.2014.03.007 1368-8375/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Thomas AA et al. Quality of life in urban and rural settings: A study of head and neck cancer survivors. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.03.007
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and time involved in traveling to hospitals to attend appointments with healthcare professionals may preclude some rural cancer survivors from receiving services, thereby resulting in poorer QOL. Specifically, mental health has been shown to be poorer for rural breast, hematologic, and colorectal survivors [24]. QOL, both health-related and breast cancer-specific, has also been shown to be poorer for rural than urban survivors [25,26]. Most of this work has been conducted in the United States and Australia, with an emerging literature in Canada and Scotland. Understanding the unique aspects of rural cancer survivorship is especially pertinent in Ireland, which is unique among more economically developed countries in that a significant portion of its population (37%) lives in rural areas [27]. In the United States, Australia, the United Kingdom, and Canada, less than one-fifth the population lives in rural areas [27]. A further limitation of the existing evidence base around QOL is that the majority of studies focus on survivors of the most common cancers – breast, colorectal, and prostate cancer. Less is known about the post-treatment life experiences of survivors with less common, but potentially more burdensome, cancers. Survivors of head and neck cancer (HNC) are an important group to consider because the treatment and the cancer itself may have immense and long-lasting effects on the everyday lives of survivors [28]. Research indicates that pain [29], compromised nutritional status, and weight loss [30,31] are common issues among HNC survivors. Radiotherapy, a standard and important treatment for HNC, may cause short-term issues such as taste loss, as well as irreversible side effects such as difficulty swallowing [32]. Studies show that HNC survivors’ QOL can be adversely affected by pain [33,34], compromised nutritional status [35–37], and eating problems [38]. Although there is growing interest in HNC survivors’ QOL, little attention has been paid to urban–rural variation. Investigating this is important because potential support services, including speech therapists, dieticians, and dentists, may not be locally available for rural HNC survivors. The present study aimed to extend the existing evidence base by identifying the magnitude and significance of differences in various QOL domains for urban versus rural HNC survivors in Ireland. Patients and methods Participants and procedures In April 2012, we identified individuals eligible for the study from the National Cancer Registry Ireland, which aims to record all incident primary cancers of people usually resident in the Republic of Ireland. Eligibility criteria were: (1) 18 years or older at the time of diagnosis, (2) a stage I–III head and neck cancer (ICD 10 C00-C14, C32), (3) at least eight months post-diagnosis, and (4) treated in one or more of 14 hospitals throughout Ireland, which included all of the major treating centers for HNC. The treating consultant of each survivor confirmed that the individual was alive, was aware they had cancer, had completed treatment, was considered disease-free, and that there was no medical or other reason why it would be inappropriate to contact the potential participant about the study. We posted surveys with explanatory letters, information sheets, and consent forms to 991 eligible individuals. The research ethics committee for each of the participating hospitals approved the study. Measures The outcome variables for this analysis were derived from the Functional Assessment of Cancer Therapy (FACT-G), a QOL measure validated for use in different countries [39,40] and with rural
populations [41]. We used the component on concerns specific to HNC survivors (FACT-HN), which is also validated and widely used [42]. This instrument measures five domains: physical, social/family, emotional, functional, and HNC-specific. Participants were asked to rate 39 QOL statements as they applied in the 7 days prior to taking the survey. The domain scores were calculated in SPSS version 20.0, using a scoring program from the organization that produced FACT-HN [43]. Respondents must have answered at least half of the questions in a domain to be included in the subscale score for that domain. A higher domain score indicates higher QOL. In their research on Irish geographical areas and health outcomes, Teljeur and Kelley [44] encourage the use of multiple measures to classify rural and urban. We therefore created a composite variable using three component variables to categorize survivors as ‘‘urban’’ or ‘‘rural.’’ For the composite measure, if a participant was classified as ‘‘rural’’ for at least two of these three component variables, then we classified them as ‘‘rural’’ for the composite measure. The first component variable, self-reported area where the participant was living at the time of the survey, was a measure of settlement size. In keeping with the Irish Census Office definition of rural [45], we coded responses ‘‘Dublin city/ county,’’ ‘‘City other than Dublin,’’ and ‘‘Town (1500+)’’ as ‘‘urban.’’ We coded ‘‘Village’’ and ‘‘Open country’’ as ‘‘rural.’’ The second component variable was distance from the participant’s current residence to the hospital of his/her treating consultant, which we obtained from the Registry. The last tertile of distance (P49.88 km) was classified as ‘‘rural,’’ while ‘‘<49.88 km’’ was classified as ‘‘urban.’’ The third component variable was population density of the area in which the survivor lived at the time of the survey, based on 2006 census small-area population figures. In this variable, we considered ‘‘<1 person per hectare’’ as ‘‘rural,’’ and ‘‘P1 person per hectare’’ as ‘‘urban.’’ This classification has been used in Ireland in previous studies [46,47]. We obtained data on gender, age at the time of the survey, cancer site, chemotherapy, radiotherapy, surgery, and stage at diagnosis from the National Cancer Registry Ireland. We used participants’ survey responses as the source of information on marital status, education level, whether the respondents’ cancer had returned or spread, and whether the individual had a medical card at the time of diagnosis. In Ireland, a medical card entitles the holder to free or substantially-subsidized health care. Having a medical card is a proxy for income since eligibility for a medical card is means-tested. Eligibility is less stringent for people over 70, but still means-tested. Statistical analysis We compared respondents and non-respondents on demographic and clinical variables. Then we examined urban–rural variation on those variables within respondents using chi-square tests. We used the non-parametric Wilcoxon–Mann–Whitney test to determine if there was a difference between urban and rural participants’ age at survey. The FACT domain scores were skewed, so we conducted tests of significant group differences (rural versus urban) using Wilcoxon–Mann–Whitney tests. We developed bootstrap linear regression models to investigate associations between the composite urban–rural variable and each FACT domain, controlling for demographic and clinical characteristics. We used bias-corrected and accelerated confidence intervals to determine significance (at the p < 0.05 level), which account for the skewness of the scores. We conducted a sensitivity analysis in which we re-ran the regression models using each of the component urban–rural variables, and compared the results to those obtained for the composite variable. Due to the small number of respondents with lip cancer (n = 7), we excluded them from the regression analyses.
Please cite this article in press as: Thomas AA et al. Quality of life in urban and rural settings: A study of head and neck cancer survivors. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.03.007
A.A. Thomas et al. / Oral Oncology xxx (2014) xxx–xxx
Following methods of researchers working on unmet support needs of cancer survivors [48,49], we examined urban–rural differences on each FACT question. For each item, we coded the two responses indicating the lowest scores as ‘‘low score’’; all other response were considered not to indicate a low score. For example, a low score for the item ‘‘My mouth is dry,’’ were the responses, ‘‘Quite a bit’’ or ‘‘Very much.’’ However, for the item, ‘‘I feel close to my friends’’ the responses, ‘‘A little bit,’’ or ‘‘Not at all’’ indicated a low score. We calculated the percentage of respondents with a low score for each item, and compared urban and rural survivors on each item using chi-square tests. We performed all statistical analyses using Stata, version 12.1. Results Study sample
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were more concerned with their relationships with their friends than rural dwellers: the two items about friends, ‘‘I get support from my friends’’ (v2 (df) = 4.11(1), p = 0.043) and ‘‘I feel close my friends’’ (v2 (df) = 4.81(1), p = 0.028) showed significantly lower scores for urban versus rural survivors. In addition, urban dwellers reported lower scores on the item, ‘‘I am able to eat as much food as I want’’ (v2 (df) = 4.03(1), p = 0.045). FACT domain scores Table 3 summarizes the statistics for the FACT domains for the entire sample and by urban and rural residence. Rural cancer survivors reported better emotional (Wilcoxon–Mann–Whitney z-score = 2.80, p = 0.005), functional (z-score = 2.38, p = 0.018), and HNC-specific (z-score = 2.06, p = 0.039) QOL than their urban counterparts. Physical and social domain scores did not significantly differ for rural versus urban respondents.
Of the 991 individuals invited to participate, 583 survivors (58.8% response rate) returned completed surveys. There were no statistically significant differences between responders and nonresponders in terms of gender, cancer site, stage at diagnosis, or time since diagnosis. However, the proportion of people older than 65 years old was lower in the respondent group (26.6%) than in the non-respondent group (35.5%, p-value = 0.012). Two-thirds of the respondents were men (n = 392, 67.2%). About half of the respondents had a medical card (n = 272, 48.1%). Mean age at survey completion was 63.0 years (SD = 11.4; range = 28–92 years). Most of the respondents were married or cohabiting (n = 413, 71.5%). Approximately one-fifth of the respondents reported completing third level or post-graduate education (n = 121, 21.4%). The site of the primary tumor was: lip (n = 7, 1.2%), mouth (n = 242, 41.5%), salivary glands (n = 44, 7.6%), pharynx (n = 112, 19.2%), and larynx (n = 178, 30.5%). The majority of respondents reported no tumor progression or recurrence by the time of survey completion (n = 516, 93.8%). A previous study of long-term HNC survivors shows no relationship between QOL and treatment-related factors [50], and, in this study, no statistically significant differences were found between urban and rural survivors in terms of stage at diagnosis and treatment (data not shown), so these variables were not included in the model. On the basis of the composite variable, 37% (n = 214) of the participants were ‘‘rural’’ and 63% (n = 361) were ‘‘urban.’’ No statistically significant differences emerged between rural and urban respondents on demographic and clinical variables (Table 1), with the exception of a higher proportion of rural participants who were married/cohabiting as compared with urban participants (p = 0.049).
Table 4 shows the results of five separate bootstrap linear regression models used to determine factors associated with each of the domain scores. For emotional and HNC-specific QOL, the lower scores for urban subjects seen in the bivariate analyses held even when controlling for demographic and clinical variables. In addition, the regression analysis showed significantly lower scores for urban survivors in the physical domain. However, functional QOL was no longer significantly associated with living in a rural area. The sensitivity analysis showed that the regression coefficients of the component variables used to measure ‘‘urban’’ and ‘‘rural’’ were broadly similar to the coefficients for the composite variable. The magnitude of the effects were slightly different, but the overall associations were consistent across these variables (data not shown). As for other factors associated with QOL, female respondents had significantly higher social but lower emotional domain scores. Possession of a medical card at the time of diagnosis had a significant negative relationship with all domains except social QOL. Being married or cohabiting was significantly positively associated with social and functional domains. Respondents with higher levels of education had higher physical and HNC-specific, but lower social domain scores. Increasing age was significantly associated with higher physical and emotional scores. In terms of clinical variables, for survivors whose cancer had returned or spread showed a significant negative association with physical, emotional, and HNC-specific QOL. Compared to respondents with larynx cancer, those with pharynx cancer reported lower scores in physical and HNC-specific QOL.
Individual QOL items
Discussion
HNC-specific concerns dominated the top QOL issues for survivors. Over one-third of respondents had problems with dry mouth (n = 200, 38.0%) or with the quality and strength of their voice (n = 182, 35.0%). Approximately one-quarter also had trouble swallowing naturally and easily (n = 150, 28.3%) and with the amount they could eat (n = 125, 23.9%). Lack of energy also emerged as an important issue (n = 150, 28.4%). A large proportion of those who answered the sexual question reported a low score (n = 103, 42.0%). Differences in QOL issues emerged between urban and rural survivors (Table 2). For each item on which there was a statistically significant difference, urban dwellers had a lower score. Urban survivors more often had lower scores on the item ‘‘My work (including at home) is fulfilling’’ (v2 (df) = 7.28(1), p = 0.007). They
Important differences in QOL between urban and rural cancer survivors emerged from this study. Controlling for demographic and clinical variables, HNC survivors in rural Ireland are more likely to report higher physical, emotional, and HNC-specific QOL than those living in urban areas. These findings are consonant with studies on the general population [19–21], including in the Irish context [51], that suggest a rural advantage in terms of psychosocial wellbeing. However, the findings run counter to previous QOL research on cancer survivors, which points to a rural disadvantage [23–26]. More rural respondents were married or cohabiting compared to urban respondents, which could contribute to the higher emotional, functional, and HNC-specific scores in the bivariate analysis. Being married or cohabiting was positively associated
Factors associated with FACT domain scores
Please cite this article in press as: Thomas AA et al. Quality of life in urban and rural settings: A study of head and neck cancer survivors. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.03.007
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A.A. Thomas et al. / Oral Oncology xxx (2014) xxx–xxx
Table 1 Demographic and clinical characteristics of urban and rural head and neck cancer survivors.a Demographics
a b c d
Urban (n = 361)
Rural (n = 214)
p-Value
n
%
n
%
Sexb Female Male
117 244
32.4 67.6
71 143
33.2 66.8
Medical card at diagnosisc Yes No
171 179
48.9 51.1
95 112
45.9 54.1
Marital statusc With a partner Not with a partner Age at surveyb – mean (SD)
246 112 62.7 (11.5)
68.7 31.3
162 50 63.4 (11.4)
76.4 23.6
Highest level of education completedc Primary or secondary Third level or post-graduate
272 79
77.5 22.5
165 42
79.7 20.3
Cancer returned or spreadc Yes No
17 322
5.0 95.0
17 187
8.33 91.7
Cancer siteb,d Larynx Lip Mouth Pharynx Salivary glands
104 4 166 66 21
28.8 1.1 46.0 18.3 5.8
72 2 74 45 21
33.6 0.9 34.6 21.0 9.8
0.850
0.499
0.049
0.361 0.539
0.122
0.069
Based on 575 respondents. We could not categorize 8 respondents due to missing data. National cancer registry data. Self-reported. ICD 10 C00-C14, C32.
Table 2 FACT items on which urban and rural cancer survivors have significantly different scores, number and percent of those who are experiencing a problem with each item. Item (Domain)
Urban
My work (including at home) is fulfilling (functional) I am able to eat as much food as I want (HNC-specific) I get support from my friends (social) I feel close to my friends (social) I am content with the quality of my life right now (functional) I am able to enjoy life (functional) I feel close to my partner (or the person who is my main support) (social) I have pain (physical) I have pain in my mouth, throat, or neck (HNC-specific) I feel sad (emotional) I am forced to spend time in bed (physical) I have nausea (physical) I feel ill (physical) a b
Rural
n
%
n
%
86 88 85 81 63 54 50 50 45 38 34 24 20
27.7 26.8 26.2 24.4 19.1 16.4 16.0 15.8 13.7 12.8 10.5 7.5 6.2
32 36 34 31 24 16 15 14 14 10 8 5 4
17.1 19.0 18.3 16.2 12.4 8.3 8.4 7.6 7.3 5.9 4.3 2.8 2.2
chi-square statistic
p-Value
7.28 4.03 4.11 4.81 3.89 6.85 5.79 7.03 4.92 5.46 6.10 4.82 4.25
0.007b 0.045a 0.043a 0.028a 0.049a 0.009b 0.016a 0.008b 0.026a 0.019a 0.013a 0.028a 0.039a
Significant at p < 0.05. Significant at p < 0.01.
Table 3 Urban and rural head and neck cancer survivors’ median and interquartile range for FACT domain scores.
Physical domain Social domain Emotional domain Functional domain Head and neck specific domain a
All respondents
Urban
Rural
Urban–rural comparison
Median
Interquartile range
n
Median
Interquartile range
n
Median
Interquartile range
25.0 21.0 20.0 21.0 30.0
20.0–28.0 16.8–25.7 17.0–23.0 15.2–26.0 22.2–35.0
327 332 302 329 333
25.0 21.0 20.0 20.0 29.0
19.0–28.0 16.3–25.7 17.0–23.0 15.0–25.0 22.0–35.0
189 189 173 195 194
25.0 22.2 21.0 22.0 31.0
21.0–28.0 18.0–25.7 19.0–23.0 16.0–26.6 23.0–35.6
z-Scorea
p-Value
1.84 1.36 2.80 2.38 2.06
0.066 0.173 0.005⁄⁄ 0.018⁄ 0.039⁄
Test statistic for Wilcoxon–Mann–Whitney.
with the social and functional domains in the multivariate analysis. These results were in accordance with a study of cancer survivors in the rural United States, which found that divorce had a negative effect on wellbeing [52].
The extant literature suggests that people living in rural areas are more stoic about their health [53–56]. In our study, significantly fewer rural survivors reported problems with pain or being able to eat as much as they like. Moreover, controlling for
Please cite this article in press as: Thomas AA et al. Quality of life in urban and rural settings: A study of head and neck cancer survivors. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.03.007
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A.A. Thomas et al. / Oral Oncology xxx (2014) xxx–xxx Table 4 Bootstrap linear regression coefficients with bias-corrected and accelerated confidence intervals for FACT domain scores. Physical
Social BCA 95% CI
Coef
Lower
Upper
Emotional BCA 95% CI
Coef
Lower
Upper
Functional
BCA 95% CI Coef
Lower
Upper
Head and neck
BCA 95% CI Coef
Lower
Upper
BCA 95% CI Coef
Lower
Upper
1.27
0.54
2.43a
0.89
0.18
2.32
0.99
0.21
2.02a
1.41
0.10
2.79
1.55
0.32
3.54a
0.22
1.00
1.50
1.64
0.12
2.62a
1.15
1.96
0.17a
0.56
0.94
1.82
0.91
0.59
2.83
1.78
2.85
0.23a
0.79
2.11
0.24
1.63
2.50
0.62a
2.44
3.70
0.98a
2.24
3.87
0.82a
0.42
0.71
2.17
2.36
0.96
3.78a
0.18
0.79
0.66
1.76
0.38
3.42a
1.10
0.56
2.96
1.96
0.77
3.08a
1.51
3.46
0.32a
0.61
0.23
1.67
0.69
1.17
2.23
2.62
0.84
4.63a
Age at survey (continuous)
0.10
0.06
0.14a
0.03
0.03
0.08
0.07
0.03
0.12a
0.04
0.01
0.11
0.04
0.01
0.11
Cancer returned or spread Yes No (reference)
3.77
6.10
1.67a
0.44
1.60
2.24
1.93
4.15
0.21a
2.22
5.29
0.08
4.34
7.30
1.74a
Cancer type Salivary glands Mouth Pharynx Larynx (reference)
0.54 0.60 2.09
1.25 1.13 3.61
2.47 1.46 0.63a
0.85 0.85 0.93
0.21 0.21 2.79
2.34 2.34 0.61
1.22 0.37 0.29
0.17 0.84 1.42
2.71 1.20 1.26
1.65 1.38 1.00
1.31 0.12 2.54
4.08 3.01 1.68
0.96 0.96 5.38
2.64 2.64 7.72
1.07 1.07 3.50a
Rural Urban (reference) Female Male (reference) Medical card Yes No (reference) Married or cohabiting Not married/cohabiting (reference) Highest education Third level Primary or secondary (reference)
Coef, coefficient; BCA, bias-corrected and accelerated; CI, confidence interval. a Significant at p < 0.05.
confounding variables, rural survivors had higher scores in the domains of physical and HNC-specific QOL. Another way that the urban and rural communities may differ is in their network structures. Voluntary relationships (e.g. friendships) may be important to urban dwellers because the heterogeneity and critical mass of people in cities allows urban dwellers to associate based on common interests [57–60]. This would account for the finding that significantly more urban cancer survivors were concerned about feeling close to and receiving support from their friends. Despite these differences, urban and rural cancer survivors share many of the same QOL issues. Issues already documented in the literature were affirmed in this study: compromised vocal quality, problems with eating, and lack of energy. An issue brought to light in this study and not prominent in the previous literature on QOL of HNC survivors, is the importance of satisfaction with sex life. While there are some methodological issues to consider regarding missing data on sex questions [61–63], those who answered this question overwhelmingly voiced their dissatisfaction with their sex life. Possible explanations are suggested in by theories about urban– rural differences in health. The Biophilia Hypothesis, the idea that green space is therapeutic [19,20], would explain why rural cancer survivors have higher scores in the emotional domain than urban cancer survivors. The Drifter Hypothesis, the tendency for ill people to move to urban center, in part for access to specialized medical care [21], would account for the higher physical and HNC-specific QOL in rural areas. The way rural and urban are measured imply different explanations for the relationship to QOL. For example, using distance to an urban center as a measure implies that the influence of the city is related to how closely one resides to that city. Categorizing areas based on population density could suggest that green space is an important factor. A composite variable, such as the one used in this study, gives a holistic measure of urbanicity and rurality. Rather than privileging one type of measurement over another, a composite variable attempts to capture idea of urban
and rural. In this way, a composite variable is more relevant to the norms and culture of each area. Having said this, it was noteworthy that in our sensitivity analysis, in which we examined associations between each of the component variables and QOL domains, the results were broadly similar to those we obtained with the composite variable. Possession of a medical card at the time of diagnosis, which was used as a proxy for low income, was negatively related to all QOL domains except social. Low-income survivors may not be able to pay for or take time off of work for physical therapy or counseling services after cancer treatment. Previous studies have demonstrated that low income and QOL are negatively related in the general population [64,65] and within cancer survivors [66]. The findings of this study are consonant with and add to the existing literature. Several limitations to our study should be noted. People older than 70 were under-represented in the study sample, which would likely affect the results. The present study and previous research have found that increasing age was positively associated with wellbeing [25,67]. The study was cross-sectional, so we could not assess changes over time, investigate determinants of QOL, or establish causal relationships. It is well established that weight loss and compromised nutritional status are issues for HNC survivors [30,31,36] and the analysis of individual QOL items shows that significantly more urban survivors have a problem with being able to eat as much food as they want. However, these factors were not explored fully in the analysis. Information about nutritional support in urban compared to rural areas could be conducted to determine what services are needed. In conclusion, this study explores the increasingly relevant topic of urban and rural variation in QOL with an under-researched group, HNC survivors. Future qualitative studies could explore social networks and behavioral norms around health in both urban and rural areas. In the meantime, policy makers and service providers may need to consider services that better address the physical, emotional, and HNC-specific needs of urban cancer survivors in Ireland.
Please cite this article in press as: Thomas AA et al. Quality of life in urban and rural settings: A study of head and neck cancer survivors. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.03.007
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A.A. Thomas et al. / Oral Oncology xxx (2014) xxx–xxx
Role of the funding sources The SuN study data collection was supported by a Health Research Board Project Grant (HRA/2009/262).This analysis was supported by Health Research Board Interdisciplinary Capacity Enhancement Award (ICE/2012/09). Conflict of interest statement None declared. Acknowledgements The SuN study was supported by a Health Research Board Project Grant (HRA/2009/262).This analysis was supported by Health Research Board Interdisciplinary Capacity Enhancement Award (ICE/2012/09). We thank Eamonn O’Leary at the National Cancer Registry Ireland for statistical advice. Geographic information system support was provided by Neil McCluskey and Sandra Deady at the National Cancer Registry Ireland. Finally, we are grateful to the tumor registration officers and data team at the National Cancer Registry Ireland who collected and processed the details of the patients with head and neck cancer who formed the study population. References [1] Malvezzi M, Bertuccio P, Levi F, et al. European cancer mortality predictions for the year 2013. Ann Oncol 2013;24:792–800. http://dx.doi.org/10.1093/ annonc/mdt010. [2] Siegel R, DeSantis C, Virgo K, et al. Cancer treatment and survivorship statistics, 2012. CA Cancer J Clin 2012;62:220–41. http://dx.doi.org/10.3322/caac.21149. [3] Maddams J, Utley M, Møller H. Projections of cancer prevalence in the United Kingdom, 2010–2040. Br J Cancer 2012;107:1195–202. http://dx.doi.org/ 10.1038/bjc.2012.366. [4] Rushton G, Peleg I, Banerjee A, et al. Analyzing geographic patterns of disease incidence: rates of late-stage colorectal cancer in Iowa. J Med Syst 2004;28:223–36. [5] Carsin AE, Sharp L, Comber H. Geographical, urban/rural and socioeconomic variations in nonmelanoma skin cancer incidence: a population-based study in Ireland. Br J Dermatol 2011;164:822–9. [6] Baade PD, Youlden DR, Coory MD, et al. Urban-rural differences in prostate cancer outcomes in Australia: what has changed. Med J Aust 2011;194:293–6. [7] Campbell NC, Elliott AM, Sharp L, et al. Rural and urban differences in stage at diagnosis of colorectal and lung cancers. Br J Cancer 2001;84:910–4. [8] Liff JM, Chow W-H, Greenberg RS. Rural–urban differences in stage at diagnosis Possible relationship to cancer screening. Cancer 1991;67:1454–9. [9] Baade PD, Dasgupta P, Aitken J, et al. Geographic remoteness and risk of advanced colorectal cancer at diagnosis in Queensland: a multilevel study. Br J Cancer 2011;105:1039–41. [10] Parikh-Patel A, Bates JH, Campleman S. Colorectal cancer stage at diagnosis by socioeconomic and urban/rural status in California, 1988–2000. Cancer 2006;107:1189–95. [11] Coory MD, Baade PD. Urban–rural differences in prostate cancer mortality, radical prostatectomy and prostate-specific antigen testing in Australia. Med J Aust 2005;182:112–5. [12] Campbell NC, Elliott AM, Sharp L, et al. Impact of deprivation and rural residence on treatment of colorectal and lung cancer. Br J Cancer 2002;87:585–90. [13] Singh GK, Williams SD, Siahpush M, et al. Socioeconomic, rural–urban, and racial inequalities in US cancer mortality: Part I – All cancers and lung cancer and Part II – Colorectal, prostate, breast, and cervical cancers. J Cancer Epidemiol 2012;2011:27. [14] Dasgupta P, Baade PD, Aitken JF, et al. Multilevel determinants of breast cancer survival: association with geographic remoteness and area-level socioeconomic disadvantage. Breast Cancer Res Treat 2012;132:701–10. [15] Campbell NC, Elliott AM, Sharp L, et al. Rural factors and survival from cancer: analysis of Scottish cancer registrations. Br J Cancer 2000;82:1863–6. [16] Cramb SM, Mengersen KL, Turrell G, et al. Spatial inequalities in colorectal and breast cancer survival: premature deaths and associated factors. Health Place 2012;18:1412–21. [17] Milgram S. The experience of living in cities. Science 1970;167:1461–8. [18] Wirth L. Urbanism as a way of life. Am J Sociol 1938;44:1–24. http:// dx.doi.org/10.2307/2768119. [19] Verheij RA, Maas J, Groenewegen PP. Urban–rural health differences and the availability of green space. Eur Urban Reg Stud 2008;15:307–16.
[20] Van den Berg AE, Maas J, Verheij RA, et al. Green space as a buffer between stressful life events and health. Soc Sci Med 2010;70:1203–10. http:// dx.doi.org/10.1016/j.socscimed.2010.01.002. [21] Lankila T, Näyhä S, Rautio A, et al. Health and well-being of movers in rural and urban areas – A grid-based analysis of northern Finland birth cohort 1966. Soc Sci Med 2013;76:169–78. http://dx.doi.org/10.1016/j.socscimed.2012.10.021. [22] Dhingra SS, Strine TW, Holt JB, et al. Rural–urban variations in psychological distress: findings from the behavioral risk factor surveillance system, 2007. Int J Public Health 2009;54:16–22. http://dx.doi.org/10.1007/s00038-009-0002-5. [23] Butow PN, Phillips F, Schweder J, et al. Psychosocial well-being and supportive care needs of cancer patients living in urban and rural/regional areas: a systematic review. Support Care Cancer 2012;20:1–22. [24] Burris JL, Andrykowski M. Disparities in mental health between rural and nonrural cancer survivors: a preliminary study. Psychooncology 2010;19:637–45. http://dx.doi.org/10.1002/pon.1600. [25] DiSipio T, Hayes SC, Newman B, et al. Does quality of life among breast cancer survivors one year after diagnosis differ depending on urban and non-urban residence? A comparative study. Health Qual Life Outcomes 2010;8:1–10. http://dx.doi.org/10.1186/1477-7525-8-3. [26] Reid-Arndt SA, Cox CR. Does rurality affect quality of life following treatment for breast cancer? J Rural Health 2010;26:402–5. [27] The World Bank. Data: Rural population (% of total population). Data. 2013.
Please cite this article in press as: Thomas AA et al. Quality of life in urban and rural settings: A study of head and neck cancer survivors. Oral Oncol (2014), http://dx.doi.org/10.1016/j.oraloncology.2014.03.007
A.A. Thomas et al. / Oral Oncology xxx (2014) xxx–xxx [47] Sharp L, Donnelly D, Hegarty A, et al. Risk of several cancers is higher in urban areas after adjusting for socioeconomic status, Results from a two-country population-based study of 18 common cancers. J Urban Health 2014:1–16. http://dx.doi.org/10.1007/s11524-013-9846-3. [48] Hall A, Campbell HS, Sanson-Fisher R, et al. Unmet needs of Australian and Canadian haematological cancer survivors: a cross-sectional international comparative study. Psychooncology 2013;22:2032–8. http://dx.doi.org/ 10.1002/pon.3247. [49] Campbell HS, Sanson-Fisher R, Turner D, et al. Psychometric properties of cancer survivors’ unmet needs survey. Support Care Cancer 2011;19:221–30. http://dx.doi.org/10.1007/s00520-009-0806-0. [50] Mehanna Hm, Morton Rp. Deterioration in quality-of-life of late (10-year) survivors of head and neck cancer. Clin Otolaryngol 2006;31:204–11. <10.1111/j.1749-4486.2006.01188.x>. [51] Van Lente E, Barry MM, Molcho M, et al. Measuring population mental health and social well-being. Int J Public Health 2012;57:421–30. http://dx.doi.org/ 10.1007/s00038-011-0317-x. [52] Schultz AA, Winstead-Fry P. Predictors of quality of life in rural patients with cancer. Cancer Nurs 2001;24:12–9. [53] Kroneman M, Verheij R, Tacken M, et al. Urban–rural health differences: primary care data and self reported data render different results. Health Place 2010;16:893–902. [54] Larson SL, Fleishman JA. Rural–urban differences in usual source of care and ambulatory service use: analyses of national data using urban influence codes. Med Care 2003;41:III65–74. http://dx.doi.org/10.2307/376769. [55] Weinert C, Long KA. Understanding the health care needs of rural families. Fam Relations 1987;36:450–5. [56] Judd F, Jackson H, Komiti A, et al. Help-seeking by rural residents for mental health problems: the importance of agrarian values. Aust N Z J Psychiatry 2006;40:769–76. http://dx.doi.org/10.1111/j.1440-1614.2006.01882.x. [57] White KJC, Guest AM. Community lost or transformed? urbanization and social ties. City Community 2003;2:239–59. http://dx.doi.org/10.1111/15406040.00053.
7
[58] Finke Roger, Guest Avery M, Stark Rodney. Mobilizing local religious markets: Religious pluralism in the Empire State, 1855–1865. Am Sociol Rev 1996;61:203–18. [59] Fischer CS. The subcultural theory of urbanism: a twentieth-year assessment. Am J Sociol 1995;101:543–77. http://dx.doi.org/10.2307/2781994. [60] Fischer CS. Toward a subcultural theory of urbanism. Am J Sociol 1975;80:1319–41. http://dx.doi.org/10.2307/2777297. [61] Bell ML, Butow PN, Goldstein D. Informatively missing quality of life and unmet needs sex data for immigrant and Anglo-Australian cancer patients and survivors. Qual Life Res;:1–4.
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