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Travel time to radiotherapy and uptake of breast-conserving surgery for early stage cancer in Northern England
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Health & Place 14 (2008) 424–433 www.elsevier.com/locate/healthplace
Travel time to radiotherapy and uptake of breast-conserving surgery for early stage cancer in Northern England V.A. Sauerzapfa, A.P. Jonesa,, R. Haynesa, S.M. Crawfordb, D. Formanc a
School of Environmental Sciences, University of East Anglia, Norwich NR4 7TJ, UK Airedale General Hospital, Skipton Road, Steeton, Keighley, West Yorkshire BD20 6TD, UK c Northern and Yorkshire Cancer Registry and Information Service, Arthington House, Cookridge Hospital, Leeds LS16 6QB, UK b
Received 14 June 2007; received in revised form 2 August 2007; accepted 4 September 2007
Abstract Patients with early stage breast cancer can opt for either mastectomy or breast-conserving surgery (BCS), but BCS requires daily radiotherapy for some weeks. The hypothesis that ease of access to radiotherapy might affect choice of surgery was investigated using records of 6014 breast cancer patients in Northern England. Adjusting for the effects of age, deprivation and hospital type, the choice of BCS was not associated with the estimated car journey time to radiotherapy for most women but there was an association for patients living in places without a regular bus service, so transport problems might influence surgery choice for a minority of women. r 2007 Elsevier Ltd. All rights reserved. Keywords: Health service accessibility; Radiotherapy; Breast cancer
Introduction Equity in access to healthcare is one of the founding principles of the UK National Health Service (NHS) (Benzeval and Donald, 1999). Nevertheless, the provision of equal access to healthcare wherever people live is not generally possible. ‘Accessibility’ is the term geographers and planners use to describe the ease or difficulty of reaching services in another place. It is influenced by factors such as the degree of service centralisation (Campbell et al., 1999), travel times and distances (Lovett et al., 2002), and the availability of public or Corresponding author. Tel.: +44 1603 593127; fax: +44 1603 591327. E-mail address: [email protected] (A.P. Jones).
1353-8292/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2007.09.002
other forms of transport (Martin et al., 2002). For an overview of the development of theoretical and empirical work in the field see Haynes (2003). Previous research has suggested that geography may significantly affect use of health facilities in the UK. A distance-decay effect whereby those living furthest from treatment are least likely to use the service has been demonstrated for some primary and secondary health services (Carr-Hill et al., 1997; Jones et al., 1998; Haynes et al., 1999). There are also indications that the deterrent effect of travel effort is worst for those with no household car living in rural areas (Haynes, 1991). Since the 1960s there has been a tendency to concentrate UK health services in larger, predominantly urban centres. Such units offer economies of scale and the advantages of specialist expertise.
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This process of centralisation has been particularly marked for the provision of cancer services (EACG, 1995). For treatments such as radiotherapy, where installation and operation is costly, it is inevitable that some patients will be faced with long journeys to receive therapy. Centralisation has led to concerns that those living at distance from healthcare will be deterred from using the service by the cost and inconvenience of the journey (Watt et al., 1993). However, Carr-Hill et al. (1997) considered that the distance decay effect would only occur where the patient considered the medical problem trivial. The cost in terms of time and effort to seek medical help would be perceived to be greater than the potential health benefits. They found that travel effort did not deter patients from using cancer clinics. Breast cancer patients with disease localised to the breast may be offered two forms of surgical treatment. Both mastectomy and breast-conserving surgery (BCS) have been shown to produce equivalent five year survival rates (Fisher et al., 2002). Mastectomy involves a more extensive operation and may be psychologically unacceptable for some women (Hall et al., 2004). BCS may be more satisfactory cosmetically. However, unless BCS is followed by adjuvant radiotherapy administered daily for several consecutive weeks, there may be significant chance of local recurrence of disease leading to the requirement for subsequent mastectomy (EBCTCG, 2000). In the UK, standard guidance is that patients opting for BCS be advised to undergo post-operative radiotherapy (NICE, 2002). In the UK radiotherapy units typically serve a population of around one million and treatment may require some patients to undertake long journeys. A review of radiotherapy provision in the UK undertaken in 2000 found that ‘‘demand has hugely exceeded capacity. Inadequate fundingyhas led toysignificant inequity of access to radiotherapy within the UK’’ (RCR, 2000, p. 5). Even given sufficient radiotherapy provision to meet demand, previous studies have shown that the travel effort involved may deter some patients from accepting radiotherapy, especially where the health benefits are perceived to be uncertain (Greenberg et al., 1988). This raises the possibility that some women may opt for mastectomy and so avoid the commitment of time required for daily radiotherapy. Indeed the RCR (2000) study called for a review of the availability and funding of patient transport schemes.
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BCS plus irradiation became an acceptable (and for some authorities the preferred) treatment option for early stage breast cancer in the early 1990s (Morrow et al., 2001). Initial uptake of this treatment regime was poor and varied geographically (Nattinger et al., 1992). Workers in a number of countries have examined factors associated with low utilisation of BCS (Molenaar et al., 2004; Nattinger et al., 2001; Meden et al., 2002; Morrow et al., 2001; Schroen et al., 2005; Hall et al., 2004; Martin et al., 2006). Most studies have shown that older patients and those with lower socioeconomic status are significantly more likely to opt for mastectomy. The reasons for choice are poorly understood and have come from small-scale qualitative studies (for example Molenaar et al., 2004). The effect of distance to treatment has been examined in both Australia and the US. The Australian studies have examined travel effort by categorising patients by home location (for example using a crude metropolitan, rural or remote classification). The greater distances involved in accessing healthcare in Australia may make extrapolation to the UK situation unwise. Australian results with respect to distance to healthcare have been equivocal. Controlling for age and deprivation Hall et al. (2004) found that BCS uptake was not significantly associated with distance. Martin et al. (2006) found that rural, but not remote, patients were significantly less likely to receive BCS compared with metropolitan patients. US studies examining the effect of travel to treatment have, with the exception of the work of Athas et al. (2000), used crow-flies estimates of distance to hospital as a proxy for travel effort (Athas et al., 2000; Nattinger et al., 2001; Meden et al., 2002; Schroen et al., 2005). Of the US work the Meden et al. (2002) study was small-scale (involving 81 patients) and did not control for confounders. They found that patients living over 45 miles from hospital were significantly less likely to receive BCS compared with those living closer than the 45 mile cut-off. Nattinger et al. (2001) used the SEER database and examined nearly 18,000 patient records. Controlling for age, race and education they found that patients living further than 15 miles straight-line distance from therapy were significantly less likely to choose BCS compared with those living closer than 5 miles from hospital. Schroen et al. (2005) used a populationbased cancer registry database and controlled for age, race and tumour size. Women living over 10
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miles from hospital were significantly more likely to choose mastectomy. Athas et al. (2000) also used a cancer registry database. They determined travel distance to hospital along a digital road network and found that BCS patients living further than 75 miles from radiotherapy were significantly less likely to receive adjuvant post-operative radiotherapy. However, Athas et al. (2000) found that distance to radiotherapy was not significantly associated with whether a patient chose BCS or mastectomy. With the exception of Athas et al. (2000) and Schroen et al. (2005), the US studies have used either Medicare patient records or the SEER database. The former detail older retired patients without private healthcare. The SEER database is recognised in having an urban bias (Michalski and Nattinger, 1997). Breast cancer affects both pre and post-menopausal women and is acknowledged to be more prevalent among the more affluent (McPherson et al., 2000). Extrapolation of previous US findings to the UK may be problematic, especially given that transport to treatment may be provided at no or low-cost by the UK NHS. Advances in GIS technology have meant that calculation of travel time between two points on a digital road network is feasible using a modest PC. The methodology used in this study has been validated against UK patient-reported travel times (Haynes et al., 2006). By utilising a populationbased Cancer Registry database this study has been able to examine treatment options chosen by women with a spectrum of socioeconomic backgrounds, ages and travel experiences and with potentially longer journeys to therapy than observed in previous US work. This is the first study examining access to radiotherapy and BCS uptake in a UK setting. Are those living at greater distance from a radiotherapy unit in the UK more likely to opt for mastectomy for early stage breast cancer? Methods Setting Patient data for this study was supplied by the Northern and Yorkshire Cancer Registry Information Service (NYCRIS). The Registry is a population-based database and serves a population of around 6.7 million. The area is diverse demographically, with disadvantaged, predominantly urban, and comparatively affluent, more rural areas. Similarly, the area is varied geographically with
upland, sparsely populated agricultural and moorland areas and densely populated conurbations formerly associated with heavy industry. Radiotherapy is provided at six hospitals (Fig. 1). Subjects Female breast cancer patients diagnosed in the Northern and Yorkshire Cancer Registry area from 1 January 1994 to 31 December 2002 were identified by NYCRIS. The Northern and Yorkshire Registry was formed from the amalgamation of the former Yorkshire and Northern Cancer Registries. For the first four years of the study (1994–1998 inclusive) data was only available from the former Yorkshire region. Ductal carcinoma in situ, those with atypical pathologies and death certificate only cases were excluded from analysis. Analyses were restricted to patients whose records identified them as having localised disease (Stages I or II) at the time of diagnosis (n ¼ 6014). Outcomes The outcome measured was whether the patient had undergone BCS as opposed to mastectomy for their cancer. The number of patients undergoing each type of surgery is detailed in Table 1. Altogether, 184 patients did not undergo breast surgery and they were treated as missing data in the statistical analyses. A proportion of patients underwent more than one surgical procedure. Patients were categorised on the type of surgery undertaken on the first occasion. Breast surgery was categorised as BCS or mastectomy using the classification described by Morrow et al. (2001). Previous workers have found that oncology treatment can vary with type of hospital visited (Sainsbury et al., 1995; Richards et al., 1996). Those patients whose initial hospital treatment was undertaken at a larger, more specialist hospital which, following the Calman–Hine reforms of oncology services in the UK (EAGC, 1995), would be designated a Cancer Centre were identified. Measures of access to radiotherapy Travel time to the closest hospital where radiotherapy was available was estimated for all patients. NYCRIS initially supplied a list of the home postcodes of all potential patients in the study. At that stage no other patient information was
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Fig. 1. Location of radiotherapy units serving the study patients.
supplied. Each postcode was converted to an Ordnance Survey grid reference using a lookup table (The Central Postcode Directory). These were inserted into a GIS package (ArcGIS, ESRI, UK). The location of the six radiotherapy units serving the area, a digital road network (MeridianTM) and relevant administrative boundaries were also entered into the GIS. The sections of road within the digital road network were assigned average car travel times dependent on length of road section,
road class, whether single or dual carriageway and whether in an urban or rural location (Haynes et al., 2006). The GIS was used to determine the fastest journey from each patient’s home to the nearest radiotherapy unit. Each patient postcode was located within a lower level Super Output Area (SOA). These are areas defined for the 2001 England and Wales population census. Each SOA has been assigned an area-level measure of deprivation, the Index of Multiple
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Table 1 Number of patients (%) undergoing surgery and radiotherapy and estimated travel times, by type of surgery
Number of patients (%) Received radiotherapy Did not receive radiotherapy Radiotherapy status not known Mean travel time to radiotherapy (min) (95% CI) Median journey time Minimum–maximum estimated journey (min) Percent patients with journey 30 min or less 430–60 min 460 min
Breastconserving surgery
Mastectomy
4525 (75.24) 3784 (83.62) 722 (15.96) 19 (0.42) 38.58 (38.04–39.11) 37.55 0.51–121.71
1305 (21.70) 381 (29.20) 911 (69.81) 13 (1.00) 35.42 (34.47–36.37) 32.72 0.52–98.30
35.5 52.9 11.6
42.6 48.0 9.4
of data assembly maintained patient confidentiality and was acceptable to the Patient Information Advisory Group. Analyses
po0.01 (Mann Whitney U-test).
Deprivation (IMD 2004) (ODPM, 2004). IMD 2004 is a composite measure and includes an access to services domain. Before statistical analysis, each SOA’s deprivation score was amended to remove the access domain and so avoid over-controlling for access. Postcodes were also mapped to 1998 administrative ward boundaries. Each ward was designated either rural or urban using the Countryside Agency (2000) categorisation. The availability of public and community transport for each patient was assessed. Sections of the road network with at least an hourly weekday bus service along them were identified from consulting service timetables. Those patient postcodes falling within an 800 m buffer of those roads were identified. An 800 m buffer was chosen since this represents an approximately 10 min walk. Local transport coordinators provided details of provision of community transport and postcodes that fell within wards where some community transport service was available were identified. The postcodes plus travel and deprivation measures were returned to NYCRIS where the additional information was merged to the relevant patient records using the patient home postcode as the common field. The final anonymised data set consisted of information on patient age, stage of disease, treatment(s) received, at which hospital(s), deprivation of place of residence, estimated travel times and other accessibility variables. This process
The database was maintained and all analyses were undertaken using SPSS (vers. 14.0) statistics package. Conditional logistic regression analysis was performed with the dependent variable being whether the patient underwent BCS. Predictors were patient age, area-level deprivation, whether initial treatment was given at a cancer centre and travel time to radiotherapy. Travel time to radiotherapy was a categorical variable. Those with journeys of less than 30 min were the reference cohort and were compared with those with journeys of 30–60 min or greater than 1 h. Patients were categorised on age at diagnosis with those under 50 years being the referent group. Fifty years is the age at which women are first called for breast screening in the UK and is accepted to be an approximation for age of menopause (Department of Health, 2001). Surgery choice for those aged 50–59.99, 60–69.99, 70–79.99 and those 80 years or older was compared with that for younger, pre-menopausal patients. Patients were divided into quartiles based on their area-level deprivation score. Quartile one (patients from the least deprived areas) was used as baseline comparator. To assess the effect of rurality and access to public and community transport the conditional logistic regression model was run with each of these secondary measures of access replacing the travel time to radiotherapy variable. The analyses were repeated for groups of patients with particular characteristics who were considered most likely to be affected by access issues. The groups were patients living in places with no regular bus service, rural dwellers, those without some community transport service and those living in places in the least favourable deprivation quartile. Finally, to test whether receipt of radiotherapy after BCS was associated with travel effort, the 4252 patients who had undergone BCS were examined separately. Conditional logistic regression was performed with the dependent variable being whether the patient had received radiotherapy. Predictors were the age, deprivation, hospital type and travel time to radiotherapy variables described above.
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Results The majority of the patients were younger than 70 years at diagnosis: 1301 (22%) were aged under 50 years; 1999 (33%) were 50–59.99 years; 1535 (26%) were 60–69.99; 885 (15%) were 70–79.99 and 294 (5%) were 80 years or older. They were predominantly urban dwellers with good access to public and community transport: 4095 (68%) lived in an urban ward, 5389 (90%) lived within 800 m of a regular bus service and 3381 (56%) had access to community transport. Most patients (75%) underwent BCS (Table 1). Over 80% of those who underwent BCS also received radiotherapy. Five hundred and fifty two BCS patients (12%) underwent subsequent mastectomies. Table 1 also shows that estimated journey times tended to be longer for BCS patients than for mastectomy patients. Journey times to radiotherapy could be substantial, with the maximum estimated car journey being over 2 h for the mastectomy cohort and over 3 h for the BCS cohort. Just 235 (5.6%) of the 4165 patients who underwent radiotherapy did not attend the closest unit offering that treatment. Table 2 gives the results from the first logistic regression. Older patients were significantly less likely to undergo BCS, with women aged between 60 and 70 years having 73% the odds of receiving BCS compared with patients younger than 50 years. The over 70 and over 80 cohorts were half as likely to receive BCS as were the over 60 s. Patients receiving initial treatment at a cancer centre were significantly less likely to undergo BCS compared with patients visiting other NHS or private hospitals, and patients in the two most deprived quartiles were significantly less likely to undergo BCS compared with those in the least deprived quartile. Adjusting for patient age, deprivation and type of hospital visited, conditional logistic regression showed that patients living 30–60 or over 60 min journey from a radiotherapy unit were no less likely to undergo BCS compared with those with a journey of less than 30 min to treatment. Of the secondary access variables examined, only availability of a community transport service was significantly associated with uptake of BCS. Rural patients or those living close to a frequent bus service were no more or less likely to choose BCS. Examining the cohorts for whom accessibility might be most likely to be a difficulty (Table 3), travel time to radiotherapy was only a significant
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Table 2 Odds ratio (95% confidence interval) for undergoing breastconserving surgery rather than mastectomy for early stage cancer Odds ratio (95% CI) Age at diagnosis (years) o50 50–59.99 60–69.99 70–79.99 480 Deprivation Quartile 1 (least deprived) Quartile 2 Quartile 3 Quartile 4 (most deprived) Initial treatment at a cancer centre
1 0.992 (0.825–1.194) 0.736 (0.610–0.888) 0.367 (0.300–0.450) 0.321 (0.233–0.442) 1 0.887 (0.738–1.066) 0.814 (0.678–0.977) 0.769 (0.640–0.924) 0.619 (0.535–0.717)
Travel time to radiotherapy Less than 30 min 30–60 min Over 1 h
1 1.032 (0.888–1.201) 1.108 (0.871–1.410)
Lives within 800 m of frequent bus service
1.143 (0.921–1.418)
Lives in a ward with some community transport
1.508 (1.323–1.719)
Lives in a rural ward
0.955 (0.817–1.115)
po0.05. po0.01.
predictor of surgery choice for patients living further than 800 m from a frequent weekday bus service. Those with journeys of 30–60 min and over 1 h and no regular bus service were half as likely to receive BCS compared with those living less than 30 min from a radiotherapy facility. Travel time to radiotherapy was not associated with the choice of BCS for patients with no access to community transport, those living in rural wards or those living in the most deprived areas. Finally, we investigated whether receiving radiotherapy after BCS was associated with travel time. In total, 3784 (83.62%) of the 4525 patients who had received BCS also received radiotherapy. Only age was significantly associated with radiotherapy use. Patients aged 70 to just under 80 years and those 80 years or older were significantly less likely
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Table 3 Odds ratio (95% confidence interval) for undergoing breast-conserving surgery rather than mastectomy for early stage cancer: cohorts with no regular bus service, no community transport, rural dwellers and most deprived cohorts
Age less than 50 years at diagnosis 50–59.99 60–69.99 70–79.99 Aged 80 yrs or older at diagnosis Deprivation Quartile 1 (least deprived) Quartile 2 Quartile 3 Quartile 4 (most deprived) Initial treatment at a cancer centre Travel time (min) to radiotherapy Less than 30 min 30–60 min Over 1 h
No regular bus service (n ¼ 613)
No community transport service (n ¼ 2541)
Live in rural ward (n ¼ 1876)
Most deprived quartile (n ¼ 1440)
1
1
1
1
1.035 (0.579–1.851) 1.014 (0.541–1.900) 0.500 (0.257–0.972) 0.169 (0.048–0.595)
1.103 (0.851–1.429) 0.834 (0.638–1.090) 0.382 (0.284–0.513) 0.237 (0.146–0.383)
1.100 (0.792–1.556) 0.815 (0.578–1.151) 0.407 (0.281–0.590) 0.334 (0.186–0.600)
0.890 (0.618–1.281) 0.686 (0.474–0.992) 0.321 (0.219–0.472) 0.429 (0.226–0.817)
1
1
1
n/a
0.844 (0.533–1.336) 0.942 (0.478–1.856) 0.737 (0.197–2.757)
0.834 (0.637–1.093) 0.893 (0.685–1.165) 0.924 (0.710–1.201)
0.835 (0.642–1.085) 0.788 (0.558–1.112) 0.920 (0.550–1.541)
n/a n/a n/a
0.242 (0.157–0.375)
0.581 (0.482–0.700)
0.381 (0.299–0.484)
0.752 (0.554–1.020)
1 0.453 (0.220–0.934) 0.411 (0.186–0.907)
1 0.942 (0.772–1.150) 1.531 (1.043–2.246)
1 0.935 (0.677–1.292) 0.985 (0.666–1.455)
1 0.992 (0.731–1.348) 1.007 (0.538–1.887)
po0.05. po0.01.
to receive adjuvant radiotherapy than were younger patients. The over 80 s were particularly less likely to receive post-operative radiotherapy with only 16% receiving this treatment compared with the under 50 s. (Aged 70–o80, OR ¼ 0.748, 95% CI ¼ 0.570–0.983, po0.05; aged 80 and older, OR ¼ 0.163, 95% CI ¼ 0.109–0.244, po0.01). Neither area-level deprivation, initial treatment at a cancer centre or travel time to radiotherapy were significantly associated with odds of receiving radiotherapy subsequent to BCS. Discussion The level of BCS uptake in this cohort was higher than in many previous studies in other countries (43%, Morrow et al., 2001; 55%, Macleod et al., 2000; 46%, Henley et al., 2005) though similar to that found in earlier UK work (82%, Moritz et al., 1997). A larger proportion of the patient group reported here lived over 24 km (15 miles) straightline distance from radiotherapy compared with
previous US studies (33%, this study; 11%, Nattinger et al., 2001; 22%, Schroen et al., 2005). We found age and area-level deprivation were significantly associated with surgical choice for women with breast cancer. This is consistent with previous work (Downing et al., 2007; Louwman et al., 2005; Schroen et al., 2005; Wyld et al., 2004). It is known that older patients and those from more disadvantaged backgrounds are more likely to present with tumours requiring more aggressive treatment (Adams et al., 2004; Henley et al., 2005; Dalton et al., 2006; Downing et al., 2007). Molenaar et al. (2004) showed that surgeon’s preferences and patients’ concerns regarding breast loss and local tumour recurrence were the strongest predictors of treatment preference. Hence it may be that older women or those from more deprived areas may be more radiation-averse or more fearful of recurrence of disease, or their surgeons may be more likely to promote mastectomy as a surgical option. They could also be women with care commitments or, if in work, with employment where prolonged absence
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for treatment is penalised financially. These interpretations are no more than speculative, however. In the absence of any direct measure of the income of individuals, an area measure of deprivation was used, so it cannot be assumed that the women from deprived areas were necessarily deprived themselves or that the relationship with deprivation is causal. Patients receiving initial treatment at a cancer centre were two thirds as likely to undergo BCS as were patients visiting other types of hospital (NHS and private). This finding could reflect the expertise present at a cancer centre, with more complex cases being referred there. The finding could also reflect the characteristics of the patients within the predominantly urban catchments of most cancer centres. Though not reported in depth here, univariate analysis showed the cohort attending a cancer centre as first hospital was significantly older, from more deprived areas and with shorter journeys to radiotherapy than patients who attended any other type of hospital. In logistic regression, surgical choice for patients attending a cancer centre was significantly and negatively associated with age (over 70 and over 80 cohorts). Both deprivation and travel time to radiotherapy were not significant predictors of BCS uptake. This study found that car journey time to radiotherapy was not associated with choice of BCS as initial treatment for early stage cancer for most patients. Generally, those living at greater distance from radiotherapy were no less likely to undergo BCS than were those living within half an hour of the facility. The requirement for postoperative radiotherapy, and the attendant travel effort, time and costs involved, did not appear to deter most patients from BCS in north east England. Futhermore, the patients who received BCS but did not receive radiotherapy were just as likely to live close to the radiotherapy facility as further away. There were two exceptions to the general finding that choice of surgery was not associated with travel effort or geographical accessibility. Women who lived in places with community transport were more likely to opt for BCS, but, when we examined women living in places with no community transport separately, we found no evidence of a travel time association. The second exception may be more important, although it was based on a relatively small number of cases (N ¼ 594). Patients who lived in places without a regular weekday bus service were less than half as likely to choose BCS if
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their estimated travel times exceeded 30 min, compared with those with less than 30 min travel. This observation is consistent with other studies in the UK which have suggested that the group most likely to be affected by transport difficulties are people without personal transport who live in more remote rural locations (Bentham and Haynes, 1985; Haynes, 1991; Lovett et al., 2002). In the UK, most urban areas have regular public transport services, and the main roads between urban centres are also comparatively well served by public transport. It is therefore in the rural areas away from the main arterial roads that transport problems are most likely to be felt. With the data available it was not possible to ascertain the individual circumstances of the people concerned, so the evidence available is no more than a suggestion that for a small minority of women, transport difficulties might be a part of the decision to receive mastectomy rather than BCS. One weakness of this study was its inability to control for all the factors likely to influence surgery choice. Information was not available on comorbidity, size of the tumour with respect to size of the breast, histologic grade, pregnancy, previous breast or vascular disease, multifocal tumour or previous breast irradiation (Staradub et al., 2002; Henley et al., 2005). Previous authors have cited tumour size as being particularly influential in choice of surgery (Martin et al., 2006). Although recommended practice, not all of the patients in our study received radiotherapy after BCS. We do not know the reasons for this, but most cases are likely to be due to the gradual acceptance of this treatment as being good practice during the 1990s. In addition there may have been clinical reasons not to give radiotherapy for a small number of patients. Furthermore, we did not know if radiotherapy patients were admitted to hospital during their treatment, and it is possible that some were taken as in-patients so as to avoid the travel effort associated with repeated treatments. However, such instances are likely to be rare, and in their study of a radiation oncology service in Ontario Canada, Hayter and Mackillop (1997) found that almost all admissions were associated with the treatment of cancer complications or other active medical problems. The main strength of this study was its use of relatively sophisticated measures of geographical accessibility. We were able to determine travel time to therapy more precisely than was possible for previous studies using a validated method made
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possible by developments in GIS technology. Alternative measures of accessibility were also included. The diverse nature of the study area both geographically and demographically meant that patients should have presented a wide range of travel experiences, and the number of patient records examined gave the study good statistical power. From a policy point of view, there was much debate concerning the benefits of service centralisation for cancer treatment in recent years. Authors such as Selby et al. (1996) have provided convincing evidence that the improved levels of specialisation that come with centralisation are associated with better outcomes from breast cancer. Our research suggests that treatment patterns for breast cancer patients are not associated with travel effort to centralised services for the majority of patients. However, we found some evidence that the least mobile patients, those without good access to a car or public transport, may be put off receiving BCS following diagnosis. It may be that the travel needs of these women require particular consideration when their treatment options are being considered. Acknowledgements Alison Crawford, NYCRIS performed the data matching and patient record abstraction. Dr Eva Morris and Professor Bob Haward gave advice regarding tumour pathology. Dr Chris Dibben, St Andrews University, gave assistance with amendment of IMD 2004 scores. Hongxin Zhao constructed the digital road network and digitised the bus routes. The project, of which this is part, was funded by HM Treasury and the UK Departments for Transport and Environment, Food and Rural Affairs under the Treasury Evidence Based Policy Fund.
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ARTICLE IN PRESS V.A. Sauerzapf et al. / Health & Place 14 (2008) 424–433 Hayter, C.R., Mackillop, W.J., 1997. Admissions to a radiation oncology inpatient service. Cancer Prevention and Control 1, 116–121. Henley, N.C., Hole, D.J., Kesson, E., Burns, H.J.G., George, W.D., Cooke, T.G., 2005. Does deprivation affect breast cancer management? British Journal of Cancer 92, 631–633. Jones, A.P., Bentham, G., Harrison, B.D.W., Jarvis, D., Badminton, R.M., Wareham, N.J., 1998. Accessibility and health service utilisation for asthma in Norfolk, England. Journal of Public Health Medicine 20 (3), 312–317. Louwman, W.J., Janssen-Heijnen, M.L.G., Houterman, S., Voogd, A.C., van der Sangen, M.J.C., Nieuwenhuizen, G.A.P., Coebergh, J.W.W., 2005. Less extensive treatment and inferior prognosis for breast cancer patient with comorbidity: a population-based study. European Journal of Cancer 41, 779–785. Lovett, A., Haynes, R., Suennenberg, G., Gale, S., 2002. Car travel time and accessibility by bus to general practitioner services: a study using patient registers and GIS. Social Science & Medicine 55, 97–111. Macleod, U., Ross, S., Twelves, C., George, W.D., Gillis, C., Watt, G.C.M., 2000. Primary and secondary care management of women with early breast cancer from affluent and deprived areas: retrospective review of hospital and general practice records. British Medical Journal 320, 1442–1445. Martin, D., Wrigley, H., Barnett, S., Roderick, P., 2002. Increasing the sophistication of access measurement in a rural healthcare study. Health and Place 8, 3–13. Martin, M.A., Meyricke, R., O’Neill, T., Roberts, S., 2006. Mastectomy or breast conserving surgery? Factors affecting type of surgical treatment for breast cancer—a classification tree approach. BMC Cancer 6, 98. McPherson, K., Steel, C.M., Dixon, J.M., 2000. Breast cancerepidemiology, risk factors and genetics. British Medical Journal 321, 624–628. Meden, T., St. John-Larkin, C., Hermes, D., Sommerschield, S., 2002. Relationship between travel distance and utilization of breast cancer treatment in rural northern Michigan. Journal of the American Medical Association 287 (1), 111. Michalski, T.A., Nattinger, A.B., 1997. The influence of black race and socioeconomic status on the use of breast-conserving surgery for Medicare beneficiaries. Cancer 79, 314–319. Molenaar, S., Oort, F., Sprangers, M., Rutgers, E., Luiten, E., Mulder, J., de Haes, H., 2004. Predictors of patients’ choices for breast-conserving therapy or mastectomy: a prospective study. British Journal of Cancer 90, 2123–2130. Moritz, S., Bates, T., Henderson, S.M., Humphreys, S., Michell, M.J., 1997. Variation in the management of small invasive breast cancers detected on screening in the former South East
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Health & Place 14 (2008) 424–433 www.elsevier.com/locate/healthplace
Travel time to radiotherapy and uptake of breast-conserving surgery for early stage cancer in Northern England V.A. Sauerzapfa, A.P. Jonesa,, R. Haynesa, S.M. Crawfordb, D. Formanc a
School of Environmental Sciences, University of East Anglia, Norwich NR4 7TJ, UK Airedale General Hospital, Skipton Road, Steeton, Keighley, West Yorkshire BD20 6TD, UK c Northern and Yorkshire Cancer Registry and Information Service, Arthington House, Cookridge Hospital, Leeds LS16 6QB, UK b
Received 14 June 2007; received in revised form 2 August 2007; accepted 4 September 2007
Abstract Patients with early stage breast cancer can opt for either mastectomy or breast-conserving surgery (BCS), but BCS requires daily radiotherapy for some weeks. The hypothesis that ease of access to radiotherapy might affect choice of surgery was investigated using records of 6014 breast cancer patients in Northern England. Adjusting for the effects of age, deprivation and hospital type, the choice of BCS was not associated with the estimated car journey time to radiotherapy for most women but there was an association for patients living in places without a regular bus service, so transport problems might influence surgery choice for a minority of women. r 2007 Elsevier Ltd. All rights reserved. Keywords: Health service accessibility; Radiotherapy; Breast cancer
Introduction Equity in access to healthcare is one of the founding principles of the UK National Health Service (NHS) (Benzeval and Donald, 1999). Nevertheless, the provision of equal access to healthcare wherever people live is not generally possible. ‘Accessibility’ is the term geographers and planners use to describe the ease or difficulty of reaching services in another place. It is influenced by factors such as the degree of service centralisation (Campbell et al., 1999), travel times and distances (Lovett et al., 2002), and the availability of public or Corresponding author. Tel.: +44 1603 593127; fax: +44 1603 591327. E-mail address: [email protected] (A.P. Jones).
1353-8292/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2007.09.002
other forms of transport (Martin et al., 2002). For an overview of the development of theoretical and empirical work in the field see Haynes (2003). Previous research has suggested that geography may significantly affect use of health facilities in the UK. A distance-decay effect whereby those living furthest from treatment are least likely to use the service has been demonstrated for some primary and secondary health services (Carr-Hill et al., 1997; Jones et al., 1998; Haynes et al., 1999). There are also indications that the deterrent effect of travel effort is worst for those with no household car living in rural areas (Haynes, 1991). Since the 1960s there has been a tendency to concentrate UK health services in larger, predominantly urban centres. Such units offer economies of scale and the advantages of specialist expertise.
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This process of centralisation has been particularly marked for the provision of cancer services (EACG, 1995). For treatments such as radiotherapy, where installation and operation is costly, it is inevitable that some patients will be faced with long journeys to receive therapy. Centralisation has led to concerns that those living at distance from healthcare will be deterred from using the service by the cost and inconvenience of the journey (Watt et al., 1993). However, Carr-Hill et al. (1997) considered that the distance decay effect would only occur where the patient considered the medical problem trivial. The cost in terms of time and effort to seek medical help would be perceived to be greater than the potential health benefits. They found that travel effort did not deter patients from using cancer clinics. Breast cancer patients with disease localised to the breast may be offered two forms of surgical treatment. Both mastectomy and breast-conserving surgery (BCS) have been shown to produce equivalent five year survival rates (Fisher et al., 2002). Mastectomy involves a more extensive operation and may be psychologically unacceptable for some women (Hall et al., 2004). BCS may be more satisfactory cosmetically. However, unless BCS is followed by adjuvant radiotherapy administered daily for several consecutive weeks, there may be significant chance of local recurrence of disease leading to the requirement for subsequent mastectomy (EBCTCG, 2000). In the UK, standard guidance is that patients opting for BCS be advised to undergo post-operative radiotherapy (NICE, 2002). In the UK radiotherapy units typically serve a population of around one million and treatment may require some patients to undertake long journeys. A review of radiotherapy provision in the UK undertaken in 2000 found that ‘‘demand has hugely exceeded capacity. Inadequate fundingyhas led toysignificant inequity of access to radiotherapy within the UK’’ (RCR, 2000, p. 5). Even given sufficient radiotherapy provision to meet demand, previous studies have shown that the travel effort involved may deter some patients from accepting radiotherapy, especially where the health benefits are perceived to be uncertain (Greenberg et al., 1988). This raises the possibility that some women may opt for mastectomy and so avoid the commitment of time required for daily radiotherapy. Indeed the RCR (2000) study called for a review of the availability and funding of patient transport schemes.
425
BCS plus irradiation became an acceptable (and for some authorities the preferred) treatment option for early stage breast cancer in the early 1990s (Morrow et al., 2001). Initial uptake of this treatment regime was poor and varied geographically (Nattinger et al., 1992). Workers in a number of countries have examined factors associated with low utilisation of BCS (Molenaar et al., 2004; Nattinger et al., 2001; Meden et al., 2002; Morrow et al., 2001; Schroen et al., 2005; Hall et al., 2004; Martin et al., 2006). Most studies have shown that older patients and those with lower socioeconomic status are significantly more likely to opt for mastectomy. The reasons for choice are poorly understood and have come from small-scale qualitative studies (for example Molenaar et al., 2004). The effect of distance to treatment has been examined in both Australia and the US. The Australian studies have examined travel effort by categorising patients by home location (for example using a crude metropolitan, rural or remote classification). The greater distances involved in accessing healthcare in Australia may make extrapolation to the UK situation unwise. Australian results with respect to distance to healthcare have been equivocal. Controlling for age and deprivation Hall et al. (2004) found that BCS uptake was not significantly associated with distance. Martin et al. (2006) found that rural, but not remote, patients were significantly less likely to receive BCS compared with metropolitan patients. US studies examining the effect of travel to treatment have, with the exception of the work of Athas et al. (2000), used crow-flies estimates of distance to hospital as a proxy for travel effort (Athas et al., 2000; Nattinger et al., 2001; Meden et al., 2002; Schroen et al., 2005). Of the US work the Meden et al. (2002) study was small-scale (involving 81 patients) and did not control for confounders. They found that patients living over 45 miles from hospital were significantly less likely to receive BCS compared with those living closer than the 45 mile cut-off. Nattinger et al. (2001) used the SEER database and examined nearly 18,000 patient records. Controlling for age, race and education they found that patients living further than 15 miles straight-line distance from therapy were significantly less likely to choose BCS compared with those living closer than 5 miles from hospital. Schroen et al. (2005) used a populationbased cancer registry database and controlled for age, race and tumour size. Women living over 10
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miles from hospital were significantly more likely to choose mastectomy. Athas et al. (2000) also used a cancer registry database. They determined travel distance to hospital along a digital road network and found that BCS patients living further than 75 miles from radiotherapy were significantly less likely to receive adjuvant post-operative radiotherapy. However, Athas et al. (2000) found that distance to radiotherapy was not significantly associated with whether a patient chose BCS or mastectomy. With the exception of Athas et al. (2000) and Schroen et al. (2005), the US studies have used either Medicare patient records or the SEER database. The former detail older retired patients without private healthcare. The SEER database is recognised in having an urban bias (Michalski and Nattinger, 1997). Breast cancer affects both pre and post-menopausal women and is acknowledged to be more prevalent among the more affluent (McPherson et al., 2000). Extrapolation of previous US findings to the UK may be problematic, especially given that transport to treatment may be provided at no or low-cost by the UK NHS. Advances in GIS technology have meant that calculation of travel time between two points on a digital road network is feasible using a modest PC. The methodology used in this study has been validated against UK patient-reported travel times (Haynes et al., 2006). By utilising a populationbased Cancer Registry database this study has been able to examine treatment options chosen by women with a spectrum of socioeconomic backgrounds, ages and travel experiences and with potentially longer journeys to therapy than observed in previous US work. This is the first study examining access to radiotherapy and BCS uptake in a UK setting. Are those living at greater distance from a radiotherapy unit in the UK more likely to opt for mastectomy for early stage breast cancer? Methods Setting Patient data for this study was supplied by the Northern and Yorkshire Cancer Registry Information Service (NYCRIS). The Registry is a population-based database and serves a population of around 6.7 million. The area is diverse demographically, with disadvantaged, predominantly urban, and comparatively affluent, more rural areas. Similarly, the area is varied geographically with
upland, sparsely populated agricultural and moorland areas and densely populated conurbations formerly associated with heavy industry. Radiotherapy is provided at six hospitals (Fig. 1). Subjects Female breast cancer patients diagnosed in the Northern and Yorkshire Cancer Registry area from 1 January 1994 to 31 December 2002 were identified by NYCRIS. The Northern and Yorkshire Registry was formed from the amalgamation of the former Yorkshire and Northern Cancer Registries. For the first four years of the study (1994–1998 inclusive) data was only available from the former Yorkshire region. Ductal carcinoma in situ, those with atypical pathologies and death certificate only cases were excluded from analysis. Analyses were restricted to patients whose records identified them as having localised disease (Stages I or II) at the time of diagnosis (n ¼ 6014). Outcomes The outcome measured was whether the patient had undergone BCS as opposed to mastectomy for their cancer. The number of patients undergoing each type of surgery is detailed in Table 1. Altogether, 184 patients did not undergo breast surgery and they were treated as missing data in the statistical analyses. A proportion of patients underwent more than one surgical procedure. Patients were categorised on the type of surgery undertaken on the first occasion. Breast surgery was categorised as BCS or mastectomy using the classification described by Morrow et al. (2001). Previous workers have found that oncology treatment can vary with type of hospital visited (Sainsbury et al., 1995; Richards et al., 1996). Those patients whose initial hospital treatment was undertaken at a larger, more specialist hospital which, following the Calman–Hine reforms of oncology services in the UK (EAGC, 1995), would be designated a Cancer Centre were identified. Measures of access to radiotherapy Travel time to the closest hospital where radiotherapy was available was estimated for all patients. NYCRIS initially supplied a list of the home postcodes of all potential patients in the study. At that stage no other patient information was
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427
Fig. 1. Location of radiotherapy units serving the study patients.
supplied. Each postcode was converted to an Ordnance Survey grid reference using a lookup table (The Central Postcode Directory). These were inserted into a GIS package (ArcGIS, ESRI, UK). The location of the six radiotherapy units serving the area, a digital road network (MeridianTM) and relevant administrative boundaries were also entered into the GIS. The sections of road within the digital road network were assigned average car travel times dependent on length of road section,
road class, whether single or dual carriageway and whether in an urban or rural location (Haynes et al., 2006). The GIS was used to determine the fastest journey from each patient’s home to the nearest radiotherapy unit. Each patient postcode was located within a lower level Super Output Area (SOA). These are areas defined for the 2001 England and Wales population census. Each SOA has been assigned an area-level measure of deprivation, the Index of Multiple
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Table 1 Number of patients (%) undergoing surgery and radiotherapy and estimated travel times, by type of surgery
Number of patients (%) Received radiotherapy Did not receive radiotherapy Radiotherapy status not known Mean travel time to radiotherapy (min) (95% CI) Median journey time Minimum–maximum estimated journey (min) Percent patients with journey 30 min or less 430–60 min 460 min
Breastconserving surgery
Mastectomy
4525 (75.24) 3784 (83.62) 722 (15.96) 19 (0.42) 38.58 (38.04–39.11) 37.55 0.51–121.71
1305 (21.70) 381 (29.20) 911 (69.81) 13 (1.00) 35.42 (34.47–36.37) 32.72 0.52–98.30
35.5 52.9 11.6
42.6 48.0 9.4
of data assembly maintained patient confidentiality and was acceptable to the Patient Information Advisory Group. Analyses
po0.01 (Mann Whitney U-test).
Deprivation (IMD 2004) (ODPM, 2004). IMD 2004 is a composite measure and includes an access to services domain. Before statistical analysis, each SOA’s deprivation score was amended to remove the access domain and so avoid over-controlling for access. Postcodes were also mapped to 1998 administrative ward boundaries. Each ward was designated either rural or urban using the Countryside Agency (2000) categorisation. The availability of public and community transport for each patient was assessed. Sections of the road network with at least an hourly weekday bus service along them were identified from consulting service timetables. Those patient postcodes falling within an 800 m buffer of those roads were identified. An 800 m buffer was chosen since this represents an approximately 10 min walk. Local transport coordinators provided details of provision of community transport and postcodes that fell within wards where some community transport service was available were identified. The postcodes plus travel and deprivation measures were returned to NYCRIS where the additional information was merged to the relevant patient records using the patient home postcode as the common field. The final anonymised data set consisted of information on patient age, stage of disease, treatment(s) received, at which hospital(s), deprivation of place of residence, estimated travel times and other accessibility variables. This process
The database was maintained and all analyses were undertaken using SPSS (vers. 14.0) statistics package. Conditional logistic regression analysis was performed with the dependent variable being whether the patient underwent BCS. Predictors were patient age, area-level deprivation, whether initial treatment was given at a cancer centre and travel time to radiotherapy. Travel time to radiotherapy was a categorical variable. Those with journeys of less than 30 min were the reference cohort and were compared with those with journeys of 30–60 min or greater than 1 h. Patients were categorised on age at diagnosis with those under 50 years being the referent group. Fifty years is the age at which women are first called for breast screening in the UK and is accepted to be an approximation for age of menopause (Department of Health, 2001). Surgery choice for those aged 50–59.99, 60–69.99, 70–79.99 and those 80 years or older was compared with that for younger, pre-menopausal patients. Patients were divided into quartiles based on their area-level deprivation score. Quartile one (patients from the least deprived areas) was used as baseline comparator. To assess the effect of rurality and access to public and community transport the conditional logistic regression model was run with each of these secondary measures of access replacing the travel time to radiotherapy variable. The analyses were repeated for groups of patients with particular characteristics who were considered most likely to be affected by access issues. The groups were patients living in places with no regular bus service, rural dwellers, those without some community transport service and those living in places in the least favourable deprivation quartile. Finally, to test whether receipt of radiotherapy after BCS was associated with travel effort, the 4252 patients who had undergone BCS were examined separately. Conditional logistic regression was performed with the dependent variable being whether the patient had received radiotherapy. Predictors were the age, deprivation, hospital type and travel time to radiotherapy variables described above.
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Results The majority of the patients were younger than 70 years at diagnosis: 1301 (22%) were aged under 50 years; 1999 (33%) were 50–59.99 years; 1535 (26%) were 60–69.99; 885 (15%) were 70–79.99 and 294 (5%) were 80 years or older. They were predominantly urban dwellers with good access to public and community transport: 4095 (68%) lived in an urban ward, 5389 (90%) lived within 800 m of a regular bus service and 3381 (56%) had access to community transport. Most patients (75%) underwent BCS (Table 1). Over 80% of those who underwent BCS also received radiotherapy. Five hundred and fifty two BCS patients (12%) underwent subsequent mastectomies. Table 1 also shows that estimated journey times tended to be longer for BCS patients than for mastectomy patients. Journey times to radiotherapy could be substantial, with the maximum estimated car journey being over 2 h for the mastectomy cohort and over 3 h for the BCS cohort. Just 235 (5.6%) of the 4165 patients who underwent radiotherapy did not attend the closest unit offering that treatment. Table 2 gives the results from the first logistic regression. Older patients were significantly less likely to undergo BCS, with women aged between 60 and 70 years having 73% the odds of receiving BCS compared with patients younger than 50 years. The over 70 and over 80 cohorts were half as likely to receive BCS as were the over 60 s. Patients receiving initial treatment at a cancer centre were significantly less likely to undergo BCS compared with patients visiting other NHS or private hospitals, and patients in the two most deprived quartiles were significantly less likely to undergo BCS compared with those in the least deprived quartile. Adjusting for patient age, deprivation and type of hospital visited, conditional logistic regression showed that patients living 30–60 or over 60 min journey from a radiotherapy unit were no less likely to undergo BCS compared with those with a journey of less than 30 min to treatment. Of the secondary access variables examined, only availability of a community transport service was significantly associated with uptake of BCS. Rural patients or those living close to a frequent bus service were no more or less likely to choose BCS. Examining the cohorts for whom accessibility might be most likely to be a difficulty (Table 3), travel time to radiotherapy was only a significant
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Table 2 Odds ratio (95% confidence interval) for undergoing breastconserving surgery rather than mastectomy for early stage cancer Odds ratio (95% CI) Age at diagnosis (years) o50 50–59.99 60–69.99 70–79.99 480 Deprivation Quartile 1 (least deprived) Quartile 2 Quartile 3 Quartile 4 (most deprived) Initial treatment at a cancer centre
1 0.992 (0.825–1.194) 0.736 (0.610–0.888) 0.367 (0.300–0.450) 0.321 (0.233–0.442) 1 0.887 (0.738–1.066) 0.814 (0.678–0.977) 0.769 (0.640–0.924) 0.619 (0.535–0.717)
Travel time to radiotherapy Less than 30 min 30–60 min Over 1 h
1 1.032 (0.888–1.201) 1.108 (0.871–1.410)
Lives within 800 m of frequent bus service
1.143 (0.921–1.418)
Lives in a ward with some community transport
1.508 (1.323–1.719)
Lives in a rural ward
0.955 (0.817–1.115)
po0.05. po0.01.
predictor of surgery choice for patients living further than 800 m from a frequent weekday bus service. Those with journeys of 30–60 min and over 1 h and no regular bus service were half as likely to receive BCS compared with those living less than 30 min from a radiotherapy facility. Travel time to radiotherapy was not associated with the choice of BCS for patients with no access to community transport, those living in rural wards or those living in the most deprived areas. Finally, we investigated whether receiving radiotherapy after BCS was associated with travel time. In total, 3784 (83.62%) of the 4525 patients who had received BCS also received radiotherapy. Only age was significantly associated with radiotherapy use. Patients aged 70 to just under 80 years and those 80 years or older were significantly less likely
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Table 3 Odds ratio (95% confidence interval) for undergoing breast-conserving surgery rather than mastectomy for early stage cancer: cohorts with no regular bus service, no community transport, rural dwellers and most deprived cohorts
Age less than 50 years at diagnosis 50–59.99 60–69.99 70–79.99 Aged 80 yrs or older at diagnosis Deprivation Quartile 1 (least deprived) Quartile 2 Quartile 3 Quartile 4 (most deprived) Initial treatment at a cancer centre Travel time (min) to radiotherapy Less than 30 min 30–60 min Over 1 h
No regular bus service (n ¼ 613)
No community transport service (n ¼ 2541)
Live in rural ward (n ¼ 1876)
Most deprived quartile (n ¼ 1440)
1
1
1
1
1.035 (0.579–1.851) 1.014 (0.541–1.900) 0.500 (0.257–0.972) 0.169 (0.048–0.595)
1.103 (0.851–1.429) 0.834 (0.638–1.090) 0.382 (0.284–0.513) 0.237 (0.146–0.383)
1.100 (0.792–1.556) 0.815 (0.578–1.151) 0.407 (0.281–0.590) 0.334 (0.186–0.600)
0.890 (0.618–1.281) 0.686 (0.474–0.992) 0.321 (0.219–0.472) 0.429 (0.226–0.817)
1
1
1
n/a
0.844 (0.533–1.336) 0.942 (0.478–1.856) 0.737 (0.197–2.757)
0.834 (0.637–1.093) 0.893 (0.685–1.165) 0.924 (0.710–1.201)
0.835 (0.642–1.085) 0.788 (0.558–1.112) 0.920 (0.550–1.541)
n/a n/a n/a
0.242 (0.157–0.375)
0.581 (0.482–0.700)
0.381 (0.299–0.484)
0.752 (0.554–1.020)
1 0.453 (0.220–0.934) 0.411 (0.186–0.907)
1 0.942 (0.772–1.150) 1.531 (1.043–2.246)
1 0.935 (0.677–1.292) 0.985 (0.666–1.455)
1 0.992 (0.731–1.348) 1.007 (0.538–1.887)
po0.05. po0.01.
to receive adjuvant radiotherapy than were younger patients. The over 80 s were particularly less likely to receive post-operative radiotherapy with only 16% receiving this treatment compared with the under 50 s. (Aged 70–o80, OR ¼ 0.748, 95% CI ¼ 0.570–0.983, po0.05; aged 80 and older, OR ¼ 0.163, 95% CI ¼ 0.109–0.244, po0.01). Neither area-level deprivation, initial treatment at a cancer centre or travel time to radiotherapy were significantly associated with odds of receiving radiotherapy subsequent to BCS. Discussion The level of BCS uptake in this cohort was higher than in many previous studies in other countries (43%, Morrow et al., 2001; 55%, Macleod et al., 2000; 46%, Henley et al., 2005) though similar to that found in earlier UK work (82%, Moritz et al., 1997). A larger proportion of the patient group reported here lived over 24 km (15 miles) straightline distance from radiotherapy compared with
previous US studies (33%, this study; 11%, Nattinger et al., 2001; 22%, Schroen et al., 2005). We found age and area-level deprivation were significantly associated with surgical choice for women with breast cancer. This is consistent with previous work (Downing et al., 2007; Louwman et al., 2005; Schroen et al., 2005; Wyld et al., 2004). It is known that older patients and those from more disadvantaged backgrounds are more likely to present with tumours requiring more aggressive treatment (Adams et al., 2004; Henley et al., 2005; Dalton et al., 2006; Downing et al., 2007). Molenaar et al. (2004) showed that surgeon’s preferences and patients’ concerns regarding breast loss and local tumour recurrence were the strongest predictors of treatment preference. Hence it may be that older women or those from more deprived areas may be more radiation-averse or more fearful of recurrence of disease, or their surgeons may be more likely to promote mastectomy as a surgical option. They could also be women with care commitments or, if in work, with employment where prolonged absence
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for treatment is penalised financially. These interpretations are no more than speculative, however. In the absence of any direct measure of the income of individuals, an area measure of deprivation was used, so it cannot be assumed that the women from deprived areas were necessarily deprived themselves or that the relationship with deprivation is causal. Patients receiving initial treatment at a cancer centre were two thirds as likely to undergo BCS as were patients visiting other types of hospital (NHS and private). This finding could reflect the expertise present at a cancer centre, with more complex cases being referred there. The finding could also reflect the characteristics of the patients within the predominantly urban catchments of most cancer centres. Though not reported in depth here, univariate analysis showed the cohort attending a cancer centre as first hospital was significantly older, from more deprived areas and with shorter journeys to radiotherapy than patients who attended any other type of hospital. In logistic regression, surgical choice for patients attending a cancer centre was significantly and negatively associated with age (over 70 and over 80 cohorts). Both deprivation and travel time to radiotherapy were not significant predictors of BCS uptake. This study found that car journey time to radiotherapy was not associated with choice of BCS as initial treatment for early stage cancer for most patients. Generally, those living at greater distance from radiotherapy were no less likely to undergo BCS than were those living within half an hour of the facility. The requirement for postoperative radiotherapy, and the attendant travel effort, time and costs involved, did not appear to deter most patients from BCS in north east England. Futhermore, the patients who received BCS but did not receive radiotherapy were just as likely to live close to the radiotherapy facility as further away. There were two exceptions to the general finding that choice of surgery was not associated with travel effort or geographical accessibility. Women who lived in places with community transport were more likely to opt for BCS, but, when we examined women living in places with no community transport separately, we found no evidence of a travel time association. The second exception may be more important, although it was based on a relatively small number of cases (N ¼ 594). Patients who lived in places without a regular weekday bus service were less than half as likely to choose BCS if
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their estimated travel times exceeded 30 min, compared with those with less than 30 min travel. This observation is consistent with other studies in the UK which have suggested that the group most likely to be affected by transport difficulties are people without personal transport who live in more remote rural locations (Bentham and Haynes, 1985; Haynes, 1991; Lovett et al., 2002). In the UK, most urban areas have regular public transport services, and the main roads between urban centres are also comparatively well served by public transport. It is therefore in the rural areas away from the main arterial roads that transport problems are most likely to be felt. With the data available it was not possible to ascertain the individual circumstances of the people concerned, so the evidence available is no more than a suggestion that for a small minority of women, transport difficulties might be a part of the decision to receive mastectomy rather than BCS. One weakness of this study was its inability to control for all the factors likely to influence surgery choice. Information was not available on comorbidity, size of the tumour with respect to size of the breast, histologic grade, pregnancy, previous breast or vascular disease, multifocal tumour or previous breast irradiation (Staradub et al., 2002; Henley et al., 2005). Previous authors have cited tumour size as being particularly influential in choice of surgery (Martin et al., 2006). Although recommended practice, not all of the patients in our study received radiotherapy after BCS. We do not know the reasons for this, but most cases are likely to be due to the gradual acceptance of this treatment as being good practice during the 1990s. In addition there may have been clinical reasons not to give radiotherapy for a small number of patients. Furthermore, we did not know if radiotherapy patients were admitted to hospital during their treatment, and it is possible that some were taken as in-patients so as to avoid the travel effort associated with repeated treatments. However, such instances are likely to be rare, and in their study of a radiation oncology service in Ontario Canada, Hayter and Mackillop (1997) found that almost all admissions were associated with the treatment of cancer complications or other active medical problems. The main strength of this study was its use of relatively sophisticated measures of geographical accessibility. We were able to determine travel time to therapy more precisely than was possible for previous studies using a validated method made
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possible by developments in GIS technology. Alternative measures of accessibility were also included. The diverse nature of the study area both geographically and demographically meant that patients should have presented a wide range of travel experiences, and the number of patient records examined gave the study good statistical power. From a policy point of view, there was much debate concerning the benefits of service centralisation for cancer treatment in recent years. Authors such as Selby et al. (1996) have provided convincing evidence that the improved levels of specialisation that come with centralisation are associated with better outcomes from breast cancer. Our research suggests that treatment patterns for breast cancer patients are not associated with travel effort to centralised services for the majority of patients. However, we found some evidence that the least mobile patients, those without good access to a car or public transport, may be put off receiving BCS following diagnosis. It may be that the travel needs of these women require particular consideration when their treatment options are being considered. Acknowledgements Alison Crawford, NYCRIS performed the data matching and patient record abstraction. Dr Eva Morris and Professor Bob Haward gave advice regarding tumour pathology. Dr Chris Dibben, St Andrews University, gave assistance with amendment of IMD 2004 scores. Hongxin Zhao constructed the digital road network and digitised the bus routes. The project, of which this is part, was funded by HM Treasury and the UK Departments for Transport and Environment, Food and Rural Affairs under the Treasury Evidence Based Policy Fund.
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