Analysing risk factors for poorer breast cancer outcomes in residents of lower socioeconomic areas of Australia.

OBJECTIVE: To investigate patient, cancer and treatment factors associated with the residence of female breast cancer patients in lower socioeconomic areas of Australia to better understand factors that may contribute to their poorer cancer outcomes. METHODS: Bivariable and multivariable analyses were performed using the Breast Quality Audit database of Breast Surgeons of Australia and New Zealand. RESULTS Multivariable regression indicated that patients from lower socioeconomic areas are more likely to live in more remote areas and to be treated at regional than major city centres. Although they appeared equally likely to be referred to surgeons from BreastScreen services as patients from higher socioeconomic areas, they were less likely to be referred as asymptomatic cases from other sources. In general, their cancer and treatment characteristics did not differ from those of women from higher socioeconomic areas, but ovarian ablation therapy was less common for these patients and bilateral synchronous lesions tended to be less frequent than for women from higher socioeconomic areas. CONCLUSIONS: The results indicate that patients from lower socioeconomic areas are more likely to live in more remote districts and have their treatment in regional rather than major treatment centres. Their cancer and treatment characteristics appear to be similar to those of women from higher socioeconomic areas, although they are less likely to have ovarian ablation or to be referred as asymptomatic patients from sources other than BreastScreen. What is known about this topic? It is already known from Australian data that breast cancer outcomes are not as favourable for women from areas of socioeconomic disadvantage. The reasons for the poorer outcomes have not been understood. Studies in other countries have also found poorer outcomes in women from lower socioeconomic areas, and in some instances, have attributed this finding to more advanced stages of cancers at diagnosis and more limited treatment. The reasons are likely to vary with the country and health system characteristics. What does this paper add? The present study found that in Australia, women from lower socioeconomic areas do not have more advanced cancers at diagnosis, nor, in general, other cancer features that would predispose them to poorer outcomes. The standout differences were that they tended more to live in areas that were more remote from specialist metropolitan centres and were more likely to be treated in regional settings where prior research has indicated poorer outcomes. The reasons for these poorer outcomes are not known but may include lower levels of surgical specialisation, less access to specialised adjunctive services, and less involvement with multidisciplinary teams. Women from lower socioeconomic areas also appeared more likely to attend lower case load surgeons. Little difference was evident in the type of clinical care received, although women from lower socioeconomic areas were less likely to be asymptomatic referrals from other clinical settings (excluding BreastScreen). What are the implications for practitioners? Results suggest that poorer outcomes in women from lower socioeconomic areas in Australia may have less to do with the characteristics of their breast cancers or treatment modalities and more to do with health system features, such as access to specialist centres. This study highlights the importance of demographic and health system features as potentially key factors in service outcomes. Health system research should be strengthened in Australia to augment biomedical and clinical research, with a view to best meeting service needs of all sectors of the population.

Survival from breast cancer: an analysis of Australian data by surgeon case load, treatment centre location, and health insurance status.

OBJECTIVE: Early invasive breast cancer data from the Australian National Breast Cancer Audit were used to compare case fatality by surgeon case load, treatment centre location and health insurance status. METHOD: Deaths were traced to 31 December 2007, for cancers diagnosed in 1998-2005. Risk of breast cancer death was compared using Cox proportional hazards regression. RESULTS: When adjustment was made for age and clinical risk factors: (i) the relative risk of breast cancer death (95% confidence limit) was lower when surgeons' annual case loads exceeded 20 cases, at 0.87 (0.76, 0.995) for 21-100 cases and 0.83 (0.72, 0.97) for higher case loads. These relative risks were not statistically significant when also adjusting for treatment centre location (P ≥ 0.15); and (ii) compared with major city centres, inner regional centres had a relative risk of 1.32 (1.18, 1.48), but the risk was not elevated for more remote sites at 0.95 (0.74, 1.22). Risk of death was not related to private insurance status. CONCLUSION: Higher breast cancer mortality in patients treated in inner regional than major city centres and in those treated by surgeons with lower case loads requires further study.

Optimal Cancer Care for Aboriginal and Torres Strait Islander People: A Shared Approach to System Level Change.

PURPOSE: To improve cancer outcomes for Aboriginal and Torres Strait Islander people through the development and national endorsement of the first population-specific optimal care pathway (OCP) to guide the delivery of high-quality, culturally appropriate, and evidence-based cancer care. METHODS: An iterative methodology was undertaken over a 2-year period, and more than 70 organizations and individuals from diverse cultural, geographic, and sectorial backgrounds provided input. Cancer Australia reviewed experiences of care and the evidence base and undertook national public consultation with the indigenous health sector and community, health professionals, and professional colleges. Critical to the OCP development was the leadership of Aboriginal and Torres Strait Islander health experts and consumers. RESULTS: The OCP received unanimous endorsement by all federal, state, and territory health ministers. Key elements of the OCP include attention to the cultural appropriateness of the health care environment; improvement in cross-cultural communication; relationship building with local community; optimization of health literacy; recognition of men's and women's business; and the need to use culturally appropriate resources. The OCP can be used as a tool for health services and health professionals to identify gaps in current cancer services and to inform quality improvement initiatives across all aspects of the care pathway. CONCLUSION: The development of the OCP identified a number of areas that require prioritization. Ensuring culturally safe and accessible health services is essential to support early presentation and diagnosis. Multidisciplinary treatment planning and patient-centered care are required for all Aboriginal and Torres Strait Islander people, irrespective of location. Health planners and governments acknowledge the imperative for change and have expressed strong commitment to work with indigenous Australians to improve the accessibility, cultural appropriateness, and quality of cancer care.

Reasons for improved survival from ovarian cancer in New South Wales, Australia, between 1980 and 2003: implications for cancer control.

We analyzed New South Wales Central Cancer Registry data for 1980-2003, to determine time trends in case fatality from ovarian cancer, after adjusting for stage, histological, and sociodemographic factors, and to consider service-delivery and research implications. After adjusting for covariates, the relative risk (95% confidence limit) of ovarian-cancer death reduced to 0.51 (0.46, 0.57) for 1999-2003 compared with 1980-1983. Relative risks were higher for adenocarcinomas and other specified and unspecified cancers than serous carcinomas, but lower for endometrioid carcinomas, sex cord-stromal and germ cell tumors. The probability of diagnosis with localized as opposed to more advanced disease was lower in older patients, the lowest socioeconomic stratum, women born in non-English-speaking countries, and more recent diagnostic periods. Approximately 61% of ovarian cancers had distant metastases at diagnosis in 1999-2003. Poorer survivals apply to older patients. Research directed at finding an effective screening test for epithelial ovarian cancer remains a priority.

Age effects on survival from early breast cancer in clinical settings in Australia.

BACKGROUND: The study aim was to determine whether age is an independent risk factor for survival from early invasive breast cancer in contemporary Australian clinical settings. METHODS: The study included 31 493 breast cancers diagnosed in 1998-2005. Risk of death from breast cancer was compared by age, without and with adjustment for clinical risk factors, using Cox proportional hazard regression. RESULTS: Risk of breast cancer death was elevated for cancers of larger size, higher grade, positive nodal status, oestrogen receptor negative status, vascular invasion and multiple foci. Ductal lesions presented a higher risk than other lesions. Adjusting for these factors, the relative risk of breast cancer death (95% confidence limits) was lower for 40-49-year-olds at 0.80 (0.66, 0.96) than for the reference category under 40 years, but higher for 70-79-year-olds at 1.64 (1.36, 1.98) and women aged 80 years or more at 2.19 (1.79, 2.69). The risk for 50-69-year-olds and women under 40 years was similar. Risk-factor adjustment reduced the difference in risk between the reference category under 40 years and 40-49-year-olds, largely eliminated the lower relative risk for 50-69-year-olds, and increased the relative risks for women aged 70-79 years and older. DISCUSSION: Survivals in women under 40 and over 70 years of age are poorer than for 40-69-year-olds. Research is needed into the best treatment modalities for younger women and older women with co-morbidity.

Australian women's perceptions of breast cancer risk factors and the risk of developing breast cancer.

BACKGROUND: Numerous studies have shown that the majority of women overestimate both their own risk and the populations' risk of developing breast cancer. A number of factors have been found to correlate with perceived risk. METHODS: This paper reports on a telephone survey of a nationally representative sample of approximately 3,000 Australian women aged 30 to 69 years, conducted in 2007, and compares the findings with those of a similar survey conducted in 2003. RESULTS: There was a clear tendency for respondents to overestimate the proportion of women who will develop breast cancer during their lifetime. Approximately half the respondents perceived themselves as being at the same risk of developing breast cancer as other women their age; older respondents were more likely to perceive themselves to be at a lower than average risk. Family history was recognized as a risk factor for breast cancer, although there was evident confusion in relation to risk from paternal family history. It was also evident that the association between age and risk status is poorly understood, and misconceptions of breast cancer risk factors identified in the previous survey persisted in 2007. CONCLUSION: Overall, these results suggest that there remains an educational challenge if we seek to increase the accuracy of women's perceptions of their risk for developing breast cancer, primarily in relation to the significance of age and family history as breast cancer risk factors.

Pathways to the diagnosis of epithelial ovarian cancer in Australia.

OBJECTIVE: To describe the diagnostic pathways experienced by a large, representative group of Australian women with ovarian cancer, and to document the time between first presentation to a medical professional and clinical diagnosis. DESIGN, SETTING AND PARTICIPANTS: 1463 women with epithelial ovarian cancer from an Australia-wide population-based study (2002-2005) completed a telephone interview in which they described the events that led to the diagnosis of their cancer. MAIN OUTCOME MEASURES: Number and type of doctors consulted, investigations performed, referral patterns and the time from first presentation to diagnosis. RESULTS: Of the 1463 women, 145 had their cancer diagnosed incidentally and were excluded from analysis. Most of the remaining 1318 women (1222, 93%) presented first to their general practitioner. As a result of their first medical consultation, 75 women (6%) were given a diagnosis, and 484 (37%) were referred to a gynaecologist, gynaecological oncologist or oncologist for further assessment. Overall, 85% of women visited three or fewer doctors before their cancer was diagnosed; 66% of cancers were diagnosed within 1 month of the initial presentation, and 80% were diagnosed within 3 months. For 12% of women, the diagnostic process took longer than 6 months; this was more likely for women residing in remote Australia, those with lower incomes, and those presenting with abdominal pain or bowel symptoms, or with more than one symptom. CONCLUSIONS: Despite anecdotal suggestions to the contrary, most women with ovarian cancer in Australia are investigated and diagnosed promptly. The diagnostic process is more protracted for a minority of women, and the factors we found to be associated with diagnostic delay warrant further investigation.

Medicolegal implications of a multidisciplinary approach to cancer care: consensus recommendations from a national workshop.

Concerns about medicolegal implications of a multidisciplinary approach to cancer care may act as a barrier to the implementation of best practice approaches. While multidisciplinary meetings carry a low level of medicolegal risk, improved documentation and transparency in approach will assist in limiting liability for individual health professionals and health services. The medicolegal implications of a multidisciplinary approach are not affected by whether a health professional bills the patient for attendance at multidisciplinary meetings.

Breast cancer screening.

Achieving and maintaining a high rate of attendance for screening and two-yearly re-screening is essential for the success of the BreastScreen Australia program. A low participation rate will result in fewer breast cancer-related deaths being prevented. Results of two recent large randomised trials do not show that a systematic approach to breast self examination finds breast cancers early or impacts on survival. "Breast awareness" and the prompt reporting of breast symptoms are important early detection messages for women of all ages. General practitioners have a key role in the promotion and provision of information about effective public-health initiatives for the early detection of breast cancer.