Rural factors in cancer treatment and survival
Treatment of cancer is becoming increasingly successful, particularly if conducted in specialist centres. For 20% of the UK population who live in rural areas, however, there may be difficulties accessing this care. The aim of the research in this thesis was to establish whether people in rural areas are disadvantaged in cancer care. Two studies were conducted. In the first, survival rates from six common cancers were analysed for 63 976 people with cancer diagnosed between 1991 and 1995 in Scotland. Living further from a cancer centre was associated with higher chance of early death (on the date of diagnosis) for stomach (adjusted odds ratio 3.92, 95% confidence intervals 2.17 to 7.08), breast (2.87, 1.74 to 4.74) and colorectal cancers (1.78, 1.19 to 2.67). After diagnosis, increasing distance was associated with poorer survival for prostate (proportional hazard ratio 1.23; 95% confidence intervals 1.02 to 1.48) and lung (1.09, 1.01 to 1.18) cancers. The second study compared disease stage at diagnosis, modes of cancer treatment and time between referral and treatment for 1323 patients diagnosed with lung or colorectal cancer in 1995 or 1996 in north and northeast Scotland. People living more than 58 kilometres from a cancer centre were 56% more likely to have disseminated disease at diagnosis (P = 0.046). The proportions of patients receiving surgery, chemotherapy and radiotherapy were similar for rural and urban patients although, fewer outlying rural patients received radiotherapy for colorectal cancer. Times between first referral and treatment also appeared similar in urban and rural groups. To conclude, rural patients, who live further from cities with specialist cancer facilities, have more advanced cancer at the diagnosis and poorer survival. This suggests there may be delays before diagnosis, but these must occur before initial referral perhaps related to consulting behaviour.