title: Variation in the management of early breast cancer in rural and metropolitan centres: implications for the organisation of rural cancer services.
abstract: The study examines the management and outcomes of women with early invasive breast cancer treated in rural and metropolitan centres over a nine-year observation period. A prospective audit of the treatment and outcomes of 2081 women with early breast cancer who underwent potentially curative surgery between 1997 and 2006 in metropolitan Canberra or in the surrounding rural region was completed. Overall, there was good agreement between published guidelines and the treatment received by the women in the study. However, women treated in rural centres were less likely to receive postoperative radiotherapy after breast-conserving surgery, or to undergo axillary lymph node surgery or sentinel lymph node biopsy compared with women treated in metropolitan centres. Surgery in a rural centre was associated with increased breast cancer recurrence (HR = 1.54, p < 0.001) and increased breast cancer mortality (HR = 1.84, p < 0.001), after adjustment for age and tumour characteristics. Non-cancer related mortality was increased in women treated in rural centres compared with women travelling to a metropolitan centre for surgery (HR = 2.08; p = 0.005). There were differences in both the care provided and treatment outcomes between women treated in rural centres and women treated in metropolitan centres. However, the increased non-cancer related mortality in women treated in rural centres suggests an increased medical comorbidity in this group. Initiatives supporting rural-based surgeons to adopt new procedures such as sentinel node biopsy may help to optimise rural breast cancer treatment.
authors.affiliation: The Canberra Hospital, Canberra, Australia; Australian National University Medical School, Canberra, Australia. paul.craft@act.gov.au
authors.forename: Paul S
authors.initials: PS
authors.lastname: Craft
authors.forename: John M
authors.initials: JM
authors.lastname: Buckingham
authors.forename: Jane E
authors.initials: JE
authors.lastname: Dahlstrom
authors.forename: Kerri R
authors.initials: KR
authors.lastname: Beckmann
authors.forename: Yanping
authors.initials: Y
authors.lastname: Zhang
authors.forename: Robin
authors.initials: R
authors.lastname: Stuart-Harris
authors.forename: George
authors.initials: G
authors.lastname: Jacob
authors.forename: David
authors.initials: D
authors.lastname: Roder
authors.forename: Noel
authors.initials: N
authors.lastname: Tait
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001315:Australia; D001943:Breast Neoplasms / Q000401:mortality / Q000532:radiotherapy* / Q000601:surgery*; D005260:Female; D019983:Guideline Adherence; D006780:Hospitals, Rural; D006786:Hospitals, Urban; D006801:Humans; D016015:Logistic Models; D008875:Middle Aged; D009362:Neoplasm Metastasis; D009364:Neoplasm Recurrence, Local; D005791:Patient Care; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D021701:Sentinel Lymph Node Biopsy / Q000706:statistics & numerical data; D018709:Statistics, Nonparametric; D016896:Treatment Outcome