For patients with breast cancer, geographic and social disparities are independent determinants of access to specialized surgeons. A eleven-year population-based multilevel analysis.
BACKGROUND
It has been shown in several studies that survival in cancer patients who were operated on by a high-volume surgeon was better. Why then do all patients not benefit from treatment by these experienced surgeons? The aim of our work was to study the hypothesis that in breast cancer, geographical isolation and the socio-economic level have an impact on the likelihood of being treated by a specialized breast-cancer surgeon.


METHODS
All cases of primary invasive breast cancer diagnosed in the Côte d'Or from 1998 to 2008 were included. Individual clinical data and distance to the nearest reference care centre were collected. The Townsend Index of each residence area was calculated. A Log Rank test and a Cox model were used for survival analysis, and a multilevel logistic regression model was used to determine predictive factors of being treated or not by a specialized breast cancer surgeon.


RESULTS
Among our 3928 patients, the ten-year survival of the 2931 (74.6 %) patients operated on by a high-volume breast cancer surgeon was significantly better (LogRank p < 0.001), independently of age at diagnosis, the presence of at least one comorbidity, circumstances of diagnosis (screening or not) and TNM status (Cox HR = 0.81 [0.67-0.98]; p = 0.027). In multivariate logistic regression analysis, patients who lived 20 to 35 minutes, and more than 35 minutes away from the nearest reference care centre were less likely to be operated on by a specialized surgeon than were patients living less than 10 minutes away (OR = 0.56 [0.43; 0.73] and 0.38 [0.29; 0.50], respectively). This was also the case for patients living in rural areas compared with those living in urban areas (OR = 0.68 [0.53; 0.87]), and for patients living in the two most deprived areas (OR = 0.69 [0.48; 0.97] and 0.61 [0.44; 0.85] respectively) compared with those who lived in the most affluent area.


CONCLUSIONS
A disadvantageous socio-economic environment, a rural lifestyle and living far from large specialized treatment centres were significant independent predictors of not gaining access to surgeons specialized in breast cancer. Not being treated by a specialist surgeon implies a less favourable outcome in terms of survival.
Côte d'Or Breast and Gynaecological Cancers Registry, Centre de Lutte Contre le Cancer Georges-François Leclerc, Dijon, France. jgentil@cgfl.fr
Julie
J
Gentil
Tienhan Sandrine
TS
Dabakuyo
Samiratou
S
Ouedraogo
Marie-Laure
ML
Poillot
Olivier
O
Dejardin
Patrick
P
Arveux
D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000453:epidemiology* / Q000401:mortality / Q000601:surgery; D005260:Female; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006801:Humans; D008875:Middle Aged; D055361:Multilevel Analysis; D009367:Neoplasm Staging; D011379:Prognosis; D012042:Registries; D012424:Rural Population; D012959:Socioeconomic Factors