title: Geographical disparities of rectal cancer local recurrence and outcomes: a population-based analysis.
abstract: BACKGROUND
  Challenges exist in providing high-quality cancer treatments to populations spread over large geographical areas. Local recurrence of rectal cancer is a complicated clinical problem associated with high morbidity and mortality.
  
  
  OBJECTIVE
  objectives of this study were to evaluate population-based rates and predictors of local recurrence of rectal cancer in the Province of Manitoba, Canada, with emphasis on the effects of geography.
  
  
  METHODS
  : This was a population-based retrospective analysis. Administrative data from the Manitoba Cancer Registry and individual patient charts were reviewed.
  
  
  METHODS
  Patients with stages I to III rectal cancer who underwent surgery with curative intent in Manitoba between 2004 and 2006 were included.
  
  
  METHODS
  The primary outcome was the development of local recurrence after surgical resection.
  
  
  RESULTS
  Three hundred seventy patients with a mean age of 67 years were identified. The 5-year local recurrence rate was 17.4%. In multivariate analysis, relative to Winnipeg residents, rural residents, regardless of where they underwent surgery, had an increased risk of local recurrence (HR, 3.47; 95% CI, 1.74-6.92 for surgery in Winnipeg; HR, 2.98; 95% CI, 1.59-5.57 for surgery in rural Manitoba). The absence of both neoadjuvant radiotherapy and adjuvant chemotherapy was associated with a higher risk of local recurrence. Higher risk of mortality was noted for rural patients (HR, 1.90; 95% CI, 1.24-2.89) and for those who developed local recurrence (HR, 2.01; 95% CI, 1.27-3.19).
  
  
  CONCLUSIONS
  Local recurrence rates for rectal cancer are high in Manitoba. Geography is an important variable, because rural status is associated with higher local recurrence rates and decreased survival. The use of neoadjuvant radiotherapy was an important predictor of lower local recurrence rates. Further initiatives are imperative to identify why rural patients experience differences in outcomes in Manitoba.
authors.affiliation: Department of Surgery, The University of Manitoba, Winnipeg, Canada.
authors.forename: Ramzi M
authors.initials: RM
authors.lastname: Helewa
authors.forename: Donna
authors.initials: D
authors.lastname: Turner
authors.forename: Debrah
authors.initials: D
authors.lastname: Wirtzfeld
authors.forename: Jason
authors.initials: J
authors.lastname: Park
authors.forename: David J
authors.initials: DJ
authors.lastname: Hochman
authors.forename: Piotr
authors.initials: P
authors.lastname: Czaykowski
authors.forename: Shahida
authors.initials: S
authors.lastname: Ahmed
authors.forename: Emma
authors.initials: E
authors.lastname: Shu
authors.forename: Andrew
authors.initials: A
authors.lastname: McKay
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008350:Manitoba / Q000453:epidemiology; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D011159:Population Surveillance / Q000379:methods*; D012004:Rectal Neoplasms / Q000453:epidemiology* / Q000628:therapy; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends