title: Rural-urban disparities in incidence and outcomes of neuroendocrine tumors: A population-based analysis of 6271 cases.
abstract: BACKGROUND
  Despite their rising incidence, neuroendocrine tumors (NETs) remain a poorly understood disease. Living in a rural area (RA) affects the incidence and outcomes of other types of cancer. This study compared the incidence and outcomes of NETs for patients in RAs and patients in urban areas (UAs).
  
  
  METHODS
  A population-based cohort study of patients with NETs in Ontario, Canada from 1994 to 2011 was conducted. An RA was defined as any community with a population < 10,000 and outside the commuting zone of a metropolitan area. Incidence, advanced stage at presentation, distant recurrence-free survival (dRFS), and overall survival (OS) were compared between patients who lived in RAs and patients who lived in UAs with univariate and multivariate regression analyses.
  
  
  RESULTS
  The cohort included 6271 patients diagnosed with NETs, of whom 13.5% (n = 846) resided in RAs. The incidence of NETs was higher in RAs at 3.01 per 100,000 per year versus UAs at 2.82 per 100,000 per year (relative rate, 1.10; P = .04). RA living was not associated with an advanced stage at presentation (odds ratio, 1.15; 95% confidence interval, 0.96-1.38). Patients who lived in RAs had worse 10-year dRFS (62.8% vs 65.9%, P = .03) and OS (44.6% vs 48.8%, P = .004). RAs were independently associated with decreased OS (hazard ratio, 1.16; 95% confidence interval, 1.04-1.30).
  
  
  CONCLUSIONS
  Patients are more commonly diagnosed with NETs in RAs, but they do not present at more advanced stages in comparison with patients diagnosed in UAs. Patients living in RAs experience worse cancer recurrence and OS, and this is possibly related to variations in socioeconomic status, rural environmental factors, and access to specialized health care.
authors.affiliation: Division of General Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada.|Department of Surgery, University of Toronto, Toronto, Canada.
authors.forename: Julie
authors.initials: J
authors.lastname: Hallet
authors.affiliation: Division of General Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada.|Department of Surgery, University of Toronto, Toronto, Canada.
authors.forename: Calvin H L
authors.initials: CH
authors.lastname: Law
authors.affiliation: Division of General Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada.|Department of Surgery, University of Toronto, Toronto, Canada.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Karanicolas
authors.affiliation: Institute of Clinical Evaluative Sciences, Toronto, Canada.
authors.forename: Refik
authors.initials: R
authors.lastname: Saskin
authors.affiliation: Institute of Clinical Evaluative Sciences, Toronto, Canada.
authors.forename: Ning
authors.initials: N
authors.lastname: Liu
authors.affiliation: Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada.
authors.forename: Simron
authors.initials: S
authors.lastname: Singh
mesh_terms: D000368:Aged; D015331:Cohort Studies; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D054624:Health Status Disparities; D054625:Healthcare Disparities / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D008875:Middle Aged; D018358:Neuroendocrine Tumors / Q000453:epidemiology* / Q000401:mortality; D009864:Ontario / Q000453:epidemiology; D011446:Prospective Studies; D012424:Rural Population / Q000706:statistics & numerical data; D016019:Survival Analysis; D016896:Treatment Outcome; D014505:Urban Population / Q000706:statistics & numerical data
keywords: carcinoid; incidence; neuroendocrine; outcomes; rural