title: Examining Determinants of Radiotherapy Access: Do Cost and Radiotherapy Inconvenience Affect Uptake of Breast-conserving Treatment for Early Breast Cancer?
abstract: OBJECTIVE
  Radiotherapy utilisation is likely affected by multiple factors pertaining to radiotherapy access. Radiotherapy is an integral component of breast-conserving treatment (BCT) for early breast cancer. We aimed to determine if stepwise improvements in radiotherapy access in regional Australia affected the uptake of BCT and thus radiotherapy.
  
  
  METHODS
  Breast cancer operations in the Central Coast of New South Wales between January 2010 and March 2014 for T1-2N0-1M0 invasive or in situ (≤5 cm) disease in female patients eligible for BCT were examined. BCT uptake was calculated for three 1 year periods: period 1 (local radiotherapy available at cost to user or out of area radiotherapy with travel cost and inconvenience); period 2 (as per period 1 + publicly funded transport and radiotherapy at out of area facilities at no cost to user); period 3 (as per period 1 + publicly funded local radiotherapy at no cost to user).
  
  
  RESULTS
  In total, 574 cases met eligibility criteria. BCT declined with increasing distance to publicly funded radiotherapy (P = 0.035). BCT rates for periods 1, 2 and 3 were 63% (113/180), 61% (105/173) and 71% (156/221). There were no statistically significant differences in BCT between periods 1 and 2 in the whole cohort or within age, histology or tumour size subgroups. Overall, there was a 9% increase in BCT in the whole cohort in period 3 compared with periods 1 and 2 (P = 0.031). This increase was statistically significant for women over 70 years (19% increase, P = 0.034), for women with ductal carcinoma in situ (25% increase, P = 0.013) and for women with primary tumours that were ≤10 mm (21% increase, P = 0.016).
  
  
  CONCLUSIONS
  Improving the affordability of radiotherapy through publicly funded transport and radiotherapy at out of area facilities did not improve BCT uptake in a region where radiotherapy was locally available, albeit at cost to the user. Improving both affordability and convenience through the provision of local publicly funded radiotherapy increased BCT uptake. Service availability and affordability have long been recognised as important determinants of radiotherapy access. Our findings suggest that inconvenience may also influence radiotherapy utilisation.
authors.affiliation: Central Coast Cancer Centre, Gosford Hospital, Gosford, NSW, Australia.
authors.forename: J
authors.initials: J
authors.lastname: Lam
authors.affiliation: Joint Medical Program, University of Newcastle, Newcastle, Australia.
authors.forename: T
authors.initials: T
authors.lastname: Cook
authors.affiliation: Central Coast Cancer Centre, Gosford Hospital, Gosford, NSW, Australia.
authors.forename: S
authors.initials: S
authors.lastname: Foster
authors.affiliation: Department of Surgery, Gosford Hospital, Gosford, NSW, Australia.
authors.forename: R
authors.initials: R
authors.lastname: Poon
authors.affiliation: Sydney Medical School, University of Sydney, Sydney, Australia.
authors.forename: C
authors.initials: C
authors.lastname: Milross
authors.affiliation: Central Coast Cancer Centre, Gosford Hospital, Gosford, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, Australia. Electronic address: psun8480@uni.sydney.edu.au.
authors.forename: P
authors.initials: P
authors.lastname: Sundaresan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000191:economics / Q000453:epidemiology* / Q000473:pathology / Q000628:therapy; D002285:Carcinoma, Intraductal, Noninfiltrating / Q000191:economics / Q000453:epidemiology / Q000628:therapy; D005260:Female; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D015412:Mastectomy, Segmental / Q000706:statistics & numerical data*; D008875:Middle Aged; D009517:New South Wales / Q000453:epidemiology; D018714:Radiotherapy, Adjuvant / Q000191:economics / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: Access; availability; cost; inconvenience; radiotherapy; utilisation