title: A systematic review of geographical variation in access to chemotherapy.
abstract: BACKGROUND
  Rising cancer incidence, the cost of cancer pharmaceuticals and the introduction of the Cancer Drugs Fund in England, but not other United Kingdom(UK) countries means evidence of 'postcode prescribing' in cancer is important. There have been no systematic reviews considering access to cancer drugs by geographical characteristics in the UK.
  
  
  METHODS
  Studies describing receipt of cancer drugs, according to healthcare boundaries (e.g. cancer network [UK]) were identified through a systematic search of electronic databases and grey literature. Due to study heterogeneity a meta-analysis was not possible and a narrative synthesis was performed.
  
  
  RESULTS
  8,780 unique studies were identified and twenty-six included following a systematic search last updated in 2015. The majority of papers demonstrated substantial variability in the likelihood of receiving chemotherapy between hospitals, health authorities, cancer networks and UK countries (England and Wales). After case-mix adjustment, there was up to a 4-5 fold difference in chemotherapy utilisation between the highest and lowest prescribing cancer networks. There was no strong evidence that rurality or distance travelled were associated with the likelihood of receiving chemotherapy and conflicting evidence for an effect of travel time.
  
  
  CONCLUSIONS
  Considerable variation in chemotherapy prescribing between healthcare boundaries has been identified. The absence of associations with natural geographical characteristics (e.g. rurality) and receipt of chemotherapy suggests that local treatment habits, capacity and policy are more influential.
authors.affiliation: School of Social and Community Medicine, University of Bristol, 39 Whatley Rd, Bristol, BS8 2PS, UK. Charlotte.chamberlain@bristol.ac.uk.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Chamberlain
authors.affiliation: School of Social and Community Medicine, University of Bristol, 39 Whatley Rd, Bristol, BS8 2PS, UK. A.Owen-Smith@bristol.ac.uk.
authors.forename: Amanda
authors.initials: A
authors.lastname: Owen-Smith
authors.affiliation: School of Social and Community Medicine, University of Bristol, 39 Whatley Rd, Bristol, BS8 2PS, UK. Jenny.Donovan@bristol.ac.uk.
authors.forename: Jenny
authors.initials: J
authors.lastname: Donovan
authors.affiliation: School of Social and Community Medicine, University of Bristol, 39 Whatley Rd, Bristol, BS8 2PS, UK. William.Hollingworth@bristol.ac.uk.
authors.forename: William
authors.initials: W
authors.lastname: Hollingworth
mesh_terms: D000970:Antineoplastic Agents / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care; D006801:Humans; D009369:Neoplasms / Q000188:drug therapy / Q000453:epidemiology*; D006113:United Kingdom
chemical_list: D000970:Antineoplastic Agents