Analysing risk factors for poorer breast cancer outcomes in residents of lower socioeconomic areas of Australia
David Roder A B L , Helen M. Zorbas A , James Kollias C D E , Chris M. Pyke C F G , David Walters C E H I , Ian D. Campbell C J , Corey Taylor H and Fleur Webster KA Cancer Australia, Locked Bag 3, Strawberry Hills, NSW 2012, Australia. Email: helen.zorbas@canceraustralia.gov.au
B School of Population Health, University of South Australia, Adelaide, SA 5001, Australia. Email: roder@internode.on.net
C Breast Quality Audit Steering Committee, Breast Surgeons of Australia and New Zealand, Botany, NSW 1455, Australia.
D Breast, Endocrine and Surgical Oncology Unit, Royal Adelaide Hospital, North Terrace, SA 5000, Australia. Email: jim.kollias@health.sa.gov.au
E University of Adelaide, North Terrace, SA 5005, Australia.
F Breast Quality Audit, Breast Surgeons of Australia and New Zealand, Botany, NSW 1455, Australia.
G Mater Medical Centre, 293 Vulture St, South Brisbane, QLD 4101, Australia. Email: c_pyke@mc.mater.org.au
H Breast Quality Audit, Royal Australasian College of Surgeons, 199 Ward St, North Adelaide, SA 5006, Australia. Email: djw@walterssurgery.com.au, corey.taylor@surgeons.org
I The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA 5011, Australia.
J Waikato Clinical School, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 3200, Hamilton, New Zealand. Email: ian.campbell@waikatodhb.health.nz
K Cancer Australia, Locked Bag 3, Strawberry Hills, NSW 2012, Australia. Email: fleur.webster@canceraustralia.gov.au
L Corresponding author. Email: roder@internode.on.net
Australian Health Review 38(2) 134-141 https://doi.org/10.1071/AH13080
Submitted: 6 June 2013 Accepted: 22 October 2013 Published: 8 April 2014
Abstract
Objective To investigate patient, cancer and treatment factors associated with the residence of female breast cancer patients in lower socioeconomic areas of Australia to better understand factors that may contribute to their poorer cancer outcomes.
Methods Bivariable and multivariable analyses were performed using the Breast Quality Audit database of Breast Surgeons of Australia and New Zealand.
Results Multivariable regression indicated that patients from lower socioeconomic areas are more likely to live in more remote areas and to be treated at regional than major city centres. Although they appeared equally likely to be referred to surgeons from BreastScreen services as patients from higher socioeconomic areas, they were less likely to be referred as asymptomatic cases from other sources. In general, their cancer and treatment characteristics did not differ from those of women from higher socioeconomic areas, but ovarian ablation therapy was less common for these patients and bilateral synchronous lesions tended to be less frequent than for women from higher socioeconomic areas.
Conclusions The results indicate that patients from lower socioeconomic areas are more likely to live in more remote districts and have their treatment in regional rather than major treatment centres. Their cancer and treatment characteristics appear to be similar to those of women from higher socioeconomic areas, although they are less likely to have ovarian ablation or to be referred as asymptomatic patients from sources other than BreastScreen.
What is known about this topic? It is already known from Australian data that breast cancer outcomes are not as favourable for women from areas of socioeconomic disadvantage. The reasons for the poorer outcomes have not been understood. Studies in other countries have also found poorer outcomes in women from lower socioeconomic areas, and in some instances, have attributed this finding to more advanced stages of cancers at diagnosis and more limited treatment. The reasons are likely to vary with the country and health system characteristics.
What does this paper add? The present study found that in Australia, women from lower socioeconomic areas do not have more advanced cancers at diagnosis, nor, in general, other cancer features that would predispose them to poorer outcomes. The standout differences were that they tended more to live in areas that were more remote from specialist metropolitan centres and were more likely to be treated in regional settings where prior research has indicated poorer outcomes. The reasons for these poorer outcomes are not known but may include lower levels of surgical specialisation, less access to specialised adjunctive services, and less involvement with multidisciplinary teams. Women from lower socioeconomic areas also appeared more likely to attend lower case load surgeons. Little difference was evident in the type of clinical care received, although women from lower socioeconomic areas were less likely to be asymptomatic referrals from other clinical settings (excluding BreastScreen).
What are the implications for practitioners? Results suggest that poorer outcomes in women from lower socioeconomic areas in Australia may have less to do with the characteristics of their breast cancers or treatment modalities and more to do with health system features, such as access to specialist centres. This study highlights the importance of demographic and health system features as potentially key factors in service outcomes. Health system research should be strengthened in Australia to augment biomedical and clinical research, with a view to best meeting service needs of all sectors of the population.
References
[1] Stringhini S, Sabia S, Shipley M, Brunner E, Nabi H, Kivimaki M, et al Association of socioeconomic position with health behaviors and mortality. JAMA 2010; 303 1159–66.| Association of socioeconomic position with health behaviors and mortality.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC3cXktVWitb0%3D&md5=3a76a754ee730a51d8383939ac786ee4CAS | 20332401PubMed |
[2] Williams DR. Race, socioeconomic status, and health. The added effects of racism and discrimination. Ann N Y Acad Sci 1999; 896 173–88.
| Race, socioeconomic status, and health. The added effects of racism and discrimination.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c7ks1Ckug%3D%3D&md5=241d7b743c2750139c4ebdecd8448b3aCAS | 10681897PubMed |
[3] Sabanayagam C, Shankar A. Income is a stronger predictor of mortality than education in a national sample of U.S. adults. J Health Popul Nutr 2012; 30 82–6.
| Income is a stronger predictor of mortality than education in a national sample of U.S. adults.Crossref | GoogleScholarGoogle Scholar | 22524123PubMed |
[4] Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD. The burden of disease and injury in Australia 2003. Catalogue no. PHE82. Canberra: Australian Institute of Health and Welfare; 2007.
[5] Turrell G, Mathers CD. Socioeconomic status and health in Australia. Med J Aust 2000; 172 434–8.
| 1:STN:280:DC%2BD3czivVKhsQ%3D%3D&md5=140d1f5cf74859719bca1e674e7c7f4aCAS | 10870537PubMed |
[6] Turrell G, Kavanagh A, Draper G, Subramanian SV. Do places affect the probability of death in Australia? A multilevel study of area-level disadvantage, individual-level socioeconomic position and all-cause mortality. 1998–2000. J Epidemiol Community Health 2007; 61 13–9.
| Do places affect the probability of death in Australia? A multilevel study of area-level disadvantage, individual-level socioeconomic position and all-cause mortality. 1998–2000.Crossref | GoogleScholarGoogle Scholar | 17183009PubMed |
[7] Hupalo P, Herden K. Health policy and inequality. Occasional papers, new series no. 5. Canberra: Commonwealth Department Health and Aged Care; 1999.
[8] National Health and Medical Research Council. 2010–2012 Strategic plan: working to build a healthy Australia. Canberra: Australian Government; 2010.
[9] Draper G, Turrell G, Oldenburg B. Health inequalities in Australia, mortality. Health inequalities monitoring series no. 1. Cat. no. PHE 55. Canberra: Australian Institute of Health and Welfare; 2005.
[10] Australian Institute of Health and Welfare (AIHW). Cancer survival and prevalence in Australia: period estimates from 1982 to 2010. Cancer series no. 69. Catalogue no. CAN65. Canberra: AIHW; 2012.
[11] Australian Institute of Health and Welfare (AIHW). Cancer Australia & Australasian Association of Cancer Registries. Cancer survival and prevalence in Australia: cancers diagnosed from 1982 to 2004. Cancer series no. 42. Catalogue no. CAN38. Canberra: AIHW; 2008.
[12] Woods LM, Rachet B, Coleman MP. Origins of socio-economic inequalities in cancer survival: a review. Ann Oncol 2006; 17 5–19.
| Origins of socio-economic inequalities in cancer survival: a review.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2MnntFKitw%3D%3D&md5=7e02c3d4c22e348120d88886c19493c1CAS | 16143594PubMed |
[13] Singh GK, Miller BA, Hankey BF, Edwards BK. Area socioeconomic variations in U.S. cancer incidence, mortality, stage, treatment, and survival, 1975–1999. NCI cancer surveillance monograph series, number 4. NIH Publication No. 03-5417. Bethesda, MD: National Cancer Institute; 2003.
[14] Booth CM, Li G, Zhang-Salomons J, Mackillop WJ. The impact of socioeconomic status on stage of cancer at diagnosis and survival. Cancer 2010; 116 4160–7.
| The impact of socioeconomic status on stage of cancer at diagnosis and survival.Crossref | GoogleScholarGoogle Scholar | 20681012PubMed |
[15] Beiki O, Hall P, Ekbom A, Moradi T. Breast cancer incidence and case fatality among 4.7 million women in relation to social and ethnic background: a population-based cohort study. Breast Cancer Res 2012; 14 R5
| Breast cancer incidence and case fatality among 4.7 million women in relation to social and ethnic background: a population-based cohort study.Crossref | GoogleScholarGoogle Scholar | 22225950PubMed |
[16] Braaten T, Weiderpass E, Lund E. Socioeconomic differences in cancer survival: the Norwegian Women and Cancer Study. BMC Public Health 2009; 9 178
| Socioeconomic differences in cancer survival: the Norwegian Women and Cancer Study.Crossref | GoogleScholarGoogle Scholar | 19505303PubMed |
[17] Merletti F, Galassi C, Spadea T. The socioeconomic determinants of cancer. Environ Health 2011; 10 S7
| The socioeconomic determinants of cancer.Crossref | GoogleScholarGoogle Scholar | 21489217PubMed |
[18] Jeffreys M, Sarfati D, Stevanovic V, Tobias M, Lewis C, Pearce N, et al Socioeconomic inequalities in cancer survival in New Zealand: the role of extent of disease at diagnosis. Cancer Epidemiol Biomarkers Prev 2009; 18 915–21.
| Socioeconomic inequalities in cancer survival in New Zealand: the role of extent of disease at diagnosis.Crossref | GoogleScholarGoogle Scholar | 19223561PubMed |
[19] Schrijvers CTM, Coebergh JWW, Mackenbach JP. Socioeconomic status and comorbidity among newly diagnosed cancer patients. Cancer 1997; 80 1482–8.
| Socioeconomic status and comorbidity among newly diagnosed cancer patients.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2svnvVWkug%3D%3D&md5=46af64207af5050e8a7a10602300a64eCAS |
[20] Kroenke CH, Kubzansky LD, Schernhammer ES, Holmes MD, Kawachi I. Social networks, social support, and survival after breast cancer diagnosis. J Clin Oncol 2006; 24 1105–11.
| Social networks, social support, and survival after breast cancer diagnosis.Crossref | GoogleScholarGoogle Scholar | 16505430PubMed |
[21] Le H, Zioqas A, Lipkin SM, Zell JA. Effects of socioeconomic status and treatment disparities in colorectal cancer survival. Cancer Epidemiol Biomarkers Prev 2008; 17 1950–62.
| Effects of socioeconomic status and treatment disparities in colorectal cancer survival.Crossref | GoogleScholarGoogle Scholar | 18708384PubMed |
[22] Roder D, Currow D. Cancer in Aboriginal and Torres Strait Islander people of Australia. Asian Pac J Cancer Prev 2009; 10 729–33.
| 20104959PubMed |
[23] Chong A, Roder D. Exploring differences in survival from cancer among Indigenous and non-Indigenous Australians: implications for health service delivery and research. Asian Pac J Cancer Prev 2010; 11 953–61.
| 21133607PubMed |
[24] Morrell S, You H, Baker D. Estimates of cancer incidence, mortality and survival in aboriginal people from NSW, Australia. BMC Cancer 2012; 12 168
| Estimates of cancer incidence, mortality and survival in aboriginal people from NSW, Australia.Crossref | GoogleScholarGoogle Scholar | 22559220PubMed |
[25] Australian Institute of Health and Welfare (AIHW) and National Breast and Ovarian Cancer Centre. Breast cancer in Australia: an overview, 2009. Cancer series no. 50. Catalogue no. CAN46. Canberra: AIHW; 2009.
[26] Australian Institute of Health and Welfare (AIHW) and Cancer Australia. Breast cancer in Australia: an overview. Cancer series no. 71. Catalogue no. CAN67. Canberra: AIHW; 2012.
[27] Roder D, Webster F, Zorbas H, Sinclair S. Breast screening and breast cancer survival in Aboriginal and Torres Strait Island women of Australia. Asian Pac J Cancer Prev 2012; 13 147–55.
| Breast screening and breast cancer survival in Aboriginal and Torres Strait Island women of Australia.Crossref | GoogleScholarGoogle Scholar | 22502658PubMed |
[28] Standing Council on Health. National strategic framework for rural and remote health.. Canberra: Commonwealth of Australia; 2012.
[29] Roder D, Wang JX, Zorbas H, Kollias J, Maddern G. Survival from breast cancers managed by surgeons participating in the National Breast Cancer Audit of the Royal Australasian College of Surgeons. ANZ J Surg 2010; 80 776–80.
| Survival from breast cancers managed by surgeons participating in the National Breast Cancer Audit of the Royal Australasian College of Surgeons.Crossref | GoogleScholarGoogle Scholar | 20969682PubMed |
[30] Roder D, de Silva P, Zorbas HM, Kollias J, Malycha PL, Pyke CM, et al Survival from breast cancer: an analysis of Australian data by surgeon case load, treatment centre location, and health insurance status. Aust Health Rev 2012; 36 342–8.
| Survival from breast cancer: an analysis of Australian data by surgeon case load, treatment centre location, and health insurance status.Crossref | GoogleScholarGoogle Scholar | 22935129PubMed |
[31] Roder DM, de Silva P, Zorbas HM, Kollias J, Malycha PL, Pyke CM, et al Age effects on survival from early breast cancer in clinical settings in Australia. ANZ J Surg 2012; 82 524–8.
| Age effects on survival from early breast cancer in clinical settings in Australia.Crossref | GoogleScholarGoogle Scholar | 22776502PubMed |
[32] National Breast Cancer Centre. Clinical practice guidelines for the management of early breast cancer, 2nd edn. Canberra: Commonwealth of Australia; 2001.
[33] Australian Bureau of Statistics (ABS). 1996 census of population and housing. Socio-economic index for areas. Canberra: ABS; 1998.
[34] Armitage P, Berry G. Statistical methods in medical research. Oxford: Blackwell Scientific Publications; 1987.
[35] StataCorp. Stata Statistical Software. Release 12. College Station, TX: StataCorp LP; 2012.
[36] Australian Institute of Health and Welfare (AIHW). BreastScreen Australia monitoring report 2009–2010. Cancer series no. 72. Catalogue no. CAN68. Canberra: AIHW; 2012.
[37] Australian Government, Department of Health and Ageing. BreastScreen Australia mortality (ecological) study. Screening monograph no. 4/2009. Canberra: Commonwealth of Australia; 2009.
