The influence of geographical access to health care and material deprivation on colorectal cancer survival: Evidence from France and England
Introduction
Colorectal cancer survival differs notably between France and England. The EUROCARE 4 study estimated the age-adjusted 5-year survival at 51.8% in England and 59.9% in France for patients diagnosed with a colorectal cancer in 2000–2002 (Verdecchia et al., 2007). The reasons behind lower survival in England are not well known, but potential explanations include the higher number of deaths in older patients, higher co-morbidity prevalences and differences in management (Dejardin et al., 2013).
Large inequalities in cancer survival have been consistently identified in relation to socioeconomic deprivation in both France (Dejardin et al., 2006) and England (Coleman et al., 2004, Woods et al., 2006). Indeed it has been estimated that a reduction in social inequalities in cancer survival in England could prevent more than 7000 cancer deaths in England annually (Ellis et al., 2012). Although later stage at diagnosis amongst more deprived patients in both countries may represent one potentially attractive explanation for the disparities observed, the observed deprivation gap in survival may also be associated with drivers such as sub-optimal treatment provision, patient lifestyles, and other factors associated with the provision of health care services (Woods et al., 2006).
In response to research evidence indicating a relationship between material deprivation and cancer survival, considerable efforts have been made to tackle deprivation related inequalities in survival (Mackenbach et al., 2003).
For example National cancer plans, the first of which was published in 2000 in England and 2002 in France, include some specific components relating to material deprivation and cancer control and prevention efforts. These include multidisciplinary team meetings for all patients; efforts to ensure early detection in all population groups; funds for research interventions dedicated to tackle social disparities in France around use of patient navigator programmes; and efforts for early detection, screening and optimal treatment in England such as actions to encourage smoking cessation in deprived areas, to encourage walking and cycling, particularly in deprived areas, and funding opportunities to develop palliative care for socially deprived groups.
Geographical inequalities are known to vary according to the type of health care organization. For example, in Scotland, a longer distance to hospital was associated with a higher probability of being diagnosed with colorectal cancer at time of death (Campbell et al., 2000) but was not significantly associated with survival in either Scotland or the North of England (Jones et al., 2008b). Yet research in other settings has shown strong associations with survival, including studies from France (Dejardin et al., 2008), the United States (US) (Henry et al., 2009, Huang et al., 2007) and Australia (Baade et al., 2011).
The putative mechanisms of how geographical factors impact cancer survival are complex and multidimensional (Meilleur et al., 2013). One potential explanation is the effect of travel times on patients׳ likelihood to seek care, and the consequent impact of this on stage at diagnosis. However, this relationship is unclear since some publications report an association (Campbell et al., 2001, Huang et al., 2009) whilst others do not (Haynes et al., 2008, Henry et al., 2013, Koka et al., 2002). Some publications have also reported that patients living far from treatments centres receive sub-optimal treatments (Crawford et al., 2009, Dejardin et al., 2008), although such findings are not universal (Campbell et al., 2002, Jones et al., 2008a). Another potential factor is specific to the French health care system, which is based on patients being able to choose freely the hospital they wish to go to. Whilst this means that all patients theoretically have access to specialized care, free hospital choice combined with high preference for proximity (Bouche et al., 2008) could mean that some patients miss out on the best possible treatment.
Population-based cancer registries offer an attractive way to investigate the effect of geographical differences in access to health care on cancer outcomes. Since the influence of such geographical inequalities may be partially mediated by the stage at diagnosis, it is crucial to control for stage at diagnosis. Population-based cancer registries also ensure the completeness of cases in the study areas.
The aim of this article was to investigate the influence of distance to health care and material deprivation on cancer survival for patients diagnosed with a colorectal cancer between 1997 and 2004 in France and England.
Section snippets
Population
This study included all cases of colorectal cancer (C18.0–C20.9) (ICDO-3) (Fritz et al., 2000) diagnosed between 1997 and 2004 (follow-up to 31/12/2007) in 3 cancer registries in France (Calvados, Côte d׳Or and Saone et Loire, 3% the whole national population) and 1 cancer registry in England (Northern and Yorkshire Region), which covers 13.3% of England (N=40,613) (Table 1). Patients with secondary cancer and patients under 15 years old were excluded. The methods of this study have been
Results
The travel time to the nearest cancer centre was significantly greater in France than in England (Fig. 1), with a mean of 49.57 min (95%CI 48.80–50.34 min) in France compared to 32.87 min (32.57–33.17 min) in England (Online S1).
Discussion
Our study shows that the survival of individuals with colorectal cancer differs according to both material deprivation and distance from health care services, but the effects were not the same in England and France. In England, the better prognosis observed for remote patients can be explained by a correlation with material deprivation; distance to health services alone did not affect survival whilst material deprivation level had a major influence, with lower survival for patients living in
Acknowledgements
The authors thank the French National Cancer Institute and the “Fondation de France”, which provided financial support for this study. BR and EM were supported by Cancer Research UK (C1336/A5735 and C23434/A9805 respectively).
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