bs_bs_banner
Aust. J. Rural Health (2014) 22, 257–263
Original Research Characteristics of cancer diagnoses and staging in South Western Victoria: A rural perspective Patricia Banks, MBBS BSc (Hons),1 Leigh M. Matheson, BHIM BHSci BEd,2 Kate Morrissy, BEd (Hons) BA Grad Dip Bus Man,2 Inger Olesen, BPharm MBBS (Hons) FRACP,1 Graham Pitson, MBBS FRANZCR,1 Adam Chapman, BA/Sc (Hons) MPH MHSc,3 David M. Ashley, MBBS (Hon) FRACP PhD,1,4 and Margaret J. Henry, BSc (Hons) PhD2,4 1
Andrew Love Cancer Centre and 2Barwon South Western Region Integrated Cancer Services, Geelong, and 3Department of Health (Victoria) and 4Department of Medicine, Barwon Health, Deakin University, Melbourne, Victoria, Australia
Abstract Objective: Australian states and territories have legislation mandating reporting of cancer diagnoses; however, tumour stage at diagnosis, treatment plan and associated outcomes are not routinely recorded in cancer registries for all tumour types. This study describes the Evaluation of Cancer Outcomes study that collects detailed information for patients diagnosed with cancer in south-western Victoria. Design: Retrospective data collection. Setting: Population based. Participants: New cancer patients within the Barwon South Western region. Main outcome measures: Cancer incidence and staging data for a regional and rural area. Results: In 2009, there were 1778 primary tumours. Prominent tumour streams included prostate, breast, colon, lung, lymphoma, melanoma and rectum. Stage at diagnosis was recorded for more than 50% of patients for the tumour streams of testis, breast, bowel, renal, lung, and head and neck. Patients reporting to health centres with an on-site oncologist as part of their team had a higher rate of staging recorded at diagnosis (48.0 versus 36.9%, P = 0.01). More women (55.4%) than men (41.4%) had stage-recorded. Conclusion: The Evaluation of Cancer Outcomes study is an important initiative that collects information about newly diagnosed cases of cancer more detailed than is currently collected by the Cancer Council of Victoria. Future studies will build on this base dataset and
provide valuable insight into the regional and rural experience of treatment pathways after diagnosis. More work is needed to bring more services to our rural patients, or more education is needed to encourage the recording of tumour staging. KEY WORDS: cancer, diagnosis, regional and rural, tumour staging.
Introduction
Accepted for publication 12 March 2014.
Cancer is a major cause of morbidity and mortality in Australia. With almost half of Australians expected to develop cancer before the age of 85, Australia has been reported to have one of the highest incidence rates of cancer overall worldwide.1,2 While the incidence rates of some types of cancer are declining, the incidence of cancer overall appears to be increasing, and this is not wholly accounted for by an ageing population.2 Australians living in regional and rural areas have consistently been found to have poorer health outcomes compared with their metropolitan counterparts. Some rural areas have displayed higher rates of smoking, hazardous levels of alcohol consumption, and a greater proportion of population with a sedentary lifestyle and obesity, all of which increase the risk of developing cancer.3–5 Despite people in rural areas having similar or even higher participation rates in cancer screening programs,2,6,7 outcomes continue to be poorer,8,9 and people in rural areas seem more likely to present with advanced cancer than their urban counterparts.10–15 Treatment patterns differ between urban and rural populations, and might be in part due to later presentation. This affects treatment options and prognosis. Men with prostate cancer in rural areas are less likely to undergo radical prostatectomy and have a higher mortality than those living in capital cities.16 Women with
© 2014 National Rural Health Alliance Inc.
doi: 10.1111/ajr.12112
Correspondence: Associate Professor Margaret Henry, Barwon South Western Region Integrated Cancer Services, Barwon Health, PO Box 281, Geelong, Victoria, 3220, Australia. Email: [email protected]
258
What is already known on this subject: • Cancer patients from regional and rural areas have poorer health outcomes. • Patients in rural areas seem more likely to present with advanced cancer.
breast cancer in rural areas are less likely to undergo breast-conserving surgery and radiotherapy, and more likely to undergo mastectomy, independent of tumour characteristics.17,18 Rural patients with colon cancer in WA are less likely to complete adjuvant fluorouracil (5-FU) chemotherapy and have worse survival.19 These differences might be influenced by the significant logistical and financial challenges faced by rural cancer patients. Access to services in rural regions might limit the ability of tumours to be staged at diagnosis. Tumour staging is important, assisting decisions for treatment pathways. Results from a study in the USA showed that unstaged tumours are more likely with increasing age, more lethal tumours, patients with lower education levels and those without medical insurance.20 Proportions of unstaged tumours vary across tumour streams and the sexes. Substantive comorbidity increases the odds of being unstaged.21 Australian states and territories have legislation mandating reporting of cancer diagnoses to state registries; however, tumour stage at diagnosis, treatment plan and associated outcomes are not routinely recorded. These data would allow a more comprehensive understanding of cancer and be important for improving care among cancer patients to close the gap between rural and urban cancer outcomes.2,22 The Evaluation of Cancer Outcomes (ECO) study is a collaboration between the Barwon South Western Region Integrated Cancer Services, Cancer Council Victoria (CCV) and Department of Health (Victoria), and collects this detailed information for all patients diagnosed with cancer admitted to hospital in the Barwon South Western region of Victoria commencing with the pilot data of 2009. The Barwon South Western region is comprised of Geelong, the largest regional centre in Victoria, and the surrounding rural area extending to the South Australian border. The purpose of this article is to describe the incidence of cancer and tumour staging in this regional and rural area.
Methods Region The Barwon South Western Region (Fig. 1) is an area in south-western Victoria surrounding the regional cities
P. BANKS ET AL.
What does this study add: • The Evaluation of Cancer Outcomes study is an important initiative that collects more detailed information about newly diagnosed cases of cancer than is currently collected by the Cancer Council of Victoria. • Our study highlights that more work is needed to bring more services to our rural patients or more education is needed to encourage the recording of tumour staging. • Future studies will build on this base dataset of cancer diagnosis and tumour staging, and provide valuable insight into the regional and rural experience of treatment pathways.
of Geelong, Portland, Hamilton, Warrnambool and Colac. The Local Government Areas for the region include Greater Geelong, Queenscliffe, Surf Coast, Colac-Otway, Corangamite, Warrnambool, Golden Plains, Moyne, Southern Grampians and Glenelg. The population for the Barwon South Western Region in 2009 included 184 976 men and 188 215 women (ABS census data). The health centres, both public and private, that support the region are Barwon Health, Colac Area Health, Geelong Private, Western District Health Service (Hamilton), Portland and District Hospital, SW Healthcare Warrnambool, SW Healthcare Camperdown, St John of God Geelong, and St John of God Warrnambool. The Andrew Love Cancer Centre, based in Geelong, is one of the primary centres of support in the region.
ECO study The ECO study is an initiative that was piloted in 2008. It is the first regional study under the Victorian Cancer Outcomes Network project that aims to extend population-based cancer data collection to include clinical and treatment information. The Barwon South Western region of Victoria was selected as the pilot region, as it was considered to be a ‘microcosm’ of Victoria in its representation of population and health services. The study is a collaboration between the Victorian Department of Health, the CCV and the Barwon South Western Regional Integrated Cancer Service. The data items collected fall under the precinct of mandatory reporting to the CCV in accordance with the Cancer Act 1958. The collection does not contravene any of the statutes of Privacy Principles as contained in the Health Records Act 2001. © 2014 National Rural Health Alliance Inc.
259
CANCER DIAGNOSES: A RURAL PERSPECTIVE
FIGURE 1: Barwon South Western Region in south-west Victoria.
Data collection A nationally developed and agreed set of clinical cancer data items known as the Victorian Clinical Cancer Registration Dataset was to be collected. This included tumour stage recorded in medical records at diagnosis for this study, and future studies will report on treatment plan and treatment choices, recurrence and associated outcomes. This article reports on 2009 data for the region collated in 2011, the first complete year of the ECO study. Data were manually and electronically collected from medical records, clinical notes and information systems for all new patients with cancer who presented to hospital for diagnosis or treatment. This included day case patients admitted for a diagnostic biopsy in the operating theatre or radiology department. It also included patients undergoing outpatient chemotherapy through a hospital. Patients who had previously been diagnosed with cancer but presented in 2009 with recurrence were excluded from this report. Patients who normally reside outside the region were excluded, and residents who were diagnosed outside the region but then returned for treatment were included. Data were integrated into the Regional Aggregated Cancer E-Repository based at Barwon Health. All new cancer diagnoses were included. Primary tumours were recorded as head and neck (ICD-10 C01C14, C30-C32), oesophagus (C15), stomach (C16), colon (C18), rectum (C19-C20, partial C21.8), anus (C21.0, C21.1, partial (c21.8)), liver (c22), gallbladder (C23-C24), pancreas (C25), lung (C33-C34), melanoma (C43), breast (C50), gynaecological (C51-C58), prostate (C61), testis (C62), renal (C64), bladder (C67), central nervous system (C70-C72), lymphoma (C81C85), myeloma (C90), leukaemia (C91-C95), thyroid © 2014 National Rural Health Alliance Inc.
(C73) and other. Tumour staging was included in the ECO database if recorded in a patient’s medical record at diagnosis by the treating clinician or pathologist. Tumour staging of solid tumours is often based on a combination of size, nodal involvement and presence of metastatic disease. Haematological cancers are often staged based on nodal involvement, extranodal disease, and the presence or absence of B symptoms. Patterns associated with unstaged tumours are reported.
Statistical analysis Cancer incidence was calculated per 100 000 person years. Proportion of patients unstaged within different categories were assessed using the chi-square statistic.
Results Primary tumours for 2009 tallied 1778 and included for men 36 bladder, 14 central nervous system, 100 colon, 7 gallbladder, 34 head or neck, 26 leukaemia, 13 liver, 94 lung, 47 lymphoma, 64 melanoma, 19 myeloma, 24 oesophagus, 24 pancreas, 335 prostate, 62 rectum, 29 renal, 25 stomach, 10 testis, 9 thyroid and 57 other. Tumours for women included 223 breast, 91 colon, 65 lung, 53 melanoma, 17 bladder, 16 leukaemia, 46 lymphoma, 22 pancreas, 14 stomach, 10 thyroid, 6 central nervous system, 3 gallbladder, 58 gynaecological, 9 head and neck, 4 liver, 7 myeloma, 11 oesophagus, 40 other, 37 rectum and 17 renal. Distribution of men and women for these tumours included 1029 (57.9%) males, 749 females. Median age was 68.6 year (interquartile range 58.9–78.5 year). The crude incidence rate of cancer in the Barwon South West region in 2009 was 555.8 cases per 100 000
260
P. BANKS ET AL.
181.11
200
Cancer incidence per 100 000 person years 180 160
118.48
140 120 100
4.87 5.31
5.41
13.52 7.44
15.68 9.03
33.52 22.85
12.98 11.696
30.82 21.25
12.98 5.84
10.27 3.72
34.6 28.16
25.41 24.44
34.54 7.03 2.13
4.78
3.78 1.59
0
7.57 3.19
9.03
20
18.38
19.46
40
14.06 8.5
30.82
60
50.82
53.52 45.16
80
0
FIGURE 2: Cancer incidence per 100 000 person years for the Barwon South Western Region. ( ) Male; ( ) female. CNS, Central Nervous System.
person years in men and 398.0 cases per 100 000 person years in women. Cancer incidence for the Barwon South Western Region displayed some similarities for men and women across tumour streams (Fig. 2). Prostate cancer was the highest for men and breast cancer for women. Prominent tumour streams for both sexes include colon, lung, lymphoma, melanoma and rectum. Patterns of tumour stage recorded at diagnosis displayed more women staged (55.4%) compared with men (41.4%) (P < 0.01). It is clinical practice for some tumour streams to be staged later in the course of clinical care; however, the pattern for those that were staged at diagnosis showed higher than 50% for testis, breast, bowel, renal, lung, head and neck, and gynaecological (Fig. 3). Distance appeared to be a factor in those that were staged with patients residing closest to Geelong or the south-Australian border more likely to have stagerecorded by a clinician at diagnosis (Fig. 4) (men P = 0.12 and women P = 0.15). The first health centre that a patient presented to was recorded. Patients reporting to health centres with an on-site oncologist as
part of their team had a higher rate of stage recorded at diagnosis (48.0% versus 36.9%, P = 0.01).
Discussion The most common cancers for men were prostate, colon, lung, melanoma, rectum and lymphoma, and for women, breast, colon, lung, gynaecological, melanoma, lymphoma and rectum. This pattern of incidence is comparable with national data.2 Over 50% of testis, breast, rectum, colon, lung, renal, and head and neck cancers had stage explicitly recorded in patient records at the time of diagnosis. To the authors’ knowledge, this is the first comprehensive regional study in Australia to look at this important component of cancer care. Patients closer to larger centres and health centres with an oncologist as part of their service team, were more likely to have staging recorded. The reasons for staging results not to be recorded could be varied and include incomplete histology or diagnostic imaging reports, staging not © 2014 National Rural Health Alliance Inc.
261
CANCER DIAGNOSES: A RURAL PERSPECTIVE
Females 90 Males Central ner 0 16.7 Myeloma 10.5 % STAGED 0 80 Liver 7.7 25 Leukaemia 15.4 12.5 Melanoma 17.2 13.2 70 28.6 33.3 Gallbladder Bladder 22.2 47.1 Prostate60 30.8 Thyroid 55.6 10 Stomach 40 21.4 50 Pancreas 37.5 31.8 Lymphoma 44.7 41.3 Oesophagu 54.2 36.4 40 Gynaecological 50 Head and N 58.8 22.2 30 Renal 51.7 82.4 Lung 62.8 66.2 Colon 20 74.8 62.4 Rectum 72.6 75.7 Breast 79.4 Tess 10 80
Staged (%) 5 7.7 11.8 14.3 15.4 30 30.2 30.8 31.6 33.3 34.8 43 48.6 50 51.2 63 64.2 69.2 73.5 79.4 80
0
FIGURE 3:
Percentage of patients staged by a clinician and recorded in the medical records at diagnosis. ( ) Male; ( ) female.
100 90 80 70 60 50
43.9 % STAGED 39.3 29.5 36.2 55.6 37.1 43.9
55.6 54 45.7 51.3 54 69
48.8 46 43.1 36.5 51.349
69
45.7 39.3
40
36.2
37.1
29.5
30 20 10 0 0–49 km
50–99 km
100–149 km 150–199 km
>200 km
FIGURE 4: Percentage of patients staged at diagnosis by distance residential address is from central Geelong. ( ) Male; ( ) female.
completed, or completed but not recorded. Availability and accessibility of imaging in regional areas would restrict tumour staging at diagnosis. Ideally, staging rates would be higher (in line with the Victorian government’s cancer action plan), and future work will © 2014 National Rural Health Alliance Inc.
attempt to elucidate the factors related to staging further. Prior reporting of unstaged cases in the US from a 10-year database showed that as little as 5.1–7.8% of cases were unstaged for colon and rectal cancer.23 For this study, stage was not recorded for 30.8% and 26.5% of patients with colon and rectal cancer; however, those whose residential home was closer to Geelong (
Aust. J. Rural Health (2014) 22, 257–263
Original Research Characteristics of cancer diagnoses and staging in South Western Victoria: A rural perspective Patricia Banks, MBBS BSc (Hons),1 Leigh M. Matheson, BHIM BHSci BEd,2 Kate Morrissy, BEd (Hons) BA Grad Dip Bus Man,2 Inger Olesen, BPharm MBBS (Hons) FRACP,1 Graham Pitson, MBBS FRANZCR,1 Adam Chapman, BA/Sc (Hons) MPH MHSc,3 David M. Ashley, MBBS (Hon) FRACP PhD,1,4 and Margaret J. Henry, BSc (Hons) PhD2,4 1
Andrew Love Cancer Centre and 2Barwon South Western Region Integrated Cancer Services, Geelong, and 3Department of Health (Victoria) and 4Department of Medicine, Barwon Health, Deakin University, Melbourne, Victoria, Australia
Abstract Objective: Australian states and territories have legislation mandating reporting of cancer diagnoses; however, tumour stage at diagnosis, treatment plan and associated outcomes are not routinely recorded in cancer registries for all tumour types. This study describes the Evaluation of Cancer Outcomes study that collects detailed information for patients diagnosed with cancer in south-western Victoria. Design: Retrospective data collection. Setting: Population based. Participants: New cancer patients within the Barwon South Western region. Main outcome measures: Cancer incidence and staging data for a regional and rural area. Results: In 2009, there were 1778 primary tumours. Prominent tumour streams included prostate, breast, colon, lung, lymphoma, melanoma and rectum. Stage at diagnosis was recorded for more than 50% of patients for the tumour streams of testis, breast, bowel, renal, lung, and head and neck. Patients reporting to health centres with an on-site oncologist as part of their team had a higher rate of staging recorded at diagnosis (48.0 versus 36.9%, P = 0.01). More women (55.4%) than men (41.4%) had stage-recorded. Conclusion: The Evaluation of Cancer Outcomes study is an important initiative that collects information about newly diagnosed cases of cancer more detailed than is currently collected by the Cancer Council of Victoria. Future studies will build on this base dataset and
provide valuable insight into the regional and rural experience of treatment pathways after diagnosis. More work is needed to bring more services to our rural patients, or more education is needed to encourage the recording of tumour staging. KEY WORDS: cancer, diagnosis, regional and rural, tumour staging.
Introduction
Accepted for publication 12 March 2014.
Cancer is a major cause of morbidity and mortality in Australia. With almost half of Australians expected to develop cancer before the age of 85, Australia has been reported to have one of the highest incidence rates of cancer overall worldwide.1,2 While the incidence rates of some types of cancer are declining, the incidence of cancer overall appears to be increasing, and this is not wholly accounted for by an ageing population.2 Australians living in regional and rural areas have consistently been found to have poorer health outcomes compared with their metropolitan counterparts. Some rural areas have displayed higher rates of smoking, hazardous levels of alcohol consumption, and a greater proportion of population with a sedentary lifestyle and obesity, all of which increase the risk of developing cancer.3–5 Despite people in rural areas having similar or even higher participation rates in cancer screening programs,2,6,7 outcomes continue to be poorer,8,9 and people in rural areas seem more likely to present with advanced cancer than their urban counterparts.10–15 Treatment patterns differ between urban and rural populations, and might be in part due to later presentation. This affects treatment options and prognosis. Men with prostate cancer in rural areas are less likely to undergo radical prostatectomy and have a higher mortality than those living in capital cities.16 Women with
© 2014 National Rural Health Alliance Inc.
doi: 10.1111/ajr.12112
Correspondence: Associate Professor Margaret Henry, Barwon South Western Region Integrated Cancer Services, Barwon Health, PO Box 281, Geelong, Victoria, 3220, Australia. Email: [email protected]
258
What is already known on this subject: • Cancer patients from regional and rural areas have poorer health outcomes. • Patients in rural areas seem more likely to present with advanced cancer.
breast cancer in rural areas are less likely to undergo breast-conserving surgery and radiotherapy, and more likely to undergo mastectomy, independent of tumour characteristics.17,18 Rural patients with colon cancer in WA are less likely to complete adjuvant fluorouracil (5-FU) chemotherapy and have worse survival.19 These differences might be influenced by the significant logistical and financial challenges faced by rural cancer patients. Access to services in rural regions might limit the ability of tumours to be staged at diagnosis. Tumour staging is important, assisting decisions for treatment pathways. Results from a study in the USA showed that unstaged tumours are more likely with increasing age, more lethal tumours, patients with lower education levels and those without medical insurance.20 Proportions of unstaged tumours vary across tumour streams and the sexes. Substantive comorbidity increases the odds of being unstaged.21 Australian states and territories have legislation mandating reporting of cancer diagnoses to state registries; however, tumour stage at diagnosis, treatment plan and associated outcomes are not routinely recorded. These data would allow a more comprehensive understanding of cancer and be important for improving care among cancer patients to close the gap between rural and urban cancer outcomes.2,22 The Evaluation of Cancer Outcomes (ECO) study is a collaboration between the Barwon South Western Region Integrated Cancer Services, Cancer Council Victoria (CCV) and Department of Health (Victoria), and collects this detailed information for all patients diagnosed with cancer admitted to hospital in the Barwon South Western region of Victoria commencing with the pilot data of 2009. The Barwon South Western region is comprised of Geelong, the largest regional centre in Victoria, and the surrounding rural area extending to the South Australian border. The purpose of this article is to describe the incidence of cancer and tumour staging in this regional and rural area.
Methods Region The Barwon South Western Region (Fig. 1) is an area in south-western Victoria surrounding the regional cities
P. BANKS ET AL.
What does this study add: • The Evaluation of Cancer Outcomes study is an important initiative that collects more detailed information about newly diagnosed cases of cancer than is currently collected by the Cancer Council of Victoria. • Our study highlights that more work is needed to bring more services to our rural patients or more education is needed to encourage the recording of tumour staging. • Future studies will build on this base dataset of cancer diagnosis and tumour staging, and provide valuable insight into the regional and rural experience of treatment pathways.
of Geelong, Portland, Hamilton, Warrnambool and Colac. The Local Government Areas for the region include Greater Geelong, Queenscliffe, Surf Coast, Colac-Otway, Corangamite, Warrnambool, Golden Plains, Moyne, Southern Grampians and Glenelg. The population for the Barwon South Western Region in 2009 included 184 976 men and 188 215 women (ABS census data). The health centres, both public and private, that support the region are Barwon Health, Colac Area Health, Geelong Private, Western District Health Service (Hamilton), Portland and District Hospital, SW Healthcare Warrnambool, SW Healthcare Camperdown, St John of God Geelong, and St John of God Warrnambool. The Andrew Love Cancer Centre, based in Geelong, is one of the primary centres of support in the region.
ECO study The ECO study is an initiative that was piloted in 2008. It is the first regional study under the Victorian Cancer Outcomes Network project that aims to extend population-based cancer data collection to include clinical and treatment information. The Barwon South Western region of Victoria was selected as the pilot region, as it was considered to be a ‘microcosm’ of Victoria in its representation of population and health services. The study is a collaboration between the Victorian Department of Health, the CCV and the Barwon South Western Regional Integrated Cancer Service. The data items collected fall under the precinct of mandatory reporting to the CCV in accordance with the Cancer Act 1958. The collection does not contravene any of the statutes of Privacy Principles as contained in the Health Records Act 2001. © 2014 National Rural Health Alliance Inc.
259
CANCER DIAGNOSES: A RURAL PERSPECTIVE
FIGURE 1: Barwon South Western Region in south-west Victoria.
Data collection A nationally developed and agreed set of clinical cancer data items known as the Victorian Clinical Cancer Registration Dataset was to be collected. This included tumour stage recorded in medical records at diagnosis for this study, and future studies will report on treatment plan and treatment choices, recurrence and associated outcomes. This article reports on 2009 data for the region collated in 2011, the first complete year of the ECO study. Data were manually and electronically collected from medical records, clinical notes and information systems for all new patients with cancer who presented to hospital for diagnosis or treatment. This included day case patients admitted for a diagnostic biopsy in the operating theatre or radiology department. It also included patients undergoing outpatient chemotherapy through a hospital. Patients who had previously been diagnosed with cancer but presented in 2009 with recurrence were excluded from this report. Patients who normally reside outside the region were excluded, and residents who were diagnosed outside the region but then returned for treatment were included. Data were integrated into the Regional Aggregated Cancer E-Repository based at Barwon Health. All new cancer diagnoses were included. Primary tumours were recorded as head and neck (ICD-10 C01C14, C30-C32), oesophagus (C15), stomach (C16), colon (C18), rectum (C19-C20, partial C21.8), anus (C21.0, C21.1, partial (c21.8)), liver (c22), gallbladder (C23-C24), pancreas (C25), lung (C33-C34), melanoma (C43), breast (C50), gynaecological (C51-C58), prostate (C61), testis (C62), renal (C64), bladder (C67), central nervous system (C70-C72), lymphoma (C81C85), myeloma (C90), leukaemia (C91-C95), thyroid © 2014 National Rural Health Alliance Inc.
(C73) and other. Tumour staging was included in the ECO database if recorded in a patient’s medical record at diagnosis by the treating clinician or pathologist. Tumour staging of solid tumours is often based on a combination of size, nodal involvement and presence of metastatic disease. Haematological cancers are often staged based on nodal involvement, extranodal disease, and the presence or absence of B symptoms. Patterns associated with unstaged tumours are reported.
Statistical analysis Cancer incidence was calculated per 100 000 person years. Proportion of patients unstaged within different categories were assessed using the chi-square statistic.
Results Primary tumours for 2009 tallied 1778 and included for men 36 bladder, 14 central nervous system, 100 colon, 7 gallbladder, 34 head or neck, 26 leukaemia, 13 liver, 94 lung, 47 lymphoma, 64 melanoma, 19 myeloma, 24 oesophagus, 24 pancreas, 335 prostate, 62 rectum, 29 renal, 25 stomach, 10 testis, 9 thyroid and 57 other. Tumours for women included 223 breast, 91 colon, 65 lung, 53 melanoma, 17 bladder, 16 leukaemia, 46 lymphoma, 22 pancreas, 14 stomach, 10 thyroid, 6 central nervous system, 3 gallbladder, 58 gynaecological, 9 head and neck, 4 liver, 7 myeloma, 11 oesophagus, 40 other, 37 rectum and 17 renal. Distribution of men and women for these tumours included 1029 (57.9%) males, 749 females. Median age was 68.6 year (interquartile range 58.9–78.5 year). The crude incidence rate of cancer in the Barwon South West region in 2009 was 555.8 cases per 100 000
260
P. BANKS ET AL.
181.11
200
Cancer incidence per 100 000 person years 180 160
118.48
140 120 100
4.87 5.31
5.41
13.52 7.44
15.68 9.03
33.52 22.85
12.98 11.696
30.82 21.25
12.98 5.84
10.27 3.72
34.6 28.16
25.41 24.44
34.54 7.03 2.13
4.78
3.78 1.59
0
7.57 3.19
9.03
20
18.38
19.46
40
14.06 8.5
30.82
60
50.82
53.52 45.16
80
0
FIGURE 2: Cancer incidence per 100 000 person years for the Barwon South Western Region. ( ) Male; ( ) female. CNS, Central Nervous System.
person years in men and 398.0 cases per 100 000 person years in women. Cancer incidence for the Barwon South Western Region displayed some similarities for men and women across tumour streams (Fig. 2). Prostate cancer was the highest for men and breast cancer for women. Prominent tumour streams for both sexes include colon, lung, lymphoma, melanoma and rectum. Patterns of tumour stage recorded at diagnosis displayed more women staged (55.4%) compared with men (41.4%) (P < 0.01). It is clinical practice for some tumour streams to be staged later in the course of clinical care; however, the pattern for those that were staged at diagnosis showed higher than 50% for testis, breast, bowel, renal, lung, head and neck, and gynaecological (Fig. 3). Distance appeared to be a factor in those that were staged with patients residing closest to Geelong or the south-Australian border more likely to have stagerecorded by a clinician at diagnosis (Fig. 4) (men P = 0.12 and women P = 0.15). The first health centre that a patient presented to was recorded. Patients reporting to health centres with an on-site oncologist as
part of their team had a higher rate of stage recorded at diagnosis (48.0% versus 36.9%, P = 0.01).
Discussion The most common cancers for men were prostate, colon, lung, melanoma, rectum and lymphoma, and for women, breast, colon, lung, gynaecological, melanoma, lymphoma and rectum. This pattern of incidence is comparable with national data.2 Over 50% of testis, breast, rectum, colon, lung, renal, and head and neck cancers had stage explicitly recorded in patient records at the time of diagnosis. To the authors’ knowledge, this is the first comprehensive regional study in Australia to look at this important component of cancer care. Patients closer to larger centres and health centres with an oncologist as part of their service team, were more likely to have staging recorded. The reasons for staging results not to be recorded could be varied and include incomplete histology or diagnostic imaging reports, staging not © 2014 National Rural Health Alliance Inc.
261
CANCER DIAGNOSES: A RURAL PERSPECTIVE
Females 90 Males Central ner 0 16.7 Myeloma 10.5 % STAGED 0 80 Liver 7.7 25 Leukaemia 15.4 12.5 Melanoma 17.2 13.2 70 28.6 33.3 Gallbladder Bladder 22.2 47.1 Prostate60 30.8 Thyroid 55.6 10 Stomach 40 21.4 50 Pancreas 37.5 31.8 Lymphoma 44.7 41.3 Oesophagu 54.2 36.4 40 Gynaecological 50 Head and N 58.8 22.2 30 Renal 51.7 82.4 Lung 62.8 66.2 Colon 20 74.8 62.4 Rectum 72.6 75.7 Breast 79.4 Tess 10 80
Staged (%) 5 7.7 11.8 14.3 15.4 30 30.2 30.8 31.6 33.3 34.8 43 48.6 50 51.2 63 64.2 69.2 73.5 79.4 80
0
FIGURE 3:
Percentage of patients staged by a clinician and recorded in the medical records at diagnosis. ( ) Male; ( ) female.
100 90 80 70 60 50
43.9 % STAGED 39.3 29.5 36.2 55.6 37.1 43.9
55.6 54 45.7 51.3 54 69
48.8 46 43.1 36.5 51.349
69
45.7 39.3
40
36.2
37.1
29.5
30 20 10 0 0–49 km
50–99 km
100–149 km 150–199 km
>200 km
FIGURE 4: Percentage of patients staged at diagnosis by distance residential address is from central Geelong. ( ) Male; ( ) female.
completed, or completed but not recorded. Availability and accessibility of imaging in regional areas would restrict tumour staging at diagnosis. Ideally, staging rates would be higher (in line with the Victorian government’s cancer action plan), and future work will © 2014 National Rural Health Alliance Inc.
attempt to elucidate the factors related to staging further. Prior reporting of unstaged cases in the US from a 10-year database showed that as little as 5.1–7.8% of cases were unstaged for colon and rectal cancer.23 For this study, stage was not recorded for 30.8% and 26.5% of patients with colon and rectal cancer; however, those whose residential home was closer to Geelong (
