Impact of travel time and rurality on presentation and outcomes of symptomatic colorectal cancer: a cross-sectional cohort study in primary care

Abstract

Background: Several studies have reported a survival disadvantage for rural dwellers who develop colorectal cancer, but the underlying mechanisms remain obscure. Delayed presentation to GPs may be a contributory factor, but evidence is lacking. Aim: To examine the association between rurality and travel time on diagnosis and survival of colorectal cancer in a cohort from northeast Scotland. Design and setting: The authors used a database linking GP records to routine data for patients diagnosed between 1997 and 1998, and followed up to 2011. Method: Primary outcomes were alarm symptoms, emergency admissions, stage, and survival. Travel time in minutes from patients to GP was estimated. Logistic and Cox regression were used to model outcomes. Interaction terms were used to determine if travelling time impacted differently on urban versus rural patients. Results: Rural patients and patients travelling farther to the GP had better 3-year survival. When the travel outcome associations were explored using interaction terms, the associations differed between rural and urban areas. Longer travel in urban areas significantly reduced the odds of emergency admissions (odds ratio [OR] 0.62, P<0.05), and increased survival (hazard ratio 0.75, P<0.05). Longer travel also increased the odds of presenting with alarm symptoms in urban areas; this was nearly significant (OR 1.34, P = 0.06). Presence of alarm symptoms reduced the likelihood of emergency admissions (OR 0.36, P<0.01). Conclusion: Living in a rural area, and travelling farther to a GP in urban areas, may reduce the likelihood of emergency admissions and poor survival. This may be related to how patients present with alarm symptoms

Socioeconomic and demographic inequalities in stage at diagnosis and survival among colorectal cancer patients: evidence from a Swiss population‐based study

“…Patients living in periurban and rural areas showed lower stage-adjusted survival compared with their urban counterparts. Some studies from other countries reported similar results for patients with CRC [46,47], but other studies found the opposite result [48]. Although Switzerland has a high hospital density [23], inhabitants of remote regions, peripheral valleys, or mountainous areas may have long travel distances for care.…”

Geographical access to GPs and modes of cancer diagnosis in England: a cross-sectional study

“…Further research should also examine rural urban differences in routes to diagnosis, and the extent of travel time moderation on rural and urban outcomes. Rural areas have poorer geographical access to services (39), but this does not necessarily translate to higher emergency department visits (13,40), suggesting that rurality may be a distinct variable that measures a different parameter to travel time. This needs to be tested empirically.…”

Which indicators of early cancer diagnosis from population-based data sources are associated with short-term mortality and survival?

“…Typically the TNM classification system was used, directly or using ordinal stage (I–IV). Dukes’ stage for colorectal cancer [16] and tumour thickness for melanoma [23] were also used. Stage was frequently dichotomised into ‘early’ (localised, stage I or II, non-metastatic) vs. ‘late’ (advanced, stage III or IV, metastatic) [16,22].…”

“…Dukes’ stage for colorectal cancer [16] and tumour thickness for melanoma [23] were also used. Stage was frequently dichotomised into ‘early’ (localised, stage I or II, non-metastatic) vs. ‘late’ (advanced, stage III or IV, metastatic) [16,22]. The CancerData dashboard uses a binary indicator for whether the patient has a record of stage I/II disease, and presents this as a percentage of all patients (including those without a recorded stage) [37].…”

“…This is defined as an admission coded as ‘emergency’ and/or ‘accident & emergency’ [16], or a route to diagnosis via the Accident & Emergency department or via an emergency referral or transfer [11]. …”