Rural breast cancer treatment: evidence from the Reaching Communities for Cancer Care (REACH) project.

BACKGROUND: Research shows that rural populations are more likely than their urban counterparts to be diagnosed with late-stage cancer, but less is known about appropriateness of cancer treatment in rural locations after diagnosis. The objective of this analysis was to assess the degree to which rural breast cancer treatment was received in concordance with national recommendations. METHODS: Data came from 251 stage I and II breast cancer patients residing in rural North Carolina. State-of-the-art care was defined using the National Cancer Institute's (NCI) physician data query (PDQ) database, and cases were categorized into appropriate primary and/or adjuvant treatment. Chi-square and Fishers' exact tests were used to assess changes in appropriate treatment over time (1991-1996) and between stage. Multiple logistic regression was used to determine whether any patient or disease characteristics were associated with receipt of appropriate treatment. RESULTS: Most (81-90%) of the breast cancer cases received the appropriate primary therapy (mastectomy or lumpectomy followed by radiation therapy); of these, the majority received a mastectomy (66-72%). Fewer women received adjuvant therapy as recommended (27-61%), although significantly more stage II than stage I cases did so (p < or = 0.05). Regression showed that stage and estrogen-receptor (ER) status were associated with appropriate therapy. CONCLUSIONS: The findings suggest that there exist deviations from NCI established treatment recommendations among rural breast cancer patients. More research is needed to develop better methods for dissemination of state-of-the-art cancer information to rural physicians and patients, and to understand how treatment decisions are made.

Rural physicians' understanding of the state-of-the-art in breast, colon and rectum cancer treatment.

OBJECTIVES: This study measured the impact of an educational intervention aimed at heightening rural physicians' awareness of state-of-the-art breast and colorectal cancer therapies. METHODS: Pre- and post-intervention mailed surveys were administered to all primary-care physicians and referring physicians in the seven-county intervention region in North Carolina (NC) and a comparison region in South Carolina (SC). RESULTS: The survey revealed few significant changes in physicians' perspectives that could be attributed to the intervention. Physicians erroneously stated that lumpectomy without follow-up radiation was acceptable for treating breast cancer (55%), failed to indicate that adjuvant therapy was an accepted practice for treating Stage I breast cancer (67%), failed to acknowledge chemotherapy as experimental for Dukes' B colon cancer patients (70%), and failed to recognize a combination of surgery, chemotherapy, and radiation as a standard treatment for rectal cancer (25%). CONCLUSIONS: The low levels of awareness of National Cancer Institute guidelines were reflected in low breast-sparing surgery rates for women living in the intervention region. Stronger consensus on appropriate cancer treatments is needed throughout the medical community in order to reduce undesired variation in rural, community-based cancer care.

Colon cancer treatment in rural North and South Carolina.

The purpose of this study was to determine the degree to which colon cancer treatment in rural North and South Carolina in 1991 and 1996 conformed to national treatment recommendations. Data came from medical records of colon cancer patients residing in rural North and South Carolina. The National Cancer Institute's Physician Data Query (PDQ) database was used to define state-of-the-art care and to categorize receipt of primary and/or adjuvant treatment. Changes in treatment over time, location, and stage and bivariate relationships between treatment and selected covariates were assessed with chi-square and Fisher's exact tests. Regression was used to control for possible interactions between patient and/or disease characteristics and treatment. The majority of colon cancer cases received primary therapy as suggested by the PDQ which was not significantly related to other factors examined. There was variation in provision of adjuvant therapy. Stage III patients received adjuvant therapy significantly more often than did stage II patients (p

Migration of obstetrician-gynecologists into and out of rural areas, 1985-1990.

This study sought to determine if county-level demographic, health care resource, policy, and competitive factors are associated with the movement of obstetrician-gynecologists (ob-gyns) into and out of rural areas. County-level descriptive data from the Area Resource File, the American Medical Association Physician Masterfile, and the American Hospital Association Guide were used for hospital descriptions. This was a correlational study that measured the association of ecologic indicators of nonmetropolitan counties with indicators of gain or loss of ob-gyns. Descriptive statistics characterize the supply and movement of ob-gyns by size and location of the counties. Multinomial logistic regression models describe the net effect of the ecologic indicators on physician movement. During the period 1985 to 1990, a total of 962 patient care ob-gyns moved out of 531 nonmetropolitan counties, and 979 ob-gyns moved into 528 counties. Counties in the southern Atlantic states experienced the greatest net inflow, whereas Illinois, Missouri, and Texas had the greatest net outflow. Counties that retained ob-gyns during this period were in the mid-range of population. Positive correlates of outward migration were adjacency to a metropolitan county and loss of hospital bed supply; negative correlates with outward migration were the supply of hospital beds and total population. Inward migration was positively correlated with retention or gain of county family physicians and with adjacency; negative correlates were overall population and total family physician supply. The movement of ob-gyns in nonmetropolitan counties is influenced by state policies, local resources, and relative location. No clear evidence shows that there are competitive relations between family physician supply and ob-gyn supply.