Informaci´ on precisa en la gesti´ on de la salud: Dream en Mozambique

The Calman-Hine report101, published in 1995, recommended that specialist cancer teams in locations with the necessary specialist resources should manage women w ith breast cancer in England and Wales. The Scottish Cancer Coordinating and Advisory Committee (SCCAQ proposed a similar network for Scotland in 1996102, with the aim that all women should have access to high levels of specialist cancer care to provide optimal treatment. Audit data for women diagnosed in 1987 and 1993 showed that older women and those living in more deprived areas were less likely to travel to a cancer centre151. These disparities, whether appropriate or not, are still present. Among women diagnosed in 1997, 81% of those aged under 75 attended one of the regional centres with radiotherapy provision (regional RT centre) within their cancer spell, but only 50% o f those aged over 75. Of the affluent women, 81% attended a regional RT centre compared to 64% of deprived women (Table 5.2). It is, therefore, evident that inequalities in access to treatment by age and deprivation were still prevalent in 1997.

Overall, 74% o f women attended a regional RT centre at some point during their cancer spell (Table 5.2), a further 10% attended other high-workload hospitals, 9% medium-

workload hospitals and 6% low-workload hospitals (data not shown). The main hospital of treatment w as a regional RT centre for 58% of affluent women and 35% o f deprived women. A correspondingly higher proportion of deprived women were treated at other high-workload hospitals (9% affluent and 34% deprived). These gradients were seen for women living in both urban and rural areas; however, deprived urban residents were less likely to attend a regional RT centre or other high-workload hospital (74% compared to 85% of affluent urban women).

There were also differences in the proportion o f women seen by a high-workload consultant (seeing at least 30 breast cancer cases per year), with those from the affluent areas more likely to see a high-workload consultant (66% compared to 56% in the deprived group). Those from the deprived areas were seen by more medium-workload consultants (10-29 cases; 19% compared to 12% for affluent women), with similar proportions being seen by only a low-workload consultant (12% compared to 10% for affluent women). The proportion o f women for whom no details o f contact with a consultant physician were recorded (around 11%), was similar between the deprivation groups.

The majority (87%) o f women were seen in a specialist department (85% within 3 months o f diagnosis), but with less likelihood for deprived women (81%). Women from the deprived group were more likely to have been initially admitted as an emergency (13% compared to 9% of affluent women; p=0.016).

Delay

For over h alf (51%) o f the 3 233 women with a known treatment date, at least two weeks elapsed between diagnosis and definitive treatment (Table 5.2). Women from deprived areas were less likely to have a wait (45% waited at least 2 weeks compared to 50% o f affluent patients; p<0.001). Over half (58%) of women were seen throughout their cancer spell at one hospital, with 38% o f women were seen at two hospitals. Deprived women were more likely to stay in hospital between diagnosis and treatment (86% compared to 69% of affluent women). These factors could reflect poorer health of these women at admission, or varying hospital policy, or lack o f support to return home.

T ab le 5 .2 : W o m e n d iagn osed w ith b re a st c a n c e r in S c o tla n d in 1 9 9 7 : access to h ealth care b y d e p riv a tio n cate g o ry (n u m b e r an d p ercen tag e o f p atients) Deprivation category No. of Attended a regional RT centre1 Attended a specialist department2 Main treatment at a regional RT centre Treated in a high-workload hospital3 Seen by a higb- woridoad consultant4 Emergency admission Treated at first admission More than two weeks’ delay between diagnosis and treatment5 All of care in one hospital Affluent 734 592 (81%) 623 <**•) 424 (581.) 491 (671.) 484 (66%) 63 (91.) 506 (691.) 358 (501.) 445 (61%) 2 684 526 (77%) 604 (881.) 312 (46%) 418 (61%) 451 (66%) 51 (71.) 529 (77%) 386 (571.) 391 (571.) 3 651 475 (731.) 558 (86%) 257 (391.) 408 (631.) 395 (61%) 60 (91.) 493 (76%) 346 (54%) 359 (55%) 4 644 463 (72%) 553 (86%) 238 (371.) 417 (631.) 386 (601.) 69 (11%) 494 (771.) 308 (491.) 345 (54%) Deprived 596 379 (W%) 481 181%) 206 (331.) 413 (691.) 332 (561.) 77 (131.) 512 (86%) 262 (451.) 378 (631.) Total 3 J09 2,435 (74%) 2 J19 (85%) 1,437 (43%) 2J47 (65%) 2,048 (62%) 320 (10%) 2,534 _{(77%) f}

I

1 At some point in the cancer spell 2 Within 3 months of diagnosis

3 Hospital seeing at least 104 breast cancer patients per year (see Chapter 2 for details of the workload groupings) 4 Consultant who saw at least 30 breast cancer patients in 1997 (see Chapter 2 for details of the workload groupings) 3 Days between diagnosis and definitive treatment; percentage of 3 233 patients with a definitive treatment date 6 Chi-square test for association

Mode of presentation

When a women presents with a suspected breast tumour, a clinical assessment is usually performed, followed by a fine needle aspiration, biopsy and possibly a mammogram, to confirm diagnosis. Once malignancy is confirmed, a pathological (surgical) examination is then performed to establish the size and nodal status of the disease. Métastasés are usually assessed by clinical examination or imaging. Large tumour size, nodal involvement and métastasés are all important prognostic indicators associated with poor survival37,154,155.

Pathological tumour size (pT) and nodal status (pN) are the most reliable prognostic indicators156, and these, along with clinical stage (cTNM) have been collected on the SOCRATES database for breast tumours for patients diagnosed from 1997 onwards. Among women diagnosed in Scodand in 1997, 27% o f women had no pT recorded, 23% had no pN, 15% had no cT, 19% had no cN, and 34% had no metastatic status recorded. This could be because the CRO missed the information when extracting from the medical notes, but is more often because the information is not explicidy stated in the notes. Informadon was more often missing in deprived women for each of these factors (p<0.05). Of women with known details, there were no differences in tumour size or nodal status between the deprivation groups; however, deprived women did appear to be more likely to present with metastatic tumours (p<0.01; Table 5.3).

Based on previous, more complete stage information from Scottish audits153, 8.3% o f women diagnosed in 1987 and 7.0% o f women diagnosed in 1993 had metastatic disease, so it is likely that the unknowns in the 1997 data analysed here largely comprise non-metastatic cases. This is further supported by examination of the 1-year survival estimates (96% for women with non-metastatic disease, 58% for women with métastasés and 86% for women whose metastatic status was unknown).

Other important prognostic indicators include tumour grade37,154,157 with survival decreasing as grade increases; oestrogen receptor (ER) status, with ER-negative tumours having the poorer prognosis155,15* and comorbidity141,159 Among all women diagnosed in Scotland in 1997, 22% had ER-negative tumours, 59% ER-positive tumours and 20% had unknown ER status (Table 5.4; different percentages shown, see table footnote 1).

Table 5.3: Women diagnosed with breast cancer in Scotland in 1997: tumour stage by deprivation category (number and percentage of cases)

Deprivation No. of Pathological size1 Pathological nodal statua1

category _n T2 T3 Unknown NO N1 N0- inadeq Unknown Affluent 734 349 (637.) 181 03%) 24 0%) 180 05%) 319 06%) 230 00%) 21 0%) 164 02%) 2 684 281 04%) 214 (41%) 30 (67, 159 05%) 307 06%) 220 00%) 19 0%) 138 00%) 3 651 289 00%) 173 06%) 18 (% ) 171 06%) 267 05%) 215 02%) 25 0%) 144 02%) 4 644 265 07%) 184 09%) 18 4%) 177 07%) 297 09%) 186 07%) 21 0%) 140 02%) Deprived 5% 218 07%) 153 00%) 14 0%) 211 05%) 234 04%) 190 04%) 10 0%) 162 07%) Total 3,309 1,402 (58%) 905 (58%) 104 (4%) 898 (27%)1,424 (56%) 1,041 (41%) 96 (4%) 748 (23%) p= 0.07t K O M I' fi=0271! P=0.047)

Deprivation fUniffl SÍSC1 Clinical nodal statua1 Metas tases1

caaegoty

T l T2 T3 T4 Unknown NO N1 N2/N3 Unknown MO Ml Unknown

Affluent 273 04%) 239 (38%) 43 0%) 69 07%) 110 05%) 438 05%) 149 05%) 17 (37.) 130 (187.) 477 03%) 37 0%) 220 00%) 2 243 02%) 234 00%) 48 (8%) 58 004.) 101 05%) 431 04%) 127 02%) 25 0%) 101 05%) 483 (917.) 47 (97.) 154 05%) 3 239 02%) 231 (41%) 37 0%) 56 00%) 88 04%) 397 04%) 123 05%) 16 (3%) 115 (187.) 433 05%) 31 (77.) 187 09%) 4 216 09%) 218 00%) 50 (97.) 66 02%) 94 05%) 390 04%) 107 00%) 29 (6%) 118 (187.) 374 00%) 43 00%) 227 05%) Deprived 192 00%) 202 02%) 32 0%) 51 (117.) 119 00%) 307 05%) 99 03%) 16 0%) 174 09%) 234 (867.) 37 04%) 325 05%) Total U 63 (42%) 1,124 (40%) 210 (8%) 300 07% ) 512 (15%)L963 ¿7.3%) 605 ¿23%) 103 (4%) 638 (19%)2,001 (91%) 195 ¿9%) 1413 ¿34%)

Stpmñúma p=0226! p^O O l? P=0292p P<0.001‘ PKOOIO? pO .001’

1 Percentage of women with a known category. For 'unknown' category, percentage of all women

2 Significance of association between depnvanon category and percentage of women in each category, excluding those in the unknown category

T ab le 5.4 : W o m e n d iag n o sed w ith b re a st c a n c e r in S c o tla n d in 1 9 9 7 : o e stro g e n re c e p to r (ER) statu s, g rad e an d h isto lo g ical ty p e b y d e p n v a tio n c a te g o ry (n u m b e r a n d p erc e n ta g e o f cases)

Deprivation No. of ER status1 Micro- Histological type Grade1 category c a w _{Negative Positive Unknown} acoptcaUy

verified Ductal Lobular O th er 1 2 3/4 U nknow n

A ffluent 734 145 (25V,) 435 (75V.) 154 (21V.) 711 (97V.) 485 (65V.) 59 (8V.) 190 (25V.) 93 (18*/.) 231 (44V.) 204 (39V.) 206 (28V.) 2 684 157 (27V,) 414 (73V.) 113 (17V.) 661 (97V.) 451 (64V.) 67 (10V.) 166 (24V.) 93 (19V.) 196 (40%) 202 (41V.) 193 (28V.) 3 651 141 (27V.) 385 (73V.) 125 (19V.) 626 (96V.) 492 (74V.) 66 (10V.) 156 (24V.) 70 (15V.) 191 (42V.) 197 (43V.) 193 (30V.) 4 644 120 (23V,) 404 (77V.) 120 (19V.) 614 (95V.) 407 (62V.) 72 (11V.) 165 (25V.) 78 (17V.) 186 (41V.) 185 (41V.) 195 (30V.) D eprived 596 151 (33V,) 310 (67V.) 135 (23V.) 562 (94V.) 385 (63V.) 30 (5V.) 181 (30V.) 51 (15%) 137 (40V.) 154 (45V.) 254 (43V.) Total 3,309 714 (27%)1,948 (73%) 647 (20%)3474 (96%) 2220 (66%) 294 (9%) 858 (26%) 385 (17%) 941 (41%) 942 (42%) 1,041 (31%) r p o .o o ? $=0,085’ $=0.0612 $=0,004* $=0,605* $<0.001‘

1 Percentage of women with a known category. For 'unknown' category, percentage of all women

2 Significance of association between depnvation category and percentage of women in each category, excluding those in the unknown category (where applicable) 1 Significance of proportion unknown across the deprivation categories

Among those with known ER status, deprived women were more likely to have ER-negative tumours (33% compared to around 25% in the other deprivation groups).

Diagnosis was microscopically verified for m ost (96%) women, with no significant difference between the deprivation groups. Overall, 99% of sutgical and 77% o f non- surgical patients had microscopically verified tumours. Ductal tumours were the m ost common histological type (66%) followed by lobular carcinomas (9%). There was evidence that the most deprived women were less likely to have lobular carcinomas.

Information on grade was missing for a high proportion (31%) o f women, particularly in the deprived group. When only women with known grade were considered, then the deprived women were somewhat more likely to have poorly differentiated tumours (45% compared to 39% o f affluent women; p=0.605).

Due to the large number of women with missing information on metastatic status, grade and treatment intent, two approaches were adopted in the multivariate analyses: (1) Missing information was treated as an extra category and (2) missing values were imputed (see Chapter 1). Before performing multiple imputation, women whose metastatic status was unknown were re-assigned to the non-metastatic group if their therapy objective was curative (21%) or they were screen-detected (1%). For the remaining 386 (12%) women with unknown metastatic status, multiple imputation was performed using information on age, clinical tumour size and nodal status. The multiple imputation of grade was performed using information on type o f surgery, tumour morphology, ER status and imputed metastatic status. The multiple imputation o f treatment intent was performed using information on age, surgery, metastatic status and grade.