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. 1999 Jan 30;318(7179):326. doi: 10.1136/bmj.318.7179.326

Deprivation and emergency admissions for cancers

Other possible explanations for findings need to be explored

Jennifer Mindell 1
PMCID: PMC1114788  PMID: 9924067

Editor—The reasons for Pollock and Vickers’s findings about the relation between deprivation and emergency admissions for cancers remain speculative.1 To impute the differences in care to failures of primary care seems unfair at this stage. The authors discuss a range of possible explanations, but many other could also be relevant.

Day case treatment may require a certain level of facilities at home that are less commonly available in deprived areas. The presence of another adult at home may also be a prerequisite. Single people may be more likely to live in deprived areas; patients from deprived areas may be more likely to have a working partner who cannot afford to take time off work or who has a job where such absences would be unacceptable.

Patients with lung cancer due to smoking (more common in areas where smoking is more prevalent) may be less likely to have an operable malignancy because of concomitant disease related to smoking. The authors mention this in their discussion, but limiting the study to inpatient finished consultant episodes with a primary diagnosis of any of the three cancers of interest does not give any information about comorbidity.

I hope further research will be carried out to help elucidate the reasons behind the apparently inequitable access and treatment decisions that Pollock and Vickers have found. Both qualitative and quantitative research methods could be used to study patients’ and professionals’ experiences as patients pass through the system. Perhaps allocation of blame should wait until such results are available.

References

  • 1.Pollock AM, Vickers N. Deprivation and emergency admissions for cancers of colorectum, lung, and breast in south east England: ecological study. BMJ. 1998;317:245–252. doi: 10.1136/bmj.317.7153.245. . (25 July.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 1999 Jan 30;318(7179):326.

Social factors affect patterns of referral for breast cancer

C J Twelves 1,2,3, C S Thomson 1,2,3, J A Dewar 1,2,3

Editor—Pollock and Vickers reported that deprivation did not affect the admission of women with breast cancer to units treating more than 100 cases a year.1-1 We examined patterns of care in Scotland by studying referrals outside the local health board for initial treatment.

The Scottish breast cancer audit identified 3681 women from the Scottish cancer registry who underwent surgery for non-metastatic breast cancer diagnosed in 1987 and 1993.1-2 Patients were allocated to the least deprived fifth of the population, the most deprived, or an intermediate group (2nd, 3rd, and 4th fifths), the Carstairs classification of social deprivation being used for this.1-3 The 541 cases detected by screening were excluded from this analysis since their referral may have been determined by the screening programme.

In all, 257 women were operated on outside their health board of residence (132/1585 (8.4%) in 1987 and 125/1555 (8.0%) in 1993) whereas 2883 were first treated in their own health board area. Univariate analysis showed that women who lived in an area with a cancer centre were less likely to be referred externally than those living elsewhere (30/1729 (1.7%) v 227/1411 (16.1%); P<0.001, χ2 test for association). The most deprived women, however, were less likely to be referred to another health board than those who were more affluent (16/467 (3.4%) v 241/2673 (9.0%); P<0.001).

Women aged ⩾65 were referred to another health board less frequently than younger women (58/1124 (5.2%) v 199/2016 (9.9%); P<0.001). Clinical stage at presentation did not influence patterns of referral so cannot explain the effects of deprivation and age. Neither can these effects be explained by more of the older or more deprived women living in health boards with cancer centres, as they remained significant in an analysis restricted to women living in health boards without a cancer centre. A multivariate analysis supported these results.

Although social factors seem to influence patterns of referral, the importance of this finding is unclear. In the Scottish study the adverse effect of deprivation on survival was no longer significant after adjustment for clinical factors (P=0.28).1-4 Women treated outside their health board were, however, significantly more likely to have their axillary node status and oestrogen receptor status defined (P<0.001). If deprived or elderly women are less likely to be referred outside their health board, the staging of their disease and the treatment they receive may be compromised.

Footnotes

For the Scottish Breast Cancer Focus Group and the Scottish Cancer Therapy Network.

References

  • 1-1.Pollock AM, Vickers N. Deprivation and emergency admissions for cancers of colorectum, lung, and breast in south east England: ecological study. BMJ. 1998;317:245–252. doi: 10.1136/bmj.317.7153.245. . (25 July.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Scottish Breast Cancer Focus Group; Scottish Cancer Trials Breast Group; Scottish Cancer Therapy Network. Scottish breast cancer audit 1987 and 1993. Edinburgh: Scottish Cancer Therapy Network; 1996. [Google Scholar]
  • 1-3.Carstairs V, Morris R. Deprivation and health in Scotland. Aberdeen: Aberdeen University Press; 1991. [Google Scholar]
  • 1-4.Twelves CJ, Thomson CS, Gould A, Dewar J. Variation in the survival of women with breast cancer in Scotland. Br J Cancer. 1998;78:566–571. doi: 10.1038/bjc.1998.541. [DOI] [PMC free article] [PubMed] [Google Scholar]

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