Table 1.
Characteristics of included studies.
| Study | Design and sources | Population | Rural/urban classification | Key findings relating to surgery | Key findings relating to chemotherapy | Key findings relating to radiotherapy | Quality rating |
|---|---|---|---|---|---|---|---|
| Armstrong et al. (13, 19, 20) | Population-based cross-sectional cohort study New South Wales colorectal cancer care survey |
CRC patients (N = 3,095 surgery, N = 778 chemo, N = 238 radiotherapy) | ARIA | Percentage of preoperative investigations by location of residence | Recommended chemotherapy treatment was most likely to be received by patients in “highly accessible” or “accessible” areas (68–69%) compared to “moderately accessible to very remote” patients (43%) | Patients in highly accessible areas had a lower use of radiotherapy (30%) compared to patients in accessible (36%), moderately accessible (35%) and remote/very remote areas (38%) | Moderate |
| Highly accessible = 84%, accessible = 14% | |||||||
| Moderately accessible = 2% | |||||||
| Remote/very remote areas = 1% | |||||||
| Beckmann et al. (15) | Population-based data linkage study South Australian Cancer Registry, hospital data, radiotherapy databases, hospital-based cancer registries |
Residents aged 50 to 79 years with CRC N = 4,641 |
ARIA+ (combined remote/very remote category) | Prevalence ratio of variations in receipt of surgical treatment Inner urban = 1.00 reference outer urban PR = 0.98 Rural PR = 0.99 Remote PR = 1.01 |
Prevalence ratio of variations in receipt of chemotherapy for stage III CRC Inner urban = 1.00 reference Outer urban PR = 1.03, p = 0.63 Rural PR = 0.87, p = 0.046 emote PR = 0.86, p = 0.14 |
Prevalence ratio of variations in receipt of radiotherapy | High |
| Inner urban PR = 1.00 reference | |||||||
| Outer urban PR = 0.87 | |||||||
| Rural PR = 0.87 | |||||||
| Remote PR = 1.13 | |||||||
| Beckmann et al. (21) | Population-based data South Australian Cancer Registry, hospital data, and radiotherapy databases |
Residents aged 50–79 years diagnosed with CRC who underwent surgical resection (N = 3,887; N = 3,940 resections) | ARIA (collapsed into metropolitan and non-metropolitan) | No significant differences in risk of post-procedural complications, or risk of readmission were observed in relation to place of residence | High | ||
| Chan et al. (22) | Quasi-experimental design using retrospective chart audit, and hospital data from Mt Isa hospital and Townsville Cancer Centre (TCC) | Patients who received chemotherapy at TCC and Mt Isa (N = 206). Mt Isa patients received chemotherapy through a tele-oncology model | ASGC classification (Mt Isa = Remote, Townsville = Outer Regional) | There were no significant differences between the Mt Isa and Townsville patients in mean number of treatment cycles, dose intensities, proportions of side effects, and hospital admissions. There were no toxicity-related deaths in either group | High | ||
| Clinical Governance Unit (23) | Cross-sectional cohort study National Colorectal Cancer Care Survey |
Clinicians treating CRC patients, including surgeons, medical and radiation oncologists (N = 2,669) | Patients postcode (capital city, urban, or rural) | Preoperative radiotherapy was more likely to be received by patients in capital city (68%) and urban locations (83%) than rural locations (44%), p = 0.004 | Moderate | ||
| Goldsbury et al. (24) | Retrospective cohort analysis of linked data New South Wales central cancer registry; 45 and Up study; admitted patient data collection; and Medicare claims |
Residents participating in the 45 and Up study diagnosed with CRC who had a colonoscopy before diagnosis and surgery after diagnosis (N = 407) | Place of residence at diagnosis (metropolitan, other urban, or rural) | Hazard ratio of variation in rectal cancer time to surgery: Rural HR = 0.47; other urban HR = 1.55; metro HR = ref 1.00 Hazard ratio of variation in colon cancer time to surgery: rural HR = 1.21; other urban HR = 1.19; metro HR = ref 1.00 Surgery in a specialist cancer center was more frequent among those living in metro areas (HR = 1.00) compared to other urban areas (HR = 0.27) or rural areas (HR = 0.14) |
High | ||
| Hall et al. (25) | Retrospective data linkage study West Australian Data Linkage System |
Residents with diagnosis of invasive primary CRC N = 14,587 |
ARIA | Patients in remote areas most likely to receive surgery (OR 1.21), compared to very remote (OR 0.70) accessible (OR 1.08), moderately accessible (OR 1.01), and highly accessible (OR 1.00 reference) | High | ||
| Henry et al. (26) | Population-based cohort study ECO database (extension of Victorian Cancer Registry, which includes clinical and treatment information) |
Residents in the Barwon South Western Region (Victoria) with a cancer diagnosis (N = 1,778 for all cancer types) | Distance from Geelong city (km) | Lower radiotherapy utilization was observed for patients living in rural areas compared with those living in Geelong for rectal cancer (32.8 vs 44.7%, p = 0.11). Time from diagnosis to radiotherapy was not significantly different for the different geographical regions | Moderate | ||
| Hocking et al. (27) | Retrospective cohort study South Australian Clinical Registry for Metastatic Colorectal Cancer |
Patients with metastatic CRC (N = 2,289) |
Postcodes within state capital were “city,” remaining postcodes were “rural” | No significant differences in colorectal surgery (51.5% city vs 55.3% rural, p = 0.11), liver surgery (13.7 vs 11.5%, p = 0.17), or lung surgery (3.2 vs 2.1%, p = 0.10) | Equivalent rates of chemotherapy between metropolitan and rural patients across each line of treatment (56.0 vs 58.3%, respectively, p = 0.32). A higher proportion of city patients received combination chemotherapy in the first-line setting (67.4 vs 59.9%; p = 0.01). When an oxaliplatin combination was prescribed, oral capecitabine was used more frequently in rural patients (22.9 vs 8.4%; p < 0.001) | Moderate | |
| Jorgensen et al. (28) | Linked population-based cohort study New South Wales cancer registry; admitted patients data collection; births, deaths and marriages |
Individuals with lymph node-positive colon cancer (N = 580) and high-risk rectal cancer (N = 498) who underwent surgery following diagnosis | ARIA (remoteness areas); surgeon, and hospital caseload | The majority of the variability in receipt of chemotherapy was attributable to patient characteristics (≈84%), with hospital of surgery accounting for the remaining variability (ICC = 0.16) | Approximately 28% of the total variability in radiotherapy receipt was attributable to hospitals (ICC = 0.28), 2% was attributable to surgeons and the remaining 70% to patient characteristics | High | |
| Morris et al. (29) | Population-based cohort study Pathology records from four West Australian hospitals |
Stage III colon cancer patients (N = 1,312) |
One rural hospital vs three metropolitan hospitals (teaching, private, and district) | Rates of chemotherapy initiation not different between rural hospitals (33.3%) and metropolitan district, private and teaching hospitals (21.1, 47.1, and 31.8%) Rates of chemotherapy completion not different between metropolitan district hospitals and rural hospitals (48.4 vs 45.2%, respectively), but higher in metropolitan private and teaching hospitals (73.3 and 69.3%) |
High | ||
| Pathmanathan et al. (30) | Retrospective clinical chart audit Hospital records (Townsville Cancer Center) |
Patients from Townsville or North West Queensland districts aged > 18 years diagnosed with colorectal cancer (N = 51) | RRMA 3 ≥3 classified as rural, RRMA 2 (Townsville) classified as urban | A similar number of patients received XELOX as a second-line treatment in urban (n = 10; 40%) and rural (n = 8; 31%) areas with a similar number of cycles (urban n = 49; 31% vs rural n = 37; 24%). No differences in dose intensities were apparent | Moderate | ||
| Queensland Government (31) | Retrospective population-based audit Queensland Oncology Repository |
Queensland patients diagnosed with colon (N = 1,537) and rectal (N = 656) cancer who had a major resection | ASGC | Colon cancer % days from diagnosis to surgery ≤30 Major city = 77%; inner regional = 74%; outer regional = 70%; remote = 70% Rectal cancer % days from diagnosis to surgery ≤30 Major city = 44%; inner regional = 34%; outer regional = 35%; remote = 21% |
Moderate | ||
| Singla et al. (32) | Retrospective cohort study South Australian Clinical Registry for Metastatic Colorectal Cancer |
SA patients with metastatic CRC (N = 2,001) |
ASGC | No significant differences between major city, inner regional, outer regional, and remote patients in rates of lung surgery (1.8, 3.8, 1.1, and 1.0% respectively; p = 0.104) or liver surgery (13.0, 13.2, 13.6, and 9.4%; p = 0.753) | High | ||
| Young et al. (33) | Prospective audit New South Wales Central Cancer Registry |
NSW patients newly diagnosed with CRC (N = 3,095) | Hospital location (metropolitan or rural) | Patients offered recommended adjuvant chemotherapy for colon cancer were more likely to be treated in a metropolitan hospital than rural hospital (OR = 1.00 vs OR = 0.56, p = 0.04) | High | ||
ARIA = Accessibility/Remoteness Index of Australia; ASGC = Australian Standard Geographical Classification; CRC = colorectal cancer; HR = hazard ratio; OR = odds ratio; PR = prevalence ratio; RRMA = Rural, Remote, Metropolitan Area.