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Abstract：
BACKGROUND: There is an urgent need to improve breast cancer survival in sub-Saharan Africa. Geospatial barriers delay diagnosis and treatment, but their effect on survival in these settings is not well understood. We examined geospatial disparities in 4-year survival in the African Breast Cancer-Disparities in Outcomes cohort.
METHODS: In this prospective cohort study, women (aged ≥18 years) newly diagnosed with breast cancer were recruited from eight hospitals in Namibia, Nigeria, South Africa, Uganda, and Zambia. They reported sociodemographic information in interviewer-administered questionnaires, and their clinical and treatment data were collected from medical records. Vital status was ascertained by contacting participants or their next of kin every 3 months. The primary outcome was all-cause mortality in relation to rural versus urban residence, straight-line distance, and modelled travel time to hospital, analysed using restricted mean survival time, Cox proportional hazards, and flexible parametric survival models.
RESULTS: 2228 women with breast cancer were recruited between Sept 8, 2014, and Dec 31, 2017. 127 were excluded from analysis (58 had potentially recurrent cancer, had previously received treatment, or had no follow-up; 14 from minority ethnic groups with small sample sizes; and 55 with missing geocoded home addresses). Among the 2101 women included in analysis, 928 (44%) lived in a rural area. 1042 patients had died within 4 years of diagnosis; 4-year survival was 39% (95% CI 36-42) in women in rural areas versus 49% (46-52) in urban areas (unadjusted hazard ratio [HR] 1·24 [95% CI 1·09-1·40]). Among the 734 women living more than 1 h from the hospital, the crude 4-year survival was 37% (95% CI 32-42) in women in rural areas versus 54% (46-62) in women in urban areas (HR 1·35 [95% CI 1·07-1·71] after adjustment for age, stage, and treatment status). Among women in rural areas, mortality rates increased with distance (adjusted HR per 50 km 1·04, 1·01-1·07) and travel time (adjusted HR per h 1·06, 1·02-1·10). Among women with early-stage breast cancer receiving treatment, women in rural areas had a strong survival disadvantage (overall HR 1·54, 1·14-2·07 adjusted for age and stage; >1 h distance adjusted HR 2·14, 1·21-3·78).
CONCLUSIONS: Geospatial barriers reduce survival of patients with breast cancer in sub-Saharan Africa. Specific attention is needed to support patients with early-stage breast cancer living in rural areas far from cancer treatment facilities.
BACKGROUND: US National Institutes of Health (National Cancer Institute), Susan G Komen for the Cure, and the International Agency for Research on Cancer.
METHODS: In this prospective cohort study, women (aged ≥18 years) newly diagnosed with breast cancer were recruited from eight hospitals in Namibia, Nigeria, South Africa, Uganda, and Zambia. They reported sociodemographic information in interviewer-administered questionnaires, and their clinical and treatment data were collected from medical records. Vital status was ascertained by contacting participants or their next of kin every 3 months. The primary outcome was all-cause mortality in relation to rural versus urban residence, straight-line distance, and modelled travel time to hospital, analysed using restricted mean survival time, Cox proportional hazards, and flexible parametric survival models.
RESULTS: 2228 women with breast cancer were recruited between Sept 8, 2014, and Dec 31, 2017. 127 were excluded from analysis (58 had potentially recurrent cancer, had previously received treatment, or had no follow-up; 14 from minority ethnic groups with small sample sizes; and 55 with missing geocoded home addresses). Among the 2101 women included in analysis, 928 (44%) lived in a rural area. 1042 patients had died within 4 years of diagnosis; 4-year survival was 39% (95% CI 36-42) in women in rural areas versus 49% (46-52) in urban areas (unadjusted hazard ratio [HR] 1·24 [95% CI 1·09-1·40]). Among the 734 women living more than 1 h from the hospital, the crude 4-year survival was 37% (95% CI 32-42) in women in rural areas versus 54% (46-62) in women in urban areas (HR 1·35 [95% CI 1·07-1·71] after adjustment for age, stage, and treatment status). Among women in rural areas, mortality rates increased with distance (adjusted HR per 50 km 1·04, 1·01-1·07) and travel time (adjusted HR per h 1·06, 1·02-1·10). Among women with early-stage breast cancer receiving treatment, women in rural areas had a strong survival disadvantage (overall HR 1·54, 1·14-2·07 adjusted for age and stage; >1 h distance adjusted HR 2·14, 1·21-3·78).
CONCLUSIONS: Geospatial barriers reduce survival of patients with breast cancer in sub-Saharan Africa. Specific attention is needed to support patients with early-stage breast cancer living in rural areas far from cancer treatment facilities.
BACKGROUND: US National Institutes of Health (National Cancer Institute), Susan G Komen for the Cure, and the International Agency for Research on Cancer.
摘要：
背景：迫切需要提高撒哈拉以南非洲的乳腺癌生存率。地理空间障碍延迟诊断和治疗，但是它们在这些环境中对生存的影响还没有得到很好的理解。我们研究了非洲乳腺癌-结果差异队列中4年生存率的地理空间差异。
方法：在这项前瞻性队列研究中，从纳米比亚的八家医院招募了新诊断为乳腺癌的女性（年龄≥18岁），尼日利亚,南非,乌干达，赞比亚。他们在面试官管理的问卷中报告了社会人口统计信息，他们的临床和治疗数据是从医疗记录中收集的。通过每3个月联系参与者或他们的近亲来确定生命状态。主要结果是与农村和城市居住有关的全因死亡率，直线距离,模拟了去医院的旅行时间，使用受限平均生存时间进行分析，Cox比例危险，和灵活的参数生存模型。
结果：在2014年9月8日至2017年12月31日之间招募了2228名患有乳腺癌的女性。127人被排除在分析之外(58人患有潜在复发癌症，以前接受过治疗，或没有随访；14个来自少数族裔，样本量小；55个缺少地理编码的家庭地址）。在分析的2101名女性中，928（44％）居住在农村地区。1042例患者在诊断后4年内死亡；农村地区女性的4年生存率为39%（95%CI36-42），城市地区为49%（46-52）（未调整的风险比[HR]1·24[95%CI1·09-1·40]）。在734名离医院超过1小时的妇女中，农村地区女性的粗4年生存率为37%(95%CI32-42)，城市地区女性为54%(46-62)(HR1·35[95%CI1·07-1·71]，舞台,和治疗状态)。在农村地区的妇女中，死亡率随距离(调整后HR/50km1·04,1·01-1·07)和旅行时间(调整后HR/h1·06,1·02-1·10)而增加.在接受治疗的早期乳腺癌女性中，农村地区的女性有很强的生存劣势(总体HR1·54,1·14-2·07,经年龄和分期调整;>1小时距离调整HR2·14,1·21-3·78).
结论：地理空间障碍降低了撒哈拉以南非洲乳腺癌患者的生存率。需要特别注意支持生活在远离癌症治疗设施的农村地区的早期乳腺癌患者。
背景：美国国立卫生研究院（国家癌症研究所），苏珊·G·科曼的治疗，和国际癌症研究机构。
方法：在这项前瞻性队列研究中，从纳米比亚的八家医院招募了新诊断为乳腺癌的女性（年龄≥18岁），尼日利亚,南非,乌干达，赞比亚。他们在面试官管理的问卷中报告了社会人口统计信息，他们的临床和治疗数据是从医疗记录中收集的。通过每3个月联系参与者或他们的近亲来确定生命状态。主要结果是与农村和城市居住有关的全因死亡率，直线距离,模拟了去医院的旅行时间，使用受限平均生存时间进行分析，Cox比例危险，和灵活的参数生存模型。
结果：在2014年9月8日至2017年12月31日之间招募了2228名患有乳腺癌的女性。127人被排除在分析之外(58人患有潜在复发癌症，以前接受过治疗，或没有随访；14个来自少数族裔，样本量小；55个缺少地理编码的家庭地址）。在分析的2101名女性中，928（44％）居住在农村地区。1042例患者在诊断后4年内死亡；农村地区女性的4年生存率为39%（95%CI36-42），城市地区为49%（46-52）（未调整的风险比[HR]1·24[95%CI1·09-1·40]）。在734名离医院超过1小时的妇女中，农村地区女性的粗4年生存率为37%(95%CI32-42)，城市地区女性为54%(46-62)(HR1·35[95%CI1·07-1·71]，舞台,和治疗状态)。在农村地区的妇女中，死亡率随距离(调整后HR/50km1·04,1·01-1·07)和旅行时间(调整后HR/h1·06,1·02-1·10)而增加.在接受治疗的早期乳腺癌女性中，农村地区的女性有很强的生存劣势(总体HR1·54,1·14-2·07,经年龄和分期调整;>1小时距离调整HR2·14,1·21-3·78).
结论：地理空间障碍降低了撒哈拉以南非洲乳腺癌患者的生存率。需要特别注意支持生活在远离癌症治疗设施的农村地区的早期乳腺癌患者。
背景：美国国立卫生研究院（国家癌症研究所），苏珊·G·科曼的治疗，和国际癌症研究机构。
