We compared association of travel burden and CRC outcome between Denmark and Scotland.
We used restricted cubic splines to analyse travel burden as a continuous variable.
Travel burden appears to impact CRC outcomes differently in Denmark and Scotland.
Mechanisms compromising outcome for rural cancer patients may differ internationally.
Rurald wellers with colorectal cancer have poorer outcomes than their urban counterparts. The reasons why are not known but are likely to be complex and be determined by an interplay between geography and health service organization. By comparing the associations related to travel-time to primary and secondary healthcare facilities in two neighbouring countries, Denmark and Scotland, we aimed to shed light on potential mechanisms.
Analysis was based on two comprehensive cohorts of patients diagnosed with colorectal cancer in Denmark (2010−16) and Scotland (2007−14). Associations between travel-time and cancer pathway intervals, tumour stage at diagnosis and one-year mortality were analysed using generalised linear models. Travel-time was modelled using restricted cubic splines for each country and combined. Adjustments were made for key confounders.
Travel-time to key healthcare facilities influenced the diagnostic experience and outcomes of CRC patients from Scotland and Denmark to some extent differently. The longest travel-times to a specialised hospital appeared to afford the most rapid secondary care interval, whereas moderate travel-times to hospital (about 20−60 min) appeared to impact on later stage and greater one-year mortality in Scotland, but not in Denmark. A U-shaped association was seen between travel-time to the GP and one year-mortality.
This is the first international data-linkage study to explore how different national geographies and health service structures may determine cancer outcomes. Future research should compare more countries and more cancer sites and evaluate the impact and implications of differences in national health service organisation.
Throughout the developed world rural-dwellers diagnosed with cancer have higher mortality than urban counterparts, but underlying mechanisms are poorly understood [ , ]. This is intriguing, since rurality and health service organization differ markedly between countries [ ]. Several explanatory mechanisms for poorer rural cancer survival have been proposed, at the levels of patient and practitioner behaviour; service organization, and wider health policy [ ]. Studies exploring travel burden, an obvious aspect of rurality, and cancer outcomes vary in findings between countries, suggesting mechanisms could operate differently between countries and cancer sites [ , ].
In Europe the impact of travel burden on colorectal cancer (CRC) diagnosis and survival has received particular attention [ ]. This includes Denmark and the UK where CRC survival has historically lagged behind other developed nations, prompting effective health service changes [ ].
Studies with CRC patients diagnosed in Northeast Scotland between 1997 and 1998 found rural patients and those travelling furthest to their general practitioner (GP) were more likely to have alarm symptoms and advanced stage at diagnosis, more likely to experience difficulties in accessing health services, but also more likely to survive for at least three years [ , , ]. In England, routes to diagnosis of CRC have been linked to travel burden with higher likelihood of emergency presentation and lower rates of urgent referral and screen-detection among patients with more than 30 min’ travel to their GP [ ]. In Denmark, increased travelling distance to hospital was associated with later stage at diagnosis for rectal but not colon cancer [ ].
Considered in the context of geography and health service organization, these studies suggest geography could impact rural CRC patients and pathways to diagnosis differently in different countries. This study aimed to compare Denmark vs Scotland in the association between travel burden to healthcare, CRC pathway intervals, tumor stage at diagnosis and mortality.