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Patterns of Care Received by Women with Breast Cancer Living in Affluent and Deprived Areas

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Patterns of Care Received by Women with Breast Cancer Living in Affluent and Deprived Areas PATTERNS OF CARE RECEIVED BY WOMEN WITH BREAST CANCER LIVING IN AFFLUENT AND DEPRIVED AREAS Una Margaret Macleod MB ChB, MRCGP Submission for the degree of Doctor of Philosophy To the University of Glasgow From the Department of General Practice November 2000 ProQuest Number: 13818957 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a com plete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest ProQuest 13818957 Published by ProQuest LLC(2018). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States C ode Microform Edition © ProQuest LLC. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 GLASGOW UK'VERSITY ' library TUe^fe 12139 c oPH \ This thesis is dedicated to the memory of my father Donaid B Macleod M.A. 16.10.1929- 16.1.1995 2 Abstract Breast cancer occurs less commonly in socio-economically deprived women than in affluent women. Following diagnosis however, deprived women have poorer survival rates from breast cancer. Previous research suggests that their poorer survival is not due to the stage of the cancer at time of presentation. If poorer outcomes are not due to more advanced stage of disease at time of presentation alternative explanations are that the difference may be due to variations in treatment or host response mechanisms or environmental factors. The research described in this thesis explores whether the known poorer survival of deprived women is related to the care they receive for breast cancer from the National Health Service. The process of care is described from presentation through referral, treatment and follow up, and comparison is made between patterns of care received by affluent and deprived women. Patterns of care were described and compared by means of a three phase study: hospital records data collection, general practice records data collection and a postal questionnaire study. The review of case records in hospital and general practice produced data regarding diagnosis, delays, surgical and oncological treatment and follow-up in primary and secondary care. The postal questionnaire to patients provided further information on health status, current anxieties, sources of information about breast cancer, help seeking behaviour and life style changes as a result of a diagnosis with breast cancer. The process of care is investigated for women diagnosed with breast cancer in 1992 and 1993 in the most affluent and deprived areas in Greater Glasgow Health Board. The data presented in this thesis show that women from affluent and deprived areas received similar surgical and oncological care and had the same access to services. Previous studies, which showed no relationship between stage at presentation and deprivation, are challenged by data demonstrating a greater proportion of advanced and metastatic presentations in women from deprived areas compared to women from affluent areas. 3 Evidence from all three phases of data collection (hospital records data collection, general practice records data collection, questionnaire study) point to women from deprived areas experiencing greater physical and psychological co-morbidity than those from affluent areas. Women from deprived areas were admitted to hospital for conditions not related to breast cancer more often than women from affluent areas. Although an increase in consultations with GPs were seen for all women, this increase was greater for deprived women. Deprived women had poorer SF-36 scores indicating greater psychological morbidity several years after diagnosis and reported greater anxiety than affluent women regarding health problems unrelated to breast cancer. Women living in deprived areas also expressed a greater degree of anxiety than women living in affluent areas about financial and family problems. These indications of greater co-morbidity may help to explain the poorer survival of deprived women with breast cancer. This study produces evidence that the National Health Service in Glasgow delivered health care equitably to affluent and deprived women with breast cancer in 1992 and 1993. The presence of other co-existing physical and psychological morbidities in the context of greater social adversity may explain the known poorer survival of deprived women with breast cancer. 4 Table of Contents Abstract..................................................................................................................3 Table of Contents ..................................................................................................5 List of Tables......................................................................................................... 7 Acknowledgement ...............................................................................................10 Author’s declaration.......................................................................................... 11 Definitions .............................................................................................................13 Chapter 1 INTRODUCTION...........................................................................14 1.1 Background to study............................................................................... 15 1.2 Deprivation and health care.................................................................. 20 1.3 Deprivation and breast cancer..............................................................25 1.4 Optimal care of breast cancer...............................................................33 1.5 Aims of research and hypothesis of thesis.......................................... 38 Chapter 2 METHODS - A GENERAL OVERVIEW ............................... 40 2.1 Introduction ................ .41 2.2 Study design .............................................................................................. 42 2.3 Ethical considerations .............................................................................44 2.4 Statistical considerations .........................................................................45 2.5 Summary....................................................................................................47 Chapter 3 STUDY POPULATION .................................................................48 3.1 Introduction .............................................................................................. 49 3.2 Sample selection ................................................................................ 50 3.3 Characteristics of study population ..................................................... 54 3.4 Summary....................................................................................................58 Chapter 4 HOSPITAL RECORDS DATA COLLECTION.................... 65 4.1 Introduction .............................................................................................. 66 4.2 Methods ......................................................................................................67 4.3 Results ......................................................................................................... 74 4.4 Discussion...................................................................................................79 4.5 Summary....................................................................................................94 Chapter 5 GENERAL PRACTICE RECORDS DATA COLLECTION 116 5.1 Introduction .............................................................................................117 5.2 M ethods .................................................................................................... 118 5.3 Results ........................................................................................................121 5.4 Discussion................................................................................................. 124 5.5 Summary.................................................................................................. 130 Chapter 6 POSTAL QUESTIONNAIRE.....................................................141 6.1 Introduction .............................................................................................142 6.2 M ethods .....................................................................................................143 6.3 Results ........................................................................................................146 6.4 Discussion................................................................................................. 150 5 6.5 Summary................................................................................................. 161 Chapter 7 DISCUSSION............................................................................... 174 7.1 Introduction............................................................................................175 7.2 A critique of the study methodology...................................................176 7.3 Access to care..........................................................................................180 7.4 Co-morbidity...........................................................................................182 7.5 Communication and information.........................................................185 7.6 Follow up................................................................................................
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