Social determinants of access to reference care centres for patients with colorectal cancer – A multilevel analysis



      Although social disparities in survival for patients with cancer are documented in an increasing number of papers, knowledge on the underlying mechanisms concerning screening, diagnosis, treatment or follow-up, is relatively poor. Our study was aimed at investigating the social determinants of access to reference cancer care centres for surgery for colorectal cancer in France.


      Retrospective analysis was conducted on population-based data from a specialised cancer registry (County of Calvados, France). The population consisted of 5156 patients with surgical treatment for colorectal cancer recorded between January 1st 1981 and December 31st 2000.


      The probability of being cared for in a reference care centre was 1.3-fold lower for people living in a deprived district (mean income < 15000€) and 3-fold lower for people living in a district where more than 7% of houses were devoid of bath and shower in comparison with districts where this rate was under 2%. After adjustment for distance from reference care centre, the probability of being cared for in a reference care centre was still over one third lower for people living in a district with more than 7% of houses devoid of bath and shower. Social disparities in management of patients with colorectal cancer have increased in the last decade. The reduction of access to reference care with distance was stronger in elderly patients.


      There is a social and geographical determination of type of treatment centre for care management of colorectal cancer in France. Special attention needs to be paid to the high quality of care management in non-specialised care centres in order to avoid an increased social gradient in cancer mortality in France.


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        • Remontet L.
        • Estève J.
        • Bouvier A.M.
        • et al.
        Cancer incidence and mortality in France over the period 1978-2000.
        Rev Epidemiol Sante Publique. 2003; 51: 3-30
        • Berrino F.
        • Capocaccia R.
        • Coleman M.P.
        • et al.
        Survival of cancer patients in Europe: the EUROCARE-3 study.
        Ann Oncol. 2003; 14: 62-118
        • Kunst A.E.
        • Groenhof F.
        • Mackenbach J.P.
        • Health E.W.
        Occupational class and cause specific mortality in middle aged men in 11 European countries: comparison of population based studies.
        EU Working Group on Socioeconomic Inequalities in Health. BMJ. 1998; 30: 1636-1642
        • Monnet E.
        • Boutron M.C.
        • Faivre J.
        • et al.
        Influence of socio-economic status on prognosis of colorectal cancer.
        A population-based study in Côte d’Or, France. Cancer. 1993; 72: 1165-1170
        • Desoubeaux N.
        • Herbert C.
        • Launoy G.
        • et al.
        Social environment and prognosis of colorectal cancer patients: a French population-based study.
        Int J Cancer. 1997; 73: 317-322
        • Coleman M.P.
        • Rachet B.
        • Woods L.M.
        • et al.
        Trends and socioeconomic inequalities in cancer survival in England and Wales up to 2001.
        Br J Cancer. 2004; 90: 1367-1373
        • Boyle P.
        • Langman J.S.
        ABC of colorectal cancer: epidemiology.
        BMJ. 2000; 312: 805-808
        • Smith J.A.
        • King P.M.
        • Lane R.H.
        • et al.
        Evidence of the effect of ‘specialization’on the management surgical outcome and survival from colorectal cancer in Wessex.
        Br J Surg. 2003; 90: 583-592
        • McArdle C.S.
        • Hole D.J.
        Influence of volume and specialization on survival following surgery for colorectal cancer.
        Br J Surg. 2004; 91: 610-617
        • Shrag D.
        • Cramer L.
        • Bach P.
        • et al.
        Influence of hospital volume on outcome following surgery for colon cancer.
        JAMA. 2000; 23: 3028-3035
        • Kee F.
        • Wilson R.H.
        • Harper C.
        • et al.
        Influence of hospital and clinican workload on survival from colorectal cancer :cohort study.
        BMJ. 2001; 318: 1381-1386
      1. L’évaluation de la sécurité, de la qualité et de la continuité des soins chirurgicaux dans les petits hôpitaux publics en France; Rapport à l’attention de Monsieur Xavier Bertrand ; Ministre de la Santé et des Solidarités; présenté par Guy Vallancien ; Paris ;6 avril 2006.

        • Dejardin O.
        • Bouvier A.M.
        • Herbert C.
        • et al.
        Social and geographic disparities in access to reference care site for patients with colorectal cancer in France.
        Br J Cancer. 2005; 92: 1842-1845
        • Pickett K.E.
        • Pearl M.
        Multilevel analyses of neighbourhood socioeconomic context and health outcomes: a critical review.
        J Epidemiol Community Health. 2001; 55: 111-122
        • Goldstein H.
        Multilevel statistical models.
        Second ed. Arnold, London1995 (pp. 178)
        • Hox J.J.
        Applied multilevel model.
        TT Publikaten, Amsterdam1995
        • Snijders T.A.B.
        • Bosker R.J.
        Multilevel analysis : an introduction to basic and advanced multilevel modelling.
        sage publishers, London1999
        • Chaix B.
        • Merlo J.
        • Chauvin P.
        Comparison of a spatial approach with the multilevel approach for investigating place effects on health : the example of healthcare utilisation in France.
        J Epidemiol Community Health. 2005; 59: 517-526
        • Schrijvers C.T.M.
        • Mackenbach J.P.
        • Lutz J.M.
        • Quinn M.J.
        • Coleman M.P.
        Deprivation, stage at diagnosis and cancer survival.
        Int J Cancer. 1995; 63: 324-329
        • Mullee M.A.
        • De Stavola B.
        • Romanengo M.
        • et al.
        Geographical variation in breast cancer survival rates for women diagnosed in England between 1992 and 1994.
        Br J Cancer. 2004; 90: 2153-2156
        • Coleman M.P.
        • Babb P.
        • Sloggett A.
        • et al.
        Socioeconomics inequalities in cancer survival in England and Wales.
        Cancer. 2001; 91: 208-216
        • Greenberg E.R.
        • Chute C.G.
        • Stukel T.
        • et al.
        Social and economic factors in the choice of lung treatment.
        N Engl J Med. 1988; 318: 612-617
        • Nemet G.F.
        • Bailey A.J.
        Distance and health care utilization among the rural ederly.
        Soc Sci Med. 2000; 50: 1197-1208
        • Mooney C.
        • Zwanziger J.
        • Phibbs S.
        • et al.
        Is travel distance a barrier to veterans’use of VA hospitals for medical surgical care.
        Soc Sci Med. 2000; 50: 1743-1755
        • La Vela S.L.
        • Smith B.
        • Weaver F.M.
        • et al.
        Geographical proximity and health care utilization in veterans with SCI&D in the USA.
        Soc Sci Med. 2004; 59: 2387-2399
        • Jack R.H.
        • Guillford M.C.
        • Ferguson J.
        • et al.
        Geographical inequalities in lung cancer management and survival in South East England : evidence of variation in access to oncology services?.
        Br J Cancer. 2003; 88: 1025-1031
        • Campbell N.C.
        • Elliot A.M.
        • Sharp L.
        • et al.
        Impact of deprivation and rural residence on treatment of colorectal and lung cancer.
        Br J Cancer. 2002; 87: 585-590
        • Gorey K.M.
        • Holowaty E.J.
        • Fehringer G.
        • et al.
        An international comparison of cancer survival: Toronto, Ontario, and Detroit, Michigan, Metropolitan areas.
        Am J Public Health. 1997; 87: 1156-1163
        • Launoy G.
        • Le Coutour X.
        • Gignoux M.
        • et al.
        Influence of rural environment on diagnosis, treatment, and prognosis of colorectal cancer.
        J Epidemiol Commun Health. 1992; 46: 365-367
        • Herbert C.
        • Lefevre H.
        • Gignoux M.
        • et al.
        Influence of social and occupational class and area of residence on management and survival in patients with gigestive tract cancer.
        Rev Epidemiol Sante Publ. 2002; 50: 253-264