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Geographical Variation in Breast Cancer Outcomes

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A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Global Health".

Deadline for manuscript submissions: closed (28 February 2017) | Viewed by 78135

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Special Issue Editor

Prof. Dr. Peter Baade

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Guest Editor

Cancer Research Centre, Cancer Council Queensland, GPO Box 201, Spring Hill, QLD 4006, Australia
Interests: descriptive cancer epidemiology; cancer survival; spatial inequalities; indigenous health

Special Issue Information

Dear Colleagues,

Worldwide, breast cancer is the most frequently diagnosed cancer among females, accounting for 25% of all new diagnoses in 2012 and the leading cause of cancer mortality (15% of total cancer deaths), particularly among less developed nations. Incidence rates of breast cancer are generally high in Northern America, Australia/New Zealand, and Northern and Western Europe, and lower in most African and Asian countries.

Factors associated with this international variation in incidence include those related to early detection, particularly the availability of mammography screening, as well as the prevalence of established risk factors, including, among others, overweight/obesity, use of menopausal hormone therapy, physical inactivity, and alcohol consumption.

In many Western countries, the reduction in mortality rates due to breast cancer are stable or continuing to reduce, which has been attributed to the role of some as-yet unknown combination of early detection using mammographic screening and improved treatment. In contrast, mortality rates in many South American, African, and Asian countries are increasing, highlighting the global inequalities in breast cancer outcomes faced by women.

In addition to the international variation in breast cancer-related outcomes, a range of international studies have consistently reported geographical variations across the breast cancer continuum of care within countries, with a clear pattern for inequalities to be evident for women living in more rural areas and socio-economically disadvantaged areas.

There remains a need to better understand the extent of these inequalities from a local, regional and international perspective, and, ideally, to increase our understanding of what factors are contributing to these inequalities.

This Special Issue is open to any body of research that adds to our understanding of variations in breast cancer epidemiology, particularly those highlighting inequalities in breast cancer-related outcomes faced by women depending on where they live.

The listed keywords below suggest just a few of the many possibilities.

Prof. Peter Baade
Guest Editor

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Keywords

Breast cancer
Geography
Spatial
Inequalities
Disparities
Rural health
Urban health
Socioeconomic
Disadvantage
Incidence
Mortality
Survival
Prognosis
quality of life

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Editorial

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221 KiB

Open AccessEditorial

Geographical Variation in Breast Cancer Outcomes

by Peter Baade

Int. J. Environ. Res. Public Health 2017, 14(5), 523; https://doi.org/10.3390/ijerph14050523 - 12 May 2017

Cited by 18 | Viewed by 6855

Abstract

Among females worldwide, breast cancer is the most frequently diagnosed cancer, accounting for 25% of all new diagnoses in 2012, and is the leading cause of cancer mortality (15% of total cancer deaths), particularly among less developed nations [1].[...] Full article

(This article belongs to the Special Issue Geographical Variation in Breast Cancer Outcomes)

Research

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1460 KiB

Open AccessArticle

Modeling Geospatial Patterns of Late-Stage Diagnosis of Breast Cancer in the US

by Lee R. Mobley, Tzy-Mey Kuo, Lia Scott, Yamisha Rutherford and Srimoyee Bose

Int. J. Environ. Res. Public Health 2017, 14(5), 484; https://doi.org/10.3390/ijerph14050484 - 5 May 2017

Cited by 18 | Viewed by 6253

Abstract

In the US, about one-third of new breast cancers (BCs) are diagnosed at a late stage, where morbidity and mortality burdens are higher. Health outcomes research has focused on the contribution of measures of social support, particularly the residential isolation or segregation index, on propensity to utilize mammography and rates of late-stage diagnoses. Although inconsistent, studies have used various approaches and shown that residential segregation may play an important role in cancer morbidities and mortality. Some have focused on any individuals living in residentially segregated places (place-centered), while others have focused on persons of specific races or ethnicities living in places with high segregation of their own race or ethnicity (person-centered). This paper compares and contrasts these two approaches in the study of predictors of late-stage BC diagnoses in a cross-national study. We use 100% of U.S. Cancer Statistics (USCS) Registry data pooled together from 40 states to identify late-stage diagnoses among ~1 million new BC cases diagnosed during 2004–2009. We estimate a multilevel model with person-, county-, and state-level predictors and a random intercept specification to help ensure robust effect estimates. Person-level variables in both models suggest that non-White races or ethnicities have higher odds of late-stage diagnosis, and the odds of late-stage diagnosis decline with age, being highest among the <age 50 group. After controlling statistically for all other factors, we examine place-centered isolation and find for anyone living in an isolated Asian community there is a large beneficial association (suggesting lower odds of late-stage diagnosis) while for anyone living in an isolated White community there is a large detrimental association (suggesting greater odds of late-stage diagnosis). By contrast, living in neighborhoods among others of one’s own race or ethnicity (person-centered isolation) is associated with greater odds of late-stage diagnosis, as this measure is dominated by Whites (the majority). At the state level, living in a state that allows unfettered access to a specialist is associated with a somewhat lower likelihood of being diagnosed at a late stage of BC. Geographic factors help explain the likelihood of late-stage BC diagnosis, which varies considerably across the U.S. as heterogeneous compositional and contextual factors portray very different places and potential for improving information and outcomes. The USCS database is expanding to cover more states and is expected to be a valuable resource for ongoing and future place-based cancer outcomes research. Full article

(This article belongs to the Special Issue Geographical Variation in Breast Cancer Outcomes)

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Open AccessArticle

Breast Cancer Screening Programmes across the WHO European Region: Differences among Countries Based on National Income Level

by Emma Altobelli, Leonardo Rapacchietta, Paolo Matteo Angeletti, Luca Barbante, Filippo Valerio Profeta and Roberto Fagnano

Int. J. Environ. Res. Public Health 2017, 14(4), 452; https://doi.org/10.3390/ijerph14040452 - 23 Apr 2017

Cited by 56 | Viewed by 9206

Abstract

Breast cancer (BC) is the most frequent tumour affecting women all over the world. In low- and middle-income countries, where its incidence is expected to rise further, BC seems set to become a public health emergency. The aim of the present study is to provide a systematic review of current BC screening programmes in WHO European Region to identify possible patterns. Multiple correspondence analysis was performed to evaluate the association among: measures of occurrence; GNI level; type of BC screening programme; organization of public information and awareness campaigns regarding primary prevention of modifiable risk factors; type of BC screening services; year of screening institution; screening coverage and data quality. A key difference between High Income (HI) and Low and Middle Income (LMI) States, emerging from the present data, is that in the former screening programmes are well organized, with approved screening centres, the presence of mobile units to increase coverage, the offer of screening tests free of charge; the fairly high quality of occurrence data based on high-quality sources, and the adoption of accurate methods to estimate incidence and mortality. In conclusion, the governments of LMI countries should allocate sufficient resources to increase screening participation and they should improve the accuracy of incidence and mortality rates. Full article

(This article belongs to the Special Issue Geographical Variation in Breast Cancer Outcomes)

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Open AccessArticle

Advanced Stage at Presentation Remains a Major Factor Contributing to Breast Cancer Survival Disparity between Public and Private Hospitals in a Middle-Income Country

by Yek-Ching Kong, Nirmala Bhoo-Pathy, Shridevi Subramaniam, Nanthini Bhoo-Pathy, Nur Aishah Taib, Suniza Jamaris, Kiran Kaur, Mee-Hoong See, Gwo-Fuang Ho and Cheng-Har Yip

Int. J. Environ. Res. Public Health 2017, 14(4), 427; https://doi.org/10.3390/ijerph14040427 - 16 Apr 2017

Cited by 15 | Viewed by 4698

Abstract

Background: Survival disparities in cancer are known to occur between public and private hospitals. We compared breast cancer presentation, treatment and survival between a public academic hospital and a private hospital in a middle-income country. Methods: The demographics, clinical characteristics, treatment and overall survival (OS) of 2767 patients with invasive breast carcinoma diagnosed between 2001 and 2011 in the public hospital were compared with 1199 patients from the private hospital. Results: Compared to patients in the private hospital, patients from the public hospital were older at presentation, and had more advanced cancer stages. They were also more likely to receive mastectomy and chemotherapy but less radiotherapy. The five-year OS in public patients was significantly lower than in private patients (71.6% vs. 86.8%). This difference was largely attributed to discrepancies in stage at diagnosis and, although to a much smaller extent, to demographic differences and treatment disparities. Even following adjustment for these factors, patients in the public hospital remained at increased risk of mortality compared to their counterparts in the private hospital (Hazard Ratio: 1.59; 95% Confidence Interval: 1.36–1.85). Conclusion: Late stage at diagnosis appears to be a major contributing factor explaining the breast cancer survival disparity between public and private patients in this middle-income setting. Full article

(This article belongs to the Special Issue Geographical Variation in Breast Cancer Outcomes)

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Open AccessArticle

Geospatial Analysis of Inflammatory Breast Cancer and Associated Community Characteristics in the United States

by Lia Scott, Lee R. Mobley and Dora Il’yasova

Int. J. Environ. Res. Public Health 2017, 14(4), 404; https://doi.org/10.3390/ijerph14040404 - 11 Apr 2017

Cited by 16 | Viewed by 5100

Abstract

Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer, almost always diagnosed at late stage where mortality outcomes and morbidity burdens are known to be worse. Missed by mammography screening, IBC progresses rapidly and reaches late stage by the time of diagnosis. With an unknown etiology and poor prognosis, it is crucial to evaluate the distribution of the disease in the population as well as identify area social and economic contextual risk factors that may be contributing to the observed patterns of IBC incidence. In this study, we identified spatial clustering of county-based IBC rates among US females and examined the underlying community characteristics associated with the clusters. IBC accounted for ~1.25% of all primary breast cancers diagnoses in 2004–2012 and was defined by the Collaborative Stage (CS) Extension code 710 and 730. Global and local spatial clusters of IBC rates were identified and mapped. The Mann-Whitney U test was used to compare median differences in key contextual variables between areas with high and low spatial clusters of IBC rates. High clusters are counties and their neighbors that all exhibit above average rates, clustered together in a fashion that would be extremely unlikely to be observed by chance, and conversely for low clusters. There was statistically significant evidence of spatial clustering into high and low rate clusters. The average rate in the high rate clusters (n = 46) was approximately 12 times the average rate in low rate clusters (n = 126), and 2.2 times the national average across all counties. Significant differences were found in the medians of the underlying race, poverty, and urbanicity variables when comparing the low cluster counties with the high cluster counties (p < 0.05). Cluster analysis confirms that IBC rates differ geographically and may be influenced by social and economic environmental factors. Particular attention may need to be paid to race, urbanicity and poverty when considering risk factors for IBC and when developing interventions and alternative prevention strategies. Full article

(This article belongs to the Special Issue Geographical Variation in Breast Cancer Outcomes)

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Open AccessArticle

Urban–Rural Variations in Quality-of-Life in Breast Cancer Survivors Prescribed Endocrine Therapy

by Caitriona Cahir, Audrey Alforque Thomas, Stephan U. Dombrowski, Kathleen Bennett and Linda Sharp

Int. J. Environ. Res. Public Health 2017, 14(4), 394; https://doi.org/10.3390/ijerph14040394 - 7 Apr 2017

Cited by 20 | Viewed by 5179

Abstract

The number of breast cancer survivors has increased as a result of rising incidence and increased survival. Research has revealed significant urban–rural variation in clinical aspects of breast cancer but evidence in the area of survivorship is limited. We aimed to investigate whether quality of life (QoL) and treatment-related symptoms vary between urban and rural breast cancer survivors prescribed endocrine therapy. Women with a diagnosis of stages I–III breast cancer prescribed endocrine therapy were identified from the National Cancer Registry Ireland and invited to complete a postal survey (N = 1606; response rate = 66%). A composite measure of urban–rural classification was created using settlement size, population density and proximity to treatment hospital. QoL was measured using the Functional Assessment of Cancer Therapy (FACT-G) and an endocrine subscale. The association between urban–rural residence/status and QoL and endocrine symptoms was assessed using linear regression with adjustment for socio-demographic and clinical covariates. In multivariable analysis, rural survivors had a statistically significant higher overall QoL (β = 3.81, standard error (SE) 1.30, p < 0.01), emotional QoL (β = 0.70, SE 0.21, p < 0.01) and experienced a lower symptom burden (β = 1.76, SE 0.65, p < 0.01) than urban survivors. QoL in breast cancer survivors is not simply about proximity and access to healthcare services but may include individual and community level psychosocial factors. Full article

(This article belongs to the Special Issue Geographical Variation in Breast Cancer Outcomes)

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Open AccessArticle

Hispanic and Immigrant Paradoxes in U.S. Breast Cancer Mortality: Impact of Neighborhood Poverty and Hispanic Density

by Sandi L. Pruitt, Jasmin A. Tiro, Lei Xuan and Simon J. Craddock Lee

Int. J. Environ. Res. Public Health 2016, 13(12), 1238; https://doi.org/10.3390/ijerph13121238 - 14 Dec 2016

Cited by 25 | Viewed by 6015

Abstract

To test the Hispanic and Immigrant Paradoxes—i.e., survival advantages despite a worse risk factor profile—and the modifying role of neighborhood context, we examined associations between patient ethnicity, birthplace, neighborhood Hispanic density and neighborhood poverty among 166,254 female breast cancer patients diagnosed 1995–2009 in Texas, U.S. Of all, 79.9% were non-Hispanic White, 15.8% Hispanic U.S.-born, and 4.2% Hispanic foreign-born. We imputed birthplace for the 60.7% of Hispanics missing birthplace data using multiple imputation. Shared frailty Cox proportional hazard models (patients nested within census tracts) adjusted for age, diagnosis year, stage, grade, histology, urban/rural residence, and local mammography capacity. Whites (vs. U.S.-born Hispanics) had increased all-cause and breast cancer mortality. Foreign-born (vs. U.S.-born) Hispanics had increased all-cause and breast cancer mortality. Living in higher Hispanic density neighborhoods was generally associated with increased mortality, although associations differed slightly in magnitude and significance by ethnicity, birthplace, and neighborhood poverty. We found no evidence of an Immigrant Paradox and some evidence of a Hispanic Paradox where protective effects were limited to U.S.-born Hispanics. Contrary to prior studies, foreign birthplace and residence in higher Hispanic density neighborhoods were associated with increased mortality. More research on intersections between ethnicity, birthplace and neighborhood context are needed. Full article

(This article belongs to the Special Issue Geographical Variation in Breast Cancer Outcomes)

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2234 KiB

Open AccessArticle

Geographical and Temporal Variations in Female Breast Cancer Mortality in the Municipalities of Andalusia (Southern Spain)

by Ricardo Ocaña-Riola, Carmen Montaño-Remacha and José María Mayoral-Cortés

Int. J. Environ. Res. Public Health 2016, 13(11), 1162; https://doi.org/10.3390/ijerph13111162 - 22 Nov 2016

Cited by 8 | Viewed by 5014

Abstract

The last published figures have shown geographical variations in mortality with respect to female breast cancer in European countries. However, national health policies need a dynamic image of the geographical variations within the country. The aim of this paper was to describe the spatial distribution of age-specific mortality rates from female breast cancer in the municipalities of Andalusia (southern Spain) and to analyze its evolution over time from 1981 to 2012. An ecological study was devised. Two spatio-temporal hierarchical Bayesian models were estimated. One of these was used to estimate the age-specific mortality rate for each municipality, together with its time trends, and the other was used to estimate the age-specific rate ratio compared with Spain as a whole. The results showed that 98% of the municipalities exhibited a decreasing or a flat mortality trend for all the age groups. In 2012, the geographical variability of the age-specific mortality rates was small, especially for population groups below 65. In addition, more than 96.6% of the municipalities showed an age-specific mortality rate similar to the corresponding rate for Spain, and there were no identified significant clusters. This information will contribute towards a reflection on the past, present and future of breast cancer outcomes in Andalusia. Full article

(This article belongs to the Special Issue Geographical Variation in Breast Cancer Outcomes)

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The Impact of Rurality and Disadvantage on the Diagnostic Interval for Breast Cancer in a Large Population-Based Study of 3202 Women in Queensland, Australia

by Philippa H. Youl, Joanne F. Aitken, Gavin Turrell, Suzanne K. Chambers, Jeffrey Dunn, Christopher Pyke and Peter D. Baade

Int. J. Environ. Res. Public Health 2016, 13(11), 1156; https://doi.org/10.3390/ijerph13111156 - 19 Nov 2016

Cited by 24 | Viewed by 6265

Abstract

Delays in diagnosing breast cancer (BC) can lead to poorer outcomes. We investigated factors related to the diagnostic interval in a population-based cohort of 3202 women diagnosed with BC in Queensland, Australia. Interviews ascertained method of detection and dates of medical/procedural appointments, and clinical information was obtained from medical records. Time intervals were calculated from self-recognition of symptoms (symptom-detected) or mammogram (screen-detected) to diagnosis (diagnostic interval (DI)). The cohort included 1560 women with symptom-detected and 1642 with screen-detected BC. Symptom-detected women had higher odds of DI of >60 days if they were Indigenous (OR = 3.12, 95% CI = 1.40, 6.98); lived in outer regional (OR = 1.50, 95% CI = 1.09, 2.06) or remote locations (OR = 2.46, 95% CI = 1.39, 4.38); or presented with a “non-lump” symptom (OR = 1.84, 95% CI = 1.43, 2.36). For screen-detected BC, women who were Indigenous (OR = 2.36, 95% CI = 1.03, 5.80); lived in remote locations (OR = 2.35, 95% CI = 1.24, 4.44); or disadvantaged areas (OR = 1.69, 95% CI = 1.17, 2.43) and attended a public screening facility (OR = 2.10, 95% CI = 1.40, 3.17) had higher odds of DI > 30 days. Our study indicates a disadvantage in terms of DI for rural, disadvantaged and Indigenous women. Difficulties in accessing primary care and diagnostic services are evident. There is a need to identify and implement an efficient and effective model of care to minimize avoidable longer diagnostic intervals. Full article

(This article belongs to the Special Issue Geographical Variation in Breast Cancer Outcomes)

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Open AccessArticle

Associations of Breast Cancer Risk Factors with Premenopausal Sex Hormones in Women with Very Low Breast Cancer Risk

by Lauren C. Houghton, Davaasambuu Ganmaa, Philip S. Rosenberg, Dambadarjaa Davaalkham, Frank Z. Stanczyk, Robert N. Hoover and Rebecca Troisi

Int. J. Environ. Res. Public Health 2016, 13(11), 1066; https://doi.org/10.3390/ijerph13111066 - 31 Oct 2016

Cited by 11 | Viewed by 5120

Abstract

Breast cancer incidence rates are low but rising in urban Mongolia. We collected reproductive and lifestyle factor information and measured anthropometrics and serum sex steroid concentrations among 314 premenopausal women living in Ulaanbaatar, Mongolia. Mean differences in hormone concentrations by these factors were calculated using age-adjusted quadratic regression splines. Estrone and estradiol in college-educated women were, respectively, 18.2% (p = 0.03) and 23.6% (p = 0.03) lower than in high-school-educated women. Progesterone concentrations appeared 55.8% lower (p = 0.10) in women residing in modern housing compared with women living in traditional housing (gers), although this finding was not statistically significant. Testosterone concentrations were positively associated with adiposity and central fat distribution; 17.1% difference (p = 0.001) for highest vs. lowest quarter for body mass index and 15.1% difference (p = 0.005) for waist-to-height ratio. Estrogens were higher in the follicular phase of women who breastfed each child for shorter durations. A distinct hormonal profile was associated with an urban lifestyle in premenopausal, Mongol women. In particular, heavier, more-educated women living in urban dwellings had higher testosterone and lower estrogen and progesterone levels. Higher breast cancer incidence in urban compared with rural women suggest that the hormonal profile associated with a more traditional lifestyle may be protective among Mongol women. Full article

(This article belongs to the Special Issue Geographical Variation in Breast Cancer Outcomes)

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Urban Rural Differences in Breast Cancer in New Zealand

by Ross Lawrenson, Chunhuan Lao, Mark Elwood, Charis Brown, Diana Sarfati and Ian Campbell

Int. J. Environ. Res. Public Health 2016, 13(10), 1000; https://doi.org/10.3390/ijerph13101000 - 11 Oct 2016

Cited by 11 | Viewed by 5669

Abstract

Many rural communities have poor access to health services due to a combination of distance from specialist services and a relative shortage of general practitioners. Our aims were to compare the characteristics of urban and rural women with breast cancer in New Zealand, to assess breast cancer-specific and all-cause survival using the Kaplan–Meier method and Cox proportional hazards model, and to assess whether the impact of rurality is different for Māori and New Zealand (NZ) European women. We found that rural women tended to be older and were more likely to be Māori. Overall there were no differences between urban and rural women with regards their survival. Rural Māori tended to be older, more likely to be diagnosed with metastatic disease and less likely to be screen detected than urban Māori. Rural Māori women had inferior breast cancer-specific survival and all-cause survival at 10 years at 72.1% and 55.8% compared to 77.9% and 64.9% for urban Māori. The study shows that rather than being concerned that more needs to be done for rural women in general it is rural Māori women where we need to make extra efforts to ensure early stage at diagnosis and optimum treatment. Full article

(This article belongs to the Special Issue Geographical Variation in Breast Cancer Outcomes)

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Temporal Trends in Geographical Variation in Breast Cancer Mortality in China, 1973–2005: An Analysis of Nationwide Surveys on Cause of Death

by Changfa Xia, Clare Kahn, Jinfeng Wang, Yilan Liao, Wanqing Chen and Xue Qin Yu

Int. J. Environ. Res. Public Health 2016, 13(10), 963; https://doi.org/10.3390/ijerph13100963 - 28 Sep 2016

Cited by 17 | Viewed by 5913

Abstract

To describe geographical variation in breast cancer mortality over time, we analysed breast cancer mortality data from three retrospective national surveys on causes of death in recent decades in China. We first calculated the age-standardized mortality rate (ASMR) for each of the 31 provinces in mainland China stratified by survey period (1973–1975, 1990–1992 and 2004–2005). To test whether the geographical variation in breast cancer mortality changed over time, we then estimated the rate ratio (RR) for the aggregated data for seven regions and three economic zones using generalized linear models. Finally, we examined the correlation between mortality rate and several macro-economic measures at the provincial level. We found that the overall ASMR increased from 2.98 per 100,000 in 1973–1975 to 3.08 per 100,000 in 1990–1992, and to 3.85 per 100,000 in 2004–2005. Geographical variation in breast cancer mortality also increased significantly over time at the regional level (p = 0.002) but not at the economic zone (p = 0.089) level, with RR being generally lower for Western China (Northwest and Southwest) and higher in Northeast China over the three survey periods. These temporal and spatial trends in breast cancer mortality were found to be correlated with per capita gross domestic product, number of hospitals and health centres’ beds per 10,000 population and number of practicing doctors per 10,000 population, and average number of live births for women aged 15–64. It may be necessary to target public health policies in China to address the widening geographic variation in breast cancer mortality, and to take steps to ensure that the ease of access and the quality of cancer care across the country is improved for all residents. Full article

(This article belongs to the Special Issue Geographical Variation in Breast Cancer Outcomes)

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Geographical Inequalities in Surgical Treatment for Localized Female Breast Cancer, Queensland, Australia 1997–2011: Improvements over Time but Inequalities Remain

by Peter D. Baade, Paramita Dasgupta, Philippa H. Youl, Christopher Pyke and Joanne F. Aitken

Int. J. Environ. Res. Public Health 2016, 13(7), 729; https://doi.org/10.3390/ijerph13070729 - 19 Jul 2016

Cited by 18 | Viewed by 5818

Abstract

The uptake of breast conserving surgery (BCS) for early stage breast cancer varies by where women live. We investigate whether these geographical patterns have changed over time using population-based data linkage between cancer registry records and hospital inpatient episodes. The study cohort consisted of 11,631 women aged 20 years and over diagnosed with a single primary invasive localised breast cancer between 1997 and 2011 in Queensland, Australia who underwent either BCS (n = 9223, 79%) or mastectomy (n = 2408, 21%). After adjustment for socio-demographic and clinical factors, compared to women living in very high accessibility areas, women in high (Odds Ratio (OR) 0.58 (95% confidence intervals (CI) 0.49, 0.69)), low (OR 0.47 (0.41, 0.54)) and very low (OR 0.44 (0.34, 0.56)) accessibility areas had lower odds of having BCS, while the odds for women from middle (OR 0.81 (0.69, 0.94)) and most disadvantaged (OR 0.87 (0.71, 0.98)) areas was significantly lower than women living in affluent areas. The association between accessibility and the type of surgery reduced over time (interaction p = 0.028) but not for area disadvantage (interaction p = 0.209). In making informed decisions about surgical treatment, it is crucial that any geographical-related barriers to implementing their preferred treatment are minimised. Full article

(This article belongs to the Special Issue Geographical Variation in Breast Cancer Outcomes)

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