Impact of rurality on processes and outcomes in melanoma care: results from a whole-Scotland melanoma cohort in primary and secondary care.

Background: Those living in rural areas have poorer cancer outcomes, but current evidence on how rurality impacts melanoma care and survival is contradictory.
Aim: To investigate the impact of rurality on setting of melanoma excision and mortality in a whole-nation cohort.
Design and Setting: Analysis of linked routine healthcare data comprising every individual in Scotland diagnosed with melanoma, January 2005-December 2013, in primary and secondary care.
Method: Multivariate binary logistic regression was used to explore the relationship between rurality and setting of melanoma excision; Cox proportional hazards regression between rurality and mortality was used, with adjustments for key confounders.
Results: In total 9519 patients were included (54.3% [ n = 5167] female, mean age 60.2 years [SD 17.5]). Of melanomas where setting of excision was known, 90.3% ( n = 8598) were in secondary care and 8.1% ( n = 771) in primary care. Odds of primary care excision increased with increasing rurality/remoteness. Compared with those in urban areas, those in the most remote rural locations had almost twice the odds of melanoma excision in primary care (adjusted odds ratio [aOR] 1.92; 95% confidence interval [CI] = 1.33 to 2.77). No significant association was found between urban or rural residency and all-cause mortality. Melanoma-specific mortality was significantly lower in individuals residing in accessible small towns than in large urban areas (adjusted hazards ratio [HR] 0.53; 95% CI = 0.33 to 0.87) with no trend towards poorer survival with increasing rurality.
Conclusion: Patients in Scottish rural locations were more likely to have a melanoma excised in primary care. However, those in rural areas did not have significantly increased mortality from melanoma. Together these findings suggest that current UK melanoma management guidelines could be revised to be more realistic by recognising the role of primary care in the prompt diagnosis and treatment of those in rural locations.
(© British Journal of General Practice 2018.)