Abstract P6-11-12: Access to certified breast cancer centers in the mainly rural state of Bavaria, Germany: A structural health geographical analysis
Authors: Stangl Stephanie , Rauch Sebastian , Rauh Jürgen , Meyer Martin , Müller-Nordhorn Jacqueline , Wildner Manfred , Heuschmann Peter U. , Wöckel Achim 
Published: March 2020

Abstract
Background: In Germany, evidence- and consensus-based recommendations for the treatment of breast cancer patients are available from the national guideline. To ensure implementation of these standards in clinical routine care, two different certification programs for breast cancer exist in Germany: 1) accreditation ‘Organ Cancer Center’ of the German Cancer Society (“Deutsche Krebsgesellschaft” DKG); 2) Disease Management Program (DMP) developed by Health Insurance Companies. For our analysis we focused on Bavaria due to its mainly rural character, which can lead to challenges in patients’ medical supply with long travel distances. We aimed to investigate the accessibility of certified Breast Cancer Centers (cBCC) in rural and urban areas of Bavaria and to estimate how many inhabitants and potentially breast cancer patients might be affected.
Methods: Accessibility of cBCC was defined according to travel time by car (or taxi) within 30 minutes. Addresses of cBCCs were identified through the homepages of the DKG, the Bavarian Association of Statutory Health Insurance Physicians (KVB), and a health insurance company. Data collection took place between August and December 2018. Only cBCC located in Bavaria with valid certification at point of search were eligible. Using ArcGIS, a routing network was created to identify clear catchment areas for each facility. The modeled speeds on which the traffic is based are street specific and consider the average regional traffic situations. The latter was then combined with the disaggregated 100 × 100 meters population data for the Census 2011, which allowed analyzing absolute population on a fine spatial resolution. Aggregated data on incident and prevalent breast cancer rates (women only) were obtained from the Epidemiological Bavarian Cancer Registry and merged on district level. As only aggregated data from the Bavarian Cancer Registry were utilized, a formal ethics committee (EC) review was not required. A declaration of no objection by the EC of the University of Würzburg is available (#2019042402).
Results: A total of 58 cBCC (both DKG/DMP: n=44, DMP only: n=14) were identified and included in our analysis. The predefined accessibility coverage comprises 76% of Bavaria. Focusing on all Bavarian administrative areas (n=96) we identified following categories: n=38 had full access, n=56 partial access and n=2 no access. On population level, n=5,533,166 (87.5%) females reach a cBCC within 30min travel time. Whereas about 800.000 (12.5%) women have hampered access with about 3/4 living in rural regions.
Data from the Bavarian Cancer Registry reveal that non-accessibility might affect ca. 5.000 prevalent and ca. 1.500 newly-diagnosed female breast cancer patients - based on a hypothetical stable age-standardized (EU) incidence and 5-yrs prevalence rate.
Conclusion: Our analysis revealed that there is no Bavaria-wide accessibility to cBCC and that disparities between rural and urban areas exist. Integrating GIS methods to health care service research allows 1) identifying regions with limited access to evidence-based structures (e.g. cBCC) and 2) planning of structures needed from a public health point of view. Our findings can be used to inform policy makers about injustice regarding health care accessibility. Furthermore, results can serve for developing and evaluating telemedical strategies to deliver high quality health care to all inhabitants regardless of residence.
Citation Format: Stephanie Stangl, Sebastian Rauch, Jürgen Rauh, Martin Meyer, Jacqueline Müller-Nordhorn, Manfred Wildner, Peter U. Heuschmann, Achim Wöckel. Access to certified breast cancer centers in the mainly rural state of Bavaria, Germany: A structural health geographical analysis [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-11-12.