Disparities in breast cancer stage at diagnosis in urban and rural adult women: a systematic review and meta-analysis

Factors associated with breast cancer detection method in California women: an analysis of California Health Interview Survey data

PURPOSE

Breast cancer mortality has significantly declined in the U.S. due in part to effective clinical screening methods. However, previous studies have found many women first detect their breast cancers through means other than their providers. Given that detection method has been shown to be an important prognostic factor, we examined the association between breast cancer detection method and various demographic and health-related factors in a representative sample of female breast cancer patients aged 40 + in California.

METHODS

We analyzed data from the 2009 and 2011-2012 California Health Interview Survey. Weighted percentages of breast cancer patients by detection method were calculated. A multivariable logistic regression model was used to quantify each factor's association with the likelihood of having a patient-detected versus clinically detected breast cancer using odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

36% of female breast cancer patients first detected their cancer themselves. Compared to U.S.-born women, those who had spent 40% or less of their lifetime in the U.S. were more than twice as likely to report their breast cancer being patient-detected versus clinically detected (OR = 2.27, 95% CI 1.06-4.86, p = 0.035). Rural women were also more likely to report a patient-detected breast cancer than urban women (OR = 1.51, 95% CI 1.01-2.11, p = 0.044).

CONCLUSIONS

Recent immigrants and those residing in rural areas were more likely to report self-detecting their breast cancer. Given the persistent disparities with regard to breast cancer mortality, particularly among underserved communities, strategies addressing barriers to screening uptake in these populations may be warranted.

Exploring disparities in post-cancer treatment instructions: an analysis of rural vs. urban breast cancer survivors in Missouri using BRFSS data

BACKGROUND

There are more than 4 million breast cancer survivors in the United States. With continuing improvements in early detection and treatment, the number of breast cancer survivors will only continue to increase. Breast cancer survivors face a lifetime risk of long-term or late-effects from cancer treatments, thus post-cancer treatment care, referred to as survivorship care, is critical. Social determinants of health, including where a breast cancer survivor lives, may impact cancer survivorship care. Our purpose was to evaluate the relationship between rural/urban status and receipt of cancer survivorship care and instructions for Missouri breast cancer survivors using state-level data from a nationwide telephone survey-the Behavioral Risk Factor Surveillance System (BRFSS).

METHODS

Missouri included the BRFSS Cancer Survivorship Module in 2014, 2016, 2018, and 2020. Module items ask cancer survivors about receipt of a "post-cancer-treatment summary" and "follow-up instructions." We hypothesized chances of receipt of both components would differ among four level Rural-Urban Commuting Area (RUCA) Code groups (Rural, Small-Town, Micropolitan, Metropolitan). Data from 430 breast cancer survivors over four survey years were combined and grouped according to RUCA status. Using a logistic model with a multilevel approach (after sampling weights calibration), the relationship between receipt of survivorship instructions and RUCA group was examined.

RESULTS

46% of Missouri breast cancer survivors reported receipt of complete survivorship instructions. Compared to rural breast cancer survivors, micropolitan breast cancer survivors had 5.9 times higher odds of receiving survivorship instructions (p < 0.0001).

CONCLUSIONS

Less than half of respondents reported receiving complete post-cancer treatment instructions. More urban respondents were more likely to receive instructions than their rural counterparts which raises questions about the quality of post-treatment care between rural and urban survivors. A sophisticated and purposeful approach to mitigating potential disparities is warranted. Receipt of cancer survivorship care plans may be impacted by rurality/urbanicity. Clinicians caring for cancer survivors living in rural or urban settings must continue to be diligent with providing personalized survivorship care.

Mammography Among Women Residing in Urban Versus Rural Utah: Breast Cancer Survival

BACKGROUND

Annual or biennial breast cancer screenings are recommended for women 40 and older. Women residing in rural areas have worse breast cancer survival rates than urban women, but no study has focused on rural versus urban residence in Utah regarding breast cancer screening and mortality.

METHODS

Cases (n = 14,516) were women aged > 39 diagnosed with a first primary invasive breast cancer between 1998 and 2017 in Utah. Controls (n = 63,117) without a history of breast cancer were matched to cases by birth year and birth state. Mammography screening status was identified by Current Procedural Terminology (CPT) codes. Logistic regression was used to assess the odds of breast cancer diagnosis. The Cox proportional hazards model was used to assess survival outcomes for rural and urban breast cancer patients based on screening status.

RESULTS

Screening mammography usage among rural patients diagnosed with breast cancer was lower (17.7%) than urban usage (20.7%). Usage of screening mammograms resulted in higher odds of breast cancer diagnosis at localized stage rather than at a regional and distant stage. Rural breast cancer cases had a higher proportion of deaths, and a lower proportion screened, than urban breast cancer cases. Hazard ratios showed that screening mammography usage was associated with better survival among both rural (HR = 0.50, 95% CI = 0.44-0.57) and urban (HR = 0.56, 95% CI = 0.39-0.82) breast cancer cases.

CONCLUSION

Screening mammography usage was associated with better overall survival regardless of place of residence. Removing barriers and improving information regarding breast cancer screenings are needed in both rural and urban settings in Utah to increase mammography usage, with the overall goal of increasing early detection and outcomes of breast cancer.

Differential Access to Breast Magnetic Resonance Imaging Compared with Mammography and Ultrasound

INTRODUCTION

For high-risk women, breast magnetic resonance (MR) is the preferred supplemental imaging option, but spatial access differences may exacerbate disparities in breast care.

METHODS

This was a cross-sectional study examining distance between ZIP codes and the nearest breast imaging facility (MR, mammography, ultrasound) using 2023 data from the Food and Drug Administration and the American College of Radiology. Linear regression was used to assess distance differences controlling for Area Deprivation Index (ADI), urbanicity, and population size. Analyses were conducted in 2024.

RESULTS

Among the 29,629 ZIP codes with an ADI and known urbanicity, unadjusted mean distance to breast MR was 23.2±25.1 miles (SD) compared with 8.2±8.3 for mammography and 22.2±25.0 for ultrasound. Hence, the average distance to breast MR facilities was 2.8 times further than to mammography facilities. ADI and urbanicity were associated with increased distance to the nearest breast imaging facility. The additional miles associated with the least advantaged areas compared with most advantaged areas was 12.2 (95%CI: 11.3, 13.2) for MR, 11.5 miles (95%CI: 10.6, 12.3) for ultrasound, and 2.4 (95%CI: 2.1, 2.7) for mammography. Compared with metropolitan areas, the additional miles to breast MR facilities was 23.2 (95%CI: 22.5, 24.0) for small/rural areas.

CONCLUSIONS

Spatial access is substantially better for mammography sites compared with breast MR or ultrasound sites. Given these findings, consideration of options to mitigate the impact of differential access should be considered. For example, mammography sites could offer contrast-enhanced mammography. Future research should examine the feasibility and effectiveness of this and other options.

Factors Associated with Abnormal Mammogram Results Among Low-Income Uninsured Populations in Medically Underserved And Rural Texas Regions

Background

This study investigated the potential associations between neighborhood characteristics, rurality, ethnicity/race, and breast cancer screening outcomes in designated Health Professional Shortage Areas in Central Texas. Limited access to preventive medical care can impact screening rates and outcomes. Previous research on the effects of factors such as rurality, neighborhood socioeconomic status, and education level on cancer prevention behaviors has yielded inconsistent results.

Materials and Methods

We analyzed data from a state-funded breast and cervical cancer screening programs for disadvantaged and medically underserved individuals. A mixed-effects logistic regression model was used to assess the impact of residency characteristics (rurality, educational attainment, unemployment, and poverty) on abnormal breast cancer screening outcomes, with individual level (age, ethnicity, race, and education) as control variables.

Results

During the studied time, there were 1,139 women screened and 134 abnormal mammograms found. Residency characteristics were not significantly associated with abnormal mammography outcomes at 0.05. However, individual factors are strongly associated with abnormal screening results. Non-Hispanic or Latino white women had increased odds of abnormal clinical outcomes compared with Hispanic or Latino women (OR = 2.03, CI 1.25-3.28; p = 0.004). Additionally, women residing in counties with more than 30% of the population completing college had increased odds of abnormal mammogram outcomes compared with counties with less than 15% college attainment (OR = 2.89, CI 0.99-8.38; p = 0.051).

Conclusions

This study found a significant correlation between area-level educational characteristics and abnormal mammography outcomes. Future research should explore the contextual risk factors influencing breast cancer occurrence and develop targeted interventions for this population.

Patient reports of cancer care coordination in rural Hawaii

PURPOSE

Rural residents experience disproportionate burdens of cancer, and poorer cancer health outcomes in rural populations are partly attributed to care delivery challenges. Cancer patients in rural areas often experience unique challenges with care coordination. In this study, we explored patient reports of care coordination among rural Hawaii patients with cancer and compared rural and urban patients' perceptions of cancer care coordination.

METHODS

80 patients receiving active treatment for cancer from rural Hawaii participated in a care coordination study in 2020-2021. Participants completed the Care Coordination Instrument, a validated oncology patient questionnaire.

FINDINGS

Mean age of rural cancer patients was 63.0 (SD = 12.1), and 57.7% were female. The most common cancer types were breast and GI. Overall, rural and urban patients' perceptions of care coordination were comparable (p > 0.05). There were statistically significant differences between rural and urban patients' perceptions in communication and navigation aspects of care coordination (p = 0.02 and 0.04, respectively). Specific differences included a second opinion consultation, clinical trial considerations, and after-hours care. 43% of rural patients reported traveling by air for part or all of their cancer treatment.

CONCLUSIONS

Findings suggest that while overall perceptions of care coordination were similar between rural and urban patients, differential perceptions of specific care coordination areas between rural and urban patients may reflect limited access to care for rural patients. Improving access to cancer care may be a potential strategy to enhance care coordination for rural patients and ultimately address rural-urban cancer health disparities.

Insights into the Refusal of Free Screening Mammograms: Exploring Contributing Factors

Background

Despite the availability of free screening mammograms (SMG) through the Breast Cancer Early Detection (BCED) Program in the Qassim region of Saudi Arabia, a notable gap exists between program implementation and the actual uptake of SMG. This study aims to assess the refusal rate, identify barriers to participation, and shed light on the factors influencing women's decisions regarding SMG.

Methods

A cross-sectional study was conducted among consecutive women aged 40-69 participating anonymously in the BCED program in September 2023. The participants were administered a validated Arabic language survey encompassing breast cancer screening backgrounds and knowledge, reasons for refusal, and factors influencing SMG reconsideration. Logistic regression was employed to identify factors linked with SMG refusal using SPSS version 28.

Results

Of the 2446 eligible women in the study, 576 (23.6%) declined to undergo SMG. The median age of participants was 49 years, primarily married (91.5%) and residing in central cities (60.3%). Previous mammogram history was reported by 21.4%, with only 12.9% performing regular SMGs every 1-2 years. Married women had a 31% lower refusal likelihood to SMG compared to widowed/divorced women (Adjusted Odds Ratio [aOR] = 0.69, p = 0.02). Women residing in peripheral areas showed approximately 1.45 times higher odds of refusal compared to those in central cities (aOR = 1.45, p < 0.001), and women without prior history of SMG had 2.13 times higher odds of refusal (aOR = 2.14, p < 0.001).

Conclusion

The refusal rate for SMG in the Qassim region aligns closely with rates observed in developed countries. Despite this progress, significant barriers to SMG uptake persist, and tailored interventions targeting specific demographic groups and addressing these barriers are essential to improving screening participation, promoting a culture of proactive screening behavior, and ensuring equitable access to screening services for all eligible women.

EBCC-14 manifesto: Addressing disparities in access to innovation for patients with metastatic breast cancer across Europe

The European Breast Cancer Council (EBCC) traditionally identifies controversies or major deficiencies in the management of patients with breast cancer and selects a multidisciplinary expert team to collaborate in setting crucial principles and recommendations to improve breast cancer care. The 2024 EBCC manifesto focuses on disparities in the care of patients with metastatic breast cancer. There are several reasons for existing disparities both between and within countries. Our recommendations aim to address the stigma of metastatic disease, which has led to significant disparities in access to innovative care regardless of the gross national income of a country. These recommendations are for different stakeholders to promote the care of patients with metastatic breast cancer across Europe and worldwide.

Late-stage diagnosis: The driving force behind high breast cancer mortality in Ethiopia: A systematic review and meta-analysis

INTRODUCTION

Breast cancer continues to be the most common malignancy and the leading cause of cancer-related deaths in Ethiopia. The poor prognosis and high mortality rate of breast cancer patients in the country are largely caused by late-stage diagnosis. Hence, understanding the epidemiology of late-stage diagnosis is essential to address this important problem. However, previous reports in Ethiopia indicated inconsistent findings. Therefore, this literature review was conducted to generate dependable evidence by summarizing the prevalence and determinants of late-stage diagnosis among breast cancer patients in Ethiopia.

METHODS

Pertinent articles were retrieved by systematically searching on major electronic databases and gray literature. Data were extracted into an Excel spreadsheet and analyzed using the STATA 17 statistical software. The pooled estimates were summarized using the random effect meta-analysis model. Heterogeneity and small study effect were evaluated using the I2 statistics and Egger's regression test in conjunction with the funnel plot, respectively. Meta-regression, sub-group analysis, and sensitivity analysis were also employed. Protocol registration number: CRD42024496237.

RESULTS

The pooled prevalence of late-stage diagnosis after combining reports of 24 studies with 8,677 participants was 65.85 (95% CI: 58.38, 73.32). Residence (adjusted OR: 1.92; 95% CI: 1.45, 2.53), patient delay at their first presentation (adjusted OR: 2.65; 95% CI: 1.56, 4.49), traditional medicine use (adjusted OR: 2.54; 95% CI: 1.89, 3.41), and breast self-examination practice (adjusted OR: 0.28; 95% CI: 0.09, 0.88) were significant determinants of late-stage diagnosis.

CONCLUSION

Two-thirds of breast cancer patients in Ethiopia were diagnosed at an advanced stage. Residence, delay in the first presentation, traditional medicine use, and breast self-examination practice were significantly associated with late-stage diagnosis. Public education about breast cancer and its early detection techniques is crucial to reduce mortality and improve the survival of patients. Besides, improving access to cancer screening services is useful to tackle the disease at its curable stages.

Transcultural Adaptation of the Breast Cancer Awareness Measure in a Rural Border Area of Greece

BACKGROUND

Breast cancer awareness is a concept suggesting that awareness of signs and symptoms and early seeking of medical advice may decrease mortality, especially in limited resource settings.

METHODS

A modified questionnaire based on the breast cancer awareness measure (BCAM) by Cancer Research UK was translated into Greek and used for the first time. Participants were women residing in a rural border area in Greece. For statistical analysis the χ2 goodness-of-fit and Cramer's V test for categorical comparisons were used and Cronbach's alpha for reliability analysis.

RESULTS

In total, 110 women filled out and returned the questionnaire. Respondents appeared to be inappropriately informed regarding the less common warning signs of breast cancer, the most common age of breast cancer occurrence, the national screening program, and the less important risk factors of breast cancer. On the other hand, most women appeared to be confident in recognizing breast changes and seeking medical advice if needed.

CONCLUSIONS

The translated modified BCAM tool can be used to evaluate breast cancer awareness in Greek women. Future campaigns developed by policymakers should focus on improving breast cancer awareness, especially in socioeconomically deprived areas.

Why location matters: associations between county-level characteristics and availability of National Cancer Oncology Research Program and National Cancer Institute sites

BACKGROUND

The majority of patients with cancer seek care at community oncology sites; however, most clinical trials are available at National Cancer Institute (NCI)-designated sites. Although the NCI National Cancer Oncology Research Program (NCORP) was designed to address this problem, little is known about the county-level characteristics of NCORP site locations.

METHODS

This cross-sectional analysis determined the association between availability of NCORP or NCI sites and county-level characteristic theme percentile scores from the Center for Disease Control and Prevention's Social Vulnerability Index themes. Health Resources and Services Administration's Area Health Resource Files were used to determine contiguous counties. We estimated risk ratios and 95% confidence intervals (CIs) using modified Poisson regression models to evaluate the association between county-level characteristics and site availability within singular and singular and contiguous counties.

RESULTS

Of 3141 included counties, 14% had an NCORP, 2% had an NCI, and 1% had both sites. Among singular counties, for a standard deviation increase in the racial and ethnic theme score, there was a 22% higher likelihood of NCORP site availability (95% CI = 1.10 to 1.36); for a standard deviation increase in the socioeconomic status theme score, there was a 24% lower likelihood of NCORP site availability (95% CI = 0.67 to 0.87). Associations were of smaller magnitude when including contiguous counties. NCI sites were located in more vulnerable counties.

CONCLUSIONS

NCORP sites were more often in racially diverse counties and less often in socioeconomically vulnerable counties. Research is needed to understand how clinical trial representation will increase if NCORP sites strategically increase their locations in more vulnerable counties.

Breast Cancer Risk Factors among Women with Solid Breast Lesions

BACKGROUND

Breast cancer is the most frequent malignancy in women worldwide and one of the most curable cancers if diagnosed at an early stage. Female patients presenting solid breast lesions are greatly predisposed to breast cancer development, and as such, effective screening of high-risk patients is valuable in early-stage breast cancer detection.

OBJECTIVES

The aim of our study was to identify the most relevant demographic, reproductive and lifestyle risk factors for breast cancer among women with solid breast lesions living in western Romania, namely the urban region consisting of Timisoara and the rural surrounding regions.

METHODS

From January 2017 to December 2021, 1161 patients with solid breast lesions, as detected by sonoelastography, were divided into two groups: patients with benign lesions (1019, 87.77%) and patients with malignant nodules (142, 12.23%). The malignancy group was confirmed by a histopathological result. Variables including age, BMI, menarche, menopause, years of exposure to estrogen, number of births, breastfeeding period, use of oral combined contraceptives, smoker status, family medical history and living area (rural-urban) were recorded.

RESULTS

It was evidenced by our study that the main risk factors for malignancy were elevated age (OR = 1.07, 95% CI 1.05-1.08), BMI (OR = 1.06, 95% CI 1.02-1.10), living area (rural) (OR = 1.86, 95% CI 1.13-2.85) and family medical history (negative) (OR 3.13, 95% CI 1.43-8.29). The other proposed risk factors were not found to be statistically significant.

CONCLUSIONS

Age and BMI were observed to be the most significant factors for breast cancer risk increase, followed by living in a rural area. A family history of breast cancer was shown to be inversely correlated with cancer risk increase.

Disparities in Thyroid Cancer Diagnosis Based on Residence and Distance From Medical Facility

Context

Rural-urban disparities have been reported in cancer care, but data are sparse on the effect of geography and location of residence on access to care in thyroid cancer.

Objective

To identify impact of rural or urban residence and distance from treatment center on thyroid cancer stage at diagnosis.

Methods

We evaluated 800 adults with differentiated thyroid cancer in the iCaRe2 bioinformatics/biospecimen registry at the Fred and Pamela Buffett Cancer Center. Participants were categorized into early and late stage using AJCC staging, and residence/distance from treating facility was categorized as short (≤ 12.5 miles), intermediate (> 12.5 to < 50 miles) or long (≥ 50 miles). Multivariable logistic regression was used to identify factors associated with late-stage diagnosis.

Results

Overall, 71% lived in an urban area and 29% lived in a rural area. Distance from home to the treating facility was short for 224 (28%), intermediate for 231 (28.8%), and long for 345 (43.1%). All 224 (100%) short, 226 (97.8%) intermediate, and 120 (34.7%) long distances were for urban patients; in contrast, among rural patients, 5 (2.16%) lived intermediate and 225 (65.2%) lived long distances from treatment (P < .0001). Using eighth edition AJCC staging, the odds ratio of late stage at diagnosis for rural participants ≥ 55 years was 2.56 (95% CI, 1.08-6.14) (P = .03), and for those living ≥ 50 miles was 4.65 (95% CI, 1.28-16.93) (P = .0075). Results were similar using seventh edition AJCC staging.

Conclusion

Older age at diagnosis, living in rural areas, and residing farther from the treatment center are all independently associated with late stage at diagnosis of thyroid cancer.

Development of the Rural Perception Scale (RPS-18)

BACKGROUND

People living in rural areas often experience limited access to health resources, slow knowledge diffusion, and geographical isolation, and tend to be at higher risk for poor physical and mental health outcomes compared with nonrural populations. It is unclear, yet, how the concept of "rural" shapes observed differences from nonrural populations. We aim to develop a psychometrically sound scale to assess key dimensions that constitute individual-level perceived rurality.

METHODS

We first conducted a broad literature review to identify a priori concepts related to rurality and adapted survey items measuring relevant constructs, such as loneliness, attitudes toward people living in rural areas, and perceived social membership. We used these conceptual constructs and measures to develop a survey questionnaire focused on rural perceptions. We recruit residents in 3 rural states: Kentucky, New Hampshire, and Vermont. Using the explorative factor analysis and second-order measurement model in the structural equation model framework, we developed a rural perception scale consisting of 18 items.

RESULTS

We recruited 1,384 participants (n = 686 from KY; n = 698 from NH/VT) using Amazon Mechanical Turk (n = 897, 64.8%) and social media paid ads (n = 487, 35.2%). The average age of participants was 41 years old (SD = 15); 54.7% of respondents had less than college graduate education, and 94.2% reported their race as non-Hispanic White. Majority of the participants were from Rural Urban Commuting Area (RUCA)-designated urban areas (n = 798, 57.7%), followed by RUCA-designated large rural areas (257, 18.6%), RUCA-designated rural areas (n = 174, 12.6%) and RUCA-designated isolated areas (n = 133, 9.6%). Our final model revealed 4 latent constructs: "belonging" (Cronbach's α = 0.896), "attitudes toward rural life" (Cronbach's α = 0.807), "loneliness" (Cronbach's α = 0.898), and "community social ties to people in their community" (Cronbach's α = 0.846).

CONCLUSIONS

We identified 4 subfactors of the umbrella concept of rurality that explain how people in rural regions may perceive being in rural environments and having rural lifestyles.

Socioeconomic and geographic disparities of breast cancer incidence according to stage at diagnosis in France

PURPOSE

Low socioeconomic background (SB) has been associated with lower breast cancer (BC) incidence and higher BC mortality. One explanation of this paradox is the higher frequency of advanced BC observed in deprived women. However, it is still unclear if SB affects similarly BC incidence. This study investigated the link between SB and early/advanced BC incidence from Loire-Atlantique/Vendee Cancer registry data (France).

MATERIALS AND METHODS

Fourteen thousand three hundred fifty three women living in the geographic area covered by the registry and diagnosed with a primary BC in 2008-2015 were included. SB was approached by a combination of two ecological indexes (French European Deprivation Index and urban/rural residence place). Mixed effects logistic and Poisson regressions were used, respectively, to estimate the odds of advanced (stage ≥ II) BC and the ratio of incidence rates of early (stage 0-I) and advanced BC according to SB, overall and by age group (< 50, 50-74, ≥ 75).

RESULTS

Compared to women living in affluent-urban areas, women living in deprived-urban and deprived-rural areas had a higher proportion of advanced BC [respectively, OR = 1.11 (1.01-1.22), OR = 1.60 (1.25-2.06)] and lower overall (from - 6 to - 15%) and early (from - 9 to - 31%) BC incidences rates Advanced BC incidence rates were not influenced by SB. These patterns were similar in women under 75 years, especially in women living in deprived-rural areas. In the elderly, no association between SB and BC frequency/incidence rates by stage was found.

CONCLUSION

Although advanced BC was more frequent in women living in deprived and rural areas, SB did not influence advanced BC incidence. Therefore, differences observed in overall BC incidence according to SB were only due to higher incidence of early BC in affluent and urban areas. Future research should confirm these results in other French areas.

Individual and area level factors associated with the breast cancer diagnostic-treatment interval in Queensland, Australia

BACKGROUND

Delays to breast cancer treatment can lead to more aggressive and extensive treatments, increased expenses, increased psychological distress, and poorer survival. We explored the individual and area level factors associated with the interval between diagnosis and first treatment in a population-based cohort in Queensland, Australia.

METHODS

Data from 3216 Queensland women aged 20 to 79, diagnosed with invasive breast cancer (ICD-O-3 C50) between March 2010 and June 2013 were analysed. Diagnostic dates were sourced from the Queensland Cancer Registry and treatment dates were collected via self-report. Diagnostics-treatment intervals were modelled using flexible parametric survival methods.

RESULTS

The median interval between breast cancer diagnosis and first treatment was 15 days, with an interquartile range of 9-26 days. Longer diagnostic-treatment intervals were associated with a lack of private health coverage, lower pre-diagnostic income, first treatments other than breast conserving surgery, and residence outside a major city. The model explained a modest 13.7% of the variance in the diagnostic-treatment interval [Formula: see text]. Sauerbrei's D was 0.82, demonstrating low to moderate discrimination performance.

CONCLUSION

Whilst this study identified several individual- and area-level factors associated with the time between breast cancer diagnosis and first treatment, much of the variation remained unexplained. Increased socioeconomic disadvantage appears to predict longer diagnostic-treatment intervals. Though some of the differences are small, many of the same factors have also been linked to screening and diagnostic delay. Given the potential for accumulation of delay at multiple stages along the diagnostic and treatment pathway, identifying and applying effective strategies address barriers to timely health care faced by socioeconomically disadvantaged women remains a priority.

Environmental pressures, tumor characteristics, and death rate in a female breast cancer cohort: a seven-years Bayesian survival analysis using cancer registry data from a contaminated area in Italy

Introduction

In Taranto, Southern Italy, adverse impacts on the environment and human health due to industrial installations have been studied. In the literature, few associations have been reported between environmental factors and breast cancer mortality in women. The aim of this study was to investigate the relationships between residence in areas with high environmental pressures, female breast cancer characteristics, and death rate.

Methods

Data from the Taranto Cancer Registry were used, including all women with invasive breast cancer diagnosed between 01 January 2015 and 31 December 2020 and with follow-up to 31 December 2021. Bayesian mixed effects logistic and Cox regression models were fitted with the approach of integrated nested Laplace approximation, adjusting for patients and disease characteristics.

Results

A total of 10,445 person-years were observed. Variables associated with higher death rate were residence in the contaminated site of national interest (SIN) (HR 1.22, 95% CrI 1.01-1.48), pathological/clinical stage III (HR 2.77, 95% CrI 1.93-3.97) and IV (HR 17.05, 95% CrI 11.94-24.34), histological grade 3 (HR 2.50, 95% CrI 1.20-5.23), Ki-67 proliferation index of 21-50% (HR 1.42, 95% CrI 1.10-1.83) and > 50% (HR 1.81, 95% CrI 1.29-2.55), and bilateral localization (HR 1.65, 95% CrI 1.01-2.68). Variables associated with lower death rate were estrogen and/or progesterone receptor positivity (HR 0.61, 95% CrI 0.45-0.81) and HER2/neu oncogene positivity (HR 0.59, 95% CrI 0.44-0.79).

Discussion

The findings confirmed the independent prognostic values of different female breast cancer characteristics. Even after adjusting for patients and disease characteristics, residence in the SIN of Taranto appeared to be associated with an increased death rate.

Quality of breast surgery care at a comprehensive cancer center and its rural affiliate hospital

BACKGROUND

Cancer centers are increasingly affiliating with rural hospitals to perform surgery. Perioperative and oncologic outcomes for cancer center surgeons operating at rural hospitals are understudied.

METHODS

For patients with non-metastatic breast cancer from a rural catchment area who had oncologic surgery at an NCI-designated comprehensive cancer center (CC) or its rural affiliate (RA) from 2017 to 2022, we compared perioperative outcomes (composite of surgical site infection, seroma requiring drainage, and reoperation for margins) and receipt of guideline-concordant care (if patient received all applicable treatments) using descriptive statistics and chi-squared tests.

RESULTS

Among 168 patients, 99 had surgery at RA, 60 CC. RA patients were older, higher stage, and more often had lumpectomy. There were no differences in perioperative outcomes (CC 10%, RA 14%, p ​= ​0.445) or guideline concordant care (RA 76%, CC 78%, p ​= ​0.846).

CONCLUSIONS

Cancer center surgeons operating at a rural affiliate had comparable perioperative outcomes and guideline-concordant care.

A catchment and location-allocation analysis of mammography access in Delaware, US: implications for disparities in geographic access to breast cancer screening

BACKGROUND

Despite a 40% reduction in breast cancer mortality over the last 30 years, not all groups have benefited equally from these gains. A consistent link between later stage of diagnosis and disparities in breast cancer mortality has been observed by race, socioeconomic status, and rurality. Therefore, ensuring equitable geographic access to screening mammography represents an important priority for reducing breast cancer disparities. Access to breast cancer screening was evaluated in Delaware, a state that experiences an elevated burden from breast cancer but is otherwise representative of the US in terms of race and urban-rural characteristics. We first conducted a catchment analysis of mammography facilities. Finding evidence of disparities by race and rurality, we next conducted a location-allocation analysis to identify candidate locations for the establishment of new mammography facilities to optimize equitable access.

METHODS

A catchment analysis using the ArcGIS Pro Service Area analytic tool characterized the geographic distribution of mammography sites and Breast Imaging Centers of Excellence (BICOEs). Poisson regression analyses identified census tract-level correlates of access. Next, the ArcGIS Pro Location-Allocation analytic tool identified candidate locations for the placement of additional mammography sites in Delaware according to several sets of breast cancer screening guidelines.

RESULTS

The catchment analysis showed that for each standard deviation increase in the number of Black women in a census tract, there were 68% (95% CI 38-85%) fewer mammography units and 89% (95% CI 60-98%) fewer BICOEs. The more rural counties in the state accounted for 41% of the population but only 22% of the BICOEs. The results of the location-allocation analysis depended on which set of screening guidelines were adopted, which included increasing mammography sites in communities with a greater proportion of younger Black women and in rural areas.

CONCLUSIONS

The results of this study illustrate how catchment and location-allocation analytic tools can be leveraged to guide the equitable selection of new mammography facility locations as part of a larger strategy to close breast cancer disparities.

Adverse Health Outcomes among Rural and Urban Breast Cancer Survivors: A Population-Based Cohort Study

BACKGROUND

Limited population-based studies have focused on breast cancer survivors in rural populations. We sought to evaluate the risk of adverse health outcomes among rural and urban breast cancer survivors and to evaluate potential predictors for the highest risk outcomes.

METHODS

A population-based cohort of rural and urban breast cancer survivors diagnosed between 1997 and 2017 was identified in the Utah Cancer Registry (UCR). Rural breast cancer survivors were matched on year (±1 year) and age at cancer diagnosis (±1 year) with up to 5 urban breast cancer survivors (2,359 rural breast cancer survivors; 11,748 urban breast cancer survivors). Cox proportional hazards models were used to calculate HRs with 99% confidence intervals (CI) for adverse health outcomes overall, within 5 years, and >5 years after cancer diagnosis.

RESULTS

Compared with urban breast cancer survivors, rural breast cancer survivors had a 39% (HR, 1.39; 95% CI, 1.02-1.65) higher risk of heart failure (HF) within the 5 years of follow-up. Overall, there was no increase in the risk of other evaluated adverse health outcomes. A higher baseline body mass index and Charlson Comorbidity Index, family history of cardiovascular diseases, family history of breast cancer, and advanced cancer stage were risk factors for HF for rural and urban breast cancer survivors, with similar levels of HF risk.

CONCLUSIONS

Rural residence was associated with an increased risk of HF among breast cancer survivors.

IMPACT

Our study highlights the need for primary preventive strategies for rural cancer survivors at risk of heart failure.

County characteristics associated with refusing breast cancer surgery: Evidence from the Surveillance, Epidemiology, and End Results program

BACKGROUND

Individuals' communities impact cancer disparities and are intimately related to social determinants of health. Studies show that personal factors affect treatment refusals for a potentially curable cancer, but few studies have investigated whether community-based characteristics affect the receipt of surgery.

METHODS

We used Surveillance Epidemiology and End Results Program registries from 2010 to 2015 to examine differences in rates of surgery refusal among non-Hispanic White, non-Hispanic Black, and Hispanic women diagnosed with nonmetastatic breast cancer. The community factor measures were based on county-level factors. Sociodemographic and community differences were analyzed using Pearson's χ2 tests and analysis of variance. Multivariate logistic regression of predictors of surgery refusal and the Cox proportional hazard model of disease-specific mortality were performed.

RESULTS

Surgery refusers among non-Hispanic Black and Hispanic all races lived in counties with lower rates of educational attainment, median family and household income, and higher rates of poverty, unemployment, foreign-born, language isolation, urban population, and women more than 40 years old having mammography in last 2 years. Multivariate analysis shows surgery refusal rates increased in counties having a high percentage of urban population and declined in counties with an increased percentage of less than high school level education, unemployment, and median household income. Breast cancer-specific mortality increased significantly with surgery refusal.

CONCLUSION

Residence in counties with the lowest socioeconomic status and disproportionately populated by racial and ethnic minorities is associated with surgery refusal. Given the high mortality associated with refusing surgery, culturally sensitive education on the benefits of care may be appropriate.

Screening Mammography Utilization in the United States

Breast cancer is the second leading cause of cancer mortality in adult women in the United States. Screening mammography reduces breast cancer mortality between 22% and 48%; however, screening mammography remains underutilized. Screening mammography utilization data are available from insurance claims, electronic medical records, and patient self-report via surveys, and each data source has unique benefits and challenges. Numerous barriers exist that adversely affect the use of screening mammography in the United States. This article will review screening mammography utilization in the United States, explore factors that impact utilization, and briefly discuss strategies to improve utilization.

The contribution of prognostic factors to socio-demographic inequalities in breast cancer survival in Victoria, Australia

BACKGROUND

Breast cancer survival in Australia varies according to socio-economic status (SES) and between rural and urban places of residence. Part of this disparity may be due to differences in prognostic factors at the time of diagnosis.

METHODS

Women with invasive breast cancer diagnosed from 2008 until 2012 (n = 14,165) were identified from the Victorian Cancer Registry and followed up for 5 years, with death from breast cancer or other causes recorded. A prognostic score, based on stage at diagnosis, cancer grade, whether the cancer was detected via screening, reported comorbidities and age at diagnosis, was constructed for use in a mediation analysis.

RESULTS

Five-year breast cancer mortality for women with breast cancer who were in the lowest quintile of SES (10.3%) was almost double that of those in the highest quintile (5.7%). There was a small survival advantage (1.7% on average, within each socio-economic quintile) of living in inner-regional areas compared with major cities. About half of the socio-economic disparity was mediated by prognostic factors, particularly stage at diagnosis and the presence of comorbidities. The inner-regional survival advantage was not due to differences in prognostic factors.

CONCLUSIONS

Part of the socio-economic disparity in breast cancer survival could be addressed by earlier detection in, and improved general health for, more disadvantaged women. Further research is required to identify additional causes of socio-economic disparities as well as the observed inner-regional survival advantage.

Underuse of Gastric Cancer Screening Services among Koreans with Type 2 Diabetes

We aimed to compare the gastric cancer screening rates between participants with diabetes and those without diabetes in the Korean population. The data of 4284 participants from the Korea National Health and Nutrition Examination Survey 2019 were used. Cancer-free people aged ≥40 years were included, and cancer screening rates in diabetes and non-diabetes participants were analyzed. Baseline characteristics and screening rates were calculated using weighted frequencies and multivariable regression at a 95% confidence interval in both groups. Screening for gastric cancer was significantly lower (odd ratio [OR]: 0.77, 95% CI: 0.64-0.95) in patients with diabetes than in those without diabetes. The odds of performing the recommended gastric cancer screening were also lower (OR: 0.72, 95% CI: 0.58-0.90) in participants with diabetes than in those without diabetes. After adjusting for socio-demographic factors, the multivariable logistics regression analysis also showed lower odds for gastric cancer screening participation in diabetic patients than in non-diabetes participants. Conclusively, people with diabetes were less likely to have ever had or been recommended screening compared with those without diabetes. Greater efforts need to be made by health specialists to increase the awareness and the need of long-term preventive care including gastric cancer screening in high-risk groups.

A Catchment and Location-Allocation Analysis of Mammography Access in Delaware, US: Implications for disparities in geographic access to breast cancer screening

Background

Despite a 40% reduction in breast cancer mortality over the last 30 years, not all groups have benefited equally from these gains. A consistent link between later stage of diagnosis and disparities in breast cancer mortality has been observed by race, socioeconomic status, and rurality. Therefore, ensuring equitable geographic access to screening mammography represents an important priority for reducing breast cancer disparities. This study conducted a catchment and location-allocation analysis of mammography access in Delaware, a state that is representative of the US in terms of race and urban-rural characteristics and experiences an elevated burden from breast cancer.

Methods

A catchment analysis using the ArcGIS Pro Service Area analytic tool characterized the geographic distribution of mammography sites and Breast Imaging Centers of Excellence (BICOEs). Poisson regression analyses identified census tract-level correlates of access. Next, the ArcGIS Pro Location-Allocation analytic tool identified candidate locations for the placement of additional mammography sites in Delaware according to several sets of breast cancer screening guidelines.

Results

The catchment analysis showed that for each standard deviation increase in the number of Black women in a census tract, there were 64% (95% CI, 0.18-0.66) fewer mammography units and 85% (95% CI, 0.04-0.48) fewer BICOEs. The more rural counties in the state accounted for 41 % of the population but only 22% of the BICOEs. The results of the location-allocation analysis depended on which set of screening guidelines were adopted, which included increasing mammography sites in communities with a greater proportion of younger Black women and in rural areas.

Conclusions

The results of this study illustrate how catchment and location-allocation analytic tools can be leveraged to guide the equitable selection of new mammography facility locations as part of a larger strategy to close breast cancer disparities.

Racial disparities in overall survival after the introduction of cyclin-dependent kinase 4/6 inhibitors for patients with hormone receptor-positive, HER2-negative metastatic breast cancer

PURPOSE

CDK4/6 inhibitors (CDK4/6i) combined with endocrine therapy have improved HR + /HER2- metastatic breast cancer (MBC) outcomes. However, it is still unclear whether the response to CDK4/6i is similar for all races. Therefore, we aimed to assess overall survival (OS) trends stratified by race in patients with HR + /HER2- MBC after the approval of CDK4/6i, as part of the standard of care, in 2015.

METHODS

We performed a population-based study using the SEER database. Patients with HR + /HER2- MBC were divided into two time-based cohorts: 1) pre-CDK4/6i era (diagnosed in 2011-2013) and 2) post-CDK4/6i era (diagnosed in 2015-2017). We used propensity score matching and identified 2,684 patients in each cohort that matched in several characteristics. Kaplan-Meier methods were used to estimate 2-year OS. Association between cohort and OS was evaluated using marginal Cox proportional hazards models with robust sandwich variance estimator. We conducted competing risk analysis to estimate the risk of breast cancer death in both cohorts.

RESULTS

The 2-year OS rate was 65% for the post-CDK4/6i era and 62% for the pre-CDK4/6i era (stratified log-rank p = 0.025). The 2-year OS for non-Hispanic White (NHW) patients improved in the post-CDK4/6i era compared to the pre-CDK4/6i era (67% vs. 63%, p = 0.033). However, OS did not improve for non-Hispanic Black (NHB) (54% vs. 54%, p = 0.876) or Hispanic (67% vs. 65%, p = 0.617) groups. The risk of breast cancer death decreased in the post-CDK4/6i era as compared to the pre-CDK4/6i era (2-year risk of breast cancer death: 33% vs. 30%, p = 0.015); however, this effect was observed only in NHW (sHR 0.84, p = 0.005) women, but not in NHB (sHR 0.94, p = 0.630) or Hispanic (sHR 0.91, p = 0.550) women.

CONCLUSIONS

Our study confirms that outcomes for HR + /HER2- MBC have improved after CDK4/6i were introduced in 2015. However, this effect is primarily driven by the improved OS in NHW patients, without significant improvement in OS in NHB or Hispanics.

Feasibility and acceptability of home-based strength training in endometrial cancer survivors

PURPOSE

Physical activity is important for healthy cancer survivorship, yet many endometrial cancer survivors do not participate in recommended muscle-strengthening activity. The purpose of this study was to determine the feasibility of home-based muscle strengthening activity in endometrial cancer survivors.

METHODS

Forty post-treatment endometrial cancer survivors were enrolled in a randomized trial, of twice-weekly home-based strength exercise versus wait-list control. The intervention included educational materials, exercise equipment (dumbbells, resistance bands), and support/feedback via video coaching sessions. Participants completed the exercises twice per week for 10 weeks, with a 5-week follow-up period. Feasibility was measured by program adherence, as well as safety of and satisfaction with the study.

RESULTS

On average, participants were 60.9 years old (SD = 8.7), had a BMI of 39.9 kg/m2 (SD = 15.2), and were 2.9 years (SD = 1.2) since diagnosis. The majority (83%) had stage I disease at diagnosis. Seventy-five percent adhered to the exercise prescription of twice/week, with 85% of participants missing fewer than 3 of the workouts. Forty percent of participants continued workouts during the 5-week follow-up. Participants were highly satisfied with intervention. No injuries or adverse everts occurred.

CONCLUSION

This home-based program was feasible in endometrial cancer survivors. While adherence was measured, future research should focus on long-term maintenance of exercise and should explore progressions and modifications of exercises at a distance for various abilities.

IMPLICATIONS FOR CANCER SURVIVORS

Muscle strengthening activities are recommended for all cancer survivors. This study shows that a home-based muscle strengthening exercise is feasible in endometrial cancer survivors.

Designing home-based physical activity programs for rural cancer survivors: A survey of technology access and preferences

Background

While technology advances have increased the popularity of remote interventions in underserved and rural cancer communities, less is understood about technology access and preferences for home-based physical activity programs in this cancer survivor population.

Purpose

To determine access, preferences, and needs, for a home-based physical activity program in rural cancer survivors.

Methods

A Qualtrics Research Panel was recruited to survey adults with cancer across the United States. Participants self-reported demographics, cancer characteristics, technology access and usage, and preferences for a home-based physical activity program. The Godin Leisure Time Exercise Questionnaire (GLTEQ) assessed current levels of physical activity. Descriptive statistics included means and standard deviations for continuous variables, and frequencies for categorical variables. Independent samples t-tests explored differences between rural and non-rural participants.

Results

Participants (N=298; mean age=55.2 ± 16.5) had a history of cancer (mean age at diagnosis=46.5), with the most commonly reported cancer type being breast (25.5%), followed by prostate (16.1%). 74.2% resided in rural hometowns. 95% of participants reported accessing the internet daily. On a scale of 0-100, computer/laptop (M=63.4) and mobile phone (M=54.6) were the most preferred delivery modes for a home-based physical activity intervention, and most participants preferred balance/flexibility (72.2%) and aerobic (53.9%) exercises. Desired intervention elements included a frequency of 2-3 times a week (53.5%) for at least 20 minutes (75.7%). While there were notable rural disparities present (e.g., older age at diagnosis, lower levels of education; ps<.001), no differences emerged for technology access or environmental barriers (ps>.08). However, bias due to electronic delivery of the survey should not be discounted.

Conclusion

These findings provide insights into the preferred physical activity intervention (e.g., computer delivery, balance/flexibility exercises) in rural cancer survivors, while highlighting the need for personalization. Future efforts should consider these preferences when designing and delivering home-based interventions in this population.

Population-Based Impact of Rurality and Neighborhood-Level Socioeconomic Disadvantage on Pediatric Cancer Mortality in Washington State

BACKGROUND

Childhood cancer-related mortality differs by socioeconomic factors, but the impact of residential location, including rurality and neighborhood-level socioeconomic disadvantage, is not well-characterized.

METHODS

This retrospective cohort study linked Washington State cancer registry data (1992-2013) to state birth (1974-2013) and death records (1992-2013) to identify residents <20 years diagnosed with cancer (n = 4,306). Census-based rural-urban commuting area codes and Area Deprivation Index (ADI) defined rural residence and neighborhood socioeconomic disadvantage at time of cancer diagnosis, respectively. Neighborhoods in the highest state ADI quintile were classified as the most disadvantaged. Kaplan-Meier estimates and Cox hazards models, adjusted for key characteristics, were used to compare mortality by rural and ADI classification.

RESULTS

Five-year overall survival for children from non-rural low ADI neighborhoods (referent) was 80.9%±0.8%, versus 66.4%±2.9% from non-rural high ADI neighborhoods, 69.4%±3.8% from rural low ADI neighborhoods, and 66.9%±3.8% from rural high ADI neighborhoods (P < 0.01 for each comparison versus referent). Compared with the referent group, children from comparator neighborhoods had a greater mortality risk: Rural low ADI [hazard ratio (HR), 1.50; 95% confidence interval (CI), 1.12-2.02], rural high ADI (HR, 1.53; 95% CI, 1.16-2.01), and non-rural high ADI (HR, 1.64; 95% CI, 1.32-2.04). Associations of ADI and rurality with mortality varied in sub-analyses by cancer type.

CONCLUSIONS

Children with cancer living in rural and/or socioeconomically disadvantaged neighborhoods at diagnosis experienced greater mortality relative to those without either factor.

IMPACT

Future investigation is needed to examine how rurality and poverty potentially impact healthcare utilization and health-related outcomes in pediatric oncology.

Quality of life assessment of breast cancer survivors in Northern Morocco: Rural-urban disparity

This article is a cross-sectional study of 216 women undergoing adjuvant hormone therapy for breast cancer in two oncology centers in northern Morocco. Quality of life (QoL) was assessed using the Functional Assessment of Cancer Therapy (FACT) questionnaire and its endocrine subscale (ES). The relationship between rural-urban status in our sample and QoL was assessed by linear regression analysis using sociodemographic and clinical variables as covariates. Our results show that physical and functional well-being are significantly (p < 0.001) higher in rural areas (24 and 29, respectively) than in urban areas (16 and 19, respectively), while social and emotional well-being are significantly (p < 0.001) higher in urban areas (22 and 21, respectively) than in rural areas (15 and 16, respectively). However, there was no significant difference (p = 0.097) between rural and urban breast cancer survivors regarding endocrine symptom burden. Regarding the effect of sociodemographic and clinical factors on overall HRQOL of breast cancer survivors, hormone type was shown to have a significant effect on overall HRQOL (FACT-ES) of rural and urban breast cancer survivors (𝛽 = +0.849 and 𝛽 = +0.678, respectively). A similar effect was observed for ES (𝛽 = +0.896 and 𝛽 = +0.180, respectively).In contrast, other factors (age, marital status, economic status, menopausal status, type of surgery) did not have a significant effect on HRQOL (FACT-ES) or ES.The study highlighted the need for increased psychosocial supportive care efforts for rural breast cancer survivors to improve their QoL.

Quality of Life of Chilean Breast Cancer Survivors: Multicentric Study

Introduction: As breast cancer survivorship rates increase, so does the necessity to improve survivors’ health-related quality of life (HRQoL). Objective: To analyze HRQoL among Chilean breast cancer survivors, in general and considering geographic location. In addition, to correlate HRQoL with age, education level and body mass index (BMI). Method: Cross-sectional observational study which included 125 female breast cancer survivors from three public hospitals in three Chilean Macroregions: Central, North Central, and South. The EORTC Questionnaires, QLQ-C30 and QLQ-BR23, and sociodemographic and clinical records were applied. Results: The mean age was 56.1 (±11.9) years with a HRQoL summary score of 67.6 (21.9). HRQoL was reduced mainly in emotional functioning, pain, and insomnia. Fatigue, dyspnea, appetite loss, constipation, financial difficulties, breast and arm symptoms were also reported. The women from the South Macroregion Hospital presented the worst HRQoL scores for most of the domains [general health, functioning (physical, emotional, cognitive and social), fatigue, and nausea], p<0.001. The summary score of HRQoL was correlated to age (Spearman´s rho=0.202, p=0.033), BMI (rho=-0.341, p<0.001), and education level (rho=0.310, p=0.001). Conclusion: Women from three Macroregions showed differences in HRQoL. The latter correlated to age, BMI, and education level. Considering the high presence of symptoms, it is necessary to improve survivorship care plans, providing access to rehabilitation in the continuum of care.

Retrenchment of Wisconsin's Well Woman Program and changes in insurance coverage around the Affordable Care Act

Since before the Affordable Care Act (ACA), states have partnered with the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to support access to cancer screening and treatment for uninsured/underinsured women. The Wisconsin Well Woman Program (WWWP) was one such program, supporting low-income women across the state. With ACA introduction, Wisconsin substantially downsized/restructured the WWWP, expecting the reduction in services to be offset by the rise in ACA-provided insurance coverage. This study assesses whether retrenchment in the WWWP following the ACA indeed prompted a differential rise in insurance coverage among the program's target population. We use a difference-in-differences (DID) design to contrast changes in county-level, target-population insurance rates, over 2008-2018, in Wisconsin counties previously most served by the WWWP vs those least served, adjusting for systematic differences across counties, including pre-policy trends. Pre-ACA (2011-2013), most-served counties had lower insurance rates by 2.5 percentage points (pp) than least-served counties; WWWP services likely compensated for some of that gap. In 2014-2015, along with WWWP's steep contraction, insurance rates rose sharply across all counties. Our primary DID analysis and event study suggest that WWWP contraction might have differentially driven more insurance take-up in most-served counties, by 1.88 pp [95 % Confidence Interval: 0.23,3.54], thus narrowing the pre-ACA gap. Sensitivity analyses suggest much smaller gains. Notwithstanding such potential insurance gains following program contraction, continued support for care navigation and coordination remain necessary to truly meet the needs of the vulnerable women previously served by the WWWP and similar programs across states.

Disparities in Breast Cancer Mortality Rates in Israel among Urban and Rural Women

Breast cancer is a leading cause of death. There are a number of risk factors for breast cancer mortality including parity, age, ethnicity, genetic history, and place of residence. This study examined the disparities in breast cancer-related mortality rates among women from urban areas compared to rural areas in Israel. This was a retrospective, follow-up study on mortality from breast cancer among 894,608 Israeli women born between the years of 1940 and 1960. Data was collected from the Israeli Central Bureau of Statistics, the Population Authority, the Education Ministry, and the Health Ministry. Over 80% of women lived in urban areas. A higher incidence of mortality from breast cancer in Israel was found among urban women compared to rural women (1047.8/100,000 compared to 837/100,000, respectively). Even after adjusting for sociodemographic variables, higher mortality rates were found among women from urban areas in Israel compared to women from rural areas in Israel. It is believed that environmental factors can partially explain the geographic variation of breast cancer incidence, and that breast cancer incidence is likely a complex interaction between genetic, environmental, and health factors.

A comparison of survey incentive methods to recruit rural cancer survivors into cancer care delivery research studies

Unconditional (upfront) incentives are proposed to improve acceptance of cancer research among underrepresented, racial/ethnic minority populations, but few studies have tested incentive strategies among rural cancer survivors. Descriptive statistics summarized demographic characteristics of survey respondents, and response rates by arm were compared using Chi-square tests. We compared upfront ($2) and response-based ($10 conditional) incentives in a mailed survey of adult post-treatment rural survivors. Individuals meeting eligibility criteria from the electronic medical record (n = 2,830) were randomized into two incentive arms (n = 1,414 for the upfront arm and n = 1,416 for the contingent arm). Of the total delivered, presumed eligible participants (n = 1,304 upfront arm; n = 1,317 contingent arm), 67.8% were aged 65y+, 49.8% were female, and 95.1% were non-Hispanic white. The response rate for all participants was 18.5%. We received eligible surveys from 281 rural survivors in the first arm (response rate: 21.5%); and 205 surveys in the second arm (response rate: 15.6%). Participants who received the upfront incentive had a higher response rate than those receiving a response-based incentive, X2 (1, 2,621) = 15.53, p < 0.0001. Incentivizing survey completion with an upfront $2 bill encouraged a higher survey response rate; other supplemental strategies are needed to achieve a higher response rate for this population.

From the patient to the population: Use of genomics for population screening

Genomic medicine is expanding from a focus on diagnosis at the patient level to prevention at the population level given the ongoing under-ascertainment of high-risk and actionable genetic conditions using current strategies, particularly hereditary breast and ovarian cancer (HBOC), Lynch Syndrome (LS) and familial hypercholesterolemia (FH). The availability of large-scale next-generation sequencing strategies and preventive options for these conditions makes it increasingly feasible to screen pre-symptomatic individuals through public health-based approaches, rather than restricting testing to high-risk groups. This raises anew, and with urgency, questions about the limits of screening as well as the moral authority and capacity to screen for genetic conditions at a population level. We aimed to answer some of these critical questions by using the WHO Wilson and Jungner criteria to guide a synthesis of current evidence on population genomic screening for HBOC, LS, and FH.

Drivers of racial, regional, and socioeconomic disparities in late-stage breast cancer mortality

BACKGROUND

The authors identified tumor, treatment, and patient characteristics that may contribute to differences in breast cancer (BC) mortality by race, rurality, and area-level socioeconomic status (SES) among women diagnosed with stage IIIB-IV BC in Georgia.

METHODS

Using the Georgia Cancer Registry, 3084 patients with stage IIIB-IV primary BC (2013-2017) were identified. Cox proportional hazards regression was used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) comparing mortality among non-Hispanic Black (NHB) versus non-Hispanic White (NHW), residents of rural versus urban neighborhoods, and residents of low- versus high-SES neighborhoods by tumor, treatment, and patient characteristics. The mediating effects of specific characteristics on the association between race and BC mortality were estimated.

RESULTS

Among the study population, 41% were NHB, 21% resided in rural counties, and 72% resided in low SES neighborhoods. The authors observed mortality disparities by race (HR, 1.27; 95% CI, 1.13, 1.41) and rurality (HR, 1.14; 95% CI, 1.00, 1.30), but not by SES (HR, 1.04; 95% CI, 0.91, 1.19). In the stratified analyses, racial disparities were the most pronounced among women with HER2 overexpressing tumors (HR, 2.30; 95% CI, 1.53, 3.45). Residing in a rural county was associated with increased mortality among uninsured women (HR, 2.25; 95% CI, 1.31, 3.86), and the most pronounced SES disparities were among younger women (<40 years: HR, 1.46; 95% CI, 0.88, 2.42).

CONCLUSIONS

There is considerable variation in racial, regional, and socioeconomic disparities in late-stage BC mortality by tumor, treatment, and patient characteristics.

Risk factors and outcomes of fatal respiratory events after esophageal cancer surgery from 2011 through 2018: a nationwide cohort study in South Korea

BACKGROUND

Pulmonary complications are common after esophageal cancer surgery, but information regarding fatal respiratory events, such as postoperative acute respiratory distress syndrome (ARDS) and respiratory failure, is lacking. We aimed to investigate the prevalence, risk factors, and outcomes of fatal respiratory events after esophageal cancer surgery.

METHODS

We performed a retrospective population-based cohort study based on data from the National Health Insurance Service database in South Korea. All adult patients diagnosed with esophageal cancer who underwent esophageal surgery between January 2011 and December 2018 were included.

RESULTS

A total of 7039 patients were included in the final analysis. Among them, 100 patients (1.4%) experienced fatal respiratory adverse events (ARDS, 55 patients [0.8%]; respiratory failure, 45 patients [0.6%]). On multivariable logistic regression, residence in rural areas (vs. urban areas) at the time of surgery, open thoracotomy (vs. video-assisted thoracoscopic surgery), and lower annual case volume were associated with a higher prevalence of fatal respiratory adverse events. Moreover, postoperative fatal respiratory adverse events were related to increased in-hospital mortality, 1 year mortality, prolonged hospitalization, and increased total hospitalization costs.

CONCLUSION

In South Korea, 1.4% of patients experienced fatal respiratory events (ARDS or respiratory failure) after esophageal cancer surgery. Some factors were revealed as risk factors for fatal respiratory events, and fatal respiratory events worsened clinical outcomes after esophageal cancer surgery.

Regional inequalities of tumour size at diagnosis in Germany: An ecological study in eight federal states

There is growing recognition of the importance of the residential environment for early detection of cancer. However, few studies have investigated area socioeconomic deprivation, social capital, and rurality in combination. Therefore, we aimed to estimate mutually adjusted associations of these characteristics with tumour size at diagnosis in Germany. We included incident cases of female breast cancer, colorectal cancer, malignant melanoma, uterine cancer, and male bladder cancer, collected by the cancer registries of eight German federal states between 2010 and 2014. Using information on T status, we defined an advanced tumour size for each cancer type. Sex-specific mutually adjusted associations of area socioeconomic deprivation, social capital, and rurality with advanced tumour size and variance partition coefficients were estimated in multilevel logistic regression. Missing data of the outcome were addressed by multiple imputation. Overall, 386,223 cases were included in this analysis. High area socioeconomic deprivation was associated with advanced tumour size at diagnosis of colorectal cancer and malignant melanoma. For malignant melanoma, low social capital was associated with an advanced tumour size among females and males, while a rural settlement structure was associated with advanced tumour size among males only. Since meaningful general contextual effects were found for malignant melanoma, our results underscore that the context of an area is an important predictor of melanoma tumour size. Secondary prevention programs for this cancer type should target areas with high area socioeconomic deprivation, low social capital, and a rural settlement structure in order to reach those most vulnerable.

Impact of socioeconomic status and rurality on cancer-specific survival among women with de novo metastatic breast cancer by race/ethnicity

PURPOSE

There are approximately 150,000 women living with metastatic breast cancer (mBC) in the United States. Disparities in de novo mBC incidence and mortality exist across race/ethnicity, socioeconomic status (SES), and rurality. However, how SES and rurality independently impact mBC outcomes across different racial/ethnic groups is not fully understood. The purpose of this study was to determine the impact of SES and rurality on cancer-specific mortality among women with mBC by race/ethnicity.

METHODS

We conducted a large, population-based retrospective cohort study in women aged 18 + years diagnosed with de novo mBC using the Surveillance, Epidemiology and End Results Census Tract-level SES and Rurality Database (2000-2015). Associations between SES/rurality and cancer-specific mortality were determined using Fine and Gray regression models. Subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) by race/ethnicity and hormone receptor (HR) status were calculated.

RESULTS

A cohort of 33,976 women were included with the majority being White (67%), 17% Black, 0.4% American Indian/Alaskan Native, 6% Asian/Pacific Islander, and 10% Latina/Hispanic. We observed the greatest increased risk of BC mortality among Black women with HR-negative mBC residing in neighborhoods with lower SES (lowest versus highest quintile: SHR 1.38, 95% CI 1.00-1.90) and in rural areas compared to urban areas (SHR 1.27, 95% CI 1.01-1.59).

CONCLUSION

Overall, BC-specific survival among women with de novo mBC differs by race/ethnicity, with the greatest adverse impacts of SES and rurality affecting Black women with HR-negative disease.

Did Medicaid Expansion Mitigate Disparities in Post-mastectomy Reconstruction Rates?

Background

Patient and socioeconomic factors both contribute to disparities in post-mastectomy reconstruction (PMR) rates. We sought to explore PMR patterns across the US and to determine if PMR rates were associated with Medicaid expansion.

Methods

The NCDB was used to identify women who underwent PMR between 2004-2016. The data was stratified by race, state Medicaid expansion status, and region. A multivariate model was fit to determine the association between Medicaid expansion and receipt of PMR.

Results

In comparison to Caucasian women receiving PMR in Medicaid expansion states, African American (AA) women in Medicaid expansion states were less likely to receive PMR (OR .96 [.92-1.00] P < .001). Patients in the Northeast (NE) had better PMR rates vs any other region in the US, for both Caucasian and AA women (Caucasian NE ref, Caucasian-South .80 [.77-.83] vs AA NE 1.11 [1.04-1.19], AA-South (.60 [.58-.63], P < .001). Interestingly, AA patients residing in the NE had the highest receipt of PMR 1.11 (1.04-1.19), even higher than their Caucasian counterparts residing in the same region (ref). Rural AA women had the lowest rates of PMR vs rural Caucasian women (.40 [.28-.58] vs .79 [.73-.85], P < .001].

Discussion

Racial disparities in PMR rates persisted despite Medicaid expansion. When stratified by region, however, AA patients in the NE had higher rates of PMR than AA women in other regions. The largest disparities were seen in AA women in the rural US. Breast cancer disparities continue to be a complex problem that was not entirely mitigated by improved insurance coverage.

Rural-Urban Differences in Breast Cancer Stage at Diagnosis

Purpose: To analyze the extent to which rural-urban differences in breast cancer stage at diagnosis are explained by factors including age, race, tumor grade, receptor status, and insurance status.

Methods: Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) 18 database, analysis was performed using data from women aged 50–74 diagnosed with breast cancer between the years 2013 and 2016. Patient rurality of residence was coded according to SEER's Rural-Urban Continuum Code 2013: Large Urban (RUCC 1), Small Urban (RUCC 2,3), and Rural (RUCC 4,5,6,7,8,9). Stage at diagnosis was coded according to SEER's Combined Summary Stage 2000 (2004+) criteria: Localized (0,1), Regional (2,3,4,5), and Distant (7). Descriptive statistics were analyzed, and variations were tested for across rural-urban categories using Kruskall–Wallis and Kendall's tau-b tests. Additionally, odds ratios (ORs) and 95% confidence intervals for the three ordinal levels of rural-urban residence were calculated while adjusting for other independent variables using ordinal logistic regression.

Results: The rural residence category showed the largest proportion of women diagnosed with distant stage breast cancer. Additionally, we determined that patients with residence in both large and small urban areas had statistically significantly lower odds of higher stage diagnosis compared to rural patients even after controlling for age, race, tumor grade, receptor status, and insurance status.

Conclusions: Rural women with breast cancer show small but statistically significant disparities in stage-at-diagnosis. Further research is needed to understand local area variation in these disparities across a wide range of rural communities, and to identify the most effective interventions to eliminate these disparities.

Phenotype Discovery and Geographic Disparities of Late-Stage Breast Cancer Diagnosis across U.S. Counties: A Machine Learning Approach

BACKGROUND

Disparities in the stage at diagnosis for breast cancer have been independently associated with various contextual characteristics. Understanding which combinations of these characteristics indicate highest risk, and where they are located, is critical to targeting interventions and improving outcomes for patients with breast cancer.

METHODS

The study included women diagnosed with invasive breast cancer between 2009 and 2018 from 680 U.S. counties participating in the Surveillance, Epidemiology, and End Results program. We used a machine learning approach called Classification and Regression Tree (CART) to identify county "phenotypes," combinations of characteristics that predict the percentage of patients with breast cancer presenting with late-stage disease. We then mapped the phenotypes and compared their geographic distributions. These findings were further validated using an alternate machine learning approach called random forest.

RESULTS

We discovered seven phenotypes of late-stage breast cancer. Common to most phenotypes associated with high risk of late-stage diagnosis were high uninsured rate, low mammography use, high area deprivation, rurality, and high poverty. Geographically, these phenotypes were most prevalent in southern and western states, while phenotypes associated with lower percentages of late-stage diagnosis were most prevalent in the northeastern states and select metropolitan areas.

CONCLUSIONS

The use of machine learning methods of CART and random forest together with geographic methods offers a promising avenue for future disparities research.

IMPACT

Local interventions to reduce late-stage breast cancer diagnosis, such as community education and outreach programs, can use machine learning and geographic modeling approaches to tailor strategies for early detection and resource allocation.

Developing an Academic and Community Practice Collaborative Care Model for Metastatic Breast Cancer Care: A Protocol using the Dynamic Adaptation Process (Preprint)

Background

Metastatic breast cancer (MBC) remains incurable despite significant treatment advances. Coordinating care for patients with MBC can be challenging given the various treatment options, available clinical trials, and frequent need for ancillary services. To optimize MBC care, we designed a project for adapting and developing an academic and community practice collaborative care model for MBC care (Project ADAPT), based on the Ending Metastatic Breast Cancer for Everyone (EMBRACE) program developed at Dana Farber Cancer Institute.

Objective

We aim to describe the implementation science–based study design and innovative components of Project ADAPT.

Methods

Project ADAPT uses the Dynamic Adaptation Process informed by the Exploration, Preparation, Implementation, Sustainment framework. Washington University School of Medicine (WUSM) partnered with 3 community hospitals in the St. Louis region covering rural and urban settings. The exploration and preparation phases provide patient and provider feedback on current referral practices to finalize the approach for the implementation phase. At the implementation phase, we will enroll patients with MBC at these 3 community sites to evaluate potential collaborative care at WUSM and assess the impact of this collaborative care model on referral satisfaction and acceptability for patients with MBC and their providers. Patients may then return to their community site for care or continue to receive part of their care at WUSM. We are incorporating virtual and digital health strategies to improve MBC care coordination in order to minimize patient burden.

Results

The exploration phase is ongoing. As of August 2021, we have recruited 21 patient and provider participants to complete surveys of the current collaborative care process at WUSM. Using a 2-tailed paired t test, 44 patients (including 10 patients from the exploration phase) and 32 oncologists are required to detect an effect size of 0.5 with 80% power at a level of significance of .05. Throughout this phase and in preparation for the implementation phase, we have iteratively updated and refined our surveys for the implementation phase based on testing of our data collection instruments. Our partner sites are in various stages of the single institutional review board (IRB) approval process. We have ongoing engagement with all partner sites, which has helped solidify our participant recruitment strategies and design patient-friendly recruitment materials. In addition, we have included a patient advocate on the research team. Members of the research team have launched a single IRB Support Network at WUSM to create a repository of the single IRB procedures in order to streamline the partner site onboarding process and facilitate enhanced collaboration across institutions.

Conclusions

With this robust model, we expect that patients with MBC will receive optimal care regardless of geographical location and the model will improve patient and provider experiences when navigating the health system.

International Registered Report Identifier (IRRID)

DERR1-10.2196/35736

Trends in breast cancer incidence rates by race/ethnicity: Patterns by stage, socioeconomic position, and geography in the United States, 1999-2017

BACKGROUND

The incidence rate of breast cancer has been increasing over time across race/ethnicity in the United States. It is unclear whether these trends differ among stage, poverty, and geography subgroups.

METHODS

Using data from the North American Association of Central Cancer Registries, this study estimated trends in age-adjusted breast cancer incidence rates among women aged 50 to 84 years from 1999 to 2017 by race/ethnicity (non-Hispanic Black, non-Hispanic White, and Hispanic) and across subgroups (stage, county-level poverty, county urban/rural status, and geographic region [West, Midwest, South, and Northeast]).

RESULTS

From 2004 to 2017, breast cancer incidence rates increased across race/ethnicity and subgroups, with the greatest average annual percent increases observed for non-Hispanic Black women, overall (0.9%) and those living in lower poverty areas (0.8%), rural areas (1.2%), and all regions except the West (0.8%-1.0%). Stronger increases among non-Hispanic Black women were observed for local-stage disease and for some subgroups of distant-stage disease. Non-Hispanic Black women had the smallest decrease in regional-stage disease across most subgroups. Similarly, Hispanic women had the strongest increases in some subgroups, including areas with higher poverty (0.6%-1.2%) and in the West (0.8%), for local- and distant-stage disease.

CONCLUSIONS

These trends highlight concerns for an increasing burden of breast cancer among subpopulations, with some already experiencing disparate breast cancer mortality rates, and they highlight the need for targeted breast cancer prevention and efforts to reduce mortality disparities in areas with increasing incidence.

Identifying key barriers to effective breast cancer control in rural settings

Breast cancer is the most common cancer and the second most common cause of cancer mortality among women in the United States. Efforts to promote breast cancer control in rural settings face specific challenges. Access to breast cancer screening, diagnosis, and treatment services is impaired by shortages of primary care and specialist providers, and geographic distance from medical facilities. Women in rural areas have comparable breast cancer mortality rates compared to women in urban settings, but this is due in large part to lower incidence rates and masks a substantial rural/urban disparity in breast cancer survival among women diagnosed with breast cancer. Mammography screening utilization rates are slightly lower among rural women than their urban counterparts, with a corresponding increase in late stage breast cancer. Differences in breast cancer survival persist after controlling for stage at diagnosis, largely due to disparities in access to treatment. Travel distance to treatment centers is the most substantial barrier to improved breast cancer outcomes in rural areas. While numerous interventions have been demonstrated in controlled studies to be effective in promoting treatment access and adherence, widespread dissemination in public health and clinical practice remains lacking. Efforts to improve breast cancer control in rural areas should focus on implementation strategies for improving access to breast cancer treatments.

Rural Cancer Disparities: Understanding Implications for Breast and Cervical Cancer Diagnoses

BACKGROUND

Rural populations experience several disparities, influenced by structural-, community-, and individual-level barriers, across the breast and cervical cancer continuum.

OBJECTIVES

This study seeks to identify structural-, community-, and individual-level barriers that affect rural populations across the cancer continuum, understand the role of nurses serving rural populations in breast and cervical cancer screening and diagnostics, and provide recommendations for working with rural patients.

METHODS

This is a secondary analysis of qualitative interviews conducted with public health nurses serving rural populations.

FINDINGS

Emergent themes indicate that rural populations experience barriers that affect disparities across the breast and cervical cancer continuum, including a changing healthcare landscape, access to cancer-focused care, access to insurance, collective poverty, and demographic factors. Nurses working with rural communities can address these disparities as they fulfill multiple roles and responsibilities.

Tracing the potential of networks to improve community cancer care: an in-depth single case study

Background

Despite overall declines in cancer mortality in the USA over the past three decades, many patients in community settings fail to receive evidence-based cancer care. Networks that link academic medical centers (AMCs) and community providers may reduce disparities by creating access to specialized expertise and care, but research on network effectiveness is mixed. The objective of this study was to identify factors related to whether and how an exemplar AMC network served to provide advice and referral access in community settings.

Methods

An embedded in–depth single case study design was employed to study a network in the Midwest USA that connects a leading cancer specialty AMC with community practices. The embedded case units were a subset of 20 patients with young-onset colorectal cancer or risk-related conditions and the providers involved in their care. The electronic health record (EHR) was reviewed from January 1, 1990, to February 28, 2018. Social network analysis identified care, advice, and referral relationships. Within-case process tracing provided detailed accounts of whether and how the network provided access to expert, evidence-based care or advice in order to identify factors related to network effectiveness.

Results

The network created access to evidence-based advice or care in some but not all case units, and there was variability in whether and how community providers engaged the network, including the path for referrals to the AMC and the way in which advice about an evidence-based approach to care was communicated from AMC specialists to community providers. Factors related to instances when the network functioned as intended included opportunities for both rich and lean communication between community providers and specialists, coordinated referrals, and efficient and adequately utilized documentation systems.

Conclusions

Network existence alone is insufficient to open up access to evidence-based expertise or care for patients in community settings. In-depth understanding of how this network operated provides insight into factors that support or inhibit the potential of networks to minimize disparities in access to evidence-based community cancer care, including both personal and organizational factors.

Exploring the influence of rural residence on uptake of organized cancer screening - A systematic review of international literature

Lower screening uptake could impact cancer survival in rural areas. This systematic review sought studies comparing rural/urban uptake of colorectal, cervical and breast cancer screening in high income countries. Relevant studies (n = 50) were identified systematically by searching Medline, EMBASE and CINAHL. Narrative synthesis found that screening uptake for all three cancers was generally lower in rural areas. In meta-analysis, colorectal cancer screening uptake (OR 0.66, 95 % CI = 0.50-0.87, I² = 85 %) was significantly lower for rural dwellers than their urban counterparts. The meta-analysis found no relationship between uptake of breast cancer screening and rural versus urban residency (OR 0.93, 95 % CI = 0.80-1.09, I² = 86 %). However, it is important to note the limitation of the significant statistical heterogeneity found which demonstrates the lack of consistency between the few studies eligible for inclusion in the meta-analyses. Cancer screening uptake is apparently lower for rural dwellers which may contribute to poorer survival. National screening programmes should consider geography in planning.

Improving the quality of breast ultrasound examination performed by inexperienced ultrasound doctors with synchronous tele-ultrasound: a prospective, parallel controlled trial

PURPOSE

This prospective study explored the value of synchronous tele-ultrasound (US) to aid doctors inexperienced in US with breast US examinations.

METHODS

In total, 99 patients were enrolled. Two trainee doctors who were inexperienced in US (trainee A [TA] and trainee B [TB]) and one doctor who was an expert in US completed the US examinations sequentially. TA completed the US examinations independently, while TB was instructed by the expert using synchronous tele-US. Subsequently, the expert performed on-site US examinations in person. Separately, they selected the most clinically significant nodule as the target nodule. Consistency with the expert and image quality were compared between TA and TB to evaluate tele-US. Furthermore, TB and the patients evaluated tele-US through questionnaires.

RESULTS

TB demonstrated higher consistency with the expert in terms of target nodule selection than TA (93.3% vs. 63.3%, P<0.001). TB achieved good inter-observer agreement (>0.75) with the expert on five US features (5/9, 55.6%), while TA only did so for one (1/9, 11.1%) (P=0.046). TB's image quality was higher than TA's in gray value, time gain compensation, depth, color Doppler adjustment, and the visibility of key information (P=0.018, P<0.001, P<0.001, P=0.033, and P=0.006, respectively). The comprehensive assessment score was higher for TB than for TA (3.96±0.82 vs. 3.09±0.87, P<0.001). Tele-US was helpful in 69.7% of US examinations and had a training effect in 68.0%. Furthermore, 63.6% of patients accepted tele-US and 60.6% were willing to pay.

CONCLUSION

Tele-US can help doctors inexperienced in US to perform breast US examinations.