Breast cancer mortality in Appalachia: reversing patterns of disparity over time

Differences in Distress Between Rural and Non-rural Appalachian Breast Cancer Patient/Caregiver Dyads During the First Year of Treatment

Introduction

Breast cancer patients and their caregivers living in rural Appalachia face substantial health disparities compared to their non-rural Appalachian counterparts. However, there is limited research on how these specific health disparities in rural Appalachian communities may impact patient psychological distress and caregiver strain during the first year of breast cancer treatment.

Purpose

The purpose of the current study was to assess differences in patient psychological distress (depression and anxiety) and caregiver strain between rural non-rural Appalachian breast-cancer-affected dyads (patients and their caregivers) during the first year of treatment.

Methods

A total of 48 Appalachian breast cancer patients (with a Stage I through Stage III diagnosis) and their identified caregiver (together, 'dyads') were identified from The University of Tennessee Medical Center across 2019 to 2020. Dyads completed follow-up surveys throughout the first year of treatment. In this prospective pilot study, measures on anxiety, depression and caregiver strain were self-reported and then analyzed using RM-ANOVA.

Results

There was a statistically significant higher number of reports of patient depression and caregiver strain in rural-residing dyads compared to non-rural-residing dyads. However, there was not a statistically significant difference between rural and non-rural Appalachian dyads for patient-reported anxiety during the first year of treatment.

Implications

The higher reported patient depression and caregiver strain among rural-residing Appalachian patients may indicate the need for implementing remote (e.g., telehealth) Cognitive Behavioral Therapy (CBT) to address the psychological needs of rural-residing dyads. Additionally, greater education from physicians to rural dyads on what to expect during treatment could alleviate caregiver strain.

Relationship quality and psychophysiological distress for underserved breast cancer patients and their caregiver before treatment

OBJECTIVE

Breast cancer patients and caregivers experience biobehavioral reactivity (e.g., depression, anxiety, pain, fatigue) during breast cancer treatment which predicts cancer recurrence and mortality. High quality patient-caregiver relationships can mitigate this distress during treatment, but this association is unclear pre-treatment. Identifying early interventions that target high risk Appalachian patients could impact biobehavioral reactivity.

METHODS

We recruited 55 breast cancer patient-caregiver dyads to complete a self-report survey after diagnosis but before treatment. We used a series of Actor-Partner Interdependence Models to test the hypotheses that both patient and caregiver relationship quality would be linked to their own and their partners' biobehavioral reactivity.

RESULTS

Caregiver reported marital quality lower caregiver anxiety, patient anxiety, caregiver depression, patient depression, caregiver pain, and caregiver fatigue. Interestingly, patient-reported marital quality was linked with higher caregiver anxiety, higher patient anxiety, lower patient depression, and lower patient pain. Patients reported family quality was linked to lower patient and caregiver pain.

CONCLUSIONS

This study demonstrates that pre-treatment marital and family quality levels are directly related to psychophysiological measures in both the caregiver and the patient, though sometimes in unexpected directions. Additionally, our findings potentially reveal an opportunity to intervene at the time of diagnosis to improve relationship quality, impacting patient and caregiver psychophysiological outcomes.

Sociodemographic Factors and Health Insurance Coverage Are Associated with Invasive Breast Cancer in Tennessee: Appalachian and Non-Appalachian County Comparison

Background:

Tennessean women experience the 12th highest breast cancer (BC) mortality in the United States. Yet, few studies have examined BC outcomes among Tennessean women in and outside of Appalachia. We examined whether sociodemographic factors and health insurance status were associated with invasive BC in Tennessee by Appalachian and non-Appalachian county designation.

Materials and Methods:

Using the Tennessee Cancer Registry, we identified 52,187 women, aged ≥18, diagnosed with BC between 2005 and 2015. Multivariable logistic regression was performed to examine associations between invasive BC and sociodemographic characteristics, health insurance coverage, and county designation (Appalachian/non-Appalachian). Regression analyses stratified by county designation were subsequently performed.

Results:

In Tennessee, younger women had lower odds of invasive BC diagnosis (<45: odds ratio [OR] = 0.74, 95% confidence interval [CI] = 0.67–0.81; 55–64: OR = 0.91, 95% CI = 0.84–0.97) compared to women ≥65. Married Tennessean women had 12% (95% CI = 1.04–1.21) higher odds of invasive BC than single women. Further, both public (OR = 1.81, 95% CI = 1.41–2.33) and private (OR = 1.36, 95% CI = 1.06–1.76) health insurance were found to increase odds of invasive BC compared to no insurance/self-pay. Results from the subpopulation analyses were largely consistent with overall findings. In Appalachian counties, women on public health insurance had increased odds (OR = 1.42, 95% CI = 1.00–2.03) of invasive BC compared to uninsured/self-pay women, while in non-Appalachian counties, women insured both publicly (OR = 2.25, 95% CI = 1.57–3.24) and privately (OR = 1.68, 95% CI = 1.16–2.24) had increased odds of invasive BC.

Conclusions:

The results identify risk factors for Tennessean women in Appalachian and non-Appalachian counties whose malignancies evaded early detection, increasing risk of mortality.

Assessing health disparities in breast cancer incidence burden in Tennessee: geospatial analysis

Background

Tennessee women experience the 12th highest breast cancer mortality in the United States. We examined the geographic differences in breast cancer incidence in Tennessee between Appalachian and non-Appalachian counties from 2005 to 2015.

Methods

We used ArcGIS 10.7 geospatial analysis and logistic regression on the Tennessee Cancer Registry incidence data for adult women aged ≥ 18 years (N = 59,287) who were diagnosed with breast cancer from 2005 to 2015 to evaluate distribution patterns by Appalachian county designation. The Tennessee Cancer Registry is a population-based, central cancer registry serving the citizens of Tennessee and was established by Tennessee law to collect and monitor cancer incidence. The main outcome was breast cancer stage at diagnosis. Independent variables were age, race, marital status, type of health insurance, and county of residence.

Results

Majority of the sample were White (85.5%), married (58.6%), aged ≥ 70 (31.3%) and diagnosed with an early stage breast cancer (69.6%). More than half of the women had public health insurance (54.2%), followed by private health insurance coverage (44.4%). Over half of the women resided in non-Appalachian counties, whereas 47.6% were in the Appalachian counties. We observed a significant association among breast cancer patients with respect to marital status and type of health insurance coverage (p =  < 0.0001). While the logistic regression did not show a significant result between county of residence and breast cancer incidence, the spatial analysis revealed geographic differences between Appalachian and non-Appalachian counties. The highest incidence rates of 997.49–1164.59/100,000 were reported in 6 Appalachian counties (Anderson, Blount, Knox, Rhea, Roane, and Van Buren) compared to 3 non-Appalachian counties (Fayette, Marshall, and Williamson).

Conclusions

There is a need to expand resources in Appalachian Tennessee to enhance breast cancer screening and early detection. Using geospatial techniques can further elucidate disparities that may be overlooked in conventional linear analyses to improve women’s cancer health and associated outcomes.

Cancer screening utilization by residence and sexual orientation

PURPOSE

Although few studies have examined screening uptake among sexual minorities (lesbian, gay, bisexual, queer), almost none have examined it in the specific context of rural populations. Therefore, our objective was to assess how cancer screening utilization varies by residence and sexual orientation.

METHODS

Publicly available population-level data from the 2014 and 2016 Behavioral Risk Factor Surveillance System were utilized. Study outcomes included recommended recent receipt of breast, cervical, and colorectal cancer screening. Independent variables of interest were residence (rural/urban) and sexual orientation (heterosexual/gay or lesbian/bisexual). Weighted proportions and multivariable logistic regressions were used to assess the association between the independent variables and the outcomes, adjusting for demographic, socioeconomic, and healthcare utilization factors.

RESULTS

Rates for all three cancer screenings were lowest in rural areas and among sexual minority populations (cervical: rural lesbians at 64.8% vs. urban heterosexual at 84.6%; breast: rural lesbians at 66.8% vs. urban heterosexual at 80.0%; colorectal for males: rural bisexuals at 52.4% vs. urban bisexuals at 81.3%; and colorectal for females: rural heterosexuals at 67.2% vs. rural lesbians at 74.4%). In the multivariate analyses for colorectal screening, compared to urban heterosexual males, both rural gay and rural heterosexual males were less likely to receive screening (aOR = 0.45; 95% = 0.24-0.73 and aOR = 0.79; 95% = 0.72-0.87, respectively) as were rural heterosexual females (aOR = 0.87; 95% = 0.80-0.94) compared to urban heterosexual females. For cervical screening, lesbians were less likely to receive screening (aOR = 0.62; 95% = 0.41-0.94) than heterosexuals, and there were no differences for breast screening.

CONCLUSION

We found that rural sexual minorities may experience disparities in cancer screening utilization associated with the compounding barriers of rural residence and sexual minority status, after adjusting for demographic, socioeconomic, and healthcare utilization factors. Further work is needed to identify factors influencing these disparities and how they might be addressed.

Postmastectomy Radiotherapy: Barriers to Implementation in a Disparate Population

Appalachian Kentucky (AK) has a disproportionally high breast cancer mortality rate. Postmastectomy radiotherapy (PMRT) in N2/N3 nodal disease improves survival and locoregional recurrence. We evaluated Kentucky patient compliance to the quality measure of PMRT received within one year of diagnosis. A population-based retrospective review of patients who received mastectomy with N2/N3 nodal disease from 2006 to 2015 was obtained through the Kentucky Cancer Registry. A total of 1489 patients met the inclusion criteria. Of these, 1104 (66.6%) received PMRT. AK patients were less likely to receive PMRT (58.3%) than non-AK patients (70%, P < 0.001). After adjusting for significant factors, private insurance, education level, treatment center, and receipt of adjuvant chemotherapy were independently associated with PMRT compliance. Patients who received PMRT had improved overall survival (OS, P < 0.0001) and disease-free survival (DFS, P < 0.0001). Appalachian status was not a major factor in OS ( P = 0.1929) or DFS ( P = 0.5840). Nearly two decades after the recommendation of PMRT, compliance remains poor in Kentucky. PMRT continues to be a major factor in survival and recurrence in this population. Interventions focusing on improving insurance coverage, education level, and guideline adherence in nonacademic centers are needed to improve compliance.

Investigating confounders of the association between survival and adjuvant radiation therapy after breast conserving surgery in a sample of elderly breast Cancer patients in Appalachia

Background

To explain the association between adjuvant radiation therapy after breast conserving surgery (BCS RT) and overall survival (OS) by quantifying bias due to confounding in a sample of elderly breast cancer beneficiaries in a multi-state region of Appalachia.

Methods

We used Medicare claims linked registry data for fee-for-service beneficiaries with AJCC stage I-III, treated with BCS, and diagnosed from 2006 to 2008 in Appalachian counties of Kentucky, Ohio, North Carolina, and Pennsylvania. Confounders of BCS RT included age, rurality, regional SES, access to radiation facilities, marital status, Charlson comorbidity, Medicaid dual status, institutionalization, tumor characteristics, and surgical facility characteristics. Adjusted percent change in expected survival by BCS RT was examined using Accelerated Failure Time (AFT) models. Confounding bias was assessed by comparing effects between adjusted and partially adjusted associations using a fully specified structural model.

Results

The final sample had 2675 beneficiaries with mean age of 75, with 81% 5-year survival from diagnosis. Unadjusted percentage increase in expected survival was 2.75 times greater in the RT group vs. non-RT group, with 5-year survival of 85% vs 60%; fully adjusted percentage increase was 1.70 times greater, with 5-year rates of 83% vs 71%. Quantification of incremental confounding showed age accounted for 71% of the effect reduction, followed by tumor features (12%), comorbidity (10%), dual status(10%), and institutionalization (8%). Adjusting for age and tumor features only resulted in only 4% bias from fully adjusted percent change (70% change vs 66%).

Conclusion

Quantification of confounding aids in determining covariates to adjust for and in interpreting raw associations. Substantial confounding was present (60% of total association), with age accounting for the largest share (71%); adjusting for age plus tumor features corrected for most of the confounding (4% bias). The direct effect of BCS RT on OS accounted for 40% of the total association.

Glioblastoma Survival Outcomes at a Tertiary Hospital in Appalachia: Factors Impacting the Survival of Patients Following Implementation of the Stupp Protocol

BACKGROUND

Glioblastoma is a fatal brain cancer with low median and yearly survival rates. Standard of care for treating glioblastoma is gross total resection (GTR) coupled with the Stupp protocol, but various factors influence the interventions undertaken and survival achieved. As health disparities exist in rural areas, survival in these areas needs to be assessed to understand which factors detract from the successes of these standard medical interventions.

METHODS

We retrospectively determined impact of age at diagnosis, number of lesions, the molecular marker O⁶-methylguanine methyltransferase (MGMT), extent of surgery, and completion of the Stupp protocol on survival in patients treated at West Virginia University Hospitals. We also compared our findings with a pre-Stupp protocol study done in West Virginia in 1996.

RESULTS

Age <60 years at diagnosis, having the MGMT gene methylated, having a unifocal tumor, receiving GTR, adhering to the Stupp protocol, and undergoing a treatment course of GTR followed by the Stupp protocol significantly increased survival. Comparison with the 1996 study showed that although overall median survival has not increased, all interventions involving GTR have resulted in a significantly higher survival.

CONCLUSIONS

We can serve our patient population by offering GTR to all adult patients with glioblastoma when no contraindications exist and ensuring that patients follow the Stupp protocol. After discharge, the Stupp protocol may not be followed or completed for a variety of reasons. In the future, we aim to assess these reasons and analyze other significant interventional and socioeconomic factors that influence survival.

Lay Epistemology of Breast Cancer Screening Guidelines Among Appalachian Women

Recent changes to the U.S. Preventive Services Task Force guidelines for breast cancer screening have contributed to increased patient uncertainty regarding the timing and appropriateness of screening behaviors. To gain insight into the lay epistemology of women regarding breast cancer screening practices, we conducted in-depth, face-to-face interviews with 24 adult women living in a medically underserved Appalachian region. We found that women were unaware of breast cancer screening guidelines (i.e., start age, frequency, stop age). Qualitative analysis revealed two lay epistemological narratives establishing (a) uncertain knowledge and ambiguity about breast cancer screening guidelines but certain knowledge of other women's experiences with breast cancer diagnoses, and (b) feelings of knowing one's own body best and seeing the value in "overscreening" to save even one life. Our findings have theoretical and practical implications for scholars and practitioners seeking to improve knowledge or behavior regarding adherence to breast cancer screening recommendations.

Rural Family Perspectives and Experiences with Early Infant Hearing Detection and Intervention: A Qualitative Study

Infant hearing loss has the potential to cause significant communication impairment. Timely diagnosis and intervention is essential to preventing permanent deficits. Many infants from rural regions are delayed in diagnosis and treatment of hearing loss. The purpose of this study is to characterize the barriers in timely infant hearing healthcare for rural families following newborn newborn hearing screening (NHS) testing. Using stratified purposeful sampling, the study design involved semi-structured phone interviews with parents/guardians of children who failed NHS testing in the Appalachian region of Kentucky between 2012 and 2014 to describe their experiences with early hearing detection and intervention program. Thematic qualitative analysis was performed on interview transcripts to identify common recurring themes in content. 40 parents/guardians participated in the study and consisted primarily of mothers. Demographic data revealed limited educational levels of the participants and 70 % had state-funded insurance coverage. Participants reported barriers in timely infant hearing healthcare that included poor communication of hearing screening results, difficulty in obtaining outpatient testing, inconsistencies in healthcare information from primary care providers, lack of local resources, insurance-related healthcare delays, and conflict with family and work responsibilities. Most participants expressed a great desire to obtain timely hearing healthcare for their children and expressed a willingness to use resources such as telemedicine to obtain that care. There are multiple barriers to timely rural infant hearing healthcare. Minimizing misinformation and improving access to care are priorities to prevent delayed diagnosis and treatment of hearing loss.

Geographic disparities in adherence to adjuvant endocrine therapy in Appalachian women with breast cancer

BACKGROUND

Appalachia is a largely rural, mountainous, poor and underserved region of the United States. Adherence to adjuvant endocrine therapy among Appalachian women with breast cancer is suboptimal.

OBJECTIVES

To explore small-area geographic variations and clustering patterns of breast cancer patient adherence to adjuvant endocrine therapy and associated factors in Appalachia.

METHODS

In this retrospective study, we analyzed Medicare claims data linked with cancer registries from four Appalachian states (PA, OH, KY, and NC) in 2006-2008. We included adult women who were diagnosed with stage I-III, hormone-receptor positive, primary breast cancer and who newly started adjuvant endocrine therapy after the primary treatment for breast cancer. Hot spot analysis was conducted to explore geographic variations in adjuvant endocrine therapy adherence. Geographically weighted logistic regression (GWLR) was used to examine whether the impacts of factors associated with adherence varied across the region.

RESULTS

Breast cancer patients living in PA and OH showed higher adherence to adjuvant endocrine therapy than those living in KY and NC. We identified clusters of high adherence in most of PA but poor adherence in Erie County, PA and in Buncombe, Transylvania, Henderson, and Polk Counties, NC. Adherence to adjuvant endocrine therapy was significantly associated with the Health Professional Shortage Area designation, catastrophic coverage, dual-eligibility status of Medicaid and Medicare, adjuvant endocrine therapy drug class, and side effects. And among these factors, the impacts of dual-eligibility status and the use of pain medications to treat side effects on adherence were more pronounced in KY and NC than in PA.

CONCLUSIONS

There were significant geographic disparities in adherence to adjuvant endocrine therapy in the Appalachian counties in PA, OH, KY, and NC. This study explored these geographic areas with poor adherence as well as geographically varying effects of predictors on adherence; our results may provide more localized information that may be used to improve adjuvant therapy use and breast cancer care in these high-risk and underserved areas.

Adherence to Multiple Cancer Screening Tests among Women Living in Appalachia Ohio

BACKGROUND

There is a lack of information about the correlates of completing all three cancer screening tests among women living in Appalachia.

METHODS

Cross-sectional telephone interviews were conducted (April-September 2013) among women (n = 637) ages 51 to 75 years from 12 Appalachia Ohio counties. Outcomes of within screening guidelines were verified by medical records. Multivariable logistic regression models identified correlates of being within guidelines for all three cancer screening tests.

RESULTS

Screening rates included mammography (32.1%), Pap test (36.1%), and a colorectal cancer test (30.1%). Only 8.6% of women were within guidelines for all tests. Having had a check-up in the past 2 years and having received a screening recommendation were significantly related to being within guidelines for all three tests (P < 0.01). Participants with higher annual household incomes [$60,000+; OR, 3.53; 95% confidence interval (CI), 1.49-8.33] and conditions requiring regular medical visits (OR, 3.16; 95% CI, 1.29-7.74) were more likely to be within guidelines for all three screening tests.

CONCLUSION

Less than 10% of women had completed screening within guidelines for all three screening tests. Regular contact with the health care system and higher incomes were significant predictors of being within guidelines.

IMPACT

Within guidelines rates for the three recommended cancer screening tests are low among women in Appalachia Ohio. This finding illustrates the need for innovative interventions to improve rates of multiple cancer screening tests.

Receiver operating characteristic curve analysis of SEER medulloblastoma and primitive neuroectodermal tumor (PNET) outcome data: identification and optimization of predictive models

PURPOSE

This study used receiver operating characteristic curves to analyze Surveillance, Epidemiology and End RESULTS (SEER) medulloblastoma (MB) and primitive neuroectodermal tumor (PNET) outcome data. The aim of this study was to identify and optimize predictive outcome models.

MATERIALS AND METHODS

Patients diagnosed from 1973 to 2009 were selected for analysis of socio-economic, staging and treatment factors available in the SEER database for MB and PNET. For the risk modeling, each factor was fitted by a generalized linear model to predict the outcome (brain cancer specific death, yes/no). The area under the receiver operating characteristic curve (ROC) was computed. Similar strata were combined to construct the most parsimonious models. A Monte Carlo algorithm was used to estimate the modeling errors.

RESULTS

There were 3,702 patients included in this study. The mean follow up time (S.D.) was 73.7 (86.2) months. Some 40% of the patients were female and the mean (S.D.) age was 16.5 (16.6) years. There were more adult MB/PNET patients listed from SEER data than pediatric and young adult patients. Only 12% of patients were staged. The SEER staging has the highest ROC (S.D.) area of 0.55 (0.05) among the factors tested. We simplified the 3-layered risk levels (local, regional, distant) to a simpler non-metastatic (I and II) versus metastatic (III) model. The ROC area (S.D.) of the 2-tiered model was 0.57 (0.04).

CONCLUSIONS

ROC analysis optimized the most predictive SEER staging model. The high under staging rate may have prevented patients from selecting definitive radiotherapy after surgery.

Under-use of radiotherapy in stage III bronchioaveolar lung cancer and socio-economic disparities in cause specific survival: a population study

BACKGROUND

This study used the receiver operating characteristic curve (ROC) to analyze Surveillance, Epidemiology and End RESULTS (SEER) bronchioaveolar carcinoma data to identify predictive models and potential disparity in outcomes.

MATERIALS AND METHODS

Socio-economic, staging and treatment factors were assessed. For the risk modeling, each factor was fitted by a Generalized Linear Model to predict cause specific survival. The area under the ROC was computed. Similar strata were combined to construct the most parsimonious models. A random sampling algorithm was used to estimate modeling errors. Risk of cause specific death was computed for the predictors for comparison.

RESULTS

There were 7,309 patients included in this study. The mean follow up time (S.D.) was 24.2 (20) months. Female patients outnumbered male ones 3:2. The mean (S.D.) age was 70.1 (10.6) years. Stage was the most predictive factor of outcome (ROC area of 0.76). After optimization, several strata were fused, with a comparable ROC area of 0.75. There was a 4% additional risk of death associated with lower county family income, African American race, rural residency and lower than 25% county college graduate. Radiotherapy had not been used in 2/3 of patients with stage III disease.

CONCLUSIONS

There are socio-economic disparities in cause specific survival. Under-use of radiotherapy may have contributed to poor outcome. Improving education, access and rates of radiotherapy use may improve outcome.

Breast cancer screening, area deprivation, and later-stage breast cancer in Appalachia: does geography matter?

OBJECTIVE

To model the relationship of an area-based measure of a breast cancer screening and geographic area deprivation on the incidence of later stage breast cancer (LSBC) across a diverse region of Appalachia.

DATA SOURCE

Central cancer registry data (2006-2008) from three Appalachian states were linked to Medicare claims and census data.

STUDY DESIGN

Exploratory spatial analysis preceded the statistical model based on negative binomial regression to model predictors and effect modification by geographic subregions.

PRINCIPAL FINDINGS

Exploratory spatial analysis revealed geographically varying effects of area deprivation and screening on LSBC. In the negative binomial regression model, predictors of LSBC included receipt of screening, area deprivation, supply of mammography centers, and female population aged>75 years. The most deprived counties had a 3.31 times greater rate of LSBC compared to the least deprived. Effect of screening on LSBC was significantly stronger in northern Appalachia than elsewhere in the study region, found mostly for high-population counties.

CONCLUSIONS

Breast cancer screening and area deprivation are strongly associated with disparity in LBSC in Appalachia. The presence of geographically varying predictors of later stage tumors in Appalachia suggests the importance of place-based health care access and risk.

Radiation therapy resources and guideline-concordant radiotherapy for early-stage breast cancer patients in an underserved region

OBJECTIVE

To examine the relationship between radiation therapy resources and guideline-concordant radiotherapy after breast-conserving surgery (BCS) in Kentucky.

DATA SOURCES

The SEER registry and Area Resource File provided county-level data describing cancer care resources and socioeconomic conditions of Kentucky residents.

STUDY DESIGN

The outcome variable was rate of BCS without radiotherapy in each county for 2000-2007. Eight-year weighted average rates of radiation therapy providers and hospitals per 100,000 residents were explanatory variables of interest. Exploratory spatial data analyses and spatial econometric models were estimated.

PRINCIPAL FINDINGS

Appalachian counties in Kentucky had significantly fewer radiation oncologists, hospitals with radiation therapy facilities, and surgeons per 100,000 residents than non-Appalachian counties. The likelihood of BCS without radiation was significantly higher among Appalachian compared to non-Appalachian women (42.5 percent vs. 29.0 percent, p < .001). Higher proportions of women not receiving recommended radiotherapy after BCS were clustered in Eastern Kentucky around Lexington. This geographic disparity was partially explained by significantly fewer radiation therapy facilities in Appalachian Kentucky in adjusted analyses.

CONCLUSIONS

Scarce radiation therapy resources in Appalachian Kentucky are associated with disparities in receipt of guideline-concordant radiotherapy, suggesting that policy action is needed to improve the cancer treatment infrastructure in disadvantaged mountainous areas.

Adaptation of an evidence-based intervention for Appalachian women: new STEPS (Strength Through Education, Physical fitness and Support) for breast health

Appalachia is characterized by a high prevalence of individual-level risks for breast cancer, including physical inactivity and postmenopausal obesity. The availability of local, evidence-based programs to improve physical fitness is limited. We adapted an evidence-based intervention, StrongWomen, to improve physical fitness and increase breast cancer knowledge among women 40 years and older in Appalachian Pennsylvania. Utilizing a multi-site, community-based design, we tested the adapted 12-week, supervised program-New STEPS (Strength Through Education, Physical fitness and Support)-among 139 women. The completion rate was 67.6 %. Pre/post scores improved for each of six fitness assessments (P<0.01). We found differences in overall fitness by study site (P<0.001), but no differences by age (P=0.13) or by previous breast cancer diagnosis (P=0.73). New STEPS is an adapted, evidence-based program that can improve physical fitness and breast cancer awareness among women in Appalachian Pennsylvania. New STEPS may help fill a void in local fitness programs for Appalachian women at risk for breast cancer or breast cancer recurrence.