Effect of rurality and travel distance on contralateral prophylactic mastectomy for unilateral breast cancer

PURPOSE

Despite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been demonstrated in Midwestern rural women. Greater travel distance for surgical treatment is associated with CPM. Our objective was to examine the relationship between rurality and travel distance to surgery with CPM.

METHODS

Women diagnosed with stages I-III unilateral breast cancer between 2007 and 2017 were identified using the National Cancer Database. Logistic regression was used to model likelihood of CPM based on rurality, proximity to metropolitan centers, and travel distance. A multinomial logistic regression model compared factors associated with CPM with reconstruction versus other surgical options.

RESULTS

Both rurality (OR 1.10, 95% CI 1.06-1.15 for non-metro/rural vs. metro) and travel distance (OR 1.37, 95% CI 1.33-1.41 for those who traveled 50 + miles vs. < 30 miles) were independently associated with CPM. For women who traveled 30 + miles, odds of receiving CPM were highest for non-metro/rural women (OR 1.33 for 30-49 miles, OR 1.57 for 50 + miles; reference: metro women traveling < 30 miles). Non-metro/rural women who received reconstruction were more likely to undergo CPM regardless of travel distance (ORs 1.11-1.21). Both metro and metro-adjacent women who received reconstruction were more likely to undergo CPM only if they traveled 30 + miles (ORs 1.24-1.30).

CONCLUSION

The impact of travel distance on likelihood of CPM varies by patient rurality and receipt of reconstruction. Further research is needed to understand how patient residence, travel burden, and geographic access to comprehensive cancer care services, including reconstruction, influence patient decisions regarding surgery.

Choice of Survival Metric and Its Impacts on Cancer Survival Estimates for American Indian and Alaska Native People

BACKGROUND

Different survival metrics have different applicability to clinical practice and research. We evaluated how choice of survival metric influences assessment of cancer survival among American Indian and Alaska Native (AIAN) people relative to non-Hispanic Whites (NHW). A secondary objective was to present variations in survival among AIAN people by age, sex, stage, and Indian Health Service (IHS) region.

METHODS

Five-year survival was calculated using the North American Association of Central Cancer Registries Cancer in North America dataset. We calculated survival among AIAN people, compared with NHW using four approaches: (i) observed (crude) survival, (ii) cause-specific survival, (iii) relative survival using age- and sex-adjusted lifetables, and (iv) relative survival using lifetables additionally adjusted for race, geography, and socioeconomic status. For AIAN people, we evaluated how survival varied by age, stage at diagnosis, and IHS region.

RESULTS

Observed survival methods produced the lowest estimates, and-excepting prostate cancer-cause-specific methods produced the highest survival estimates. Survival was lower among AIAN people than NHW for all methods. Among AIAN people, survival was higher among those 20-64 years, females, and tumors diagnosed at local stage. Survival varied by IHS region and cancer sites.

CONCLUSIONS

These results support the assertion that using the same methodology to compare survival estimates between racial and ethnic groups is of paramount importance, but that the choice of metric requires careful consideration of study objectives.

IMPACT

These findings have the potential to impact choice of survival metric to explore disparities among AIAN people.

Identifying Core Functions of an Evidence-Based Intervention to Improve Cancer Care Quality in Rural Hospitals

Background:

Rural patients experience worse cancer survival outcomes than urban patients despite similar incidence rates, due in part to significant barriers to accessing quality cancer care. Community hospitals in non-metropolitan/rural areas play a crucial role in providing care to patients who desire and are able to receive care locally. However, rural community hospitals typically face challenges to providing comprehensive care due to lack of resources. The University of Kentucky’s Markey Cancer Center Affiliate Network (MCCAN) is an effective complex, multi-level intervention, improving cancer care in rural/under-resourced hospitals by supporting them in achieving American College of Surgeons Commission on Cancer (CoC) standards. With the long-term goal of adapting MCCAN for other rural contexts, we aimed to identify MCCAN’s core functions (i.e., the components key to the intervention’s effectiveness/implementation) using theory-driven qualitative data research methods.

Methods:

We conducted eight semi-structured virtual interviews with administrators, coordinators, clinicians, and certified tumor registrars from five MCCAN affiliate hospitals that were not CoC-accredited prior to joining MCCAN. Study team members coded interview transcripts and identified themes related to how MCCAN engaged affiliate sites in improving care quality (intervention functions) and implementing CoC standards (implementation functions) and analyzed themes to identify core functions. We then mapped core functions onto existing theories of change and presented the functions to MCCAN leadership to confirm validity and completeness of the functions.

Results:

Intervention core functions included: providing expertise and templates for achieving accreditation, establishing a culture of quality-improvement among affiliates, and fostering a shared goal of quality care. Implementation core functions included: fostering a sense of community and partnership, building trust between affiliates and Markey, providing information and resources to increase feasibility and acceptability of meeting CoC standards, and mentoring and empowering administrators and clinicians to champion implementation.

Conclusion:

The MCCAN intervention presents a more equitable strategy of extending the resources and expertise of large cancer centers to assist smaller community hospitals in achieving evidence-based standards for cancer care. Using rigorous qualitative methods, we distilled this intervention into its core functions, positioning us (and others) to adapt the MCCAN intervention to address cancer disparities in other rural contexts.