Urban versus Rural Residence and Outcomes in Older Patients with Breast Cancer
Menée à partir des données des registres américains des cancers portant sur 109 608 patientes atteintes d’un cancer du sein diagnostiqué après 65 ans entre 2000 et 2011, cette étude analyse l’association entre le lieu de résidence (zone rurale ou urbaine) et l’utilisation des soins de santé ainsi que la survie globale
Background: A total of 20% of the U.S. population resides in rural areas, yet is served by 3% of oncologists, and 7% of nononcology specialists. Access to care issues can be compounded by lower socioeconomic status (SES) in rural areas, yet this issue is unexplored among older patients with breast cancer. Methods: Using Surveillance Epidemiology and End Results-Medicare, 109,608 patients diagnosed at ?65 years with breast cancer between 2000 and 2011 were identified. Residence status was combined with Federal Poverty levels: urban (high, medium, and low poverty) and rural (high, medium, and low poverty). Five-year overall survival (OS) and healthcare utilization [HCU: visits to primary care provider (PCP), oncologist, nononcology specialist, and emergency department (ED)] were examined using urban/low poverty as reference. The residence, HCU, and mortality association was examined using mediation and moderation analyses. Results: Median age was 76 years; 12.5% were rural, 15.6% high poverty. Five-year OS was 69.8% for rural and 70.9% for urban. Both urban- and rural/high-poverty patients had a 1.2-fold increased mortality hazard. Rural/high-poverty patients had a higher rate of PCP [year 1 (Y1): incidence rate ratio (IRR) = 1.23; year 2 (Y2)–year 5 (Y5): IRR = 1.19] and ED visits (Y1: IRR = 1.82; Y2–Y5: IRR = 1.43), but lower nononcology specialist visit rates (Y1: IRR = 0.74; Y2–Y5: IRR = 0.71). Paucity of nononcology specialist visits mediated 23%–57% of excess mortality risk. The interaction between residence/SES and paucity of nononcology specialist visits accounted for 49%–92% of excess mortality risk experienced by rural/high-poverty patients versus urban/low poverty. Conclusions: Urban–rural residence mortality differences among older patients with breast cancer are highly predicated by poverty level. Impact: Rural/high-poverty patients demonstrate less use of nononcology specialistscompared with urban/low poverty, with disparities moderated by specialist use.