Exploration of Urban/Rural Differences in Breast Cancer Treatment among Medicare Beneficiaries

Sorbero M, Shugarman LR, Tian H, Asch SM, Jain AK, Ashwood JS. Exploration of Urban/Rural Differences in Breast Cancer Treatment among Medicare Beneficiaries. Poster session presented at: AcademyHealth Annual Research Meeting; 2007 Jun 3; Orlando, FL.

Research Objective: Rural areas experience challenges recruiting and retaining providers, and rural health care facilities may offer limited services. As a result, rural patients may have to travel farther and wait longer for care than urban patients. This study examines the relationship between rural residence and the timely receipt of breast cancer treatment. Study Design: Secondary data analysis using Surveillance, Epidemiology, and End Results (SEER) data linked Medicare claims and the Area Resource File. Rural-Urban Commuting Area Codes were used to create 4 residence categories: urban, large rural city, small rural town, and isolated small rural town. Three measures of breast cancer treatment were examined: 1) receipt of breast conserving surgery within 6 weeks of diagnosis among women with Stage I or II disease (timely receipt of BCS); 2) receipt of radiation therapy within 6 weeks of surgery or chemotherapy for women undergoing BCS (timely receipt of radiation); and 3) receipt of chemotherapy within 7.5 weeks (median in our sample) of surgery by women who were candidates for chemotherapy (timely receipt of chemotherapy). Descriptive analyses and multivariate logistic regressions controlling for patient characteristics, tumor characteristics, socioeconomic characteristics, and provider supply were performed to examine relationships between rural residence and timely receipt of treatments. Population Studied: Medicare beneficiaries age 65 and older residing in a SEER region at the time of their breast cancer diagnosis between 1995 and 1999 and followed until December 2003 (N = 32,626). Principle Findings: Bivariate analyses revealed that rural breast cancer patients were less likely to have timely receipt of BCS, (p < .01) and radiation therapy (p < .01). A non-linear relationship was observed in the timely receipt of chemotherapy (p < .01); breast cancer patients in large rural towns were more likely to have timely receipt of chemotherapy than other women (p < .01). In multivariate analyses, rural residence was no longer associated with the timely receipt of BCS; living in a higher income area was positively associated with the timely receipt of BCS, while increasing age was negatively associated. Living in a small or isolated rural area remained negatively associated with timely receipt of radiation in multivariate analyses; increasing age and being on Medicaid were also negatively associated, while living in wealthier areas and areas with a greater supply of radiation oncologists were positively associated with the timely receipt of radiation. In multivariate analyses, residence was no longer associated with the timely receipt of chemotherapy; increasing age, black race and being on Medicaid were negatively associated with timely receipt of chemotherapy, while the supply of hospitalbased oncologists was positively associated. Conclusions: These findings indicate that geographic residence, socioeconomic factors as well as some measures of provider supply are associated with the timely receipt of breast cancer treatments. Implications for Policy, Practice or Delivery: Rural residents are at a disadvantage when it comes to the timely receipt of some breast cancer treatments. Health care planners and policymakers should consider whether cancer treatment is suitably accessible for rural patients. Funding Source: HRSA