Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama.
Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama.
Cancer Epidemiol Biomarkers Prev. 2020 Jul;29(7):1313-1320. doi: 10.1158/1055-9965.EPI-19-1414. Epub 2020 Apr 16.
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.
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.
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.
Urban-rural residence mortality differences among older patients with breast cancer are highly predicated by poverty level.
Rural/high-poverty patients demonstrate less use of nononcology specialists compared with urban/low poverty, with disparities moderated by specialist use.
美国总人口的 20%居住在农村地区，但仅有 3%的肿瘤学家和 7%的非肿瘤学专家为其提供服务。在农村地区，较低的社会经济地位（SES）会使获得医疗服务的问题更加复杂，但这一问题在老年乳腺癌患者中尚未得到探讨。
利用监测、流行病学和最终结果-医疗保险数据库，确定了 2000 年至 2011 年间诊断为≥65 岁且患有乳腺癌的 109608 名患者。居住状况与联邦贫困水平相结合：城市（高、中、低贫困）和农村（高、中、低贫困）。使用城市/低贫困作为参考，检查了五年总体生存率（OS）和医疗保健利用情况[就诊于初级保健提供者（PCP）、肿瘤学家、非肿瘤学专家和急诊部（ED）]。使用中介和调节分析检查了居住、医疗保健利用和死亡率的相关性。
中位年龄为 76 岁；12.5%的患者来自农村地区，15.6%的患者来自高贫困地区。农村地区的五年 OS 为 69.8%，城市地区为 70.9%。城市和农村/高贫困地区的患者死亡率均增加了 1.2 倍。农村/高贫困地区的患者 PCP 就诊率更高[第 1 年（Y1）：发病率比（IRR）=1.23；第 2 年（Y2）至第 5 年（Y5）：IRR = 1.19]和 ED 就诊率更高（Y1：IRR = 1.82；Y2-Y5：IRR = 1.43），而非肿瘤学专家就诊率较低（Y1：IRR = 0.74；Y2-Y5：IRR = 0.71）。非肿瘤学专家就诊不足部分解释了农村/高贫困地区患者 23%-57%的额外死亡风险。居住/SES 与非肿瘤学专家就诊不足之间的相互作用解释了农村/高贫困地区患者与城市/低贫困地区相比额外 49%-92%的死亡风险。
农村和城市的居住差异是导致老年乳腺癌患者死亡率差异的重要原因。
与城市/低贫困地区相比，农村/高贫困地区的患者较少使用非肿瘤学专家，但专家使用情况的差异得到了调节。
