Purpose: Women with breast cancer are increasingly being diagnosed and cared for within the VA. Breast cancer specialists are available only at large VA hospitals in urban regions, possibly impacting the outcomes of rural women. The health outcomes of rural women at the VA have not been well described and are currently a research priority. We described the differences between urban and rural women’s demographics and breast cancer characteristics. We then compared urban and rural women with nonmetastatic breast cancer on type of lymph node biopsy, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and hormone therapy.
Methods: Following IRB approval, 4,025 women with nonmetastatic breast cancer from 1995 to 2012 were identified from the Veterans Affairs Central Cancer Registry (VACCR). This dataset contained diagnosis date, histology, tumor size, tumor grade, lymph node status, and estrogen receptor status. The VACCR also gathered type of lymph node surgery, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and adjuvant hormone therapy. Patient-specific data included date of birth, ethnicity, and zip code of residence at the time of diagnosis. The Rural Urban Commuting Areas 2.0 (RUCA) was used to define rural status and collated further into 3 categories of urban, large rural, and small rural. STATA data analysis and statistical software was used to organize and analyze data. The associations between the 3 rural/urban categories and diagnosis year, age, ethnicity, histology and tumor grade were assessed by ordinal logistic regression. Tumor size was compared using rank sum test. Lymph node and estrogen receptor status were compared with logistic regression, and lymph node sampling methods with multinomial regression. All other treatments were compared between small rural and urban women using logistic regression, and further analyzed with adjustments for factors that could influence treatment choices, including diagnosis year, age, ethnicity, tumor size and grade, lymph node status, and estrogen receptor status.
Results: Most women (n = 3,192) with nonmetastatic breast cancer resided in urban regions, 423 women in large rural regions, and 410 in small rural regions. The number of women living in urban and rural regions did not shift significantly over time (P = .48). The age distributions of rural and urban women did not differ. Women with breast cancer in rural regions were more likely to be white (P ≤ .001, 69% white urban; 90% white small rural; 24% black urban, and 6% black small rural). Tumor histology, size, grade, and lymph node and estrogen receptor status did not differ significantly between rural and urban. Mastectomy was more common among rural women initially, but after adjustments for patient demographics and breast cancer characteristics, urban and rural women received similar proportions of mastectomies. After adjustments, urban and rural women received equivalent breast cancer surgery, adjuvant radiation and adjuvant hormone therapy. However, after controlling for confounding factors, a disproportionate number of urban women receive no lymph node biopsy (P = .05). Additionally, women from large rural regions were statistically more likely to receive adjuvant chemotherapy (P = .04), although the chemotherapy administration did not differ statistically between women from urban and small rural regions (P = .7).
Conclusions: Most women diagnosed with breast cancer at the VA from 1995 to 2012 resided in urban areas. Rural women were much more likely to be white, but the age at diagnosis did not differ. Breast cancer characteristics were similar between rural and urban women. Women living in large rural regions were more likely to receive adjuvant chemotherapy than were women from urban or small rural regions; however reporting differences should be considered as an explanation. A higher proportion of urban women received no lymph node biopsy, which merits further investigation. Breast conservation therapy was administered consistently among rural and urban women veterans.
