Purpose This study evaluated spatial access to mammography centers in Appalachia using both traditional access measures and the two-step floating catchment area (2SFCA) method. Methods Ratios of county mammography centers to women age 45 and older, driving time to nearest mammography facility, and various 2SFCA approaches were compared throughout Pennsylvania, Ohio, Kentucky, and North Carolina. Results Closest travel time measures favored urban areas. The 2SFCA method produced varied results depending on the parameters chosen. Appalachia areas had greater travel times to their closest mammography center. Appalachia areas in OH and NC had worse 2SFCA scores than non-Appalachia areas of the same states. Conclusion A relative 2SFCA approach, the spatial access ratio (SPAR) method, was recommended because it helped minimize the differences between various 2SFCA approaches.

The different parameters of the 2SFCA method-distance decay weights and variable catchment sizes-have a large impact on the resulting spatial access to primary care scores. The findings of this study suggest that using a relative 2SFCA approach, the spatial access ratio method, when detailed patient travel data are unavailable. The 2SFCA method shows promise for measuring access to care in Appalachia, but more research on patient travel preferences is needed to inform implementation.

Purpose The two-step floating catchment area (2SFCA) method of measuring access to care has never been used to study cancer disparities in Appalachia. First, we evaluated the 2SFCA method in relation to traditional methods. We then examined the impact of access to mammography centers and primary care on late stage breast cancer diagnosis and receipt of adjuvant hormonal therapy. Methods Cancer registries from Pennsylvania, Ohio, Kentucky, and North Carolina were linked with Medicare data to identify the stage of breast cancer diagnosis for Appalachia women diagnosed between 2006–2008. Women eligible for adjuvant therapy had stage I, II, or III diagnosis; mastectomy or breast conserving surgery; and hormone-receptor positive breast cancers. Geographically weighted regression (GWR) was used to explore non-stationarity in the demographic and spatial access predictor variables. Results Over 21% of 15,299 women diagnosed with breast cancer had late-stage (stages III–IV) diagnosis. Predictors included age at diagnosis (odds ratio [OR], 0.86; P < 0.001), insurance status (OR, 1.32; P < 0.001), county primary care to population ratio (OR, 0.95; P < 0.001), and primary care 2SFCA score (OR, 0.96; P = 0.006). Only 46.9% of eligible women received adjuvant hormonal therapy, and predictors included comorbidity status (OR, 1.18; P = 0.047), county economic status (OR, 1.32; P = 0.006), and mammography center 2SFCA scores (OR, 1.12; P = 0.021). Conclusion Methodologically, the 2SFCA method offered the greatest predictive validity of the access measures examined. Substantively, rates of late stage breast cancer diagnosis and adjuvant hormonal therapy are substandard in Appalachia.

There is a paucity of literature systemically examining the effects of access to cancer care resources on adjuvant endocrine therapy (AET) use behaviors, especially in underserved regions such as the Appalachian region in the United States, where gaps in healthcare access are well documented. The objectives of this study were to explore AET adherence and persistence in Appalachia, delineate the effects of access to care cancer on adherence/persistence, and evaluate the influences of adherence and persistence on overall survival.A retrospective cohort study from 2006 to 2008 was conducted among female breast cancer survivors living in the Appalachian counties of 4 states (PA, OH, KY, and NC). We linked cancer registries to Medicare claims data and included patients with invasive, nonmetastatic, hormone-receptor-positive breast cancer who received guideline-recommended AET. Medication adherence was defined as corresponding to a Medication Possession Ratio (MPR) ≥0.8 and logistic regression was utilized to assess predictors of adherence. Medication nonpersistence was defined as the discontinuation of drugs after exceeding a 60-day medication gap, and multivariate adjusted estimates of nonpersistence were obtained using the Cox proportional hazards (PH) model.About 31% of the total 428 patients were not adherent to AET, and 30% were not persistent over an average follow-up period of 421 days. Tamoxifen, relative to aromatase inhibitors, was associated with higher odds of adherence (odds ratio = 2.82, P < 0.001) and a lower risk of nonpersistence (hazard ratio = 0.40, P < 0.001). Drug-related side effects like pain may be an important factor leading to nonadherence and early discontinuation. In addition, aromatase inhibitor (AI) adherence and persistence were significantly influenced by out-of-pocket drug costs, dual eligibility status, and coverage gaps. Nonadherence to and nonpersistence with AET were associated with higher risks of all-cause mortality.Our findings of suboptimal AET adherence/persistence in Appalachia as well as positive associations between AET adherence/persistence and overall survival outcomes further underscore the importance of ensuring appropriate AET use in this population to reduce breast cancer mortality disparities. Our findings also suggest that intervention strategies focusing on individualized treatment and medication-related factors may improve adjuvant treatment use.