Impact of age, rurality and distance in predicting contralateral prophylactic mastectomy for breast cancer in a Midwestern state: a population-based study

Abstract

Background: There is substantial variability in the use of contralateral prophylactic mastectomy (CPM) in women with unilateral breast cancer across the United States. Iowa is one of several rural Midwestern states found to have the highest proportions of CPM nationally in women <45 years of age. We evaluated the role of rurality and travel distance as factors related to these surgical patterns. Methods: Women with unilateral breast cancer (2007-2017) were identi ed using Iowa Cancer Registry records. Patients and treating hospitals were classi ed as metro, nonmetro and rural based on Rural-Urban Continuum Codes. Differences in patient, tumor, and treatment characteristics and median travel distances (MTD) were compared. Characteristics associated with CPM were evaluated with multivariate logistic regression. Results: 22,158 women were identi ed: 57% metro, 26% nonmetro and 18% rural. The overall proportion of CPM in Iowa was consistently higher than in the national Surveillance, Epidemiology, and End Results (SEER18) throughout the interval from 2007-2015. Young rural women had the highest proportion of CPM (<40 years: 52%, 39% and 40% for rural, metro, nonmetro, respectively). Half of all rural women had surgery at metro hospitals; these women had the longest MTD (56 miles). Of all women treated at metro hospitals, rural women had the highest proportion with CPM (17% rural; vs 14% metro/nonmetro, p=0.007). On multivariate analysis, traveling ≥50 miles (ORs 1.48-2.34) or being rural regardless of travel distance was predictive of CPM (OR = 1.36). Other risk factors were young age (<40 years: OR=7.18, 95% CI: 5.89-8.76) and surgery at a metro hospital that offers reconstruction (OR=2.3, 95% CI: 1.70-3.21) and is not NCIdesignated (OR=2.19, 95% CI: 1.78-2.69). Conclusion: There is an unexpectedly high proportion of CPM use in young rural women in Iowa. Travel ≥50 miles and rural residence are independently associated with likelihood of CPM. Disparities in access to specialty care may underlie the desire for surgery that is perceived to minimize follow-up visits. Methods: Women with unilateral breast cancer (2007-2017) were identi ed using Iowa Cancer Registry records. Patients and treating hospitals were classi ed as metro, nonmetro and rural based on Rural-Urban Continuum Codes. Differences in patient, tumor, and treatment characteristics and median travel distances (MTD) were compared. Characteristics associated with CPM were evaluated with multivariate logistic regression. Results: 22,158 women were identi ed: 57% metro, 26% nonmetro and 18% rural. The overall proportion of CPM in Iowa was consistently higher than in the national Surveillance, Epidemiology, and End Results (SEER18) throughout the interval from 2007-2015. Young rural women had the highest proportion of CPM (< 40 years: 52%, 39% and 40% for rural, metro, nonmetro, respectively). Half of all rural women had surgery at metro hospitals; these women had the longest MTD (56 miles). Of all women treated at metro hospitals, rural women had the highest p...

The Impact of Travel Distance and Income on Breast Reconstruction after Mastectomy in a Rural Population

“…The impact of breast cancer diagnosis and management on patients is not uniform across the country, as certain populations may face increased challenges in terms of awareness, education, socioeconomics, access to care, and culture. 1,8,14 This is especially pronounced in women from a rural population, [8][9][10] and deserves further investigation to identify the most impactful factors that affect breast reconstruction. A study published in 2019 demonstrated that in the state of Tennessee, lower income is associated with significantly worse health outcomes and life expectancy, reinforcing the importance of identifying and addressing specific social determinants of health.…”

“…8 Although academic programs have the highest rates of reconstruction, they may be located farthest from patients' residences, and older, non-White patients, with lower education level and higher out-of-pocket costs may be less likely to undergo reconstruction. 1,[4][5][6][7][9][10][11][12] Previous studies examining factors that impact reconstruction after mastectomy have focused on national or statewide databases. The aim of this study was to identify specific factors that may affect rates and type of breast reconstruction after mastectomy in a rural patient population compared with national trends.…”

Effect of rurality and travel distance on contralateral prophylactic mastectomy for unilateral breast cancer

“…These findings may represent lack of access to reconstruction in areas proximate to non-metro counties, or a lack of suitability or inclination for reconstruction in non-metro women who elect not to or are unable to travel farther. While we cannot determine from this dataset whether the distance traveled by the patient represents the distance to the nearest available treating facility, one study using Iowa Cancer Registry data found that rural women frequently traveled to large tertiary care centers for surgery, which were often not the nearest hospitals offering breast cancer surgery [23]. In that study, rural women traveling to large tertiary facilities were more likely to elect CPM and have reconstruction than metro women treated in similar facilities [23].…”

“…However, unexpectedly high proportions (42.8-48.5%) of CPM have been reported among women aged 20-44 with early-stage unilateral breast cancer who underwent surgery in Midwestern states that have a high proportion of rural residents. A study in Iowa, which had the second highest proportion of breast cancer patients electing CPM [22], identified the highest rates of CPM among rural-residing women under the age of 40 [23]. Rural patients often travel farther for many aspects of cancer treatment, which contributes to the lower rates of guideline concordant care in this population [24][25][26][27].…”

“…Because CPM is considered low-value care in average-risk women, with potential to cause morbidity and adversely impact quality of life, disproportionately high rates of CPM in rural women is concerning and warrants investigation. However, the relationship between rurality and CPM observed in Iowa has not been replicated; indeed, one study using the National Cancer Database (NCDB) did not identify a significant relationship between rurality and receipt of CPM [20,23].…”