Background: Cancer care in rural areas poses unique challenges, including access and proximity to care. This study examined differences in time to treatment initiation (TTI), a potential surrogate for access, and predictors of overall survival (OS) between rural and nonrural patients with breast cancer.
Methods: Women with stage I to III breast cancer diagnosed between 2004 and 2012 in facilities accredited by the National Cancer Database of Commission on Cancer (CoC) were included. Differences between rural and nonrural patients in demographics, disease and treatment characteristics, socioeconomic factors, and TTI were assessed by χ2 test. The effects on OS of age, insurance status, cancer center type, community median income, percentage of the community who had not graduated from high school, and TTI were assessed using Cox models.
Results: The study population was composed of 1,205,031 patients, 18,417 (2%) of whom were rural. Compared with nonrural patients, rural patients were more likely to be older, to be White, to receive care at nonacademic centers, to have government insurance or annual income less than $38,000, and to be less educated (P < .0001). Rural patients also had shorter median TTI (3 vs 4 weeks; P < .0001), which was associated with improved OS (P < .0001), and were more likely to have TTI less than 4 weeks and less than 8 weeks (P < .0001 for both). Shorter TTI (both <4 weeks vs 8 weeks and 4-8 weeks vs >8 weeks) was also associated with improved OS (P < .0001 for both). After adjusting for disease stage and demographic-, socioeconomic-, and treatment-related factors, rural status was associated with improved OS compared with nonrural status (HR, 0.92; 95% CI, 0.89-0.96; P < .0001).
Conclusions: Despite several adverse demographic and socioeconomic factors, rural patients with breast cancer with access to CoC-accredited facilities had significantly shorter TTI and better OS compared with nonrural patients. The clinical significance of this is undetermined; however, these data suggest that improving TTI can mitigate disparities in rural cancer care.