And these disparities can translate into poorer disease outcomes in rural women compared with their urban counterparts, wrote a team led by Dr. Brian Sprague from the University of Vermont in Burlington: Women living in rural areas experience higher false-positive cancer rates on diagnostic mammography and have similar incidence of aggressive breast cancer subtypes compared with women in urban areas -- despite having lower overall incidence. They also have lower screening mammography uptake and more advanced stage cancer at diagnosis.
"While numerous interventions have been demonstrated in controlled studies to be effective in promoting [breast cancer] treatment access and [screening] adherence, widespread dissemination [of interventions] in public health and clinical practice remains lacking," Sprague and his team wrote.
Breast cancer disparities between women in rural settings and those living in urban settings have been noted in previous studies. Although incidence of the disease is about 10% lower in rural areas than urban ones, mortality is comparable due to poorer survival rates among rural women. This could be due to differences in breast cancer biology, early detection and stage at diagnosis, access to high-quality treatments, and access to follow-up surveillance imaging and supportive care, the authors noted.
The team sought to identify key barriers women in rural areas face when it comes to breast cancer diagnosis and treatment, reviewing previous studies to evaluate factors that contribute to poorer survival rates and interventions that could ease the burden on women in these settings.
Sprague and colleagues found that socioeconomic differences played a significant part in how women in rural areas are diagnosed and receive treatment compared to women in urban areas. For example, a 2011 study found rural mammography facilities have diagnostic mammography sensitivity comparable to urban facilities, but they also have poorer specificity, with an approximately 55% higher false-positive rate. Because of this, women undergoing diagnostic breast imaging at rural facilities are more likely to experience a higher burden of additional imaging and biopsies for benign lesions.
Primary care density by geography is another factor the investigators noted, with recent research showing lower density in rural areas compared to urban areas. The 2020 study the team cited found that the density of primary care physicians in U.S. rural counties in 2017 was 2.54 per 3,500 residents, compared with 3.25 per 3,500 residents in urban counties.
A low density of radiology facilities impairs utilization of mammography screening in rural areas, according to Sprague and colleagues. They also cited research that reported median travel times to breast imaging services being four to eight times longer for rural women compared with their urban counterparts.
Lower utilization of screening among women living in rural areas is expected to result in a later stage disease at diagnosis, with rural breast cancer patients having about 20% higher odds of late-stage breast cancer compared with urban breast cancer patients, the group wrote. However, the authors also noted that women undergoing mammography screening in rural areas do not appear to experience poorer screening services than women in urban areas.
Efforts to improve these breast cancer diagnosis disparities should focus on strategies for better access to breast cancer treatments, according to Sprague's team.
"Initiatives seeking to improve access to high-quality diagnostic management and treatments would be expected to provide the most benefit for improving breast cancer outcomes in rural settings," the group wrote. "Healthcare finance reform is needed to support the implementation of existing interventions shown to improve access to care for rural patients."
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