C. Markey1, J. Weiss2,3, A. Loehrer4,5 1Geisel School of Medicine at Dartmouth,Hanover, NH, USA 2Geisel School of Medicine at Dartmouth,Department Of Biomedical Data Science,Hanover, NH, USA 3Dartmouth-Hitchcock Medical Center,Norris Cotton Cancer Center,Lebanon, NH, USA 4Dartmouth-Hitchcock Medical Center,Department Of Surgery,Lebanon, NH, USA 5Geisel School of Medicine at Dartmouth,The Dartmouth Institute For Health Policy And Clinical Practice,Lebanon, NH, USA
Introduction: Racial, socioeconomic, and geographic disparities have been studied independently in regards to stage at diagnosis and receipt of optimal treatment with curative intent surgery for breast cancer. However, considerable gaps in knowledge remain regarding the intersectionality between rurality, race, insurance status, and other aspects of socioeconomic deprivation that contribute in concert to disparities in cancer care delivery.
Methods: The study cohort included non-Hispanic women aged 18-64 years old with either private or no insurance coverage and a diagnosis with breast cancer from the North Carolina Central Cancer Registry (2010-2015). Logistic regression models examined the impact on advanced stage (III, IV) and receipt of curative intent surgery (CIS) from race, rurality, insurance, and the Social Deprivation Index (SDI). Models were adjusted for age at diagnosis, diagnosis year, and comorbidities and included two-way interactions among race, rurality, insurance, and SDI. The CIS model was among women with non-metastatic breast cancer and also adjusted for stage.
Results: Of the study population (n=20,530), 13.1% were diagnosed with advanced stage (III, IV), and 97.4% of women with non-metastatic breast cancer (n= 19,709) received curative intent surgery (CIS). 20.8% of women were non-Hispanic Black (NHB), 6.0% were uninsured/self-pay, 19.1% of women resided in rural areas, and 17.4% resided in communities of highest quartile SDI. NHB race/ethnicity (vs non-Hispanic White [NHW]), residence in rural (vs urban) or high social deprivation (vs lower quartiles) areas, and uninsured/self-pay status (vs private) were associated advanced stage breast cancer (Table). Among women presenting with non-metastatic breast cancer, NHB and uninsured/self-pay women were significantly less likely to receive CIS than NHW and women with private insurance, respectively (Table). Evaluating intersectionality between Black race, residency in a rural or high social deprivation community, and uninsured/self-pay status, there were no statistically significant interactions influencing stage at diagnosis or receipt of curative intent surgery.
Conclusion: In a large and heterogeneous population across the state of North Carolina with breast cancer prevalence comparable to the United States at large, uninsured status, non-Hispanic Black race/ethnicity, and residency in a rural or high social deprivation community are independently associated with decreased access to and receipt of breast cancer care. However, there was no measured interactions between these factors. Future studies on socioeconomic inequity and systemic racism should account for important geospatial heterogeneity of populations.
