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Grantee: Kelly M. Kenzik, PhD
Institution: University of Alabama, Birmingham
Area of Focus: Cancer Control and Prevention: Psychosocial and Behavioral Research
“The concept of ‘place-based’ health has become increasingly important in cancer research. Where people live has emerged as a critical component to consider when evaluating their risks for developing cancer, getting adequate treatment for cancer, and short- and long-term survival after a cancer diagnosis. Our study highlighted that a singular factor—rural residence—can not accurately evaluate risks for cancer outcomes.
“Now my research team is seeking to fully examine the characteristics of a person’s environment—including rurality, poverty, access to care, transportation, and community resources—and how these interplay with personal factors to affect cancer outcomes.”
—Kelly M. Kenzik, PhD
The Challenge: In the United States, people who live in a rural area may have different challenges accessing cancer care than those who live in an urban area. One problem may be workforce shortages for health care staff in rural counties. For instance, while 20% of the US population lives in a rural area, those areas are only served by 3% of oncologists. Specialists in fields other than oncology are also more likely to have offices in urban settings.
The challenges can be worse if the person needing cancer care is experiencing poverty.
Mortality rates for people diagnosed with breast cancer is known to be affected by the rural versus urban divide, with those living in rural settings having higher rates. What hasn’t been studied is how these issues affect people over age 65 who have breast cancer.
The Research: Kelly Kenzik, PhD, and colleagues specifically looked at Medicare data for women age 65 and older who were diagnosed with breast cancer between January 2000 and December 2011. They focused on how income and location affect use of the health care system and survival.
To get the data they needed, Kenzik’s researchers captured patients’ Medicare claims from one year before diagnosis to establish pre-existing conditions through December 2013 or death, whichever occurred first. They tracked visits to primary care providers, oncologists, non-oncology specialists, and the emergency department.
When more than 20% of people living in an area had incomes below the Federal Poverty Level (FPL), Kenzik defined the area as a high poverty one. Less than 10% of the population had an income below the FPL in “low-poverty” areas.
Here are some of their key findings.
Poverty is more strongly related to 5-year survival rates for people with breast cancer over age 65 than their area of residence. The authors found that after a diagnosis of breast cancer, women who were living in a low poverty area, whether it was urban or rural, had a 5-year survival rate of 74%.
In comparison, people living in high-poverty areas had much lower 5-year survival rates, with those in rural areas having a 66% 5-year survival rate and those in urban areas having a 63% survival rate.
Factors contributing to these lower survival rates may differ by location of residence. Studies report that rural residence is associated with delays in diagnosis. Such delays mean women are more likely to be diagnosed with cancer at a later stage, when treatment is less likely to cure the cancer.
For urban, high-poverty residences, studies show patients were more likely to be Black and have more health problems in addition to cancer (comorbidities) than White women in those areas. Previous evidence has shown that Black women with early-stage breast cancer are less likely to receive treatment, more likely to discontinue therapy, and have worse survival outcomes than White women.
Compared to older breast cancer patients living in urban areas (with low- or high- poverty levels), patients living with high poverty in rural areas:
Regardless of their location, breast cancer patients living in a high-poverty area had more health problems in addition to cancer (comorbidities) than people living in areas where more people had higher incomes. Interestingly, Kenzik found that patients living in high poverty areas had a lower rate of non-oncology specialist visits, even though treatment for comorbidities relies on care from non-oncology specialists.
Why Does it Matter? Overall, the authors found that for older breast cancer patients, where they lived had less of an effect on their survival than their socioeconomic status. Continued research is needed to better understand why outcomes differ in these communities and what might be done to decrease the disparities.