Rural-Urban Cancer Incidence and Trends in the United States, 2000-2019.

Background Despite consistent improvements in cancer prevention and care, rural and urban disparities in cancer incidence persist in the United States. Our objective was to further examine rural-urban differences in cancer incidence and trends. Methods We used the North American Association of Central Cancer Registries (NAACCR) dataset to investigate rural-urban differences in 5-year age-adjusted cancer incidence (2015-2019) and trends (2000-2019), also examining differences by region, sex, race/ethnicity, and tumor site. Age-adjusted rates were calculated using SEER*Stat 8.4.1, and trend analysis was done using Joinpoint, reporting annual percent changes (APCs). Results We observed higher all cancer combined 5-year incidence rates in rural areas (457.6 per 100,000) compared to urban a (447.9), with the largest rural-urban difference in the South (464.4 vs 449.3). Rural populations also exhibited higher rates of tobacco-associated, HPV-associated, and colorectal cancer, including early-onset. Tobacco-associated cancer incidence trends widened between rural and urban from 2000-2019, with significant, but varying, decreases in urban areas throughout the study period, while significant rural decreases only occurred between 2016 and 2019 (APC=-0.96). HPV-associated cancer rates increased in both populations until recently with urban rates plateauing while rural rates continued to rise (e.g., APC =1.56, 2002-2019). Conclusions Rural populations had higher overall cancer incidence rates and higher rates of cancers with preventive opportunities compared to urban. Improvements in these rates were typically slower in rural populations. Impact Our findings underscore the complex nature of rural-urban disparities, emphasizing the need for targeted interventions and policies to reduce disparities and achieve equitable health outcomes.

Eliminating Medicaid dental benefits and early-stage oral cancer diagnoses.

BACKGROUND: Despite the importance of regular dental visits for detecting oral cancer, millions of low-income adults lack access to dental services. In July 2009, California eliminated adult Medicaid dental benefits. We tested if this impacted oral cancer detection for Medicaid enrollees. METHODS: We analyzed Surveillance, Epidemiology, and End Results-Medicaid data, which contains verified Medicaid enrollment status, to estimate a difference-in-differences model. Our design compares the change in early-stage (Stages 0-II) diagnoses before and after dropping dental benefits in California with the change in early-stage diagnoses among eight states that did not change Medicaid dental benefits. Patients were grouped by oropharyngeal cancer (OPC) and non-OPC (oral cavity cancer), type, and the length of Medicaid enrollment. We also assessed if the effect of dropping dental benefits varied by the number of dentists per capita. RESULTS: Dropping Medicaid dental benefits was associated with a 6.5%-point decline in early-stage diagnoses of non-OPC (95% CI = -14.5, -3.2, p = 0.008). This represented a 20% relative reduction from baseline rates. The effect was highest among beneficiaries with 3 months of continuous Medicaid enrollment prior to diagnosis who resided in counties with more dentists per capita. Specifically, dropping dental coverage was associated with a 1.25%-point decline in the probability of early-stage non-OPC diagnoses for every additional dentist per 5000 population (p = 0.006). CONCLUSIONS: Eliminating Medicaid dental benefits negatively impacted early detection of cancers of the oral cavity. Continued volatility of Medicaid dental coverage and provider shortages may be further delaying oral cancer diagnoses. Alternative approaches are needed to prevent advanced stage OPC.

Equitable implementation of lung cancer screening: avoiding its potential to mirror existing inequities among people who use tobacco.

PURPOSE: Lung cancer is the leading cause of cancer death, but the advent of lung cancer screening using low-dose computed tomography offers a tremendous opportunity to improve lung cancer outcomes. Unfortunately, implementation of lung cancer screening has been hampered by substantial barriers and remains suboptimal. Specifically, the commentary emphasizes the intersectionality of smoking history and several important sociodemographic characteristics and identities that should inform lung cancer screening outreach and engagement efforts, including socioeconomic considerations (e.g., health insurance status), racial and ethnic identity, LGBTQ + identity, mental health history, military experience/veteran status, and geographic residence in addressing specific community risk factors and future interventions in efforts to make strides toward equitable lung cancer screening. METHODS: Members of the Equitable Implementation of Lung Cancer Screening Interest Group with the Cancer Prevention and Control Network (CPCRN) provide a critical commentary based on existing literature regarding smoking trends in the US and lung cancer screening uptake to propose opportunities to enhance implementation and support equitable distribution of the benefits of lung cancer screening. CONCLUSION: The present commentary utilizes information about historical trends in tobacco use to highlight opportunities for targeted outreach efforts to engage communities at high risk with information about the lung cancer screening opportunity. Future efforts toward equitable implementation of lung cancer screening should focus on multi-level implementation strategies that engage and work in concert with community partners to co-create approaches that leverage strengths and reduce barriers within specific communities to achieve the potential of lung cancer screening.

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

PURPOSE: Despite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been demonstrated in Midwestern rural women. Greater travel distance for surgical treatment is associated with CPM. Our objective was to examine the relationship between rurality and travel distance to surgery with CPM. METHODS: Women diagnosed with stages I-III unilateral breast cancer between 2007 and 2017 were identified using the National Cancer Database. Logistic regression was used to model likelihood of CPM based on rurality, proximity to metropolitan centers, and travel distance. A multinomial logistic regression model compared factors associated with CPM with reconstruction versus other surgical options. RESULTS: Both rurality (OR 1.10, 95% CI 1.06-1.15 for non-metro/rural vs. metro) and travel distance (OR 1.37, 95% CI 1.33-1.41 for those who traveled 50 + miles vs. < 30 miles) were independently associated with CPM. For women who traveled 30 + miles, odds of receiving CPM were highest for non-metro/rural women (OR 1.33 for 30-49 miles, OR 1.57 for 50 + miles; reference: metro women traveling < 30 miles). Non-metro/rural women who received reconstruction were more likely to undergo CPM regardless of travel distance (ORs 1.11-1.21). Both metro and metro-adjacent women who received reconstruction were more likely to undergo CPM only if they traveled 30 + miles (ORs 1.24-1.30). CONCLUSION: The impact of travel distance on likelihood of CPM varies by patient rurality and receipt of reconstruction. Further research is needed to understand how patient residence, travel burden, and geographic access to comprehensive cancer care services, including reconstruction, influence patient decisions regarding surgery.

The COVID-19 pandemic impact on independent and provider-based rural health clinics' operations and cancer prevention and screening provision in the United States.

INTRODUCTION: The COVID-19 pandemic has disrupted cancer care, but it is unknown how the pandemic has affected care in Medicare-certified rural health clinics (RHCs) where cancer prevention and screening services are critical for their communities. This study examined how the provision of these cancer services changed pre- and peri-pandemic overall and by RHC type (independent and provider-based). METHODS: We administered a cross-sectional survey to a stratified random sample of RHCs to assess clinic characteristics, pandemic stressors, and the provision of cancer prevention and control services among RHCs pre- and peri-pandemic. We used McNemar's test and Wilcoxon signed rank tests to assess differences in the provision of cancer prevention and screening services pre- and peri-pandemic by RHC type. RESULTS: Of the 153 responding RHCs (response rate of 8%), 93 (60.8%) were provider-based and 60 (39.2%) were independent. Both RHC types were similar in their experience of pandemic stressors, though a higher proportion of independent RHCs reported financial concerns and challenges obtaining personal protective equipment. Both types of RHCs provided fewer cancer prevention and screening services peri-pandemic-5.8 to 4.2 for provider-based and 5.3 to 3.5 for independent (P<.05 for both). Across lung, cervical, breast, and colorectal cancer-related services, the proportion of both RHC groups providing services dropped peri-pandemic. DISCUSSION: The pandemic's impact on independent and provider-based RHCs and their patients was considerable. Going forward, greater resources should be targeted to RHCs-particularly independent RHCs-to ensure their ability to initiate and sustain evidence-based prevention and screening services.

Measuring and addressing health equity: an assessment of cancer center designation requirements.

PURPOSE: By requiring specific measures, cancer endorsements (e.g., accreditations, designations, certifications) promote high-quality cancer care. While 'quality' is the defining feature, less is known about how these endorsements consider equity. Given the inequities in access to high-quality cancer care, we assessed the extent to which equity structures, processes, and outcomes were required for cancer center endorsements. METHODS: We performed a content analysis of medical oncology, radiation oncology, surgical oncology, and research hospital endorsements from the American Society of Clinical Oncology (ASCO), American Society of Radiation Oncology (ASTRO), American College of Surgeons Commission on Cancer (CoC), and the National Cancer Institute (NCI), respectively. We analyzed requirements for equity-focused content and compared how each endorsing body included equity as a requirement along three axes: structures, processes, and outcomes. RESULTS: ASCO guidelines centered on processes assessing financial, health literacy, and psychosocial barriers to care. ASTRO guidelines related to language needs and processes to address financial barriers. CoC equity-related guidelines focused on processes addressing financial and psychosocial concerns of survivors, and hospital-identified barriers to care. NCI guidelines considered equity related to cancer disparities research, inclusion of diverse groups in outreach and clinical trials, and diversification of investigators. None of the guidelines explicitly required measures of equitable care delivery or outcomes beyond clinical trial enrollment. CONCLUSION: Overall, equity requirements were limited. Leveraging the influence and infrastructure of cancer quality endorsements could enhance progress toward achieving cancer care equity. We recommend that endorsing organizations 1) require cancer centers to implement processes for measuring and tracking health equity outcomes and 2) engage diverse community stakeholders to develop strategies for addressing discrimination.

Prioritizing rural populations in state comprehensive cancer control plans: a qualitative assessment.

PURPOSE: The Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program (NCCCP) requires that states develop comprehensive cancer control (CCC) plans and recommends that disparities related to rural residence are addressed in these plans. The objective of this study was to explore rural partner engagement and describe effective strategies for incorporating a rural focus in CCC plans. METHODS: States were selected for inclusion using stratified sampling based on state rurality and region. State cancer control leaders were interviewed about facilitators and barriers to engaging rural partners and strategies for prioritizing rural populations. Content analysis was conducted to identify themes across states. RESULTS: Interviews (n = 30) revealed themes in three domains related to rural inclusion in CCC plans. The first domain (barriers) included (1) designing CCC plans to be broad, (2) defining "rural populations," and (3) geographic distance. The second domain (successful strategies) included (1) collaborating with rural healthcare systems, (2) recruiting rural constituents, (3) leveraging rural community-academic partnerships, and (4) working jointly with Native nations. The third domain (strategies for future plan development) included (1) building relationships with rural communities, (2) engaging rural constituents in planning, (3) developing a better understanding of rural needs, and (4) considering resources for addressing rural disparities. CONCLUSION: Significant relationship building with rural communities, resource provision, and successful strategies used by others may improve inclusion of rural needs in state comprehensive cancer control plans and ultimately help plan developers directly address rural cancer health disparities.

Pre-pandemic geographic access to hospital-based telehealth for cancer care in the United States.

IMPORTANCE: Little is known about US hospitals' capacity to ensure equitable provision of cancer care through telehealth. OBJECTIVE: To conduct a national analysis of hospitals' provision of telehealth and oncologic services prior to the SARS-CoV-2 pandemic, along with geographic and sociodemographic correlates of access. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional analysis with Geographic Information Systems mapping of 1) 2019 American Hospital Association (AHA) Annual Hospital Survey and IT Supplement, 2) 2013 Urban Influence Codes (UIC) from the United States Department of Agriculture, 3) 2018 Area Health Resources Files from the Health Services and Resources Administration (HRSA). INTERVENTIONS: Hospitals were categorized by telehealth and oncology services availability. Counties were classified as low-, moderate-, or high-access based on availability of hospital-based oncology and telehealth within their boundaries. MAIN OUTCOMES AND MEASURES: Geospatial mapping of access to hospital-based telehealth for cancer care. Generalized logistic mixed effects models identified associations between sociodemographic factors and county- and hospital-level access to telehealth and oncology care. RESULTS: 2,054 out of 4,540 hospitals (45.2%) reported both telehealth and oncology services. 272 hospitals (6.0%) offered oncology without telehealth, 1,369 (30.2%) offered telehealth without oncology, and 845 (18.6%) hospitals offered neither. 1,288 out of 3,152 counties with 26.6 million residents across 41 states had no hospital-based access to either oncology or telehealth. After adjustment, rural hospitals were less likely than urban hospitals to offer telehealth alongside existing oncology care (OR 0.27; 95% CI 0.14-0.55; p < .001). No county-level factors were significantly associated with telehealth availability among hospitals with oncology. CONCLUSIONS AND RELEVANCE: Hospital-based cancer care and telehealth are widely available across the US; however, 8.4% of patients are at risk for geographic barriers to cancer care. Advocacy for adoption of telehealth is critical to ensuring equitable access to high-quality cancer care, ultimately reducing place-based outcomes disparities. Detailed, prospective, data collection on telehealth utilization for cancer care is also needed to ensure improvement in geographic access inequities.

Financial navigation: Staff perspectives on patients' financial burden of cancer care.

PURPOSE: To describe perceptions of financial navigation staff concerning patients' cancer-related financial burden. METHODS: This qualitative descriptive study used a semi-structured interview guide to examine perceptions of financial navigation staff concerning patients' cancer-related financial burden. Staff who provided financial navigation support services to cancer patients were interviewed from different types of cancer programs across seven states representing rural, micropolitan, and urban settings. Interviews lasted approximately one hour, were audio recorded, and transcribed. Transcripts were double coded for thematic analysis. RESULTS: Thirty-five staff from 29 cancer centers were interviewed. The first theme involved communication issues related to patient and financial navigation staff expectations, timing and the sensitive nature of financial discussions. The second theme involved the multi-faceted impact of financial burden on patients, including stress, difficulty adhering to treatments, and challenges meeting basic, non-medical needs. CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS: Cancer-related financial burden has a profound impact on cancer survivors' health and non-health outcomes. Discussions regarding cancer-related costs between cancer survivors and healthcare team members could help to normalize conversations and mitigate the multi-faceted determinants and effects of cancer-related financial burden. As treatment may span months and years and unexpected costs arise, having this discussion regularly and systematically is needed.

Availability of hospital-based cancer services before and after rural hospital closure, 2008-2017.

INTRODUCTION: Rural populations have less access to cancer care services and experience higher cancer mortality rates than their urban counterparts, which may be exacerbated by hospital closures. Our objective was to examine the impact of hospital closures on access to cancer-relevant hospital services across hospital service areas (HSAs). METHODS: We used American Hospital Association survey data from 2008 to 2017 to examine the change in access to cancer-related screening and treatment services across rural HSAs that sustained hospitals over time, experienced any closures, or had all hospitals close. We performed a longitudinal analysis to assess the association between hospital closure occurrence and maintenance or loss of cancer-related service lines accounting for hospital and HSA-level characteristics. Maps were also developed to display changes in the availability of services across HSAs. RESULTS: Of the 2,014 rural HSAs, 3.8% experienced at least 1 hospital closure during the study period, most occurring in the South. Among HSAs that experienced hospital closure, the loss of surgery services lines was most common, while hospital closures did not affect the availability of overall oncology and radiation services. Screening services either were stable (mammography) or increased (endoscopy) in areas with no closures. DISCUSSION: Rural areas persistently experience less access to cancer treatment services, which has been exacerbated by hospital closures. Lack of Medicaid expansion in many Southern states and other policy impacts on hospital financial viability may play a role in this. Future research should explore the impact of closures on cancer treatment receipt and outcomes.

Impact of Endocrinologist and Surgeon Density on Well-Differentiated Thyroid Cancer Survival.

BACKGROUND: The influence of provider density and access on well-differentiated thyroid cancer (DTC) survival is uncertain. METHODS: We used the SEER18 database to study DTC patients undergoing surgery from 2000-2012. County-level endocrinologist and surgeon density were calculated. We evaluated the relationship between provider density and cause-specific survival controlling for demographic, socioeconomic, and treatment characteristics. RESULTS: Median endocrinologist density was 1.4/100 000 residents, with 15.5% of patients living in a county with no endocrinologist. Survival increased by 11% for each endocrinologist/100,000 people (P = .007). Median surgeon density was 14.8/100 000 residents, with only 1.7% of patients living in a county with no general surgeon or otolaryngologist. No significant association between surgeon density and survival was identified (P = .06). Rural residence was independently associated with lower survival (P = .009). CONCLUSIONS: County-level endocrinologist density is associated with improved DTC survival. Results may reflect endocrinologist expertise, earlier diagnosis, or represent surrogacy for higher county-level access to specialized care.

Sociodemographic disparities in molecular testing for breast cancer.

PURPOSE: Molecular testing is a critical component of breast cancer care used to identify the presence of estrogen and/or progesterone receptors (jointly hormone receptors-HRs) and the expression of human epidermal growth factor 2 (HER2) on a tumor. Our objective was to characterize trends and predictors of lack of molecular testing among female breast cancer patients overall and by sociodemographic characteristics. METHODS: We examined data on female breast cancer patients diagnosed between 2010 and 2016 from Surveillance Epidemiology and End Results-18. Joinpoint regression analyses assessed annual percent change (APC) in lack of ER, PR, or HER2 testing. Multivariable, multilevel logistic regression models identified factors associated with lack of molecular testing. RESULTS: A nominally lower proportion of rural patients did not receive molecular testing (e.g., 1.8% in rural vs. 2.3% in urban for HER2). For all tests, a higher proportion of Hispanic and non-Hispanic Black women were not tested. Across all characteristics, improvement in testing was noted, although disparities among groups remained. For example, lack of HER2 testing improved from 3.2 to 1.7% in White patients (APC = - 10.05) but was consistently higher in Black patients 3.9 to 2.3% (APC = - 8.21). Multivariable, multilevel models showed that older, non-Hispanic Black, and unpartnered women were at greater odds of not receiving molecular testing. CONCLUSIONS: While lack of molecular testing of breast cancer patients is relatively rare, racial/ethnic, insurance status, and age-related disparities have been identified. To reduce testing and downstream treatment and outcome disparities, it is imperative for all breast cancer patients to receive molecular testing.

The Problem Of The Color Line: Spatial Access To Hospital Services For Minoritized Racial And Ethnic Groups.

Examining how spatial access to health care varies across geography is key to documenting structural inequalities in the United States. In this article and the accompanying StoryMap, our team identified ZIP Code Tabulation Areas (ZCTAs) with the largest share of minoritized racial and ethnic populations and measured distances to the nearest hospital offering emergency services, trauma care, obstetrics, outpatient surgery, intensive care, and cardiac care. In rural areas, ZCTAs with high Black or American Indian/Alaska Native representation were significantly farther from services than ZCTAs with high White representation. The opposite was true for urban ZCTAs, with high White ZCTAs being farther from most services. These patterns likely result from a combination of housing policies that restrict housing opportunities and federal health policies that are based on service provision rather than community need. The findings also illustrate the difficulty of using a single metric-distance-to investigate access to care on a national scale.

Rural and racial disparities in colorectal cancer incidence and mortality in South Carolina, 1996 - 2016.

PURPOSE: Colorectal cancer (CRC) is the third leading cause of cancer mortality among men and women in the United States and South Carolina (SC). Since SC has one of the highest proportions of Black (27.9%) and rural residents (33.7%), the purpose of this investigation was to describe the burden of CRC on racial disparities in rural populations. METHODS: Count data from 2012 to 2016 were obtained from the state central cancer registry using an online data retrieval system. Rural-urban status was determined using Urban Influence Codes (1-2 = urban; 3-12 = rural). Chi-square tests were calculated to examine differences in CRC stage by rurality and race. Annual percent change and annual average percent change (AAPC) were calculated to examine trends in incidence and mortality rates across rural-urban and racial groups between 1996 and 2016. RESULTS: Areas with high mortality-to-incidence ratios tended to be in rural counties. Furthermore, rural residents had higher proportions of distant stage CRC compared to urban residents, and Black populations had higher proportions of distant stage CRC compared to White populations (22.7% vs. 26.3% and 29.3% vs. 23.7%, respectively; P value < 0.05). From 1996 to 2016, Black and White urban-dwelling residents experienced a significant decline in incidence. Urban White, urban Black, and rural White populations experienced significant declines in mortality (AAPC = -2.6% vs -2.4% vs -1.6% vs -0.9%, respectively). CONCLUSIONS: Despite improvements in CRC screening in recent decades, focused evidenced-based interventions for lowering incidence and mortality among rural and Black populations in South Carolina are necessary.

Interventions to address cancer-related financial toxicity: Recommendations from the field.

PURPOSE: Addressing financial toxicity among cancer patients is a complex process that requires a multifaceted approach, particularly for rural patients who may face additional cost-related barriers to care. In this study, we examined interventions being implemented by financial navigation staff at various cancer centers that help address financial toxicity experienced by oncology patients. METHODS: We conducted semistructured interviews with a convenience sample of financial navigation staff across 29 cancer centers in both rural and urban areas in 7 states. Interviews were audio-recorded and transcribed. Descriptive coding and thematic analysis techniques were used to analyze the data. FINDINGS: Thirty-five participants were interviewed, the majority of whom worked in cancer centers located in rural counties. Participants identified the use of screening tools, patient education, and access to tailored financial assistance resources as best practices. Immediate resource needs included additional financial navigation staff, including lay navigators and community health workers, to promote linkages to local resources. Suggested clinical areas for intervention included proactive and early implementation of financial assessments and discussions between providers and patients, along with training and access to regularly updated resources for those in financial navigator/counselor roles. Participants also discussed the need for policy-level interventions to reform health systems (including employment protections) and health insurance programs. CONCLUSIONS: Implementing proactive methods to screen for and address financial needs of patients is essential to improving cancer-related outcomes. Additional programs and research are needed to help establish systematic and standardized methods to enhance financial navigation services, especially for underserved rural communities.

Low-dose CT lung cancer screening uptake: A rural-urban comparison.

PURPOSE: The US Preventive Services Task Force recommends lung cancer screening with Low-Dose Computed Tomography (LDCT) in high-risk individuals. Our objective was to identify demographic, health, and financial factors associated with screening uptake, with a focus on urban-rural differences. METHODS: We analyzed data from the 2018 and 2019 Behavioral Risk Factor Surveillance System and its optional Lung Cancer Screening Module to examine factors associated with screening uptake among 20 states that administered the optional module. We compared differences in factors associated with uptake overall and by geographical regions and conducted multivariable logistic mixed-effects regression, accounting for participant clustering by state to assess the impact of these factors on uptake. FINDINGS: Overall 1,268 participants underwent LDCT screening with no significant differences observed between rural (16.3%) and urban residents (17.7%, p = 0.67). In multivariable models, rural residents did not differ significantly in their LDCT screening uptake (OR = 0.85; 95% CI: 0.67-1.09, p = 0.20), but uptake was significantly higher for participants with underlying chronic respiratory conditions, veterans, those with higher pack-year history, and those with poor/fair general health and prior history of cancer. Uptake declined with age, higher education level, concerns about paying for medical care, and lack of primary care. CONCLUSIONS: Modifiable targets can be leveraged to increase LDCT screening. Based on significant predictors of screening uptake, clinicians should prioritize interventions that effectively consider smoking history as well as those identified as effective in veterans' health settings. Additionally, reducing structural barriers to care related to insurance and income will be key to reducing disparities.

How cancer programs identify and address the financial burdens of rural cancer patients.

PURPOSE: Financial toxicity is associated with negative patient outcomes, and rural populations are disproportionately affected by the high costs of cancer care compared to urban populations. Our objective was to (1) understand cancer programs' perceptions of rural-urban differences in cancer patients' experiences of financial hardship, (2) evaluate the resources available to cancer patients across the rural-urban continuum, and (3) determine how rural and urban health care teams assess and address financial distress in cancer patients. METHODS: Seven research teams within the Cancer Prevention and Research Control Network conducted semi-structured interviews with cancer program staff who have a role in connecting cancer patients with financial assistance services in both rural and urban counties. Interviews were audio-recorded and transcribed. We identified themes using descriptive content and thematic analysis. RESULTS: We interviewed 35 staffs across 29 cancer care programs in seven states, with roughly half of respondents from programs in rural counties. Participants identified differences in rural and urban patients' experiences of financial hardship related to distance required to travel for treatment, underinsurance, and low socioeconomic status. Insufficient staffing was an identified barrier to addressing rural and urban patients' financial concerns. CONCLUSIONS: Improved financial navigation services could mitigate the effects of financial toxicity experienced by cancer patients, particularly rural patients, throughout treatment and survivorship. Future research is needed to improve how cancer programs assess financial hardship in patients and to expand financial navigation services to better serve rural cancer patients.

Trends in Cancer Treatment Service Availability Across Critical Access Hospitals and Prospective Payment System Hospitals.

BACKGROUND: Rural residents experience worse cancer prognosis and access to cancer care providers than their urban counterparts. Critical access hospitals (CAHs) represent over half of all rural community hospitals. However, research on cancer services provided within CAHs is limited. OBJECTIVE: The objective of this study was to investigate trends in cancer services availability in urban and rural Prospective Payment System (PPS) hospitals and CAHs. DESIGN: Retrospective, time-series analysis using data from 2008 to 2017 American Hospital Association Annual Surveys. Multivariable logistic regressions were used to examine differential trends in cancer services between urban PPS, rural PPS, and CAHs, overall and among small (<25 beds) hospitals. SUBJECTS: All US acute care and cancer hospitals (4752 in 2008 to 4722 in 2017). MEASURES: Primary outcomes include whether a hospital provided comprehensive oncology services, chemotherapy, and radiation therapy each year. RESULTS: In 2008, CAHs were less likely to provide all cancer services, especially chemotherapy (30.4%) and radiation therapy (2.9%), compared with urban (64.4% and 43.8%, respectively) and rural PPS hospitals (42.0% and 23.3%, respectively). During 2008-2017, compared with similarly sized PPS hospitals, CAHs were more likely to provide oncology services and chemotherapy, but with decreasing trends. Radiation therapy availability between small PPS hospitals and CAHs did not differ. CONCLUSIONS: Compared with all PPS hospitals, CAHs offered fewer cancer treatment services and experienced a decline in service capability over time. These differences in chemotherapy services were mainly driven by hospital size, as small urban and rural PPS hospitals had lower rates of chemotherapy than CAHs. Still, the lower rates of radiotherapy in CAHs highlight disproportionate challenges facing CAHs for some specialty services.

Association between Neighborhood Social Deprivation and Stage at Diagnosis among Breast Cancer Patients in South Carolina.

The purpose of this study was to examine the association between neighborhood social deprivation and individual-level characteristics on breast cancer staging in African American and white breast cancer patients. We established a retrospective cohort of patients with breast cancer diagnosed from 1996 to 2015 using the South Carolina Central Cancer Registry. We abstracted sociodemographic and clinical variables from the registry and linked these data to a county-level composite that captured neighborhood social conditions-the social deprivation index (SDI). Data were analyzed using chi-square tests, Student's t-test, and multivariable ordinal regression analysis to evaluate associations. The study sample included 52,803 female patients with breast cancer. Results from the multivariable ordinal regression model demonstrate that higher SDI (OR = 1.06, 95% CI: 1.02-1.10), African American race (OR = 1.35, 95% CI: 1.29-1.41), and being unmarried (OR = 1.17, 95% CI: 1.13-1.22) were associated with a distant stage at diagnosis. Higher tumor grade, younger age, and more recent year of diagnosis were also associated with distant-stage diagnosis. As a proxy for neighborhood context, the SDI can be used by cancer registries and related population-based studies to identify geographic areas that could be prioritized for cancer prevention and control efforts.