Differences in Breast Cancer Care Between Rural Women Undergoing Treatment at a Referral Center and Those Treated Locally.

backgroundReferral of rural women to specialty centers may change breast cancer treatment and improve outcomes. This study aimed to evaluate breast cancer care among rural women treated at their diagnosing institution (non-referred women [NRW]) compared with those treated at another facility after diagnosis (referred women [RW]).

methodsWomen from rural zip codes with stages I to III breast cancer were identified from the National Cancer Database, 2010-2021. Patient, tumor, and treatment characteristics were compared.

resultsOf 184,156 rural women, 11 % were RW. The referral rate increased from 7 % in 2010 to 14 % in 2021 (p < 0.0001). On multivariable analysis, referred women were less likely to be black or have ER+HER2+ or clinical N2 disease. Referred women were more likely to be of Asian race or Hispanic ethnicity or to have larger clinical tumor size or ER-HER2- disease. Referred women were less likely to undergo breast-conserving surgery (BCS) (52 % vs 60 %), receive post-BCS radiation (79 % vs 86 %), or receive endocrine therapy (81 % vs 85 %) (all p < 0.001). Referred women were more likely to undergo reconstruction (41 % vs 32 %) and travel ≥50 miles (45 % vs 28 %) (all p < 0.001). Referred women more often had ≥60 days from diagnosis to first treatment (22 % vs 13 %; p < 0.0001).

conclusionsReferral of rural women for breast cancer treatment is increasing. Differences exist between RW and NRW with regard to race/ethnicity, distance to facility, tumor characteristics, and treatment. Further investigation into the underlying causes of these differences may identify opportunities to ensure that rural women have timely access to the full spectrum of treatment options.