Breast Cancer in Rural America

October is nationally recognized as Breast Cancer Awareness month across the United States. Breast cancer is the most commonly diagnosed cancer across nearly every racial and ethnic group in the country, but care for those with the disease has greatly improved, as have survival rates. According to the Susan G. Komen Foundation, breast cancer deaths have decreased by as much as 34% and continue to decline. Unfortunately, improvement has not occurred equally among all populations.

Just as with so many other diseases, those with breast cancer in rural America are less likely to have the cancer diagnosed early and to receive the treatment necessary. Dr. Anne Schuchat, the former acting director of the CDC explained in a press release:

“While geography alone can’t predict your risk of cancer, it can impact prevention, diagnosis, and treatment opportunities — and that’s a significant public health problem in the United States… Many cancer cases and deaths are preventable and with targeted public health efforts and interventions, we can close the growing cancer gap between rural and urban Americans.”

According to the CDC, rural areas have lower incidence of cancer than urban areas, but they have higher cancer death rates (slower reduction in cancer death rates in rural America - a decrease of 1.0 percent per year- compared with urban America - a decrease of 1.6 percent per year). This number may sound small and abstract, but each of these unnecessary deaths is a child growing up without a mother, a family losing their daughter, a husband losing his partner, and a community losing a member. The differences in death rates between rural and urban areas are increasing over time, but this does not have to continue. Understanding rural-urban disparities in breast cancer diagnosis and treatment in rural America is critically important in efforts to ensure that rural women are not dying from an otherwise preventable and curable disease.

Catching Cancer Quickly
The stage of cancer at diagnosis has an enormous impact on treatment, recovery, and survival. In most cases, and especially with breast cancer, the earlier the cancer is detected and treated the higher the survival rate for the patient. Women living in rural areas are screened for breast cancer less often than women in urban areas. One study from the WWAMI Rural Health Research Center (RHRC) found that, although overall participation in breast cancer screenings have increased over time, there is a persistent disparity between urban and rural women. At the time of the study, 75.7% of urban respondents had received timely mammography, but only 70.8% of rural women had.

Rural women are on average poorer than those in urban and suburban areas and are unable to afford both travel, prevention, and treatment. Lower income women, especially those living in rural areas, have longer times to follow-up after abnormal mammogram than women of higher income or those living in urban areas closer to medical facilities. Immediate follow-up after abnormal screenings is critically important in addressing and treating the cancer as soon as possible.

Like many other rural health disparities, there are also inequalities within rural communities. The CDC has found that screening disparities between rural and nonrural women are even more pronounced among minorities: African-Americans and Native American women receive less breast cancer screening than their white rural counterparts.

All About Access
Many rural regions have fewer medical facilities and less health services, limiting access to breast cancer screening. Differences in cancer death rates might be related to disparities in access to healthcare services. Electra Paskett, PhD, co-leader of the cancer control research program at The Ohio State University Comprehensive Cancer Center, agreed with that assessment. She told Healthline that we can expect an exponential rise in these disparities as some rural populations continue to lose access to health care.

According to the Sheps Center at UNC, nearly 90 rural hospitals have closed since 2010. Today, 44% rural hospitals operate at a loss, and nearly 700 rural hospitals are at risk of closure. When a hospital closes, patients lose access to care. When Congress chips away at rural health safety net programs, some hospitals who manage to keep their doors open still cannot afford to provide care for patients with advanced diseases like late stage breast cancer.

For example, multiple hospitals report the 340B program is the reason the hospital can provide oncology infusions to those in their local community, despite consistent Congressional attacks on the program. Childress Hospital in Texas is about 100 miles from another hospital that provides oncology care, for one patient the opening of the oncology infusion unit meant he did not have to travel four hours each way to receive his chemotherapy, as he had done with this first round of treatment. This sort of travel is particularly difficult in light of common chemotherapy side effects such as fatigue, nausea and vomiting, and diarrhea. Fort Madison Community Hospital in Fort Madison Iowa is a 1 hour and 45 minute drive from the next hospital providing chemotherapy infusions.

Supporting Survivors
“These (rural) survivors are more likely to be isolated and have trouble dealing with their cancer,” explains Dr. Christie Befort, Co-leader, Cancer Control and Population Health Research Program, The University of Kansas Cancer Center. “They also don’t have as much access to support services as someone in a bigger city does.”

As we move forward in addressing care access, we must also consider what follow-up and support services look like for breast cancer survivors living in rural areas. This Breast Cancer Awareness Month, we need to take time to focus on policies and opportunities to address the needs of rural breast cancer patients and survivors.

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