Original Research

The association between breast cancer capacity and resources with incidence and mortality in Arizona’s low populous counties

AUTHORS

name here
Adrienne B Lent1
DrPH, Manager, Research *

name here
Prashanthinie Mohan2
DrPH, Analyst

name here
Daniel Derksen3
MD, Professor

name here
William G Cance4
MD, Chief Medical and Scientific Officer

name here
Leila Barraza5
JD, MPH, Associate Professor

name here
Elizabeth T Jacobs6
PhD, Professor

name here
Elizabeth A Calhoun7
PhD, Professor

AFFILIATIONS

1 University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ 85724, USA; and Department of Community, Environment, & Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N Martin Ave, Tucson, AZ 85724, USA

2 Department of Community, Environment, & Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N Martin Ave, Tucson, AZ 85724, USA. Present address: Health Services Advisory Group, 3133 East Camelback Road Suite 100, Phoenix, AZ 85016, USA

3, 5 Department of Community, Environment, & Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N Martin Ave, Tucson, AZ 85724, USA

4 University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ 85724, USA. Present address: American Cancer Society, Inc., 250 Williams St, Atlanta, GA 30303, USA

6 University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ 85724, USA; and Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N Martin Ave, Tucson, AZ 85724, USA

7 University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ 85724, USA; and Department of Community, Environment, & Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N Martin Ave, Tucson, AZ 85724, USA. Present address: University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA

ACCEPTED: 29 March 2021


early abstract:

Introduction: While cancer deaths have decreased nationally, declines have been much slower in rural areas compared to urban areas. Previous studies on rural cancer service capacity are limited to specific points along the cancer care continuum (eg, screening, diagnosis, or treatment) and require updating to capture the current rural health landscape since implementation of the 2010 Affordable Care Act. The association between current rural cancer service capacity across the cancer care continuum and cancer incidence and death is unclear. This cross-sectional study explored the association between breast cancer service capacity and incidence and mortality in Arizona’s low populous counties.  
Methods: To measure county-level cancer capacity, clinical organizations operating within low populous areas of Arizona were surveyed to assess on-site breast cancer services provided (screening, diagnosis, and treatment) and number of healthcare providers were pulled from Centers for Medicare and Medicaid Services National Provider Identifier database. The number of clinical sites and healthcare providers were converted to county-level per capita rates. Rural-Urban Continuum codes were used to designate rural or urban county status. Age adjusted county-level breast cancer incidence and death rates from 2010 through 2016 were obtained from the Arizona Department of Health Services, Arizona Cancer Registry. Descriptive statistics were used to summarize the results. Multivariate regression was used to evaluate the association between cancer capacity and incidence and mortality in 13 out of Arizona’s 15 counties.
Results: Rural counties had more per capita clinical sites (20.4) than urban counties (8.9) (p=0.02). Urban counties had more per capita pathologists (1.0) than rural counties (0) (p =<0.01). In addition to zero pathologists, rural counties had zero medical oncologists. Rural county status was associated with a decrease in breast cancer incidence (β = -20.1, 95% CI: -37.2, 3.1).
Conclusions: While Arizona’s sparsely populated rural counties may have more physical infrastructure per capita, these services are dispersed over vast geographic areas. They lack specialists providing cancer services. Non-physician clinical providers may be more prevalent in rural areas and represent opportunities for improving access to cancer preventive services and care. Compared to urban counties, rural county status was associated with lower breast cancer incidence rates although there were no statistically significant differences in breast cancer mortality. Other factors may contribute to rural-urban differences in breast cancer incidence. Future research should explore these factors and the association between cancer capacity and local resources because the use of county level data represents a challenge in Arizona, where counties average over 7,500 sq. mi.