DISPARITIES IN BREAST AND CERVICAL CANCER SCREENING AND TREATMENT IN RURAL AREAS

Ashley Saunders, PA-S2, ATC

Gannon University- Ruskin Campus

Master of Physician Assistant Studies

CANCER FACTS AND STATISTICS

• Estimated 2022 Numbers in the US
• 1.9 million new cancer cases¹
• ~610,000 deaths due to cancer¹
• That’s 4 new cases and 1 death per minute¹
• Breast cancer is the most prevalent cancer worldwide.²
• Occurs in every single country of the world ²
• Cervical cancer is the 7^th most prevalent cancer worldwide. ³
• 4^th most common cancer in women ³

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GLOBAL RATES OF BREAST CANCER

• ~2.3 million new breast cancer diagnoses made in 2020 ²
• ~685,000 deaths due to breast cancer in 2020 ²
• Number of cases higher in developed countries
• Areas with the highest number of cases based on population ⁴:
• Australia, New Zealand, Western and Northern European countries, North America
• Mortality rate higher in developing countries
• Areas with the highest mortality rates based on population ⁵:
• Barbados, Fiji, Jamaica, Bahamas, Papua New Guinea

Figure 1. Global mortality rates of breast cancer⁶

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RATES OF BREAST CANCER IN THE UNITED STATES

• ~290,000 new breast cancer diagnoses will be made in 2022 ¹
• ~44,000 deaths will be due to breast cancer in 2022 ¹
• Number of cases are higher in New Hampshire, Connecticut, and Hawaii ⁴
• Not the most conclusive data because there are a lot of outliers
• Based on multiple factors that can change on yearly basis to significantly influence numbers
• Access to imaging, rural screening efforts, population
• Mortality rates are higher in DC, Mississippi, and Oklahoma ⁴
• Similar and different factors play a role
• Access to screening, providers, and treatment
• Late-stage diagnosis in more rural areas of a state
• Some states may have a larger rural population due to size of the state

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Figure 2. Lifetime Risk of Breast Cancer in Females⁶

GLOBAL RATES OF �CERVICAL CANCER

• ~604,000 new cervical cancer diagnoses made in 2020 ³
• ~342,000 deaths due to cervical cancer in 2020 ³
• Number of cases and mortality rates are higher in low-resource countries ³
• Areas with the highest number of cases based on population ³:
• Eswatini, Malawi, Zambia, Zimbabwe, Tanzania, Uganda
• Areas with the highest morality rates based on population ³:
• Eswatini, Malawi, Zambia, Zimbabwe, Tanzania, Uganda
• Little variation in the top 10 countries in both cases and mortality rates
• Both lists are almost identical

Figure 3. Cervical cancer statistics²

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RATES OF CERVICAL CANCER IN THE UNITED STATES

• ~14,100 new cervical cancer diagnoses will be made in 2022 ¹
• ~4,300 deaths will be due to cervical cancer in 2022 ¹
• Women are most frequently diagnosed between the ages of 35-44, but average age at time of diagnosis is 50 ⁷

SCREENING GUIDELINES

American Cancer Society

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• Breast Cancer
• Ages 40-45: individual choice
• Ages 45-54: every year
• Ages 55 and up: every two years or every year (if preferred by patient)
• Cervical Cancer
• Ages 25-65: primary HPV test every 5 years

United States Preventive Screening Task Force ²

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• Breast Cancer
• Ages 40-49: individual choice
• Ages 50-74: every two years
• Cervical Cancer
• Ages 21-29: cytology every 3 years
• Ages 30-65: cytology every 3 years, primary HPV test every 5 years, or co-testing every 5 years

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IMPACT OF RURAL LIVING: BREAST AND CERVICAL CANCERS

• Rural living is often considered a risk factor for poorer cancer outcomes, due to accessibility of timely screening and treatment.
• Similar outcomes to urban patients if access to timely screening and treatment is comparable⁸
• Significantly increased odds of late-stage diagnoses of breast and cervical cancer⁸
• Why is this a notable finding, particularly in breast cancer?
• Rural living as a protective factor in breast care incidences
• Number of breast cancer diagnoses is increased in urban populations compared to cervical cancer incidence, which is increased in rural populations.⁹
• Differences in screening patterns, access to care, lifestyle, and socioeconomic factors vary depending on site of cancer and local community⁸
• Time between awareness of symptoms, 1^st clinic visit, diagnosis, and treatment is increased in rural patients¹⁰
• Average time between awareness of symptoms to diagnosis of cervical cancer in Ethiopian women was 30 weeks.¹⁰
• Average time between awareness of breast cancer symptoms to first clinic visit in Ethiopian women was 81 weeks.¹⁰
• Typically results in poorer outcomes due to delay in taking an initial or next step

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DISPARITIES IN SCREENING THE RURAL POPULATION FOR BREAST AND CERVICAL CANCERS

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• Emotional and physical discomfort during breast and cervical cancer screenings¹¹
• Screenings for breast and cervical cancer through mammograms and pap smears are decreased in rural vs urban women.⁹
• Shortage of providers to initiate and perform screenings
• Lack of patient education in the importance of these screenings
• Fear of cancer related death decreased number of screenings¹²
• Only 25% of women screened at federally qualified health centers reported they knew the purpose of a pap smear¹³

DISPARITIES IN SCREENING THE RURAL POPULATION FOR BREAST AND CERVICAL CANCERS

• Fear of cost
• Cost is one of the biggest factors that prevents rural residents from getting screened.¹²
• Cultural variations and stigmas
• Cultural views on modesty can decrease breast and cervical cancer screening rates.¹²
• HPV is the most prevalent STI in the world and cause most cases of cervical cancer.¹³
• Mistrust of the medical system
• Previous negative experience with healthcare
• Family or friend had a negative experience

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DISPARITIES IN TREATING THE RURAL POPULATION FOR BREAST AND CERVICAL CANCERS

• Lack of primary care providers in rural areas
• Follow-ups after abnormal screenings
• Referrals to oncologists and other specialists come from PCPs
• Increased provider turn-over rates¹³
• Only 5.6% of oncologists in the US work in rural settings.¹⁴
• Transportation and travel distance to primary care or specialty offices
• Inadequate diagnostic capacities and weak referral systems in low-to-middle income countries¹⁰

DISPARITIES IN TREATING THE RURAL POPULATION FOR BREAST AND CERVICAL CANCERS

• Insurance status
• Affordable Care Act mandates coverage of screenings, but cost-sharing for follow-up care¹³
• Increased gatekeeping/referrals from PCPs to oncologists if universal healthcare, especially if patient lives in a rural area.¹⁵
• Rural residents are less likely to establish care with a PCP.
• Those enrolled in Medicaid, other public insurances, or those uninsured are all less likely to get screened for cervical cancer than those enrolled in private or military insurance.¹³

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DISPARITIES IN EDUCATING THE RURAL POPULATION FOR BREAST AND CERVICAL CANCERS

• Health literacy
• Obtaining, processing, and understanding health information in order to make an informed decision
• Misguided perceptions of breast and cervical cancer
• Cancer is contagious.¹⁰
• Cancer inevitably ends in death.¹⁰
• Misinformation about cost
• Diagnosing and treating cancer can be incredibly expensive, but there are programs to help aid in cost that the patient may be unaware of.
• Cost should not stop a patient from seeking help.
• Access to health-related resources and information
• Studies show that this is an increasing demand with rural patients.¹⁴
• Internet resources may not be an option.

RESEARCH IN RURAL POPULATIONS AND CANCER OUTCOMES

• More research needs to be done!
• Research will vary across all rural living, so it is crucial that local studies be conducted before reliable comparisons can be made on a larger scale.
• Important to remember that incidences of breast and cervical cancers will not be evenly distributed.

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WAYS TO IMPROVE DISPARITIES

• Improve PCP density in rural areas
• Increases patient accessibility
• Loan repayment options
• Community-based education programs
• Anyone can help
• Allows for and demonstrates a support system
• Calls or letters for reminders/overdue screenings improves screening rates¹³
• Develop and implement efficient screening programs
• Invitations, mobile screening, extended hours, travel vouchers¹³, HPV self-sampling¹³
• Find an organized way of managing and monitoring screening performance to ensure thoroughness

WAYS TO IMPROVE DISPARITIES

• Develop and implement efficient follow-up strategies, regardless of screening results.
• Can help eliminate miscommunication
• Patient leaves screening with assurance of an answer
• Phone calls, video calls (if accessible), in-person
• Aid with transition of care and scheduling, if appropriate
• Provide cost transparency for follow-up care.
• Partnerships between healthcare systems and the community
• Get involved, advocate, and get others involved.
• Anyone that wants to help has something to offer, medical or non-medical.

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REFERENCES�

1. American Cancer Society. Cancer Statistics Center. cancer.org. Updated 2022. Accessed August 9, 2022. https://cancerstatisticscenter.cancer.org/?_ga=2.91321884.701665709.1660068841-1312707437.1654182026#!/.

2. World Health Organization. Breast Cancer. who.int. Published March 26, 2021. Accessed August 9, 2022. https://www.who.int/news-room/fact-sheets/detail/breast-cancer.

3. World Cancer Research Fund International. Cervical Cancer Statistics. wcrf.org. Accessed August 9, 2022. https://www.wcrf.org/cancer-trends/cervical-cancer-statistics/.

4. Susan G. Komen. Breast Cancer Statistics. komen.org. Updated July 26, 2022. Accessed August 9, 2022. https://www.komen.org/breast-cancer/facts-statistics/breast-cancer-statistics/.

5. World Cancer Research Fund International. Breast Cancer Statistics. wcrf.org. Accessed August 9, 2022. https://www.wcrf.org/cancer-trends/breast-cancer-statistics/.

6. National Breast Cancer Coalition. Breast Cancer Facts and Figures. stopbreastcancer.org. Published 2022. Accessed August 9, 2022. https://www.stopbreastcancer.org/information-center/facts-figures/.

7. American Cancer Society. Key Statistics for Cervical Cancer. cancer.org. Update January 12, 2022. Accessed August 9, 2022. https://www.cancer.org/cancer/cervical-cancer/about/key-statistics.html.

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8. Thompson, J.A., Chollet-Hinton, L., Keighley, J. et al. The need to study rural cancer outcome disparities at the local level: a retrospective cohort study in Kansas and Missouri. BMC Public Health 21, 2154 (2021). https://doi.org/10.1186/s12889-021-12190-w

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9. Moss JL, Liu B, Feuer EJ. Urban/Rural Differences in Breast and Cervical Cancer Incidence: The Mediating Roles of Socioeconomic Status and Provider Density. Womens Health Issues. 2017;27(6):683-691. doi:10.1016/j.whi.2017.09.008

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10. Nnaji CA, Ezenwankwo EF, Kuodi P, Walter FM, Moodley J. Timeliness of diagnosis of breast and cervical cancers and associated factors in low-income and middle-income countries: a scoping review. BMJ Open. 2022;12(2):e057685. Published 2022 Feb 4. doi:10.1136/bmjopen-2021-057685

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11. Roberts J, Smith JL, Hall IJ. Interventions to increase breast and cervical cancer screening uptake among rural women: a scoping review. Cancer Causes Control. 2020;31(11):965-977. doi:10.1007/s10552-020-01340-x

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12. Falk D. A Mixed Methods Review of Education and Patient Navigation Interventions to Increase Breast and Cervical Cancer Screening for Rural Women. Social Work in Public Health. 2018;33(3):173-186. doi:10.1080/19371918.2018.1434583

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13. Fuzzell LN, Perkins RB, Christy SM, Lake PW, Vadaparampil ST. Cervical cancer screening in the United States: Challenges and potential solutions for underscreened groups. Prev Med. 2021;144:106400. doi:10.1016/j.ypmed.2020.106400

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14. Anbari AB, Wanchai A, Graves R. Breast cancer survivorship in rural settings: a systematic review. Support Care Cancer. 2020;28(8):3517-3531. doi:10.1007/s00520-020-05308-0

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15. Bergin RJ, Emery JD, Bollard R, White V. Comparing Pathways to Diagnosis and Treatment for Rural and Urban Patients With Colorectal or Breast Cancer: A Qualitative Study. J Rural Health. 2020;36(4):517-535. doi:10.1111/jrh.12437

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