Influence of Race, Insurance, and Rurality on Equity of Breast Cancer Care.

BACKGROUND:Considerable gaps in knowledge remain regarding the intersectionality between race, insurance status, rurality, and community-level socioeconomic status that contribute in concert to disparities in breast cancer care delivery. METHODS:Women age 18-64 y old with either private, Medicaid, or no insurance coverage and a diagnosis of breast cancer from the North Carolina Central Cancer Registry (2010-2015) were identified and reviewed. Logistic regression models examined the impact of race, insurance status, rurality, and the Social Deprivation Index (SDI) on advanced stage disease at diagnosis (III, IV) and receipt of cancer directed surgery (CDS). Models tested two-way interactions between race, insurance status, rurality, and SDI. RESULTS:Of the study population (n = 23,529), 14.6% were diagnosed with advanced stage disease (III, IV), and 97.1% of women with non-metastatic breast cancer (n = 22,438) received cancer directed surgery (CDS). Twenty percent of women were non-Hispanic Black (NHB), 3.0% Hispanic, 10.9% Medicaid insured, 5.9% uninsured, 20.0% of women resided in rural areas, and 20.0% resided in communities of the highest quartile SDI. NHB race, Medicaid or uninsured status, and residence in rural or socially deprived areas were associated with advanced stage breast cancer at diagnosis. NHB and Medicaid or uninsured women were significantly less likely to receive CDS. There were no statistically significant interactions found influencing stage at diagnosis or receipt of cancer directed surgery. CONCLUSIONS:In a heterogeneous population across the state of North Carolina, non-Hispanic Black race, Medicaid or uninsured status, and residence in rural or high social deprivation communities are independently associated with advanced stage breast cancer at diagnosis, while non-Hispanic Black race and Medicaid or uninsured status are associated with lower odds to receive cancer directed surgery.