The Effect of Rurality on Time to Surgery and Overall Survival among Women with Breast Cancer

Objective: How does distance to care affect time to surgery (TTS) and overall survival (OS) among rural patients with breast cancer? Summary Background Data: TTS>60 days is associated with known sociodemographic characteristics and worse OS after breast cancer diagnosis, but the relationship between rurality, proximity to care, TTS, and OS remains unknown. Methods: We identified females≥18 years with stage 0-III breast cancer diagnosed 2004-2019 who received upfront surgery in the National Cancer Database. Mediation and Cox proportional hazards analyses were conducted to assess the relationship between rurality, distance to treatment facility, prolonged TTS (i.e., >60 days), and OS. Results: Of 1,979,194 patients meeting inclusion criteria, 1.4% resided in rural areas. In the multivariate mediation analysis, the total effect of rurality on prolonged TTS corresponded to an aOR of 0.89 (95% CI 0.86-0.93), the direct effect corresponded to an aOR of 0.84 (95% CI 0.79-0.89), and the indirect effect corresponded to an aOR of 1.10 (95% CI 1.09-1.10). Over 50% of the total effect of rurality on prolonged TTS was mediated by proximity to treatment facility. After adjusting for clinical and sociodemographic factors, TTS of 61-90 days was associated with worse OS in both rural (HR 1.37, 95% CI 1.14-1.63) and urban (HR 1.75, 95% CI 1.72-1.78) patients with comparable results observed for TTS >90 days. Conclusions: Although geographic proximity to care mediates the relationship between rurality and prolonged TTS, rurality has an intrinsic protective effect on TTS that is independent of the adverse effect of increased distance to care.