Ashley Leak Bryant

The Role of Rurality, Travel Time, and Neighborhood Socioeconomics on Patterns of Adjuvant Therapy Receipt among Patients with Endometrial Cancer

Abstract Background: Rural patients with endometrial cancer are more likely to receive lower-quality treatment compared with their urban peers. We evaluated the role of contextual factors [rurality, distance to care, and community socioeconomics (SES)] on the receipt of adjuvant therapy (AT): vaginal brachytherapy (VBT), external beam radiation, and chemotherapy. Methods: We analyzed Surveillance Epidemiology and End Results–Medicare and included stages IB grade 3 and stages II to IV. We used county-level rural–urban continuum codes to define rurality, the Yost index to measure community SES, and measure of average driving time to gynecologic oncology care. Multivariable logistic regression was used to estimate adjusted ORs (aOR) and 95% confidence intervals (CI) evaluating AT receipt, adjusting for patient-level clinical and demographic characteristics. Results: A total of 7,572 individuals met inclusion criteria; 15% were rural residing. Rurality was only associated with lower odds of any AT receipt among patients with stage IB endometrial cancer (aOR = 0.62; 95% CI, 0.46–0.83). Increasing travel time was associated with lower odds of VBT (aOR = 0.89; 95% CI, 0.84–0.95). Residence in a low-SES neighborhood was associated with lower odds of chemotherapy (aOR = 0.79; 95% CI, 0.67–0.92) and VBT (aOR = 0.81; 95% CI, 0.69–0.95); however, associations were no longer significant after adjusting for individual SES. Conclusions: Travel time to gynecologic oncology care negatively affects the receipt of treatment regardless of rural or urban residence. Travel time may be a proxy for access to brachytherapy services and may explain the associations between travel and receipt of VBT. Impact: Factors characterizing the place of residence beyond rural/urban residence are important for predicting inequitable access to AT.