Stephanie B. Wheeler

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.

Cost-effectiveness of Human Papillomavirus Self-collection Intervention on Cervical Cancer Screening Uptake among Underscreened U.S. Persons with a Cervix

Abstract Background: We evaluate the cost-effectiveness of human papillomavirus (HPV) self-collection (followed by scheduling assistance for those who were HPV+ or inconclusive) compared with scheduling assistance only and usual care among underscreened persons with a cervix (PWAC). Methods: A decision tree analysis was used to estimate the incremental cost-effectiveness ratios (ICER), or the cost per additional PWAC screened, from the Medicaid/state and clinic perspectives. A hypothetical cohort represented 90,807 low-income, underscreened individuals. Costs and health outcomes were derived from the MyBodyMyTest-3 randomized trial except the usual care health outcomes were derived from literature. We performed probabilistic sensitivity analyses (PSA) to evaluate model uncertainty. Results: Screening uptake was highest in the self-collection alternative (n = 65,721), followed by the scheduling assistance alternative (n = 34,003) and usual care (n = 18,161). The self-collection alternative costs less and was more effective than the scheduling assistance alternative from the Medicaid/state perspective. Comparing the self-collection alternative with usual care, the ICERs were $284 per additional PWAC screened from the Medicaid/state perspective and $298 per additional PWAC screened from the clinic perspective. PSAs demonstrated that the self-collection alternative was cost-effective compared with usual care at a willingness-to-pay threshold of $300 per additional PWAC screened in 66% of simulations from the Medicaid/state perspective and 58% of simulations from the clinic perspective. Conclusions: Compared with usual care and scheduling assistance, mailing HPV self-collection kits to underscreened individuals appears to be cost-effective in increasing screening uptake. Impact: This is the first analysis to demonstrate the cost-effectiveness of mailed self-collection in the United States.