Breast| Volume 168, ISSUE 4, P653-661, October 2020

Do rural patients with operable breast cancer fare worse than urban patients in Louisiana? Results of the Louisiana cancer consortium



      It is unknown whether rural patients with operable breast cancer do worse than urban patients in Louisiana. We performed an analysis of breast cancer based on rural versus urban residencies and evaluate factors associated with worse survival.


      Data on women diagnosed with stages I to III breast cancer from 2004 to 2016 were obtained from the Louisiana Tumor Registry. Overall survival and cancer-specific survival were compared between rural and urban residencies by sociodemographic, clinical-pathologic, and treatment variables. Kaplan-Meier method and the log-rank test were used to compare the survival curves. Cox regression model was used to assess independent factors associated with overall survival and cancer-specific survival.


      Of the 27,780 patients, 2,441 patients (8.7%) resided in rural areas. Compared with urban patients, rural patients tended to be older, underinsured, more impoverished, less likely to be treated at an American College of Surgeons accredited institution, and more likely to be treated at a low-volume center (P < .005 each). For stages I and II diseases, there was a statistically significant difference in overall survival favoring urban regions, but no difference in cancer-specific survival. For stage III disease, there was no difference in either overall survival or cancer-specific survival between the 2 cohorts. Overall survival and cancer-specific survival curves for the entire cohort were not different at the 5-year mark, but become statistically significant with greater time; although rural patients had a lower long-term overall survival (P = .0001) and cancer-specific survival (P = .049) compared with urban patients, the rural-urban differences in overall survival and cancer-specific survival were no longer different after adjusting for other covariates, indicating the observed differences in univariate analysis were attributable to sociodemographic, clinicpathologic, and treatment factors.


      Despite rural patients with operable breast cancer having an overall lesser overall survival and cancer-specific survival than their urban counterpart, rural residence itself was not an independent predictor of outcome. In fact, particular socioeconomic factors increased the risk of death among patients residing in rural areas. Additional analysis at the patient-level is needed to understand the interactions between rurality and breast cancer outcomes in Louisiana.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Heron M.
        Deaths: Leading causes for 2017.
        (Published 2019. Accessed November 6, 2019)
        • Coughlin S.S.
        Social determinants of breast cancer risk, stage, and survival.
        Breast Cancer Res Treat. 2019; 177: 537-548
        • Organization W.H.
        Social determinants of health.
        • Henley S.J.
        • Anderson R.N.
        • Thomas C.C.
        • Massetti G.M.
        • Peaker B.
        • Richardson L.C.
        Invasive Cancer Incidence, 2004−2013, and Deaths, 2006−2015, in Nonmetropolitan and Metropolitan Counties: United States.
        MMWR Surveill Summ. 2017; 66: 1-13
        • Liff J.M.
        • Chow W.H.
        • Greenberg R.S.
        Rural-urban differences in stage at diagnosis. Possible relationship to cancer screening.
        Cancer. 1991; 67: 1454-1459
        • Markossian T.W.
        • Hines R.B.
        Disparities in late stage diagnosis, treatment, and breast cancer-related death by race, age, and rural residence among women in Georgia.
        Women Health. 2012; 52: 317-335
        • Leins C.
        States with the highest poverty rates.
        • National Cancer Institute
        Surveillence, Epidemiology, and End Results Program.
        Date accessed: November 7, 2019
        • Centers for Disease Control and Prevention
        Date accessed: July 1, 2019
      1. Unequal treatment: Confronting racial and ethnic disparities in health. National Academies Press, Washington, DC2003
        • McNulty J.A.
        • Nail L.
        Cancer survivorship in rural and urban adults: a descriptive and mixed methods study.
        J Rural Health. 2015; 31: 282-291
      2. Chu Q. The fight against breast cancer illustrated the health care challenges of women in poverty. The Catalyst A Journal of Ideas from the Bush Institute. 2019.

        • Mai V.
        • Sullivan T.
        • Chiarelli A.M.
        Breast cancer screening program in Canada: successes and challenges.
        Salud Publica Mex. 2009; 51: s228-235
        • Feig S.A.
        Effect of service screening mammography on population mortality from breast carcinoma.
        Cancer. 2002; 95: 451-457
        • Gooiker G.A.
        • van Gijn W.
        • Post P.N.
        • van de Velde C.J.
        • Tollenaar R.A.
        • Wouters M.W.
        A systematic review and meta-analysis of the volume-outcome relationship in the surgical treatment of breast cancer. Are breast cancer patients better of with a high volume provider?.
        Eur J Surg Oncol. 2010; 36: S27-S35
        • Greenup R.A.
        • Obeng-Gyasi S.
        • Thomas S.
        • et al.
        The effect of hospital volume on breast cancer mortality.
        Ann Surg. 2018; 267: 375-381
        • Agarwal S.
        • Pappas L.
        • Neumayer L.
        • Kokeny K.
        • Agarwal J.
        Effect of breast conservation therapy vs mastectomy on disease-specific survival for early-stage breast cancer.
        JAMA Surg. 2014; 149: 267-274
        • Hwang E.S.
        • Lichtensztajn D.Y.
        • Gomez S.L.
        • Fowble B.
        • Clarke C.A.
        Survival after lumpectomy and mastectomy for early stage invasive breast cancer: the effect of age and hormone receptor status.
        Cancer. 2013; 119: 1402-1411
        • US Department of Agriculture Economic Research Service
        Rural America at a tlance. Washington, DC: US Department of Agriculture.
        (Available at) (Accessed on July 1, 2019)