Association of rurality, socioeconomic status, and race with pancreatic cancer surgical treatment and survival.

Abstract

Pancreatectomy is a necessary component of curative intent therapy for pancreatic cancer, and patients living in non-metropolitan areas may face barriers to accessing timely surgical care. We evaluated the intersecting associations of rurality, socioeconomic status (SES), and race on treatment and outcomes of Medicare beneficiaries with pancreatic cancer. We conducted a retrospective cohort study, using fee-for-service Medicare claims of beneficiaries with incident pancreatic cancer (2016-2018). We categorized beneficiary place of residence as metropolitan, micropolitan, or small town/rural. Measures of SES were Medicare-Medicaid dual eligibility and the Area Deprivation Index (ADI). Primary study outcomes were receipt of pancreatectomy and one-year mortality. Exposure-outcome associations were assessed with competing risks and logistic regression. We identified 45,915 beneficiaries with pancreatic cancer, including 78.4%, 10.9%, and 10.7% residing in metropolitan, micropolitan, and rural areas, respectively. In analyses adjusted for age, sex, comorbidity, and metastasis, residents of micropolitan and rural areas were less likely to undergo pancreatectomy (adjusted subdistribution hazard ratio=0.88 for rural, 95%CI 0.81-0.95) and had higher one-year mortality (aOR=1.25 for rural, 95%CI 1.17-1.33), compared with metropolitan residents. Adjustment for measures of SES attenuated the association of non-metropolitan residence with mortality, and there was no significant association of rurality with pancreatectomy after adjustment. Black beneficiaries had lower likelihood of pancreatectomy than White, non-Hispanic beneficiaries (aSHR=0.80, 95%CI 0.72-0.89, adjusted for SES). One-year mortality in metropolitan areas was higher for Black beneficiaries (aOR=1.15 95%CI 1.05-1.26). Rurality, socioeconomic deprivation, and race have complex interrelationships and are associated with disparities in pancreatic cancer treatment and outcomes.