Abstract
Iowa is among several rural Midwestern states with the highest proportions of contralateral prophylactic mastectomy (CPM) in women < 45 years of age. We evaluated the role of rurality and travel distance in these surgical patterns. Women with unilateral breast cancer (2007-2017) were identified using Iowa Cancer Registry records. Patients and treating hospitals were classified as metro, nonmetro, and rural based on Rural-Urban Continuum Codes. Differences in patient, tumor, and treatment characteristics and median travel distance (MTD) were compared. Characteristics associated with CPM were evaluated with multivariate logistic regression. 22,158 women were identified: 57% metro, 26% nonmetro and 18% rural. Young rural women had the highest proportion of CPM (52%, 39% and 40% for rural, metro, nonmetro women < 40 years). Half of all rural women had surgery at metro hospitals; these women had the longest MTD (62 miles). Among all women treated at metro hospitals, rural women had the highest proportion of CPM (17% rural vs 14% metro/nonmetro, p = 0.007). On multivariate analysis, traveling ≥ 50 miles (ORs 1.43-2.34) and rural residence (OR = 1.29) were independently predictive of CPM. Other risk factors were young age (< 40 years: OR = 7.28, 95% CI 5.97-8.88) and surgery at a metro hospital that offers reconstruction (OR = 2.30, 95% CI 1.65-3.21) and is not NCI-designated (OR = 2.34, 95% CI 1.92-2.86). There is an unexpectedly high proportion of CPM in young rural women in Iowa, and travel distance and availability of reconstructive services likely influence decision-making. Improving access to multidisciplinary care in rural states may help optimize decision-making.
Highlights
There is substantial variability in the use of contralateral prophylactic mastectomy (CPM) in women with unilateral breast cancer across the United States
Of all women treated at metro hospitals, rural women had the highest proportion with CPM (17% rural; vs 14% metro/nonmetro, p = 0.007)
We found that travel distance ≥ 50 miles predicted CPM regardless of rurality
Summary
There is substantial variability in the use of contralateral prophylactic mastectomy (CPM) in women with unilateral breast cancer across the United States. The US Midwest was recently noted to have a high proportion of CPM use with the state of Iowa having the second highest proportion nationally (44.9%) among women aged 20–44 during 2010–2012 [7, 8]. The etiology for this trend in the Midwest was unclear. Women who travel further for surgical care were shown to be more likely to undergo CPM in the National Cancer Database (NCDB), the relationship between travel distance and rurality was not studied [7]
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