Researchers have taken a new approach to understanding why so many patients with breast cancer in Appalachia are not getting the care they need, and their findings are set to change how people view the obstacles to receiving care that beset the region. For example, the distance patients have to travel for cancer care is often viewed as a critical factor. But this new study underscores the crucial importance of access to primary care providers, who are the frontline doctors who could catch cancer earlier.

The study was published in Medical Care (2015; doi:10.1097/MLR.0000000000000432).

The researchers at the University of Virginia School of Medicine Cancer Center in Charlottesville have applied new demographic techniques to evaluate why breast cancer is diagnosed in so many women in Appalachia at late stage, rather than it being caught early, when it is more easily treatable. They also evaluated why so many do not receive the adjuvant hormone therapy that could save their lives.

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Often this is blamed on travel times and distances, but the new research suggests this fails to tell the whole story. The researchers were more accurately able to predict late-stage diagnosis, for example, with the new approach than using traditional metrics such as travel times or provider-to-population ratios.

“We found almost a fifth of the women, 21% of the women diagnosed with breast cancer, had a late-stage diagnosis of breast cancer. The predictors of this late-stage diagnosis included things like insurance, but the biggest predictor was the measure of geospatial access that we had created,” said researcher Rajesh Balkrishnan, PhD, of the UVA Department of Public Health Sciences. “Access played a really important factor in determining late-stage diagnosis, as well as whether women received adjuvant hormone therapy.”

The approach Balkrishnan and his colleagues used, which is known as the two-step floating catchment area, has been widely used by demographers, but the UVA researchers believe this is the first time it has been applied to health care.

The researchers reviewed cancer registries in four Appalachian states—Kentucky, North Carolina, Ohio, and Pennsylvania—to identify more than 15,000 women with a breast cancer diagnosis between 2006 and 2008. They then evaluated 3 measures of care access: the ratio of care providers to the population; the distances patients must travel to see a provider; and the new demographic method, known as the 2SFCA method.

“Traditionally when looking at disparities, people have looked at distances: distances to hospitals, distances to physicians, the travel time between the patients and providers,” Balkrishnan explained. “One of the problems is that this doesn’t account for the supply-and-demand factors, which are particularly important in areas of geographic disparity, such as Appalachia.”

Instead, he found that the 2SFCA method, which factors in a host of variables, was the best predictor of the methods assessed. His conclusion: Traditional methods, such as distance to physicians, may not provide an accurate indicator of how much of a barrier patients actually face.