title: Breast cancer stage at diagnosis and geographic access to mammography screening (New Hampshire, 1998-2004).
abstract: BACKGROUND
  Early detection of breast cancer by screening mammography aims to increase treatment options and decrease mortality. Recent studies have shown inconsistent results in their investigations of the possible association between travel distance to mammography and stage of breast cancer at diagnosis.
  
  
  OBJECTIVE
  The purpose of the study was to investigate whether geographic access to mammography screening is associated with the stage at breast cancer diagnosis.
  
  
  METHODS
  Using the state's population-based cancer registry, all female residents of New Hampshire aged > or =40 years who were diagnosed with breast cancer during 1998-2004 were identified. The factors associated with early stage (stages 0 to 2) or later stage (stages 3 and 4) diagnosis of breast cancer were compared, with emphasis on the distance a woman lived from the closest mammography screening facility, and residence in rural and urban locations.
  
  
  RESULTS
  A total of 5966 New Hampshire women were diagnosed with breast cancer during 1998-2004. Their mean driving distance to the nearest mammography facility was 8.85 km (range 0-44.26; 5.5 miles, range 0-27.5), with a mean estimated travel time of 8.9 min (range 0.0-42.2). The distribution of travel distance (and travel time) was substantially skewed to the right: 56% of patients lived within 8 km (5 miles) of a mammography facility, and 65% had a travel time of less than 10 min. There was no significant association between later stage of breast cancer and travel time to the nearest mammography facility. Using 3 categories of rural/urban residence based on Rural Urban Commuting Area classification, no significant association between rural residence and stage of diagnosis was found. New Hampshire women were more likely to be diagnosed with breast cancer at later stages if they lacked private health insurance (p<0.001), were not married (p<0.001), were older (p<0.001), and there was a borderline association with diagnosis during non-winter months (p=0.074).
  
  
  CONCLUSIONS
  Most women living in New Hampshire have good geographical access to mammography, and no indication was found that travel time or travel distance to mammography significantly affected stage at breast cancer diagnosis. Health insurance, age and marital status were the major factors associated with later stage breast cancer. The study contributes to an ongoing debate over geographic access to screening mammography in different states, which have given contradictory results. These inconsistencies in the rural health literature highlight a need to understand the complexity of defining rural and urban residence; to characterize more precisely the issues that contribute to good preventive care in different rural communities; and to appreciate the efforts already made in some rural states to provide good geographic access to preventive care. In New Hampshire, specific subgroups such as the uninsured and the elderly remain at greatest risk of being diagnosed with later stage breast cancer and may benefit from targeted interventions to improve early detection.
authors.affiliation: New Hampshire State Cancer Registry, Dartmouth Medical School, Hanover, New Hampshire, USA. Maria.Celaya@Dartmouth.Edu
authors.forename: Maria O
authors.initials: MO
authors.lastname: Celaya
authors.forename: Ethan M
authors.initials: EM
authors.lastname: Berke
authors.forename: Tracy L
authors.initials: TL
authors.lastname: Onega
authors.forename: Jiang
authors.initials: J
authors.lastname: Gui
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Riddle
authors.forename: Sai S
authors.initials: SS
authors.lastname: Cherala
authors.forename: Judy R
authors.initials: JR
authors.lastname: Rees
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000453:epidemiology / Q000473:pathology / Q000517:prevention & control*; D042241:Early Diagnosis; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D016015:Logistic Models; D008327:Mammography / Q000706:statistics & numerical data*; D008403:Mass Screening / Q000706:statistics & numerical data*; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D009513:New Hampshire / Q000453:epidemiology; D012111:Residence Characteristics; D012424:Rural Population; D014505:Urban Population