title: Patterns of care with regard to surgical choice and application of adjuvant radiation therapy for preinvasive and early stage breast cancer in rural Appalachia.
abstract: BACKGROUND
  Many disparities exist in treatment of early stage breast cancer. Our objective was to conduct a cross-sectional registry analysis of women with early stage breast cancer in Appalachian Kentucky to identify factors affecting surgical choice [breast conserving surgery (BCS) vs mastectomy] and appropriate use of adjuvant radiation therapy (RT).
  
  
  METHODS
  Database collection was done through the Kentucky Cancer Registry. Inclusion criteria included female breast cancer patients diagnosed between 1998 and 2007. Patients were diagnosed with ductal carcinoma in situ or American Joint Committee on Cancer stage I or II disease. Database search was limited to Appalachian residents. Statistical analyses were carried out to identify variables affecting surgical choice, receipt of RT, and survival.
  
  
  RESULTS
  Analysis evaluated 5,541 Appalachian patients. The distribution of surgery favored BCS (54.1%) over mastectomy (45.9%). On multivariate analysis, the most significant factors for mastectomy were advanced stage [odds ratio (OR) 2.571, P<0.0001], rural location (OR 2.075, P<0.0001), and insurance status (OR 1.546, P<0.0001). Of patients choosing BCS, 56.2% received adjuvant RT. On multivariate analysis age >70 years (OR 2.506, P<0.0001), rural location (OR 2.416, P<0.0001), and lack of insurance (OR 1.651, P=0.0168) were the strongest predictors for not receiving adjuvant RT.
  
  
  CONCLUSIONS
  Mastectomy rate remains higher and the rate of RT after BCS is lower in Appalachian women compared with other contemporary studies of women with ductal carcinoma in situ and early stage breast cancer.
authors.affiliation: Department of Radiation Oncology, University of Louisville, KY, USA. andrew.freeman@chhi.org
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Freeman
authors.forename: Bin
authors.initials: B
authors.lastname: Huang
authors.forename: Anthony E
authors.initials: AE
authors.lastname: Dragun
mesh_terms: D000368:Aged; D001943:Breast Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D018270:Carcinoma, Ductal, Breast / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D002285:Carcinoma, Intraductal, Noninfiltrating / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D018275:Carcinoma, Lobular / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D002755:Choice Behavior; D003131:Combined Modality Therapy; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008408:Mastectomy; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D009367:Neoplasm Staging; D005791:Patient Care; D011379:Prognosis; D018714:Radiotherapy, Adjuvant; D012424:Rural Population; D015996:Survival Rate