title: Breast cancer screening, area deprivation, and later-stage breast cancer in Appalachia: does geography matter?
abstract: OBJECTIVE
  To model the relationship of an area-based measure of a breast cancer screening and geographic area deprivation on the incidence of later stage breast cancer (LSBC) across a diverse region of Appalachia.
  
  
  METHODS
  Central cancer registry data (2006-2008) from three Appalachian states were linked to Medicare claims and census data.
  
  
  METHODS
  Exploratory spatial analysis preceded the statistical model based on negative binomial regression to model predictors and effect modification by geographic subregions.
  
  
  RESULTS
  Exploratory spatial analysis revealed geographically varying effects of area deprivation and screening on LSBC. In the negative binomial regression model, predictors of LSBC included receipt of screening, area deprivation, supply of mammography centers, and female population aged>75 years. The most deprived counties had a 3.31 times greater rate of LSBC compared to the least deprived. Effect of screening on LSBC was significantly stronger in northern Appalachia than elsewhere in the study region, found mostly for high-population counties.
  
  
  CONCLUSIONS
  Breast cancer screening and area deprivation are strongly associated with disparity in LBSC in Appalachia. The presence of geographically varying predictors of later stage tumors in Appalachia suggests the importance of place-based health care access and risk.
authors.affiliation: Department of Public Health Science, College of Medicine, The Pennsylvania State University, Hershey, PA.
authors.forename: Roger T
authors.initials: RT
authors.lastname: Anderson
authors.forename: Tse-Chang
authors.initials: TC
authors.lastname: Yang
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Matthews
authors.forename: Fabian
authors.initials: F
authors.lastname: Camacho
authors.forename: Teresa
authors.initials: T
authors.lastname: Kern
authors.forename: Heath B
authors.initials: HB
authors.lastname: Mackley
authors.forename: Gretchen
authors.initials: G
authors.lastname: Kimmick
authors.forename: Christopher
authors.initials: C
authors.lastname: Louis
authors.forename: Eugene
authors.initials: E
authors.lastname: Lengerich
authors.forename: Nengliang
authors.initials: N
authors.lastname: Yao
mesh_terms: D000368:Aged; D001061:Appalachian Region / Q000453:epidemiology; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000453:epidemiology*; D055088:Early Detection of Cancer / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D008327:Mammography; D060787:Neoplasm Grading; D011204:Poverty Areas
keywords: Appalachia; area deprivation; geographically weighted regression; later stage breast cancer; screening rates