title: Rural-Urban Differences in Late-Stage Breast Cancer: Do Associations Differ by Rural-Urban Classification System?
abstract: BACKGROUND
  Rural residence is associated with later stage of breast cancer diagnosis in some but not all prior studies. The lack of a standardized definition of rural residence may contribute to these mixed findings. We characterize and compare multiple definitions of rural vs. non-rural residence to provide guidance regarding choice of measures and to further elucidate rural disparities in breast cancer stage at diagnosis.
  
  
  METHODS
  We used Texas Cancer Registry data of 120,738 female breast cancer patients ≥50 years old diagnosed between 1995-2009. We defined rural vs. non-rural residence using 7 different measures and examined their agreement using Kappa statistics. Measures were defined at various geographic levels: county, ZIP code, census tract, and census block group. Late-stage was defined as regional or distant disease. For each measure, we tested the association of rural residence and late-stage cancer with unadjusted and adjusted logistic regression. Covariates included: age; patient race/ethnicity; diagnosis year; census block group-level mammography capacity; and census tract-level percent poverty, percent Hispanic, and percent Black.
  
  
  RESULTS
  We found moderate to high levels of agreement between measures of rural vs. non-rural residence. For 72.9% of all patients, all 7 definitions agreed as to rural vs. non-rural residence. Overall, 6 of 7 definitions demonstrated an adverse association between rural residence and late-stage disease in unadjusted and adjusted models (Adjusted OR Range = 1.09-1.14).
  
  
  CONCLUSIONS
  Our results document a clear rural disadvantage in late-stage breast cancer. We contribute to the heterogeneous literature by comparing varied measures of rural residence. We recommend use of the census tract-level Rural Urban Commuting Area Codes in future cancer outcomes research where small area data are available.
authors.affiliation: Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX U.S.A; Harold C. Simmons Comprehensive Cancer Center, Dallas, TX U.S.A.
authors.forename: Sandi L
authors.initials: SL
authors.lastname: Pruitt
authors.affiliation: Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC U.S.A; Cancer Prevention and Control Program, University of South Carolina, Columbia, SC U.S.A.
authors.forename: Jan M
authors.initials: JM
authors.lastname: Eberth
authors.affiliation: Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX U.S.A; School of Economic, Political, and Policy Sciences, University of Texas Dallas, Dallas TX U.S.A.
authors.forename: E Scott
authors.initials: ES
authors.lastname: Morris
authors.affiliation: Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX U.S.A.
authors.forename: David B
authors.initials: DB
authors.lastname: Grinsfelder
authors.affiliation: Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX U.S.A.
authors.forename: Erica L
authors.initials: EL
authors.lastname: Cuate
keywords: breast cancer; cancer stage; health disparities; measurement; rural