1. Presented by Bryan Rettig, MS Nebraska Dept. of Health & Human Services At the NAACCR 2013 Annual Conference Austin, TX June 11, 2013 The effects of age, income, and place of residence on the stage of disease at diagnosis of breast cancer

2. ObjectiveObjective To evaluate the associations between socioeconomic status, place of residence, and the stage of disease at diagnosis of female breast cancer

3. PurposePurpose Compare Nebraska findings to similar studies conducted elsewhere Provide information to DHHS Comprehensive Cancer Control Program – Planning and evaluation Develop methodology for geocoded dataset analysis to be applied in future analyses

4. MethodsMethods Invasive breast cancers diagnosed between 1995 and 2009 among non-Hispanic white Nebraska women age ≥50 years (N=14,353) Address at diagnosis used to geocode each case to Census tract Census tracts classified into 4 poverty levels – % residents living below 100% federal poverty level (from 2000 US Census) – ≥20%, 10-19.9%, 5-9.9%, <5%

5. MethodsMethods Urban/rural residence – USDA-RUCA categories combined into two: urban (urban, suburban, large rural town) and rural (small town/isolated rural area) Stage of disease at diagnosis classification – Local (stage 1) – Regional/distant (stages 2-7)

6. MethodsMethods Multiple logistic regression model with random effect for Census tract – 2005-2009 cases only – Controlled for age – Odds ratios with 95% confidence intervals Joinpoint regression analysis – Trends in early-stage and late-stage incidence during 1995-2009 by poverty level – Average annual percentage change

7. ResultsResults All cases (N=4,695)Late stage (N=1,530) Age at diagnosis (years)n (%) 50-641,957 (41.7)702 (45.9) 65+2,738 (58.3)828 (54.1) Poverty <5%1,318 (28.1)421 (27.5) 5-9.9%1,808 (38.5)566 (37.0) 10-19.9%1,391 (29.6)482 (31.5) ≥20%178 (3.8)61 (4.0) Place of residence Urban3,263 (69.5)1,063 (69.5) Rural1,432 (30.5)467 (30.5)

8. ResultsResults Incidence, 2005-2009 Age (years)Rate (per 100,000 female population) 50-64340 65+417 Poverty <5%459 5-9.9%370 10-19.9%340 ≥20%381 Place of residence Urban402 Rural341

9. ResultsResults Odds Ratio95% Confidence Intervals Age (years) 50-64Referent 65+0.80.7-0.9 Poverty <5%Referent 5-9.9%1.00.8-1.2 10-19.9%1.20.96-1.4 ≥20%1.20.8-1.7 Place of residence UrbanReferent Rural1.00.9-1.2

10. ResultsResults

11. ConclusionsConclusions Rural residence might not hinder access to screening and care Increasing early-stage and late-stage incidence during 1995-2009 among women living in low- poverty areas Power low to detect differences in late-stage diagnosis among women living in high-poverty areas

12. LimitationsLimitations Few cases of minority race/ethnicity and age <50 years Few cases in high-poverty Census tracts Few high- and low-poverty Census tracts in rural areas Appropriate urban/rural classification scheme unknown Ecologic analysis: Census tract rather than individual poverty level

13. AcknowledgementAcknowledgement The authors wish to thank Kristin Yeoman, MD, MPH of the Centers for Disease Control and Prevention (CDC) for her invaluable and generous efforts on behalf of this research