Abstract PD1-01: Causes of diminished outcomes among rural breast cancer survivors

Abstract Introduction: Multiple reports have indicated that rural breast cancer survivors have worse clinical and patient-reported outcomes than do urban/suburban survivors. However, causes of these discrepancies are unclear. While numerous factors contribute to these observed differences, specific causes for diminished outcomes among rural breast cancer survivors must be identified to develop effective interventions and policies to support this underserved population. Methods: We used data from the 2020-2023 National Health Interview Survey (NHIS), a nationally representative household survey of the civilian noninstitutionalized U.S. population. All women aged 18 or older self-reporting a history of breast cancer were included in the study population. Three outcome significantly worse among rural (vs. urban/suburban) survivors were selected: increased emergency department (ED) utilization; decreased self-reported health status; and lower life satisfaction. We conducted causal mediation analysis to identify factors that partially explained the relationship between rural residence and worse outcomes among breast cancer survivors. Potential mediators from the NHIS included access to telemedicine, counseling, and homecare services; health limitations in ability to work; lack of employer-provided sick leave and health insurance; Medicare, Medicaid, or no health insurance; and decreased medication use due to costs. Causal mediation analysis was performed using SAS 9.4, incorporating the statistical design of the NHIS to provide results generalizable to the overall U.S. population. Results: Three NHIS items significantly mediated associations between rural status and poor outcomes among breast cancer survivors: lack of telemedicine use, health limitations in ability to work, and Medicaid insurance. Lack of telemedicine use mediated 20.3% of the association of rural residence and increased ED use (p=0.01), 22.3% of worse health status (p=0.004), and 26.6% of decreased life satisfaction (p=0.04). Health limitation in working significantly mediated 39.1% (p=0.005), 59.4% (p=0.003), and 59.1% (p=0.005) of associations with ED use, health status, and satisfaction, respectively. Medicaid insurance significantly mediated associations of rural residence with worse health status (43.9%, p=0.01) and lower life satisfaction (43.1%, p=0.04). Not receiving homecare marginally (p