Evaluating the Role of Contextual Factors in Access to Care for Endometrial Cancer Patients

Endometrial cancer (EC) is the most common gynecologic malignancy in United States. Prior research has found that rural women with EC have an 8-17% higher mortality risk than their urban peers. However, few studies have examined the role of rurality in EC outcomes. Even fewer studies have examined how geographic contextual factors interact to either explain or increase risk for poor outcomes in rural patients. To address this research gap, the proposed study will examine rural/urban differences in EC outcomes through the lenses of the Behavioral Model of Access to Care. Aims 1 and 2 determine the role of contextual factors in explaining rurality’s influence on accessing adjuvant therapy (AT) and survival for EC patients. Aim 3 explores rural EC patients’ experiences accessing cancer treatment and understanding the mechanisms by which contextual factors impact access to care. This knowledge is essential for advancing knowledge of rural EC disparities and developing interventions to improve EC patients’ abilities to access care. The proposed study uses a secondary analysis of SEER-Medicare data (Aims 1 and 2) and qualitative interviews with 10 EC patients. The proposed study and associated research training also provide a foundation for developing a new nurse researcher’s program of research focused on understanding and developing interventions to minimize rural/urban cancer disparities.This dissertation found no variation in receipt of adjuvant therapy by rural/urban residence in a large, population-based cohort. Our study found limited evidence of the association between community socioeconomics measured by the Yost Index, and receipt of AT and that and individual measure of socioeconomic status, Medicaid eligibility, was a more sensitive predictor of receipt of AT. No differences in survival were observed by rural/urban residence when adjusting for patient, treatment, and disease characteristics. Differences in EC survival outcomes were observed by neighborhood SES and race in. In our qualitative work, we found that patient identified multilevel determinants of access to care throughout diagnosis and treatment. Participants discussed long travel times and the cost associated with those travel burdens as major barriers to care. This work highlights two main conclusions. One, is that the use of rural/urban to characterize a person’s place of residence as a risk factor for poor outcomes, may not be the most sensitive measure for EC patients. Two, while large, secondary data analyses may not show differences between rural and urban patients in receipt of care or mortality, patient experiences of hardship (financial or otherwise) may greatly impact quality of care and survivorship.