Rural–urban disparities and trends in utilization of palliative care services among US patients with metastatic breast cancer

Purpose

To assess trends and rural–urban disparities in palliative care utilization among patients with metastatic breast cancer.

Methods

We analyzed data from the 2004–2019 National Cancer Database. Palliative care services, including surgery, radiotherapy, systemic therapy, and/or other pain management, were provided to control pain or alleviate symptoms; utilization was dichotomized as “yes/no.” Rural–urban residence, defined by the US Department of Agriculture Economic Research Service's Rural–Urban Continuum Codes, was categorized as “rural/urban/metropolitan.” Multivariable logistic regression was used to examine rural–urban differences in palliative care use. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated.

Findings

Of 133,500 patients (mean age 62.4 [SD = 14.2] years), 86.7%, 11.7%, and 1.6% resided in metropolitan, urban, and rural areas, respectively; 72.5% were White, 17.0% Black, 5.8% Hispanic, and 2.7% Asian. Overall, 20.3% used palliative care, with a significant increase from 15.6% in 2004–2005 to 24.5% in 2008–2019 (7.0% increase per year; p-value for trend <0.001). In urban areas, 23.3% received palliative care, compared to 21.0% in rural and 19.9% in metropolitan areas (p < 0.001). After covariate adjustment, patients residing in rural (AOR = 0.84; 95% CI: 0.73–0.98) or metropolitan (AOR = 0.85, 95% CI: 0.80–0.89) areas had lower odds of having used palliative care than those in urban areas.

Conclusions

In this national, racially diverse sample of patients with metastatic breast cancer, the utilization of palliative care services increased over time, though remained suboptimal. Further, our findings highlight rural–urban disparities in palliative care use and suggest the potential need to promote these services while addressing geographic access inequities for this patient population.