Urban/Rural Differences in Breast and Cervical Cancer Incidence: The Mediating Roles of Socioeconomic Status and Provider Density

Background: Breast and cervical cancer incidence vary by urbanicity, and several ecological factors could contribute to these patterns. In particular, cancer screening or other sociodemographic and health care system variables could explain geographic disparities in cancer incidence. Methods: Governmental and research sources provided data on 612 counties in the Surveillance, Epidemiology, and End Results program for rural-urban continuum code, socioeconomic status (SES) quintile, percent non-Hispanic White residents, density of primary care physicians, cancer screening, and breast and cervical cancer incidence rates (2009-2013). Ecological mediation analyses used weighted least squares regression to examine whether candidate mediators explained the relationship between urbanicity and cancer incidence. Results: As urbanicity increased, so did breast cancer incidence ((beta) over cap = 0.23; p<.001). SES quintile and density of primary care physicians mediated this relationship, whereas percent non-Hispanic White suppressed it (all p<.05); county-level mammography levels did not contribute to the relationship. After controlling for these variables, urbanicity and breast cancer incidence were no longer associated ((beta) over cap = 0.11; p>.05). In contrast, as urbanicity increased, cervical cancer incidence decreased ((beta) over cap = -0.33; p<.001). SES quintile and density of primary care physicians mediated this relationship (both p<.05); percent non-Hispanic White and Pap screening levels did not contribute to the relationship. After controlling for these variables, the relationship between urbanicity and cervical cancer incidence remained significant ((beta) over cap = -0.13; p<.05). Conclusions: County-level SES and density of primary care physicians explained the relationships between urbanicity and breast and cervical cancer incidence. Improving these factors in more rural counties could ameliorate geographic disparities in breast and cervical cancer incidence. Published by Elsevier Inc. on behalf of Jacobs Institute of Women's Health.