CHICAGO — Where a woman lives significantly affects whether her breast cancer is diagnosed at an early or late stage, according to a national analysis published in the Journal of the American College of Surgeons (JACS).
Researchers found prominent geographic variations within rural regions across the United States, and that race and insurance status also strongly influenced a woman’s stage of breast cancer at diagnosis.
“The geographic disparities were quite striking,” said Omolade Sogade, MD, MPHS, lead author of the study, and a resident in the Department of Surgery at Washington University in St. Louis, Missouri. “We found the highest rates of disparities in the South, and that even among different rural regions across the country, a woman’s geographic residence was one important factor impacting her risk of being diagnosed with advanced-stage breast cancer.”
While women in rural areas are known to face a higher risk of advanced breast cancer, less is understood about geographic differences within rural communities and the factors driving these disparities. Using the American College of Surgeons (ACS) National Cancer Database, researchers analyzed data from 52,287 rural women diagnosed with breast cancer between 2004 and 2021. Counties were defined as rural if they had no towns or cities, or if their largest town had fewer than 2,500 residents. The researchers used the U.S. Census regions and divisions to categorize rural areas.
Characteristics of Rural Breast Cancer Patients
Among rural patients, 13.6% were diagnosed with advanced breast cancer (Stage 3 or 4) compared with 12% of patients in non-rural areas.
Most rural patients were White (84%), between the ages of 50 and 69 at diagnosis (53%), and residing in the West North Central, South Atlantic, and East South Central regions (67%). The majority of patients were covered by Medicare (47%) or private insurance (39%), and more than half (62%) lived in areas in the lower half of income distribution (median income of less than $57,856).
About half of the patients received treatment at a comprehensive community cancer program. After adjusting for other factors, facility type was not associated with advanced-stage diagnosis.
Geographic Differences Within Rural Regions
Using the West North Central region (Iowa to the Dakotas) as a statistical reference point, the researchers found that:
- Women in the East South Central region (Alabama, Kentucky, Mississippi, Tennessee) were about 34% more likely to be diagnosed with Stage 4 breast cancer.
- Women in the West South Central region (Arkansas, Louisiana, Oklahoma, Texas) were 33% more likely to receive a Stage 4 breast cancer diagnosis.
Racial Disparities
Compared with White women:
- Black women were 58% more likely to be diagnosed with Stage 3 breast cancer and 28% more likely to be diagnosed with Stage 4 breast cancer.
- Hispanic women were 52% more likely to be diagnosed with Stage 3 breast cancer.
Insurance Status and Risk
Insurance coverage strongly influenced the stage at diagnosis.
- Compared with patients with private insurance, women without insurance were about twice as likely to be diagnosed with Stage 3 breast cancer and nearly four times as likely to be diagnosed with Stage 4 breast cancer.
- Medicaid coverage offered some protection but was still associated with an elevated risk of developing advanced breast cancer; women with Medicaid were nearly three times as likely as patients with private insurance to be diagnosed with Stage 4 breast cancer.
Breast cancer is highly treatable when detected early, but outcomes decline sharply with advanced-stage disease. According to the American Cancer Society, five-year survival rates for patients with breast cancer range from 87% to 99% when the disease has not spread beyond nearby lymph nodes, dropping to around 33% in advanced stages.
Addressing Gaps in Rural Communities
Several factors likely contribute to later breast cancer diagnoses in rural areas. Approximately 60% of rural counties lack an active general surgeon, and only about 3% of oncologists primarily practice in rural communities, the authors noted. Long travel distances, workforce shortages, limited access to screening, and reduced health literacy may further delay diagnosis.
The authors emphasize that solutions must be multifaceted and region-specific. Expanding access to screening, strengthening the rural surgical workforce, and tailoring health policies to meet local needs are critical steps. Programs such as fellowships offered through the ACS Rural Surgery Program aim to train surgeons committed to rural practice.
“Cancer disparities in rural areas are complex and driven by multiple factors,” said senior author Julie Margenthaler, MD, FACS, an ACS Governor, and professor of surgery and director of breast surgical services at the Washington University School of Medicine in St. Louis, Missouri. “Effective solutions must be tailored to the region and informed by a deep understanding of local barriers and the community’s specific needs. Surgical training is essential, but prevention, early detection, and providing comprehensive cancer care are equally important.”
The study relied on hospital-level data from the National Cancer Database and may not capture individual factors contributing to delayed diagnoses, the authors noted. Larger population-level analyses may reveal patient-specific barriers that hinder timely breast cancer detection in rural communities.
The findings were presented at the 137th Annual Meeting of the Southern Surgical Association (Hot Springs, Virginia, December 2025) and are published as an article in press on the JACS website.
Citation: Sogade O and Margenthaler J. Evaluating factors associated with advanced-stage breast cancer presentation in rural patients in the National Cancer Database. Journal of the American College of Surgeons, 2026. DOI: 10.1097/XCS.0000000000001759
