Background: Breast cancer (BC) is the most commonly diagnosed cancer in women veterans and up to 50% will experience symptoms of depression and/or anxiety after diagnosis, which are associated with poor prognosis, poor quality of life, and reduced survival. An increasing number of women veterans reside in rural areas, where access to behavioral health services may be limited. This study sought to evaluate disparities in mental health screening and follow-up evaluation after a new BC diagnosis by rural vs urban status.
Methods: Women veterans with a new BC diagnosis were identified between 2017 and 2021. Data for mental health screenings (PHQ-2, PHQ-9, GAD-7) were collected subsequent to an initial BC diagnosis. Rurality was defined per the USDA RUCA codes framework. Data were abstracted from several VA and non-VA datasets, including the Corporate Data Warehouse (CDW) Outpatient files, non-VA Care Medical and Pharmacy System files, VA Program Integrity Tool, and the VA Central Cancer Registry. All categorical variables were analyzed using chi-square tests and mean differences analyzed using t-tests.
Results: 14,225 women veterans with a new BC diagnosis were identified. The mean age was 63.4 years (SD 11.7). Nearly 60% (59.6%) lived in an urban setting vs 40.4% in a rural setting. In the entire cohort, only 14% had a mental health screening within 3 months of diagnosis. Urban women veterans were more likely to be screened than rural women veterans (17.4% vs 9.2%, p< 0.001). For women screened within 3 months, most screened negative regardless of rurality (75.7% urban, 76.1% rural). Of women who had a positive mental health screen, approximately one-third (34.2% urban, 31.8% rural) had additional screening. However, for those with a negative initial screen, urban veterans were more likely to have any additional screening at subsequent visits (17% urban, 10.2% rural, p= 0.001). The PHQ-2 was the most common tool used (73.8%) followed by a combination of PHQ-9 and GAD-7 (9.6%).
Conclusions: Mental health screening within 3 months of BC diagnosis is low for women veterans and there is a significant difference in screening between rural and urban veterans. It is critical to improve mental health screening in the BC population and bridge disparities in rural and urban women veterans. These efforts have implications for care in VA and non-VA settings and may impact mental health and breast cancer outcomes during the period encompassing treatment and survivorship.