Women living in rural areas in the U.S. are significantly more likely to have metastatic disease at the time of their ovarian cancer diagnosis than those living in metropolitan areas, a study of patients in three Midwest states found.

This finding is likely not a consequence of travel time to reach a primary care provider. Rather, researchers said, it may be due to greater distances for obstetric gynecologists, fewer clinical resources, lesser expertise among specialists, and a hesitancy among women in rural areas to seek medical care.

The study, “Impact of Rurality on Stage IV Ovarian Cancer at Diagnosis: A Midwest Cancer Registry Cohort Study,” was published in the Journal of Rural Health.

Individuals who live in rural areas are more likely to have poorer cancer outcomes, including lower survival rates. These poorer outcomes are likely related to a number of factors, including lesser access to healthcare services and a lower socioeconomic status.

Ovarian cancer patients in rural areas are also less likely to easily be able to access specialty surgical care and treatment once diagnosed.

Given that the stage of ovarian cancer at diagnosis is one of the strongest predictors of survival, a group of  researchers in the U.S. set out to determine whether ovarian cancer patients in rural areas are diagnosed at a more advanced stage than those in urban areas.

Specifically, they looked at how a rural location affected metastatic cancer (stage IV) at diagnosis, regardless of distance to primary care provider and patients’ socioeconomic status.

Using statewide registries, data covering 1,000 women, diagnosed with primary ovarian cancer in 2011–12, living in three Midwestern states — Iowa, Kansas, and Missouri — were analyzed.

At diagnosis, 111 women had stage IV metastatic cancer, and 889 had stage early stage to locally advanced cancer, or cancer that has spread to nearby lymph nodes and tissue.

Compared with patients with early stage to locally advanced cancer, women with metastatic disease were older on average (66.9 vs. 63.2 years), were more likely to live in rural areas (28% vs. 17%), to have more comorbidities (simultaneous presence of two chronic diseases; 14% vs. 7%), and to have nonepithelial ovarian cancer ( 6% vs 3%).

Rural women were also 2.4 times more likely to have metastatic ovarian cancer at diagnosis than in metropolitan locations, statistical analysis showed.

“Our results, from a sample of women in 3 Midwestern states, indicate that rural women were more likely than those not living in rural areas to present with stage IV ovarian cancer,” the scientists wrote.

Interestingly, living farther from the primary care physician did not increase a women’s risk of metastatic cancer at diagnosis. In fact, women who lived between 31 and 60 miles away from their primary care physician were less likely to have metastatic disease compared to those who lived 15 or fewer miles away.

Rather, the study’s investigators suggested, the greater risk of an advanced cancer at diagnosis may be due to greater distances to gynecologists, fewer resources and speciality gynecology training, higher rate of obesity (limiting the ability to notice signs of ovarian cancer), and a lower likelihood that women in rural areas seek medical care when symptoms arise.

Further studies are needed to better understand the relationship between rurality and metastatic ovarian cancer, and address problems found, the team added.