Colonna S

Purpose: To demonstrate Lean Process Improvement methodologies in a multidisciplinary, multicenter model to screen for increased risk of breast cancer in Women Veterans. We strive to deliver a team-based, cross-functional model that meets the unique healthcare needs of female Veterans and results in a Veteran-centric delivery of care.

Relevant Background/ Problem: Women are the fastest growing veterans population seeking care at the VA Health Administration (VHA). There is also an increased risk of breast cancer in Women Veterans. Based on national guidelines we are developing tools to promote the use of screening for high risk breast cancer and its prevention as well as other breast health issues.

Methods: A 9 institution, multidisciplinary team including oncology, surgery, nursing, pharmacy, biostatistics, genetic counseling, mental health, and health systems engineering was launched at the 2014 AVAHO annual meeting. Since then, the group has met every 2 weeks by conference call and has developed subcommittees focusing on International Review Board approval, data collection, grant writing, survey design, and strategic planning. We have developed tools to collect data, CPRS research notes, and a multiple choice questionnaire.

Results: As a result of combined efforts, currently 5 studies are being conducted: Know your breast cancer risk factors and prevention options-pilot program currently enrolling patients at 2 sites. The preliminary data will be presented at AVAHO. Chemoprevention in VHA system: A VINCI data review from 2000-2015 VINCI data review of prophylactic mastectomies at VHA from 2000-2015. Survey for Primary Care physicians regarding awareness of increased risk breast cancer screening and prevention options. Lean Process Improvement project to roll out a program to increase the use of CVT so that VAMCs may offer screening and primary prevention for high risk breast cancer. Additionally, we are offering genetic counseling and plan to improve adherence to chemoprevention through the use of CVT.

Implications/Future Directions: Lean Process Improvement may be an effective method to coordinate clinical care in high risk breast cancer screening and awareness. This process should be considered as a model throughout the VHA system to offer care in accordance with national guidelines for our Women Veterans.

Purpose: To demonstrate Lean Process Improvement methodologies in a multidisciplinary, multicenter model to screen for increased risk of breast cancer in Women Veterans. We strive to deliver a team-based, cross-functional model that meets the unique healthcare needs of female Veterans and results in a Veteran-centric delivery of care.

Relevant Background/ Problem: Women are the fastest growing veterans population seeking care at the VA Health Administration (VHA). There is also an increased risk of breast cancer in Women Veterans. Based on national guidelines we are developing tools to promote the use of screening for high risk breast cancer and its prevention as well as other breast health issues.

Methods: A 9 institution, multidisciplinary team including oncology, surgery, nursing, pharmacy, biostatistics, genetic counseling, mental health, and health systems engineering was launched at the 2014 AVAHO annual meeting. Since then, the group has met every 2 weeks by conference call and has developed subcommittees focusing on International Review Board approval, data collection, grant writing, survey design, and strategic planning. We have developed tools to collect data, CPRS research notes, and a multiple choice questionnaire.

Results: As a result of combined efforts, currently 5 studies are being conducted: Know your breast cancer risk factors and prevention options-pilot program currently enrolling patients at 2 sites. The preliminary data will be presented at AVAHO. Chemoprevention in VHA system: A VINCI data review from 2000-2015 VINCI data review of prophylactic mastectomies at VHA from 2000-2015. Survey for Primary Care physicians regarding awareness of increased risk breast cancer screening and prevention options. Lean Process Improvement project to roll out a program to increase the use of CVT so that VAMCs may offer screening and primary prevention for high risk breast cancer. Additionally, we are offering genetic counseling and plan to improve adherence to chemoprevention through the use of CVT.

Implications/Future Directions: Lean Process Improvement may be an effective method to coordinate clinical care in high risk breast cancer screening and awareness. This process should be considered as a model throughout the VHA system to offer care in accordance with national guidelines for our Women Veterans.

Purpose: To demonstrate Lean Process Improvement methodologies in a multidisciplinary, multicenter model to screen for increased risk of breast cancer in Women Veterans. We strive to deliver a team-based, cross-functional model that meets the unique healthcare needs of female Veterans and results in a Veteran-centric delivery of care.

Relevant Background/ Problem: Women are the fastest growing veterans population seeking care at the VA Health Administration (VHA). There is also an increased risk of breast cancer in Women Veterans. Based on national guidelines we are developing tools to promote the use of screening for high risk breast cancer and its prevention as well as other breast health issues.

Methods: A 9 institution, multidisciplinary team including oncology, surgery, nursing, pharmacy, biostatistics, genetic counseling, mental health, and health systems engineering was launched at the 2014 AVAHO annual meeting. Since then, the group has met every 2 weeks by conference call and has developed subcommittees focusing on International Review Board approval, data collection, grant writing, survey design, and strategic planning. We have developed tools to collect data, CPRS research notes, and a multiple choice questionnaire.

Results: As a result of combined efforts, currently 5 studies are being conducted: Know your breast cancer risk factors and prevention options-pilot program currently enrolling patients at 2 sites. The preliminary data will be presented at AVAHO. Chemoprevention in VHA system: A VINCI data review from 2000-2015 VINCI data review of prophylactic mastectomies at VHA from 2000-2015. Survey for Primary Care physicians regarding awareness of increased risk breast cancer screening and prevention options. Lean Process Improvement project to roll out a program to increase the use of CVT so that VAMCs may offer screening and primary prevention for high risk breast cancer. Additionally, we are offering genetic counseling and plan to improve adherence to chemoprevention through the use of CVT.

Implications/Future Directions: Lean Process Improvement may be an effective method to coordinate clinical care in high risk breast cancer screening and awareness. This process should be considered as a model throughout the VHA system to offer care in accordance with national guidelines for our Women Veterans.

Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.

Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.

Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.

Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.

Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.

Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.

Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.

Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.

Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.

Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.

Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.

Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.

Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.

Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.

Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.

An 88-year-old male with locally advanced basal-cell carcinoma (BCC) of the scalp who had received multiple resections, stem cell graft, and amniotic allograft continued to progress with severe ulcerations that extended into the dura. Patient was initiated on vismodegib 150 mg daily and subsequently developed a diffuse maculopapular rash within 14 days of treatment. The rash resolved with topical triamcinolone 0.1% and discontinuation of vismodegib. Loratadine 10 mg daily was concurrently administered for rash prophylaxis upon vismodegib re-initiation. Within 7 days of therapy, the rash returned, and subsequently vismodegib was discontinued and oral prednisone taper was initiated. Given limited effective treatment options, vismodegib was continued at a modified schedule of 150 mg daily for 2 weeks then 1 week off with prednisone 5 mg daily. To date, patient has completed 2 years of treatment with no return of rash or disease progression.

BCC occurs in 2 million patients annually in the US. Fortunately, most of these cases are responsive to local therapy with rare metastatic progression. The emergence of novel Hedgehog pathway inhibitors (vismodegib, sonidegib) provide effective options for advanced BCC. Although vismodegib has been reported to cause Grade 3-4 adverse events in 25% of patients, there are no reports of vismodegib-induced rash nor recommendations regarding management.

For many novel targeted therapies, the appropriate management of toxicities has not been well described. This case study presents a patient that continues to respond to therapy with a novel modified dosing scheme in addition to low-dose prednisone. We present this case report to offer a potential treatment option in patients who experience a vismodegib-induced rash.

An 88-year-old male with locally advanced basal-cell carcinoma (BCC) of the scalp who had received multiple resections, stem cell graft, and amniotic allograft continued to progress with severe ulcerations that extended into the dura. Patient was initiated on vismodegib 150 mg daily and subsequently developed a diffuse maculopapular rash within 14 days of treatment. The rash resolved with topical triamcinolone 0.1% and discontinuation of vismodegib. Loratadine 10 mg daily was concurrently administered for rash prophylaxis upon vismodegib re-initiation. Within 7 days of therapy, the rash returned, and subsequently vismodegib was discontinued and oral prednisone taper was initiated. Given limited effective treatment options, vismodegib was continued at a modified schedule of 150 mg daily for 2 weeks then 1 week off with prednisone 5 mg daily. To date, patient has completed 2 years of treatment with no return of rash or disease progression.

BCC occurs in 2 million patients annually in the US. Fortunately, most of these cases are responsive to local therapy with rare metastatic progression. The emergence of novel Hedgehog pathway inhibitors (vismodegib, sonidegib) provide effective options for advanced BCC. Although vismodegib has been reported to cause Grade 3-4 adverse events in 25% of patients, there are no reports of vismodegib-induced rash nor recommendations regarding management.

For many novel targeted therapies, the appropriate management of toxicities has not been well described. This case study presents a patient that continues to respond to therapy with a novel modified dosing scheme in addition to low-dose prednisone. We present this case report to offer a potential treatment option in patients who experience a vismodegib-induced rash.

An 88-year-old male with locally advanced basal-cell carcinoma (BCC) of the scalp who had received multiple resections, stem cell graft, and amniotic allograft continued to progress with severe ulcerations that extended into the dura. Patient was initiated on vismodegib 150 mg daily and subsequently developed a diffuse maculopapular rash within 14 days of treatment. The rash resolved with topical triamcinolone 0.1% and discontinuation of vismodegib. Loratadine 10 mg daily was concurrently administered for rash prophylaxis upon vismodegib re-initiation. Within 7 days of therapy, the rash returned, and subsequently vismodegib was discontinued and oral prednisone taper was initiated. Given limited effective treatment options, vismodegib was continued at a modified schedule of 150 mg daily for 2 weeks then 1 week off with prednisone 5 mg daily. To date, patient has completed 2 years of treatment with no return of rash or disease progression.

BCC occurs in 2 million patients annually in the US. Fortunately, most of these cases are responsive to local therapy with rare metastatic progression. The emergence of novel Hedgehog pathway inhibitors (vismodegib, sonidegib) provide effective options for advanced BCC. Although vismodegib has been reported to cause Grade 3-4 adverse events in 25% of patients, there are no reports of vismodegib-induced rash nor recommendations regarding management.

For many novel targeted therapies, the appropriate management of toxicities has not been well described. This case study presents a patient that continues to respond to therapy with a novel modified dosing scheme in addition to low-dose prednisone. We present this case report to offer a potential treatment option in patients who experience a vismodegib-induced rash.

Purpose: Women with breast cancer are increasingly being diagnosed and cared for within the VA. Breast cancer specialists are available only at large VA hospitals in urban regions, possibly impacting the outcomes of rural women. The health outcomes of rural women at the VA have not been well described and are currently a research priority. We described the differences between urban and rural women’s demographics and breast cancer characteristics. We then compared urban and rural women with nonmetastatic breast cancer on type of lymph node biopsy, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and hormone therapy.

Methods: Following IRB approval, 4,025 women with nonmetastatic breast cancer from 1995 to 2012 were identified from the Veterans Affairs Central Cancer Registry (VACCR). This dataset contained diagnosis date, histology, tumor size, tumor grade, lymph node status, and estrogen receptor status. The VACCR also gathered type of lymph node surgery, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and adjuvant hormone therapy. Patient-specific data included date of birth, ethnicity, and zip code of residence at the time of diagnosis. The Rural Urban Commuting Areas 2.0 (RUCA) was used to define rural status and collated further into 3 categories of urban, large rural, and small rural. STATA data analysis and statistical software was used to organize and analyze data. The associations between the 3 rural/urban categories and diagnosis year, age, ethnicity, histology and tumor grade were assessed by ordinal logistic regression. Tumor size was compared using rank sum test. Lymph node and estrogen receptor status were compared with logistic regression, and lymph node sampling methods with multinomial regression. All other treatments were compared between small rural and urban women using logistic regression, and further analyzed with adjustments for factors that could influence treatment choices, including diagnosis year, age, ethnicity, tumor size and grade, lymph node status, and estrogen receptor status.

Results: Most women (n = 3,192) with nonmetastatic breast cancer resided in urban regions, 423 women in large rural regions, and 410 in small rural regions. The number of women living in urban and rural regions did not shift significantly over time (P = .48). The age distributions of rural and urban women did not differ. Women with breast cancer in rural regions were more likely to be white (P ≤ .001, 69% white urban; 90% white small rural; 24% black urban, and 6% black small rural). Tumor histology, size, grade, and lymph node and estrogen receptor status did not differ significantly between rural and urban. Mastectomy was more common among rural women initially, but after adjustments for patient demographics and breast cancer characteristics, urban and rural women received similar proportions of mastectomies. After adjustments, urban and rural women received equivalent breast cancer surgery, adjuvant radiation and adjuvant hormone therapy. However, after controlling for confounding factors, a disproportionate number of urban women receive no lymph node biopsy (P = .05). Additionally, women from large rural regions were statistically more likely to receive adjuvant chemotherapy (P = .04), although the chemotherapy administration did not differ statistically between women from urban and small rural regions (P = .7).

Conclusions: Most women diagnosed with breast cancer at the VA from 1995 to 2012 resided in urban areas. Rural women were much more likely to be white, but the age at diagnosis did not differ. Breast cancer characteristics were similar between rural and urban women. Women living in large rural regions were more likely to receive adjuvant chemotherapy than were women from urban or small rural regions; however reporting differences should be considered as an explanation. A higher proportion of urban women received no lymph node biopsy, which merits further investigation. Breast conservation therapy was administered consistently among rural and urban women veterans.

Purpose: Women with breast cancer are increasingly being diagnosed and cared for within the VA. Breast cancer specialists are available only at large VA hospitals in urban regions, possibly impacting the outcomes of rural women. The health outcomes of rural women at the VA have not been well described and are currently a research priority. We described the differences between urban and rural women’s demographics and breast cancer characteristics. We then compared urban and rural women with nonmetastatic breast cancer on type of lymph node biopsy, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and hormone therapy.

Methods: Following IRB approval, 4,025 women with nonmetastatic breast cancer from 1995 to 2012 were identified from the Veterans Affairs Central Cancer Registry (VACCR). This dataset contained diagnosis date, histology, tumor size, tumor grade, lymph node status, and estrogen receptor status. The VACCR also gathered type of lymph node surgery, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and adjuvant hormone therapy. Patient-specific data included date of birth, ethnicity, and zip code of residence at the time of diagnosis. The Rural Urban Commuting Areas 2.0 (RUCA) was used to define rural status and collated further into 3 categories of urban, large rural, and small rural. STATA data analysis and statistical software was used to organize and analyze data. The associations between the 3 rural/urban categories and diagnosis year, age, ethnicity, histology and tumor grade were assessed by ordinal logistic regression. Tumor size was compared using rank sum test. Lymph node and estrogen receptor status were compared with logistic regression, and lymph node sampling methods with multinomial regression. All other treatments were compared between small rural and urban women using logistic regression, and further analyzed with adjustments for factors that could influence treatment choices, including diagnosis year, age, ethnicity, tumor size and grade, lymph node status, and estrogen receptor status.

Results: Most women (n = 3,192) with nonmetastatic breast cancer resided in urban regions, 423 women in large rural regions, and 410 in small rural regions. The number of women living in urban and rural regions did not shift significantly over time (P = .48). The age distributions of rural and urban women did not differ. Women with breast cancer in rural regions were more likely to be white (P ≤ .001, 69% white urban; 90% white small rural; 24% black urban, and 6% black small rural). Tumor histology, size, grade, and lymph node and estrogen receptor status did not differ significantly between rural and urban. Mastectomy was more common among rural women initially, but after adjustments for patient demographics and breast cancer characteristics, urban and rural women received similar proportions of mastectomies. After adjustments, urban and rural women received equivalent breast cancer surgery, adjuvant radiation and adjuvant hormone therapy. However, after controlling for confounding factors, a disproportionate number of urban women receive no lymph node biopsy (P = .05). Additionally, women from large rural regions were statistically more likely to receive adjuvant chemotherapy (P = .04), although the chemotherapy administration did not differ statistically between women from urban and small rural regions (P = .7).

Conclusions: Most women diagnosed with breast cancer at the VA from 1995 to 2012 resided in urban areas. Rural women were much more likely to be white, but the age at diagnosis did not differ. Breast cancer characteristics were similar between rural and urban women. Women living in large rural regions were more likely to receive adjuvant chemotherapy than were women from urban or small rural regions; however reporting differences should be considered as an explanation. A higher proportion of urban women received no lymph node biopsy, which merits further investigation. Breast conservation therapy was administered consistently among rural and urban women veterans.

Purpose: Women with breast cancer are increasingly being diagnosed and cared for within the VA. Breast cancer specialists are available only at large VA hospitals in urban regions, possibly impacting the outcomes of rural women. The health outcomes of rural women at the VA have not been well described and are currently a research priority. We described the differences between urban and rural women’s demographics and breast cancer characteristics. We then compared urban and rural women with nonmetastatic breast cancer on type of lymph node biopsy, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and hormone therapy.

Methods: Following IRB approval, 4,025 women with nonmetastatic breast cancer from 1995 to 2012 were identified from the Veterans Affairs Central Cancer Registry (VACCR). This dataset contained diagnosis date, histology, tumor size, tumor grade, lymph node status, and estrogen receptor status. The VACCR also gathered type of lymph node surgery, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and adjuvant hormone therapy. Patient-specific data included date of birth, ethnicity, and zip code of residence at the time of diagnosis. The Rural Urban Commuting Areas 2.0 (RUCA) was used to define rural status and collated further into 3 categories of urban, large rural, and small rural. STATA data analysis and statistical software was used to organize and analyze data. The associations between the 3 rural/urban categories and diagnosis year, age, ethnicity, histology and tumor grade were assessed by ordinal logistic regression. Tumor size was compared using rank sum test. Lymph node and estrogen receptor status were compared with logistic regression, and lymph node sampling methods with multinomial regression. All other treatments were compared between small rural and urban women using logistic regression, and further analyzed with adjustments for factors that could influence treatment choices, including diagnosis year, age, ethnicity, tumor size and grade, lymph node status, and estrogen receptor status.

Results: Most women (n = 3,192) with nonmetastatic breast cancer resided in urban regions, 423 women in large rural regions, and 410 in small rural regions. The number of women living in urban and rural regions did not shift significantly over time (P = .48). The age distributions of rural and urban women did not differ. Women with breast cancer in rural regions were more likely to be white (P ≤ .001, 69% white urban; 90% white small rural; 24% black urban, and 6% black small rural). Tumor histology, size, grade, and lymph node and estrogen receptor status did not differ significantly between rural and urban. Mastectomy was more common among rural women initially, but after adjustments for patient demographics and breast cancer characteristics, urban and rural women received similar proportions of mastectomies. After adjustments, urban and rural women received equivalent breast cancer surgery, adjuvant radiation and adjuvant hormone therapy. However, after controlling for confounding factors, a disproportionate number of urban women receive no lymph node biopsy (P = .05). Additionally, women from large rural regions were statistically more likely to receive adjuvant chemotherapy (P = .04), although the chemotherapy administration did not differ statistically between women from urban and small rural regions (P = .7).

Conclusions: Most women diagnosed with breast cancer at the VA from 1995 to 2012 resided in urban areas. Rural women were much more likely to be white, but the age at diagnosis did not differ. Breast cancer characteristics were similar between rural and urban women. Women living in large rural regions were more likely to receive adjuvant chemotherapy than were women from urban or small rural regions; however reporting differences should be considered as an explanation. A higher proportion of urban women received no lymph node biopsy, which merits further investigation. Breast conservation therapy was administered consistently among rural and urban women veterans.