Date of Graduation


Document Type


Degree Type



School of Pharmacy


Pharmaceutical Sciences

Committee Chair

Suresh Madhavan

Committee Co-Chair

Hannah Hazard

Committee Member

Xiaoyun Lucy Pan

Committee Member

Michael Regier

Committee Member

Usha Sambamoorthi


West Virginia (WV) which is the only state which lies entirely in Appalachia and which is predominantly rural and medically underserved region, has lower incidence of breast cancer (BC) but a higher BC-related mortality as compared to the national averages in elderly women age 65 and above. This may be due to lower mammography utilization in these rural elderly women, limited physical access to services, shortage of healthcare professionals and services, and untimely and/or inappropriate care. This is dearth of epidemiological studies that have focused on understanding the factors associated with these disparities among these rural and underserved population such as WV. The purpose of this project was to do a detailed evaluation of burden of BC and its associated health and economic outcomes in elderly women in WV, and to compare these estimates with the national estimates. Three retrospective observational studies were conducted using West Virginia Cancer Registry-Medicare and Surveillance, Epidemiology, and End Results (SEER)-Medicare linked datasets for the years 2002-2007. In the first study, persistence with mammography screening and its effect on stage at BC diagnosis was investigated for the elderly rural WV women and was compared to the national estimates from SEER-Medicare data. The study found no significant differences in the representation of disease between WV-Medicare and SEER-Medicare cohorts even after controlling for persistence with mammography screening. In the second study, timeliness of BC care in regards to diagnosis and treatment as per the published opinion-based recommendations and its effect on chances of being alive at the follow-up period was determined for the WV-Medicare cohort and then was compared to the SEER-Medicare cohort. The study found that the WV-Medicare cohort was significantly less likely to receive timely diagnosis of BC as per recommendations when compared to the SEER-Medicare cohort. However, there were no significant differences between these cohorts for the timely treatment of BC. Also, delayed diagnosis was not associated with poorer prognosis in the WV-Medicare cohort. In the third study, average total healthcare costs in the initial phase of 12-months following BC diagnosis and costs by types of specific services were estimated for the WV-Medicare cohort and these were compared to the national estimates derived from the SEER-Medicare cohort. This study reported that average total healthcare costs, inpatient costs and physician services costs were significantly lower for the WV-Medicare cohort as compared to the SEER-Medicare cohort. Also, the decomposition analyses only explained total 16% of the differences in the average costs due to the cohorts' characteristics. Overall, the findings of this project highlight the importance of persistence with mammography screening and timely BC care in the elderly, rural and underserved women diagnosed with BC. Moreover, these studies can serve as a foundation for larger studies aimed at decreasing BC disparities in a rural and geographically challenged state such as WV, through the development of strategies and interventions to foster early detection and timely treatment of BC among rural populations.