Older women residing in the U.S territories are less likely to receive recommended or timely care for breast cancer compared with similar women residing in the continental United States, according to Yale researchers. Their findings were published in the March issue of Health Affairs.
Using Medicare claims data from 2008 to 2014, the researchers analyzed breast cancer care for women in the U.S. territories, including American Samoa, the Northern Mariana Islands, Guam, U.S. Virgin Islands, and Puerto Rico. Compared to women living in the continental United States (defined as 48 contiguous states, Alaska, and the District of Columbia), women in these territories who had surgical treatment for breast cancer were significantly less likely to receive other recommended care, the researchers said.
In the period preceding surgery, women in the territories had 24% lower odds of receiving diagnostic needle biopsy. Following breast conserving surgery, they were less likely to receive radiation therapy, noted the researchers.
These women also experienced significant delays in receiving timely care. For example, one month after diagnosis, 42% of women in the U.S. territories had breast surgery, compared to 63% of women in the continental United States. For women in the territories who received breast-conserving surgery, 41% also received radiation therapy, compared to 77% of those in the continental United States.
"The pronounced inequality in breast cancer care for women in the territories demonstrates the importance of research focused on this understudied U.S. population," said Tracy Layne, first author, who contributed to the project as part of her doctoral training at the Yale School of Public Health.
The U.S. territories are home to nearly 5 million people; the majority identify as racial or ethnic minorities. By law, residents of the territories are U.S. citizens (except for those living on American Samoa). However, federal funding for Medicare in the territories is substantially lower than in the continental United States, limiting resources for healthcare services, including breast cancer care, said the researchers.
"Inferior breast cancer care in U.S. territories is particularly concerning, given that our study focused on a time period prior to Hurricane Maria," said Cary Gross, M.D., professor of medicine at Yale School of Medicine and senior author of the study. "Our findings suggest that efforts to address the devastating impact of the hurricane on the citizens and healthcare infrastructure of the Caribbean territories need to focus on making the system better than it was." Gross is a member of Yale Cancer Center.
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June 17, 2025 
