Cancer survivors who live in rural areas are in poorer health than their urban counterparts, likely due to higher rates of health-compromising behaviors, new research confirms. As a result, specifically tailored interventions are needed.
That is the conclusion of a study now available online ahead of print in %Cancer Causes & Control (DOI 10.1007/s10552-013-0225-x). “The take-home message is that rural cancer survivors may be at risk for poor outcomes after cancer diagnosis due to behaviors such as smoking and lack of physical activity,” said the study's lead author, Kathryn E. Weaver, PhD, Assistant Professor of Social Sciences and Health Policy at Wake Forest Baptist Medical Center in North Carolina.
The overall message of the paper, agreed OT Clinical Advisory Editor Mikkael Sekeres, MD, MS, Director of the Leukemia Program at Cleveland Clinic Taussig Cancer Institute, “is that cancer survivors in those areas are engaging in behaviors that put them at risk for relapse of their cancer or at risk for developing other cancers—I always tell my patients not to give their body an excuse to develop future cancer.”
And, said, Anthony E. Dragun, MD, Associate Professor of Radiation Oncology at the University of Louisville James Graham Brown Cancer Center, the paper speaks to rural patients unfortunately being less likely to survive a cancer diagnosis than their urban counterparts. If patients have poor health habits before diagnosis, changing them afterward is that much more challenging.
Fortunately, oncologists and cancer care centers are working toward improving access to supportive programs for rural cancer survivors, said the experts interviewed for this article.
The cross-sectional study by Weaver et al used data from the 2006-2010 National Health Interview Survey, a population-based sample of adults conducted by the National Center for Health Statistics. Included were 1,642 rural and 6,162 urban cancer survivors. Survivors were defined as adults age 18 and older who reported ever being told by a doctor that they had cancer; excluded were those with unknown skin or non-melanoma cancers.
The investigators evaluated self-reported behaviors, including leisure-time physical activity, alcohol use, smoking status, and maintenance of healthy body weight, as well as the survivors' overall health status and whether they lived in a rural or urban area.
Smoking was reported by 25.3 percent of the rural cancer survivors compared with 15.8 percent of those in urban areas. In addition, 50.7 percent of rural survivors reported having no regular physical activity compared with 38.7 percent of urban survivors.
There was no significant difference in the rates of being overweight or obese between the groups—65.4 percent for those in rural areas and 62.6 percent for those in cities. “I was a little bit surprised by the obesity results, because many studies have found higher rates of obesity among rural adults,” Weaver noted in an interview. Overall, about 63 percent of cancer survivors were overweight or obese, so this seems to be a problem regardless of setting, she said.
Alcohol use was lower for rural survivors, at 46.3 percent compared with 58.6 percent for urban survivors. These rates are also similar to the known drinking patterns in general population, Weaver noted.
The study also showed that rural cancer survivors reported poorer overall health, at a rate of 36.7 percent compared with 26.6 percent for urban survivors. Rural survivors were also more likely to report health-related unemployment than urban survivors were (18.5% vs. 10.6%).
Additionally, individuals who currently smoked were more likely to be in fair to poor health (odds ratio [OR] = 1.76, 95% CI 1.46-2.13) and unemployed due to their health (OR = 1.93, 95% CI 1.50-2.49) when compared with never smokers.
Compared with individuals with normal bone mineral density, obese cancer survivors were more likely to have fair or poor health (OR = 1.50, 95% CI 1.28-1.75) and to be unemployed due to health (OR = 1.68, 95% CI 1.35-2.09).
When compared with survivors who were sufficiently active, inactive survivors were at greater risk of having fair or poor health (OR = 2.56, 95% CI 2.07-3.16) and to be out of work because of their health (OR = 2.72, 95% CI 2.02-3.66).
Obstacles to Healthy Behavior
Physical activity is a challenge in rural communities, which may lack sidewalks or areas with restaurants and stores that encourage walking, as well as fitness facilities and gyms, she said.
The lack of physical activity in rural versus urban areas “is not so surprising in some ways,” said Kathy J. Helzlsouer, MD, MHS, Director of the Prevention and Research Center at Mercy Medical Center in Baltimore. Still, urban areas have their own challenges—for example, certain neighborhoods may not be safe for walking. Picking up exercise after a cancer diagnosis, therefore, can be challenging no matter where you are living.
“With regards to smoking, tobacco use is a particular problem in rural areas,” Weaver said. “I'm from North Carolina and a lot of patients grew up with tobacco being a big part of their lives. They have either grown tobacco themselves or lived in farming communities.” Additionally, smoking bans tend to be implemented first in urban areas, while rural communities may not have smoke-free laws.
Sekeres pointed out that the rate of smoking in the study indicates that individuals are getting cessation counseling and ignoring it, not getting counseled at all, or are unable to access smoking-cessation programs.
Added Eric Bernicker, MD, FACP, an oncologist in the Department of Thoracic Medical Oncology at Methodist Cancer Center in Houston: “It continues to remain frustrating that with all the good data on many adverse outcomes from tobacco utilization, patients still smoke. It's not like it was 16 years ago when I went into practice, but it's still a relatively persistent issue.”
Solving the Problem
“It's one thing to identify a [health] disparity, it's another thing to solve it,” Dragun said. “The next level of research will examine what programs can be brought to these patients.”
Helzlsouer agreed: While the Weaver et al study was well done and pointed out health problems among survivors, “you then have to delve deeper to find out how these challenges can be addressed for both rural and urban populations and how you can promote more healthy activities.”
Weaver said she hoped the study makes health care providers who are treating rural cancer survivors more aware that this population is at risk for poor health behaviors.
Sekeres notes that while his practice is based in Northeast Ohio, where about 20 percent of the population lives in rural areas, he hasn't noticed the types of health differences described in the study. However, he said, based on the paper, “I'll now be more keyed into asking my patients, particularly those from rural areas, questions about these behaviors.”
Once these behaviors are identified by physicians, survivors need to be able to access programs and resources to manage their health. For example, Weaver said, tobacco-cessation programs can be offered by telephone, and physical activity plans can be conducted in in the patient's home.
Being sensitive to patients' travel time to the clinic for treatment can also help them eventually tap into supportive programs as a survivor, Sekeres added. Discounted lodging for overnight stays and helping with gas costs can ease the financial burden. Once patients are able to come into a comprehensive cancer center for treatment they may be more likely to take advantage of available support.
Also, Dragun said, getting patients into the clinic for initial treatment may involve changing protocols. Through his own research, he found that about one third of women prescribed radiation therapy for breast cancer in Kentucky did not receive it, often due to how often and how far they had to travel. As a result, he instituted a protocol allowing women to come into the center for radiation therapy once a week for five to six weeks, rather than every day for three to six weeks.
“After treatment, patients then get plugged into a lot of networks to help with survivorship, whether through support groups with other patients, dietary consultants, physical therapists or smoking-cessation programs,” he said.
In addition to easing the challenges of travel, patients need help with costs. Bernicker said that his institution has a wellness program with dietitians and tobacco and smoking cessation, which some insurance programs do not cover.
The Cleveland Clinic tries to reach out to patients without resources through partnerships with organizations such as the Aplastic Anemia & Myelodysplastic Syndromes International Foundation, the Leukemia and Lymphoma Society, and the American Cancer Society, all of which provide support programs, and many of which are accessible in rural areas, Sekeres said.
Additionally, he noted, the 4th Angel Mentoring Program (4thAngel.org) through the Scott Hamilton CARES Initiative (ScottCares.org) helps cancer survivors reach out to one another while navigating treatment and survivorship.
If for any reason, these programs are not physically accessible by rural residents, Internet access may provide virtual access, he said. “There's the question of Internet access not being as deep in rural areas, but we have reached the stage where it's almost ubiquitous.”