ASCO has established a new task force to reduce the disparities in cancer care that exist between patients in rural areas and those in urban areas. Speakers discussed the new initiative at an ASCO State of Cancer Care in America event called Closing the Rural Cancer Care Gap; the meeting was held at the National Press Club in Washington, D.C.
“The divide in this case is a real one that we can quantify,” said ASCO Chief Executive Officer Clifford A. Hudis, MD, FACP, FASCO, nothing that while the racial gap in cancer care is narrowing, “the urban/rural divide is widening.”
Rural Cancer Care Task Force
ASCO data show that cancer patients living in rural areas often suffer from geographic isolation, are often diagnosed with more advanced cancer, and have recently been shown to have higher cancer mortality. Many still have only dial-up telephone access, lack cell phones, and have no internet access.
Hudis said that, in addition to establishing the new Rural Cancer Care Task Force, ASCO is planning to develop a paper summarizing some of the insights from the meeting at the National Press Club, along with new research findings on cancer care in the rural U.S. The paper will be submitted for publication as part of ASCO's State of Cancer Care in America series in the Journal of Oncology Practice in late 2019 or early 2020.
“I grew up on a ranch in rural Wyoming,” said ASCO President Monica M. Bertagnolli, MD, the Richard E. Wilson Professor of Surgery in the Field of Surgical Oncology at Harvard Medical School and Associate Surgeon at Dana-Farber/Brigham and Women's Cancer Center. So, she understands personally what it means for a cancer patient to live 100 miles from the nearest hospital and the burdens that distance places on patients, caregivers, health care providers, and the community.
“Every patient deserves access to the highest quality care no matter where they live,” she noted. But, “it's a sad truth that where a patient lives often dictates their chances of surviving cancer.”
Bertagnolli has been traveling around the country and meeting with community oncologists and health care workers. In Appalachia, she visited an economically distressed area in Gallia County, Ohio, where one in three women have high-risk HPV; the women with abnormal Pap smears could not afford a colposcopy. “What a tragedy,” said Bertagnolli.
She described the persistent efforts of Patty Toler, RN, to build a colposcopy clinic in the Gallia County Health Department; Toler is a lifetime resident of the area. “These efforts have made a tremendous difference in Gallia County,” said Bertagnolli. In that region high-risk HPV is present in 33.5 percent of female residents.
Access to Radiation Oncologists
The problem of access for rural patients is especially acute for radiation oncologists, said Hedvig Hricak, MD, PhD, Chair of the Department of Radiology at Memorial Sloan Kettering Cancer Center and Professor of Radiology at Weill Medical College of Cornell University.
In many rural areas, there are few or no radiologists, and no specialty oncology radiologists, she said. Hricak noted that cancer care delivery is a team effort today and, if any members of the team are missing, such as radiologists, the patient may suffer.
It does not help that there are wide variations in Medicaid payment rates for radiation oncology, as revealed in a new study in the International Journal of Radiation Oncology (2019; doi.org/10.1016/j.ijrobp.2019.02.031).
If left unaddressed, “the disparity could aggravate the growing maldistribution of radiation oncologists in rural and urban communities—and place low-income patients in rural communities at even greater threat,” warned lead author Ankit Agarwal, MD, MBA, Radiation Oncology Resident Physician at the University of North Carolina at Chapel Hill.
Rural America is “a unique health care delivery environment,” said Alan Morgan, MPA, CEO of the National Rural Health Association. Providing rural health care encompasses a culture issue, a distance issue, and a provider issue, he noted.
Often rural residents have lower incomes and higher poverty rates than urban residents. In some rural areas, there are also higher rates of obesity and smoking. Because of their unique attributes, rural areas can be a test-bed for new health care delivery models such as telehealth and new payment models, said Morgan.
“Local problems need local solutions,” emphasized Electra D. Paskett, PhD, the Marion N. Rowley Professor of Cancer Research; Director of the Division of Cancer Prevention and Control in the College of Medicine; and Professor in the Division of Epidemiology in the College of Public Health at the Ohio State University (OSU). It is vital to listen to people in the community to know how to help them, said Paskett, who is also Associate Director of Population Sciences and Community Outreach and Program Leader of the Cancer Control Program in the Comprehensive Cancer Center of OSU.
Paskett has worked with local organizations for years in underserved Appalachian counties to improve rates of breast, cervical, and colorectal cancer screening; use of the HPV vaccine; smoking cessation; and access to healthy foods. She is combating the common feeling in Appalachia that “cancer appears to be a death sentence,” because diagnoses at late stages mean that patients die. She stressed the need for reliability and longevity when bringing a program to underserved rural patients. “We don't just go in and leave them. They need to know that we're there for the long haul.”
Rural communities often prize independence and distrust those they see as outsiders. Asked by Oncology Times if some people in remote rural areas may delay care not just because of lack of access or insurance but because they are suspicious of science and medical procedures, Paskett said the key is to work with trusted members of the local community, such as nurses and pharmacists. This trust is especially important for HPV vaccination, she said.
Morgan agreed. Having an initial trusted advisor within the local community is important in getting cancer patients connected to the health care system, he said. It is also vitally important for rural cancer patients to have the support of trusted family members—especially when they are being signed up for a clinical trial, noted Leslie Byatt, CPht, CCRC, Clinical Research Manager for the New Mexico Cancer Care Alliance and grant administrator for the New Mexico Minority/Underserved NCI Community Oncology Research Program (NCORP).
Bridging the Rural Gap
NCI has recognized and is concerned about the gap in rural cancer care, said Robert Croyle, PhD, NCI's Director of the Division of Cancer Control and Population Sciences. He noted that, about 3 years ago, the NCI started a rural health initiative, and it seems as if there is “a lot of lack of understanding” among those in academic medical centers of what health providers in rural areas face.
NCI is forming partnerships to help broaden cancer care access in rural areas. For example, Croyle cited a partnership with the Federal Communications Commission to expand broadband access for symptom management. He noted that NCI has “tried to do a lot of bridge building” with rural health centers, and cited NCORP as an effective vehicle for reaching out to cancer patients in rural areas.
Clinical trial access for rural cancer patients needs to be improved, emphasized Alan Lyss, MD, the Sub-Principal Investigator for Heartland Research NCORP, for which he serves as Principal Investigator for the NCORP's Cancer Care Delivery Research Committee. Rural cancer patients need education on the benefits of clinical trials as well as expanded eligibility criteria, noted Lyss, who in addition to his private medical oncology practice in suburban St. Louis, Mo., sees patients on a biweekly basis in rural Ste. Genevieve County, Mo. Lyss said that rural cancer patients thinking about enrolling in a clinical trial tend to have more co-morbidities and more secondary cancers than urban patients.
Speakers cited the promise of information technology (IT) in bridging the urban/rural gap in cancer care. Project ECHO (Extension for Community Healthcare Outcomes) is a telementoring program which trains experts to share knowledge with community physicians; the goal is to increase access to best practices in cancer care for vulnerable populations in the U.S. and around the world, said Oliver Bogler, PhD, Vice President for Global Academic Programs and Senior Vice President for Academic Affairs at MD Anderson Cancer Center and Chief Operating Officer of the ECHO Institute.
Bogler said Project ECHO is a partnership model, which builds capacity in the community through such IT applications as teleconferencing. In a world of exploding scientific knowledge, ECHO can extend expertise to health care providers in rural areas, he noted.
Peggy Eastman is a contributing writer.
Statistics on the Rural Divide in Cancer Care
- While 19 percent of the U.S. population lives in rural areas, only 7 percent of oncologists practice there.
- More than 70 percent of U.S. counties do not have medical oncologists.
- In rural areas, there is only one oncologist per 100,000 residents, while in urban areas this ratio is five oncologists per 100,000 residents.
- Medical students and residents often choose to stay in the large cities where they received their education and training.
- Four in 10 rural Americans who have or had cancer say there aren't cancer specialists near their home.
- Thirty-six percent of patients in rural areas say they had to travel too far to see the physician managing their care, versus 19 percent of non-rural patients.
- A total of 1.6 million U.S. rural households do not have cars, with the highest proportion found in the south, Appalachia, the southwest, and Alaska.
- Just 60 percent of rural residents use broadband, compared to 70 percent of urban residents and 73 percent of suburban residents.
- In rural communities, 42 percent of community oncologists report challenges with finding clinical trials close enough to be considered by their patients.
- Rural patients face health insurance obstacles. Historically, rural areas have lower proportions of residents covered by employer-sponsored health insurance plans. Nearly two-thirds of the rural uninsured live in states that have not expanded Medicaid (2014 figures). About 25 percent of veterans live in rural areas, and one in five uninsured veterans live in states that did not expand Medicaid.