By Paul Nicolaus

October 10, 2018 | If cancer care were equal for patients residing in rural and urban areas, would we see equal outcomes? It’s a thought-provoking question and one that new research tackles head-on.

Previous studies have shown that cancer patients living in rural regions experience worse outcomes than their urban peers. For example, a report published last year revealed that (from 2011 to 2015) the age-adjusted rate of cancer deaths in rural areas was 180 per 100,000 individuals, compared with 158 in large metropolitan areas.

The reason behind this urban/rural disparity has been debated. Some have pointed to the distances rural patients must travel to receive specialty care, which can place an added burden on family and job responsibilities, or lead to delayed diagnoses. Others point to insurance access or health literacy issues. Are there environmental or socioeconomic factors at play, still others have wondered, that could be the underlying cause?

Over time, researchers have pondered all of these possibilities and more, but these issues are difficult to get at using cancer population data because it is tricky to account for differences in access to care. “That confounder is sort of imbued in population data, Joseph Unger, a health services researcher and biostatistician at the Fred Hutchinson Cancer Research Center told Clinical Informatics News. “You have a wide, heterogeneous mix of patients with all different types of issues around access to care for both rural and urban patients.”

He and colleagues found a way to work around this challenge, however, by relying on retrospective clinical trial data from patients in treatment trials. Their results were published in JAMA Network Open study (doi: 10.1001/jamanetworkopen.2018.1235) in August. “It is the advantage of our analysis that that issue of access to care is implicitly accounted for because we’re using clinical trial patients,” Unger explained. “So we could sort of take that issue off the board and examine outcomes between rural and urban patients and see whether they still differed.”

He and colleagues analyzed nearly 37,000 cancer patients from across the United States enrolled in 44 treatment trials run by SWOG, a National Clinical Trials Network and Community Oncology Research Program group sponsored by the National Cancer Institute. They looked at trial data from 1986 to 2012. “I had expected to find the same things that others had found,” he said, considering the existing research literature has been so uniform using other data sources. What they actually found, however, surprised Unger.

Mortality rates varied significantly in only 1 of the 17 cancer-specific cohorts. (Rural patients experienced higher mortality for adjuvant-stage estrogen receptor–negative and progesterone receptor–negative breast cancer.) In other words, when rural patients are given the same kind of access to the type of quality, guideline-based care provided in clinical trials, those disparities that have been observed so often in other analyses relying on cancer population data virtually disappear.

The findings suggest that the issue at hand is, in fact, one of access. “Better access to affordable health care insurance, better access to screening and prevention tools, better access to treating specialists, improved resources for traveling to receive care, and innovative new networks to give rural patients better access to new, novel treatments and clinical trials are all likely to improve outcomes for patients with cancer in rural areas,” the researchers noted within the study.

Strengths And Limitations

“One of the nice things with this study is that it builds upon a large sample of cases,” Vanessa B. Sheppard, associate director for disparities research at the Virginia Commonwealth University (VCU) Massey Cancer Center told Clinical Informatics News, “and by focusing within the clinical trial arena you’re able to compare more apples to apples in the sense that there is standardized care within a clinical trial setting.”

In an accompanying commentary (doi:10.1001/jamanetworkopen.2018.1243), Emory University’s Lauren McCullough and Christopher Flowers also pointed out advantages of the study’s design, including the comprehensive coverage (all 50 states), diversity of cancer sites, and standardized treatment regimens. However, there are some caveats to consider regarding selection bias. “The current study did not account for other important barriers that potentially contribute to disparities between rural and urban patients with cancer,” they wrote.

Additional analyses with individual patient-level data on factors such as income, socioeconomic status, treatment regimen, adherence, and outcomes are needed to come up with strategies for improving survival for rural patients, they added, and stratification by (rather than adjustment for) race and gender could also help inform the design of future interventions and planning care. Also, because the current study was limited to the first five years after registration, it remains unclear whether differences in survival rates would exist if this restriction were removed. Examining survival disparities beyond this duration of time could also provide useful insight.

Despite any limitations to the findings, McCullough and Flowers noted that this research “sheds light on an important clinical issue” as it suggests that “congruent therapy in rural and urban settings may, in part, improve survival disparities in cancer.” Furthermore, clinicians and policy specialists can make use of this data to inform practice and develop cancer care and survivorship planning programs that meet the need of rural patients with methods that use “standardized protocol-driven care.”

How To Improve Access

There are potential interventions that can be launched at both the community and the individual level, Unger said. Nearly 1 in 5 cancer patients reside in rural areas, according to research published in the Journal of Oncology Practice, compared with just 3% of oncologists. This wide disparity in terms of access to an oncologist creates all kinds of hurdles that patients have to overcome just to receive care. At the community level, incentives need to be provided to nudge more oncologists to work in rural regions of the United States to better address the skewed geographic distribution of these specialists.

“Technology can also be our friend,” Unger said. It is possible to create strategies for better linking rural providers to oncologists using telehealth models. This way, oncologists can be in the room (virtually anyway), participating in the evaluation of patients.

At the individual level, there is a need to ensure that rural cancer patients have the right kind of transportation and financial resources required to travel to care settings. Beyond that, “insurance plays a big role here because rural patients have benefitted greatly from the ACA Medicaid expansion,” he said, “so efforts to weaken those provisions could really have an outsized impact on rural cancer patients.”

Even though this study took two years and involved data from thousands of patients, Unger acknowledged that identifying potential solutions is, in a sense, the easy part. Researchers and advocacy organizations can suggest best practices for improving medical access and availability of good cancer care for rural communities, but it’s ultimately the policymakers and lawmakers who need to make sure that rural patients can receive this kind of care. “But this [research] hopefully helps guide the way,” he added.

Learning From Existing Models

Models for improving access to quality cancer care in rural settings do already exist, Unger and colleagues pointed out. In Australia, for example, urban cancer centers are linked to Regional Cancer Centers of Excellence to “provide multidisciplinary care, improve support services, and improve clinical trial participation.” The program has improved access to care and increased treatment of rural patients in their communities.

In the United States, the National Cancer Institute's Community Oncology Research Program (NCORP) brings cancer clinical trials and cancer care delivery studies to people in their communities. While cancer clinical trials have typically been carried out at academic medical centers, most individuals receive cancer-related care in community settings, according to the NCORP website, and this network brings cancer research to larger and more diverse patient populations.

VCU’s Massey Cancer Center, where Sheppard works, is one of a variety of NCORP Sites strewn across the country. “I think that there is a growing focus on the need to understand cancer in rural communities—both from a treatment perspective and for prevention and control,” she said. There are hot spots, for example, that seem to have a higher incidence of certain cancers in rural communities versus urban communities that we need to understand better moving forward.

Another crucial factor is that overall, minority populations tend to reside in urban communities, but “there are certain pockets of rural communities that have larger minority populations,” Sheppard pointed out, “so that may give us the opportunity to examine the impact of mortality within different racial-ethnic groups.”

She is currently leading efforts focused on rural communities in Virginia. “We’re located in Richmond in an urban area, but we have patients that may come two hours for treatment,” Sheppard said, “and so that’s a barrier in terms of getting timely and quality care.” Along with her research team, she provides transportation assistance to some patients by securing the funding needed to help defray travel costs.

In addition, outreach is provided via two cancer research and resource centers to help demystify aspects of cancer, offer basic education about cancer prevention and control, and inform others about the advantages of participating in clinical research. That education outreach is important, she said, especially in communities that may be a bit isolated when it comes to state-of-the-art research.

“And that grassroots, sort of ground-level work of educating the community opens the door to being able to do research,” Sheppard added, “whether it’s behavioral research around getting people to exercise and diet or testing different methodologies to improve uptake of early initiation of treatment.”

Paul Nicolaus is a freelance writer specializing in science, nature, and health. Learn more at www.nicolauswriting.com.