Stronger collaborations, better information sharing, and innovative approaches are enhancing cancer care in rural areas.

When it comes to progress against cancer, there’s good news to celebrate. Between 1990 and 2014, the overall cancer death rate in the United States fell by 25 percent. But not all parts of the country shared these improvements equally. Disparities in cancer outcomes continue to be an issue, including in rural areas where death rates are higher than urban areas. Cancer mortality also is decreasing more slowly in rural areas than urban areas.

Mary Charlton, CPH assistant professor of epidemiology and an investigator with the Iowa Cancer Registry, studies rural–urban cancer disparities. In 2015, she and colleagues published a paper that outlined numerous challenges of rural cancer care in the U.S. The barriers to receiving care included limited availability of cancer treatments and cancer support providers (such as oncologists, social workers, mental health care providers, and palliative care specialists), long travel distances for care, transportation barriers, and financial barriers, including having no insurance or insufficient insurance coverage.

Three years later, “a lot of the challenges are the same,” says Charlton, “but now there’s a bigger push, especially at the National Cancer Institute (NCI), to put funding and resources into projects to improve rural cancer care.”

Strengthening Rural Cancer Research

Charlton, along with Anjali Deshpande, CPH clinical associate professor of epidemiology, are co-leading an initiative supported by NCI supplemental funding to the UI Holden Comprehensive Cancer Center (HCCC) aimed at strengthening cancer control research in Iowa’s rural underserved populations. George Weiner, HCCC director, serves as principal investigator.

The goal of the project is to establish a statewide research infrastructure, based at HCCC, that will support rural hospitals and other rural health care providers in their search for new, sustainable cancer-control methods.

“We’ll be working with six Critical Access Hospitals located in rural counties that will serve as the core of a rural cancer research advisory board,” says Charlton. “We want to hear what their biggest challenges and interests are.”

Critical Access Hospital (CAH) is a designation given to eligible rural hospitals by the Centers for Medicare and Medicaid Services. The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to health care by keeping essential services in rural communities. These hospitals receive certain benefits, such as cost-based reimbursement for Medicare services.

Every three years CAHs conduct a Community Health Needs Assessment and develop a strategic plan to address their findings.

“We’ve looked closely at many hospitals’ needs assess­ments, and a lot don’t mention cancer as one of their priorities, or if they do mention it, they don’t have a lot of data in their plan to help guide them,” Charlton explains. “The Iowa Cancer Registry has great data and resources that we can help provide to these hospitals.”

The Iowa Cancer Registry gathers statistics on cancer incidence and mortality at the county level. This information can be used to generate maps and reports that provide actionable, relevant evidence to guide community health assessments and cancer control decision-making in the six identified counties.

The project will rely on established collaborations among HCCC, the Iowa Cancer Consortium, and the Iowa Cancer Registry, while building new relationships with the UI Rural Policy Research Institute’s Center for Rural Health Policy Analysis and the UI Cancer Prevention and Control Research Network.

The supplemental funding will lay valuable groundwork for additional grants and projects going forward, Charlton adds.

From Diagnosis to Treatment Decision

Charlton’s research isn’t limited to specific cancers, but “the cancers that tend to be the bigger numbers in rural areas are breast and colorectal cancer because they can be treated by any hospital that has a general surgeon,” Charlton says. “So we see a lot of cancer patients in Iowa—about 40 percent—who go to hospitals that have no specific cancer accreditation.”

Charlton and colleagues recently published a paper that examined rectal cancer patients’ decision-making process about where to receive surgery. Although colon cancer and rectal cancer tend to get grouped together, the two diseases are very different.

“Rectal cancer is much rarer, and it’s a much more complicated surgery and course of treatment than colon cancer,” Charlton points out.

Several studies have shown that rectal cancer patients treated by specialized surgeons who perform large volumes of rectal cancer resections have better outcomes and survival rates compared to patients treated at lower volume centers. Despite evidence of a volume-outcome relationship, less than half of rectal cancer resections are performed by high-volume surgeons in comprehensive facilities.

Charlton’s research team interviewed 15 rectal cancer patients about their decisions regarding where to receive surgery. All lived in Iowa, averaged 63 years of age, and a little more than half resided in non-metropolitan areas.

Overall, the researchers found that advice from primary care physicians, gastroenterologists, friends, and relatives was the most critical factor in choosing a surgical center. And while almost all of the respondents indicated that surgeon experience was important, most didn’t research their surgeon’s experience and none sought a second opinion.

Because Iowa is a very rural state, distance was a factor in the decisions of some of the patients. However, in most cases where patients chose more local, lower volume centers, it wasn’t because they were unable to travel to a higher volume center. Rather, they chose the closer, low-volume centers because they were recommended to them by a local physician or because they were just more familiar with local providers. This highlights the importance of referrals received from physicians who diagnose rectal cancer.

The researchers noted that primary care physicians and gastroenterologists aren’t typically involved with staging, treatment, or follow-up of rectal cancer; are often unfamiliar with the specifics of rectal cancer surgery; and may not be aware that there is a difference in care and outcomes at high-volume versus low-volume centers. As a result, they may base referrals on their professional relationships with surgeons rather than on expertise.

The findings suggest that developing educational inter­ventions to help guide more informed decision-making by patients and referring providers could be beneficial.

Innovative Approaches

Technology offers additional tools for enhancing rural cancer care. Telehealth is the use of electronic information and telecommuni­cations technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration, according to the Health Resources and Services Administration.

Instead of remotely connecting rural cancer patients to specialists, it often makes more sense to link rural health providers to oncology specialists, says Marcia Ward, CPH professor of health management and policy and director of the Rural Telehealth Research Center.

“Oncology specialists can serve as consultants and be a resource for primary care providers and other frontline health professionals in rural areas,” Ward explains. “Using telehealth, a family physician can ask questions or say, ‘I have this case, what would be the best referral?’”

But, Ward notes, the telehealth consultant role “raises all sorts of issues about reimbursement” in the current fee-for-service health care system. “There are still challenges to putting this approach into place,” she says.

Other solutions for rural cancer care include outreach clinics, where specialists travel to certain rural sites several times a week or month, thereby reducing cancer patients’ travel time; and incentives and programs to increase recruitment and retention of the oncology workforce.

Although rural cancer disparities can be addressed in a number of ways, Charlton summarizes the goal behind these efforts into one overarching question: “What is the best way to get everyone the best care without making them go farther than they need to go?”

This story originally appeared in the fall 2018 issue of InSight magazine