Implementing Solutions to Close the Rural Cancer Care Gap

Great strides have been made against cancer in recent decades, with certain cancers experiencing significant drops in mortality and the racial divide narrowing. However, not all disparities have improved, most notably the rural cancer care gap.

“While we are closing some gaps, we are not closing all gaps, and perhaps we are allowing some gaps to widen,” said Cliff Hudis, MD, FACP, FASCO, chief executive officer of the American Society of Clinical Oncology (ASCO), as he opened up a convening of physicians, advocates, and rural health experts for an in-depth conversation on closing the gap that exists in rural America.

While 19% of the US population resides in rural areas, just 6% to 7% of oncology practices have a practice that includes a rural area, creating an access to care issue among older, sicker, and poorer populations, explained Monica M. Bertagnolli, MD, FACS, FASCO, president of ASCO; professor of surgery at Harvard Medical School; and associate surgeon at Brigham and Women’s/Dana Farber Cancer Institute.

And access to care doesn’t just include fewer providers in the area and greater distances traveled to get to these providers. Patients in rural areas also often lack the resources needed to get to the appointment, including transportation. As a result, people in rural areas are diagnosed with cancer in later stages and, consequently, have higher mortality rates despite cancer incidence being comparable between rural and urban settings.

In recognition of these disparities, Hudis announced ASCO’s launch of their Rural Access to Cancer Care Task Force, which will both examine major drivers of rural cancer care disparities and recommend 4 concrete actions: provider education and training, workforce development, tele-oncology, and research.

Efforts like this have started to gain traction as more federal, state, and local officials recognize the need for effective and sustainable solutions. Walking through some of these solutions, a panel of experts highlighted 3 themes: local efforts, clinical trial access, and telehealth.

“Local problems need local solutions,” said Electra D. Paskett, PhD, Marion N. Rowley Professor of Cancer Research, College of Medicine, The Ohio State University. “When we go into communities, we go in as partners and work with community members because they not only understand the problems but also the causes of the problem and the solutions.”

It’s about building local capacity, she explained. This means educating cancer coalitions within the community and utilizing community hubs, such as churches, to develop programs to address risk factors like obesity, sugar intake, and lack of physical activity. Paskett also emphasized the importance of utilizing all members of the care team, which include not just the doctor but also nurses, pharmacists, patient navigators, and community health workers.

Alan P. Lyss, MD, oncologist, Missouri Baptist Medical Center and Heartland Cancer Research, added that providers in rural areas have close relationships with their patients because they're involved in the community.

“Local providers have a stake in whether or not patients develop cancer,” he said. “These are their community members. They care if a woman comes in with a benign tumor ends up getting cancer. It’s their community and their friends.”

Offering a federal perspective, Robert T. Croyle, PhD, director of the Division for Cancer Control and Population Sciences at the National Cancer Institure (NCI), explained how efforts in the community can be aided by federal programs. According to Croyle, NCI has provided supplemental funding to 21 of their NCI-designated cancer centers to create solutions in rural areas and another round of funding is on its way. He explained that this is a way to get rural communities on the radar screens of the directors of NCI-designated cancer centers.

NCI has also changed expectations of programs they fund, requiring their NCI-designated cancer centers to have a program on community outreach and engagement. Now, said Croyle, the institute will also require the cancer centers to understand and define their catchment population and to better collect data on their characteristics in order to better serve them and their needs.

Lyss then highlighted the importance of providing access to clinical trials for rural populations, which he said requires 3 actions: providing access and education, broadening eligibility, and removing financial impediments. Referencing his own Heartland Cancer Research, which is part of the NCI Community Oncology Research Program, Lyss explained that three quarters of their sites span communities where more than 30% of the population is rural.

Through the program, oncologists with access to clinical trials are sent to rural communities to train nurses on research methodology and how to handle investigational drugs. This, he said, galvanizes enthusiasm and creates advocates within the community to get patients involved with clinical trials.

Citing higher rates of comorbidities and second cancers in rural communities, Lyss argued that clinical trial criteria needs to be broadened and commended ASCO’s and the FDA’s efforts to expand criteria. With regard to financial impediments, Lyss explained that Medicaid is often the primary provider for rural populations and is the only major insurer that doesn’t require routine costs of care associated with clinical trial participation to be covered.

While telehealth is often touted as a way to reach these populations, the panel agreed that this isn’t the reality, with many communities lacking the broadband capabilities to use these services.

“The good news is knowledge is exploding. But the bad news is that it’s traveling very slowly, particularly to underserved communities, and we will never have enough experts training to manage the long-term complex diseases that require complex management,” said Oliver Bogler, PhD, chief operating officer of the ECHO Institute. However, one use of telehealth has been able to reach these populations through the education of providers: Project ECHO.

Project ECHO is a partnership model that links specialist teams at an academic hub to providers in local communities. “It’s people finding local solutions to local issues,” said Bogler, who explained that the model includes caretakers throughout the continuum of care. Through the program, these specialty care teams train primary care clinicians to be able to perform specialty care services and increase their capabilities to better serve their patients.