Laurence J. Heifetz, MD
It was not news to Joseph Unger, PhD, MS, that patients in rural areas had worse oncology outcomes than their urban counterparts. But what did astonish him in his research, presented at the 2018 American Society of Clinical Oncology (ASCO) Annual Meeting, was that patients in clinical trials had similar outcomes, regardless of ZIP code. “To our surprise—and it was a surprise— we found very little evidence that outcomes were different between rural and urban patients receiving protocol- directed therapy,” said Unger, an assistant member of the Cancer Prevention Program in the Public Health Sciences Division at Fred Hutchinson Cancer Research Center in Seattle, Washington.
Simply by being in a study protocol, they’re getting care, and it’s guided by high standards, whereas “patients who aren’t in a clinical trial can be receiving the best care in the world to no care at all. It spans the entire spectrum,” Unger said.
However, beyond clinical trials, some rural clinics are finding ways to successfully raise the level of cancer care for their patients, and methods vary according to the amount of time and other resources available. For example, clinics are finding that systematically calling higher-risk patients to check on them makes a difference. Others are forming alliances with larger urban care centers, which provide expert opinions and consultations via virtual tumor boards and telehealth visits. Although rural clinics may have financial challenges, some of these improvements can be instituted without a large cash outlay.
Rural Care Quality
There are many reasons why rural patients with cancer tend to have worse outcomes. Resources, both financial and human, are stretched. Clinicians and staff do the best they can within time constraints and other limiting circumstances. Rural clinics don’t usually have a variety of cancer specialists on hand, nor are there unlimited support personnel to transport patients for appointments or ways to provide the medications they need at affordable prices.
Since it is a multidisciplinary disease, cancer involves surgeons, medical oncologists, radiation oncologists, and other specialists. Often, the local community may not have the expertise needed. In some rural areas, cancer care is spearheaded by primary care physicians, said Laurence J. Heifetz, MD, medical director of the Gene Upshaw Memorial Tahoe Forest Cancer Center in Truckee, California. When he started working in Lake Tahoe, he was the area’s only medical oncologist, and there was no radiation oncologist. The rural clinics that now send patients to his cancer center lack oncologists of their own and are staffed by primary care physicians and physician extenders.
It’s difficult, also, to stay current on treatment standards. In some rural communities, “you end up with physicians who may not be up-to-date on what is now standard of care. We see that a lot,” said Gladys Rodriguez, MD, a medical oncologist/ hematologist at the START Center for Cancer Care, serving patients in San Antonio and rural South Texas. She has seen many doctors in rural areas using the same treatment regimens they did 10 to 15 years ago. Even oncologists who are more current may not be familiar with newer treatments that can improve patient survival, she said. “I see that with new drugs that are 2 or 3 years old. They are not familiar with them and don’t know which patients benefit from them,” she said.
At ASCO this year, Rodriguez was surprised to learn that treatment has changed for one cancer in which she specializes. To keep up with advances, she’s now considering reducing the number of tumor types she treats. She anticipates that for many oncologists, staying current will be an increasing challenge.
Patients need to take some responsibility for their care as well, and in rural areas, patients don’t always know to go regular screening exams. “The patient base itself is somewhat responsible for its poor statistics,” Heifetz said. He said most of the patients with colon cancer coming to his clinic from deep rural areas present at stage III or IV, while patients in Tahoe typically begin treatment at stage I or II.
Finances can be an issue for patients in rural areas. Not everyone can travel to cancer clinics out of the area to seek more specialized care. Others can’t take a day off work to drive several hours each way or don’t have a friend or a family member who can take time off to accompany them. Some cannot afford the gas to make the trip to San Antonio, Rodriguez said.