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Outcomes for Rural Patients With Cancer Enrolled in Clinical Trials

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Key Points

  • There was no meaningful difference in survival patterns between rural and urban patients for almost all of the 17 different cancer types.
  • The only exception was patients with estrogen receptor­–negative, progesterone receptor–negative breast cancer. Rural patients with this cancer didn’t live as long as their urban counterparts.
  • NCORP sites exist in 13 states where the rural population exceeds 30%. Thus, tens of thousands of rural patients with cancer can enroll in NCI clinical trials and be cared for at their local hospital and clinic.

The disparity in survival rates between rural and urban patients is reduced when patients in both settings are enrolled in clinical trials, SWOG study results show. The study results were published in JAMA Network Open by a team led by Joseph Unger, PhD, a SWOG biostatistician and health services researcher at Fred Hutchinson Cancer Research Center.

The results cast new light on decades of research that starkly outline cancer disparities. About 19% of Americans live in rural areas, and studies have shown that when faced with cancer, rural patients don’t live as long as urban patients. Statistics published by the Centers for Disease Control and Prevention in 2017 show a significant difference in the rate of cancer deaths, with 180 people out of 100,000 dying of cancer in rural areas compared with 158 of 100,000 dying of cancer in urban areas between 2011 and 2015.

In the new analysis by SWOG, the international cancer clinical trials network funded by the National Cancer Institute (NCI) indicates that this difference in survival is not due to patients, but to the care they receive.

“These findings were a surprise, since we thought we might find the same disparities others had found,” Dr. Unger said. “But clinical trials are a key difference here. In trials, patients are uniformly assessed, treated, and followed under a strict, guidelines-driven protocol. This suggests that giving people with cancer access to uniform treatment strategies could help resolve the disparities in outcomes that we see between rural and urban patients.”

Analysis Methods

Dr. Unger and SWOG member Banu Symington, MD, MACP, an oncologist who practices at the Sweetwater Regional Cancer Center in rural Idaho, studied cancer disparities by analyzing existing data from the group’s trials. Dr. Unger and his team identified 36,995 patients who enrolled in 44 SWOG phase II or III treatment trials between 1986 and 2012.

Patients hailed from all 50 states and had 17 different cancer types, including acute myeloid leukemia, sarcoma, lymphoma, and myeloma, as well as brain, breast, colorectal, lung, ovarian, and prostate cancers. The team limited their analysis of survival to the first 5 years after trial enrollment to emphasize outcomes related to cancer and its treatment.

Using U.S. Department of Agriculture population classifications known as Rural-Urban Continuum Codes, the team categorized patients as either rural or urban and analyzed their outcomes. Patient outcomes included overall survival, progression-free survival, and cancer-specific survival. The team used a multivariate Cox regression to analyze their data.

Analysis Results

There was no meaningful difference in survival patterns between rural and urban patients for almost all of the 17 different cancer types. The only exception was patients with estrogen receptor­–negative, progesterone receptor–negative breast cancer. Rural patients with this cancer didn’t live as long as their urban counterparts, a finding the team says could be attributed to a few factors, including timely access to follow-up chemotherapy after their first round of cancer treatment.

“If people diagnosed with cancer, regardless of where they live, receive similar care and have similar outcomes, then a reasonable inference is that the best way to improve outcomes for rural patients is to improve their access to quality care,” Dr. Unger said.

Dr. Unger noted that the NCI Community Oncology Research Program (NCORP) brings clinical trials into community hospitals and clinics, including in rural areas, and represents the community-level outreach that can provide the quality cancer care that may be needed. In 2014, NCI officials broadened NCORP eligibility to include oncology practices that serve large rural populations.

Currently, there are NCORP sites in 13 states where the rural population exceeds 30%—Alaska, Arkansas, Iowa, Kentucky, Mississippi, Montana, North Carolina, North Dakota, South Carolina, South Dakota, Tennessee, Wisconsin, and Wyoming. Thus, tens of thousands of rural patients with cancer can enroll in NCI clinical trials and be cared for at their local hospital and clinic.

“The goal of this expansion was to provide access and test interventions to reduce disparities by improving the quality of care across the cancer continuum among rural populations,” said Worta McCaskill-Stevens, MD, Chief of the Community Oncology and Prevention Trials Research Group at NCI. “Clinical trials provide access to high-quality care, and NCORP sites bring trials to people where they live.”

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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