Despite growing national awareness of health-care inequities, cancer care for many rural Americans remains inadequate. To shed some light on the challenges faced by patients with cancer in rural areas, The ASCO Post spoke with Mary Charlton, PhD, Associate Professor of Epidemiology in the University of Iowa College of Public Health, who has been awarded a grant from the National Cancer Institute (NCI). Dr. Charlton will serve as principal investigator for research that focuses on a collaborative network intervention to improve the quality of cancer care in rural hospitals caring for rural, underserved patients.
Mary Charlton, PhD
Urban vs Rural: Multiple Definitions
To begin, in population science, what does rural mean in relation to urban?
The dividing line between urban and rural is a transition where one imperceptibly melds into the other. There are also multiple definitions. For instance, the census bureau defines urbanized areas as having 50,000 or more people, whereas rural areas encompass all population, housing, and territory not included within an urban area. Sometimes population density is the defining concern, and in other cases, it is geographic isolation.
NCI Grant
You recently received an NCI grant as principal investigator on an intervention program. Please tell us how this grant came about and its central purpose(s).
In 2018, the NCI hosted its first meeting focused on rural cancer care disparities called Accelerating Rural Cancer Control Research (ARCCR). Tim Mullett, MD, a thoracic surgeon from the University of Kentucky Markey Cancer Center, was one of the speakers at the meeting. He discussed the Markey Cancer Center’s affiliate network, which was succeeding in helping community cancer centers achieve and maintain the standards of care set by the American College of Surgeons Commission on Cancer. They were able to build trust and extend the resources and expertise of their NCI-designated cancer center to hospitals across Kentucky.
So, we want to do something like that in Iowa, with some of our larger hospitals that serve most of our patients with cancer living in rural areas. We currently have 118 hospitals in the state, and only 10 of them are accredited by the Commission on Cancer. Most states have a much higher percentage of Commission on Cancer–accredited hospitals.
The grant is called “Effectiveness and Implementation of a Health System Intervention to Improve Quality of Cancer Care for Rural, Underserved Patients.” The purpose is to identify the core functions of the Markey Cancer Center Affiliate Network (MCCAN) of the University of Kentucky Markey Cancer Center model, so we can find ways to adapt it to Iowa.
We have identified four rural Iowa community hospitals to participate in this intervention trial and developed expert support teams to assist key stakeholder groups within each hospital. They will assess determinants and outcomes of the implementation process, along with stakeholders’ perception of the value and utility of the Commission on Cancer accreditation standards and the intervention itself to improve the quality of cancer care for their patients. We hope this work leads to dissemination of similar models across rural settings, to improve quality of care, reduce rural disparities in cancer outcomes, and give rural hospitals an avenue to demonstrate their quality of care.
Are there any tools derived from this work that can be used to accelerate your goals?
Yes. We’ve been interviewing the staff from the MCCAN Kentucky model about the processes and resources they use to assist hospitals in rural areas. To that end, we are creating a manual based on the interviews. It should serve as a guide for any center that wants to expand out into hospitals in rural, underserved areas and help them work toward achieving accreditation. In short, it gives hospitals certain metrics and methods that will help them without having to reinvent the wheel, so to speak. These smaller rural hospitals have multiple challenges, and this work is designed to establish an evidence-based path to sharing resources between rural and urban cancer programs that will make achieving Commission on Cancer standards more feasible.
Challenges of COVID-19
How did the COVID-19 pandemic affect rural patients with cancer, who already faced access challenges?
I haven’t seen this question articulated in the literature yet, but just from our work and interviews with rural hospitals, it appears like the COVID-19 pandemic exacerbated the existing challenges, such as access to providers and services. When a small rural hospital becomes overwhelmed with patients who have COVID-19 and staffing issues, it does not have nearby providers to help, so it snowballs into emergency situations.
COVID-19 also created more transportation gaps and challenges. Many of the volunteer ride-share programs closed and have not reopened. For instance, our local American Cancer Society road-to-recovery program essentially shut down, which was a big hit to the community. At the University of Iowa, we have a Hope Lodge, where patients with cancer can stay for free during their treatment period, which was also shut down. So, COVID-19 simply made challenges to care even more challenging.
We currently have 118 hospitals in the state [Iowa], and only 10 of them are accredited by the Commission on Cancer.— Mary Charlton, PhD
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Growing Use of Telemedicine
What is the impact on emerging telemedicine on rural cancer systems and their patients?
It’s been a good trend that will continue to improve the ability for rural patients with cancer to receive at least a portion of their care virtually. In the provider realm, it makes things such as virtual tumor boards or virtual second opinions feasible for oncologists at larger cancer centers to extend their expertise to their colleagues in small rural hospitals. Moreover, symptom management and palliative care consultations can now be handled remotely, which is a huge benefit for rural patients.
However, one hole in the telehealth space centers on genetic counselors, because they cannot bill out to Medicare for their telehealth visits. I believe there is a federal bill out there to change that, but for now, there’s a void in that valuable service that could easily be provided virtually. And, unfortunately, we have broadband issues in rural areas, which further hampers access. If such difficulties are addressed, it could have an immediate impact on the health-care delivery systems in rural America.
Closing Thoughts
Please share a closing thought about the challenges of delivering high-quality cancer care in rural settings.
Simply meeting the standard of care in cancer is very challenging for rural hospitals. It’s important to note, that many of these hospitals do not have specialized oncology surgeons, and all such intense surgery is performed by general surgeons. In addition, besides the unmet material needs, patients with cancer have psychosocial issues that are often insufficiently met in rural areas, because we just don’t have enough social workers and mental health providers. Gathering and assessing quality data are vital to achieve Commission on Cancer accrediting standards, and we do not have the infrastructure in place for that effort. That said, the Markey Cancer Center model had great success, so we are optimistic about the future of cancer care in Iowa.
DISCLOSURE: Dr. Charlton reported no conflicts of interest.
