Rural-Urban Disparities in Stage of Diagnosis Among Cancers With Preventive Opportunities

Influence of Medicaid Expansion on Rural Medicare Beneficiaries Undergoing Colon Cancer-Directed Surgery in the United States

BACKGROUND

The 2010 Affordable Care Act increased access to colon cancer care for millions of non-elderly adults; however, the direct and indirect impact of Medicaid expansion on Medicare beneficiaries with cancer remains less clear, especially for elderly beneficiaries in rural communities.

METHODS

Medicare Provider Analysis and Review file was queried for all fee-for-service (FFS) beneficiaries undergoing cancer-directed surgery for colon cancer between 2012 and 2019. Our primary outcomes included 90-day postoperative morbidity, mortality, return to an emergency department, or readmission in the form of an inpatient hospitalization. Multivariable hierarchical logistic regression analyses akin to a difference-in-difference model were performed, allowing the intervention units (US states) to undergo expansion at different times while also controlling for demographic, clinical, and residential geospatial characteristics. Secondary analyses examined for an interaction between rurality and expansion.

RESULTS

Final analysis included 221,814 Medicare beneficiaries who underwent colon cancer-directed surgery between 2012 and 2019. Overall, 141,159 (63.6%) beneficiaries resided in states that adopted expanded Medicaid eligibility. Controlling for confounding factors, Medicaid expansion was not associated with postoperative surgical outcomes, including 90-day morbidity (p = 0.56), mortality (p = 0.30), presentation to an emergency department (p = 0.79), or readmission to an inpatient hospital (p = 0.43). Similarly, analyses evaluating differential association of expansion on rural beneficiaries found no significant differences associated with Medicaid expansion for rural compared with metropolitan beneficiaries.

CONCLUSIONS

In these analyses of over 200,000 Medicare beneficiaries across the United States, we found that Medicaid expansion was not associated with any changes in postoperative outcomes for Medicare beneficiaries undergoing colon cancer-directed surgery, either overall or by rural place of residence.

Socioeconomic disparities: a more important risk factor for advanced-stage oral cancer in Florida than smoking?

PURPOSE

To explore the associations between sociodemographic factors with advanced-stage oral cavity cancer (OCC) presentation among Floridians.

METHODS

Demographic and cancer data on OCC patients (n = 7,826) diagnosed between 2010 and 2017 were retrieved from the Florida Cancer Data System (FCDS). Census tract median income and percentage of population with a bachelor's degree or higher were used to infer income and education. Pearson's chi-square tests of independence were used to compare sociodemographic factors between racial/ethnic groups and staging groups. Multinomial logistic regression analyzed predictors of advanced disease. Incidence and percent late-stage diagnosis versus income were mapped using ArcGIS Pro.

RESULTS

Among 5,252 cases analyzed: 5.7% were Black, 82.4% White Non-Hispanic, 61.5% male, 63.3% publicly insured, 6.5% uninsured, 58.7% current or former smokers, and 73.0% urban residents. Black patients were more likely to present with advanced disease, be single/unmarried, uninsured, and less likely to be former smokers. Male sex, Black race, non-married status, no insurance, Medicaid, VA/military insurance, and lower educational status were associated with increased risk of regional vs. early disease in multivariable analysis (MVA) (p < 0.05). These factors, in addition to Medicare, were associated with distant disease in MVA. Geospatial mapping revealed higher rates of regional and distant disease presentation in the Tampa Bay and Orlando areas.

CONCLUSION

Black race, male sex, non-married status, lower education, Medicaid, VA/Military insurance and no insurance were associated with advanced OCC in Florida. Smoking status was not associated with advanced disease presentation after adjusting for sociodemographic variables.

Leveraging Pharmacy Education through a Train-the-Trainer Model to Enhance Breast Cancer Literacy in Rural Communities

Rural versus urban communities experience disproportionate challenges in breast cancer outcomes, with higher breast cancer mortality and later stage disease presentation, despite similar diagnosis rates. These disparities are driven by structural barriers, including rural hospital closures, transportation difficulties, and limited access to oncology specialists. This study evaluated a train-the-trainer program designed to equip PharmD students located at a pharmacy school in a rural county in South Carolina with breast cancer education training, leveraging the pharmacists' position as accessible healthcare professionals in rural communities. Training focused on breast cancer risk factors, prevention, screening, genetics, staging, and treatment options. Effectiveness was measured through pre- and post-workshop confidence surveys and knowledge assessments. Results showed significant improvement in student confidence across educational domains, with average scores increasing from 6.30 to 8.59 (p<0.0001). Understanding of screening guidelines (mean difference: 4.30; p-value: <.0001) and target therapy options showed the greatest improvement (mean difference: 3.65; p-value: <.0001), while knowledge of BRCA gene inheritance showed the smallest change (mean difference: 0.369; p-value: ns), suggesting some pre-existing awareness but limited understanding of its clinical applications. Overall, this pilot program demonstrates how pharmacy education can address healthcare disparities in rural communities. By preparing pharmacists to deliver accurate breast cancer education and to increase rural patient agency, this model creates a sustainable approach to improving health literacy in medically underserved areas. Future research could further expand this model to include diverse healthcare professionals and incorporate long-term impact assessments in community settings.

Longer travel times to acute hospitals are associated with lower likelihood of cancer screening receipt among rural-dwelling adults in the U.S. South

PURPOSE

Given rural hospitals' role in providing outpatient services, we examined the association between travel burdens and receipt of cancer screening among rural-dwelling adults in the U.S. South region.

METHODS

First, we estimated network travel times and distances to access the nearest and second nearest acute care hospital from each rural census tract in the U.S. South. After appending the Centers for Disease Control's PLACES dataset, we fitted generalized linear mixed models.

RESULTS

Longer distances to the second nearest hospital are negatively associated with breast, colorectal, and cervical cancer screening receipt among eligible rural-dwelling adults. Rural-dwelling women in counties with 1 closure had reduced likelihood of breast cancer screening. Residence in a partial- or whole-county Health Professional Shortage Area (HPSA) was negatively associated with cancer screening receipt. Specialist (OB/GYN and gastroenterologist) supply was positively associated with receipt of cancer screening. Uninsurance was positively associated with cervical and breast cancer screening receipt. Medicaid expansion was associated with increased breast and cervical cancer screening.

CONCLUSIONS

Rural residents in partial-county primary care HPSAs had the lowest rates of breast, cervical, and colorectal cancer screening, compared with whole-county HPSAs and non-shortage areas. These residents also faced the greatest distances to their nearest and second nearest hospital. This is notable because rural residents in the South face greater travel burdens for cancer care compared with residents in other regions. Finally, the positive association between uninsurance and breast and cervical cancer screening may reflect the CDC's National Breast and Cervical Cancer Early Detection Program's effectiveness.

High-Cost Cancer Drug Use in Medicare Advantage and Traditional Medicare

Importance

Medicare Advantage (MA) plans are designed to incentivize the use of less expensive drugs through capitated payments, formulary control, and preauthorizations for certain drugs. These conditions may reduce spending on high-cost therapies for conditions such as cancer, a condition that is among the most expensive to treat.

Objective

To determine whether patients insured by MA plans receive less high-cost drugs than those insured by traditional Medicare (TM).

Design, Setting, and Participants

This cohort study used data from the linked Colorado All Payer Claims Database and Colorado Central Cancer Registry. This population-based cohort included adults 65 years and older insured by Medicare with prescription coverage who reside in Colorado and were diagnosed with colorectal (CRC) or non-small cell lung cancer (NSCLC) between January 2012 and December 2021. The data were analyzed between December 2023 and August 2024.

Exposure

Enrollment in TM or MA insurance plans.

Main Outcomes and Measures

Claims for chemotherapy and oral targeted agents were identified. Thresholds for high-cost drugs were based on the distribution of drug costs. Inverse probability weighted logistic regression for receiving any cancer drug and for receiving a high-cost cancer drug was estimated, controlling for patient and ecological characteristics. The sample was stratified by cancer site and local/regional and distant stage.

Results

Of 4240 patients included in the analysis (mean [SD] age, 75 [7] years; 2327 [54.9%] female), 1991 were diagnosed with CRC and 2249 with NSCLC. A total of 1647 patients had local or regional CRC, and 344 had distant CRC; 1351 patients had local or regional NSCLC, and 898 had distant NSCLC. In the covariate-adjusted analysis, patients diagnosed with local or regional CRC who were insured by MA were 6.0 percentage points less likely to receive a cancer drug than similar patients insured by TM. Patients diagnosed with distant NSCLC were 10.0 percentage points less likely to receive a cancer drug if insured by MA. Among patients who received a cancer drug, patients insured by MA were less likely to receive a high-cost drug for local or regional CRC (by 10.0 percentage points) and distant CRC (by 9.0 percentage points).

Conclusions and Relevance

In this cohort study, high-cost drugs were more commonly prescribed among patients enrolled in TM and diagnosed with CRC. A similar pattern was not observed for patients with NSCLC, perhaps because clinical evidence suggests survival benefits to be associated only with certain drugs, all of which are expensive. Nonetheless, MA was modestly associated with reduced high-cost drug utilization and may reduce overall treatment costs.

What cancers explain the growing rural-urban gap in human papillomavirus-associated cancer incidence?

PURPOSE

Human papillomavirus (HPV) can cause cancers of the genital system, anus/rectum, and oropharynx. Prior research showed that HPV-associated cancer incidence was rising faster in nonmetro than in metro populations. Our study identified which cancers contributed to the widening disparity.

METHODS

Representing ∼93% of all cancers in the United States, we analyzed data from the North American Association of Central Cancer Registries (2000-2019). Restricting the analysis to HPV-associated cancers, we compared 5-year average age-adjusted incidence rates (per 100,000 population) for nonmetropolitan (Rural-Urban Continuum Codes 4-9) and metropolitan populations, by sex and cancer site. To quantify the rural-urban gap, we calculated rate ratios and absolute differences of incidence trends.

RESULTS

Although incidence was similar in 2000-2004 (nonmetropolitan = 9.9; metropolitan = 9.9), incidence in 2015-2019 was significantly higher in nonmetropolitan (12.3) than metropolitan (11.1) populations. The gap was widest for cervical cancers (females) in 2015-2019 (1.0 case per 100,000) but grew the most since 2000-2004 in oropharyngeal cancers among males (+1.1 cases per 100,000). The nonmetropolitan rate ratios for females (RR = 1.15, 95% C.I. = 1.13, 1.17) and males (RR = 1.07, 95% C.I. = 1.05, 1.09) in 2015-2019 were higher than the respective RRs for all other years. Since 2000, the nonmetropolitan disparity has significantly grown for anal and cervical cancers in females, and oropharyngeal cancers in both sexes.

DISCUSSION

Although preventable, nonmetropolitan Americans have shouldered a growing burden of HPV-associated cancers. To address these cervical, anal, and oropharyngeal cancer disparities, it is imperative that HPV vaccination programs are effectively implemented at scale.

The American Cancer Society National Lung Cancer Roundtable strategic plan: Implementation of high-quality lung cancer screening

More than a decade has passed since researchers in the Early Lung Cancer Action Project and the National Lung Screening Trial demonstrated the ability to save lives of high-risk individuals from lung cancer through regular screening by low dose computed tomography scan. The emergence of the most recent findings in the Dutch-Belgian lung-cancer screening trial (Nederlands-Leuvens Longkanker Screenings Onderzoek [NELSON]) further strengthens and expands on this evidence. These studies demonstrate the benefit of integrating lung cancer screening into clinical practice, yet lung cancer continues to lead cancer mortality rates in the United States. Fewer than 20% of screen eligible individuals are enrolled in lung cancer screening, leaving millions of qualified individuals without the standard of care and benefit they deserve. This article, part of the American Cancer Society National Lung Cancer Roundtable (ACS NLCRT) strategic plan, examines the impediments to successful adoption, dissemination, and implementation of lung cancer screening. Proposed solutions identified by the ACS NLCRT Implementation Strategies Task Group and work currently underway to address these challenges to improve uptake of lung cancer screening are discussed. PLAIN LANGUAGE SUMMARY: The evidence supporting the benefit of lung cancer screening in adults who previously or currently smoke has led to widespread endorsement and coverage by health plans. Lung cancer screening programs should be designed to promote high uptake rates of screening among eligible adults, and to deliver high-quality screening and follow-up care.

Caught Between a Radiation Oncology Case Rate (ROCR) and a Hard Place: Improving Proposed Radiation Oncology Alternative Payment Models

PURPOSE

The Radiation Oncology Case Rate (ROCR) aims to shift radiation reimbursement from fee-for-service (FFS) to bundled payments, which would decouple fractionation from reimbursement in the United States. This study compares historical reimbursement rates from 3 large centers and a national Medicare sample with proposed base rates from ROCR. It also tests the impact of methodological inclusion of treatment and disease characteristics to determine if any variables are associated with greater rate differences that may lead to inequitable reimbursement.

METHODS AND MATERIALS

Using Mayo Clinic electronic medical record data from 2017 to 2020 and part B claims from the Medicare 5% research identifiable files, episodic 90-day historical reimbursement rates for 15 cancer types were calculated per the ROCR payment methodology. Mayo Clinic reimbursement rates were stratified by disease and treatment characteristics and multiple linear regression was performed to assess the association of these variables on historical episode reimbursement rates.

RESULTS

From Mayo Clinic, 3498 patient episodes were included and 480,526 from the research identifiable files. From both data sets, 25% of brain metastases and 13% of bone metastases episodes included ≥2 treatment courses with an average of 51 days between courses. Accounting for all 15 cancer types, ROCR base rates resulted in an average -2.4% and -2.9% reduction in rates for Mayo Clinic and the research identifiable files respectively compared with historical reimbursement. On multivariate analysis of Mayo Clinic data, treatment intent (curative vs palliative) was associated with higher historical reimbursement (+$477 to +$7417; P ≤.05) for 12 out of 12 applicable cancer types. Stage (III-IV vs I-II) was associated with higher historical reimbursement (+$1169 to +$3917; P ≤ .05) for 8 out of 12 applicable cancer types.

CONCLUSIONS

Our data suggest ROCR base rates introduce an average ≤3% reimbursement rate decrease compared with historical FFS reimbursement per cancer type, which could produce the Medicare savings required for congressional approval of ROCR. Estimating comparisons with future FFS reimbursement would require consideration of additional factors such as the increased utilization of hypofractionation, proposed FFS rate cuts, and inflationary updates. A distinct rate and shortened episode duration (≤30 days) should be considered for palliative episodes. Applying a base rate modifier per cancer stage may mitigate disproportionate reductions in reimbursement for facilities with a higher volume of curative advanced-stage patients such as freestanding centers in rural settings.

Challenges and lessons learned in recruiting participants for school-based disease prevention programs during COVID-19

Schools provide an ideal setting for delivery of disease prevention programs due to the ability to deliver health education and counseling, including health behavior interventions, to large numbers of students. However, the remote and hybrid learning models that arose during the coronavirus (COVID-19) pandemic created obstacles to these efforts. In this article, we provide insights on collaborating with schools to deliver disease prevention programming during the height of the COVID-19 pandemic, and in subsequent years. We illustrate these strategies by drawing upon our firsthand research experiences engaging high schools in a school-based cancer prevention trial focused on sun safety. Delivery of a cluster-randomized trial of a school-based skin cancer prevention program was initiated in the spring of 2020 at the onset of the COVID-19 pandemic in the U.S. We present multilevel evaluation data on strategies used to reach schools remotely and share lessons learned that may inform similar approaches moving forward during times of crises. Although the COVID-19 pandemic interrupted school-based recruitment for this trial, enrollment improved one year later and did not appear to differ between rural and urban schools. Recruitment strategies and trial-related procedures were modified to address new challenges brought about by the pandemic. Despite the COVID-19 crisis altering US classrooms, disease prevention programming can continue to be offered within schools, given close community partnerships and new adaptations to the ways in which such programming and research are conducted.

Trends in the use of granulocyte colony stimulating factors for older patients with cancer, 2010 to 2019

INTRODUCTION

Older patients with cancer receiving myelosuppressive treatment are at an increased risk for developing febrile neutropenia (FN) or having chemotherapy dose-reductions or delays, resulting in suboptimal health outcomes. Granulocyte colony stimulating factors (G-CSF) are effective medications to reduce these adverse events and are recommended for patients ≥65 years receiving chemotherapy with >10 % FN risk. We sought to characterize the trends and predictors of G-CSF use between the youngest-old (66-74 years), middle-old (75-84 years), and oldest-old (≥85 years) patients with cancer.

MATERIALS AND METHODS

We used registry data from SEER-Medicare for breast, lung, ovarian, colorectal, esophageal, gastric, uterine, prostate, pancreatic cancer, and non-Hodgkin lymphoma (NHL) diagnoses from 2010 to 2019. Cox proportional hazard analysis was used.

RESULTS

Overall, 41.4 % of patients received G-CSF from chemotherapy initiation to three days after completion of the first chemotherapy course. The use rate remained relatively stable for all cancers, except for an increase in use for those with pancreatic cancer. G-CSF use decreased as patients got older. The oldest-old were 43.0 % (95 % confidence interval: 40.7-45.2 %) less likely to receive G-CSF compared to the youngest-old. Patients with breast cancer or NHL were more likely to receive G-CSF than those with other cancers. Patients who were female, married, White or Hispanic, and had fewer comorbidities were more likely to receive G-CSF.

DISCUSSION

G-CSF is used less often in populations at higher risk of developing FN and related complications. Improving adherence to recommendations can improve health outcomes, especially in the oldest adults, older males, and Black patients.

Disparities in Cancer Stage of Diagnosis by Rurality in California, 2015 to 2019

BACKGROUND

Cancer rates in rural areas vary by insurance status, socioeconomic status, region, race, and ethnicity.

METHODS

California Cancer Registry data (2015-2019) were used to investigate the stage of diagnosis by levels of rurality for the five most common cancers. The percentage of residents in rural blocks within census tract aggregation zones was categorized into deciles up to 50%. Multivariable logistic regression was used to estimate associations with rurality, with separate models by cancer site, sex, race, and ethnicity (non-Hispanic White and Hispanic). Covariates included individual-level and zone-level factors.

RESULTS

The percentage of late-stage cancer diagnosis was 28% for female breast, 27% for male prostate, 77% for male lung, 71% for female lung, 60% for male colorectal, 59% for female colorectal, 7.8% for male melanoma, and 5.9% for female melanoma. Increasing rurality was significantly associated with increased odds of late-stage cancer diagnosis for female breast cancer (Ptrend < 0.001), male lung cancer (Ptrend < 0.001), female lung cancer (Ptrend < 0.001), and male melanoma (Ptrend = 0.01), after adjusting for individual-level and zone-level factors. The strength of associations varied by sex and ethnicity. For males with lung cancer, odds of late-stage diagnosis in areas with >50% rural population was 1.24 (95% confidence interval, 1.06-1.45) for non-Hispanic White patients and 2.14 (95% confidence interval, 0.86-5.31) for Hispanic patients, compared with areas with 0% rural residents.

CONCLUSIONS

Increasing rurality was associated with increased odds for late-stage diagnosis for breast cancer, lung cancer, and melanoma, with the strength of associations varying across sex and ethnicity.

IMPACT

Our findings will inform cancer outreach to these rural subpopulations.

Rural-urban disparities and trends in cancer screening: an analysis of Behavioral Risk Factor Surveillance System data (2018-2022)

BACKGROUND

Despite evidence of the benefit of routine cancer screenings, data show a concerning decline in cancer screening uptake for multiple cancers. This analysis aimed to examine rural-urban differences in recent trends for being up-to-date with screenings for breast, cervical, and colorectal cancers.

METHODS

We used 2018, 2020, and 2022 Behavioral Risk Factor Surveillance System data to assess up-to-date cancer screening status among eligible adults in the United States. We calculated weighted prevalence estimates overall and stratified by county-level rural-urban classification. We used survey-weighted multivariable logistic regression models to examine rural-urban disparities in cancer screening up-to-date status by year.

RESULTS

Prevalence of being up-to-date with each cancer screening was lower in 2022 than it was in 2018. The largest decline in screening overall was for cervical cancer, which dropped from 81.89% in 2018 to 47.71% in 2022. Rural-urban disparities were observed for breast cancer screening from 2018 to 2022, with the odds of up-to-date screening being 14% to 27% lower for rural populations than for urban populations. For colorectal and cervical cancers, the odds of being up-to-date with screenings were lower for rural populations in 2018 and 2020, but no statistically significant difference was observed in 2022 (colorectal screening odds ratio = 0.96, 95% CI = 0.90 to 1.02; cervical screening odds ratio = 0.97, 95% CI = 0.93 to 1.03).

CONCLUSION

There is a concerning trend of decreasing uptake of cancer screenings that will challenge future efforts in cancer prevention and control. There is a need to better understand the factors contributing to the decline in cancer screening update.

Racial and ethnic disparities in access to total neoadjuvant therapy for rectal cancer

BACKGROUND

Total neoadjuvant therapy has revolutionized the treatment of locally advanced rectal cancer and quickly become the new standard of care. Whether patients from all racial and ethnic groups have had equal access to these potential benefits, however, remains unknown.

METHODS

We identified all adults diagnosed with locally advanced rectal cancer in California who underwent neoadjuvant chemotherapy and radiation from 2010 to 2020 using the California Cancer Registry. We used logistic regression to estimate the predicted probability of receiving total neoadjuvant therapy as opposed to traditional chemoradiotherapy for each racial and ethnic group and used a time-race interaction to evaluate trends in access to total neoadjuvant therapy over time. We also compared survival by racial and ethnic group and total neoadjuvant therapy status using Kaplan-Meier plots and Cox proportional hazards models.

RESULTS

In total, 6,856 patients met inclusion criteria. Overall, 36.6% of patients received total neoadjuvant therapy in 2010 compared with 66.3% in 2020. Latino patients were significantly less likely than non-Latino White patients to undergo total neoadjuvant therapy ; however, there was no difference in the rate of growth in total neoadjuvant therapy over time between racial and ethnic groups. Non-Latino Black patients appeared to have lower risk-adjusted survival compared with non-Latino White patients, although not among patients who underwent total neoadjuvant therapy .

CONCLUSION

Access to total neoadjuvant therapy has increased significantly over time in California with no apparent difference in the rate of growth between racial and ethnic groups. We found no evidence of racial or ethnic disparities in survival among patients treated with total neoadjuvant therapy, suggesting that increasing access to high-quality cancer care may also improve health equity.

Investigating sex, race, and geographic disparities in bronchus and lung cancer mortality in the United States: a comprehensive longitudinal study (1999-2020) utilizing CDC WONDER data

Background

Lung and bronchus cancer has become the leading cause of cancer-related mortality in the United States. Understanding the patterns of mortality is an absolute requirement.

Methods

This study analyzed Lung and Bronchus cancer-associated mortality rates from 1999 to 2020 using death certificate data from the Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research (CDC WONDER). Age-adjusted mortality rates (AAMRs), per 100 000 people, and annual percentage change (APCs) were also calculated.

Results

3 599 577 lung and bronchus cancer-related deaths occurred in patients aged younger than 1-85+ years between 1999 and 2020. Overall AAMRs declined from 59.1 in 1999 to 58.9 in 2001 (APC: -0.1364) then to 55.9 in 2005 (APC: -1.4388*) 50.5 by 2010 (APC: -2.0574*) 44.7 by 2014 (APC: -2.9497*) and 35.1 by 2020 (APC: -4.1040*). Men had higher AAMRs than women (overall AAMR men: 61.7 vs. women: 38.3). AAMRs were highest among non-Hispanic (NH) Black or African American (52.7) patients followed by NH White (51.8), NH American Indian or Alaska Native (38.6), NH Asian or Pacific Islander (24.7) and Hispanic or Latino race (20.2). AAMRs varied in region (overall AAMR; South: 52.4; Midwest: 52.3; Northeast: 46.3; West: 39.1). Non-metropolitan areas had a higher AAMR (55.9) as compared to metropolitan areas (46.7). The top 90th percentile states of Lung and Bronchus cancer AAMR were Arkansas, Kentucky, Mississippi, Tennessee, and West Virginia.

Conclusion

An overall decreasing trend in AAMRs for lung and bronchus cancer was seen. Public health measures to regulate risk factors and precipitating events are needed.

Patient reports of cancer care coordination in rural Hawaii

PURPOSE

Rural residents experience disproportionate burdens of cancer, and poorer cancer health outcomes in rural populations are partly attributed to care delivery challenges. Cancer patients in rural areas often experience unique challenges with care coordination. In this study, we explored patient reports of care coordination among rural Hawaii patients with cancer and compared rural and urban patients' perceptions of cancer care coordination.

METHODS

80 patients receiving active treatment for cancer from rural Hawaii participated in a care coordination study in 2020-2021. Participants completed the Care Coordination Instrument, a validated oncology patient questionnaire.

FINDINGS

Mean age of rural cancer patients was 63.0 (SD = 12.1), and 57.7% were female. The most common cancer types were breast and GI. Overall, rural and urban patients' perceptions of care coordination were comparable (p > 0.05). There were statistically significant differences between rural and urban patients' perceptions in communication and navigation aspects of care coordination (p = 0.02 and 0.04, respectively). Specific differences included a second opinion consultation, clinical trial considerations, and after-hours care. 43% of rural patients reported traveling by air for part or all of their cancer treatment.

CONCLUSIONS

Findings suggest that while overall perceptions of care coordination were similar between rural and urban patients, differential perceptions of specific care coordination areas between rural and urban patients may reflect limited access to care for rural patients. Improving access to cancer care may be a potential strategy to enhance care coordination for rural patients and ultimately address rural-urban cancer health disparities.

Human papillomavirus circulating tumor DNA assays as a mechanism for head and neck cancer equity in rural regions of the United States

The rates of human papillomavirus-positive oropharyngeal cancer (HPV-OPC) are rising worldwide and in the United States, particularly in rural regions including Appalachia. Rural areas face unique health challenges resulting in higher cancer incidence and mortality rates, and this includes HPV-OPC. The recent advent of highly sensitive liquid biopsies for the non-invasive detection of HPV-OPC recurrence (circulating tumor HPV DNA, HPV ctDNA) has been swiftly adopted as part of surveillance paradigms. Though knowledge gaps persist regarding its use and clinical trials are ongoing, the ease of collection and cost-effectiveness of HPV ctDNA make it more accessible for HPV-OPC survivors than usual surveillance methods of frequent exams and imaging. Herein, we discuss how implementing HPV ctDNA assays in rural regions of the United States provide one poignant example of how liquid biopsies can improve cancer care equity.

Rural-urban disparities in psychosocial functioning in epithelial ovarian cancer patients

OBJECTIVE

Although rural residence has been related to health disparities in cancer patients, little is known about how rural residence impacts mental health and quality of life (QOL) in ovarian cancer patients over time. This prospective longitudinal study investigated mental health and QOL of ovarian cancer patients in the first-year post-diagnosis.

METHOD

Women with suspected ovarian cancer completed psychosocial surveys pre-surgery, at 6 months and one-year; clinical data were obtained from medical records. Histologically confirmed high grade epithelial ovarian cancer patients were eligible. Rural/urban residence was categorized from patient counties using the USDA Rural-Urban Continuum Codes. Linear mixed effects models examined differences in psychosocial measures over time, adjusting for covariates.

RESULTS

Although disparities were not observed at study entry for any psychosocial variable (all p-values >0.22), urban patients showed greater improvement in total distress over the year following diagnosis than rural patients (p = 0.025) and were significantly less distressed at one year (p = 0.03). Urban patients had a more consistent QOL improvement than their rural counterparts (p = 0.006). There were no differences in the course of depressive symptoms over the year (p = 0.17). Social support of urban patients at 12 months was significantly higher than that of rural patients (p = 0.04).

CONCLUSION

Rural patients reported less improvement in psychological functioning in the year following diagnosis than their urban counterparts. Clinicians should be aware of rurality as a potential risk factor for ongoing distress. Future studies should examine causes of these health disparities and potential long-term inequities and develop interventions to address these issues.

American Cancer Society's report on the status of cancer disparities in the United States, 2023

In 2021, the American Cancer Society published its first biennial report on the status of cancer disparities in the United States. In this second report, the authors provide updated data on racial, ethnic, socioeconomic (educational attainment as a marker), and geographic (metropolitan status) disparities in cancer occurrence and outcomes and contributing factors to these disparities in the country. The authors also review programs that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. There are substantial variations in risk factors, stage at diagnosis, receipt of care, survival, and mortality for many cancers by race/ethnicity, educational attainment, and metropolitan status. During 2016 through 2020, Black and American Indian/Alaska Native people continued to bear a disproportionately higher burden of cancer deaths, both overall and from major cancers. By educational attainment, overall cancer mortality rates were about 1.6-2.8 times higher in individuals with ≤12 years of education than in those with ≥16 years of education among Black and White men and women. These disparities by educational attainment within each race were considerably larger than the Black-White disparities in overall cancer mortality within each educational attainment, ranging from 1.03 to 1.5 times higher among Black people, suggesting a major role for socioeconomic status disparities in racial disparities in cancer mortality given the disproportionally larger representation of Black people in lower socioeconomic status groups. Of note, the largest Black-White disparities in overall cancer mortality were among those who had ≥16 years of education. By area of residence, mortality from all cancer and from leading causes of cancer death were substantially higher in nonmetropolitan areas than in large metropolitan areas. For colorectal cancer, for example, mortality rates in nonmetropolitan areas versus large metropolitan areas were 23% higher among males and 21% higher among females. By age group, the racial and geographic disparities in cancer mortality were greater among individuals younger than 65 years than among those aged 65 years and older. Many of the observed racial, socioeconomic, and geographic disparities in cancer mortality align with disparities in exposure to risk factors and access to cancer prevention, early detection, and treatment, which are largely rooted in fundamental inequities in social determinants of health. Equitable policies at all levels of government, broad interdisciplinary engagement to address these inequities, and equitable implementation of evidence-based interventions, such as increasing health insurance coverage, are needed to reduce cancer disparities.

Rural-urban otolaryngologic observational workforce analysis: The state of Nebraska

Objective

To analyze the rural-urban access to otolaryngology (OHNS) care within the state of Nebraska.

Design

Cross-sectional study.

Methods

Counties in Nebraska were categorized into rural versus urban status based upon the 2013 National Center for Health Statistics urban-rural classification scheme with I indicating most urban and VI indicating most rural. The information on otolaryngologists was gathered utilizing the Health Professions Tracking System. Otolaryngologists were categorized based on the county of their primary and outreach clinic location(s). Travel burden was estimated using census tract centroid distance to the nearest clinic location, aggregated to county using weighted population means to determine the average county distance to the nearest otolaryngologist.

Results

Nebraska is a state with a population of 1.8 million people unequally distributed across 76,824 square miles, with rural counties covering 2/3 of the land area. Nebraska has 78 primary OHNS clinics and 70 outreach OHNS clinics distributed across 93 counties. More than half (54.8%) of the counties in Nebraska lacked any OHNS clinic. Overall, a statistically significant difference was found when comparing mean primary OHNS per 100,000 population and mean miles to a primary OHNS clinic with Level III counties being 5.17 linear miles from primary OHNS compared to Level V counties being 29.94 linear miles.

Conclusion

Overall, a clear discrepancy between rural and urban primary OHNS clinics in Nebraska can be seen visually and statistically with rural Nebraskans having to travel at least 5.5 times farther to primary OHNS clinics when compared to urban Nebraskans.

Area deprivation and rurality impact overall survival and adjuvant therapy administration in patients with pancreatic ductal adenocarcinoma (PDAC)

BACKGROUND

The impact of neighborhood deprivation on outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) is not well-described and represents an area to improve disparities.

METHODS

We retrospectively queried our prospectively maintained database of patients with PDAC (2014-2022). Patients were grouped by Area Deprivation Index (ADI) and rural-urban commuting area (RUCA) codes. Cox proportional hazards models and logistic regressions were used to investigate effect on overall survival (OS) and adjuvant therapy administration.

RESULTS

536 patients were included. High ADI patients (more disadvantaged, n = 184) were more likely to identify as non-Hispanic Black (17.9% vs. 4.8%, p < 0.01) and were more likely to be from rural areas (49.5% vs. 18.5%, p < 0.01). High ADI was independently associated with decreased OS (HR (95% CI): 1.31 (1.01-1.69), p = 0.04). Urban high ADI patients were 3.5 times more likely to receive adjuvant therapy than rural high ADI patients (OR [95% CI]: 3.48 [1.26-9.61], p = 0.02).

CONCLUSION

Patients from the most disadvantaged neighborhoods have decreased OS. Access to adjuvant therapy likely contributes to this disparity in rural areas. Investigation into sources of this OS disparity and identification of barriers to adjuvant therapy will be crucial to improve outcomes in underserved patients with PDAC.

Adverse Health Outcomes among Rural and Urban Breast Cancer Survivors: A Population-Based Cohort Study

BACKGROUND

Limited population-based studies have focused on breast cancer survivors in rural populations. We sought to evaluate the risk of adverse health outcomes among rural and urban breast cancer survivors and to evaluate potential predictors for the highest risk outcomes.

METHODS

A population-based cohort of rural and urban breast cancer survivors diagnosed between 1997 and 2017 was identified in the Utah Cancer Registry (UCR). Rural breast cancer survivors were matched on year (±1 year) and age at cancer diagnosis (±1 year) with up to 5 urban breast cancer survivors (2,359 rural breast cancer survivors; 11,748 urban breast cancer survivors). Cox proportional hazards models were used to calculate HRs with 99% confidence intervals (CI) for adverse health outcomes overall, within 5 years, and >5 years after cancer diagnosis.

RESULTS

Compared with urban breast cancer survivors, rural breast cancer survivors had a 39% (HR, 1.39; 95% CI, 1.02-1.65) higher risk of heart failure (HF) within the 5 years of follow-up. Overall, there was no increase in the risk of other evaluated adverse health outcomes. A higher baseline body mass index and Charlson Comorbidity Index, family history of cardiovascular diseases, family history of breast cancer, and advanced cancer stage were risk factors for HF for rural and urban breast cancer survivors, with similar levels of HF risk.

CONCLUSIONS

Rural residence was associated with an increased risk of HF among breast cancer survivors.

IMPACT

Our study highlights the need for primary preventive strategies for rural cancer survivors at risk of heart failure.

The COVID-19 pandemic impact on independent and provider-based rural health clinics' operations and cancer prevention and screening provision in the United States

INTRODUCTION

The COVID-19 pandemic has disrupted cancer care, but it is unknown how the pandemic has affected care in Medicare-certified rural health clinics (RHCs) where cancer prevention and screening services are critical for their communities. This study examined how the provision of these cancer services changed pre- and peri-pandemic overall and by RHC type (independent and provider-based).

METHODS

We administered a cross-sectional survey to a stratified random sample of RHCs to assess clinic characteristics, pandemic stressors, and the provision of cancer prevention and control services among RHCs pre- and peri-pandemic. We used McNemar's test and Wilcoxon signed rank tests to assess differences in the provision of cancer prevention and screening services pre- and peri-pandemic by RHC type.

RESULTS

Of the 153 responding RHCs (response rate of 8%), 93 (60.8%) were provider-based and 60 (39.2%) were independent. Both RHC types were similar in their experience of pandemic stressors, though a higher proportion of independent RHCs reported financial concerns and challenges obtaining personal protective equipment. Both types of RHCs provided fewer cancer prevention and screening services peri-pandemic-5.8 to 4.2 for provider-based and 5.3 to 3.5 for independent (P<.05 for both). Across lung, cervical, breast, and colorectal cancer-related services, the proportion of both RHC groups providing services dropped peri-pandemic.

DISCUSSION

The pandemic's impact on independent and provider-based RHCs and their patients was considerable. Going forward, greater resources should be targeted to RHCs-particularly independent RHCs-to ensure their ability to initiate and sustain evidence-based prevention and screening services.

Disparities in geospatial patterns of cancer care within urban counties and structural inequities in access to oncology care

OBJECTIVE

To examine geospatial patterns of cancer care utilization across diverse populations in New Jersey-a state where most residents live in urban areas.

DATA SOURCES/STUDY SETTING

We used data from the New Jersey State Cancer Registry from 2012 to 2014.

STUDY DESIGN

We examined the location of cancer treatment among patients 20-65 years of age diagnosed with breast, colorectal, or invasive cervical cancer and investigated differences in geospatial patterns of care by individual and area-level (e.g., census tract-level) characteristics.

DATA COLLECTION/EXTRACTION METHODS

Multivariate generalized estimating equation models were used to determine factors associated with receiving cancer treatment within residential counties, residential hospital service areas, and in-state (versus out-of-state) care.

PRINCIPAL FINDINGS

We observed significant differences in geospatial patterns of cancer treatment by race/ethnicity, insurance type, and area-level factors. Even after adjusting for tumor characteristics, insurance type, and other demographic factors, non-Hispanic Black patients had a 5.6% higher likelihood of receiving care within their own residential county compared to non-Hispanic White patients (95% CI: 2.80-8.41). Patients insured with Medicaid and those without insurance had higher likelihoods of receiving care within their residential county compared to privately insured individuals. Patients living in census tracts with the highest quintile of social vulnerability were 4.6% more likely to receive treatment within their residential county (95% CI: 0.00-9.30) and were 2.7% less likely to seek out-of-state care (95% CI: -4.85 to -0.61).

CONCLUSIONS

Urban populations are not homogenous in their geospatial patterns of cancer care utilization, and individuals living in areas with greater social vulnerability may have limited opportunities to access care outside of their immediate residential county. Geographically tailored efforts, along with socioculturally tailored efforts, are needed to help improve equity in cancer care access.

County Rurality is Associated with Increased Tumor Size and Decreased Survival in Patients with Ewing Sarcoma

Background

Ewing Sarcoma (ES) is an aggressive tumor affecting adolescents and young adults. Prior studies investigated the association between rurality and outcomes, although there is a paucity of literature focusing on ES.

Objective

This study aims to determine whether ES patients in rural areas are subject to adverse outcomes.

Methods

This study utilized the Surveillance, Epidemiology, and End Results (SEER) database. A Poisson regression model was used with controls for race, sex, median county income, and age to determine the association between rurality and tumor size. A multivariate Cox Proportional Hazard Model was utilized, controlling for age, race, gender, income, and tumor size.

Results

There were 868 patients eligible for analysis, with a mean age of 14.14 years. Of these patients, 97 lived in rural counties (11.18%). Metropolitan areas had a 9.50% smaller tumor size (p<0.0001), compared to non-metropolitan counties. Patients of Black race had a 14.32% larger tumor size (p<0.0001), and male sex was associated with a 15.34% larger tumor size (p<0.0001). The Cox Proportional Hazard model estimated that metropolitan areas had a 36% lower risk of death over time, compared to non-metropolitan areas (HR: 0.64, p ≤ 0.04).

Conclusion

Patients in metropolitan areas had a smaller tumor size at time of diagnosis and had a more favorable survival rate for cancer-specific mortality compared to patients residing in rural areas. Further work is needed to examine interventions to reduce this discrepancy and investigate the effect of extremely rural and urban settings and why racial disparities occur.

Disparities in cancer incidence by rurality in California

BACKGROUND

Cancer rates in rural areas across the United States have different patterns than in urban areas. This study examines associations between rurality and incidence for the top 5 cancers in California and evaluates whether these associations vary jointly by sex, race, and ethnicity.

METHODS

We used 2015-2019 California Cancer Registry data to compare incidence rate ratios (IRRs) and trends for breast, prostate, lung, colorectal, and skin (melanoma) cancers. We leveraged census tract aggregation zones and 7 levels of percentage rural population (0%, >0% to <10%, 10% to <20%, 20% to <30%, 30% to <40%, 40% to <50%, and 50+%).

RESULTS

Zones with higher proportions of rural population were significantly associated with lower incidence of female breast cancer and prostate cancer, though the trends were not statistically significant overall. Zones with higher proportions of rural population were significantly associated with higher incidence of lung cancer and melanoma. There were no statistically significant trends for colorectal cancer overall. Comparing areas with 50% and over rural population with areas with 0% rural population, the IRR for lung cancer in Hispanic females was higher (IRR = 1.43, 95% confidence interval [CI] = 1.17 to 1.74) than in Hispanic males (IRR = 0.90, 95% CI = 0.72 to 1.11). Also, in areas with 50% or more rural population, the IRR for melanoma was higher in Hispanic females (IRR = 1.75, 95% CI = 1.23 to 2.45) than non-Hispanic White females (IRR = 0.87, 95% CI = 0.80 to 0.95).

CONCLUSIONS

Our findings show that rurality is associated with cancer incidence and underscore the importance of jointly examining rural disparities with sex, race, and ethnicity by cancer site.

ASCO Ethical Guidance for the US Oncology Community Where Reproductive Health Care Is Limited by Law

The decision in Dobbs v Jackson Women's Health Organization overturned federal protections for abortion rights, making way for states to enact abortion bans with or without exceptions for the health or life of the pregnant patient. Patient care across many areas of medicine including oncology continues to be affected. Although the change in the legal landscape is widely felt, the core ethical considerations for physicians do not change because of restrictions on the practice of medicine. ASCO offers this guidance to assist US oncologists and institutions who must balance limitations with established ethical duties. This paper articulates principles for cancer care and pregnancy, offers a framework for ethical reflection and action for oncologists who care for pregnant patients, and makes recommendations for individual and institutional action to support evidence-based, patient-centered care in the United States where abortion is illegal or access is limited.

Adoption of Innovative Therapies Across Oncology Practices-Evidence From Immunotherapy

Importance

Immunotherapies reflect an important breakthrough in cancer treatment, substantially improving outcomes for patients with a variety of cancer types, yet little is known about which practices have adopted this novel therapy or the pace of adoption.

Objective

To assess adoption of immunotherapies across US oncology practices and examine variation in adoption by practice type.

Design, Setting, and Participants

This cohort study used data from Medicare fee-for-service beneficiaries undergoing 6-month chemotherapy episodes between 2010 and 2017. Data were analyzed January 19, 2021, to September 28, 2022, for patients with cancer types for which immunotherapy was approved by the US Food and Drug Administration (FDA) during the study period: melanoma, kidney cancer, lung cancer, and head and neck cancer.

Exposures

Oncology practice location (rural vs urban), affiliation type (academic system, nonacademic system, independent), and size (1 to 5 physicians vs 6 or more physicians).

Main Outcomes and Measures

The primary outcome was whether a practice adopted immunotherapy. Adoption rates for each practice type were estimated using multivariate linear models that adjusted for patient characteristics (age, sex, race and ethnicity, cancer type, Charlson Comorbidity Index, and median household income).

Results

Data included 71 659 episodes at 1732 oncology practices. Of these, 264 practices (15%) were rural, 900 (52%) were independent, and 492 (28%) had 1 to 5 physicians. Most practices adopted immunotherapy within 2 years of FDA approval, but there was substantial variation in adoption rates across practice types. After FDA approval, adoption of immunotherapy was 11 (95% CI, -16 to -6) percentage points lower at rural practices than urban practices and 27 (95% CI, -32 to -22) percentage points lower at practices with 1 to 5 physicians than practices with 6 or more physicians. Adoption rates were similar at independent practices and nonacademic systems; however, both practice types had lower adoption than academic systems (independent practice difference, -6 [95% CI, -9 to -3] percentage points; nonacademic systems difference, -9 [95% CI, -11 to -6] percentage points).

Conclusions and Relevance

In this cohort study of Medicare claims, practice characteristics, especially practice size and rural location, were associated with adoption of immunotherapy. These findings suggest that there may be geographic disparities in access to important innovations for treating patients with cancer.

Rural-Urban Disparities in Receipt of Surgery for Potentially Resectable Non-Small Cell Lung Cancer

INTRODUCTION

Access to cancer care, especially surgery, is limited in rural areas. However, the specific reasons rural patient populations do not receive surgery for non-small cell lung cancer (NSCLC) is unknown. We investigated geographic disparities in reasons for failure to receive guideline-indicated surgical treatment for patients with potentially resectable NSCLC.

METHODS

The National Cancer Database was used to identify patients with clinical stage I-IIIA (N0-N1) NSCLC between 2004 and 2018. Patients from rural areas were compared to urban areas, and the reason for nonreceipt of surgery was evaluated. Adjusted odds of (1) primary nonsurgical management, (2) surgery being deemed contraindicated due to risk, (3) surgery being recommended but not performed, and (4) overall failure to receive surgery were determined.

RESULTS

The study included 324,785 patients with NSCLC with 42,361 (13.0%) from rural areas. Overall, 62.4% of patients from urban areas and 58.8% of patients from rural areas underwent surgery (P < 0.001). Patients from rural areas had increased odds of (1) being recommended primary nonsurgical management (adjusted odds ratio [aOR]: 1.14, 95% confidence interval [CI]: 1.05-1.23), (2) surgery being deemed contraindicated due to risk (aOR: 1.19, 95% CI: 1.07-1.33), (3) surgery being recommended but not performed (aOR: 1.13, 95% CI: 1.01-1.26), and (4) overall failure to receive surgery (aOR: 1.21, 95% CI: 1.13-1.29; all P < 0.001).

CONCLUSIONS

There are geographic disparities in the management of NSCLC. Rural patient populations are more likely to fail to undergo surgery for potentially resectable disease for every reason examined.

Availability of hospital-based cancer services before and after rural hospital closure, 2008-2017

INTRODUCTION

Rural populations have less access to cancer care services and experience higher cancer mortality rates than their urban counterparts, which may be exacerbated by hospital closures. Our objective was to examine the impact of hospital closures on access to cancer-relevant hospital services across hospital service areas (HSAs).

METHODS

We used American Hospital Association survey data from 2008 to 2017 to examine the change in access to cancer-related screening and treatment services across rural HSAs that sustained hospitals over time, experienced any closures, or had all hospitals close. We performed a longitudinal analysis to assess the association between hospital closure occurrence and maintenance or loss of cancer-related service lines accounting for hospital and HSA-level characteristics. Maps were also developed to display changes in the availability of services across HSAs.

RESULTS

Of the 2,014 rural HSAs, 3.8% experienced at least 1 hospital closure during the study period, most occurring in the South. Among HSAs that experienced hospital closure, the loss of surgery services lines was most common, while hospital closures did not affect the availability of overall oncology and radiation services. Screening services either were stable (mammography) or increased (endoscopy) in areas with no closures.

DISCUSSION

Rural areas persistently experience less access to cancer treatment services, which has been exacerbated by hospital closures. Lack of Medicaid expansion in many Southern states and other policy impacts on hospital financial viability may play a role in this. Future research should explore the impact of closures on cancer treatment receipt and outcomes.

Disparities in melanoma incidence and mortality in rural versus urban Michigan

INTRODUCTION

We sought to identifying the possible existence of disparities between rural and urban residents of Michigan for the incidence by stage of disease and disease-specific mortality for cutaneous melanoma (CM).

METHODS

Incidence rates for stage of disease and disease-specific mortality of cutaneous melanoma were calculated and controlled for gender, age, and area of residence from January 1, 2014, to December 31, 2018, from data collected form the Michigan Department of Health and Human Services and the Centers for Disease Control and Prevention.

RESULTS

The incidence rates for CM were significantly higher in rural Michigan counties, from 2014-2018, for all patients, both age groups, both genders and all stages. Melanoma-specific mortality rates were also significantly higher for all patients, both age groups and both genders in rural Michigan counties. Using logistic regression analysis, while controlling for age and gender, rural Michigan counties continued to have a higher melanoma-specific morality rate during our study period (OR = 1.491; 95% CI, 1.27-1.74; p = <.001).

CONCLUSION

We found significant disparities in the incidence rates and disease specific mortality for cutaneous melanoma in rural compared to urban Michigan from 2014-2018.

Exploring the intersectionality of race/ethnicity with rurality on breast cancer outcomes: SEER analysis, 2000-2016

PURPOSE

Disparities in breast cancer survival have been observed within marginalized racial/ethnic groups and within the rural-urban continuum for decades. We examined whether there were differences among the intersectionality of race/ethnicity and rural residence on breast cancer outcomes.

METHODS

We performed a retrospective analysis among 739,448 breast cancer patients using Surveillance Epidemiology and End Results (SEER) 18 registries years 2000 through 2016. We conducted multilevel logistic-regression and Cox proportional hazards models to estimate adjusted odds ratios (AORs) and hazard ratios (AHRs), respectively, for breast cancer outcomes including surgical treatment, radiation therapy, chemotherapy, late-stage disease, and risk of breast cancer death. Rural was defined as 2013 Rural-Urban Continuum Codes (RUCC) of 4 or greater.

RESULTS

Compared with non-Hispanic white-urban (NH-white-U) women, NH-black-U, NH-black-rural (R), Hispanic-U, and Hispanic-R women, respectively, were at increased odds of no receipt of surgical treatment (NH-black-U, AOR = 1.98, 95% CI 1.91-2.05; NH-black-R, AOR = 1.72, 95% CI 1.52-1.94; Hispanic-U, AOR = 1.58, 95% CI 1.52-1.65; and Hispanic-R, AOR = 1.40, 95% CI 1.18-1.67), late-stage diagnosis (NH-black-U, AOR = 1.32, 95% CI 1.29-1.34; NH-black-R, AOR = 1.29, 95% CI 1.22-1.36; Hispanic-U, AOR = 1.25, 95% CI 1.23-1.27; and Hispanic-R, AOR = 1.17, 95% CI 1.08-1.27), and increased risks for breast cancer death (NH-black-U, AHR = 1.46, 95% CI 1.43-1.50; NH-black-R, AHR = 1.42, 95% CI 1.32-1.53; and Hispanic-U, AHR = 1.10, 95% CI 1.07-1.13).

CONCLUSION

Regardless of rurality, NH-black and Hispanic women had significantly increased odds of late-stage diagnosis, no receipt of treatment, and risk of breast cancer death.

Rural-urban survival disparities for patients with surgically treated lung cancer

BACKGROUND

Nonsmall-cell lung cancer (NSCLC) is a common diagnosis among patients living in rural areas and small towns who face unique challenges accessing care. We examined differences in survival for surgically treated rural and small-town patients compared to those from urban and metropolitan areas.

METHODS

The National Cancer Database was used to identify surgically treated NSCLC patients from 2004 to 2016. Patients from rural/small-town counties were compared to urban/metro counties. Differences in patient clinical, sociodemographic, hospital, and travel characteristics were described. Survival differences were examined with Kaplan-Meier curves and Cox proportional hazards models.

RESULTS

The study included 366 373 surgically treated NSCLC patients with 12.4% (n = 45 304) categorized as rural/small-town. Rural/small-town patients traveled farther for treatment and were from areas characterized by lower income and education(all p < 0.001). Survival probabilities for rural/small-town patients were worse at 1 year (85% vs. 87%), 5 years (48% vs. 54%), and 10 years (26% vs. 31%) (p < 0.001). Travel distance >100 miles (hazard ratio [HR] = 1.11, 95% confidence interval [CI]: 1.07-1.16, vs. <25 miles) and living in a rural/small-town county (HR = 1.04, 95% CI: 1.01-1.07) were associated with increased risk for death.

CONCLUSIONS

Rural and small-town patients with surgically treated NSCLC had worse survival outcomes compared to urban and metropolitan patients.

Proportions and incidence of locally advanced cervical cancer: a global systematic literature review

BACKGROUND

Optimal treatment of cervical cancer is based on disease stage; therefore, an understanding of the global epidemiology of specific stages of locally advanced disease is needed.

OBJECTIVE

This systematic literature review was conducted to understand the global and region-specific proportions of patients with cervical cancer with locally advanced disease and to determine the incidence of the locally advanced disease.

METHODS

Systematic searches identified observational studies published in English between 2010 and June 10, 2020, reporting the proportion of patients with, and/or incidence of, locally advanced stages of cervical cancer (considered International Federation of Gynecology and Obstetrics (FIGO) IB2-IVA). Any staging criteria were considered as long as the proportion with locally advanced disease was distinguishable. For each study, the proportion of locally advanced disease among the cervical cancer population was estimated.

RESULTS

The 40 included studies represented 28 countries in North or South America, Asia, Europe, and Africa. Thirty-eight studies reported the proportion of locally advanced disease among populations with cervical cancer. The estimated median proportion of locally advanced disease among all cervical cancer was 37.0% (range 5.6-97.5%; IQR 25.8-52.1%); estimates were generally lowest in North America and highest in Asia. Estimated proportions of ≥50% were reported in nine studies from Asia, Europe, Brazil, and Morocco; estimates ≤25% were reported in six studies from Asia, United States, Brazil, and South Africa. Locally advanced disease was reported for 44% and 49% of women aged >70 and ≥60 years, and 5-100% of younger women with cervical cancer. A greater proportion of locally advanced disease was reported for Asian American (19%) versus White women (8%) in one United States study. Two of five studies describing the incidence of locally advanced disease reported rates of 2-4/100 000 women among different time frames.

CONCLUSION

This review highlights global differences in proportions of locally advanced cervical cancer, including regional variance and disparities according to patient race and age.

Impact of Low-dose Chest CT Screening on the Association Between Rurality and Lung Cancer Outcomes

INTRODUCTION

Lung cancer mortality is higher among rural United States populations compared with nonrural ones. Little is known about screening low-dose chest computed tomography (LDCT) outcomes in rural settings.

MATERIALS AND METHODS

This retrospective cohort study examined all patients (n=1805) who underwent screening LDCT in a prospective registry from March 1, 2015, through December 31, 2019, in a majority-rural health care system. We assessed the proportion of early-stage lung cancers (American Joint Committee on Cancer stage I-II) diagnosed among LDCT-screened patients, and analyzed overall survival after early-stage lung cancer diagnosis according to residency location.

RESULTS

The screening cohort had a median age of 63 and median 40-pack-year smoking history; 62.4% had a rural residence, 51.2% were female, and 62.7% completed only 1 LDCT scan. Thirty-eight patients were diagnosed with lung cancer (2.1% of the cohort), of which 65.8% were early-stage. On multivariable analysis, rural (vs nonrural) residency was not associated with a lung cancer diagnosis (adjusted hazard ratio 1.59; 95% CI, 0.74-3.40; P =0.24). At a median follow-up of 37.1 months (range, 3.3 to 67.2 months), 88.2% of rural versus 87.5% of nonrural patients with screen-diagnosed early-stage lung cancer were alive ( P =0.93).

CONCLUSIONS

In a majority-rural United States population undergoing LDCT, most screen-detected lung cancers were early-stage. There were no significant differences observed between rural and nonrural patients in lung cancer diagnosis rate or early-stage lung cancer survival. Increased implementation of LDCT might blunt the historical association between rural United States populations and worse lung cancer outcomes.

Help wanted: low provider density is associated with advanced stage cervical cancer

BACKGROUND

Patients in rural areas have a higher incidence of cervical cancer with increased rates of metastatic disease than their urban counterparts.

OBJECTIVE

To evaluate whether medical provider density, acting as a surrogate for screening availability, is associated with the incidence of cervical cancer or proportion diagnosed with advanced stage disease.

METHODS

Cervical cancer cases by county from 2015 were retrieved from the SEER database. The numbers of primary obstetric-gynecologists (OB-GYN), family practice, and internal medicine providers were obtained from the Area Health Resource File, and population estimates for each county were used to calculate provider to resident ratios. Spearman rank correlations were used to compare the number of providers per 100 000 residents with the overall incidence of cervical cancer as well as the proportion diagnosed at an advanced stage. Multivariable logistic regression was performed to assess factors independently associated with advanced stage disease, accounting for county of residence. Mortality was compared across different OB-GYN provider density categories.

RESULTS

A total of 3505 cases of cervical cancer from 405 counties were included. Spearman correlation demonstrated a significant inverse association between the number of OB-GYN providers per 100 000 residents and the incidence of cervical cancer (p<0.0001) as well as the proportion diagnosed at an advanced stage (p=0.003). Compared with those living in counties with ≤5 OB-GYN providers per 100 000 residents, those living in counties with >10 providers had a 29% reduction in the odds of presenting with advanced stage disease (OR=0.71; 95% CI 0.55 to 0.91). An inverse association between cervical cancer-related mortality and OB-GYN provider density was also noted.

CONCLUSION

A significant inverse correlation between provider density and incidence of cervical cancer, proportion with advanced stage disease, and cervical cancer-related mortality was observed. Increasing provider density in these underserved, high-risk areas may improve timely cancer detection.

"If I wasn't in a rural area, I would definitely have more support": social needs identified by rural cancer caregivers and hospital staff

BACKGROUND

The social needs of rural families facing cancer warrant investigation to inform psychosocial care planning and policy development.

METHODS

Using purposive sampling, we interviewed 24 rural caregivers and 17 hospital staff from an academic cancer center in the U.S. South. Social needs were defined as the support needed to effectively provide informal caregiving across economic, physical, interpersonal, and service domains. We used the framework method to code and synthesize findings.

FINDINGS

Caregiver economic and physical needs were interconnected and most pressing, including common examples of distance to care and transportation barriers. Caregivers desired additional support from the health system, insurance providers, and community resources. Staff identified similar need patterns and gaps in health system capacity.

CONCLUSIONS

Rural cancer caregivers experience multiple unmet social needs. Supportive interventions for this population will benefit from flexible implementation and multilevel, multisector approaches. In particular, interventions that address financial hardship and limited internet access are needed.

Understanding geographic and racial/ethnic disparities in mortality from four major cancers in the state of Georgia: a spatial epidemiologic analysis, 1999–2019

We examined geographic and racial variation in cancer mortality within the state of Georgia, and investigated the correlation between the observed spatial differences and county-level characteristics. We analyzed county-level cancer mortality data collected by the Centers for Disease Control and Prevention on breast, colorectal, lung, and prostate cancer mortality among adults (aged ≥ 18 years) in 159 Georgia counties from years 1999 through 2019. Geospatial methods were applied, and we identified hot spot counties based on cancer mortality rates overall and stratified by non-Hispanic white (NH-white) and NH-black race/ethnicity. Among all adults, 5.0% (8 of 159), 8.2% (13 of 159), 5.0% (8 of 159), and 6.9% (11 of 159) of Georgia counties were estimated hot spots for breast cancer, colorectal, lung, and prostate cancer mortality, respectively. Cancer mortality hot spots were heavily concentrated in three major areas: (1) eastern Piedmont to Coastal Plain regions, (2) southwestern rural Georgia area, or (3) northern-most rural Georgia. Overall, hot spot counties generally had higher proportion of NH-black adults, older adult population, greater poverty, and more rurality. In Georgia, targeted cancer prevention strategies and allocation of health resources are needed in counties with elevated cancer mortality rates, focusing on interventions suitable for NH-black race/ethnicity, low-income, and rural residents.

Pre-implementation evaluation for an HPV vaccine provider communication intervention among primary care clinics

OBJECTIVES

Interventions to improve health care provider communication about HPV vaccination can increase vaccine acceptance. Our objectives were to (1) identify clinics in locations with high HPV-associated cancer and low HPV-vaccination rates that would potentially benefit from dissemination of a proposed HPV Provider Communication intervention and (2) use qualitative interviews and a dissemination and implementation framework to assess readiness for change and fit of the HPV Provider Communication intervention to the context of these clinics.

METHODS

Local HPV-associated cancer and HPV vaccination rates were assigned to Practice-Based Research Network clinics using data from the Colorado Central Cancer Registry, the Colorado Immunization Information System, and the American Community Survey. Staff from 38 clinics located in areas with high numbers of adolescents not up-to-date for HPV vaccine and high rates of HPV-associated cancers were recruited for qualitative interviews. Interview questions used the Promoting Action on Research Implementation in Health Services (PARIHS) conceptual framework and addressed the proposed intervention, current vaccination practices and prior quality improvement (QI) experience.

RESULTS

Twenty-seven interviews were completed with clinicians, clinic managers, and other staff across 17 clinics (9 pediatric, 5 family medicine, 3 public/school-based health). Most clinics had some prior QI experience and there were few thematic differences between sites with more or less foundation for QI/immunization work. Participants were motivated to improve the health of their patients and valued both guidelines and local experience as important evidence to consider adopting an intervention. Interviewees were more interested in implementing the proposed intervention if it aligned with existing priorities and fit within clinic workflows. Facilitation needs included adequate time and external facilitation support for data tracking and analysis.

CONCLUSIONS

Qualitative interviews to understand clinic context and fit of an HPV Provider Communication intervention can inform implementation in settings with the highest potential for clinical impact.

HPV and COVID-19 vaccines: Social media use, confidence, and intentions among parents living in different community types in the United States

Our study measured parental confidence and intention/uptake of two adolescent vaccines (HPV and COVID-19), focusing on differences among community types including urban, suburban, and rural. Although social media provides a way for misinformation to spread, it remains a viable forum for countering misinformation and engaging parents with positive vaccine information across community types. Yet, little is understood about differences in social media use and vaccine attitudes and behaviors for parents living in rural, suburban and urban areas. We sought to determine how to better reach parents living in different community types with targeted social media channels and messaging. In August 2021, we used a cross-sectional survey programmed in Qualtrics to collect data from 452 parents of children ages 9 to 14 living in different community types across the United States. Participants came from a survey panel maintained by CloudResearch. Survey questions asked about demographics, political affiliation, community type, social media use, health and vaccine information sources, and attitudes and behaviors regarding the HPV and COVID-19 vaccines. Our sample of parents (n = 452) most frequently used Facebook (76%), followed by YouTube (55%), and Instagram (43%). When comparing social media use by community type, parents used the top platforms at similar rates. Social media use was associated with vaccine confidence and intention/uptake in unadjusted models but not in adjusted models. Further, there were no significant differences in HPV vaccine confidence or intention/uptake by community type (i.e., rural, suburban, urban). For the COVID-19 vaccine, parents in rural communities were less likely to have vaccine confidence and intention/uptake in the unadjusted model. For both HPV and COVID-19 vaccines, political affiliation was the only common factor associated with both vaccine confidence and intention/uptake. Parents who identified as Democrat compared to Republican had greater confidence in the vaccines and had higher odds of vaccine intention/uptake for their children. Although rurality has been associated with vaccine confidence in the past we did not find that in our study. Instead, political affiliation appeared to explain most of the variation in vaccine confidence and intention/uptake, suggesting that more research is needed to identify best practices for using social media to reach parents with different political beliefs.

Influence of Race, Insurance, Rurality, and Socioeconomic Status on Equity of Lung and Colorectal Cancer Care

BACKGROUND

This study evaluated the influence that social determinants of health had on stage at diagnosis and receipt of cancer-directed surgery for patients with lung and colorectal cancer in the North Carolina Central Cancer Registry (2010-2015).

METHODS

This study examined non-Hispanic uninsured or privately-insured patients 18 to 64 years of age. Multivariable logistic regression models, including two-way interaction terms, assessed the influence of race, insurance status, rurality, and Social Deprivation Index on stage at diagnosis and receipt of surgery.

RESULTS

6574 lung cancer patients and 5355 colorectal cancer patients were included. Among the lung cancer patients, the uninsured patients had higher odds of having stage IV disease (odds ratio [OR] = 1.46; 95 % confidence interval [CI] = 1.22-1.76) and lower odds of receiving surgery (OR = 0.48; 95 % CI = 0.34-0.69) than the privately-insured patients. Among the colorectal cancer patients, uninsured status was associated with higher odds of stage IV disease (OR = 1.53; 95 % CI = 1.17-2.00) than privately-insured status. A significant insurance status and rurality interaction (p = 0.03) was found in the colorectal model for receipt of surgery. In the privately-insured group, non-Hispanic Black and rural patients had lower odds of receiving colorectal surgery (OR = 0.69; 95 % CI = 0.50-0.94 and OR = 0.68; 95 % CI = 0.52-0.89; respectively) than their non-Hispanic White and urban counterparts.

CONCLUSIONS

After controlling for confounding and evaluation of interactions between patient-, community-, and geographic-level factors, uninsured status remained the strongest driver of patients' presentation with late-stage lung and colorectal cancer. As policy and care delivery transformation targets uninsured and vulnerable populations, explicit recognition, and measurement of intersectionality should be considered.

Decreases in Radiation Oncology Medicare Reimbursement over time: Analysis by Billing Code

PURPOSE

Radiation oncology (RO) has seen declines in Medicare reimbursement (MCR). However, there are no recent studies analyzing the contributions of specific billing codes to overall RO reimbursement. We compared total MCR for specific Healthcare Common Procedure Coding System (HCPCS) codes in 2019 with MCR for those codes in 2010 and 2015, corrected for inflation, to see how the same basket of RO services in 2019 would have been reimbursed in 2010 and 2015 (adjusted MCR).

METHODS AND MATERIALS

The Centers for Medicare & Medicaid Services Physician/Supplier Procedure Summary database was used to obtain MCR data for RO HCPCS codes in 2010, 2015, and 2019. For each code, the total allowed charge was divided by the number of submitted claims to calculate the average MCR per claim in 2010, 2015, and 2019. The 2019 billing frequency for each code was then multiplied by the inflation-adjusted average MCR for those codes in 2010 and 2015 to determine what the MCR would have been in 2010 and 2015 using 2019 dollars and utilization rates. Results were compared with actual 2019 MCR to calculate the projected difference.

RESULTS

Total inflation-adjusted RO MCR was $2281 million (M), $1991 M, and $1848 M in 2010, 2015, and 2019 respectively. This represents a cut of $433 M (19%) and $143 M (7%) from 2010 and 2015, respectively, to 2019. After utilization adjustment, total reimbursement was $2534 M, $2034 M, and $1848 M for 2010, 2015, and 2019, respectively, representing a cut of $686 M (27%) and $186 M (9%) from 2010 and 2015, respectively, to 2019. Intensity modulated radiation therapy (IMRT) treatment delivery and planning accounted for $917 M (36%), $670 M (33%), and $573 M (31%) of the adjusted MCR in 2010, 2015, and 2019, respectively.

CONCLUSIONS

Medicare reimbursement decreased substantially from 2010 to 2019. A decline in IMRT treatment reimbursement was the primary driver of MCR decline. When considering further cuts, policymakers should consider these trends and their consequences for health care quality and access.

A Coordinated Approach to Implementing Low-Dose CT Lung Cancer Screening in a Rural Community Hospital

PURPOSE

The authors describe a rural community hospital's approach to lung cancer screening using low-dose CT (LDCT) to address the high incidence of lung cancer mortality.

METHODS

An implementation project was conducted, documenting planning, education, and restructuring processes to implement a lung cancer screening program using LDCT in a rural community hospital (population 64,917, Rural-Urban Continuum Code 5) located in a region with the highest lung cancer mortality in Oregon. The hospital and community partners organized the implementation project around five recommendations for an efficient and effective lung cancer screening program that accurately identifies high-risk patients, facilitates timely access to screening, provides appropriate follow-up care, and offers smoking cessation support.

RESULTS

Over a 3-year period (2018-2020), 567 LDCT scans were performed among a high-risk population. The result was a 4.8-fold increase in the number of LDCT scans from 2018 to 2019 and 54% growth from 2019 to 2020. The annual adherence rate increased from 51% in 2019 to 59.6% in 2020. Cancer was detected in 2.11% of persons scanned. Among the patients in whom lung cancer was detected, the majority of cancers (66.6%) were categorized as stage I or II.

CONCLUSIONS

This rural community hospital's approach involved uniting primary care, specialty care, and community stakeholders around a single goal of improving lung cancer outcomes through early detection. The implementation strategy was intentionally organized around five recommendations for an effective and efficient lung cancer screening program and involved planning, education, and restructuring processes. Significant stakeholder involvement on three separate committees ensured that the program's design was relevant to local community contexts and patient centered. As a result, the screening program's reach and adherence increased each year of the 3-year pilot program.

Cancer Screening among Rural People Who Use Drugs: Colliding Risks and Barriers

Rural cancer disparities are associated with lesser healthcare access and screening adherence. The opioid epidemic may increase disparities as people who use drugs (PWUD) frequently experience healthcare-associated stigmatizing experiences which discourage seeking routine care. Rural PWUD were recruited to complete surveys and interviews exploring cancer (cervical, breast, colorectal, lung) risk, screening history, and healthcare experiences. From July 2020–July 2021 we collected 37 surveys and 8 interviews. Participants were 24.3% male, 86.5% White race, and had a mean age of 44.8 years. Females were less likely to report seeing a primary care provider on a regular basis, and more likely to report stigmatizing healthcare experiences. A majority of females reporting receiving recommendations and screens for cervical and breast cancer, but only a minority were adherent. Similarly, only a minority of males and females reported receiving screening tests for colorectal and lung cancer. Screening rates for all cancers were substantially below those for the US generally and rural areas specifically. Interviews confirmed stigmatizing healthcare experiences and suggested screening barriers and possible solutions. The opioid epidemic involves millions of individuals and is disproportionately experienced in rural communities. To avoid exacerbating existing rural cancer disparities, methods to engage PWUD in cancer screening need to be developed.

Trends in Cancer Treatment Service Availability Across Critical Access Hospitals and Prospective Payment System Hospitals

BACKGROUND

Rural residents experience worse cancer prognosis and access to cancer care providers than their urban counterparts. Critical access hospitals (CAHs) represent over half of all rural community hospitals. However, research on cancer services provided within CAHs is limited.

OBJECTIVE

The objective of this study was to investigate trends in cancer services availability in urban and rural Prospective Payment System (PPS) hospitals and CAHs.

DESIGN

Retrospective, time-series analysis using data from 2008 to 2017 American Hospital Association Annual Surveys. Multivariable logistic regressions were used to examine differential trends in cancer services between urban PPS, rural PPS, and CAHs, overall and among small (<25 beds) hospitals.

SUBJECTS

All US acute care and cancer hospitals (4752 in 2008 to 4722 in 2017).

MEASURES

Primary outcomes include whether a hospital provided comprehensive oncology services, chemotherapy, and radiation therapy each year.

RESULTS

In 2008, CAHs were less likely to provide all cancer services, especially chemotherapy (30.4%) and radiation therapy (2.9%), compared with urban (64.4% and 43.8%, respectively) and rural PPS hospitals (42.0% and 23.3%, respectively). During 2008-2017, compared with similarly sized PPS hospitals, CAHs were more likely to provide oncology services and chemotherapy, but with decreasing trends. Radiation therapy availability between small PPS hospitals and CAHs did not differ.

CONCLUSIONS

Compared with all PPS hospitals, CAHs offered fewer cancer treatment services and experienced a decline in service capability over time. These differences in chemotherapy services were mainly driven by hospital size, as small urban and rural PPS hospitals had lower rates of chemotherapy than CAHs. Still, the lower rates of radiotherapy in CAHs highlight disproportionate challenges facing CAHs for some specialty services.

Urban-rural differences in financial toxicity and its effect on cancer survivors' health-related quality of life and emotional status: a latent class analysis

OBJECTIVE

This study aimed to investigate the urban-rural differences in associations between financial toxicity (FT), physical health-related quality of life (HRQoL), negative emotional status, and the effect of patients' socioeconomic status and clinical and cost-related characteristics on the levels of FT in a sample of Chinese cancer survivors.

METHODS

Data were obtained from a cross-sectional survey conducted by the oncology department at two tertiary level hospitals in China. The COmprehensive Score for financial Toxicity, Euroqol five-level instrument (EQ-5D), and Depression Anxiety Stress Scale - 21 (DASS-21) were used to measure patients' FT, physical HRQoL, and negative emotional status. A latent class analysis was used to identify patient subgroups with distinct symptom experiences based on self-reported data on symptom occurrence using the EQ-5D and DASS-21.

RESULTS

Four distinct latent classes were identified: all low (47.6%); high physical and low psych (18.6%); low physical and high psych (17.1%); and all high (17.1%). Rural patients younger than 50 years showed a statistically significantly higher FT than urban patients. Rural patients who were male, highly educated, insured, first hospitalization, new cases, received surgery or immunotherapy, and had low cancer-related costs in all low classes showed a higher FT than urban patients.

CONCLUSIONS

Rural patients with cancer suffered from higher FT than their urban counterparts, and the negative impact of psychological distress on FT was higher than that of physical HRQoL.

Influence of Race, Insurance, and Rurality on Equity of Breast Cancer Care

BACKGROUND

Considerable gaps in knowledge remain regarding the intersectionality between race, insurance status, rurality, and community-level socioeconomic status that contribute in concert to disparities in breast cancer care delivery.

METHODS

Women age 18-64 y old with either private, Medicaid, or no insurance coverage and a diagnosis of breast cancer from the North Carolina Central Cancer Registry (2010-2015) were identified and reviewed. Logistic regression models examined the impact of race, insurance status, rurality, and the Social Deprivation Index (SDI) on advanced stage disease at diagnosis (III, IV) and receipt of cancer directed surgery (CDS). Models tested two-way interactions between race, insurance status, rurality, and SDI.

RESULTS

Of the study population (n = 23,529), 14.6% were diagnosed with advanced stage disease (III, IV), and 97.1% of women with non-metastatic breast cancer (n = 22,438) received cancer directed surgery (CDS). Twenty percent of women were non-Hispanic Black (NHB), 3.0% Hispanic, 10.9% Medicaid insured, 5.9% uninsured, 20.0% of women resided in rural areas, and 20.0% resided in communities of the highest quartile SDI. NHB race, Medicaid or uninsured status, and residence in rural or socially deprived areas were associated with advanced stage breast cancer at diagnosis. NHB and Medicaid or uninsured women were significantly less likely to receive CDS. There were no statistically significant interactions found influencing stage at diagnosis or receipt of cancer directed surgery.

CONCLUSIONS

In a heterogeneous population across the state of North Carolina, non-Hispanic Black race, Medicaid or uninsured status, and residence in rural or high social deprivation communities are independently associated with advanced stage breast cancer at diagnosis, while non-Hispanic Black race and Medicaid or uninsured status are associated with lower odds to receive cancer directed surgery.

Urban-Rural Variations in Quality of Care Among Patients With Cancer in California

INTRODUCTION

Previous research suggests cancer patients living in rural areas have lower quality of care, but population-based studies have yielded inconsistent results. This study examines the impact of rurality on care quality for 7 cancer types in California.

METHODS

Breast, ovarian, endometrial, cervix, colon, lung, and gastric cancer patients diagnosed from 2004 to 2017 were identified in the California Cancer Registry. Multivariable logistic regression and proportional hazards models were used to assess effects of residential location on quality of care and survival. Stratified models examined the impact of treatment at National Cancer Institute designated cancer centers (NCICCs). Quality of care was evaluated using Commission on Cancer measures. Medical Service Study Areas were used to assess urban/rural status. Data were collected in 2004-2019 and analyzed in 2020.

RESULTS

989,747 cancer patients were evaluated, with 14% living in rural areas. Rural patients had lower odds of receiving radiation after breast conserving surgery compared to urban residents. Colon and gastric cancer patients had 20% and 16% lower odds, respectively, of having optimal surgery. Rural patients treated at NCICCs had greater odds of recommended surgery for most cancer types. Survival was similar among urban and rural subgroups.

CONCLUSIONS

Rural residence was inversely associated with receipt of recommended surgery for gastric and colon cancer patients not treated at NCICCs, and for receiving recommended radiotherapy after breast conserving surgery regardless of treatment location. Further studies investigating the impact of care location and availability of supportive services on urban-rural differences in quality of care are warranted.

State-level rurality and cigarette smoking-associated cancer incidence and mortality: Do individual-level trends translate to population-level outcomes?

County-level analyses demonstrate that overall cancer incidence is generally lower in rural areas, though incidence and mortality from tobacco-associated cancers are higher than in non-rural areas and have experienced slower declines over time. The goal of our study was to examine state-level rurality and smoking-related cancer outcomes. We used publicly-available national data to quantify rurality, cigarette smoking prevalence, and smoking-attributable cancer incidence and mortality at the state level and to estimate the population-attributable fraction of cancer deaths attributable to smoking for each state, overall and by gender, for 12 smoking-associated cancers. Accounting for a 15-year lag between smoking exposure and cancer diagnosis, the median proportion of smoking-attributable cancer deaths was 28.2% in Virginia (24.6% rural) and ranged from 19.9% in Utah (9.4% rural) to 35.1% in Kentucky (41.6% rural). By gender, the highest proportion of smoking-attributable cancer deaths for women (29.5%) was in a largely urban state (Nevada, 5.8% rural) and for men (38.0%) in a largely rural state (Kentucky). Regression analyses categorizing state-level rurality into low (0-13.9%), moderate (15.3-29.9%) and high (33.6-61.3%) levels showed that high rurality was associated with 5.8% higher cigarette smoking prevalence, higher age-adjusted smoking-associated cancer incidence (44.3 more cases per 100,000 population), higher smoking-associated cancer mortality (29.8 more deaths per 100,000 population), and 3.4% higher proportion of smoking-attributable cancer deaths compared with low rurality. Our findings highlight the magnitude of the relationship between state-level rurality and smoking-attributable cancer outcomes and the importance of tobacco control in reducing cancer disparities in rural populations.