Rural cancer care – if you build it (and measure it!), they will come



Rural surgeons who provide cancer care face a particular set of challenges. Rural patients tend to be older, sicker, less educated and economically disadvantaged. Rural areas have a higher prevalence of chronic diseases including heart disease and cancer. Rural patients present with more advanced cancers than their urban counterparts. Specific rural regions (i.e., Appalachia) have documented higher cancer incidences and mortality rates.

In addition, there are several barriers to providing cancer care for rural populations. These include poor access to health care services and specialists; geographic barriers preventing access to providers, services, and technology; minimal transportation options for either cancer screening or treatment; limited knowledge of cancer and low participation in screening and other healthy practices; prohibitive costs of screening and cancer treatment; and, in some cases, suboptimal care provided to cancer patients (J. Am. Coll. Surg. 2014;219:814-8; Gosschalk, A. and Carozza, S., “Cancer in rural areas: A literature review,” Rural Healthy People 2010, Vol. 2 [College Station: The Texas A&M University System Health Science Center, 2003]).

Dr. Michael Sarap

Several examples of suboptimal care for rural cancer patients have appeared in professional journals and meetings and in the lay press. Examples of rural cancer care inadequacies include lower use of needle biopsy and sentinel lymph node biopsy techniques for breast cancer patients (Am. J. Surg. 2014;208:382-90; Am. J. Surg. 2013;206:674-81; ACS Surgery News, “Use of minimally invasive biopsy lags in Texas,” February 2013, p. 15); significantly lower rates of radiation treatment in breast lumpectomy patients (USA Today, Nov. 18, 2012); lower rates of adequate lymph node dissection, appropriate chemotherapy, and higher death rates in colon cancer patients (Chow, C.J., ACS Clinical Congress Presentation 2012); higher mastectomy rates and later-stage cancers in breast cancer patients (Jethwa, K., AACR Annual Conference Presentation 2013); higher likelihood of discharge to a skilled nursing facility instead of home in colon cancer patients; and the list goes on and on. These articles all come from academic centers through database studies. It is rare indeed to see data collected and published by the rural centers and providers actually caring for rural cancer patients.

My personal bias is that rural surgeons provide very competent, compassionate, high quality care that allows the cancer patient to remain close to their homes and support systems. This opinion has been reinforced by my involvement with the ACS Advisory Council on Rural Surgery, the rural listserve /ACS Rural Community and through my interaction with surgeons across the country at ACS Chapter meetings and at the Congress.

A study done by Finlayson (Med. Care 1999;37:204-9) documented that nearly 100% of rural patients preferred to receive their care locally, especially if the quality of care was the same as the larger distant hospital. In fact, nearly half of the patients polled would choose to remain local even if the mortality rate at the local hospital was double that of a hospital requiring the patient to travel for care. More recent papers however suggest that patients may be bypassing their local hospitals for care because of concerns about the quality of care provided locally (J. Rural Health 1999;10:70-9; J. Rural Health 2007;23:17-24).

A 2013 ASCO presentation documented that General Surgeons perform a majority of cancer surgeries in the United States (Stizenberg, K.; SSO 66th Annual Cancer Symposium; Abstract 75, March 8, 2013). Only 303 (< 8%) counties in the United States even have a surgical oncologist. A 2014 ASCO presentation estimated a 43% increase in inpatient oncology procedures and a 25% increase in outpatient procedures between 2002 and 2020. By 2025 the total demand for oncology care will rise by 43% (ASCO, “The state of cancer care 2014,” J. Oncol. Prac. 2014;10:119-42). Another study (ACS Surgery News, “Surgeon supply to drop 18% by 2028,” January 2013, p. 1) has estimated that, with predicted future surgeon shortages, general surgeons will be called upon to perform 25% of cases now done by other surgical specialists. General surgeons, both rural and urban, are clearly providing the bulk of cancer care to patients and this trend is on the rise in coming years.

Rural surgeons have certain barriers that prevent them from measuring, documenting, and publicizing the specifics of the care provided to their patients. These surgeons often are in single or small group practices and manage their own businesses. They have no office or hospital staff dedicated to quality endeavors. Financial and time constraints prevent them from being champions of quality care in their communities. Additionally, small numbers of specific cases can result in high statistical complication and mortality rates even if these events happen infrequently. This inability to collect data and assess the quality of care provided can lead to patient outmigration and even “tiering” by third-party payers that forces patients away from their hometown hospitals and providers using financial disincentives.

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