Palliative and supportive interventions to improve patient-reported outcomes in rural residents with cancer

People in rural areas have increased rates of advanced cancer and mortality compared with those who live in more affluent and urban areas.^1,2 Indeed, a recent report from the Center for Disease Control found that rural residents have higher mortality rates from 5 leading causes of death, including cancer, compared with their urban counterparts.¹ Significant challenges facing rural residents are due largely to not having easy access to cancer care and supportive care services.³ In addition, living in a rural area is associated with: a lower socioeconomic status, inadequate health insurance coverage, and less flexible employment that in turn decreases the ability to obtain the full range of supportive oncology services.⁴ The closest available specialists may be several hours away. Individuals may be unwilling or unable to travel hundreds of miles or more to see a specialist.³ Traveling places financial burdens on patients because of the cost of traveling and loss of work, which can compound the stress and fatigue associated with cancer treatment. People living in rural areas also may have less social support in commuting between their place of living and hospitals.⁵

Background

Typically, the primary goals of treatment for individuals with advanced cancer are to control the spread of the disease; maintain important patient-reported outcomes (PROs) such as physical, mental, and psychosocial function; and optimize quality of life (QoL). Health-related QoL (ie, the physical and mental health perceptions) are increasingly being used to assess effectiveness of cancer treatment.⁶ Palliative care and supportive oncology focus on managing physical, social, psychological, and spiritual needs of patients and have been recommended by the American Society of Clinical Oncology to be integrated into standard oncology care.⁷

People living in rural areas are less likely to get their care within a single health system. Often, their care is divided across multiple facilities and providers, which increases the chances of miscommunication between providers and can lead to inferior clinical outcomes and decreased patient QoL.⁸ There is a growing body of research describing the impact of palliative care on people with advanced cancer. Specifically, palliative care has been shown to reduce symptoms, improve QoL, and increase survival.^9-11 Differences have been observed in the palliative care needs between people with cancer living in urban and suburban areas.¹² It is likely that palliative care needs as well as the impact of palliative care services for people with advanced cancer in rural areas differs from those of their urban and suburban counterparts. Despite the known differences in access to care and impact of cancer between rural and nonrural residents, the impact of palliative care on people with advanced cancer living in rural areas has not been well described in the literature.

The purpose of this systematic review is to examine effect of palliative care and supportive oncology interventions on QoL in people with advanced cancer living in rural areas.
 

Methods

This systematic review was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.¹³

Eligibility criteria

To achieve the objective of a systemic review of studies describing supportive oncology and palliative care interventions in rural communities articles had to meet 4 inclusion criteria:

All research methods were eligible, including mixed-methods and program evaluations, as long as the article met the 4 inclusion criteria. Review articles were ineligible for inclusion as only original research was considered.
 

Search process

Search terms were developed by the research team with consultation from a medical librarian. Four main search terms were developed and included: palliative care, supportive oncology, rural, and cancer. Synonyms and terms closely related to the main terms were included in the search using the OR command. Examples of closely related search terms include: Palliative care: palliative; Rural: remote; Cancer: neoplasms (Table).

We systematically searched PyschINFO, PubMed, CINHAL, and Scopus for articles that had been published during 1991-2016 and written in English. Databases were chosen to reflect the different subfields that encompass palliative care and supportive oncology: PyschINFO to capture the psychological perspective, CINHAL to capture the nursing perspective, and PubMed to capture the medical perspective. Finally, Scopus was searched to ensure that articles not indexed by the other databases would be included. The search was limited to the past 25 years to capture the most up-to-date literature.

Selection process

In accordance with PRISMA guidelines, articles underwent an initial screening and an eligibility screening for inclusion in the final review.¹³ After duplicates were removed, 2 research team members reviewed all abstracts to screen for initial eligibility. Articles that successfully passed the screening process were reviewed in full by 4 research team members. Each member made an independent inclusion decision based on the stated inclusion criteria. Disagreements across team members were resolved through discussion and consensus.