Policy Issue Brief: Rural Cancer Care

Ensuring All Patients Have Access to High-Quality Cancer Care, Regardless of Where They Live
April 4, 2019

ASCO’s Policy Issue Briefs provide succinct overviews and relevant data on major policy issues impacting patients with cancer and the physicians who care for them. These briefs are designed to be especially helpful for journalists, offering background information on key issues across health policy today. Access ASCO’s full collection of Policy Issue Briefs.

Issue Overview

Millions more Americans are surviving cancer and living healthy, productive lives. There is now a record 15.5 million survivors of cancer compared with about 7 million in 1991 and 3 million in 1971.1 Cancer death rates are down about 25% since the early 1990s. Patients are not only living longer – they’re living better lives, with fewer side-effects as a result of their cancer treatment.

Unfortunately, these gains have not been realized in all regions of the United States. In rural areas, particularly, patients with cancer face a worse outlook than those in other parts of the country. Although cancer incidence in rural areas tends to be lower, patients tend to be diagnosed later and are more likely to die from common cancers. Rural patients with cancer are also often older and in poorer health, which presents additional challenges in treating their cancer. Rural cancer survivors experience poorer mental health functioning, as well as greater symptoms of anxiety, depression, distress, and emotional problems compared with urban cancer survivors.2

Between 2011-2015, death rates from cancer were higher in rural areas (180 deaths per 100,000 persons) compared with urban areas (158 deaths per 100,000 persons).3

Patients in rural areas are more likely to face longer travel times, have fewer financial resources, and experience limited access to specialists and clinical trials – all factors that impede high-quality cancer care.

Key challenges include:

  • Limited oncology workforce: There are disproportionately fewer oncologists and other cancer care providers rural areas as compared to the number of patients and survivors in need of care.4
  • Geographic barriers: Patients in rural areas often need to travel long distances to access treatment and follow-up care.5
  • Lack of clinical trial infrastructure: It’s harder for patients in rural areas to access clinical trials, which often offer the best and latest treatment options.6
  • Insurance obstacles: Rural patients with cancer are less likely to have employer-provided health insurance and may not have access to Medicaid or comprehensive, affordable individual coverage.7

Limited Oncology Workforce in Rural America

The U.S. oncology workforce is made up of approximately 12,854 oncologists and nearly 7,000 nurse practitioners and physicians assistants who practice in oncology. However, while 19% of the population resides in rural areas, only 7% of oncologists practice in rural areas8, significantly reducing rural patients’ proximity to nearby cancer care.

Additional Data:

  • More than 70% of counties in the United States do not have medical oncologists.9
  • In rural areas, there is only one oncologist per 100,000 residents. In urban areas, this ratio is five oncologists per 100,000 residents.
  • Medical students and residents often opt to stay in the large cities where they received their education and training.10
  • Four in 10 rural Americans who have or had cancer say there aren’t cancer specialists near their home.11

Geographic Isolation

The nature of rural areas means that residents often have to travel long distances to access health care, including cancer care. Those living in large rural towns must travel a median of 51 minutes to get to any specialized oncology care, and those in small or isolated towns travel 59 minutes. In order to reach the nearest academic-based care, they must travel a median of 83 and 97 minutes, respectively.12

This distance is exacerbated by transportation barriers. Given the high poverty levels in many rural areas, some patients face financial barriers to accessing transportation, including not having enough money for gas or a vehicle.

Additional Data:

  • 36% of patients in rural areas say they had to travel too far to see the doctor managing their cancer care, versus 19% of nonrural patients.13
  • 1.6 million rural households do not have cars. The highest proportion of ‘carlessness’ is in the south, Appalachia, the southwest, and Alaska.14
  • 60% of rural residents use broadband, compared with 70% of urban and 73% of suburban residents.15,16

Lack of Clinical Trial Infrastructure

Clinical trials often offer patients the best opportunity for treating their cancer, but patients in rural areas have a harder time accessing those life-saving opportunities. A major barrier is finding a clinical trial close enough to be considered feasible by rural patients. In rural communities, 42% of community oncologists report issues with finding clinical trials close enough to be considered by their patients.17 Small rural cancer centers do not have sufficient volume to support dedicated clinical trial research nurses, which makes it harder to accrue patients onto trials.

Insurance Obstacles

Historically, rural areas have lower proportions of residents covered by employer-sponsored health insurance, which are often more generous than non–employer-sponsored plans. On top of that, as of 2014, nearly two-thirds of the rural uninsured live in states that have not expanded Medicaid,18 leaving millions of low-income, childless adults without affordable access to health insurance. This gap also impacts veterans in particular; nearly 25% of veterans live in rural areas, and one in five uninsured veterans live in states that did not expand Medicaid.19

Provider reimbursement also presents an obstacle in rural areas. For example, the proportion of services covered by Medicaid and Medicare is higher in rural areas compared with private health insurance, which has significant implications for the reimbursement of rural providers and may exacerbate access challenges in rural areas. In addition, while Medicare recently moved forward an expansion of telehealth payments and Medicaid provides coverage for some telehealth in 48 states and the District of Columbia, private payers have not adopted a universal set of payment policies for these services, which may limit uptake of telemedicine services.

ASCO’s Role in Closing the Rural Cancer Care Gap

ASCO is deeply concerned about disparities in cancer access and care and believes that every patient, no matter where they live, deserves access to the highest quality cancer care. On April 10, 2019, ASCO convened leading experts from across health care to draw attention to the challenges facing Americans with cancer in rural areas and explore ways to improve cancer outcomes. Visit ASCO's State of Cancer Care in America page to learn more.

“I understand what it means for a patient to be 100 miles from the nearest hospital, and the kind of burden that it places on patients, caregivers, providers, and the community as a whole. It’s a sad truth that where a patient lives often dictates their chances of surviving cancer. We must work to ensure every patient has access to cancer care that reflects their individual needs as well as the opportunity to participate in research and contribute to progress.” – Monica M. Bertagnolli, MD, FACS, FASCO, ASCO President 2018 – 2019

For More Information

  • Stay up-to-date on trends in the oncology workforce and delivery system with ASCO’s State of Cancer Care in America™ at asco.org/state-of-cancer-care.
  • Learn about ASCO’s community town halls, which provide a forum for patients, providers, and the general public to discuss opportunities to address real-world barriers to quality cancer care on Cancer.Net.
  • Visit ASCO in Action (asco.org/ascoaction) for the latest news and information on this and other cancer policy topics.
  • To schedule a media interview with an ASCO spokesperson or oncology expert on rural cancer care, please contact mediateam@asco.org.

References

  1. Cancer Facts and Figures: Death Rate Down 25% Since 1991; American Cancer Society, Jan. 5, 2017
  2. Burris JL, Andrykowski M. Disparities in mental health between rural and nonrural cancer survivors: a preliminary study. Psychooncology. 2010;19:637‐45.
  3. Centers for Disease Control and Prevention, 2017: https://www.cdc.gov/media/releases/2017/p0706-rural-cancer-deaths.html
  4. Kirkwood MK, Hanley A, Bruinooge SS, et al: The state of oncology practice in America, 2018: Results of the ASCO practice census survey. J Oncol Pract 14(7): e412-e240, 2018.
  5. Onega T, Duell EJ, Shi X, et al. Geographic access to cancer care in the U.S. Cancer. 2008;112:909-18.
  6. Fenton L, Rigney M, Herbst RS. Clinical trial awareness, attitudes, and participation among patients with cancer and oncologists. Commun Oncol. 2009;6:207-13.
  7. Kaiser Family Foundation, 2014 https://www.kff.org/uninsured/issue-brief/the-affordable-care-act-and-insurance-coverage-in-rural-areas/
  8. Kirkwood MK, Hanley A, Bruinooge SS, et al: The state of oncology practice in America, 2018: Results of the ASCO practice census survey. J Oncol Pract 14(7): e412-e240, 2018.
  9. Kirkwood MK, Bruinooge SS, Goldstein MA, et al. J Oncol Pract. 2014;10:32‐8
  10. Huff C. Location, location, location. Trustee. 2012;65:8‐12
  11. 2018 National Cancer Opinion Survey, American Society of Clinical Oncology/The Harris Poll. October 2018.
  12. Onega T, Duell EJ, Shi X, et al. Geographic access to cancer care in the U.S. Cancer. 2008;112:909-18.
  13. 2018 National Cancer Opinion Survey, American Society of Clinical Oncology/The Harris Poll. October 2018
  14. United States Department of Agriculture: Economic research service. Rural America at a glance. 2014. http://www.ers.usda.gov/media/1697681/eb26.pdf
  15. Pew Research Center. Broadband technology fact sheet. 2013. http://www.pewinternet.org/fact-sheets/broadband-technology-fact-sheet/
  16. FCC, https://www.fcc.gov/sites/default/files/launch-connected-cancer-care-appalachia.pdf
  17. enton L, Rigney M, Herbst RS. Clinical trial awareness, attitudes, and participation among patients with cancer and oncologists. Commun Oncol. 2009;6:207-13.
  18. Kaiser Family Foundation, 2014 https://www.kff.org/uninsured/issue-brief/the-affordable-care-act-and-insurance-coverage-in-rural-areas/
  19. Boudreaux M, Barath D, Blewett LA. Recent Changes in Health Insurance Coverage for Urban and Rural Veterans: Evidence from the First Year of the Affordable Care Act. Mil Med. 2019 Jan 1;184(1-2):e76-e82. doi:  0.1093/milmed/usy053. PubMed PMID: 29697846.