The interplay of financial toxicity, health care team communication, and psychosocial well-being among rural cancer patients and survivors

BACKGROUND

Financial toxicity contributes to psychosocial distress among cancer patients and survivors. Yet, contextual factors unique to rural settings affect patient experiences, and a deeper understanding is needed of the interplay between financial toxicity and health care team communication and its association with psychosocial well-being among rural oncology patients.

PURPOSE

We examined associations between financial toxicity and psychosocial well-being among rural cancer patients, exploring variability in these linkages by health care team communication.

METHODS

Using data from 273 rural cancer patients who participated in Cancer Support Community's Cancer Experience Registry, we estimated multivariable regression models predicting depression, anxiety, and social function by financial toxicity, health care team communication, and the interplay between them.

RESULTS

We demonstrate robust associations between financial toxicity and psychosocial outcomes among our sample of rural cancer patients and survivors. As financial toxicity increased, symptoms of depression and anxiety increased. Further, financial toxicity was linked with decreasing social function. Having health care team conversations about treatment costs and distress-related care reduced the negative impact of financial toxicity on depressive symptoms and social function, respectively, in rural cancer patients at greatest risk for financial burden.

CONCLUSIONS

Financial toxicity and psychosocial well-being are strongly linked, and these associations were confirmed in a rural sample. A theorized buffer to the detrimental impacts of financial toxicity-health care team communication-played a role in moderating these associations. Our findings suggest that health care providers in rural oncology settings may benefit from tools and resources to bolster communication with patients about costs, financial distress, and coordination of care.

Quality of breast surgery care at a comprehensive cancer center and its rural affiliate hospital

BACKGROUND

Cancer centers are increasingly affiliating with rural hospitals to perform surgery. Perioperative and oncologic outcomes for cancer center surgeons operating at rural hospitals are understudied.

METHODS

For patients with non-metastatic breast cancer from a rural catchment area who had oncologic surgery at an NCI-designated comprehensive cancer center (CC) or its rural affiliate (RA) from 2017 to 2022, we compared perioperative outcomes (composite of surgical site infection, seroma requiring drainage, and reoperation for margins) and receipt of guideline-concordant care (if patient received all applicable treatments) using descriptive statistics and chi-squared tests.

RESULTS

Among 168 patients, 99 had surgery at RA, 60 CC. RA patients were older, higher stage, and more often had lumpectomy. There were no differences in perioperative outcomes (CC 10%, RA 14%, p ​= ​0.445) or guideline concordant care (RA 76%, CC 78%, p ​= ​0.846).

CONCLUSIONS

Cancer center surgeons operating at a rural affiliate had comparable perioperative outcomes and guideline-concordant care.

The impact of rural structural and community health factors on postmastectomy complications among south central Appalachian breast cancer patients

PURPOSE

The study examined how structural and community health factors, including primary care physicians (PCP), food insecurity, diabetes, and mortality rate per county, are linked to the number and severity of postmastectomy complications among south central Appalachian breast cancer patients depending on rural status.

METHODS

Data was obtained through a retrospective review of 473 breast cancer patients that underwent a mastectomy from 2017 to 2021. Patient's ZIP Code was used to determine their rural-urban community area code and their county of residence for census data. We conducted a zero inflated Poisson regression.

FINDINGS

Results demonstrated that patients in small rural/isolated areas with low (B = -4.10, SE = 1.93, OR = 0.02, p = 0.03) to average (B = -2.67, SE = 1.32, OR = 0.07, p = 0.04) food insecurity and average (B = -2.67, SE = 1.32, OR = 0.07, p = 0.04) to high (B = -10.62, SE = 4.71, OR = 0.00, p = 0.02) PCP have significantly fewer postmastectomy complications compared to their urban counterparts. Additionally, patients residing in small rural/isolated areas with high (B = 4.47, SE = 0.49, d = 0.42, p < 0.001) diabetes and low mortality (B = 5.70, SE = 0.58, d = 0.45, p < 0.001) rates have significantly more severe postmastectomy complications.

CONCLUSION

These findings demonstrate that patients who reside in small/rural isolated areas may experience fewer and less severe postmastectomy when there is certain optimal structural and community health factors present compared to their urban counterparts. Oncologic care teams could utilize this information in routine consult for risk assessment and mitigation. Future research should further examine additional risks for postmastectomy complications.

Urban-Rural Differences in Receipt of Cancer Surgery at High-Volume Hospitals and Sensitivity to Hospital Volume Thresholds

Methods for identifying high-volume hospitals affect conclusions about rural cancer care access.

Realizing the Dream of Precision Oncology: A Solution for All Patients

MICRO-ABSTRACT

As molecularly informed oncology care has increasingly become standard practice for patients with cancer, society must prioritize equitable access to genetic testing that guides subsequent care. Despite the availability of genomic testing laboratories, published guidelines, US Food and Drug Administration-approved targeted therapies, financial assistance programs, and clinical decision tools, precision medicine remains out of reach for many patients. While there has been modest improvement in testing rates in recent years, molecular testing and targeted therapy for cancer patients continue to vary by practice setting and patient insurance status, and racial and socioeconomic disparities persist. National standards and centralized solutions are needed to promote the equitable distribution of patient benefit from precision medicine technology. Although various online resources are currently available, no single all-encompassing precision oncology tool currently exists. A one-stop shop to address all aspects of precision oncology-tissue selection and test ordering, interpretation of results, prescribing targeted therapies, and enrolling patients in clinical trials-would disrupt cancer care. Recent advances in artificial intelligence, digital pathology, and data science provide an opportunity for stakeholders to partner together to leverage these technologies to develop this unified, freely accessible, national solution. Whether locoregionally, nationally, or internationally, only collaborative efforts can fully realize the potential of technological advancements in molecular pathology and oncology therapeutics for all cancer patients.

Social Determinants of Cancer Disparities

Cancer is a major public health issue that is associated with significant morbidity and mortality across the globe. At its root, cancer represents a genetic aberration, but socioeconomic, environmental, and geographic factors contribute to different cancer outcomes for selected population subsets. The disparities in the delivery of healthcare affect all aspects of cancer management from early prevention to end-of-life care. In an effort to address the inequality in the delivery of healthcare among socioeconomically disadvantaged populations, the World Health Organization defined social determinants of health (SDOH) as conditions in which people are born, live, work, and age. These factors play a significant role in the disproportionate cancer burden among different population groups. SDOH are associated with disparities in risk factor burden, screening modalities, diagnostic testing, treatment options, and quality of life of patients with cancer. The purpose of this article is to describe a more holistic and integrated approach to patients with cancer and address the disparities that are derived from their socioeconomic background.

Colorectal Cancer Knowledge and Screening Change in African Americans: Implementation Phase Results of the EPICS Cluster RCT

Introduction

African Americans are disproportionately affected by mortality risk for colorectal cancer. This study aimed to determine the most effective educational approach of 4 study arms that enhances the likelihood of pursuing subsequent colorectal cancer screening, and to identify the associated factors.

Methods

Age-eligible adults (N=2,877) were recruited to participate in a cluster randomized control dissemination and intervention implementation trial titled Educational Program to Increase Colorectal Cancer Screening. The project began in May 2012 and ended in March 2017 (the implementation phase lasted 36 months). Educational sessions were conducted through 16 community coalitions that were randomized into 1 of 4 conditions: website access (to facilitator training materials and toolkits) without technical assistance, website access with technical assistance, in-person training (provided by research staff and website access) without technical assistance, and in-person training with technical assistance. A follow-up to determine participant CRC screening was conducted 3 months later.

Results

Compared with the website access with technical assistance intervention group, 2 groups, in-person training with technical assistance and without technical assistance, indicated significantly higher odds for obtaining colorectal cancer screening (OR=1.31; 95% CI=1.04, 1.64; p=0.02 and OR=1.35; 95% CI=1.07, 1.71; p=0.01, respectively). Though sociodemographic factors were not significantly associated with pursuing subsequent colorectal cancer screening, the postintervention cancer knowledge increased significantly among the study participants.

Conclusions

The importance of in-person interactions, local coalitions, and community contexts may play a key role for successfully increasing colorectal cancer screening rates among African Americans as reflected through this study. The integration of telehealth and use of other virtual technologies to engage the public in research have increased since the COVID-19 pandemic and should be assessed to determine their impact on the degree to which in-person interventions are significantly more effective when compared with solely web-assisted ones.

Trial registration

The study is registered at www.clinicaltrials.gov NCT01805622.

Behavior Change Techniques for the Maintenance of Physical Activity in Cancer

Ester et al report the findings from a 2-arm cluster randomized controlled trial nested within a hybrid effectiveness-implementation study, which involved a 12-week exercise and behavior change program for rural and remote Canadians (Exercise for Cancer to Enhance Living Well [EXCEL]). The addition of 23 weeks of app-based physical activity monitoring to the EXCEL program did not result in significant between-group differences in physical activity at 6 months. While several behavior change techniques were included in the initial 12-week intervention, additional techniques were embedded within the mobile app. However, there is currently a lack of evidence regarding how many and which behavior change techniques are the most effective for people with cancer and if these differ based on individual characteristics. Potentially, the use of the mobile app was not required in addition to the behavior change support delivered to both groups as part of the EXCEL program. Further research should involve participants who may be in most need of behavioral support, for example, those with lower levels of self-efficacy. Suggestions for future research to tailor behavior change support for people with cancer are discussed.

The impact of travel time to cancer treatment centre on post-diagnosis care and mortality among cancer patients in Scotland

Limited data exist on the effect of travelling time on post-diagnosis cancer care and mortality. We analysed the impact of travel time to cancer treatment centre on secondary care contact time and one-year mortality using a data-linkage study in Scotland with 17369 patients. Patients with longer travelling time and island-dwellers had increased incidence rate of secondary care cancer contact time. For outpatient oncology appointments, the incidence rate was decreased for island-dwellers. Longer travelling time was not associated with increased secondary care contact time for emergency cancer admissions or time to first emergency cancer admission. Living on an island increased mortality at one-year. Adjusting for cancer-specific secondary care contact time increased the hazard of death, and adjusting for oncology outpatient time decreased the hazard of death for island-dwellers. Those with longer travelling times experience the cancer treatment pathway differently with poorer outcomes. Cancer services may need to be better configured to suit differing needs of dispersed populations.

Access to Care and Healthcare Quality Metrics for Patients with Advanced Genitourinary Cancers in Urban versus Rural Areas

Compared to the urban population, patients in rural areas face healthcare disparities and experience inferior healthcare-related outcomes. To compare the healthcare quality metrics and outcomes between patients with advanced genitourinary cancers from rural versus urban areas treated at a tertiary cancer hospital, in this retrospective study, eligible patients with advanced genitourinary cancers were treated at Huntsman Cancer Institute, an NCI-Designated Comprehensive Cancer Center in Utah. Rural-urban commuting area codes were used to classify the patients' residences as being in urban (1-3) or rural (4-10) areas. The straight line distances of the patients' residences from the cancer center were also calculated and included in the analysis. The median household income data were obtained and calculated from "The Michigan Population Studies Center", based on individual zip codes. In this study, 2312 patients were screened, and 1025 eligible patients were included for further analysis (metastatic prostate cancer (n = 679), metastatic bladder cancer (n = 184), and metastatic renal cell carcinoma (n = 162). Most patients (83.9%) came from urban areas, while the remainder were from rural areas. Both groups had comparable demographic profiles and tumor characteristics at baseline. The annual median household income of urban patients was $8604 higher than that of rural patients (p < 0.001). There were fewer urban patients with Medicare (44.9% vs. 50.9%) and more urban patients with private insurance (40.4% vs. 35.1%). There was no difference between the urban and rural patients regarding receiving systemic therapies, enrollment in clinical trials, or tumor genomic profiling. The overall survival rate was not significantly different between the two populations in metastatic prostate, bladder, and kidney cancer, respectively. As available in a tertiary cancer hospital, access to care can mitigate the difference in the quality of healthcare and clinical outcomes in urban versus rural patients.

Barriers, blocks, and barricades: Disparities to access of palliative care in cancer care

Palliative care (PC) is specialized medical care for people living with a serious illness. PC models have stressed pain and symptom management, communication that is patient- and family-centric and longitudinal support for families living with serious illness that is contiguous across multiple settings. Despite the benefits that PC provides from a patient, family and quality of care standpoint, several barriers and disparities exist. Included in these barriers are the lack of geographic access to PC programs as well as the focus on inpatient, hospital-based PC programs versus outpatient and home-based models. Workforce shortages, challenges with defining and designing PC, and racial, cultural and language barriers have all contributed to disparities within PC. This review article outlines PC disparities including geographic access challenges, cross-cultural barriers and symptom and communication specific disparities. We discuss the impact these inequities have on patients living with cancer.

The Impact of the COVID-19 Pandemic on Cancer Mortality in Pennsylvania: A Retrospective Study with Geospatial Analysis

BACKGROUND

We sought to quantify the impact of the COVID-19 pandemic on cancer mortality and identify associated factors in Pennsylvania.

METHODS

The retrospective study analyzed cross-sectional cancer mortality data from CDC WONDER for 2015 through 2020 for Pennsylvania and its 67 counties. The spatial distributions of 2019, 2020, and percentage change in age-adjusted mortality rates by county were analyzed via choropleth maps and spatial autocorrelation. A Wilcoxon Signed Rank Test was used to analyze whether the rates differed between 2019 and 2020. Quasi-Poisson and geographically weighted regression at the county level were used to assess the association between the 2019 rates, sex (percent female), race (percent non-White), ethnicity (percent Hispanic/Latino), rural-urban continuum codes, and socioeconomic status with the 2020 rates.

RESULTS

At the state level, the rate in 2020 did not reflect the declining annual trend (-2.7 per 100,000) in the rate since 2015. Twenty-six counties had an increase in the rate in 2020. Of the factors examined, the 2019 rates were positively associated with the 2020 rates, and the impact of sociodemographic and geographic factors on the 2020 rates varied by county.

CONCLUSIONS

In Pennsylvania, the 2020 cancer mortality rates did not decline as much as reported before the COVID-19 pandemic. The top five cancer types by rate were the same type for 2019 and 2020. Future cancer control efforts may need to address the impact of the COVID-19 pandemic on trends and geospatial distribution in cancer mortality.

Impact of COVID-19 on hospital screening, diagnosis and treatment activities among prostate and colorectal cancer patients in Canada

BACKGROUND

Suspension of cancer screening and treatment programs were instituted to preserve medical resources and protect vulnerable populations. This research aims to investigate the implications of COVID-19 on cancer management and clinical outcomes for patients with prostate and colorectal cancer in Canada.

METHODS

We examined hospital cancer screening, diagnosis, treatment, length of stay, and mortality data among prostate and colorectal cancer patients between April 2017 and March 2021. Baseline trends were established with data between April 2017 and March 2020 for comparison with data collected between April 2020 and March 2021. Scenario analyses were performed to assess the incremental capacity requirements needed to restore hospital cancer care capacities to the pre-pandemic levels.

RESULTS

For prostate cancer, A 12% decrease in diagnoses and 5.3% decrease in treatment activities were observed during COVID-19 between April 2020 and March 2021. Similarly, a 43% reduction in colonoscopies, 11% decrease in diagnoses and 10% decrease in treatment activities were observed for colorectal cancers. An estimated 1,438 prostate and 2,494 colorectal cancer cases were undiagnosed, resulting in a total of 620 and 1,487 unperformed treatment activities for prostate and colorectal cancers, respectively, across nine provinces in Canada. To clear the backlogs of unperformed treatment procedures will require an estimated 3%-6% monthly capacity increase over the next 6 months.

INTERPRETATION

A concerted effort from all stakeholders is required to immediately ameliorate the backlogs of cancer detection and treatment activities. Mitigation measures should be implemented to minimize future interruptions to cancer care in Canada.

Community efforts to promote vaccine uptake in a rural setting: a qualitative interview study

Vaccine hesitancy has been identified as one of the top 10 threats to global health. The causes of low vaccine uptake are many and vary at micro and macro levels. However, rural and remote coastal areas in the UK experience unique vaccine inequalities due to high levels of deprivation and their unique and complex access-related problems. This study aimed to explore community efforts to promote vaccine uptake during the COVID-19 pandemic and understand how the COVID-19 vaccination campaign was experienced by the public. We conducted an exploratory descriptive qualitative study using semi-structured interviews with decision-makers, health professionals and community members in Lincolnshire, a predominantly rural county with a long coastline, a large population of white minority ethnicities, and those living in caravan and temporary housing. Data were analysed using conventional content analysis. Overcoming the various access barriers to vaccination uptake involved working with local media stations, local communities and local community groups, translation of information, bringing vaccines closer to the people through pop-up and mobile clinics and provision of transport and ensuring confidentiality. There is a need to employ inclusive targeted non-conventional care interventions whilst dealing with complex problems as occur in rural and remote coastal regions.

Availability of cancer care services and the organization of care delivery at critical access hospitals

INTRODUCTION

Critical access hospitals (CAHs) provide an opportunity to meet the needs of individuals with cancer in rural areas. Two common innovative care delivery methods include the use of traveling oncologists and teleoncology. It is important to understand the availability and organization of cancer care services in CAHs due to the growing population with cancer and expected declines in oncology workforce in rural areas.

METHODS

Stratified random sampling was used to generate a sample of 50 CAHs from each of the four U.S. Census Bureau-designated regions resulting in a total sample of 200 facilities. Analyses were conducted from 135 CAH respondents to understand the availability of cancer care services and organization of cancer care across CAHs.

RESULTS

Almost all CAHs (95%) provided at least one cancer screening or diagnostic service. Forty-six percent of CAHs reported providing at least one component of cancer treatment (chemotherapy, radiation, or surgery) at their facility. CAHs that offered cancer treatment reported a wide range of health care staff involvement, including 34% of respondents reporting involvement of a local oncologist, 38% reporting involvement of a visiting oncologist, and 28% reporting involvement of a non-local oncologist using telemedicine.

CONCLUSION

Growing disparities within rural areas emphasize the importance of ensuring access to timely screening and guideline-recommended treatment for cancer in rural communities. These data demonstrated that CAHs are addressing the growing need through a variety of approaches including the use of innovative models that utilize non-local providers and telemedicine to expand access to crucial services for rural residents with cancer.

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.

Daily pain and opioid administration in hospitalized patients with cancer: the importance of psychological factors, recent surgery, and current opioid use

ABSTRACT

Pain is common and variable in its severity among hospitalized patients with cancer. Although biopsychosocial factors are well established as modulators of chronic pain, less is known about what patient-level factors are associated with worse pain outcomes among hospitalized cancer patients. This prospective cohort study included patients with active cancer presenting to the emergency department (ED) with pain severity of ≥4/10 and followed pain outcomes longitudinally throughout hospital admission. Baseline demographic, clinical, and psychological factors were assessed on ED presentation, and daily average clinical pain ratings and opioid consumption during hospitalization were abstracted. Univariable and multivariable generalized estimating equation analyses examined associations of candidate biopsychosocial, demographic, and clinical predictors with average daily pain and opioid administration. Among 113 hospitalized patients, 73% reported pain as the primary reason for presenting to the ED, 43% took outpatient opioids, and 27% had chronic pain that predated their cancer. Higher pain catastrophizing ( B = 0.1, P ≤ 0.001), more recent surgery ( B = -0.2, P ≤ 0.05), outpatient opioid use ( B = 1.4, P ≤ 0.001), and history of chronic pain before cancer diagnosis ( B = 0.8, P ≤ 0.05) were independently associated with greater average daily pain while admitted to the hospital. Higher pain catastrophizing ( B = 1.6, P ≤ 0.05), higher anxiety ( B = 3.7, P ≤ 0.05), lower depression ( B = -4.9, P ≤ 0.05), metastatic disease ( B = 16.2, P ≤ 0.05), and outpatient opioid use ( B = 32.8, P ≤ 0.001) were independently associated with higher daily opioid administration. Greater psychological distress, especially pain catastrophizing, as well as pain and opioid use history, predicted greater difficulty with pain management among hospitalized cancer patients, suggesting that early assessment of patient-level characteristics may help direct consultation for more intensive pharmacologic and nonpharmacologic interventions.

Rural research capacity: a co-created model for research success

PURPOSE

The United States' National Institutes of Health (NIH) have long challenged academia to improve clinical trial enrollment, especially in underrepresented populations; inclusive of geography, age, disability status, racial and ethnic minorities. It has been shown that rural and urban residents enrolled in clinical trials have similar outcomes, yet, rural healthcare systems struggle to provide opportunities to rural residents to participate in clinical trials when infrastructure is limited or unsupportive of research programs and/or research staffing levels are insufficient. To fully address the barriers to clinical trial access in rural areas, it is not adequate to simply open more trials. Community receptivity of research as well as organizational and community capacity must be considered. This project was determined by the Oregon Health and Science University's Institutional Review Board to be generalizable research across the chosen counties and was approved to operate under a waiver of written consent. Participants received a cash incentive in appreciation for their time and verbally agreed to participate after reviewing a project information sheet.

METHODS

The research team co-created a community-responsive approach to the receipt, review, and acceptance of clinical trials in a rural community setting. An adapted 5 step Implementation Mapping approach was used to develop a systematic strategy intended to increase the success, and therefore, the number of clinical trials offered in a rural community.

RESULTS

The research team and participating rural community members pilot-tested the implementation of a co-designed research review strategy, inclusive of a Regional Cultural Landscape and three co-created project submission and feasibility review forms, with a cancer early detection clinical trial. The proposed clinical trial required engagement from primary care and oncology. Utilizing the research review strategy demonstrated strong researcher-community stakeholder communication and negotiation, which resulted in early identification and resolution of potential barriers, hiring a local clinical research coordinator, and timely trial opening.

CONCLUSION

To the knowledge of the research team, the work described is the first to use a community-engaged approach for creating a clinical trial implementation strategy directly supportive of rural-sitting community stakeholders in receiving, reviewing, and approving cancer-related clinical trials in their community. Participating community members and leaders had the chance to negotiate research protocol changes or considerations directly with researchers interested in conducting a cancer clinical trial in their rural setting.

Refining 2SVCA Method for Measuring Telehealth Accessibility of Primary Care Physicians in Baton Rouge, Louisiana

Equity in health care delivery is a longstanding concern of public health policy. Telehealth is considered an important way to level the playing field by broadening health services access and improving quality of care and health outcomes. This study refines the recently developed "2-Step Virtual Catchment Area (2SVCA) method" to assess the telehealth accessibility of primary care in the Baton Rouge Metropolitan Statistical Area, Louisiana. The result is compared to that of spatial accessibility via physical visits to care providers based on the popular 2-Step Floating Catchment Area (2SFCA) method. The study shows that both spatial and telehealth accessibilities decline from urban to low-density and then rural areas. Moreover, disproportionally higher percentages of African Americans are in areas with higher spatial accessibility scores; but such an advantage is not realized in telehealth accessibility. In the study area, absence of broadband availability is mainly a rural problem and leads to a lower average telehealth accessibility than physical accessibility in rural areas. On the other side, lack of broadband affordability is a challenge across the rural-urban continuum and is disproportionally associated with high concentrations of disadvantaged population groups such as households under the poverty level and Blacks.

Integrating Early-Stage Drug Development with Clinical Networks; Challenges and Opportunities: The City of Hope Developing Experience

Recent data suggest that patients with advanced cancer who participate in biomarker/genomically informed early-stage clinical trials experience clinical benefit. While most early-stage clinical trials are conducted in major academic centers, the majority of cancer patients in the United States are treated in community practices. Here, we describe ongoing efforts at the City of Hope Cancer Center to integrate our network community oncology clinical practices into our academic, centralized biomarker/genomic-driven, early-stage clinical trial program to build an understanding of the approaches that provide the benefits of early-stage clinical trial participation to community patients. Our efforts include three key initiatives: the development of a virtual "Refractory Disease" phase 1 trial matching televideo clinic, the construction of infrastructure to support the expansion of phase 1 clinical trials to a distant regional clinical satellite hub, and the implementation of an enterprise-wide precision medicine, germline, and somatic testing program. Our work at City of Hope may serve as an example to facilitate similar efforts at other institutions.

Access To Oncology Services In Rural Areas: Influence Of The 340B Drug Pricing Program

Rural-urban cancer disparities, including greater mortality rates, are partially attributable to the limited availability of oncology services in rural communities. Without these services, rural residents may experience delays in timely treatment and may be less likely to complete recommended care. The 340B Drug Pricing Program allows eligible not-for-profit and public hospitals to purchase covered outpatient drugs, including high-cost oncology drugs, at discounted prices. Using 2011-20 data, we evaluated the relationship between new enrollment in the 340B program and oncology services initiation in rural general acute care hospitals that lacked oncology services in 2011. Compared with hospitals that remained unenrolled in the 340B program through 2020, hospitals that enrolled during 2012-18 were 8.3 percentage points more likely to have added oncology services as of 2020. The newly participating hospitals that added oncology services were disproportionately located in Medicaid expansion states and in counties with lower uninsurance rates. These findings suggest that the 340B program facilitates expanded access to oncology services in some rural communities, but opportunities remain to address disparities in the most disadvantaged service areas.

Patient Perspectives and Side-Effects Experience on Chemotherapy of Non-Small Cell Lung Cancer: A Qualitative Study

Purpose

This study aimed to explore patients' experiences of palliative chemotherapy for non-small cell lung cancer (NSCLC), how patients adapt to their new and challenging life after chemotherapy, their beliefs, and their quality of life.

Patients and Methods

The study used an exploratory descriptive qualitative approach that was designed to explore the experiences and side effects of NSCLC patients on chemotherapy in Pakistan. The study was designed to obtain a deeper understanding of 22 NSCLC patients' experiences, using a face-to-face approach and interviews were conducted. Patients who have completed chemotherapy agreed to participate in semi-structured interviews.

Results

The data were arranged into five themes: hospital facilities and environment, patient's beliefs in alternative treatments, presenting a positive/negative face, life is for living, and health insurance coverage. The major complaints related to bad experiences of chemotherapy-induced side effects, but these patients still managed to complete the full course of their respective chemotherapy. Additionally, the current study revealed the real experience of patients with NSCLC which had been less studied. The patient's experience was summarized into four themes and several subthemes.

Conclusion

This study aid healthcare providers when deciding on treatment options that will improve shared decision-making between clinicians and treatment outcomes.

Defining rurality: an evaluation of rural definitions and the impact on survival estimates

BACKGROUND

Patients with cancer living in rural areas have inferior cancer outcomes; however, studies examining this association use varying definitions of "rural," complicating comparisons and limiting the utility of the results for policy makers and future researchers.

METHODS

Surveillance, Epidemiology, and End Results data (2000-2016) were used to assess risk of cancer mortality and mortality from any cause across 4 definitions of rurality: Urban Influence codes (UIC), National Center for Health Statistics (NCHS), Rural-Urban continuum codes (RUCC), and Index of Relative Rurality. Binary (urban vs rural) and ternary (urban, micropolitan, rural) definitions were evaluated. Multivariable parametric survival models estimated hazards of mortality overall and among 3 cancer groupings: screening related, obesity related, and tobacco related. Definition agreement was also assessed.

RESULTS

Overall, 3 788 273 patients with an incident cancer representing 605 counties were identified. There was little discordance between binary definitions of rural vs urban and moderate agreement at the 3 levels. Adjusted models using binary definitions revealed 15% to 17% greater hazard of cancer mortality in rural compared with urban. At the 3 levels when comparing rural with metropolitan, RUCC and NCHS saw similarly increased hazard ratios; however, Index of Relative Rurality did not. Screening-related cancers saw the highest hazards of mortality and the largest divergence between definitions. Obesity-related and tobacco-related cancers saw similarly increased hazards of mortality at the binary and ternary levels.

CONCLUSIONS

Hazard of death is similar across binary definitions; however, this differed when categorized as ternary or continuous, especially among screening-related cancers. Results suggest that study purpose should direct choice of definitions and categorization.

Neighborhood Deprivation and Rurality Associated With Patient-Reported Outcomes and Survival in Men With Prostate Cancer in NRG Oncology RTOG 0415

PURPOSE

Rurality and neighborhood deprivation can contribute to poor patient-reported outcomes, which have not been systematically evaluated in patients with specific cancers in national trials. Our objective was to examine the effect of rurality and neighborhood socioeconomic and environmental deprivation on patient-reported outcomes and survival in men with prostate cancer in NRG Oncology RTOG 0415.

METHODS AND MATERIALS

Data from men with prostate cancer in trial NRG Oncology RTOG 0415 were analyzed; 1,092 men were randomized to receive conventional radiation therapy or hypofractionated radiation therapy. Rurality was categorized as urban or rural. Neighborhood deprivation was assessed using the area deprivation index and air pollution indicators (nitrogen dioxide and particulate matter with a diameter less than 2.5 micrometers) via patient ZIP codes. Expanded Prostate Cancer Index Composite measured cancer-specific quality of life. The Hopkins symptom checklist measured anxiety and depression. EuroQoL-5 Dimension assessed general health.

RESULTS

We analyzed 751 patients in trial NRG Oncology RTOG 0415. At baseline, patients from the most deprived neighborhoods had worse bowel (P = .011), worse sexual (P = .042), and worse hormonal (P = .015) scores; patients from the most deprived areas had worse self-care (P = .04) and more pain (P = .047); and patients from rural areas had worse urinary (P = .03) and sexual (P = .003) scores versus patients from urban areas. Longitudinal analyses showed that the 25% most deprived areas (P = .004) and rural areas (P = .002) were associated with worse EuroQoL-5 Dimension visual analog scale score. Patients from urban areas (hazard ratio, 1.81; P = .033) and the 75% less-deprived neighborhoods (hazard ratio, 0.68; P = .053) showed relative decrease in risk of recurrence or death (disease-free survival).

CONCLUSIONS

Patients with prostate cancer from the most deprived neighborhoods and rural areas had low quality of life at baseline, poor general health longitudinally, and worse disease-free survival. Interventions should screen populations from deprived neighborhoods and rural areas to improve patient access to supportive care services.

Rural-urban disparities in mortality and geriatric assessment among older adults with cancer: The cancer & aging resilience evaluation (CARE) registry

INTRODUCTION

Rural-urban disparities persist in cancer mortality, despite improvement in cancer screening and treatment. Although older adults represent the majority of cancer cases and are over-represented in rural areas, few studies have explored rural-urban disparities in mortality and age-related impairments among older adults with cancer.

MATERIALS AND METHODS

We included 962 newly-diagnosed older adults (≥60 years) with cancer who underwent geriatric assessment (GA) at their first pre-chemotherapy visit to an academic medical center in the Southeastern United States. We used Rural-Urban Commuting Area (RUCA) codes to classify residence at time of diagnosis into urban and rural areas. We used one-year survival and pre-treatment frailty as outcomes. We used Cox proportional hazards regression to evaluate the association between residence and one-year mortality, and logistic regression to evaluate the association between residence and pre-treatment frailty. All tests were two-sided.

RESULTS

Median age at GA was 68.0 (interquartile rage [IQR]: 64.0, 74.0) years; most had colorectal cancer (24.3%) with advanced stage (III/IV 73.2%) disease. Overall, 11.4% resided in rural and 88.6% in urban areas. Rural areas had a higher proportion of White and less educated participants. After adjustment for age, sex, race, education, employment status, and cancer type/stage, rural residence was associated with higher hazard of one-year mortality (hazard ratio [HR] = 1.78, 95% confidence interval [CI] = 1.23, 2.57) compared to urban residence. Frailty was an effect modifier of this association (HROverall = 1.83, 95% CI = 1.27, 2.57; HRFrail = 2.05, 95% CI = 1.23, 3.41; HRNot Frail = 1.55, 95% CI = 0.90, 2.68).

DISCUSSION

Among older adults with newly diagnosed cancer, rural residence was associated with reduced one-year survival, particularly among frail older adults. The rural-urban disparities observed in the current study may be due to frailty in conjunction with disparities in social determinants of health across rural and urban areas. Future studies should focus on understanding and intervening on underlying causes of these disparities.

A Hybrid Algorithm of ML and XAI to Prevent Breast Cancer: A Strategy to Support Decision Making

Worldwide, the coronavirus has intensified the management problems of health services, significantly harming patients. Some of the most affected processes have been cancer patients' prevention, diagnosis, and treatment. Breast cancer is the most affected, with more than 20 million cases and at least 10 million deaths by 2020. Various studies have been carried out to support the management of this disease globally. This paper presents a decision support strategy for health teams based on machine learning (ML) tools and explainability algorithms (XAI). The main methodological contributions are: first, the evaluation of different ML algorithms that allow classifying patients with and without cancer from the available dataset; and second, an ML methodology mixed with an XAI algorithm, which makes it possible to predict the disease and interpret the variables and how they affect the health of patients. The results show that first, the XGBoost Algorithm has a better predictive capacity, with an accuracy of 0.813 for the train data and 0.81 for the test data; and second, with the SHAP algorithm, it is possible to know the relevant variables and their level of significance in the prediction, and to quantify the impact on the clinical condition of the patients, which will allow health teams to offer early and personalized alerts for each patient.

Rural–Urban Disparities in Patient Care Experiences among Prostate Cancer Survivors: A SEER-CAHPS Study

Background: We sought to evaluate rural–urban disparities in patient care experiences (PCEs) among localized prostate cancer (PCa) survivors at intermediate-to-high risk of disease progression. Methods: Using 2007–2015 Surveillance Epidemiology and End Results (SEER) data linked to Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, we analyzed survivors’ first survey ≥6 months post-diagnosis. Covariate adjusted linear regressions were used to estimate associations of treatment status (definitive treatment vs. none) and residence (large metro vs. metro vs. rural) with PCE composite and rating measures. Results: Among 3779 PCa survivors, 1798 (53.2%) and 370 (10.9%) resided in large metro and rural areas, respectively; more rural (vs. large metro) residents were untreated (21.9% vs. 16.7%; p = 0.017). Untreated (vs. treated) PCa survivors reported lower scores for doctor communication (ß = −2.0; p = 0.022), specialist rating (ß = −2.5; p = 0.008), and overall care rating (ß = −2.4; p = 0.006). While treated rural survivors gave higher (ß = 3.6; p = 0.022) scores for obtaining needed care, untreated rural survivors gave lower scores for obtaining needed care (ß = −7.0; p = 0.017) and a lower health plan rating (ß = −7.9; p = 0.003) compared to their respective counterparts in large metro areas. Conclusions: Rural PCa survivors are less likely to receive treatment. Rural–urban differences in PCEs varied by treatment status.

Differential adoption of castration-resistant prostate cancer treatment across facilities in a national healthcare system

BACKGROUND

Over the past decade, abiraterone and enzalutamide have largely replaced ketoconazole as oral treatments for castration-resistant prostate cancer (CRPC). We investigated the differential adoption of abiraterone and enzalutamide across facilities in a national healthcare system to understand the impact a facility has on the receipt of these novel therapies.

METHODS

Using data from the VA Corporate Data Warehouse, we identified a cohort of men with CRPC who received the most common first-line therapies: abiraterone, enzalutamide, docetaxel, or ketoconazole between 2010 and 2017. We described variability in the adoption of abiraterone and enzalutamide across facilities by time period (2010-2013 or 2014-2017). We categorized facilities depending on the timing of adoption of abiraterone and enzalutamide relative to other facilities and described facility characteristics associated with early and late adoption.

RESULTS

We identified 4998 men treated with ketoconazole, docetaxel, abiraterone, or enzalutamide as first-line CRPC therapy between 2010 and 2017 at 125 national facilities. When limiting the cohort to oral therapies, most patients treated earlier in the study period (2010-2013) received ketoconazole. A dramatic shift was seen by the second half of the study period (2014-2017) with most men treated with first-line abiraterone (61%). Despite this shift and a new standard of care, some facilities persisted in the widespread use of ketoconazole in the later period, so-called late adopting facilities. After multivariable adjustment, patients who received treatment at a late adopting facility were more likely receiving care at a lower complexity, rural facility, with less urology and hematology/oncology workforce (all p < 0.01).

CONCLUSION

Many facilities persisted in their use of ketoconazole as first-line CRPC therapy, even when other facilities had adopted the new standard of care abiraterone and enzalutamide. Further work is needed to identify the effect of this late adoption on outcomes important to patients.

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.

Urban-Rural and Socioeconomic Differences in Patient Knowledge and Perceptions of Genomic Tumor Testing

PURPOSE

Social determinants of health, such as rurality, income, and education, may widen health disparities by driving variation in patients' knowledge and perceptions of medical interventions. This effect may be greatest for medical technologies that are hard to understand and less accessible. This study explored whether knowledge and perceptions (expectations and attitudes) of patients with cancer toward large-panel genomic tumor testing (GTT), an emerging cancer technology, vary by patient rurality independent of other socioeconomic characteristics (education and income).

METHODS

Patients with cancer enrolled in a large precision oncology initiative completed surveys measuring rurality, sociodemographic characteristics, and knowledge and perceptions of GTT. We used multivariable linear models to examine differences in GTT knowledge, expectations, and attitudes by patient rurality, education, and income level. Models controlled for age, sex and clinical cancer stage and type.

RESULTS

Rural patients had significantly lower knowledge of GTT than urban patients using bivariate models (P = .025). However, this association disappeared when adjusting for education and income level: patients with lower educational attainment and lower income had lower knowledge and higher expectations (P ≤ .002), whereas patients with higher income had more positive attitudes (P = .005). Urban patients had higher expectations of GTT compared with patients living in large rural areas (P = .011). Rurality was not associated with attitudes.

CONCLUSION

Patients' education and income level are associated with knowledge, expectations, and attitudes toward GTT, whereas rurality is associated with patient expectations. These findings suggest that efforts to promote adoption of GTT should focus on improving knowledge and awareness among individuals with low education and income. These differences may lead to downstream disparities in GTT utilization, which should be explored in future research.

Health-Promoting Behaviours following Primary Treatment for Cancer: A Rural-Urban Comparison from a Cross-Sectional Study

AIM

To compare health-promoting behaviours among rural and urban residents following primary treatment for cancer.

METHODS

A cross-sectional survey collecting demographic variables and data pertaining to health-promoting behaviours, documented using the 52-item Health Promotion Lifestyle Profile II (HPLP-II) measure, which is categorised into six subscales: (1) health responsibility, (2) spiritual growth, (3) physical activity, (4) interpersonal relations, (5) nutrition, and (6) stress management. Residence was defined using the U.K. Office for National Statistics RUC 2011 Rural Urban Classifications. The Index of Multiple Deprivation (IMD) Decile was used to measure deprivation. Quantitative data were analysed using independent samples t-test and multiple linear regression. Qualitative data from open-ended questions were analysed thematically.

RESULTS

In total, 227 participants with a range of cancer types completed the questionnaire. Fifty-three percent were residents in urban areas and forty-five percent in rural areas. Rural participants scored significantly higher on health responsibility (p = 0.001), nutrition (p = 0.001), spiritual growth (p = 0.004), and interpersonal relationships (p = 0.001), as well as on the overall HPLP-II (p = 0.001). When controlling for deprivation, age, marital status, and education, rural-urban residence was a significant predictor of exhibiting health-promoting behaviours. A central theme from the qualitative data was the concept of "moving on" from cancer following treatment, by making adjustments to physical, social, psychological, spiritual, and emotional wellbeing.

CONCLUSIONS

This research revealed, for the first time, differences in health-promoting behaviours among rural and urban U.K. populations who have completed primary cancer treatment. Rural residence can provide a positive environment for engaging with health-promoting behaviours following a cancer diagnosis and treatment.

First-Year Implementation of the EXercise for Cancer to Enhance Living Well (EXCEL) Study: Building Networks to Support Rural and Remote Community Access to Exercise Oncology Resources

Barriers to exercise-oncology programs remain for those living with and beyond cancer in rural and remote communities, including geographic isolation and access to programs. The EXercise for Cancer to Enhance Living Well (EXCEL) study was designed to support exercise-oncology implementation in rural and remote communities across Canada. The purpose of this analysis was to evaluate the first-year reach, adoption, and implementation of the EXCEL study. Reach outcomes included participant characteristics, study enrolment, and referral type (self vs. healthcare-provider [HCP] referral). Adoption outcomes included the number of clinical contacts, trained qualified exercise professionals (QEPs), and QEPs delivering EXCEL exercise classes. Implementation outcomes included retention, adherence, assessment completion rates, and adverse-event reporting. A total of 290 individuals living with cancer enrolled in EXCEL in year one, with an 81.4% retention to the study intervention. Most participants self-referred to EXCEL (75.8%). EXCEL's HCP network consisted of 163 clinical contacts, and the QEP network included 45 trained QEPs, 22 of whom delivered EXCEL classes. Adherence to the exercise intervention was 78.2%, and only one adverse event (mild) was reported. Fitness assessment and patient-reported outcome completion rates were above 85% pre- and post-intervention. EXCEL has developed HCP and QEP networks supporting exercise referral and online delivery, and the intervention is meeting feasibility markers. These implementation findings will inform the continued gathering of feedback across stakeholders to ensure that best evidence informs best practices.

A capability framework to inform the fundamental requirements for clinical trial unit development, growth and long term success in outer metropolitan and rural areas

Background

Participation in clinical trials is linked to improved patient outcomes. Despite this, most trial participants either reside in, or are treated in metropolitan areas. TrialHub developed hub-and-spoke models to support and grow clinical trial units in outer metropolitan and regional/rural centres in order to boost clinical trial engagement and reduce demands of trial participation on patients from outer metropolitan and regional/rural areas. The aim of this project was to establish a capability framework for clinical trial unit growth and development.

Methods

An integrative methods study design was used to inform the co-design and development of the capability framework based on data collected in Victoria during 2020-21. This included reviews of the literature and of existing local resources, infrastructure, and staffing; as well as education, mentoring and support, and a needs assessment through multidisciplinary working groups.

Results

We developed a capability framework based on the level of support required for outer metropolitan and regional/rural centres with diverse existing capabilities across Victoria. The framework applies a maturity model to assess resources, processes and practices which impact the capacity and capability of centres to conduct trials safely and sustainably. Each level of the model uses a consistent set of factors to describe the core elements required for safe clinical trial delivery. This benchmarking allows targeted investment to ensure safe and high-quality delivery of trials at newly establishing trial units.

Conclusion

The capability framework developed by TrialHub provides a basis for staged, planned and successful trial unit development and trial implementation. Further validation of the framework is required.

Association of distance traveled on receipt of surgery in patients with locally advanced rectal cancer

PURPOSE

Studies have shown patients residing in rural settings have worse cancer-related outcomes than those in urban settings. Specifically, rural patients with colorectal cancer have lower rates of screening and longer time to treatment. However, physical distance traveled has not been as well studied. This study sought to determine disparities in receipt of surgery in patients by distance traveled for care.

METHODS

A retrospective cohort study of patients with AJCC stage II/III rectal adenocarcinoma was identified within the National Cancer Database (2004-2017). Primary outcome was correlation of distance traveled to receipt of surgery. Multi-variable logistic regression was used to adjust for confounding factors.

RESULTS

65,234 patients were included in the analysis. 94.6% resided in urban-metro areas while 2.2% resided in rural areas. Patients were predominantly non-Hispanic White (NHW) (75.2%) with an overall median age at diagnosis of 61 (IQR 52-71). Overall, 82.6% of patients received surgery. NHW patients were more likely to receive surgery than non-Hispanic Black patients (OR 0.67; 95% CI 0.61-0.73, p < 0.001), as were patients who were privately insured (OR 1.90, 95% CI 1.67-2.15, p < 0.001) or had Medicare (OR 1.68, 95% CI 1.47-1.92, p < 0.001) compared to uninsured patients. Patients traveling distances in the 4th quartile (median 47.9 miles) were more likely to receive surgery than those traveling the shortest distances (1st quartile: median 2.5 miles) (OR 1.37, 95% CI 1.24-1.50, p < 0.001).

CONCLUSION

Patients traveling farther distances were more likely to receive surgery than those traveling shorter distances. Shorter distance traveled does not appear to be associated with higher rates of surgical resection in patients with stage II/III rectal cancer.

Adapting a Research and Community Capacity-Building Program to Address Rural Cancer Burden and Facilitate Partnership Development Between Rural Community Stakeholders and an Urban Comprehensive Cancer Center

While rural-urban cancer disparities persist, the research building capacity between rural communities and high-quality cancer centers remains limited. Thus, we describe how a National Cancer Institute-designated cancer center partnered with rural community stakeholders to adapt a cancer prevention-focused research and community capacity-building workshop. The workshop's goal was to strengthen community-academic partnerships and facilitate the development of sustainable well-resourced rural cancer-focused research. Researchers from the Siteman Cancer Center partnered with community leaders from rural counties in southern Illinois. We adapted the workshop from an existing evidence-based program. We analyzed changes in knowledge and research capacity and relevance to their community work. From February to May 2019, community partners guided all elements of the workshop development. Workshop participants were mostly White race (93%), had a college degree or beyond (75%), reported living in a rural community (93%), and represented an academic, faith-based, or healthcare institution (78%). Participants' mean knowledge scores of the presented content increased significantly after each session, from 9.3 to 9.9 for session 1 (p = 0.05) and 6.8 to 9.7 (p < 0.001) for session two. Through the workshop, participant scores also increased in research capacity skills, confidence, and their understanding of conducting research in the community. The workshop, co-curated and led by rural community leaders and researchers from Siteman Cancer Center, successfully increased knowledge of and interest in building cancer research capacity. Lessons from our work can inform the implementation of similar programs that address rural cancer health through research and community capacity building between rural community partners and urban cancer centers.

Geographic Employment Outcomes for Graduating Residents in Radiation Oncology: 2021

PURPOSE

In light of the persistent disparity in the prevalence of radiation oncologists between rural and urban areas in the United States, we sought to characterize the geographic employment outcomes of the radiation oncology (RO) residency class of 2021.

METHODS AND MATERIALS

We identified the employment positions accepted by 2021 RO residency graduates using publicly available information. Then, we classified each position as academic or nonacademic and determined the rural-urban continuum code and core-based statistical area (CBSA) of each position, residency program, and medical school associated with the 2021 graduates. Last, we compared the geographic employment outcomes of the 2021 class with those of the 2019 class.

RESULTS

Most 2021 graduates accepted employment positions outside of the counties, CBSAs, and states in which they attended medical school or residency. A total of 116 graduates accepted nonacademic positions, and 65 graduates accepted academic positions. Nine graduates accepted fellowships and were excluded from this analysis. As with the class of 2019, most 2021 graduates (n = 104; 57.5%) accepted positions in the largest metropolitan areas, and few (n = 11; 6.1%) accepted positions in nonmetropolitan areas. Female residents were more likely to accept academic (48.9% vs 31.3%; P = .03) and academic main site (36.2% vs 21.6%; P = .05) positions than male residents. The distribution of jobs in both the 5 and 10 largest CBSAs was not significantly different from what would have been expected if jobs were equally distributed across the country on the basis of population (P = .81 and P = .87, respectively). However, the distribution was significantly different from what would have been expected if the distribution of such positions reflected the number of residents who graduated from residency programs in those CBSAs (P < .01 and P < .01, respectively).

CONCLUSIONS

As with the class of 2019, the majority of graduates in the class of 2021 accepted employment positions in large metropolitan areas. Relatively few graduates accepted positions in nonmetropolitan areas. How key RO stakeholders respond to the challenge of maintaining a stable supply of rural radiation oncologists while also ensuring that jobs available to graduating RO residents reflect their preferences will have a significant effect on the field going forward.

Disparities in spatial accessibility of primary care in Louisiana: From physical to virtual accessibility

Telehealth has been widely employed and has transformed how healthcare is delivered in the United States as a result of COVID-19 pandemic. While telehealth is utilized and encouraged to reduce the cost and travel burden for access to healthcare, there are debates on whether telehealth can promote equity in healthcare services by narrowing the gap among diverse groups. Using the Two-Step Floating Catchment Area (2SFCA) and Two-Step Virtual Catchment Area (2SVCA) methods, this study compares the disparities of physical and virtual access to primary care physicians (PCPs) in Louisiana. Both physical and virtual access to PCPs exhibit similar spatial patterns with higher scores concentrated in urban areas, followed by low-density and rural areas. However, the two accessibility measures diverge where broadband availability and affordability come to play an important role. Residents in rural areas experience additive disadvantage of even more limited telehealth accessibility than physical accessibility due to lack of broadband service provision. Areas with greater Black population proportions tend to have better physical accessibility, but such an advantage is eradicated for telehealth accessibility because of lower broadband subscription rates in these neighborhoods. Both physical and virtual accessibility scores decline in neighborhoods with higher Area Deprivation Index (ADI) values, and the disparity is further widened for in virtual accessibility compared to than physical accessibility. The study also examines how factors such as urbanicity, Black population proportion, and ADI interact in their effects on disparities of the two accessibility measures.

Implementing an exercise oncology model to reach rural and remote individuals living with and beyond cancer: a hybrid effectiveness-implementation protocol for project EXCEL (EXercise for Cancer to Enhance Living Well)

INTRODUCTION

Individuals living with and beyond cancer from rural and remote areas lack accessibility to supportive cancer care resources compared with those in urban areas. Exercise is an evidence-based intervention that is a safe and effective supportive cancer care resource, improving physical fitness and function, well-being and quality of life. Thus, it is imperative that exercise oncology programs are accessible for all individuals living with cancer, regardless of geographical location. To improve accessibility to exercise oncology programs, we have designed the EXercise for Cancer to Enhance Living Well (EXCEL) study.

METHODS AND ANALYSIS

EXCEL is a hybrid effectiveness-implementation study. Exercise-based oncology knowledge from clinical exercise physiologists supports healthcare professionals and community-based qualified exercise professionals, facilitating exercise oncology education, referrals and programming. Recruitment began in September 2020 and will continue for 5 years with the goal to enroll ~1500 individuals from rural and remote areas. All tumour groups are eligible, and participants must be 18 years or older. Participants take part in a 12-week multimodal progressive exercise intervention currently being delivered online. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework is used to determine the impact of EXCEL at participant and institutional levels. Physical activity, functional fitness and patient-reported outcomes are assessed at baseline and 12-week time points of the EXCEL exercise intervention.

ETHICS AND DISSEMINATION

The study was approved by the Health Research Ethics Board of Alberta. Our team will disseminate EXCEL information through quarterly newsletters to stakeholders, including participants, qualified exercise professionals, healthcare professionals and community networks. Ongoing outreach includes community presentations (eg, support groups, fitness companies) that provide study updates and exercise resources. Our team will publish manuscripts and present at conferences on EXCEL's ongoing implementation efforts across the 5-year study.

TRIAL REGISTRATION NUMBER

NCT04478851.

Differences in urban and suburban/rural settings regarding care provision and barriers of cancer care for older adults during COVID-19

PURPOSE

Care for older adults with cancer became more challenging during the COVID-19 pandemic, particularly in urban hotspots. This study examined the potential differences in healthcare providers' provision of as well as barriers to cancer care for older adults with cancer between urban and suburban/rural settings.

METHODS

Members of the Advocacy Committee of the Cancer and Aging Research Group, with the Association of Community Cancer Centers, surveyed multidisciplinary healthcare providers responsible for the direct care of patients with cancer. Respondents were recruited through organizational listservs, email blasts, and social media messages. Descriptive statistics and chi-square tests were used.

RESULTS

Complete data was available from 271 respondents (urban (n = 144), suburban/rural (n = 127)). Most respondents were social workers (42, 44%) or medical doctors/advanced practice providers (34, 13%) in urban and suburban/rural settings, respectively. Twenty-four percent and 32.4% of urban-based providers reported "strongly considering" treatment delays among adults aged 76-85 and > 85, respectively, compared to 13% and 15.4% of suburban/rural providers (Ps = 0.048, 0.013). More urban-based providers reported they were inclined to prioritize treatment for younger adults over older adults than suburban/rural providers (10.4% vs. 3.1%, p = 0.04) during the pandemic. The top concerns reported were similar between the groups and related to patient safety, treatment delays, personal safety, and healthcare provider mental health.

CONCLUSION

These findings demonstrate location-based differences in providers' attitudes regarding care provision for older adults with cancer during the COVID-19 pandemic.

A Rapid Systematic Review on the Experiences of Cancer Survivors Residing in Rural Areas during the COVID-19 Pandemic

The COVID-19 pandemic has caused considerable disruption to cancer care and may have exacerbated existing challenges already faced by cancer survivors from rural areas. This has created a need for a rapid evidence synthesis to inform the development of tailored interventions that address the specific needs of rural cancer survivors who continue to be affected by the pandemic. The review was conducted following guidance from the Cochrane Rapid Review Methods Group. Database searches were performed via the EBSCOHost interface (includes MEDLINE, CINAHL, PsycINFO) on 25 May 2022 and supplemented with searches on Google Scholar. Peer-reviewed articles published after March 2020 that reported primary data on the experiences of cancer survivors residing in rural and remote settings during the pandemic were included. Findings were tabulated and written up narratively. Fourteen studies were included. The COVID-19 pandemic had a mostly detrimental impact on the experiences of rural cancer survivors. People's individual coping mechanisms were challenging for a range of reasons. Specifically, the pandemic impacted on their ability to access testing, treatment, check-ups and supportive care, their ability to maintain and access social support with close friends and family, as well as negative consequences to their finances and emotional wellbeing with some reporting feelings of psychological distress including depression and anxiety. This review provides important insight into the experiences of rural cancer survivors that may help inform tailored support in line with the needs and challenges faced because of the pandemic.

Cancer-related emergency and urgent care: expanding the research agenda

Purpose of review

Cancer-related emergency department (ED) visits often result in higher hospital admission rates than non-cancer visits. It has been estimated many of these costly hospital admissions can be prevented, yet urgent care clinics and EDs lack cancer-specific care resources to support the needs of this complex population. Implementing effective approaches across different care settings and populations to minimize ED and urgent care visits improves oncologic complication management, and coordinating follow-up care will be particularly important as the population of cancer patients and survivors continues to increase. The National Cancer Institute (NCI) and the Office of Emergency Care (OECR) convened a workshop in December 2021, “Cancer-related Emergency and Urgent Care: Prevention, Management, and Care Coordination” to highlight progress, knowledge gaps, and research opportunities. This report describes the current landscape of cancer-related urgent and emergency care and includes research recommendations from workshop participants to decrease the risk of oncologic complications, improve their management, and enhance coordination of care.

Recent findings

Since 2014, NCI and OECR have collaborated to support research in cancer-related emergency care. Workshop participants recommended a number of promising research opportunities, as well as key considerations for designing and conducting research in this area. Opportunities included better characterizing unscheduled care services, identifying those at higher risk for such care, developing care delivery models to minimize unplanned events and enhance their care, recognizing cancer prevention and screening opportunities in the ED, improving management of specific cancer-related presentations, and conducting goals of care conversations.

Summary

Significant progress has been made over the past 7 years with the creation of the Comprehensive Oncologic Emergency Research Network, broad involvement of the emergency medicine and oncology communities, establishing a proof-of-concept observational study, and NCI and OECR’s efforts to support this area of research. However, critical gaps remain.

Toward a More Just System of Care in Molecular Pathology

Policy Points American health care policy must be critically assessed to establish the role it plays in sustaining and alleviating the health disparities that currently exist in molecular genetic testing. It is critical to understand the economic and sociocultural influences that drive patients to undergo or forgo molecular testing, especially in marginalized patient populations. A multipronged solution with actions necessary from multiple stakeholders is required to reduce the cost of health care, rebalance regional disparities, encourage physician engagement, reduce data bias, and earn patients' trust.

CONTEXT

The health status of a population is greatly influenced by both biological processes and external factors. For years, minority and low socioeconomic patient populations have faced worse outcomes and poorer health in the United States. Experts have worked extensively to understand the issues and find solutions to alleviate this disproportionate burden of disease. As a result, there have been some improvements and successes, but wide gaps still exist. Diagnostic molecular genetic testing and so-called personalized medicine are just now being integrated into the current American health care system. The way in which these tests are integrated can either exacerbate or reduce health disparities.

METHODS

We provide case scenarios-loosely based on real-life patients-so that nonexperts can see the impacts of complex policy decisions and unintentional biases in technology without needing to understand all the intricacies. We use data to explain these findings from an extensive literature search examining both peer-reviewed and gray literature.

FINDINGS

Access to diagnostic molecular genetic testing is not equitable or sufficient, owing to at least five major factors: (1) cost to the patient, (2) location, (3) lack of provider buy-in, (4) data-set bias, and (5) lack of public trust.

CONCLUSIONS

Molecular genetic pathology can be made more equitable with the concerted efforts of multiple stakeholders. Confronting the five major factors identified here may help us usher in a new era of precision medicine without its discriminatory counterpart.

The current status of survivorship care provision at the state level: a Wisconsin-based assessment

PURPOSE

As the number of cancer survivors grows, the responsibility for addressing their unique physical and emotional needs also increases. Survivorship care services vary by geography, health system, and insurance coverage. We aimed to understand the state of survivorship care services in Wisconsin's cancer facilities.

METHODS

The selection of cancer treatment facilities sought to provide a geographically representative sample. An adapted Patient-Centered Survivorship Care Index was comprised of questions regarding different aspects of survivorship practices. Areas of interest included disciplines incorporated, services provided, standards of care, and discussion of late-term effects, among others.

RESULTS

Out of 90 sites invited, 40 responded (44.4%). Oncologists, physician assistants, and nurse practitioners were the most common follow-up care disciplines. Risk reduction services, dietary services, access to physical activity, and behavioral health specialist referral were described as standards of care in less than half of sites. All sites reported working with community partners, 92.5% of which worked with YMCA-related programs. Discussion of long-term effects was a standard of care for all sites. Effects such as emotional distress and health practice changes were frequently discussed with almost all patients, while sexual functioning and fertility were not.

CONCLUSIONS

Services and specialties related to behavioral health, fertility/sexual health, and rehabilitation and physical activity varied between sites. Such services may be offered less often due to variable insurance coverage.

IMPLICATIONS FOR CANCER SURVIVORS

Policy solutions should be explored to increase insurance coverage and provision rates of necessary survivorship services to keep up with the projected increase in demand. Given imperfect and evolving measurement tools to assess needs for cancer survivorship care services, cancer survivors should feel empowered to voice when they have unmet needs and request referrals.

Multilevel factors associated with inequities in multidisciplinary cancer consultation

OBJECTIVE

To assess changes in the prevalence of multidisciplinary cancer consultations (MDCc) over the last decade and examine patient, surgeon, hospital, and neighborhood factors associated with receipt of MDCc among individuals diagnosed with cancer.

DATA SOURCE

Surveillance, Epidemiology and End Results (SEER)-Medicare data from 2006 to 2016.

STUDY DESIGN

We used time-series analysis to assess change in MDCc prevalence from 2007 to 2015. We also conducted multilevel logistic regression with random surgeon- and hospital-level effects to assess associations between patient, surgeon, neighborhood, and health care organization-level factors and receipt of MDCc during the cancer treatment planning phase, defined as the 2 months following cancer diagnosis.

DATA COLLECTION/EXTRACTION METHODS

We identified Medicare beneficiaries >65 years of age with surgically resected breast, colorectal (CRC), or non-small cell lung cancer (NSCLC) stages I-III (n = 103,250).

PRINCIPAL FINDINGS

From 2007 to 2015, the prevalence of MDCc increased from 35.0% to 61.2%. Overall, MDCc was most common among patients with breast cancer compared to CRC and NSCLC. Cancer patients who were Black, had comorbidities, had dual Medicare-Medicaid coverage, were residing in rural areas or in areas with higher Black and Hispanic neighborhood composition were significantly less likely to have received MDCc. Patients receiving surgery at disproportionate payment-sharing or rural-designated hospitals had 2% (95% CI: -3.55, 0.58) and 17.6% (95% CI: -21.45, 13.70), respectively, less probability of receiving MDCc. Surgeon- and hospital-level effects accounted for 15% of the variance in receipt of MDCc.

CONCLUSIONS

The practice of MDCc has increased over the last decade, but significant geographical and health care organizational barriers continue to impede equitable access to and delivery of quality care across cancer patient populations. Multilevel and multicomponent interventions that target care coordination, health system, and policy changes may enhance equitable access to and receipt of MDCc.

Closing the Cancer Care Gap in India

Cancer burden in India is increasing. Cancer treatment today is multi-disciplinary requiring the coordination of many specialists for best outcomes. Bringing such expertise together to the district level is the greatest challenge for cancer care in any country, moreover in India. This article focuses on the step-wise journey to make comprehensive cancer care center in a small city.

Implementation and Clinical Adoption of Precision Oncology Workflows Across a Healthcare Network

BACKGROUND

Precision oncology relies on molecular diagnostics, and the value-proposition of modern healthcare networks promises a higher standard of care across partner sites. We present the results of a clinical pilot to standardize precision oncology workflows.

METHODS

Workflows are defined as the development, roll-out, and updating of disease-specific molecular order sets. We tracked the timeline, composition, and effort of consensus meetings to define the combination of molecular tests. To assess clinical impact, we examined order set adoption over a two-year period (before and after roll-out) across all gastrointestinal and hepatopancreatobiliary (GI) malignancies, and by provider location within the network.

RESULTS

Development of 12 disease center-specific order sets took ~9 months, and the average number of tests per indication changed from 2.9 to 2.8 (P = .74). After roll-out, we identified significant increases in requests for GI patients (17%; P < .001), compliance with testing recommendations (9%; P < .001), and the fraction of "abnormal" results (6%; P < .001). Of 1088 GI patients, only 3 received targeted agents based on findings derived from non-recommended orders (1 before and 2 after roll-out); indicating that our practice did not negatively affect patient treatments. Preliminary analysis showed 99% compliance by providers in network sites, confirming the adoption of the order sets across the network.

CONCLUSION

Our study details the effort of establishing precision oncology workflows, the adoption pattern, and the absence of harm from the reduction of non-recommended orders. Establishing a modifiable communication tool for molecular testing is an essential component to optimize patient care via precision oncology.

A comparison of survey incentive methods to recruit rural cancer survivors into cancer care delivery research studies

Unconditional (upfront) incentives are proposed to improve acceptance of cancer research among underrepresented, racial/ethnic minority populations, but few studies have tested incentive strategies among rural cancer survivors. Descriptive statistics summarized demographic characteristics of survey respondents, and response rates by arm were compared using Chi-square tests. We compared upfront ($2) and response-based ($10 conditional) incentives in a mailed survey of adult post-treatment rural survivors. Individuals meeting eligibility criteria from the electronic medical record (n = 2,830) were randomized into two incentive arms (n = 1,414 for the upfront arm and n = 1,416 for the contingent arm). Of the total delivered, presumed eligible participants (n = 1,304 upfront arm; n = 1,317 contingent arm), 67.8% were aged 65y+, 49.8% were female, and 95.1% were non-Hispanic white. The response rate for all participants was 18.5%. We received eligible surveys from 281 rural survivors in the first arm (response rate: 21.5%); and 205 surveys in the second arm (response rate: 15.6%). Participants who received the upfront incentive had a higher response rate than those receiving a response-based incentive, X2 (1, 2,621) = 15.53, p < 0.0001. Incentivizing survey completion with an upfront $2 bill encouraged a higher survey response rate; other supplemental strategies are needed to achieve a higher response rate for this population.