Identification of underserved areas for urologic cancer care

Insurance Type and Area Deprivation Are Associated With Worse Overall Mortality for Patients With Muscle-invasive Bladder Cancer

OBJECTIVE

To examine the association of area-level socioeconomic status, rural-urban residence, and type of insurance with overall and cancer-specific mortality among patients with muscle-invasive bladder cancer.

METHODS

Using the Pennsylvania Cancer Registry, which collects demographic, insurance, and clinical information on every patient with cancer within the state, we identified all patients diagnosed with non-metastatic muscle-invasive bladder cancer between 2010 and 2016 based on clinical and pathologic staging. We used the Area Deprivation Index (ADI) as a surrogate for socioeconomic status and Rural-Urban Commuting Area codes to classify urban, large town, and rural communities. ADI was reported in quartiles, with 4 representing the lowest socioeconomic status. We fit multivariable logistic regression and Cox models to assess the relationship of these social determinants with overall and cancer-specific survival adjusting for age, sex, race, stage, treatment, rural-urban classification, insurance and ADI.

RESULTS

We identified 2597 patients with non-metastatic muscle-invasive bladder cancer. On multivariable analysis, Medicare (hazards ratio [HR] 1.15), Medicaid (HR 1.38), ADI 3 (HR 1.16) and ADI 4 (HR 1.21) were independent predictors of greater overall mortality (all P < 0.05). Female sex and receipt of non-standard treatment were associated with increased overall mortality and bladder cancer-specific mortality. There was no significant difference in both overall and cancer-specific survival between patients who were non-Hispanic White compared to non-White or between those from urban areas, large towns, or rural locations.

CONCLUSION

Lower socioeconomic status and Medicare and Medicaid insurance were associated with a greater risk of overall mortality while rural residence was not a significant factor. Implementation of public health programs may help reduce the gap in mortality for low SES at-risk populations.

Geography Should Not Be an "Oncologic Destiny" for Urothelial Cancer: Improving Access to Care by Removing Local, Regional, and International Barriers

Urothelial cancer care is particularly susceptible to geographical health disparity given its complex nature, requiring access to several specialists such as a urologist, a medical oncologist, a radiation oncologist, a surgical oncologist, and multidisciplinary care teams. Furthermore, other barriers to care access in underserved areas include travel burden, longer wait times, late-stage disease at the time of diagnosis, cost, type of treatment, less enrollment in clinical trials, lack of follow-up among cancer survivors, and less research funding in this area. Here, we discuss the impact of geographical location on access to urothelial cancer care, management decisions, and outcomes and we reflect on how to address geographical disparities in care delivery.

GIS-Automated Delineation of Hospital Service Areas in Florida: From Dartmouth Method to Network Community Detection Methods

Since the Dartmouth hospital service areas (HSAs) were proposed three decades ago, there has been a large body of work using the unit in examining the geographic variation in health care in the U.S. for evaluating health care system performance and informing health policy. However, many studies question the replicability and reliability of the Dartmouth HSAs in meeting the challenges of ever-changing and a diverse set of health care services. This research develops a reproducible, automated, and efficient GIS tool to implement Dartmouth method for defining HSAs. Moreover, the research adapts two popular network community detection methods to account for spatial constraints for defining HSAs that are scale flexible and optimize an important property such as maximum service flows within HSAs. A case study based on the state inpatient database in Florida from the Healthcare Cost and Utilization Project is used to evaluate the efficiency and effectiveness of the methods. The study represents a major step toward developing HSA delineation methods that are computationally efficient, adaptable for various scales (from a local region to as large as a national market), and automated without a steep learning curve for public health professionals.

Evaluation of the association of health care system access with kidney cancer surgical outcomes for hispanic and non-hispanic white patients

OBJECTIVE

To determine the impact of health care system access on outcomes for Hispanic and Non-Hispanic White patients with renal cell carcinoma (RCC).

METHODS

We retrospectively analyzed Hispanic and non-Hispanic White patients diagnosed with localized RCC between 2007 and 2020. We used Health Resources and Services Administration criteria to identify patients living in Medically Underserved Areas (MUA). Primary outcome all-cause mortality and cancer-specific survival using Log Rank test on Kaplan Meier Analysis. Secondary outcome was all-cause mortality and cancer specific survival on Cox Regression when adjusting for risk factors.

RESULTS

We analyzed 774 patients, 246 (31.8%) Hispanic patients and 528 (68.2%) Non-Hispanic White patients. Hispanic ethnicity was associated with lower risk of ACM (HR 0.53, P = 0.019) and there was no difference for cancer specific survival (HR 0.57, P = 0.059). Living in a MUA was associated with worse all-cause mortality (P = 0.010) but not cancer specific survival (CSS) (P = 0.169). Comparing Hispanic and Non-Hispanic Whites, KMA revealed no difference in 5-year all-cause mortality (83.1% vs. 78.8%, P = 0.254) and 5-year CSS (85.7% vs. 85.4%, P = 0.403).

CONCLUSIONS

Hispanics had lower all-cause mortality risk and no significant differences in 5-year overall survival and CSS compared to non-Hispanic Whites. Our findings indicate that tertiary referral centers may help mitigate inequalities in access to care.

Urology Residency Training in Medically Underserved Areas Through the Integration of a Federally Qualified Health Center Rotation

OBJECTIVE

To identify workforce related barriers to urologic care in Medically Underserved Areas (MUA) and Health Professional Shortage Areas (HPSA). Federally Qualified Health Centers (FQHC) are community-based organizations that aim to close gaps, but little is known about exposure to underserved areas during residency training.

METHODS

The objective of this study was to characterize the experiences of urology residents who participated in a rotation within a FQHC. The study consisted of: (1) 12-item post-rotation self-assessment (2) review of career paths of former graduates who completed the rotation, and (3) retrospective review of patients treated at FQHC from 2016 to 2018.

RESULTS

There were a total of 1735 patient visits, 97 were for cystoscopy, 76.36% of patients had Medicaid or no insurance. There were 1092 unique patients seen and 281 (25.73%) were referred for surgery. A majority of residents (100%) stated they had a better appreciation of treating patients in underserved areas. A majority of residents (71.6%) of residents said they were more likely to practice in an underserved area after residency. Among former graduates who rotated through the clinic, 100% (n = 4) were practicing in a MUA or HPSA.

CONCLUSION

The integration of an FQHC during urology residency training was associated with highly favorable satisfaction by trainees. Given persistent workforce related shortages in urology, these findings support exposure to medically underserved areas during training.

Racial and Socioeconomic Disparities in Bladder Cancer Survival: Analysis of the California Cancer Registry

PURPOSE

To examine the California Cancer Registry (CCR) for bladder cancer survival disparities based on race, socioeconomic status (SES), and insurance in California patients.

PATIENTS AND METHODS

The CCR was queried for bladder cancer cases in California from 1988 to 2012. The primary outcome was disease-specific survival (DSS), defined as the time interval from date of diagnosis to date of death from bladder cancer. Survival analyses were performed to determine the prognostic significance of racial and socioeconomic factors.

RESULTS

A total of 72,452 cases were included (74.5% men, 25.5% women). The median age was 72 years (range, 18-109 years). The racial distribution among the patients was 81% white, 3.8% black, 8.8% Hispanic, 5.2% Asian, and 1.2% from other races. In black patients, tumors presented more frequently with advanced stage and high grade. Medicaid patients tended to be younger and had more advanced-stage, higher-grade tumors compared to patients with Medicare or managed care (P < .0001). Kaplan-Meier analysis demonstrated significantly poorer 5-year DSS in black, low SES, and Medicaid patients (P < .0001). When controlling for stage, grade, age, and gender, multivariate analysis revealed that black race (DSS hazard ratio = 1.295; 95% confidence interval, 1.212-1.384), low SES (DSS hazard ratio = 1.325; 95% confidence interval, 1.259-1.395), and Medicaid insurance (DSS hazard ratio = 1.349; 95% confidence interval, 1.246-1.460) were independent prognostic factors (P < .0001).

CONCLUSION

An analysis of the CCR demonstrated that black race, low SES, and Medicaid insurance portend poorer DSS. These findings reflect a multifaceted socioeconomic and public health conundrum, and efforts to reduce inequalities should be pursued.

Barriers to obtaining prostate multi-parametric magnetic resonance imaging in African-American men on active surveillance for prostate cancer

Purpose

Magnetic resonance imaging is playing an ever‐bigger role in the management of prostate cancer. This study investigated barriers to obtaining multi‐parametric MRI (mpMRI) in African‐American men on active surveillance for prostate cancer in comparison to white men affected by the same type of cancer.

Materials and Methods

Retrospective review of prostate mpMRI orders from August 2015 to October 2017 at a single health organization treating a diverse population was performed. Data was extracted from the electronic medical records and cancellations were examined based on the documented reason for mpMRI cancellation, race, median zip code household income, and distance from healthcare facility.

Results

Out of 793 prostate mpMRI orders, 201 (25%) went unscanned. Access to care issues accounted for 46% of unscanned orders. Patient cancellations were the most common, followed by difficulty contacting patients, and insurance denials. African‐American patients disproportionately went unscanned because institution staff were unable to contact patients (29% vs 10% in white men, P = 0.0015). Median zip code household income was significantly different between racial groups but did not vary between indication for cancellation.

Conclusions

African‐American prostate cancer patients' access to mpMRI is hindered more by barriers to care than White patients. Urology providers must consider these issues before using prostate mpMRI within their active surveillance pathways.

Systematic Review of Factors Associated with the Utilization of Radical Cystectomy for Bladder Cancer

CONTEXT

Despite established guidelines for the treatment of muscle-invasive bladder cancer, it has been reported that radical cystectomy (RC) is markedly underused, especially among patients of advanced age and those with higher comorbidity burden and lower access to care. Understanding the interactions between patient, provider, and hospital factors may inform targeted interventions to optimize RC utilization.

OBJECTIVE

To systematically review the literature regarding factors associated with RC utilization.

EVIDENCE ACQUISITION

A systematic search was conducted using Ovid and Medline according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2017 reporting on RC utilization. Prospective and retrospective studies were included.

EVIDENCE SYNTHESIS

There are no published randomized control trials on RC utilization. Variations in study quality and design precluded a formal statistical meta-analysis. RC receipt significantly depended on patient, provider, and hospital factors. Patient factors associated with lower RC use included advanced age, African American and Hispanic race/ethnicity, higher comorbidity burden, unmarried marital status, higher tumor stage and grade, and lower socioeconomic status. Provider factors associated with underutilization included lower surgeon volume and a metropolitan location. Finally, hospital factors associated with lower RC use included low hospital volume, nonacademic affiliation, and hospital location in the Midwest.

CONCLUSIONS

RC is reportedly underutilized. We found that age, race, marital status, socioeconomic factors, cancer severity, comorbidity burden, surgeon volume, and facility type and location significantly determined RC receipt. Improved understanding of the varying contributions of the risk factors according to patient, provider, and hospital determinants may assist in developing targeted interventions to improve RC utilization.

PATIENT SUMMARY

In this review we explored the clinical evidence for factors predicting the utilization of radical cystectomy for muscle-invasive bladder cancer. Many factors related to the patient, provider, and hospital determine whether patients receive this guideline-recommended treatment. However, there remains a lack of understanding on characterization and targeted interventions according to these levels, which may improve use.

Survey of Surgical Oncology Fellowship Graduates 2005-2016: Insight into Initial Practice

BACKGROUND

Despite burgeoning interest in Complex General Surgical Oncology (CGSO) fellowship training, little is reported about postgraduate employment. The goal of this study was to characterize CGSO graduates' first employment and to identify factors that influenced this decision.

METHODS

The National Cancer Institute (NCI) and Society of Surgical Oncology developed and distributed an electronic survey to CGSO fellows who graduated from 2005 to 2016.

RESULTS

The survey response rate was 47% (237/509). Fifty-seven percent of respondents were first employed as faculty surgeons at a university-based/affiliated hospital, with 15% returning to their residency institution. The distribution of respondents' current employment across the United States mirrored the locations of their hometowns. Eighty-five percent of respondents care for patients across at least three disease types, most commonly hepatopancreatobiliary (81%), esophagus/gastric (75%), and sarcoma (74%). Twenty-seven percent of respondents spend the majority of their time in one area of surgical oncology; melanoma, breast, and head/neck were the most common. Two-thirds of respondents (67%) reported that they performed either clinical or basic science research as part of their current position. Multiple factors influenced the decision of first faculty position.

CONCLUSIONS

Most CGSO graduates are employed at academic medical centers across the country in proximity to NCI-designated centers, treat a variety of disease types, and spend a percentage of their time dedicated to clinical research.

The Connection Between Testicular Cancer, Minority Males, and Planned Parenthood

Testicular cancer (TCa) is the most prevalent neoplasm diagnosed in males aged 15-40 years. Lack of access to care is a key impediment to early-stage TCa diagnosis. Health equity concerns arise, however, as poor access largely manifests within underserved male populations, therefore, placing them at a higher risk to develop late-stage TCa. Planned Parenthood Federation of America (PPFA) offers a myriad of male reproductive/sexual health care options, including TCa screening and referral services. Therefore, expanding these amenities in traditionally underserved communities may address the concern of TCa screening opportunities. An ecological analysis was performed using data from the United States Cancer Statistics, American Community Survey, and PPFA databases to assess the impact of TCa upon minority males, identify associations between PPFA services and minority males, and provide future implications on the role PPFA may play in bridging health-care access gaps pertaining to TCa screenings. Results indicate that states with higher rates of poverty and uninsured individuals, as well as specifically Black/African American males, have lower TCa incidence and limited access to screening services. PPFA service presence and Black/African American, as well as uninsured, males had a negative association but revealed positive correlations with TCa incidence. Considering the emerging TCa outcome disparities among minority males, expanding PPFA men's health services is crucial in providing affordable options to help identify testicular abnormalities that are early stage or carcinoma in situ. Many at-risk males have limited means to obtain TCa screening services. Expanding this discussion could provide a foundation for future advocacy.

Contextual effects and cancer outcomes in the United States: a systematic review of characteristics in multilevel analyses

PURPOSE

There is increasing call for the utilization of multilevel modeling to explore the relationship between place-based contextual effects and cancer outcomes in the United States. To gain a better understanding of how contextual factors are being considered, we performed a systematic review.

METHODS

We reviewed studies published between January 1, 2002 and December 31, 2016 and assessed the following attributes: (1) contextual considerations such as geographic scale and contextual factors used; (2) methods used to quantify contextual factors; and (3) cancer type and outcomes. We searched PubMed, Scopus, and Web of Science and initially identified 1060 studies. One hundred twenty-two studies remained after exclusions.

RESULTS

Most studies utilized a two-level structure; census tracts were the most commonly used geographic scale. Socioeconomic factors, health care access, racial/ethnic factors, and rural-urban status were the most common contextual factors addressed in multilevel models. Breast and colorectal cancers were the most common cancer types, and screening and staging were the most common outcomes assessed in these studies.

CONCLUSIONS

Opportunities for future research include deriving contextual factors using more rigorous approaches, considering cross-classified structures and cross-level interactions, and using multilevel modeling to explore understudied cancers and outcomes.

Does uneven geographic distribution of urologists effect bladder and prostate cancers mortality? National health insurance data in Korea from 2007-2011

The relationship between distribution of urologists and mortality of bladder and prostate cancers has not been clearly established. The aim of this study was to investigate the relationship between uneven distribution of urologists and urologic cancer specific mortality at country level. Data from the National Health Insurance Service and National Statistical Office in Korea from 2007 to 2011 were analyzed in this ecological study. Univariate and multivariable regression analyses were performed to determine risk factors for age standardized mortality rates (ASMR) of bladder and prostate cancers. Linear regression analysis showed a markedly (p < 0.001) uneven distribution of urologists between metropolitan and non-metropolitan areas. There was no significant difference in cancer specific ASMRs for either bladder cancer or prostate cancer. Univariate analysis after adjusting for time showed that country area, urologist density, and income were significant factors affecting bladder cancer incidence (p < 0.001, p = 0.013, and p < 0.001, respectively). It also showed that the number of training hospitals was a significant factor for prostate cancer incidence (p = 0.002). Although country area showed borderline significance (p = 0.056) for ASMR of bladder cancer, urologist density was not related to ASMR of bladder cancer or prostate cancer. Although there was a marked difference in urologist density between metropolitan and non-metropolitan areas for these years analyzed, mortality rates of bladder and prostate cancers were not significantly affected by country area or urologist density.

Geographical Factors Associated with Health Disparities in Prostate Cancer

Background

Treatment variation in prostate cancer is common, and it is driven by clinical and clinician factors, patient preferences, availability of resources, and access to physicians and treating facilities. Most research on treatment disparities in men with prostate cancer has focused on race and socioeconomic factors. However, the geography of disparities — capturing racial and socioeconomic differences based on where patients live — can provide insight into barriers to care and help identify outlier areas in which access to care, health resources, or both are more pronounced.

Methods

Research regarding treatment patterns and disparities in prostate cancer using the Geographical Information System (GIS) was searched. Studies were limited to English-language articles and research focused on US populations. A total of 43 articles were found; of those, 30 provided information about or used spatial or geographical analyses to assess and describe differences or disparities in prostate cancer and its treatment. Two additional GIS resources were included.

Results

The research on geographical and spatial determinants of prostate cancer disparities was reviewed. We also examined geographical analyses at the state level, focusing on Florida. Overall, we described a geographical framework to disparities that affect men with prostate cancer and reviewed existing published evidence supporting the interplay of geographical factors and disparities in prostate cancer.

Conclusions

Disparities in prostate cancer are common and persistent, and notable differences in treatment are observable across racial and socioeconomic strata. Geographical analysis provides additional information about where disparate groups live and also helps to map access to care. This information can be used by public health officials, health-systems administrators, clinicians, and policymakers to better understand and respond to geographical barriers that contribute to disparities in care.

15 Years of penile cancer management in the United States: An analysis of the use of partial penectomy for localized disease and chemotherapy in the metastatic setting

BACKGROUND

Penile cancer remains a rare disease in the United States, and its understanding may be limited by the uncommon nature of the malignancy. We sought to describe recent penile cancer treatment patterns using the National Cancer Data Base.

METHODS

A retrospective review of data obtained from the National Cancer Data Base from 1998 to 2012 was performed. We obtained demographic information and therapeutic approaches within the following2 clinical scenarios: performance of partial penectomy for early stage disease (clinical Ta-T2) and the use of chemotherapy for metastatic disease. Multivariate logistic analysis was performed.

RESULTS

A total of 2,677 patients presented with early stage penile carcinoma. The proportion receiving partial penectomy increased from 74% in 1998 to 2000 to 80% in 2010 to 2012 (P<0.001). Partial penectomy was more common in the elderly (age>80, odd ratios [OR] = 1.53, 95% CI: 1.05-2.23), young (age<50, OR = 1.46, 95% CI: 1.02-2.07), and in African Americans (OR = 1.45, 95% CI: 1.00-2.12). Increasing tumor size was significantly associated with decreased likelihood of receiving partial penectomy. Of those presenting with metastatic disease (n = 819), use of chemotherapy increased over the time period from 39% receiving chemotherapy in 1998 to 2000 to 49% in 2010 to 2012 (P<0.03). Patients least likely to receive chemotherapy were older and with higher Comorbidity score (both P<0.05), African American (OR = 0.46, 95% CI: 0.30-0.73), and living≥50 miles from the nearest treatment hospital (OR = 0.37, 95% CI: 0.25-0.55).

CONCLUSIONS

Penile-sparing surgery for early stage disease and the use of chemotherapy for metastatic disease are becoming more commonly utilized over the past several years. Further work is needed to define clinical and nonclinical factors associated with the treatment.

Travel Burden and the Direct Medical Costs of Urologic Surgery

Background: Increased surgical volume is associated with better patient outcomes and shorter lengths of hospitalization. As a consequence, traveling to receive care from a high volume provider may be associated with better outcomes. However, travel may also be associated with a decision by the healthcare provider to increase the length of stay due to a decreased ability to return to the primary hospital should complications arise. Thus, research is needed to understand the relationship between the distance a patient must travel and their outcomes following urologic surgery. Objective: The purpose of this study was to determine whether the distance a patient travels to receive urologic surgery is associated with their length of hospital stay and direct medical hospitalization costs. Methods: This was a retrospective observational cohort study of 12 106 patients over 50 years of age undergoing transurethral resection of the prostate (TURP), radical prostatectomy (RP) or radical cystectomy (RC) in Washington State hospitals between 2009 and 2013. Distance traveled was determined by calculating the linear distance between zip code centroids of patient residence and the hospital performing their procedure. Patients were sorted into four groups classified by distance traveled (≤5 miles, 6-20 miles, 21-50 miles and ≥51 miles) and cost calculated using a charges-to-reimbursement ratio for each hospital. Statistical significance was determined using a Kruskal-Wallis test. Results: Patients traveling greater distances had significantly lower median medical costs compared with patients who lived closer to the hospitals where they underwent TURP and RP (TURP: ≤5 miles, $6243 and ≥51 miles, $5105, p≤0.001; RP: ≤5 miles, $12 407 and ≥51 miles, $11 882, p≤0.001), whereas there was no significant difference for patients undergoing RC (≤5 miles, $27 554 and ≥51 miles, $26 761, p=0.17). Likewise, patients traveling greater distances had significantly lower median lengths of hospitalization for TURP and RP (TURP: p≤0.001, RP: p≤0.001), while there was no difference for RC (p=0.50). Conclusions: Patient travel burden does appear to play a role in cost and length of hospital stay for select urologic procedures with variable levels of morbidity and recovery time. Although these findings are statistically significant, the magnitude of the effect is small.

Travel patterns of cancer surgery patients in a regionalized system

BACKGROUND

Regionalization of complex surgeries has increased patient travel distances possibly leaving a substantial burden on those at risk for poorer surgical outcomes. To date, little is known about travel patterns of cancer surgery patients in regionalized settings. To inform this issue, we sought to assess travel patterns of those undergoing a major cancer surgery within a regionalized system.

MATERIALS AND METHODS

We identified 4733 patients who underwent lung, esophageal, gastric, liver, pancreatic, and colorectal resections from 2002-2014 within a multihospital system in the Mid-Atlantic region of the United States. Patient age, race and/or ethnicity, and insurance status were extracted from electronic health records. We used Geographical Information System capabilities in R software to estimate travel distance and map patient addresses based on cancer surgery type and these characteristics. We used visual inspection, analysis of variance, and interaction analyses to assess the distribution of travel distances between patient populations.

RESULTS

A total of 48.2% of patients were non-white, 49.9% were aged >65 y, and 54.9% had private insurance. Increased travel distance was associated with decreasing age and those undergoing pancreatic and esophageal resections. Also, black patients tend to travel shorter distances than other racial and/or ethnic groups.

CONCLUSIONS

These maps offer a preliminary understanding into variations of geospatial travel patterns among patients receiving major cancer surgery in a Mid-Atlantic regionalized setting. Future research should focus on the impact of regionalization on timely delivery of surgical care and other quality metrics.

Low Use of Immediate and Delayed Postoperative Radiation for Prostate Cancer with Adverse Pathological Features

PURPOSE

Level 1 evidence supports immediate radiation in post-prostatectomy patients with adverse pathological features while analogous evidence for delayed radiation is lacking. We evaluated immediate and delayed radiation practice patterns and identified factors affecting their use.

MATERIALS AND METHODS

Using the National Cancer Data Base we identified 57,448 men diagnosed with pT3 disease and/or positive margins from 2004 to 2009. Postoperative radiation use through 2011 was analyzed by time trends and multivariate analysis.

RESULTS

A total of 4,316 men (7.5%) received immediate radiation, 1,637 (2.8%) received delayed radiation and 51,495 (90%) were observed. Immediate and delayed radiation use remained relatively stable except for a small but significant decrease in immediate radiation in 2008. This decrease was associated with a relative increase in delayed radiotherapy. Compared to 2004 men diagnosed in 2007 to 2009 had 1.3-fold to 1.5-fold higher odds of delayed radiation than of immediate radiation (p <0.01). The strongest predictors of immediate radiation were margin status, T stage, N stage, Gleason score and patient age. Men with positive margins, seminal vesicle invasion, nodal disease, or Gleason score 8 or greater and younger men had 2.3-fold to sixfold greater odds of receiving immediate radiation than observation (p <0.01). Men with positive margins, seminal vesicle invasion or nodal metastases were also more likely to receive immediate rather than delayed radiation (p <0.01).

CONCLUSIONS

Post-prostatectomy radiation is performed sparingly. Immediate radiation rates remain low but do not appear to be influenced substantially by delayed radiation use. Consistent with the evidence, patients at high risk for recurrence are more likely to undergo immediate radiation rather than observation or delayed radiation.

Delivering kidney cancer care in rural Central and Southern Illinois: a telemedicine approach

There is a growing body of experience and research suggesting that telemedicine (video conferencing, smart phones and online patient portals) could be the solution to addressing gaps in the provision of specialised healthcare in rural areas. The proposed role of telemedicine in providing needed services in hard to reach areas is not new. The United States Telecommunication Act of 1996 provided the initial traction for telemedicine by removing important economic and legal obstacles regarding the use of technology in healthcare delivery. This initial ruling has been supplemented by the availability of federal funding to support efforts aimed at developing telemedicine in underserved areas. In this paper, we explore one aspect of disease disparity pertinent to rural Illinois (kidney cancer incidence and mortality) and describe how we are planning to use an existing telemedicine program at Southern Illinois University School of Medicine (SIUSOM) to improve kidney cancer (Kca) care in rural Illinois. This represents an example of the possible role of telemedicine in addressing healthcare disparities in rural areas/communities and provides a description of general challenges and barriers to the implementation and maintenance of such systems.