Rural residence is related to shorter survival in epithelial ovarian cancer patients

Rural-urban disparities in psychosocial functioning in epithelial ovarian cancer patients

OBJECTIVE

Although rural residence has been related to health disparities in cancer patients, little is known about how rural residence impacts mental health and quality of life (QOL) in ovarian cancer patients over time. This prospective longitudinal study investigated mental health and QOL of ovarian cancer patients in the first-year post-diagnosis.

METHOD

Women with suspected ovarian cancer completed psychosocial surveys pre-surgery, at 6 months and one-year; clinical data were obtained from medical records. Histologically confirmed high grade epithelial ovarian cancer patients were eligible. Rural/urban residence was categorized from patient counties using the USDA Rural-Urban Continuum Codes. Linear mixed effects models examined differences in psychosocial measures over time, adjusting for covariates.

RESULTS

Although disparities were not observed at study entry for any psychosocial variable (all p-values >0.22), urban patients showed greater improvement in total distress over the year following diagnosis than rural patients (p = 0.025) and were significantly less distressed at one year (p = 0.03). Urban patients had a more consistent QOL improvement than their rural counterparts (p = 0.006). There were no differences in the course of depressive symptoms over the year (p = 0.17). Social support of urban patients at 12 months was significantly higher than that of rural patients (p = 0.04).

CONCLUSION

Rural patients reported less improvement in psychological functioning in the year following diagnosis than their urban counterparts. Clinicians should be aware of rurality as a potential risk factor for ongoing distress. Future studies should examine causes of these health disparities and potential long-term inequities and develop interventions to address these issues.

Role of neighborhood context in ovarian cancer survival disparities: current research and future directions

Ovarian cancer is the fifth leading cause of cancer-associated mortality among US women with survival disparities seen across race, ethnicity, and socioeconomic status, even after accounting for histology, stage, treatment, and other clinical factors. Neighborhood context can play an important role in ovarian cancer survival, and, to the extent to which minority racial and ethnic groups and populations of lower socioeconomic status are more likely to be segregated into neighborhoods with lower quality social, built, and physical environment, these contextual factors may be a critical component of ovarian cancer survival disparities. Understanding factors associated with ovarian cancer outcome disparities will allow clinicians to identify patients at risk for worse outcomes and point to measures, such as social support programs or transportation aid, that can help to ameliorate such disparities. However, research on the impact of neighborhood contextual factors in ovarian cancer survival and in disparities in ovarian cancer survival is limited. This commentary focuses on the following neighborhood contextual domains: structural and institutional context, social context, physical context represented by environmental exposures, built environment, rurality, and healthcare access. The research conducted to date is presented and clinical implications and recommendations for future interventions and studies to address disparities in ovarian cancer outcomes are proposed.

A Survey of Cancer Risk Behaviors, Beliefs, and Social Drivers of Health in New Hampshire and Vermont

Compared with urban areas, rural areas have higher cancer mortality and have experienced substantially smaller declines in cancer incidence in recent years. In a New Hampshire (NH) and Vermont (VT) survey, we explored the roles of rurality and educational attainment on cancer risk behaviors, beliefs, and other social drivers of health. In February-March 2022, two survey panels in NH and VT were sent an online questionnaire. Responses were analyzed by rurality and educational attainment. Respondents (N = 1,717, 22%) mostly lived in rural areas (55%); 45% of rural and 25% of urban residents had high school education or less and this difference was statistically significant. After adjustment for rurality, lower educational attainment was associated with smoking, difficulty paying for basic necessities, greater financial difficulty during the COVID-19 pandemic, struggling to pay for gas (P < 0.01), fatalistic attitudes toward cancer prevention, and susceptibility to information overload about cancer prevention. Among the 33% of respondents who delayed getting medical care in the past year, this was more often due to lack of transportation in those with lower educational attainment (21% vs. 3%, P = 0.02 adjusted for rurality) and more often due to concerns about catching COVID-19 among urban than rural residents (52% vs. 21%; P < 0.001 adjusted for education). In conclusion, in NH/VT, smoking, financial hardship, and beliefs about cancer prevention are independently associated with lower educational attainment but not rural residence. These findings have implications for the design of interventions to address cancer risk in rural areas.

Significance

In NH and VT, the finding that some associations between cancer risk factors and rural residence are more closely tied to educational attainment than rurality suggest that the design of interventions to address cancer risk should take educational attainment into account.

Preventive behaviors and behavioral risk factors among gynecologic cancer survivors: Results from the 2020 Behavioral Risk Factor Surveillance System Survey

BACKGROUND

Maintaining a healthy lifestyle is an important factor in promoting positive outcomes for gynecologic cancer survivors.

METHODS

We examined preventive behaviors among gynecologic cancer survivors (n = 1824) and persons without a history of cancer in a cross-sectional analysis, using data from the 2020 Behavioral Risk Factor Surveillance System survey (BRFSS). BRFSS is a cross-sectional telephone-based survey of U.S. residents 18 years of age and older, which collects information about health-related factors and use of preventive services.

RESULTS

The prevalence rates of colorectal cancer screening were respectively 7.9 (95% CI: 4.0-11.9) and 15.0 (95% CI: 4.0-11.9) %-points higher among gynecologic and other cancer survivors compared to that of 65.2% among those without any history of cancer. However, no differences were observed in breast cancer screening between gynecologic cancer survivors (78.5%) and respondents without any history of cancer (78.7%). Coverage of influenza vaccination among gynecologic cancer survivors were 4.0 (95% CI: 0.3-7.6) %-points higher than that of the no cancer group, but 11.6 (95% CI: 7.6-15.6) %-points lower than that of the other cancer group. Pneumonia vaccination rate among gynecologic cancer survivors, however, was not statistically different than that of other cancer survivors and respondents with no history of cancer. When examining modifiable risk behaviors, the prevalence of smoking among gynecologic cancer survivors was 12.8 (95% CI: 9.5-16.0) and 14.2 (95% CI: 10.8-17.7) %-points higher than smoking prevalence among other cancer survivors and respondents without any history of cancer. The rate differentials were even higher in rural areas, 17.4 (95% CI: 7.2-27.6) and 18.4 (95% CI: 7.4-29.4) %-points respectively. There were no differences in the prevalence of heavy drinking across the groups. Lastly, gynecologic and other cancer survivors were less likely to be physically active (Δ = -12.3, 95% CI: -15.8 to -8.8 and Δ = -6.9, 95% CI: -8.5 to -5.3, respectively) than those without any history of cancer.

CONCLUSION

Smoking prevalence among gynecologic cancer survivors is alarmingly high. Intervention studies are needed to identify effective ways to assist gynecologic cancer survivors to quit smoking and refrain from hazardous alcohol consumption. In addition, women with gynecologic malignancies should made aware of the importance of physical activity.

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.

Healthcare Access Domains Mediate Racial Disparities in Ovarian Cancer Treatment Quality in a US Patient Cohort: A Structural Equation Modelling Analysis

BACKGROUND

Ovarian cancer survival disparities have persisted for decades, driven by lack of access to quality treatment. We conducted structural equation modeling (SEM) to define latent variables representing three healthcare access (HCA) domains: affordability, availability, and accessibility, and evaluated the direct and indirect associations between race and ovarian cancer treatment mediated through the HCA domains.

METHODS

Patients with ovarian cancer ages 65 years or older diagnosed between 2008 and 2015 were identified from the SEER-Medicare dataset. Generalized SEM was used to estimate latent variables representing HCA domains by race in relation to two measures of ovarian cancer-treatment quality: gynecologic oncology consultation and receipt of any ovarian cancer surgery.

RESULTS

A total of 8,987 patients with ovarian cancer were included in the analysis; 7% were Black. The affordability [Ω: 0.876; average variance extracted (AVE) = 0.689], availability (Ω: 0.848; AVE = 0.636), and accessibility (Ω: 0.798; AVE = 0.634) latent variables showed high composite reliability in SEM analysis. Black patients had lower affordability and availability, but higher accessibility compared with non-Black patients. In fully adjusted models, there was no direct effect observed between Black race to receipt of surgery [β: -0.044; 95% confidence interval (CI), -0.264 to 0.149]; however, there was an inverse total effect (β: -0.243; 95% CI, -0.079 to -0.011) that was driven by HCA affordability (β: -0.025; 95% CI, -0.036 to -0.013), as well as pathways that included availability and consultation with a gynecologist oncologist.

CONCLUSIONS

Racial differences in ovarian cancer treatment appear to be driven by latent variables representing healthcare affordability, availability, and accessibility.

IMPACT

Strategies to mitigate disparities in multiple HCA domains will be transformative in advancing equity in cancer treatment.

Community access to primary care is an important geographic disparity among ovarian cancer patients undergoing cytoreductive surgery

Objective

Given the importance of understanding neighborhood context and geographic access to care on individual health outcomes, we sought to investigate the association of community primary care (PC) access on postoperative outcomes and survival in ovarian cancer patients.

Methods

This was a retrospective cohort study of Stage III-IV ovarian cancer patients who underwent surgery at a single academic, tertiary care hospital between 2012 and 2015. PC access was determined using a Health Resources and Services Administration designation. Outcomes included 30-day surgical and medical complications, extended hospital stay, ICU admission, hospital readmission, progression-free and overall survival. Descriptive statistics and chi-squared analyses were used to analyze differences between patients from PC-shortage vs not PC-shortage areas.

Results

Among 217 ovarian cancer patients, 54.4 % lived in PC-shortage areas. They were more likely to have Medicaid or no insurance and live in rural areas with higher poverty rates, significantly further from the treating cancer center and its affiliated hospital. Nevertheless, 49.2 % of patients from PC-shortage areas lived in urban communities. Residing in a PC-shortage area was not associated with increased surgical or medical complications, ICU admission, or hospital readmission, but was linked to more frequent prolonged hospitalization (26.3 % vs 14.1 %, p = 0.04). PC-shortage did not impact progression-free or overall survival.

Conclusions

Patients from PC-shortage areas may require longer inpatient perioperative care in order to achieve the same 30-day postoperative outcomes as patients who live in non-PC shortage areas. Community access to PC is a critical factor to better understanding and reducing disparities among ovarian cancer patients.

Cancer disparities in the context of rurality: risk factors and screening across various U.S. rural classification codes

PURPOSE

Prior cancer research is limited by inconsistencies in defining rurality. The purpose of this study was to describe the prevalence of cancer risk factors and cancer screening behaviors across various county-based rural classification codes, including measures reflecting a continuum, to inform our understanding of cancer disparities according to the extent of rurality.

METHODS

Using an ecological cross-sectional design, we examined differences in cancer risk factors and cancer screening behaviors from the Behavioral Risk Factor Surveillance System and National Health Interview Survey (2008-2013) across rural counties and between rural and urban counties using four rural-urban classification codes for counties and county-equivalents in 2013: U.S. Office of Management and Budget, National Center for Health Statistics, USDA Economic Research Service's rural-urban continuum codes, and Urban Influence Codes.

RESULTS

Although a rural-to-urban gradient was not consistently evident across all classification codes, the prevalence of smoking, obesity, physical inactivity, and binge alcohol use increased (all p_trend < 0.03), while colorectal, cervical and breast cancer screening decreased (all p_trend < 0.001) with increasing rurality. Differences in the prevalence of risk factors and screening behaviors across rural areas were greater than differences between rural and urban counties for obesity (2.4% vs. 1.5%), physical activity (2.9% vs. 2.5%), binge alcohol use (3.4% vs. 0.4%), cervical cancer screening (6.8% vs. 4.0%), and colorectal cancer screening (4.4% vs. 3.8%).

CONCLUSIONS

Rural cancer disparities persist across multiple rural-urban classification codes, with marked variation in cancer risk factors and screening evident within rural regions. Focusing only on a rural-urban dichotomy may not sufficiently capture subpopulations of rural residents at greater risk for cancer and cancer-related mortality.

Rural-Urban Disparities in Cancer Outcomes: Opportunities for Future Research

Cancer care disparities among rural populations are increasingly documented and may be worsening, likely because of the impact of rurality on access to state-of-the-art cancer prevention, diagnosis, and treatment services, as well as higher rates of risk factors such as smoking and obesity. In 2018, the American Society of Clinical Oncology undertook an initiative to understand and address factors contributing to rural cancer care disparities. A key pillar of this initiative was to identify knowledge gaps and promote the research needed to understand the magnitude of difference in outcomes in rural vs nonrural settings, the drivers of those differences, and interventions to address them. The purpose of this review is to describe continued knowledge gaps and areas of priority research to address them. We conducted a comprehensive literature review by searching the PubMed (Medline), Embase, Web of Science, and Cochrane Library databases for studies published in English between 1971 and 2021 and restricted to primary reports from populations in the United States and abstracted data to synthesize current evidence and identify continued gaps in knowledge. Our review identified continuing gaps in the literature regarding the underlying causes of rural-urban disparities in cancer outcomes. Rapid advances in cancer care will worsen existing disparities in outcomes for rural patients without directed effort to understand and address barriers to high-quality care in these areas. Research should be prioritized to address ongoing knowledge gaps about the drivers of rurality-based disparities and preventative and corrective interventions.

Understanding the Experience of Canadian Women Living with Ovarian Cancer through the Every Woman StudyTM

The Every Woman StudyTM: Canadian Edition is the most comprehensive study to date exploring patient-reported experiences of ovarian cancer (OC) on a national scale. An online survey conducted in Fall 2020 included individuals diagnosed with OC in Canada, reporting responses from 557 women from 11 Canadian provinces/territories. Median age at diagnosis was 54 (11−80), 61% were diagnosed between 2016−2020, 59% were stage III/IV and all subtypes of OC were represented. Overall, 23% had a family history of OC, 75% had genetic testing and 19% reported having a BRCA1/2 mutation. Most (87%) had symptoms prior to diagnosis. A timely diagnosis of OC (≤3 months from first presentation with symptoms) was predicted by age (>50) or abdominal pain/persistent bloating as the primary symptom. Predictors of an acute diagnosis (<1 month) included region, ER/urgent care doctor as first healthcare provider or stage III/IV disease. Regional differences in genetic testing, treatments and clinical trial participation were also noted. Respondents cited substantial physical, emotional, practical and financial impacts of an OC diagnosis. Our national survey has revealed differences in the pathway to diagnosis and post-diagnostic care among Canadian women with OC, with region, initial healthcare provider, specific symptoms and age playing key roles. We have identified many opportunities to improve both clinical and supportive care of OC patients across the country.

Reoperation Rates of Stress Incontinence Surgery in Rural versus Urban Hospitals

BACKGROUND

OBJECTIVE

STUDY DESIGN

RESULTS

CONCLUSION

Disparity of ovarian cancer survival between urban and rural settings

Objective

To determine if there is a difference in overall survival of patients with epithelial ovarian cancer in rural, urban, and metropolitan settings in the United States.

Methods

We performed a retrospective cohort study using 2004–2016 National Cancer Database (NCDB) data including high and low grade, stage I-IV disease. Bivariate analyses used Student’s t-test for continuous variables and χ² test for dichotomous variables. Kaplan-Meier curves estimated survival of patients based on location of residence, and univariate analyses using Cox proportional HR assessed survival based on baseline characteristics. Multivariate analysis was performed to account for significant covariates. Propensity score matching was used to validate the multivariate survival model. For all tests, p<0.05 was considered statistically significant.

Results

A total of 111 627 patients were included with a mean age of 62.5 years for metroolitan (range 18–90), 64.0 years for rural (range 19–90) and 63.2 years for urban areas (range 18–90). Of all patients included, 94 290 were in a metropolitan area (counties >1 million population or 50 000–999 999), 15 386 were in an urban area (population of 10 000–49 999), and 1951 were in a rural area (non-metropolitan/non-core population). Univariate Cox proportional hazards models showed clinically significant differences in survival in patients from metropolitan, urban, and rural areas. Multivariate Cox proportional hazards models showed a clinically significant increase in HRs for patients in rural settings (HR 1.17; 95% CI 1.06 to 1.29). Increasing age and stage, non-insured status, non-white race, and comorbidity were also significant for poorer survival.

Conclusion

Patients with ovarian cancer who live in rural settings with small populations and greater distance to tertiary care centers have poorer survival. These differences hold after controlling for stage, age, and other significant risk factors related to poorer outcomes. To improve clinical outcomes, we need further studies to identify which of these factors are actionable.

Succinct Cancer Clinical Trial Consent Forms in Rural Patients With Cancer: A Secondary Analysis of a Randomized, Double-Blinded study

Rural patients are often underrepresented in cancer clinical trials. This is a secondary analysis of a study that tested short (2000 word) versus long (6000 word) consent forms with a focus on rurality. Among 240 patients, 89 (37%) were rural. Seventy-one (80%) rural and 117 (77%) nonrural patients signed a consent form of any length (P = .68). Forty-one of 47 (87%) rural patients signed a short consent form; in contrast, 30 of 42 (71%) signed a long form. These trends suggest rural patients are more likely to sign short consent forms. Further study is indicated.