A new survey of cancer centers across the United States, believed to be the first of its kind, shows where geographical gaps in care exist due to lack of coverage. The study provides insight into why disparities in U.S. cancer care persist in part due to geography. It lends credence to the adage among patient advocates that "where you live affects if you live." Cancer disparities include differing rates in early diagnosis, surgery, and cancer outcome.
The survey study, Assessing the Coverage of U.S. Cancer Center Primary Catchment Areas, was released ahead of publication in the journal Cancer Epidemiology, Biomarkers & Prevention (2022; doi: 10.1158/1055-9965.EPI-21-1097). Overall, the survey shows that, while 85 percent of U.S. counties are covered by a cancer center primary catchment area, fully 15 percent of counties are uncovered-which translates into 25 million Americans who do not live in a catchment area. This lack of cancer center coverage is greatest in very rural areas, especially Appalachia, the Deep South, and Indigenous tribal lands.
The study states that the "most disconcerting finding" is the large number of Americans who live outside of a cancer center primary catchment area. These people are excluded from the attention and resources, including prevention efforts, that cancer centers usually devote to population-level efforts in their catchment areas. Data show that many people in Appalachia and the South tend to be poorly informed about cancer prevention and screening and are less likely to enroll in a clinical trial.
The study concludes that "geographic gaps in cancer center catchment area coverage exist and may be propagating cancer disparities. Efforts to ensure coverage to all Americans should be a priority of cancer center leadership." It added that "findings suggest gaps in cancer center coverage and have the potential to influence policy that distributes resources and care adequately to all."
Study Details
The study was the presidential initiative of Karen E. Knudsen, MBA, PhD, when she was President of the Association of American Cancer Institutes (AACI) and when she served as Director of the Sidney Kimmel Cancer Center (SKCC) at Thomas Jefferson University. Knudsen, who is listed as a co-author, is now CEO of the American Cancer Society and its advocacy affiliate, the American Cancer Society Cancer Action Network. First co-authors of the study are Amy E. Leader, DrPH, MPH, Associate Director for Community Integration at SKCC, and Christopher McNair, PhD, Associate Director for Data Science at SKCC.
The new study surveyed all the 102 members of the AACI to document and map each cancer center's primary population catchment area; there was a 100 percent return rate on survey data. The survey, conducted county by county, analyzed population density, cancer incidence, and cancer mortality compared to each county's cancer center catchment area. "Cancer incidence and mortality, as well as disparities, display strong geographic patterns across the United States," the authors noted.
There is some leeway in how a cancer center defines its catchment area. As the new study describes, it is usually defined as the area where the majority of cancer patients treated by a specific center live, where research participants live, the boundaries of a cancer center's or hospital's marketing approach, or a combination of these factors. Catchment areas are almost always defined using a data-driven approach, and are often guided by a community advisory board.
The new survey results were released against a background of some urgency. The study noted that the first publication on differences in cancer outcomes by race or ethnicity came out nearly 50 years ago, and Black Americans have had the highest overall cancer death rate of any U.S. racial or ethnic group for more than 40 years. During that time, socioeconomic, behavioral, systemic, and environmental factors have emerged as contributors to cancer disparities.
The study authors noted that it is estimated that eliminating socioeconomic disparities could prevent 34 percent of cancer deaths among all American adults between the ages of 25 and 74. In addition to lack of insurance or type of insurance, health risk behaviors, and health literacy, the authors stated that, "more recently, attention has been focused on environmental factors, such as where people live, in identifying root causes of cancer disparities." Thus the geographic environment is "increasingly being recognized as important across the cancer control continuum, including cancer risk, detection, diagnosis, treatment, and survivorship."
The new survey concluded that "these findings provide clear evidence that 'place' is an important factor in cancer risk, outcomes, and disparities." It added that the survey findings can be used to achieve a more equal distribution of cancer center efforts and resources. "From here, we can begin to work towards catchment area equity, where every American is covered by a primary cancer center catchment area, linking all populations to a cancer center home."
A number of cancer groups are focusing on reducing disparities in cancer care. As recently reported by Oncology Times, the Association of Community Cancer Centers, in collaboration with Stand Up to Cancer, hosted a call-to-action virtual summit to address and improve equity in community oncology research (https://bit.ly/3uwnnHn). Some 120 summit attendees from more than 60 organizations participated, including the American Cancer Society, American Society of Clinical Oncology, and FDA. Following the summit, the ACCC released specific action items developed at the summit to provide a foundation for creating systemic change in community oncology research.
Peggy Eastman is a contributing writer.
Achieving Equity in Community Cancer Research
Against a backdrop of challenges posed by the ongoing pandemic, the Association of Community Cancer Centers (ACCC)-in collaboration with Stand Up to Cancer-released a report from a virtual 2-day summit for achieving equity in community oncology research. Read more details at https://bit.ly/3uwnnHn.
Ensuring Equity Among Cancer Centers
The new study, Assessing the Coverage of U.S. Cancer Center Primary Catchment Areas, suggested some specific ways of working toward cancer center "catchment area equity." The research included the following findings.
* Only 22.3 percent of covered counties exhibited balanced cancer center coverage.
* Counties with the highest cancer center coverage scores tended to cluster along the East Coast.
* Half of all counties (51.3%) were covered by a single cancer center.
* While many states had cancer center coverage across all their counties, five states and one U.S. territory were sparsely covered (under 75%): New York, Missouri, Florida, Arizona, Delaware, and Puerto Rico.
* Eight states, mostly rural, were entirely uncovered by a primary cancer center catchment area.
* Some 72 percent of counties that had coverage by AACI cancer centers were undercovered as defined by their cancer incidence overlay scores.
* The concentration of highest age-adjusted incidence in areas without cancer center coverage was seen throughout Maine, parts of the Midwest, and Alaska.
* High cancer mortality rates in uncovered cancer center catchment area counties were identified across Maine, Alaska, and parts of the Rockies.
The study authors suggest some ways of bridging the cancer center geographical divide to achieve equity, including the following initiatives.
* Having cancer centers publicly report their catchment areas, through the National Cancer Institute (NCI) or AACI, would allow for more transparency and "could spur efforts to realign catchment areas." The authors noted that, while NCI-designated cancer centers are required to describe their catchment area and its cancer burden and to engage in community outreach and engagement, non NCI-designated centers do not need to disclose their catchment area. The study stated that each cancer center must continually monitor its catchment area to make sure its research "is driven by the needs and population burden of the catchment area."
* In counties covered by more than one cancer center catchment area, establishing coalitions among cancer centers "to align and synergize efforts" may be appropriate to reach populations in need and make efficient use of resources.
* Overcrowded counties with multiple cancer centers should consider redistributing valuable and expensive cancer resources to help patient populations in more sparsely served areas.
* State comprehensive cancer control coalitions could work with county cancer centers to ensure cancer center catchment area equity across each state.