The National Comprehensive Cancer Network (NCCN) held a policy summit at the National Press Club in Washington, DC, to shine a spotlight on how the places where cancer patients live can adversely affect their diagnosis, treatment, and outcomes. Rural areas are especially susceptible to being places of "high-risk geography."
To bridge geographical gaps in care, speakers at the policy summit stressed a number of strategies. These include establishing trust with patients, cultural sensitivity, partnerships between major medical centers and community cancer centers, legislation, reaching patients where they are (such as with mobile screening vans), help with transportation, community engagement, use of telehealth, and favorable reimbursement.
In his welcome message, Robert W. Carlson, MD, NCCN Chief Executive Officer, emphasized that "where you live should not impact whether you live." Carlson said the NCCN is dedicated to ensuring every cancer patient, no matter his or her geographical place of residence, receives guideline-directed care. He said NCCN's free guidelines can serve as "guardrails to standardize treatment."
Carlson is very familiar with the impact of living in geographically underserved regions on cancer care. He served as Co-Chair of a National Academy of Medicine (NAM) workshop on cancer care in low-resource areas and the organization released a report on workshop findings in 2017. That report contained suggestions on interventions for cancer patients in low-resource areas.
People who live far away from medical centers in counties with few health care providers have "poor aggregate health outcomes," said Elisa Rodriguez, PhD, MS, Vice President and Associate Director of Diversity, Equity, and Inclusion (DEI) at Roswell Park Comprehensive Cancer Center, in a keynote address.
Many of these people have lower educational levels, inadequate employment, higher rates of underinsurance or no insurance, and limited transportation services, said Rodriguez, who is also Director of Community Engagement Resource for Roswell Park and a member of the NCCN DEI Directors Forum. She noted some patients in rural areas suffer from social stigma and opiate addiction, which she called "diseases of despair," and stressed the need to take the time to build relationships based on trust with them.
Rodriguez emphasized the need for major centers like Roswell Park to serve as a model for enhancing their infrastructure and developing "effective strategies to address the cancer burden, including access to care for all patients." She cited the organization's diverse community advisory board, which has a say in the center's strategic priorities; a new lung cancer screening mobile truck, which takes screening to the people; and the Roswell Cares program, which helps neighbors in need.
Rodriguez also cited a new research project to implement HPV vaccination in rural areas in partnership with rural community-based pediatric and family medicine practitioners. "This is a vaccination study," Rodriguez said, and given the recent misinformation on vaccines and some well-publicized public hesitancy, the partnership is essential. "If you can't recruit the practices, you can't do the work," she said.
Agreeing on the need to go to the people was panelist Waleed Mourad, MD, Professor of Radiation Oncology and Medical Director of Morehead Cancer Center at the University of Kentucky, which also has a mobile van.
"If patients can't come, we will go to them as much as possible," he noted, emphasizing the need to be sensitive and build trust with patients in poverty, who are often illiterate and suffer from "cancer phobia"-fear that leads them to come in at late stages, often in pain and with severe bleeding. Mourad, an international head and neck specialist and the radiation oncology physician founder of sub-Saharan Cameroon Oncology Center, said he tries to convert patients' cancer phobia into the idea that cancer can be diagnosed early and treated.
In a second keynote address, Congressman Brian Higgins (D-NY) examined use of the policy landscape to improve cancer care for people in geographically underserved regions. He cited major treatment advances, such as immunotherapy, but stressed that much more needs to be done to prevent cancer.
"Early detection is our best protection against cancer of all types, but many Americans, especially those living in underserved communities, lack access to regular screenings, which puts them at a greater risk," said Higgins, who is Co-Chair of the Cancer Caucus in the U.S. House of Representatives.
In December 2022, Higgins co-introduced the Increasing Access to Lung Cancer Screening Act (H.R. 9336) with his colleague Congresswoman Kathy Castor (D-FL). This bill would increase lung cancer screening rates across the U.S. and reduce barriers to care and preventive services in underserved communities.
Specifically, the bill would amend the Social Security Act to require all state Medicaid programs to cover lung cancer screening for eligible enrollees. It would also expand coverage under Medicaid for counseling and medication-assisted treatment for tobacco cessation for all enrollees without the need for prior authorization. Additionally, the bill would prohibit both public and private insurers from subjecting annual lung cancer screenings to prior authorization.
"Cancer exacts-both morally and financially-a huge price on our society," Higgins stated. He said passage of this bill would not only improve survival through early detection, but would also save money. He stressed the need for advocacy on behalf of patients and encouraged summit attendees to speak up for policies to benefit cancer patients.
Respecting cultural values is essential when serving patients in geographically underserved communities, said panelist Keith Argenbright, MD, Director of the Moncrief Cancer Institute and Professor at the University of Texas Southwestern Harold C. Simmons Comprehensive Cancer Center. He noted that people in rural communities feel comfortable with those they know, and may be leery of city health care providers.
"We respect the standard of care in a rural community," Argenbright noted. "We try to educate but we never impose." He said his cancer center sends experts out to the community to meet with local physicians for educational sessions over lunch.
Collaboration between major medical centers and local health care providers can help bridge gaps in providing specialized care in underserved areas, agreed panelist Ursa Brown-Glaberman, MD, Associate Professor of Hematology/Oncology and Medical Director of Clinical Research at the University of New Mexico Comprehensive Cancer Center. She said her cancer center is using Project Echo (Extension for Community Healthcare Outcomes) to mentor community oncologists. It was founded to meet the needs of individuals in underserved areas using video conferencing and telementoring. It is a collaborative model of medical education and care management that helps clinicians provide expert-level, specialized care wherever they live.
Speakers agreed that one good thing to come from the COVID-19 pandemic was the massive explosion in telehealth. But even with the expansion of remote clinical trial monitoring, rural patients who manage to make it to a major medical center are much less likely to sign up for a clinical trial, said panelist Mary Charlton, PhD, Associate Professor in the Department of Epidemiology at the University of Iowa and Director of the Iowa Cancer Registry. She noted that even with remote monitoring, communication with the trial site is still essential, and a large number of rural patients prefer to receive cancer care locally.
"In order to provide quality cancer care across varying locales, we must develop a multi-faceted, collaborative cancer network approach that extends the resources and expertise from larger cancer centers out to rural hospitals and providers," she said. "This must be done in a way that capitalizes on everyone's strengths while fostering trust and engagement between providers."
Ultimately, bridging geographical gaps to improve cancer outcomes boils down to going where the people are and letting them know that you care, said panelist Alma McCormick, BS, Executive Director of Messengers for Health, Crow Nation, and member of the Advisory Panel on Patient Engagement for the Patient-Centered Outcomes Research Institute (PCORI). "Do what you say you are going to do," McCormick noted. "It's passion from the heart."
Peggy Eastman is a contributing writer.