Rural cancer patients’ treatment lacking

Bill Knight column for Mon., Tues. or Wed., July 22, 23 or 24

Despite skilled health providers, rural residents who get cancer may get treatment that’s not as good as urban patients get, their choices may be limited, and their subsequent health may not be as good – all because hospitals aren’t as well-equipped and there aren’t enough doctors.

That’s according to a few new studies – and help is not on the way since fewer physicians are choosing to practice in rural communities.

First, rural women with breast cancer are less likely than their urban counterparts to get recommended radiation therapy after a lumpectomy (a breast-sparing surgery that removes only tumors and surrounding tissue), a study by Mayo Clinic and others found. The difference is one of several rural disparities in breast cancer diagnosis and treatment the researchers discovered, such as rural women being more likely to choose mastectomy – the complete removal of the breast – instead of lumpectomy.

About 66 million Americans live in rural areas or urban neighborhoods that have too few primary-care physicians or access to primary care. That’s about one in five Americans who lack adequate access to this kind of care.

“These study results are concerning,” said Elizabeth Habermann, Ph.D., associate scientific director, Surgical Outcomes, Mayo Clinic Center for the Science of Health Care Delivery. “All women should receive guideline-recommended cancer care, regardless of where they live.

“The lumpectomy findings are worrisome because lack of follow-up radiation therapy could lead to recurrence, another surgery, and another time period of concern for the woman and her family,” she added.

Elsewhere, a study from Health Services Research found that delays in starting chemotherapy or radiation after breast-cancer surgery aren’t uncommon for rural patients (and African Americans, too). Such delays have been more prevalent since 2004 despite increased attention to disparities in medical resources, said researchers, who added that intervention is needed at resource-poor hospitals because they still don’t have the treatment advantages that high-volume cancer centers offer.

After treatment, rural cancer survivors aren’t as healthy as their urban counterparts, according to new research from Wake Forest Baptist Medical Center, which found that many rural cancer survivors still smoke, engage in little physical activity, and are in generally poorer health than city dwellers – maybe because they’re not told about how important such changes can be.

“It is concerning that we found higher rates of health-compromising behaviors among rural survivors, when we know cancer survivors who smoke, are overweight, or are inactive are at higher risk for poor outcomes, including cancer recurrence and second cancers,” said Kathryn E. Weaver, Ph.D., assistant professor of social sciences and health policy at Wake Forest Baptist.

“We need to pay particular attention to this group of cancer survivors who we already know have worse outcomes,” she continued. “Our findings suggest that health behaviors may very well play a role in that. So we need to make sure rural survivors receive information about how to improve their health after cancer and think about interventions such as home-based exercise programs or smoking-cessation programs … accessible regardless of where survivors live.”

Finally, rural areas are not getting the physicians they need, according to a study by researchers at the George Washington University School of Public Health and Health Services, which suggest the nation’s output of primary-care physicians falls short of the demonstrated need and won’t be able to solve the growing shortage in underserved areas anytime soon.

The graduate medical education system (GME) in the United States relies on public funding, including nearly $10 billion in funds from the Medicare program and another $3 billion from Medicaid. Despite the large infusion of tax money, experts say that the federal government doesn’t hold residency programs accountable for producing physicians trained to serve in rural or other underserved parts of the country. Although Medicare and Medicaid represent the largest public investment in the U.S. health workforce, there are still serious shortfalls in the number of primary-care physicians in some geographical regions and in other high-need specialties, such as general surgery.

The researchers found that 198 out of 759 institutions graduating medical residents between 2006 and 2008 produced no rural physicians at all.

“If residency programs do not ramp up the training of these physicians, the shortage in primary care, especially in remote areas, will get worse,” said lead study author Candice Chen, M.D., MPH, an assistant research professor of health policy at George Washington University. “The study’s findings raise questions about whether federally funded graduate medical education institutions are meeting the nation’s need for more primary care physicians.”

There’s a growing disconnect between federal funding to pay for medical residency programs and the nation’s shortage of primary-care doctors, this study showed.

Meanwhile, rural patients wait, and cope with overworked medical providers working with inferior resources.

[PICTURED: Kaiser Family Foundation's map of medically underserved areas as of 2008, showing Illinois as one of the 14 worst states.]