Breaking rural barriers to early lung cancer screening

Rian Hasson with patient

Rural populations, which make up almost half of the patients cared for by Dartmouth Cancer Center's Norris Cotton Care Pavilion at Dartmouth Hitchcock Medical Center (NCCC Pavilion), face health disadvantages compared to urban areas. Among them: easy access to life-saving cancer screening programs.

As a first step to improving access, a team of researchers from Dartmouth Cancer Center’s Comprehensive Thoracic Oncology Program recently published a study in the Journal of Rural Health on rural barriers to screening, particularly for early lung cancer. Their findings pinpointed these factors:

Access: “Urban dwellers have academic medical centers in the heart of town that they can get to fairly easily, but rural populations often have a distance barrier,” according to Rian M. Hasson, MD, a thoracic surgeon at the NCCC Pavilion and lead author.

Healthcare maintenance is also not as current in rural areas. Rural populations generally fall behind in screening procedures. Delayed screening can lead to a later diagnosis that requires more complex care, and the frequency of care poses the same access challenges.

“If you're traveling 50 miles for every doctor's appointment, and you have radiation therapy 5 days a week for 5 weeks straight, commuting can be overwhelming,” Hasson said. “Especially if you don't have the social support or resources to help get you to those appointments.”

Education: In rural areas, general education and medical literacy levels tend to be lower. During her team’s research, Hasson said, “We asked focus groups in New Hampshire and Vermont to give us their thoughts on lung cancer and other screenings.” They understood that breast and colorectal cancer screening needed to be done yearly. But they thought lung and other screenings should be done after symptoms present, which actually defeats the purpose of the screening.”

The study revealed some participants’ assumptions that a clean lung cancer screening meant tobacco users didn’t have to quit smoking. New Hampshire’s lung cancer incidence and mortality rate may be connected to a larger population that uses tobacco. Eighty percent of lung cancers are thought to be directly caused by tobacco use. Research shows marijuana use can lead to tobacco use or to vaping, which can also cause lung injury.

“There definitely needs to be education on updated criteria for lung cancer screening specifically and the many benefits of quitting tobacco and other substances,” Hasson said.  

A need for screening centers: Hasson’s study suggests screening centers should be placed in areas of lower education and higher cancer incidence rates. In towns known to have high rates of smoking and tobacco use, there should be a focus on “provider buy-in.”  

“This is where the providers come into play,” said Hasson. “Most patients will be more likely to get screened if their provider encourages it. But if you already have a lower education level, and your provider is not talking about screening, and you're far away from an accredited center, then you're less likely to get screened.”

Other focus areas: improving insurance reimbursement rates, standardizing screening scoring mechanisms, helping providers interpret the results and determining next steps.

Tools to act: One of Hasson’s projects is getting mobile CT lung cancer screening units into areas that don't have screening programs. “Mobile units have been helpful with breast and cervical cancer screening. A town in North Carolina piloted a program through private funding to have low-dose lung cancer screening for patients who don't have insurance, and it worked out very well. I think we could use that model to help reach patients in New Hampshire and Vermont.”

Hasson’s team also has survey efforts underway for patients and providers to gather specifics to the barriers in play for lung cancer screening. Survey results may shed light on why patients do or don’t get screened—and why providers do or don’t recommend screening.

At the NCCC Pavilion, a Pulmonary Nodule Clinic opened to help primary care providers if screening scans need follow-up. It takes the burden off the providers’ shoulders to have them simply refer patients to the clinic.

A call to action

Lung cancer screening saves lives. “I encourage my medical colleagues to educate themselves about screening,” Hasson said. “There's already so much you do to help keep our patients alive and healthy. This is an opportunity to participate in something that has been shown over and over again to save lives.

“Lung cancer is treatable and potentially curable,” she added, “but we have to catch it early.”

Hasson encourages patients to ask their providers about screening and not to be afraid of what comes along with that. “We will help you along the way, and this is something that could save your life.”