As a cancer center, we have acknowledged that disparities exist and that work needs to be done. We don’t have the magic answer but are being quite intentional about putting resources toward resolving challenges. That’s an important first step.Sandra L. Wong, MD, MS, FSSO
Fifty years ago, with funds secured by the National Cancer Act of 1971, U.S. Senator Norris Cotton broke ground on the first cancer center to bring the advanced cancer care available in urban areas to New Hampshire. Today, Norris Cotton Cancer Center (NCCC) is the only cancer center in a rural area to earn the National Cancer Institutes (NCI)’s highest designation as a Comprehensive Cancer Center. But this designation is not without unique challenges in need of thoughtful solutions.
Adding rurality to health care disparities
Conversations about disparities in health care are gaining traction. But what does “disparities” mean? “It’s when we see unequal access to screening and care, resulting in differential outcomes,” explains Sandra L. Wong, MD, MS, FSSO, a surgical oncologist at NCCC, chair of the Department of Surgery at Dartmouth-Hitchcock (D-H) and president-elect of the Society of Surgical Oncology.
Often, disparities are boiled down to outcomes, as in who lives versus who dies from cancer. But Wong acknowledges many layers in between. “Screening, timely diagnosis and treatment delivery can be impacted by finances and coverage, travel time and distance, quality and consistency in standard of care, among other factors. We know there’s a lot of variation.”
Wong, together with colleagues from Geisel School of Medicine at Dartmouth and The Dartmouth Institute for Health Policy and Clinical Practice, recently published an editorial about the role of space and place in rural cancer care delivery. They note that while evaluation of cancer care from race and ethnicity to insurance-based and broader socioeconomic inequities is extensive, understanding of how space and place influence care delivery remains strikingly lacking. Data from the National Cancer Database show that rurality is contributing to inequities at multiple points of care delivery; as a result, rates of screening, timely diagnosis and overall survival are lagging.
What is rural?
“Rural” is not just where a patient lives. Within rural populations, measures including local area employment and transportation, poverty, segregation, age, Medicaid expansion and income inequality, to name a few, need to be considered for system-level improvement. Data needs to be both hospital-level and from a larger comprehensive population level. “It’s tempting to ‘bucket’ rurality as one thing when in fact, it’s not appropriate to do so. Rural Mississippi is not the same as rural Massachusetts, nor is it the same as the Native American reservations in New Mexico,” says Wong. In their editorial, the authors conclude that more data is needed on the diversity of rural communities and their respectively unique challenges.
Tailoring the approach
From a surgical perspective, in addition to data, Wong is invested in better coordinating care for patients. “I worry that people who need surgery are not getting it,” she says, noting a gap between the number of cancer diagnoses that likely need some type of surgery and the actual number of surgeries being performed. “We don’t know if the discrepancy is because a patient didn’t get referred for surgery or because they didn’t want surgery. And if they didn’t want surgery, is it because they had a misperception of what surgery meant or because they were truly well informed and still opted out? If we know the reason, we can facilitate a solution.”
Facilitating solutions means tailoring the approach to the need. In northern New England, for instance, transportation is a known problem. Limited availability of cabs and rideshare apps, slippery winter roads, an aging population and not feeling well from cancer treatment all contribute. In addition, cancer care, from lab draws to consultations to treatments to follow-up care, is not a single trip. “Telling people to come and we’ll take care of you is the easiest thing to say but can be the hardest thing to do,” says Wong. “As a cancer center, we have acknowledged that disparities exist and that work needs to be done. We don’t have the magic answer but are being quite intentional about putting resources toward resolving challenges. That’s an important first step.”
Neighbors taking care of neighbors
How is NCCC working to resolve rural disparities? Despite its size and location, or more likely because of them, NCCC ranks 6th in the nation for innovation and entrepreneurship. This level of close-knit, collaborative action stems from researchers who are not just in the community but truly of the community. The challenges they work to resolve every day are for the cancer patients and families they call neighbors. Their efforts include:
NCCC was chosen as a site and awarded a large grant from the NCI called “Creating Access to Targeted Cancer Therapy for Underserved Populations (CATCH-UP).” The grant is aimed at increasing clinical trial awareness and participation for rural patients who make up almost half of the area served by NCCC. Through CATCH-UP, clinical research teams are opening 15 clinical trials across 10 disease types that wouldn’t otherwise be available to patients without driving to a big city.
NCCC’s Community Outreach and Engagement team reaches Vermont and New Hampshire residents through programs that help patients quit using tobacco, educate them about the importance of cancer screenings, improve awareness of cancer research and clinical trials and more. They also actively engage input from cancer survivors, caregivers and community members into NCCC’s cancer research projects.
Nurse Navigators partner with patients to make connections to needed resources and services and overcome barriers that may prevent patients from completing care. Connections may include transportation options, social workers, volunteers, financial resources, lodging coordination and more. Importantly, they also guide patients through their cancer journey, explaining what to expect, educating and answering questions as they come up.
Telehealth has worked so well during the COVID-19 pandemic that it will remain a permanent fixture in the cancer care landscape. “As we emerge from the pandemic, telehealth is really useful to keep us in touch with our rural patients,” says Wong. “Why not also use telehealth to connect physician networks and really partner with our colleagues across health systems and across the urban rural divide to better coordinate patient care?”
Funds raised by NCCC’s own dedicated community are also going right back into the community to reduce disparities, through Prouty Pilot Project grants. For example, Principal Investigators Inas Khayal, PhD, and Amber E. Barnato, MD, MPH, MS, are using Prouty funds to develop images of our health care system that can be used to identify health disparities in end-of-life cancer care. “A method that visualizes health disparities along the care continuum and supports decision making to reduce these disparities can ensure that all patients receive the highest quality cancer care,” says Khayal.
Wong herself shares NCI-funded grants with colleagues to study surgical oncology disparities. “We’re gathering data on Medicare patterns across the country and electronic patient-reported outcomes to learn about variations in rural cancer surgery. If we can identify similarities and differences, then we can really drill down into what we’re doing locally. It feels like slow-going, but we need to do this background work,” says Wong.
Rurality is somewhat new to the study of health care disparities. “It’s time to move on from the acknowledgment phase to the action phase,” says Wong—actions such as the Mobile Lung Cancer Screening Unit, a team of NCCC investigators working on how to help address northern New England’s transportation challenges. “With health systems and policymakers alike focusing on rural disparities, collectively we can move the needle toward more equitable cancer care for all Americans,” says Wong.