A Rural Challenge

SINCE GLORIA ROSALES’ ​double mastectomy in early 2011, she has undergone myriad rounds of chemotherapies and other drug regimens—including Faslodex (fulvestrant) and Afinitor (everolimus)—as her stage IV breast cancer has spread elsewhere in her body, including to her liver and near her lungs.

These days, she makes a 10-minute trip several times a week from her home in Gallup, New Mexico, to a nearby cancer clinic for chemotherapy, lab work or related visits. If the clinic—which opened nearly a decade ago in the community of 20,000—weren’t available, Rosales would be forced to drive four hours round trip to Albuquerque. In good weather, the long trip would be difficult, but during snowstorms, her route on Interstate 40 could be impassable.

“In the winter, forget it,” the 67-year-old says. “I don’t think I would have even gone in the winter because the roads are so bad.”

While nearly one in five Americans live in rural areas, just 3 percent of oncologists have their practices in them, according to an analysis published in 2014. Seventy percent of U.S. counties don’t have any oncologists. The situation isn’t likely to improve in the short term as rural cancer practices cope with the escalating costs of technology and drugs, says medical oncologist Praveen Vikas, who treats patients in Fairfield, Iowa, and published a 2015 journal article about the challenges of rural cancer care. “So a lot of those small, stand-alone cancer clinics that have served rural America, they have been dying, they are closing their practices,” he says.

Vikas is among the physicians and hospital leaders attempting to fill gaps in the cancer treatment landscape. One solution is to convince cancer specialists to periodically visit rural communities that can’t support a local oncologist. Leaders at Childress Regional Medical Center in West Texas, working with an academic medical center more than two hours away, used that approach to open the doors to local chemotherapy treatment three years ago. Other physicians are harnessing the potential of technology to bring their expertise closer to far-flung doctors and patients.

Does Geography Influence Treatment?

To what extent does geography affect care? One difficulty for researchers trying to analyze the situation is that no single definition exists for what constitutes a rural rather than an urban region. Plus, some patients who live in rural areas seek out cancer care in the nearest big city, even if a closer option exists. That makes comparisons more difficult, Vikas says.

Nevertheless, a patient’s decision about whether to get radiation is likely to depend on travel distance, according to a 2013 overview of rural care in the journal Cancer Epidemiology, Biomarkers & Prevention, published by the American Association for Cancer Research. That’s not surprising given that radiation treatments are often needed daily for several weeks or longer. The authors cited several studies showing that women with breast cancer living in a rural region are more likely to opt for a mastectomy rather than a lumpectomy. Extended radiation treatments—often daily for six weeks—are recommended for most patients following a lumpectomy.

Barbara McAneny, chief executive officer of the New Mexico Cancer Center in Albuquerque, doesn’t need studies and data to know location matters. McAneny, a hematologist-oncologist, hears it from her patients. “If you tell a woman that she’s going to have to travel every day for six to seven weeks, she’s got a kid in school, she’s got a job. She can’t do that.”

McAneny says the cancer center’s nonprofit foundation covered hotel costs for patients from the Gallup area who couldn’t afford to stay in Albuquerque for a month or longer to get radiation or other frequent treatments. Still, patients had to adjust to new quarters, unfamiliar food and missed loved ones, all while experiencing the side effects of cancer drugs or radiation. In some cases, McAneny says, “patients, after being away from home for three or four weeks, would say, ‘Forget it. I’m going home. If I die, I die.’ ” In 2007, the physician-owned practice operating the cancer center opened the Gallup clinic that Rosales visits, offering chemotherapy and radiation to area residents, including those living in the nearby Navajo Nation.

Bridging Rural Gaps

Until recently, patients in Childress, Texas, were shuttling more than 100 miles in any direction for cancer care—to Lubbock or Amarillo or Wichita Falls, according to John Henderson, chief executive officer of the 39-bed Childress Regional Medical Center. At least 65 patients were diagnosed with cancer in 2012, the year before the medical 
center’s chemotherapy clinic opened.

Since 2013, the Childress hospital has provided chemotherapy on-site—primarily for common cancers like breast, colon and lung—through a partnership with Texas Tech University Health Sciences Center in Lubbock, about 150 miles from Childress. A federal drug discount program allows the hospital to purchase cancer drugs at a reduced cost, says Henderson.

Every four to five weeks, medical oncologist Fred Hardwicke of Texas Tech gets behind the wheel of his car around 6 a.m. to make the more than two-hour drive from Lubbock to Childress to visit his patients in the community of roughly 6,000. Kathy Ivy, an oncology nurse based at Childress, coordinates patient care between his visits. Some days it can be foggy or stormy, says Hardwicke. “I’ve developed an appreciation of what some of my patients have to go through in order to see me [in Lubbock],” he says.

Research in Iowa, a state with large rural areas, illustrates how oncologists visiting outlying communities even a few days a month can significantly ease access to cancer care. One analysis determined that, after factoring in the presence of visiting oncologists, the median travel time for patients to the nearest cancer treatment site fell from nearly 52 minutes to 19 minutes.

Improving rural access to radiation, though, has proved to be a trickier problem. Forty-four percent of health services areas in the U.S. lacked any radiation oncologists based there as of 2007, according to study results published in 2012. Upfront costs of establishing a radiation facility, including investing in high-tech equipment, make it difficult to open a site where the number of potential patients is low, says radiation oncologist James Yu of Yale School of Medicine in New Haven, Connecticut, who co-authored the study.

Among other challenges: The equipment is typically not mobile, and its technical complexity means that—unlike the route Childress is taking—primary care doctors and nurse practitioners are unlikely to step in to help with radiation in rural areas.

Virtual Care

Even if an oncologist practices in a remote area, there may be a lack of other specialists available locally, particularly for more complex or rarer malignancies, says surgical oncologist Daniel Anaya, who heads the section of hepatobiliary tumors at Moffitt Cancer Center in Tampa, Florida. “That may result in people getting substandard treatment,” he says.

Anaya, a liver cancer specialist who worked previously at Houston’s Michael E. DeBakey Veterans Affairs (VA) Medical Center, launched a virtual tumor board in 2011 that helped link the Houston VA medical center with nine other VA medical centers in the southern region of the U.S. More than 50 percent of veterans served by the VA in that region live in rural communities.

Using a video connection, a doctor in one of the other VA locations can get feedback on a patient’s case when the tumor board gathers in Houston. The doctor at the outlying facility is told before the meeting what information to provide, Anaya says, “so all the decisions can be made in that one stop.”

In a study that reviewed care for 116 liver cancer patients who were referred from one of those nine VA medical centers to the Houston VA, Anaya and other researchers discovered that patients were more likely to get their treatment plan evaluated by a multidisciplinary team of doctors through the virtual tumor board than if they traveled to the Houston center. Patients who got the virtual tumor board evaluation also completed the process much sooner, requiring a median of 23 days from the time of referral to 39 days for those who traveled to a facility.

Another use of technology is to to update cancer doctors practicing far from urban areas on the latest advances in diagnosis and treatment. Many rural oncologists “don’t have up-to-date knowledge on every cancer,” since they might see some malignancies infrequently, says gastroenterologist Sanjeev Arora of the University of New Mexico School of Medicine in Albuquerque. “But they are still treating, because there are no liver oncologists there or there are no pulmonary oncologists there.”

Arora directs Project ECHO (Extension for Community Healthcare Outcomes), an initiative based at the University of New Mexico that uses teleconferenced clinics to educate clinicians in rural or underserved areas of the U.S. or elsewhere in the world. Doctors seeking more expertise in a specific clinical area can connect with specialists at a Project ECHO clinic via teleconferencing as patient cases are discussed. Arora, who says Project ECHO offers expertise for more than 40 diseases and medical conditions in the U.S. and other countries, is eager to start connecting with rural U.S.-based oncologists within the next year.

Reaching Out to Patients

While video technology can help with physician education or virtual tumor board consults, McAneny of the New Mexico Cancer Center says she prefers personal contact when caring for her patients. “I really need to examine patients,” she says. “And sometimes I just need to hold their hand.”

The medical oncologists at the New Mexico Cancer Center make a commitment to travel around the state four days a month. The practice also has a clinic in Silver City, a community of 10,000 in remote southwestern New Mexico.

Fred Hardwicke, the medical oncologist from Texas Tech who treats patients at Childress Regional Medical Center, says he is confident in the ability of oncology nurse Kathy Ivy to assess patients between his visits there, and he listens closely to her feedback if she worries whether a particular patient is strong enough for the next chemotherapy session.

Cecil Truelock has had more than 50 chemotherapy and immunotherapy treatments at Childress under the care of Hardwicke and Ivy since he was diagnosed in 2013 with non–small cell lung cancer. Surgery was attempted but stopped on Truelock because of worries about the strain on his cardiovascular system, says Hardwicke. Nor did radiation help after he made the trips to Lubbock, says Truelock, age 83.

Since late 2013, Truelock has undergone several types of chemotherapy. After the cancer continued to progress, he received an immunotherapy drug, Opdivo (nivolumab), which enables his immune system to attack the disease. His cancer, now stage IV, is stable, Hardwicke says.

The oncologist says he wonders if Truelock would have consented to trying so many different cancer drugs if he had to travel more than four hours round trip for each treatment. “It very well may be that he may have quit altogether a good while back if he did not have ready access locally,” Hardwicke says.

Instead, Truelock relishes having more time to spend with his wife and pursuing his hobbies—metalworking, woodworking and as much fishing as he can fit in.

“They are doing OK there at Childress as far as I know,” he quips. “I’m still alive.”

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