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A Rural Challenge

Nearly 20 percent of Americans live in rural areas, but only 3 percent of oncologists practice in them. Health care providers are establishing rural outposts and using advanced technology to diagnose and treat patients living in the country. By Charlotte Huff
Photos © iStockphoto / Dreamstime / Shutterstock
Photos © iStockphoto / Dreamstime / Shutterstock

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.

 
Maximizing Care Options
Additional legwork can ensure patients in rural areas are getting the best care.
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.

09/26/2016
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