Improving Cancer Control in Rural Communities: Next Steps

July 7, 2017, by Robert T. Croyle, Ph.D.

The decrease in cancer death rates in the United States has been uplifting news for the nation and a great source of hope for the cancer research community. A point of frustration, however, has been the continued ethnic/racial and socioeconomic disparities in cancer outcomes.

Two new studies are putting a spotlight on disparities that have received less attention: those in rural communities across the country. The studies—one by NCI researchers (on which I’m a coauthor) and one led by researchers from the Centers for Disease Control and Prevention (CDC)—found that cancer death rates are higher in rural areas than in urban areas. The CDC study also showed that, although cancer deaths rates are decreasing in rural areas, they are doing so more slowly than they are in urban areas.

Rural health disparities are not a new issue for NCI. In an interview for Cancer Currents last yearCancer Currents, in fact, I discussed cancer disparities in rural communities across the country, and some of our early efforts toward revisiting this long-standing public health challenge.

What I did not and could not predict at the time, however, was the impact the recent presidential election would have on the visibility of rural America in the national debate about our economy, the future of the middle class, and the role of poverty and geography in access to quality health care.

Cancer in Rural America: An Ongoing Dialogue

The cancer community has long been part of this dialogue. In the early 1990s, for instance, NCI funded the Central Highlands Appalachian Leadership Initiative on Cancer, which focused not on a minority group, as traditionally defined, but on a mostly white rural population in one of the poorest regions of the country.

NCI-funded researchers in Kentucky, Ohio, and West Virginia, among others states, have continued this long tradition of attention to cancer control in Appalachia, with signature efforts in cancer surveillance, colorectal cancer screening, and more recently, HPV vaccination.

The increased attention toward rural health has been driven not only by politics but also by important advances in population health research. For example, the availability of more granular data—the result of improved surveillance of both diseases and risk factors—has allowed scientists to describe disease patterns in regions of the United States at a more localized level.

Also, more sophisticated analyses of disease trends and patterns have stimulated research in a variety of disciplines—including health policy, environmental epidemiology, and medical sociology.

Finally, as the new studies discussed above demonstrate, the publication and dissemination of compelling work in health geography by investigators in both academia (e.g., the University of Wisconsin’s County Health Rankings and Roadmaps) and government (e.g., the CDC’s MMWR Rural Health Series) have engaged both scholars and policy makers through effective data visualizations, such as maps, that powerfully highlight the stark differences in disease trends between urban and rural areas. This type of work has further stimulated discussion and the need for research to explain the factors that contribute to these trends.

These discussions are important, because much of this research has revealed a situation in rural America that is not only worrisome but, unfortunately, getting worse. As researchers from the University of Washington reported recently, for example, geographic disparities in life expectancy among US counties are large and increasing.

The rapid growth of geospatial data utilization in many areas of health research was the impetus for NCI’s first national conference on its use in cancer research. Exemplars of this work were published in April 2017 in Cancer Epidemiology, Biomarkers and Prevention.

Reaching Out to the Community

To inform NCI’s efforts to better address cancer disparities in rural communities, NCI has been busy consulting a wide variety of experts and analyzing the research evidence on rural cancer control.

These efforts will dovetail with work on rural health already underway by other federal agencies, including the Health Resources and Services Administration’s Federal Office of Rural Health Policy, the Centers for Medicare and Medicaid Services’ (CMS) Rural Health Council, and the CDC’s recently launched rural health initiative.

CDC, in particular, will be a key partner as we scale up NCI’s research efforts. Our two agencies already have several ongoing collaborative initiatives that can be leveraged, including the Cancer Prevention and Control Research Network, which includes eight centers funded through CDC’s Prevention Research Centers program.

Recently, I joined colleagues from CDC, CMS, the Veterans Health Administration, and 10 other agencies at the 5th Annual Public–Private Collaborations in Rural Health Meeting in Washington, DC. Participants discussed challenges in many areas—including health reform (especially Medicaid), rural hospital closures, and the hollowing out of local public health infrastructure—and shared lessons learned from a wide variety of research projects and programs.

An important conclusion that emerged from this meeting is that NCI can respond to the needs of government agencies and nonprofit partners working on rural health by supporting implementation science that informs the allocation of precious resources at the local level.

For instance, during this meeting, telehealth was often cited as a tool that can help to solve some of these disparities. Unfortunately, the evidence base on how best to scale-up and implement telehealth solutions is incomplete.

Clearly, we and our colleagues in the cancer community need to make better use of the wealth of experience and knowledge within these organizations, and we plan to do just that.

Critical Role of NCI-Designated Cancer Centers

NCI-Designated Cancer Centers can play a larger role in rural cancer control, and some centers already are.

NCI requires each NCI-Designated Cancer Center to define its catchment areas—in other words, the characteristics of the population in the geographic area it serves—and describe how the center extends its reach within and beyond that area to bring its expertise to bear on more diverse, wider populations.

To incentivize cancer center engagement in population health and facilitate adherence to NCI’s catchment area characterization requirements, we provided supplemental funding to 15 cancer centers to collect additional data concerning their catchment area population and align local measures with national ones, enabling more direct comparisons across centers and with national surveillance data.

In addition, to advance rural health research methods, we are also working with the National Academies of Science, Engineering, and Medicine to conduct research in small population groups.

Tackling Challenges

Although there are numerous challenges to making progress in this area, some that seem to be surprisingly simple are far from it.

For example, one of the biggest disconnects that remains between science and policy discussions around rural health is the idea that “rural” populations are often only thought to include whites. The data clearly demonstrate, however, that some of the most severely disadvantaged and unhealthy people in America are people of color in rural areas.

A recent analysis of counties served by rural health clinics, in fact, found that in the southeastern United States, 23% of the rural population is African American. The same counties had the lowest per capita number of primary care physicians of any region in the country. As Mara Casey Tieken, Ed.D., the author of Why Rural Schools Matter, recently wrote, this narrow definition of rural is not only wrong, but has important repercussions.

“In defining rural white America as rural America, academics and lawmakers are perpetuating an incomplete and simplistic story about the many people who make up rural America and what they want and need,” Dr. Tieken explained.

Sadly, many of today’s research questions in rural health appear to have changed very little from those that were being asked more than two decades ago.

Given our modest progress in answering these questions, I believe the time is right for NCI to convene the cancer research community around the status, challenges, and opportunities in cancer control in rural communities. The planning for this meeting, scheduled for May 2018, has already begun.

In the meantime, NCI will continue to work with the cancer community and others to refine and reinvigorate our cancer control efforts in rural areas across the country.