During the On Demand session Panel on Rural Cancer Control, panelists discussed the development of studies and programs to address rural cancer disparities and improve access to cancer prevention and treatment services, as well as policies that target the rural health care safety net to improve outcomes across the cancer continuum.

The panelists will participate in a live Panel Discussion on Thursday, April 15, at 1:30 p.m. EDT. When viewing the On Demand session, viewers can submit their questions in a provided Q&A box. All questions submitted before the live session will reach the panelists.

The changing landscape in rural communities

“For many cancers, we have observed widening rural disparities over time, with access to cancer care limited and, in some cases, declining,” said Jan Eberth, PhD, University of South Carolina. “And this matters for multiple reasons. Obviously, from an equity lens it matters, but it also matters from an outcomes perspective, because patients who live farther from cancer care have been shown to be less likely to receive appropriate diagnosis or treatment and have lower odds of some types of cancer screening.”

Additionally, rural non-white residents are significantly burdened, she said, because they are less likely than the rural white residents in their communities to receive care from NCI-designated centers, and less likely to receive care from specialists.

“When we think about the implications of this from a policy standpoint, there are many different avenues we could go to address this,” Eberth said. “The first is how to incentivize endoscopy specialists to perform colonoscopies in rural areas, even if it’s on a part-time basis, rather than asking those rural residents to come an hour or two away to receive care at an ambulatory surgery center or academic hospital.”

Given the huge influx of ambulatory surgery centers in urban-advantaged markets, Eberth said it’s important to find ways to incentivize the building of freestanding ambulatory surgery centers in rural and less socioeconomically advantaged markets.

“We also need to stop or reverse the loss of rural hospitals and cancer-related service lines,” she said. “There are some ways we can improve on cancer screening, as well. We should consider our options for ‘FIT-to-colonoscopy’ programs, understanding that we really need to balance the benefits of these screenings with the costs and population benefit.”

Participatory implementation science and practice-based research networks

Melinda Davis, PhD, Oregon Health & Science University, discussed the context and factors associated with colorectal cancer (CRC) screening and follow-up rates in rural Oregon.

“Relevant to Oregon, and nationally, is that rural populations experience multiple disparities in relation to income, poverty, education, and employment,” Davis said. “One of the laboratories I work in is the Oregon Rural Practice-based Research Network (ORPRN), and the work we do includes research, technical assistance, and education to help bridge that gap between what we know about research discoveries and what we see in routine practice.”

Among the current ORPRN initiatives, Davis said, is SMARTER CRC, a project that includes a direct mail fecal testing program with targeted outreach and patient navigation for follow-up colonoscopy. The goal of SMARTER CRC is to improve colorectal cancer screening rates, follow-up colonoscopy, and referral to care in rural Medicaid patients.

“We finished the pilot phase last year, which was really focused on adapting our interventions to rural context, so we used a Boot Camp Translation process to make sure that the mailed FIT (fecal immunochemical test) program and the materials were appropriate for our rural stakeholder group,” Davis said. “We’re just getting started moving into the phase II intervention with randomization and then we’ll be moving into the phase III scale-up study in in 2023.”

Improving CRC screening among Alaska Native people

Diana Redwood, PhD, Alaska Native Epidemiology Center discussed ongoing programmatic and research work to improve CRC screening among Alaska Native people.

“Alaska Native people are a diverse people, with different histories, cultures, and activities throughout Alaska,” Redwood said. “But Alaska Native people face a challenge and a burden—the world’s highest reported rate of colorectal cancer; in fact, both incidence and mortality of CRC is twice as high among Alaska Native people compared to U.S. whites. This presents a critical need for increased screening and early detection.”

Redwood said a recently launched randomized controlled trial is designed to test the feasibility of the stool DNA (sDNA) test for screening in rural remote Alaska Native communities.

The study’s basic framework, she said, is a cluster randomized design in which they will recruit tribal health region communities, conduct baseline assessment to figure out who is currently due for screening, and then communities will be randomized into one of three study arms—high intervention, medium intervention, and usual care.

“We’ll be looking at what might be some of the contextual factors, what things we might be able to identify for future intervention, and ways in which we can increase screening in this population,” Redwood said. “Despite our geographic challenges and extreme rural setting, we hope that by expanding outreach programs, working on finding novel and innovative ways to get people screened, as well as understanding more about the underlying cause of colorectal cancer, we will do all we can to ensure that fewer Alaska Native people die from this preventable disease.”

Cancer control research in geographically underserved populations

Shobha Srinivasan, PhD, National Cancer Institute, ended the session with a discussion of the importance of “rethinking our approaches” to clinical trials and study designs that account for the social context and needs of rural and other underserved populations.

“We have to encourage within-subgroup comparisons,” she said. “In the Rural program at NCI, focusing only on rural and not having comparisons to urban areas allows us to focus on the unique structural barriers in rural America.”

Sustaining the work is very important, she said, by building partnerships with communities and organizations to address immediate issues and identify gaps.

“We have the methodological and design tools, but we also have instituted barriers which have to be brought down if we are to meet the goal of the highest level of health for all and realize the hope of health equity,” Srinivasan said.