Improving Cancer Control in Rural Communities: An Interview with Dr. Robert Croyle
May 18, 2016, by NCI Staff
Researchers from several NCI-Designated Cancer Centers and NCI Community Oncology Research Program (NCORP) sites that serve rural parts of the United States recently met with NCI leaders to discuss the disparities in cancer outcomes in many rural areas of the country. The meeting was part of NCI’s efforts to prioritize its research activities to improve cancer control in rural areas.
In this interview, Robert Croyle, Ph.D., director of NCI’s Division of Cancer Control and Population Sciences, discusses some of the issues faced by rural communities and how NCI is approaching this important problem.
How does living in a rural area affect issues like cancer prevention, treatment, and survivorship care?
It’s clear that there is a lot of geographic variation in cancer risk factors, incidence, and mortality. People who live in rural areas often face significant health care access challenges, including fewer physicians, long distances to facilities, and limited transportation options. In some rural areas, we also see high rates of tobacco use, poverty, poor health literacy, and drug and alcohol abuse.
All of these challenges can contribute to higher incidence of certain cancers in rural areas, and worse outcomes.
For example, in the Appalachian region of Ohio—where access to primary care, let alone oncology care, is limited, and you have high rates of poverty and obesity, among other problems—the incidence rates of colorectal, lung, and cervical cancers are substantially higher than they are in wealthier and more populated areas of the state. Similar types of geographic disparities are commonly seen in states like Utah, Montana, and Kansas.
So it’s clear that where a person lives has an important influence on their health through a variety of mechanisms.
So living in a rural part of the country should be part of the health disparities conversation?
I think it’s clear that when we talk about health disparities, the geographic variation in cancer outcomes, as well as the diverse populations within rural areas, should be included in that discussion.
In many regions of the United States, for instance, you can’t talk about rural cancer control without addressing the cancer disparities seen in American Indian populations. These populations have specific needs and issues, and they can be especially challenging. We’re very mindful of that, and we want to ensure that as we strengthen our efforts in rural cancer control the needs of American Indians are front and center.
Is there a growing recognition of the disparities in cancer outcomes in rural areas of the United States?
The disparities are not new, but there is definitely more cross talk among the scientific disciplines that touch on issues related to geography and health.
From a research perspective, the problem is complex and large in scope. So the main challenge facing NCI is identifying where, as a research agency, we can have the biggest impact in addressing this significant problem.
A number of federal agencies and state and local health departments have key roles as well, and we recognize that the nonprofit sector has played an essential role for many years. What we’re trying to do is engage local investigators and community leaders to get a better sense of where problems exist and where additional evidence is needed to inform action at the local level.
Are there examples of cancer control success stories in rural areas that could serve as a model for other areas to follow?
There are a number of success stories. One good example is telehealth, which can facilitate health care in all kinds in communities and is being actively used by several cancer centers for everything from cancer screening to survivorship care.
A rate-limiting step of telehealth, however, is a lack of access to broadband internet in many parts of the country. That’s been discussed this year by the President’s Cancer Panel, and I would guess that the panel’s next report will address some of those issues.
Another federal agency with a key role in rural cancer control is the Federal Communications Commission. It has a program called Universal Service that supports expanding access to communication services across the country, including broadband services. Dissemination of and access to the communication technology infrastructure clearly is a key to improving rural cancer control and public health.
Broadband access and affordability aren’t NCI’s responsibilities, of course, but we can support research on how to use these technologies to promote improved cancer prevention and care.
Are there opportunities in rural cancer control where you think NCI can play a prominent role?
There are several. One is supporting implementation science. This includes research that demonstrates how to effectively incorporate proven cancer control interventions in a coordinated way into broader health programs that are designed to reach rural populations. In this way, we can take advantage of the infrastructure that’s been developed for primary care or other health domains.
We’re also very interested in learning how we can work more with NCI-Designated Cancer Centers and NCORP sites to build on their experiences with community outreach and developing partnerships with local organizations.
Over the last several years, we haven’t made as much progress in building up the kind of research portfolio in rural health and rural cancer control as we would like. The same areas that lack health care access tend to also lack a real research infrastructure, so we’re especially interested in learning from those investigators who have been able to conduct cancer research successfully in these really challenging environments.
Is studying cancer control in rural areas different from biomedical research? Do you often need “boots on the ground,” so to speak?
Yes. For years, we’ve been hearing from many investigators about the importance of involving members of the community in the conduct of research projects.
Another issue is incentivizing our research community to invest the time and effort into the trust building that is required to do this type of research. It can take many years, in some cases, to build relationships with local communities, especially those with low health literacy or a good bit of mistrust of the medical and science communities.
NCI’s Community Networks Program Centers have supported this kind of work in many parts of the country, but there still are a lot of people we haven’t reached.
What are NCI’s top priorities when it comes to improving rural cancer control?
One thing that’s clear is that there’s no one-size-fits-all solution. We’re looking to develop research initiatives that allow local customization and adaptation. We’re also especially interested in developing research activities that can facilitate programs that are sustainable and can be expanded and scaled up to have a bigger downstream effect on population health.
A good example is some of the success we’ve seen with state and community tobacco control initiatives. While many initiatives aren’t focused specifically on rural populations, they provide good examples of how we can partner with local organizations to increase the sustainable impact of NCI-funded research.
Another highly relevant effort in this regard is the addition of cancer care delivery research to NCORP, which will allow us to have a broader perspective on understanding the many ways that people “fall through the cracks” across the whole cancer control continuum.
The Comprehensive Cancer Control National Partnership includes many of the key players addressing these challenging issues. NCI wants to engage more academic investigators to collaborate with these community partners to develop more effective cancer control strategies. State and local policy makers need actionable, relevant evidence to guide their decision making on cancer control efforts in their communities. For them, a peer-reviewed journal publication is only the first step, not the last.