Rural comprehensive cancer care: A qualitative analysis of current challenges and limitations.
Authors: Engelbart Jacklyn M , Evans Sydney , Gao Xiang , Schroeder Mary Chen , Hrabe Jennifer , Averill Sarah , Phadke Sneha Deepak , Lizarraga Ingrid , Vikas Praveen , Charlton Mary E. 
Published: June 2021

e18538 Background: Providing comprehensive and coordinated cancer care in rural settings can be difficult due to limited resources. Meeting cancer care standards established by the American Society of Clinical Oncology Quality Oncology Practice Initiative or the American College of Surgeons Commission on Cancer is also challenging due to limited resources; the vast majority of certified or accredited practices/hospitals are in metropolitan areas. It is critical to describe barriers faced by rural providers so models can be developed to facilitate high quality cancer care. Qualitative interviews were conducted to elicit current challenges and barriers among rural Iowa cancer care providers, with the goal of identifying strategies that could facilitate high quality cancer care in rural areas. Methods: Eleven cancer providers associated with 10 (out of 12) Iowa hospitals that diagnose or treat > 100 cancer patients annually and are in non-metropolitan/rural counties (Rural-Urban Continuum Code: 4-9) were interviewed via telephone or video conference. Questions focused on services offered, perceived patient- and system-level barriers to cancer care, perceived strengths and challenges in providing and assessing quality cancer care, challenges to meeting standards of cancer care set forth by national organizations, and referral experiences. Results: The major identified strength of rural hospitals was their geographic proximity to rural patients. Most hospitals provided outpatient chemotherapy, and a minority provide radiation oncology services. Common reasons for referral outside rural hospital networks were lack of specialized diagnostic procedures and complex surgical resections more commonly available at tertiary institutions. Other reasons for referrals include 1) lack of advanced technologies and treatments; 2) lack of certification secondary to inadequate staffing to support data infrastructure for quality improvement or to meet accreditation standards of national organizations; and 3) lack of ancillary patient services such as navigation, survivorship programs, genetic counseling, and education. A final important cause of referral is limited access to clinical trials, an impediment to rural patient participation in investigational treatments. Identified benefits of strengthening collaborations with larger urban/academic cancer centers were access to educational opportunities, tumor boards, shared resources and strategies for data management, clinical trials, patient navigation services and survivorship programs. Conclusions: Rural cancer care providers identified a number of challenges that could be addressed through resource sharing from larger cancer centers. Further research is needed to develop models and approaches that extend resources, services and expertise to rural providers to facilitate high-quality cancer care for all rural patients.