Cancer treatment for rural and remote patients

About a third of Australians live in rural, regional, and remote areas of the country, for example outside metropolitan centres. People in these communities can have additional challenges with cancer care, such as having to travel for tests or treatment. For some people, this can cause financial and emotional stress. In addition, rural cancer patients have unique needs that should be recognised, so treatment may need to be adjusted in comparison to those living in big cities.

Dr Kate Gunn of the University of South Australia, Department of Rural Health, presented at the ANZUP Annual Scientific Meeting in July and provided an important insight into what should be kept in mind when working with, or undertaking research with rural people affected by cancer. Dr Gunn’s main research interests include addressing the psychosocial needs of rural people affected by cancer, rural help-seeking behaviour and online and telephone-based cancer support interventions. “I grew up on a sheep, wheat and barley property in South Australia, 650 kilometres from Adelaide,” says Kate. “From that community I watched people struggle with the challenges a diagnosis of cancer brings, particularly when it is accompanied by isolation and the need to travel for medical treatment”.

DR KATE GUNN

https://www.adelaide.edu.au/lumen/issues/66602/ news66742.html

Dr Gunn explained the concerns of cancer treatment for a patient based in a metropolitan setting versus a rural patient are very different. The rural patient has additional burdens as outlined in the table below.

Concerns of the metropolitan versus rural cancer patient

Metropolitan cancer patient Rural cancer patient

• Treatment is tiring

• Side effects are unpleasant • Treatment is extra complicated due to being several hours from home and the support of family, friends, and support networks

• Parking is difficult

• Information provided is overwhelming

• Fear of cancer recurrence • Self employed so have no sick leave

• Worries if a neighbour or wife/partner can manage the livestock or property

• Living away from home is expensive, lonely, and stressful

There are many reasons why rural cancer patients must travel for treatment. This can include:

• the closest town does not have the type of cancer specialists needed

• the type of treatment required (surgery, radiation therapy or chemotherapy) is not available near by

• if a rare cancer is diagnosed, or a cancer requires complex treatment, then certain hospitals will be recommended.

People living with cancer in regional and rural areas also have poorer survival rates than those living in major cities, and the further from a major city cancer patients live, they are 35% more likely to die within five years of diagnosis.

Contributing factors which lead to lower survival rates for people with cancer in rural areas include:

• less availability of diagnostic and treatment services; • later diagnosis; • lower socioeconomic status; • reduced rates of physical activity; • increased rates of highrisk alcohol consumption; • higher rates of smoking; • the higher proportion of Aboriginal and Torres Strait

Islander people; and • increased sun exposure.

In addition, throughout her research, Dr Gunn found that rural cancer patients experience various key differences to urban based patients including:

• Poorer treatment outcomes • Staff in small rural hospitals know their patients. The anonymity of large urban hospitals is overwhelming, impersonal, distressing, and difficult to navigate.

• Additional stressors, e.g., travel and financial burdens

• Later diagnosis – possibly due to access or the use of screening services • Differences in treatment type – possibly to minimise the amount of time a rural patient spends away from home • The further a patient lives from radiation therapy treatment, the less likely they are to receive it • There is a higher incidence of some cancers in rural areas, particularly bowel, prostate, melanoma, cervical, lung and cancer of an unknown primary. This may be due to lifestyle factors, increased sun exposure and elevated rates of smoking • In many areas of regional and rural Australia there are a lack of general practitioners, allied healthcare professionals and support services, clinical trialists and specialists with knowledge for follow-up • The cost of accessing essential services is greater in the rural setting • There are attitudinal barriers, such as stoicism and privacy, influence accessing of services

What can be done to reduce the gap in the diagnosis and treatment of rural cancer patients?

A patient’s preference to be treated close to their home and family should not compromise access to highquality care. In addition to providing better services in larger regional centres there is a need to utilise new technologies such as tele-oncology to enable improved access without compromising quality of care. The travel and accommodation schemes for cancer patients and their families in each state and territory are complex and unsatisfactory. Reform is required to provide better assistance to cancer patients.

The burden of cancer in Australia is increasing as our population ages and there is evidence that people in rural and remote areas will continue to bear an unequal part of this burden. Addressing current shortcomings in rural and regional cancer services is vital to improving survival and outcomes for country people.

Urban-based healthcare professionals can improve the experience of a rural cancer patient by acknowledging:

• Being away from family, friends and support networks during treatment adds to levels of distress.

• The patient has travelled a long distance so help make the patient feel understood.

• Travelling is tiring and difficult so have appointments scheduled together and do not change appointments at the last minute.

• It is helpful to find ways to have tests and data collection done closer to home and offer telehealth if it is possible.

• Rural people find it difficult to ask for and/or accept help, especially to deal with emotional issues, so if making a referral or recommendation, point out that it is what most people in their situation do, i.e., normalise help-seeking.

Rural cancer patients and carers cancer treatment experiences can be made easier by improving health systems and coordination to ease the burden of travel, providing information about available support and what to expect throughout cancer treatment that is relevant to the rural context, and increasing access to quality health, community, and support services, including palliative care, in rural areas. More training on the specific needs of rural patients and their carers is needed for urban healthcare professionals. Peer support groups may have value for cancer carers in rural settings, where there are known to be multiple barriers to accessing professional sources of psychosocial support.

Rural cancer patients want their unique needs to be recognised and to be treated differently to their urban counterparts. There is a need for more targeted and rurally relevant information for rural cancer patients, both to inform them of, and change their attitudes towards diagnosis, treatment, and supportive care.