HRQOL Disparities Identified in Older Patients Living in Rural Communities

Jennifer Moss, PhD

Based on findings from over 200,000 patients who survived either breast cancer, colorectal cancer, lung cancer, or prostate cancer, older patients living in rural communities have poorer health-related quality-of-life (HRQOL) compared with those in urban communities.

Generally, in the older cancer survivor population, health-related quality-of-life (HRQOL) outcomes are impaired. Factors like treatment, the presence of comorbidities, and social issues impact HRQOL of the older population, according to investigators led by Jennifer Moss, PhD.

“Something we see across the board in rural communities is that there just aren't enough providers around to meet the needs of older adults, particularly older adults with cancer or older cancer survivors. The formal healthcare infrastructure in rural communities tends to be underdeveloped,” said Jennifer Moss, PhD, assistant professor in the Department of Family and Community Medicine and Department of Public Health Sciences at Penn State Cancer Institute, in an interview with Targeted Oncology™.

According to findings, the mean score for physical HRQOL was 38.7 in urban communities vs 37.9 in rural communities. Low vitality was seen in rural cancer survivors who had colorectal cancer compared with urban survivors (P =.05). Rural cancer survivors had worse social functioning compared with the urban community (P =.05). More physical role limitation (P <.01) and emotional role limitation (P <.01) was observed in older patients in rural communities vs urban. There was also a worse global mental component summary (P =.02).

In the interview, Jennifer Moss, MD, discussed HRQOL in older rural vs urban patients with cancer and survivor. She also explained factors contributing to the disparity and how to improve outcomes for the population.

TARGETED ONCOLOGY: What factors impact health-related quality-of-life in older patients with cancer?

Moss: There are a lot of factors. Number one is being able to access good quality health care. If a patient has a tumor, can it be detected and diagnosed in a timely manner, and can they get good access to high quality treatment are important factors. After treatment, quality-of-life is related to the supportive environment. That's going to include family members, friends, the community, as well as the health care system. Being sure that there are good places to walk and engage in physical activity that are close and accessible, or that patients have a supportive social network are important.

Can you discuss community cancer care in rural communities? What are the biggest challenges?

Something we see across the board in rural communities is that there aren't enough providers around to meet the needs of older adults, particularly older adults with cancer or older cancer survivors. The formal healthcare infrastructure in rural communities tends to be underdeveloped. In certain locations, we do see more social cohesion and social support that can help to make sure older adults with cancer integrated and part of the community. That’s crucial for quality-of-life and for survivorship.

In rural communities, people have to wait longer for appointments that can be scheduled further out, and they have to drive further to see a provider. Sometimes that carries with it a lot of questions. Can the patient drive themselves? Do they need someone to come with them? Will they need a procedure at the appointment? Do they need someone to drive them home, and are they going to need to take off work? Not having easy access to providers is difficult clinically as well as socially for older adults in rural communities.

What does access to clinical trials look like for patients with cancer living in rural communities?

Access to clinical trials is also more difficult for people in rural communities. We know that if rural patients are enrolled in clinical trials, the differences that we see in their cancer outcomes disappear. Making sure that rural patients are well-represented in clinical trials is good for science as well as good for patient outcomes. The more we can do to engender trust from rural patients and other underserved patients and make it as easy as possible for them to participate in clinical trials, that's going to benefit everyone.

Can you explain how this study the registry study was conducted?

The data focuses on quality-of-life, so, they're not necessarily all the same people. There are several people who are in the SEER district and SEER states who have also enrolled in Medicare and completed 1 of these surveys. What we were able to do was link the responses from survey with the cancer data in SEER. We looked at these patients from across the US, including older adults who had completed the survey, and we assessed their quality-of-life after a cancer diagnosis.

We had all the clinical information and demographic information from the SEER dataset, and their quality-of-life data. When we had all of that together, we were able to look at rural urban differences in quality-of-life. We have these good measures of a lot of different dimensions of quality-of-life like social, psychological, physical. We wanted to see if there's any difference for older adults who have had cancer who are living in rural communities versus urban communities. We see pretty striking differences like lower quality-of-life for folks in those rural communities.

Can you explain the findings of your study?

One thing we focused on was older adults who had been diagnosed with breast cancer, colorectal cancer, lung cancer, or prostate cancer. These are the 4 most common cancer types in the US.

What we saw is that, in general, for different cancers, we saw different outcomes. Generally, quality-of-life was higher for people in urban environments rather than rural environments, particularly for lung and prostate cancers. Then, when we compare them also to folks who never had cancer, their quality-of-life is markedly lower.

The rural cancer survivors had poorer quality-of-life than urban cancer survivors and rural and urban noncancer survivors. For lung and prostate cancer in particular, these lung cancers are very aggressive types of cancer, and treatment causes a lot of toxicity. As you might expect, we see a lot of poor physical quality-of-life associated with lung cancer. For prostate cancer we used more of the social quality-of-life metrics, because I think prostate cancer carries with it a lot of stigma. Also, the treatment can cause symptoms such as incontinence and impotence, so the consequences of treatment can cause a lot of social issues resulting in poor quality-of-life.

Again, we gathered data on different dimensions of quality-of-life. What we saw is that, in general, for different cancers, we saw different outcomes. Generally, quality-of-life was higher for people in urban environment. rather than rural environments, particularly for lung and prostate cancers, so these are and then when we compare them also to folks who never had cancer, their quality-of-life, as you might expect is markedly lower. The rural cancer survivors had poorer quality-of-life than urban cancer survivors and rural and urban noncancer survivors. For lung and prostate cancer, these lung cancers are a very aggressive type of cancer, and treatment causes a lot of side effects and toxicity.

As you might expect, we see a lot of poor physical quality-of-life associated with lung cancer. For prostate cancer it was more than the social quality-of-life metrics. I think prostate cancer carries with it a lot of stigma around the cancer itself and the treatment, which can cause symptoms such as incontinence and impotence. Socially, those prostate cancer and the consequences of treatment can cause a lot of social issues resulting in poor quality-of-life.

What are your recommendations for the community oncologists treating patients in rural communities, based on your research?

One of the recommendations would be the importance of clinical trials. We must get people enrolled in clinical trials, so they can potentially be a part of cutting-edge treatment research. Number 2 is to work with patients to make sure that they have a supportive social network behind them, such as access to family and friends, religious communities, and community organizations that are going to come alongside them during and after treatment. This is where online support groups are also helpful. Some rural communities have challenges with internet access, but it's usually pretty good to be able to access online support groups.

We also must make sure we’re treating the whole patient and not just their cancer. Oncologists should talk to their patients about physical activity, diet, and trying to link them to the extent possible with ancillary clinical services, such as, mental health and social work.

How do you think real-world research should approach measuring HRQOL in patient with cancer going forward?

I think we have good measures of health-related quality-of-life. I would encourage researchers to use these well-established metrics for quality-of-life when they're doing this research so we can make comparisons across different studies and interpret the findings that we see in a consistent manner.

I tend to use quantitative scales and measures focused on quality-of-life, but these qualitative and mixed methods approaches are going to be a nice complement to quantitative approaches, and really help to understand people's lived experiences. For example, what does it mean to have good or bad quality-of-life? What does it mean to have poor quality-of-life in a rural community versus an urban community? Numbers can only tell us so much. We need stories to interpret the numbers, and to motivate policymakers and the public to try and make changes that support research and clinical care improvement for rural communities and other communities that experience health disparities. It's going to be helpful as we focus on quality-of-life among older cancer survivors.

_REFERENCES:

_{Moss JL, Pinto CN, Mama SK, et al. Rural–urban differences in health‑related quality-of-life: patterns for cancer survivors compared to other older adults. Qual Life Res. 2021;30(4):1131-1143. doi: 10.1007/s11136-020-02683-3.}