Rural-Urban Divide: Disparities in Prostate Cancer Care

Patients with cancer who live in rural areas face challenges in receiving optimal medical treatment compared with their urban counterparts, with geographic barriers and limited availability of medical specialists cited as possible contributing factors.^1,2 Urologists are among the specialists in short supply in sparsely populated areas. According to the American Urological Association’s 2019 annual urology workforce census, 62.4% of counties in the United States had no urologist.³ Further, it has been found that men with prostate cancer (PCa) in rural areas are less likely to receive treatment^2,4 and make follow-up visits with urologists after undergoing radical prostatectomy (RP).⁵ These patients are also more likely to receive surgery rather than androgen deprivation therapy (ADT).⁶

The decreased likelihood of receiving PCa treatment in rural areas surfaced in a recent study of 51,024 men with either localized or metastatic prostate cancer in Pennsylvania.⁴ In this study, researchers found that patients living in rural areas had a 28% decreased odds overall of undergoing treatment compared with urban patients after adjusting for potential confounding factors. Avinash Maganty, MD, a 6th year resident at the University of Pittsburgh, and colleagues documented similar findings when patients were stratified according to disease risk. Among men with low-, intermediate-, and high-risk cancer, rural residents had a 23%, 29%, and 32% decreased odds of undergoing treatment, respectively, compared with urban patients.

For the study, which was published in The Journal of Urology, Dr Maganty and his collaborators used the Pennsylvania Cancer Registry to identify all patients diagnosed with PCa in the state from 2009 to 2015. The study is among the first to examine rural and urban disparities in PCa among all payers within a state, the investigators noted.

“Our most important finding is that rural patients are undertreated for prostate cancer, even when stratified by disease risk,” Dr Maganty told Renal & Urology News. “Meaning, even patients with intermediate- or high-risk cancers were less likely to be treated if they resided in rural areas, when controlling for age, race, insurance, stage, and other clinical factors. We included this risk stratification in our study because for some types of prostate cancer, such as low-risk cancers, active surveillance, as opposed to definitive treatment, is a reasonable course of action.”

Mounting evidence suggests that the healthcare gap between urban and rural populations is on the rise, Dr Maganty said. “Few studies have examined this gap as it relates to urologic malignancies. In this study, we have shown that the health disparity is also affecting urologic cancer care.”

Reasons for the healthcare disparity remain unclear, Dr Maganty said. Current theories attribute the differences to determinants of health that include socioeconomics, environmental factors, health-related behaviors, access to care, and quality of care. The data gathered by his team did not directly allow the researchers to identify the etiology for this disparity, but they attempted to account for some of these health determinants. They added Area Deprivation Index (which takes into account education, income/employment, housing, and household characteristics) and urologist density as surrogates for socioeconomic status and access to care, respectively.

“After adding these variables to our model, we found that the reduced rates of treatment for rural patients previously identified was mitigated, although still less compared to their urban counterparts,” Dr Maganty said. “This suggests that some of the treatment differences we are seeing within the rural population is accounted for by socioeconomic status and proximity to a urologist. However, there are still additional factors that are intrinsic to a rural population that we could not account for with the available data.”

He and his colleagues found that rural patients are more likely than their urban counterparts to have Medicare coverage, whereas urban resident are more likely to have private insurance. “Some theorize that this difference in insurance status can be attributed to several factors,” Dr Maganty explained. “Rural residents are thought to be older and of varying socioeconomic status, making them more likely to have Medicare.

Additionally, rural residents may be more likely to be self-employed in small businesses or farming, which could make obtaining private insurance less economically feasible.”

Lower Definitive Treatment Rates

In an earlier study, Laura-Mae Baldwin, MD, MPH, of the University of Washington in Seattle, and colleagues found that rural patients had lower rates of definitive treatment for early-stage PCa and were less likely to undergo RP compared with urban patients.² The study, which included 51,982 men with early-stage PCa identified using Surveillance, Epidemiology and End Results (SEER) cancer registry data, found that the adjusted rate of definitive treatment was 83.7% for rural patients compared with 87.1% for urban patients.

The investigators pointed out that they conducted their analyses with and without men who were candidates for active surveillance (AS), and in both analyses, rural patients were less likely to receive definitive therapy compared with urban patients. “This suggests that the lower rate of definitive treatment in our rural study population cannot be explained by the higher use of active surveillance,” Dr Baldwin’s team wrote.

Moreover, rural patients had a lower adjusted rate of radical prostatectomy (RP) compared with urban patients (52.9% vs 55.9%), but a higher adjusted rate of receiving brachytherapy (20.7% vs 17.9%).

Dr Baldwin’s team reported that 94.2% of urban patients had both a urologist and radiation oncologist in their county, whereas only 51.1% and 23.4% of rural patients had a urologist and radiation oncologist, respectively, in their county. Still, rural and urban patients had similar rates of receiving external beam radiation therapy (21.9% vs 21.4%), a finding that suggests rural patients in SEER registry areas were not making treatment decisions based on distance to care, according to the investigators. “It appears that rural patients were taking advantage of the multiple treatment options available for early-stage prostate cancer,” they wrote.

Follow-Up Visits Less Likely

In addition, among men who undergo RP, those in rural places are less likely than those in urban areas to make follow-up visits with a urologist after surgery.⁵ In a study of 1158 men who underwent RP, a team led by Bettina F. Drake, PhD, MPH, of Washington University in St Louis School of Medicine in Missouri, demonstrated that patients living in rural areas had a 39% and 28% decreased odds of follow-up visits with a urologist within the first and second year post-RP, respectively, compared with their urban counterparts.

Surgical vs Medical ADT

Rural–urban differences also may extend to the type of ADT patients receive. A study of 10,675 men with metastatic PCa found that those who lived in rural areas had a 49% increased odds of undergoing surgical (bilateral orchiectomy) rather than medical ADT compared with urban patients.⁶ “Because individuals diagnosed in rural settings were more likely to receive surgical ADT, these results support the idea that travel burden may affect cancer treatment plans, even in individuals with advanced disease,” the investigators, led by Hala T. Borno, MD, of the University of California, San Francisco, wrote.

Urologists Absent in Many Places

Part of the access-to-care issue in rural areas could relate to the scarcity of specialists.^1,2 According to the United States Census Bureau, 19.3% of the nation’s population lives in rural areas,⁷ yet data from the American Urological Association’s 2019 workforce census show that only 1358 (10.4%) of 13,044 practicing urologists in the United States practiced in nonmetropolitan areas.² Specifically, only 57 urologists (0.4%) practiced in rural areas, 221 (1.7%) practiced in small towns and 1080 (8.3%) practiced in micropolitan areas, which are defined by the US Office of Management and Budget as an urban cluster with a population of at least 10,000 but fewer than 50,000 people. Oncologists also are rare in rural America. According to 2018 practice census data from the American Society of Clinical Oncology, only 849 (7%) of the 12,423 oncologists in the United States practiced in rural areas.⁸

PCa Mortality Not Necessarily Worse

Although rural residents apparently are less likely to receive treatment than urban residents, they may not have worse survival outcomes. Study data presented at the American Urological Association’s 2020 Virtual Experience suggest that state rurality does not increase the risk of PCa mortality.⁹ For each state, the study compared the percent of the population that is rural with both the PCa death rate and PSA screening rate among men older than 50 years and found no correlation between rurality and either rate.

Lead investigator Katie S. Murray, DO, of the University of Missouri in Columbia, said she attributes the lack of a correlation between PCa mortality and rurality to PSA screening. “Prostate cancer screening has a low barrier to entry,” Dr Murray told Renal & Urology News. “It consists of a simple blood test that does not require a highly skilled and specialized operator. For this reason, we believe prostate cancer mortality is not negatively affected by living in a rural community.”

As for why she and her colleagues conducted the study, Dr Murray observed, “In recent years, there has been a push in medicine to expand care to underserved areas throughout America. We wanted to investigate if the barriers associated with living in these communities negatively affected prostate cancer mortality.”

Rural Urologists’ View

Patrick E. Davol, MD, who practices in Medford, Oregon, is among the urologists who serve a largely rural population. In his area, the challenge is not patient access to technology, but rather ensuring patients can make appointments. “Many patients come from a couple of hours away,” Dr Davol explained. The logistics and cost of transportation are difficult for some patients, many of whom live on Social Security, he said. A major problem he sees among rural residents is limited access to primary care, with many patients not getting annual checkups.

He has found that patients with PCa who reside in places far from medical facilities tend to opt for surgery (“a one-and-done treatment with an overnight hospital stay”) over radiation therapy, which requires frequent travel.

Dr Davol also observed that “there is a cultural difference in the rural populations.” Patients from rural areas are more likely than urban patients to put their care in the doctor’s hands. Urban patients typically have researched their condition and treatments prior to consultation (“they’ve Googled everything”) and “have a pretty good idea of what they want.”

Another urologist who treats rural patients, John S. Banerji, MD, who completed his fellowship training at Virginia Mason Medical Center in Seattle and now practices at Penn Highlands Urology in DuBois, Pennsylvania, (2018 population of 7415), has made the same observation.

“In the urban environment, a lot of people come [to the doctor] with what they think they want,” Dr Banerji said. “The average person who walked into our clinic [in Seattle] had a college degree.” Patients tended to research their condition and treatments before a visit and often have formed a decision about what they want after getting input from their peers or perhaps doctors they know, he said. “They look at [the doctor] as a means of achieving that end.”

In rural communities, however, patients rely to a greater extent on the doctor for information and advice. “They want you to be part of their decision-making process,” he explained. “That’s the biggest difference that I’ve noticed [between urban and rural patients].”

Rurality may influence treatment selection, he said. For example, AS is more likely to be accepted by urban patients because they are apt to be aware that their cancer, at its current stage, is unlikely to kill them, Dr Banerji said. “They are happy to go through the multiple processes in an AS protocol, whereas in a rural area, the moment you tell patients that they’ve got a diagnosis of cancer, even though you say this cancer is not likely to kill them in their lifetime, they want something done. They’re not very comfortable in knowing they have a cancer and doing nothing about it.”

The Future of Rural Urology

The underlying causes of PCa care disparities between rural and urban areas remain unclear, but if a shortage of rural urologists is a major factor, the outlook for narrowing the care gap is ominous in part because of an aging rural urologist workforce. An analysis of 2014 to 2016 AUA census data found that the proportion of rural urologists aged 65 years or older rose from 29% in 2014 to 48% in 2016, investigators reported in The Journal of Rural Health.¹⁰

“A high proportion of urologists in rural communities is approaching retirement age without signs of impending replacement with younger workers,” Andrew J. Cohen, MD, of the University of California, San Francisco, and colleagues concluded. “Simultaneously, dramatic increases in the number of older Americans seeking health care are forthcoming.”

Possible solutions to the rural urologist shortage, according to the investigators, include realigning financial incentives for rural recruitment, incorporating telemedicine and advance care practitioners into practices, and increasing residency training opportunities.

References

1. Charlton M, Schlichting J, Chioreso C, et al. Challenges of rural cancer care in the United States. Oncology (Williston Park). 2015;29(9):633-640.
2. Baldwin LM, Andrilla CHA, Porter MP, et al. Treatment of early-stage prostate cancer among rural and urban residents. Cancer. 2020;119(16):3067-3075.
3. 2019 The State of the Urology Workforce and Practice in the United States. American Urological Association. https://www.auanet.org/research/research-resources/aua-census/census-results. Accessed July 28, 2020.
4. Maganty A, Sabik LM, Sun Z, et al. Undertreatment of prostate cancer in rural residents. J Urol. 2020;203(1):108-114.
5. Khan S, Hicks V, Rancilio D, et al. Predictors of follow-up visits post radical prostatectomy. Am J Mens Health. 2018;12(40:760-765.
6. Borno HT, Lichtensztajn DY, Gomez SL, et al. Differential use of medical versus surgical androgen deprivation therapy for patients with metastatic prostate cancer. Cancer. 2019;125(33):453-462.
7. America Counts Staff. One in five Americans lives in rural areas. US Census Bureau. https://www.census.gov/library/stories/2017/08/rural-america.html. Published August 9, 2017. Accessed July 11, 2020.
8. Kirkwood MK, Hanley A, Bruinooge SS, et al. The state of oncology practice in America, 2018: Results of the ASCO Practice Census Survey. J Oncol Pract. 2018;14(7):e412-e420.
9. Anderson A, Woldu H, Mitchem J, Murray KS. State rurality does not increase the risk of prostate cancer death. Poster presented at: the American Urological Association’s 2020 Virtual Experience; June 27-28, 2020. Poster MP75-02.
10. Cohen AJ, Ndoye M, Fergus KB, et al. Forecasting limited access to urology in rural communities: Analysis of the American Urological Association census. J Rural Health. 2020;36(3):300-306.