The Journal of Rural Health

Rural patients’ experiences with diagnosis and treatment of endometrial cancer

AbstractBackgroundRural endometrial cancer (EC) patients are less likely to receive lymph node evaluation, high‐quality surgical care, and adjuvant therapy compared to urban patients. Developing interventions to effectively address barriers to quality care requires understanding patient experiences across the cancer care continuum. Our objective was to understand the diagnostic and treatment experiences of rural EC patients.MethodsWe conducted semistructured interviews with 23 participants (22 patients, one caregiver) from rural counties in North Carolina. We developed a semistructured interview guide to examine the experiences of patients during diagnosis and treatment. Initial codes were derived from a multilevel conceptual framework of rural cancer control, and transcribed interviews were analyzed using thematic analysis.ResultsWe identified six themes reflecting determinants of diagnosis and seven themes for treatment of EC for rural patients. Provider knowledge of EC symptoms, patient symptom normalization, and fear were all discussed as major factors impacting delays in EC diagnosis. Participants noted that social networks influenced them to seek care for symptoms they did not otherwise see as concerning. During treatment, participants experienced financial burdens, and many reported significant challenges traveling to treatment. Social networks were critical for financial support and transportation to and from treatment. Personal health care experiences and community perceptions about rural cancer care also influenced decisions about where to seek gynecologic cancer treatment.ConclusionsThis study highlights the need to improve rural provider adherence to guidelines for EC detection, increase symptom knowledge among rural communities, and implement comprehensive assessments of unmet needs of rural patients during treatment.

Perspectives on self‐sampling for cancer screening among rural and urban women: Multilevel factors related to acceptability

AbstractPurposeSelf‐sampling tests may be used to overcome barriers to screening that are more prevalent in rural populations compared to urban populations. This study aims to qualitatively examine the attitudes toward established and novel self‐sampling tests for cervical and colorectal cancer among women, comparing themes from rural versus urban areas.MethodsWe recruited women (ages 45‐65) from 28 counties in Pennsylvania. Four focus groups were conducted with women from metropolitan counties, and 7 focus groups were conducted with women from nonmetropolitan counties. A brief survey was conducted prior to the focus group regarding general health and willingness to complete self‐sampling tests for cervical and colorectal cancer.FindingsWe identified 3 themes about the potential for self‐sampling for cancer screening: advantages and disadvantages of self‐sampling compared to traditional testing, impact of self‐sampling on patient interactions with their health care providers/clinics, and implications for improving/worsening access to quality health care services. We detected differences in responses from rural versus urban participants in the potential impact of self‐sampling for cancer screening.ConclusionsThere are several barriers and facilitators at the individual, interpersonal, and organizational levels that influence the feasibility of implementing self‐sampling for cancer screening in routine clinical practice. Rural participants face unique barriers to cancer screening across all levels. These findings can be used to guide interventions aimed at increasing the use of self‐sampling methods.

Psychological factors among Appalachian women with abnormal Pap results

AbstractPurposeWomen who receive an abnormal Pap result may experience negative psychological factors. The purpose of this study is to assess the baseline occurrence of negative psychological factors and evaluate the relationships between psychological factors and demographic characteristics among Appalachian women who received abnormal Pap results.MethodsWe conducted a secondary analysis of data collected from Appalachia Kentucky women (N = 521) ages ≥18 enrolled in an intervention. Data included sociodemographics, Beck depression and anxiety inventories, fatalism, and personal control measures. Multiple variable logistic regression was used to investigate the association between demographics and psychological factors.FindingsParticipants were predominantly White (96.2%), with mean age 28.93 ± 11.03 years, and the majority (77%) had yearly income below $20,000. Depression was reported by 34.6% (n = 173); 10% (n = 50) experienced moderate or severe anxiety; 20.6% (n = 107) had fatalistic beliefs; and 55.1% (n = 289) believed they lacked personal control over cancer. Women with lower income had higher occurrence of depression (P = .003). Women with moderate to severe anxiety were significantly older than those with low to moderate depression (34.44 vs 28.34, P < .001). Controlling for other variables, as age increased, the odds of fatalistic beliefs increased, OR (95%) = 1.042 (1.022, 1.062). When education level increased, the odds of fatalistic beliefs decreased, OR (95%) = 0.873 (0.800, 0.952).ConclusionsGiven the high occurrence of depression, anxiety, and fatalistic beliefs among this population, health care providers should assess for underlying mental health diagnoses and psychological distress during each patient encounter and provide recommendations to address them.

Rural‐urban differences in HPV testing for cervical cancer screening

AbstractPurposeRural preventable cancer disparities are often attributed in part to lower screening rates secondary to compromised health care access. When considering higher cervical cancer incidence and mortality, existing analyses primarily consider differences in Pap testing rather than the preferred method of HPV testing, which is more sensitive in identifying severe cases of cervical dysplasia.MethodsLogistic regression using data from the 2016 and 2018 Behavioral Risk Factor Surveillance System was used to examine urban and rural rates of cervical cancer screening according to national guidelines. Propensity score weighting was used to account for baseline sociodemographic differences between rural and urban populations in the 2016 landline sample.FindingsIn 2016 and 2018, rural women were less likely than urban women to have current cervical cancer screening. This disparity was explained by sociodemographic variables in 2016. Among women with current cervical cancer screening, rural women were significantly less likely than urban women to undergo HPV testing in both 2016 and 2018.ConclusionRural women with current cervical cancer screening were significantly less likely than their urban counterparts to have HPV testing. It is possible that updates to preventive care guidelines may be slower to reach rural providers, rural patients may be unaware that HPV testing was completed, or rural practice configuration may complicate the integration of HPV testing into clinical practice. Failure to undergo HPV testing may lead to delayed cervical dysplasia diagnosis, missed opportunities for early intervention, and contribute to rural/urban disparities in cervical cancer incidence and mortality.

Impact of Rurality on Stage IV Ovarian Cancer at Diagnosis: A Midwest Cancer Registry Cohort Study

AbstractPurposeWe aim to understand if rurality impacts patients’ odds of presenting with stage IV ovarian cancer at diagnosis independent of distance to primary care provider and the socioeconomic status of a patient's residential census tract.MethodsA cohort of 1,000 women with ovarian cancer in Iowa, Kansas, and Missouri were sampled and analyzed from the cancer registries’ statewide population data. The sample contained those with a histologically confirmed primary ovarian cancer diagnosis in 2011‐2012. All variables were captured through an extension of standard registry protocol using standardized definitions and abstraction manuals. Chi‐square tests and a multivariable logistic regression model were used.FindingsAt diagnosis, 111 women in our sample had stage IV cancer and 889 had stage I‐III. Compared to patients with stage I‐III cancer, patients with stage IV disease had a higher average age, more comorbidities, and were more often living in rural areas. Multivariate analysis showed that rural women (vs metropolitan) had a greater odds of having stage IV ovarian cancer at diagnosis (odds ratio = 2.41 and 95% confidence interval = 1.33‐4.39).ConclusionRural ovarian cancer patients have greater odds of having stage IV cancer at diagnosis in Midwestern states independent of the distance they lived from their primary care physician and the socioeconomic status of their residential census tract. Rural women's greater odds of stage IV cancer at diagnosis could affect treatment options and mortality. Further investigation is needed into reasons for these findings.