It is a truism that rural communities in the United States suffer disproportionately from poor access and poor quality health care. Rural residents consistently rank lower on numerous health indicators compared to their urban counterparts, suggesting the current health system is failing this population.

The divide between rural and urban health appears to be impacting prostate cancer care, specifically screening and diagnosis. Work in this area has been pioneered by researchers in Australia and New Zealand, likely due to the sizable population that resides in rural communities. Obertová et al performed a retrospective study of 34,960 patients and found that men in rural practices were 43% less likely to be screened with a prostate specific antigen (PSA) test and were more likely to be diagnosed with high risk cancer and metastatic disease.¹ The impact of rurality on urological cancer care is being further explored in the United States. In 2018 the Centers for Disease Control and Prevention (CDC) reported that prostate cancer incidence was higher in urban areas compared to rural areas,² and some hypothesize this may be secondary to reduced screening in rural communities. Using cancer registry data, Holmes et al examined the association between distance to a urologist and delayed prostate cancer diagnosis.³ The authors discovered that longer distances to a urologist were associated with increased rates of high risk cancer diagnoses. In light of these data, rural communities may suffer more from high risk disease given that only 2.4% of urologists practice in rural communities. Furthermore, of these urologists, half are nearing retirement age, implying that access to care will only continue to dwindle.⁴

Not only are screening and diagnosis negatively impacted by rurality, but definitive treatment of disease appears to be as well. Several studies have recently shown that rural residents have lower rates of definitive treatment for localized urological cancer, even when controlling for clinical parameters, urologist density and sociodemographic factors.^5–7 In our recent work using cancer registry data, we found that rural patients were less likely to be treated for prostate cancer, even when stratified by disease risk.⁵ This implies that patients who could benefit from treatment, such as those with intermediate or high risk disease, were still less likely to be treated if they resided in rural areas. We attempted to understand the reason for this phenomenon by controlling for access to care using urologist density and for socioeconomic factors using area deprivation index. We found that some of the reduced treatment rates were explained by these 2 factors, but not completely, implying there are additional factors inherent to rural residence that we could not account for in our model. Work by Baldwin et al using SEER (Surveillance, Epidemiology, and End Results) data similarly showed reduced rates of definitive treatment in rural patients, although the cohort was largely men with lower risk disease.⁷

Figure.

While rural residents may be less likely to receive definitive treatment, the type of treatment they receive may also differ from their urban counterparts. It has been extrapolated from the breast cancer literature that the longer the distance to treatment centers, the more rural residents may opt for surgery over radiation, which would require multiple visits to treatment facilities. Muralidhar et al showed that the greater the distance to the radiation treatment facility, the less likely a patient is to receive radiation as a treatment for localized prostate cancer.⁸ Treatment differences between urban and rural residents also exist for metastatic disease. Borno et al analyzed state cancer registry data and found that rural residents were more likely to receive surgical castration as opposed to medical castration when compared to urban residents.⁹ On the other hand, Cetnar et al used statewide cancer registry data from Wisconsin and did not find any difference in treatment based on rurality of residence or distance to a radiation facility.¹⁰ However, the authors noted that the majority of patients were insured and resided within 15 miles of a hospital, reflecting the state’s strategic infrastructure with easier access to care. This may suggest that with better access, the lower treatment rates found in other studies could be mitigated.

It is conceivable that these differences in diagnosis and treatment may lead to variation in survival. In fact, several systematic reviews concluded that prostate cancer patients had worse survival if they resided in rural areas when examining both international data and data from the United States. However, results of systematic reviews must be interpreted with caution, as comparison of studies of varying design and quality is difficult.^11,12 These findings were corroborated by the CDC, which used the National Program of Cancer Registries and SEER data to reveal higher rates of prostate cancer mortality in rural counties compared to urban counties.²

Several health determinants likely perpetuate this inequality in prostate cancer treatment between rural and urban populations. These include behavioral, socioeconomic, environmental and clinical factors (see figure). The first step to rectifying this disparity is to understand the specific barriers that exist to physicians providing care and patients receiving care. Such barriers likely vary from one region to the next. In our region, we attempted to identify these barriers by interviewing rural providers. Physicians reported that patients experience numerous hardships after being referred to a specialist, as they often have to travel long distances, lack means of transportation, are unwilling to skip work, have low health care literacy and tend to be suspicious of medical treatment. Almost all responders identified lack of access to specialists and lack of transportation as major barriers to receiving care. In fact, numerous interviewees reported patients having to travel over 2 hours to see a specialist including a urologist. Often, making an appointment with a urologist would mean forgoing a day of work, losing wages and eliciting the help of a family member to drive them over 4 hours total for their visit. Therefore, something many may deem as simple, such as keeping a doctor’s appointment, can be exceedingly challenging for others. Policy in our region will need to be directed toward rectifying these specific barriers in order to begin to improve care for our rural patients.

There is no doubt that the divide between rural and urban health is growing. This disparity seems to have impacted prostate cancer care, possibly resulting in reduced screening and delayed diagnosis. Even after diagnosis, rural patients likely continue to experience hardships, as they seem to receive differential treatment and sometimes no treatment at all. This may eventually lead to increased cancer mortality. As physicians, the onus remains on us to identify the hardships our patients face in receiving care, particularly for the population that resides in rural areas. Only when we identify these barriers can we begin to enact policy to remove them.