Collaboration, Determination Improves Cancer Screenings in Rural Areas

Carol Estwing Ferrans, PhD, RN, FAAN

Improving cancer screening in rural areas poses certain challenges not always seen in more populated settings. However, oncology nurses are adept at way-finding, particularly when the need is great. Early detection and treatment of cancer saves lives, yet for residents living in outlying and rural areas, risk factors for developing cancer tend to be greater than in urban areas, whereas screening rates are lower.¹ Factors contributing to these disparities include differences in accessibility to care, lifestyle, culture, and financial stability.

The COVID-19 pandemic, which resulted in delays of care across the geographical spectrum, hit rural areas hard, as financial strain forced out some providers or led to closures of numerous clinics and hospitals.² While the impact of the pandemic on cancer detection and treatment is not yet fully known, the need to improve screening in rural areas remains unquestionably urgent.

So what can be done to address this issue? To answer this question, Oncology Nursing News® spoke with several oncology nurses who took on the challenge to improve rural cancer screening. Their efforts are inspiring and underscore the value of collaboration, innovation, and determination.

Carol Estwing Ferrans, PhD, RN, FAAN, is professor merita at the University of Illinois Chicago College of Nursing. She has coauthored numerous publications addressing rural cancer care, including an article with lead author Leslie Carnahan, MPH, PhD, on rural cancer disparities.³ She shared with us her experience and success improving cancer screening and early detection in the Chicago area and described disparities inherent in rural communities.

With grant money awarded from the National Institutes of Health (NIH), Ferrans and her colleagues set out to reduce late-stage breast cancer diagnoses, particularly among African American women in Chicago. “Fear is a huge barrier to screening,” Ferrans said. “When people are afraid of what screening may reveal, they are reluctant to participate. We addressed this barrier by producing a 14-minute video, ‘Beating Breast Cancer,’ featuring 5 beautiful African American women—all breast cancer survivors—telling their stories.”

The video, in addition to allaying fear, was created to clear up misconceptions pertaining to breast cancer and resonate with the intended target audience. As women responded to the cancer screening promotion, they were shown the video or provided the link to watch at home. The intervention worked. Thousands of women throughout Chicago responded, not only by completing cancer screening but also by following up as when recommended. The 5-year campaign and other such efforts were so successful, Chicago saw a 14% reduction in breast cancer death rates for African American women, more than any other major city in the US.

Motivated by the impressive results of the work done in Chicago, Ferrans has now shifted her attention to rural Illinois, where she will be working to reduce disparities alongside colleague Yamilé Molina, PhD, MS, MPH, who is spearheading the effort and seeking additional NIH grant money. Regarding barriers to care in rural communities, Ferrans explained that the work they’ve done has shown 4 primary drivers of cancer disparities. Lack of insurance stands as a major factor. “We think about farmers with large farms, and [although] they may have wealth tied up in their farms, people in rural areas often struggle with collective poverty and no insurance,” Ferrans said. Migrant workers are another concern, as they often have language barriers and are also without insurance. Culturally, there is a rural reluctance to go on public aid or use government resources, making these issues tricky to address. For people with insurance, their deductibles are often too high or screening isn’t covered. Some make too much money for Medicaid but not enough for insurance and slip between the cracks.

Lack of cancer resources in the community, such as mammography centers and oncology specialists, poses another challenge. Clinic closures and consolidations further reduce screening and treatment access. “It’s difficult when few specialists are available. Wait times are long, [and] it might take 2 months to see a specialist or have an initial visit,“ Ferrans said. “Delays in detection can advance cancer, setting up for later-stage diagnosis.”

Residents in rural communities may also face long travel times and associated fuel costs. Some have little or no time off from work or unreliable transportation.

The fourth disparity driver is fear, and although it’s not unique to residents in rural areas, it may be experienced differently. Rural residents may delay medical evaluation after finding symptoms, especially as COVID-19 continues to make its way through these communities. For many, the fear of cancer in addition to a COVID-19 diagnosis can be immobilizing.

These barriers may seem insurmountable, but Ferrans was quick to point out the hope and good news. “Nurses are making a difference. Nurses are doing what nurses do. They build relationships in the community, and they build trust. They fill the gaps. They understand the strength and value of family,” she said.

The same approaches used in urban areas can be used in rural settings when tailored and targeted for the community. These include personal engagement and communicating via phone, Zoom, and telehealth technologies. Residents in rural communities are used to communicating via these methods because of the distance factor, even more so since the pandemic. Ferrans suggests creating videos specifically for the rural audience and their concerns.

Nurses can guide people to resources, allay their fears, confront misconceptions, direct them to safety net resources, get them fast-tracked to medical care, and connect them to free or low-cost screening programs and diagnostic follow-ups. “Nurses are doing this work, we just need more,” Ferrans said. “They have a unique role and the tools in their pocket. We have reason for hope.”

Carnahan’s work also focuses on rural disparities from a holistic approach, including working on Centers for Disease Control and Prevention (CDC)-funded programs for breast and cervical cancer screening and early detection and cancer prevention program evaluations for the Illinois Department of Public Health, and the development and implementation of a community engagement strategy for the forthcoming 2022-2027 Illinois Comprehensive Cancer Control Plan. She works in Chicago but maintains connections in the rural space and is working on a number of statewide evaluation projects. Through her work, Carnahan found that local programs often do not go far enough to address the financial disparities of underinsurance, but national programs are in place to help meet these gaps in coverage. The National Breast and Cervical Cancer Early Detection Program is one example.

“Nurses are positioned to facilitate the linkage between patients, programs, and resources,” Carnahan said.

In rural communities, some of the outreach and support services available provide transportation to screening services, which can address one of the barriers to care. When patients worry about who will pay for a biopsy if needed, nurses can discuss the different available resources and ensure patients’ financial concerns are addressed. Carnahan urges use of telehealth for risk assessment, for which primary care nurse involvement can be helpful. Partnering with public health nurses and helping develop and sustain a strong nursing workforce will be vital as the fallout from COVID-19, including delayed screenings, becomes more evident.

Marsha Woodall, DNP, MBA, RN, is a professor and Nurse Administrator Division chair at Madisonville Community College in Kentucky. She is the lead author of an article on improving education and screening in a rural population.⁴ Her insight on improving cancer screening in rural settings demonstrates how impactful interventions can be when using a carefully targeted and
tailored approach.

Woodall had participated in rural community outreach before, handing out pamphlets and informational brochures, signing up residents for screening, and chatting with community members during monthly events. Her booth featured a bagged cancerous lung that residents could see and touch, along with a walk-through depiction of a real colon with cancerous nodules. Although the approach was attention grabbing and engaging, follow-through was poor in response to screening tests handed out.

For her doctoral project, Woodall chose to employ a different and much more effective approach. She scheduled a meeting with the Madisonville mayor and asked for permission to visit every city department over 3 weeks to provide education about colorectal cancer. Focused on this target population, Woodall, along with a nurse navigator from Baptist Health Deaconess Madisonville, educated 193 city employees at the sewer plant, trash, water, and electric departments. Sessions were scheduled to align with department meetings during day, evening, and night shifts, making it convenient for employees to attend. They provided basic education and written materials about colon cancer. Pre- and posttests were completed to assess change in knowledge.

“They seemed to really be engaged,” Woodall said. “A few shared stories of a relative or friend that had been diagnosed with colon cancer and spoke out about the importance of screening.”

Half the attendees took home fecal immunochemical tests provided by the oncology nurse navigator, which detect occult blood in the stool. Twenty-nine submitted their tests, a return rate double that of the earlier community booth event. Eight tests were positive and were referred for follow-up.

Woodall encourages nurses to make it easy for rural residents to learn about cancer and participate in cancer screening. “Make it as hassle free and convenient as possible,” she said. She also stresses the importance of collaboration.

“It takes a team effort, but increasing cancer screening in rural communities is absolutely doable by utilizing a targeted approach and exercising persistence.” 

References

1. Preventing and treating cancer in rural America. CDC. April 24, 2018. Accessed November 10, 2021. https://www.cdc.gov/ruralhealth/docs/Policy-Brief-Cancer-H.pdf
2. Cancino RS, Su Z, Mesa R, Tomlinson GE, Wang J. The impact of COVID-19 on cancer screening: challenges and opportunities. JMIR Cancer. 2020;6(2):e21697. doi:10.2196/21697
3. Carnahan LR, Abdelrahim R, Ferrans CE, Rizzo GR, Molina Y, Handler A. Rural cancer disparities: understanding implications for breast and cervical cancer diagnoses. Clin J Oncol Nurs. 2021;25(5):10-16. doi:10.1188/21.CJON.S1.10-16
4. Woodall M, DeLetter M. Colorectal cancer: a collaborative approach to improve education and screening in a rural population. Clin J Oncol Nurs. 2018;22(1):69-75. doi:10.1188/18.CJON.68-75