Access to Cancer Care

Abstract

Access to cancer care is crucial for patients to receive equitable treatment and enhance survival rates. While it is well-established that regular screenings can reduce morbidity and mortality, not all patients have the same access to these services. Barriers to screening include racial and socioeconomic disparities, geographic limitations, lack of insurance, and insufficient educational awareness. To improve access to cancer care, interventions such as enhancing health insurance coverage, bridging the urban-rural divide in cancer care through telemedicine and mobile clinics, and establishing community-based initiatives with community health workers are essential. Additionally, developing innovative methods to enhance screening, including self-sampling options, will be vital in improving cancer survival rates.

Introduction

Cancer is the second leading cause of death in the United States, with an estimated 2,001,140 new cancer cases expected in 2024. ¹ To achieve better outcomes and improved survival rates, access to early detection and diagnosis is essential. Early diagnosis significantly enhances cancer treatment outcomes, while lack of accessible care can result in a lower chance of survival, adverse clinical outcomes, increased risk of recurrence, and poor disease-free and overall survival, ultimately diminishing quality of life.^2-4 Several barriers hinder access to cancer care, including cost, socioeconomic status, age, and geographic location. In this discussion, we will explore these access issues and examine how to improve them.

Types of Access

Preventative Care

Access to cancer care plays an integral role in each step of cancer treatment and patient outcomes. Regular screenings have been shown to reduce morbidity and mortality, ² with breast cancer mortality dropping 39% from 1989 to 2015 and lung cancer about 20% in 2011. ⁵ Access to screenings is based on 3 core principles: (1) systems making screenings available, (2) capable providers to execute and determine eligibility, and (3) patients carrying out these recommendations. Limited access to screening is due to failure in one of these components. ⁴ To complicate matters, cancers without early symptoms, often delay screenings, as patients deem these tests unnecessary. ⁶

Vaccinations like HPV and hepatitis B play a crucial role in cancer prevention, yet participation rates in screenings remain low. Opportunities for improvement include inconsistent provider recommendations and loss of follow-up to complete multiple shots. ⁷

Diagnostic Access

Once screened patients require access to appropriate diagnostic testing. In breast cancer, the recent increase in breast cancer incidence cannot be attributed to improved detection through screening mammography, ⁵ even with an increase in facilities and insurance coverage. Barriers to diagnostic access are transportation, misunderstanding of screening results, lack of trust, language or cultural barriers, and fear of discrimination in marginalized groups. ⁸

Treatment Access

Access to surgery, chemotherapy, radiotherapy, and other novel therapies is limited by clustering of resources in urban areas and the lack of provider knowledge which can affect referral patterns. ¹⁰

A survey of US lung oncologists found that differences in immunotherapy knowledge, based on age and graduation year, lead to fewer treatments for non-Hispanic Black and elderly patients. These disparities result from medical literacy, language barriers, and communication gaps, rather than biological differences. ¹¹ Educating providers to foster patient trust and advocate for insurance coverage can help reduce these barriers. ⁹

Nearly 70% of adult cancer patients are eligible for oncologic trials; however, fewer than 1 in 20 participate. This is despite a positive correlation between participation, prolonged survival, and reduced mortality. Access to clinical trials is limited by structural, clinical, attitudinal, demographic, and socioeconomic factors, and is lower in those over 65. ¹²

Supportive Care Access

Patients with advanced cancer can benefit from palliative treatment, yet a majority do not receive it before death. The absence of standardized referral practices, along with the fear of abandoning patients, has played a role in this issue. ¹³

Barriers to Cancer Care Access

Insurance coverage presents challenges regardless of patient location. Local health departments provide some low or no-cost screening care, but knowledge of these resources and transport access is low. Reform of insurance coverage, cost transparency, and cost reduction are needed. ¹⁴

Racial and ethnic disparities are associated with increased cancer mortality. ² Facilities that serve underserved populations and prioritize patient-centered care, build trust, and communicate effectively tend to achieve better outcomes. Limited English proficiency poses a barrier; however, increasing the implementation of interpreters and patient navigators system-wide can help address linguistic and cultural differences. ¹³ Other barriers include geographic limitations and lack of educational awareness.

Outcomes of Access

Early Detection

Early detection of cancer has markedly proven to influence survival rates. Cervical, breast, and colon cancer studies demonstrate that patients who are diagnosed at an earlier stage and have standard of care treatment options will have improved outcomes.

Cervical cancer is the third leading cancer amongst women worldwide ranking among the leading causes of mortality. Screening for cervical cancer and human papillomavirus has proven to be highly effective in increased survival rates and to have a significant global impact. Screening 1 woman after the age of 35 one time reduces her risk of dying from cervical cancer by 70%. ¹⁵

Similarly, Novotny et al demonstrated that CRC screening programs, such as the fecal occult blood test and colonoscopy, facilitate earlier diagnoses, which correlate with improved survival rates. The study found that patients diagnosed through screening tend to present with early-stage cancers, whereas those diagnosed after the onset of symptoms often experience advanced disease and higher mortality rates. ¹⁶

A diagnosis of early-stage breast cancer has remarkably higher survival rates. The screening rates are similar for black and white women; however, black women are sometimes screened at facilities with fewer resources, which can impact the time between diagnosis, the identification of an abnormal finding, and the necessary follow-up. ¹⁷

These studies highlight the essential role of early detection.

Survival Rates and Treatment Efficacy

Cancer survival rates and treatment effectiveness are influenced by a variety of factors, including early detection, lifestyle choices, and timely treatment. The evolving landscape of cancer treatment highlights the important relationship between therapeutic strategies and patient survival outcomes. The AJCC TNM staging system for breast cancer illustrates this evolution by combining anatomic staging with biomarker data. This approach provides a more detailed prognostic assessment for patients. ¹⁸

Time to treatment has been shown to impact outcomes in cancer. Polverini et al demonstrated that the survival benefits of expedited time to surgical intervention varied by stage, with early-stage disease experiencing greater advantages. ¹⁹ In addition, significant increases in mortality have been associated with delays in treatments such as curative surgical resection, neoadjuvant chemotherapy, and radiation therapy.

Certain lifestyles such as obesity and smoking can lead to poorer cancer outcomes. A study evaluating colon cancer patients younger than the age of 50 years showed that the overall 5-year survival rate was 92 months in the overweight group compared to 64 months in the obese group. ²⁰ Additionally, nicotine has been shown to promote tumor growth and decrease the effectiveness of treatment modalities such as immunotherapy, radiation therapy, and chemotherapy. Smokers metabolize chemotherapy drugs faster than non-smokers resulting in worse overall outcomes; however, outcomes can improve with smoking cessation. ²¹

Quality of life (QoL) is a critical area of research in cancer care, as it encompasses the diverse effects of cancer and its treatments on patients’ daily lives. QoL can be influenced by the type of procedure and timing of the treatment, affecting patient outcomes. ²² In a complementary study, De Leo et al found that telenursing interventions can positively impact patients’ QoL by enhancing therapeutic adherence and satisfaction with care.

Palliative care plays a crucial role in providing comfort to patients facing serious illnesses, particularly in critical care settings. One significant aspect of palliative care is palliative extubation (PE), which focuses on honoring patient preferences and maximizing comfort during end-of-life care. ²³

Collectively, these studies emphasize the necessity of tailored interventions and the consideration of prior treatments to enhance the QoL of cancer patients.

Health Disparities and Outcomes

Health equity can be defined as all individuals having a fair and just opportunity to be as healthy as possible, which is an ethical and human rights principle. ²⁴ In 2018, approximately 610,000 individuals died of cancer. It is estimated that approximately 22% or 134,000 of those cases could have been prevented if those individuals had access to quality health care and the same outcomes experience of college-educated individuals. ²⁵

Disparities are noted in enrollment and participation in clinical trials, genomic medicine, and genetic testing, with only 4 to 6% of trial participants being Black, despite this group representing 15% of individuals with cancer. ²⁶ A meta-analysis of 35 studies, documented that 40% of white patients completed testing compared to only 26% of black patients. ²⁷ Further, immunotherapy clinical trials documented that black patients were enrolled at a 32-fold lower rate with an 11-fold lower enrollment rate in breast cancer clinical trials. ²⁸

Having a diverse health care workforce is essential for reducing disparities in oncology care, as a diverse workforce offers multiple benefits, such as trust and enhanced cultural competency, contributing to improved outcomes. ²⁹

Addressing these issues through policy changes, community interventions, and improved access to health care is vital for reducing these disparities.

Innovations and Future Directions

The future of early cancer detection and treatment options is promising. Multi-cancer early detection (MCED), which combines biomarker analysis, liquid biopsy, and appropriate imaging techniques, may offer a potential solution for early detection in specific cancer populations. ³⁰

To address disparities, certain patient populations with high mortality rates should be included in these multi-cancer early detection trials.

Policy and Systemic Interventions to Improve Access

Health Insurance

The lack of health insurance for cancer care causes patients to be diagnosed with late-stage cancer, receive suboptimal cancer care, and have poor cancer survival. Establishing the Affordable Care Act, and the expansion of Medicaid from 2011 to 2014 for low-income populations, resulted in a decline in the percentage of uninsured and improved access to cancer care. ¹ This resulted in a decrease in newly diagnosed cancers in nonelderly adults, with the percentage of uninsured low-income patients decreasing from 9.6% to −3.6% in expansion states, but not in the non-expansion states.

Traditional Medicaid coverage still requires copayments for preventive services like cancer screenings and diagnostic tests. High out-of-pocket expenses for cancer care can lead to financial hardship, known as financial toxicity. ³¹ Cost discussions with doctors have been shown to help; over half of the patients report lower out-of-pocket costs as a result. ³² A system-level infrastructure is needed to support conversations about cancer-related costs and employment disruptions while screening for financial hardship, as well as increasing access to insurance.

Telemedicine and Remote Care

The rural-urban gap in cancer care and outcomes is steadily increasing, despite the overall improvement of cancer screening and advances in cancer care. ³³ A reason for this is that most providers who practice in rural areas are unspecialized solo practitioners with limited multidisciplinary cancer care.

Telemedicine can serve as an important tool to bridge the gap in health care access for populations with limited resources. It is beneficial for supporting cancer screenings, including consultations before colonoscopy, risk assessments for lung cancer screening, facilitating self-sampling for colorectal or cervical cancer screening, and providing genetic counseling, along with discussions of results and next steps in care. Teleoncology visits, a component of telemedicine, are cost-effective, yielding high levels of patient satisfaction and improved access to cancer services. ³⁴

Community-Based Initiatives

Community engagement is critical in addressing cancer disparities, as it actively involves the affected communities, encouraging them to design, implement, and evaluate initiatives and interventions. ³⁵ Community engagement involves a multidisciplinary team that collaborates to address cancer disparities by developing interventions sensitive to cultural beliefs and values, building trust between community leaders and health care providers, and creating sustainable interventions to address the specific needs of the community.

An important component of community engagement initiatives is the involvement of community health workers (CHWs), or “promotoras de salud,” who focus on promoting cancer prevention and education in underserved communities. Quantitative data has shown that CHWs contribute to increased rates of cancer screenings and the adoption of healthier lifestyles and behaviors, including smoking cessation, improved nutritional choices, and increased physical activity.

Community engagement is crucial for addressing cancer disparities, and efforts should be made to implement this across states. However, before these initiatives can be effective, barriers such as limited resources, mistrust, time commitment, language and cultural differences, and the diverse needs of communities must be addressed.

Mobile Clinics

Mobile clinics represent a dynamic approach to help overcome health care disparities by providing health care services to the doorsteps of underserved populations, ³⁶ homeless, displaced populations, immigrants, migrant workers, the under-insured, and children. Malone et al estimated that 5.2 to 7 million visits to mobile health clinics are made per year, with 2.1 million by uninsured persons, with the majority being nonwhite. ³⁷

Mobile health clinics have been found to address disparities in social determinants of health by assessing and responding to unmet health care and social needs. They connect clients to other community resources, community health centers, and health care systems.

Important benefits of mobile cancer clinics are increased accessibility, strengthened patient–provider relationships, convenience, community engagement, educational outreach, and early detection through services like mobile mammography. Mobile mammography units (MMUs) have been shown to reduce the impact of disparities by reaching women unable to travel to in-person clinics. ³⁸ A study indicated that only 26% of low-income, under-insured women utilized free available screening programs. Suggesting that barriers to accessing screening programs extend beyond cost and may include logistical challenges and convenience factors.

Mobile clinics represent a promising approach to enhancing cancer screening, yet they encounter obstacles like limited resources, funding challenges, fragmented care, and regulatory hurdles, which hinder the broad implementation and expansion of their efforts^38.

Public Health Campaigns and Screening Programs

Guidelines and policies for cancer prevention and control can be set by National organizations but the implementation of public health initiatives to reduce the burden of cancer mainly falls to state and local health departments, and their partners, such as consumer and advocacy organizations, universities, and area health care providers.

The Colorectal Cancer Control Program partners with health care systems to serve populations that have an increased need for colorectal cancer screening. One hundred million dollars in grants were awarded to 25 states from 2009 to 2015, for the CRCCP to provide direct funding provision for CRC screenings to 50-74-year-old individuals without insurance. ³⁹

National Breast and Cervical Cancer Early Detection Program serves more than 300,000 women per year by providing Pap tests, human papillomavirus (HPV) tests, mammograms, magnetic resonance imaging, clinical breast exams, and diagnostic services. NBCCEDP helps low-income populations with inadequate insurance gain access to timely breast and cervical cancer screening, diagnostic, and treatment services. NBCCEDP has provided more than 16.5 million breast and cervical cancer screening examinations. ⁴⁰

Despite existing screening programs, many patients still lack adequate access to health care due to geographic, financial, or logistical challenges. Self-sampling screening offers a solution, allowing individuals to collect samples at home for colon and cervical cancer screening. This method increases access for those living far from medical facilities, facing transportation issues, or those uncomfortable with traditional exams. ⁴¹

Conclusion

Access to cancer care is essential for achieving better outcomes and increased survival rates. It's crucial to improve access to preventive services, screenings, diagnostics, and treatment options, including palliative care. However, before achieving this, we must overcome barriers such as health equity, the rural-urban divide, and the need for cancer education. To tackle health equity, targeted funding is necessary to improve early detection and reduce mortality rates. Developing a stronger infrastructure that ensures adequate access to cancer care through improved insurance options, services in rural locations, community involvement, and encouraging participation in clinical trials and multicenter detection efforts is imperative. Ultimately, these initiatives will lead to better patient survival and improved overall cancer care.