Rural Cancer Survivors Research Articles

Abstract C22: Cancer-related financial burden, employment, and health among rural cancer survivors

Abstract Purpose: A growing body of literature has begun to document rural-urban disparities among cancer survivors. Rural survivors report worse mental health, health behaviors (e.g., smoking, physical activity), and self-rated health relative to urban counterparts. There is a need to determine modifiable determinants of these disparities, including work. Only one study of which we are aware has explored financial determinants of health: Weaver and colleagues found rural survivors were more likely to report not being able to work because of health-related reasons than urban counterparts. Little, however, is known about cancer-related financial burden during (e.g., filing for bankruptcy) and after treatment (e.g., not returning to work). Objective: This study seeks to: 1) characterize cancer-related financial burden and employment among rural survivors and 2) examine how these factors pertain to their self-rated health. Methods: We drew from an ongoing larger study that is characterizing the health needs of 600 rural cancer survivors and caregivers of cancer patients throughout Illinois State. Participants were recruited via non-probability based sampling methods, including physical flyers placed in rural community organizations (e.g., churches, hair salons, support groups), public health departments, clinics, hospitals, and cancer centers as well as at cancer-related events (e.g., Relay for Life); word of mouth; and electronic flyers distributed via websites, listservs, and social media. Interested participants contacted staff via the study website or phone number. To be eligible for the study, individuals self-reported: 1) being 18 years or older, 2) identifying as a survivor and/or caregiver, and 3) living in a rural part of Illinois State. After screening and providing informed consent, participants completed surveys by mail, phone, or website. Participants received $15 for their time and effort. Results: Since February, we have recruited 72 current survivors, 84% of whom completed the survey online and 27% of whom also self-reported having been caregivers of cancer patients during their lifetime. Our sample was largely female, married, and non-Latino White (NLW). Survivors in the sample are well-educated overall, with 52% holding a bachelor's degree or above. The median annual household income (AHI) was $50,001 to $75,000, with 40% reporting an AHI of more than $75,000. Approximately 26% of respondents indicated cancer-related financial burden. With regard to work, 52% indicated cancer-related work stoppage, 18% indicated they did not return to work, and 40% indicated a reduced workload during treatment. Cancer-related financial burden was associated with family income, in that work stoppage was associated with lower annual household income (B = -0.32, 95% CI [-0.14, -1.35], p = .02). Finally, we examined how cancer-related financial burdens and employment factors were associated with rural residents' self-rated health. Cancer-related employment factors were associated with self-rated health, in that returning to work at a different job (as opposed to the same job) was associated with lower self-rated health (B = -.49, 95% CI [-.34, -.06], p = .008). Discussion: Our study suggests that work may be an important determinant of rural-urban disparities among cancer survivors. Specifically, financial burden and work difficulties were fairly prevalent among our sample. Returning to work at a different job was significantly associated with lower self-rated health. Limitations include small sample size, generalizability, and an inability to make causal inferences. Our next steps will be to further explore how these work-related factors pertain to specific health behaviors, mental health, and physical health outcomes among survivors and caregivers. Citation Format: Emily Hallgren, Leslie R. Carnahan, Kristine Zimmermann, Yamile Molina. Cancer-related financial burden, employment, and health among rural cancer survivors [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C22.

Physical functioning and psychological morbidity among regional and rural cancer survivors: A report from a regional cancer centre.

To identify factors associated with psychosocial, physical and practical difficulties of daily living and distress among cancer survivors from a regional area in Australia. Cross-sectional study. Riverina region of southern New South Wales. The sample included 134 patients who completed treatment for breast, colorectal, lung or cancer at the Riverina Cancer Care Centre. Distress was assessed by the Distress Thermometer. Psychosocial, physical and practical difficulties of daily living were assessed by the Patient-Reported Outcomes Measurement Information System questionnaires. A high proportion of cancer survivors had abnormal scores for physical function, sleep disturbance, satisfaction with role, fatigue and pain interference, with many also displaying abnormal scores for anxiety, depression and distress. Survivors living in rural areas and those who had undergone surgery had higher odds of having abnormal scores for sleep disturbance than their counterparts. Living without a partner increased the odds of anxiety and depression. Having advanced disease increased the odds of anxiety and pain. Colorectal cancer and higher education were associated with depression. Monitoring for abnormal physical and psychosocial issues after cancer treatment is essential to maintain or improve psychosocial well-being during survivorship. When developing survivorship care plans for patients residing in regional centres, health professionals should consider availability of high-quality and accessible support services in regional areas of Australia.

Decision aids and health information technology: One size does not fit all.

74 Background: Nearly 3 million cancer survivors in the US reside in rural areas. Existing survivorship care models were developed mainly at large academic centers, and thus require adaption to meet the challenging needs of the rural community. Rural cancer survivors (RCS) face issues with coordination of care, decision-making, access to specialty services, supportive care resources, and time and resources required for travel. RCS are at greater risk for social isolation and inadequate emotional support. To address these challenges, many studies propose information technology (IT), mobile, and video solutions. We assessed the potential of online and mobile video technology applications to reduce barriers to survivorship care for RCS, families, and caregivers. Methods: We conducted 2 in-person focus groups with rural care managers, providers, and public health professionals, and one virtual cross-disciplinary focus group of patients, caregivers, and provider stakeholders to evaluate acceptability of video modules. Using a Community-Based Participatory Research approach, we worked with community partners to design and develop materials that adequately addressed their needs. Results: Focus group results indicate that video modules added little value for RCS due to sporadic internet access, limited patient IT literacy, vision and memory problems, and patient difficulty interpreting information. Therefore, we designed and piloted a paper RCS Checklist to be taken to appointments, available in waiting areas or through care managers, and to serve as a guide for shared patient-provider decision-making. The resulting checklist includes evidence-based information about survivorship care goals and approaches, care coordination strategies, information about local cancer supportive services, health insurance reimbursement, state disability policies, psychosocial support, and stress-reduction tips. Conclusions: In some special patient populations like RCS, use of health IT for patient empowerment and care coordination may be a poor choice. Engaging relevant stakeholders in the development of location-specific communication and decision aid materials is paramount to successful engagement of patients and caregivers.

Cancer survivorship in the rural U.S. Columbia Pacific: A pilot study.

106 Background: We provide the only fully staffed cancer center in the rural Columbia Pacific, serving multiple counties in OR and WA. Rural areas can lack resources to provide comprehensive survivorship care. Higher rates of medical comorbidities and socioeconomic barriers add challenges to rural survivorship. We conducted a pilot study to 1) develop a program for lifestyle and behavior modifications to fit the needs of our rural community and 2) determine feasibility and preliminary efficacy of a survivorship program for breast cancer patients. Methods: : 9 women with stage I-III breast cancer completed a 12-week program consisting of 1:1 meetings every 2 weeks with a physical therapist and registered dietician; health coach support; and access to a social worker. The following pre-post measures of physical health were taken: fasting lipids and glucose, HbA1C, waist circumference, blood pressure, BMI, 3-day physical activity log and food journal, joint range of motion, and muscle strength. Pre-post well-being was assessed by EORTC QLQC30 and focus groups. Results: Decreases in systolic BP, weight, waist circumference, fasting glucose, and HbA1c were seen in a majority of participants; however, only decreases in waist circumference reached statistical significance (p = .043). On post-program survey using a 0-10 rating scale, program acceptability was rated at an average of 7, and likelihood to continue at an average of 9.4; however, overall QOL rating had no change. Focus group feedback indicated participants valued dietician visits, but requested more social work support, exercise customization, and group support to foster mentoring, education, and sense of community. Conclusions: Developing a rural comprehensive survivorship care program is feasible. More work is needed to translate physical health goals into enhancement of well-being and improved QOL. As of 10/2/17 we have opened a comprehensive cancer center housing medical oncology and radiation oncology services in one facility. We now have a full-time dietitian, resource coordinator, and social worker. This unique facility is well poised to deliver long-term care to rural cancer survivors, and we believe could serve as a model for other rural regions.

Cancer survivorship in the rural U.S. Columbia Pacific: A pilot study.

e21614 Background: We provide the only fully staffed cancer center in the rural Columbia Pacific, serving multiple counties in OR and WA. Rural areas can lack resources to provide comprehensive survivorship care. Higher rates of medical comorbidities and socioeconomic barriers add challenges to rural survivorship. We conducted a pilot study to 1) develop a program for lifestyle and behavior modifications to fit the needs of our patients in our rural community and 2) determine feasibility and preliminary efficacy of a survivorship program for breast cancer patients. Methods: 9 women with stage I-III breast cancer completed a 12-week program consisting of 1:1 meetings every 2 weeks with a physical therapist and registered dietician; health coach support; and access to a social worker. The following pre-post measures of physical health were taken: fasting lipids and glucose, HbA1C, waist circumference, blood pressure, BMI, 3-day physical activity log and food journal, joint range of motion, and muscle strength. Pre-post well-being was assessed by EORTC QLQC30 and focus groups. Results: Decreases in systolic BP, weight, waist circumference, fasting glucose, and HbA1c were seen in a majority of participants; however, only decreases in waist circumference reached statistical significance (p = .043). On post-program survey using a 0-10 rating scale, program acceptability was rated at an average of 7, and likelihood to continue at an average of 9.4; however, overall QOL rating had no change. Focus group feedback indicated participants valued dietician visits, but requested more social work support, exercise customization, and group support to foster mentoring, education, and sense of community. Conclusions: Developing a rural comprehensive survivorship care program locally is feasible. More work is needed to translate physical health goals into enhancement of well-being and improved QOL of rural cancer survivors.

Self-reported Ltpa Versus Expected Ltpa In Rural Cancer Survivors

Self-reported Ltpa Versus Expected Ltpa In Rural Cancer Survivors

The rural women connecting for better health trial—A landmark study that establishes several “firsts”

The study by Befort et al. is a pioneering effort that charts several “firsts” with regard to weight management interventions (1). This study establishes several noteworthy benchmarks in the following areas: (1) it is among a handful of trials to target rural cancer survivors and the first to test a weight management intervention; (2) it utilizes unique approaches that heretofore have not been employed in cancer survivor populations, i.e., prepackaged meals and shakes and group conference calls; (3) it utilizes a two-phase approach to specifically address weight maintenance; and (4) it is the first weight management intervention among cancer survivors to assess cost. All of these are remarkable accomplishments which make substantial contributions to the extant literature, not only with respect to weight management specifically in cancer survivors, but to the general body of weight management evidence. To begin, the team is to be commended for reaching out to a rural population. Rural cancer survivors are acknowledged as underserved and are at significantly higher risk of poorer health outcomes (2). Moreover, the problem of obesity is far more prevalent in rural or frontier areas (3), yet there are few documented interventions that effectively tackle the challenging logistics of delivering weight loss programs to rural dwellers. Befort et al. overcome barriers of distance using group conference calls which not only offer provider contact but also afford the support inherent with group classes. Fidelity to caloric restriction is enhanced by a dietary regimen that includes prepackaged meals and shakes. This approach is innovative; moreover, it is laudable since the magnitude of weight loss, i.e., 14% at 6 months, is roughly double that reported by other weight loss trials that have been conducted among breast cancer survivors to date, including those that were clinic based (4). Not only was weight loss impressive, but this two-phase trial was specifically designed to test a weight maintenance strategy that continued to rely on regular conference calls, though the frequency was scaled back from weekly to biweekly, and was compared with a control condition of mailed newsletters. Given that recidivism (i.e., weight regain) is a major issue with weight loss trials (5), the strides made in this study are notable and may be particularly noteworthy in cancer survivor populations in whom durable weight loss may be potentially important for cancer control. Here, Befort et al. show that a fairly minimal intervention of biweekly conference calls appears effective in sustaining much of the initial weight loss and provide data that indicate a mean weight loss of 10% from baseline to 18 months—again, roughly double the long-term weight loss achieved in other trials, both among cancer survivors and in the general population at large (4, 5). Moreover, since cost data were collected and analyzed, it should be noted that this weight maintenance was achieved at costs that were fairly nominal, i.e., $882. Thus, the breakthroughs made by the Rural Women Connecting for Better Health Trial are commendable and represent a quantum leap in the science of cancer survivorship and weight management.

Engaging a statewide network to expand survivorship care to rural and urban cancer survivors.

23 Background: Advances have been made in elevating cancer survivorship as a public health priority and defining elements needed to deliver high-quality follow-up care to survivors. However, a lack of research on how best to care for survivors and the most effective and efficient strategies for delivering survivorship care in the community setting still exists. We report our assessment of the current state of practice, knowledge and professional development, and plan to increase access to care of urban and rural practices across the state of Kansas. Methods: In 2014, the Midwest Cancer Alliance (MCA), a membership-based outreach arm of The University of Kansas Cancer Center, convened an educational summit and survey to assess the survivorship landscape in Kansas. Post-summit, individual interviews were conducted. Survey and interviews included questions regarding health records, treatment summaries, survivorship care plans (SCP), availability of survivorship programs and resources, access to primary care and specialists, distress screening, community support, and educational needs. Results: Ten MCA member health systems were invited to participate and 7 indicated interest in participating in the project. Only one organization provided an SCP to survivors. Barriers included lack of an integrated approach and knowledge. A majority of survivorship care could be delivered close to home, however, services including fertility preservation, genetic counseling, oncology rehab, sexual health, and second opinions, required travel of more than 50 miles. Identified educational needs focused on comprehensive survivorship care across the health care team. Conclusions: Survivorship care remains fragmented across the state of Kansas. Based on this project, we have secured a CDC survivorship grant that will facilitate clinical and technical assistance related to process improvement and electronic health record integration focused on survivorship care and delivery of an SCP. Next steps include engaging primary care providers and survivors to assure the SCP meets the needs of stakeholders. This work will focus on a translational process to meet the growing needs of the survivors and complex health care organizations.

Posttraumatic growth and benefit-finding in lung cancer survivors: The benefit of rural residence?

Rural cancer survivors report more distress than non-rural survivors. Little research has examined whether rural residence might also be linked to positive psychological outcomes. Rural ( n = 117) and non-rural ( n = 76) lung cancer survivors completed measures of posttraumatic growth, benefit-finding, and distress. Rural survivors reported more posttraumatic growth than urban survivors. There were no differences in benefit-finding. Mediation analyses indicated distress mediated the relationship between rural residence and posttraumatic growth. Findings suggest rural residence might be beneficial with regard to potential for posttraumatic growth among cancer survivors. Consistent with trauma theory, distress mediated the relationship between rural residence and posttraumatic growth.

Abstract A62: Post-treatment follow-up care and health-related information needs among rural breast, prostate, and colorectal cancer survivors

Abstract Purpose: Rural compared to urban residence is associated with worse health outcomes after a cancer diagnosis, including greater distress, higher prevalence of negative health behaviors, lower self-reported health, and increased mortality. Prior studies have suggested that rural residents may have greater cancer-related information needs compared to their urban counterparts, yet little is known about the most common health-related information needs among rural cancer survivors and predictors of greater information needs among this vulnerable sub-population of cancer survivors. Methods: We identified breast, prostate, and colorectal cancer survivors from an institutional cancer registry who: 1) currently resided in a rural zip code (defined as non-metro according to the USDA Rural-Urban Commuting Area coding system), 2) had non-metastatic disease with no treatment in the past 12 months, and 3) were 2-5 years post-diagnosis. Participants completed a survey via mail or telephone on post-treatment follow-up care received and health needs. They were asked about discussions with follow-up care providers regarding weight, diet, exercise, smoking, and health behavior change to create a health promotion score (ranging from 0-100% of topics covered). Participants were queried about 24 health-related information needs in 8 domains (tests and treatment, side effects and symptoms, health promotion, fertility, interpersonal, occupation, emotional, and insurance) drawn from prior National Cancer Institute survivor surveys. Poisson regression models were used to assess relationships between demographic and cancer characteristics, follow-up care components received, and number of health-related information needs. Results: The majority of eligible respondents (N=170: 41% breast, 43% prostate, 16% colorectal; mean age= 66 ± 10 years) were non-Hispanic white (91.8%) and reported less than a college education (66.7%). Inadequate financial resources were reported by 13.7% of the sample. A large majority of rural survivors reported cancer-related follow-up care in the past year (86.5%), generally by oncology or other specialists exclusively (57.0%) or both oncology and primary care (18.9%). Only half of rural survivors reported any discussion about mental health after treatment (49.0%), and 39.1% reported a detailed discussion about treatment side effects. The median health promotion score was only 36.7%. Survivors reported an average of 4.0 information needs (±4.5) in 1.6 different domains (±1.8). The most common domains of information needs included side effects and symptoms (57.6% with at least one need), health promotion (53.5%), tests and treatment (40.9%), and interpersonal concerns (30.1%). A greater number of information needs were reported by survivors who were younger [rate ratio(RR) compared to 5-years older = 1.11, 95% CI 1.01-1.20], ethnic or racial minority (RR= 1.89, 95% CI 1.17-3.06], and financially stressed [RR=1.87, 95% 1.25-2.81]. Discussion: Although the vast majority of rural survivors report receipt of post-treatment follow-up care, survivors may not be receiving key components such as mental health screening and health promotion advice. Rural cancer survivors still report health-related information needs several years post-treatment and may benefit from survivorship educational interventions focused on side effect monitoring and management and health promotion. Younger, ethnic minority, and low income rural survivors may especially benefit from education interventions to address information needs. Citation Format: Kathryn E. Weaver, Nancy Avis, Nynikka Palmer, Nora Fitzgerald, Janet Tooze. Post-treatment follow-up care and health-related information needs among rural breast, prostate, and colorectal cancer survivors. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A62. doi:10.1158/1538-7755.DISP13-A62

Effective recruitment of rural breast cancer survivors into a lifestyle intervention.

Lifestyle interventions targeting exercise and weight control in cancer survivors have become increasingly common due to the strong associations with improvements in function, quality of life, and cancer prognosis [1]. One of the most challenging aspects of conducting these trials is recruitment, especially for underserved populations. Rural residents who represent 20% of the U.S. population experience many of the same disparities as other minority groups including poorer lifestyle behaviors [2] and higher obesity rates [3]. Rural cancer survivors have less access to survivorship care, poorer mental health and quality of life [4, 5] and limited access to lifestyle intervention [6]. Geographic isolation and travel requirements pose additional barriers, however, little has been written about successful recruitment of this group. This paper describes the recruitment of rural breast cancer survivors into a randomized trial investigating the effects of an 18-month intensive lifestyle intervention. We describe a variety of recruitment methods and data on participant yield by different recruitment strategies.

The experiences of participants in an innovative online resource designed to increase regular walking among rural cancer survivors: a qualitative pilot feasibility study

Physical activity has been associated with improved outcomes for cancer survivors. Compared to their urban counterparts, rural Australians experience a health disadvantage, including poorer survival rates after diagnosis of cancer. The aim of this pilot feasibility study was to gain insight into the experiences of rural cancer survivors engaging in an online resource designed to increase regular walking. A 6-week online lifestyle intervention was implemented among eight cancer survivors living in three rural regions of South Australia. Participants used a pedometer to monitor daily steps taken, reported daily steps using a specially designed website and were provided with daily step goals based on their affective state. Participants took part in semi-structured face-to-face interviews to gauge their impressions of the program. Data were analysed using qualitative description and content analysis to derive major themes from the interviews. The program motivated participants to increase their walking and resulted in improvements in several self-reported physical and quality of life outcomes. The resource was clear and easy to navigate. The three-tiered step goal system reduced feelings of guilt if participants were unable to reach a goal. The step log and graph allowed participants to self-monitor their progress. The forum fostered social support; however, more interaction with intervention personnel was suggested. This online pedometer-based walking intervention is feasible and effectively increases motivation for walking and enhances health-related quality of life in South Australian rural cancer survivors. A randomized controlled trial of this intervention is warranted.

Access to Medical and Supportive Care for Rural and Remote Cancer Survivors in Northern British Columbia

Rural cancer survivors (RCS) potentially have unique medical and supportive care experiences when they return to their communities posttreatment because of the availability and accessibility of health services. However, there is a limited understanding of cancer survivorship in rural communities. The purpose of this study is to describe RCS experiences accessing medical and supportive care postcancer treatment. Interviews and focus groups were conducted with 52 RCS residing in northern British Columbia, Canada. The data were analyzed using qualitative content analysis methods. General Population RCS and First Nations RCS experienced challenges accessing timely medical care close to home, resulting in unmet medical needs. Emotional support services were rarely available, and, if they did exist, were difficult to access or not tailored to cancer survivors. Travel and distance were barriers to medical and psychological support and services, not only in terms of the cost of travel, but also the toll this took on family members. Many of the RCS lacked access to trusted and useful information. Financial assistance, for follow-up care and rehabilitation services, was rarely available, as was appropriate employment assistance. Medical and supportive care can be inaccessible, unavailable, and unaffordable for cancer survivors living in rural northern communities.

Highlights of This Issue

Two articles in this issue address important “neighborhoods and health” cancer disparities issues. In a research article, Palmer and colleagues examined rural–urban disparities in forgoing healthcare due to cost amongst 7,804 cancer survivors. Compared to urban cancer survivors, rural cancer survivors were more likely to forgo medical or dental care due to cost. Adjustment for health insurance attenuated these rural–urban disparities among younger cancer survivors, but not older cancer survivors. In a separate review, Meilleur and colleagues highlight key points regarding rural residence and cancer outcomes in the US, identifying conventions that will assist future investigations into the effects of rural residence on cancer outcomes.To increase the cohesiveness of tissue type assessments across centers within consortia, Köbel and colleagues used a biomarker-based prediction model to evaluate histological type assessments across different centers in the Ovarian Tumor Tissue Analysis Consortium. Ovarian cancer tissue microarrays were examined and histological assessments were compared. Using the original histological-based assessment, research cohorts showed significant variability. In contrast, the biomarker-based tumor assessments produced more homogeneous results across centers. Similar biomarker-based tumor assessment models could help reduce variability across research cohorts.Ideally, predictive genetic testing for melanoma promotes early detection and reduces mortality. Aspinwall and colleagues evaluated the long-term impact of melanoma genetic testing and counseling on screening. Family members carrying different CDKN2A/p16 melanoma genetic risk alleles were assessed for adherence to recommended annual or monthly total body skin examinations. Two years following test reporting, adherence to annual total body skin examinations among unaffected carriers increased from 40% to 70%. These encouraging findings suggest that melanoma genetic counseling and test reporting may improve adherence to skin cancer screening practices.Omega-3 and omega-6 polyunsaturated fatty acids may affect skin carcinogenesis but epidemiological evidence is inconsistent. Wallingford and colleagues evaluated the association of plasma omega-3 and omega-6 fatty acids and cutaneous basal cell carcinomas and squamous cell carcinomas (SCC) in Australian adults. Concentrations of omega-3/omega-6 fatty acids and omega-3/omega-6 ratios showed significant inverse associations with SCC tumors. This study provides support for reduced skin cancer risk with high plasma concentrations of omega-3 and omega-6 fatty acids, but further investigation in larger datasets is needed.

Prospective Evaluation of Unmet Needs of Rural Cancer Survivors: Comparison between Rural Aboriginal and Non-Aboriginal Communities

Prospective Evaluation of Unmet Needs of Rural Cancer Survivors: Comparison between Rural Aboriginal and Non-Aboriginal Communities

The Health and Welfare of Rural and Urban Cancer Survivors in Missouri

IntroductionAn estimated 2.8 million cancer survivors reside in rural areas in the United States. We compared the risk behaviors, psychosocial factors, health outcomes, quality of life, and follow-up care of rural and urban cancer survivors in Missouri.MethodsWe used 2009–2010 Missouri Behavioral Risk Factor Surveillance System data to examine various health outcomes, behaviors, and psychosocial factors among rural and urban cancer survivors and their respective rural and urban counterparts without a cancer history. Cancer survivors also were asked about receipt of survivorship care plan components. Sociodemographic factors, access to medical care, and chronic conditions were examined as potential explanatory factors for differences among the 4 groups.ResultsAn estimated 9.4% of rural and 7.9% of urban Missourians aged 18 years or older reported a cancer history. Rural survivors reported the highest rates of poor self-reported health, physical distress, and activity limitation; however differences between rural and urban survivors were attributable largely to sociodemographic differences. Both rural and urban cancer survivors reported more fatigue than their respective counterparts without a cancer history. Rural survivors also were less likely to meet Centers for Disease Control and Prevention recommendations for physical activity than their rural controls. The prevalence of smoking among rural survivors was higher than among urban survivors. Only 62% of rural survivors versus 78% of urban survivors reported receiving advice about cancer follow-up care.ConclusionRural cancer survivors face many health challenges. Interventions to improve quality of life and health behaviors should be adapted to meet the needs of rural cancer survivors.

Strategies to retain rural breast cancer survivors in longitudinal research

AimsTo describe the retention of rural women in the Rural Breast Cancer Survivors (RBCS) Intervention. BackgroundFew studies describe strategies and procedures for retention of participants enrolled in cancer research. Fewer studies focus on underserved rural cancer survivors. MethodsA descriptive design was used. A conceptual model of retention based on three factors: researcher, participant, and context with primary, secondary, and tertiary strategies was used to unify the data. Results432 women enrolled in the RBCS study, of which 332 (77%) were retained and completed the 12month study. Favorable retention strategies included: run-in period, persistent attempts to re-contact hard to reach, recruitment and enrollment tracking database, and a trusting and supportive relationship with the research nurse. ConclusionA conceptual model of retention with differential strategies can maintain participant retention in a longitudinal research study.

Rural-urban disparities in health status among US cancer survivors.

Although rural residents are more likely to be diagnosed with more advanced cancers and to die of cancer, little is known about rural-urban disparities in self-reported health among survivors. The authors identified adults who had a self-reported history of cancer from the National Health Interview Survey (2006-2010). Rural-urban residence was defined using US Census definitions. Logistic regression with weighting to account for complex sampling was used to assess rural-urban differences in health status after accounting for differences in demographic characteristics. Of the 7804 identified cancer survivors, 20.8% were rural residents. This translated to a population of 2.8 million rural cancer survivors in the United States. Rural survivors were more likely than urban survivors to be non-Hispanic white (P < .001), to have less education (P < .001), and to lack health insurance (P < .001). Rural survivors reported worse health in all domains. After adjustment for sex, race/ethnicity, age, marital status, education, insurance, time since diagnosis, and number of cancers, rural survivors were more likely to report fair/poor health (odds ratio, 1.39; 95% confidence interval, 1.20-1.62), psychological distress (odds ratio, 1.23; 95% confidence interval, 1.00-1.50), ≥2 noncancer comorbidities (odds ratio, 1.15; 95% confidence interval, 1.01-1.32), and health-related unemployment (odds ratio, 1.66; 95% confidence interval, 1.35-2.03). The current results provide the first estimates of the proportion and number of US adult cancer survivors who reside in rural areas. Rural cancer survivors are at greater risk for a variety of poor health outcomes, even many years after their cancer diagnosis, and should be a target for interventions to improve their health and well being.

Abstract A39: Health care barriers for rural and urban adult survivors of child and adolescent cancer.

Abstract Introduction: By 30 years after diagnosis, 73% of child and adolescent cancer survivors develop at least one chronic health condition. However, there is little information on the health care needs of rural adults treated for child and adolescent cancer and whether they lack access to care to identify and manage chronic health problems. We explored health care barriers of rural and urban adult survivors of childhood and adolescent cancer. Methods: We performed semi-structured interviews with 36 adult survivors (currently ages 19-56; mean=41.3 years) identified by Utah Cancer SEER Registry. Eligible survivors were diagnosed before age 21 from 1973-2005. We randomly selected participants from gender, age (18-29, 30-45, and 46-60), and rural/urban strata (rural defined as living in a county with less than 75% of population in an urban area [population ≥2,500]). Interviews were performed from April-June 2012. We asked survivors questions about their health insurance coverage, current use of health care, and barriers to accessing care, and whether they discussed their cancer history with their current provider. Interviews were recorded, transcribed, and analyzed for themes using NVivo 9. Themes were compared by urban and rural status. Results: Half of participants were male and 90% (N=34) were white. The average age at diagnosis was 12.6 years (SD=6.7). The most common cancers were gonad/germ cell (N=8; 22%), leukemia (N=7; 19%), and lymphoma (N=6, 17%). A total of 15 survivors were rural and 21 urban. The majority of both urban and rural survivors were insured. Common themes among both rural and urban survivors included: general satisfaction about the services covered by their health insurers, concern about increasing insurance costs, and a history of being denied insurance in the past due to their cancer. Most survivors had a primary health care provider; however, urban survivors described seeing specialty providers more often than rural survivors. About half of survivors discussed their cancer diagnosis and treatment with their current primary care provider. Barriers to discussing their cancer history with providers included a belief that their cancer was in the past so there was no need to discuss it with providers, an impression that their providers did not think their cancer history was worth discussing, and a belief that health problems would have already emerged because their cancer diagnosis and treatment occurred years ago. Health care barriers described only by rural survivors included: difficulty finding quality health care for specific health problems, limitations in finding providers that were familiar with cancer survivors, and having to drive long distances to see providers. Interestingly, most rural survivors were willing to travel long distances to get the care they needed. Conclusions: Survivors were generally satisfied with their health insurance, but were concerned about future coverage. Despite access to primary care providers, many survivors are unaware of their health risks and do not discuss their cancer history with their providers. Rural survivors lack access to providers who are knowledgeable about cancer and specialty care to screen for specific health conditions. Both rural and urban child and adolescent cancer survivors and their health care providers require education about the risk of late effects from childhood cancer. Citation Format: Anne C. Kirchhoff, Echo L. Warner, Elyse R. Park, Roberto E. Montenegro, Jennifer Wright, Antoinette M. Stroup, Mark Fluchel, Anita Y. Kinney. Health care barriers for rural and urban adult survivors of child and adolescent cancer. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A39.

Dietary Patterns Differ between Urban and Rural Older, Long-Term Survivors of Breast, Prostate, and Colorectal Cancer and Are Associated with Body Mass Index

BackgroundOlder adult cancer survivors are at greater risk of cancer recurrence and other comorbidities that can be prevented through improved diet and weight management. The tertiary prevention needs of rural-dwelling survivors can be even greater, yet little is known about rural and urban differences in lifestyle factors among this high-risk population. ObjectivesTo compare dietary patterns of urban and rural cancer survivors and to examine associations of dietary patterns with body mass index (BMI). DesignA secondary analysis was performed of baseline data from the Reach Out to Enhance Wellness (RENEW) trial, a diet and exercise intervention among overweight, long-term (≥5 years), older survivors of colorectal, breast, and prostate cancer. Survivors in the present analysis (n=729) underwent two 45- to 60-minute telephone surveys, which included two 24-hour dietary recalls. Principal components analysis and multivariable general linear models were used to derive dietary patterns and to evaluate associations between dietary patterns and BMI, respectively. ResultsPrincipal components analysis identified three primary dietary patterns among rural dwellers (high sweets and starches, high reduced-fat dairy, cereal, nuts, and fruits, and mixed) and three among urban dwellers (high fruits and vegetables, high meat and refined grains, and high sugar-sweetened beverages). Among rural survivors, greater adherence to the high reduced-fat dairy, cereal, nuts, and fruits pattern was positively associated with lower BMI (P trend <0.05), whereas higher scores on the mixed pattern was associated with greater BMI (P trend <0.05). Greater adherence to the high fruits and vegetables pattern among urban survivors was inversely associated with BMI (P trend <0.05). ConclusionsUrban and rural differences in dietary intake behavior should be considered in designing public health interventions among the increasing population of older cancer survivors. In addition, targeting overall dietary patterns might be one approach to help reduce the burden of obesity among this population.