Kaplan-Meier model results for differences in survival of surgically treated NSCLC patients, National Cancer Database 2004-2016*. Similar differences are seen when analysis is per- formed by stage. (Source:Danger in America’s Small Towns: Rural-Urban Survival Disparities for Patients with Surgically Treated Lung Cancer)

Most people don’t think of U.S. small towns as dangerous. Yet according to researchers at Northwestern University, small towns are dangerous due to health disparities.

Research Results reports on academic studies exploring a wide range of rural topics.

Charles Logan, M.D., and David Odell, M.D., recently published “Danger in America’s Small Towns: Rural-Urban Survival Disparities for Patients with Surgically Treated Lung Cancer” in the Journal of the American College of Surgeons. Using data from the National Cancer Database, the authors found the risk of death increased for patients from rural areas and small towns following surgery from lung cancer.

We asked Logan and Odell to tell us more about their research, including how it relates to the current Covid-19 pandemic. The researchers also shared suggestions for improving rural health outcomes.

Daily Yonder: What led you to study survival rates following surgery from lung cancer?

Logan (First Author): There were a number of studies that indicated lung cancer survival is worse for patients in rural areas, and there were many possible contributing factors. One factor that stands out is difficulty accessing cancer care, especially surgery, which is potentially curative for early disease. We wanted to know if rural-urban survival disparities persisted for the patients who were able to access surgical care.

Charles Logan (Photo submitted)

Daily Yonder: Your research indicates that lung cancer patients who lived in rural areas or small towns were less likely to survive one year, five years, and 10 years after their operations. Patients’ risk of death also was greater with increased distance from their home to the treatment hospital. Can you explain more about these results and if you were surprised by the findings?

Logan: When we were looking at long-term survival, we evaluated it at several time points to see when differences become apparent between the patients from rural areas and patients from urban areas. What was surprising to me is that the differences in survival became apparent so early, and that was true for every stage of lung cancer. As for risk increasing with travel distance — intuitively this makes sense to me that if you are farther from care, you will have more difficulty accessing many of the services that cancer patients need. These services range from follow-up appointments, to getting labs drawn, getting surveillance imaging, undergoing chemotherapy or radiation therapy, and also emergency care. In this study, we found that increasing travel distance is associated with escalating risk in patients who specifically underwent surgery. Notably, in previous research that included non-surgical patients, the risk from increasing travel distance was not apparent. Why this might be is currently being investigated. 

Daily Yonder: You state that rural and small-town residents face unique challenges accessing health care. Can you further explain these challenges, especially now during the Covid-19 pandemic?

Logan: There are many challenges specific to access, including long travel distances and disparities in the availability and capability of local healthcare resources. The Covid-19 pandemic places a global burden on the healthcare system which disproportionately impacts patients from rural areas. In rural areas, limited local resources are stressed causing interference with normal operations related to cancer screening, diagnosis and treatment.  Additionally, if a patient in a rural area is especially sick or medically complex with needs beyond local capabilities, the more advanced facility that the patient might typically be transferred to may be unavailable to assist due to the overwhelming number of Covid patients being cared for. 

Daily Yonder: Do you plan to conduct future research on rural versus urban health disparities?

Logan: Yes, absolutely. Being from Alaska, these disparities are part of what I plan to focus on in my career. Also, this study raised several important questions related to rural health disparities that we are actively investigating. 

Odell (Senior Author): Our lab is also interested more broadly in better understanding the communication between physicians in rural settings and the providers that they refer to for care in more distant specialized centers, and specifically how these lines of communication can be improved so that patients can receive more and more of their care in their community. We are also interested in understanding how new technology, including telehealth, can be used to bridge the gap in access to care that distance from these specialized centers can pose for rural patients. 

David D. Odell (Photo submitted)

Daily Yonder: Do you have any recommendations for practical policies or procedures to improve health outcomes post-operation?

Odell (Senior Author): In some ways, this relates to your prior question — permanently expanding coverage for telehealth services, which were temporarily included in Medicare coverage due to the Covid-19 pandemic, would offer an immediate solution to some access problems faced by rural patients. Also, programs to incentivize physicians to practice in rural locations have demonstrated some success particularly in rural areas in the western United States. For specialty care, such as that required by lung cancer patients, developing networks that allow physicians who remain in rural settings to collaborate with urban and specialized centers for clinical decision making, skills development, and ongoing professional education is critically important to maintain a high level of care in rural communities. Our group has recently established a cancer collaborative across the state of Illinois (Illinois Cancer Collaborative, www.ILcancer.org), which we hope will serve as a model for these types of collaborations between urban and rural physicians who provide cancer care. 

Charles D. Logan, M.D., grew up in a small town in Alaska and served in the U.S. Coast Guard before obtaining his bachelor’s degree from the University of Alaska and medical degree from the University of Washington School of Medicine.  He is currently a general surgery resident at Northwestern University’s Feinberg School of Medicine. His research interests are veterans’ health and rural health disparities.

David D. Odell, M.D., is an associate professor of thoracic surgery at Northwestern University’s Feinberg School of Medicine. He earned a medical degree from the University of Washington and did an academic residency in general surgery at Harvard Medical School’s Beth Israel Deaconess Medical Center and holds a master’s degree through the Clinical Investigator Training Program at Harvard. He did fellowships in thoracic surgery and minimally invasive thoracic oncology and lung transplantation at the University of Pittsburgh Medical Center. 

Kelly Taber is a former print journalist who works in higher education in West Virginia.

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