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Between 2010 and 2021, more than 100 , with 19 alone. That puts a pretty heavy burden on traveling providers to make their way to those rural areas and provide much-needed care.

In a study, Erika L. Moen, PhD, of the Dartmouth Cancer Center-Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, and colleagues explained that although oncology outreach is a common strategy for extending cancer care to rural patients, there is a lack of "a nationwide characterization" of the traveling workforce to enable this outreach, and the extent to which outreach reduces the travel burden for rural patients is unknown.

The researchers conducted a cross-sectional study analyzing a rural subset of a 100% fee-for-service sample of 355,139 Medicare beneficiaries with incident solid tumors including lung cancers. According to data from a , rural residents have lung cancer rates 18-20% higher than those found among urban populations, while a noted that "rural residents had lower total rates of localized cancers and higher total rates of advanced-stage cancers, suggesting possible rural-urban differences in cancer screening and detection."

According to the , 15% of all U.S. lung cancer deaths were in patients who lived in less-urban settings.

Moen's group reported that out of about 40,000 U.S. oncologists, an average of about 10,000 conducted annual rural outreach, and nearly 58% of those traveled with low frequency, or a maximum of one outreach visit/month. When they did engage in outreach, these surgical, medical, and radiation oncologists were providing a full-freight of care per their specialty to up to 7% of rural patients.

The results also showed that rural patients who received oncology outreach traveled 16% and 11% fewer minutes to chemotherapy and radiotherapy compared with those who did not receive oncology outreach. That corresponded to an "expected one-way savings" of 15.9 and 11.9 minutes, respectively, the researchers said.

In a recent study, Tobias Janowitz, MD, PhD, of Northwell Health Cancer Institute in Manhasset, New York, and colleagues took on the topics of patient travel time and patient race/ethnicity, in terms of how they both related to proximity to high-volume cancer clinical trial sites and other hospitals in the U.S.

"Minoritized and socioeconomically disadvantaged populations are underrepresented in clinical trials. This may reduce the generalizability of trial results and propagate health disparities," the investigators wrote. "Socioeconomic deprivation and travel time to trial centers can impair trial participation. Data on these parameters and population data on self-identified race exist, but their interrelation with clinical research facilities has not been systematically analyzed."

Janowitz and co-authors analyzed data from the U.S. Census 2020 survey, a free, online mapping program, and other national data for the longitudinal quantitative study. They reported that 94% of all U.S. cancer trials are done in 78 major U.S. cancer trial centers that are located in areas with socioeconomically more affluent populations with higher proportions of self-identified white individuals.

In addition, some of the 78 cancer trial sites were surrounded with nearly equal representation of the three racial groups -- Asian/multiracial/other, Black or African American, and white -- but that in other areas, the "minoritized population" made up about 2-3%.

Finally, the team reported that based on sensitivity analyses of the catchment populations within 30-, 60-, and 120-minute one-way driving times from all U.S. hospitals, "populations that lived within the 30-minute commute catchment area around the major US cancer research centers were composed of more affluent census tracts," and that "hospitals within cities that exist within or near urban areas with high racially and socioeconomically diverse populations and are also located close to existing cancer research hospitals that have the infrastructure in place to conduct cancer clinical trials."

"Most urban areas in the U.S. have hospitals located in socioeconomically disadvantaged and racially diverse areas, areas that frequently colocalize," the researchers added.

Janowitz and co-author Karen Winkfield, MD, PhD, of Meharry-Vanderbilt Alliance-Vanderbilt University Medical Center in Nashville, offered some take-home messages from the study in a JAMA interview.

Separately in a JAMA Oncology , Kekoa Taparra, MD, PhD, of the Stanford Cancer Institute in Palo Alto, California, and colleagues weighed in on the authors' decision to aggregate American Indian, Alaska Native, Native Hawaiian, and Pacific Islander (AAPI) populations with the larger Asian population.

What is the significance of these findings for future trial designs?

Winkfield: We know that for most clinical trials, oftentimes there is a very homogenous population from a racial and ethnic standpoint. We also know from previous studies, that people of lower economic status are often excluded from clinical trials.

So if indeed we are intending to be more inclusive, the people who are closest to where these clinical trials are being held are often of that same homogenous population. It means we might have to think a little bit differently about how we're doing clinical research. It's very important for trialists and clinical trial centers to think about "Are we doing the right thing by having clinical trials only at the main [trial] hub?"

One of the beautiful things about this paper is that it also looked at what other sites could potentially be utilized that might be part of a healthcare system, that might potentially be sites of research, and that's important because we know that individuals who are of lower socioeconomic status struggle, oftentimes, with transportation.

That is a major issue, just to receive clinical care. The complexity of clinical trials may make it such that individuals need to travel more frequently to a site, so we need to think differently about doing clinical trials so we can become more inclusive in the design and implementation at all levels.

Janowitz: What is important is that not only can we capture what the current distribution is, and that there is this imbalance in that we have a very homogenous population that tends to be well off compared with the average U.S. population in the proximity of clinical trial centers, but it's also important to know that with the data that are available, that we have analyzed, we can look at the question the other way around: We can ask, "Where would you want to go? Which other sites would you want to include in order to get closer to the populations that may represent what you hope to include in your clinical trial?" In other words, that might be both racially and socioeconomically more diverse.

What is problematic about grouping American Indian and AAPI populations with the Asian population?

Taparra et al: The authors developed a diversity score representing the percent deviation from equal representation of three categories: Asian/multiracial/other, Black/African American, and white. This methodology makes a flawed assumption that members of the Asian/multiracial/other group experience similar challenges in accessing healthcare.

American Indian and Alaska Native patients experience significant cancer disparities and are often excluded in clinical trial site selection. Older American Indian and Alaska Native individuals report being less likely to participate in trials 50 or more miles away, underscoring the need for clinical trial sites near American Indian and Alaska Native communities.

Native Hawaiian and Pacific Islander patients often require thousands of miles of air travel to access healthcare due to limited infrastructure across the Pacific. Even Hawaii has no comprehensive cancer centers and needs significant workforce recruitment for their one future trial center.

We urge [Janowitz and colleagues] to develop a future revision of the diversity score calculation to appropriately separate American Indian and Alaska Native, Asian Native, and Hawaiian and Pacific Islander populations into racial categories as federally defined and use that consider smaller sample sizes.

These adjustments may advance this tool to more equitably identify commuter-friendly trial sites for American Indian and Alaska Native and Native Hawaiian and Pacific Islander patients, bridging our communities closer to the equitable cancer care they need.

Read the study here.