Building bridges between clinic and community: Supporting patients and caregivers living in rural and remote Canada

Reanne Booker


Advances in the detection, diagnosis, and treatment of cancer have paralleled signif- icant developments in the understanding of tumour biology, pathophysiology, and genomics. In spite of this, cancer remains the lead- ing cause of death in Canada, with an estimated two in five Canadians expected to be diagnosed with cancer and one in four Canadians expected to die of cancer in their lifetime. Although Canada has a pub- licly funded, universal healthcare system, profound inequities exist across the country. Such inequities are often due to a multitude of intersecting factors. The focus of this paper is to review the impact of rurality on cancer care. People residing in rural and remote regions are known to have reduced access to and availability of cancer care, from prevention through diagnosis, treatment, follow-up, and palliative care. Potential strategies to mitigate the challenges associated with rurality will be discussed, including an overview of the role that nurses can play in addressing the needs of patients in rural regions. Oncology nurses are well suited to help support patients, their loved ones, and healthcare colleagues in rural settings with a view to helping improve equity in access to care, quality of care, and outcomes of care for all Canadians.

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Afshar, N., English, D. R., & Milne, R. L. (2019). Rural-urban residence and cancer survival in high-income countries: A systematic review. Cancer, 125(13), 2172–2184.

Arora, S., & Byers, E. L. (2020). Leveraging local expertise to improve rural cancer care outcomes using Project ECHO: A response to Levit et al. JCO Oncology Practice, 16(7), 399–403.

Bhatia, S., Landier, W., Paskett, E. D., Peters, K., Merrill, J. K., Phillips, J., & Osarogiagbon, R. U. (2022). Rural-urban disparities in cancer outcomes: Opportunities for future research. Journal of the National Cancer Institute, 114(7), 940–952.

Booker, R., & Haase, K.R . (2022). Virtual cancer care equity in Canada: Lessons from COVID-19. Clinical Journal of Oncology Nursing, 26(2), 224–227.

Boudreau A. (2019). Practical considerations for the integration of subcutaneous targeted therapies into the oncology clinic. Canadian Oncology Nursing Journal, 29(4), 267–270.

Brenner, D. R., Poirier, A., Woods, R. R., Ellison, L. F., Billette, J. M., Demers, A. A., Zhang, S. X., Yao, C., Finley, C., Fitzgerald, N., Saint-Jacques, N., Shack, L., Turner, D., Holmes, E., & Canadian Cancer Statistics Advisory Committee (2022). Projected estimates of cancer in Canada in 2022. CMAJ, 194(17), E601–E607.

Brunello, G., Fort, M., Schneeweis, N., & Winter-Ebmer, R. (2016). The causal effect of education on health: What is the role of health behaviors? Health Economics, 25(3), 314–336.

Burnett, K., Sanders, C., Halperin, D., & Halperin, S. (2020). Indigenous Peoples, settler colonialism, and access to health care in rural and northern Ontario. Health & Place, 66, 102445.

Canadian Association for Rural & Remote Nursing. (2020). Rural and remote nursing practice in Canada: An updated discussion paper. Canadian Association for Rural & Remote Nursing.

Canadian Cancer Society. (2022). Canadian cancer statistics. A 2022 special report on cancer prevalence. Government of Canada.

Canadian Cancer Society. (2023). Transportation – wheels of hope. Canadian Cancer Society.

Canadian Institute for Health Information. (2022, November 17). A lens on the supply of Canada’s health workforce.

Canadian Institute for Health Information. (2023, August 8). A profile of physicians in Canada [infographic].

Canadian Medical Association. (2019a). Quick facts on Canada’s physicians. Canadian Medical Association.

Canadian Medical Association. (2019b). Radiation oncology profile. Canadian Medical Association.

Canadian Medical Association. (2019c). Medical oncology profile. Canadian Medical Association.

Carriere, R., Adam, R., Fielding, S., Barlas, R., Ong, Y., & Murchie, P. (2018). Rural dwellers are less likely to survive cancer - An international review and meta-analysis. Health & Place, 53, 219–227.

Chan, R. J., Milch, V. E., Crawford-Williams, F., Agbejule, O. A., Joseph, R., Johal, J., Dick, N., Wallen, M. P., Ratcliffe, J., Agarwal, A., Nekhlyudov, L., Tieu, M., Al-Momani, M., Turnbull, S., Sathiaraj, R., Keefe, D., & Hart, N. H. (2023). Patient navigation across the cancer care continuum: An overview of systematic reviews and emerging literature. CA: A Cancer Journal for Clinicians. Advance online publication.

Chen, J., Lu, Y., & Kummar, S. (2023). Increasing patient participation in oncology clinical trials. Cancer Medicine, 12(3), 2219–2226.

Chini, C., Bascialla, L., Giaquinto, A., Magni, E., Gobba, S.M., Proserpio, I., Suter, M.B., Nigro, O., Tinelli, G., & Pinotti, G. (2021). Homcology: home chemotherapy delivery in a simultaneous care project for frail advanced cancer patients. Supportive Care in Cancer, 29(2), 917–923.

Cothran, A., & Martin, J.C. (2022). Hypofractionated radiation: Understanding the modality and impact on patient outcomes. Clinical Journal of Oncology Nursing, 26(1), 23–26.

Coughlin, S.S. (2021). Social determinants of health and cancer survivorship. Journal of Environment and Health Sciences, 7(1), 11–15.

Delgado Guay, M. O., Tanzi, S., San Miguel Arregui, M. T., Chisholm, G., De la Cruz, M. G., & Bruera, E. (2014). Characteristics and outcomes of advanced cancer patients who miss outpatient supportive care consult appointments. Supportive Care in Cancer, 22(10), 2869–2874.

de Moor, J. S., Williams, C. P., & Blinder, V. S. (2022). Cancer-related care costs and employment disruption: Recommendations to reduce patient economic burden as part of cancer care delivery. Journal of the National Cancer Institute. Monographs, 2022(59), 79–84.

Eek, D., Krohe, M., Mazar, I., Horsfield, A., Pompilus, F., Friebe, R., & Shields, A. L. (2016). Patient-reported preferences for oral versus intravenous administration for the treatment of cancer: A review of the literature. Patient Preference and Adherence, 10, 1609–1621.

Egilsdóttir, H., Jónsdóttir, H., & Klinke, M. E. (2022). Living in rural areas and receiving cancer treatment away from home: A qualitative study foregrounding temporality. Global Qualitative Nursing Research, 9, 23333936221111802.

Frosch Z. A. K. (2022). Where have we been with rural-urban cancer care disparities and where are we headed? JAMA Network Open, 5(5), e2212255.

Garcia, M. C., Faul, M., Massetti, G., Thomas, C. C., Hong, Y., Bauer, U. E., & Iademarco, M. F. (2017). Reducing potentially excess deaths from the five leading causes of death in the rural United States. Morbidity and Mortality Weekly Report. Surveillance Summaries, 66(2), 1–7.

Graboyes, E. M., Chaiyachati, K. H., Sisto Gall, J., Johnson, W., Krishnan, J. A., McManus, S. S., Thompson, L., Shulman, L. N., & Yabroff, K. R. (2022). Addressing transportation insecurity among patients with cancer. Journal of the National Cancer Institute, 114(12), 1593–1600.

Gruca, T. S., Nam, I., & Tracy, R. (2014). Trends in medical oncology outreach clinics in rural areas. Journal of Oncology Practice, 10(5), e313–e320.

Guiliani, M., & Gospodarowicz, M. (2018). Radiation oncology in Canada. Japanese Journal of Clinical Oncology, 48(1), 22–25.

Hanna, T. P., King, W. D., Thibodeau, S., Jalink, M., Paulin, G. A., Harvey-Jones, E., O’Sullivan, D. E., Booth, C. M., Sullivan, R., & Aggarwal, A. (2020). Mortality due to cancer treatment delay: Systematic review and meta-analysis. BMJ, 371, m4087.

Henley, S. J., Anderson, R. N., Thomas, C. C., Massetti, G. M., Peaker, B., & Richardson, L. C. (2017). Invasive cancer incidence, 2004–2013, and deaths, 2006–2015, in nonmetropolitan and metropolitan counties - United States. Morbidity and Mortality Weekly Report. Surveillance Summaries, 66(14), 1–13.

Henley, S. J., & Jemal, A. (2018). Rural cancer control: bridging the chasm in geographic health inequity. Cancer Epidemiology, Biomarkers & Prevention, 27(11), 1248–1251.

Infrastructure Canada. (2022, August 11). Rural opportunity, national prosperity: an economic development strategy for rural Canada. Government of Canada.

Kenamond, M. C., Mourad, W. F., Randall, M. E., & Kaushal, A. (2022). No oncology patient left behind: Challenges and solutions in rural radiation oncology. Lancet Regional Health. Americas, 13, 100289.

Kornelsen, J., Khowaja, A. R., Av-Gay, G., Sullivan, E., Parajulee, A., Dunnebacke, M., Egan, D., Balas, M., & Williamson, P. (2021). The rural tax: Comprehensive out-of-pocket costs associated with patient travel in British Columbia. BMC Health Services Research, 21(1), 854.

Lambert, L. K., Horrill, T. C., Beck, S. M., Bourgeois, A., Browne, A. J., Cheng, S., Howard, A. F., Kaur, J., McKenzie, M., Stajduhar, K. I., & Thorne, S. (2023). Health and healthcare equity within the Canadian cancer care sector: A rapid scoping review. International Journal for Equity in Health, 22(1), 20.

Leveque, D. (2014). Subcutaneous administration of anticancer agents. Anticancer Research, 34(4), 1579–1586.

Levit, L. A., Byatt, L., Lyss, A. P., Paskett, E. D., Levit, K., Kirkwood, K., Schenkel, C., & Schilsky, R. L. (2020). Closing the rural cancer care gap: Three institutional approaches. JCO Oncology Practice, 16(7), 422–430.

Lin, C. C., Bruinooge, S. S., Kirkwood, M. K., Olsen, C., Jemal, A., Bajorin, D., Giordano, S. H., Goldstein, M., Guadagnolo, B. A., Kosty, M., Hopkins, S., Yu, J. B., Arnone, A., Hanley, A., Stevens, S., & Hershman, D. L. (2015). Association between geographic access to cancer care, insurance, and receipt of chemotherapy: Geographic distribution of oncologists and travel distance. Journal of Clinical Oncology, 33(28), 3177–3185.

Longo, C. J., Fitch, M. I., Loree, J. M., Carlson, L. E., Turner, D., Cheung, W. Y., Gopaul, D., Ellis, J., Ringash, J., Mathews, M., Wright, J., Stevens, C., D’Souza, D., Urquhart, R., Maity, T., Balderrama, F., & Haddad, E. (2021). Patient and family financial burden associated with cancer treatment in Canada: A national study. Supportive Care in Cancer, 29(6), 3377–3386.

Lopez, M. S., Baker, E. S., Milbourne, A. M., Gowen, R. M., Rodriguez, A. M., Lorenzoni, C., Mwaba, C., Msadabwe, S. C., Tavares, J. H., Fontes-Cintra, G., Zucca-Matthes, G., Callegaro-Filho, D., Ramos-Martin, D., Thiago de Carvalho, I., Coelho, R., Marques, R. M., Chulam, T., Pontremoli-Salcedo, M., Nozar, F., Fiol, V., … Schmeler, K. M. (2016). Project ECHO: A telementoring program for cervical cancer prevention and treatment in low-resource settings. Journal of Global Oncology, 3(5), 658–665.

MacLean, T. L., Qiang, J. R., Henderson, L., Bowra, A., Howard, L., Pringle, V., Butsang, T., Rice, E., Di Ruggiero, E., & Mashford-Pringle, A. (2023). Indigenous cultural safety training for applied health, social work, and education professionals: A PRISMA scoping review. International Journal of Environmental Research and Public Health, 20(6), 5217.

MacLeod, M. L., Kulig, J. C., & Stewart, N. J. (2019). Lessons from 20 years of research on nursing practice in rural and remote Canada. Canadian Nurse,115(3).

Mitra, D., Shaw, A., Tjepkema, M., & Peters, P. (2015). Social determinants of lung cancer incidence in Canada: A 13-year prospective study. Health Reports, 26(6), 12–20.

Nass, S. J., Cogle, C. R., Brink, J. A., Langlotz, C. P., Balogh, E. P., Muellner, A., Siegal, D., Schilsky, R. L., & Hricak, H. (2019). Improving cancer diagnosis and care: Patient access to oncologic imaging expertise. Journal of Clinical Oncology, 37(20), 1690–1694.

Nowell, A., & Campbell, C. (2020). Facing forward: The development of a cancer nursing knowledge and practice framework. Canadian Oncology Nursing Journal, 30(3), 208–211.

Ohri, N., Rapkin, B. D., Guha, C., Kalnicki, S., & Garg, M. (2016). Radiation therapy noncompliance and clinical outcomes in an urban academic cancer center. International Journal of Radiation Oncology, Biology, Physics, 95(2), 563–570.

Pfister, D. G., Rubin, D. M., Elkin, E. B., Neill, U. S., Duck, E., Radzyner, M., & Bach, P. B. (2015). Risk adjusting survival outcomes in hospitals that treat patients with cancer without information on cancer stage. JAMA Oncology, 1(9), 1303–1310.

Rural Health Information Hub. (2022, June 6). Social determinants of health for rural people. Rural Health Information Hub.

Schill, K., & Caxaj, S. (2019). Cultural safety strategies for rural Indigenous palliative care: a scoping review. BMC Palliative Care, 18(1), 21.

Shulman, L. N., Palis, B. E., McCabe, R., Mallin, K., Loomis, A., Winchester, D., & McKellar, D. (2018). Survival as a quality metric of cancer care: Use of the national cancer data base to assess hospital performance. Journal of Oncology Practice, 14(1), e59–e72.

Statistics Canada. (2018, January 17). Geography. Statistics Canada.

Statistics Canada. (2022, December 15). Population growth in Canada’s rural areas, 2016 to 2021. Statistics Canada.

Subedi, R., Greenberg, T. L., & Roshanafshar, S. (2019). Does geography matter in mortality? An analysis of potentially avoidable mortality by remoteness index in Canada. Health Reports, 30(5), 3–15.

Sundquist, S., Batist, G., Brodeur-Robb, K., Dyck, K., Eigl, B. J., Lee, D.K., Limoges, J., Longstaff, H., Pankovich, J., Sadura, A., Sullivan, P., & Dancey, J. E. (2021). CRAFT-A proposed framework for decentralized clinical trials participation in Canada. Current Oncology, 28(5), 3857–3865.

Thompson, M. K., Poortmans, P., Chalmers, A. J., Faivre-Finn, C., Hall, E., Huddart, R. A., Lievens, Y., Sebag-Montefiore, D., & Coles, C. E. (2018). Practice-changing radiation therapy trials for the treatment of cancer: Where are we 150 years after the birth of Marie Curie? British Journal of Cancer, 119(4), 389–407.

Tremblay, D., Latreille, J., Bilodeau, K., Samson, A., Roy, L., L’Italien, M. F., & Mimeault, C. (2016). Improving the transition from oncology to primary care teams: A case for shared leadership. Journal of Oncology Practice, 12(11), 1012–1019.

Ulrich, C. M., Ratcliffe, S. J., Zhou, Q., Huang, L., Hochheimer, C., Gordon, T., Knafl, K., Miller, V., Naylor, M. D., Schapira, M. M., Richmond, T. S., Grady, C., & Mao, J. J. (2022). Association of perceived benefit or burden of research participation with participants’ withdrawal from cancer clinical trials. JAMA Network Open, 5(11), e2244412.

Unger, J. M., Cook, E., Tai, E., & Bleyer, A. (2016). The role of clinical trial participation in cancer research: Barriers, evidence, and strategies. American Society of Clinical Oncology Educational Book. American Society of Clinical Oncology. Annual Meeting, 35, 185–198.

Unger, J. M., Moseley, A., Symington, B., Chavez-MacGregor, M., Ramsey, S. D., & Hershman, D. L. (2018). Geographic distribution and survival outcomes for rural patients with cancer treated in clinical trials. JAMA Network Open, 1(4), e181235.

Walji, L. T., Murchie, P., Lip, G., Speirs, V., & Iversen, L. (2021). Exploring the influence of rural residence on uptake of organized cancer screening - A systematic review of international literature. Cancer Epidemiology, 74, 101995.

Wercholuk, A. N., Parikh, A. A., & Snyder, R. A. (2022). The road less traveled: Transportation barriers to cancer care delivery in the rural patient population. JCO Oncology Practice, 18(9), 652–662.

Wilson, E. C., Pammett, R., McKenzie, F., & Bourque, H. (2021). Engagement of nurse practitioners in primary health care in northern British Columbia: A mixed-methods study. CMAJ Open, 9(1), E288–E294.

Wilson, C. R., Rourke, J., Oandasan, I. F., Bosco, C., On behalf of the Rural Road Map Implementation Committee, & Au nom du Comité sur la mise en œuvre du Plan d’action sur la médecine rurale (2020). Progress made on access to rural health care in Canada [Progrès réalisés dans l’accès aux soins de santé ruraux au Canada]. Canadian Family Physician, 66(1), 31–36.

World Population Review. (2023). Total population by country. World Populaiton Review.

Yabroff, K. R., Han, X., Zhao, J., Nogueira, L., & Jemal, A. (2020). Rural cancer disparities in the United States: A multilevel framework to improve access to care and patient outcomes. JCO Oncology Practice, 16(7), 409–413.

Zahnd, W. E., James, A. S., Jenkins, W. D., Izadi, S. R., Fogleman, A. J., Steward, D. E., Colditz, G. A., & Brard, L. (2018). Rural-urban differences in cancer incidence and trends in the United States. Cancer Epidemiology, Biomarkers & Prevention,27(11), 1265–1274.


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