Precision Medicine in Rural and Underserved Areas: Unique Solutions for Unique Challenges

J Clin Pathways.2023;9(6):13-14.

Life-changing precision medicine is only effective if it can be accessed by patients with cancer. However, social drivers of health, such as socioeconomic status, race and ethnicity, health literacy, and insurance status, continue to create a barrier between breakthrough science like biomarker testing and the patients who need it. Patients living in underserved, under-resourced, or ruralareas are often left behind as diagnostic advancements are made.

Patients in these communities lack access to high-quality healthcare and financial resources, and they may also experience more complex psychosocial needs. Meanwhile, community providers who treat patients in these rural or underserved areas also face challenges due to limited program resources, staffing, and infrastructure.

Understanding these unique challenges, in 2022 the Association of Community Cancer Centers (ACCC) conducted a study on the barriers to equitable biomarker testing in patients with non–small cell lung cancer (NSCLC).¹ Findings of this study indicate that despite the likelihood of oncology providers to discuss and order guideline-concordant biomarker testing at some point during a patient’s disease trajectory, decreases in biomarker testing were seen in patients of lower socioeconomic status and those perceived to have low health literacy.

In July 2023, ACCC explored these topics further with oncology providers, program directors, and nurse navigators working in rural cancer programs across the US, in part with its Cancer Diagnostics education program.² ACCC shares how community oncology programs are finding unique solutions to the ever-present barriers to biomarker testing.

In rural settings, nearly all biomarker testing is performed outside of the cancer program or practice. However, critical patient conversations and facilitation of complex preauthorization and test ordering processes still begin onsite, and for programs or practices with limited navigators and financial counselors (sometimes a single full-time employee tasked with multiple roles), these conversations can be daunting.

Understanding the purpose and importance of biomarker testing, comprehending clinical terms, and breaking down complex orders and results—education, both for patients and for the multidisciplinary team who must explain these nuances—continues to be one of the most significant hurdles cancer programs and practices in underserved areas face.

“It’s been an ongoing educational process for so many people on the team—including our physicians, providers, the extenders, our nursing team, navigators, and even financial counselors,” said Wendi Waugh, BS, RT(R)(T), CMD, CTR, administrative director of Cancer Services and Ambulatory Infusion at Southern Ohio Medical Center, a community cancer program located in a rural setting in Portsmouth, Ohio. “We do all our [biomarker] testing outside of our organization, so oftentimes it’s the financial counselor who is responsible for talking to the patient not only about potential out-of-pocket expenses for the testing facility, but they really have to be able to explain to the patient what they are talking about and what biomarker testing is.”

Patient and provider education is only half the challenge. Outside of academic medical centers or larger institutions that have dedicated financial navigation and prior authorization teams, the approval waters can get murky. Smaller, rural programs struggle daily with insurance denials and appeals processing for biomarker testing for their patients, regardless of insurance status. While many testing companies offer robust patient assistance programs, sometimes reducing out-of-pocket fees to $200, $100, or less for testing, many patients with lower levels of health literacy are easily discouraged and deterred from testing due to cumbersome financial assistance applications and forms.

In response to these challenges, cancer programs and practices are doubling down on provider education and collaboration across the multidisciplinary team to emphasize that securing prior authorization for biomarker testing is nearly as important as placing the order for testing. In addition, community programs are increasing their efforts to engage with patient advocacy and community organizations to tap into local resources like ridesharing services, gas cards, and other psychosocial support for patients.

Yet, even cancer programs with staff who are knowledgeable about biomarker testing and who are ready to assist patients in securing financial coverage for testing still face additional challenges, as many patients experience significant language or literacy barriers. To overcome this, programs have sought creative ways around these barriers.

Many programs have had success with video-based translation services, which can be arranged quickly and support patients who speak multiple languages. Other programs shared remedial interventions, such as illustrated instructions and descriptions rather than text, to support patients who are illiterate or have lower levels of literacy. Yet despite these solutions, some face additional complications.

As one rural cancer program—UAB Medicine Russell Medical Cancer Center in Alexander City, Alabama—describes, most of its patients live in areas without reliable broadband internet connection, which makes conducting telemedicine or video interpretation services with patients at home extremely difficult. To work around this challenge, the center got creative. “We’ve actually set up telemedicine centers in our rural health clinics that folks can drive to so they can receive telemedicine services through the local clinic,” said George Miranda, MDiv, MBA, the director of the cancer center.

These challenges, while numerous and formidable, can be surmounted by increased education, collaboration, and innovative solutions. As a result, ACCC remains committed to providing the resources the multidisciplinary cancer care team will need to navigate the complex precision medicine landscape.

Affiliation: Senior Writer and Editor, Association of Community Cancer Centers.

Disclosure: The author reported no relevant financial or other conflicts of interest.