Cancer screening in rural Appalachia

Background: While evidence-based guidelines for different types of cancer have been developed, cancer screening continues to be underutilized in rural areas, such as rural Appalachia. The Appalachian region includes a large rural and medically underserved population and is characterized by high cancer incidence and death rates and later stage of diagnosis. Residents of rural Appalachia are at high risk for not receiving recommended cancer screening tests including Pap smears, mammograms and colorectal screening. Objectives: To identify key barriers, at the individual and community levels, to receiving guideline-concordant cancer screening in rural Appalachia. Methods: A systematic literature review, guided by the expanded behavioral model of health services utilization, using PubMed and other databases, and combined with the authors' research studies in rural areas. Results: Multi-level barriers to screening are evident in rural Appalachia. At the health care system level, the availability and proximity of health care providers (e.g. referring primary care physicians, mammography facilities, sigmoidoscopy/colonoscopy facilities) is a major issue, e.g., travel distance over 15 miles to the nearest mammography facility was associated with later stage of diagnosis of breast cancer in Appalachian Kentucky, suggesting that geographic distance is a barrier to screening. Other community-level characteristics, including regional cultural issues and prevailing norms and attitudes in rural Appalachia (e.g. fatalism, mistrust), also play a role in cancer screening. In addition, individual-level factors, including the poor socioeconomic characteristics of Appalachian residents (income, education) and lack of awareness of cancer screening recommendations, have been shown to impact screening. Finally, regional provider attitudes and practices also impact screening rates. Studies suggest that Appalachian providers may not routinely provide guideline-concordant screening due to a multitude of factors, and a recent study found that regional variation in primary care physicians' recommendations regarding colorectal cancer screening was associated with individuals' receipt of colorectal screening. In medically underserved areas, however, provider recommendation may be confounded with availability of certified mammography centers or endoscopy providers, but this has not been studied yet. Conclusion: Disparities in cancer screening rates in rural Appalachia are well-documented. Due to multi-level barriers to screening, expansion of services alone would not necessarily improve screening rates in this region. Further research is indicated to delineate the relative impact of individual-, provider-, and community-level characteristics on screening rates and to identify geographic areas at greatest need for screening enhancements. This research would inform the development of interventions to improve screening rates in the highest risk rural areas.