With more than 2 million cancer diagnoses projected for 2025, and cancer incidence rates increasing for those younger than 50 years, cancer remains the second leading cause of death in the United States.1 Disparities in cancer incidence and death rates for under-resourced populations persist and, in some cases, are increasing. Those at greatest risk are from racial and ethnic minority groups, those from non-English language backgrounds, those in lower socioeconomic or medically underserved communities, and those living in rural and remote areas.2 Rural cancer-related death rates remain higher,3 and while declining, the trend is slower in rural communities (–4% compared with –22% in metro areas from 2007 to 2017).4 Risk factors more prevalent in rural areas and associated with this disparity include smoking, obesity, older age, lower educational attainment, lower household income, and reduced access to care.5 ASCO has previously described a framework for rural-urban disparities in survival.5 With the oncology workforce heavily concentrated in urban counties, only 3% of medical oncologists practice in rural communities.6 This shortage directly impacts timely diagnosis, survival rates, quality of life, and treatment costs.7 Patient navigation—provided locally in rural settings, in urban settings with programs designed to support rural residents, or a combination of in-person and virtual support through innovative programs like ACS CARES (American Cancer Society Community Access to Resources, Education, and Support)—can enhance care delivery and mitigate the rural oncologist shortage while providing quality and culturally tailored cancer care for patients and caregivers.
Since the conception of patient navigation following the ACS National Hearings on Cancer in the Poor in 1989, ACS has been a pioneer in bringing navigation to cancer patients and caregivers.2 ACS supports patient navigation through programs such as ACS CARES and ACS Leadership in Oncology Navigation (ACS LION), addressing direct-to-patient support and navigation workforce education, respectively, with the shared goal of expanding navigation reach to under-resourced populations.
The tiered program structure provides multiple access points for those with varying levels of digital or health literacy and to combat the widening digital divide noted among rural populations.
Launched on June 1, 2023, the ACS CARES program provides tailored information and resources accessible to patients via multiple modalities: a digital app, round-the-clock telephone assistance through the ACS National Cancer Information Center, virtual volunteer peer support, and in-person volunteer support at partner health systems. Using the NCCN Distress Thermometer and problem list, the ACS CARES program identifies patient or caregiver concerns and provides tailored information and support. The tiered program structure provides multiple access points for those with varying levels of digital or health literacy and to combat the widening digital divide noted among rural populations.8 Strategies for reducing geographic disparities include a targeted marketing campaign for app dissemination in rural communities, virtual volunteer peer support matching based on shared rural experience, and geographical information system (GIS) mapping using rural-urban commuting area (RUCA) codes during health system partner selection.
The 8230 ACS CARES app users include 58% patients, 29% caregivers, and 13% supporters, representing 67 distinct reported cancer types. Of the 7340 zip codes represented by app users, 17% are rural areas as classified by RUCA codes (Figure 1). Fourteen percent to 19% of the US population resides in rural areas, illustrating geographic reach within the ACS CARES app.9 The ACS CARES needs assessment is classified into 5 categories: emotional, physical, practical, social, and spiritual or religious concerns. For all ACS CARES app users, practical concerns are the most prevalent, accounting for 34%, followed by physical concerns at 27%. Key practical issues identified by urban residents include the need for cancer-related information, financial challenges, and self-management. Rural residents endorse financial challenges, the need for cancer-related information, and transportation as their primary practical concerns, respectively. Of note, paying for rent or utilities falls within the top 3 practical concerns endorsed by rural residents, though not for urban users. The ACS CARES needs assessment data align with previous research, identifying transportation concerns as needs disproportionately faced by rural residents.10 Top physical concerns faced by rural and urban users align and are fatigue, pain, and challenges with sleep. The ACS CARES app addresses these needs by providing 1,107,873 tailored content pieces for users and hosting 5771 interactions between users and virtual ACS CARES volunteers.
The in-person support component of ACS CARES launched in September 2023 at 3 partner health systems nationwide and has expanded in 2024 to 8 additional sites. The site selection process was performed with geographic equity in mind: GIS mapping of potential sites allowed for the visualization of rurality of patient population served, and focus on serving under-resourced rural patients was placed in the site application review criteria (Figure 2). Of the 1250 patients utilizing in-person ACS CARES support from 489 zip codes, 16% are from rural counties, again reflective of the national rate.9 At sites serving a higher percentage of rural patients, such as the University of Mississippi Medical Center, up to 27% of patients supported are rural residents (Figure 3).
While ACS CARES provides direct patient and caregiver navigation support, the ACS LION program is designed to advance patient navigation training and professional education. ACS LION equips navigators to deliver vital cancer navigation support and address barriers that may limit a patient’s ability to receive the treatment they need. This training program aligns with Centers for Medicare & Medicaid Services requirements and the Oncology Navigation Standards of Professional Practice while also partnering with oncology providers to enhance navigation initiatives and sustainability. In the first year, ACS LION has engaged more than 1000 navigation professionals through ACS LION training, as well as supported more than 1800 oncology professionals with learning collaboratives, webinars, and business case development support to ensure the expansion and sustainability of patient navigation nationally.
Rural communities, with limited access to oncology specialists, face significant barriers to timely cancer diagnosis and treatment. The ACS CARES program, with 8230 app users representing 7340 zip codes and 17% from rural areas, has demonstrated effective reach in engaging under-resourced populations. Navigation increases access to care and treatment adherence, particularly important for rural populations with decreased specialist availability.6 The ACS is committed to increasing the reach of navigation services through developing innovating patient support programming and navigation workforce training and credentialing. By combining digital accessibility, in-person assistance, and professional development, the ACS continues to advance equitable cancer care, helping to close the gap in accessing equitable cancer care, embodying the mission to end cancer as we know it, for everyone.
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