Small-town patients face major hurdles as rural hospitals scale back cancer care

The night before her chemotherapy, Herlinda Sanchez lays out her clothes and checks that she has everything she needs: a blanket, medications, an iPad and chargers, a small Bible and rosary, soft socks, and snacks for the road.

After the 36-year-old was diagnosed with stage 3 breast cancer In December, she learned there was no cancer care in her community of Del Rio, a town of 35,000 near the Texas-Mexico border.

To get treatment, she and her husband, Manuel, have to drive nearly three hours east to San Antonio. So they set their alarms for 4 a.m., just enough time to roll out of bed, brush their teeth and begin the long drive over dark roads, keeping an eye out for deer.

About an hour before they arrive at the cancer clinic, the couple stops for a quick bite to eat in the car. The break gives Herlinda time to apply ointment to the port where the needle for her chemotherapy will be inserted.

“It numbs the area so the needle doesn’t hurt when I get to the IV room,” she said.

For rural patients, it’s always been tough to get cancer treatments close to home. But in recent years, chemotherapy deserts have expanded across the United States, with 382 rural hospitals cutting services from 2014 to 2022, according to a report published this spring by Chartis, a health analytics and consulting firm.

Texas topped that list, with 57 rural hospitals — nearly half of the state’s hospitals that offered chemotherapy — planning to cut the service by 2022, according to the analysis. Rural hospitals in states like Texas that have not expanded Medicaid are more likely to close, according to data from the Cecil G. Sheps Center for Health Services Research.

To keep their doors open, cash-strapped institutions in small communities across the country continue to cut basic health care services such as obstetrics and chemotherapy, said Michael Topchik, director of the Chartis Center for Rural Health.

“The data is staggering,” Topchik said. “Can you imagine feeling that sick and having to drive an hour in each direction multiple times a week, or maybe even more?”

Losing chemotherapy services could also signal other gaps in cancer care, such as a shortage of local specialists and nurses, according to Marquita Lewis-Thames, an assistant professor at Northwestern University in Chicago. That’s bad news for patients. She studies cancer care in rural areas.

Patients in rural areas are less likely to survive at least five years after a cancer diagnosis compared with their urban counterparts, concluded a study co-authored by Lewis-Thames and published in 2022 in JAMA Network Open. While the gap between rural and urban survival narrowed over the nearly 40 years the researchers studied, the disparity persisted across most racial and ethnic groups, with only a few exceptions, she said.

A lot of cancer drugs are now administered orally and can be taken at home, but some breast treatments, colon and other common cancers still need to be administered intravenously in a medical facility. Even distances of an hour or two each way can be taxing for patients who already suffer from nausea, diarrhea and other side effects, doctors and patient advocates say.

“It’s quite uncomfortable for some patients who may have bone metastases or severe muscle pain to have to sit in the car for so long and drive over bumps in the road,” said Shivum Agarwal, a family physician who practices in rural communities an hour’s drive west of Fort Worth, Texas.

Plus, traveling can cost much more than just filling the tank.

“It usually requires an able-bodied family member to take a full day or at least a half day off from work,” Agarwal said. “So, there is a huge economic cost to the family.”

In that sense, the Sanchez family is blessed. Herlinda’s mother drives four hours from Abilene to Del Rio to babysit the couple’s youngest children, 2-year-old twins.

Cancer infusions can take up to eight hours, in addition to the travel time, posing significant financial and logistical challenges, said Erin Ercoline, executive director of the San Antonio-based ThriveWell Cancer Foundation. The nonprofit provides financial assistance to adult patients, including for insurance gaps and transportation-related costs. It has helped pay for gas for Sanchez, who received her final round of chemotherapy in late June. The financial assistance will also pay for her hotel when she travels for breast surgery in August.

Not all rural hospitals are abandoning chemotherapy. Childress Regional Medical Center, a 39-bed hospital in West Texas, is building a 65,000-square-foot center for patients who need infusions for cancer and other diagnoses, including multiple sclerosis and rheumatology.

The infusion center, which started with two chairs in 2013 and now has four, will grow to 10 chairs and offer more patient privacy when it opens next year. The nearest infusion center in this sprawling region is an hour or more away, which discourages some patients from seeking care, said Holly Holcomb, Childress’ CEO.

“We’ve had a handful of patients say, ‘If you can’t do it here, I won’t do it,’” Holcomb said. She credits the federal 340B drug rebate program for allowing the remote hospital to provide IV medications.

Hospitals that qualify for 340B can buy outpatient medications at deep discounts. The program provides “a huge pillar of support for rural hospitals,” Chartis Center’s Topchik said. Hospitals can use the savings to support or expand services provided to the community, he said.

But some patients are not deterred by long car journeys and travel expenses.

“I’m from the country, so small is better — it’s just more personal,” said Dennis Woodward, 69, who lives in Woodson, Texas. He has a sort of non-Hodgkin lymphoma and decides to drive two hours to Childress. He had previously visited an oncology clinic in Abilene, about an hour away. The clinicians were nice, but “I felt like a number,” he said.

After his first appointment with Childress this year, his oncologist, Fred Hardwicke, took him to the nurses who would administer the medications, Woodward recalls.

Most Fridays during Herlinda Sanchez’s chemotherapy, Manuel napped in the car. But during her final treatment in June, he stayed close by, counting down the hours.

Several family members joined Herlinda when she rang the bell later that afternoon to signal the end of her treatment.

“I don’t want to be in San Antonio anymore,” said Herlinda, a mother of four who works as an administrative assistant at Laughlin Air Force Base near Del Rio. “I’m looking forward to the holidays.”

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