Small-town patients face big hurdles as rural hospitals cut cancer care

The evening before chemotherapy, Herlinda Sanchez prepares her clothes and makes sure she has everything she needs: a blanket, medications, an iPad and chargers, a small Bible and rosary, soft socks, and snacks for the road.

When the 36-year-old was diagnosed with stage three breast cancer in December, she learned there were no cancer clinics in her area of ​​Del Rio, a town of 35,000 people near the Texas-Mexico border.

To get treatment, she and her husband, Manuel, must drive nearly three hours east to San Antonio. So they set their alarm for 4 a.m., which gives them just enough time to get out of bed, brush their teeth, and begin the long drive along dark roads, looking for deer.

About an hour before arriving at the cancer clinic, the couple stops for a quick fast food drive-thru, giving Herlinda time to apply ointment to the port where the chemotherapy needle will be inserted.

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

Getting cancer treatment close to home has always been difficult for rural patients. But chemotherapy deserts have expanded across the United States in recent years, with 382 rural hospitals ceasing services between 2014 and 2022, according to a report this year by Chartis, a health analytics and consulting firm.

Texas leads the list, with 57 rural hospitals — nearly half of those statewide that offered chemotherapy — cutting the service by 2022, according to the analysis. Rural hospitals in states like Texas that did not expand Medicaid were more likely to close, according to data from the Cecil G. Sheps Center for Health Services Research.

To stay in business, financially strapped facilities in small communities across the country continue to cut out basic health care services like obstetrics and chemotherapy, said Michael Topchik, executive 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 — maybe even longer in each direction — several times a week?”

The lack of chemotherapy services could be a signal of other gaps in cancer care, such as a shortage of local physician and nurse specialists, which is bad news for patients, said Marquita Lewis-Thames, an assistant professor at Northwestern University in Chicago whose research focuses on rural cancer care.

Patients living in rural areas are less likely to survive at least five years after a cancer diagnosis compared with city dwellers, according to a study co-authored by Lewis-Thames and published in the journal JAMA Network Open in 2022. While the rural-urban survival gap has narrowed over the researchers’ nearly 40 years of study, the disparity has persisted across most racial and ethnic groups, with a few exceptions, she said.

Many cancer drugs are now administered orally and can be taken at home, but some drugs for breast, colon and other common cancers still must be administered intravenously in a medical facility. Even driving an hour or two each way can be a burden for patients who may already be struggling with 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, who have to sit in a car for that long and hit bumps in the road,” said Shivum Agarwal, a family doctor who practices in rural communities an hour west of Fort Worth, Texas.

Plus, the trip can cost significantly more than refueling.

“It usually requires the able-bodied family member to take a full day or at least half a day off work,” Agarwal said. “So it’s a big economic cost to the family.”

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

Intravenous infusions can take up to eight hours, in addition to travel time, which creates 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 to cover gaps in insurance and transportation costs. It helped cover gas costs for Sanchez, who received her last round of chemotherapy in late June. The financial assistance will also cover her hotel costs when she travels for breast surgery later this month.

Not all rural hospitals are ending chemotherapy. Childress Regional Medical Center, a 39-bed hospital in West Texas, is building a 6,000-square-foot center for patients who need infusions for cancer and other diagnoses, including multiple sclerosis and rheumatology.

The infusion area, which started with two chairs in 2013 and now has four, will expand to 10 chairs and have more privacy for patients when it opens next year. The closest infusion center in this sprawling region is an hour or more away, discouraging some patients from seeking care, said Childress CEO Holly Holcomb.

“We had a handful of patients who said, ‘If you can’t do it here, I can’t do it,’” Holcomb said. She credits the federal 340B drug rebate program with allowing the hospital to provide infusion medications remotely.

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

However, some patients are not discouraged by the long journeys and travel costs.

“I come from a rural background, so small is better—it’s just more personal,” said Dennis Woodward, 69, of Woodson, Texas. He has a form of non-Hodgkin’s lymphoma and decided to drive two hours to Childress. He first visited a cancer clinic in Abilene, about an hour away. The doctors were nice, but “I felt like a number,” he said.

After his first visit to Childress Hospital this year, Woodward recalls, his oncologist, Fred Hardwicke, walked him to meet the nurses who would administer the drug.

Most Fridays during Herlinda Sanchez Manuel’s chemotherapy, he slept in his car. But during her last treatment in June, he stayed nearby, counting down the hours.

Several family members joined Herlinda as 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 in administrative work at Laughlin Air Force Base near Del Rio. “I can’t wait for a break.”

KFF Health News is a national newsroom dedicated to in-depth journalism on health issues and is one of the main operational programs KFF — an independent source of health policy research, polling, and journalism. This story also appeared on CBS News. This can be reprinted for free.