psychosocial well-being and supportive care needs of

REVIEW ARTICLE

Psychosocial well-being and supportive care needs of cancer patientsand survivors living in rural or regional areas: a systematic reviewfrom 2010 to 2021

Shannen R. van der Kruk1,2,3 & Phyllis Butow4& Ilse Mesters1 & Terry Boyle3

& Ian Olver5 & Kate White6&

Sabe Sabesan7& Rob Zielinski8,9 & Bryan A. Chan10

& Kristiaan Spronk2,11 & Peter Grimison12&

Craig Underhill13 & Laura Kirsten14& Kate M. Gunn2,11

& on behalf of the Clinical Oncological Society of Australia

Received: 3 March 2021 /Accepted: 13 July 2021# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

AbstractPurpose To summarise what is currently known about the psychosocial morbidity, experiences, and needs of people with cancerand their informal caregivers, who live in rural or regional areas of developed countries.Methods Eligible studies dating from August 2010 until May 2021 were identified through several online databases, includingMEDLINE, EMBASE, PsychINFO, and RURAL (Rural and Remote Health Database). Results were reported according to thePRISMA guidelines and the protocol was registered on PROSPERO (CRD42020171764).Results Sixty-five studies were included in this review, including 20 qualitative studies, 41 quantitative studies, and 4 mixedmethods studies. Qualitative research demonstrated that many unique psychosocial needs of rural people remain unmet, partic-ularly relating to finances, travel, and accessing care. However, most (9/19) quantitative studies that compared rural and urbangroups reported no significant differences in psychosocial needs, morbidity, or quality of life (QOL). Five quantitative studiesreported poorer psychosocial outcomes (social and emotional functioning) in urban cancer survivors, while three highlightedpoorer outcomes (physical functioning, role functioning, and self-reported mental health outcomes) in the rural group.Conclusion Recent research shows that rural people affected by cancer have unique unmet psychosocial needs relating to rurality.However, there was little evidence that rural cancer survivors report greater unmet needs than their urban counterparts. This contraststo the findings from a 2011 systematic review that found rural survivors consistently reported worse psychosocial outcomes. Morepopulation-based research is needed to establish whether uniquely rural unmet needs are due to general or cancer-specific factors.

Keywords Cancer . Rural . Psychosocial . Healthcare needs . Informal caregivers . Oncology

* Kate M. [email protected]

Shannen R. van der [email protected]

Phyllis [email protected]

Ilse [email protected]

Terry [email protected]

Ian [email protected]

Kate [email protected]

Sabe [email protected]

Rob [email protected]

Bryan A. [email protected]

Kristiaan [email protected]

Peter [email protected]

Craig [email protected]

Laura [email protected]

Extended author information available on the last page of the article

https://doi.org/10.1007/s00520-021-06440-1

/ Published online: 14 August 2021

Supportive Care in Cancer (2022) 30:1021–1064

http://crossmark.crossref.org/dialog/?doi=10.1007/s00520-021-06440-1&domain=pdf

https://orcid.org/0000-0002-5132-668X

https://orcid.org/0000-0003-3562-6954

https://orcid.org/0000-0003-0605-6286

https://orcid.org/0000-0001-6741-330X

https://orcid.org/0000-0001-5478-1576

https://orcid.org/0000-0003-4763-1734

https://orcid.org/0000-0002-9068-8755

https://orcid.org/0000-0002-4807-8523

https://orcid.org/0000-0002-6492-1197

https://orcid.org/0000-0002-7773-1587

https://orcid.org/0000-0002-2653-1657

https://orcid.org/0000-0001-9335-2678

http://orcid.org/0000-0003-0837-6814

mailto:[email protected]

Introduction

Understanding the psychosocial well-being and supportivecare needs of people with cancer has become an importantpublic health concern [1]. As the number of people diagnosedwith cancer and survival rates improve [2], more people livingwith cancer will require ongoing cancer treatment, surveil-lance, and supportive care to address their psychosocial needs[3, 4]. Supportive care can be defined as care that helps aperson with cancer and their family cope with cancer and itstreatment, from pre-diagnosis through the process of diagnosisand treatment to cure, continuing illness or death and intobereavement [5]. Unfortunately, given the increasing preva-lence of cancer survivors and limited health workforce, cur-rent survivorship care leaves survivors with significant unmetneeds [6–8]. Previous research indicates survivors living inrural or regional areas are likely to have more unmet needsthan those residing in urban areas [9, 10]. Fortunately, targetedresearch is being undertaken to understand the specific, cul-turally complex indigenous cancer issues [11], as outcomesare even worse for these members of the rural population.However, it is also important to develop understanding aboutthe supportive care needs of the significant number of non-indigenous rural people affected by cancer and caregivers, toimprove service delivery models, and to inform newapproaches.

Research suggests that rurality negatively impacts survival.A survival analysis in Australian cancer patients showed thatcancer patients living in remote areas are 35% more likely todie within 5 years of a cancer diagnosis than those living inurban areas [12, 13]. Similar patterns have been found in var-ious geographical regions around the world and usingmultipledefinitions of rurality [14]. Contributing factors may includemore labour-intensive work schedules, delayed diagnosis,geographic isolation, and lower levels of income, education,and socioeconomic status (SES) [12, 15, 16]. As there arefewer cancer services in rural or regional areas, rural peoplewith cancer may also experience a lack of local support andservices, and often have to travel significant distances or relo-cate to access cancer care [17–20]. This may affect their treat-ment decisions and follow-up care post-treatment, and pro-foundly impact their psychosocial well-being, resulting inpoorer health status [20–22].

In 2011, a systematic review on psychosocial well-beingand the supportive care needs of people living in urban andrural/regional areas, diagnosed with cancer, was publishedonline [23]. Bringing together the literature on psychosocialmorbidity in rural areas (excluding studies on medical out-comes, survival, interventions etc.), this influential 2011 re-view included 37 studies and found that the majority of con-trolled studies reported worse psychosocial outcomes for ruralcancer patients, who had higher needs, particularly in the do-mains of daily living and physical functioning, compared to

urban cancer patients. Furthermore, many rural patients andfamilies reported rural-specific challenges including travel,financial, emotional, and relationship challenges. The reviewconcluded that more research was needed that included peoplewith heterogenous cancers from rural and urban settings toconfirm these disparities. Since then, increasing research in-terest in this field has been driven, at least in part, by thefinding that although cancer survival is improving overall,disparities between rural and urban populations are continuingto grow [24]. Addressing rural cancer disparities has become akey priority area for the National Cancer Institute in theUnited States (US), which has led to an increase in the amountof research funding being directed towards this field [25].However, the impact of rurality on psychosocial morbidityremains less clear than the impact that it has on physicalmor-bidity and survival. Therefore, the purpose of this study was tosystematically review studies on levels of psychosocial mor-bidity and the experiences and needs of people with cancerand their informal caregivers, living in rural or regional areas,that have been published in the last 10 years, since the 2011review.Where studies included data on both psychosocial andphysical morbidity, we report only the former.

Methods

This systematic literature reviewwas conducted in accordancewith the Preferred Reporting Items for Systematic Reviewsand Meta-Analyses (PRISMA) [26]. The study protocol wasregistered in the online database of PROSPERO(CRD42020171764).

Eligibility criteria

Papers eligible for inclusion were published in English afterJuly 2010 (i.e., the end date of the previous systematic review)and reported on studies comparing rural versus urban-dwelling cancer survivors in terms of their psychosocial mor-bidity or supportive care needs, or alternatively reported onthese issues specifically for rural cancer survivors and/or theirinformal caregivers. Eligible studies included study partici-pants who were adults (18 years or older) within a settingdescribed as a regional or rural area(s) of Australia (i.e., theAccessibility/Remoteness Index of Australia (ARIA) as de-fined by the Australian Bureau of Statistics [27]), or as a ruralarea for countries of the developed world, as defined by theHuman Development Index (HDI) of 0.8 or higher (i.e., highhuman development) [28]. The ARIA classifies locations intofive categories: very remote, remote, moderately accessible,accessible, and highly accessible [27]. Both qualitative andquantitative (non-experimental) studies were included in thereview. As per the previous review [23], studies were exclud-ed if they did not report on the prevalence of psychosocial

1022 Support Care Cancer (2022) 30:1021–1064

morbidity or supportive care needs, i.e., they were interven-tion studies, focussed on medical outcomes or survival rates,reported differences in the uptake of cancer screening or fo-cussed on health attitudes or treatment decision making, anddiscussed service delivery or discussed the effectiveness ofsupport groups or support via videoconferencing. In addition,studies were excluded if they explored psychosocial outcomesin indigenous populations (as the issues facing these popula-tions are unique).

Information sources

Searches were identified via searching four electronic biblio-graphic databases, including RURAL: Rural and RemoteHealth Database (which specifically covers a range of subjectsrelated to rural and remote area health issues and care),PsychINFO, Embase, and Medline. Additionally, backwardand forward citation searching of all included articles wasperformed to identify any additional studies.

Search strategy

The searches were conducted in the final week of April 2020and updated in the third week of May 2021. Search strategieswere amended to the requirements of each database. In gen-eral, the searches included the following combinations ofterms and were combined as (#1 OR #6) AND (#2 OR #7)AND (#3 OR #8) AND (#4 OR #9) NOT (#5 OR #10;Table 1). The search was limited to August 2010 untilMay 2021.

Search selection

Initial search results from all databases were screened for du-plicates and eliminated through a systematic review manage-ment software (Covidence). Screening of articles was com-pleted in two stages: of information provided in the title and

abstract, and subsequently, full text. One reviewer (SK)screened all papers individually and the other reviewersscreened a percentage in duplicate, 20% in the first stage(KG) and 100% in the second stage. Any disagreement wasresolved by discussion and where consensus could not beeasily reached, a third independent reviewer (KS) made thefinal decision.

Data collection and items

Data extraction was conducted by one reviewer (SK). A sec-ond reviewer (KS) checked the data extracted from 20% of thearticles to assess the quality of data collection. Additional datawas extracted for one paper. As per the previous review [23],the included articles were summarised according to reference,study design, response rate, sample size, setting, measures,type of cancer, results, and study quality. In addition, dataon study population was collected to allow for clearer docu-mentation of whether study participants were adult cancersurvivors undergoing treatment (i.e., people who were receiv-ing cancer treatment at time of study — not including hor-monal therapy), adult cancer survivors post-treatment (i.e.,people who had finished cancer treatment at time of study),cancer patients in palliative care, and/or family or friends car-ing for a person with cancer.

Risk of bias

The quality of individual studies was assessed independentlyby two reviewers (SK and KS). Studies were critically ap-praised using the appropriate appraisal tool for the study de-sign (both quantitative and qualitative), available from theJoanna Briggs Institute [29]. Included articles werecategorised as having poor, good, or very good methodolog-ical reporting by calculating the percentages of items onwhichstudies were rated as including essential quality characteristics(i.e., less than 40% were classified as poor, 40–70% as good,

Table 1 Search strategy*Medical SubjectHeading (MeSH)terms

Text terms included in titles and/or abstract

1 Neoplasms 6 cancer OR neoplasm OR carcinoma OR oncology

2 Rural population 7 regional OR remote OR travel

3 ‘Quality of life’ 8 well-being OR ‘quality of life’ OR QOL OR psycho* OR social OR emoti* ORmorbidity OR adjust* OR depress* OR anx* OR distress OR ‘unmet needs’OR need*

4 Adult 9 adult OR adults OR men OR women OR man OR woman OR elderly OR ‘theaged’ OR ‘middle aged’ OR senior* OR geriatric*

5 Oceanic ancestrygroup

10 aborigi* OR indigenous*

*Combined as (#1 OR #6) AND (#2 OR #7) AND (#3 OR #8) AND (#4 OR #9) NOT (#5 OR #10)

1023Support Care Cancer (2022) 30:1021–1064

and higher than 70% as very good). Studies that combinedqualitative and quantitative methods (i.e., mixed methods)were assessed by the Mixed Methods Appraisal Tool(MMAT) [30]. Any initial differences (17%) were resolvedthrough discussion and consensus. Studies of all levels ofquality were included in the data synthesis.

Summary measures

Levels of psychosocial morbidity and quality of life (QOL)were measured in proportions. The unmet needs and experi-ences of people with cancer were documented thematically.

Results

Study selection

The search of electronic databases identified 4589 unique pa-pers published online since August 2010 (Figure 1). Afterremoval of duplicates, 4332 studies remained and were eval-uated on title and abstract. A total of 259 potentially relevantpapers were assessed on full text, of which 61 papers were

included. Four additional papers were identified through back-ward and forward citation searching, resulting in 65 studiesbeing included in this systematic review (August 2010–May 2021).

Study characteristics

Characteristics of studies identified through the systematicreview are presented in Tables 2, 3, 4, 5, 6. Of the 20 qualita-tive studies included, data collection methods included one-on-one interviews (n = 14), focus groups (n = 2), and com-bined interviews and focus groups (n = 4). Of these 20 studies,ten were conducted in Australia, five in the US, four inCanada, and one in Europe.Most studies focussed on a varietyof cancer types (n = 10), three each on breast and haemato-logical cancers, two on gynaecological cancer, and one eachon prostate and myeloma cancer.

Among quantitative studies, 35 utilised a cross-sectionalstudy design while six studies employed a longitudinal studymethodology. Of these 41 studies, 18 were conducted inAustralia, 16 in the US, six in Europe, and one in Canada.Most studies (n = 18) included participants with heterogenouscancers, eight with breast cancer, five with haematological

Records identified

through Embase

database search

(n = 441)

gnineercSdedulcnI

ytilibigilEnoitacifitnedI

Records after duplicates removed

(n = 4332)

Records screened

(n = 4332)

Records excluded

(n = 4073)

Full-text articles assessed for

eligibility

(n = 259)

Full-text articles excluded,

with reasons

(n = 198):

Not a primary study (n =

11)

Design was not

descriptive/ non-

experimental

(n = 8)

Not described as a rural

cancer population (n =

86)

Not focused on

psychosocial morbidity

or needs (n = 86)

Not a developed country

(n = 4)

Other reasons (n = 3)

Eligible studies for inclusion

(n = 61)

Studies included in

qualitative synthesis

(n = 65)

Records identified

through Medline

database search

(n = 3745)

Records identified

through PsycInfo

database search

(n = 231)

Records identified

through RURAL

database search

(n = 172)

Additional records

identified through

citations

(n = 4)

Figure 1 PRISMA studyselection flowchart


Table2

Qualitativestudiesincludingboth

ruraland

urbansurvivors

Author,

year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

Studieson

unmetneedsof

cancer

survivors

Jones,

2011

(United

States)

[31]

Cancer

survi-

vors

Qualitativedescriptive

study(hermeneutic

phenom

enological

approach

usingfocus

groups;

semi-structured

interview)

N/A

12urbanand

11urban

African

American

prostatecancer

survivorswererecruitedfrom

community

-based

centres(churches,

barbershops,diners,and

prim

arycare

clinics)in

centralV

irginiaand

Maryland

N/A

Prostatecancer

Twocommon

them

esem

erged:

(1)

family

andphysiciansupportare

important;and(2)insuranceisa

necessity

forappropriatehealthcare;

onemajor

difference

betweenrural

andurbanAfrican

American

prostate

cancer

survivorsem

erged:

rural

participantstalked

moreaboutu

sing

spiritu

ality

throughout

their

diagnosisandtreatm

entthanthose

who

lived

inurbanareas

Very go-

od

Miedema,

2013

(Canad-

a)[32]

Cancer

survi-

vors

Qualitativestudy

(open-ended

interviewsusingthe

Constructivist

GroundedTheory

approach)

N/A

15from

New

Brunswick

and15

from

theGreater

Toronto

Area

Twodistinctareasof

Canada:New

Brunswick,aruralE

astern

Canadian

province,and

Toronto,C

anada’s

largestm

etropolitan

centre

N/A

Various

(1to

5years

post--

diagnosis)

Three

them

esem

ergedfrom

the

analysisof

thedata:(1)

delayed

diagnosis(dismissedcomplaints,

wrong

diagnosis,unusualage

for

diagnosis);(2)

costrelatedto

cancer

treatm

ent(medicationcosts,

part-tim

ework,lack

ofsick

leaveand

limitedhealth

insurancecoverage,

andrelianceupon

parental

assistance);and(3)community

support(benefitevents,mealsand

supportfrom

friends,cancer

organisatio

nsupport);additional

them

ewas

satisfactionwith

care

(lackof

inform

ationandsupport,

regionalissues,top

classcancer

facility,andintensefollo

w-up

screening)

Very go-

od

Wenzel,

2012

(United

States)

[33]

Cancer

survi-

vors

Qualitativestudy

(sem

i-structured

focusgroups)

N/A

28urbanand

20rural

(snowball

sampling)

African

Americansresiding

inaruralarea

inVirginiaor

anurbanarea

inMarylandrecruitedfrom

community

-based

centres

N/A

Various

Four

mainissues

emergedfrom

the

analysisof

thedata:(1)

theneed

for

morehealth-related

and

cancer-specificeducation;

(2)the

importance

offaith

andspiritu

ality

;(3)the

availabilityof

support;and(4)

participants’difficulty

identifying

andarticulatingfinancialn

eeds

Good

Studieson

needsandpsychologicalm

orbidity

Galica,

2020

(Canad-

a)[34]

Cancer

survi-

vors


study

(sem

i-structured

N/A

6sm

allu

rban

and9rural

Participantscompleted

treatm

entatthe

CancerCentreof

South-eastern

Ontario

inKingston,Ontario,C

anada

N/A

Ovarian

cancer

(average

time

since

Fivethem

esforcoping

wereexpressed

byallw

omen:(1)

healthcare

provider

support;(2)know

ing,

trustin

g,andprioritisingself;(3)

Very go-

od


Tab

le2

(contin

ued)

Author,

year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

focusgroups

ortelephoneinterviews)

(conve-

nience

sample)

diagnosiswas

2.7years)

findingwhatw

orks;(4)

uniqueness

andbelonging;

and(5)redirecting

thoughtsandactio

ns.O

neadditio

nal

them

ewas

expressedby

most

wom

en:(6)

preparingforthefuture

Studieson

financialissuesandtravelissues

McG

rath,

2015

(Austra-

lia)[35]

Cancer

patients


study(open-ended,

in-depth

interviews)

N/A

5metro,16

regional,14

rural,9

remote,1

interstate

(purposive

sample)

The

studywas

funded

bytheLeukaem

iaFo

undatio

nof

Queensland(LFQ

)Australiaandparticipantswerechosen

from

theLFQ

patient

contactd

atabase

for2012;g

eographicallocation

definedby

distance

toprim

ary

specialistcentres

N/A

Haematological

cancer

Twoim

portantstrategies:(1)visitsby

metropolitan

haem

atologistto

regionalareas(benefits

included

not

having

toexperience

thestress

ofseparatio

nfrom

family

,reductio

nin

theneed

forlengthytravel,regional

hospitalisfamiliar,reductio

nin

the

financialcosto

ftreatm

ent,local

treatm

entw

ithregard

totaking

time

off);and

(2)opportunities

for

haem

atologypatientstoundergopart

orallo

ftheirtreatm

entatregional

hospitals(allo

wspatientsto

stay

with

inthecomfortof

theirow

nhome,physically

less

demanding,

very

convenient

andtim

esaving

for

thosewho

livelocally

,more

convenient,bonds

oftrustand

friendship

with

regionalhealth

professionals,regionalhospitalcan

beaccessed

bycar);lessens

the

emotionalimpactof

diagnosisand

treatm

ent,andpatientsarebetteroff

financially

beingtreatedregionally

Good

McG

rath,

2015

(Austra-

lia)[36]

Cancer

patients


study(open-ended,

in-depth

interviews)

N/A

5metro,16

regional,14

rural,9

remote,1

interstate

(purposive

sample)

The

studywas

funded

bytheLeukaem

iaFo

undatio

nof

Queensland(LFQ


from

theLFQ

patient

contactd

atabase

for2012;g

eographicallocation

definedby

distance

toprim

ary

specialistcentres

N/A

Haematological

cancer

Atthe

pointo

fdiagnosisandalongthe

continuum

oftreatm

ent,the

experience

ofrelocatio

nwas

associated

with

psychosocialstress;

major

issues

werethesenseof

disorientatio

nandbeing

overwhelm

edby

thespeedand

complexity

ofthecity;n

eeds

resulting

from

family

separatio

nare

notalwaysaddressedandwas

describedas

the‘biggest’issue

creatin

gdistress;the

distress

was

not

only

associated

with

lack

ofsupport

Good


Tab

le2

(contin

ued)

Author,

year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

andlonelin

essforpatientsbutw

asalso

relatedto

concerns

aboutthe

impactof

separatio

non

family

mem

bersremaining

athome;strong

them

eforthosewho

hadto

relocate

forspecialisttreatmentw

asthesense

ofbeingstuckin

thecity;stoicism

isassociated

with

ruralliving,which

couldtranslateinto

individualsnot

talkingabouttheirlongingto

gohome;manywould

prefer

theoptio

nof

accessingtreatm

entlocally

McG

rath,

2015

(Austra-

lia)[37]

Cancer

survi-

vors


study(open-ended,

in-depth

interviews)

N/A

5metro,16

regional,14

rural,9

remote,1

interstate

(purposive

sample)

The

studywas

funded

bytheLeukaem

iaFo

undatio

nof

Queensland(LFQ


from

theLFQ

patient

contactd

atabase

for2012;g

eographicallocation

definedbasedon

thegovernment

schemeforassistingpatientswith

travelandaccommodation(The

Patient

TransitSu

bsidySchem

e=PTSS)

N/A

Haematological

cancer

Eightthem

esem

ergedfrom

theanalysis

ofthedata:(1)

thechallengeof

accessingtreatm

entfrom

adistance;

(2)strategies

forovercomingthe

distance

barrier,includingwhat

works

nowandideasforthefuture;

(3)theim

portance

ofworkissues

for

both

thepatient

andtheirfamily

;(4)

theadditio

nalcostsof

relocatio

nand

treatm

ent;(5)the

factorscontributin

gtofinancialdistressandhardship;(6)

thefinancialb

uffers;(7)

the

possibility

ofaspiralto

poverty;

and

(8)thecontributio

nof

Leukaem

iaFo

undatio

nof

Queensland’s

supportiv

ecare

servicedeliv

eryto

amelioratin

gtheim

pactof

relocatio

n

Good


Table3

Qualitativestudiesincludingonly

ruralsurvivors

Author,

year

(country)

Populatio

nStudy

design

Response

rate

Sam

plesize

Settin

gMeasure

Typeof

cancer

Results

Study

quality

Studieson

theuseof

form

alandinform

almentalh

ealth

resources

Gunn,

2013

(Austra-

lia)[38]

Cancer

survi-

vors

Qualitativestudy

(sem

i-structured,

face-to-face,hour-long

interviews)

N/A

17Participantswererecruitedthrough

CancerCouncilSo

uthAustralia’s

supportedaccommodation

facilities,theruralm

ediaand

personalcontacts;rurality

was

definedby

the

Accessibility/Rem

otenessIndex

ofAustralia(A

RIA

)

N/A

Various

The

them

esidentifiedcouldbe

split

into

twobroadcategories:(A)

Issues

intheprovisionof

psychosocialcare:(1)

psychosocialsupportishighly

valued

bythosewho

have

accessed

it;(2)having

access

toboth

layandprofessional

psychosocialsupportisvitally

important;(3)accessing

psychosocialservices

ismade

difficultbyseveralbarrierssuch

aslack

ofinform

ationaboutservices,

initialbeliefsthey

are

unnecessary,feeling

overwhelm

ed,and

concerns

about

stigmaanddualrelatio

nships;(4)

medicalstafflocatedin

metropolitan

treatm

entcentres

are

notsufficiently

awareof

the

unique

needsof

ruralp

atients;(5)

patientsrequirebetteraccess

topsychosocialservices

post-treatment;(B)How

the

provisionof

psychosocialcare

couldbe

improved:(1)

providing

morerural-specificinform

ationon

psychosocialcare;(2)

improving

communicationbetween

healthcare

providersandreferral

topsychosocialservices;(3)

makingpsychosocialservices

astandard

partof

care

Very go-

od

Pascal,

2014

(Austra-

lia)[39]

Cancer

survi-

vors

Qualitativedescriptivestudy

(in-depthinterviews)

N/A

19(purposive

sampling)

The

samplewas

draw

nfrom

the

geographicsetting

with

inthe

Loddon-Malleeregion

ofCentral

Victoria,Australia;rurality

was

definedby

theAustralianInstitu

teof

Health

andWelfare

definitio

n

N/A

Various

(2years

post--

treatm

ent)

Psychosocialcare

provisionunmet

needsincluded

feelingletd

own

byform

alserviceprovision,sense

ofisolation,lack

ofaccess

topsychosocialcare,lackof

inform

ationandreferrals,lack

offollo

w-upcare,inaccessibilityof

services

dueto

distance

costor

waittim

es,and

lack

ofappropriate

Good


Tab

le3

(contin

ued)

Author,

year

(country)

Populatio

nStudy

design

Response

rate

Sam

plesize

Settin

gMeasure

Typeof

cancer

Results

Study

quality

carebasedon

age,stage,ortype

ofcancer;u

nmetneedsbasedon

professionalpsychosocialsupport

werebasedon

luck

ofgetting

support,or

having

family

mem

bers/friends,w

hohad

professionalor

medical

know

ledge;thereisamajor

gapin

psychosocialcare

provision

Studieson

unmetneedsof

cancer

survivorsandpatientsin

palliativecare

Adams,

2017

(United

States)

[40]

Cancer

survi-

vors

Qualitativestudy(focus

groups

andin-depth

interviews,using

semi-structured)

N/A

15Participantswho

lived

inoneof

three

ruralB

lack

Beltcountiesin

Alabamarecruitedthroughthe

Com

munity

Health

Advisorsas

ResearchPartner

(CHARP)

network;

ruralitynotd

efined

N/A

Wom

enwith

breastcancer

(average

5yearsin

survivorship)

Four

overarchingthem

esem

erged

during

theanalysisof

thedata:(1)

cancer

isasecret;(2)

perish

with

lack

ofknow

ledge;(3)startw

itha

good

prayer

life;and(4)lim

ited

survivorship

supportand

education;

thesefour

them

escan

furtherbe

dividedinto

thirteen

subthemes,asfollo

ws:(1)fatalism

atdiagnosis,delayin

treatm

ent,

fear

ofdisclosure;(2)

whatis

lymphedem

a,whatare

theside

effectsof

horm

onaltherapy,

sexuality

andbody

image,fatig

ue,

fearof

weightloss,depression;(3)

relig

ionandspiritu

ality

;and

(4)

family

/friendsupport,education

andsupport,cancer

surveillance,

awarenessof

breastcancer

advocacy

Good

Allen,

2014

(United

States)

[41]

Cancer

survi-

vors

Qualitativestudy

(face-to-faceor

telephone

interviews,

semi-structured

open-ended

interviews

grounded

inasocial

constructio

nisttheoretical

fram

ework)

N/A

20RuralAppalachiarecruitedfrom

cancer

centres:Southwestand

WestV

irginia

N/A

Gynaecological

cancer

The

studyprovides

threenew

perspectives:(A)participants

follo

wed

four

differentroutesin

learning

they

hadcancer:(1)

receivingadiagnosisim

mediately

upon

suspectin

gsymptom

s;(2)

enduring

aseries

oftestsand

waitin

gup

toayear

for

confirmation;

(3)liv

ingwith

the

suspicionthatsomething

was

wrong

butd

elayed

medical

confirmationuntil

aftermeetin

gfamily

responsibilities;(4)having

Very go-

od


Tab

le3

(contin

ued)

Author,

year

(country)

Populatio

nStudy

design

Response

rate

Sam

plesize

Settin

gMeasure

Typeof

cancer

Results

Study

quality

theircancer

discovered

during

routinegynaecologicalexam

;(B)

There

was

greatv

ariatio

nam

ong

thewom

enin

theirbeliefsabout

cancer

andfour

differentp

atterns

ofcancer

survivorship

were

revealed:(1)

positiv

eattitude;(2)

cautious;(3)

distanced;

(4)

resigned;and

(C)Alth

ough

not

everywom

enresonatedwith

beingacancer

survivor,every

wom

endidperceive

herselfto

bestrong

andfeltsupportedby

strong

family

tiesandstrong

connectio

nsto

higher

power

Coyne,

2019

(Austra-

lia)[42]

Cancer

survi-

vors

Qualitativestudy(in-depth

telephoneinterviews)

200 invited;

16 complet-

ed consent;

14 complet-

ed inter-

view

s

8survivorsand

6family

mem

bers

The

participantsforthisstudy

residedin

ruralQ

ueenslandand

hadstayed

inCancerCouncil

Queensland[CCQ]

accommodationduring

treatm

ent;

ruralisdefinedas

livingup

toand

over

180km

away

from

amajor

city

N/A

Various

Three

them

esem

ergedfrom

the

analysisof

thedata:(1)

confrontingdiagnosis,i.e.,the

initialshock,senseof

disbelief,

working

throughtheshock,and

theim

portance

ofsupportatthis

time,was

imperativ

e;(2)

challenges,i.e.,getting

through

thetreatm

ent,travellin

gto

and

from

treatm

ent;and(3)

negotiatin

gsupport,i.e.,person

with

cancer

feltconcernedabout

beingaburden

totheirfamily

and

inform

ationwas

achallengeas

itwas

notalwaysattheirlevelo

funderstanding(included

community

,spiritual,and

instrumentalsupport)

Very go-

od

Devik,

2013

(Norwa-

y)[43]

Cancer

patients

in pallia-

tive

care

Qualitativestudy

(interview

s;combined

phenom

enological

philo

sophywith

herm

eneutic

interpretatio

n)

N/A

5Contactwas

mediatedthroughan

oncologicpoliclin

icin

alocal

hospitalinNorway;the

participantsresidedin

communities

(bothmountainand

coastal)with

lowpopulatio

ndensity

;rangedfrom

920to

7775

N/A

Various

(incurable

cancer,

receiving

life--

prolonging

chem

othera-

py)

Four

them

esem

ergedfrom

the

analysisof

thedata:(1)

enduring

bykeepinghope

alive(subthem

es:

having

confidence

intheexpertise

atthepoliclin

ic,copingwith

conflictin

gfeelings,dream

ingand

makingplans);(2)

becoming

awarethatyouareyour

own

(subthem

e:navigatin

galone);(3)

livingup

toexpectations

ofbeing

Very go-

od


Tab

le3

(contin

ued)

Author,

year

(country)

Populatio

nStudy

design

Response

rate

Sam

plesize

Settin

gMeasure

Typeof

cancer

Results

Study

quality

agood

patient

(subthem

e:having

limitedcontrol,becominga

burden);and(4)beingatrisk

oflosing

identityandvalue

(subthem

e:beingin

decline,

losing

dignity

,losingcontinuity)

Duggleby,

2011

(Canad-

a)[44]

Cancer

patients

in pallia-

tive

care

Qualitativestudy

(open-endedinterviews

andfocusgroups

defined

ingrounded

theory)

N/A

6patients,10

family

caregivers,

and12

rural

healthcare

professionals

(purposive

sampling)

The

palliativecarecoordinatorsfrom

the3ruralh

ealth

regionsin

western

Canadacontacted

participants,self-reported

toliv

ein

aruralarea

N/A

Various

Four

them

esem

ergedfrom

the

analysisof

thedata:(1)

community

connectedness/isolation

(participantsdescribedfeeling

connectedto

theircommunity

aspartof

thesocialcontextb

utalso

isolated,ruralhealthcareproviders

connectedthroughliv

ingand

working

with

peoplethey

knew

both

personally

and

professionally);(2)lack

ofaccessibilitytocare(lackofaccess

topalliativecareservices

andlack

ofcontinuity

ofcare);(3)

communicationandinform

ation

issues

(poorcommunicationwith

healthcare

providersresultedin

palliativepatientsandtheirfamily

mem

bersperceiving

thatthey

werelackingim

portant

inform

ationregardingtheircare);

and(4)independence/dependence

(sharedsensethatpalliative

patients,together

with

their

inform

alandform

alcaregivers,

felttheneed

forretainingthe

patient’ssenseof

independence

asthey

becamemoredependento

nothers)

Very go-

od

Garrard,

2017

(Austra-

lia)[45]

Cancer

patients

and

their

family

Qualitativestudy

(sem

i-structured

interviewsbasedupon

the

Resilience

Modelof

Fam

ilyAdjustm

entand

Adaption)

N/A

10families,34

patientstotal

Participantswererecruitedviaa

mediareleaseandby

rurally

based

doctors;postcode

as‘outer

regional’accordingto

the

Accessibility/Rem

otenessIndex

ofAustralia(A

RIA

)

N/A

Not

reported

Three

keychallenges

were

identified:

(1)frequent

travel;(2)

increasedwork/financial

demands;and

(3)family

separatio

n;protectiv

einternal

factorswerean

adaptiv

ecommunicationapproach,

Very go-

od


Tab

le3

(contin

ued)

Author,

year

(country)

Populatio

nStudy

design

Response

rate

Sam

plesize

Settin

gMeasure

Typeof

cancer

Results

Study

quality

strength

offamily

relatio

nships

andits

value,andfamily

’sability

toproblem-solve

toprom

ote

norm

ality

;protectiveexternal

factorswereavailabilityand

engagemento

fcommunity

support,andtheability

toaccess

professionalsupportservices

Grimison.

2013

(Austra-

lia)[46]

Cancer

patients

Qualitative(focus

groups

andstructured

interviews

viatelephoneor

face-to-face)

N/A

36patients,14

carers,and

32health

professionals

New

South

Wales,A

ustraliaatfour

ruraland

regionalhospitalsand

threemetropolitan

locatio

ns;rural

area

definedby

Accessibility/remotenessindexof

Australia(A

RIA

)

N/A

Various

(diagnosed

inthelast2

years)

Sixthem

esem

ergedfrom

the

analysisof

thedata:(1)

access

tohealthcare

professionals;(2)

accesstoservices

forinvestig

ation

andtreatm

ent;(3)traveland

accommodation;

(4)quality

oftreatm

ent;(5)inform

ationand

supportn

eeds;and

(6)experience

ofhealthcare

professionals

Good

Loughery,

2019

(Canad-

a)[47]

Cancer

survi-

vors

Qualitativeinterpretiv

estudy

(open-ended,

semi-structured

interviews,face-to-face)

N/A

20(purposive

sampling)

Ruralor

northareasof

Manito

ba,

Canada

N/A

Wom

enwith

breastcancer

Findings

accordingtothedomains

ofthesupportiv

ecarefram

ework:(1)

physical:travelling

andaccess

toexperiencedandqualifiedhealth

professionalsresultedin

additio

nalb

urdens

onfamily

and

friends;however,the

positiv

erolesof

theruralcancerprogram

helped

manytransitio

nthrough

thephysicaldemands

thatwere

encountered;

(2)inform

ation:

numberof

factorsim

pacted

the

ability

toprocesstheinform

ation

such

asescalatin

gfears,long

traveldays,and

lack

ofasupport

person

availableto

attend

the

appointm

ent;(3)social:living

alonewas

positiv

eandnegativ

e,nurses

areim

portantinrural

setting,strongsenseof

community

butlackof

anonym

ityandinvasion

ofprivacy;

(4)

practical:b

urdenof

extensive

travel,relocation,em

ployment

challenges,and

financiallosses;

(5)em

otional:shock,disbelief,

Good


Tab

le3

(contin

ued)

Author,

year

(country)

Populatio

nStudy

design

Response

rate

Sam

plesize

Settin

gMeasure

Typeof

cancer

Results

Study

quality

denial,fear,uncertainty,anger,

guilt,feelin

gsof

anxiety,and

travelburden;(6)

psychological:

loss

ofcontrolo

vertheillness

experience,alteredbody

image

relatedto

hairloss,ordecreased

self-esteem;(7)

spiritu

al:as

difficultasthejourneywas,itw

asoftendescribedas

atim

efor

discovery

Saw

in,

2010

(United

States)

[48]

Cancer

survi-

vors

Qualitativestudy

(sem

i-structured

interview

usingaherm

eneutic

phenom

enological

strategy)

N/A

9(convenience

sample)

Ruralwom

enfrom

community

settingsin

western

Virginiaand

WestV

irginial;R

urality

was

determ

ined

byparticipants’

responsestotheRuralSu

rvey

and

confirmed

bymatching

participants’zipcodeswith

statisticson

ruralityfrom

the

VirginiaDepartm

ento

fHealth

,theUSCensusBureau,andthe

UnitedStates

Departm

ento

fAgriculture

(USD

A)

N/A

Wom

enwith

breastcancer

(average

9.8

years

post--

diagnosis)

Severalthemes

emergedrelatedto

theexperience

ofbreastcancer

with

anon-supportiv

eintim

ate

partnerin

aruralsettin

g:(1)

driving(driving

was

exhaustin

gandstressful);(2)

gossip

(wom

endidnotm

entio

nloss

ofprivacyin

term

sof

thebreastcancer,but

rather

inthecontexto

ftheir

difficultintim

atepartner

relatio

nships,w

hich

hadboth

positiv

eandnegativ

emanifestatio

ns);(3)rurallocation

astherapeutic

(alth

ough

the

participantsdidnoth

avethe

supporto

ftheirintim

atepartner,

they

describedtherurallocation

andphysicalspaceas

anim

portant

partof

theircancer

recovery);and

(4)community

support

(com

munity

supportw

asan

importantaspecto

fsupportfor

theseruralw

omen)

Good

Wagland,

2015

(Austra-

lia)[49]

Cancer

survi-

vors

Qualitative(sem

i-structured

interviewsthrough

interpretativ

ephenom

enological

analysis)

N/A

5Participantswererecruitedthrough

theLeukaem

iaFo

undatio

nNationalM

yelomaCoordinator

andthe‘M

yeloma’

newsletter

(ruralAustralia)

N/A

Myeloma

(average

5.2

years

post--

diagnosis)

Three

them

esem

ergedfrom

the

analysisof

thedata:(1)

isolation

duetoliv

ingwith

ararecancer;(2)

isolationwith

inthemyeloma

populatio

n;and(3)isolationdue

tothediseaseeffectsand

treatm

ent;isolationdepicted

the

senseof

beingaloneor

separated,

both

physically

and

Good


Tab

le3

(contin

ued)

Author,

year

(country)

Populatio

nStudy

design

Response

rate

Sam

plesize

Settin

gMeasure

Typeof

cancer

Results

Study

quality

psychologically

,from

potential

sourcesof

support

Studieson

needsandquality

oflife

Gunn,

2021

(Austra-

lia)[50]

Cancer

survi-

vors

and

their

carers

Qualitative(sem

i-structured,

face-to-face

interviews

throughthem

aticanalysis)

N/A

22Participantsexpressedinterestin

participatingin

response

tomedia

articles,posters,andnotices;rural

area

definedby

Accessibility/remotenessindexof

Australia(A

RIA

)

N/A

Various

(1–5

years

post--

treatm

ent)

Studyconsistedof

twoparts;partA

investigated

theim

pactof

post-treatmentchallenges

onquality

oflifeandfoundfour

overarchingthem

es:(1)

quality

oflifeisnotrestoredaftertreatm

ent

completion,e.g.,fearof

recurrence

andfeelingdepressed

orfatig

ued;

(2)lack

ofconfidence

inruralh

ealth

services’ability

tohelp

addresspost-treatment

quality

oflife;(3)challenges

with

returningto

metropolitan

centres,

such

astim

eaw

ayandfinancial

costs;and(4)mostsupport

provided

byfamily

,friend,nurses,

andsupportg

roups.PartB

investigated

howquality

oflife-relatedneedscouldbe

better

addressedandfoundsix

overarchingthem

es:(1)

engage

with

telephoneor

face-to-face

services;(2)

serviced

need

toreachout;(3)barrierstoaccessing

supportv

iainternet-based

programsstill

exist;(4)continuity

ofcare

highly

valued;(5)

nurses

areappropriateto

deliv

erpost-treatment,quality

oflife-focussed

support;and(6)

telehealth

ispopularalternativeto

face-to-face

appointm

ents

Very go-

od


Table4

Quantitativ

estudieswith

ruraland

urbancomparisongroups

Author,year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

Studieson

theuseof

form

alandinform

almentalh

ealth

resources

Andykow

ski,

2010

(United

States)[51]

Cancer

survivors

Cross-sectio

nal

34%

51ruraland

62 nonrural

Cancersurvivorswererecruited

from

thestate-wide,

population-basedKentucky

SEERCancerR

egistry(K

CR);

therural-nonruraldistinction

was

definedby

objective,

geographic,and

population-basedcriteria:2003

UnitedStates

Departm

ento

fAgriculture

(USD

A)

Rural-U

rban

Continuum

(RUC)Codes

The

MentalH

ealth

Resource

Questionnaire(M

HRQ)

Femalebreast

cancer,

colorectalor

haem

atological

cancer;1

to5

years

post-diagnosis

Ruralsurvivorswerelesslik

elyto

reportapsychologist(χ

2=

8.40,p

<0.01)or

support

group(χ

2=9.20,p

<0.01)

with

in30

milesof

home;rural

survivorswereless

likelyto

reportthey

couldaccess

asupportgroup

ifthey

wantedto

(χ2=4.56,p

<0.05);rural

cancer

survivorsreported

less

favourablepersonalattitudes

regardingtalkingto

friends/family

aboutemotional

difficulties(t(111)

=2.31;p

<0.05);ruralsurvivorsreported

less

favourablesocialnorm

sregardingaddressing

emotionald

ifficulties

bytalkingto

friends/family

(t(111)

=2.04;p

<0.05)or

participatinginasupportgroup

(t(111)

=2.17;p

<0.05);rural

survivorsreported

less

favourableattitudes

(t(111)

=2.05;p

<0.05)andsocial

norm

s(t(111)

=2.20;p

<0.05)

regardingMHresource

usage

Very goo-

d

Beraldi,2015

(Germany)

[52]

Cancer

patients

Cross-sectio

nal

89%

251ruraland

283urban

Datawas

obtained

from

the

MunichCancerRegistry;

ruralitywas

categorisedin

asimilarw

ayas

theRural-U

rban

Contin

uum

(RUC)Code,

consideringtheregional

conditionsof

Southern

Germany

Distresswas

evaluatedusingthe

DistressTherm

ometer(D

T)

andtheStress

inCancer

Patients(Q

SC-R10);

depression

andanxietywere

evaluatedby

thePatientHealth

Questionnaire(PHQ-4)

Colorectalcancer;

3monthsafter

surgery

Urban

patientstalked

less

with

theirdoctor

abouttheir

emotionalstate(65%

,p<0.01)

andshow

edpoorerknow

ledge

ofcancer-specificmental

health

resources(60%

,p<

0.002);a

good

doctor-patient

relatio

nshipwas

associated

with

abettermentalh

ealth

outcom

e;asignificant

predictorforacceptance

was

distress;9

4%of

patients

with

outa

nearby

support

facilitylived

inruralareas

(p<

0.001);there

wereno

group

differencesconcerning

distress,m

entalh

ealth

outcom

es,oracceptance

of

Very goo-

d


Tab

le4

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

cancer-specificmentalh

ealth

resources

Corboy,

2014

(Australia)

[53]

Cancer

survivors

Cross-sectio

nal

31%

286major

cities,104

inner

regional,

46outer

regional,

8remote,

3very

remote

Registeredwith

Australia

Medicare;geographic

remotenesswas

measuredas

acontinuous

variable,using

the

Accessibility/Rem

oteness

Indexof

Australia(A

RIA

+)

The

Liverpool

Stoicism

Scale

(LSS

);theNeedforControl

andSelf-reliancesubscaleof

theBarriersto

HelpSeeking

Scale

Australianmen

who

had

undergonea

radical

prostatectom

yas

treatm

entfor

prostatecancer;

9.11

months

post-diagnosis

Anincrease

ingeographic

remotenesswas

associated

with

adecrease

inintentions

touseatelephone-basedsupport

service;geographic

remotenessdidnotp

redict

perceivedbehaviouralcontrol;

relatio

nshipbetween

geographicremotenessand

intentionto

usea

telephone-basedsupport

servicewas

partially

mediated

bystoicism

andsubjectiv

enorm

s(r=−0

.04,p<0.001);a

significantd

irectp

ath

indicatedthatstoicism

significantly

increasedwith

distance

from

metropolitan

areas

Very goo-

d

Studieson

unmetneedsof

cancer

survivorsandsupportp

ersons

Ahern,2015

(Australia)

[54]

Cancer

survivors

Cross-sectio

nal

(10-year

replication

study)

81%

224major

cities,62

inner

regional,

39outer

regional,

remote,or

very

remote

Participantsweresourcesfrom

twoAustraliandatabases:

Register4

andtheBCNA

ReviewandSu

rvey

Group;

ruralitywas

definedby

the

AustralianBureauof

Statistics

(ABS)

Rem

otenessArea(RA)

code

Studyused

apreviouslyvalidated

survey;six

questions

were

added

Australianwom

enwith

breast

cancer

who

had

been

diagnosed

between6and

30months

before

thestart

ofthestudy

Therewereno

statistically

significantdifferences

foundin

inform

ationissues

received

andsatisfactionwith

sourcesof

supportb

ased

ongeographic

locatio

n;percentagesof

wom

enusingthenewspaperas

aninform

ationsource

was

statistically

significantlow

er(χ

2=8.033,p=0.018)inouter

regional,rem

ote,andvery

remoteareas(n

=8,21%)

comparedto

major

cities(n

=91,41%

)andinnerregional

areas(n

=30,48%

);a

statistically

significant

difference

was

foundwith

the

breastcancer

nurseas

asource

ofsupport(χ2=6.253,p=

0.044)atahigherpercentage

intheouterregional,rem

ote,and

very

remoteareas(16/39,

41%)comparedto

major

cities

Good


Tab

le4

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

(50/224,22%)andinner

regionalareas(17/62,27%

)Ahern,2016

(Australia)

[55]

Cancer

survivors

Cross-sectio

nal

(survey)

Not re

ported

604major

cities,207

inner

regional,

91outer

regional,

remote,or

very

remote

Participantsweresourcesfrom

twoAustraliandatabases:

Register4

andtheBCNA

ReviewandSu

rvey

Group;an

AustralianBureauof

Statistics

(ABS)

Rem

otenessArea(RA)

code

wasmanually

allocatedto

thephysicalresidentialaddress

ofeach

participanttoidentify

theirgeographicallocatio

n

Studyused

apreviouslyvalidated

survey;the

Supportiv

eCare

Needs

Survey

(SCN-SF3

4);

theCom

municationand

AttitudinalS

elf-EfficacyScale

forcancer

(CASE

-cancer)

Australianwom

enwith

breast

cancer

who

had

completed

activ

etreatm

ent

atleast6

months

before

starto

fthestudy

The

analysisof

unmetneedsby

geographicalresidence

revealed

twostatistically

significantfindings:(1)outer

regional,rem

ote,andvery

remoteareasweresignificantly

morelik

elyto

reportunmet

needsin

thechoice

about

which

healthcare

serviceor

hospitaltheyattended

(χ2=

8.780,p=0.012);and

(2)

major

citiesweresignificantly

morelik

elyto

reportunmet

needsin

beingtreatedin

ahospitalo

rclinicthatwas

asphysically

pleasant

aspossible

(χ2=6.151,p=0.046);n

osignificantd

ifferences

were

reported

inself-efficacyscores

across

geographicareas

Good

Lynagh,

2018

(Australia)

[56]

Inform

ative

care-

givers

Cross-sectio

nal

(population--

based)

35%

792urban

and193

rural

Recruitedfrom

5Australianstate

population-basedcancer

registries;residentialpostcodes

wereused

toclassify

support

personsas

‘rural’or

‘urban’

basedon

theAccessibilityand

Rem

otenessIndexof

Australia

(ARIA

+)

The

SupportP

ersonUnm

etNeeds

Survey

(SPU

NS);the

DepressionAnxiety

andStress

Scale(D

ASS

-21)

Haematological

cancer

Significantly

higherproportio

nof

ruralsupportpersons(76%

)hadatleasto

nemoderate/high/veryhigh

unmetneed

comparedwith

urbansupportp

ersons

(64%

,χ2=8.72,p

=0.003);

significantly

higher

proportio

nof

participantsliv

ingin

rural

areaswereforced

torelocate

temporarily

incomparison

with

thoseliv

inginurbanareas

(35vs

8%,p

<0.0001);40%

ofruralp

articipantshadto

travel

between2and5hcompared

with

only

5%of

urbansupport

persons,whiletraveltim

efor

themajority

ofthosein

urban

areas(81%

)was

less

than

1h

comparedwith

35%

inrural

areas(p

<0.0001);

significantly

,moreparticipants

from

ruralareas

reported

that

they

hadto

take

timeoffwork

Very goo-

d


Tab

le4

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

(52vs

43%,p

=0.023),had

less

income(37vs

27%,p

=0.009),had

difficulty

paying

bills

(22vs

13%,p

=0.002),

hadtroublemeeting

day-to-day

expenses

(15vs

8%,p

=0.011),and

were

forced

touseup

theirsavings

(28vs

16%,p

=0.0003)

Tzelepis,

2018

(Australia)

[57]

Cancer

survivors

Survey

35%

1145

urban

and272

rural

Recruitedfrom

5Australianstate


registries;residentialpostcodes

wereused

toclassify

support

personsas

‘rural’or

‘urban’

The

Survivor

Unm

etNeeds

Survey

(SUNS);the

Depression,Anxiety

and

Stress

Scale(D

ASS

-21)

Haematological

cancer

Feelin

gtired

was

themost

common

high/veryhigh

unmet

need

forrural(15.2%)and

urban(15.5%

)survivors;the

emotionalh

ealth

domainhad

thehighestm

eanscoreforrural

(M=0.66,S

D=0.84)and

urban(M

=0.73,S

D=0.92);

incontrast,the

access

and

continuity

ofcare

domainhad

thelowestm

eanunmetneed

scoreforruralsurvivors(M

=0.39,S

D=0.60)andurban

survivors(M

=0.37,S

D=

0.64);beingaruralresident

was

associated

with

adecreasedunmetem

otional

health

domainscore(ES=

−0.06;

95%

CI:−0

.11to

−0.01)

Very goo-

d

White,2011

(Australia)

[58]

Cancer

patients

Cross-sectio

nal

(survey)

47%

383metro,

234rural,

and169

remote

Participantswereidentified

throughtheWestern

AustralianCancerRegistry

(WACR);to

determ

ine

geographicalareas,the

AustralianBureauof

Statistics

(ABS)

remotenessclasses

wereadaptedusingtheABS

classifications

andcollapsed

into

metropolitan

(ABS=0);

rural/regional(ABS=1and2);

andremote(A

BS=3and4)

The

LongFo

rmSu

pportiveCare

Needs

Survey

(SCNS-LF5

9)Various

(6months

to2years

post-diagnosis)

Participantn

eeds

didnotv

aryby

geographicallocation,with

nosignificantd

ifferences

found

foranyof

the15

items;the

item

forwhich

thegreatest,

albeitnon-significant(p=

0.12)difference

was

seen,w

asconcernaboutfinancial

situation;

Differences

among

allo

ther

itemswerenot

significant(p-values

from

0.28

to0.96);proportio

nof

participantsreporting

‘moderateto

high

need’on

theseitemsdidnotd

iffer

significantly

across

Very goo-

d


Tab

le4

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

geographicalpopulatio

ns(p-valuesfrom

0.13

to0.91)

Studieson

needsandquality

oflife

Cahir,2017

(Ireland)

[59]

Cancer

survivors

Cross-sectio

nal

66%

698ruraland

870urban

Wom

enwith

breastcancer

were

identifiedinAugust2015from

theNationalC

ancerRegistry

Ireland(N

CRI)database;a

compositemeasure

ofurban–ruralclassificationwas

createdusingthreeindicators;

settlem

entsize,populatio

ndensity

,and

proxim

ityto

treatm

enth

ospital

The

Functio

nalA

ssessm

ento

fCancerT

herapy

(FACT-G

);an

endocrinesubscale(ES)

Wom

enwith

breastcancer

1–5years

post-diagnosis

The

associationbetween

urban–ruralresidence/status

andQOLandendocrine

symptom

swas

assessed

using

linearregression

with

adjustmentfor

sociodem

ographicandclinical

covariates;inmultiv

ariable

analysis,ruralsurvivorshada

statistically

significanth

igher

overallQ

OL(β

=3.81,

standard

error(SE1.30,p

<0.01),em

otionalQ

OL(β

=0.70,S

E0.21,p

<0.01),and

experiencedalower

symptom

burden

(β=1.76,S

E0.65,p

<0.01)than

urbansurvivors

Very goo-

d

Pateman,

2018

(Australia)

[60]

Cancer

patients

Prospectivestudy

with

baselin

e(prior

totreatm

ent),1

month,and

6months

post-treatment

86% ba

selin

eand

56.8%

lostto

follo

w--

up

48major

city,25

inner

regional.

18outer

regional,

3remote,

1very

remote

Tertiary

hospitalinBrisbane,

Australia;rurality

was

classified

accordingto

the

AustralianStandard

Geographic

Classification-Rem

oteness

Area(A

SCG-RA)system

The

University

ofWashington

Qualityof

LifeSu

rvey

(UW-Q

OL)

New

lydiagnosed

patientswho

werereferred

for

thediagnosis,

and/or

treatm

ent

ofhead

and

neck

cancer

Atb

aseline,theregional/rem

ote

groupscored

significantly

worse

inthepain

domain

comparedwith

the

metropolitan

group(p

=0.031);P

osth

ocχ2testsdid

notreveala

significant

difference

betweenurbanand

regional/rem

otegroups

for

tumour-relatedvariables,such

asstaging;

therewas

atrend

towards

lower

scores

inthe

globalQOLam

ongthe

regional/rem

otegroupatall

threetim

epoints;h

owever,

thisassociationdidnotreach

statisticalsignificance

Very goo-

d

Pedro,2014

(United

States)[61]

Cancer

survivors

Cross-sectio

nal

(survey)

35%

for

RUCC

7,31%

for

RUCC

8,and

41%

for

RUCC

9

49RUCC7,

28RUCC

8,14

RUCC9

Participantswererecruitedfrom

theColoradoCentralCancer

Registry(CCCR);ruralitywas

basedon

the2003

Rural-U

rban

Contin

uum

Codes

(RUCCs):

RUCC7(urban

populationof

2,500–19,999,not

adjacent

toametro

area),RUCC8

(com

pleteruralityor

less

than

The

RosenbergSelf-EsteemScale

(RSE

S);the

PersonalResource

Questionnaire

(PRQ)2000,a

measure

ofsocialsupport;and

theEuropeanOrganisationfor

theResearchandTreatmento

fCancerQ

ualityof

LifeCore30

(EORTCQLQ-C30)

Various

Asignificantd

ifferencewas

notedbetweenRUCC7and

RUCC9in

socialfunctio

ning

(β=−0

.25,p<0.05),

symptom

-related

QOL(β

=0.26;p

<0.05),andfinancial

difficulties(β

=0.31,p

<0.05);

thoseresiding

inRUCC7

reported

poorer

social

Very goo-

d


Tab

le4

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

2,500urbanpopulation,

adjacent

toametro

area),and

RUCC9(com

pleteruralityor

less

than

2,500urban

populatio

n,notadjacenttoa

metro

area)

functio

ning

scores,w

orse

symptom

score,andgreater

financiald

ifficulties

than

those

residing

inRUCC9;

differencesbetweenRUCC8

andRUCC9follo

wed

asimilarpattern,but

RUCC8

reportingmoresymptom

s(β

=0.31,p

<0.05);self-esteem

andsocialsupportstrongly

correlated

with

HRQOL

Thomas,

2014

(Ireland)

[62]

Cancer

survivors

Cross-sectio

nal

(population

survey)

59%

361urban

and214

rural

The

NationalC

ancerRegistry

Irelandwas

used;3

composite

measuresfordefining

rurality

wereused:self-reported

area,

distance

from

theparticipant’s

currentresidence

tothe

hospitalfrom

theregistry,and

populationdensity

The

Functio

nalA

ssessm

ento

fCancerTherapy

(FACT-G

)—

specificto

head

andneck

cancer

survivors(FACT-H

N)

Headandneck

cancer(atleast8

months

post-diagnosis)

Controllin

gfordemographicand

clinicalvariables,rural

survivorsreported

higher

physical(coefficient

1.27,

bias-corrected

andaccelerated

95%

CI0.54–2.43),emotional

(coef.0.99,95%

CI

0.21–2.02),and

HNC-specific

(coef.1.55,95%

CI0

.32–3.54)

QOLthan

theirurban

counterparts;socialand

functio

nalQ

OLdidnotd

iffer

significantly

Very goo-

d

Thomas,

2015

(Ireland)

[63]

Cancer

survivors

Cross-sectio

nal

(survey)

39%

166remote

and330

not

remote

The

NationalC

ancerRegistry

Irelandwas

used;d

istance

from

residenceto

hospitalw

asused

todefine

rurality‘urban’

basedon

theAccessibilityand

Rem

otenessIndexof

Australia

(ARIA

+)

The

EuropeanOrganisationfor

theResearchandTreatmento

fCancerQ

ualityof

LifeCore30

(EORTCQLQ-C30)

Colorectalcancer

(atleast6

months

post-diagnosis)

Livingremotefrom

thetreating

hospitalw

asassociated

with

lower

physicalfunctio

ning

(coefficient

−4.38[95%

CI

−8.13,−0

.91])androle

functio

ning

(coef.−7

.78

[−12.64,−2

.66])am

ongall

colorectalcancer

survivors;in

separategender

models,

remotenesswas

significantly

associated

with

lower

physical

(coef.−7

.00[−13.47,−1

.49])

androlefunctioning

(coef.

−11.50

[−19.66,−2

.65])for

wom

en,but

notfor

men;

remotenesshadasignificant

negativ

erelatio

nshipto

global

health

status

(coef.−4

.31

[−8.46,−

0.27])formen

lowest

meanunmetneed

scorefor

rural(M

=0.39,S

D=0.60)

Very goo-

d


Tab

le4

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

andurban(M

=0.37,S

D=

0.64)

Studieson


orbidity

Andykow

ski,

2014

(United

States)[64]

Cancer

survivors

Cross-sectio

nal

26% cancer

group;

23%

health

control

group

193cancer

group;

152health

control

match


from

thepopulation-based

SEERKentuckyCancer

Registry(K

CR);ruralnessof

residencewas

categorised

basedon

county

ofresidence

using2003

UnitedStates

Departm

ento

fAgriculture

Rural–U

rban

Continuum

(RUC)Codes

The

Medicaloutcom

esstudy

36-item

short-form

health

Survey

(SF-36);theHospital

Anxiety

andDepressionScale

(HADS);the

Distress

Therm

ometer(D

T);Perceived

Stress

Scale(PSS

)

Non-smallcell

lung

cancer

10–15months

post-diagnosis

43%

ofruralreportedclinically

importantd

istress

(HADS-Total≥15)compared

with

24%

ofurbansurvivors

(χ2=8.44,p

<0.01);60%

ofruralsurvivorsmetcriteriafor

moderate/severedistresson

the

DT(D

Tratin

g≥4)

compared

with

43%

foru

rban

(χ2=4.82;

p<0.05);ruralcancer

survivorsreported

poorer

mentalh

ealth

relativeto

urban

cancer

survivorswith

amean

effectsize

of0.43

SDin

unadjusted

analyses

and0.29

SDadjusted

foreducationand

physicalcomorbidity

onthree

mentalh

ealth

indices;therural

cancer

groupreported

poorer

mentalh

ealth

than

therural

controlg

roup

onallm

ental

health

indiceswith

ameanES

of0.51

SD;the

mentalh

ealth

ofurbancancer

andhealth

controlg

roupsdidnotd

iffer

(meanES=0.00

SD)

Very goo-

d

Andykow

ski,

2017

(United

States)[65]

Cancer

survivors

Cross-sectio

nal

26%

117ruraland

76urban


from

thestate-wide,

population-based,Su

rveillance

Epidemiology

andEnd

Results

(SEER)KentuckyCancer

Registry(K

CR);ruralnessof

residencewas

categorised

basedon

county

ofresidence

usingthe2003

UnitedStates

Departm

ento

fAgriculture

The

PosttraumaticGrowth

Inventory(PTGI);the

Benefit-FindingQuestionnaire

(BFQ

);theHospitalA

nxiety

andDepressionScale(H

ADS);

theMedicaloutcom

esstudy

36-item

short-form

(SF-36)

Non-smallcell

lung

cancer

10–15months

post-diagnosis

Nosignificantd

ifferencewas

foundbetweenruraland

urban

forBFQ

totalscores;ruraland

urbandiffer

with

regard

toPT

GItotalscores(p

=0.042;

ES=0.30

SD);ruralcancer

survivorsreported

greater

grow

thon

allfivePT

GI

subscales(binom

ialtest,p=

0.062,two-tailed);significant

difference

betweenruraland

urbanwas

evidentfor

the

Spiritu

alChangesubscale(p

=0.03,E

S=0.32

SD);

difference

betweentherural

andurbancancer

survivor

groups

with

regard

toPT

GI

Very goo-

d


Tab

le4

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

totalscores(p

=0.045,ES=

0.32

SD);ruralcancer

survivorscontinuedto

report

greatergrowthon

allfivePT

GI

subscales(binom

ialtest,p=

0.062,two-tailed);a

significant

difference

betweenruraland

urbangroups

was

evidentfor

theAppreciationforLife

subscale(p

=0.043,ES=0.31

SD)

Carey,2017

(Australia)

[66]

Inform

ative

care-

givers

Cross-sectio

nal

35% returned

com-

plete

survey;

66%

ofsurvi-

vors

hada

support

person

187ruraland

783urban

Recruitedfrom

5population-basedcancer

registries

inAustralia;the

AccessibilityandRem

oteness

Indexof

Australia(A

RIA

+)

classificationwas

used

todefine

rurality

The

Depression,Anxiety,and

Stress

Scale(D

ASS

-21);the

SupportPerson

Unm

etNeeds

Survey

(SPU

NS)

Haematological

cancer

Nosignificantd

ifferences

inproportionof

urbanversus

ruralsupportpersonsin

elevated

levelsof

depression

(21%

vs23%),anxiety(16%

vs17%),or

stress

(16%

vs20%);odds

ofhaving

atleast1

DASS

outcom

eincreased

between12

and18%

foreach

additio

nalh

igh/very

high

unmetneed

(p<0.0001);odds

ofreportingatleast1

indicator

ofpsychologicalm

orbidity

increasedby

10to17%

andby

2%forthosewho

had

relocatedto

receivetreatm

ent

andwas

decreasedby

5to54%

forthosesupportp

ersons

who

reported

thatthey

hadno

chronichealth

conditions;

supportp

ersons

who

hadto

relocatehad2.06

higher

odds

ofhaving

DASS

≥1(95%

CI:

1.15

to3.70,p

=0.015)

Very goo-

d

Corboy,

2019

(Australia)

[67]

Cancer

survivors

Cross-sectio

nal

Not re

ported

286urban

and161

rural

Registeredwith

Australia

Medicare;geographic

remotenesswas

definedby

the

Accessibility/Rem

oteness

Indexof

Australia(A

RIA

+)

The

Brief

Symptom

Inventory

(BSI);theFu

nctio

nal

Assessm

ento

fCancer

Therapy–P

rostateCancer

Subscale(FACT-PC);the

NeedforControl

and

Self-RelianceSu

bscaleof

the

BarrierstoHelpSeekingScale;

theLiverpool

Stoicism

Scale

(LSS)

Australianmen

who

had

undergonea

radical

prostatectom

yas

treatm

entfor

prostatecancer

Average

psychologicald

istress

scoremeasuredby

BSIwas

49.25(SD=12.54);sim

ilar

percentage

ofmen

intheurban

cohort(n

=61;2

1.3%

)and

men

intheregional/rem

ote

cohort(n

=33;20.4%

)metthe

criteriaforcaseness;p

lace

ofresidencedidnotp

redict

psychologicald

istress;

Stoicism

×Placeof

Residence

Very goo-

d


Tab

le4

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

was

asignificantp

redictor

ofpsychologicald

istress(urban:

b=0.18,t(443)=2.20,p

=0.02);regional/rem

otecohort,

theassociationbetween

stoicism

andpsychological

distress

was

notsignificant

Grov,2011

(Norway)

[68]

Cancer

survivors

Cross-sectio

nal

53%

223urban

and256

rural;

1437

control

The

Nord-Trøndelag

Countyof

Norway

consistsof

four

cities,

which

weredefinedurban;

othermunicipalities

were

definedarural

The

HospitalA

nxiety

and

DepressionScale(H

ADS);

Rosenberg

Self-Esteem

instrument

Elderly

cancer

survivors

(ECSs)with

variouscancer;

short-term

ECSs

1–5years

post-diagnosis,

long-term

beyond

5years

Ruralversus

urbanareasof

living

explained6.3%

variance

inbeingaruralinhabitant;

self-reportedhealth

was

significanto

nthemodeland

explained3%

ofthevariance

betweenruraland

urban(O

R=

2.03,95%

CI1.28–3.21,p=

0.003)

Good

Gunn,2020

(Australia)

[69]

Cancer

survivors

Cross-sectio

nal

(survey)

11.8%

3379

urban,

776rural,

140

remote

Datacollected

betweenJanuary

2010

andJune

2015

were

obtained

from

theSo

uth

AustralianMonitoring

and

SurveillanceSy

stem

(SAMSS

)

Self-reportedhealth,

psychologicald

istress(K

essler

PsychologicalD

istressScale–

K10),suicidalideatio

n(four

questions

from

theGeneral

Health

Questionnaire)

Various

Nodifference

intheproportio

nof

cancer

survivorswho

reported

high/veryhigh

levelsof

distress

(urban

9.6%

vsrural

7.0%

,p=0.04);ruralcancer

survivors’lower

odds

ofreportinghigh/veryhigh

distress

was

evidentinthe

partially

adjusted

(OR=0.59,

95%

CI0.41–0.84,p=0.004)

andfully

adjusted

model(O

R=0.47,95%

CI0.32–0.69,p<

0.001);h

igherproportio

nof

ruralcancersurvivorswho

indicatedthey

believedpeople

theirneighbourhoodtrusted

oneanother(89%

vs80%,p

<0.001)

Very goo-

d

Hall,2016

(Australia)

[70]

Cancer

patients

and

survivors

Cross-sectio

nal

(survey)

35%

1144

urban

and270

rural

Survivorswererecruitedfrom

5Australianstate


registries(registriesA,B

,C,D

,andE);residentialp

ostcodeat

diagnosisclassified

bythe

AustralianBureauof

Statistics

AccessibilityandRem

oteness

Indexof

Australia(A

RIA

+)

definedrurality

The

DepressionAnxiety

and

Stress

Scale21-item

version

(DASS

-21)

Haematological

cancer

Ofurbansurvivors,25%

(n=

274),24%

(n=268),and

17%

(n=194)

reported

above

norm

allevelsof

anxiety,

depression,and

stress,

respectiv

ely;

27%

(n=70),

28%

(n=74),and15%

(n=

38)of

ruralsurvivorsreported

abovenorm

allevelsofanxiety,

depression,and

stress;anxiety,

depression,and

stresswerenot

significantfor

locatio

n;

Very goo-

d


Tab

le4

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

however,O

Rforruralv

ersus

urbanwas

anxietyOR=1.14,

depression

OR=1.38,stress

OR=0.87

Schootman,

2013

(United

States)[71]

Cancer

survivors

Cross-sectio

nal

57.4%

in2009

and

59.5%

2010

471ruraland

3088

control;

701urban

and5270

control

The

2009-2010Missouri

BehaviouralRiskFactor

SurveillanceSy

stem

was

used;

thecounty

ofresidencewas

codedaccordingto

itslocation

inametropolitan

statistical

area

(MSA

)as

definedby

the

USOfficeof

Managem

entand

Budget

Self-reportedby

interview;the

Patient

Health

Questionnaire

(PHQ-8)

Various

Prevalence

offair/poorhealth

was

38.5%

amongruralcom

pared

with

27.4%

amongurban

survivorsandless

than

20%

amongboth

controlg

roups;

aftercontrolling

for

sociodem

ographicfactors,

prevalence

offair/poorhealth

was

similarforruraland

urban

survivorsbuth

igheram

ong

controls;ruralsurvivors

(48.8%

)hadahigher

prevalence

offatig

uethan

rural

controls(27.9%

)andurban

survivors(36.1%

)reported

morefatig

uethan

urban

controls(26.5%

);no

differencesam

ongthe4

groups

whencontrolling

for

sociodem

ographic

characteristics,access

tomedicalcare,orchronic

conditions;percentage

who

reported

getting

socialand

emotionalsupportdidnotvary

significantly

across

the4

groups;ruralsurvivors

(61.7%

)wereless

likelyto

receivefollow-upcare

instructions

than

urban

(78.2%

)survivors(p

=0.2)

Very goo-

d

Watts,2016

(Australia)

[72]

Cancer

patients

Cross-sectio

nal

Not re

ported

67major

city,162

inner

regional,

189outer

regional,

21 remote,

and2very

remote

Distressscreeningdatawere

routinelycollected

follo

wing

implem

entatio

nof

screening

acrosssevenWesternAustralia

health

regions;theAustralian

Standard

Geographical

Classification(A

SGC)

Rem

otenessAreas

was

used

DistressTherm

ometerand

Problem

List(DT-PL)

Various

Nosignificantd

ifferences

indistress

levelsacross

the

remotenesscategories

(χ2=

3.91,p

=0.27);Kruskal-W

allis

testrevealed

asignificant

difference

innumberof

problemsacross

thefour

remotenesscategories

(χ2=

10.58,p=0.01);patientsinthe

remotecategory

reported

alower

mediannumberof

Very goo-

d


Tab

le4

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

problems(M

d=7.0)

than

patientsin

theotherthree

categories

combined(M

d=

10.0;U

=3482,z

=−2

.23,p=

0.03,r

=0.11);significant

associationbetween

remotenessand

insurance/financialp

roblem

s(χ

2=8.19,p

=0.04,C

ramer’s

V=0.14),andremotenessand

transportatio

ndifficulties(χ

2=

13.07,p=0.004,Cramer’sV=

0.17);in

theem

otional

domain,remotenesswas

significantly

associated

with

fears(χ

2=16.03,p=0.001,

Cramer’sV=0.19),sadness

(χ2=14.33,p=0.002,

Cramer’sV=0.18),andworry

(χ2=18.56,p<0.001,

Cramer’sV=0.21)

Studieson

financialissuesandtravelissues

Paul,2013

(Australia)

[73]

Cancer

patients

Registry-based

study

37%

149urban

and119

rural

Astate-based(W

estern

Australia)

cancer

registry

inAustralia;

ruralitydefinedby

the

AccessibilityandRem

oteness

Indexof

Australia(A

RIA

+)

The

DepressionAnxiety

and

Stress

Scale(D

ASS

-21)

Haematological

cancer

who

had

been

diagnosed

intheprevious

3years

53%

inouterregional/rem

ote

locatio

nshadto

relocatefor

treatm

entcom

paredto

20%

from

innerregionaland3.4%

from

metropolitan

locatio

ns(χ

2=74.32,p<0.001);5

5%liv

ingin

anonm

etropolitan

area

travelled≥1hcompared

to13%

from

major

city

(χ2=

49.1,p

<0.001);logistic

regression

analysisindicated

thatparticipantsliv

ingin

nonm

etropolitan

areashad17×

theodds

ofreportinga

locatio

nal/financialbarrieron

access

tocare

comparedto

thosein

metropolitan

areas;

survivorslivingin

major

city

reported

significantly

more

financialimpact(χ

2=6.06,p

=0.014)

Very goo-

d

Vanderpool,

2020

Cancer

survivors

Survey

ASK

was

22%

and

179ASK

and504

HIN

TS

Appalachian

Kentucky;

Geographicstratawerebased

onthe2013

U.S.D

epartm

ent

The

Health

Status

ofKentucky

(ASK

)survey;H

ealth

Various

77%

oftheAppalachian

survivors

residedin

countiesdesignated

asstrata3–4;geographicstrata

Very goo-

d


Tab

le4

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

(United

States)[74]

HIN

TS

was

34%

ofAgriculture’sRural-U

rban

Contin

uum

Codes

(RUCC):

strataIincluded

countieswith

RUCCcodes1–3,which

are

considered

metro

counties,

whilestrataII(RUCC4–5),

strata3(RUCC6–7),and

strata4(RUCC8–9)

included

countieswith

populatio

nsizes

of20,000

ormore,

2,500–19,999,and

less

than

2,500,respectively

Inform

ationNationalT

rends

Survey

(HIN

TS)

was

significantly

correlated

with

cancer-related

financial

distress

amongAppalachian

Kentuckysurvivorswith

higher

percentagesof

distress

reported

amongresidentsof

strata3and4(p

=0.0013);

majority

ofHIN

TS

respondents(85%

)residedin

strata1counties;am

ong

HIN

TSrespondents,

geographicstratawas

not

significantly

associated

with

cancer-related

financial

distress;A

SKcancersurvivors

weresignificantly

morelik

ely

toreportfinanciald

istress

(64%

)comparedto

HIN

TS

cancer

survivors(37%

,p<

0.0001);geographicstratadid

notretainsignificance

inthe

finalm

odel(p

=0.355)

for

ASK

;intheHIN

TS

multiv

ariateanalysis,

geographicstratawas

not

associated

with

financial

distress

(p=0.983)

Zahnd,2019

(United

States)[75]

Cancer

survivors

Cross-sectio

nal

(population--

basedsurvey)

Between

32and

40.0%

1136

urban

and223

rural

Nationalsurveyby

theNational

CancerInstitu

te;rural-urban

status

was

determ

ined

using

the2003

USDepartm

ento

fAgriculture

Rural-U

rban

Contin

uum

Codes

(RUCC)

The

NationalC

ancerInstitute’s

(NCI)Health

Inform

ation

NationalT

rendsSu

rvey

(HIN

TS):2

012,2014,and

2017

Various

Overallprevalence

offinancial

burden

was

20%

higheram

ong

survivors;50.4%

oftotalrural

cancer

survivorsindicated

financialp

roblem

sfollowing

theirdiagnosisandtreatm

ent

comparedto

38.8%

ofurban

survivors(difference=11.6%,

p=0.02);however,after

adjustmentfor

covariates,

49.3%

ofruralcancer

survivorsreported

financial

problemsfollo

wingdiagnosis

andtreatm

entcom

paredto

38.7%

ofurbansurvivors,but

notstatisticallysignificant(p=

0.06)

Very goo-

d

Cancer

patients

Populatio

n-based

longitudinal

44%

890major

cities,373

Participantswereselected

from

NSW

andVictorian

Cancer

Datawereobtained

byself-report

survey

andfrom

theCancer

Duringthefirst1

2monthsafter

diagnosis,outer


Tab

le4

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Samplesize

Setting

Measure

Typeof

cancer

Results

Study

quality

Zucca,2011

(Australia)

[76]

cohort(at6

and

12months)

inner

regional,

136outer

regional,

and11

remote

Registries;cut-pointfor

travel

burden

as≥2honeway

Registries;singleitem

from

The

EuropeanOrganisationfor

ResearchandTreatmento

fCancerQualityof

Life

Questionnaire

(EORTC

QLQ-C30

v3);singleitem

from

theSu

pportiv

eCare

Needs

Survey

Accessto

Services

Module

Various

(duringthe

first1

2months

afterdiagnosis)

regional/rem

oteresidentshad

thegreatesttravelburden;61%

travelledatleast2

honeway

toreceivetreatm

entand

49%

lived

away

from

hometo

receivetreatm

ent;strongest

associates

oftravelburden

wereliv

ingin

regional/rem

ote

areas(O

R=18.9–135.7),

having

received

surgery(O

R=

6.7)

orradiotherapy

(OR=

3.6);between6and12

months

afterdiagnosis,2%

ofpatients

declined

cancer

treatm

ent

becauseof

thetim

eitwould

take

togettotreatm

ent;

patientswho

travelledmore

than

2hor

lived

away

for

treatm

entreported

significantly

greaterfinancial

difficulties(38%

;40%

)than

thosewho

didnot(12%;14%

),even

afteradjustingfor

covariates

Very goo-

d

Studieson

satisfactionwith

life

Cipora,2018

(Polan-

d)[77]

Cancer

patients

Cross-sectio

nal

Not re

ported

48ruraland

73urban

Wom

enwho

hadundergone

surgicaltreatm

entinthe

Sub-CarpathianOncology

Centrein

Brzozów

,Poland

The

Satisfactionwith

LifeScale

(SLS)

Wom

enwith

illbreastcancer

Levelof

satisfactionwith

life

varied

accordingto

placeof

residence:urbanwas

22.04

(6.15sten

score)vs

18.56(4.85

sten

score)

forruralw

omen

(p<0.001);ineach

category

ofthescale,ruralw

omen

(low

satisfaction)

hadsignificantly

lower

scores

than

urban

wom

en(m

ediocre

satisfaction),the

p-valuefor

individualstatem

entsremained

p=0.001andp=0.000

Good


Table5

Quantitativ

estudiesincludingonly

ruralsurvivors

Author,

year

(country)

Populatio

nStudydesign

Response

rate

Sam

ple

size

Settin

gMeasure

Typeof

cancer

Results

Study

quality

Studieson

theuseof

form

alandinform

almentalh

ealth

resources

Corboy,

2011

(Australi-

a)[78]

Cancer

patients

and

survivors

Cross-sectional

Not re

port-

ed

40inner

region-

al,31

outer,

and5

remote

The

men

wereliv

ingin

ruraland

regionalareaswithin

the

Grampiansregion

inthestateof

Victoria,Australia;ruraland

regionalareasweredefinedusing

theARIA

+index(M

oderately

Accessible,Accessible,and

Rem

ote)

Listo

fPh

ysicalCom

plaints;Brief

Symptom

Inventory(BSI);S

ocial

SupportS

ubscaleof

theCoping

Resources

Inventory

Men

with

various

cancers

27participantsmetthedefinitionof

caseness

(i.e.,BSIT-score

of63),

indicatingprobableclinically

significantp

sychologicaldistress;

regression

analysisdemonstrated

thatlevelo

fphysicaldistress

was

significantfor

psychological

distress;8

2%wereaw

areof

atleasto

neform

alserviceoffering

emotionalsupportand49%

had

used

such

aservice;telephone-and

Internet-based

services

weremost

used

type

ofsupport;lower

age

was

apredictorofparticipationina

form

alservice(average

8years

younger;M

=65.00(SD=7.68)

(SD=11.2)versus

M=73.05(SD

=7.68))

Poor

McD

owell,

2011

(Australi-

a)[79]

Cancer

survivors

Longitudinal

study

(baselineand

6months)

61%

396

Regionalcancertreatm

entcentrein

Queensland,Australia;rurality

not

defined

The

ENRICHDSo

cialSu

pport

Instrument;theIm

pactof

Events

Scale(IES)

Various

14%

ofcancerpatientsreported

using

psychosocialsupport;females

(OR

=2.73;9

5%CI1.26–5.94)

and

patientswith

morepositive

attitudes

(OR=1.69;9

5%CI

1.03–2.79)

towards

help

seeking

weremorelik

elyto

have

utiliseda

supportservice;the

relationship

betweenpositiv

eattitudes

toseekinghelp

andpsychosocial

supportservice

usewas

mediated

bybehaviouralintentio

ns(O

R=

1.91,95%

CI1.26–2.90);p

atients

reported

high

levelsof

social

support(M

=20.81,SD

=4.78),

andlowsocialconstraints(M

=1.68,S

D=0.69)

Very goo-

d

Studieson

unmetneedsof

cancer

patientsandsurvivors

Bazzell,

2015

(United

States)

[80]

Cancer

patients

Cross-sectional

(survey)

Not re

port-

ed

52Participantw

ererecruitedatthe

American

CancerSo

ciety

sponsoredevents;the

Health

Resources

andServices

Ad m

inistrationof

theUS

Departm

ento

fHealth

andHum

anServices

definitio

nof

ruralw

asused

The

Survivors’Unm

etNeeds

Survey

(SUNS)

Failedto

collectdata

onthis;

meanyears

since

diagnosis

was

9.65

25%

oftheruralsurvivorsreported

high/veryhigh

emotionalhealth

oraccess

andcontinuity

ofcare

unmetneeds;ANOVAresults

provideevidence

thatthereisa

difference

betweensurvivor

years

sincediagnosisandaccess

and

continuity

ofcare

unmetneeds(F

=4.891,p=.002);ANOVA

results

founddifferencesbetween

Very goo-

d


Tab

le5

(contin

ued)

Author,

year

(country)

Populatio

nStudydesign

Response

rate

Sam

ple

size

Settin

gMeasure

Typeof

cancer

Results

Study

quality

survivor

ageandem

otionalu

nmet

needs;access

tointerventio

nsand

survivorship

resourceswerefound

tobe

limitedin

ruralareas

Glasser,

2013

(United

States)

[81]

Cancer

survivors

andtheir

signifi-

cant

other

Cross-sectional

(survey)

Not re

port-

ed

29survi-

vors

and15

part-

ners

Survivorsof

cancer

wererecruited

from

tworuralcom

munity

cancer

programsin

Illinois;ruralitynot

defined

The

DistressTherm

ometer(D

T);the

Durham

GeriatricResearch,

Educatio

nandClin

icalCentre

(GRECC)DepressionScale;the

PROMIS

SF-G

lobalH

ealth

inventory;

theCancerSu

rvivors’

Unm

etNeeds

(CaSUN)

Not

reported

38%

ofsurvivorsreported

fatigue

and

28%

depression;m

orethan

50%

ofsurvivorsandpartnergroups

were

atrisk

fordepression,and

34%

ofthesurvivorswereatrisk

forsome

type

ofpsychosocialproblem

that

currently

required

assistance;

survivorsexpressing

unmetneeds

tended

toscoreworse

than

those

expressing

noneedsfor

depression,distress,chronic

conditions,quality

oflife,and

generalh

ealth

Good

Riley-Clark,

2014

(United

States)

[82]

Cancer

patients

Cross-sectional

(survey)

Not re

port-

ed

47Adirondackregion

ofnorthern

New

York;

ruralitynotd

efined

Self-designedquestio

nnaire

Various

Supportg

roupswerefoundhelpful,

whileothersindicatednot

attendingcauseof

lack

ofknow

ledgeaboutcurrent

groups

andtim

es,and

lack

ofevening

meetings

andtransportationissues;

high

degree

ofinterestin

acounsellor,yoga

orrelaxation

classes,howevernotp

resent

inruralareas

Poor

Studieson

needsandquality

oflife

Coker,2018

(United

States)

[83]

Cancer

survivors

Cross-sectional

40%

inKentuc-

kyand

41%

inNorth

Carolin-

a

3320

The

KentuckyCancerRegistry

(KCR)andtheNorth

Carolina

CentralCancerRegistry(N

CCR)

wereused;B

ealecode

was

used

todefine

rurality

The

Functio

nalA

ssessm

entofC

ancer

Therapy-G

eneral(FACT-G

);Fu

nctio

nalA

ssessm

ento

fChronic

IllnessTherapy-Spiritual

Well-being(FACIT-SP);the

PerceivedStress

Scale;theBrief

Symptom

Inventory(BSI)

Wom

enwith

various

cancers

(diagnosed

intheprior

12months)

UnadjustedFA

CT-G

scores

were

poorer

amongAppalachian

versus

non-Appalachian

residentsfor

totalscores(61.24

vs63.39)

and

physical(13.03

vs13.91),

emotional(13.67vs

14.09),and

work/lifefunctio

nality(16.66

vs17.31)

domains;h

igherstress

scores

(3.49vs

3.22)w

erereported

byparticipantsliv

ingin

Appalachian;additional

adjustmentfor

depression

and

stress

atdiagnosis,FA

CT-G

total,

physical,w

ork/lifefunctio

nality

domains,and

comorbidconditions

remainedassociated

with

Appalachian

residence;differences

byAppalachian

residence

remainedonly

forFA

CT-G

Very goo-

d


Tab

le5

(contin

ued)

Author,

year

(country)

Populatio

nStudydesign

Response

rate

Sam

ple

size

Settin

gMeasure

Typeof

cancer

Results

Study

quality

physicalandnumberof

comorbid

physicalconditions,afteradjustin

gforsocioeconomicfactors

Costrini,

2011

(United

States)

[84]

Cancer

survivors

Cross-sectional

Not re

port-

ed

39Patientsweredraw

nfrom

the

2001–2010recordsof

Georgia

GastroenterologyGroup

andfrom

publicsolicitations

inruralp

ress

outlets;ruralzipcodes(asdefined

bythe2000

Census)in

therural

zoneswestofS

avannahandeastof

Macon

wereused

todefine

rurality

The

Medicaloutcom

esstudy36-item

short-form

health

survey

(SF-36);

theFu

nctio

nalA

ssessm

ento

fCancerTherapy-G

eneral

(FACT-G

)with

the

FACT-Colorectal

Colorectal

cancer

Ofthe71%

ofpatientswho

hadto

travelmorethan

100milesround,

8%judged

distance

asan

impedimenttocare;financial

impactwas

significantand

limited

in18%

ofpatients;ruralG

eorgia

self-reportw

orse

generalh

ealth

,psychicalfunctioning,physical

rolelim

itatio

ns,bodily

pain,and

vitalityscores

comparedtogeneral

populatio

n(p

<0.05);using

FACT-C

tool,ruralpatients

reported

bettersocial/fam

ilywell-beingcomparedto

general

populationwith

effectsize

of0.42

(p=0.002);longertim

esince

diagnosiswas

associated

with

betterfunctio

nalw

ell-beingand

colorectalcancer-related

scores

Poor

Steenland,

2011

(United

States)

[85]

Cancer

patients

Follow-up

study

(baseline,6

and12

months)

58%

260

Southw

estG

eorgia;rurality

not

defined

The

MedicalOutcomes

Study

Short-Fo

rm12-itemHealth

Survey

(SF-12);theUniversity

ofCalifornia,Los

Angles,Prostate

CancerIndex

Prostatecancer

(new

lydiagnosed)

Self-reportedphysical(p

<0.0001)

andem

otional(p<0.0001)QOL

declined

significantly

after

treatm

entfor

alltreatmentg

roups

(declin

edafter6monthsand

remainedaboutthe

sameat12

months);the

declinein

physical/emotionalQ

OLdidnot

differ

byage,race,educatio

n,or

Gleason

score;patientstreated

with

horm

ones

show

edtheworst

deteriorationin

physicaland

emotionalQ

OL

Very goo-

d

Studieson


orbidity

Befort,2011

(United

States)

[86]

Cancer

survivors

Cross-sectional

(survey)

77%

770

Three

cancer

centreslocatedin

rural

Kansas;rurald

esignatio

nwas

definedby

theZIP

code

approxim

ationof

theRural-U

rban

Com

mutingArea(RUCA)codes

Studydevelopedsurvey

modelled

aftertheBreastC

ancerPreventio

nTrialSy

mptom

Checklist(BCPT

)

Wom

enwith

breast

cancer

(3monthsto

6years

post--

treatm

ent)

Prem

enopausalw

omen

weremore

likelyto

experience

depression

(39%

vs23%)atthetim

eof

treatm

ent;across

thetotalsam

ple,

themostcom

mon

concerns

were

fear

ofrecurrence

(52%

),diminishedphysicalstrength

(39%

),change

inbody

image

(31%

),andfinancialstress(19%

);wom

enprem

enopausalat

diagnosisweresignificantly

more

Very goo-

d


Tab

le5

(contin

ued)

Author,

year

(country)

Populatio

nStudydesign

Response

rate

Sam

ple

size

Settin

gMeasure

Typeof

cancer

Results

Study

quality

likelythan

postmenopausal

wom

ento

reportpsychosocial

factors,includingfear

ofrecurrence

(68%

vs47%),fear

ofdeath(16%

vs5%

),change

inbody

image(43%

vs27%),change

inrelationships

(21%

vs5%

),and

financialstress(32%

vs15%;allp

≤0.001);w

omen

prem

enopausal

atdiagnosisreported

significantly

lower

satisfactionlevels(3.4–1.5)

comparedto

wom

enpostmenopausalatd

iagnosis

(3.8–1.5)(p

=0.001),alsoafter

adjusting

Duggleby,

2014

(Canada)

[87]

Inform

ative

care-

givers

Cross-sectional

(prospectiv

ecorrelational

design)

16%

122

Western

Canadianprovincialcancer

registries

(Albertaand

Saskatchewan);homeaddresshad

tobe

ruralp

ostcode:postalcodes

inAlbertaincludeanyone

who

does

notlivein

thetwotertiary

orfive

regionalcentres

The

Herth

HopeIndex(H

HI);the

GeneralSelf-EfficacyScale

(GSE

S);the

Non-D

eath

Version

Revised

Grief

Experience

Inventory(N

DRGEI);the

Short

Form

Health

Survey

(SF-12v2)

Various

Mentalh

ealth

/well-beingwas

found

tobe

apredictorof

hope

forrural

wom

encaregivers(p

=0.002);the

mentaland

physicalhealth

ofthe

participantsof

thisstudy,when

comparedtoUSpopulatio

nnorm

s,wereator

belowthe25th

percentile,thisfindingsuggests

thatthehealth

oftheruralw

omen

participantswas

poor;g

eneral

self-efficacywas

asignificant

factor

predictinghope

inthe

participants(p

≤0.05);guilt

(p=

0.002)

was

asignificantp

redictor

ofhope

(one

component

ofgrief)

Very goo-

d

Lashbrook,

2018

(Australi-

a)[88]

Cancer

survivors

Cross-sectional

88%

85region-

aland

49 rural

Studywas

conductedattheRiverina

CancerCareCentre(RCCC)and

itstwooutreach

clinicslocatedin

outly

ingruralareas

oftheRiverina

region

ofsouthern

NSW,

Australia;

Accessibility/Rem

otenessIndexof

Australia(A

RIA

)was

used

forthe

classificatio

nof

remoteness

DT;P

atient-ReportedOutcome

MeasurementInformationSy

stem

(PROMIS)

Survivorswith

breast,

prostate,

colorectal,

orlung

who

had

completed

treatm

ent

Cancersurvivorswithouta

partner

(OR=2.60,95%

CI1.06–6.39)

andwith

advanced

cancer

atdiagnosis(O

R=2.70,95%

CI

1.20–6.08)

hadhigher

odds

for

anxiety;

thosewith

colorectal

cancer

(OR=5.80,95%

CI

1.33–24.91),who

lived

with

outa

partner(O

R=3.90,95%

CI

1.46–10.35)andhadahigher

educationallevel(O

R=4.14,95%

CI1

.60–10.91)

hadincreasedodds

ofdepression;participantslivingin

ruralareas

(OR=5.0,95%

CI

1.75–14.29)hadhigh

odds

ofhaving

sleepdisturbance

comparedto

regional;those

who

Very goo-

d


Tab

le5

(contin

ued)

Author,

year

(country)

Populatio

nStudydesign

Response

rate

Sam

ple

size

Settin

gMeasure

Typeof

cancer

Results

Study

quality

hadsurgeryhadhigh

odds

(OR=

7.64,95%

CI2.40–24.20)for

sleepdisturbance,whilethoseof

disadvantagedsocioeconomic

status

(OR=0.30,95%

CI

0.12–0.78)

haddecreasedodds

ofhaving

abnorm

alscores

forsleep

disturbance;cancer

survivorswith

ahigher

educationhadincreased

odds

ofhaving

abnorm

alscoresfor

fatigue

(OR=2.3,95%

CI

1.06–5.10);those

with

advanced

stageatdiagnosishadincreased

odds

ofhaving

abnorm

alscoresfor

paininterference

(OR=2.71,95%

CI1.22–6.02)

Schlegel,

2012

(United

States)

[89]

Cancer

patients

Longitudinal

study(4

surveysover

13months)

92% second

survey,

91%

third,

and

90%

fourth

224

9radiationclinicsin

Missouri;

ruralitywas

quantifiedwith

acontinuous

variableanddefinedby

2indicesof

rurality(countycode

andcity

populatio

n)

The

CentreforEpidemiologic

Studies-DepressionScale

Wom

enwith

breast

cancer

Wom

enwho

werenotm

arried

(p=

0.00)or

hadchild

renliv

ingat

home(p

=0.01)reported

higher

levelsof

depressive

symptom

s;wom

enwith

lower

incomes

reported

increaseddepressive

symptom

safterthecompletionof

treatm

ent(p=0.02);younger

wom

enreported

elevated

depressive

symptom

sduring

initial

treatm

ent(p=0.01)butd

issipated

afterthe

completionoftreatm

ent(p

=0.12)

Very goo-

d

Studieson

financialissues

Mandaliya,

2016

(Australi-

a)[90]

Cancer

patients

Cross-sectional

78%

45Ruraloncology

clinicin

theNew

England

region,N

SW,A

ustralia;

ruralitynotd

efined

The

Qualityof

Lifein

AdultCancer

(QLACS)

SurvivorsScale;the

PersonalandHousehold

Finances

Questionnaire

(HILDA)

Various

(3–5

years

post--

treatm

ent)

There

was

noevidence

ofassociations

betweenany

demographicvariableandeither

financialstressor

cancer-specific

quality

oflifedomains;financial

stress

was

howeversignificantly

associated

with

thecancer-specific

quality

oflifedomains

ofappearance-related

concerns

(estim

ate0.37,p

=0.0152),

family-related

distress

(estim

ate

0.30,p

=0.0132),anddistress

relatedto

recurrence

(estim

ate

0.52,p

=0.0012)

Very goo-

d

Pisu,2017

(United

Cancer

survivors

Longitudinal

study(data

from

atrialat

16% attrition

432

Datawereused

from

theRuralBreast

CancerSurvivorInterventio

ntrial;

ruraleligibility

was

established

The

WorkandFinances

Inventory

(WFI);theBreastC

ancerSu

rvivor

Socio-demographicandTreatment

Wom

enwith

breast

cancer

Meanout-of-pocket(OOP)

burden

was

9%atbaselineandbetween7

and8%

atthenext

assessments;

Very goo-

d


cancer, three each with colorectal and prostate cancer, and twoeach with lung and head and neck cancer. Of these 41 quan-titative studies, 27 included both urban and rural cancersurvivors.

There were four mixed methods studies, of which threewere conducted in the US and one in Scotland. Two of thesestudies were conducted in people with breast cancer and twoin a heterogenous cancer population. None of these four stud-ies integrated the quantitative and qualitative data.

Risk of bias within the studies

Of the 20 qualitative studies, none were considered of poormethodological quality. Ten studies were considered to be ofvery good methodological quality and 10 considered good(Tables 2 and 3). Of the 41 quantitative studies, 33 studieswere considered to be of very good methodological quality,five of good quality, and three poor (Tables 4 and 5). Mostmixed methods studies were of good methodological quality,except for one study that was very good (Table 6).

Results of studies

Results of qualitative studies including both rural and urbansurvivors are presented below, followed by qualitative studiesincluding only rural survivors, quantitative studies with ruraland urban comparison groups, quantitative studies includingonly rural survivors, and mixed methods studies.

Qualitative studies including both rural and urban survivors

Seven qualitative studies with both rural and urban cancergroups [31–37], exploring respectively general needs and psy-chological morbidity, and financial issues and travel issues,were identified (Table 2). Compared with urban cancer survi-vors, more rural cancer survivors discussed having experi-enced a delay in their cancer diagnosis [32]. However, ruralparticipants were more satisfied with their cancer care, eventhough they were aware that not all cancer care services wereavailable where they lived. Rural African American cancerparticipants also talked more about using spirituality through-out their diagnosis and treatment than those who lived in ur-ban areas [31, 33].

An Australian study on travel issues that included bothrural and urban survivors [36] found that the experience ofrelocation was associated with psychosocial stress, due to alack of support and loneliness but also because of concernsabout the impact of separation on family members remainingat home. Another Australian study [37] found that lengthytravel, distance, lack of opportunity to take leave from work,and the additional costs of relocation and treatment all addedto the stress of relocation. A third Australian study [35] foundthat visits by metropolitan haematologists to regional areasT

able5

(contin

ued)

Author,

year

(country)

Populatio

nStudydesign

Response

rate

Sam

ple

size

Settin

gMeasure

Typeof

cancer

Results

Study

quality

States)

[91]

baseline,6,

9,and12

months)

basedon

residencein

oneof

33Floridaruralcountiesor

inarural

pocketof

oneof

34Floridaurban

counties

Survey;

theCentersfor

EpidemiologicStudiesDepression

Scale(CES-D)

thepredictedmeanOOPburden

was

higher

atbaselin

ethan

inthe

otherassessments(p

=0.007);

factorssuggestiveof

contributin

gto

higher

OOPcostsandOOP

burden

wereyoungerage,lower

income,tim

ein

survivorship

from

diagnosis,anduseof

supportiv

eservices;the

lowestpredicted

OOP

burden

was

forwom

enon

disability(5.1%),andthehighest

was

forparticipantswith

incomes

below$20,000(13.0%

)


Table6

Mixed

methods

studies

Author,year

(country)

Populatio

nStudy

design

Response

rate

Sam

plesize

Settin

gMeasure

Typeof

cancer

Results

Study

quality

Mixed

methods

studiescomparing

urbanandruralp

articipants

McN

ulty,2015

(UnitedStates)

[92]

Cancer

survi-

vors

Mixed

methods

Not re

port-

ed

42urbanAlaska

and34

urban

Oregon;

26ruralA

laska

and30

rural

Oregon;

19interviews

(convenience

sample)

Cancersurvivorsliv

ingin

AlaskaandOregon;

Alaskaruralw

asdefined

by>1-htraveltim

eto

amajor

regionalhospital;

Oregonruralw

asdefined

asageographicarea

that

isatleast30milesby

road

from

anurbancommunity

The

Impactof

Cancer

version2(IOCv2);the

Mem

orialS

ymptom

Assessm

entS

cale-Short

Form

(MSA

S-SF

)

Various

(average

6.7

years

post--

treatm

ent)

Overallcomparisons

betweenlocatio

n(rural/urban)andregion

(Alaska/Oregon)

show

edno

statistically

significant

ormeaningfuld

ifferences

betweengroups;

follo

w-uptests

comparisons

between4

places

show

edsignificant

results

for:worry,

negativ

eim

pact,and

employmentconcerns;

rural-urbandifferences

from

interviewdata

included

access

tohealthcare

access,care

coordinatio

n,connectin

gandcommunity

,thinking

aboutd

eath

anddying,

public/privatejourney,

andadvocatin

gforself

andhealthcare

services

Very go-

od

Mixed

methods

studieson

ruralp

articipants

Hubbard,2015

(Scotland)[93]

Cancer

patients

and

survi-

vors

Mixed

methods

(surveyand

semi-structured

telephone

interviews)

25%

44;1

0interviews

(purpose

sample)

Samplewas

obtained

from

BreastC

ancerCare’s

electronicdatabase

inruralS

cotland;rurality

was

definedby

residential

postcode

The

short-form

Supportive

CareNeeds

Survey

(SCNS-SF3

4)

Wom

enwith

breast

cancer(55%

were

receiving

treatm

ent)

57%

ofparticipantsreported

atleasto

nemoderateto

high

unmetneed

and11%

reported

lowneeds;the

mostp

revalent

moderate

tohigh

need

was

being

inform

edaboutcancerin

remission,fearsaboutthe

cancer

spreading,being

adequately

inform

edaboutthe

benefitsand

side

effectsof

treatm

ent

andconcerns

aboutthe

worries

ofthosecloseto

you;

wom

en≤5years

reported

greaterunmet

need

than

those>5years

from

diagnosis,and

statistically

significantly

Good


Tab

le6

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Sam

plesize

Settin

gMeasure

Typeof

cancer

Results

Study

quality

higher

needswere

observed

forthehealth

system

sandinform

ation

domain(67%

vs22%;

Pearson’sχ2=9.03,p

=0.003);interview

shighlig

hted

thefollo

wing

unmetneeds:inform

ation

abouttreatmentand

side

effects,overview

ofcare,

fear

ofrecurrence,impact

onfamily

,and

distance

from

support

Martin

ez-D

onate,

2013

(United

States)[94]

Cancer

patients

Mixed

methods

based

ontheChronic

CareModel

(sem

i-structured,

interviews,and

health

literacy

assessments;focus

groups

andsurveys

with

clinicalstaff)

Not re

port-

ed

53interviews;

30completed

STOFHLA;

51completed

follo

w-up;41

clinicalstaff

(purposive

sample)

Fiveclinicsin

rural

Wisconsin

The

ShortTesto

fFu

nctio

nalH

ealth

Literacy

inAdults

(STOFHLA);follo

w-up

basedon

theConsumer

Assessm

ento

fHealth

careProvidersand

System

sandthe

Assessm

ento

fCancer

CareandSatisfaction

surveys

Various

(receiving

cancer

care)

Resultsalignedwith

4/5

dimensionsof

the

ChronicCareModel:(1)

limitedavailabilityof

form

alsupportservices

andcultu

ralv

aluesof

stoicism

,pragm

atism,

independence,privacy,

andself-reliancewere

oftenin

conflictw

ithpatients’needsresulting

inpatientssufferingin

silence;(2)allw

hocompleted

STOFHLA

reported

adequatehealth

literacy,butstaffreported

thatpatientsstrugglewith

understandingmedical

inform

ation;

(3)need

for

greaterlevelsof

care

coordinatio

n,burden

ofassessingnon-medical

needs,andshorterclinical

form

s;and(4)shared

decision

making,patient

empowerment,andverbal

communicationstrategies

Good

Torres,2015

(UnitedStates)

[95]

Cancer

survi-

vors

Mixed

methods

(surveyand

in-depth,

open-ended

Not re

port-

ed

31(snowball

sampling)

Three

ruralcountiesin

easternNorth

Carolina;

ruralitynotd

efined

Survey

Wom

enwith

breast

cancer

The

mainthem

eswere:(1)

breastcancer

diagnosis

(mostcom

mon

wayswere

self-discovery,via

Good


reduce stress associated with separation from family, the needfor lengthy travel, and the financial cost of treatment.Furthermore, this study found that the opportunity to undergopart or all of treatment at regional hospitals is physically lessdemanding, more convenient and time saving, establishesbonds of trust and friendship with regional health profes-sionals, lessens the emotional impact of diagnosis and treat-ment, and has financial benefits for patients.

Qualitative studies including only rural survivors

Thirteen qualitative studies including only rural cancer survi-vors were identified (Table 3) [38–50]. Two Australian stud-ies [38, 39] found several issues in the provision of psychoso-cial care including access to appropriate psychosocial services(e.g., lack of information about services and concerns aboutstigma and dual relationships with service providers as friend/physician) and lack of knowledge of the unique needs of ruralcancer survivors bymedical staff located inmetropolitan treat-ment centres. However, those rural survivors who hadaccessed psychosocial support highly valued that support asit helped reduce uncertainty, fear and loneliness, and normal-ised patients’ experiences [38]. Unmet needs included feelinglet down by formal service provision, a sense of isolation, lackof referrals and follow-up care, inaccessibility of services dueto distance, cost or wait times, and lack of appropriate carebased on age, stage, or type of cancer [39]. Rural cancer pa-tients suggested this could be improved by providing rural-specific information on psychosocial care, improving commu-nication between healthcare providers, and making psychoso-cial services a standard part of care [38]. Another Australianstudy [50] investigated rural cancer survivors’ experiencepost-treatment in relation to QOL. This study found that arange of issues impacted the post-treatment QOL of rural can-cer survivors, including fatigue and fear of cancer recurrence,and that these rural survivors lack information on how to ac-cess support to manage these issues. Participants highlightedseveral acceptable strategies to improve their QOL post-treat-ment, including nurse-led, telephone-based, or face-to-faceinterventions that include support with managing emotionalchallenges [50].

One Canadian study [44] looked at rural people with cancerin the palliative care setting. Four themes emerged: (1) com-munity connectedness/isolation; (2) lack of accessibility tocare; (3) communication and information issues; and (4) inde-pendence/dependence. Some of these findings resonated witha Norwegian study [43] that examined the lived experience ofolder rural persons receiving palliative treatment. This studyfound their participants struggled with having limited control,avoided becoming a burden, tried to live up to the expecta-tions of being a ‘good patient’, and kept hope alive by dream-ing and making plans. Several studies [40–42, 45–49]highlighted rural difficulties with support and isolation, andT

able6

(contin

ued)

Author,year

(country)

Populatio

nStudy

design

Response

rate

Sam

plesize

Settin

gMeasure

Typeof

cancer

Results

Study

quality

questio

nsfocus

groupinterviews)

age-recommended

screening,and/or

their

gynaecologists);(2)

psychosocialwell-being

(fear,coping

mechanism

s,andQOL

concerns);and(3)quality

ofcare

factors

(doctor-patient

relatio

nship,side

effects

oftreatm

ent,adherenceto

follo

w-upcare,and

financialresources)


psychological issues such as a loss of control over the illness,anxiety, and a lack of knowledge. Some rural cancer patientsstated that the information given was complex and in combi-nation with condensed appointment schedules (to minimisetravel) made the processing of information difficult.However, the support of family and home care services helpedmany transition through the physical and psychological de-mands that were encountered.

Quantitative studies with rural and urban comparison groups

Quantitative studies with an urban control group (n = 27) arepresented in Table 4 [51–77]. Three addressed the use of for-mal and informal mental health resources, five examined fi-nancial and travel issues, one measured satisfaction with life,and the remainder explored the general needs, psychologicalmorbidity, and QOL of cancer survivors and informal care-givers. Only two studies were longitudinal [60, 76].

Of the 19 studies exploring needs, psychological morbidi-ty, and QOL, three (one US and two European) reportedpoorer outcomes for rural cancer survivors [63, 64, 68] andone (Australian) reported poorer outcomes for rural informalcaregivers [56]. Five (one Australian, two US, and twoEuropean) reported poorer outcomes for urban cancer survi-vors [57, 59, 61, 62, 65], one (Australian) found needs dif-fered between groups [55], while nine (eight Australian andone US) concluded there were no meaningful differences be-tween groups [54, 58, 60, 66, 67, 69–72]. Physical function-ing, role functioning, and reported mental health outcomeswere more likely to be worse in rural samples, whereas urbancancer survivors reported poorer social functioning and emo-tional QOL.

One US study of 113 heterogenous cancer survivors [51]found that rural cancer survivors reported significantly lessfavourable attitudes (t(111) = 2.05, p < 0.05) and social norms(t(111) = 2.20, p < 0.05) towards mental health resources thanurban cancer survivors. Conversely, a German study of 534colorectal cancer patients [52] showed that urban cancer pa-tients were significantly less likely to talk with their doctorabout their emotional state (65%, p < 0.01) and showed poorerknowledge (60%, p < 0.002) of cancer-specific mental healthresources than rural cancer patients. There were no differencesconcerning distress, mental health outcomes, or acceptance ofcancer-specific mental health resources between rural and ur-ban cancer survivors (undergoing treatment and post-treatment) in the German sample [52].

A study conducted in Appalachian Kentucky (US) foundthat geographic location was significantly correlated withcancer-related financial distress among rural cancer survivors(p = 0.0013) [74]. Survivors who lived in regional or remotelocations were 17 times more likely to report locational orfinancial barriers to accessing care compared to survivors liv-ing in metropolitan locations [73]. Another US study [75]

found that the overall prevalence of financial burden was20% higher among rural cancer survivors than urban cancersurvivors. However, after adjusting for covariates, this findingbecame not statistically significant (p = 0.06). Another study[76] (Australian) found that regional or remote cancer patients(first year after diagnosis) were more likely to report travelburden compared to cancer patients living in major cities(OR = 18.9, p < 0.001; OR = 135.7, p < 0.001, respectively).Similar findings were found for financial difficulties (p <0.05) [61], for which patients who travelled more than 2 h(OR = 2.65, p = 0.0178) or lived away for treatment (OR =2.79, p = 0.0152) reported significantly greater financial dif-ficulties than those who did not 6 months post-diagnosis [76].

One US study of 193 lung cancer survivors [65] examineddifferences between rural and urban cancer survivors in re-ports of positive outcomes, namely posttraumatic growthand benefit-finding of one’s cancer experience. Although nosignificant differences were found for benefit-finding betweenthe two groups, rural cancer survivors reported significantgreater posttraumatic growth (effect size (ES) = 0.30 SD; p= 0.042). Another study examined the satisfaction with lifeamong women with breast cancer and found that rural womenwith breast cancer reported lower satisfaction with life thantheir urban counterparts (p < 0.001) [77].

Quantitative studies including only rural survivors

There were 14 quantitative studies including only rural cancersurvivors [78–91], two on the use of formal and informalmental health resources, four on psychological needs and psy-chological morbidity, two on financial issues, and six on gen-eral needs and QOL. In total, four studies [79, 85, 89, 91] werelongitudinal and only one study [87] was on informal care-givers (Table 5).

The single study on rural informal caregivers [87], with asample of 122 participants, found that participants with higherhope had higher mental health scores (β = 0.266; p = 0.002),lower perceptions of loss and grief (β = −0.356; p = 0.001),and were more confident in their ability to deal with difficultsituations (β = 0.511; p = 0.000). Other studies on psycholog-ical morbidity [86, 88, 89] found that rural cancer survivorswho lived without a partner (OR = 3.90, 95% CI 1.46–10.35)or had a higher educational level (OR = 4.14, 95% CI 1.60–10.91) had increased odds of mild to severe levels of depres-sion (i.e., score of ≥ 55) [88]. One US study in rural womenwith breast cancer found that premenopausal women weremore likely to experience depression at the time of treatmentcompared to postmenopausal women (39% versus 23%, re-spectively; p < 0.001) [86]. This study also found that the mostcommon concerns among all rural women with breast cancer(i.e., percentage of women who reported experiencing psy-chosocial factors) were fear of recurrence (52%), diminished


physical strength (39%), change in body image (31%), andfinancial stress (19%) [86].

Four longitudinal studies [79, 85, 89, 91] reported find-ings on several topics. One Australian study [79] found thatrural cancer patients with a more positive attitude towardshelp seeking were more likely to have utilised a supportservice 6 months following study commencement (OR =1.69, p < 0.05). One US study [91] found that the out-of-pocket (OOP) burden (i.e., OOP costs as a percentage ofincome) significantly declined over time for rural cancersurvivors (p = 0.007); the predicted mean OOP burdenwas 9.8% at baseline, and between 7 and 8% at follow-up.Factors suggestive of contributing to higher OOP burden forrural cancer survivors included younger age, lower income,time in survivorship from diagnosis, and use of supportiveservices [91]. Another rural US study [89] found a decreasein depressive symptoms in the first 3 months after the startof treatment but an increase 5 months thereafter. This trendwas observed due to the decrease in psychological distressimmediately after completion of active treatment but in-crease thereafter due to the fear of recurrence. Lastly, onelongitudinal study [85], on the needs and QOL of men withprostate cancer in rural Georgia, found that self-reportedphysical QOL (coefficient = −5.8, p < 0.0001) and emotion-al QOL (coefficient = −5.7, p < 0.0001) declined signifi-cantly after treatment.

A rural-focussed Australian study on financial issues foundthat financial stress was significantly associated with thecancer-specific QOL domains of appearance-related concerns(ES = 0.37, p = 0.015), family-related distress (ES = 0.30, p =0.013), and distress-related to recurrence (ES = 0.52, p =0.001) [90]. One Australian study on service use [78] foundthat despite most (82%) of the rural men being aware of aformal service offering psychosocial support, only 49% ofthe rural men used such a service. This is contrary to anotherrural-focussed Australian study [79] that found only 14% ofparticipants reported having used a psychosocial supportservice.

The remainder of studies [80–85] were on the generalneeds and QOL of rural people affected by cancer, for whichsome also reported data on psychological morbidity and com-pared rural cancer patients with the general population, how-ever excluded urban cancer groups. These studies found that25% of the rural cancer survivors reported high/very highemotional health needs, 38% reported fatigue, and 28% re-ported depression. QOL scores seemed to be lower in ruralcancer survivors compared to the general population.However, rural cancer patients reported better social/familywell-being compared to the general population. Finally, ruralcancer patients reported that support groups were very helpful,though some participants reported that they did not attendbecause of a lack of knowledge about current support groupsand times.

Mixed methods studies

There were four studies that used a mixed methods approach(Table 6) [92–95]. One study, comparing rural and urban can-cer survivors, found no statistically meaningful differencesbetween groups in the quantitative analysis [92]. However,the qualitative analysis revealed that rural cancer survivorshad more challenges than urban cancer survivors includingaccess to healthcare, care coordination, and the very publicjourney of their survivorship due to the close-knit nature oftheir communities. The other three studies among rural cancersurvivors showed that health systems and information, psy-chological needs, and quality of care were the most frequentlyreported domains of unmet needs [93–95]. The interviewsfrom one study [93] also highlighted the following unmet ruralneeds: information about treatment and side effects, overviewof care, fear of recurrence, impact on family, and distancefrom support.

Discussion

Summary of evidence

Main findings

This systematic review examined the research conducted overthe last 10 years on the psychosocial well-being and support-ive care needs of cancer patients and survivors living in urbanand rural/regional areas. The 65 studies included in this re-view, of which most studies were conducted in Australia (28/65; 43%) followed by the US (24/65; 37%), demonstrated thatamong the studies that found a difference, rural cancer survi-vors were more likely to report worse outcomes in physicalfunctioning, role functioning, and reported mental health,whereas urban cancer survivors were more likely to reportpoorer outcomes in social functioning and emotional QOL.However, most studies that compared rural and urban cancersurvivors found no differences between the two populationswith regard to psychosocial well-being and QOL. This reviewalso found that rural cancer survivors were more likely toreport unmet needs relating to financial and travel issues andexperience more difficulties with accessing care compared tourban cancer survivors. This highlights that rural and urbancancer survivors have different psychological needs and con-cerns, and rural cancer survivors have some additional unmetneeds related to rurality that require careful assessment andmanagement

Context within the 2011 systematic review

Over the last 10 years, research on the psychosocial well-being and supportive care needs of rural and urban cancer


survivors has increased. The previous systematic review onthe same topic identified 37 studies that were published beforeAugust 2010. Our review included 65 studies published be-tween August 2010 and May 2021. Compared to the 2011review, more studies included in this review were conductedin people with heterogenous cancers (30 versus 11), and in-cluded a control group of urban cancer survivors (27 versus11) or used a general population control group (3 versus 1).Moreover, the quality of studies seems to have improved overthe last 10 years as the studies included in this review hadbetter reporting of design (68% versus 54%), and more oftendefined rurality or used a validated measurement tool, com-pared to the 2011 systematic review.

This review identified three studies [64, 68, 71] that includ-ed rural and urban general population control groups, anddirectly compared rural and urban cancer populations. Thesestudies found that significant differences existed in health out-comes between rural and urban cancer survivors and healthycontrols (one study was matched on age [68], and one studywas matched on age, gender, and country of residence [64]).More specifically, cancer survivors in general reported poorerself-rated health compared to healthy controls, for which ruralcancer survivors reported slightly poorer outcomes than urbancancer surv ivors . However , a f t e r ad jus t ing forsociodemographic factors, rural and urban cancer survivorsreported similar outcomes, nonetheless poorer than healthycontrols. Conversely, the 2011 review that included onlyone population-based control study found that the age-adjusted QOL was similar among all groups. However, whileour review identified three population-based control studiesthat included a heterogenous or lung cancer population, the2011 review identified a single population-based control studythat included only breast cancer survivors, who in generalreport better QOL outcomes compared to lung cancer survi-vors for example, and have better overall survival rates [96].

While 9 quantitative studies with an urban control group inthis review showed no evidence of meaningful differencesbetween rural and urban cancer survivors [54, 58, 60, 66,67, 69–72], five studies concluded that urban cancer survivorsreported poorer psychosocial outcomes than rural cancer sur-vivors [57, 59, 61, 62, 65] and three studies found that ruralcancer survivors reported poorer psychosocial outcomes thantheir urban counterparts [63, 64, 68]. These findings differfrom the 2011 review on this topic, which found that ruralcancer survivors generally reported worse outcomes than ur-ban cancer survivors. Recent research suggests that rural can-cer survivors may have greater protective factors againstpoorer emotional health, including active coping styles, posi-tive reinterpretation [16], and the belief that a person’s healthis decided by powerful others [97], that urban cancer survivorsmay be lacking. Studies have also shown that people living inrural areas not only tend to be more stoic about their health,which could result in under-reporting of distress, but also

differ in their expectations of health services than people liv-ing in urban areas [98, 99]. In addition, rural cancer survivorsreport higher levels of community trust, which may buffer theimpact of a lack of professional psychosocial support servicesin rural areas [69]. This may explain rural cancer survivorsreporting fewer unmet emotional needs than urban cancer sur-vivors. Further, it is also possible that the introduction of nu-merous regional cancer centres in the last 10 years inAustralia, where many of these studies were conducted, hashelped reduce the psychosocial toll of a cancer diagnosis forrural Australians. Moreover, the increase use in technology(e.g., telehealth) and digital healthcare may also have helpedto overcome the tyranny of distance and led to improvements.

The majority of studies focussed on a heterogenous groupof cancer survivors (30/65; 46%), followed by breast cancersurvivors (13/65; 20%) and haematological cancer patients(8/65; 12%).

In the qualitative studies with urban comparison groups,findings were similar to the 2011 review regarding unmetneeds and travel issues. In both reviews, rural cancer survivorsreported more frequent episodes of delayed diagnosis com-pared to urban cancer survivors [32]. Other challenges thatwere similar to the 2011 review included difficulties withaccess to healthcare and care coordination/navigation, forwhich rural cancer survivors reported more challenges thanurban cancer survivors [92]. Furthermore, in both systematicreviews, the qualitative studies confirmed the findings on trav-el issues in quantitative studies [35–37]. Both reviews foundthat travelling caused additional stress, can put pressure onfamily relationships, and in general posed difficulties to pa-tients. This was also found in qualitative studies without anurban control group in both reviews, highlighting that ruralcancer survivors and families report difficulties with supportand isolation, psychological issues such as a loss of controlover the illness, anxiety, and a lack of knowledge, and accessto mental health services. The current review also highlightedan additional finding that a lack of opportunity to take leavefrom work may mean that some rural cancer survivors cannotundergo treatment [37]. This may be related to the greaterproportion of people who are self-employed in rural versusurban areas [100]. However, although these challenges arestill apparent in rural cancer survivors, more research is need-ed that investigates whether these challenges have improvedwith the increased use and quality of telehealth and digitalhealthcare over time.

In total, six longitudinal studies (four without a controlgroup) were identified in this study. The longitudinal studieswith a control group [60, 76] found that rural cancer survivorsreported lower QOL (6 months post-treatment) and greatertravel burden (12 months post-diagnosis) compared with ur-ban cancer survivors over time. The studies without a controlgroup [79, 85, 89, 91] found that the out-of-pocket burden andQOL declined over time (1–3 years post-diagnosis). However,


levels of depression increased 12 months post-diagnosis afteran initial decline 3 months after the start of treatment. The2011 review also found that the health system and informationneeds of rural cancer patients decreased over time. These find-ings suggest that needs may change along the cancer survivor-ship continuum. For instance, post-diagnosis needs might re-volve around providing information and support, whereaspost-treatment needs focus more around the practical issuesof being able to perform activities of daily living.

Limitations

While this systematic review provides updated information onwhat is known about levels of psychosocial morbidity and theneeds of rural people with cancer and their informal care-givers, the results should be interpreted with the followinglimitations in mind. First, this review has brought togetherstudies that were conducted in multiple developed countriesthat used different definitions for rurality, such as the ARIA(Australia) and the Rural-Urban Continuum (RUC; US).Additionally, studies included in this review used differentmethodological approaches and different data sources.Conducting a separate qualitative and quantitative reviewmay have had merit, but we wanted to follow the successfulapproach employed in the previous review. As these studieswere very heterogeneous, no meta-analysis was conducted,and the findings of this review are conceptual rather thanstatistical. As most studies included in this review used across-sectional design, it was impossible to explore causality.Further, all data reported on in the studies contained in thisreviewwere collected prior to the COVID-19 epidemic, whichmay have led to improvements in remote access to supportservices, with particular benefits for rural populations.Second, the search strategy was restricted to English-language publications, which made it impossible to commenton the experiences of rural cancer survivors living in non-English-speaking countries. Lastly, as the scope of this reviewwas psychosocial in nature, physical morbidity and medicaloutcomes or survival rates were excluded. As these outcomesare closely related to a cancer survivor’s psychosocial well-being and needs, there may have been merit in broadening thescope of the review to include them. However, this wouldhave limited our ability tomake comparisons with the findingsfrom the previous review.

Conclusions

Over the last 10 years, the number of studies on the topic ofpsychosocial morbidity and unmet needs in rural cancer sur-vivors has almost doubled.While 37 studies were identified inthe 2011 review, this study identified 65 new studies pub-lished after July 2010. Many (9/19) quantitative studies with

an urban control group did not report any meaningful differ-ences between rural and urban cancer survivors with regard topsychosocial morbidity or general unmet needs. There wereslightly more quantitative studies with control groups that re-ported worse outcomes in urban cancer survivors (5/19) thanrural cancer survivors (3/19), for which urban cancer survivorsreported worse social and emotional functioning and ruralcancer survivors reported worse physical functioning, rolefunctioning, and reported mental health outcomes comparedto their counterparts. Nonetheless, many needs were still un-met in both populations, and people with cancer living in ruralareas were found to face different, additional financial andtravel issues, and experience difficulties accessing care.These uniquely rural psychosocial challenges need carefulassessment and management by health professionals, if equal-ity in treatment outcomes between rural and urban populationsis to be achieved. Further longitudinal research is also war-ranted that includes both rural and urban cancer groups andincludes population-based control groups, to establish wheth-er differences in psychosocial outcomes between rural andurban survivors are due to general geographic or cancer-specific factors. This will help inform the development offuture intervention trials that seek to test new strategies toaddress key issues, in the populations who need them most.

Availability of data and material We have control of all data and agree toallow the journal to review our data if required.

Author contribution Shannen R. van der Kruk: conceptualisation, datacuration, formal analysis, methodology, project administration, writing— original draft

Phyllis Butow: conceptualisation,methodology, supervision, writing— review and editing

Ilse Mesters: methodology, formal analysis, supervision, writing —review and editing

Terry Boyle: methodology, supervision, writing— review and editingIan Olver: methodology, formal analysis, writing — review and

editingKate White: formal analysis, writing— review and editingSabe Sabesan: formal analysis, writing — review and editingRob Zielinski: formal analysis, writing — review and editingBryan A. Chan: formal analysis, writing— review and editingKristiaan Spronk: data curation, formal analysis, writing — review

and editingPeter Grimison: writing — review and editingCraig Underhill: writing — review and editingLaura Kirsten: writing — review and editingKateM.Gunn: conceptualisation, formal analysis,methodology, pro-

ject administration, resources, supervision, writing— review and editing

Declarations

Ethics approval Not applicable.

Consent to participate Not applicable.

Consent for publication Not applicable.


Conflict of interest The authors declare no competing interests.

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https://www.aihw.gov.au/reports/cancer/cancer-in-australia-2019

https://www.aihw.gov.au/reports/cancer/cancer-in-australia-2019

https://doi.org/10.1093/fampra/17.6.475

https://doi.org/10.1093/fampra/17.6.475

https://doi.org/10.1016/j.healthplace.2010.04.015

https://doi.org/10.1016/j.healthplace.2010.04.015

https://australianjobs.employment.gov.au/

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Affiliations

Shannen R. van der Kruk1,2,3 & Phyllis Butow4& Ilse Mesters1 & Terry Boyle3

& Ian Olver5 & Kate White6&

Sabe Sabesan7& Rob Zielinski8,9 & Bryan A. Chan10

& Kristiaan Spronk2,11 & Peter Grimison12&

Craig Underhill13 & Laura Kirsten14& Kate M. Gunn2,11

& on behalf of the Clinical Oncological Society of Australia

1 Department of Epidemiology, Maastricht University,

Maastricht, The Netherlands

2 Cancer Research Institute, University of South Australia,

Adelaide, SA, Australia

3 Australian Centre for Precision Health, School of Health Sciences,

University of South Australia, Adelaide, SA, Australia

4 Centre for Medical Psychology and Evidence-Based Decision-

Making, The University of Sydney, Sydney, NSW, Australia

5 Faculty of Health and Medical Sciences, University of Adelaide,

Adelaide, SA, Australia

6 Faculty of Medicine and Health, The University of Sydney,

Sydney, NSW, Australia

7 College of Medicine and Dentistry (CMD), James Cook University,

QLD, Townsville, Australia

8 Central West Cancer Care Centre, Orange Base Hospital,

Orange, NSW, Australia

9 Western Sydney University, Sydney, NSW, Australia

10 School of Medicine, Griffith University, Brisbane QLD, Australia

11 Department of Rural Health, Allied Health and Human

Performance, University of South Australia, Adelaide, SA,

Australia

12 Department of Medical Oncology, Chris O’Brien Lifehouse,

Sydney, NSW, Australia

13 Border Medical Oncology, Albury, Australia

14 Nepean Cancer Care Centre, Penrith, NSW, Australia


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http://orcid.org/0000-0003-0837-6814

http://orcid.org/0000-0003-0837-6814

http://orcid.org/0000-0003-0837-6814

http://orcid.org/0000-0003-0837-6814

http://orcid.org/0000-0003-0837-6814

http://orcid.org/0000-0003-0837-6814

http://orcid.org/0000-0003-0837-6814

http://orcid.org/0000-0003-0837-6814

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http://orcid.org/0000-0003-0837-6814

psychosocial well-being and supportive care needs of

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