Twa-le Abrahamson-Swan has seen firsthand how Indigenous and rural communities are at a disadvantage when they need cancer treatment.
“Traveling even a short distance is very hard on the body,” said Abrahamson-Swan, an activist and member of the Spokane Tribe whose mother, Deb Abrahamson, died of cancer in 2021. “They feel nauseous from the treatment and need to have someone else drive them. That deters a lot of people from seeking treatment at all.”
The problems are shown by a Washington State University study published in the journal Value in Health that found that people living in neighborhoods with majority American Indian and Alaska Native populations have to travel about 40 miles farther to the nearest radiation therapy facility than those living in neighborhoods dominated by other racial groups.
More than half of all American Indians and Alaska Natives live in small towns and rural areas, according to the study.
“We know that Native Americans have the worst outcomes once they are diagnosed with cancer, and one of the reasons they may not be getting optimal treatment may be related to treatment access,” said Solmaz Amiri, a professor specializing in geographic information systems who served as the lead researcher on the study with WSU’s Elson S. Floyd College of Medicine’s Institute for Research and Education to Advance Community Health. “Very few of these multimillion-dollar buildings housing radiation therapy facilities are located in rural areas, and so they can’t serve all populations.”
To identify the disparities, Amiri and her co-authors used a database of addresses of radiation therapy facilities and calculated the distance to the closest facility for each block group, a geographic unit used by the U.S. Census Bureau that includes up to 3,000 people. The researchers then used data from the 2019 American Community Survey to compare travel distances by racial and ethnic composition. The study excluded Alaska and Hawaii because of major differences in travel patterns in those states.
Comparing neighborhoods by racial majority and rurality, they found that travel distances for block groups with an American Indian and Alaska Native majority ranged between 26 and 103 miles, compared to a range of 3 to 35 miles for block groups with other majority populations.
Amiri said breast and prostate cancers are the most common in Indigenous communities.
“In terms of prostate cancers and rectal cancers, people who have access to radiation therapy have better survival and lower mortality compared to people who do not have (access).”
These cancer types can be treated by radiation, but with the Indigenous community disproportionately affected by “radiation therapy deserts,” they are also the most likely to receive invasive surgeries that remove the cancers entirely to avoid financial bankruptcy and other complications.
Radiation treatments can be multiple times a week, sending patients back and forth from their residence to the nearest hospital. For example, if an Indigenous cancer patient lived on the Spokane Indian Reservation in Wellpinit, commuting to and from the downtown Providence Regional Care Center would take 2 hours and 15 minutes. That would make a patient’s weekly commute up to a total of 470 miles and nearly 16 weekly hours of travel. Treatments last an average of six to eight weeks.
This can take a tremendous physical toll on the patient.
To cut the costs of commuting, some may choose to relocate. “They leave the family and go find lodging in another city,” Amiri said. “That person doesn’t even have the emotional and psychological support that a regular cancer patient gets from the immediate family. That person has to go to the treatment on (their) own in a different environment that is not familiar to him or her.”
Abrahamson-Swan said there needs to be better access to preventative care in order catch cancers early. Her mother had multiple misdiagnoses before being diagnosed with stage 4 cancer, she said. Abrahamson attributed her cancer to radioactive uranium mines on the Spokane reservation.
Patients may need to travel even farther to find a specialist for these rarer cancers, Abrahamson-Swan said.
Abrahamson-Swan continues to advocate for the creation of a holistic cancer center for tribal members in the region – an effort she started with her mother, who was inspired by Salish Cancer Center on the Puyallup Reservation in Fife, Washington.
The Salish Cancer Center takes an integrative approach to treating the whole patient, combining conventional oncology and naturopathic care, administrative assistant Mikala McGlone said. A number of traditional Native healers from tribes across the United States visit the center to provide spiritual healing through various practices using sacred objects, herbs, songs or stories.
The center serves tribal members and nontribal members from the local community, as well as patients from long distances. To assist those who travel for their appointments, the center offers discounted rooms at the Puyallup Tribe’s Emerald Queen Casino. Most patient stays are short term, however, since the center provides chemotherapy, but not radiation therapy, McGlone said.
Cassie Lowe-Yee, an acupuncturist at the Salish Cancer Center, said many of her patients have to go outside of their tribal health care system because they need to see multiple specialists such as surgeons, radiation oncologists and MRI or CT scan facilities. Referrals take longer than normal and information does not always flow back to their primary care doctor.
“It is challenging to coordinate care and manage side effects from longer distances, while timely treatment is critical to effective cancer care,” Lowe-Yee said. “Having a cancer center like Salish in rural areas or on the east side of the mountain should help removing these obstacles to care.”
One solution proposed by the researchers is to use mobile units to bring radiation treatment closer to patients. Moving the large equipment and linear accelerators that provide the radiation therapy is a challenge, but the bigger obstacle is providing the large specialized staff that includes medical physicists, engineers and radiation therapists to deliver treatment.
The researchers also suggest strategically locating future radiation oncology centers.
“If we are just placing (another center) in another metropolitan area that already has one, that’s not going to honestly solve the issue,” Amiri said, “it’s just going to exacerbate it.”
Additional facilities in rural areas would still have staffing issues, however. Some rural practices have teams that rotate through sites to cover more ground.
“In a lot of places, you can think about building a machine, but keeping it running is what’s difficult,” said Lia Halasz, a radiation oncologist at the University of Washington who worked on the study. “On the other hand, I know these are problems that we should work on as a field, because they’re important problems to solve.”
Improving transportation and lodging benefits might be the most practical solution.
“Trying to get the patients to good care at this point seems like it’s more doable,” Halasz said.
Patrick Johansson, director of the Northwest Health Education Research Outcomes Network at WSU’s College of Medicine, served as a co-investigator on the project. He created the survey for patient and health care providers to detail their radiation treatment experiences. Johansson advised using multiple research methods with both surveys and interviews among cancer patients and radiation treatment providers. Johansson emphasized the participation of those who declined or did not finish the radiation treatment.
“If you only get the people who went through the treatment, you’re not getting the whole picture of people who may have refused treatment, so that’s a community engagement approach,” he said.
Interviews identified specific hindrances between Indigenous communities and access to radiation oncology services. This meant engaging with Indigenous tribes differently, including conducting surveys at powwows and other Indigenous communing spaces.
WSU partnered with Indigenous researchers such as Cole Allick, a member of the Turtle Mountain Band of Chippewa Indian tribe, and is studying community engagement in Indigenous health. For the WSU study, Allick based his questions on lived experience and the effects of isolation away from health care services.
“Growing up in North Dakota, if you need to get specialty care for something like cancer, I’m expecting a drive for a couple hours, bare minimum,” Allick said. “It’s something that goes unsaid when you look at the data that goes around with the cancer disparities that we face.”
Allick called Amiri’s decision to provide both health and geographic data “unique,” since it provides cultural context to health inequities in Indigenous communities. This, Allick said, will identify where grants can be most effective.
“When it comes to funding agencies and different organizations, they want to see this kind of data. It’s an important first step to generate dialogue and come up with specific solutions to help us,” he said.
The researchers also examined lack of access to radiation treatment for rural communities in general. They found that Americans of any racial group living in small towns and rural areas have to travel around 30 miles extra compared to their urban counterparts.
Median travel distances to the nearest radiation therapy facility are 16 to 32 miles longer in small towns and rural block groups than in metropolitan block groups. Another study published in the International Journal of Radiation Oncology, Biology, Physics found that a subset of isolated rural census tracts representing 9.4 million Americans have at least an additional hour travel time relative to urban census tracts.
The picture is similar in Washington, where the researchers studied the same disparities in an earlier paper published last year.
Using Washington Department of Health mortality data based on persons who died of cancer, they found that non-Hispanic American Indians and Alaskan Natives would have had to travel on average 19 miles one way to reach the nearest radiation therapy facility, whereas non-Hispanic white persons would have had to travel, on average, 12 miles.
Those in nonmetro counties lived 35 miles on average from treatment centers and Native Americans in nonmetro counties, 53 miles.
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