Rural Lung Cancer Survivors Face Higher Mental Distress

ANAHEIM, CALIF. – Coping with the emotional burdens of cancer can be a lonely struggle in rural America, results of a population-based, cross-sectional study suggest.

Researchers analyzed mental health data from a statewide cancer registry in Kentucky, and found that non–small cell lung cancer (NSCLC) survivors in rural counties had profoundly greater levels of mental health distress, but fewer interpersonal and intrapersonal coping resources, than did those living in nonrural regions of the state.

Rural survivors fared worse on every mental health outcome variable that was measured by the university researchers, including subscales of the Medical Outcomes Study (MOS-36), the Hospital Anxiety and Depression Scale (HADS), and the National Comprehensive Cancer Network Distress Thermometer Rating and Problem List.

Michael A. Andrykowski, Ph.D., professor of behavioral science at the University of Kentucky in Lexington, presented results of the study at the annual meeting of the American Psychosocial Oncology Society.

While conducting previous studies of symptoms and psychosocial outcomes among cancer patients, Dr. Andrykowski became interested in possible disparities in disease burden among rural populations in a diverse state of bustling university towns, bluegrass thoroughbred farms, coal mines, and forested Appalachian hills.

"I thought there was a pretty compelling reason to believe that cancer survivors living in rural areas experience more stress in association with the cancer experience, and fewer resources – a double whammy," said Dr. Andrykowski.

He also began to wonder whether presumed supportive factors associated with living in small, tight-knit communities might actually foster "attitudes, beliefs, and social norms less supportive of using formal and informal mental health resources," he said during his podium presentation.

To explore the question of potential disparities (a key goal of federal Healthy People 2020 guidelines), Dr. Andrykowski and associates sent questionnaires to – and conducted telephone interviews with – 144 NSCLC survivors, 76 of whom lived in counties that were designated as rural by USDA Rural-Urban Continuum Codes. The remaining 68 survivors lived in nonrural counties of Kentucky.

The two groups were well matched in terms of age (average, early 60s), minority status (7%-9%), and comorbidities (3.0-3.6). Patients from both groups had been diagnosed approximately 12-15 months prior to the study.

The rural patients had significantly less formal education (10.7 years vs. 12.9 years). They were also less optimistic, as measured by the Life Orientation Test, and less efficacious in seeking mental health support and cancer information than were nonrural patients, with significant effect sizes on those variables of 0.31, 0.39, and 0.34.

Highly significant differences were also seen in social constraint, which Dr. Andrykowski defined as a response to signals from family and friends that lead a person to limit the sharing of thoughts and feelings about a stressful event, such as a diagnosis or recurrence of cancer. Rural patients were far more likely to notice or perceive such behaviors, and to behave accordingly, he said.

Significant or highly significant differences were seen in scores on the MOS mental health subscale (63.0 rural vs. 73.2 nonrural), the HADS anxiety subscale (7.4 vs. 5.7), the HADS depression subscale (6.4 vs. 4.4), and the HADS total score (13.9 vs. 10.1).

Rural patients had access to fewer tangible and informational mental health resources, including a psychologist within 30 miles (67% vs. 75%), a support group within 30 miles (25% vs. 49%), a household computer (50% vs. 70%), the use of a computer for Internet access (54% vs. 79%), and the use of a computer "quite a bit" for the Internet (11% vs. 36%) or e-mail (7% vs. 36%).

Financial resources were scarcer as well, with 39% of rural residents reporting mental health insurance coverage and 28% reporting that they had some money left after paying bills, compared with 59% and 33%, respectively, of nonrural residents.

In an interview following his presentation, Dr. Andrykowski said simply providing rural cancer patients with more mental health resources may be too simplistic a solution to address disparities.

Earlier studies suggest that in some small, rural communities, social norms cast doubt on individuals who access help in the form of support groups, psychologists, spiritual counselors, or psychotropic medications. "Friends and family may be less supportive if [the survivors] use mental health services," he said.

Privacy and confidentiality may also be compromised, said Dr. Andrykowski, although he has not yet collected data to investigate this possibility.

Until he began collecting research on geographic disparities, he said, "I thought it was a good thing [that rural patients] were embedded in a close-knit community. But it could be too close knit. [Patients may feel that] ‘if I talk to a local mental health provider or a minister, there is no possibility of anonymity. They know everyone I know.’ "