Addressing Public Health Aspects of Cancer Center Catchment Areas

The concept of serving the catchment area has become an important function that cancer center directors and senior leadership incorporate when developing strategies, long-term visions and research expansion within the cancer center, as well as when evaluating cancer center effectiveness. One of the clearest missions of cancer centers is to reduce the cancer burden in the population it serves. A recent published study (1) identifies for the first time, geographic gaps in cancer centers’ coverage, as well as duplicate efforts within similar geographic areas to provide care. Despite the acknowledged limitations of the analysis, including relying on self-reported data on catchment area coverage, the published report is the first attempt to systematically describe the gaps and extent of overlap in cancer centers’ catchment areas among the Association of American Cancer Institute members.

The parameters included in the published analysis are population density, cancer incidence, and mortality. While the first item is a rough index of need, cancer incidence and mortality are mainly indices of effect, as appropriate interventions on cancer risk factors should decrease cancer incidence, while screening, early detection, and appropriate treatment should reduce cancer mortality. We thus suggest that an extension and next steps of this important work should include parameters measuring the ability of cancer centers to reduce the prevalence of risk factors, to improve screening rates, and to introduce novel cancer therapies in the catchment area. We also suggest that population density should be augmented with information on insurance, healthcare literacy, education, socioeconomic status, and languages, all parameters that help delineate barriers to, and disparities in, access to care.

We provide a brief examination of some additional relevant parameters according to geographic need (Fig. 1). While heterogeneity exists at the county-level in terms of the spatial distribution of risk factors for cancer and cancer screening, the Southern and South Eastern United States have a high prevalence of current smokers and adult obesity, and low prevalence of colorectal endoscopy screening. The prevalence of women ages 40 years and above who received a mammogram in the past 2 years is high throughout the Eastern United States and in pockets of the Northern United States, but has lower values throughout the Southern United States. We note that these areas where the prevalence of cancer risk factors is high also have the highest cancer incidence and mortality rates in the United States (1). This suggests that next steps in the battle against cancer should be to reinforce programs geared towards cancer risk factors and early detection; this intervention will act swiftly on cancer incidence and mortality in the long run.

When examining the prevalence of some social determinants of access to care (Fig. 2), areas of the Southwest, Western United States, Florida, and counties throughout the North Eastern United States have the largest proportions of the population that speaks English less than “very well”, while counties in the Southern, South Eastern, and Western United States have the largest proportions of the population lacking health insurance. These highlighted regions could face additional factors that influence the likelihood of seeking care and reducing disparities in cancer care.

The Leader et al. article notes that many Americans reside outside of a cancer center primary catchment area, especially areas of the Southern United States and Appalachia. Many states without an NCI-Designated Cancer Center/Comprehensive Cancer Center (e.g. Maine, Nevada, Wyoming, Montana, North Dakota, South Dakota, Alaska, and Idaho) are part of the lowest population-density states (1). Within these states we can observe county-level variability in cancer burden: in some counties, all-cancer incidence and mortality are among the lowest in the nation, while in others, values are among the highest. When examining risk factors profiles, we also find extreme heterogeneity: some states have lower percent adult obesity rates (Montana, Idaho, Wyoming, Vermont, Rhode Island), but that is not the case for other states (North Dakota, Louisiana, Mississippi, and Arkansas). Likewise, using the percent of those ever receiving a colonoscopy as a proxy for cancer screening success, we observe that this metric is high in Wyoming, Maine, and Vermont, while many counties in Nevada, Louisiana, Mississippi, and Arkansas score in the lowest quintile. States without a cancer center also have the lowest number of clinical trials per cancer incidence per 100,000 population (Fig. 3), a testimony of how important cancer centers are in bringing the latest innovative cancer therapies to their catchment areas. Many of these states without a cancer center also have counties scoring in the highest proportions of residents without health insurance, further underscoring the impact of bringing treatments to underserved populations. Geographic areas without cancer centers are in clear need for targeted programs to increase health insurance rates, reduce cancer risk factors, increase early detection, and introduce novel cancer therapies.

The analysis by Leader and colleagues 2022 also reported that the majority of counties in the United States are either undercovered or balanced by existing cancer centers, when primary coverage was measured according to population density, cancer incidence, or cancer mortality data. However, some counties were classified as overcovered. Cancer centers should effectively communicate to avoid large overlapping, and offer diversified, complementary services to their catchment areas in order to provide optimal coverage for the population, with efficient allocation of available resources. Some collaborative efforts are ongoing among cancer centers. For example, the New York City Cancer Collaborative is a partnership among academic and hospital cancer centers, the New York City Department of Health and Mental Hygiene, and supporting community-based organizations in New York City that shares information and educational materials to promote comprehensive cancer care.

In terms of population, cancer incidence, and cancer mortality metrics, the Leader and colleagues 2022 analysis identifies the pressing concern of providing appropriate care to large areas of the United States that are undercovered. As the need to provide high-quality cancer care for the entire population increases, it is important to recognize several concepts simultaneously, broadly classified as risk factors, early detection and screening, access to care determinants, and availability of cutting-edge therapies in future efforts to reduce gaps in cancer coverage and care, with the ultimate goal of reducing the cancer burden.

The data analyzed in this study were obtained from the NCI at https://statecancerprofiles.cancer.gov/, the CDC at https://www.cdc.gov/places/, and ClinicalTrials.gov at https://clinicaltrials.gov/.

No disclosures were reported.