Leveraging telehealth and collaborative care models to improve rural cancer survivorship

There are currently 18.6 million cancer survivors in the United States, representing about 5.4% of the population (1). Approximately 21% of cancer survivors in the United States live in rural areas (2). Compared to urban cancer survivors, rural survivors are more likely to report multiple comorbidities, psychological distress, and fair or poor health (3). Rural cancer survivors often face barriers to receiving timely and appropriate follow-up care, such as a lack of transportation and longer distance to healthcare clinicians who are knowledgeable about survivorship care (3). Other challenges frequently faced by rural cancer survivors include the financial cost of travel or staying away from home, a lack of coordination between oncologists and rural healthcare clinicians, and a higher prevalence of unemployment, cigarette smoking, and physical inactivity (2,4). Rural cancer survivors are more likely to experience financial distress related to oncology care compared to urban survivors (5).

Once rural patients complete treatment at specialized cancer centers and resume routine healthcare and follow-up care in their community, they may lack access to supportive services such as rehabilitation and behavioral health that can reduce morbidity and improve quality of life (6,7). Access to clinical specialists and multidisciplinary care is limited in many rural areas of the United States where healthcare clinicians are often in solo practices (6). Rural health care clinicians may lack education and awareness about survivorship needs or available resources. To provide effective cancer survivorship care in rural communities, healthcare systems must address barriers such as long travel distances, limited access to specialists, and a scarcity of supportive services.

In the context of public health and policy, such constraints on rural cancer survivorship care can be viewed within the lens of structural urbanism, which refers to a systematic bias within health care and public health systems that disadvantages rural communities (8). The concept encompasses funding bias (i.e., policies and funding mechanisms that favor large population centers) and inequitable access, which result in a systematic siphoning of resources away from rural areas, leading to hospital closures, a shortage of healthcare providers, and limited access to essential services (8). Proposed policy solutions to address structural urbanism include a paradigm shift to view essential services—whether physical infrastructure or healthcare systems—as a community utility that requires equitable funding regardless of population density.

Several approaches and models have emerged to bridge these gaps and improve outcomes for rural cancer survivors. Telemedicine and other technological solutions can help to alleviate structural urbanism in healthcare by bridging geographical and resource gaps that disadvantage rural communities. Telehealth has been increasingly used to provide cancer survivorship care in rural areas (3). This innovative approach to cancer survivorship care can overcome barriers related to distance, lack of transportation, and lack of healthcare clinicians with expertise in providing follow-up care (3). As a result, telehealth may be especially useful for rural cancer survivors who lack access to community-based support services such as nutrition, behavioral health, and social work (9,10). Telehealth allows rural patients to receive follow-up consultations, psychological counseling, nutritional advice, and physical therapy without traveling to distant urban centers. Oncologists and other specialists in urban cancer centers can use telehealth to conduct virtual appointments, review patient cases, and provide guidance to primary care physicians in rural areas (9,10). This hub-and-spoke model improves care coordination and reduces the need for patients to travel for every appointment. For many cancer survivors, however, particularly those undergoing monitoring for locoregional recurrence or managing physical side effects like lymphedema, the lack of a physical exam is a significant clinical risk. Thus, telehealth is often an adjunct to, rather than a replacement for, in-person care. A further issue is that some rural areas may have inadequate broadband coverage, cybersecurity protections, or computer resources.

Developing programs that leverage local resources and foster collaboration between healthcare entities is essential. Since rural residents often rely on their primary care clinicians for ongoing health management, it is crucial to empower primary care clinicians to deliver survivorship care. Programs like Project Extension for Community Healthcare Outcomes (ECHO) use telementoring to train primary care clinicians in rural areas on specialized survivorship topics, increasing their confidence and capacity to provide this care locally (11). Nevertheless, efforts to train rural primary care providers in cancer survivorship care, such as through Project Echo, are hindered by severe time constraints, high burnout rates, and administrative burdens that are faced by rural practitioners. Primary care providers may be hesitant to undertake complex oncology surveillance without accompanying changes in reimbursement or administrative support.

Some healthcare systems deploy mobile clinics staffed with multidisciplinary team—including nurses, social workers, dietitians, and other specialists (12)—to provide accessible care directly to the communities. These units travel to rural communities, offering a range of services from cancer screening and surveillance to survivorship care plans and long-term side effect management (12). This model brings care directly to patients, addressing transportation barriers.

Another approach to improving follow-up care for rural cancer survivors is the use of patient navigators (13,14). The use of patient navigators may be an effective and acceptable approach to the provision of cancer survivorship care in rural communities (13). These professionals act as a reliable point of contact for patients, helping them overcome barriers to care by assisting with appointment scheduling, transportation, and access to community resources (14). They ensure a seamless transition from active treatment to survivorship, especially when care is transferred from an urban specialist to a local primary care clinician. Navigators may also assist patients with financial barriers.

Providing a comprehensive survivorship care plan is an important tool for rural cancer survivors (15), although rural survivors may be less likely to receive a survivorship care plan than urban survivors. This document summarizes the patient’s diagnosis and treatment, outlines a personalized schedule for follow-up care and surveillance, and includes recommendations for managing long-term side effects and promoting a healthy lifestyle (16). Survivorship care plans empower patients to manage their own care and help local primary care clinicians understand the patient’s specific needs. Survivorship care plans should be developed upon diagnosis so that patients and local doctors can plan and prepare.

Finally, collaborating with community-based organizations, such as churches, senior centers, or public health departments, can help deliver supportive services (17). For instance, a program might partner with a local Young Men’s Christian Association (YMCA) to offer supervised exercise programs tailored for cancer survivors, partner with a community center to host support groups or educational seminars, or engage with churches to offer faith-based wellness initiatives.

While cancer often places a heavy physical, emotional, and financial burden on patients, rural cancer survivors are faced with an additional array of challenges related to their geographic location and limited access to specialized healthcare (6). Approaches to cancer survivorship care such as telehealth, mobile clinics, and the use of patient navigators can help to overcome these challenges. Tailored survivorship care models are needed that meet the needs of rural cancer survivors and which are customized according to the healthcare clinician landscape and characteristics of the survivor population (3). Although several models for comprehensive survivorship programs have been developed in community oncology settings, little is known about the timely receipt of survivorship services by rural patients in the United States (3,6).

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Hospital Management and Health Policy. The article has undergone external peer review.

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-83/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-83/coif). S.S.C. serves as an unpaid Associate Editor of Journal of Hospital Management and Health Policy from November 2024 to December 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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References

1. Tonorezos E, Devasia T, Mariotto AB, et al. Prevalence of cancer survivors in the United States. J Natl Cancer Inst 2024;116:1784-90. [Crossref] [PubMed]
2. Weaver KE, Geiger AM, Lu L, et al. Rural-urban disparities in health status among US cancer survivors. Cancer 2013;119:1050-7. [Crossref] [PubMed]
3. Singh A, Jain AG, Hamilton BK, et al. Care Models for Cancer Survivors. Annu Rev Med 2025;76:225-41. [Crossref] [PubMed]
4. Tzelepis F, Paul CL, Sanson-Fisher RW, et al. Unmet supportive care needs of haematological cancer survivors: rural versus urban residents. Ann Hematol 2018;97:1283-92. [Crossref] [PubMed]
5. Zahnd WE, Davis MM, Rotter JS, et al. Rural-urban differences in financial burden among cancer survivors: an analysis of a nationally representative survey. Support Care Cancer 2019;27:4779-86. [Crossref] [PubMed]
6. Crabtree-Ide C, Sevdalis N, Bellohusen P, et al. Strategies for Improving Access to Cancer Services in Rural Communities: A Pre-implementation Study. Front Health Serv 2022;2:818519. [Crossref] [PubMed]
7. Stout NL, Boatman D, Rice M, et al. Unmet Needs and Care Delivery Gaps Among Rural Cancer Survivors. J Patient Exp 2024;11:23743735241239865. [Crossref] [PubMed]
8. Probst J, Eberth JM, Crouch E. Structural Urbanism Contributes To Poorer Health Outcomes For Rural America. Health Aff (Millwood) 2019;38:1976-84. [Crossref] [PubMed]
9. Lopez AM. Telehealth in Cancer Care: Inequities, Barriers, and Opportunities. Cancer J 2024;30:2-7. [Crossref] [PubMed]
10. Totten AM, Womack DM, Griffin JC, et al. Telehealth-guided provider-to-provider communication to improve rural health: A systematic review. J Telemed Telecare 2024;30:1209-29. [Crossref] [PubMed]
11. Centers for Disease Control and Prevention. Using Project ECHO and patient navigation to improve care for cancer survivors in rural areas, 2024 [Accessed on August 26, 2025]. Available online: https://www.cdc.gov/comprehensive-cancer-control/success-stories/echo-navigation.html
12. Malone NC, Williams MM, Smith Fawzi MC, et al. Mobile health clinics in the United States. Int J Equity Health 2020;19:40. [Crossref] [PubMed]
13. Centers for Disease Control and Prevention. Strategies to help people with cancer in rural communities, 2024 [Accessed on August 26, 2025]. Available online: https://www.cdc.gov/cancer-survivors/hcp/rural/index.html
14. Natale-Pereira A, Enard KR, Nevarez L, et al. The role of patient navigators in eliminating health disparities. Cancer 2011;117:3543-52. [Crossref] [PubMed]
15. Rowe A, Crawford-Williams F, Goodwin BC, et al. Survivorship care plans and information for rural cancer survivors. J Cancer Surviv 2023;17:441-8. [Crossref] [PubMed]
16. Coughlin SS. Cancer survivorship care plans. Current Topics in Breast Cancer Survivorship. Newcastle upon Tyne: Cambridge Academic Publishing; 2024.
17. Neil-Sztramko SE, Smith-Turchyn J, Fong A, et al. Community-Based Exercise Programs for Cancer Survivors: A Scoping Review of Program Characteristics Using the Consolidated Framework for Implementation Research. Arch Phys Med Rehabil 2022;103:542-558.e10. [Crossref] [PubMed]