Exploring the influence of rural residence on uptake of organized cancer screening – A systematic review of international literature

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Introduction

Cancer screening programmes aim to identify specific cancers at the earliest pre-symptomatic stage [ 1 ]. Colorectal, breast and cervical screening programmes have been found to reduce mortality because of the opportunity to detect precancerous lesions and preclinical cancer enabling early and potentially curative treatment leading to better cancer outcomes [ 23456 ]. Cancer screening is currently the preserve of high income countries (as defined by the World Bank in 2019 as those with a gross national income per capita of more than US $12,535 [ 7 ]); the World Health Organization does not recommend cancer screening in low-income countries due to the lack of supporting health service infrastructure [ 8 ]. In many countries there are national screening programmes for breast cancer using x-ray mammography usually at a screening facility [ 9 ]; pap-smears for cervical cancer usually in primary care [ 10 ]; and faecal occult blood test (FOBT) or faecal immunochemical testing (FIT) for colorectal cancer screening often administered by post [ 11 ]. In the USA a colonoscopy in secondary care every 10 years after the age of 50 is a popular form of bowel cancer screening [ 11 ].

Those who do not engage with screening present with cancer more advanced in stage and have poorer outcomes. Differential screening uptake has been identified in terms of several factors including for example, income, immigration status and geography [ 12 ]. In rural areas access to cancer screening is hampered by distance to screening facilities, few available transport options for rural residents [ 13 ] and the nature of rural communities where the lack of anonymity can affect health care seeking behaviours [ 14 ].

Overall cancer outcomes between urban and rural-dwellers demonstrates inequalities, with rural-dwellers being less likely to survive [ 15161718 ], this includes for example poorer two year survival [ 15 ] and relative five year survival rates [ 16 ] from lung cancer and one year mortality after diagnosis with eight common cancers (colorectal, lung, breast, prostate, melanoma, oesophagogastric, cervical and ovarian) [ 17 ]. A systematic review examining international survival differences between rural and urban cancer patients found that rural residents are 5% less likely to survive cancer compared to urban dwellers [ 18 ]. These survival differences have been attributed to variations in cancer treatment and follow-up care between rural and urban areas [ 19 , 20 ], and demographic differences [ 13 , 21 , 22 ].

Several studies suggest that the rural cancer survival disadvantage occurs because rural dwellers with cancer live further from hospitals, with consequent difficulties in accessing diagnosis and treatment facilities [ 232425 ]. This view is supported by studies which have found that rural dwellers are more likely to be diagnosed with more advanced cancer than their urban counterparts [ 262728 ]. There have been attempts to address this with policy initiatives such as avoiding centralization [ 29 ] and using technology and telemedicine [ 30 , 31 ] although practical considerations mean that health services can never completely overcome the geographical challenges to efficiently manage symptomatic rural patients [ 32 ].

Although a number of studies have assessed the effectiveness of targeted interventions to improve cancer screening uptake in rural areas [ 33 ] in general less attention has been given to the pre-symptomatic stage of cancer development and whether differential uptake of cancer screening exists which could be a component of rural cancer survival disadvantage. We suggest that it is conceivable that lower overall rural cancer screening uptake results in a lower proportion of early stage curable cancer in rural areas. If true, this could be an important factor in determining poorer rural cancer survival overall. Further, it is also possible that geography has more impact on uptake of some screening modalities compared to others. Health care insurance aside it may be less burdensome, for example, for rural dwellers to adhere to colorectal screening administered by post than to travel to a breast screening centre.

Currently, there is only one systematic review comparing breast cancer screening uptake between rural and urban areas [ 34 ]. Conducted in 2012, this global review comprising 28 studies found reduced uptake of screening mammogram by rural compared to urban-dwellers. Studies have also reported lower uptake of cervical screening [ 35 , 36 ] and colorectal cancer screening [ 37 , 38 ] in rural areas in comparison to urban areas. To our knowledge, no systematic reviews have yet explored potential geographical impacts on colorectal or cervical cancer screening uptake between rural and urban areas. We conducted a systematic review and meta-analyses of global literature examining the influence of rural residence on the uptake of colorectal, cervical and breast cancer screening in high income countries.