Despite a similar overall cancer incidence, rural patients have higher cancer mortality rates compared with urban patients, and the gap is widening.1
This disparity is at least partly due to differences in access to cancer screening and high-quality cancer care for rural patients, as rural and urban cancer patients treated in clinical trials with uniform protocols have similar outcomes.2
Rural cancer patients are less likely to receive guideline-concordant surgery, chemotherapy, and radiation, as well as survivorship services, genetic testing, and palliative care.3 Centralization of cancer care to large urban tertiary care centers results in significant travel and financial burden for rural patients and is limited by referral patterns in rural communities and patients’ desire to access care closer to home.
Rural hospitals play an important role in providing cancer care to rural patients but face serious challenges, including difficulty with recruiting and retaining providers, limited access to specialty services, unfavorable payer mix, and an older patient population with more comorbidities and fewer financial resources. These hospitals also frequently lack the infrastructure to collect and monitor their own cancer data, making performance tracking and improvement very challenging.
Commission on Cancer (CoC) accreditation addresses rural disparities in cancer care because it provides both a comprehensive framework for program development and tools for continuous data monitoring and quality improvement. Treatment at CoC-accredited hospitals is associated with increased access to guideline-concordant care and improved mortality for patients with high social vulnerability.4
However, only 156 (7.9%) of the 1,965 rural hospitals (excluding critical access hospitals) in the US are CoC accredited, compared to 35% of urban hospitals. Rural patients travel an average of 10 times farther than urban patients to access the nearest CoC-accredited hospital.5 Additional challenges related to achieving accreditation for rural hospitals include limited staff and resources necessary to provide services and perform the tracking and documentation required by the standards.
Increasing CoC Accreditation in Rural Hospitals in Kentucky and Iowa
One favorable approach to mitigating these challenges is for a rural hospital to partner with a network supported with the resources of a tertiary care cancer center. Such a model has proven successful in Kentucky, where the University of Kentucky Markey Cancer Center Affiliate Network (MCCAN) extends resources from the Markey Cancer Center to community hospitals across the state.
The network, which requires that its affiliates become CoC accredited, has developed a robust infrastructure to support its hospitals in achieving and maintaining accreditation. MCCAN has been able to demonstrate that within 3 years of joining the network, affiliates markedly improved their compliance with disease-specific treatment-related quality measures and were three times more likely to achieve CoC accreditation than matched control hospitals in the state.6
Similar to Kentucky, Iowa is a rural state, in which 40% of breast and colon cancer patients receive most or all of their definitive treatment at rural, non-CoC-accredited hospitals. Patients at non-CoC-accredited Iowa hospitals are less likely to receive guideline-concordant breast and colon cancer care, and the difference is more pronounced for rural non-CoC-accredited programs, which fail to demonstrate improvement over time.
Iowa Adopts Strategies Used by MCCAN
Inspired by the success of MCCAN in Kentucky, a research group was formed at the University of Iowa in Iowa City, under the leadership of Mary Charlton, PhD, MS, a cancer epidemiologist and director of the Iowa Cancer Registry, and Ingrid Lizarraga, MBBS, FACS, a breast surgeon and CoC State Chair.
The group was awarded a National Institutes of Health R01 grant to study MCCAN in order to create a network of rural hospitals in Iowa that can assist centers in meeting CoC-accreditation standards. They hypothesized that extending resources at high-volume cancer centers could support rural hospitals in improving their quality of care and adopting emerging treatment guidelines more rapidly, allowing rural patients to obtain high-quality cancer care close to home.
The study researchers recruited four rural non-CoC-accredited Iowa hospitals providing surgery, radiation, and chemotherapy to the highest number of rural, underserved patients—ranging from 191 to 499 new cancer patients each year per hospital—to create the Iowa Cancer Affiliate Network (I-CAN). They used qualitative methods to perform process mapping of the MCCAN intervention and determine the key elements of their network that made it successful.7 These drivers included building relationships with affiliate hospitals, fostering a culture of quality improvement, and providing accreditation expertise and support, as well as access to services not locally available. External facilitation was used to guide hospitals through the accreditation process while leveraging the resources of their National Cancer Institute-designated cancer center.
Implementation science methods were used to adapt the strategies used by MCCAN in Kentucky to Iowa. The I-CAN Plan consisted of an evaluative phase to understand the rural hospital’s services, goals, barriers and strengths in the context of the accreditation standards; and an implementation phase, which included regular facilitation meetings with cancer program leadership. This phase also focused on data collection and analysis support, providing accreditation and clinical resources, mentoring and training of clinical staff, networking opportunities, and access to clinical trials. Interval assessments of determinants of success were performed.
Ultimately, one hospital withdrew from the study in the evaluation phase, and two additional rural Iowa hospitals approached I-CAN to join the network. Now in the fourth year of intervention, all five I-CAN hospitals have made significant progress toward meeting the standards. Three of the five hospitals have instituted a cancer committee or governing body of physicians, administrators, and clinical staff responsible for meeting regularly to review the standards and plan implementation.
Three hospitals also have started a regular multidisciplinary tumor board. All the hospitals have made progress toward implementing the standards related to clinical practice (oncology nursing education, rehabilitation, nutrition, psychosocial distress screening, genetic counseling), and four of the five are now providing formal survivorship services. Iowa Cancer Registry data are being used to approximate the CoC quality measures for breast and colon cancer and provide programs with their own performance data to drive quality improvement.
Certain standards have been particularly impactful for changing patient care delivery. The cancer committee standard represented a culture change for all the participating hospitals, as it was the first time that each hospital’s cancer services were evaluated in a comprehensive fashion. Implementation of the tumor board had a similar effect, resulting not only in management changes for specific patients, but also broader practice changes and process improvement, and better communication between clinicians in different specialties.
The standards addressing clinical services, such as nutrition, rehabilitation and survivorship, provided a useful framework for programs to ensure that cancer patients were better screened and directed to services that already existed. In some cases, the standards even helped clinicians and cancer center administrators advocate to senior leadership for additional services for their patients, such as dietitians or social workers.
Although the CoC framework had a clear positive impact on cancer patient care, the study also found that CoC accreditation remained a significant challenge to I-CAN hospitals, even with the support of the network. Some standards are particularly challenging, such as the requirement to enroll a specified proportion of patients into clinical trials, which is difficult for many small hospitals. Access to palliative care services and genetic counseling is limited in rural areas and also presents challenges for centers seeking accreditation.
A key benefit of CoC accreditation is the continuous quality improvement that it facilitates. These enhancements are driven by timely collection of institutional data on all cancer patients, which is then submitted to the National Cancer Database, analyzed, and returned to participating hospitals to use for self-monitoring and improvement. The infrastructure required for this process can be prohibitively expensive for rural hospitals and usually requires hiring personnel with specific training who may not be able to contribute to clinical work. In Iowa, this was addressed by having hospitals contract with the state cancer registry to provide these services for a per-case fee, but solutions would likely differ elsewhere.
In addition to the challenges presented by specific standards, a major barrier for rural hospitals with limited administrative and clinical staff is the amount of tracking, monitoring, and reporting work that is required to meet the 38 accreditation standards annually, even with network support.
CoC Addresses Challenges for Accreditation of Rural Hospitals
The CoC has committed to addressing the challenges in accessing high-quality cancer care for rural patients by making the benefits of accreditation more accessible to rural hospitals. Qualitative data from the University of Iowa study were used to inform the creation of a set of modified standards specific to rural hospitals, which were then refined by a work group of rural cancer physicians, administrators, and CoC Site Reviewers.
The new rural accreditation track will be offered to hospitals identified as rural (non-metropolitan), based on US Department of Agriculture rural-urban continuum codes, and will provide an affiliate accreditation status for a smaller fee than the full accreditation, with implementation planned for 2026.
Modifications to the standards include less stringent requirements for cancer program leadership, flexibility in provider tumor board participation, elimination of the minimum clinical trial enrollment requirement, and the ability to focus on selected cancer support services at the time of application. The initial requirements represent a lower threshold for rural hospitals to access their own quality data and CoC resources.
The goal is to make CoC accreditation more feasible, appealing, and relevant to rural hospitals, allowing them to participate more easily in data-driven quality improvement and develop their comprehensive cancer care services incrementally.
The I-CAN model demonstrates that partnering with a larger CoC-accredited site in the same catchment area enhances the ability of rural hospitals to meet quality standards, and further research is planned to extend that model to other states. The Rural CoC accreditation track is an exciting step forward in improving outcomes for rural cancer patients across the county.
For more information about the new Rural CoC accreditation track, contact Erin Reuter at ereuter@facs.org.
Dr. Ingrid Lizarraga is a fellowship-trained breast surgeon and clinical professor of surgery at the University of Iowa Health Care in Iowa City. She serves as the CoC State Chair for Iowa and medical director of I-CAN. Her research focuses on addressing disparities in rural cancer outcomes and healthcare delivery.
References
- Semprini J, Gadag K, Williams G, Muldrow A, Zahnd WE. Rural-urban cancer incidence and trends in the United States, 2000 to 2019. Cancer Epidemiol Biomarkers Prev. 2024;33(8):1012-1022.
- Unger JM, Moseley A, Symington B, Chavez-MacGregor M, et al. Geographic distribution and survival outcomes for rural patients with cancer treated in clinical trials. JAMA Netw Open. 2018;1(4):e181235.
- Bhatia S, Landier W, Paskett ED, Peters KB, et al. Rural-urban disparities in cancer outcomes: Opportunities for future research. J Natl Cancer Inst. 2022;114(7):940-952.
- Chan K, Palis BE, Cotler JH, Janczewski LM, et al. Social vulnerability and receipt of guideline-concordant care among patients with colorectal cancer. J Am Coll Surg. 2025;240(2):167-178.
- Schroeder MC, Semprini J, Kahl AR, Lizarraga IM, et al. Geographic distance to Commission on Cancer-accredited and nonaccredited hospitals in the United States. J Rural Health. 2025 41(1):e12862.
- Tucker TC, Charlton ME, Schroeder MC, Jacob J, et al. Improving the quality of cancer care in community hospitals. Ann Surg Oncol. 2021;28(2):632-638.
- Wahlen MM, Schroeder MC, Johnson EC, Lizarraga IM, et al. Identifying core functions of an evidence-based intervention to improve cancer care quality in rural hospitals. Front Health Serv. 2022;2:891574.
