Equipping Rural Sites With Necessary Resources
Corey Zankowski

I was involved in programs to increase global access to high-quality cancer carefor two decades. While at Varian Medical Systems, we agonized about ways to make radiotherapy more cost-effective, reliable,  safer, and easier to use in low-resource environments. When discussing how to increase access to care with governments worldwide, we often focused on the hub and spoke care delivery model. This solution involves concentrating expertise and the most advanced technologies at a central hub while locating satellite clinics with generalists in the local communities with the goal of offering “bread and butter” services at the satellite facilities under the remote guidance of specialists from the central hub.  The challenge facing this model is that it is impossible for a generalist to keep up with the rapid changes in all cancer subspecialties, and it isn’t possible to treat all patients with limited medical equipment.  This care model is designed so that complex patient cases are sent to the well-equipped and better-staffed central hub for therapy. The hub-and-spoke model is adopted extensively in lower-middle-income countries (LMIC) and across many well-resourced countries like the US.


The hub-and-spoke model is effective when introducing treatment centers in regions with no previous services. Yet, it should not be considered a permanent solution. Once a region has gone from zero to one center, disparities in care are immediately created. Action must be taken to swiftly close the gap in the quality of care available at the central hub and the satellite clinics. The discrepancy in care isn’t limited to LMICs but exists here in the US.  Rural and non-urban cancer patients encounter limited access to cancer care providers and low recruitment to clinical trials in their communities, which affect patient outcomes.  For those able to seek care at a tertiary facility, they face long travel times, higher expenses, and life-impacting inconveniences.  

Many rural patients cannot travel to a distant academic medical center for their care. In many cases, the academic center can be 100 miles or more from the patient’s home. Travel alone creates direct and indirect expenses for the rural patient: gas, wear and tear on their vehicle, and time away from work. This is in addition to straining the patient’s local support network, creating additional stress and anxiety.


It never hit me that some well-resourced patients might choose not to travel long distances for their care until my mother refused to seek a second opinion or receive treatment outside of her hometown when she was diagnosed with stage I endometrial cancer.  Maybe she didn’t want to leave the support of her friends and church community. Perhaps she was uncomfortable with travel, or she didn’t want to be a burden on anyone. It’s possible she didn’t want to upset her oncologist. My mom’s decision made me realize that the hub-and-spoke model is necessary but insufficient, so I co-founded a company to help every cancer patient receive exceptional care close to home. Primum equips community oncologists with the knowledge to offer the latest treatment options to more patients. Our platform lets community oncologists consult with cancer subspecialists nationwide in a virtually distributed model broader than the traditional hub and spoke.


ASCO published an article, “Closing the Rural Cancer Care Gap: Three Institutional Approaches,” highlighting three institutions’ approaches to improving access to cancer care in different settings. [Levit LS, Byatt L,  Lyss, AP.et al: Closing the Rural Cancer Care Gap: Three Institutional Approaches. JCO 16:422-430, 2020.] This paper illustrates ways to increase access to care in rural settings, create partnerships that allow more patients to be treated locally, lower travel requirements, mitigate financial burdens on patients, and increase clinical trial participation. Virtual consultation technology, like Primum, brings expertise to the patients so patients don’t have to travel to the experts. As a result, patients can receive treatment close to home, save on travel time, and lower their financial and social burden.


Drug infusions and doctor visits can be delivered in rural settings, but what about more resource-intensive procedures like radiation therapy or an MRI? Many rural centers can’t afford the equipment they need because their low patient volumes do not cover the equipment costs. Poor economics place some rural cancer clinics at risk of closure, which exacerbates the lack of access to cancer care.  For centers with low patient volumes, cost-effectiveness, and productivity aren’t the only considerations– sometimes, the price of the equipment is paramount. While I would not have come to this conclusion while working for a major manufacturer of diagnostic and therapeutic equipment, I now believe that it is important to evaluate refurbished equipment for low-volume rural cancer clinics that need sophisticated yet affordable PET, CT, MRI, and linear accelerators to enable high-quality cancer care locally.

At ASTRO last year, a conversation with John Vano (CEO of Radiology Oncology Systems) opened my eyes to the importance of refurbished medical equipment in making quality radiation therapy accessible to rural communities.  In a ROS blog post, one of their employees shares a personal story underscoring the barriers to care faced by cancer patients in low-density areas, and what can be done to overcome them. Refurbished medical equipment can help rural hospitals lower expenses and improve margins, ensuring sustainability. This can be the difference between life and death for some patients unable or unwilling to travel for their care.


To close the cancer care gap in the US and abroad, we need creative and practical solutions to increase access to technology and expertise in non-urban cancer centers. Where you live should not determine if you live.  One way is to share knowledge broadly through partnerships between cancer subspecialists and general oncologists, while another is to lower the cost of equipment through responsible adoption of refurbished medical equipment.

Corey Zankowski

Corey is the CEO and founder of Primum Health