A Rapid Systematic Review on the Experiences of Cancer Survivors Residing in Rural Areas during the COVID-19 Pandemic.

1. Introduction

There are over 17 million individuals living with cancer in North America [ 1 ] and an estimated 3 million in the UK, where cases are predicted to rise to nearly 5.3 million by 2040 [ 2 ], with similar patterns of increase projected throughout Europe [ 3 ]. Since the beginning of the COVID-19 pandemic, there has been considerable global disruption to the way cancer care has been delivered [ 4 ]. Screening and diagnostic services have been drastically reduced and treatment pathways were altered to mitigate the potential risk of COVID-19 exposure [ 5 , 6 ]. Key elements of ongoing care of existing patients were also deprioritised to allow health systems to better tackle the COVID-19 pandemic, resulting in the suboptimal delivery of cancer care [ 7 ]. Whilst healthcare systems have rapidly reorganised services to ensure patients continue to receive essential care, the pandemic has had a significant impact on cancer patients and survivors with respect to adapting to alternative healthcare delivery and managing their own physical, psychosocial, and economic wellbeing [ 8 ]. In sum, the pandemic has the potential to disproportionately affect and disrupt the lives of cancer survivors in the short, medium and long-term, including those currently receiving treatment, those who have completed treatment, and those who are now living disease free [ 9 ].

Prior to the COVID-19 pandemic it had been widely acknowledged that significant disparities already exist between cancer survivors who reside in urban and rural areas [ 10 , 11 , 12 , 13 , 14 , 15 , 16 ]. Individuals residing in rural and regional areas are shown to have higher cancer and other causes mortality in addition to an increased risk of experiencing worse health outcomes, poorer long-term survival, and greater unmet psychosocial needs compared to their urban counterparts [ 10 , 16 , 17 , 18 , 19 , 20 , 21 ]. This may be further exacerbated by additional challenges including greater travel distance to receive treatment, limited access to health and care facilities and to bespoke or individually tailored support [ 22 ]. Research also suggests that people with cancer from rural communities may be at risk of experiencing a reduction in quality of life following the completion of treatment [ 23 ], reflecting the need to provide tailored supportive care to improve their quality of life [ 24 ]. A recent systematic review concluded that rural survivors should be seen as having unique psychosocial needs when compared to urban survivors but not necessarily greater levels of need [ 17 ]. It is important to note that there are a range of characteristics belonging to rural communities that can positively influence the experiences of cancer survivors who reside in rural areas [ 25 , 26 , 27 ]. For example, people living in rural communities frequently report more close relationships with family and friends and sometimes have access to greater levels of community support and green spaces which can improve both physical and mental health [ 15 , 28 , 29 , 30 ]. Rural cancer survivors can have unique values and different attitudes to help-seeking as well as maintaining a stronger degree of stoicism [ 31 ]. Furthermore, rural cancer survivors have been shown to have greater cancer-related self-efficacy, engagement with self-management and higher self-reported health status when compared to their urban counterparts [ 30 , 32 , 33 ] and are less likely to report higher levels of distress [ 34 ].

As the COVID-19 pandemic continues to influence the way cancer care is delivered, it may also further exacerbate the unique set of existing challenges that cancer survivors from rural areas already face. A recent rapid review examined the broad impact of the pandemic on cancer survivors but did not report any findings in relation to rurality [ 35 ]. Furthermore, the review included studies published between Dec 2019–Aug 2020. There is therefore an urgent and timely need to conduct a more up to date evidence synthesis to help inform the development of tailored interventions that will address the specific needs of rural cancer survivors who continue to be affected by the pandemic. It is also important to note that there were stark geographic and regional differences regarding the impact of COVID-19 including between rural and urban areas [ 36 ]. Moreover, there were differences in the timing and duration of local lockdowns including public health imposed social isolation measures [ 37 ]. The aim of this research was to conduct a rapid systematic review of the peer-reviewed evidence to explore the impact of the COVID-19 pandemic on cancer survivors who reside in rural areas.

2. Methods

2.1. Protocol Registration

The review protocol has been registered on the Open Science Framework [ https://osf.io/2fjgc/ , accessed on 2 September 2022] to promote reproducibility and facilitate methodological transparency [ 38 ].

2.2. Study Design

The study utilised a rapid review approach in line with the published guidance from the Cochrane Rapid Reviews Methods Group [ 39 ] and for reporting used the Preferred Reporting Item for Systematic Reviews (PRISMA) checklist [ 40 ]. Rapid reviews are now considered a key component of the knowledge synthesis family alongside systematic reviews, scoping reviews, and realist reviews [ 41 ]. They provide a streamlined, efficient, and pragmatic approach to evidence synthesis. In summary, rapid reviews are a form of evidence synthesis in which components of the systematic review process are simplified, with a view to producing findings in a timely manner [ 42 , 43 ]. Still, rapid reviews must remain systematic in their approach and have a duty to report their methods in a transparent manner making sure they are clear about deviations or omissions from the PRISMA criteria.

2.3. Search Strategy

The search strategy was devised by DN, SC and BMcL. DN performed keyword searches together with Boolean operators (OR and AND) and truncation (*) to search for relevant peer-reviewed literature in EBSCOHost (includes MEDLINE, CINAHL and PsycINFO) on 25 May 2022. The EBSCOHost interface provides access to a range of academic databases in relation to health, allied health, nursing, social science, and multi-disciplinary literature. The syntax included keywords and alternative terms in relation to (1) cancer survivors (2) rurality and (3) COVID-19. The full search strategy for EBSCOHost can be found at Table 1 below. All database searches were supplemented by searches on Google Scholar to ascertain if there were any important literature that we missed from our initial search.

To identify cancer survivors the following keywords were used: “Cancer survivors” OR “Cancer survivorship” OR “Living with and beyond cancer” OR “Cancer patient” OR “People affected by cancer” OR “People living with cancer” OR “People living with and beyond cancer”

To identify rural settings the following keywords were used: “Rural health” OR “Rural health service*” OR Rural* OR Remote OR “Remote population” OR “Rural communit*” OR “Medically underserved area” OR Non-urban OR Nonurban OR Non-metropolitan OR “Geographic isolat*”

To identify evidence related to the COVID-19 pandemic the following keywords were used: COVID-19 or Coronavirus OR 2019-nCoV OR SARS-CoV-2 OR COV-19 OR “COVID-19 pandemic”

All retrieved records were collated into a data file and then stored and managed using Rayyan software [ 44 ]. The titles and abstracts were screened against the eligibility criteria by DN and AN. Where there were uncertainties over the eligibility of a study DN discussed this with SC to reach a decision. Following title and abstract screening, the remaining articles were independently screened by full text for inclusion by BMcL and then checked by DN and SC.

Eligibility Criteria

Inclusion Criteria

Peer-reviewed publications were selected for inclusion in the review if they met the following pre-defined eligibility based on the PICO approach. Population: People who have (or who have had in the past) a confirmed diagnosis of cancer as well as people who support them (e.g., spouse, partner, children and health professionals). Intervention: Articles published after 11 March 2020 (beginning of COVID-19 pandemic and global lockdowns as identified by the World Health Organisation) that explore the experiences of cancer survivors and their caregivers (informal and formal) who reside in a rural, remote or regional area during the COVID-19 pandemic. Comparison: Not applicable. Outcomes: Articles that report primary data (quantitative and/or qualitative) on individual experiences, perceptions, reflections, beliefs, and attitudes of rural cancer survivors and the people who support them. Only publications written in the English language were included with no limitations set on geographical location

Exclusion Criteria

Publications were excluded based on the following exclusion criteria. Population: People who do not have a confirmed diagnosis of cancer or people who do not directly support them. Intervention: Articles published prior to 11 March 2020 or published articles that do not explore the experiences of cancer survivors and their caregivers (informal and formal) who reside in a rural, remote or regional area during the COVID-19 pandemic. Comparison: Not applicable. Outcomes: Articles that do not report primary data on individual experiences, perceptions, reflection, beliefs, and attitudes of rural cancer survivors and the people who support them. Any publication that was not written in the English language were excluded.

2.4. Data Extraction

The first author (DN) led on data extraction for each full text article (see Table 2 ) with cross checking for accuracy taking place by the second author (SC). The following study characteristics were extracted including: (1) authors, title, year of publication and country (2) setting (3) participants (4) methods and (5) findings in relation to rurality.

2.5. Quality Assessment

The focus of this rapid review was on exploring the experiences of cancer survivors who reside in rural areas during the COVID-19 pandemic, therefore a quality assessment of included articles was not deemed appropriate. The omission of a quality assessment was in line with the methodological approach taken by other rapid systematic reviews where the focus is on producing evidence quickly [ 45 ].

2.6. Data Analysis

To identify and map the experiences of rural cancer survivors during the COVID-19 pandemic we tabulated the results. This was accompanied by a narrative summary where comments on the prominent issues within the literature were reported. Due to the wide heterogeneity of the design and outcomes of included studies, as well as the considerable amount of qualitative data, a formal statistical meta-analysis was not conducted. Furthermore, the need to produce findings quickly meant that a formal thematic synthesis was not possible.

3. Results

3.1. Search Results

The search of EBSCOhost provided a total of 144 citations. Of these 144, 45 were duplicates and were excluded leaving 99 records that were then screened by title and abstract. Following title and abstract screening a further 74 articles were excluded leaving 25 to be screened by full text. Fourteen articles did not meet the eligibility criteria following full text screening. The primary reason was that the article did not explicitly report on whether all or some of their participants were resident in a rural area. A total of three additional articles were identified via Google Scholar leaving a total of twelve articles that met the pre-defined eligibility criteria were included in the final review. The process has been reported on in the PRISMA Flow diagram below (see Figure 1 ).

3.2. Study Characteristics

A total of fourteen studies were included in the review [ 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ]. The studies were conducted in a range of different geographies in mostly high income countries and to a lesser extent low-middle income countries: Australia n = 3 [ 47 , 54 , 59 ]; Canada n = 3 [ 48 , 50 , 51 ]; France n = 1 [ 46 ]; India n = 2 [ 55 , 57 ]; United Kingdom n = 1 [ 58 ]; United States of America n = 3 [ 49 , 53 , 56 ]; Mixed geographies n = 1 [ 52 ]. In studies with both rural and non-rural participants the rural/remote/regional n ranged from seventeen to seventy-three per cent of the total sample [ 48 , 49 , 50 , 51 , 52 , 53 , 55 , 57 , 58 , 59 ]. Only two studies reported their total n as coming from rural or regional areas [ 47 , 56 ]. Baffert et al. [ 46 ] did not report how many of their participants were resident in a rural area but did refer to the hospital being located in a rural setting and report on some of their findings unique to rural participants as well as the differences they found between those in rural versus city locations.

Most studies collected data with cancer survivors with a range of different diagnoses [ 46 , 47 , 48 , 49 , 50 , 51 , 53 , 55 , 56 , 57 ]. Only one study (Krok-Schoen et al.) looked explicitly at healthcare providers as opposed to cancer survivors [ 52 ]. One UK study looked specifically at patients with bladder cancer [ 58 ] and another Australian study collected data with people who had a haematological cancer diagnosis [ 59 ]. The Australian study by Podubinski et al. [ 54 ] did not focus specifically on cancer survivors, rather they looked at individuals in Australia who raised issues around healthcare access in a COVID-19 study, they do report some primary qualitative experience data with people who had skin cancer and were resident in rural areas therefore their article was included. Only one study explicitly reported on and included caregivers in their sample [ 56 ].

Most of the studies ( n = 8) reported using a solely quantitative design [ 46 , 49 , 51 , 53 , 55 , 57 , 58 , 59 ]. Two studies reported collecting both quantitative and qualitative data [ 47 , 50 ] but only one study explicitly reported adhering to a mixed methods design [ 48 ]. Finally, three studies used only qualitative methods to collect their data [ 52 , 54 , 56 ]. Across all the studies data were collected between April 2020–May 2021 [ 46 , 47 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ] with the exception of research by Galica et al. [ 48 ] which did not report the data collection period but did report that this took place during the COVID-19 pandemic. The characteristics of the included studies is reported on in Table 2 .

3.3. Narrative Overview

Across the included studies, the COVID-19 pandemic had a mostly detrimental impact on the experiences of rural cancer survivors. People’s individual coping mechanisms were challenging for a range of reasons. Specifically, the pandemic impacted on their ability to access testing, treatment, check-ups and supportive care, their ability to maintain and access social support with close friends and family, as well as negative consequences to their finances and emotional wellbeing with some reporting feelings of psychological distress including depression and anxiety [ 47 , 48 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ]. In an Australian study with a solely rural/regional sample ( n = 66), older participants (65 years and over) were more negatively impacted by the pandemic with their ability to access supportive services and to access social support when compared to younger participants [ 47 ]. The same study found no significant differences between gender or cancer status and access to services [ 47 ]. In America, rural cancer survivors were more likely to be older, unemployed, uninsured, former or current smokers, to consume more alcohol and suffer from pandemic related changes to their medical appointments compared to those from urban areas [ 53 ]. Other American research with cancer survivors and their caregivers highlighted the workforce challenges around recruiting and retaining specialist Cancer Center staff in rural areas in Nebraska [ 56 ].

In Australia, living in a regional area, was associated with greater psychological distress during the pandemic [ 59 ]. Although in France, cancer patients’ anxiety scores remained low post-lockdown in rural regions where the rate and risk of COVID-19 infection was lower and the organisation of care was considered to be mostly maintained [ 46 ]. Furthermore, they found that living in a city apartment was an identified risk factor for post-lockdown anxiety. The odds of having a negative impact on cancer care were higher for participants living in Central Canada as opposed to those living in the Territories which are much more rural and remote [ 50 ]. Those living in rural or remote locations in Canada were less likely to experience loneliness than those from urban areas which could be down to a strong sense of community and belonging in these rural areas with smaller population sizes [ 51 ]. Although there were reports of the need to have access to a car as well as support with grocery shopping for those that did not own a vehicle. American research found that urban cancer survivors were more likely to socially distance, wear a face mask and use hand sanitizer as well as experience significant changes in their daily lives when compared to those from rural areas [ 53 ].

The only UK study that was included in the review found that the level of disruption between rural and urban participants was not statistically significant and that both sets of patients had been equally impacted by delays and cancellations to treatment during the COVID-19 pandemic [ 58 ]. The two studies from India that were included found that those from rural areas were negatively impacted in terms of access and that urban people had better access to transport and consequently were less impacted in accessing their care [ 55 , 57 ]. People from rural India were more likely to miss their scheduled appointments [ 57 ] due to difficult in reaching the hospital and arranging accommodation [ 55 ].

The use of the telephone and online services to connect with friends and family was considered a helpful strategy for staying in touch where physical contact was not possible [ 47 ]. Online activities extended beyond keeping in touch with friends and family to include things such as yoga and cancer support groups [ 47 ]. The increased use of telehealth and digital technologies were not without their challenges and these included access and support issues as well as communication and connectivity difficulties due to sensory impairment, rurality and inadequate equipment [ 52 ]. There was a perception that living in a rural area with a lower population density provided some degree of ‘insulation’ from the negative effects of COVID-19 [ 48 ] and some rural cancer survivors in Australia reported that there were now more opportunities to engage in physical activity practices compared to before the pandemic [ 47 ]. In the USA, patients living in rural areas appeared to not change their exercise habits as much when compared to their urban counterparts [ 49 , 53 ].

4. Discussion

This is the first review to report solely on the experiences of rural cancer survivors during the COVID-19 pandemic. Rapid reviews are increasingly becoming a well-established methodology to produce findings quickly in relation to topical and important research areas [ 41 ] and this review builds on a recently published rapid review on the broader impact of COVID-19 on cancer survivors [ 35 ]. The searches for that review were conducted in August 2020 and our search in comparison was completed almost two years later in May 2022 as well as including a more developed search strategy with the addition of terms in relation to rurality. Therefore, these findings provide new and more up-to-date findings for cancer researchers, specifically those with an explicit interest in cancer care and rurality.

This research was further strengthened by a predetermined study protocol and adherence to the PRIMSA guidelines ensuring that the process was systematic and transparent [ 39 , 40 ]. Another strength of this review was the geographic reach of the articles with the inclusion of literature from a range of different countries in both high and low-middle income settings. Not surprisingly, the majority of the research that was included in this review was conducted in North America and Australia which is similar to pre-pandemic scholarship on rurality and cancer that has been dominated by these areas for the past decade [ 11 , 12 , 13 , 15 , 16 , 17 , 18 , 31 , 34 ]. Only two of the COVID-19 studies that were included in this rapid review were from the European continent with one of these being from the UK where there is now a small but increasing body of pre-pandemic research that considers the impact of rurality on cancer experiences and outcomes [ 30 , 32 , 33 ]. Future research that looks at cancer and geographic residence, particularly that in the UK, should extend out to include coastal areas which are amongst the most deprived in the country and there is now a shifting policy focus to reduce growing health inequalities in deprived coastal communities [ 60 ].

It has been acknowledged that the challenges presented by the COVID-19 pandemic may disproportionately impact the overall health and wellbeing of cancer survivors which can result in unintended long-term consequences [ 35 ] and it could be argued that those who reside in rural and remote areas are particularly susceptible to disparities in cancer care and poorer health outcomes [ 61 ]. Indeed, this review has provided novel insight into the experiences of cancer survivors who resided in rural areas during the pandemic and has highlighted the negative impact on their ability to access care and social support as well as on their mental health. Social support has been identified as being beneficial to the management of depressive symptoms [ 62 ] and not being able to access it could have considerable negative consequences for rural cancer survivors’ mental health. It is important to acknowledge pre-COVID-19 research that suggests distance might not always be such a salient concern and that rural dwellers sometimes accept their issues around access given that some of them have lived in a rural area for a prolonged period of time [ 63 ]. Telemedicine is a scalable technology that has largely been a response to the issues and needs of rural providers and people [ 64 ]. The use of telemedicine approaches is certainly not novel and has been used to facilitate access to care for people in rural, remote, and non-rural settings for several years now. During the initial stages of the pandemic, healthcare providers including oncology nurses across the world were required to rapidly shift to a telehealth model of delivery to provide care to people living with cancer [ 65 , 66 , 67 ]. Whilst this has considerably increased engagement with digital healthcare, it should not be considered a total solution for the healthcare challenges in rural areas. There is a need to consider digital health literacy and digital poverty particularly in rural areas with high levels of deprivation [ 68 ]. This review has shown that access to digital technology and connectivity issues are still prominent within rural settings and so investment as well as education is required [ 69 ] to ensure that digital inequalities do not widen as telemedicine models of care continue to be rolled out in a post-pandemic world. People in rural areas may also rely on digital health information provided through social media platforms such as YouTube although the extent to which these provide good quality and reliable information has been questioned by other cancer researchers [ 70 , 71 ].

For rural people, the literature suggests that ‘good health’ is commonly characterised as being able to work, engage in social relationships and to maintain independence [ 72 ]. Future interventions and support should be tailored to the needs of rural cancer survivors in relation to the medium and longer-term impacts of the pandemic as well as more generally. Importantly, the role and needs of informal caregivers should not be neglected especially in rural areas where cancer survivors can already lack access to both medical and social support [ 64 ]. Much like rural cancer survivors, informal and unpaid caregivers from rural areas are susceptible to high levels of depression and anxiety, feelings of isolation and financial problems because of their role as a carer [ 31 , 73 , 74 ]. Despite being part of the inclusion criteria for this review, there was only one study that looked explicitly at the experiences of informal caregivers of cancer survivors in rural areas during COVID-19 and future research should make concentrated efforts to include and involve them. Whilst evidence from this review and the wider literature continues to highlight a workforce shortage of both health and mental health professionals in rural and remote areas [ 64 , 75 ], informal carers and the wider community have a vital role to play in supporting people through their diagnosis, treatment, and recovery.

Much like the wider health sciences literature, the evidence base within cancer research is often weakened by the absence of good quality studies with parallel comparison groups [ 72 ]. This would allow us to verify and or challenges some of the negative and positive assumptions in relation to health and rural-urban residence. In order to ascertain the longer-term fallout of the pandemic on the experiences of rural cancer survivors future primary research and good quality evidence syntheses will be warranted.

Limitations

There are several limitations to this review. Whilst it followed a systematic and comprehensive search strategy using a pre-defined protocol, this was not a full systematic review and as such there could be studies that were missed via the search strategy detailed above. Future searches should be optimised by searching additional multi-disciplinary databases such as Scopus and Web of Science. The searching of reference lists and citations would also be welcomed in subsequent reviews of the literature. The omission of a quality assessment stage in the review is largely in keeping with the aims of a rapid review, however, we encourage future evidence syntheses in this area to consider evaluating the scientific quality of included studies so the academic community can be informed on the quality, importance and originality of the extant literature. Whilst we have noted that the inclusion of a wide range of studies from different geographic settings was a strength, the heterogeneity of settings also somewhat limits the local applicability of the findings where definitions and conceptualisations of ‘rural’ will greatly vary, as well as the public health and policy approaches to the management of COVID-19. Finally, future evidence syntheses will be warranted in the near future to ensure that all of the pertinent evidence from the COVID-19 pandemic is collated and available to the academic community who are interested in cancer and rurality. This rapid review could provide a useful template to inform the development of a full systematic review.

5. Conclusions

As we continue to deal with the longer-term impact of the COVID-19 pandemic, this review provides novel and important insight into the experiences of rural cancer survivors that may help inform tailored support in line with the additional needs and challenges they face because of the pandemic.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Author Contributions

D.N. and S.C. led on the initial idea, study design and development of the protocol. The search strategy was developed by D.N., S.C. and B.M.; D.N. performed the searches and extracted the data files. Title and abstract screening were performed by D.N. and A.N. Full text screening was conducted by B.M. and D.N.; D.N. and S.C. led on data extraction for each full text article. D.N. and B.M. drafted the narrative overview with support from S.C., A.N., R.K. and M.G. All authors contributed to the interpretation of the findings. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

This was a desk-based review of the literature therefore ethical approval was not required.

Informed Consent Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

References

1. Miller K.D. Nogueira L. Mariotto A.B. Rowland J.H. Yabroff K.R. Alfano C.M. Jemal A. Kramer J.L. Siegel R.L. Cancer treatment and survivorship statistics, 2019 CA Cancer J. Clin. 2019 69 363 385 10.3322/caac.21565 31184787

2. Maddams J. Utley M. Møller H. Projections of cancer prevalence in the United Kingdom, 2010–2040 Br. J. Cancer 2012 107 1195 1202 10.1038/bjc.2012.366 22892390 PMC3461160

3. De Lorenzo F. Apostolidis K. Florindi F. Makaroff L.E. Improving European policy to support cancer survivors J. Cancer Policy 2018 15 72 75 10.1016/j.jcpo.2018.01.004

4. Bakouny Z. Hawley J.E. Choueiri T.K. Peters S. Rini B.I. Warner J.L. Painter C.A. COVID-19 and Cancer: Current Challenges and Perspectives Cancer Cell 2020 38 629 646 10.1016/j.ccell.2020.09.018 33049215 PMC7528740

5. Alkatout I. Biebl M. Momenimovahed Z. Giovannucci E. Hadavandsiri F. Salehiniya H. Allahqoli L. Has COVID-19 Affected Cancer Screening Programs? A Systematic Review Front. Oncol. 2021 11 675038 10.3389/fonc.2021.675038 34079764 PMC8165307

6. Riera R. Bagattini Â.M. Pacheco R.L. Pachito D.V. Roitberg F. Ilbawi A. Delays and Disruptions in Cancer Health Care Due to COVID-19 Pandemic: Systematic Review JCO Glob. Oncol. 2021 7 311 323 10.1200/GO.20.00639 33617304 PMC8081532

7. Richards M. Anderson M. Carter P. Ebert B.L. Mossialos E. The impact of the COVID-19 pandemic on cancer care Nat. Cancer 2020 1 565 567 10.1038/s43018-020-0074-y 35121972 PMC7238956

8. Jones J.M. Saeed H. Katz M.S. Lustberg M.B. Forster V.J. Nekhlyudov L. Readdressing the Needs of Cancer Survivors During COVID-19: A Path Forward JNCI J. Natl. Cancer Inst. 2021 113 955 961 10.1093/jnci/djaa200 33367655 PMC7799033

9. Nekhlyudov L. Duijts S. Hudson S.V. Jones J.M. Keogh J. Love B. Lustberg M. Smith K.C. Tevaarwerk A. Yu X. Addressing the needs of cancer survivors during the COVID-19 pandemic J. Cancer Surviv. 2020 14 601 606 10.1007/s11764-020-00884-w 32335850 PMC7183255

10. Moss J.L. Pinto C.N. Mama S.K. Rincon M. Kent E.E. Yu M. Cronin K.A. Rural–urban differences in health-related quality of life: Patterns for cancer survivors compared to other older adults Qual. Life Res. 2021 30 1131 1143 10.1007/s11136-020-02683-3 33136241 PMC8005417

11. Weaver K.E. Geiger A.M. Lu L. Case L.D. Rural-urban disparities in health status among US cancer survivors Cancer 2013 119 1050 1057 10.1002/cncr.27840 23096263 PMC3679645

12. Weaver K.E. Palmer N. Lu L. Case L.D. Geiger A.M. Rural–urban differences in health behaviors and implications for health status among US cancer survivors Cancer Causes Control 2013 24 1481 1490 10.1007/s10552-013-0225-x 23677333 PMC3730816

13. Zahnd W.E. Davis M.M. Rotter J.S. Vanderpool R.C. Perry C.K. Shannon J. Ko L.K. Wheeler S.B. Odahowski C.L. Farris P.E. Rural-urban differences in financial burden among cancer survivors: An analysis of a nationally representative survey Support. Care Cancer 2019 27 4779 4786 10.1007/s00520-019-04742-z 30972645 PMC6786922

14. Burris J.L. Andrykowski M. Disparities in mental health between rural and nonrural cancer survivors: A preliminary study Psycho-Oncology 2010 19 637 645 10.1002/pon.1600 19582800 PMC2880195

15. McNulty J.A. Nail L. Cancer Survivorship in Rural and Urban Adults: A Descriptive and Mixed Methods Study J. Rural. Health 2015 31 282 291 10.1111/jrh.12106 25599984

16. Afshar N. English D.R. Milne R.L. Rural–urban residence and cancer survival in high-income countries: A systematic review Cancer 2019 125 2172 2184 10.1002/cncr.32073 30933318

17. van der Kruk S.R. Butow P. Mesters I. Boyle T. Olver I. White K. Sabesan S. Zielinski R. Chan B.A. Spronk K. Psychosocial well-being and supportive care needs of cancer patients and survivors living in rural or regional areas: A systematic review from 2010 to 2021 Support. Care Cancer 2022 30 1021 1064 10.1007/s00520-021-06440-1 34392413 PMC8364415

18. Carriere R. Adam R. Fielding S. Barlas R. Ong Y. Murchie P. Rural dwellers are less likely to survive cancer—An international review and meta-analysis Health Place 2018 53 219 227 10.1016/j.healthplace.2018.08.010 30193178

19. Stolzenbach L.F. Deuker M. Collà-Ruvolo C. Nocera L. Tian Z. Maurer T. Tilki D. Briganti A. Saad F. Mirone V. Differences between rural and urban prostate cancer patients World J. Urol. 2021 39 2507 2514 10.1007/s00345-020-03483-7 33155063 PMC8332582

20. Deuker M. Stolzenbach L.F. Collà Ruvolo C. Nocera L. Tian Z. Roos F.C. Becker A. Kluth L.A. Tilki D. Shariat S.F. Bladder cancer stage and mortality: Urban vs. rural residency Cancer Causes Control 2021 32 139 145 10.1007/s10552-020-01366-1 33230694 PMC7810614

21. Ruvolo C.C. Stolzenbach L.F. Nocera L. Deuker M. Wenzel M. Tian Z. La Rocca R. Creta M. Capece M. Saad F. Higher Cancer Mortality in Rural Upper Urinary Tract Urothelial Carcinoma Patients Urol. Int. 2021 105 624 630 10.1159/000513361 33709970

22. Butow P.N. Phillips F. Schweder J. White K. Underhill C. Goldstein D. Psychosocial well-being and supportive care needs of cancer patients living in urban and rural/regional areas: A systematic review Support. Care Cancer 2012 20 1 22 10.1007/s00520-011-1270-1 21956760

23. Reid-Arndt S.A. Cox C.R. Does Rurality Affect Quality of Life Following Treatment for Breast Cancer? J. Rural. Health 2010 26 402 405 10.1111/j.1748-0361.2010.00295.x 21029176 PMC2967464

24. Noonan D. LeBlanc M. Conley C. Benecha H. Leak-Bryant A. Peter K. Zimmerman S. Mayer D. Smith S. Quality of Life and Impact of Cancer: Differences in Rural and Nonrural Non-Hodgkin’s Lymphoma Survivors J. Rural. Health 2020 36 536 542 10.1111/jrh.12420 32472708 PMC7529644

25. Nelson D. McGonagle I. Jackson C. Kane R. What is known about the role of rural-urban residency in relation to self-management in people affected by cancer who have completed primary treatment? A scoping review Support. Care Cancer 2021 29 67 78 10.1007/s00520-020-05645-0 32747989 PMC7398290

26. Loughery J. Woodgate R. Supportive care needs of rural individuals living with cancer: A literature review Can. Oncol. Nurs. J. 2015 25 10 10.5737/23688076252157166 26638285

27. Graham F. Kane R. Gussy M. Nelson D. Recovery of Health and Wellbeing in Rural Cancer Survivors Following Primary Treatment: Analysis of UK Qualitative Interview Data Nurs. Rep. 2022 12 482 497 10.3390/nursrep12030046 35894036 PMC9326683

28. Levit L.A. Byatt L. Lyss A.P. Paskett E.D. Levit K. Kirkwood K. Schenkel C. Schilsky R.L. Closing the Rural Cancer Care Gap: Three Institutional Approaches JCO Oncol. Pract. 2020 16 422 430 10.1200/OP.20.00174 32574128

29. Sugiyama T. Carver A. Koohsari M.J. Veitch J. Advantages of public green spaces in enhancing population health Landsc. Urban Plan. 2018 178 12 17 10.1016/j.landurbplan.2018.05.019

30. Nelson D. McGonagle I. Jackson C. Gussy M. Kane R. A rural-urban comparison of self-management in people living with cancer following primary treatment: A mixed methods study Psycho-Oncology 2022 31 1660 1670 10.1002/pon.6011 35971265 PMC9804546

31. Gunn K.M. Olver I. Skrabal Ross X. Harrison N. Livingston P.M. Wilson C. Improving Survivors’ Quality of Life Post-Treatment: The Perspectives of Rural Australian Cancer Survivors and Their Carers Cancers 2021 13 1600 10.3390/cancers13071600 33808464 PMC8037228

32. Nelson D. Law G.R. McGonagle I. Turner P. Jackson C. Kane R. The Effect of Rural Residence on Cancer-Related Self-Efficacy With UK Cancer Survivors Following Treatment J. Rural. Health 2022 38 28 33 10.1111/jrh.12549 33289206

33. Nelson D. McGonagle I. Jackson C. Kane R. An Exploration of Rural-Urban Residence on Self-Reported Health Status with UK Cancer Survivors Following Treatment: A Brief Report Nurs. Rep. 2022 12 574 582 10.3390/nursrep12030056 35997464 PMC9397029

34. Gunn K.M. Berry N.M. Meng X. Wilson C.J. Dollman J. Woodman R.J. Clark R.A. Koczwara B. Differences in the health, mental health and health-promoting behaviours of rural versus urban cancer survivors in Australia Support. Care Cancer 2020 28 633 643 10.1007/s00520-019-04822-0 31115668

35. Jammu A.S. Chasen M.R. Lofters A.K. Bhargava R. Systematic rapid living review of the impact of the COVID-19 pandemic on cancer survivors: Update to August 27, 2020 Support. Care Cancer 2021 29 2841 2850 10.1007/s00520-020-05908-w 33242162 PMC7690065

36. Rodríguez-Pose A. Burlina C. Institutions and the uneven geography of the first wave of the COVID-19 pandemic J. Reg. Sci. 2021 61 728 752 10.1111/jors.12541 34226760 PMC8242880

37. Asongu S.A. Diop S. Nnanna J. The geography of the effectiveness and consequences of COVID-19 measures: Global evidence J. Public Aff. 2021 21 e2483 10.1002/pa.2483

38. McLeod B. Cooke S. Kane R. Gussy M. Nelson D. A Protocol for a Rapid Systematic Review on the Experiences of Cancer Survivors Who Reside in Rural Areas during the COVID-19 Pandemic Open Sci. Framew. 2022 10.17605/OSF.IO/2FJGC PMC9778689 36554740

39. Garritty C. Gartlehner G. Nussbaumer-Streit B. King V.J. Hamel C. Kamel C. Affengruber L. Stevens A. Cochrane Rapid Reviews Methods Group offers evidence-informed guidance to conduct rapid reviews J. Clin. Epidemiol. 2021 130 13 22 10.1016/j.jclinepi.2020.10.007 33068715 PMC7557165

40. Moher D. Liberati A. Tetzlaff J. Altman D.G. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement Ann. Intern. Med. 2009 151 264 269 10.7326/0003-4819-151-4-200908180-00135 19622511

41. Moher D. Stewart L. Shekelle P. All in the Family: Systematic reviews, rapid reviews, scoping reviews, realist reviews, and more Syst. Rev. 2015 4 183 10.1186/s13643-015-0163-7 26693720 PMC4688988

42. Tricco A.C. Antony J. Zarin W. Strifler L. Ghassemi M. Ivory J. Perrier L. Hutton B. Moher D. Straus S.E. A scoping review of rapid review methods BMC Med. 2015 13 224 10.1186/s12916-015-0465-6 26377409 PMC4574114

43. Khangura S. Konnyu K. Cushman R. Grimshaw J. Moher D. Evidence summaries: The evolution of a rapid review approach Syst. Rev. 2012 1 10 10.1186/2046-4053-1-10 22587960 PMC3351736

44. Ouzzani M. Hammady H. Fedorowicz Z. Elmagarmid A. Rayyan—A web and mobile app for systematic reviews Syst. Rev. 2016 5 210 10.1186/s13643-016-0384-4 27919275 PMC5139140

45. Haby M.M. Chapman E. Clark R. Barreto J. Reveiz L. Lavis J.N. What are the best methodologies for rapid reviews of the research evidence for evidence-informed decision making in health policy and practice: A rapid review Health Res. Policy Syst. 2016 14 83 10.1186/s12961-016-0155-7 27884208 PMC5123411

46. Baffert K.-A. Darbas T. Lebrun-Ly V. Pestre-Munier J. Peyramaure C. Descours C. Mondoly M. Latrouite S. Bignon E. Nicouleau S. Quality of Life of Patients with Cancer during the COVID-19 Pandemic In Vivo 2021 35 663 10.21873/invivo.12306 33402524 PMC7880728

47. Davis C. Cadet T. Rune K. Wilson P. Banks J. Exploring the Challenges in Accessing Care and Support for Cancer Survivors in Australia during COVID-19 Taylor & Francis Ltd. Philadelphia, PA, USA 2021 Report No.: 0734-7332 10.1080/07347332.2021.1904086 PMC8689679 33787464

48. Galica J. Liu Z. Kain D. Merchant S. Booth C. Koven R. Brundage M. Haase K.R. Coping during COVID-19: A mixed methods study of older cancer survivors Support. Care Cancer Off. J. Multinatl. Assoc. Support. Care Cancer 2021 29 3389 3398 10.1007/s00520-020-05929-5 PMC7786158 33404813

49. Himbert C. Hathaway C.A. Daniels B. Salas K. Ashworth A. Gigic B. Lin T. Viskochil R. Kirchhoff A.C. Grossman D. Factors associated with changes in exercise behaviors during the COVID-19 pandemic Cancer Causes Control 2022 33 939 950 10.1007/s10552-022-01580-z 35554777 PMC9096745

50. Howden K. Glidden C. Romanescu R.G. Hatala A. Scott I. Deleemans J. Chalifour K. Eaton G. Gupta A.A. Bolton J.M. A Cross-Sectional Survey Exploring the Impact of the COVID-19 Pandemic on the Cancer Care of Adolescents and Young Adults Curr. Oncol. 2021 28 3201 3213 10.3390/curroncol28040278 34436044 PMC8395398

51. Howden K. Yan A.P. Glidden C. Romanescu R.G. Scott I. Deleemans J.M. Chalifour K. Eaton G. Gupta A.A. Bolton J.M. Loneliness among adolescents and young adults with cancer during the COVID-19 pandemic: A cross-sectional survey Support. Care Cancer 2022 30 2215 2224 10.1007/s00520-021-06628-5 34708310 PMC8549808

52. Krok-Schoen J.L. Pisegna J.L. BrintzenhofeSzoc K. MacKenzie A.R. Canin B. Plotkin E. Boehmer L.M. Shahrokni A. Experiences of healthcare providers of older adults with cancer during the COVID-19 pandemic J. Geriatr. Oncol. 2021 12 190 195 10.1016/j.jgo.2020.09.021 32978104 PMC7500913

53. Peoples A.R. Oswald L.B. Ose J. Daniels B. Himbert C. Hathaway C.A. Gigic B. Kirchhoff A.C. Lin T. Grossman D. Impact of the COVID-19 pandemic on rural and urban cancer patients’ experiences, health behaviors, and perceptions J. Rural. Health 2022 38 886 899 10.1111/jrh.12648 35243690 PMC9115146

54. Podubinski T. Townsin L. Thompson S.C. Tynan A. Argus G. Experience of Healthcare Access in Australia during the First Year of the COVID-19 Pandemic Int. J. Environ. Res. Public Health 2021 18 10687 10.3390/ijerph182010687 34682432 PMC8535411

55. Rajan S. Akhtar N. Tripathi A. Kumar V. Chaturvedi A. Mishra P. Sharma S. Misra S. Gupta S. Singh M. Impact of COVID-19 pandemic on cancer surgery: Patient’s perspective J. Surg. Oncol. 2021 123 1188 1198 10.1002/jso.26429 33592128 PMC8013664

56. Ratnapradipa K.L. Ranta J. Napit K. Luma L.B. Robinson T. Dinkel D. Schabloske L. Watanabe-Galloway S. Qualitative analysis of cancer care experiences among rural cancer survivors and caregivers J. Rural. Health 2022 38 876 885 10.1111/jrh.12665 35381622 PMC9492624

57. Singh R. Rai C. Ishan R. Impact of COVID-19 lockdown on patients with cancer in North Bihar, India: A phone-based survey Cancer Res. Stat. Treat. 2021 4 37 43 10.4103/crst.crst_349_20

58. Spencer-Bowdage S. Russell B. Rigby J. O’Kelly J. Kelly P. Page M. Raw C. Allchorne P. Harper P. Crew J. The experience of UK patients with bladder cancer during the COVID-19 pandemic: A survey-based snapshot BJU Int. 2021 127 179 181 10.1111/bju.15287 33124729 PMC7894556

59. Zomerdijk N. Jongenelis M. Short C.E. Smith A. Turner J. Huntley K. Prevalence and correlates of psychological distress, unmet supportive care needs, and fear of cancer recurrence among haematological cancer patients during the COVID-19 pandemic Support. Care Cancer 2021 29 7755 7764 10.1007/s00520-021-06369-5 34164740 PMC8221273

60. Bird W. Improving health in coastal communities BMJ 2021 374 n2214 10.1136/bmj.n2214 34535467

61. Bhatia S. Landier W. Paskett E.D. Peters K.B. Merrill J.K. Phillips J. Osarogiagbon R.U. Rural–Urban Disparities in Cancer Outcomes: Opportunities for Future Research J. Natl. Cancer Inst. 2022 114 940 952 10.1093/jnci/djac030 35148389 PMC9275775

62. Scandurra C. Muzii B. La Rocca R. Di Bello F. Bottone M. Califano G. Longo N. Maldonato N.M. Mangiapia F. Social Support Mediates the Relationship between Body Image Distress and Depressive Symptoms in Prostate Cancer Patients Int. J. Environ. Res. Public Health 2022 19 4825 10.3390/ijerph19084825 35457692 PMC9031078

63. Parsons K. Gaudine A. Swab M. Experiences of older adults accessing specialized health care services in rural and remote areas: A qualitative systematic review JBI Evid. Synth. 2021 19 1328 1343 10.11124/JBIES-20-00048 34111043

64. Adjei Boakye E. Jenkins W. Sharma A. Disproportionate impact of COVID-19 pandemic on head and neck cancer survivors Head Neck 2020 42 1329 1331 10.1002/hed.26170 32298019 PMC7262054

65. Paterson C. Bacon R. Dwyer R. Morrison K.S. Toohey K. O’Dea A. Slade J. Mortazavi R. Roberts C. Pranavan G. The Role of Telehealth During the COVID-19 Pandemic Across the Interdisciplinary Cancer Team: Implications for Practice Semin. Oncol. Nurs. 2020 36 151090 10.1016/j.soncn.2020.151090 33218886 PMC7561334

66. Paterson C. Gobel B. Gosselin T. Haylock P.J. Papadopoulou C. Slusser K. Rodriguez A. Pituskin E. Oncology Nursing During a Pandemic: Critical Reflections in the Context of COVID-19 Semin. Oncol. Nurs. 2020 36 151028 10.1016/j.soncn.2020.151028 32423833 PMC7177078

67. Hincapié M.A. Gallego J.C. Gempeler A. Piñeros J.A. Nasner D. Escobar M.F. Implementation and Usefulness of Telemedicine during the COVID-19 Pandemic: A Scoping Review J. Prim. Care Community Health 2020 11 2150132720980612 10.1177/2150132720980612 33300414 PMC7734546

68. Seah K.M. COVID-19: Exposing digital poverty in a pandemic Int. J. Surg. 2020 79 127 128 10.1016/j.ijsu.2020.05.057 32454251 PMC7245204

69. Arcury T.A. Sandberg J.C. Melius K.P. Quandt S.A. Leng X. Latulipe C. Miller D.P. Smith D.A. Bertoni A.G. Older Adult Internet Use and eHealth Literacy J. Appl. Gerontol. 2018 39 141 150 10.1177/0733464818807468 30353776 PMC6698430

70. Morra S. Napolitano L. Collà Ruvolo C. Celentano G. La Rocca R. Capece M. Creta M. Passaro F. Di Bello F. Cirillo L. Could YouTubeTM encourage men on prostate checks? A contemporary analysis Arch. Ital. Urol. Androl. 2022 94 285 290 10.4081/aiua.2022.3.285 36165471

71. Di Bello F. Collà Ruvolo C. Cilio S. La Rocca R. Capece M. Creta M. Celentano G. Califano G. Morra S. Iacovazzo C. Testicular cancer and YouTube: What do you expect from a social media platform? Int. J. Urol. 2022 29 685 691 10.1111/iju.14871 35318754

72. Gessert C. Waring S. Bailey-Davis L. Conway P. Roberts M. VanWormer J. Rural definition of health: A systematic literature review BMC Public Health 2015 15 378 10.1186/s12889-015-1658-9 25879818 PMC4406172

73. Girgis A. Lambert S. Cost of informal caregiving in cancer care Cancer Forum 2017 41 16 22

74. Nelson D. Mansfield P. Kane R. Carers of people affected by cancer and other long-term conditions at end of life: A qualitative study of providing a bespoke package of support in a rural setting Palliat. Med. 2016 31 158 161 10.1177/0269216316648073 27160699

75. Challinor J.M. Alqudimat M.R. Teixeira T.O.A. Oldenmenger W.H. Oncology nursing workforce: Challenges, solutions, and future strategies Lancet Oncol. 2020 21 e564 e574 10.1016/S1470-2045(20)30605-7 33212044