Study Shows Disparities in Psychosocial Outcomes Among Women With Ovarian Cancer in Rural vs Urban Areas

February 23, 2024 9:00 am

The following article is provided by The Clearity Foundation to support women with ovarian cancer and their families. Learn more about The Clearity Foundation and the services we provide directly to women as they make treatment decisions and navigate emotional impacts of their diagnosis.

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By Rose McNulty

Patients with ovarian cancer living in rural areas reported less psychological functioning improvements compared with patients living in urban areas in the year following ovarian cancer diagnosis, according to a prospective, longitudinal study published in Gynecologic Oncology.

Rural residence is a known driver of health care disparities among patients with cancer, but there is a lack of research on the impacts of rural residency on mental health and quality of life (QOL) in patients with ovarian cancer. Authors of the current study aimed to determine the impacts of rural residency on psychosocial functioning and QOL through surveys conducted between the clinic visit and treatment initiation, at 6 months, and at a 1-year follow-up visit. Patients were recruited at the University of Iowa and Washington University.

The final sample included 261 patients with epithelial ovarian cancer who had data available from at least 2 time points. The mean participant age was 59.9 years. Depressive symptoms were gauged using the 20-item Center for Epidemiologic Studies Depression Scale (CES-D), QOL was determined by Functional Assessment of Cancer Therapies (FACT) scales, distress was measured using the Profile of Mood States short form, and the 24-item Social Provisions Scale gauged social support.

A total of 43.7% of patients at the University of Iowa and 30.6% of patients at Washington University were classified as rural, with no significant differences in age, disease stage, smoking, relationship status, or body mass index between the rural and urban groups. More patients in rural areas (90%) made $80,000 or less compared with patients in urban areas (75%). Additionally, more patients in urban settings were college graduates or received post-graduate education (41%) compared with rural patients (19%).

Distress levels were similar at baseline for rural and urban patients, but the groups showed significantly different trajectories of distress between the start of the study and the 1-year follow-up visit. By 12 months, distress among patients in urban areas had decreased to about one-third the original level (baseline score, 25.0; 12 months, 8.4), but those in rural areas still showed elevated distress compared with patients in urban areas at 12 months despite a significant decrease from the time of diagnosis (baseline score, 24.7; 12 months, 15.2).

Among rural patients, depressive symptoms were moderate based on the mean CES-D score (16.57), whereas the mean CES-D score among urban patients (15.5) fell just below the cutoff of 16 for moderate clinical depression, though the means were not statistically significantly different (P = .35). In both the rural and urban groups, nearly half of patients were classified as experiencing moderate clinical depression (49% and 46%, respectively) at study entry. At 1 year, 29% and 24% of patients, respectively, still met the cutoff for clinical depression. In both groups, depressive moods decreased over time and fell within the mild range by 12 months.

Total FACT scores were in the moderately impaired range for both urban and rural patients at study entry and did not statistically significantly differ, but patterns of QOL change over the course of the study were significantly different (P = .005). Among rural patients, QOL scores increased from study entry (73.3) to 6 months (82.09) but did not further increase through 12 months (81.3). Among urban patients, there was a consistent increase in QOL from study entry (74.57) to 6 months (79.74) that continued through 12 months (84.34). FACT-Ovarian Cancer Specific subscale scores improved from baseline to 12 months in both groups and did not differ significantly.

At study entry, social support did not significantly differ between rural and urban patients (P = .18), but trajectories differed significantly over the 12-month period. Social support among urban patients was slightly higher than social support among rural patients at 12 months (85.13 vs 82.55; P = .04).

The study’s findings suggest while there are not baseline disparities for psychosocial variables between urban and rural patients with ovarian cancer, urban patients showed greater improvements in total distress and QOL over time, as well as significantly higher social support.

The authors noted several limitations, such as the inclusion of women at midwestern sites, which may limit the findings’ generalizability across other rural areas. The included patients also received care from gynecologic oncologists at tertiary care academic medical centers, which are often inaccessible for rural patients. Further, the study population was mostly non-Hispanic White women, limiting analysis of intersectional variables such as ethnic and racial diversity.

“Although differences may not be apparent at the time of diagnosis, clinicians should be aware of rurality as a potential risk factor for psychosocial impairments, particularly distress, and potentially for QOL, over the course of treatment and recovery for ovarian cancer patients,” the authors wrote. “Here, rural patients showed impaired recovery in QOL and distress and poorer social support as compared to their urban counterparts over the year following diagnosis. Future research should evaluate long-term mental health disparities in rural ovarian cancer patients that may persist beyond one year following diagnosis.”


Telles R, Zimmerman MB, Thaker PH, et al. Rural-urban disparities in psychosocial functioning in epithelial ovarian cancer patients. Gynecol Oncol.Published online February 2, 2024. doi:10.1016/j.ygyno.2024.01.024

This article was published by: AJMC

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