Access To Cancer Care In Rural Georgia

The principles of World Cancer Day are applied in our own little corner of the world

A Liberty County woman was suffering from renal failure—her kidneys were not able to filter her blood properly, causing a harmful buildup of waste products—and her only respite was pain medication. She had no diagnosis and no insurance to cover the treatment of whatever disease was causing her symptoms. Then she met Ajaz Bulbul, MBBS, MD, who was able to give her some answers and some hope.

“This woman had been on pain medication for months to cope with her symptoms,” recalls Dr. Bulbul, a medical oncologist serving Hinesville and Liberty County. “We diagnosed her with multiple myeloma, a condition of the bone marrow that can cause renal failure and bone pain.”

The uninsured patient now had a diagnosis, but was facing a long road of cancer treatment ahead.

“With the help of our social worker and financial worker on site here, we were able to get her chemotherapy and biological medication for free for a few cycles of treatment,” Dr. Bulbul says. “We helped her acquire health insurance, which started covering her treatment charges. Now she is doing great—she is off the pain medication and her kidney function has completely recovered. She is waiting to be evaluated for a curative transplant.”

This is just one among many examples of how Dr. Bulbul and his staff were able to close the care gap for a patient in rural Georgia that was otherwise running out of options.

Close the care gap—that’s the theme of this year’s World Cancer Day. Every year on February 4, the Union for International Cancer Control leads an initiative to raise awareness of equitable cancer care across the globe. The mission of World Cancer Day is to create a world in which everyone has access to cancer care, no matter where they live.

The void between a patient and what’s available through advanced diagnosis and treatment can often be closed, but only once certain barriers are removed and certain inequalities dealt with. This is true for all corners of the world, including our own.

So how do we close the care gap for even more patients in rural Georgia?

Identifying Problems and Finding Solutions

As a medical oncologist, Dr. Bulbul and his fellow physicians have seen how cancer treatment has advanced in the past several years. His mission now is to help those who previously would not have access to those advanced treatments.

“Healthcare disparities are a very complex problem,” Dr. Bulbul says. “There are issues with economic and racial inequalities. There are cultural barriers. There is a lack of education. We have multiple causes that require multiple solutions.”

From his office on Main Street in Hinesville, Dr. Bulbul sees the day-to-day reality that his patients have to manage in order to receive life-saving care.

Liberty Regional Medical Center and the Nancy N. and J.C. Lewis Cancer & Research Pavilion at St. Joseph’s/Candler have partnered to create a new oncology program to deliver the latest treatments to Liberty County cancer patients.

This partnership was fueled by the commitment of the Liberty community who came together to raise more than $400,000 to bring in needed chemotherapy and medical oncology services. But it also fits perfectly with the Lewis Cancer & Research Pavilion’s longstanding goal to bring the best cancer treatments to people where they live.

“When I talk to my patients, the three limits to care that I hear about most often are financial insecurity, lack of health insurance and transportation,” he says. “They may not have a job or a salary that can manage the costs of treatment. They may be uninsured or underinsured. And in some cases, they just can’t get here.”

So if someone needs a ride? St. Joseph’s/Candler can get them one.

“We provide access to transportation from the home to treatment,” Dr. Bulbul says. “Some of this is aided by a grant we received from the American Cancer Society. Often we will use services such as Lyft or Uber, or whatever is the simplest way for a patient to get to where they need to be.”

Dr. Bulbul says St. Joseph’s/Candler uses a hub and spoke model for services needed in Savannah.

“St. Joseph’s/Candler in Savannah is the hub, while this Hinesville office and others out here are the spokes,” he says. “So we can provide transportation for a CT scan or biopsy and things like that.”

Another unique aspect of Dr. Bulbul’s practice is the onsite social worker and financial worker, who work together to help patients such as the woman with multiple myeloma.

“When I see a patient and recognize that they need social support, our amazing social worker Tonya Ruffin will come in right after me to get started on making that happen,” he says.

Patients sometimes need help getting insurance so they can continue on the next step to treatment. For example, a patient without insurance was able to get checked out by Dr. Bulbul and was discovered to have an elevated prostate-specific antigen, or PSA, level. High PSA levels can be a sign of prostate cancer.

“I recommended him to a urologist, but without insurance he was having trouble finding one who would accept him as a patient, and even if he was accepted, he wasn’t sure how to pay for the visit,” Dr. Bulbul says. “We are working to get this patient insured so that he can get a biopsy.”

Structural Inequality

Dr. Bulbul believes that patients need to be reached where they live, both literally and figuratively. That includes cultural beliefs and attitudes that may affect their care.

“When we talk to patients about screenings, treatment or clinical trials, they see these things through the lens of their own life,” Dr. Bulbul says. “They may say, ‘that screening didn’t help my mom or my aunt, so it won’t help me.’ Or if we discuss a clinical trial, they may ask ‘am I going to be a guinea pig?’ This is why education is so important. It helps overcome a fatalistic attitude to cancer.”

Education can be an effective tool in breaking down cultural barriers, Dr. Bulbul believes, if it is utilized properly.

“Hospitals, physicians and caregivers can do a better job, I think, in using social media, which is easily accessible to most people even in rural areas,” he says.

The cultural barrier has a ripple effect on care, which can be seen in the lack of minority groups in clinical trials. This discrepancy can affect the data that researchers use to develop treatments. Dr. Bulbul cites the change in the screening recommendations for colorectal cancers. The recommended age to start screening was lowered from 50 to 45. The new guidelines didn’t occur until it became clear that a disproportionate number of African-American and Hispanic men were being diagnosed at age 45 with early-onset colorectal disease.

Similarly, the recommended age for lung cancer screening for smokers was lowered from 55 to 50 to mitigate the disparity in African-American men, who were found to have a higher incidence of lung cancer at a younger age.

“This is where these structural inequalities really count, because we naturally ask ourselves, ‘Why didn’t we see this sooner?’” Dr. Bulbul says. “Part of the reason is because these minority groups were not represented in clinical trials.”

Inclusion and The Work Ahead

Dr. Bulbul is hopeful that clinical research is more inclusive and will become even more so over time. The effect on new treatments can be dramatic, as with the case of the EGFR mutation. EGFR, or epidermal growth factor receptor, is a protein that helps make cells grow. The mutation of the gene can cause a type of lung cancer.

“Researchers noticed that Asian-American women were responding differently to certain treatments,” Dr. Bulbul says. “This was because the EGFR mutation was a driver of their lung cancer.”

Knowledge of the roles that genetics and biology play in cancer treatment can help ensure minorities receive the best individualized care for them. But that brings the issue full circle again—how do we make sure patients have access to this care?

In the wide open spaces of rural Georgia, Dr. Bulbul and his staff work tirelessly for that answer for their patients. And as this year’s World Cancer Day rolls around, he is encouraged by the worldwide push to close the care gap.

“The good news is that the cancer treatments we have now are good and are only getting better,” he says. “Now we need to make sure all people have access to it, no matter where they may live.”