Response to “Built and Natural Environment Barriers and Facilitators to Physical Activity in Rural, Suburban, and Small Urban Neighborhoods”

DeGuzman et al. (2019) should be commended for their article “Built and Natural Environment Barriers and Facilitators to Physical Activity in Rural, Suburban, and Small Urban Neighborhoods.” The work is a meaningful contribution to the oncology field, given the health disparity among patients with cancer living in rural and suburban communities. Nurses need to be part of the larger conversation and advocate for patients through policy reform that supports access to an equitable built environment. DeGuzman et al.’s (2019) article starts this conversation. In this letter, I wish to build on that initial conversation by deepening the discussion of built environment and costs as significant barriers to physical activity in cancer survivors.

The authors defined built environment as “aspects of the environment that are human-made” (DeGuzman et al., 2019, p. 546). A significant addition to this definition is that being equitable and accessible to all is necessary. The concept of universal design as providing access to the built environment outlined the potential to minimize healthcare disparity (Imrie, 2012). By including accessibility as an essential attribute of how we assess the built environment, it enables us to critique the environment in our patients’ neighborhoods further by addressing barriers, including cost, inequity, and the importance of government and societal involvement. The authors noted that the use of an indoor gym and participation in physical activity are associated with higher income individuals. However, the authors only briefly noted cost as a barrier to access. Cost is a significant barrier that affects the trajectory of survivorship. The high cost of cancer treatment in addition to the cost of transportation to medical appointments, cost of living, and increased rate of unemployment (de Boer et al., 2009) contribute to the magnitude of financial toxicity among cancer survivors.

Financial toxicity is defined as financial problems resulting from medical care that leads to debt and bankruptcy, affecting patients’ quality of life and access to care (National Cancer Institute, 2019). Banegas et al. (2016) estimated that 37% of cancer survivors were in debt. A subsequent study from Chan et al. (2019) noted a strong positive relationship between financial toxicity and psychological distress among cancer survivors, highlighting the significance of addressing financial issues. Cancer survivors who live in rural areas report and experience a higher level of financial hardship than their urban counterparts (Odahowski et al., 2019), stressing the health disparity between the two geographic locations.

Cost is deeply embedded in all aspects of cancer care. The high cost of treatment alone can lead to financial toxicity, not to mention the additional costs of transportation, time away from work, fees to access health resources for exercise, and health visits with other medical teams that can further worsen financial toxicity and affect patients’ quality of life and survivorship. There is no arguing with the importance of evaluating the built environment of patients. However, assessment of financial toxicity is also warranted in all patients with cancer because the cost is a significant hindrance to their health, well-being, and success in survivorship, particularly for those who live in rural areas. Without the collaboration and support of our communities and government, healthcare disparity and inequity will continue among patients with cancer. Nurses working with cancer survivors are in a unique position to continue to advance research and policy to reduce health disparities.

About the Author(s)

Karl Cristie F. Figuracion, MSN, ARNP, AOCNP^®, is an advanced registered nurse practitioner in the department of radiation oncology at the Alvord Brain Tumor Center and a T32 predoctoral fellow in the School of Nursing, both at the University of Washington in Seattle. No financial relationships to disclose. This work was supported, in part, by the National Institutes of Health, National Institute of Nursing Research Omics and Symptom Science Training Program at the University of Washington (No. T32NR016913). The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health. Figuracion can be reached at kfigurac@uw.edu, with copy to ONFEditor@ons.org.