EP669 - Watch & Wait in Rural America: a qualitative assessment of motivations and barrier for participation in rural rectal cancer patients

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Purpose/Background: There is growing support for a Watch and Wait approach to rectal cancer to avoid surgery-associated morbidity, but success in this approach requires intensive surveillance for recurrence. As a rural tertiary care facility, we began a project to assess the feasibility of this approach in our rural patient population. As an outgrowth of this ongoing study, we interviewed its participants to better understand their motivations for Watch and Wait and the barriers they face.

Methods/Interventions: Patients were identified from enrollment in our Watch and Wait feasibility study and approached about their willingness to participate in a telephone interview. Interviews were guided by a preset list of questions that explored initial interest in the protocol, attitudes toward surgery, interactions with their healthcare team, and treatment costs. Discussions were conducted by a single interviewer. Transcribed responses were then coded by the team using thematic analysis to identify salient themes.

Results/Outcomes: When discussing the reason for pursuing Watch and Wait, there was near uniform agreement that quality of life after surgery was the major motivator, most expressing a desire to avoid an ostomy. When discussing obstacles to treatment, themes of financial, emotional, and symptom burden emerged. Many felt financial hardship due to the cost of treatment. Transportation was also a major burden, with participants living up to 1.5 hours away from the hospital. Other burdens included anxiety from inconclusive test results, uncertain next steps, and side effects from chemoradiation limiting quality of life and ability to participate in care.

A concurrent major theme was the impact of participants’ engagement in their own treatment plan. While most participants deferred to the recommendations of their physician, some participants admitted to being confused by the protocol or having regrets, ranging from concerns about not asking enough questions to fears they made the wrong choice. Fewer patients sought outside resources and second opinions to better understand their options. However, most expressed significant confidence in their healthcare team, which appeared to help allay their concerns. Further mitigating factors included social support system, relationships with their healthcare providers, and faith or spirituality.

Participants varied widely in their worldviews, which affected their healthcare system experience and the tone of the interviews. Several expressed fatalism and/or acceptance of death. Others believed all measures should be taken to extend life, some going as far as to say it should be done without complaint. When faced with such discussions of their mortality, various participants used a mix of humor, emotional vulnerability, and disengagement/denial to cope with their illness-related grief.

Conclusion/Discussion: Rural patients identify quality of life as the main motivating factor for participation in Watch and Wait. They are particularly vulnerable to certain treatment obstacles, including financial cost, transportation availability, and health illiteracy. Overall attitude, social support systems, and relationship to their healthcare providers appear protective; however, more must be done to assess whether or not the surveillance required by this protocol is feasible in a rural setting. Next steps include further interviews and comparison of patients’ subjective experiences with chart reviewed data to assess the success of a rural Watch and Wait protocol.