Bending the Trends in Cancer Care in Rural North Carolina

Off the coast of North Carolina, the barrier islands—called the Outer Banks—often draw tourists who flock to the area’s stretches of beaches in the warmer summer months. But when the beach crowds subside, the community remains home to an aging population of about 40,000 residents who need quality health care services year-round.

When Outer Banks Health, a 19-bed hospital in the beach town of Nags Head, North Carolina, first opened in 2002, the hospital’s goal was to provide comprehensive immediate care to the area’s aging population. But early on, hospital staff noticed that when diagnosed with cancer, residents often had to leave Nags Head, making a several-hour round trip to Norfolk, Virginia, or other larger cities, often many times a month during their cancer treatment.

“We realized very early that cancer was a growing issue on the island,” said Charles Shelton, MD, medical director of Outer Banks Health and a member of the Commission on Cancer (CoC) Quality Improvement Committee. “Even though there were some cancer services on the island, they were very sporadic and poorly coordinated. Patients would get what they could on the island, but most of the time, they would still leave the area to get some component of their care.”

By hospital estimates, in the first five years of its opening, Outer Banks Health staff interacted with less than 10% of local cancer patients, suggesting that the vast majority of patients in the area had to leave the county to receive cancer treatment.

A Manual for Survival

Looking to improve cancer care at their hospital, Dr. Shelton and his team sought accreditation from the CoC. CoC accreditation ensures hospitals meet a core set of more than 34 broad standards that help improve the quality of care through evidence-based cancer-related programs and activities. These programs are concerned with the full continuum of cancer care—from prevention to survivorship and end-of-life care—while addressing both survival and quality of life.

Approximately 1,400 hospitals and cancer centers are CoC-accredited in the U.S. About a quarter of these hospitals are accredited as community cancer programs, which means that they treat fewer than 500 newly diagnosed cancer cases per year.

After applying for accreditation in 2015 and having a successful site visit, Outer Banks Health received CoC accreditation in 2016 and gained accreditation from the National Accreditation Program for Breast Centers (NAPBC) in 2022.

Dr. Shelton said that while receiving accreditation can initially seem like a daunting process for smaller hospitals, receiving accreditation was feasible and has offered considerable long-term benefits.

“The CoC manual is really a survival manual,” he said. “It allows us to address all aspects of the needed components of proactive cancer care, from screening to prevention. For us, that’s been a huge part of addressing and developing a process for cancer care in Nags Head.”

Dr. Shelton shares three lessons learned from his hospital’s journey to achieving CoC and NAPBC accreditation.

Lessons Learned from CoC and NAPBC Accreditation

Leverage partnerships to strengthen existing resources

CoC accreditation requires cancer care to be treated through a multidisciplinary lens, which includes input not only from surgeons but also from radiologists, pathologists, radiation oncologists, and medical oncologists. At the start of its accreditation process, Outer Banks Health sought to leverage partnerships with nearby hospitals that had a larger pool of resources. They hired a director of cancer services and developed an oncology navigation program—which helps patients through decision-making and treatment options—through a partnership with the University of North Carolina. They also have ongoing partnerships with ECU Health in North Carolina and Chesapeake General Hospital in Virginia, both of which are CoC-accredited. Leveraging these community partnerships enabled a smaller hospital like Outer Banks Health to glean from the expertise of a broad group of experts who can advise on treatment strategies and review patient cases together, Dr. Shelton said.

Quality care drives patient volumes

CoC accreditation requires that hospitals invest in the cancer services they can provide patients on-site or by referral, including diagnostic imaging and radiation oncology. Since receiving CoC accreditation, the hospital has seen a steady increase in the number of patients seeking cancer care at Outer Banks Health. The hospital is now involved with more than 70% of all cancer cases in the community in some capacity, including some from neighboring counties. Additionally, 80% of breast cancers are now diagnosed at stage 0/1 at Outer Banks Health, reflecting efforts to substantially increase the number of screening mammograms on-site.

“People want to go where they know the care is good,” Dr. Shelton said. “They know that not only you’re providing the care, but you’re providing a high level of care because you’re following standards that hold you accountable.”

The increase in patient volumes has also translated into more revenue, with the hospital investing in an $18 million cancer center that opened in 2024 to support cancer patients.

“We added and fine-tuned our services to support our growing volumes. Over time, that’s allowed us to have a greater impact on our population locally,” Dr. Shelton said. “As our volumes started to increase, we also started to think about facilities to support the growing number of patients we treat.”

Accreditation provided a framework for keeping cancer care closer to home

In cancer care, time is of the essence. Delays in screening, diagnoses, and treatment can all contribute to cancer gaps in rural areas. Outer Banks Health previously reported a mortality rate that was about 15% higher than the state’s baseline average; that number has decreased in the past 10 years so that the rural area now matches the state’s average—something Dr. Shelton attributes to a streamlined process to treating cancer aided by CoC accreditation.

“It’s rare in today’s world where a patient is one and done with cancer. Usually, cancer treatment may involve surgery plus something else like hormone therapy, chemotherapy, or possibly immunotherapy,” Dr. Shelton said. Although a percentage of patients still need to leave the area for some component of cancer care, such as seeing a surgical specialist, the hospital is now able to navigate this transition and support the patient with other complementary services, such as chemotherapy or radiation. These visits are often time-consuming and may need to occur frequently, so being able to do these visits closer to home can be of tremendous benefit to patients, Dr. Shelton added.

“When you provide access to critical parts of cancer care, such as chemotherapy or radiotherapy, even if some parts may require travel, that access helps reduce disparities,” Dr. Shelton said.

Participating in the NAPBC quality improvement project, Patient Reported Observations on Medical Timeliness for Breast Patients (PROMPT), also helped the hospital understand delays to care and develop processes for supporting patients with services closer to home.

Dr. Shelton noted that historically, Outer Banks Health had patients with stage 4 cancer visit the emergency room because they hadn’t received treatment before and, as a result, were likely facing only palliative care as an option. “Now we can possibly change the prognosis for these patients, and we can potentially change their outcomes dramatically,” he said. “It’s just a win-win for your community.”

“My advice to small programs is that you’re never too small to consider receiving accreditation,” Dr. Shelton added. “If you treat any number of patients, you are a candidate for accreditation as long as you follow the standards. I would recommend that any program, no matter their size or geography, would benefit from this process.”

Learn more about CoC accreditation and NAPBC accreditation.