The night before her chemotherapy session, Herlinda Sanchez carefully organizes her essentials: clothes, a blanket, medications, her iPad and chargers, a small Bible and rosary, fuzzy socks, and snacks for the drive.

After being diagnosed with stage 3 breast cancer in December, the 36-year-old learned that Del Rio, her town of 35,000 near the Texas-Mexico border, lacks cancer treatment services.

Consequently, she and her husband, Manuel, must drive nearly three hours east to San Antonio. To make the early morning drive manageable, they set an alarm for 4 a.m., allowing just enough time for a quick routine and a journey through dark roads, watching for deer.

About an hour before reaching the cancer clinic, the couple stops for a fast-food meal in the car. This break allows Herlinda to apply ointment to the port where her chemotherapy needle will be inserted, numbing the area to lessen discomfort.

Accessing chemotherapy has always been challenging for rural patients, but the situation has worsened recently. A report from Chartis, a health analytics firm, revealed that 382 rural hospitals in the U.S. stopped offering chemotherapy services between 2014 and 2022. Texas had the highest number, with 57 rural hospitals—nearly half of those in the state that previously provided chemotherapy—eliminating the service by 2022.

Financially strained rural hospitals are increasingly cutting essential services like chemotherapy and obstetrics, according to Michael Topchik, executive director of the Chartis Center for Rural Health. “The data is staggering,” Topchik said. “Imagine being very sick and needing to drive an hour or more each way multiple times a week.”

The loss of chemotherapy services often highlights other deficiencies in cancer care, such as a lack of local specialists and nurses, which can negatively impact patient outcomes. Research co-authored by Marquita Lewis-Thames from Northwestern University showed that rural patients are less likely to survive five years after a cancer diagnosis compared to their urban counterparts. Although the gap has narrowed over time, it persists across most racial and ethnic groups.

While some cancer treatments are now available in oral form and can be administered at home, others still require intravenous delivery at medical facilities. Long travel times can be particularly challenging for patients dealing with side effects like nausea and pain, according to Shivum Agarwal, a family physician in rural Texas.

Travel costs add to the burden, often requiring family members to take time off work. “There’s a significant economic impact on families,” Agarwal noted.

Fortunately, the Sanchez family has some support; Herlinda’s mother drives four hours from Abilene to Del Rio to care for their two-year-old twins while they are away.

Cancer treatments can last up to eight hours, compounding the financial and logistical difficulties. Erin Ercoline, executive director of the ThriveWell Cancer Foundation in San Antonio, mentioned that the nonprofit provides financial assistance for patients like Sanchez, including covering gas expenses and hotel stays for her upcoming breast surgery.

However, some rural hospitals are expanding their services. For instance, Childress Regional Medical Center in West Texas is building a new 6,000-square-foot infusion center, increasing from four chairs to ten and providing more privacy for patients. The nearest alternative facility is over an hour away, which can deter patients from seeking care, according to CEO Holly Holcomb.

The federal 340B drug discount program helps rural hospitals by offering steep discounts on outpatient drugs, supporting their ability to maintain or expand services.

Despite the long drives and costs, some patients prefer the personal touch of smaller facilities. Dennis Woodward, 69, from Woodson, Texas, has non-Hodgkin lymphoma and opts to drive two hours to Childress, despite a closer clinic in Abilene. “I felt like just another number” at the Abilene clinic, he said.

During Herlinda Sanchez’s final chemotherapy session in June, Manuel stayed close, counting down the hours. Several family members joined Herlinda to celebrate when she rang the bell to mark the end of her treatment. “I’m looking forward to a break from San Antonio,” said Herlinda, who works at Laughlin Air Force Base near Del Rio. “I’m ready to be done with this.”