Effect of distance to radiation treatment facility on use of radiation therapy after mastectomy in elderly women

Acute toxicity outcomes in Egyptian early-stage breast cancer: ultra-hypofractionated versus hypofractionated radiotherapy

BACKGROUND

Comparison of acute adverse events (acute skin reaction, acute breast pain and lung toxicities) in early-stage breast cancer using 2 different fractionation schedules: ultra-hypofractionation versus hypofractionation radiotherapy.

METHODS

Ninety-two patients were recruited and assessed using RTOG criteria for acute skin reactions at the end of radiotherapy, 1 month after, and 3 months after.

RESULTS

There have been no statistically significant differences in acute skin adverse events in 1 month after WBI, there have been neither G3 acute skin toxicity nor G2 skin reactions as were in the fast trial, and milder than skin adverse events in the FAST-FORWARD trial. Acute breast pain at the end of radiotherapy has been statistically significantly lower in arm 1 vs arm 2. Acute breast pain at 1-month follow-up has been comparable between the study arms, with no statistically significant difference. At the 3-month follow-up, acute breast pain was similar in both arms. In all arms, no acute lung toxicities have been reported.

CONCLUSION

Acute adverse events have been comparable between ultra-hypofractionation and hypofractionation.

Sociodemographic and geographic factors impacting radiotherapy recommendation, initiation, and completion for patients with cancer

BACKGROUND

More than half of patients with cancer receive radiotherapy, which often requires daily treatments for several weeks. The impact of geographic and sociodemographic factors on the odds of patients with cancer being recommended radiotherapy, starting radiotherapy, and completing radiotherapy is not well understood.

METHODS

This was a retrospective patient cohort study that included patients diagnosed with one of the 10 most common solid cancers from January 1, 2018, to December 31, 2021, in the National Cancer Database. The primary predictor was radial distance from a patient's home to their cancer treatment hospital. Other covariates included baseline patient characteristics (age, sex, comorbidities, metastatic disease, cancer site), sociodemographic characteristics (race, ethnicity, median income quartile, insurance status), geographic region, and facility type. The three primary outcomes were being recommended radiotherapy, starting recommended radiotherapy, and completing radiotherapy.

RESULTS

Of the 3,068,919 patients included, patients living >50 miles away had lower odds of being recommended radiotherapy than those living <10 miles away. Compared to White patients, Asian and Hispanic patients had lower odds of being recommended radiotherapy, and Black patients had lower odds of starting recommended radiotherapy. Uninsured patients, those with Medicaid or Medicare, and patients in lower median income quartiles had lower odds of starting or completing radiotherapy.

CONCLUSIONS

Geographic and sociodemographic factors impact access to radiotherapy at different levels in cancer care and understanding these factors could aid policymakers and practices in identifying and supporting at-risk patients.

The Impact of Socioeconomic Status and Comorbidities on Non-Melanoma Skin Cancer Recurrence After Image-Guided Superficial Radiation Therapy

BACKGROUND

Non-melanoma skin cancers (NMSCs) are the most common cancers in the United States. Image-guided superficial radiation therapy (IGSRT) is an effective treatment for NMSCs. Patient comorbidities and socioeconomic status (SES) are known contributors to health disparities. However, the impact of comorbidities or SES on the outcomes of IGSRT-treated NMSCs has not yet been studied. This study evaluated freedom from recurrence in IGSRT-treated NMSCs stratified by SES and the number of comorbidities.

METHODS

This large retrospective cohort study evaluated associations between SES (via Area Deprivation Index (ADI)) or comorbidity (via Charlson Comorbidity Index (CCI)) and 2-, 4-, and 6-year year freedom from recurrence in patients with IGSRT-treated NMSC (n = 19,988 lesions).

RESULTS

Freedom from recurrence in less (ADI ≤ 50) vs. more (ADI > 50) deprived neighborhoods was 99.47% vs. 99.61% at 6 years, respectively (p = 0.2). Freedom from recurrence in patients with a CCI of 0 (low comorbidity burden) vs. a CCI of ≥7 (high comorbidity burden) was 99.67% vs. 99.27% at 6 years, respectively (p = 0.9).

CONCLUSIONS

This study demonstrates that there are no significant effects of SES or comorbidity burden on freedom from recurrence in patients with IGSRT-treated NMSC. This supports the expansion of IGSRT in deprived neighborhoods to increase access to care, and IGSRT should be a consideration even in patients with a complex comorbidity status.

The intersection of travel burdens and financial hardship in cancer care: a scoping review

BACKGROUND

In addition to greater delays in cancer screening and greater financial hardship, rural-dwelling cancer patients experience greater costs associated with accessing cancer care, including higher cumulative travel costs. This study aimed to identify and synthesize peer-reviewed research on the cumulative and overlapping costs associated with care access and utilization.

METHODS

A scoping review was conducted to identify relevant studies published after 1995 by searching 5 electronic databases: PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsycInfo, and Healthcare Administration. Eligibility was determined using the PEO (Population, Exposure, and Outcomes) method, with clearly defined populations (cancer patients), exposures (financial hardship, toxicity, or distress; travel-related burdens), and outcomes (treatment access, treatment outcomes, health-related quality of life, and survival/mortality). Study characteristics, methods, and findings were extracted and summarized.

RESULTS

Database searches yielded 6439 results, of which 3366 were unique citations. Of those, 141 were eligible for full-text review, and 98 studies at the intersection of cancer-related travel burdens and financial hardship were included. Five themes emerged as we extracted from the full texts of the included articles: 1) Cancer treatment choices, 2) Receipt of guideline-concordant care, 3) Cancer treatment outcomes, 4) Health-related quality of life, and 5) Propensity to participate in clinical trials.

CONCLUSIONS

This scoping review identifies and summarizes available research at the intersection of cancer care-related travel burdens and financial hardship. This review will inform the development of future interventions aimed at reducing the negative effects of cancer-care related costs on patient outcomes and quality of life.

Distance Traveled by Patients Globally to Access Radiation Therapy: A Systematic Review

PURPOSE

This study aimed to systematically review the literature on the travel patterns of patients seeking radiation therapy globally. It examined the distance patients travel for radiation therapy as well as secondary outcomes, including travel time.

METHODS AND MATERIALS

A comprehensive search of 4 databases was conducted from June 2022 to August 2022. Studies were included in the review if they were observational, retrospective, randomized/nonrandomized, published between June 2000 and June 2022, and if they reported on the global distance traveled for radiation therapy in the treatment of malignant or benign disease. Studies were excluded if they did not report travel distance or were not written in English.

RESULTS

Of the 168 studies, most were conducted in North America (76.3%), with 90.7% based in the United States. Radiation therapy studies for treating patients with breast cancer were the most common (26.6%), while external beam radiation therapy was the most prevalent treatment modality (16.6%). Forty-six studies reported the mean distance traveled for radiation therapy, with the shortest being 4.8 miles in the United States and the longest being 276.5 miles in Iran. It was observed that patients outside of the United States traveled greater distances than those living within the United States. Geographic location, urban versus rural residence, and patient population characteristics affected the distance patients traveled for radiation therapy.

CONCLUSIONS

This systematic review provides the most extensive summary to date of the travel patterns of patients seeking radiation therapy globally. The results suggest that various factors may contribute to the variability in travel distance patterns, including treatment center location, patient residence, and treatment modality. Overall, the study highlights the need for more research to explore these factors and to develop effective strategies for improving radiation therapy access and reducing travel burden.

Adverse Health Outcomes among Rural and Urban Breast Cancer Survivors: A Population-Based Cohort Study

BACKGROUND

Limited population-based studies have focused on breast cancer survivors in rural populations. We sought to evaluate the risk of adverse health outcomes among rural and urban breast cancer survivors and to evaluate potential predictors for the highest risk outcomes.

METHODS

A population-based cohort of rural and urban breast cancer survivors diagnosed between 1997 and 2017 was identified in the Utah Cancer Registry (UCR). Rural breast cancer survivors were matched on year (±1 year) and age at cancer diagnosis (±1 year) with up to 5 urban breast cancer survivors (2,359 rural breast cancer survivors; 11,748 urban breast cancer survivors). Cox proportional hazards models were used to calculate HRs with 99% confidence intervals (CI) for adverse health outcomes overall, within 5 years, and >5 years after cancer diagnosis.

RESULTS

Compared with urban breast cancer survivors, rural breast cancer survivors had a 39% (HR, 1.39; 95% CI, 1.02-1.65) higher risk of heart failure (HF) within the 5 years of follow-up. Overall, there was no increase in the risk of other evaluated adverse health outcomes. A higher baseline body mass index and Charlson Comorbidity Index, family history of cardiovascular diseases, family history of breast cancer, and advanced cancer stage were risk factors for HF for rural and urban breast cancer survivors, with similar levels of HF risk.

CONCLUSIONS

Rural residence was associated with an increased risk of HF among breast cancer survivors.

IMPACT

Our study highlights the need for primary preventive strategies for rural cancer survivors at risk of heart failure.

Nationwide changes in radiation oncology travel and location of care before and during the COVID-19 pandemic

PURPOSE

Patients with cancer are particularly vulnerable to coronavirus disease (COVID). Transportation barriers made travel to obtain medical care more difficult during the pandemic. Whether these factors led to changes in the distance traveled for radiotherapy and the coordinated location of radiation treatment is unknown.

MATERIALS AND METHODS

We analyzed patients across 60 cancer sites in the National Cancer Database from 2018 to 2020. Demographic and clinical variables were analyzed for changes in distance traveled for radiotherapy. We designated the facilities in the 99th percentile or above in terms of the proportion of patients who traveled more than 200 miles as "destination facilities." We defined "coordinated care" as undergoing radiotherapy at the same facility where the cancer was diagnosed.

RESULTS

We evaluated 1,151,954 patients. There was a greater than 1% decrease in the proportion of patients treated in the Mid-Atlantic States. Mean distance traveled from place of residence to radiation treatment decreased from 28.6 to 25.9 miles, and the proportion traveling greater than 50 miles decreased from 7.7% to 7.1%. At "destination facilities," the proportion traveling more than 200 miles decreased from 29.3% in 2018 to 24% in 2020. In comparison, at the other hospitals, the proportion traveling more than 200 miles decreased from 1.07% to 0.97%. In 2020, residing in a rural area resulted in a lower odds of having coordinated care (multivariable odds ratio = 0.89; 95% confidence interval, 0.83-0.95).

CONCLUSION

The first year of the COVID pandemic measurably impacted the location of U.S. radiation therapy treatment.

Access To Oncology Services In Rural Areas: Influence Of The 340B Drug Pricing Program

Rural-urban cancer disparities, including greater mortality rates, are partially attributable to the limited availability of oncology services in rural communities. Without these services, rural residents may experience delays in timely treatment and may be less likely to complete recommended care. The 340B Drug Pricing Program allows eligible not-for-profit and public hospitals to purchase covered outpatient drugs, including high-cost oncology drugs, at discounted prices. Using 2011-20 data, we evaluated the relationship between new enrollment in the 340B program and oncology services initiation in rural general acute care hospitals that lacked oncology services in 2011. Compared with hospitals that remained unenrolled in the 340B program through 2020, hospitals that enrolled during 2012-18 were 8.3 percentage points more likely to have added oncology services as of 2020. The newly participating hospitals that added oncology services were disproportionately located in Medicaid expansion states and in counties with lower uninsurance rates. These findings suggest that the 340B program facilitates expanded access to oncology services in some rural communities, but opportunities remain to address disparities in the most disadvantaged service areas.

Large variation in radiation therapy fractionation for multiple myeloma in Australia

AIM

To evaluate the patterns of use of different radiation therapy (RT) fractionation for multiple myeloma (MM) bone disease.

METHODS

This is a population-based cohort of patients with MM who had RT between 2012 and 2017 as captured in the statewide Victorian Radiotherapy Minimum Data Set in Australia. Data linkage was performed to identify subsets of RT delivered within 3 months of death. RT fractionation was classified into four groups: single-fraction (SFRT), 2-5, 6-10, and > 10 fractions. Changes in RT fractionation use over time were evaluated with the Cochran-Armitage test for trend. Factors associated with RT fractionation were evaluated using multivariate logistic regressions.

RESULTS

Nine hundred and sixty-seven courses of RT were delivered in 623 patients. The proportion of SFRT, 2-5, 6-10 and > 10 fractions RT was 18%, 47%, 28%, and 7%, respectively. There was an increase in the use of 2-5 fractions, from 48% in 2012 to 60% in 2017 (p-trend < .001), with corresponding decrease in the use of 6-10 fractions, from 26% in 2012 to 20% in 2017 (p-trend = .003). Nine percent (40/430) of RT courses at private institutions were SFRT, compared to 25% (135/537) in public institutions (p < .001). In multivariate analyses, treatment in private institution was the strongest predictor of multifraction RT use. SFRT use was more common closer to the end of life-18%, 14%, and 33% of RT within 2-3, 1-2, < 1 month of death, respectively.

CONCLUSION

There is increasing use of shorter course RT (2-5 fractions) for MM over time. SFRT use remains low, with large variation in practice.

Drive Time and Receipt of Guideline-Recommended Screening, Diagnosis, and Treatment

IMPORTANCE

Many patients do not receive recommended services. Drive time to health care services may affect receipt of guideline-recommended care, but this has not been comprehensively studied.

OBJECTIVE

To assess associations between drive time to care and receipt of guideline-recommended screening, diagnosis, and treatment interventions.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used administrative data from the National Veterans Health Administration (VA) data merged with Medicare data. Eligible participants were patients using VA services between January 2016 and December 2019. Women ages 65 years or older without underlying bone disease were assessed for osteoporosis screening. Patients with new diagnosis of chronic obstructive pulmonary disease (COPD) indicated by at least 2 encounter codes for COPD or at least 1 COPD-related hospitalization were assessed for receipt of diagnostic spirometry. Patients hospitalized for ischemic heart disease were assessed for cardiac rehabilitation treatment.

EXPOSURES

Drive time from each patient's residential address to the closest VA facility where the service was available, measured using geocoded addresses.

MAIN OUTCOMES AND MEASURES

Binary outcome at the patient level for receipt of osteoporosis screening, spirometry, and cardiac rehabilitation. Multivariable logistic regression models were used to assess associations between drive time and receipt of services.

RESULTS

Of 110 780 eligible women analyzed, 36 431 (32.9%) had osteoporosis screening (mean [SD] age, 66.7 [5.4] years; 19 422 [17.5%] Black, 63 403 [57.2%] White). Of 281 130 patients with new COPD diagnosis, 145 249 (51.7%) had spirometry (mean [SD] age, 68.2 [11.5] years; 268 999 [95.7%] men; 37 834 [13.5%] Black, 217 608 [77.4%] White). Of 73 146 patients hospitalized for ischemic heart disease, 11 171 (15.3%) had cardiac rehabilitation (mean [SD] age, 70.0 [10.8] years; 71 217 [97.4%] men; 15 213 [20.8%] Black, 52 144 [71.3%] White). The odds of receiving recommended services declined as drive times increased. Compared with patients with a drive time of 30 minutes or less, patients with a drive time of 61 to 90 minutes had lower odds of receiving osteoporosis screening (adjusted odds ratio [aOR], 0.90; 95% CI, 0.86-0.95) and spirometry (aOR, 0.90; 95% CI, 0.88-0.92) while patients with a drive time of 91 to 120 minutes had lower odds of receiving cardiac rehabilitation (aOR, 0.80; 95% CI, 0.74-0.87). Results were similar in analyses restricted to urban patients or patients whose primary care clinic was in a tertiary care center.

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study, longer drive time was associated with less frequent receipt of guideline-recommended services across multiple components of care. To improve quality of care and health outcomes, health systems and clinicians should adopt strategies to mitigate travel burden, even for urban patients.

The impact of patient travel time on disparities in treatment for early stage lung cancer in California

BACKGROUND

Travel time to treatment facilities may impede the receipt of guideline-concordant treatment (GCT) among patients diagnosed with early-stage non-small cell lung cancer (ES-NSCLC). We investigated the relative contribution of travel time in the receipt of GCT among ES-NSCLC patients.

METHODS

We included 22,821 ES-NSCLC patients diagnosed in California from 2006-2015. GCT was defined using the 2016 National Comprehensive Cancer Network guidelines, and delayed treatment was defined as treatment initiation >6 versus ≤6 weeks after diagnosis. Mean-centered driving and public transit times were calculated from patients' residential block group centroid to the treatment facilities. We used logistic regression to estimate risk ratios and 95% confidence intervals (CIs) for the associations between patients' travel time and receipt of GCT and timely treatment, overall and by race/ethnicity and neighborhood socioeconomic status (nSES).

RESULTS

Overall, a 15-minute increase in travel time was associated with a decreased risk of undertreatment and delayed treatment. Compared to Whites, among Blacks, a 15-minute increase in driving time was associated with a 24% (95%CI = 8%-42%) increased risk of undertreatment, and among Filipinos, a 15-minute increase in public transit time was associated with a 27% (95%CI = 13%-42%) increased risk of delayed treatment. Compared to the highest nSES, among the lowest nSES, 15-minute increases in driving and public transit times were associated with 33% (95%CI = 16%-52%) and 27% (95%CI = 16%-39%) increases in the risk of undertreatment and delayed treatment, respectively.

CONCLUSION

The benefit of GCT observed with increased travel times may be a 'Travel Time Paradox,' and may vary across racial/ethnic and socioeconomic groups.

Cancer Screening Among Rural and Urban Clinics During COVID-19: A Multistate Qualitative Study

PURPOSE

The effects of COVID-19 have been understudied in rural areas. This study sought to (1) identify cancer screening barriers and facilitators during the pandemic in rural and urban primary care practices, (2) describe implementation strategies to support cancer screening, and (3) provide recommendations.

METHODS

A qualitative study was conducted (N = 42) with primary care staff across 20 sites. Individual interviews were conducted through videoconference from August 2020 to April 2021 and recorded, transcribed, and analyzed using deductive and inductive coding (hybrid approach) in NVivo 12 Plus. Practices included federally qualified health centers, tribal health centers, rural health clinics, hospital/health system-owned clinics, and academic medical centers across 10 states including urban (55%) and rural (45%) sites. Staff included individuals serving in the dual role of health care provider and administrator (21.4%), health care administrator (23.8%), physician (19.0%), advanced practice provider (11.9%), or resident (23.8%). The interviews assessed perceptions about cancer screening barriers and facilitators, implementation strategies, and future recommendations.

RESULTS

Participants reported multilevel barriers to cancer screening including policy-level (eg, elective procedure delays), organizational (eg, backlogs), and individual (eg, patient cancellation). Several facilitators to screening were noted, such as home-based testing, using telehealth, and strong partnerships with referral sites. Practices used strategies to encourage screening, such as incentivizing patients and providers and expanding outreach. Rural clinics reported challenges with backlogs, staffing, telehealth implementation, and patient outreach.

CONCLUSION

Primary care staff used innovative strategies during the pandemic to promote cancer screening. Unresolved challenges (eg, backlogs and inability to implement telehealth) disproportionately affected rural clinics.

Disparities in radiation therapy utilization for cancer patients in Victoria

Introduction

To evaluate the proportion of cancer patients who received radiation therapy (RT) within 12 months of cancer diagnosis (RTU12) and identify factors associated with RTU12.

Methods

This is a population‐based cohort of individuals with incident cancer, diagnosed between 2013 and 2017 in Victoria. Data linkages were performed between the Victorian Cancer Registry and Victorian Radiotherapy Minimum Dataset. The primary outcome was the proportion of patients who had RTU12. For the three most common cancers (i.e., prostate, breast and lung cancer), the time trend in RTU12 and factors associated with RTU12 were evaluated.

Results

The overall RTU12 in our study cohort was 26–20% radical RT and 6% palliative RT. Of the 21,735 men with prostate cancer, RTU12 was 17%, with no significant change over time (P‐trend = 0.53). In multivariate analyses, increasing age and lower socioeconomic status were independently associated with higher RTU12 for prostate cancer. Of the 20,883 women with breast cancer, RTU12 was 64%, which increased from 62% in 2013 to 65% in 2017 (P‐trend < 0.05). In multivariate analyses, age, socioeconomic status and area of residency were independently associated with RTU12 for breast cancer. Of the 13,093 patients with lung cancer, RTU12 was 42%, with no significant change over time (P‐trend = 0.16). In multivariate analyses, younger age, male and lower socioeconomic status were independently associated with higher RTU12.

Conclusion

In this large population‐based state‐wide cohort of cancer patients, only 1 in 4 had RT within 12 months of diagnosis. There were marked sociodemographic disparities in RTU12 for prostate, breast and lung cancer patients.

Vaginal cuff brachytherapy for endometrial cancer: a review of major clinical trials with a focus on fractionation

The use of vaginal cuff brachytherapy in the adjuvant management of endometrial cancer has increased over time. Recommendations from the American Brachytherapy Society, American Society of Radiation Oncology, and European Society for Medical Oncology help to guide the application of vaginal cuff brachytherapy. However, wide variation in practice remains regarding treatment techniques. This article reviews the use of vaginal cuff brachytherapy in the post-operative management of endometrial cancer. It covers risk stratification, treatment rationale, outcomes, and treatment planning recommendations with a specific focus on dose-fractionation regimens. The authors performed a thorough literature review of articles pertinent to the goals of this review. Also presented are early results of the Short Course Adjuvant Vaginal Cuff Brachytherapy in Early Endometrial Cancer Compared with Standard of Care (SAVE) trial of a two-fraction vaginal cuff brachytherapy regimen.Adjuvant vaginal cuff brachytherapy for early-stage endometrial cancer results in excellent disease control with minimal toxicity. The PORTEC-2 trial showed that vaginal cuff brachytherapy is non-inferior to external beam radiation for vaginal recurrence in patients at high-intermediate risk. Vaginal cuff brachytherapy may also be used as a boost following external beam radiation in combination with chemotherapy for high-risk histologies. Numerous techniques can be used for vaginal cuff brachytherapy, including various medical devices, dose-fractionation schedules, and treatment planning approaches. The early control results of the SAVE trial are promising and we are hopeful that this trial establishes two fraction regimens as a viable option for vaginal cuff brachytherapy.

Urban-Rural Variations in Quality of Care Among Patients With Cancer in California

INTRODUCTION

Previous research suggests cancer patients living in rural areas have lower quality of care, but population-based studies have yielded inconsistent results. This study examines the impact of rurality on care quality for 7 cancer types in California.

METHODS

Breast, ovarian, endometrial, cervix, colon, lung, and gastric cancer patients diagnosed from 2004 to 2017 were identified in the California Cancer Registry. Multivariable logistic regression and proportional hazards models were used to assess effects of residential location on quality of care and survival. Stratified models examined the impact of treatment at National Cancer Institute designated cancer centers (NCICCs). Quality of care was evaluated using Commission on Cancer measures. Medical Service Study Areas were used to assess urban/rural status. Data were collected in 2004-2019 and analyzed in 2020.

RESULTS

989,747 cancer patients were evaluated, with 14% living in rural areas. Rural patients had lower odds of receiving radiation after breast conserving surgery compared to urban residents. Colon and gastric cancer patients had 20% and 16% lower odds, respectively, of having optimal surgery. Rural patients treated at NCICCs had greater odds of recommended surgery for most cancer types. Survival was similar among urban and rural subgroups.

CONCLUSIONS

Rural residence was inversely associated with receipt of recommended surgery for gastric and colon cancer patients not treated at NCICCs, and for receiving recommended radiotherapy after breast conserving surgery regardless of treatment location. Further studies investigating the impact of care location and availability of supportive services on urban-rural differences in quality of care are warranted.

Travel distance is associated with stage at presentation and laryngectomy rates among patients with laryngeal cancer

BACKGROUND

The impact of travel distance on stage at presentation and management strategies of laryngeal squamous cell carcinoma (SCC) is unknown. We investigated this relationship.

METHODS

Retrospective review of patients with laryngeal SCC in the National Cancer Data Base from 2004 to 2016. Multivariate analysis determined relationships between travel distance, sociodemographic, geographic, and hospital factors. Logistic regression determined the influence of travel distance on T-stage and overall stage at presentation, and receipt of total laryngectomy.

RESULTS

Sixty thousand four hundred and thirty-nine patients were divided into groups based on distance to treatment: short (<12.5 miles); intermediate (12.5-49.9 miles); and long (>50 miles). Increased travel was associated with T4-stage (intermediate vs. short OR 1.11, CI 1.04-1.18, p = 0.001; long vs. short OR 1.5, CI 1.36-1.65, p < 0.001), and total laryngectomy (intermediate vs. short OR 1.40, CI 1.3-1.5, p ≤ 0.001; long vs. short OR 2.52, CI 2.28-2.79, p ≤ 0.001). In T4 disease, total laryngectomy was associated with improved survival compared to nonsurgical treatment (HR 0.75, CI 0.70-0.80, p < 0.001) regardless of travel distance.

CONCLUSION

Longer travel distance to care is associated with increased stage at presentation, rate of laryngectomy, and improved survival in advanced laryngeal SCC. Health policy efforts should be directed towards improving early access to diagnosis and care.

A Phase II Trial of Once Weekly Hypofractionated Breast Irradiation for Early Stage Breast Cancer

PURPOSE

To report an interim analysis of a phase II trial of once weekly, hypofractionated breast irradiation (WH-WBI) following breast conserving surgery (BCS).

METHODS

Patients had stage 0-II breast cancer treated with breast BCS with negative margins. WH-WBI was 28.5 or 30Gy delivered to the whole breast using tangential beams with no elective coverage of lymph nodes. The primary endpoint was ipsilateral breast tumor recurrence (IBTR). Secondary endpoints were distant disease-free survival (DDFS), recurrence free survival (RFS), overall survival (OS), adverse events and cosmesis.

RESULTS

From 2011 to 2015, 158 patients received WH-WBI. Median follow up was 4.4 years (range 0.2-8.1). Stage distribution was DCIS 22%; invasive pN0 68%; invasive pN1 10%. 80 patients received 30 Gy and 78 received 28.5 Gy with median follow up times of 5.6 and 3.7 years, respectively. There were 5 IBTR events, all in the 30 Gy group. The 5- and 7- year risks of IBRT for all patients were 2.2% (95% CI 0.6-5.8) and 6.0% (95% CI 1.1-17.2), respectively. The 7-year rates of DDFS, RFS, and OS were 96.3%, 91.5% and 89.8%, respectively. Improvement in IBTR-free time was seen in DCIS, lobular histology, low grade tumors, Her2 negative tumors and 28.5 Gy dose (all p < 0.0001).

CONCLUSIONS

Disease-specific outcomes after WH-WBI are favorable and parallel those seen with conventional radiation techniques for stage 0-II breast cancer.

Palliative Radiotherapy Within the Veterans Health Administration: Barriers to Referral and Timeliness of Treatment

PURPOSE

Most Veterans Health Administration hospitals do not have radiation oncology (RO) departments on-site. The purpose of this study is to determine the impact of on-site RO on referral patterns and timeliness of palliative radiation therapy (PRT).

MATERIALS AND METHODS

A survey was sent to medical directors at 149 Veterans Health Administration centers. Questions evaluated frequency of referral for PRT, timeliness of RO consults and treatment, and barriers to referral for PRT. Chi-square analysis was used to evaluate differences between centers that have on-site RO and centers that refer to outside facilities.

RESULTS

Of 108 respondents, 33 (31%) have on-site RO. Chi-square analysis revealed that RO consult within 1 week is more likely at centers with on-site RO (68% v 31%; P = .01). Centers with on-site RO more frequently deliver PRT for spinal cord compression within 24 hours (94% v 70%; P = .01). Those without on-site RO were more likely to want increased radiation oncologist involvement (64% v 26%; P < .001). Barriers to referral for PRT included patient ability to travel (81%), patient noncompliance (31%), delays in consult and/or treatment (31%), difficulty contacting a radiation oncologist (14%), and concern regarding excessive number of treatments (13%). Respondents with on-site RO less frequently reported delays in consult and/or treatment (6% v 41%; P < .0001) and difficulty contacting a radiation oncologist (0% v 20%; P = .0056) as barriers.

CONCLUSION

Respondents with on-site RO reported improved communication with radiation oncologists and more timely consultation and treatment initiation. Methods to improve timeliness of PRT for veterans at centers without on-site RO should be considered.

Travel, Treatment Choice, and Survival Among Breast Cancer Patients: A Population-Based Analysis

Background: Travel distance to care facilities may shape urban-rural cancer survival disparities by creating barriers to specific treatments. Guideline-supported treatment options for women with early stage breast cancer involves considerations of breast conservation and travel burden: Mastectomy requires travel for surgery, whereas breast-conserving surgery (BCS) with adjuvant radiation therapy (RT) requires travel for both surgery and RT. This provides a unique opportunity to evaluate the impact of travel distance on surgical decisions and receipt of guideline-concordant treatment. Materials and Methods: We included 61,169 women diagnosed with early stage breast cancer between 2004 and 2013 from the Surveillance Epidemiology and End Results (SEER)-Medicare database. Driving distances to the nearest radiation facility were calculated by using Google Maps. We used multivariable regression to model treatment choice as a function of distance to radiation and Cox regression to model survival. Results: Women living farthest from radiation facilities (>50 miles vs. <10 miles) were more likely to undergo mastectomy versus BCS (odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.22-1.79). Among only those who underwent BCS, women living farther from radiation facilities were less likely to receive guideline-concordant RT (OR: 1.72, 95% CI: 1.32-2.23). These guideline-discordant women had worse overall (hazards ratio [HR]: 1.50, 95% CI: 1.42-1.57) and breast-cancer specific survival (HR: 1.44, 95% CI: 1.29-1.60). Conclusions: We report two breast cancer treatments with different clinical and travel implications to show the association between travel distance, treatment decisions, and receipt of guideline-concordant treatment. Differential access to guideline-concordant treatment resulting from excess travel burden among rural patients may contribute to rural-urban survival disparities among cancer patients.

Travel Time to Radiation Oncology Facilities in the United States and the Influence of Certificate of Need Policies

PURPOSE

Radiation therapy often requires weeks of daily treatment making travel distance a known barrier to care. However, the full extent and variability of travel burden, defined by travel time, across the nation is poorly understood. Additionally, some states restrict radiation oncology (RO) services through Certificate of Need (CON) policies, but it is unknown how this affects travel times to care. Therefore, we aim to evaluate travel times to US RO facilities and assess the association with CON policies.

METHODS AND MATERIALS

RO facilities were identified from the 2018 National Plan and Provider Enumeration System (n = 2302). Travel times from populated US census tracts to nearest facility were calculated; differences by rurality, area deprivation, and region were computed. Multivariable linear regression was used to estimate adjusted differences in travel time by area characteristics. Logistic regression was used to assess the association of state CON laws with travel time >1 hour.

RESULTS

Among 72,471 census tracts, 92.4% were within 1 hour of the nearest radiation facility. Among the 12,453 rural tracts, 34.4% were >1 hour. On adjusted analysis, the 3054 isolated rural tracts had an estimated 58-minute (95% confidence interval [CI] 57, 59; P < .001) longer travel time than urban tracts. CON laws decreased rural travel time overall, but the association varied by region with decreased odds of prolonged travel in the South (P < .001), increased odds in the Northeast and Midwest (P < .001), and no association in the West (P = NS).

CONCLUSIONS

Isolated rural US census tracts, accounting for 9.4 million Americans, have nearly 1-hour longer adjusted travel time to the nearest RO facility, compared with urban tracts. CON laws had region-dependent associations with prolonged travel.

Weekly radiotherapy in elderly breast cancer patients: a comparison between two hypofractionation schedules

PURPOSE

Weekly irradiation in breast cancer in elderly patients is a treatment option, whose tolerance may be influenced by the fractionation used. The objective of this study is to compare the tolerance and long-term side effects of two different fractionations.

MATERIALS AND METHODS

47 elderly patients were recruited after conservative or radical treatment that also received irradiation with a dose per fraction of 6.25 Gy or 5 Gy for one session per week, 6 sessions in total. The long-term tolerance results are compared by assessing toxicity using CTCAE version 5.0 scales for dermatitis, telangectasia, fibrosis and pain of the irradiated breast. In addition, objective parameters of skin status (erythema, hyperpigmentation, elasticity and hydration) by a multi-probe MultiSkin Test-Center system were obtained and compared between groups.

RESULTS

After an average follow-up of 5 years, all patients were free of disease and with complete local control. A total of 20 patients with 6.25 Gy fractionation and 27 patients with 5 Gy fractionation have been included. Patients treated with lower fractionation had a lower incidence of dermatitis, telangectasia, fibrosis, or local pain. The decrease in elasticity measured by the multi-probe system was smaller with the fractionation of 5 Gy. No differences were observed in the other objective parameters.

CONCLUSION

Weekly irradiation with 5 Gy fractionation is better tolerated than with higher fractionation.

Factors Associated With Radiotherapy Utilisation In New South Wales, Australia: Results From The 45 and Up Study

AIMS

Actual radiotherapy utilisation rates tend to be lower than the estimated optimal rates. Little is known about the factors contributing to this difference. Our aim was to identify factors associated with radiotherapy receipt for a cohort of cancer patients in New South Wales (NSW), Australia.

MATERIALS AND METHODS

In total, 267 153 participants in the NSW 45 and Up Study completed a questionnaire during 2006-2009 providing detailed health and socio-demographic information and consented to record linkage with administrative health datasets. Single primary cancers diagnosed after study enrolment were identified through linkage with the NSW Cancer Registry to December 2013. Radiotherapy receipt was determined from claims to the Medicare Benefits Schedule and/or records in the NSW Admitted Patient Data Collection (2006 to June 2016). Competing risks regression was used to examine associations between health and socio-demographic characteristics and radiotherapy treatment.

RESULTS

Of 17 873 patients with an incident cancer, 5414 (30.3%) received radiotherapy during follow-up (median 5.3 years). Patients less likely to receive radiotherapy were aged <60 or 80+ years, female, had a Charlson co-morbidity index of 1+, needed help with daily tasks or lived ≥100 km from the nearest radiotherapy centre.

CONCLUSION

Distinct subgroups of patients are less likely to receive radiotherapy. Advocacy and/or policy changes are needed to improve access.

Evaluating Travel Distance to Radiation Facilities Among Rural and Urban Breast Cancer Patients in the Medicare Population

PURPOSE

The distance patients travel for specialty care is an important barrier to health care access, particularly for those living in rural areas. This study characterizes the actual distance older breast cancer patients traveled to radiation treatment and the minimum distance necessary to reach radiation care, and examines whether any patient demographic or clinical factors are associated with greater travel distance.

METHODS

We used data from the Surveillance Epidemiology and End Results (SEER)-Medicare database. Our cohort included 52,317 women diagnosed with breast cancer between 2004 and 2013. Driving distances were calculated using Google Maps. We used generalized estimating equations to estimate associations between patient demographic and disease variables and travel distance.

FINDINGS

Patients living in rural areas traveled on average nearly 3 times as far as those from urban areas (40.8 miles vs 15.4 miles), and their nearest facility was more than 4 times farther away (21.9 miles vs 4.8 miles). Older age, being single or widowed, and lower household income were significantly associated with shorter actual travel distance, while increasing rurality was significantly associated with greater actual and minimum travel distance to radiation treatment. Disease severity (stage, grade, etc) was not significantly associated with actual or minimum travel distance.

CONCLUSIONS

In this insured population, travel distance to radiation facilities may pose a significant burden for breast cancer patients, particularly among those living in rural areas. Policymakers and patient advocates should explore service delivery models, reimbursement models, and social supports aimed at reducing the impact of travel to radiation treatment for breast cancer patients.

Travel Distance as a Barrier to Receipt of Adjuvant Radiation Therapy After Radical Prostatectomy

OBJECTIVES

Following radical prostatectomy (RP), adjuvant radiation therapy (RT) decreases biochemical recurrence and potentially improves metastasis-free and overall survival for patients with high-risk pathologic features. Since adjuvant RT typically occurs daily over several weeks, the logistical challenges of extensive traveling may be a significant barrier to its use. We examined the association between distance to treatment facility and use of adjuvant RT.

MATERIALS AND METHODS

We identified 97,568 patients in the National Cancer Database diagnosed from 2004 through 2011 with cT1-4N0-xM0-x prostate cancer and found to have high-risk pathologic features (pT3-4 stage and/or positive surgical margins) at RP. Multivariable logistic regression adjusting for sociodemographic and clinicopathologic factors was used to examine the association between travel distance and receipt of adjuvant RT, defined as radiotherapy initiated within 12 months after RP.

RESULTS

Overall, 10.6% (10,346) of the study cohort received adjuvant RT. On multivariable analysis, increasing travel distance was significantly associated with decreased use of adjuvant RT, with adjusted odds ratios of 1.0 (reference), 0.67, 0.46, 0.39, and 0.32 (all P<0.001) and prevalence of use at 12.6%, 8.8%, 6.3%, 4.9%, and 3.7% for patients living ≤25.0, 25.1 to 50.0, 50.1 to 75.0, 75.1 to 100.0, and >100.0 miles away, respectively.

CONCLUSIONS

Increasing travel distance was strongly associated with decreased use of adjuvant RT in this national cohort of postprostatectomy patients with high-risk pathologic features. These results strongly suggest that the logistical challenges of extensive travel are a significant barrier to the use of adjuvant RT. Efforts aimed at improving access to radiotherapy and reducing treatment time are urgently needed.

Risks and consequences of travel burden on prophylactic granulocyte colony-stimulating factor administration and incidence of febrile neutropenia in an aged Medicare population

OBJECTIVE

Granulocyte colony-stimulating factors (G-CSFs) decrease the incidence of febrile neutropenia (FN) in patients receiving myelosuppressive chemotherapy. This study examines the impact patient travel burden has on administration of prophylactic G-CSFs and the subsequent impact on FN incidence.

METHODS

Medicare claims data were used to identify a cohort of beneficiaries age 65+ with non-myeloid cancers at high risk for FN between January 2012 and December 2014. Driving distance and time were calculated from patient residence ZIP code to the location of G-CSF and/or chemotherapy administration. Regression models were used to estimate the odds of G-CSF prophylaxis relative to patient driving distance and time, and odds of FN incidence relative to timing of G-CSF administration (optimal [days 2-4 after chemotherapy], sub-optimal [same day], or none).

RESULTS

The 52,389 study patients had a mean age of 73.5 years, and were 82% female and 89% white race; 49% had female breast cancer, 12% lung cancer, 15% ovarian cancer, and 24% non-Hodgkin's lymphoma. Of these high FN risk patients, 69% had at least one prophylactic G-CSF administration within at least one chemotherapy cycle. The percentage of patients receiving prophylactic G-CSFs in the first cycle was 56%. Median travel time was slightly longer for patients who did not receive G-CSFs and patients receiving short-acting vs long-acting G-CSFs. The odds of receiving no G-CSFs were 26-52% higher (depending on cancer type) for patients with a >80-min one-way travel time, compared to patients traveling <20-min. Concurrently, the odds of FN (using a "narrow" definition) were 18-93% higher for patients who did not receive G-CSFs in the first cycle of chemotherapy.

CONCLUSIONS

Travel burden, linked to clinic visits for G-CSF administration following myelosuppressive chemotherapy, is associated with sub-optimal use of G-CSF prophylaxis, which may result in a higher incidence of FN.

Patient choice for high-volume center radiation impacts head and neck cancer outcome

Background

Studies suggest treatment outcomes may vary between high (HVC)‐ and low‐volume centers (LVC). Radiation therapy (RT) for head and neck cancer (HNC) requires weeks of treatment, the inconvenience of which may influence a patient's choice for treatment location. We hypothesized that receipt of RT for HNC at a HVC would influence outcomes compared to patients evaluated at a HVC, but who chose to receive RT at a LVC.

Methods

From 1998 to 2011, 1930 HNC patients were evaluated at a HVC and then treated with RT at either a HVC or LVC. Time‐to‐event outcomes and treatment factors were compared.

Results

Median follow‐up was 34 months. RT was delivered at a HVC for 1368 (71%) patients and at a LVC in 562 (29%). Patients were more likely to choose HVC‐RT if they resided in the HVC's county or required definitive RT (all P < 0.001). HVC‐RT was associated with a significant improvement in 3‐year LRC (84% vs 68%), DFS (68% vs 48%), and OS (72% vs 57%) (all P < 0.001). On multivariate analysis (MVA), HVC‐RT independently predicted for improved LRC, DFS, and OS (all P < 0.05).

Conclusions

In patients evaluated at a HVC, the choice of RT location was primarily influenced by their residing distance from the HVC. HVC‐RT was associated with improvements in LRC, DFS, and OS in HNC. As treatment planning and delivery are technically demanding in HNC, the choice to undergo treatment at a HVC may result in more optimal delivered dose, RT duration, and outcome.

Travel burden associated with granulocyte colony-stimulating factor administration in a Medicare aged population: a geospatial analysis

OBJECTIVE

Prophylaxis with granulocyte colony-stimulating factors (G-CSFs) is recommended for patients receiving myelosuppressive chemotherapy regimens with a high risk of febrile neutropenia (FN). G-CSFs should be administered starting the day after chemotherapy, necessitating return trips to the oncology clinic at the end of each cycle. We examined the travel burden related to prophylactic G-CSF injections after chemotherapy in the US.

METHODS

We used 2012-2014 Medicare claims data to identify a national cohort of beneficiaries age 65+ with non-myeloid cancers who received both chemotherapy and prophylactic G-CSFs. Patient travel origin was based on residence ZIP code. Oncologist practice locations and hospital addresses were obtained from the Medicare Physician Compare and Hospital Compare websites and geocoded using the Google Maps Application Programming Interface (API). Driving distance and time to the care site from each patient ZIP code tabulation area (ZCTA) were calculated using Open Street Maps road networks. Geographic and socio-economic characteristics of each ZCTA from the US Census Bureau's American Community Survey were used to stratify and analyze travel estimates.

RESULTS

The mean one-way driving distance to the G-CSF provider was 23.8 (SD 30.1) miles and the mean one-way driving time was 33.3 (SD 37.8) minutes. When stratified by population density, the mean one-way travel time varied from 12.1 (SD 10.1) minutes in Very Dense Urban areas to 76.7 (SD 72.1) minutes in Super Rural areas. About 48% of patients had one-way travel times of <20 minutes, but 19% of patients traveled ≥50 minutes one way for G-CSF prophylaxis. Patients in areas with above average concentrations of aged, poor or disabled residents were more likely to experience longer travel.

CONCLUSIONS

Administration of G-CSF therapy after chemotherapy can present a significant travel burden for cancer patients. Technological improvements in the form and methods of drug delivery for G-CSFs might significantly reduce this travel burden.

Patient-reported factors influencing the treatment decision-making process of older women with non-metastatic breast cancer: a systematic review of qualitative evidence

PURPOSE

Older women (≥ 70 years old) with breast cancer undergo different treatments than young women. Studies have examined factors that influence this disparity, but synthesized patient-reported data are lacking in the literature. This study aims to identify, appraise, and synthesize the existing qualitative evidence on patient-reported factors influencing older women's decision to accept or decline breast cancer treatment.

METHODS

A systematic review was performed in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA) principles. Medline, Embase, CINAHL, and PsycINFO were searched for qualitative studies describing patient-reported factors influencing the decision-making process of older women (≥ 70 years old) with non-metastatic invasive breast cancer. Quality was assessed using the Standards for Reporting Qualitative Research (SRQR) criteria. Common ideas were coded, thematically organized, and synthesized within a theoretical framework.

RESULTS

Of 5998 studies identified, 10 met eligibility criteria. The median SRQR total score was 13.04 (IQR 12.84-13.81). The studies represented a range of cancer treatments; most of the studies focused on surgery and primary endocrine therapy. Our data show that the most common patient-reported factors in the decision-making process included treatment characteristics, personal goals/beliefs, patient characteristics, physician's recommendation, and personal/family experience. These factors led the patient to either accept or decline treatment, and were not consistent across all studies included. Studies used different interview guides, which may have affected these results.

CONCLUSIONS

This systematic review highlights the complexity of factors that influence an older woman's treatment decision-making process. Acknowledging and addressing these factors may improve discussions about treatment choices between older women and their health care providers, and encourage maximization of a patient-centered approach.

Associations of County-level Radiologist and Mammography Facility Supply with Screening Mammography Rates in the United States

RATIONALE AND OBJECTIVES

The present study aims to assess associations of Medicare beneficiary screening mammography rates with local mammography facility and radiologist availability.

MATERIALS AND METHODS

Mammography screening rates for Medicare fee-for-service beneficiaries were obtained for US counties using the County Health Rankings data set. County-level certified mammography facility counts were obtained from the United States Food and Drug Administration. County-level mammogram-interpreting radiologist and breast imaging subspecialist counts were determined using Centers for Medicare & Medicaid Services fee-for-service claims files. Spearman correlations and multivariable linear regressions were performed using counties' facility and radiologist counts, as well as counts normalized to counties' Medicare fee-for-service beneficiary volume and land area.

RESULTS

Across 3035 included counties, average screening mammography rates were 60.5% ± 8.2% (range 26%-88%). Correlations between county-level screening rates and total mammography facilities, facilities per 100,000 square mile county area, total mammography-interpreting radiologists, and mammography-interpreting radiologists per 100,000 county-level Medicare beneficiaries were all weak (r = 0.22-0.26). Correlations between county-level screening rates and mammography rates per 100,000 Medicare beneficiaries, total breast imaging subspecialist radiologists, and breast imaging subspecialist radiologists per 100,000 Medicare beneficiaries were all minimal (r = 0.06-0.16). Multivariable analyses overall demonstrated radiologist supply to have a stronger independent effect than facility supply, although effect sizes remained weak for both.

CONCLUSION

Mammography facility and radiologist supply-side factors are only weakly associated with county-level Medicare beneficiary screening mammography rates, and as such, screening mammography may differ from many other health-care services. Although efforts to enhance facility and radiologist supply may be helpful, initiatives to improve screening mammography rates should focus more on demand-side factors, such as patient education and primary care physician education and access.

Once-Weekly Hypofractionated Radiotherapy for Breast Cancer in Elderly Patients: Efficacy and Tolerance in 486 Patients

Purpose

Radiation therapy is a key treatment of breast cancer. Elderly patients with associated diseases that modify their performance status do not tolerate long periods of daily irradiation. The objective of this study is to analyze the results of weekly hypofractionated treatment in these patients.

Material and Methods

Between 1992 and 2016, we included 486 elderly patients presenting concomitant pathology or sociofamilial problems in which it was not feasible to propose conventional treatment. They were treated with conservative surgery or mastectomy and then adjuvant hypofractionated irradiation, administering 5 Gy or 6.25 Gy in 6 fractions, once a week (total dose 30–37.5 Gy) over 6 weeks.

Results

Breast cancer overall survival according to the Kaplan-Meier method at 5 years was 74.2% ± 2.3%; breast cancer disease-free survival was 90% ± 1.6%; local relapse-free survival was 96.5% ± 1% showing that patients die more from other causes and not from their neoplasia. Acute dermatitis was mild (75.6% of the patients grades I–III) and 30.6% had moderate chronic fibrosis.

Conclusions

The once-weekly hypofractionated radiotherapy is a feasible and convenient option for elderly patients with breast cancer. It is a safe treatment modality with similar survival and local control results compared to standard fractionation, while the side effects are acceptable.

Location-allocation model for external beam radiotherapy as an example of an evidence-based management tool implemented in healthcare sector in Poland

BACKGROUND AND PURPOSE

External beam radiotherapy (EBRT) is one of three key treatment modalities of cancer patients. Its utilisation and outcomes depend on a plethora of variables, one of which is the distance a patient must travel to undergo the treatment. The relation between distance and utilisation is clearly visible in Poland. At the same time no strategic investment plan is observed. This work proposes a method of resolving these two issues.

MATERIALS AND METHODS

We propose a mixed-integer linear programming model that aims to optimise the distribution of linear accelerators among selected locations in such a way that a patient's journey to the nearest EBRT is as short as possible. The optimisation is done with observance of international guidelines concerning EBRT capacity. With the use of proposed theoretical framework, we develop a national, strategic plan for linear accelerator investments.

RESULTS

According to model assumptions decentralisation of EBRT, together with new equipment purchases, is required to ensure optimal access to EBRT.

CONCLUSIONS

The results were incorporated into Healthcare Needs Maps for Poland. The plan based on the results of this study, implemented by 2025, should deal with the most pressing concerns of Polish EBRT.

Are Patients Traveling for Intraoperative Radiation Therapy?

Purpose

One benefit of intraoperative radiation therapy (IORT) is that it usually requires a single treatment, thus potentially eliminating distance as a barrier to receipt of whole breast irradiation. The aim of this study was to evaluate the distance traveled by IORT patients at our institution.

Methods

Our institutional prospective registry was used to identify IORT patients from 10/2011 to 2/2017. Patient's home zip code was compared to institution zip code to determine travel distance. Characteristics of local (<50 miles), regional (50-100 miles), and faraway (>100 miles) patients were compared.

Results

150 were patients included with a median travel distance of 27 miles and mean travel distance of 121 miles. Most were local (68.7%), with the second largest group living faraway (20.0%). Subset analysis of local patients demonstrated 20.4% traveled <10 miles, 34.0% traveled 10-20 miles, and 45.6% traveled 20-50 miles. Six patients traveled >1000 miles. The local, regional, and faraway patients did not differ with respect to age, race, tumor characteristics, or whole breast irradiation.

Conclusions

Breast cancer patients are traveling for IORT, with 63% traveling >20 miles for care. IORT is an excellent strategy to promote breast conservation in selected patients, particularly those who live remote from a radiation facility.

Institutional variation in surgical care for early-stage breast cancer at community hospitals

BACKGROUND

There is significant institutional variation in the surgical care of breast cancer, and this may reflect access to services and resultant physician practice patterns. In previous studies, specialty care has been associated with variation in the operative treatment of breast cancer but has not been evaluated in a community setting. This study investigates these issues in a cohort of 59 community hospitals in the United States.

MATERIALS AND METHODS

Data on patients receiving an operation for breast cancer (2006-2009) in a large, geographically diverse cohort of hospitals were obtained. Administrative data, autoabstracted cancer-specific variables from free text, and multiple other data sets were combined. Polymotous logistic regression with multilevel outcomes identified associations between these variables and surgical treatment.

RESULTS

At 59 community hospitals, 4766 patients underwent breast conserving surgery (BCS), mastectomy, or mastectomy with reconstruction. The older patients were most likely to receive mastectomy alone, whereas the younger age group underwent more reconstruction (age <50), and BCS was most likely in patients aged 50-65. Surgical procedure also varied according to tumor characteristics. BCS was more likely at smaller hospitals, those with ambulatory surgery centers, and those located in nonmetropolitan areas. The likelihood of reconstruction doubled when there were more reconstructive surgeons in the health services area (P = 0.02). BCS was more likely when radiation oncology services were available within the hospital or network (P = 0.04).

CONCLUSIONS

Interpretation of these results for practice redesign is not straightforward. Although access to specialty care is statistically associated with type of breast surgical procedure, clinical impact is limited. It may be more effective to target other aspects of care to ensure each patient receives treatment consistent with her individual preferences.

Incidence, survival, pathology, and genetics of adult Latino Americans with glioblastoma

Latino Americans are a rapidly growing ethnic group in the United States but studies of glioblastoma in this population are limited. We have evaluated characteristics of 21,184 glioblastoma patients from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. This SEER data from 2001 to 2011 draws from 28% of the U.S.

POPULATION

Latinos have a lower incidence of GBM and present slightly younger than non-Latino Whites. Cubans present at an older age than other Latino sub-populations. Latinos have a higher incidence of giant cell glioblastoma than non-Latino Whites while the incidence of gliosarcoma is similar. Despite lower rates of radiation therapy and greater rates of sub-total resection than non-Latino Whites, Latinos have better 1 and 5 year survival rates. SEER does not record chemotherapy data. Survivals of Latino sub-populations are similar with each other. Age, extent of resection, and the use of radiation therapy are associated with improved survival but none of these variables are sufficient in a multivariate analysis to explain the improved survival of Latinos relative to non-Latino Whites. As molecular data is not available in SEER records, we studied the MGMT and IDH status of 571 patients from a UCLA database. MGMT methylation and IDH1 mutation rates are not statistically significantly different between non-Latino Whites and Latinos. For UCLA patients with available information, chemotherapy and radiation rates are similar for non-Latino White and Latino patients, but the latter have lower rates of gross total resection and present at a younger age.

Patterns of Care in Adjuvant Therapy for Resected Oral Cavity Squamous Cell Cancer in Elderly Patients

PURPOSE

To characterize the patterns of care and potential barriers to access to care for elderly patients with oral cavity cancer in the adjuvant setting.

METHODS AND MATERIALS

We performed a retrospective cohort study using the National Cancer Data Base and identified patients with resected oral cavity squamous cell carcinoma diagnosed between 2004 and 2012, who survived for ≥3 months after surgery. We used logistic regression models to assess the association between age (<70, 70-79, and ≥80 years) and the receipt of adjuvant therapy within 3 months of surgery. We additionally assessed the association between patient and tumor characteristics and the receipt of adjuvant therapy among those aged ≥70 years.

RESULTS

A total of 25,829 patients were included in the study. Compared with those aged <70 years, older patients were more likely to have no neck dissection or have fewer lymph nodes dissected and were less likely to receive adjuvant therapy than younger patients. Among our cohort, 11,361 patients (44%) had pathologic T3-T4 disease or N2-N3 disease, and 4185 patients (16%) had extracapsular nodal extension or positive surgical margins. In multivariate analyses controlling for comorbidity and demographic characteristics, older age was independently associated with lower odds of receiving adjuvant radiation therapy in the subgroup with T3 or T4 disease or N2 or N3 disease and adjuvant chemoradiation therapy in the positive extracapsular nodal extension or positive surgical margin subgroup. Among elderly patients, both greater patient distance from reporting facility and older age were associated with lower odds of receiving both adjuvant radiation therapy (odds ratio 0.66; 95% confidence interval, 0.55-0.81) and chemoradiation therapy (odds ratio 0.56; 95% confidence interval, 0.40-0.79).

CONCLUSIONS

In a national hospital-based cohort of patients with oral cavity cancer, elderly patients were less likely to receive adjuvant radiation or chemoradiation therapy. Greater patient distance from reporting facility, in addition to older age, was associated with lower odds of receiving both adjuvant radiation therapy and adjuvant chemoradiation therapy.

Highly Accelerated Irradiation in 5 Fractions (HAI-5): Feasibility in Elderly Women With Early or Locally Advanced Breast Cancer

PURPOSE

To investigate, in a prospective phase 1 to 2 trial, the safety and feasibility of delivering external beam radiation therapy in 5 fractions to the breast or thoracic wall, including boost and/or lymph nodes if needed, to women aged ≥65 years with breast cancer.

METHODS AND MATERIALS

Ninety-five patients aged ≥65 years, referred for adjuvant radiation therapy, were treated in 5 fractions over 12 days with a total dose of 28.5 Gy/5.7 Gy to the breast or thoracic wall and, if indicated, 27 Gy/5.4 Gy to the lymph node regions and 32.5 Gy/6.5 Gy to 34.5 Gy/6.9 Gy to the tumor bed. The primary endpoint was clinically relevant dermatitis (grade ≥2).

RESULTS

Mean follow-up time was 5.6 months, and mean age was 73.6 years. Clinically relevant dermatitis was observed in 11.6% of patients and only occurred in breast irradiation with boost (17.5% grade 2-3 vs 0% in the no-boost group). Although doses were high, treatment delivery with intensity modulated radiation therapy was swift, except for complex treatments, including lymph nodes for which single-arc volumetric modulated arc therapy was needed to reduce beam-on time.

CONCLUSION

Accelerated radiation therapy in 5 fractions was technically feasible and resulted in low acute toxicity. Clinically relevant erythema was only observed in patients receiving a boost, but still at an acceptable rate. Although the follow-up is still short, the results on acute toxicity after accelerated radiation therapy were encouraging. A 5-fraction schedule is well tolerated in the elderly and may lower the threshold for radiation therapy in this population.

Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review

OBJECTIVES

To investigate whether there is an association between differences in travel time/travel distance to healthcare services and patients' health outcomes and assimilate the methodologies used to measure this.

DESIGN

Systematic Review. We searched MEDLINE, Embase, Web of Science, Transport database, HMIC and EBM Reviews for studies up to 7 September 2016. Studies were excluded that included children (including maternity), emergency medical travel or countries classed as being in the global south.

SETTINGS

A wide range of settings within primary and secondary care (these were not restricted in the search).

RESULTS

108 studies met the inclusion criteria. The results were mixed. 77% of the included studies identified evidence of a distance decay association, whereby patients living further away from healthcare facilities they needed to attend had worse health outcomes (eg, survival rates, length of stay in hospital and non-attendance at follow-up) than those who lived closer. 6 of the studies identified the reverse (a distance bias effect) whereby patients living at a greater distance had better health outcomes. The remaining 19 studies found no relationship. There was a large variation in the data available to the studies on the patients' geographical locations and the healthcare facilities attended, and the methods used to calculate travel times and distances were not consistent across studies.

CONCLUSIONS

The review observed that a relationship between travelling further and having worse health outcomes cannot be ruled out and should be considered within the healthcare services location debate.

Does Travel Time to a Radiation Facility Impact Patient Decision-Making Regarding Treatment for Prostate Cancer? A Study of the New Hampshire State Cancer Registry

PURPOSE

We sought to determine whether further distance from a radiation center is associated with lower utilization of external beam radiation therapy (XRT).

METHODS

We retrospectively identified patients with a new diagnosis of localized prostate cancer (CaP) within the New Hampshire State Cancer Registry from 2004 to 2011. Patients were categorized by age, D'Amico risk category, year of treatment, marital status, season of diagnosis, urban/rural residence, and driving time to the nearest radiation facility. Treatment decisions were stratified into those requiring multiple trips (XRT) or a single trip (surgery or brachytherapy). Multivariable regression analysis was performed.

RESULTS

A total of 4,731 patients underwent treatment for newly diagnosed CaP during the study period, including 1,575 multitrip (XRT) and 3,156 single-trip treatments. Of these, 87.6% lived within a 30-minute drive to a radiation facility. In multivariable analysis, time to the nearest radiation facility was not associated with treatment decisions (P = .26). However, higher risk category, older age, married status, and winter diagnosis were associated with XRT (P < .05). More recent year of diagnosis and urban residence were associated with single-trip therapy (primarily surgery) (P < .05). There was a significant interaction between travel time and season of diagnosis (P = .03), as well as a marginally significant interaction with urban/rural status (P = .07).

CONCLUSION

Overall, further travel time to a radiation facility was not associated with lower utilization of XRT. These data are encouraging regarding access to care for CaP in New Hampshire.

What is access to radiation therapy? A conceptual framework and review of influencing factors

OBJECTIVES

Optimal radiation therapy (RT) utilisation rates (RURs) have been defined for various cancer indications through extensive work in Australia and overseas. These benchmarks remain unrealised. The gap between optimal RUR and actual RUR has been attributed to inadequacies in 'RT access'. We aimed to develop a conceptual framework for the consideration of 'RT access' by examining the literature for existing constructs and translating it to the context of RT services. We further aimed to use this framework to identify and examine factors influencing 'RT access'.

METHODS

Existing models of health care access were reviewed and used to develop a multi-dimensional conceptual framework for 'RT access'. A review of the literature was then conducted to identify factors reported to affect RT access and utilisation. The electronic databases searched, the host platform and date range of the databases searched were Ovid MEDLINE, 1946 to October 2014 and PsycINFO via OvidSP,1806 to October 2014.

RESULTS

The framework developed demonstrates that 'RT access' encompasses opportunity for RT as well as the translation of this opportunity to RT utilisation. Opportunity for RT includes availability, affordability, adequacy (quality) and acceptability of RT services. Several factors at the consumer, referrer and RT service levels affect the translation of this opportunity for RT to actual RT utilisation.

CONCLUSION

'Access' is a term that is widely used in the context of health service related research, planning and political discussions. It is a multi-faceted concept with many descriptions. We propose a conceptual framework for the consideration of 'RT access' so that factors affecting RT access and utilisation may be identified and examined. Understanding these factors, and quantifying them where possible, will allow objective evaluation of their impact on RT utilisation and guide implementation of strategies to modify their effects.

Racial and socio-economic disparities in breast cancer hospitalization outcomes by insurance status

BACKGROUND

Breast cancer remains a major cause of morbidity and mortality among women in the US, and despite numerous studies documenting racial disparities in outcomes, the survival difference between Black and White women diagnosed with breast cancer continues to widen. Few studies have assessed whether observed racial disparities in outcomes vary by insurance type e.g. Medicare/Medicaid versus private insurance. Differences in coverage, availability of networked physicians, or cost-sharing policies may influence choice of treatment and treatment outcomes, even after patients have been hospitalized, effects of which may be differential by race.

PURPOSE

The aim of this analysis was to examine hospitalization outcomes among patients with a primary diagnosis of breast cancer and assess whether differences in outcome exist by insurance status after adjusting for age, race/ethnicity and socio-economic status.

METHODS

We obtained data on over 67,000 breast cancer patients with a primary diagnosis of breast cancer for this cross-sectional study from the 2007-2011 Healthcare Cost and Utilization project Nationwide Inpatient Sample (HCUP-NIS), and examined breast cancer surgery type (mastectomy vs. breast conserving surgery or BCS), post-surgical complications and in-hospital mortality. Multivariable regression models were used to compute estimates, odds ratios and 95% confidence intervals.

RESULTS

Black patients were less likely to receive mastectomies compared with White women (OR: 0.80, 95% CI: 0.71-0.90), regardless of whether they had Medicare/Medicaid or Private insurance. Black patients were also more likely to experience post-surgical complications (OR: 1.41, 95% CI: 1.12-1.78) and higher in-hospital mortality (OR: 1.57, 95%: 1.21-2.03) compared with White patients, associations that were strongest among women with Private insurance. Women residing outside of large metropolitan areas were significantly more likely to receive mastectomies (OR: 1.89, 95% CI: 1.54-2.31) and experience higher in-hospital mortality (OR: 1.74, 95% CI: 1.40-2.16) compared with those in metropolitan areas, regardless of insurance type.

CONCLUSION

Among hospitalized patients with breast cancer, racial differences in hospitalization outcomes existed and worse outcomes were observed among Black women with private insurance. Future studies are needed to determine factors associated with poor outcomes in this group of women, as well as to examine contributors to low BCS adoption in non-metropolitan areas.

Environmental and social benefits of the targeted intraoperative radiotherapy for breast cancer: data from UK TARGIT-A trial centres and two UK NHS hospitals offering TARGIT IORT

OBJECTIVE

To quantify the journeys and CO2 emissions if women with breast cancer are treated with risk-adapted single-dose targeted intraoperative radiotherapy (TARGIT) rather than several weeks' course of external beam whole breast radiotherapy (EBRT) treatment.

SETTING

(1) TARGIT-A randomised clinical trial (ISRCTN34086741) which compared TARGIT with traditional EBRT and found similar breast cancer control, particularly when TARGIT was given simultaneously with lumpectomy, (2) 2 additional UK centres offering TARGIT.

PARTICIPANTS

485 UK patients (249 TARGIT, 236 EBRT) in the prepathology stratum of TARGIT-A trial (where randomisation occurred before lumpectomy and TARGIT was delivered simultaneously with lumpectomy) for whom geographical data were available and 22 patients treated with TARGIT after completion of the TARGIT-A trial in 2 additional UK breast centres.

OUTCOME MEASURES

The shortest total journey distance, time and CO2 emissions from home to hospital to receive all the fractions of radiotherapy.

METHODS

Distances, time and CO2 emissions were calculated using Google Maps and assuming a fuel efficiency of 40 mpg. The groups were compared using the Student t test with unequal variance and the non-parametric Wilcoxon rank-sum (Mann-Whitney) test.

RESULTS

TARGIT patients travelled significantly fewer miles: TARGIT 21 681, mean 87.1 (SE 19.1) versus EBRT 92 591, mean 392.3 (SE 30.2); had lower CO2 emissions 24.7 kg (SE 5.4) vs 111 kg (SE 8.6) and spent less time travelling: 3 h (SE 0.53) vs 14 h (SE 0.76), all p<0.0001. Patients treated with TARGIT in 2 hospitals in semirural locations were spared much longer journeys (753 miles, 30 h, 215 kg CO2 per patient).

CONCLUSIONS

The use of TARGIT intraoperative radiotherapy for eligible patients with breast cancer significantly reduces their journeys for treatment and has environmental benefits. If widely available, 5 million miles (8 000 000 km) of travel, 170 000 woman-hours and 1200 tonnes of CO2 (a forest of 100 hectares) will be saved annually in the UK.

TRIAL REGISTRATION NUMBER

ISRCTN34086741; Post-results.

Disparities in the Use of Postmastectomy Radiation Therapy for Inflammatory Breast Cancer

PURPOSE

Although radiation therapy improves locoregional control and survival for inflammatory breast cancer (IBC), it is underused in this population. The purpose of this study was to identify variables associated with the underuse of postmastectomy radiation therapy (PMRT) for IBC.

METHODS AND MATERIALS

Using the 1998 to 2011 National Cancer Data Base, we identified 8273 women who underwent mastectomy for nonmetastatic IBC. We used logistic regression modeling to determine the demographic, tumor, and treatment variables associated with the underuse of PMRT.

RESULTS

Although the use of PMRT increased over time, a total of 30.3% of our cohort did not receive PMRT. On multivariate analysis, variables associated with the underuse of PMRT for IBC included the following (all P<.05): Medicare insurance (odds ratio [OR] = 0.70), annual income <$34,999 (<$30,000: OR=0.79; $30,000-$34,999: OR=0.82), cN2 and cN0 disease (cN2: OR=0.71; cN0: OR=0.63), failure to receive chemotherapy and hormone therapy (chemotherapy: OR=0.15; hormone therapy: OR=0.35), treatment at lower-volume centers (OR=0.83), and treatment in the South and West (South: OR=0.73; West: OR=0.80). Greater distance between patient's residence and radiation facility was also associated with the underuse of PMRT (P=.0001).

CONCLUSIONS

Although the use of PMRT for IBC has increased over time, it continues to be underused. Disparities related to a variety of variables impact which IBC patients receive PMRT. A concerted effort must be made to address these disparities in order to optimize the outcomes for IBC.

Annual patient and caregiver burden of oncology clinic visits for granulocyte-colony stimulating factor therapy in the US

OBJECTIVE

Prophylactic treatment with granulocyte-colony stimulating factors (G-CSFs) is indicated for chemotherapy patients with a significant risk of febrile neutropenia. This study estimates the annual economic burden on patients and caregivers of clinic visits for prophylactic G-CSF injections in the US.

METHODS

Annual clinic visits for prophylactic G-CSF injections (all cancers) were estimated from national cancer incidence, chemotherapy treatment and G-CSF utilization data, and G-CSF sales and pricing information. Patient travel times, plus time spent in the clinic, were estimated from patient survey responses collected during a large prospective cohort study (the Prospective Study of the Relationship between Chemotherapy Dose Intensity and Mortality in Early-Stage (I-III) Breast Cancer Patients). Economic models were created to estimate travel costs, patient co-pays and the economic value of time spent by patients and caregivers in G-CSF clinic visits.

RESULTS

Estimated total clinic visits for prophylactic G-CSF injections in the US were 1.713 million for 2015. Mean (SD) travel time per visit was 62 (50) min; mean (SD) time in the clinic was 41 (68) min. Total annual time for travel to and from the clinic, plus time at the clinic, is estimated at 4.9 million hours, with patient and caregiver time valued at $91.8 million ($228 per patient). The estimated cumulative annual travel distance for G-CSF visits is 60.2 million miles, with a total transportation cost of $28.9 million ($72 per patient). Estimated patient co-pays were $61.1 million, ∼$36 per visit, $152 per patient. The total yearly economic impact on patients and caregivers is $182 million, ∼$450 per patient.

LIMITATIONS

Data to support model parameters were limited. Study estimates are sensitive to the assumptions used.

CONCLUSIONS

The burden of clinic visits for G-CSF therapy is a significant addition to the total economic burden borne by cancer patients and their families.