Travel distance, hospital volume and their association with ovarian cancer short- and long-term outcomes

Effect of surgical volume on short-term outcomes of cytoreductive surgery for advanced-stage ovarian cancer: A population-based study from the Dutch Gynecological Oncology Audit

OBJECTIVE

Despite lacking clinical data, the Dutch government is considering increasing the minimum annual surgical volume per center from twenty to fifty cytoreductive surgeries (CRS) for advanced-stage ovarian cancer (OC). This study aims to evaluate whether this increase is warranted.

METHODS

This population-based study included all CRS for FIGO-stage IIB-IVB OC registered in eighteen Dutch hospitals between 2019 and 2022. Short-term outcomes included result of CRS, length of stay, severe complications, 30-day mortality, time to adjuvant chemotherapy, and textbook outcome. Patients were stratified by annual volume: low-volume (nine hospitals, <25), medium-volume (four hospitals, 29-37), and high-volume (five hospitals, 54-84). Descriptive statistics and multilevel logistic regressions were used to assess the (case-mix adjusted) associations of surgical volume and outcomes.

RESULTS

A total of 1646 interval CRS (iCRS) and 789 primary CRS (pCRS) were included. No associations were found between surgical volume and different outcomes in the iCRS cohort. In the pCRS cohort, high-volume was associated with increased complete CRS rates (aOR 1.9, 95%-CI 1.2-3.1, p = 0.010). Furthermore, high-volume was associated with increased severe complication rates (aOR 2.3, 1.1-4.6, 95%-CI 1.3-4.2, p = 0.022) and prolonged length of stay (aOR 2.3, 95%-CI 1.3-4.2, p = 0.005). 30-day mortality, time to adjuvant chemotherapy, and textbook outcome were not associated with surgical volume in the pCRS cohort. Subgroup analyses (FIGO-stage IIIC-IVB) showed similar results. Various case-mix factors significantly impacted outcomes, warranting case-mix adjustment.

CONCLUSIONS

Our analyses do not support further centralization of iCRS for advanced-stage OC. High-volume was associated with higher complete pCRS, suggesting either a more accurate selection in these hospitals or a more aggressive approach. The higher completeness rates were at the expense of higher severe complications and prolonged admissions.

Factors associated with survival of patients with advanced lung cancer and long travel distances

BACKGROUND/PURPOSE

Patients with advanced cancer sometimes travel to locations that have the treatment that they need. We explored the prognostic factors of survival in patients with advanced lung cancer who travel long distances in Taiwan.

METHODS

We obtained data from the National Taiwan University Hospital (NTUH) Integrated Medical Database. Patients who received a diagnosis of stage IV lung cancer from 2010 to 2019 and were treated in NTUH and its Hsinchu and Yunlin branches were enrolled. Factors associated with survival were analyzed using a Cox hazard regression model.

RESULTS

In total, 6178 patients with stage IV lung cancer were enrolled. Young age, female sex, smaller primary tumor size, better performance, and non-squamous cell non-small cell histology were independently associated with longer survival. Treatment in medical centers and long travel distances (>50 km) were associated with longer survival in the univariate analysis but not in the multivariate analysis (hazard ratio [HR]: 1.04, p = 0.361; HR: 0.99, p = 0.775, respectively). Participation in clinical trials was associated with longer survival in the univariate (HR: 0.53, p < 0.001) and multivariate analyses (HR: 0.62, p < 0.001). For the 1144 patients in the Hsinchu area, enrolment in clinical trials was an independent prognostic factor (HR: 0.72, p = 0.040), whereas treatment in medical centers was not (HR: 0.95, p = 0.635).

CONCLUSION

Long travel distances and treatment in medical centers were not independently associated with survival for patients with advanced lung cancer. Enrolment in clinical trials was an independent prognostic factor.

Disparities in refusal of surgery for gynecologic cancer

OBJECTIVE

To identify sociodemographic and clinical factors associated with refusal of gynecologic cancer surgery and to estimate its effect on overall survival.

METHODS

The National Cancer Database was surveyed for patients with uterine, cervical or ovarian/fallopian tube/primary peritoneal cancer treated between 2004 and 2017. Univariate and multivariate logistic regression were used to assess associations between clinico-demographic variables and refusal of surgery. Overall survival was estimated using the Kaplan-Meier method. Trends in refusal over time were evaluated using joinpoint regression.

RESULTS

Of 788,164 women included in our analysis, 5875 (0.75%) patients refused surgery recommended by their treating oncologist. Patients who refused surgery were older at diagnosis (72.4 vs 60.3 years, p < 0.001) and more likely Black (OR 1.77 95% CI 1.62-1.92). Refusal of surgery was associated with uninsured status (OR 2.94 95% CI 2.49-3.46), Medicaid coverage (OR 2.79 95% CI 2.46-3.18), low regional high school graduation (OR 1.18 95% CI 1.05-1.33) and treatment at a community hospital (OR 1.59 95% CI 1.42-1.78). Patients who refused surgery had lower median overall survival (1.0 vs 14.0 years, p < 0.01) and this difference persisted across disease sites. Between 2008 and 2017, there was a significant increase in refusal of surgery annually (annual percent change +1.41%, p < 0.05).

CONCLUSIONS

Multiple social determinants of health are independently associated with refusal of surgery for gynecologic cancer. Given that patients who refuse surgery are more likely from vulnerable, underserved populations and have inferior survival, refusal of surgery should be considered a surgical healthcare disparity and tackled as such.

Travel patterns of patients seeking cancer care during the COVID-19 pandemic: Multi-centre cohort study in Osaka, Japan

BACKGROUND

In Japan, provision of equal access to cancer care is intended to be achieved via secondary medical areas (SMAs). However, the percentage of patients receiving care within the residential area varies by SMA in Osaka Prefecture. We aimed to assess the effect size of factors associated with patient mobility, and whether patient mobility was affected by the COVID-19 pandemic.

METHODS

Records of patients diagnosed with stomach, colorectal, lung, breast, cervical, oesophageal, liver or pancreatic cancer during 2019-2020 were extracted from multi-centre hospital-based cancer registry data. Odds ratios of whether a patient received care within the SMA of residence were set as the outcome. A multivariable model was built using generalised estimating equations with multiple imputation for missing data. Change in patient mobility after the pandemic was examined by deriving age- and SMA-specific adjusted ORs (aORs).

RESULTS

A total of 78,839 records were included. Older age, more advanced stage and palliative care had up to 1.69 times higher aORs of receiving care within their own area. Patients with oesophageal, liver or pancreatic cancer tended to travel outside their area with aORs ranging from 0.71 to 0.90. Patients aged ≤ 79 and living in the East and South SMAs tended to remain in their area with aORs ranging from 1.05 to 1.11 after the pandemic.

CONCLUSION

Patient mobility decreased for higher age and stage. It also varied by SMA, cancer site and treatment type.

POLICY SUMMARY

Our results need to be linked with resource inputs to help policymakers decide whether to intervene to address current efficiency or equity issues.

Racial and ethnic disparities in access to gynecologic care

PURPOSE OF REVIEW

Despite efforts to minimize patient barriers to equitable care, health disparities persist in gynecology. This paper seeks to highlight racial and ethnic disparities in gynecologic care as represented by recent literature.

RECENT FINDINGS

Disparities exist among many areas including preventive screenings, vaccination rates, contraception use, infertility, and oncologic care. These can be identified at the patient, physician, and institutional levels.

SUMMARY

As we identify these social disparities in healthcare, we gain valuable knowledge of where our efforts are lacking and where we can further improve the health of women. Future research should focus on identifying and combating such disparities with measurable changes in health outcomes.

Assessment of Travel Distance for Hyperthermic Intraperitoneal Chemotherapy in Women with Ovarian Cancer

•

The median travel distance in women with EOC undergoing CRS with HIPEC was 57.0 miles in women with EOC.

•

Over 20% of patients treated at our institution traveled more than 100 miles for HIPEC procedures.

•

No differences were observed in post-operative complications or oncologic outcomes based upon travel distance.

Objective (s)

To evaluate travel distance in women with advanced or recurrent epithelial ovarian cancer (OC) undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) and the subsequent impact upon outcomes.

Methods

An IRB-approved single-institution prospective registry was queried for women with OC who underwent HIPEC from 1/1/2009–12/1/2020. Demographic, oncologic, and surgical data were recorded. The patient's home zip code was compared to the institutional zip code to determine travel distance using Google Maps. Patients were divided into three strata for analysis: 1) local: ≤50 miles, 2) regional: 51–99 miles, and 3) distant: ≥100 miles and univariate analysis was performed.

Results

Of 127 women, the median distance travelled was 57.0 miles (IQR: 20.6, 84.6). There were no significant differences in mild (28.3% vs. 26.3 vs. 24.1%), moderate (21.7% vs. 15.8% vs. 17.2%) or severe postoperative complications (11.7% vs. 5.3% vs. 17.2%) (p = 0.75) for local, regional and distant patients, respectively. There was no difference in progression-free survival (17.4 vs. 22.2 vs. 12.8 months, p > 0.05) or overall survival (57.3 vs. 61.6 vs. 29.2 months, p > 0.05) for local, regional or distant patients, respectively.

Conclusions

This study demonstrates that women with OC are willing to travel for HIPEC, with over 50% traveling > 50 miles. Our results suggest that women who travel for HIPEC procedures are not at increased risk for perioperative complications or worse oncologic outcomes than those local to HIPEC centers.

What underlies the observed hospital volume-outcome relationship?

Background

Studies of the hospital volume-outcome relationship have highlighted that a greater volume activity improves patient outcomes. While this finding has been known for years, most studies to date have failed to delve into what underlies this relationship.

Objective

This study aimed to shed light on the basis of the hospital volume effect on patient outcomes by comparing treatment modalities for epithelial ovarian carcinoma patients.

Data

An exhaustive dataset of 355 patients in first-line treatment for Epithelial Ovarian Carcinoma (EOC) in 2012 in three regions of France was used. These regions account for 15% of the metropolitan French population.

Methods

In the presence of endogeneity induced by a reverse causality between hospital volume and patient outcomes, we used an instrumental variable approach. Hospital volume of activity was instrumented by the distance from patients’ homes to their hospital, the population density, and the median net income of patient municipalities.

Results

Based on our parameter estimates, we found that the rate of complete tumor resection would increase by 15.5 percentage points with centralized care, and by 8.3 percentage points if treatment decisions were coordinated by high-volume centers compared to decentralized care.

Conclusion

As volume alone is an imperfect correlate of quality, policy-makers need to know what volume is a proxy for in order to devise volume-based policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07449-2.

Associations between geographic residence and US adolescent and young adult cancer stage and survival

BACKGROUND

Multiple studies have indicated that place of residence can influence cancer survival; however, few studies have specifically focused on geographic factors and outcomes in adolescents and young adults (AYAs) with cancer. The objective of this study was to evaluate evidence for geographic disparities in cancer diagnosis stage and overall survival in AYAs and to examine whether stage mediated survival associations.

METHODS

National Cancer Database data on AYAs aged 15 to 39 years who were diagnosed with cancer from 2010 to 2014 were obtained. Residence in Metropolitan (metro), urban, or rural counties at the time of diagnosis was defined using Rural-Urban Continuum Codes. Distance between the patient's residence and the reporting hospital was classified as short (≤2.5 miles), intermediate (>12.5 to <50 miles), or long (≥50 miles). Logistic and Cox proportional hazards regression models were used for analyses.

RESULTS

The stage and survival analyses included 146,418 and 178,688 AYAs, respectively. The odds of a late versus early stage at diagnosis (stages III and IV vs I and II) were 1.16 (95% CI, 1.05-1.29) times greater for AYAs living in rural versus metro counties and 1.20 (95% CI, 1.16-1.25) times greater for AYAs living at long versus short distances to the reporting hospital. The hazard of death was 1.17 (95% CI, 1.05-1.31) and 1.30 (95% CI, 1.25-1.36) times greater for those living in rural versus metro counties, respectively, and for long versus short distances to the reporting hospital, respectively. Disease stage mediated 54% and 31% of the associations between metro, urban, or rural residence and residential distance categories and survival.

CONCLUSIONS

Rural residence and living long distances from the reporting hospital were associated with later stage diagnoses and lower survival in AYAs with cancer. Further research is needed to understand mechanisms.

LAY SUMMARY

Adolescents and young adults (AYAs) with cancer are a vulnerable population because cancer is of low suspicion in this population and may not be diagnosed in a timely manner. The authors evaluated evidence for geographic disparities in cancer stage at diagnosis and survival in the AYA population. The findings indicate that AYAs living in rural versus metropolitan US counties and those living farther from the diagnosis reporting hospital are more likely to be diagnosed at a later cancer stage, when it is generally less treatable, and have lower survival compared with AYAs living in metropolitan counties.