Is patient travel distance associated with survival on phase II clinical trials in oncology?

The impact of distance to facility on treatment modality, short-term outcomes, and survival of patients with HPV-positive oropharyngeal squamous cell carcinoma

PURPOSE

This study compared treatment and outcomes for patients with HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) based on their travel distance to treatment facility.

MATERIALS AND METHODS

Patients with cT1-4, N0-3, M0 HPV-positive OPSCC in the National Cancer Database from 2010 to 2019 were identified and split into four quartiles based on distance to facility, with quartile 4 representing patients with furthest travel distances. Multivariable-adjusted logistic regression and Cox proportional hazards modeling were used to analyze the primary outcome of treatment received, and secondary outcomes of clinical stage, overall survival, surgical approach (i.e., TORS versus other), and 30-day surgical readmissions.

RESULTS

17,207 patients with HPV-positive OPSCC were evenly distributed into four quartiles. Compared to patients in quartile 1, patients in quartile 4 were 40 % less likely to receive radiation versus surgery (OR = 0.60; 95 % CI = 0.54-0.66). Among the patients who received surgery, quartile 4 had a higher odds of receiving TORS treatment compared to quartile 1 (4v1: OR = 2.38; 95 % CI = 2.05-2.77), quartile 2 (4v2: OR = 2.31, 95 % CI = 2.00-2.66), and quartile 3 (4v3: OR = 1.75; 95 % CI = 1.54-1.99). Quartile 4 had a decreased odds of mortality compared to Quartile 1 (4v1: OR = 0.87; 95 % CI = 0.79-0.97). There were no differences among the quartiles in presenting stage and 30-day readmissions.

CONCLUSIONS

This study found that patients with furthest travel distance to facility were more often treated surgically over non-surgical management, with TORS over open surgery, and had better overall survival. These findings highlight potential disparities in access to care for patients with HPV-positive OPSCC.

Social determinants of health influencing the adherence to post-endoscopic mucosal resection surveillance

BACKGROUND AND AIMS

Colorectal cancer (CRC) is a global health challenge, particularly in Alabama, where the incidence rates exceed national averages. This study investigated the factors influencing adherence to post-endoscopic mucosal resection (EMR) colonoscopies, focusing on travel distance and socioeconomic status. This study aimed to provide evidence-based insights to improve patient care in CRC management.

METHODS

This retrospective study in a tertiary care referral center analyzed 465 patients who underwent EMR. The data included demographics, clinical details, and travel-related variables. Descriptive statistics, logistic regression, and spatial analysis were used to assess the factors affecting adherence.

RESULTS

Of 465 patients, 36.6 % had adequate follow-up, 21.8 % had inadequate follow-up, and 41.6 % were lost to follow-up. Noteworthy demographic variations were observed, with median ages differing across adherence groups. Traveled distances showcased compelling insights, indicating a median distance of 22.2 miles for adequate follow-up, 15.7 miles for inadequate follow-up, and 31.6 miles for the lost-to-follow-up group (p<0.001). Longer travel distances were associated with better adherence. Longer travel distances from the hospital were associated with significantly lower odds of inadequate follow-up: 10-25 miles OR:0.29, 25-85 miles OR:0.35, and >80 miles OR:0.24 compared to the first quartile (<10 miles). Socioeconomic factors, particularly educational attainment, significantly influenced the follow-up rates.

CONCLUSIONS

This study revealed suboptimal post-EMR follow-up rates and underscored the impact of travel distance and socioeconomic factors. Targeted interventions addressing distance-related barriers can enhance treatment adherence and ensure timely CRC surveillance after EMR. Further research is needed in diverse healthcare settings.

Factors Associated With Onabotulinum Toxin-A Discontinuation in a Diverse Urban Population

IMPORTANCE

Although overactive bladder (OAB) is a common condition, affecting 16% of Americans, few patients continue on to advanced therapies. Furthermore, procedural therapies like intravesical onabotulinum toxin-A (BTX-A), which require ongoing repeat treatments, have discontinuation rates ranging from 25% to 51%.

OBJECTIVES

This study sought to investigate factors associated with dis-continuation of BTX-A injections for idiopathic OAB among a diverse urban population.

STUDY DESIGN

This was a retrospective review of adults 18 years and older who underwent BTX-A injection for idiopathic OAB. Patient demographics, past medical history, symptoms, and postprocedural outcomes such as subjective improvement, urinary retention, and incidence of urinary tract infection were compared between groups.

RESULTS

Onabotulinum toxin-A injections were administered to 246 patients who met study criteria, of whom 211 (85.7%) were women. One hundred (40.7%) patients discontinued BTX-A therapy. Patients discontinuing BTX-A therapy were more likely to have developed postprocedural urinary retention (18.4% vs 9.7%, P < 0.05) and had a higher median income by zip code ($59,000 vs $50,000; P < 0.01). Patients were significantly more likely to continue BTX-A therapy if they reported preprocedural nocturia (57.2% vs 36.8%, P < 0.01) or urgency urinary incontinence (UUI) (78.1% vs 64.6%, P < 0.05).

CONCLUSIONS

Adverse outcomes, such as postprocedural urinary retention, are associated with discontinuation of BTX-A therapy. Patients who reported nocturia and UUI before injection were more likely to continue BTX-A suggesting more severe OAB is more responsive to this therapy. Given the large proportion (>40%) of patients who discontinued BTX-A treatment, further research is needed to identify barriers to continuation of care.

Analysis of trend in the role of national and regional hubs in prostatectomy after prostate cancer diagnosis in the past 5 years: A nationwide population-based study

PURPOSE

The regions where patients diagnosed with prostate cancer by biopsy receive prostatectomy are divided into national hub and regional hubs, and to confirm the change in the role of regional hubs compared to national hub.

MATERIALS AND METHODS

Data from July 2013 to June 2017 encompassing 218,155 patients aged ≥18 years diagnosed with prostate cancer were analyzed using the Health Insurance Review & Assessment Service database. The degree of patient outflow was assessed by dividing the regional diagnosis-to-surgery ratio with the national ratio for each year. Based on this ratio, national and regional hubs were determined.

RESULTS

Seoul consistently maintained a patient influx with a ratio above 1.6. Busan and Gyeonggi consistently exceeded 0.9, while Ulsan and Daegu steadily increased, exceeding 1.0 between 2015 and 2016. Jeonnam province also consistently maintained the ratio above 0.7. Jeju, Daejeon, Gangwon, and Incheon remained below 0.5, indicative of substantial patient outflows, whereas Gwangju and Gyeongbuk had the highest patient outflows with ratios below 0.15. Therefore, Seoul was designated as a national hub, whereas Busan, Gyeonggi, Ulsan, Daegu, and Jeonnam were classified as regional hubs. Jeju, Daejeon, Gangwon, and Incheon were the dominant outflow areas, while Gwangju and Gyeongbuk were the highest outflow areas.

CONCLUSIONS

Seoul, as the national hub for prostate cancer surgery, operated on 1.76 times more patients than any other region during 2013-2017. Busan, Gyeonggi, Ulsan, Daegu, and Jeonnam functioned as regional hubs, but approximately 10%-20% of patients sought treatment at national hubs.

Predicting long‑term survival following involved site radiotherapy for oligometastases

The majority of cancer-associated mortalities are due to distant metastases, and systemic therapy alone is generally not curative. Patients with oligometastases are amenable to involved site radiotherapy with the possibility of long-term disease-free survival; however, prognostic factors remain poorly defined. The present retrospective, single institution study consisted of consecutive adult patients with oligometastases from solid tumor malignancy referred to a single high volume radiation oncologist between January 2014 and December 2021. Oligometastases were defined as ≤5 extracranial or intracranial metastatic lesions where all sites of active disease are treatable, including patients requiring treatment of the primary tumor and/or regional lymph nodes. The study population consisted of 130 patients with 207 treated distant metastases. Radical radiotherapy was administered to all areas of known residual disease and included stereotactic radiotherapy (median dose, 27 Gy in 3 fractions) or intensity modulated radiotherapy (median dose, 50 Gy in 15 fractions). At a median follow-up of 28.8 months, the median overall survival was 37.9 months with a 4-year overall survival of 41.1%. The median progression-free survival was 12.3 months and the 4-year progression-free survival was 22.6%. On multivariate an1alysis, the strongest predictors of overall survival were age, ECOG performance status, primary prostate, breast or kidney tumor and pre-radiation serum albumin (P≤0.01 for all). Overall, the present study demonstrated that long-term overall survival was possible after radical treatment for oligometastases and identified potential prognostic factors.

Long-term disease-free survival following comprehensive involved site radiotherapy for oligometastases

Introduction

Despite recent advances in drug development, durable complete remissions with systemic therapy alone for metastatic cancers remain infrequent. With the development of advanced radiation technologies capable of selectively sparing normal tissues, patients with oligometastases are often amenable to comprehensive involved site radiotherapy with curative intent. This study reports the long-term outcomes and patterns of failure for patients treated with total metastatic ablation often in combination with systemic therapy.

Materials and methods

Consecutive adult patients with oligometastases from solid tumor malignancy treated by a single high volume radiation oncologist between 2014 and 2021 were retrospectively analyzed. Oligometastases were defined as 5 or fewer metastatic lesions where all sites of active disease are amenable to local treatment. Comprehensive involved site radiotherapy consisted of stereotactic radiotherapy to a median dose of 27 Gy in 3 fractions and intensity modulated radiation therapy to a median dose of 50 Gy in 15 fractions. This study analyzed overall survival, progression-free survival, patterns of failure and toxicity.

Results

A total of 130 patients with 209 treated distant metastases were treated with a median follow-up of 36 months. The 4-year overall survival, progression-free survival, local control and distant control was 41%, 23%, 86% and 29%. Patterns of failure include 23% alive and free of disease (NED), 52% distant failure only, 9% NED but death from comorbid illness, 7% both local and distant failure, 4% NED but lost to follow-up, 4% referred to hospice before restaging, 1% local only failure, 1% alive with second primary cancer. Late grade 3+ toxicities occurred in 4% of patients, most commonly radionecrosis.

Conclusion

Involved site radiotherapy to all areas of known disease can safely achieve durable complete remissions in patients with oligometastases treated in the real world setting. Distant failures account for the majority of treatment failures and isolated local failures are exceedingly uncommon. Oligometastases represents a promising setting to investigate novel therapeutics targeting minimal residual disease.

Predictors of Quality of Life for Head and Neck Cancer Patients at an Academic Institution

Objective

Quality of life (QOL) is an important consideration in head and neck cancer (HNC) due to lasting disease and treatment-related toxicities. We performed a comprehensive review of predictors of QOL in this population, including distance to care.

Study Design

Retrospective cohort study from 2017 to 2022.

Setting

Academic medical center.

Methods

QOL was quantified in patients treated for HNC utilizing the University of Washington Quality of Life and 20-Item Short Form surveys completed at subsequent clinic visits. Distance to treatment center and other demographic, socioeconomic, disease-specific, and behavioral data were analyzed.

Results

There were 176 patients in the cohort (69% male; mean age, 64 ± 10.8 years). There was no association between miles traveled and any of the QOL subscales. Marital status was the strongest predictor of QOL, significantly associated with 7/8 QOL domains and favoring those who were married. Other significant predictors of decreased QOL included emotional/physical abuse, current tobacco use, documented religious affiliation, and treatment involving surgery plus adjuvant therapy. A significant positive trend over time existed for multiple QOL subscales.

Conclusion

QOL is unchanged in patients who travel greater distances for care. QOL is more closely linked to factors such as marital status, physical/emotional abuse, tobacco use, religious affiliation, treatment intensity, and time following surgery. This highlights the importance of a strong support structure and the influence of certain socioeconomic and lifestyle factors on patients, with opportunities for screening and intervention throughout their cancer care.

Impact of Cancer Care Regionalization on Patient Volume

BACKGROUND

Cancer centers are regionalizing care to expand patient access, but the effects on patient volume are unknown. This study aimed to compare patient volumes before and after the establishment of head and neck regional care centers (HNRCCs).

METHODS

This study analyzed 35,394 unique new patient visits at MD Anderson Cancer Center (MDACC) before and after the creation of HNRCCs. Univariate regression estimated the rate of increase in new patient appointments. Geospatial analysis evaluated patient origin and distribution.

RESULTS

The mean new patients per year in 2006-2011 versus 2012-2017 was 2735 ± 156 patients versus 3155 ± 207 patients, including 464 ± 78 patients at HNRCCs, reflecting a 38.4 % increase in overall patient volumes. The rate of increase in new patient appointments did not differ significantly before and after HNRCCs (121.9 vs 95.8 patients/year; P = 0.519). The patients from counties near HNRCCs, showed a 210.8 % increase in appointments overall, 33.8 % of which were at an HNRCC. At the main campus exclusively, the shift in regional patients to HNRCCs coincided with a lower rate of increase in patients from the MDACC service area (33.7 vs. 11.0 patients/year; P = 0.035), but the trend was toward a greater increase in out-of-state patients (25.7 vs. 40.3 patients/year; P = 0.299).

CONCLUSIONS

The creation of HNRCCs coincided with stable increases in new patient volume, and a sizeable minority of patients sought care at regional centers. Regional patients shifted to the HNRCCs, and out-of-state patient volume increased at the main campus, optimizing access for both local and out-of-state patients.

Domestic medical travel from non-Seoul regions to Seoul for initial breast cancer treatment: a nationwide cohort study

Purpose

This study was conducted to investigate the trend of domestic medical travel from non-Seoul areas to Seoul for initial breast cancer treatment, and identify factors associated with medical travel in breast cancer patients.

Methods

A nationwide retrospective cohort study was performed using the Health Insurance Review and Assessment data of South Korea. Patients were classified according to the regions in which they underwent breast biopsy (Seoul vs. metropolitan cities vs. other regions). Frequencies of biopsy, diagnosis, treatment, and domestic medical travel were analyzed according to regions, and factors associated with medical travel were investigated.

Results

A total of 150,709 breast cancer survivors who were diagnosed between January 2010 and December 2017 were included. The total rate of medical travel from non-Seoul regions to Seoul had increased from 14.2% (1,161 of 8,150) in 2010 to 19.8% (2,762 of 13,964) in 2017. Approximately a quarter of patients from other regions traveled to Seoul, and over 40% of patients from Chungbuk, Gyeongbuk, and Jeju regions traveled to Seoul for initial treatment in 2017. The difference in the annual frequencies of upfront surgery between Seoul and non-Seoul regions increased over time. Younger age and regions other than metropolitan cities were significantly related to medical travel. Patients covered by medical aid or past medical histories were significantly less likely to travel to Seoul for initial breast cancer treatment.

Conclusion

Medical travel to Seoul for upfront breast cancer surgery is increasing. Policies for appropriate healthcare delivery need to be established in the near future.

Predictors of consenting to participate in a clinical trial among urban cancer patients

BACKGROUND

Patient participation in clinical trials is influenced by demographic and other individual level characteristics. However, there is less research on the role of geography and neighborhood-level factors on clinical trial participation. This study identifies the demographic, clinical, geographic, and neighborhood predictors of consenting to a clinical trial among cancer patients at a large, urban, NCI-designated cancer center in the Mid-Atlantic region.

METHODS

We used demographic and clinical data from patients diagnosed with cancer between 2015 and 2017. We geocoded patient addresses and calculated driving distance to the cancer center. Additionally, we linked patient data to neighborhood-level educational attainment, social capital and cancer prevalence. Finally, we used generalized linear mixed-effects conditional logistic regression to identify individual and neighborhood-level predictors of consenting to a clinical trial.

RESULTS

Patients with higher odds of consenting to trials were: Non-Hispanic White, aged 50-69, diagnosed with breast, GI, head/neck, hematologic, or certain solid tumor cancers, those with cancers at regional stage, never/former tobacco users, and those with the highest neighborhood social capital index. Patients who lived further from the cancer center had higher odds of consenting to a trial. With every 1-km increase in residential distance, there was a 4% increase in the odds that patients would consent to a trial. Neither of the additional neighborhood-level variables predicted consenting to a clinical trial.

CONCLUSIONS

This study identifies important demographic, patient-level, and geographic factors associated with consenting to cancer clinical trials, and lays the groundwork for future research exploring the role of neighborhood-level factors in clinical trial participation.

Are there differences in outcomes by race among women with metastatic triple-negative breast cancer?

PURPOSE

Black women have higher breast cancer mortality rates than other groups, with Triple-negative breast cancer (TNBC) being more common among AAs with a worse prognosis. Our study seeks to explore differences among Non-Hispanic Black (NHB) vs. White (NHW) women, with Stage IV TNBC, focusing on survival and treatment patterns.

METHODS

SEER database was queried for TNBC patients diagnosed with metastatic disease from 2012 to 2016. Neighborhood socioeconomic status (nSES) was defined using the Yost index based on income, education, housing, and employment. Univariate and multivariate analyses were performed to evaluate receipt of surgery, radiation, and chemotherapy. Overall survival was evaluated using Kaplan-Meier curve and Cox proportional hazards model analysis.

RESULTS

25,761 TNBC cases were identified with 1420 being metastatic (5.5%). Bone was the most common site for metastasis, with patients' age being 63.7 years for NHW vs. 59.5 years for NHB. NHB women had the highest percentage of low nSES (62.3% vs 29.3%; p value = 0.001). On univariate analysis, fewer NHBs received radiation compared to NHWs (27.1 vs. 32.6%; p value = 0.040). On multivariate analysis, all women were less likely to undergo treatment if unmarried (p value < 0.01). NHB women had lower median survival compared to NHW women (13 vs. 15 months; p value < 0.01). Receipt of surgery and chemotherapy reduced the risk of mortality (p value < 0.01).

CONCLUSION

NHB women had lower median survival with metastatic TNBC. Race was associated with different treatment utilization. With a mortality differential between NHW and NHB women with metastatic TNBC, more investigation is needed to inform strategies to reduce this disparity.

Analysis of patient characteristics and outcomes related to distance traveled to a tertiary center for primary reverse shoulder arthroplasty

INTRODUCTION

The reasons for referral and travel patterns are lacking for patients undergoing reverse shoulder arthroplasty (RSA). The purpose of this study was to compare comorbidities, surgical time, cost and complications between local and distant primary RSA patients.

METHODS

Between 2007 and 2015, 1,666 primary RSAs were performed at our institution. Patients were divided into two cohorts, local patients (from within Olmstead county and surrounding counties, 492 RSAs) and those from a distance (1,174 RSAs).

RESULTS

Local patients were older (74 vs 71 years, p < .001), more likely to have RSA for fracture, had a higher Charlson comorbidity score (3.8 vs 3.2, p < .001) and longer hospital stays (2.0 vs 1.8 days, p < 0.001) compared to referred patients. Referral patients required longer operative times (95 vs 88 min, p = .002), had higher hospitalization costs ($19,101 vs $18,735, p < .001), and had a higher rate of prior surgery (32% vs 24%, p < .001). There were no differences between cohorts regarding complications or need for reoperation.

CONCLUSIONS

Patients traveling from a distance to undergo primary RSA had longer operative times and were more likely to have had prior surgery than local patients. This may demonstrate the referral bias seen at large academic centers and should be considered when reviewing RSA outcomes, hospital performance, and calculating insurance reimbursement.

LEVEL OF EVIDENCE

Level IV.

Evaluating Distance Bias in Chronic Rhinosinusitis Outcomes

Importance

The distance traveled by patients for medical care is associated with patient outcomes (ie, distance bias) and is a limitation in outcomes research. However, to date, distance bias has not been examined in rhinologic studies.

Objective

To evaluate the association of distance traveled by a cohort of patients with chronic rhinosinusitis with baseline disease severity and treatment outcomes.

Design, Setting, and Participants

A total of 505 patients with chronic rhinosinusitis were prospectively enrolled in a multi-institutional, cross-sectional study in academic tertiary care centers between April 2011 and January 2020. Participants self-selected continued appropriate medical therapy or endoscopic sinus surgery. The 22-item Sinonasal Outcome Test (SNOT-22) and Medical Outcomes Study Short Form 6-D (SF-6D) health utility value scores were recorded at enrollment and follow-up. Data on the distances traveled by patients to the medical centers, based on residence zip codes, and medical comorbid conditions were collected.

Exposures

Distance traveled by patient to obtain rhinologic care.

Main Outcomes and Measures

SNOT-22 and SF-6D scores. Scores for SNOT-22 range from 0 to 110; and for SF-6D, from 0.0 to 1.0. Higher SNOT-22 total scores indicate worse overall symptom severity. Higher SF-6D scores indicate better overall health utility; 1.0 represents perfect health and 0.0 represents death.

Results

The median age for the 505 participants was 56.0 years (IQR, 41.0-64.0 years), 261 were men (51.7%), 457 were White (90.5%), and 13 were Hispanic or Latino (2.6%). These categories were collected according to criteria described and required by the National Institutes of Health and therefore do not equal the entire cohort. Patients traveled a median distance of 31.6 miles (50.6 km) (IQR, 12.2-114.5 miles [19.5-183.2 km]). Baseline (r = 0.00; 95% CI, 0.00-0.18) and posttreatment (r = 0.01; 95% CI, -0.07 to 0.10) SNOT-22 scores, as well as baseline (r = -0.12; 95% CI, -0.21 to -0.04) and posttreatment (r = 0.07; 95% CI, -0.02 to 0.16) SF-6D scores, were not associated with distance. There was no clinically meaningful correlation between distance traveled and mean comorbidity burden. Nevertheless, patients with a history of endoscopic sinus surgery were more likely to travel longer distances to obtain care (Cliff delta = 0.28; 95% CI, 0.19-0.38).

Conclusions and Relevance

Although this cross-sectional study found that some patients appear more willing to travel longer distances for chronic rhinosinusitis care, results suggest that distance traveled to academic tertiary care centers was not associated with disease severity, outcomes, or comorbidity burden. These findings argue for greater generalizability of study results across various cohorts independent of distance traveled to obtain rhinologic care.

Trial Registration

ClinicalTrials.gov Identifier: NCT02720653.

Are Geographical Health Accessibility and Socioeconomic Deprivation Associated with Outcomes Following Bariatric Surgery? A Retrospective Study in a High-Volume Referral Bariatric Surgical Center

PURPOSE

Few studies have evaluated the association between non-clinical determinants (socioeconomic status and geographic accessibility to healthcare) and the outcomes of bariatric surgery, with conflicting results. This study aimed to evaluate this association.

METHODS

The medical records of 1599 consecutive patients who underwent either laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between June 2005 and December 2017 were retrieved. All relevant data, including patient characteristics, biometric values before and after surgery, related medical problems, surgical history, medications, and habitus, for each patient were prospectively collected in a database. Logistic regressions were used to assess the influence of non-clinical determinants on surgical indications and complications. Multilevel linear or logistic regression was used to evaluate the influence of non-clinical determinants on long-term %TWL and the probability to achieve adequate weight loss (defined as a %TWL > 20% at 12 months).

RESULTS

Analysis of the 1599 medical records revealed that most geographically isolated patients were more likely to have undergone laparoscopic Roux-en-Y gastric bypass (odds ratio: 0.97; 95% confidence interval: 0.94 to 0.99; P = 0.018) and had a greater likelihood of adequate weight loss (β: 0.03; 95% CI: 0.01 to 0.05; P = 0.021). Conversely, socioeconomic status (measured by the European Deprivation Index) did not affect outcomes following bariatric surgery.

CONCLUSION

Geographical health isolation is associated with a higher probability to achieve adequate weight loss after 1 year of follow-up, while neither health isolation nor socioeconomic deprivation is associated with post-operative mortality and morbidity. This results suggests that bariatric surgery is a safe and effective tool for weight loss despite socioeconomic deprivation.

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.

Neighborhood Characteristics and Cancer Survivorship: An Overview of the Current Literature on Neighborhood Landscapes and Cancer Care

There is a growing literature on the association between neighborhood contexts and cancer survivorship. To understand the current trends and the gaps in the literature, we aimed to answer the following questions: To what degree, and how, has cancer survivorship research accounted for neighborhood-level effects? What neighborhood metrics have been used to operationalize neighborhood factors? To what degree do the neighborhood level metrics considered in cancer research reflect neighborhood development as identified in the Leadership for Energy and Environmental Design for Neighborhood Development (LEED-ND) guidelines? We first conducted a review guided by PRISMA extension for scoping review of the extant literature on neighborhood effects and cancer survivorship outcomes from January 2000 to January 2021. Second, we categorized the studied neighborhood metrics under six main themes. Third, we assessed the findings based on the LEED-ND guidelines to identify the most relevant neighborhood metrics in association with areas of focus in cancer survivorship care and research. The search results were scoped to 291 relevant peer-reviewed journal articles. Results show that survivorship disparities, primary care, and weight management are the main themes in the literature. Additionally, most articles rely on neighborhood SES as the primary (or only) examined neighborhood level metric. We argue that the expansion of interdisciplinary research to include neighborhood metrics endorsed by current paradigms in salutogenic urban design can enhance the understanding of the role of socioecological context in survivorship care and outcomes.

The Impact of Socioeconomic Determinants on the Quality of Life of Moroccan Breast Cancer Survivors Diagnosed Two Years Earlier at the National Institute of Oncology in Rabat

Introduction

The objective of this study was to investigate the impact of socioeconomic determinants on the quality of life of Moroccan women with breast cancer two years after their diagnosis who are followed up at the National Institute of Oncology (INO) in Rabat.

Methods

This is a cross-sectional study that was conducted between May 2019 and September 2020. The sample size was 304 women. Data were collected using the EORTC QLQ-C30 and EORTC QLQ-BR 23 questionnaires in the Moroccan dialect.

Results

The mean age of participants was 53.5 ± 12.4 years, where the majority resided in urban areas and more than half were illiterate. Moreover, three-quarters of the survivors were not working, and almost all have basic medical coverage. Nearly one-third of the respondents had experienced discrimination from those around them, and nearly half attributed the decrease in income to their state of health. In addition, 38.2 percent of participants stated that they had great difficulty living on their monthly income after the illness, whereas more than half of the survivors had a good quality of life in terms of overall health (GHS/QOL). Besides, social function obtained the highest score, while emotional function obtained the lowest score. Furthermore, financial difficulty was the most distressing symptom. Indeed, income adjustment after the disease, discrimination, distance between home and treatment center, professional status, and medical coverage were correlated with GHS/QOL. Regression analysis revealed that income adjustment after illness and discrimination were significant predictors of GHS/QOL.

Conclusion

The data suggest establishing a financial support program and the development of education and awareness-raising policies to combat discrimination.

Traveling to Receive Treatment for Extremity Soft Tissue Sarcomas: Is it worth the drive?

BACKGROUND

Regionalization of sarcoma care may improve outcomes. Concerns exist regarding the burdens of travel and its effects on care. We evaluate the presence of a "distance bias".

METHODS

Retrospective cohort study of patients with extremity soft tissue sarcoma (stage I-III) within the NCDB. Travel distance (TD) and hospital volume (VOL) were categorized into quartiles. Alternating statistical models were used for analysis.

RESULTS

1,035 hospitals contributed 11,979 cases. Median and maximum VOL were 5 and 45 cases/year. VOL quartiles were "low-volume" (LV) (892 hospitals, < 3 cases/yr.), "intermediate low-volume" (ILV) (89, 3-5 cases/yr.), "intermediate high-volume" (IHV) (39, 6-12 cases/yr.), and "high-volume" (HV) (15, > 12 cases/yr.). TD quartiles: "short-travel" (ST) (< 8 mi), "intermediate-short travel" (IST) (8-17), "intermediate long-travel" (ILT) (18-49), and "long-travel" (LT) (> 50). VOL but not TD is associated with improved survival [HR 0.65 (CI 0.52-0.83)] and rate of R0 resection [1.87 (CI 1.4-2.5)] but has no effect on amputation rates. Matched analyses demonstrate similar results.

CONCLUSIONS

Hospital volume but not distance traveled to treatment facility is associated with improved survival and R0 resections for extremity soft tissue sarcomas. Despite the inconveniences of travel, patients may benefit from treatment at high volume centers.

Racial Disparities in Triple Negative Breast Cancer: A Review of the Role of Biologic and Non-biologic Factors

Triple-negative breast cancer (TNBC) is an aggressive subtype of breast cancer that lacks expression of the estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor (HER2). TNBC constitutes about 15–30 percent of all diagnosed invasive breast cancer cases in the United States. African-American (AA) women have high prevalence of TNBC with worse clinical outcomes than European-American (EA) women. The contributing factors underlying racial disparities have been divided into two major categories based on whether they are related to lifestyle (non-biologic) or unrelated to lifestyle (biologic). Our objective in the present review article was to understand the potential interactions by which these risk factors intersect to drive the initiation and development of the disparities resulting in the aggressive TNBC subtypes in AA women more likely than in EA women. To reach our goal, we conducted literature searches using MEDLINE/PubMed to identify relevant articles published from 2005 to 2019 addressing breast cancer disparities primarily among AA and EA women in the United States. We found that disparities in TNBC may be attributed to racial differences in biological factors, such as tumor heterogeneity, population genetics, somatic genomic mutations, and increased expression of genes in AA breast tumors which have direct link to breast cancer. In addition, a large number of non-biologic factors, including socioeconomic deprivation adversities associated with poverty, social stress, unsafe neighborhoods, lack of healthcare access and pattern of reproductive factors, can promote comorbid diseases such as obesity and diabetes which may adversely contribute to the aggression of TNBC biology in AA women. Further, the biological risk factors directly linked to TNBC in AA women may potentially interact with non-biologic factors to promote a higher prevalence of TNBC, more aggressive biology, and poor survival. The relative contributions of the biologic and non-biologic factors and their potential interactions is essential to our understanding of disproportionately high burden and poor survival rates of AA women with TNBC.

Impact of Geography on Care Delivery and Survival for Noncurable Pancreatic Adenocarcinoma: A Population-Based Analysis

BACKGROUND

Little is known about how the geographic distribution of cancer services may influence disparities in outcomes for noncurable pancreatic adenocarcinoma. We therefore examined the geographic distribution of outcomes for this disease in relation to distance to cancer centers.

METHODS

We conducted a retrospective population-based analysis of adults in Ontario, Canada, diagnosed with noncurable pancreatic adenocarcinoma from 2004 through 2017 using linked administrative healthcare datasets. The exposure was distance from place of residence to the nearest cancer center providing medical oncology assessment and systemic therapy. Outcomes were medical oncology consultation, receipt of cancer-directed therapy, and overall survival. We examined the relationship between distance and outcomes using adjusted multivariable regression models.

RESULTS

Of 15,970 patients surviving a median of 3.3 months, 65.6% consulted medical oncology and 38.5% received systemic therapy. Regions with comparable outcomes were clustered throughout Ontario. Mapping revealed regional discordances between outcomes. Increasing distance (reference, ≤10 km) was independently associated with lower likelihood of medical oncology consultation (relative risks [95% CI] for 11-50, 51-100, and ≥101 km were 0.90 [0.83-0.98], 0.78 [0.62-0.99], and 0.77 [0.55-1.08], respectively) and worse survival (hazard ratios [95% CI] for 11-50, 51-100, and ≥101 km were 1.08 [1.04-1.12], 1.17 [1.10-1.25], and 1.10 [1.02-1.18], respectively), but not with likelihood of receiving therapy. Receipt of therapy seems less sensitive to distance, suggesting that distance limits entry into the cancer care system via oncology consultation. Regional outcome discordances suggest inefficiencies within and protective factors outside of the cancer care system.

CONCLUSIONS

These findings provide a basis for clinicians to optimize their practices for patients with noncurable pancreatic adenocarcinoma, for future studies investigating geographic barriers to care, and for regional interventions to improve access.

Effects of Distance From Academic Cancer Center on Overall Survival of Acute Myeloid Leukemia: Retrospective Analysis of Treated Patients

INTRODUCTION

Patients living farther away from academic centers may not have easy access to resources for management of acute myeloid leukemia (AML). We aimed to analyze the effect of distance traveled on overall survival (OS) of AML patients treated at an academic center.

PATIENTS AND METHODS

AML patients diagnosed at the University of Nebraska Medical Center were divided into 4 groups according to the shortest distance between the cancer center and patients' residence (<25, 25-50, 50-100, and > 100 miles). Chi-square test and ANOVA were used to examine the association of distance with patient characteristics. OS, defined as the time from diagnosis of AML to death from any cause, was determined by the Kaplan-Meier method. Comparison of survival curves was done by the log-rank test. Multivariable analysis using Cox regression was performed to detect the survival effect of distance from the cancer center.

RESULTS

The total number of patients was 449. Median distance was 85 miles (interquartile range, 20-180). OS at 1 year for < 25, 25-50, 50-100, and > 100 miles was 45%, 55%, 38%, and 40% respectively (P = .6). In a Cox regression analysis, distance from treatment center, as a continuous variable, was not a significant factor for death (hazard ratio, 1.001; 95% confidence interval, 1.000-1.001). Multivariable analysis showed nonsignificant trend of increased mortality for patients traveling > 100 miles to a cancer center.

CONCLUSION

This study did not demonstrate an association between distance from an academic cancer center and OS in AML. This finding should provide some assurance to patients who live farther away from academic centers.

The effect of socioeconomic status on age at diagnosis and overall survival in patients with intracranial meningioma

BACKGROUND

Intracranial meningiomas are the most common primary tumors of the central nervous system. How socioeconomic status (SES) impacts treatment access and outcomes for brain tumor subtypes is an emerging area of research. Few studies have examined the relationship between SES and meningioma survival and management with reference to relevant clinical factors, including age at diagnosis. We studied the independent effects of SES on receiving surgery and survival probability in patients with intracranial meningioma.

METHODS

54,282 patients diagnosed with intracranial meningioma between 2003 and 2012 from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute database were included. Patient SES was divided into tertiles. Patient age groups included 'older' (>65, the median patient age) and 'younger'. Multivariable linear regression and Cox proportional hazards model were used with SAS v9.4. Results were adjusted for race, sex, and tumor grade. Kaplan-Meier survival curves were constructed according to SES tertiles and age groups.

RESULTS

Meningioma prevalence increased with higher SES tertile. Higher SES tertile was also associated with younger age at diagnosis (OR = 0.890, p < 0.05), an increased likelihood of undergoing gross total resection (GTR) (OR = 1.112, p < 0.05), and a trend toward greater 5-year survival probability (HR = 1.773, p = 0.0531). Survival probability correlated with younger age at diagnosis (HR = 2.597, p < 0.001), but not with GTR receipt.

CONCLUSION

The findings from this national longitudinal study on patients with meningioma suggest that SES affects age at diagnosis and treatment access for intracranial meningiomas patients. Further studies are required to understand and address the mechanisms underlying these disparities.

Predicting salvage laryngectomy in patients treated with primary nonsurgical therapy for laryngeal squamous cell carcinoma using machine learning

BACKGROUND

Machine learning (ML) algorithms may predict patients who will require salvage total laryngectomy (STL) after primary radiotherapy with or without chemotherapy for laryngeal squamous cell carcinoma (SCC).

METHODS

Patients treated for T1-T3a laryngeal SCC were identified from the National Cancer Database. Multiple ML algorithms were trained to predict which patients would go on to require STL after primary nonsurgical treatment.

RESULTS

A total of 16 440 cases were included. The best classification performance was achieved with a gradient boosting algorithm, which achieved accuracy of 76.0% (95% CI 74.5-77.5) and area under the curve = 0.762. The most important variables used to construct the model were distance from residence to treating facility and days from diagnosis to start of treatment.

CONCLUSION

We can identify patients likely to fail primary radiotherapy with or without chemotherapy and who will go on to require STL by applying ML techniques and argue for high-quality, multidisciplinary regionalized care.

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

OBJECTIVE

To examine patterns of patient travel among women with ovarian cancer and to explore the association between travel distance and short and long-term outcomes.

METHODS

Women with stage II-IV epithelial ovarian cancer diagnosed from 2004 to 2016 who underwent primary surgery were identified in the National Cancer Database. Mixed-effect log-linear models and proportional hazards models were developed to evaluate the association between travel distance and short and long-term outcomes after propensity score weighting. A further analysis was performed to compare patients who traveled a short distance to a low volume center (Local) to patients who traveled farther to a high volume hospital (Travel).

RESULTS

We identified 56,834 patients treated in 1201 hospitals. Hispanic women were 58% and black women 64% less likely than white women to travel to a center in the greatest distance quartile for care. Similarly, Medicaid recipients (vs. commercially insured) were less likely to travel to a quartile four hospital (compared to Q1 of distance traveled). Of all patients, 90-day mortality was significantly lower in patients who traveled farther (Q4 vs. Q1; P < 0.0001). Compared to women in the Local group, patients in the Travel group had a decreased 30-day readmission rate. There was no difference in 30-day, 90-day, or 5-year mortality when comparing the Local to the Travel group.

CONCLUSIONS

Travel distance for ovarian cancer surgery has increased over time. While there may be some short-term benefits in traveling to a regional center for care, there was little difference in long term outcomes based on travel distance.

Big Data vs. Clinical Trials in HPB Surgery

Randomized controlled clinical trials (RCTs) are at the heart of "evidence-based" medicine. However, in surgical practice, RCTs remain uncommon. Conducting well-designed RCTs for surgical procedures is often challenged by inadequate recruitment accrual, blinding, or standardization of the surgical procedure, as well as lack of funding and evolution of the treatment strategy during the many years over which such trials are conducted. In addition, most clinical trials are performed in academic high-volume centers in highly selected patients, which may not necessarily reflect a "real-world" practice setting. Over the past decades, surgical outcomes research using nationwide administrative and registry databases has become increasingly common. Large databases provide easy and inexpensive access to data on a large and diverse patient population at a variety of treatment centers. Furthermore, large database studies provide the opportunity to answer questions that would be impossible or very arduous to answer using RCTs, including questions regarding health policy efficacy, trends in surgical practice, access to health care, impact of hospital volume, and adherence to practice guidelines, as well as research questions regarding rare disease, infrequent surgical outcomes, and specific subpopulation. Prospective data registries may also allow for quality benchmarking and auditing. This review outlines the role, advantages, and limitations of RCTs and large database studies in answering important research questions in surgery.

Representativeness of Black Patients in Cancer Clinical Trials Sponsored by the National Cancer Institute Compared With Pharmaceutical Companies

Background

Many clinical trials supporting new drug applications underrepresent minority patients. Trials conducted by the National Cancer Institute’s National Clinical Trial’s Network (NCTN) have greater outreach to community sites, potentially allowing better representation. We compared the representation of Black patients in pharmaceutical company–sponsored cancer clinical trials with NCTN trials and with the US cancer population.

Methods

We established a large cohort of study publications representing the results of trials that supported new US Food and Drug Administration drug approvals from 2008 to 2018. NCTN trial data were from the SWOG Cancer Research Network. US cancer population rates were estimated using Surveillance, Epidemiology, and End Results survey data. We compared the proportion of Black patients by enrollment year for each cancer type and overall. Tests of proportions were used. All statistical tests were 2-sided.

Results

A total 358 trials (pharmaceutical company–sponsored trials, 85; SWOG trials, 273) comprised of 93 825 patients (pharmaceutical company–sponsored trials, 46 313; SWOG trials, 47 512) for 15 cancer types were analyzed. Overall, the proportion of Black patients was 2.9% for pharmaceutical company–sponsored trials, 9.0% for SWOG trials, and 12.1% for the US cancer population (P < .001 for each pairwise comparison). These findings were generally consistent across individual cancer types.

Conclusions

The poor representation of Black patients in pharmaceutical company–sponsored trials supporting new drug applications could result in the use of new drugs with little data about efficacy or side effects in this key population. Moreover, because pharmaceutical company–sponsored trials test the newest available therapies, limited access to these trials represents a disparity in access to potential breakthrough therapies.

Distance Traveled to Head and Neck Cancer Provider: A Measure of Socioeconomic Status and Access

Objective

Improved head and neck cancer survival has been associated with traveling farther distances for treatment, potentially due to patients seeking higher-quality facilities. This study investigates the role of both facility and confounding patient factors on this relationship.

Study Design

Review of national registry data.

Setting

National Cancer Database.

Subjects and Methods

Adults with head and neck cancer diagnosed from 2004 to 2014 were identified. Overall survival was compared among distance-to-facility quartiles via univariate and multivariate survival models. Then, the analysis was stratified by facility and patient factors, and the association between distance and survival was compared among strata.

Results

Overall survival was worst in the shortest-distance quartile (<5 miles; median survival, 80.7 months; 95% CI, 79.2-82.3), while other distance groups showed similar survival (range, 96.4-104 months). This finding remained in the multivariate model (adjusted hazard ratio vs first distance quartile: 0.88; 95% CI, 0.87-0.89). The association between survival and distance persisted in all subgroups when stratified by facility volume and type (adjusted hazard ratio range, 0.82-0.91), suggesting that facility quality does not fully account for this association. When stratified by income, distance remained statistically associated with survival but with a smaller effect size than that of income.

Conclusion

The association between distance to treating facility and head and neck cancer survival is limited to patients with worse survival outcomes living within 5 miles of the facility and is not fully explained by measures of facility quality.

Travel distance affects rates and reasons for inpatient visits after pancreatectomy

BACKGROUND

Centralization of complex surgical care leads to increased travel distances for patients. We sought to determine if increased travel distance to the index hospital altered inpatient Visit rates following pancreatectomy.

METHODS

Pancreatectomies from 2013-2016 were reviewed retrospectively from a single high-volume institution. Travel distance for 936 patients was determined, and patients were grouped by 50-mile increments. Visits (Observations or Readmissions) and corresponding reasons were gathered.

RESULTS

222 patients (23.7%) had a Visit to any hospital (AH) within 90 days postoperative; 195 (87.8%) were to the index hospital (IH). The <50 miles group had the highest Visit rate to AH (28.6% vs. 17.8% vs. 24.6%; P = 0.008) and the IH (26.9% vs. 15.2% vs. 20.6%; P = 0.002) compared to 50-100 and > 100 miles. This trend was statistically significant for Observations, but not Readmissions. Gastrointestinal (GI) complaints alone led to 20.7% patients requiring Visits to AH at 90-days, mostly in <50miles group for Visits and Observations at AH and IH.

CONCLUSIONS

Patients closest to the IH had the highest Visit and Observation rate following pancreatectomy without affecting Readmission rate, with GI complaints as a driving factor. Inpatient education and outpatient symptom management may reduce repeat hospitalization.

Socioeconomic Differences in Referral to Phase I Cancer Clinical Trials: A Danish Matched Cancer Case-Control Study

PURPOSE

In this nationwide registry study, we investigated socioeconomic and structural patterns in referral to phase I cancer trials in a case-control study design.

METHODS

Personal identification numbers on all Danish patients referred to the Danish Phase I Unit at Rigshospitalet from 2005 to 2016, and a control group matched on age, sex, type of cancer, year of diagnosis, and time from diagnosis to referral ensured individual-level linkage between several registries. We examined the association between nonclinical factors—indicators of socioeconomic position and distance to the Phase I Unit—and referral using a conditional logistic regression analysis adjusted for several clinical factors. Association between nonclinical factors and enrollment once referred was examined with a Cox proportional hazards regression analysis in an historical cohort study design.

RESULTS

Complete data were available for 1,026 (84%) of 1,220 referred patients. Significantly decreased odds for referral were identified for patients with long distance to the Phase I Unit compared with short distance (adjusted odds ratio [OR], 0.35; 95% CI, 0.30 to 0.41), for less education (less than 9 years) compared with more (more than 12 years; OR, 0.69; 95% CI, 0.56 to 0.91), and for belonging to the lowest income quintile compared with the highest (OR, 0.78; 95% CI, 0.62 to 0.97). Medium education (9 to 12 years) compared with more, being outside the workforce compared with being within, and living alone compared with living with a partner were also negatively associated with referral. Among patients referred, 252 enrolled in a trial. Nonclinical factors were not associated with enrollment.

CONCLUSION

On the basis of individual long-term registry data from an unselected cohort, novel anticancer therapies seem to be tested on a socially selected group of patients with cancer.

Associations between access to healthcare, environmental quality, and end-stage renal disease survival time: Proportional-hazards models of over 1,000,000 people over 14 years

Prevalence of end-stage renal disease (ESRD) in the US increased by 74% from 2000 to 2013. To investigate the role of the broader environment on ESRD survival time, we evaluated average distance to the nearest hospital by county (as a surrogate for access to healthcare) and the Environmental Quality Index (EQI), an aggregate measure of ambient environmental quality composed of five domains (air, water, land, built, and sociodemographic), at the county level across the US. Associations between average hospital distance, EQI, and survival time for 1,092,281 people diagnosed with ESRD between 2000 and 2013 (age 18+, without changes in county residence) from the US Renal Data System were evaluated using proportional-hazards models adjusting for gender, race, age at first ESRD service date, BMI, alcohol and tobacco use, and rurality. The models compared the average distance to the nearest hospital (<10, 10-20, >20 miles) and overall EQI percentiles [0-5), [5-20), [20-40), [40-60), [60-80), [80-95), and [95-100], where lower percentiles are interpreted as better EQI. In the full, non-stratified model with both distance and EQI, there was increased survival for patients over 20 miles from a hospital compared to those under 10 miles from a hospital (hazard ratio = 1.14, 95% confidence interval = 1.12-1.15) and no consistent direction of association across EQI strata. In the full model stratified by average hospital distance, under 10 miles from a hospital had increased survival in the worst EQI strata (median survival 3.0 vs. 3.5 years for best vs. worst EQI, respectively), however for people over 20 miles from a hospital, median survival was higher in the best (4.2 years) vs worst (3.4 years) EQI. This association held across different rural/urban categories and age groups. These results demonstrate the importance of considering multiple factors when studying ESRD survival and future efforts should consider additional components of the broader environment.

Effect of proximity to specialty care on outcomes for biliary cancers: a population-based retrospective cohort study

BACKGROUND

The management of biliary cancers is complex and requires a multidisciplinary approach. Because it is unknown how access to specialty care affects resource use and survival in patients with biliary cancer, we conducted a population-based study to understand the needs of these patients and the relation of geography to care delivery and clinical outcomes for biliary cancer in Alberta.

METHODS

All patients with biliary cancer diagnosed in Alberta from Sept. 1, 2001, to Dec. 31, 2015 were included in this population-based retrospective cohort study. Data were extracted from administrative databases and the 2011 Canadian census. Driving time and types of medical services were tracked throughout the patients' clinical course. We categorized proximity to specialty care according to driving time to the nearest specialist. The primary outcome was overall survival. We conducted Cox proportional hazard regression to evaluate the effects of driving time on overall survival and multivariate logistic regression to evaluate the effect of driving time on treatment types and stage at diagnosis.

RESULTS

We identified 1610 patients with biliary cancer; they accounted for 117 381 medical encounters. Patients living 120 minutes or more from the nearest hepatobiliary surgeon and from the nearest cancer centre had significantly decreased survival (hazard ratio [and 95% confidence interval (CI)] 1.27 [1.17-1.37]) and 1.27 [1.14-1.41], respectively). Location of residence was not associated with advanced stage or probability of undergoing surgery or a biliary drainage procedure. Patients who lived 120 minutes or more from a cancer centre were less likely than those who lived less than 120 minutes away to receive chemotherapy (odds ratio 0.51, 95% CI 0.29-0.88). Subgroup analysis showed that the effect of travel time was especially pronounced among those who received only best supportive care and those who had biliary drains.

INTERPRETATION

Geography and accessibility to specialty care affected survival in patients with biliary cancer. Further study is required to understand how patients with biliary drains and those receiving best supportive care are affected by proximity to specialty care. This will aid in the identification of strategies to provide improved care for this subgroup who are particularly affected by geography.

Evaluating the urban-rural paradox: The complicated relationship between distance and the receipt of guideline-concordant care among cervical cancer patients

OBJECTIVE

Urban-rural health disparities are often attributed to the longer distances rural patients travel to receive care. However, a recent study suggests that distance to care may affect urban and rural cancer patients differentially. We examined whether this urban-rural paradox exists among patients with cervical cancer.

METHODS

We identified individuals diagnosed with cervical cancer from 2004 to 2013 using a statewide cancer registry linked to multi-payer, insurance claims. Our primary outcome was receipt of guideline-concordant care: surgery for stages IA1-IB1; external beam radiation therapy (EBRT), concomitant chemotherapy, and brachytherapy for stages IB2-IVA. We estimated risk ratios (RR) using modified Poisson regressions, stratified by urban/rural location, to examine the association between distance to nearest facility and receipt of treatment.

RESULTS

62% of 999 cervical cancer patients received guideline-concordant care. The association between distance and receipt of care differed by type of treatment. In urban areas, cancer patients who lived ≥15 miles from the nearest surgical facility were less likely to receive primary surgical management compared to those <5 miles from the nearest surgical facility (RR: 0.77, 95% CI: 0.60-0.98). In rural areas, patients living ≥15 miles from the nearest brachytherapy facility were more likely to receive treatment compared to those <5 miles from the nearest brachytherapy facility (RR: 1.71, 95% CI: 1.14-2.58). Distance was not associated with the receipt of chemotherapy or EBRT.

CONCLUSIONS

Among cervical cancer patients, there is evidence supporting the urban-rural paradox, i.e., geographic distance to cancer care facilities is not consistently associated with treatment receipt in expected or consistent ways. Healthcare systems must consider the diverse and differential barriers encountered by urban and rural residents to improve access to high quality cancer care.

Travel distance: Impact on stage of presentation and treatment choices in head and neck cancer

OBJECTIVES

The objective was to examine the impact of travel distance on stage of presentation and treatment choices in head and neck squamous cell carcinoma in the rural setting.

METHODS

6029 cases diagnosed from 2002 to 2011 were obtained from the state cancer registry. Travel time was calculated to the nearest academic medical centers, otolaryngologist, and radiation treatment facilities. Multivariate logistic regression was used to examine the association of travel time with stage of presentation as well as the likelihood of appropriate therapy after adjustment for other demographic variables.

RESULTS

Patients in the highest quartile for travel distance to academic centers were 33% more likely to present with early stage disease (p = 0.02), and 42% more likely to receive appropriate surgical therapy for oral cavity cancer. Patients were 70% more likely to receive appropriate surgery if they were farthest from the nearest radiation center (p = 0.03). Proximity to otolaryngology care was not significant.

CONCLUSION

Increased travel distance to academic medical centers is associated with increased likelihood of proper therapy for surgically treated tumors of the head and neck. Impact on these findings on improvements in access to care is discussed.

The effect of distance on short-term outcomes in a regionalized, publicly funded bariatric surgery model

BACKGROUND

While high-volume Centers of Excellence (COE) for bariatric surgery may have improved clinical outcomes, their disparate distribution results in longer travel distances for patients. The purpose of this study was to investigate effect of distance from COE on outcomes and readmission.

METHODS

This was a retrospective study of all adults, aged 18 years or older, receiving bariatric surgery from April 2009 to March 2012 in the province of Ontario. Main outcomes included 30-day complication rates and readmission. Multivariable logistic regression was used to examine the impact of distance from patients' primary residence to their bariatric COE on patient outcomes and readmissions.

RESULTS

Five thousand and seven patients were identified, two-thirds residing within 100 km of a COE with a mean distance of 117.2 km. The majority of patients did not reside within a Local Integrated Health Network (LHIN) that contained a COE, while 18.3% of patients lived in rural areas. Using multivariable adjustment, for every 10 km increase from the COE where surgery was performed, the Odds Ratio (OR) for complications was 1.00 [95% Confidence Interval (CI) 0.99-1.01; P = 0.747]. Additionally, both residing in a LHIN without a COE, OR 1.10 (95% CI 0.87-1.40; P = 0.434), and rural status, OR 0.97 (95% CI 0.77-1.23; P = 0.821) showed no increase in risk of complication. Similarly, further distances did not influence rate of readmission, OR 0.99 (95% CI 0.98-1.00; P = 0.077) nor did rural status OR 1.31 (95% CI 0.97-1.76; P = 0.076).

CONCLUSION

The COE model, where a few centers in high population areas service a large geographic region, is adequate in ensuring patients that live further away receive appropriate short-term care.

Geographic Distribution and Survival Outcomes for Rural Patients With Cancer Treated in Clinical Trials

IMPORTANCE

Studies showing that patients with cancer from rural areas have worse outcomes than their urban counterparts have relied on cancer population data and did not account for differences in access to care. Clinical trial patients receive protocol-directed care by design, so large clinical trial databases are ideal for examining the impact of rural vs urban residency on outcomes.

OBJECTIVE

To compare the geographic distribution and survival outcomes for rural vs urban patients with cancer treated in clinical trials.

DESIGN, SETTING, AND PARTICIPANTS

In this comparative effectiveness retrospective cohort analysis, 36 995 patients from all 50 states enrolled in 44 phase 3 and phase 2/3 SWOG (formerly the Southwest Oncology Group) treatment trials from January 1, 1986, to December 31, 2012, were examined. Seventeen different cancer-specific analysis cohorts were constructed. Data through January 30, 2018, were analyzed.

MAIN OUTCOMES AND MEASURES

Rural vs urban residency was defined using the Rural-Urban Continuum Codes developed by the US Department of Agriculture. Multivariate Cox regression was used to estimate the association of residency with overall survival, progression-free survival, and cancer-specific survival, controlling for major disease-specific prognostic factors and demographic variables and stratifying by study. Different definitions of rurality were examined. The distribution of rural vs urban patients by geographic region was described.

RESULTS

Overall, 27.7% of patients were 65 years or older (range across 17 cohort analyses, 7.8%-74.5%), 40.3% were female in the non-sex-specific analyses (range across 17 cohort analyses, 28.1%-45.9%), and 10.8% were black (range across 17 cohort analyses, 1.9%-22.4%). Overall, 19.4% of patients (7184 of 36 995) were from rural locations. Rural patients were more likely to be aged 65 years or older (rural, 30.7% aged ≥65 years vs urban, 27.0% aged ≥65 years; difference, 3.7%; 95% CI, 2.5%-4.9%; P < .001), were less likely to be black (rural, 5.4% vs urban, 12.1%; difference, 6.7%; 95% CI, 6.1%-7.3%; P < .001), were similar with respect to sex (rural, 40.4% female vs urban, 39.7% female; difference, 0.6%; 95% CI, -1.4% to 2.6%; P = .53), and were well represented within major US geographic regions (West, Midwest, South, and Northeast). Clinical prognostic factors were similar. In multivariable regression, rural patients with adjuvant-stage estrogen receptor-negative and progesterone receptor-negative breast cancer had worse overall survival (hazard ratio, 1.27; 95% CI, 1.06-1.51; P = .008) and cancer-specific survival (hazard ratio, 1.26; 95% CI, 1.04-1.52; P = .02). No other statistically significant differences for overall, progression-free, or cancer-specific survival were found. Results were consistent regardless of the definition of rurality.

CONCLUSIONS AND RELEVANCE

Rural and urban patients with uniform access to cancer care through participation in a SWOG clinical trial had similar outcomes. This finding suggests that improving access to uniform treatment strategies for patients with cancer may help resolve the disparity in cancer outcomes between rural and urban patients.

Distance from Home to Research Center: A Barrier to In-Person Visits but Not Treatment Adherence in a Stroke Trial

BACKGROUND AND PURPOSE

Clinical trials often seek to enroll patients from both urban and rural areas to safeguard the generalizability of results. However, maintaining contact with patients who live away from a recruitment site, including rural areas, can be challenging. In this research we examine the effect of distance between patient and study centers on treatment adherence and retention.

METHODS

Secondary analysis of 2,466 participants in the Insulin Resistance Intervention after Stroke trial who were enrolled from research sites in the United States. Driving distance between the zipcodes of patient's reported place of residence and the study center was calculated. Outcome measures were loss to follow-up, completion of annual in-person visits, adherence to preventive therapy, and adherence to study drug in the first 3 years of participation. Logistic regression models were used to adjust for confounders.

RESULTS

Distance from residence to research center was not associated with loss to follow-up, adherence to study drug, or adherence to preventive therapy (p > 0.05 for each). However, patients who lived farther from the research center (>120 miles), compared to patients who lived closer (<60 miles), were less likely to complete the second annual in-person visit (62 vs. 81%; adjusted OR 0.48; 95% CI 0.31-0.75) and third visit (53 vs. 75%; adjusted OR 0.44; 95% CI 0.29-0.67).

CONCLUSIONS

Distance between patient and study center was an independent predictor of missed in-person visits but not with adherence to study treatment or preventive care.

Geospatial approaches to cancer control and population sciences at the United States cancer centers

PURPOSE

Geospatial, contextual, and multilevel research is integral to cancer prevention and control. NCI-designated Cancer Centers are at the forefront of cancer research; therefore, this paper sought to review the geospatial, contextual, and multilevel research at these cancer centers.

METHODS

Investigators used PubMed and Web of Science to compile geospatial publications from 1971 to February 2016 with cancer center-affiliated authors. Relevant abstracts were pulled and classified by six geospatial approaches, eight geospatial scales, and eight cancer sites.

RESULTS

The searches identified 802 geospatial, contextual, and multilevel publications with authors affiliated at 60 of the 68 NCI-designated Cancer Centers. Over 90% were published after 2000. Five cancer centers accounted for approximately 50% of total publications, and 30 cancer centers accounted for over 85% of total publications. Publications covered all geospatial approaches and scales to varying degrees, and 90% dealt with cancer.

CONCLUSIONS

The NCI-designated Cancer Center network is increasingly pursuing geospatial, contextual, and multilevel cancer research, although many cancer centers still conduct limited to no research in this area. Expanding geospatial efforts to research programs across all cancer centers will further enrich cancer prevention and control. Similar reviews may benefit other domestic and international cancer research institutions.

Medical Travel among Non-Seoul Residents to Seek Prostate Cancer Treatment in Medical Facilities of Seoul

PURPOSE

This study aims to investigate the trend in medical travel by non-Seoul residents to Seoul for treatment of prostate cancer and also to investigate the possible factors affecting the trend.

Materials and Methods

This study represents a retrospective cohort study using data from theKoreanNationalHealth Insurance System from 2002 to 2015. Annual trends were produced for proportions of patients who traveled according to the age group, economic status and types of treatment. Multiple logistic analysiswas used to determine factors affecting surgeries at medical facilities in Seoul among the non-Seoul residents.

RESULTS

A total of 68,543 patients were defined as newly diagnosed prostate cancer cohorts from 2005 to 2014. The proportion of patients who traveled to Seoul for treatment, estimated from cases with prostate cancer-related claims, decreased slightly over 9 years (28.0 at 2005 and 27.0 at 2014, p=0.02). The average proportion of medical travelers seeking radical prostatectomy increased slightly but the increase was not statistically significant (43.1 at 2005 and 45.4 at 2014, p=0.26). Income level and performance ofrobot-assisted radical prostatectomy were significant positive factors for medical travel to medical facilities in Seoul. Combined comorbidity diseases and year undergoing surgery were significant negative factors for medical travel to medical facilities in Seoul.

CONCLUSION

The general trend of patients travelling from outside Seoul for prostate cancer treatment decreased from 2005 to 2014. However, a large proportion of traveling remained irrespective of direct distance from Seoul.

The Effects of Travel Burden on Outcomes After Resection of Extrahepatic Biliary Malignancies: Results from the US Extrahepatic Biliary Consortium

BACKGROUND

Surgical resection of extrahepatic biliary malignancies has been increasingly centralized at high-volume tertiary care centers. While this has improved outcomes overall, increased travel burden has been associated with worse survival for many other malignancies. We hypothesized that longer travel distances are associated with worse outcomes for these patients as well.

STUDY DESIGN

Data was analyzed from the US Extrahepatic Biliary Consortium database, which retrospectively reviewed patients who received resection of extrahepatic biliary malignancies at 10 high-volume centers. Driving distance to the patient's treatment center was measured for 1025 patients. These were divided into four quartiles for analysis: < 24.5, 24.5-57.2, 57.2-117, and < 117 mi. Cox proportional hazard models were then used to measure differences in overall survival.

RESULTS

No difference was found between the groups in severity of disease or post-operative complications. The median overall survival in each quartile was as follows: 1st = 1.91, 2nd = 1.60, 3rd = 1.30, and 4th = 1.39 years. Patients in the 3rd and 4th quartile had a significantly lower median household income (p = 0.0001) and a greater proportion Caucasian race (p = 0.0001). However, neither of these was independently associated with overall survival. The two furthest quartiles were found to have decreased overall survival (HR = 1.39, CI = 1.12-1.73 and HR = 1.3, CI = 1.04-1.62), with quartile 3 remaining significant after multivariate analysis (HR = 1.45, CI = 1.04-2.0, p = 0.028).

CONCLUSIONS

Longer travel distances were associated with decreased overall survival, especially in the 3rd quartile of our study. Patients traveling longer distances also had a lower household income, suggesting that these patients have significant barriers to care.

Examining racial disparities in colon cancer clinical delay in the Colon Cancer Patterns of Care in Chicago study

PURPOSE

We explored a potential racial disparity in clinical delay among non-Hispanic (nH) Black and White colon cancer patients and examined factors that might account for the observed disparity.

METHODS

Patients aged 30-79 years with a newly diagnosed colon cancer from 2010 to 2014 (n = 386) were recruited from a diverse sample of nine public, private, and academic hospitals in and around Chicago. Prolonged clinical delay was defined as 60 days or more or 90 days or more between medical presentation (symptoms or a screen-detected lesion) and treatment initiation (surgery or chemotherapy). Multivariable logistic regression with model-based standardization was used to estimate the disparity as a difference in prevalence of prolonged delay by race.

RESULTS

Prevalence of delay in excess of 60 days was 12 percentage points (95% confidence interval: 2%, 22%) higher among nH Blacks versus Whites after adjusting for age, facility, and county of residence. Travel burden (time and distance traveled from residence to facility) explained roughly one-third of the disparity (33%, P = .05), individual and area-level socioeconomic status measures explained roughly one-half (51%, P = .21), and socioeconomic measures together with travel burden explained roughly four-fifths (79%, P = .08).

CONCLUSIONS

Low socioeconomic status and increased travel burden are barriers to care disproportionately experienced by nH Black colon cancer patients.