Disparities in the Use of Adjuvant External Beam Radiation Therapy in Node-positive Cervical Cancer Patients Following Hysterectomy

The Relationship Between Travel Distance for Treatment and Outcomes in Patients Undergoing Radiation Therapy: A Systematic Review

Purpose

Although recent technological advances in radiation therapy have significantly improved treatment outcomes, the global distribution of radiation therapy is unbalanced, making access especially challenging for patients in rural or low-resource settings because of travel burden. This systematic review aimed to explore the impact of geographic distance to treatment facilities on survival, as well as other treatment outcomes, among patients undergoing radiation therapy.

Methods and Materials

A search of four databases (PubMed, Embase, CINAHL, and Web of Science) was performed. Studies were included if they were primary literature, published between May 2000 and May 2023, and reported the travel distances for patients undergoing radiation therapy for malignant conditions and its influence on survival outcomes. Studies were excluded if they did not report primary outcomes, were published before 2000, or were non-English.

Results

After review, 23 studies were included. Most studies were conducted in the United States, with cervical cancer being the most frequently studied disease site. Data suggested that travel distances vary significantly, with patients often traveling a median distance of 20 miles to radiation therapy. Among the studies, 5 reported a negative impact on overall survival, often associating greater travel with nonadherence to recommended care. Other survival metrics, including progression-free survival and all-cause mortality, were also assessed, demonstrating similar variability in relation to travel distance. Conversely, seven studies found no significant impact on overall survival, and four suggested a positive impact on overall survival, with improved outcomes at centers with higher case volumes. Some data also revealed an inverse correlation between travel distance and the likelihood of receiving guideline-concordant radiation therapy.

Conclusions

The impact of travel distance on radiation therapy outcomes is varied. Our findings underscore the challenges posed by travel in accessing radiation therapy and the disparities affecting particular patient demographic groups. Additional studies are needed to thoroughly assess the impacts of geographic disparities and to identify effective measures to address these challenges.

Addressing transportation barriers in oncology: existing programs and new solutions

Transportation is an underrecognized, but modifiable barrier to accessing cancer care, especially for clinical trials. Clinicians, insurers, and health systems can screen patients for transportation needs and link them to transportation. Direct transportation services (i.e., ride-sharing, insurance-provided transportation) have high rates of patient satisfaction and visit completion. Patient financial reimbursements provide necessary funds to counteract the effects of transportation barriers, which can lead to higher trial enrollment, especially for low socioeconomic status and racially and ethnically diverse patients. Expanding transportation interventions to more cancer patients, and addressing knowledge, service, and system gaps, can help more patients access needed cancer care.

Association of social vulnerability on survival, treatment, and presentation in oral cavity cancer

OBJECTIVE

This study utilized a population database to investigate how social environments are associated with outcomes including stage at diagnosis, multimodal treatment, and disease-specific survival for oral cavity squamous cell carcinomas.

METHODS

Retrospective analysis of adults with oral cavity squamous cell carcinoma between 2007 and 2016 from the Surveillance, Epidemiology, End Results (SEER) registry was performed. The CDC's social vulnerability index (SVI) was used to characterize social vulnerability at the county level. Predictors of disease-specific survival, stage at diagnosis, and use of multimodal therapy were identified using Cox regression and logistic regression.

RESULTS

Our analysis included 17 043 patients. On adjusted models, patients in the highest SVI quartile (most social vulnerability) exhibited worse disease-specific survival compared to the lowest quartile (HR 1.24, 95% CI 1.12-1.37, p < 0.001), and were more likely to be diagnosed at later stages (OR 1.24, 95% CI 1.11-1.38, p < 0.001) and less likely to receive multimodal therapy (OR 0.84, 95% CI 0.77-0.99, p = 0.037).

CONCLUSION

High social vulnerability was associated with worse disease-specific survival and disease presentation in oral cavity cancer patients.

Geographical Health District and Distance Traveled Influence on Clinical Status at Admission of Patients with Gestational Trophoblastic Disease

OBJECTIVE

 To assess the potential relationship of clinical status upon admission and distance traveled from geographical health district in women with gestational trophoblastic disease (GTD).

METHODS

 This is a cross-sectional study including women with GTD from the 17 health districts from the São Paulo state (I-XVII), Brazil, referred to the Botucatu Trophoblastic Disease Center (specialized center, district VI), between 1990 and 2018. At admission, hydatidiform mole was assessed according to the risk score system of Berkowitz et al. Gestational trophoblastic neoplasia was evaluated using the International Federation of Gynecology and Obstetrics / World Health Organization (FIGO/WHO) staging/risk score. Data on demographics, clinical status and distance traveled were collected. Multiple regression analyses were performed.

RESULTS

 This study included 366 women (335 hydatidiform mole, 31 gestational trophoblastic neoplasia). The clinical status at admission and distance traveled significantly differed between the specialized center district and other districts. Patients referred from health districts IX (β = 2.38 [0.87-3.88], p = 0.002) and XVI (β = 0.78 [0.02-1.55], p = 0.045) had higher hydatidiform mole scores than those from the specialized center district. Gestational trophoblastic neoplasia patients from district XVI showed a 3.32 increase in FIGO risk scores compared with those from the specialized center area (β = 3.32, 95% CI = 0.78-5.87, p = 0.010). Distance traveled by patients from districts IX (200km) and XVI (203.5km) was significantly longer than that traveled by patients from the specialized center district (76km).

CONCLUSION

 Patients from health districts outside the specialized center area had higher risk scores for both hydatidiform mole and gestational trophoblastic neoplasia at admission. Long distances (>80 km) seemed to adversely influence gestational trophoblastic disease clinical status at admission, indicating barriers to accessing specialized centers.

Sociodemographic characteristics and cervical cancer survival in different regions of the United States: a National Cancer Database study

OBJECTIVE

To determine how sociodemographic factors impact cervical cancer survival in different geographic locations in the USA.

METHODS

A retrospective cohort of patients with cervical cancer from January 1, 2004 to December 31, 2015 in the National Cancer Database (NCDB) was identified. Tumor characteristics as well as race, income, insurance type, and treating facility types were compared among nine geographic regions. χ2 tests and Cox regression were used to compare differences between regions; p values <0.05 were considered significant.

RESULTS

A total of 48 787 patients were included. Survival was inferior in seven of nine regions for underinsured patients. In six regions survival was inferior for Medicaid and Medicare patients, respectively: Middle Atlantic: hazard ratio (HR) 1.25 and 1.22; South Atlantic: HR 1.41 and HR 1.22; East North Central: HR 1.36 and HR 1.25; East South Central: HR 1.37 and HR 1.25; West North Central: HR 1.67 and HR 1.42; West South Central: HR 1.44 and HR 1.46. In the Pacific region survival was inferior for Medicare patients (HR 1.35) but not inferior for Medicaid patients. Being uninsured was associated with worse survival in the South Atlantic (HR 1.23), East North Central (HR 1.23), East South Central (HR 1.56), and West South Central (HR 1.31) regions. Annual income level under $38 000 was associated with worse survival in the Middle Atlantic (HR 1.24), South Atlantic (HR 1.35), and East North Central (HR 1.49) regions. Lastly, when compared with academic research institutions, comprehensive community cancer centers had significantly worse survival in four of the nine regions.

CONCLUSIONS

Cervical cancer mortality is higher for women with a low income, underinsured (Medicaid or Medicare) or uninsured status, and decreased access to academic institutions in most US regions. An increase in cervical cancer mortality was associated with underinsured or uninsured populations in regions mainly located in the South and Midwest.

Looking at cancer health disparities in gynecologic oncology in 2020

PURPOSE OF REVIEW

To summarize the most recent evidence on gynecologic cancer disparities and to describe studies investigating the social determinants of health and receipt of evidence-based care and potential interventions to address inequities in care.

RECENT FINDINGS

Significant disparities in disease-specific survival by race/ethnicity, socioeconomic status, and payer status have persisted in women with gynecologic cancers. Compared with white women, black women have an increased likelihood of disease-specific mortality for endometrial cancer and are less likely to receive guideline-adherent care for ovarian cancer. The Covid-19 pandemic has brought significant attention to the structural barriers that contribute to persistent health disparities and how community-based partnerships with a focus on policy interventions are needed for equitable gynecologic cancer outcomes.

SUMMARY

In this review, we discuss structural barriers contributing to racial inequities, the role of Medicaid payer status and receipt of quality cancer care, gender, and racial workforce diversity, and community-based partnerships to create evidence-based interventions to address disparities.