Distance traveled for treatment of cervical cancer: who travels the farthest, and does it impact outcome?

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

The interaction between social determinants of health and cervical cancer survival: A systematic review

OBJECTIVE

This systematic review aimed to investigate what are the most relevant social determinants of health (SDH), how they are measured, how they interact among themselves and what is their impact on the outcomes of cervical cancer patients.

METHODS

Search was performed in PubMed, Scopus, Web of Science, Embase, Cochrane, and Google Scholar databases from January 2001 to September 2022. The protocol was registered at PROSPERO (CRD42022346854). We followed the PICOS strategy: Population- Patients treated for cervical cancer in the United States; Intervention - Any SDH; Comparison- None; Outcome measures- Cancer treatment outcomes related to the survival of the patients; Types of studies- Observational studies. Two reviewers extracted the data following the PRISMA guidelines. Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies was used for risk of bias (ROB) assessment.

RESULTS

Twenty-four studies were included (22 had low and 2 had moderate ROB). Most manuscripts analyzed data from public registries (83.3%) and only one SDH (54.17%). The SDH category of Neighborhood was not included in any study. Although the SDH were measured differently across the studies, not being married, receiving treatment at a low-volume hospital, and having public insurance (Medicaid or Medicare) or not being insured was associated with shorter survival of cervical cancer patients in most studies.

CONCLUSIONS

There is a deficit in the number of studies comprehensively assessing the impact of SDH on cervical cancer treatment-related outcomes. Marital status, hospital volume and health insurance status are potential predictors of worse outcome.

The geography of Medicare's hospital value-based purchasing in relation to market demographics

OBJECTIVE

To illustrate the association between the sociodemographic characteristics of hospital markets and the geographic patterns of Medicare hospital value-based purchasing (HVBP) scores.

DATA SOURCES AND STUDY SETTING

This is a secondary analysis of United States hospitals with a HVBP Total Performance Score (TPS) for 2019 in the Centers for Medicare and Medicaid Services (CMS) Hospital Compare database (4/2021 release) and American Community Survey (ACS) data for 2015-2019.

STUDY DESIGN

This is a cross-sectional study using spatial multivariable autoregressive models with HVBP TPS and component domain scores as dependent variables and hospital market demographics as the independent variables.

DATA COLLECTION/EXTRACTION METHODS

We calculated hospital market demographics using ZIP code level data from the ACS, weighted the 2019 CMS inpatient Hospital Service Area file.

PRINCIPAL FINDINGS

Spatial autoregressive models using eight nearest neighbors with diversity index, race and ethnicity distribution, families in poverty, unemployment, and lack of health insurance among residents ages 19-64 years provided the best model fit. Diversity index had the highest statistically significant contribution to lower TPS (ß = -12.79, p < 0.0001), followed by the percent of the population coded to "non-Hispanic, some other race" (ß = -2.59, p < 0.0023), and the percent of families in poverty (ß = -0.26, p < 0.0001). Percent of the population was non-Hispanic American Indian/Alaskan Native (ß = 0.35, p < 0.0001) and percent non-Hispanic Asian (ß = 0.12, p < 0.02071) were associated with higher TPS. Lower predicted TPS was observed in large urban cities throughout the US as well as in states throughout the Southeastern US. Similar geographic patterns were observed for the predicted Patient Safety, Person and Community Engagement, and Efficiency and Cost Reduction domain scores but are not for predicted Clinical Outcomes scores.

CONCLUSIONS

The lower predicted scores seen in cities and in the Southeastern region potentially reflect an inherent-that is, structural-association between market sociodemographics and HVBP scores.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of travel burden on clinical outcomes in lung cancer

PURPOSE

Our study explores the influence of travel burden (measured as travel distance and travel time) on clinical outcomes in lung cancer patients.

METHODS

A retrospective analysis of a single Bulgarian center was performed. A total of 9240 lung cancer patients were included in the study. Travel distance and travel time between patients' city of residence and the treating facility were calculated with an online tool to determine the shortest route for travel using the existing road network. The probability of survival was estimated using the Kaplan-Meier method, and differences in survival in each subgroup were evaluated with a log-rank test.

RESULTS

About one third of all included patients were living in the same city as the treating facility (n = 2746, 29.7%). Overall survival in our patient population was significantly lower with increasing travel distance (p < 0.001, Mantel-Cox log rank) and travel time (p < 0.001, Mantel-Cox log rank). The 1-year OS rate according to travel distance was 27.1% in the same city group, 22.4% in < 50-km group, and 20.5% in ≥ 50-km group (p < 0.001). The corresponding values for the 5-year OS rate were 2.9%, 2.6%, and 1.4% (p < 0.001).

CONCLUSION

In this retrospective study, we discovered significant differences in the overall survival of patients with lung cancer depending on travel distance and travel time to the treating oncological facility. Despite having similar clinical and pathological characteristics (age, sex, stage at initial diagnosis, histologic subtype), the median overall survival was significantly lower in those subgroups of patients with a higher travel burden.

Reimbursement for Orthopaedic Surgeries in Commercial and Public Payors: A Race to the Bottom

INTRODUCTION

The purpose of this study was to compare surgeon professional fee reimbursement and trends from Medicare versus commercial payors for inpatient orthopaedic surgeries: total knee arthroplasty (TKA), total hip arthroplasty (THA), total shoulder arthroplasty (TSA), anterior cervical diskectomy and fusion (ACDF), and posterior lumbar fusion (PLF).

METHODS

Patients undergoing TKA, THA, TSA, single-level ACDF, and single-level PLF from 2010 to 2018 were queried in a commercially insured claims database. Medicare reimbursements and the work relative value unit (wRVU) of each procedure were obtained from the Medicare Physician Fee Schedule. All costs were adjusted for inflation and reported in 2018 real dollars. Compound annual growth rates were calculated to assess the mean growth rate for each procedure. Linear regression was done to assess trends.

RESULTS

On average, payments from Medicare were 57% less than payments from commercial payors. From 2010 to 2018, both Medicare and commercial payments decreased significantly for each surgery (P < 0.05 for all). Compared with inflation-adjusted commercial payments, Medicare payments decreased 2.1 times faster for TKA (-2.1% versus -1.0%), 2.8 times faster for THA (-1.4% versus -0.5%), 1.3 times faster for TSA (-1.0% versus -0.8%), and 1.9 times faster for ACDF (-1.1% versus -0.6%). PLF was the only procedure for which Medicare payments declined slower than commercial payments (-0.6% versus -1.21%). Medicare payments per wRVU markedly declined for TKA (-0.83%), THA (-0.80%), TSA (-0.75%), and ACDF (-1.10%), whereas commercial payments per wRVU for those surgeries showed no notable change. For PLF, there was a notable decrease in both Medicare (-0.63%) and commercial (-1.21%) payments per wRVU.

CONCLUSION

Over the past decade, both commercial and Medicare surgeon payments for commonly performed inpatient orthopaedic surgeries decreased markedly, with Medicare payments decreasing an average of 1.5 times faster than commercial payments. The impact of declining reimbursements on access and quality of care merits additional investigation.

A qualitative study on the impact of long-distance travel for gynecologic cancer care

Background

Women with gynecologic malignancies experience improved clinical outcomes when they are treated by gynecologic oncologists and in high-volume cancer centers. However, geography is a major barrier to high-volume care for patients. This qualitative study was undertaken to identify facilitators and barriers to patients traveling long distances for gynecologic cancer care.

Methods

Semi-structured interviews were conducted with 19 women with gynecologic malignancies traveling >50 miles for treatment at Wake Forest Comprehensive Cancer Center. Eight interviews included caregivers. Four interview domains focused on personal challenges and coping strategies related to accessing cancer care.

Results

Mean distance traveled for care was 87 miles (range: 54-218). Most participants reported that recommendations from physicians, friends, and family motivated travel. 10/19 participants were aware of closer sites for cancer care; 5 had unfavorable experiences elsewhere. Barriers to travel included time, cost, childcare, difficulty navigating, and physical discomfort. Social support was an important facilitator of travel for care; some patients utilized loaned money or vehicles. Participants reported significant energy expenditure scheduling travel, coordinating time off work, and arranging overnight stays near the cancer center. Suggestions for care improvement included travel vouchers, transportation assistance, signage and personnel to help with navigation, and appointments later in the day. Participants supported in-person oncologist outreach to rural areas and appointments via telemedicine; few preferred the current infrastructure.

Conclusion

Patients who travel long distances for gynecologic cancer care encounter significant burdens and rely heavily on social and financial support. Interventions should be developed and evaluated to reduce the burden of long-distance travel and develop efficient methods of outreach, including telemedicine.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

The effect of distance from cancer facility on advanced clinical stage at diagnosis in patients with cervical cancer

PURPOSE/OBJECTIVES

In the United States, cervical cancer remains a significant cause of morbidity and mortality. The effect of distance has a complicated relationship with disease characteristics and outcomes in other cancers. The purpose of this study is to investigate the relationship between distance from cancer facility on clinical stage at diagnosis in women with cervical cancer.

MATERIALS/METHODS

Data were obtained from the National Cancer Database which include patient demographics, disease characteristics, and treatment details. Persons diagnosed with cervical cancer from 2004 to 2015 were included. Subjects were excluded if they had missing information, variant histology, or lived >1,000 miles from their facility resulting in 51,413 persons. Disease was classified as localized (stage 1a-2a) or advanced (stage 2b-4b). Univariate comparisons were performed using analysis of variance and chi-square test. Multivariable logistic regression was used to investigate the effect of distance quartiles on advanced stage while adjusting for other significant variables.

RESULTS

Mean age was 51.0 years, 16.9% of women were black, 14.7% were Hispanic, 45.0% had private insurance, and 10.7% were uninsured. Overall, 50.9% of women presented with advanced disease. In multivariable analysis, greater distance demonstrated a stepwise risk reduction of advanced disease where those in the farthest quartile had odds ratio of 0.73 (p<0.001) relative to the closest. Additionally, age, race, income, and insurance status significantly affected risk of advanced disease.

CONCLUSIONS

Distance from cancer facility resulted in lower risk of advanced stage disease at diagnosis. Additional research could elucidate the nuanced relationship between distance, disease characteristics and outcomes in cervical cancer.

Cervical cancer treatment initiation and survival: The role of residential proximity to cancer care

OBJECTIVE

To examine the role of driving time to cancer care facilities on days to cancer treatment initiation and cause-specific survival for cervical cancer patients.

METHODS

A retrospective cohort analysis of patients diagnosed with invasive cervical cancer during 2001-2016, using South Carolina Central Cancer Registry data linked to vital records. Kaplan-Meier survival curves and Cox proportional hazards models were used to examine the association of driving times to both a patient's nearest and actual cancer treatment initiation facility with cause-specific survival and time to treatment initiation.

RESULTS

Of 2518 eligible patients, median cause-specific survival was 49 months (interquartile, 17-116) and time to cancer treatment initiation was 21 days (interquartile, 0-40). Compared to patients living within 15 min of the nearest cancer provider, those living more than 30 min away were less likely to receive initial treatment at teaching hospitals, Joint Commission accredited facilities, and/or Commission on Cancer accredited facilities. After controlling for patient, clinical, and provider characteristics, no significant associations existed between driving times to the nearest cancer provider and survival/time to treatment. When examining driving times to treatment initiation (rather than simply nearest) provider, patients who traveled farther than 30 min to their actual providers had delayed initiation of cancer treatment (hazard ratio, 0.81; 95% confidence interval, 0.73-0.90), including surgery (0.82; 95% CI, 0.72-0.92) and radiotherapy (0.82, 95% CI, 0.72-0.94). Traveling farther than 30 min to the first treating provider was not associated with worse cause-specific survival.

CONCLUSIONS

For cervical cancer patients, driving time to chosen treatment providers, but not to the nearest cancer care provider, was associated with prolonged time to treatment initiation. Neither was associated with survival.

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.

Patient's travel distance to specialised cancer diagnostics and the association with the general practitioner's diagnostic strategy and satisfaction with the access to diagnostic procedures: an observational study in Denmark

Background

Research indicate that when general practitioners (GPs) refer their patients for specialist care, the patient often has long distance. This study had a twofold aim: in accordance to the GP’s suspicion of cancer, we investigated the association between: 1) cancer patient’s travel distance to the first specialised diagnostic facility and the GP’s diagnostic strategy and 2) cancer patient’s travel distance to the first specialised diagnostic facility and satisfaction with the waiting time and the availability of diagnostic investigations.

Method

This combined questionnaire- and registry-based study included incident cancer patients diagnosed in the last 6 months of 2016 where the GP had been involved in the diagnostic process of the patients prior to their diagnosis of cancer (n = 3455). The patient’s travel distance to the first specialised diagnostic facility was calculated by ArcGIS Network Analyst. The diagnostic strategy, cancer suspicion and the GP’s satisfaction with the waiting times and the available investigations were assessed from GP questionnaires.

Results

When the GP did not suspect cancer or serious illness, an insignificant tendency was seen that longer travel distance to the first specialised diagnostic facility increased the likelihood of the GP using ‘wait-and-see’ approach and ‘medical treatment’ as diagnostic strategies. The GPs of patients with travel distance longer than 49 km to the first specialised diagnostic facility were more likely to report dissatisfaction with the waiting time for requested diagnostic investigations (PR: 1.98, 95% CI: 1.20–3.28).

Conclusion

A insignificant tendency to use ‘wait-and-see’ and ‘medical treatment’ were seen among GPs of patients with long travel distance to the first diagnostic facility when the GP did not suspect cancer or serious illness. Long distance was associated with higher probability of GP dissatisfaction with the waiting time for diagnostic investigations.

Telemedicine and Gynecologic Cancer Care

Patients with gynecologic cancers experience better outcomes when treated by specialists and institutions with experience in their diseases. Unfortunately, high-volume centers tend to be located in densely populated regions, leaving many women with geographic barriers to care. Remote management through telemedicine offers the possibility of decreasing these disparities by extending the reach of specialty expertise and minimizing travel burdens. Telemedicine can assist in diagnosis, treatment planning, preoperative and postoperative follow-up, administration of chemotherapy, provision of palliative care, and surveillance. Telemedical infrastructure requires careful consideration of the needs of relevant stakeholders including patients, caregivers, referring clinicians, specialists, and health system administrators.

Human Papillomavirus Infection and Cervical Cancer: Epidemiology, Screening, and Vaccination-Review of Current Perspectives

Viral infections contribute as a cause of 15–20% of all human cancers. Infection by oncogenic viruses can promote different stages of carcinogenesis. Among many types of HPV, around 15 are linked to cancer. In spite of effective screening methods, cervical cancer continues to be a major public health problem. There are wide differences in cervical cancer incidence and mortality by geographic region. In addition, the age-specific HPV prevalence varies widely across different populations and showed two peaks of HPV positivity in younger and older women. There have been many studies worldwide on the epidemiology of HPV infection and oncogenic properties due to different HPV genotypes. However, there are still many countries where the population-based prevalence has not yet been identified. Moreover, cervical cancer screening strategies are different between countries. Organized cervical screening programs are potentially more effective than opportunistic screening programs. Nevertheless, screening programs have consistently been associated with a reduction in cervical cancer incidence and mortality. Developed countries have achieved such reduced incidence and mortality from cervical cancer over the past 40 years. This is largely due to the implementation of organized cytological screening and vaccination programs. HPV vaccines are very effective at preventing infection and diseases related to the vaccine-specific genotypes in women with no evidence of past or current HPV infection. In spite of the successful implementation of the HPV vaccination program in many countries all over the world, problems related to HPV prevention and treatment of the related diseases will continue to persist in developing and underdeveloped countries.

The Impact of Racial, Geographic, and Socioeconomic Risk Factors on the Development of Advanced-Stage Cervical Cancer

OBJECTIVES

Despite screening, disparities exist in cervical cancer incidence and outcomes. Demographic factors are associated with diagnosis at advanced stage (AS), but less is known about geographic factors. We sought to investigate risk factors for developing AS cervical cancer in Alabama.

MATERIALS AND METHODS

We identified women treated for cervical cancer from 2005 to 2015 at our institution. Stages II-IV were considered AS. ZIP codes were categorized by federal Rural-Urban Commuting Area Codes, and 16 historically underserved counties were categorized as Black Belt rural. Using data from the American College of Obstetricians and Gynecologists, we identified women's health provider locations. We explored associations between stage and multiple factors using logistic regression.

RESULTS

Of 934 patients, 29.2% were black, 52.7% had AS cancer, and 63.4% lived in urban areas. Average distance to nearest American College of Obstetricians and Gynecologists Fellow in urban, rural, and Black Belt rural areas was 5.0, 10.6, and 13.7 miles, respectively. Black race, public insurance and age of older than 65 years were associated with increased risk of AS cancer. Living in a rural area trended toward higher risk but was not significant. When stratified by race, insurance status and age were associated with AS cancer in white women only.

CONCLUSIONS

Living further from a women's health provider or in a rural area was not associated with a higher risk of AS cervical cancer. Black women had a higher risk of AS than white women regardless of age, insurance status, and geography. Disparities in cervical cancer are multifactorial and necessitate further research into socioeconomic, biologic, and systems causes.

The impact of traveling distance and hospital volume on post-surgical outcomes for patients with glioblastoma

BACKGROUND

High-volume hospitals are associated with improved outcomes in glioblastoma (GBM). However, the impact of travel burden to high-volume centers is poorly understood. We examined post-operative outcomes between GBM patients that underwent treatment at local, low-volume hospitals with those that traveled long distances to high-volume hospitals.

METHODS

The National Cancer Database was queried for GBM patients that underwent surgery (2010-2014). We established two cohorts: patients in the lowest quartile of travel distance and volume (Short-travel/Low-Volume: STLV) and patients in the highest quartile of travel and volume (Long-travel/High-Volume: LTHV). Outcomes analyzed were 30-day, 90-day mortality, overall survival, 30-day readmission, and hospital length of stay.

RESULTS

Of 35,529 cases, STLV patients (n = 3414) traveled a median of 3 miles (Interquartile range [IQR] 1.8-4.2) to low-volume centers (5 [3-7] annual cases) and LTHV patients (n = 3808) traveled a median of 62 miles [44.1-111.3] to high-volume centers (48 [42-71]). LTHV patients were younger, had lower Charlson scores, largely received care at academic centers (84.4% vs 11.9%), were less likely to be minorities (8.1% vs 17.1%) or underinsured (6.9% vs 12.1), and were more likely to receive trimodality therapy (75.6% vs 69.2%; all p < 0.001). On adjusted analysis, LTHV predicted improved overall survival (HR 0.87, p = 0.002), decreased 90-day mortality (OR 0.72, p = 0.019), lower 30-day readmission (OR 0.42, p < 0.001), and shorter hospitalizations (RR 0.79, p < 0.001).

CONCLUSIONS

Glioblastoma patients who travel farther to high-volume centers have superior post-operative outcomes compared to patients who receive treatment locally at low-volume centers. Strategies that facilitate patient travel to high-volume hospitals may improve outcomes.

Cervical cancer care in rural Virginia: The impact of distance from an academic medical center on outcomes & the role of non-specialized radiation centers

OBJECTIVE

To determine whether distance to a tertiary care facility affects outcomes for locally advanced cervical cancer and to evaluate the impact of receiving care at non-specialized centers in rural communities.

METHODS

Retrospective, single institution study of patients with locally advanced cervical cancer managed with chemo-radiation from January 1, 2000 to June 1, 2014. Kaplan-Meier survival curves and Cox proportional hazard models were used to compare progression free and overall survival for patients by median distance to the tertiary care facility (<72 miles or >72 miles) and facility where treatment was received.

RESULTS

180 patients met inclusion criteria. There was no difference in PFS or OS between the travel distance cohorts. When compared by location of external beam radiation, patients treated at outside facilities were older (p = 0.02) and significantly more likely to be insured (95.6% versus 71.7%, p < 0.0002). There were more recurrences among patients treated at outside facilities (31.1% versus 15.8%) but this was non-significant (p = 0.24). On multivariable analysis, FIGO stage and insurance status were associated with overall survival. Uninsured patients had a significantly increased hazard risk of death as compared to privately insured patients (HR 3.85 95% CI 3.07-4.64, p = 0.0008).

CONCLUSIONS

Median distance to a tertiary care facility had no significant impact on PFS or OS, however treating facility for radiation may influence recurrence rates. Having non-private insurance or being uninsured is significantly associated with increased risk of death and speaks to the many barriers these patients face.

The Need for Societal Investment to Improve Cervical Cancer Outcomes in Nigeria: A commentary

Although cervical cancer is a preventable cancer with a well-known natural history, it remains a huge burden in developing countries of sub-Saharan Africa where organized cervical cancer screening services are lacking. Developed countries that have invested on providing organized screening programs have made substantial progress in reducing both incidence and mortality due to cervical cancer. Implementing evidence-based interventions such as human papillomavirus (HPV) vaccination of young girls, early detection and treatment of premalignant conditions of the cervix through conventional Pap cytology, HPV screening or visual aided inspection with acetic acid could significantly reduce incidence of new cases at population level. Societal investment for such preventive services and provision of effective treatment for those diagnosed at early stages will yield economic benefits in reducing premature deaths of women at the prime of their productive lives. From a societal perspective, this should be a priority area for national investment towards the achievement of sustainable development in Nigeria and similar settings in Africa.

Effect of cervical cancer education and provider recommendation for screening on screening rates: A systematic review and meta-analysis

Background

Although cervical cancer is largely preventable through screening, detection and treatment of precancerous abnormalities, it remains one of the top causes of cancer-related morbidity and mortality globally.

Objectives

The objective of this systematic review is to understand the evidence of the effect of cervical cancer education compared to control conditions on cervical cancer screening rates in eligible women population at risk of cervical cancer. We also sought to understand the effect of provider recommendations for screening to eligible women on cervical cancer screening (CCS) rates compared to control conditions in eligible women population at risk of cervical cancer.

Methods

We used the PICO (Problem or Population, Interventions, Comparison and Outcome) framework as described in the Cochrane Collaboration Handbook to develop our search strategy. The details of our search strategy has been described in our systematic review protocol published in the International Prospective Register of systematic reviews (PROSPERO). The protocol registration number is CRD42016045605 available at: http://www.crd.york.ac.uk/prospero/display_record.asp?src=trip&ID=CRD42016045605. The search string was used in Pubmed, Embase, Cochrane Systematic Reviews and Cochrane CENTRAL register of controlled trials to retrieve study reports that were screened for inclusion in this review. Our data synthesis and reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). We did a qualitative synthesis of evidence and, where appropriate, individual study effects were pooled in meta-analyses using RevMan 5.3 Review Manager. The Higgins I² was used to assess for heterogeneity in studies pooled together for overall summary effects. We did assessment of risk of bias of individual studies included and assessed risk of publication bias across studies pooled together in meta-analysis by Funnel plot.

Results

Out of 3072 study reports screened, 28 articles were found to be eligible for inclusion in qualitative synthesis (5 of which were included in meta-analysis of educational interventions and 8 combined in meta-analysis of HPV self-sampling interventions), while 45 were excluded for various reasons. The use of theory-based educational interventions significantly increased CCS rates by more than double (OR, 2.46, 95% CI: 1.88, 3.21). Additionally, offering women the option of self-sampling for Human Papillomavirus (HPV) testing increased CCS rates by nearly 2-fold (OR = 1.71, 95% CI: 1.32, 2.22). We also found that invitation letters alone (or with a follow up phone contact), making an appointment, and sending reminders to patients who are due or overdue for screening had a significant effect on improving participation and CCS rates in populations at risk.

Conclusion

Our findings supports the implementation of theory-based cervical cancer educational interventions to increase women’s participation in cervical cancer screening programs, particularly when targeting communities with low literacy levels. Additionally, cervical cancer screening programs should consider the option of offering women the opportunity for self-sample collection particularly when such women have not responded to previous screening invitation or reminder letters for Pap smear collection as a method of screening.

Health Service Accessibility and Risk in Cervical Cancer Prevention: Comparing Rural Versus Nonrural Residence in New Mexico

PURPOSE

Multiple intrapersonal and structural barriers, including geography, may prevent women from engaging in cervical cancer preventive care such as screening, diagnostic colposcopy, and excisional precancer treatment procedures. Geographic accessibility, stratified by rural and nonrural areas, to necessary services across the cervical cancer continuum of preventive care is largely unknown.

METHODS

Health care facility data for New Mexico (2010-2012) was provided by the New Mexico Human Papillomavirus Pap Registry (NMHPVPR), the first population-based statewide cervical cancer screening registry in the United States. Travel distance and time between the population-weighted census tract centroid to the nearest facility providing screening, diagnostic, and excisional treatment services were examined using proximity analysis by rural and nonrural census tracts. Mann-Whitney test (P < .05) was used to determine if differences were significant and Cohen's r to measure effect.

FINDINGS

Across all cervical cancer preventive health care services and years, women who resided in rural areas had a significantly greater geographic accessibility burden when compared to nonrural areas (4.4 km vs 2.5 km and 4.9 minutes vs 3.0 minutes for screening; 9.9 km vs 4.2 km and 10.4 minutes vs 4.9 minutes for colposcopy; and 14.8 km vs 6.6 km and 14.4 minutes vs 7.4 minutes for precancer treatment services, all P < .001).

CONCLUSION

Improvements in cervical cancer prevention should address the potential benefits of providing the full spectrum of screening, diagnostic and precancer treatment services within individual facilities. Accessibility, assessments distinguishing rural and nonrural areas are essential when monitoring and recommending changes to service infrastructures (eg, mobile versus brick and mortar).

Impact of Distance to Treatment Center on Care Seeking for Pelvic Floor Disorders

OBJECTIVE

The aim of this study was to evaluate the impact of distance from residence to treatment center on access to care for female pelvic floor disorders at an academic institution.

METHODS

A retrospective cross-sectional study was conducted of women seen for pelvic floor disorders at an academic institution from 2008 to 2014. Patient characteristics were extracted from charts. Geographical and US census data was obtained from public records and used to calculate distance from patient residence to physician office. Statistical analysis was performed using R Software (Version 0.98.1102) and Microsoft Excel (Version 14.4.7). Statistical significance was defined as a 2-sided P value of less than 0.05, and the χ test was used to determine associations of categorical variables.

RESULTS

A total of 3015 patients were included in the analysis. The mean distance traveled was 93 miles. Thirty percent of patients traveled more than 50 miles. Many patients (43%) reported having the symptoms for more than 2 years. Patients who traveled farther were significantly more likely to be white, English-speaking, and with pelvic organ prolapse as primary complaint. These patients were more likely to plan surgery at the first visit than patients who traveled less far (29% vs 14%). Patients who traveled farther were also more likely to live in counties with a low percentage of persons older than 65 years and low percentage of female inhabitants.

CONCLUSIONS

Women who travel the farthest for treatment of pelvic floor disorders have experienced the symptoms for longer duration and are more willing to plan surgery at presentation. These women also come from counties with fewer elderly women, suggesting future outreach care should focus on similar geographic areas.

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

OBJECTIVES

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

DESIGN

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

SETTINGS

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

RESULTS

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

CONCLUSIONS

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

Travel distance to prenatal care and high blood pressure during pregnancy

OBJECTIVE

To assess whether poor geographic accessibility to prenatal care, as indicated by long distance trips to prenatal care, produced high blood pressure (HPB) during pregnancy.

METHODS

Using the 2007 Los Angeles Mommy and Baby Study for women without hypertension prior to pregnancy (n = 3405), we compared self-reported HBP by travel distance to prenatal care controlling for age, race/ethnicity, marital status, education, household income, weight status, and physical activity.

RESULTS

Results of the multilevel logistic regression shows traveling more than 50 mi to prenatal care is associated with an increased odds for having HPB during pregnancy (odds ratio [OR] = 2.867, 95% confidence interval [CI] = 1.079,7.613), as compared with a travel distance shorter than 5 mi. Traveling 5-14 mi (OR = 0.917, 95% CI = 0.715-1.176), 15-29 mi (OR = 0.955, 95% CI = 0.634-1.438), or 30-50 mi (OR = 1.101, 95% CI = 0.485-2.499) were not significantly associated with more risk of HBP during pregnancy.

CONCLUSION

To our knowledge, no previous studies have examined the association between poor geographic accessibility to care and the possible harms of travel burdens for pregnant women. Future research that replicates these findings can assist in developing recommendations for pregnant women and health-care accessibility.

Distance from a Comprehensive Cancer Center: A proxy for poor cervical cancer outcomes?

OBJECTIVE

To evaluate the potential relationship between outcomes in cervical cancer patients based on distance from our Comprehensive Cancer Center (CCC).

METHODS

A retrospective cohort study of cervical cancer patients was performed. Abstracted data included: demographics, clinicopathologic variables, treatment, and survival. Analyses both by quartiles and distance <100 and ≥100miles from our institution were performed. Data were analyzed using SAS version 9.2.

RESULTS

390 patients living a median distance of 58.1miles (range 1.2-571miles) from our CCC were identified. Patients were generally white (n=249), non-smokers (n=226), with Stage IB disease (n=222), squamous histology (n=295) and underwent primary surgical therapy (n=229). Patients were divided into both quartiles as well as two strata: <100 and ≥100miles for comparison. Progression-free survival (PFS) and overall survival (OS) favored patients living closer to our center with a lower median OS for patients living ≥100miles (65.4vs. 99.4months; p=0.040). Cox proportional hazard modeling noted that advanced stage was predictive of inferior PFS and OS, while other clinical covariates including age, BMI, race, smoking status and histology had a variable impact on outcomes and distance >100miles was associated with a higher risk of death (hazard ratio [HR]=1.68, 95% confidence interval [CI] 1.11-2.54).

CONCLUSION

Overall survival for patients living >100miles from our CCC was worse when compared to patients in closer proximity. Outreach efforts and utilization of navigators may help decrease the impact of geographic and racial disparities on outcomes.

Is the closest facility the one actually used? An assessment of travel time estimation based on mammography facilities

Background

Characterizing geographic access depends on a broad range of methods available to researchers and the healthcare context to which the method is applied. Globally, travel time is one frequently used measure of geographic access with known limitations associated with data availability. Specifically, due to lack of available utilization data, many travel time studies assume that patients use the closest facility. To examine this assumption, an example using mammography screening data, which is considered a geographically abundant health care service in the United States, is explored. This work makes an important methodological contribution to measuring access—which is a critical component of health care planning and equity almost everywhere.

Method

We analyzed one mammogram from each of 646,553 women participating in the US based Breast Cancer Surveillance Consortium for years 2005–2012. We geocoded each record to street level address data in order to calculate travel time to the closest and to the actually used mammography facility. Travel time between the closest and the actual facility used was explored by woman-level and facility characteristics.

Results

Only 35 % of women in the study population used their closest facility, but nearly three-quarters of women not using their closest facility used a facility within 5 min of the closest facility. Individuals that by-passed the closest facility tended to live in an urban core, within higher income neighborhoods, or in areas where the average travel times to work was longer. Those living in small towns or isolated rural areas had longer closer and actual median drive times.

Conclusion

Since the majority of US women accessed a facility within a few minutes of their closest facility this suggests that distance to the closest facility may serve as an adequate proxy for utilization studies of geographically abundant services like mammography in areas where the transportation networks are well established.

Influence of the distance between home and the hospital on patients with surgically resected non-small-cell lung cancer

OBJECTIVES

There have been no previous reports examining how the travel distance affects the outcomes of non-small-cell lung cancer (NSCLC) patients. In this study, we examined the influence of the distance from home to the hospital on patients with NSCLC who underwent surgical resection.

METHODS

From 2006 to 2011, 607 consecutive patients with NSCLC who had undergone pulmonary resection were enrolled. The patients were divided into three groups according to the distance from their home to the hospital: 0 < 10, 10-30 and >30 km. We analysed the short-term and long-term outcomes according to the group.

RESULTS

Two hundred and ninety-six patients lived less than 10 km from the hospital, 111 patients lived 10-30 km and 200 patients lived more than 30 km. There were no differences in the demographics, including age, European Cooperative Oncology Group performance status, histological type, surgical procedure and pathological stage, between the three groups. The mean postoperative hospital stay was as follows: 13.9 days in the <10 km group, 13.3 days in the 10-30 km group and 14.3 days in the >30 km group (P = 0.04). There were no significant differences in the median length of follow-up (50, 47, 43 months, P = 0.24), disease-free survival (DFS) (5-year DFS, 68.1, 68.2 and 70.1%, P = 0.89) or overall survival (OS) (5-year OS, 80.6, 78.8 and 79.4%, P = 0.99) between the three groups.

CONCLUSIONS

The distance between home and the hospital was not found to influence the long-term outcomes of the patients with surgically resected NSCLC. Therefore, the travel distance should not represent a contraindication to surgical resection and postoperative therapy for NSCLC.