Is distance to provider a barrier to care for medicaid patients with breast, colorectal, or lung cancer?

Travel-time barriers to specialized cancer care for adolescents and young adults with acute lymphoblastic leukemia

BACKGROUND

Prior studies demonstrate that 20%-50% of adolescents and young adults (age 15-39 years) with acute lymphoblastic leukemia (ALL) receive care at specialty cancer centers, yet a survival benefit has been observed for patients at these sites. Our objective was to identify patients at risk of severe geographic barriers to specialty cancer center-level care.

METHODS

We used data from the North American Association of Central Cancer Registries Cancer in North America database to identify adolescent and young adult ALL patients diagnosed between 2004 and 2016 across 43 US states. We calculated driving distance and travel time from counties where participants lived to the closest specialty cancer center sites. We then used multivariable logistic regression models to examine the relationship between sociodemographic characteristics of counties where adolescent and young adult ALL patients resided and the need to travel more than 1 hour to obtain care at a specialty cancer center.

RESULTS

Among 11 813 adolescent and young adult ALL patients, 43.4% were aged 25-39 years, 65.5% were male, 32.9% were Hispanic, and 28.7% had public insurance. We found 23.6% of adolescent and young adult ALL patients from 60.8% of included US counties would be required to travel more than 1 hour one way to access a specialty cancer center. Multivariable models demonstrate that patients living in counties that are nonmetropolitan, with lower levels of educational attainment, with higher income inequality, with lower internet access, located in primary care physician shortage areas, and with fewer hospitals providing chemotherapy services are more likely to travel more than 1 hour to access a specialty cancer center.

CONCLUSIONS

Substantial travel-related barriers exist to accessing care at specialty cancer centers across the United States, particularly for patients living in areas with greater concentrations of historically marginalized communities.

Income Disparities in Survival and Receipt of Neoadjuvant Chemotherapy and Pelvic Lymph Node Dissection for Muscle-Invasive Bladder Cancer

Background: Muscle-invasive bladder cancer (MIBC) is a potentially fatal disease, especially in the setting of locally advanced or node-positive disease. Adverse outcomes have also primarily been associated with low-income status, as has been reported in other cancers. While the adoption of neoadjuvant cisplatin-based chemotherapy (NAC) followed by radical cystectomy (RC) and pelvic lymph node dissection (PLND) has improved outcomes, these standard-of-care treatments may be underutilized in lower-income patients. We sought to investigate the economic disparities in NAC and PLND receipt and survival outcomes in MIBC. Methods: Utilizing the National Cancer Database, a retrospective cohort analysis of cT2-4N0-3M0 BCa patients with urothelial histology who underwent RC was conducted. The impact of income level on overall survival (OS) and the likelihood of receiving NAC and PLND was evaluated. Results: A total of 25,823 patients were included. This study found that lower-income patients were less likely to receive NAC and adequate PLND (≥15 LNs). Moreover, lower-income patients exhibited worse OS (Median OS 55.9 months vs. 68.2 months, p < 0.001). Our findings also demonstrated that higher income, treatment at academic facilities, and recent years of diagnosis were associated with an increased likelihood of receiving standard-of-care modalities and improved survival. Conclusions: Even after controlling for clinicodemographic variables, income independently influenced the receipt of standard MIBC treatments and survival. Our findings identify an opportunity to improve the quality of care for lower-income MIBC patients through concerted efforts to regionalize multi-modal urologic oncology care.

Patient Travel Distance to Neurologist Visits

BACKGROUND AND OBJECTIVES

The density of neurologists within a given geographic region varies greatly across the United States. We aimed to measure patient travel distance and travel time to neurologist visits, across neurologic conditions and subspecialties. Our secondary goal was to identify factors associated with long-distance travel for neurologic care.

METHODS

We performed a cross-sectional analysis using a 2018 Medicare sample of patients with at least 1 outpatient neurologist visit. Long-distance travel was defined as driving distance ≥50 miles 1-way to the visit. Travel time was measured as driving time in minutes. Multilevel generalized linear mixed models with logistic link function, which accounted for clustering of patients within hospital referral region and allowed modeling of region-specific random effects, were used to determine the association of patient and regional characteristics with long-distance travel.

RESULTS

We identified 563,216 Medicare beneficiaries with a neurologist visit in 2018. Of them, 96,213 (17%) traveled long distance for care. The median driving distance and time were 81.3 (interquartile range [IQR]: 59.9-144.2) miles and 90 (IQR: 69-149) minutes for patients with long-distance travel compared with 13.2 (IQR: 6.5-23) miles and 22 (IQR: 14-33) minutes for patients without long-distance travel. Comparing across neurologic conditions, long-distance travel was most common for nervous system cancer care (39.6%), amyotrophic lateral sclerosis [ALS] (32.1%), and MS (22.8%). Many factors were associated with long-distance travel, most notably low neurologist density (first quintile: OR 3.04 [95% CI 2.41-3.83] vs fifth quintile), rural setting (4.89 [4.79-4.99]), long-distance travel to primary care physician visit (3.6 [3.51-3.69]), and visits for ALS and nervous system cancer care (3.41 [3.14-3.69] and 5.27 [4.72-5.89], respectively). Nearly one-third of patients bypassed the nearest neurologist by 20+ miles, and 7.3% of patients crossed state lines for neurologist care.

DISCUSSION

We found that nearly 1 in 5 Medicare beneficiaries who saw a neurologist traveled ≥50 miles 1-way for care, and travel burden was most common for lower-prevalence neurologic conditions that required coordinated multidisciplinary care. Important potentially addressable predictors of long-distance travel were low neurologist density and rural location, suggesting interventions to improve access to care such as telemedicine or neurologic subspecialist support to local neurologists. Future work should evaluate differences in clinical outcomes between patients with long-distance travel and those without.

Organization of Cancer Specialists in US Physician Practices and Health Systems

PURPOSE

To describe the supply of cancer specialists, the organization of cancer care within versus outside of health systems, and the distance to multispecialty cancer centers.

METHODS

Using the 2018 Health Systems and Provider Database from the National Bureau of Economic Research and 2018 Medicare data, we identified 46,341 unique physicians providing cancer care. We stratified physicians by discipline (adult/pediatric medical oncologists, radiation oncologists, surgical/gynecologic oncologists, other surgeons performing cancer surgeries, or palliative care physicians), system type (National Cancer Institute [NCI] Cancer Center system, non-NCI academic system, nonacademic system, or nonsystem/independent practice), practice size, and composition (single disciplinary oncology, multidisciplinary oncology, or multispecialty). We computed the density of cancer specialists by county and calculated distances to the nearest NCI Cancer Center.

RESULTS

More than half of all cancer specialists (57.8%) practiced in health systems, but 55.0% of cancer-related visits occurred in independent practices. Most system-based physicians were in large practices with more than 100 physicians, while those in independent practices were in smaller practices. Practices in NCI Cancer Center systems (95.2%), non-NCI academic systems (95.0%), and nonacademic systems (94.3%) were primarily multispecialty, while fewer independent practices (44.8%) were. Cancer specialist density was sparse in many rural areas, where the median travel distance to an NCI Cancer Center was 98.7 miles. Distances to NCI Cancer Centers were shorter for individuals living in high-income areas than in low-income areas, even for individuals in suburban and urban areas.

CONCLUSION

Although many cancer specialists practiced in multispecialty health systems, many also worked in smaller-sized independent practices where most patients were treated. Access to cancer specialists and cancer centers was limited in many areas, particularly in rural and low-income areas.

Health Equity in Patients Receiving Durvalumab for Unresectable Stage III Non-Small Cell Lung Cancer in the US Veterans Health Administration

BACKGROUND

Real-world evidence is limited regarding the relationship between race and use of durvalumab, an immunotherapy approved for use in adults with unresectable stage III non-small cell lung cancer (NSCLC) post-chemoradiotherapy (CRT). This study aimed to evaluate if durvalumab treatment patterns differed by race in patients with unresectable stage III NSCLC in a Veterans Health Administration (VHA) population.

MATERIALS AND METHODS

This was a retrospective analysis of White and Black adults with unresectable stage III NSCLC treated with durvalumab presenting to any VHA facility in the US from January 1, 2017, to June 30, 2020. Data captured included baseline characteristics and durvalumab treatment patterns, including treatment initiation delay (TID), interruption (TI), and discontinuation (TD); defined as CRT completion to durvalumab initiation greater than 42 days, greater than 28 days between durvalumab infusions, and more than 28 days from the last durvalumab dose with no new durvalumab restarts, respectively. The number of doses, duration of therapy, and adverse events were also collected.

RESULTS

A total of 924 patients were included in this study (White = 726; Black = 198). Race was not a significant factor in a multivariate logistic regression model for TID (OR, 1.39; 95% CI, 0.81-2.37), TI (OR, 1.58; 95% CI, 0.90-2.76), or TD (OR, 0.84; 95% CI, 0.50-1.38). There were also no significant differences in median (interquartile range [IQR]) number of doses (White: 15 [7-24], Black: 18 [7-25]; P = .25) or median (IQR) duration of therapy (White: 8.7 months [2.9-11.8], Black: 9.8 months [3.6-12.0]; P = .08), although Black patients were less likely to experience an immune-related adverse event (28% vs. 36%, P = .03) and less likely to experience pneumonitis (7% vs. 14%, P < .01).

CONCLUSION

Race was not found to be linked with TID, TI, or TD in this real-world study of patients with unresectable stage III NSCLC treated with durvalumab at the VHA.

"Healthcare should be the same for everyone": perceived inequities in therapeutic trajectories of adult patients with lung cancer in Chile, a qualitative study

Background

Globally, it has been reported that different social determinants of health affect health outcomes in lung cancer (LC). Research on the therapeutic trajectories of patients (TTP) is a novel field for identifying barriers and facilitators in health. The objective of this study was to reveal perceived differences in TTP with LC in Chile according to selected social determinants of health (SDH) and the experiences of patients, health professionals, and civil society leaders.

Methods

This is a qualitative paradigm, one case-study design. Online semi-structured interviews were conducted with patients with LC, health professionals, and civil society leaders. The strategies for the recruitment process included social networks, civil society organizations, health professionals, and the snowball technique. A thematic analysis was carried out.

Results

Selected SDH impact LC's TTP in Chile, particularly concerning health system access, health services, information, and patient navigation experiences. The analysis of the experiences of the participants allowed us to identify barriers related to the selected SDH in three stages of the TTP: initiation, examinations, and diagnosis and treatment. Individuals with limited education, those residing outside the capital, women, and those in the public health system encountered more barriers throughout their TTP.

Discussion

Study findings suggest that being a woman with low education, from the public health system, and not from the capital might represent one of the most powerful intersections for experiencing barriers to effective healthcare in LC in Chile. It is necessary to monitor the TTP from an SDH perspective to guarantee the rights of access, opportunity, quality, and financial protection.

Geographic proximity to immunization providers and vaccine series completion among children ages 0-24 months

OBJECTIVES

In the U.S., vaccination coverage is lower in rural versus urban areas. Spatial accessibility to immunization services has been a suspected risk factor for undervaccination in rural children. Our objective was to identify whether geographic factors, including driving distance to immunization providers, were associated with completion of recommended childhood vaccinations.

METHODS

We analyzed records from Montana's immunization information system for children born 2015-2017. Using geolocated address data, we calculated distance in road miles from children's residences to the nearest immunization provider. A multivariable log-linked binomial mixed model was used to identify factors associated with completion of the combined 7-vaccine series by age 24 months.

RESULTS

Among 26,085 children, 16,503 (63.3%) completed the combined 7-vaccine series by age 24 months. Distance to the nearest immunization provider ranged from 0 to 81.0 miles (median = 1.7; IQR = 3.2), with the majority (92.1%) of children living within 10 miles of a provider. Long distances (>10 miles) to providers had modest associations with not completing the combined 7-vaccine series (adjusted prevalence ratio [aPR]: 0.97, 95% confidence interval [CI]: 0.96-0.99). After adjustment for other factors, children living in rural areas (measured by rural-urban commuting area) were significantly less likely to have completed the combined 7-vaccine series than children in metropolitan areas (aPR: 0.88, 95% CI: 0.85-0.92).

CONCLUSIONS

Long travel distances do not appear to be a major barrier to childhood vaccination in Montana. Other challenges, including limited resources for clinic-based strategies to promote timely vaccination and parental vaccine hesitancy, may have greater influence on rural childhood vaccination.

Insurance-Based Disparities in Congenital Cardiac Operations in the Era of the Affordable Care Act

A body of literature has previously highlighted the impact of health insurance on observed disparities in congenital cardiac operations. With aims of improving access to healthcare for all patients, the Affordable Care Act (ACA) expanded Medicaid coverage to nearly all eligible children in 2010. Therefore, the present population-based study aimed to examine the association of Medicaid coverage with clinical and financial outcomes in the era the ACA. Records for pediatric patients (≤ 18 years) who underwent congenital cardiac operations were abstracted from the 2010-2018 Nationwide Readmissions Database. Operations were stratified using the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Category. Multivariable regression models were developed to evaluate the association of insurance status on index mortality, 30-day readmissions, care fragmentation, and cumulative costs. Of an estimated 132,745 hospitalizations for congenital cardiac surgery from 2010 to 2018, 74,925 (56.4%) were insured by Medicaid. The proportion of Medicaid patients increased from 57.6 to 60.8% during the study period. On adjusted analysis, patients with Medicaid insurance were at an increased odds of mortality (1.35, 95%CI: 1.13-1.60) and 30-day unplanned readmission (1.12, 95%CI: 1.01-1.25), experienced longer lengths of stay (+ 6.5 days, 95%CI 3.7-9.3), and exhibited higher cumulative hospitalization costs (+ $21,600, 95%CI: $11,500-31,700). The total hospitalization cost-burden for patients with Medicaid and private insurance were $12.6 billion and $8.06 billion, respectively. Medicaid patients exhibited increased mortality, readmissions, care fragmentation, and costs compared to those with private insurance. Our results of outcome variation by insurance status indicate the necessity of policy changes to attempt to approach equality in surgical out comes for this high-risk cohort. Baseline characteristics, trends, and outcomes by insurance status over the ACA rollout period 2010-2018.

The Association of Socioeconomic Factors and Well-Differentiated Thyroid Cancer

INTRODUCTION

Well-differentiated thyroid cancer (WDTC) is the most common thyroid malignancy, and the worldwide incidence is increasing. Early stage disease is curable with surgery. We hypothesized that patients who live at greater distances from health care institutions or have complicating socioeconomic barriers may present with more advanced diseases and have worse outcomes.

METHODS

The National Cancer Database (NCDB) was used to identify patients who were diagnosed with WDTC between 2004 and 2018. Race, ethnicity, insurance status, income status, and distance from residence to health care clinic of diagnosis (great circle distance [GCD]) were analyzed with respect to the severity of disease at presentation (stage) and outcomes. Binary logistic regression and Cox regression were used to determine associations between socioeconomic variables and tumor stage or survival.

RESULTS

The Hispanic (OR: 1.49, CI: 1.45-1.54, P < 0.001) and Asian (OR: 1.49, CI: 1.43-1.55, P < 0.001) populations had higher odds of developing an advanced disease when compared to the White population separately. Patients without insurance displayed higher odds of developing an advanced disease at diagnosis compared to those with insurance (OR: 1.39, CI: 1.31-1.47, P < 0.001). Adjusted-Cox regression analysis of survival revealed that Black patients had detrimental survival outcomes when compared to White patients (HR: 1.24, P < 0.001), and patients with private insurance had improved survival outcomes when compared to those without insurance (HR: 0.58, P < 0.001).

CONCLUSIONS

Hispanic and Asian patients were found to be more likely to present with an advanced disease but also displayed greater overall survival when compared to the White population. The Black population, patients without insurance, and patients with lower income status exhibited worse survival outcomes.

The Relation Between Travel Distance and Overall Survival for HPV-Associated Cancers in a High-Burden State

Purpose

To assess the association between travel distance to an academic health system and overall survival for patients with human papillomavirus (HPV)-associated cancers.

Methods

Using hospital-based cancer registry data from 2005-2019, we calculated unidirectional travel distance from each patient's geocoded address to our academic health center through network analysis. We categorized distance as short (<25 miles), intermediate (25-74.9 miles), or long (≥75 miles). The primary outcome was time from the date of initial diagnosis to the date of death or last contact. We used multivariable Cox proportional hazards regression to evaluate the association between travel distance and overall survival. We also estimated the adjusted observed 5-year survival rate.

Results

Patients with HPV-associated cancers traveling distances that were intermediate (hazard ratio [HR], 1.23; 95% CI, 1.06-1.43) and long (HR, 1.15; 95% CI, 1.01-1.32) had a higher hazard of death than the short-distance group. The adjusted 5-year observed survival rates for HPV-associated cancers were lowest in the intermediate-distance group (60.4%) compared with the long-(62.6%) and short-distance (66.2%) groups.

Conclusions

Our findings indicate that travel distance to an academic health center was associated with overall survival for patients with HPV-associated cancers, reflecting the importance of considering travel burden in improving patient outcomes.

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.

Disparities in geographic access to medical oncologists

OBJECTIVE

The objective of this study is to identify disparities in geographic access to medical oncologists at the time of diagnosis.

DATA SOURCES/STUDY SETTING

2014-2016 Pennsylvania Cancer Registry (PCR), 2019 CMS Base Provider Enrollment File (BPEF), 2018 CMS Physician Compare, 2010 Rural-Urban Commuting Area Codes (RUCA), and 2015 Area Deprivation Index (ADI).

STUDY DESIGN

Spatial regressions were used to estimate associations between geographic access to medical oncologists, measured with an enhanced two-step floating catchment area measure, and demographic characteristics.

DATA COLLECTION/EXTRACTION METHODS

Medical oncologists were identified in the 2019 CMS BPEF and merged with the 2018 CMS Physician Compare. Provider addresses were converted to longitude-latitude using OpenCage Geocoder. Newly diagnosed cancer patients in each census tract were identified in the 2014-2016 PCR. Census tracts were classified based on rurality and socioeconomic status using the 2010 RUCA Codes and the 2015 ADI.

PRINCIPAL FINDINGS

Large towns and rural areas were associated with spatial access ratios (SPARs) that were 6.29 lower (95% CI -16.14 to 3.57) and 14.76 lower (95% CI -25.14 to -4.37) respectively relative to urban areas. Being in the fourth ADI quartile (highest disadvantage) was associated with a 12.41 lower SPAR (95% CI -19.50 to -5.33) relative to the first quartile. The observed difference in a census tract's non-White population from the 25th (1.3%) to the 75th percentile (13.7%) was associated with a 13.64 higher SPAR (Coefficient = 1.10, 95% CI 11.89 to 15.29; p < 0.01), roughly equivalent to the disadvantage associated with living in the fourth ADI quartile, where non-White populations are concentrated.

CONCLUSIONS

Rurality and low socioeconomic status were associated with lower geographic access to oncologists. The negative association between area deprivation and geographic access is of similar magnitude to the positive association between larger non-White populations and access. Policies aimed at increasing geographic access to care should be cognizant of both rurality and socioeconomic status.

The Road Less Traveled: Transportation Barriers to Cancer Care Delivery in the Rural Patient Population

Patients with cancer residing in geographically rural areas experience lower rates of preventative screening, more advanced disease at presentation, and higher mortality rates compared with urban populations. Although multiple factors contribute, access to transportation has been proposed as a critical barrier affecting timeliness and quality of health care delivery in rural populations. Patients from geographically rural regions may face a variety of transportation barriers, including lack of public transportation, limited access to private vehicles, and increased travel distance to specialized oncologic care. A search using PubMed was conducted to identify articles pertaining to transportation barriers to cancer care and tested interventions in rural patient populations. Studies demonstrate that transportation barriers are associated with delayed follow-up after abnormal screening test results, decreased access to specialized oncology care, and lower rates of receipt of guideline-concordant treatment. Low clinical trial enrollment and variability in survivorship care are also linked to transportation barriers in rural patient populations. Given the demonstrated impact of transportation access on equitable cancer care delivery, several interventions have been tested. Telehealth visits and outreach clinics appear to reduce patient travel burden and increase access to specialized care, and patient navigation programs are effective in connecting patients with local resources, such as free or subsidized nonemergency medical transportation. To ensure equal access to high-quality cancer care and reduce geographic disparities, the design and implementation of tailored, multilevel interventions to address transportation barriers affecting rural communities is critical.

Geographic Access to High-Volume Care Providers and Survival in Patients with Bone Sarcomas: Nationwide Patterns in the United States

BACKGROUND

Clinical practice guidelines recommend centralized care for patients with bone sarcoma. However, the relationship between the distance that patients travel to obtain care, institutional treatment volume, and survival is unknown.

METHODS

We used the National Cancer Database to examine associations between travel distance and survival among 8,432 patients with bone sarcoma diagnosed from 2004 to 2015. Associations were identified using multivariable Cox regression analyses that controlled for sociodemographic, clinical, and hospital-level factors; subgroup analyses stratified patients by histological diagnosis, tumor stage, and pediatric or adult status.

RESULTS

Mortality risk was lower among patients who traveled ≥50 miles (≥80.5 km) than among patients who traveled ≤10 miles (≤16.1 km) (hazard ratio [HR], 0.69 [95% confidence interval (CI), 0.63 to 0.76]). Among hospital-level factors, facility volume independently affected survival: mortality risk was lower among patients at high-volume facilities (≥20 cases per year) than at low-volume facilities (≤5 cases per year), with an HR of 0.72 (95% CI, 0.66 to 0.80). The proportion of patients who received care at high-volume facilities varied by distance traveled (p < 0.001); it was highest among patients who traveled ≥50 miles (53%) and lower among those who traveled 11 to 49 miles (17.7 to 78.9 km) (32%) or ≤10 miles (18%). Patients who traveled ≥50 miles to a high-volume facility had a lower risk of mortality (HR, 0.65 [95% CI, 0.56 to 0.77]) than those who traveled ≤10 miles to a low-volume facility. In subgroup analyses, this association was evident among patients with all 3 major histological subtypes; those with stage-I, II, and IV tumors; and adults.

CONCLUSIONS

This national study showed that greater travel burden was associated with higher survival rates in adults, a finding attributable to patients traveling to receive care at high-volume facilities. Despite the burdens associated with travel, modification of referral pathways to specialized centers may improve survival for patients with bone sarcoma.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Assessment of Quality of Life in Patients of Mastectomy With Chemotherapy

Background: Breast cancer is one of the most common cancers in India as well as the world. In India, 48% of patients with breast cancer are below 50 years of age, indicating a huge age shift in the last 25 years. Breast cancer in an early age group increased the five-year survival rate and increased life expectancy has created a large group of breast cancer survivors who battle scars of disease as well as treatment. Standardized multimodal treatment is either not affordable or not available, so the breast conservation surgery rate is very low. Mastectomy is still the most common modality of treatment, particularly in rural areas. In addition to psychological, social, economic, and family barriers to obtaining the diagnosis and treatment needed, economic barriers like the cost of travel and lost wages are important factors influencing the choice of treatment. Mastectomy represents a deep burden for women with breast cancer. Very little is known about the psychological consequences over time and the quality of life (QOL) of women so treated, with or without breast reconstruction. Conflicting literature is available regarding QOL after mastectomy. The survival rates of breast cancer are increasing. They are reported in the range of 80-90% in western countries while in the range of 60% in the Indian scenario. With high survival rates in cancer, the focus needs to shift from mortality indicators to QOL indicators. The QOL that these survivors experience is a comparatively newer domain of study. Though there are many instruments for assessment of breast QOL of breast cancer patients with numerous studies in western literature, QOL studies in Indian rural population are far less, and urban studies cannot be extrapolated because the method of treatment differs, with breast conservation being more common in urban population. Hence, the present study is undertaken to assess the QOL in patients who have undergone mastectomy and ongoing chemotherapy or completed chemotherapy recently using a relatively newer instrument, i.e., the Quality of Life Instrument - Breast Cancer Patient version.

Methodology: The present study was a cross-sectional study conducted at a rural tertiary healthcare center on mastectomy patients attending the outpatient department and admitted to the hospital. All the female patients of carcinoma breast treated with a mastectomy who were receiving the adjuvant or neoadjuvant chemotherapy or were within one year of completion of chemotherapy irrespective of age at diagnosis were included in this study. The assessment was performed by interview method using a questionnaire.

Results: In this study, 44.90% of the patients were <50 years old and 55.10% were more than 50 years old. Among them, 28.57% were illiterate while only 20.41% had graduate education. The majority (61.22%) were from the low socioeconomic class. Majority of women presented in the late stages of the disease, with 61.22% presenting in the third stage and only three (6.12%) presenting in the first stage of the disease. The overall global QOL score was 49 ± 2.6 and fear was assessed. Patients scored better in the physical, psychological, social, and spiritual domains, with an average score of more than 50. The worst scores were observed among distress of illness or treatment.

Conclusions: The present study shows that the average QOL scores in rural Indian women after mastectomy are moderate. Global scores and other indicators show moderate QOL.

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.

Regional variation in the survival of patients with a soft-tissue sarcoma of the extremity and trunk wall under a centralized care system : what has been the impact of national policies in the UK?

AIMS

While a centralized system for the care of patients with a sarcoma has been advocated for decades, regional variations in survival remain unclear. The aim of this study was to investigate regional variations in survival and the impact of national policies in patients with a soft-tissue sarcoma (STS) in the UK.

METHODS

The study included 1,775 patients with a STS who were referred to a tertiary sarcoma centre. The geographical variations in survival were evaluated according to the periods before and after the issue of guidance by the National Institute for Health and Care Excellence (NICE) in 2006 and the relevant evolution of regional management.

RESULTS

There had been a significant difference in survival between patients referred from the North East, North West, East Midlands, West Midlands, South West, and Wales in the pre-NICE era (five-year disease-specific survival (DSS); South West, 74% vs North East, 47% (p = 0.045) or West Midlands, 54% (p = 0.049)), which was most evident for patients with a high-grade STS. However, this variation disappeared in the post-NICE era, in which the overall DSS for high-grade STS improved from 47% to 68% at five years (p < 0.001). Variation in the size of the tumour closely correlated with the variation in DSS, and the overall size of the tumour and incidence of metastasis at the time of diagnosis also decreased after the national policies were issued.

CONCLUSION

The survival of patients with a STS improved and regional variation corrected after the introduction of national policies, as a result of a decreasing size of tumour and incidence of metastasis at the time of diagnosis, particularly in patients with a high-grade STS. This highlights the positive impact of national guidelines on regional variation in the presentation, management, and outcome in patients with a STS. Cite this article: Bone Joint J 2021;103-B(9):1541-1549.

Implications of Regionalizing Care in the Developing World: Impact of Distance to Referral Center on Compliance to Biopsy Recommendations in a Brazilian Prostate Cancer Screening Cohort

Given growing specialization in medical care, optimal care may require regionalization, which may create access barriers. We tested this within a large prostate cancer (PC) screening program in Brazil. In 2004-2007, Barretos Cancer Hospital prospectively screened men for PC throughout rural Brazil. Men with abnormal screen were referred for follow-up and possible biopsy. We tested the link between distance from screening site to Barretos Cancer Hospital and risk of noncompliance with showing up for biopsy, PC on biopsy and, among those with PC, PC grade using crude and multivariable logistic regression analysis. Among 10,467 men undergoing initial screen, median distance was 257 km (IQR: 135-718 km). On crude and multivariable analyses, farther distance was significantly linked with biopsy noncompliance (OR/100 km: 0.83, P < 0.001). Among men who lived within 150 km of Barretos Cancer Hospital, distance was unrelated to compliance (OR/100 km: 1.09, P=0.87). There was no association between distance and PC risk or PC grade (all P > 0.25). In Brazil, where distances to referral centers can be large, greater distance was related to reduced biopsy compliance in a PC screening cohort. Among men who lived within 150 km, distance was unrelated to compliance. Care regionalization may reduce access when distances are large.

Greater travel distance to specialized facilities is associated with higher survival for patients with soft-tissue sarcoma: US nationwide patterns

Purpose

The survival impact of geographic access to specialized care remains unknown in patients with soft-tissue sarcomas (STS). This study aimed to clarify the association between the patient travel distance and survival outcome and investigate the factors lying behind it.

Methods

A total of 34 528 patients with STS registered in the National Cancer Data Base, diagnosed from 2004–2016, were investigated.

Results

Tumor stage correlated with travel distance: patients with metastatic disease stayed closer to home. However, the type of facility showed greatest variation: 37.0%, 51.0%, 73.5%, and 75.9% of patients with ≤10 miles, 10.1–50 miles, 50.1–100 miles, and >100 miles, respectively (P<0.001), had a sarcoma care at academic/research centers. On a multivariable analysis, reduced mortality risk was associated with longer (versus short) travel distance (>100 miles: HR = 0.877; P = 0.001) and management at academic/research (versus non-academic/research) centers (HR = 0.857; P<0.001). The greatest divergence was seen in patients traveling very long distance (>100 miles) to an academic/research center, with a 26.9% survival benefit (HR = 0.731; P<0.001), compared with those traveling short distance (≤10 miles; 95.4% living in metropolitan area) to a non-academic/research center. There was no significant correlation between travel distance and survival in patients who had care at academic/research centers, whereas a survival benefit of management at academic/research centers was observed in every group of travel distance, regardless of tumor stage.

Conclusions

This national study demonstrated that increased travel distance was associated with superior survival, attributable to a higher proportion of patients receiving sarcoma care at distant academic/research centers. These data support centralized care for STS. Overcoming referral and travel barriers may enable more patients to be treated at specialized centers and may further improve survival rates for patients with STS, even when it imposes an increased travel burden.

[Sociodemographic and clinical factors associated with time to treatment for colorectal cancer in Brazil, 2006-2015]

Colorectal cancer presents high incidence worldwide, but case-fatality is higher in developing countries. The study's objective was to analyze sociodemographic and clinical factors associated with delay in the initiation of treatment for colorectal cancer in hospitals in Brazil. This is a retrospective study of data from hospital cancer registries in Brazil from 2006 to 2015. The target variable is time to initiation of treatment for colorectal cancer and possible associations between sociodemographic variables and clinical factors. The analysis revealed disparities in time to treatment according to sociodemographic strata and geographic regions. Higher odds of treatment delay were associated with age over 50 years, black race/color (OR = 1.50; 95%CI: 1.21-1.84) and brown race/color (OR = 1.28; 95%CI: 1.17-1.42), illiteracy or low schooling (OR = 1.50; 95%CI: 1.19-1.90), and treatment in a city far from the patient's residence (OR = 1.25; 95%CI: 1.14-1.38). For rectal cancer, higher odds of treatment delay were associated with age over 50 years, black (OR = 1.44; 95%CI: 1.20-1.72) or brown race/color (OR = 1.29; 95%CI: 1.19-1.39), illiteracy or low schooling (OR = 1.71; 95%CI: 1.40-2.09), and treatment in a city far from the patient's residence (OR = 1.35; 95%CI: 1.25-1.47). In conclusion, greater attention should be given to reducing the time to initiation of treatment in underprivileged regions and in social strata identified with barriers to timely treatment access.

The influence of facility volume on patient treatments and survival outcomes in nasopharyngeal carcinoma

BACKGROUND

This study evaluates the influence of facility case-volume on nasopharyngeal carcinoma (NPC) treatments and overall survival (OS).

METHODS

The 2004-2015 National Cancer Database was queried for patients with NPC receiving definitive treatment.

RESULTS

A total of 8260 patients (5-year OS: 63.4%) were included. The 1114 unique facilities were categorized into 854 low-volume (treating 1-8 patients), 200 intermediate-volume (treating 9-23 patients), and 60 high-volume (treating 24-187 patients) facilities. Kaplan-Meier log-rank analysis demonstrated significantly improved OS with high-volume facilities (p < 0.001). On cox proportional-hazard multivariate regression after adjusting for age, sex, income, insurance, comorbidity index, histology, AJCC clinical stage, and treatment type, high-volume facilities were associated with lower mortality risk than low-volume (HR = 0.865, p = 0.019) and intermediate-volume facilities (HR = 0.916, p = 0.004). Propensity score matching analysis confirmed this association (p < 0.001).

CONCLUSION

Higher facility volume was an independent predictor of improved OS in NPC, suggesting a possible survival benefit of referrals to high-volume medical centers.

Going the distance: Associations between adverse birth outcomes and obstetric provider distances for adolescent pregnancies in South Carolina

PURPOSE

Distances to obstetric care providers are a persistent concern, especially for rural pregnant adolescents. Births to adolescents are disproportionately affected by adverse birth outcomes (ABOs), yet little is known regarding how driving distances may impact ABOs. This study examines the association between driving distances to obstetric providers and ABOs among adolescent mothers in South Carolina.

METHODS

This retrospective cross-sectional study derived ZIP Code-level birth statistics from mothers aged 10-19 in South Carolina using 2013-2017 statewide birth certificate data. ABOs included preterm birth and/or low birthweight. Provider distance was calculated between an obstetric provider's ZIP Code tabulated area (ZCTA) centroid and a maternal resident's ZCTA centroid. Descriptive statistics and weighted generalized linear regression were conducted.

RESULTS

Mean provider distances to obstetric providers were similar between urban (11.76 miles) and rural adolescent mothers (12.04 miles). An increase in provider distance, on average, was associated with a decrease in ABO rates (-0.79, p= .0038); however, rural-urban differences were found. Living in a rural ZCTA was associated with a decrease in ABOs (4.94%, p = .0043). Urban ZCTAs showed a U-shaped association with provider distance, with ABO rates decreasing until approximately 17 miles away from a provider and then increasing.

CONCLUSION

Rural adolescent mothers with greater distance to providers had lower ABO rates, while, in urban ZCTAs, provider distance over 17 miles was associated with higher ABO rates. Understanding what mitigates the effects of driving distance on ABOs in rural South Carolina would help inform future policy planning in underserved communities.

Perceived barriers to seeking cancer care in the Gaza Strip: a cross-sectional study

BACKGROUND

Several factors might contribute to the delay to get cancer care including poor cancer awareness and having barriers to seeking help. This study described these barriers in Gaza and their association with recalling and recognizing cancer symptoms and risk factors.

METHODS

A cross-sectional study was conducted in Gaza. Adult visitors (≥18 years) to the largest three governmental hospitals and adolescent students (15-17 years) from ten high schools were recruited. A translated-into-Arabic version of the validated Cancer Awareness Measure (CAM) was used to collect data in face-to-face interviews. It described demographic data, barriers to seek cancer care as well as recall and recognition of cancer symptoms and risk factors. Responses were compared between adults and adolescents as well as males and females.

RESULTS

Of 3033 participants approached, 2886 completed the CAM (response rate= 95.2%). Among them, 1429 (49.5%) were adult (702 females; 49.1%) and 1457 (50.5%) were adolescent (781 females; 53.6%). The mean age± standard deviation (SD) of adult and adolescent participants was 33.7±11.7 years and 16.3±0.8 years, respectively. Emotional barriers were the most common barriers with 'feeling scared' as the most reported barrier (n=1512, 52.4%). Females and adolescents were more likely to report 'feeling scared' as a barrier than males and adults, respectively. Higher recall scores for cancer symptoms were associated with lower likelihood to report 'embarrassment', 'worry about wasting doctor's time' and 'difficulty arranging transport'. This was also seen for recalling risk factors, where 'embarrassment' and all practical barriers showed significant inverse associations with higher scores. In addition, greater recognition scores of cancer risk factors were inversely associated with reporting 'embarrassment' and 'feeling scared'.

CONCLUSIONS

The most commonly perceived barriers to seeking cancer care were 'feeling scared' and 'feeling worried about what the doctor might find', followed by practical and service barriers. Females and adolescents were more likely to report 'fear' as a barrier to seek medical advice. Having a higher recall of cancer symptoms and risk factors was inversely associated with reporting most barriers. To improve patient outcome, early presentation can be facilitated by targeting barriers specific to population groups.

The Outcome of Unscreened Population in Colorectal Cancer: The Impact of Sex and Other Determinants on Cancer Stage

BACKGROUND

In Saudi Arabia, there is no population-based colorectal cancer (CRC) screening, and more than two-thirds of patients are diagnosed with a late stage. We assessed the association between sex and distant metastasis CRC and hypothesize that females, younger age, non-married, and patients with colon cancer would present with metastatic tumors.

PATIENTS AND METHODS

The retrospective cohort study used data from the Ministry of National Guard Cancer Registry. Logistic regression was used to assess the association between sex and metastatic CRC adjusting for patient covariates. In a sensitivity analysis, the association between sex and late-stage CRC was evaluated.

RESULTS

A total of 1016 CRC patients met the eligibility criteria, with 37.59% of females and 30.26% of males diagnosed with metastatic CRC. After adjusting for marital status, grade, and morphology, females were 20% more likely than males to present with a metastatic tumor 1.20 (95% CI, 1.04-1.38).

CONCLUSION

Although the entire Saudi population would benefit from CRC screening, women may benefit the most from targeted screening.

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.

Travel burden and clinical presentation of retinoblastoma: analysis of 1024 patients from 43 African countries and 518 patients from 40 European countries

BACKGROUND

The travel distance from home to a treatment centre, which may impact the stage at diagnosis, has not been investigated for retinoblastoma, the most common childhood eye cancer. We aimed to investigate the travel burden and its impact on clinical presentation in a large sample of patients with retinoblastoma from Africa and Europe.

METHODS

A cross-sectional analysis including 518 treatment-naïve patients with retinoblastoma residing in 40 European countries and 1024 treatment-naïve patients with retinoblastoma residing in 43 African countries.

RESULTS

Capture rate was 42.2% of expected patients from Africa and 108.8% from Europe. African patients were older (95% CI -12.4 to -5.4, p<0.001), had fewer cases of familial retinoblastoma (95% CI 2.0 to 5.3, p<0.001) and presented with more advanced disease (95% CI 6.0 to 9.8, p<0.001); 43.4% and 15.4% of Africans had extraocular retinoblastoma and distant metastasis at the time of diagnosis, respectively, compared to 2.9% and 1.0% of the Europeans. To reach a retinoblastoma centre, European patients travelled 421.8 km compared to Africans who travelled 185.7 km (p<0.001). On regression analysis, lower-national income level, African residence and older age (p<0.001), but not travel distance (p=0.19), were risk factors for advanced disease.

CONCLUSIONS

Fewer than half the expected number of patients with retinoblastoma presented to African referral centres in 2017, suggesting poor awareness or other barriers to access. Despite the relatively shorter distance travelled by African patients, they presented with later-stage disease. Health education about retinoblastoma is needed for carers and health workers in Africa in order to increase capture rate and promote early referral.

Comparing Pathways to Diagnosis and Treatment for Rural and Urban Patients With Colorectal or Breast Cancer: A Qualitative Study

PURPOSE

Colorectal cancer patients living in rural areas have poorer outcomes than urban counterparts, but such disparities are not found for breast cancer. Although time to care may contribute to rural-urban disparities, few studies examine patient experiences to understand how and why delays may occur. We compared rural and urban patient experiences of pathways to colorectal or breast cancer diagnosis and treatment in Victoria, Australia.

METHODS

Semistructured telephone interviews were conducted with 43 patients (49% colorectal; 60% rural, median 7 months postdiagnosis). A framework analysis was applied using the Model of Pathways to Treatment.

FINDINGS

Rural and urban patients expressed similar attitudes and reasons for prolonged symptom appraisal and help-seeking triggers. However, some rural patients reported long waiting times to see a Primary Care Practitioner (PCP) and perceived greater gatekeeping to diagnostic services. Patient perceptions of the urgency of PCP referral could impact behavior, such as waiting longer to book appointments. Colorectal cancer patients reported more variable types of symptoms, interpretation, and coping strategies, as well as diverse presentation routes and reduced sense of urgency, compared to breast cancer patients. Waiting time for colonoscopy could be long, particularly in the public health system, but mammograms were quickly arranged.

CONCLUSIONS

Pathway variation was more evident by cancer type than residential location. However, access to primary care and diagnostic services for rural patients with colorectal cancer may be important policy targets. Future research should investigate the impact of diagnostic service accessibility on PCP referral behavior to further understand rural-urban disparities.

Lung Cancer Staging at Diagnosis in the Veterans Health Administration: Is Rurality an Influencing Factor? A Cross-Sectional Study

Purpose

To evaluate the association between rurality and lung cancer stage at diagnosis.

Methods:

We conducted a cross-sectional study using Veterans Health Administration (VHA) data to identify veterans newly diagnosed with lung cancer between October 1, 2011 and September 30, 2015. We defined rurality, based on place of residence, using Rural-Urban Commuting Area (RUCA) codes with the subcategories of urban, large rural, small rural, and isolated. We used multivariable logistic regression models to determine associations between rurality and stage at diagnosis, adjusting for sociodemographic and clinical characteristics. We also analyzed data using the RUCA code for patients’ assigned primary care sites and driving distances to primary care clinics and medical centers.

Findings:

We identified 4,220 veterans with small cell lung cancer (SCLC) and 25,978 with non-small cell lung cancer (NSCLC). Large rural residence (compared to urban) was associated with early-stage diagnosis of NSCLC (OR = 1.12; 95% CI: 1.00–1.24) and SCLC (OR = 1.73; 95% CI: 1.18–1.55). However, the finding was significant only in the southern and western regions of the country. White race, female sex, chronic lung disease, higher comorbidity, receiving primary care, being a former tobacco user, and more recent year of diagnosis were also associated with diagnosing early-stage NSCLC. Driving distance to medical centers was inversely associated with late-stage NSCLC diagnoses, particularly for large rural areas.

Conclusions:

We did not find clear associations between rurality and lung cancer stage at diagnosis. These findings highlight the complex relationship between rurality and lung cancer within VHA, suggesting access to care cannot be fully captured by current rurality codes.

Lung Cancer Surgical Regionalization Disproportionately Worsens Travel Distance for Rural Patients

PURPOSE

Major cancer surgeries have regionalized to fewer and higher-volume hospitals, with the goal of improving the quality of surgical care. However, regionalization may have negative effects on geographic access to care. We hypothesize that lung cancer patients have been traveling further for surgery over time as regionalization has occurred, and this increased travel has primarily impacted rural patients.

METHODS

A North Carolina all-payer state discharge database was used to capture discharges from 2005 to 2015 for patients undergoing lung cancer resection. Changes in patterns of care over time in high-volume centers (HVC) were examined. Adjusted patient straight-line travel distance was estimated over time and stratified by rural-urban location.

FINDINGS

The number of hospitals performing lung cancer resections decreased from 49 to 31 over the study period (P = .0006), and the proportion of patients receiving care at HVC increased from 23% to 44% (P < .0001). Rural patient travel distance increased over time by 8.5 miles (95% CI: 0.56-17.10, P = .048), from 45.1 to 53.6 miles. There was no change in urban patient travel distance. The difference in adjusted travel distance between rural and urban patients nearly doubled from 2005 to 2015 (9.6 to 17.9 miles,P < .0001).

CONCLUSION

In North Carolina, lung cancer surgical regionalization occurred over the study period and was accompanied by increases in travel distance for rural patients only. Further work is needed to determine the effects of greater travel distance on patterns of cancer care for rural patients.

Survival analysis of colorectal cancer patients in a Thai hospital-based cancer registry

Background: The study aimed to assess the overall and stage-specific colorectal cancer (CRC) survival and to identify the prognostic factors for survival among Thai patients.Research design and methods: The retrospective data of CRC patients from a university hospital-based cancer registry from 2001 to 2014 were used to estimate five-year overall survival (OS). Kaplan-Meier method and log-rank tests were used to assess the differences in five-year OS by age at diagnosis, diagnostic period, tumor site, stage at diagnosis and treatment modalities. A multivariate Cox's proportional hazard model was used to identify independent prognostic factors for the OS.Results: A total of 1,507 (48%) colon and 1,648 (52%) rectal cancer patients were included. Five-year OS for CRC patients was 44%. It differed significantly by stage, age group, and treatment received. Stage at diagnosis, age group, diagnostic period, receiving surgical and chemotherapy treatments were prognostic factors for OS.Conclusions: An increasing trend in the number of CRC patients mostly at stage III and IV was found. Our results emphasized that an improvement in CRC survival could be achieved through the adoption of advanced cancer therapies, as well as improved access to quality diagnosis and timely treatment.

Impact of chemotherapy schedule modification on breast cancer patients: a single-centre retrospective study

Background Nonconformity to chemotherapy schedules is common in clinical practice. Multiple clinical studies have established the negative prognostic impact of dose delay on survival outcome. Objective This study investigated the prevalence and reason for chemotherapy schedule modifications of breast cancer patients. This study also investigated the impact of schedule modifications on overall survival (OS). Setting This retrospective cohort study was done among breast cancer patient receiving chemotherapy from 2013 to 2017 and patients were followed until 31 Dec 2018. Methods Medical records of patients with cancer were reviewed. Female patients over eighteen years old were included, with primary carcinoma of the breast, who received anthracycline or taxane based chemotherapy regime and completed more than two cycles of chemotherapy. Patients were categorized into three groups of (1) no schedule modification, (2) with schedule modification and (3) incomplete schedule. The Kaplan-Meier was used to test for survival differences in the univariate setting and Cox regression model was used in the multivariate setting. Main outcome measure Prevalence, overall survival rates and hazard ratio of three schedule group Results Among 171 patient who were included in the final analysis, 28 (16.4%) had no schedule modification, 118 (69.0%) with schedule modification and 25 (14.6%) had incomplete schedule with OS of 75.0%, 59.3% and 52.0% respectively. 94% (189) of all cycle rescheduling happened because of constitutional symptoms (70), for non-medical reasons (61) and blood/bone marrow toxicity (58). When compared to patients with no schedule modification, patients with schedule modification had a 2.34-times higher risk of death (HR 2.34, 95% CI 1.03-5.32; p = 0.043). Conclusion Nonconformity to the chemotherapy schedule is common in clinical practice because of treatment complications, patients' social schedule conflicts, and facility administrative reasons. Cumulative delays of ≥ 14 days are likely to have negative prognostic effect on patient survival. Thus, the duration of the delays between cycles should be reduced whenever possible to achieve the maximum chemotherapeutic benefit.

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

PURPOSE

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Colonoscopy resource availability and its association with the colorectal cancer diagnostic interval: A population-based cross-sectional study

BACKGROUND

Colonoscopy is a key resource used to diagnose colorectal cancer (CRC). This study evaluated the relationship between colonoscopy availability and the length of the CRC diagnostic interval.

METHODS

This is a cross-sectional study of CRC patients diagnosed in Ontario, Canada, in 2008-2012. We used administrative health data to characterise colonoscopist density, private colonoscopy clinic access, distance to the closest colonoscopist and the diagnostic interval, defined as the time from patients' first cancer-related healthcare encounter to their cancer diagnosis date. We used multivariable quantile regression to evaluate the association between colonoscopy availability and the diagnostic interval, modelling the median and 90th percentile.

RESULTS

The median diagnostic interval was 84 days (90th percentile 323 days). The diagnostic interval was longer in patients residing in areas with lower colonoscopists density or private clinic access (adjusted median difference = 9 and 19 days, respectively), with evidence of effect modification by symptom status. Increased distance to a colonoscopist was associated with a longer diagnostic interval in asymptomatic patients, but a shorter diagnostic interval in symptomatic patients (adjusted median difference = 29 and -25 days, respectively).

CONCLUSIONS

This study demonstrated that reduced colonoscopy resource availability is associated with longer diagnostic intervals for CRC patients.

"Just Living With Them": Symptom Management Experiences of Rural Residents With Advanced Cancer

PURPOSE

To understand how rural residents with advanced cancer experience and manage their symptoms.

PARTICIPANTS & SETTING

16 adult patients with a diagnosis of advanced cancer, who were receiving antineoplastic treatment and living in rural areas of southeastern Iowa, participated in the study.

METHODOLOGIC APPROACH

Data were collected through semistructured, audio-recorded interviews using open-ended questions. Data were analyzed using content and dimensional analyses.

FINDINGS

Four themes were developed from the completed interviews, including (a) barriers and challenges associated with rural cancer care, (b) physical symptoms experienced from the time of diagnosis through the cancer trajectory, (c) symptom management strategies used to control physical symptoms, and (d) perceptions of having cancer and the use of technology in managing symptoms.

IMPLICATIONS FOR NURSING

Rural residents with advanced cancer experience a wide range of physical symptoms that may affect their quality of life. Although residents may develop self-management strategies to cope with symptoms, additional guidance on and interventions for how best to manage physical symptoms are needed.

Impact of Travel Time on Health Care Costs and Resource Use by Phase of Care for Older Patients With Cancer

PURPOSE

Many community cancer clinics closed between 2008 and 2016, with additional closings potentially expected. Limited data exist on the impact of travel time on health care costs and resource use.

METHODS

This retrospective cohort study (2012 to 2015) evaluated travel time to cancer care site for Medicare beneficiaries age 65 years or older in the southeastern United States. The primary outcome was Medicare spending by phase of care (ie, initial, survivorship, end of life). Secondary outcomes included patient cost responsibility and resource use measured by hospitalization rates, intensive care unit admissions, and chemotherapy-related hospitalization rates. Hierarchical linear models with patients clustered within cancer care site (CCS) were used to determine the effects of travel time on average monthly phase-specific Medicare spending and patient cost responsibility.

RESULTS

Median travel time was 32 (interquartile range, 18-59) minutes for the 23,382 included Medicare beneficiaries, with 24% of patients traveling longer than 1 hour to their CCS. During the initial phase of care, Medicare spending was 14% higher and patient cost responsibility was 10% higher for patients traveling longer than 1 hour than those traveling 30 minutes or less. Hospitalization rates were 4% to 13% higher for patients traveling longer than 1 hour versus 30 minutes or less in the initial (61 v 54), survivorship (27 v 26), and end-of-life (310 v 286) phases of care (all P < .05). Most patients traveling longer than 1 hour were hospitalized at a local hospital rather than at their CCS, whereas the converse was true for patients traveling 30 minutes or less.

CONCLUSION

As health care locations close, patients living farther from treatment sites may experience more limited access to care, and health care spending could increase for patients and Medicare.

Travel burden associated with rare cancers: The example of Merkel cell carcinoma

BACKGROUND

There are limited data on the travel burden for cancer patients with rare tumor types, such as Merkel cell carcinoma (MCC).

OBJECTIVE

The objective of this study was to understand the travel burden of MCC patients.

METHODS

This study used data from an MCC registry at the Seattle Cancer Care Alliance (SCCA). All MCC patients enrolled at SCCA with a valid 3-digit ZIP code were included. Patients were followed up from January 1, 2012 until their last follow-up, death, or end of data (January 1, 2017). Travel burden was measured by one-way travel distance to SCCA from each patient's 3-digit ZIP code. Patient demographics, tumor characteristics, and follow-up visit were evaluated and stratified by one-way driving distance of ≤300 and >300 miles.

RESULTS

A total of 391 MCC patients were included (68% men, mean age = 67 years [±SD = ±11 years], 67% residing in the West, and 70% white). At diagnosis, 53% of the patients had Stage III or IV MCC. Mean one-way distance traveled by patients was 1,137 (median: 813) miles, and 57% of patients traveled >300 miles. Compared to patients who traveled ≤300 miles, those who traveled >300 miles were more likely to be <70 years old (46% vs 65%; P < 0.001), were diagnosed with advanced stage (III or IV) MCC (46% vs 59%; P = 0.01), had shorter follow-up in the cancer registry (mean: 509 vs 212 days; P < 0.001), and had fewer visits during follow-up (mean: 5.2 vs 2.5; P < 0.001).

CONCLUSIONS

In this single cancer center study, the majority of MCC patients trav-eled long distances to receive expert care. Longer travel distances appeared to be associated with younger age, a more advanced stage of cancer at study entry and fewer in-clinic visits, suggesting that travel burden may impact timely and adequate patient care for this rare cancer.

The impact of travel time on colorectal cancer stage at diagnosis in a privately insured population

BACKGROUND

Rural residents are less likely to receive screening for colorectal cancer (CRC) than urban residents. However, the mechanisms underlying this disparity, especially among people aged 50-64 years old with private health insurance, are not well understood. We examined the impact of travel time on stage at CRC diagnosis.

METHODS

This retrospective cohort study used data from the Blue Cross and Blue Shield of Nebraska. Members of this private insurance company aged 50-64 years, diagnosed with CRC during the period 2012-2016, and continuously enrolled in the insurance plan for at least 6 months prior to CRC diagnosis, were selected for this study. Using Google Maps, we estimated patients' travel time from their home ZIP code to the ZIP code of their colonoscopy provider. Using logistic regression, we analyzed the association between stage at CRC diagnosis, travel time, use of preventive services (i.e., check-ups or counseling to prevent or detect illness at an early stage) and patient characteristics.

RESULTS

A total of 307 subjects met the inclusion criteria. People who had not used preventive services 6 months prior to CRC diagnosis had 2.80 (95% CI, 1.00-7.90) times the odds of metastatic CRC compared to those who had used these services. No statistically significant association was found between travel time and metastatic CRC diagnosis (P = 0.99; 95% CI, 0.98-1.01).

CONCLUSIONS

The fact that 13% of the study population presented with metastatic CRC suggests some noncompliance with preventive services such as screening guidelines. To increase screening uptake and reduce metastatic cases, employers should offer incentives for their employees to make use of preventive services such as CRC screening.

Disparities in the surgical management of early stage non-small cell lung cancer: how far have we come?

It is currently estimated that nearly one-third of patients with newly diagnosed non-small cell lung cancer (NSCLC) have stage I-II disease on clinical evaluation. Curative-intent surgical resection has been a cornerstone of the therapeutic management of such patients, offering the best clinical and oncologic outcomes in the long-term. In 1999, Peter Bach and colleagues brought attention to racial disparities in the receipt of curative-intent surgery in the NSCLC population. In the time since this seminal study, there is accumulating evidence to suggest that disparities in the receipt of definitive surgery continue to persist for patients with early stage NSCLC. In this review, we sought to provide an up-to-date assessment of 20 years of surgical disparities literature in the NSCLC population. We summarized common and unrecognized disparities in the receipt of surgical resection for early stage NSCLC and demonstrated that demographic and socioeconomic factors such as race/ethnicity, special patient groups, income and insurance continue to impact the receipt of definitive resection. Additionally, we found that discrepancies in patient and provider perceptions of and attitudes toward surgery, access to invasive staging, distance to treatment centers and negative stigmas about lung cancer that patients experience may act to perpetuate disparities in surgical treatment of early stage lung cancer.

Travel distance and use of salvage palliative chemotherapy in patients with metastatic colorectal cancer

Background

Salvage palliative chemotherapy in metastatic colorectal cancer has been associated with significant improvement in survival. However, not all patients receive all available therapies. Travel burden can affect patient access and use of future therapy. The present study aims to determine relationship between travel distance (TD) and salvage palliative chemotherapy in patients with metastatic colorectal cancer.

Method

A patient cohort diagnosed with metastatic colorectal cancer during 2006-2010 in the province of Saskatchewan, Canada was studied. Logistic regression analyses were performed to assess relationship between travel distance and subsequent line therapies.

Results

The median age of 264 eligible patients was 62 years [interquartile range (IQR): 53-72]. The patients who received salvage systemic therapy had a median distance to travel of 60.0 km (IQR: 4.7-144) compared with 88.1 km (IQR: 4.8-189) if they did not receive second- or third-line therapy (P=0.06). In multivariate analysis distance to the cancer center <100 km, odds ratio (OR) 1.69 (95% CI: 1.003-2.84), no metastasectomy, OR 1.89 (95% CI: 1.03-3.46), and absence of comorbid illness as per Charlson comorbid index, OR 1.45 (95% CI: 1.19-1.77) were correlated with the use of second- and subsequent line therapies.

Conclusions

Our result revealed that travel distance to the cancer center greater than 100 km was associated less frequent use of second or subsequent line therapies in patients with metastatic colorectal cancer.

Distance to hospital is not a risk factor for emergency colon cancer surgery

PURPOSE

The purpose of this study is to see if the distance to a hospital performing colon cancer surgery is a risk factor for emergency surgical intervention and to determine the variability between defined but demographically divergent catchment areas.

METHODS

Data on patients living in Västerbotten County who underwent colon cancer surgery between 2007 and 2010 were extracted from the Swedish Colorectal Cancer Register (SCRCR). Of the 436 registrations matching these criteria, 380 patients were used in the analysis, and their distance to the nearest hospital providing care for colorectal cancer (CRC) was estimated using Google Maps™. The correlations between the risk for emergency surgery and the distance to a hospital, gender, age, income level and hospital catchment area were analysed in uni- and multivariate models.

RESULTS

Distance to the nearest hospital had no significant effect on the proportion of emergency operations for colon cancer. There was significant variability in risk for emergency surgery between hospital catchment areas, where the catchment areas of the university hospital and the most rural hospital had a higher proportion than the other local hospital catchment area (OR, 2.00 (p = 0.038) and OR, 2.97 (p = 0.005)). These results were still significant when analysed with multivariate logistic regression (OR, 2.13 (p = 0.026) and OR, 3.05 (p = 0.013)).

CONCLUSION

Distance to a hospital performing colon cancer surgery had no effect on the proportion of emergency surgeries. However, a variability between defined catchment areas was seen. Future studies will focus on possible factors behind this variability.

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.

Traveling to a High-volume Center is Associated With Improved Survival for Patients With Esophageal Cancer

BACKGROUND

An association between volume and outcomes has been observed for esophagectomy, though little is known about why or how patients choose low- or high-volume centers. The purpose of this study was to evaluate how travel burden and hospital volume influence treatment and outcomes of patients with locally advanced esophageal cancer.

METHODS

Predictors of receiving esophagectomy for patients with T1-3N1M0 mid or distal esophageal cancer in the National Cancer Data Base from 2006 to 2011 were identified using multivariable logistic regression. Survival was compared using propensity score-matched groups: patients in the bottom quartile of travel distance who underwent treatment at low-volume facilities (Local) and patients in the top quartile of travel distance who underwent treatment at high-volume facilities (Travel).

RESULTS

Of 4979 patients who met inclusion criteria, we identified 867 Local patients who traveled 2.7 [interquartile range (IQR): 1.6-4 miles] miles to centers that treated 2.6 (IQR: 1.9-3.3) esophageal cancers per year, and 317 Travel patients who traveled 107.1 (IQR: 65-247) miles to centers treating 31.9 (IQR: 30.9-38.5) cases. Travel patients were more likely to undergo esophagectomy (67.8% vs 42.9%, P < 0.001) and had significantly better 5-year survival (39.8% vs 20.6%, P < 0.001) than Local patients.

CONCLUSIONS

Patients who travel longer distances to high-volume centers have significantly different treatment and better outcomes than patients who stay close to home at low-volume centers. Strategies that support patient travel for treatment at high-volume centers may improve esophageal cancer outcomes.

Patient-Perceived Access to Care When Actively Seeking Treatment

PURPOSE/OBJECTIVES

To examine predictors of perceived access to care and reported barriers to care of patients with cancer actively seeking treatment.
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DESIGN

Retrospective secondary data analysis.
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SETTING

U.S. Medical Expenditure Panel Survey, a national survey with questions about healthcare coverage and access.
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SAMPLE

1,170 adults with cancer actively seeking treatment.
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METHODS

A retrospective analysis of data. Bivariate tests for significant association between individual characteristics and low perceived access to care were conducted using a chi-square test. 
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MAIN RESEARCH VARIABLES

The dependent variable was perceived access to care. The independent variables included sex, age, race, poverty status, education level, marital status, cancer site, comorbidities, and insurance status.
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FINDINGS

Those with Medicaid insurance or no health insurance had significantly lower perceived access to care compared to those with Medicare. Institutional barriers to treatment, such as financial or insurance, were the most common reported barriers.
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CONCLUSIONS

Most adults with cancer reported adequate access to medical care and medications, but a small yet vulnerable population expressed difficulties in accessing treatment.
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IMPLICATIONS FOR NURSING

To effectively advocate for vulnerable populations with Medicaid or no insurance, nurses may require specialized knowledge beyond the scope of general oncology nursing.