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

Healthcare professionals' perspectives of barriers to cancer care delivery for American Indian, rural, and frontier populations

Objective

This descriptive qualitative study sought to understand the barriers affecting cancer care delivery from the perspective of healthcare professionals (HCPs) serving American Indian (AI), rural, and frontier populations.

Methods

One-on-one, semi-structured interviews with multidisciplinary HCPs (N = 18) who provide cancer care to AI, rural, and frontier populations were conducted between January and April 2022. Interviews were conducted via Zoom. Data were analyzed following thematic content analysis methodologies.

Results

Thematic content analysis revealed three major themes: (a) Access, (b) Time, and (c) Isolation. The themes represent the HCP perspectives of the needs and barriers of persons with cancer to whom they provide cancer care. Furthermore, these themes also reflect the barriers HCPs experience while providing cancer care to AI, rural and frontier populations.

Conclusions

This study provides preliminary evidence for the need and strong multidisciplinary support for an early palliative care intervention in rural and frontier South Dakota (SD). This intervention could support the needs of persons with advanced cancer as well as the HCPs delivering cancer care in rural settings.

Innovation

This study is the initial step to develop the first culturally responsive, nurse-led, early palliative care intervention for AI, rural, and frontier persons with advanced cancer in SD.

Analysis of travel burden and travel support among patients treated at a comprehensive cancer center in the Southeastern United States

INTRODUCTION

Travel burden leads to worse cancer outcomes. Understanding travel burden and the level and types of travel support provided at large cancer centers is critical for developing systematic programs to alleviate travel burden. This study analyzed patients who received travel assistance, including their travel burden, types and amount of travel support received, and factors that influenced these outcomes.

METHODS

We analyzed 1063 patients who received travel support from 1/1/2021 to 5/1/2023 at Winship Cancer Institute, in which ~18,000 patients received cancer care annually. Travel burden was measured using distance and time to Winship sites from patients' residential address. Travel support was evaluated using the monetary value of total travel support and type of support received. Patients' sociodemographic and clinical factors were extracted from electronic medical records. Area-level socioeconomic disadvantage was coded by the Area Deprivation Index using patient ZIP codes.

RESULTS

On average, patients traveled 57.2 miles and 67.3 min for care and received $74.1 in total for travel support. Most patients (88.3%) received travel-related funds (e.g., gas cards), 5% received direct rides (e.g., Uber), 3.8% received vouchers for taxi or public transportation, and 3% received combined travel support. Male and White had longer travel distance and higher travel time than female and other races, respectively. Patients residing in more disadvantaged neighborhoods had an increased travel distance and travel time. Other races and Hispanics received more travel support ($) than Black and White patients or non-Hispanics. Patients with higher travel distance and travel time were more like to receive travel-related financial support.

CONCLUSION

Among patients who received travel support, those from socioeconomically disadvantaged neighborhoods had greater travel burden. Patients with greater travel burden were more likely to receive travel funds versus other types of support. Further understanding of the impact of travel burden and travel support on cancer outcomes is needed.

Characterizing the Traveling Oncology Workforce and Its Influence on Patient Travel Burden: A Claims-Based Approach

PURPOSE

Oncology outreach is a common strategy for extending cancer care to rural patients. However, a nationwide characterization of the traveling workforce that enables this outreach is lacking, and the extent to which outreach reduces travel burden for rural patients is unknown.

METHODS

This cross-sectional study analyzed a rural (nonurban) subset of a 100% fee-for-service sample of 355,139 Medicare beneficiaries with incident breast, colorectal, and lung cancers. Surgical, medical, and radiation oncologists were linked to patients using Part B claims, and traveling oncologists were identified by observing hospital service area (HSA) transition patterns. We defined oncology outreach as the provision of cancer care by a traveling oncologist outside of their primary HSA. We used hierarchical gamma regression models to examine the separate associations between patient receipt of oncology outreach and one-way patient travel times to chemotherapy, radiotherapy, and surgery.

RESULTS

On average, 9,935 of 39,960 oncologists conducted annual outreach, where 57.8% traveled with low frequency (0-1 outreach visits/mo), 21.1% with medium frequency (1-3 outreach visits/mo), and 21.1% with high frequency (>3 outreach visits/mo). Oncologists provided surgery, radiotherapy, and chemotherapy to 51,715, 27,120, and 5,874 rural beneficiaries, respectively, of whom 2.5%, 6.9%, and 3.6% received oncology outreach. Rural patients who received oncology outreach traveled 16% (95% CI, 11 to 21) and 11% (95% CI, 9 to 13) less minutes to chemotherapy and radiotherapy than those who did not receive oncology outreach, corresponding to expected one-way savings of 15.9 (95% CI, 15.5 to 16.4) and 11.9 (95% CI, 11.7 to 12.2) minutes, respectively.

CONCLUSION

Our study introduces a novel claims-based approach for tracking the nationwide traveling oncology workforce and supports oncology outreach as an effective means for improving rural access to cancer care.

Reducing no-show visits and disparities in access: The impact of telemedicine

BACKGROUND

No-show visits have serious consequences for patients, providers, and healthcare systems as they lead to delays in care, increased costs, and reduced access to services. Telemedicine has emerged as a promising alternative to in-person visits by reducing travel barriers, but risks exacerbating the digital divide. The aim of this study was to assess the impact of telemedicine (video and phone) at a tertiary care academic center on no-show visits compared to in-person visits.

METHODS

A retrospective cohort analysis of all weekday clinic visits among in-state adult patients at a single tertiary care center in the southeast from January 2020 to April 2023 was performed. Rates of no-show visits for patients who were seen via phone and video were compared with those who were seen in-person. Demographic and clinical characteristics of these groups were also compared, including age, sex, race/ethnicity, socioeconomic status, and visit type. The primary outcome was the rate of no-show visits for each visit type.

RESULTS

Our analysis included 3,105,382 scheduled appointments, of which 81.2% were in-person, 13.4% via video, and 5.4% via phone calls. Compared to in-person visits, phone calls and video visits reduced the odds of no-show visits by 50% (aOR 0.5, CI 0.49-0.51) and 15% (aOR 0.85, CI 0.84-0.86), respectively. Older patients, Black patients, patients furthest from clinic, and patients from counties with the greatest degree of vulnerability and disparities in digital access were more likely to use phone visits. No-shows were more common among non-white, male, and younger patients from counties with lower socioeconomic status.

CONCLUSION

Telemedicine effectively reduced no-show visits. However, limiting telemedicine to video-based visits only exacerbated disparities in access. Phone calls allow historically underserved patients from lower socioeconomic backgrounds to access healthcare and should be included within the definition of telemedicine.

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.

Universal Germline-Genetic Testing for Breast Cancer: Implementation in a Rural Practice and Impact on Shared Decision-Making

BACKGROUND

Whereas the National Comprehensive Cancer Network (NCCN) criteria restrict germline-genetic testing (GGT) to a subset of breast cancer (BC) patients, the American Society of Breast Surgeons recommends universal GGT. Although the yield of pathogenic germline variants (PGV) in unselected BC patients has been studied, the practicality and utility of incorporating universal GGT into routine cancer care in community and rural settings is understudied. This study reports real-world implementation of universal GGT for patients with breast cancer and genetics-informed, treatment decision-making in a rural, community practice with limited resources.

METHODS

From 2019 to 2022, all patients with breast cancer at a small, rural hospital were offered GGT, using a genetics-extender model. Statistical analyses included Fisher's exact test, t-tests, and calculation of odds ratios. Significance was set at p < 0.05.

RESULTS

Of 210 patients with breast cancer who were offered GGT, 192 (91.4%) underwent testing with 104 (54.2%) in-criteria (IC) and 88 (45.8%) out-of-criteria (OOC) with NCCN guidelines. Pathogenic germline variants were identified in 25 patients (13.0%), with PGV frequencies of 15 of 104 (14.4%) in IC and ten of 88 (11.4%) in OOC patients (p = 0.495). GGT informed treatment for 129 of 185 (69.7%) patients.

CONCLUSIONS

Universal GGT was successfully implemented in a rural, community practice with > 90% uptake. Treatment was enhanced or de-escalated in those with and without clinically actionable PGVs, respectively. Universal GGT for patients with breast cancer is feasible within rural populations, enabling optimization of clinical care to patients' genetic profile, and may reduce unnecessary healthcare, resource utilization.

Urban-Rural Differences in Receipt of Cancer Surgery at High-Volume Hospitals and Sensitivity to Hospital Volume Thresholds

Methods for identifying high-volume hospitals affect conclusions about rural cancer care access.

Travel Burden to Cancer Screening and Treatment Facilities Among Washington Women: Data From an Integrated Healthcare Delivery System

PURPOSE

To characterize distance traveled for breast cancer screening and to sites of service for breast cancer treatment, among rural and urban women served by a Washington State healthcare network.

METHODS

Data for this study came from one of the largest not-for-profit integrated healthcare delivery systems in Washington State. Generalized linear mixed models with gamma log link function were used to examine the associations between travel distance and sociodemographic and contextual characteristics of patients.

RESULTS

Median travel distance for breast cancer screening facilities, hematologist/oncologists, radiation oncologists, or surgeons was 11, 19, 23, or 11 miles, respectively. Travel distance to breast cancer screening or referral facilities was longer in non-core metropolitan ZIP codes compared to metropolitan ZIP codes. AI/AN and Hispanic women travelled longer distances to reach referral facilities compared to other racial and ethnic groups.

CONCLUSION

Disparities exist in travel distance to breast cancer screening and treatment. Further research is needed to describe sociodemographic and system level characteristics that contribute to such disparities and to discover novel approaches to alleviate this burden.

The impact of travel time to cancer treatment centre on post-diagnosis care and mortality among cancer patients in Scotland

Limited data exist on the effect of travelling time on post-diagnosis cancer care and mortality. We analysed the impact of travel time to cancer treatment centre on secondary care contact time and one-year mortality using a data-linkage study in Scotland with 17369 patients. Patients with longer travelling time and island-dwellers had increased incidence rate of secondary care cancer contact time. For outpatient oncology appointments, the incidence rate was decreased for island-dwellers. Longer travelling time was not associated with increased secondary care contact time for emergency cancer admissions or time to first emergency cancer admission. Living on an island increased mortality at one-year. Adjusting for cancer-specific secondary care contact time increased the hazard of death, and adjusting for oncology outpatient time decreased the hazard of death for island-dwellers. Those with longer travelling times experience the cancer treatment pathway differently with poorer outcomes. Cancer services may need to be better configured to suit differing needs of dispersed populations.

The Association of Rural Residence With Surgery and Adjuvant Radiation in Medicare Beneficiaries With Rectal Cancer

Purpose

Radiation therapy and surgery are fundamental site-directed therapies for nonmetastatic rectal cancer. To understand the relationship between rurality and access to specialized care, we characterized the association of rural patient residence with receipt of surgery and radiation therapy among Medicare beneficiaries with rectal cancer.

Methods and Materials

We identified fee-for-service Medicare beneficiaries aged 65 years or older diagnosed with nonmetastatic rectal cancer from 2016 to 2018. Beneficiary place of residence was assigned to one of 3 geographic categories (metropolitan, micropolitan, or small town/rural) based on census tract and corresponding rural urban commuting area codes. Multivariable regression models were used to determine associations between levels of rurality and receipt of both radiation and proctectomy within 180 days of diagnosis. In addition, we explored associations between patient rurality and characteristics of surgery and radiation such as minimally invasive surgery (MIS) or intensity modulated radiation therapy (IMRT).

Results

Among 13,454 Medicare beneficiaries with nonmetastatic rectal cancer, 3926 (29.2%) underwent proctectomy within 180 days of being diagnosed with rectal cancer, and 1792 (13.3%) received both radiation and proctectomy. Small town/rural residence was associated with an increased likelihood of receiving both radiation and proctectomy within 180 days of diagnosis (adjusted subhazard ratio, 1.15; 95% CI, 1.02-1.30). Furthermore, small town/rural radiation patients were significantly less likely to receive IMRT (adjusted odds ratio, 0.62; 95% CI, 0.48-0.80) or MIS (adjusted odds ratio, 0.80; 95% CI, 0.66-0.97) than metropolitan patients.

Conclusions

Although small town/rural Medicare beneficiaries were overall more likely to receive both radiation and proctectomy for their rectal cancer, they were less likely to receive preoperative IMRT or MIS as part of their treatment regimen. Together, these findings clarify that among Medicare beneficiaries, there appeared to be a similar utilization of radiation resources and time to radiation treatment regardless of rural/urban status.

Identification of Populations at Risk for "Choosing Un-Wisely": A SEER Population-Based Study

BACKGROUND

Since 2016, the Choosing Wisely campaign has recommended against routine axillary surgery in elderly patients with early stage, hormone receptor positive (ER+) breast cancer. The objective was to evaluate factors associated with axillary surgery in breast cancer patients meeting criteria for sentinel lymph node biopsy (SLNB) omission and identify potential disparities.

METHODS

Female patients age ≥70 years with cT1-2N0M0, ER+, HER2-negative breast cancer diagnosed after publication of the Choosing Wisely recommendations, between 2016 and 2019, were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Patient demographics and tumor characteristics associated with axillary surgery were analyzed.

RESULTS

Of the 31 756 patients meeting omission criteria, 25 771 (81.2%) underwent axillary surgery. Hispanic ethnicity, median household income between $35,000 and $70,000, treatment in rural areas, poor differentiation, lobular and mixed lobular with ductal histology, T2 tumors, radiation therapy, and systemic therapy were factors associated with receiving axillary surgery on multivariable analysis. In the axillary surgery cohort, a median of 2 (IQR = 2) nodes were examined and 529 (2.1%) patients were found to have 1 or more positive lymph nodes.

DISCUSSION

Among elderly patients meeting Choosing Wisely criteria for SLNB omission, particular racial, ethnic, socioeconomic, and geographic populations may be at increased risk for potential over treatment. Identification of these factors provides specific opportunities for education and implementation of de-escalation of unnecessary procedures.

Was Unstable Medicaid Coverage Among Older Medicare Beneficiaries Associated With Worse Clinical Outcomes? Evidence From the Delivery of Breast Cancer Care

BACKGROUND

Medicare and Medicaid dually eligible beneficiaries (duals) could experience Medicaid coverage changes without losing Medicaid. It is unknown whether health care use and clinical outcomes among elderly duals with coverage changes would be like those among duals without coverage changes or duals ever lost Medicaid and whether various types of unstable coverage due to income/asset changes are associated with worse clinical outcomes.

OBJECTIVES

Examine the associations of unstable Medicaid coverage with clinical outcomes among older Medicare beneficiaries.

RESEARCH DESIGN

Population-based cohort study.

SUBJECTS

A total of 131,202 women newly diagnosed with breast cancer at 65 years and older between 2007 and 2015 were identified from the Surveillance, Epidemiology, and End Results-Medicare linked database.

MEASURES

We examined 2 types of unstable Medicaid coverage: (1) those who had changes in the types of Medicaid support they received and (2) those who ever lost Medicaid. We examined outcomes that predict better cancer survival and involve the use of inpatient and outpatient services and prescription drugs: early diagnosis, receiving surgery, receiving radiation, hormonal therapy adherence, and discontinuation. We used logistic regressions to estimate the predicted probabilities of outcomes for dual groups.

RESULTS

Duals had poorer outcomes than those who were "never dual." Women with the 2 types of unstable Medicaid coverage had similarly worse outcomes than those with stable coverage. Those with stable coverage had similar outcomes regardless of the generosity of Medicaid support.

CONCLUSIONS

These patterns are concerning and, in the context of well-defined clinical guidelines for beneficial treatments that extend survival, point to the importance of stable insurance coverage and income.

Availability of cancer care services and the organization of care delivery at critical access hospitals

INTRODUCTION

Critical access hospitals (CAHs) provide an opportunity to meet the needs of individuals with cancer in rural areas. Two common innovative care delivery methods include the use of traveling oncologists and teleoncology. It is important to understand the availability and organization of cancer care services in CAHs due to the growing population with cancer and expected declines in oncology workforce in rural areas.

METHODS

Stratified random sampling was used to generate a sample of 50 CAHs from each of the four U.S. Census Bureau-designated regions resulting in a total sample of 200 facilities. Analyses were conducted from 135 CAH respondents to understand the availability of cancer care services and organization of cancer care across CAHs.

RESULTS

Almost all CAHs (95%) provided at least one cancer screening or diagnostic service. Forty-six percent of CAHs reported providing at least one component of cancer treatment (chemotherapy, radiation, or surgery) at their facility. CAHs that offered cancer treatment reported a wide range of health care staff involvement, including 34% of respondents reporting involvement of a local oncologist, 38% reporting involvement of a visiting oncologist, and 28% reporting involvement of a non-local oncologist using telemedicine.

CONCLUSION

Growing disparities within rural areas emphasize the importance of ensuring access to timely screening and guideline-recommended treatment for cancer in rural communities. These data demonstrated that CAHs are addressing the growing need through a variety of approaches including the use of innovative models that utilize non-local providers and telemedicine to expand access to crucial services for rural residents with cancer.

Availability of hospital-based cancer services before and after rural hospital closure, 2008-2017

INTRODUCTION

Rural populations have less access to cancer care services and experience higher cancer mortality rates than their urban counterparts, which may be exacerbated by hospital closures. Our objective was to examine the impact of hospital closures on access to cancer-relevant hospital services across hospital service areas (HSAs).

METHODS

We used American Hospital Association survey data from 2008 to 2017 to examine the change in access to cancer-related screening and treatment services across rural HSAs that sustained hospitals over time, experienced any closures, or had all hospitals close. We performed a longitudinal analysis to assess the association between hospital closure occurrence and maintenance or loss of cancer-related service lines accounting for hospital and HSA-level characteristics. Maps were also developed to display changes in the availability of services across HSAs.

RESULTS

Of the 2,014 rural HSAs, 3.8% experienced at least 1 hospital closure during the study period, most occurring in the South. Among HSAs that experienced hospital closure, the loss of surgery services lines was most common, while hospital closures did not affect the availability of overall oncology and radiation services. Screening services either were stable (mammography) or increased (endoscopy) in areas with no closures.

DISCUSSION

Rural areas persistently experience less access to cancer treatment services, which has been exacerbated by hospital closures. Lack of Medicaid expansion in many Southern states and other policy impacts on hospital financial viability may play a role in this. Future research should explore the impact of closures on cancer treatment receipt and outcomes.

County-level geographic disparities in cardiovascular disease mortality among US breast cancer survivors, 2000-2018

BACKGROUND

Disparities in cardiovascular disease mortality among breast cancer survivors are documented, but geographic factors by county-level socioeconomic status (SES) and rurality are not well described.

METHODS

We analyzed 724 518 women diagnosed with localized or regional stage breast cancer between 2000 and 2017 within Surveillance, Epidemiology, and End Results Program-18 with follow-up until 2018. We calculated relative risks (RRs) of cardiovascular disease mortality using Poisson regression, accounting for age- and race-specific rates in the general population, according to county-level quintiles of SES (measured by Yost index), median income, and rurality at breast cancer diagnosis. We also calculated 10-year cumulative mortality risk of cardiovascular disease accounting for competing risks.

RESULTS

Cardiovascular disease mortality was 41% higher among breast cancer survivors living in the lowest SES (RR = 1.41, 95% confidence interval [CI] = 1.36 to 1.46, Ptrend < .001) and poorest (RR = 1.41, 95% CI = 1.36 to 1.47, Ptrend < .001) counties compared with the highest SES and wealthiest counties, and 24% higher for most rural relative to most urban counties (RR = 1.24, 95% CI = 1.17 to 1.30, Ptrend < .001). Disparities for the lowest SES relative to highest SES counties were greatest among younger women aged 18-49 years (RR = 2.32, 95% CI = 1.90 to 2.83) and aged 50-59 years (RR = 2.01, 95% CI = 1.77 to 2.28) and within the first 5 years of breast cancer diagnosis (RR = 1.53, 95% CI = 1.44 to 1.64). In absolute terms, however, disparities were widest for women aged 60+ years, with approximately 2% higher 10-year cumulative cardiovascular disease mortality risk in the poorest compared with wealthiest counties.

CONCLUSIONS

Geographic factors at breast cancer diagnosis were associated with increased cardiovascular disease mortality risk. Studies with individual- and county-level information are needed to inform public health interventions and reduce disparities among breast cancer survivors.

The Effect of Surgeon Referral and a Radiation Oncologist Productivity-Based Metric on Radiation Therapy Receipt Among Elderly Women With Early Stage Breast Cancer: Analysis From a Tertiary Cancer Network

Purpose

: Guidelines for early-stage breast cancer allow for radiation therapy (RT) omission after breast conserving surgery among older women, though high utilization of RT persists. This study explored surgeon referral and the effect of a productivity-based bonus metric for radiation oncologists in an academic institution with centralized quality assurance review.

Methods and materials

: We evaluated patients ≥70 years of age treated with breast conserving surgery for estrogen receptor (ER)+ pT1N0 breast cancer at a single tertiary cancer network between 2015 and 2018. The primary outcomes were radiation oncology referral and RT receipt. Covariables included patient and physician characteristics and treatment decisions before versus after productivity metric implementation. Univariable generalized linear effects models explored associations between these outcomes and covariables.

Results

: Of 703 patients included, 483 (69%) were referred to radiation oncology and 273 (39%) received RT (among those referred, 57% received RT). No difference in RT receipt pre- versus post-productivity metric implementation was observed (P = .57). RT receipt was associated with younger patient age (70-74 years; odds ratio [OR], 2.66; 95% confidence interval [CI], 1.54-4.57) and higher grade (grade 3; OR, 7.75; 95% CI, 3.33-18.07). Initial referral was associated with younger age (70-74; OR, 5.64; 95% CI, 3.37-0.45) and higher performance status (Karnofsky performance status ≥90; OR, 5.34; 95% CI, 2.63-10.83).

Conclusions

: Nonreferral to radiation oncology accounted for half of RT omission but was based on age and Karnofsky performance status, in accordance with guidelines. Lack of radiation oncologist practice change in response to misaligned financial incentives is reassuring, potentially reflecting incentive design and/or centralized quality assurance review. Multi-institutional studies are needed to confirm these findings.

Factors Associated With Travel Distance in the Receipt of Proton Breast Radiation Therapy

Introduction

Proton radiation therapy (PBT) may reduce cardiac doses in breast cancer treatment. Limited availability of proton facilities could require significant travel distances. This study assessed factors associated with travel distances for breast PBT.

Materials and Methods

Patients receiving breast PBT at the University of Pennsylvania from 2010 to 2021 were identified. Demographic, cancer, and treatment characteristics were summarized. Straight-line travel distances from the department to patients' addresses were calculated using BatchGeo. Median and mean travel distances were reported. Given non-normality of distribution of travel distances, Wilcoxon rank sum or Kruskal-Wallis test was used to determine whether travel distances differed by race, clinical trial participation, disease laterality, recurrence, and prior radiation.

Results

Of 1 male and 284 female patients, 67.8% were White and 21.7% Black. Median travel distance was 13.5 miles with interquartile range of 6.1 to 24.8 miles, and mean travel distance was 13.5 miles with standard deviation of 261.4 miles. 81.1% of patients traveled less than 30 and 6.0% more than 100 miles. Black patients' travel distances were significantly shorter than White patients' and non-Black or non-White patients' travel distances (median = 4.5, 16.5, and 11.3 miles, respectively; P < .0001). Patients not on clinical trials traveled more those on clinical trials (median = 14.7 and 10.2 miles, respectively; P = .032). There was no difference found between travel distances of patients with left-sided versus right-sided versus bilateral disease (P = .175), with versus without recurrent disease (P = .057), or with versus without prior radiation (P = .23).

Conclusion

This study described travel distances and demographic and clinicopathologic characteristics of patients receiving breast PBT at the University of Pennsylvania. Black patients traveled less than White and non-Black or non-White patients and comprised a small portion of the cohort, suggesting barriers to travel and PBT. Patients did not travel further to receive PBT for left-sided or recurrent disease.

Improving cancer care locally: Study of a hospital affiliate network model

PURPOSE

The University of Kentucky Markey Cancer Center Affiliate Network (MCCAN) increased access to high-quality cancer care for patients treated in community hospitals across the state by leveraging the American College of Surgeons Commission on Cancer (CoC) standards to improve quality among its member sites. This study describes the network activities and services identified as most helpful or effective to its members, as well as the perceived value of joining MCCAN or pursing accreditation.

METHODS

An independent research team conducted in-depth, semistructured interviews with 18 administrators and clinicians from 10 MCCAN hospitals in 2019. Interviews were transcribed and a thematic analysis was conducted.

FINDINGS

Network affiliation and CoC accreditation were perceived as helpful to improving quality of care. Having both clinician and administrative champions were key facilitators to achieving CoC standards and made mentoring of member sites a critical activity of the Network. Other components identified as valuable and/or key to the Network's success included providing access to specific CoC-required clinical services (eg, genetic counseling); offering regular performance monitoring and individualized feedback; establishing a culture of quality improvement; and fostering trust within the Network with patient referrals (ie, sending patients back to their local hospital for ongoing care).

CONCLUSIONS

Quality improvement in community cancer programs is challenging but several strategies were identified by members as valuable and effective. Efforts to disseminate the MCCAN model should focus on identifying the needs of community hospitals, implementing a quality monitoring system, and fostering site-level champions who can be influential drivers of change.

Rural-Urban Differences in Breast Cancer Surgical Delays in Medicare Beneficiaries

BACKGROUND

Delays between breast cancer diagnosis and surgery are associated with worsened survival. Delays are more common in urban-residing patients, although factors specific to surgical delays among rural and urban patients are not well understood.

METHODS

We used a 100% sample of fee-for-service Medicare claims during 2007-2014 to identify 238,491 women diagnosed with early-stage breast cancer undergoing initial surgery and assessed whether they experienced biopsy-to-surgery intervals > 90 days. We employed multilevel regression to identify associations between delays and patient, regional, and surgeon characteristics, both in combined analyses and stratified by rurality of patient residence.

RESULTS

Delays were more prevalent among urban patients (2.5%) than rural patients (1.9%). Rural patients with medium- or high-volume surgeons had lower odds of delay than patients with low-volume surgeons (odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.58-0.88; OR = 0.74, 95% CI = 0.61-0.90). Rural patients whose surgeon operated at ≥ 3 hospitals were more likely to experience delays (OR = 1.29, 95% CI = 1.01-1.64, Ref: 1 hospital). Patient driving times ≥ 1 h were associated with delays among urban patients only. Age, black race, Hispanic ethnicity, multimorbidity, and academic/specialty hospital status were associated with delays.

CONCLUSIONS

Sociodemographic, geographic, surgeon, and facility factors have distinct associations with > 90-day delays to initial breast cancer surgery. Interventions to improve timeliness of breast cancer surgery may have disparate impacts on vulnerable populations by rural-urban 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 Barriers Drive Disparities in Specialty Center Access for Older Adults with Huntington's Disease

BACKGROUND

Huntington's Disease Society of America Centers of Excellence (HDSA COEs) are primary hubs for Huntington's disease (HD) research opportunities and accessing new treatments. Data on the extent to which HDSA COEs are accessible to individuals with HD, particularly those older or disabled, are lacking.

OBJECTIVE

To describe persons with HD in the U.S. Medicare program and characterize this population by proximity to an HDSA COE.

METHODS

We conducted a cross-sectional study of Medicare beneficiaries ages ≥65 with HD in 2017. We analyzed data on benefit entitlement, demographics, and comorbidities. QGis software and Google Maps Interface were employed to estimate the distance from each patient to the nearest HDSA COE, and the proportion of individuals residing within 100 miles of these COEs at the state level.

RESULTS

Among 9,056 Medicare beneficiaries with HD, 54.5% were female, 83.0% were white; 48.5% were ≥65 years, but 64.9% originally qualified for Medicare due to disability. Common comorbidities were dementia (32.4%) and depression (35.9%), and these were more common in HD vs. non-HD patients. Overall, 5,144 (57.1%) lived within 100 miles of a COE. Race/ethnicity, sex, age, and poverty markers were not associated with below-average proximity to HDSA COEs. The proportion of patients living within 100 miles of a center varied from < 10% (16 states) to > 90% (7 states). Most underserved states were in the Mountain and West Central divisions.

CONCLUSION

Older Medicare beneficiaries with HD are frequently disabled and have a distinct comorbidity profile. Geographical, rather than sociodemographic factors, define the HD population with limited access to HDSA COEs.

Strategies to Advance Equity in Cancer Clinical Trials

Cancer clinical trials are critical for testing new treatments, yet less than 5% of patients with cancer enroll in these trials. Minority groups, elderly individuals, and rural populations are particularly underrepresented in cancer treatment trials. Strategies for advancing equity in cancer clinical trials for these populations include (1) optimizing clinical trial matching by broadening eligibility criteria, screening all patients for trial eligibility, expanding the number of trials against which patients are screened, and following up on all patient matches with an enrollment invitation; (2) conducting site self-assessments to identify clinical-, patient-, provider-, and system-level barriers that contribute to low rates of clinical trial screening and enrollment; (3) creating a quality improvement plan that addresses the barriers to enrollment and incorporates the use of tools and strategies such as clinical trial checklists; workforce development and trainings to improve cultural competence and reduce unconscious bias; guides to promote community education, outreach and engagement with cancer clinical trials; screening and accrual logs designed to measure participation by demographics; models of informed consent that improve understanding; clinical trial designs that reduce accessibility barriers; use of cancer clinical trial patient navigators; and programs to eliminate barriers to participation and out-of-pocket expenses; and (4) working with stakeholders to develop both protocols that are inclusive of diverse populations' geographic locations, and strategies to access those trials. These actions will support greater access for populations that have remained underrepresented in cancer clinical trials and thereby increase the generalizability and efficiency of cancer research.

The Impact of Commission on Cancer Accreditation Status, Hospital Rurality and Hospital Size on Quality Measure Performance Rates

BACKGROUND

Rural cancer patients receive lower-quality care and experience worse outcomes than urban patients. Commission on Cancer (CoC) accreditation requires hospitals to monitor performance on evidence-based quality measuresPlease confirm the list of authors is correc, but the impact of accreditation is not clear due to lack of data from non-accredited facilities and confounding between patient rurality and hospital accreditation, rurality, and size.

METHODS

This retrospective, observational study assessed associations between rurality, accreditation, size, and performance rates for four CoC quality measures (breast radiation, breast chemotherapy, colon chemotherapy, colon nodal yield). Iowa Cancer Registry data were queried to identify all eligible patients diagnosed between 2011 and 2017. Cases were assigned to the surgery hospital to calculate performance rates. Univariate and multivariate regression models were fitted to identify patient- and hospital-level predictors and assess trends.

RESULTS

The study cohort included 10,381 patients; 46% were rural. Compared with urban patients, rural patients more often received treatment at small, rural, and non-accredited facilities (p < 0.001 for all). Rural hospitals had fewer beds and were far less likely to be CoC-accredited than urban hospitals (p < 0.001 for all). On multivariate analysis, CoC accreditation was the strongest, independent predictor of higher hospital performance for all quality measures evaluated (p < 0.05 in each model). Performance rates significantly improved over time only for the colon nodal yield quality measure, and only in urban hospitals.

CONCLUSIONS

CoC accreditation requires monitoring and evaluating performance on quality measures, which likely contributes to better performance on these measures. Efforts to support rural hospital accreditation may improve existing disparities in rural cancer treatment and outcomes.

The Rural Household Production of Health Approach: Applying Lessons from Zambia to Rural Cancer Disparities in the U.S

The recent focus on rural-urban cancer disparities in the United States (U.S.) requires a comprehensive understanding of the processes and relations that influence cancer care seeking and decision making. This is of particular importance for Black, Latino, and Native populations living in rural areas in the U.S., who remain marginalized in health care spaces. In this article, we describe the household production of health approach (HHPH) as a contextually-sensitive approach to examining health care seeking and treatment decisions and actions. The HHPH approach is based on several decades of research and grounded in anthropological theory on the household, gender, and therapy management. This approach directs analytical attention to how time, money, and social resources are secured and allocated within the household, sometimes in highly unequal ways that reflect and refract broader social structures. To demonstrate the benefits of such an approach to the study of cancer in rural populations in the U.S., we take lessons from our extensive HHPH research in Zambia. Using a case study of a rural household, in which household members had to seek care in a distant urban hospital, we map out what we call a rural HHPH approach to bring into focus the relations, negotiations, and interactions that are central to individual and familial health care seeking behaviors and clinical treatment particular to rural regions. Our aim is to show how such an approach might offer alternative interpretations of existing rural cancer research in the U.S. and also present new avenues for questions and for developing interventions that are more sensitive to people's realities.

Rural-Urban Differences in Breast Cancer Stage at Diagnosis

Purpose: To analyze the extent to which rural-urban differences in breast cancer stage at diagnosis are explained by factors including age, race, tumor grade, receptor status, and insurance status.

Methods: Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) 18 database, analysis was performed using data from women aged 50–74 diagnosed with breast cancer between the years 2013 and 2016. Patient rurality of residence was coded according to SEER's Rural-Urban Continuum Code 2013: Large Urban (RUCC 1), Small Urban (RUCC 2,3), and Rural (RUCC 4,5,6,7,8,9). Stage at diagnosis was coded according to SEER's Combined Summary Stage 2000 (2004+) criteria: Localized (0,1), Regional (2,3,4,5), and Distant (7). Descriptive statistics were analyzed, and variations were tested for across rural-urban categories using Kruskall–Wallis and Kendall's tau-b tests. Additionally, odds ratios (ORs) and 95% confidence intervals for the three ordinal levels of rural-urban residence were calculated while adjusting for other independent variables using ordinal logistic regression.

Results: The rural residence category showed the largest proportion of women diagnosed with distant stage breast cancer. Additionally, we determined that patients with residence in both large and small urban areas had statistically significantly lower odds of higher stage diagnosis compared to rural patients even after controlling for age, race, tumor grade, receptor status, and insurance status.

Conclusions: Rural women with breast cancer show small but statistically significant disparities in stage-at-diagnosis. Further research is needed to understand local area variation in these disparities across a wide range of rural communities, and to identify the most effective interventions to eliminate these disparities.

Breast Cancer Disparities and the Impact of Geography

Neighborhood has significant implications for breast cancer screening, stage, treatment, and mortality. Patients residing in neighborhoods with high deprivation or rurality face barriers and challenges to accessing and receiving care. Consequently, they experience higher mortality rates than their financially affluent or urban counterparts. There are multiple gaps in the literature on the relationship between place of residence and the use of systemic therapies or emerging surgical strategies for disease management. As the management of breast cancer continues to evolve, additional studies are needed to understand the implications of place on the implementation and dissemination of new and emerging treatment modalities.

Urban-Rural Variations in Quality of Care Among Patients With Cancer in California

INTRODUCTION

Previous research suggests cancer patients living in rural areas have lower quality of care, but population-based studies have yielded inconsistent results. This study examines the impact of rurality on care quality for 7 cancer types in California.

METHODS

Breast, ovarian, endometrial, cervix, colon, lung, and gastric cancer patients diagnosed from 2004 to 2017 were identified in the California Cancer Registry. Multivariable logistic regression and proportional hazards models were used to assess effects of residential location on quality of care and survival. Stratified models examined the impact of treatment at National Cancer Institute designated cancer centers (NCICCs). Quality of care was evaluated using Commission on Cancer measures. Medical Service Study Areas were used to assess urban/rural status. Data were collected in 2004-2019 and analyzed in 2020.

RESULTS

989,747 cancer patients were evaluated, with 14% living in rural areas. Rural patients had lower odds of receiving radiation after breast conserving surgery compared to urban residents. Colon and gastric cancer patients had 20% and 16% lower odds, respectively, of having optimal surgery. Rural patients treated at NCICCs had greater odds of recommended surgery for most cancer types. Survival was similar among urban and rural subgroups.

CONCLUSIONS

Rural residence was inversely associated with receipt of recommended surgery for gastric and colon cancer patients not treated at NCICCs, and for receiving recommended radiotherapy after breast conserving surgery regardless of treatment location. Further studies investigating the impact of care location and availability of supportive services on urban-rural differences in quality of care are warranted.

Geographic Access to Radiation Therapy Facilities in the United States

BACKGROUND

The current distribution of radiation therapy (RT) facilities in the US is not well established. A comprehensive inventory of US RT facilities was last assessed in 2005, based on data from state regulatory agencies and dosimetric quality assurance bodies. We updated this database to characterize population-level measures of geographic access to RT and analyze changes over the past 15 years.

METHODS

We compiled data from regulatory and accrediting organizations to identify US facilities with linear accelerators used to treat humans in 2018-2020. Addresses were geocoded and analyzed with Geographic Information Services (GIS) software. Geographic access was characterized by assessing the Euclidian distance between zip code tabulation areas (ZCTA)/county centroids and RT facilities. Populations were assigned to each county to estimate the impact of facility changes at the population level. Logistic regressions were performed to identify features associated with increased distance to RT and associated with regions that gained an RT facility between the two time points studied.

RESULTS

In 2020, a total of 2,313 US RT facilities were reported compared to 1,987 in 2005, representing a 16.4% growth in facilities over nearly 15 years. Based on population attribution to ZCTA centroids, 77.9% of the US population lives within 12.5 miles of an RT facility, and 1.8% of the US population lives more than 50 miles from an RT facility. We found that increased distance to RT was associated with non-metro status, less insurance, older median age, and less populated regions. Between 2005 and 2020, the population living within 12.5 miles from an RT facility increased by 2.1 percentage points, while the population living furthest from RT facilities decreased 0.6 percentage points. Regions with improved geographic RT access are more likely to be higher income and better insured.

CONCLUSION

1.8% of the US population has limited geographic access to radiation therapy. We found that people benefiting from improved access to RT facilities are more economically advantaged, suggesting disparities in geographic access may not improve without intervention.

Identifying key barriers to effective breast cancer control in rural settings

Breast cancer is the most common cancer and the second most common cause of cancer mortality among women in the United States. Efforts to promote breast cancer control in rural settings face specific challenges. Access to breast cancer screening, diagnosis, and treatment services is impaired by shortages of primary care and specialist providers, and geographic distance from medical facilities. Women in rural areas have comparable breast cancer mortality rates compared to women in urban settings, but this is due in large part to lower incidence rates and masks a substantial rural/urban disparity in breast cancer survival among women diagnosed with breast cancer. Mammography screening utilization rates are slightly lower among rural women than their urban counterparts, with a corresponding increase in late stage breast cancer. Differences in breast cancer survival persist after controlling for stage at diagnosis, largely due to disparities in access to treatment. Travel distance to treatment centers is the most substantial barrier to improved breast cancer outcomes in rural areas. While numerous interventions have been demonstrated in controlled studies to be effective in promoting treatment access and adherence, widespread dissemination in public health and clinical practice remains lacking. Efforts to improve breast cancer control in rural areas should focus on implementation strategies for improving access to breast cancer treatments.

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.

Travel, Treatment Choice, and Survival Among Breast Cancer Patients: A Population-Based Analysis

Background: Travel distance to care facilities may shape urban-rural cancer survival disparities by creating barriers to specific treatments. Guideline-supported treatment options for women with early stage breast cancer involves considerations of breast conservation and travel burden: Mastectomy requires travel for surgery, whereas breast-conserving surgery (BCS) with adjuvant radiation therapy (RT) requires travel for both surgery and RT. This provides a unique opportunity to evaluate the impact of travel distance on surgical decisions and receipt of guideline-concordant treatment. Materials and Methods: We included 61,169 women diagnosed with early stage breast cancer between 2004 and 2013 from the Surveillance Epidemiology and End Results (SEER)-Medicare database. Driving distances to the nearest radiation facility were calculated by using Google Maps. We used multivariable regression to model treatment choice as a function of distance to radiation and Cox regression to model survival. Results: Women living farthest from radiation facilities (>50 miles vs. <10 miles) were more likely to undergo mastectomy versus BCS (odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.22-1.79). Among only those who underwent BCS, women living farther from radiation facilities were less likely to receive guideline-concordant RT (OR: 1.72, 95% CI: 1.32-2.23). These guideline-discordant women had worse overall (hazards ratio [HR]: 1.50, 95% CI: 1.42-1.57) and breast-cancer specific survival (HR: 1.44, 95% CI: 1.29-1.60). Conclusions: We report two breast cancer treatments with different clinical and travel implications to show the association between travel distance, treatment decisions, and receipt of guideline-concordant treatment. Differential access to guideline-concordant treatment resulting from excess travel burden among rural patients may contribute to rural-urban survival disparities among cancer patients.

Driving Distance and Patient-Reported Outcomes in Hematopoietic Cell Transplantation Survivors

Long driving distances to transplantation centers may impede access to care for hematopoietic cell transplantation (HCT) survivors. As a secondary analysis from the multicenter INSPIRE study (NCT01602211), we examined baseline data from relapse-free HCT adult survivors (2 to 10 years after allogeneic or autologous HCT) to investigate the association between driving distances and patient-reported outcome (PRO) measures of distress and physical function. We analyzed predictors of elevated distress and impaired physical function using logistic regression models that operationalized driving distance first as a continuous variable and separately as a dichotomous variable (<100 versus 100+ miles). Of 1136 patients available for analysis from 6 US centers, median driving distance was 82 miles and 44% resided 100+ miles away from their HCT centers. Elevated distress was reported by 32% of patients, impaired physical function by 19%, and both by 12%. Driving distance, whether operationalized as a continuous or dichotomous variable, had no impact on distress or physical function in linear regression modeling (95% confidence interval, 1.00 to 1.00, for both PROs with driving distance as a continuous variable). In contrast, chronic graft-versus-host-disease, lower income, and lack of Internet access independently predicted both elevated distress and impaired physical function. In summary, we found no impact of driving distance on distress and physical function among HCT survivors. Our results have implications for how long-term follow-up care is delivered after HCT, with regard to the negligible impact of driving distances on PROs and also the risk of a "digital divide" worsening outcomes among HCT survivors without Internet access.

Differences in Travel Time to Cancer Surgery for Colon versus Rectal Cancer in a Rural State: A New Method for Analyzing Time-to-Place Data Using Survival Analysis

PURPOSE

Rectal cancer is rarer than colon cancer and is a technically more difficult tumor for surgeons to remove, thus rectal cancer patients may travel longer for specialized treatment compared to colon cancer patients. The purpose of this study was to evaluate whether travel time for surgery was different for colon versus rectal cancer patients.

METHODS

A secondary data analysis of colorectal cancer (CRC) incidence data from the Iowa Cancer Registry data was conducted. Travel times along a street network from all residential ZIP Codes to all cancer surgery facilities were calculated using a geographic information system. A new method for analyzing "time-to-place" data using the same type of survival analysis method commonly used to analyze "time-to-event" data is introduced. Cox proportional hazard model was used to analyze travel time differences for colon versus rectal cancer patients.

RESULTS

A total of 5,844 CRC patients met inclusion criteria. Median travel time to the nearest surgical facility was 9 minutes, median travel time to the actual cancer surgery facilities was 22 minutes, and the median number of facilities bypassed was 3. Although travel times to the nearest surgery facilities were not significantly different for colon versus rectal cancer patients, rectal cancer patients on average traveled 15 minutes longer to their actual surgery facility and bypassed 2 more facilities to obtain surgery.

DISCUSSION

In general, the survival analysis method used to analyze the time-to-place data as described here could be applied to a wide variety of health services and used to compare travel patterns among different groups.