Patients with pancreatic ductal adenocarcinoma who traveled from urban or rural counties to receive surgical care at academic centers demonstrated significantly better survival outcomes, according to a study published in Journal of the American College of Surgeons.
Further, both patients with papillary thyroid carcinoma and pancreatic ductal adenocarcinoma (PDAC) who traveled for care reported considerable improvements in quality of care.
Raymon H. Grogan
“Little was known about whether traveling to receive surgical cancer care results in differences in perioperative outcomes and OS,” Raymon H. Grogan, MD, FACS, assistant professor of surgery at The University of Chicago Medicine, said in a press release. “We wanted to know: If you live in a rural area, does it benefit you to travel to a high-volume academic medical center for your cancer operation?”
Previous research has shown most thyroidectomies in the United States are done by surgeons who perform fewer than seven per year, which is significantly less than the 25 to 30 thyroidectomies commonly accepted as a minimal threshold to be considered a high-volume surgeon.
Further, better patient outcomes have been linked to high-volume surgeons.
Grogan and colleagues used the National Cancer Data Base to examine demographic and treatment differences, as well as OS, for patients with papillary thyroid carcinoma or PDAC who traveled for care at academic centers compared with those who received care closer to home or at community centers.
Researchers considered patients to have traveled for cancer care if the shortest distance from their home to a treatment center was greater than the square foot of the area of their county if they lived in a metropolitan or metropolitan-adjacent county, or if the distance was greater than twice the square root of the area of their county if it was outside the metropolitan area.
The minimum distance for those considered travelers ranged from 20 to 84 miles. Researchers excluded patients residing in the Pacific and mountain regions because of discordant travel lengths.
The analysis included 105,677 patients diagnosed with papillary thyroid carcinoma between 2010 and 2013, and 22,983 patients diagnosed with PDAC between 2005 and 2013 who underwent operative resection.
Among all patients with PDAC, 81.6% (n = 18,761) resided in a metropolitan area and 18.4% (n = 4,222) resided in urban or rural areas.
A greater proportion of individuals did not travel for their care than those who traveled to an academic center for both metropolitan residents (78.6% vs. 21.4%) and residents of urban or rural areas (54.6% vs. 45.4%).
Rates of complete resection and lymph node dissection appeared higher among patients who traveled.
Further, fewer patients who traveled received chemotherapy and radiation therapy for both metropolitan residents (56.6% vs. 66.6%) and urban/rural residents (54.9% vs. 75.5%).
Survival significantly improved among those who traveled to academic centers for metropolitan residents (HR = 0.93; P = 0.001) on univariable analysis and patients from urban or rural counties (HR = 0.89; 95% CI, 0.82-0.96) on multivariable analysis.
Thyroid cancer care
Of the 91,632 patients with papillary thyroid carcinoma who resided in a metropolitan area, 91% (n = 83,390) did not travel for their cancer care and 9% (n = 8,242) did. Among the 14,505 patients from urban or rural settings, 77.8% (n = 10,930) did not travel to academic centers and 22.2% (n = 3,115) did.
Traveling for care appeared more common among those with higher-stage disease, men, older patients and those with Medicare compared with nontravelers from the same geographic areas. Although treatment followed National Comprehensive Cancer Network or American Thyroid Association guidelines for most patients, guidelines adherence appeared greater for patients traveling for their care in the metropolitan group (98.2% vs. 97.8%; OR = 1.22; 95% CI, 1.05-1.48) and in the urban/rural group (98.2% vs. 97.3; OR = 2.09; 95% CI, 1.45-3.01).
On univariable analysis, patients traveling for their care had worse OS than patients who did not travel, which partially reflects that patients with papillary thyroid carcinoma who traveled for care were older and had more advanced stage. After adjusting for demographic and tumor characteristics, however, survival for travel groups showed no statistically significant differences.
Overall, Grogan and colleagues estimated that 9% of patients with thyroid cancer and 25% of patients with pancreatic cancer traveled for their surgical care.
“Our data do not necessarily show that patients who don’t travel for cancer care receive suboptimal care,” Grogan said. “Rather, patients who travel more often receive the gold standard care — care that more often conforms with evidence-based recommendations. Although we found that travel is associated with better outcomes, the vast majority of these patients with cancer are not traveling for their care.” – by Chuck Gormley
Researchers report no relevant financial disclosures.