There has been extensive centralization of complex cancer surgery over the past decade. While this process should result in population-level improvements in cancer outcomes, centralization is increasing patient travel. For some subsets of the population, increasing travel requirements may pose a significant barrier to access to quality cancer care.

The burden of readmissions after major cancer surgery is high, resulting in substantially poorer patient outcomes and higher costs. Risk of readmission was most strongly associated with length of stay and discharge destination. Travel distance also has an impact on patterns of readmission. Interventions targeted at higher risk individuals could potentially decrease the population burden of readmissions after major cancer surgery.

The social ecological perspective provides a compelling justification for multilevel intervention. Yet, it offers little guidance for selecting interventions that work together in complementary or synergistic ways. Using a causal modeling framework, we describe five strategies for increasing potential complementarity or synergy among interventions that operate at different levels of influence: accumulation, amplification, facilitation, cascade, and convergence. We illustrate these strategies with examples of multilevel interventions to improve the quality of cancer treatment.

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Background Robotic surgery has been widely adopted for radical prostatectomy. We hypothesize that this change is rapidly shifting procedures away from hospitals that do not offer robotics and consequently increasing patient travel. Methods A population-based observational study of all prostatectomies for cancer in NY, NJ, and PA from 2000–2009 was performed using hospital discharge data. Hospital procedure volume was defined as the number of prostatectomies performed for cancer in a given year. Straight-line travel distance to treating hospital was calculated for each case. Hospitals were contacted to determine year of acquisition of first robot. Results From 2000–2009, the total number of prostatectomies performed annually increased substantially. The increase occurred almost entirely at the very high volume centers (≥106 prostatectomies/year). The number of hospitals performing prostatectomy fell 37% from 2000–2009. By 2009, the 9% (21/244) of hospitals that had very high volume performed 57% of all prostatectomies, and the 35% (86/244) of hospitals with a robot performed 85% of all prostatectomies. Median travel increased 54% from 2000–2009, p<0.001. The proportion of patients traveling ≥15 miles increased from 24% to 40%, p<0.001. Conclusions Over the past decade, the number of radical prostatectomies performed has risen substantially. These procedures have been increasingly centralized at high volume centers, leading to longer patient travel distances. Few prostatectomies are now performed at hospitals that do not offer robotic surgery. Future work should focus on the impact of these trends on cancer control, functional outcomes, access to care and cost.

Practice patterns have changed substantially to follow national recommendations for centralization of complex cancer surgery. Despite this, disparities remain with regard to access to HVCs.

Resection of the HA or CA with reconstruction may prolong survival for selected patients who undergo pancreatic resection after neoadjuvant therapy. However, this aggressive approach did not result in any long-term survivors in our series.