We read with great interest the article by Sutton and colleagues, 1 who performed a retrospective population-level analysis designed to identify factors influencing referral to high-volume centers (HVCs), treatment patterns, and overall survival (OS) in patients with pancreatic adenocarcinoma. This study and others emphasize the socioeconomic disparities and selection bias for HVC referrals. 1,2 Using the Oregon State Cancer Registry, the authors found patients cared for at HVCs were more likely to receive standard of care with improved survival, and that the patients treated at these centers were advantaged with respect to age, socioeconomic status, and regional access. The authors correctly identified several limitations of the study, including a median follow-up of 4.3 months, inability to discriminate resectable from unresectable locoregional disease, and nongeneralizability given the homogeneity of the study cohort. An additional methodologic concern is the use of annual pancreatectomy volume as a surrogate for high-and low-volume treatment centers for pancreatic cancer, based on studies demonstrating a benefit in perioperative outcomes and survival at HVCs for patients undergoing resection. However, the vast majority of study participants (83.9%) did not undergo surgical resection. 1 The study demonstrated a modest OS benefit in patients who received diagnosis and treatment at an HVC compared to a lowvolume center (LVC). The longer OS observed in patients who received care in both HVCs and LVCs is almost certainly biased toward patients with a favorable predicted prognosis. This would also explain the higher pancreatectomy rate in this cohort.Not surprisingly, uninsured and Medicaid payor status were strong negative predictors for receipt of chemotherapy and/or surgery. A recent study demonstrated an increased probability of 1-year survival for patients diagnosed with and treated for pancreatic adenocarcinoma in Medicaid expansion states. 3 However, socioeconomic and racial/ethnic disparities persisted. The present study was not able to capture racial and ethnic disparities given the homogenous demographic of the study population.Although HVCs may offer the most comprehensive care at a single location, equity of care is not necessarily having all care delivered in HVCs. Traveling to HVCs places a burden on patients and their families when certain treatments, such as chemotherapy, can be delivered close to home. The authors propose utilization and expansion of telehealth as a remedy to improve access to comprehensive cancer care and referral coordination while minimizing burdens to the patient (eg, travel) and treatment delays. The study does not capture use of telemedicine, virtual multidisciplinary tumor board, or whether the LVCs are a part of a greater cancer care alliance.Overall, this study appropriately recognizes disparities that exist for underserved patients with pancreatic cancer. The conclusion that diagnosis and/or treatment at HCVs is associated with improved overall survival may be overstate...