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

Abstract

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 guidelineconcordant 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.

COVID‐19 test sites in Victoria approaching Stage 4 restrictions: evaluating the relationship between remoteness, travel time and population serviced

“… 53 The significantly longer travel times that people in remote localities within Victoria experienced to visit a COVID‐19 POCT site during the time in question could have hindered the use of such sites. An evidence‐based review conducted by Syed, Gerber and Sharp 54 confirmed that travel barriers – including distance – hinder health service use (subsequent to their review, this finding has been confirmed 55 ). Despite the severity of COVID‐19 and the recognition that swift response is needed, under the current context, people in rural and remote Victoria with poor proximate POCT site availability may have decided to forgo being tested.…”

Rural–urban differences in secular trends of locoregional treatment for ductal carcinoma in situ: A patterns of care analysis

“…Rural patients diagnosed with DCIS were less likely than urban patients to receive PORT following BCS in our analysis and, during 1991/1995 only, significantly more likely to receive mastectomy than BCS. While previous research has identified geographic and rural–urban differences in treatment for patients diagnosed with early‐stage, invasive breast cancer, 14–19 this is the first large, population‐based study to characterize a recent 25‐year trend in locoregional treatment and evaluate differences between rural and urban DCIS patients. Previous studies evaluating rural–urban treatment differences have been sparse and limited by less recent time periods and smaller geographic regions 20–22 …”

“…[7][8][9][10][11][12][13] Previous studies have reported significant differences in locoregional treatment patterns among patients diagnosed with invasive breast cancer by geographic region and across the rural-urban continuum. [14][15][16][17][18][19] However, few studies have evaluated whether such differences also exist among DCIS patients residing in rural versus urban areas. 12,[20][21][22] The purpose of this study was compare the type of cancer-directed surgery performed and use of PORT between rural and urban women diagnosed with DCIS between 1991 and 2015.…”

“…Previous studies have reported significant differences in locoregional treatment patterns among patients diagnosed with invasive breast cancer by geographic region and across the rural–urban continuum 14–19 . However, few studies have evaluated whether such differences also exist among DCIS patients residing in rural versus urban areas 12,20–22 .…”

Consensus Statement Supporting the Presence of Onsite Radiation Oncology Departments at VHA Medical Centers

“…Travel time and transportation difficulties have been established in multiple studies as barriers to radiotherapy for both definitive and palliative management. [15][16][17][18] Travel for radiotherapy was much less frequently reported as a barrier among respondents with onsite radiation oncology departments compared with those without onsite radiation departments (28% vs 71%, respectively; P < .001).…”