Travel distance to health care associated with advanced colon cancer stage at diagnosis

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1. Greater travel distance to diagnosing centers is associated with more advanced colon cancer stage and earlier initiation of treatment.

Evidence rating level: 2 (Good)

Study Rundown: The effects of travel burden on patient access to and use of health care have been documented in numerous studies demonstrating delays in diagnosis and impact on care. However, it remains unclear whether this is a national phenomenon or if the effects of travel distance are limited to more remote regions, given the geographic variability in the United States. The purpose of this study was to investigate whether travel distance impacts stage of cancer at diagnosis in a national cohort; furthermore, whether there is a relationship between travel distance and time to receipt of standard therapeutic interventions.

At the conclusion of this study, the authors found that patients traveling greater than 50 miles to the diagnosing facility were more likely to present with metastatic disease than those traveling shorter distances. They also found that greater travel distance was positively associated with earlier receipt of therapy. Based on these results, the authors suggest that disparities in cancer care may be addressed not only through issues of health care coverage but also difficulties in accessing cancer care.

Some limitations of the study are noteworthy. Since only patients with colon cancer were included in this study, generalizability may be limited. Furthermore, there was no data available on patients’ ability to travel or information of provider availability at patients’ original locations. Travel distance was estimated based on ZIP codes, with no information on mode of transport. Finally, patients who may have refused care following diagnosis were not included.

Click to read the article in JCO

Relevant reading: Geographic access to cancer care in the U.S.

In-Depth [retrospective cohort]: The authors used data from the National Cancer Data Base (NCDB) on patients with colon cancr diagnosed from 2003 through 2010. Patients without histologic or cytologic confirmation, with non-colorectal previous cancer diagnosis, patients with cancer of the appendix or rectum, non-adenocarcinoma, and unknown stage or travel distance to the diagnosing center were excluded. Ultimately 296,474 patients were included, most being diagnosed at a comprehensive community care center and more than 50% seeking care in the Southeast, Great Lakes, and Atlantic region. This cohort was divided into short (<12.5 miles), intermediate (12.5 to 49.9 miles) and long (>50 miles) travel distance, and hierarchical regression modeling was used to evaluate the primary outcome, stage at diagnosis. Secondary outcomes included time to receipt of initial therapy.

The proportion of black patients, patients with higher income, and lower education all significantly decreased with increasing travel distance (p < 0.001). Patients traveling >50 miles were more likely to present with metastatic disease than patients traveling shorter distances (odds ratio 1.18, 95% CI 1.12-1.24). Patients with cancer at any stage and among the stage IV subgroup who traveled a long distance were 10% and 9%, respectively, more likely to initiate therapy earlier (HR 1.10; 95% CI 1.08-1.13; HR 1.09, 95% CI 1.03 TO 1.15). These results held through sensitivity analysis.

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