Travel Distance to Healthcare Centers is Associated with Advanced Colon Cancer at Presentation

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1 Travel Distance to Healthcare Centers is Associated with Advanced Colon Cancer at Presentation Yan Xing, MD, PhD, Ryaz B. Chagpar, MD, MS, Y Nancy You MD, MHSc, Yi Ju Chiang, MSPH, Barry W. Feig, MD, George J Chang, MD, MS, & Janice N. Cormier, MD, MPH Center for Surgical Outcomes Group Department of Surgical Oncology The University of Texas MD Anderson Cancer Center Houston, TX

2 Disclosures No financial conflicts of interest or other disclosures.

3 Colon Cancer The third most common malignancy among both men and women in the United States 2010 estimates: 142,570 incident cases; 51,370 deaths At the time of initial diagnosis, approximately 19% of colon cancer cases are diagnosed with distant metastases (stage IV), with a reported 5 year survival of 6 12%. (Altekruse; Edge) Altekruse SF, et al: SEER Cancer Statistics Review. Bethesda, MD, National Cancer Institute, Edge SB, et al, AJCC Cancer Staging Manual, 7 th ed., 2009, Springer: New York.

4 Disease specific survival from NCDB ( ) Stage I Stage II Survival Stage III Time (years) Stage IV

5 Access to Healthcare Access to care has been examined in various conditions, including: HIV, obesity, stroke, myocardial infarction and cancer. Access to cancer care has been evaluated in the context of Diagnosis: Breast Cancer, Melanoma Treatment: surgery, chemotherapy and radiation therapy Long travel distance has been shown to be associated with poor outcome Stage at presentation Treatment compliance Survival

6 Objective We sought to determine whether advanced stage colon cancer (IV) at presentation was associated to patient travel distance from residence to diagnostic healthcare center.

7 National Cancer Database (NCDB) Joint program of the American College of Surgeons Commission on Cancer (CoC) and the American Cancer Society Nationally representative, quality controlled, hospitalbased cancer registry Captures ~70% of all cancer diagnoses within the US from more than 1400 hospitals Data collected by trained abstracters, additional electronic and site specific methods of quality assessment

8 Study Design All patients diagnosed with stage I, II, III, IV colon adenocarcinoma between (n=379,719) Patients were staged according to the 6 th edition of the American Joint Committee on Cancer staging system using pathologic variables for tumor depth of penetration, nodal status, and presence of distant metastases.

9 Study Design Class of Case Diagnosis at the reporting facility First course of treatment was performed elsewhere Diagnosis at the reporting facility, First course of treatment delivered at facility Diagnosis elsewhere First course of treatment performed at the reporting facility Hospitals identified as diagnostic facility included

10 Study Design Travel distance: the driving distance (miles), using the shortest route from a patient s zip code centroid to the hospital street address where the diagnosis of colon cancer was established. Three distance groups (Baldwin L, et al): Local ( 50 miles) Intermediate ( miles) Long (>100 miles) Multivariate logistic regression analysis Evaluate the relationship between travel distance and the likelihood of presenting with stage IV colon cancer relative to stage I III disease. Adjusted for age, gender, race, education, insurance status, year of diagnosis, facility type, and treatment site

11 Results Travel distance was available for 86.3% of the cohort. Of those with recorded travel distance (n=327,805) Intermediate (3.7%) Long (1.5%) Local (94.8%)

12 Stage IV patients stratified by the travel distance Percentage >100 Travel Distance (Miles) Stage IV patients comprised 21%, 22%, and 25% of patients traveling local, intermediate and long distances.

13 Independent Risk Factors for Stage IV Colon CA at Diagnosis Stage IV OR 95% CI Travel Distance (vs. 50 miles) > Age (vs. <50) years Year of Diagnosis vs Insurance Status (vs. Private) Medicare Medicaid Uninsured Other Govt Plan

14 Independent Risk Factors for Stage IV Colon CA at Diagnosis Stage IV OR 95% CI Gender Male vs. Female Race (vs. Caucasian) African American Hispanic Asian/Pacific Islander Diagnosis and treatment facility Same vs. different Facility type (vs. Community) Comprehensive Academic/Research

15 Limitations Distance to diagnostic site may not correspond to closest site available in all patients. Misclassification: overestimated or underestimated travel distances.

16 Conclusions When compared to local access ( 50 miles), long travel distance (> 100 miles) was associated with an 18% increase in risk for diagnosis of stage IV colon cancer.

17 Conclusions Other independent factors associated with advanced disease at diagnosis included Younger age Male gender African American race Inadequate insurance Earlier year of diagnosis Academic/Research Program Diagnosed and treated at different facility

18 Implications These data suggest that in order to improve colon cancer outcomes, policy makers should consider creative strategies to target populations that are underserved for early cancer detection with convenient, local access to diagnostic care, such as mobile screening units.

19 Acknowledgements Commissions on Cancer Department of Surgical Oncology, MDACC Institute of Cancer Care Excellence, MDACC