Travel time to hospital and treatment for breast, colon, rectum, lung, ovary and prostate cancer

Abstract

The aim was to examine the effect of geographical access to treatment services on cancer treatment patterns. Records for patients in northern England with breast, colon, rectal, lung, ovary and prostate tumours were augmented with estimates of travel time to the nearest hospital providing surgery, chemotherapy or radiotherapy. Using logistic regression to adjust for age, sex, tumour stage, selected tumour pathology characteristics and deprivation of place of residence, the likelihood of receiving radiotherapy was reduced for all sites studied with increasing travel time to the nearest radiotherapy hospital. Lung cancer patients living further from a thoracic surgery hospital were less likely to receive surgery, and both lung cancer and rectal cancer patients were less likely to receive chemotherapy if they lived distant from these services. Services provided in only a few specialised centres, involving longer than average patient journeys, all showed an inverse association between travel time and treatment take-up.

Introduction

Since the Hospital Plan of 1962, services in the UK have become increasingly concentrated in district general hospitals, located near the population centres they serve. Services such as radiotherapy and thoracic surgery were recognised as needing larger catchments and were provided only in certain district hospitals.¹ The Calman–Hine Report later reviewed services, recommending that outcomes would be improved by further consolidation in fewer, larger units with more specialist knowledge, better facilities and sufficient patient throughput to promote expertise.² The advantages of centralising services were expected to outweigh any disadvantage of longer travel for some patients, but little was known about the effects of patient travel to hospital on treatment uptake. Recently, some concern has been expressed that the centralisation of services in large city hospitals might lead to problems in gaining access for more distant, rural, populations. In particular, the demands of treatment at a distant location, especially where the intention is palliation and treatment is administered regularly, might deter some patients from undergoing therapy if the apparent cost and effort involved outweighed the perceived health benefits.3, 4 For example, in a US study, nearly 50% of cancer patients stated that long travel distance, not having access to a vehicle and having no-one to accompany them would be barriers to receiving treatment.⁵

A number of factors have been widely reported to influence the particular treatment any patient receives. These include co-morbidities and marital status,6, 7 expected lifespan, deprivation,6, 8, 9 extent of the tumour and its pathology,¹¹ type of hospital visited4, 12 and specialist consulted,13, 14 and surgical referral practice.¹⁵

Relatively few studies have examined the effect of geographical accessibility on treatment. Some have used a simple urban-rural classification. Rural colorectal patients in Scotland were found to be more likely to receive chemotherapy than were urban patients, but the difference was not statistically significant and the effect of differences in stage of disease at diagnosis could not be assessed.¹⁶ In France, no significant difference in uptake of surgery for colorectal cancer was reported between urban and rural residents after adjusting for age, sex, tumour pathology, stage and type of hospital.⁸ However, Madelaine et al. reported significantly lower treatment rates for rural lung cancer patients in France, after taking occupational class into consideration.¹⁷

Some studies have used straight line distance or estimated travel times as a proxy for travel effort. Punglia et al. found that increasing distance to the nearest radiotherapy centre was associated with a decreasing likelihood of receiving post-mastectomy radiation therapy, with an Odds Ratio of 0.996 with each additional mile.¹⁸ In rural USA, non small-cell lung cancer patients living at greater straight line distance from a specialist cancer centre were significantly more likely to undergo surgery but were less likely to receive radiotherapy or chemotherapy than closer patients.⁶ That work concluded those living at greater distance from hospital favoured surgery over other options because of travel implications: surgery required one hospitalisation whereas chemotherapy and radiotherapy may have required repeated visits for treatment. Faced with two treatment options offering equivalent survival, patients might weigh the costs in terms of time, expense and inconvenience of travel to therapy against the perceived benefits. Molenaar et al. came to similar conclusions for breast cancer patients in the Netherlands¹⁹ as did Nattinger et al. in the USA.²⁰ Older women, those in work or with childcare commitments in that study were more likely to opt for mastectomy and avoid the outpatient radiotherapy visits advised after breast conserving surgery. Using a more sophisticated methodology based on road travel times, Athas et al. found that breast cancer patients living further than 75 miles from a radiotherapy hospital were significantly less likely to receive adjuvant post-operative radiotherapy than those living closer.²¹

In the UK, Cosford et al. found no significant relationship between area-based measures of average drive time to a radiotherapy facility and the proportion of patients receiving radiotherapy.³ This was a small study in which travel times were not calculated for individual patients and no correction was made for case-mix, sex, stage or pathology. Furthermore, the setting was central England, where maximum travel times were short (up to 1 hour). A more recent study by Campbell et al. in north-east Scotland,¹⁰ where rural remoteness is much more of an issue, used straight-line distance to the closest cancer centre as a proxy for rurality and adjusted for the effects of age, tumour pathology, stage and deprivation. They found no significant relationship between this measure and uptake of chemotherapy, radiotherapy or surgery for lung cancer patients, but colorectal cancer patients living further from a cancer centre were significantly less likely to receive radiotherapy.

This study examines the effect of geographical access on the uptake of surgery, chemotherapy and radiotherapy for cancer in a region of England containing urban populations living close to health facilities and remote rural populations much more distant from hospitals. We test the hypothesis that increasing travel effort may decrease access to important treatment services. The research aims to improve on the methodology of previous work by including a large number of patient records involving several cancer sites, by allowing for other influences on treatment likelihood in a systematic way and by using more appropriate measures of access to treatment.