Travel time to hospital and treatment for breast, colon, rectum, lung, ovary and prostate cancer
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.
Section snippets
Setting
The study area was northern England, the area covered by the Northern and Yorkshire Cancer Registry (NYCRIS) stretching south from the Scottish border to beyond the River Humber. The region has a population of around 6.7 million. It is diverse both geographically and demographically. There are sparsely populated areas with remote farms and hamlets (upland North Cumbria, Northumberland and North Yorkshire) and densely populated conurbations (Leeds/Bradford, Newcastle upon Tyne, Middlesbrough)
Results
Altogether 117,097 patients were included in the study, with fewer numbers of ovarian cancer patients compared with the other sites. Numbers receiving the different treatments, stratified by age, are given in Table 1. All the treatments were primary and not for tumour recurrence or metastasis. The frequency of each treatment varied considerably. As anticipated, the provision of all treatments was more common in the younger (<70 years) age group for all tumour sites. Most breast, colon, rectal
Discussion
No clear picture of the effect of physical accessibility on the likelihood of treatment has emerged from previous studies, but they have varied in their geographical setting, measurement of physical accessibility, and ability to control for other influences. The likelihood of receiving surgery or chemotherapy was not related to the proximity of the service for most patients. The exceptions were surgery and chemotherapy for lung cancer patients and chemotherapy for rectal cancer patients, which
Conflict of interest statement
None declared.
Acknowledgements
We thank the staff at NYCRIS, especially Alison Crawford, for data matching and abstraction, and Dr. Eva Morris and Professor Bob Haward who gave advice regarding tumour pathology. We are also grateful to Dr. Chris Dibben of St Andrews University who gave assistance regarding amendment of IMD 2004 Scores. The procedure to protect the confidentiality of patients’ addresses was approved by the Patient Information Advisory Group and the study received ethical approval. The research was funded by
References (29)
- et al.
Travel times and radiotherapy uptake in two English counties
Public Health
(1997) - et al.
Hospital variation in referral for primary radiotherapy in South Netherlands, 1988–1999
Eur J Cancer
(2005) - et al.
Effect of distance to radiation treatment facility on use of radiation therapy after mastectomy in elderly women
Int J Rad Oncol Bio Phys
(2006) - et al.
Influence of delay on survival in patients with breast cancer: a systematic review
Lancet
(1999) - et al.
Travel times to health care and survival from cancers in Northern England
Eur J Cancer
(2008) Cancer in the UK – A question of culture
Eur J Cancer
(2000)- Ministry of Health. A hospital plan for England and Wales, cmnd 1604. London: Her Majesty’s Stationery Office;...
- EAGC (Expert Advisory Group on Cancer). A policy framework for commissioning cancer services: a report by the Expert...
- et al.
Access to specialist cancer care: is it equitable?
Brit J Cancer
(2002) - et al.
Transportation as a barrier to cancer treatment
Cancer Pract
(1997)
Social and economic factors in the choice of lung cancer treatment. A population-based study in two rural areas
New Engl J Med
The influence of age and comorbidity on receiving radiotherapy as part of primary treatment for cancer in South Netherlands, 1995 to 2002
Cancer
Influence of rural environment on diagnosis, treatment and prognosis of colorectal cancer
J Epidemiol Comm Health
Possible explanations for social class differences in cancer patient survival
Cited by (135)
Radiation Therapy Caseload Treatment Volume: Does It Matter?
2023, International Journal of Radiation Oncology Biology PhysicsGeographic accessibility to cancer treatment in Brazil: A network analysis
2022, The Lancet Regional Health - Americas