\\MENT OF HEALTH & HUMAN
SERVICES . USA
Published in final edited form as: J Surg Oncol. 2023 October ; 128(5): 749-763. doi:10.1002/jso.27387.
Association between travel distance and overall survival among patients with adrenocortical carcinoma
Charles D. Logan, MD1,2, Sara E. A. Nunnally, MD1, Catherine Valukas, MD1, Samantha Warwar, MD1, Joanna T. Swinarska, MD1, Frances T. Lee, MD1, David J. Bentrem, MD, MS1, David D. Odell, MD, MMSc1,2, Dina M. Elaraj, MD1, Cord Sturgeon, MD1 1Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern Medicine, Chicago, Illinois, USA
2Department of Surgery, Canning Thoracic Institute, Northwestern Medicine, Chicago, Illinois, USA
Abstract
Background and Objectives: Regionalization of care is associated with improved perioperative outcomes after adrenalectomy. However, the relationship between travel distance and treatment of adrenocortical carcinoma (ACC) is unknown. We investigated the association between travel distance, treatment, and overall survival (OS) among patients with ACC.
Methods: Patients diagnosed with ACC between 2004 and 2017 were identified with the National Cancer Database. Long distance was defined as the highest quintile of travel (≥42.2 miles). The likelihood of surgical management and adjuvant chemotherapy (AC) were determined. The association between travel distance, treatment, and OS was evaluated.
Results: Of 3492 patients with ACC included, 2337 (66.9%) received surgery. Rural residents were more likely to travel long distances for surgery than metropolitan residents (65.8% vs. 15.5%, p< 0.001), and surgery was associated with improved OS (HR 0.43, 95% CI 0.34-0.54). Overall, 807 (23.1%) patients received AC with rates decreasing approximately 1% per 4-mile travel distance increase. Also, long distance travel was associated with worse OS among surgically treated patients (HR 1.21, 95% CI 1.05-1.40).
Conclusions: Surgery was associated with improved overall survival for patients with ACC. However, increased travel distance was associated with lower likelihood to receive adjuvant chemotherapy and decreased overall survival.
Correspondence: Charles D. Logan, MD, Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery, Feinberg School of Medicine, Northwestern University, 633N St Clair St, 20th Floor, Chicago, IL 60611, USA. Charles.Logan@Northwestern.edu.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest. SUPPORTING INFORMATION
Keywords
adrenalectomy; rural population; travel
1 INTRODUCTION
Adrenocortical carcinoma (ACC) is a rare malignancy of the adrenal cortex with an annual incidence estimated at 1-2 per 1 million.1-3 It frequently portends a poor prognosis, with a median overall survival of about 3-4 years.1,3,4 Curative treatment can only be accomplished with complete surgical resection and is therefore recommended for all those who have potentially resectable tumors. Additionally, there may be a palliative benefit to surgery for unresectable functional tumors, as well as debated survival benefits to debulking in the cases of high tumor burden.2,3,5,6 Mitotane and cytotoxic agents are also cornerstones of ACC therapy, used as adjuvant therapy for resected disease at high risk of recurrence as well as for metastatic disease or tumors not amenable to surgical resection.2-6
Given the complexities of treatment as well as the importance of complete and often extensive surgical resection, guidelines strongly emphasize the importance of multidisciplinary care and surgical intervention by skilled adrenal and oncologic surgeons.3,4,6 Correspondingly, there has been a shift toward regionalization of care for ACC to enable patients to receive their care at high-volume, regional referral centers where they may benefit from greater clinical experience and evidence-based practices.7
Despite the benefits of regionalization of care for ACC and adrenalectomies in general, it is not without its drawbacks; a potential unintended consequence is the increase in travel distance for many rural patients. While numerous studies have sought to evaluate the relationship between travel distance and oncologic outcomes, particularly among hepatic, lung, and pancreatic cancers, a review of the literature suggests that the relationship between travel distance and outcomes for ACC is unknown.8-10 This study seeks to elucidate the association between travel distance, treatment, and overall survival among patients with ACC, an important consideration as regionalization of care becomes more prevalent and patient travel distances increase.
2 | METHODS
2.1 | Data source
The National Cancer Database (NCDB) is a hospital-based cancer registry with greater than 1500 contributing hospitals in the United States. Data in the NCDB is recorded by qualified cancer registrars with regular auditing and hospital program accreditation requires 90% annual follow-up for cancer patients who received treatment within a 5-year period.11 For this research study, the NCDB was used to identify patients with ACC diagnosed between 2004 and 2017 with at least 1 year of overall survival outcomes available. Patients were excluded if they had less than 1 year of outcomes available, missing travel distance or rurality data, had traveled greater than 250 miles, or received neoadjuvant therapy (Figure 1). Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)
guidelines were followed in the design of this study.12 Patient information in the NCDB is publicly available and deidentified and use in this research study was determined to be exempt from review by our institution’s institutional review board.
2.2 | Patient characteristics
Patient age at ACC diagnosis was included as a continuous variable. Race and ethnicity were categorized as non-Hispanic White, non-Hispanic Black, Hispanic, Asian American or Pacific Islander (AAPI), and other/unknown race or ethnicity. Insurance status was categorized by primary payor as Medicare or private, uninsured or Medicaid, and other insurance. Comorbidities are reported in the NCDB as Charlson-Deyo scores categorized as zero, one, two, or three or greater. Primary site included C750 and C749. Histology codes 8010, 8140, and 8370 were included. American Joint Committee on Cancer (AJCC) Eighth Edition stage was categorized as pathological stage I-IV. Patients with missing pathological stage data were categorized as missing.
2.3 Geographic characteristics
Rurality in the NCDB is reported with Rural-Urban Continuum codes and was categorized as nonrural (metropolitan) or rural (nonmetropolitan). Travel distance in the NCDB is calculated as the straight-line distance in miles between the centroid of a patient’s home address zip code to the street address of the reporting hospital. Patient travel distance was evaluated as a continuous variable and categorized into quintiles (<4.4, 4.4 to <9.1, 9.1 to <18.4, 18.4 to <42.2, and ≥42.2 miles). Where a dichotomous variable was required, long versus short travel distance was defined as ≥42.2 versus <42.2 miles. As described previously, patients who traveled >250 miles were excluded to reduce potential bias introduced by air travelers. 13
2.4 | Treatment characteristics
Surgery was defined as surgical resection at the reporting facility so that travel distance reflected distance to surgical treatment. Adjuvant therapy was defined as being administered at any facility-including at facilities other than where the patient received surgery. Treatment modalities were further categorized into observation, surgical resection only, surgical resection with adjuvant therapy, chemotherapy/chemoradiation, and radiation therapy only. Patients who received neoadjuvant therapy were excluded. Treatment at multiple facilities was categorized as a dichotomous variable.
2.5 | Statistical analysis
x2 tests were used to determine the significance of patient population differences between ☒ patients who traveled long distances or received adjuvant therapies and patients that did not. Median and interquartile range were reported for non-normally distributed continuous variables, while mean and standard deviation were reported for normally distributed variables. T tests and Mann-Whitney tests were used to evaluate the significance of differences between continuous variables, as appropriate. p values were two-sided and were considered statistically significant at p< 0.05.
2.5.1 | Multivariable regression evaluating likelihood of surgical treatment or adjuvant therapy-Multivariable Poisson regression was used to evaluate the association between rurality, travel distance, and likelihood of receipt of surgical treatment among patients with ACC while adjusting for confounders which would be known presurgery (age, race and ethnicity, year of diagnosis, comorbidities, insurance status, Medicaid state expansion status, income, education, tumor stage, and facility program type) (Poisson model 1).
An additional multivariable Poisson regression model was constructed to evaluate the association between travel distance as a continuous variable and likelihood of receipt of adjuvant therapy among patients who had received surgical treatment (Poisson model 2). The model was adjusted for confounders known both pre- and postsurgery (age, race and ethnicity, year of diagnosis, comorbidities, insurance status, Medicaid expansion status, income, education, rurality, tumor stage, vascular invasion, surgical margin, facility program type, treatment at multiple facilities). Incidence Rate Ratios (IRRs) were reported with 95% confidence intervals (CIs).
2.5.2 | Survival analysis-Separate Cox proportional hazard models were used to evaluate the association between travel distance, rurality, and treatment modality with overall survival (Cox models 1 to 7). Cox model 1 evaluated surgical versus nonsurgical management as a dichotomous variable. Cox model 2 evaluated treatment modalities as a categorical variable. Cox model 3 evaluated the association between travel distance and overall survival among patients who received surgical treatment. Cox model 4 evaluated the association between surgical versus nonsurgical treatment among rural residents who traveled long versus short distances. Cox model 5 evaluated the association between travel distance and overall survival among rural residents who received surgery.
Sensitivity analyses were conducted to evaluate the association between surgical and nonsurgical management among a cohort with nonmetastatic disease (Cox model 6) and separately among a cohort with metastatic disease (Cox model 7).
All Cox models were evaluated unadjusted as well as adjusted with confounders. Hazard Ratios were reported with 95% CIs. All model standard errors were adjusted for clustering at facilities. Kaplan-Meier curves with log-rank tests were used to compare long-term overall survival outcomes between patients who traveled long distances versus short distances for surgical treatment. All analyses were conducted with Stata MP Version 17.
3 | RESULTS
Overall, 3492 patients with ACC diagnosed between 2004 and 2017 were included (Figure 1). Among the overall cohort, 2337 (66.9%) had surgery and 1155 (33.1%) had nonsurgical management. Surgery was performed at the reporting facility in 2072 (59.3%) patients. The median age of the overall cohort was 56 (IQR 45-67) years (Table 1). The median age among those who received surgical treatment at the reporting facility was 55 (IQR 44-66) years (Table 2).
Of the overall cohort, 718 (20.6%) patients traveled long (≥42.2 miles, highest quintile) versus short (<42.2 miles) distances for care (Table 1). Patients who traveled long distances were more likely to be younger with a median age of 54 (IQR 44-65) years versus 57 (IQR 45-68) years for those who traveled short distances (p< 0.001). Long-distance travelers were also more likely to be rural residents of Medicaid nonexpansion states from zip code tabulation areas characterized by lower income and educational attainment (Table 1).
Patients from rural areas accounted for 15.0% of the overall cohort. Rural residents were more likely to travel long distances for surgical treatment than nonrural residents (65.8% vs. 15.5%, p< 0.001). The median travel distance for surgical treatment was significantly higher for rural versus nonrural residents (54, IQR 33-87 vs. 11, IQR 5-26 miles; p< 0.001). There was no statistically significant difference in prevalence of serious comorbidities, insurance status, or tumor stage between surgically treated rural and nonrural residents (Table 3).
Among patients treated near their home (<4.4 miles, lowest quintile), rural residents were statistically significantly less likely to receive surgical treatment for ACC (17.6%) compared with nonrural residents treated near their home (52.9%) (IRR 0.35, 95% CI 0.13-0.96).
In covariate adjusted Cox models evaluating the total cohort, surgical management was associated with significantly improved OS versus nonsurgical management (aHR 0.50, 95% CI 0.45-0.55).
When evaluating the association between treatment modalities and OS in the total cohort, surgery (aHR 0.37, 95% CI 0.31-0.43) and surgery with adjuvant therapy (aHR 0.42, 95% CI 0.35-0.51) were superior to observation, while observation was not statistically significantly different from chemotherapy/chemoradiation, or radiation therapy alone.
In sensitivity analysis, patients with nonmetastatic disease treated with surgery or surgery with adjuvant therapy had superior OS compared with observation, chemotherapy/ chemoradiation, or radiation therapy alone (Supporting Information: Table 1). Further, patients with metastatic disease treated with surgery or surgery and adjuvant therapy also had superior OS compared with observation, chemotherapy/chemoradiation, or radiation therapy alone (Supporting Information: Table 1).
However, among surgically treated patients, long-distance travel was an independent risk factor associated with worse OS even when controlling for patient, sociodemographic, clinical, tumor, and facility-level characteristics (aHR 1.21, 95% CI 1.05-1.40). Kaplan- Meier survival curves demonstrated worse 5-year overall survival among those who traveled long distances (Figure 2; log-rank p= 0.004). Also, median overall survival was 36.5 (95% CI, 31.3-47.0) versus 53.2 (95% CI, 45.9-60.5) months for long- versus short-distance travelers who received surgical treatment, respectively.
Adjuvant therapy was administered to 649 (31.3%) of 2072 patients surgically treated at the reporting facility (Table 4). In covariate adjusted multivariable regression, rates of adjuvant therapy decreased approximately 1% for every 4-mile increase in travel distance to the facility where the patient received surgical treatment (IRR 0.997, 95% CI 0.996-0.999; p= 0.006).
For rural residents who traveled long-distance, surgery was associated with superior OS in both unadjusted (HR 0.43, 95% CI 0.34-0.54) and covariate-adjusted Cox models (aHR 0.67, 95% CI 0.48-0.92) versus rural residents who received nonsurgical management.
However, among rural residents who received surgical treatment, long-distance travel was associated with worse OS (aHR 1.64, 95% CI 1.12-2.41 vs. short-distance travel).
4 | DISCUSSION
Regionalization of care has improved outcomes for patients in need of high-level, intensive care for ACC. In particular, adrenalectomies, which are the only potentially curative treatment for ACC, are associated with improved overall survival for patients when performed at high volume centers equipped with trained endocrine and oncologic surgeons.3,4,6 The results of this study support these findings, with surgical management associated with improved overall survival versus nonsurgical management across the total cohort. Indeed, surgery and surgery with adjuvant therapy were both superior in terms of overall survival to all other treatment modalities, including observation, chemotherapy/ chemoradiation, or radiation therapy alone.
However, regionalization of care may come at a price.13-19 Patients who must travel long distances to high-volume, regional referral centers for surgery are unlikely to receive surgery if they are unable or unwilling to travel-in this study, rural patients treated close to home (<4.4 miles, the lowest quintile), were less likely to receive surgery than their metropolitan counterparts. Even when patients in rural areas do receive surgical intervention, they are far more likely to have to travel long distances to do so. Among our cohort, rural residents were more likely to travel 42.2 miles or greater (the highest quintile of patient travel) for surgical treatment than metropolitan residents.
Additionally, this study suggests that even when patients receive operative treatment for their ACC, travel distance in and of itself is an independent variable associated with poor outcomes. Among surgically treated patients, those who traveled long distances had worse overall survival than those who did not travel long distances; this held true even when adjusted for confounding variables such as patient demographics, comorbidities, sociodemographics, tumor characteristics, and facility characteristics. Multiple studies have evaluated the relationship between travel distance and outcomes for oncologic care; while results have varied, several have found that increased travel distance is associated with poor short- and long-term outcomes.10,20-27 Siegel et al.10 hypothesize that those patients who must travel longer distances may have poorer health-related support networks close to home and must rely on virtual or telephonic care when complications arise or for routine follow-up. Stitzenberg et al.28 further suggest that these patients may disproportionately rely on local emergency room care for their complications, entrusting their care to physicians who are unfamiliar with their particulars of their cases and postoperative management. The results of this study corroborate these findings for ACC.
Furthermore, the effects of travel may also extend past surgical intervention. For instance, there was a notable decrease in rates of adjuvant therapy with increased travel in our
adjusted multivariable analysis, with an approximate 1% decrease for every 4-mile increase in travel distance. This may be due to care access disparities for those rural patients who may be unable to repeatedly travel long distances beyond a discrete event (e.g., surgery). It may also be due to care fragmentation, whereby their care is compromised as providers seek to coordinate treatment across geographically disparate sites.
This study had several limitations. First, it relied on Rural-Urban Continuum Codes (RUCC) in the NCDB to delineate rural areas; this method collapses areas into rural vs urban designations, which may suppress some important heterogeneity.29,30 Second, travel distance was calculated using a straight-line method from the centroid of a patient’s home address zip code. This may not always represent true travel distances as travel is not always feasible in a straight line, and the centroid of a zip code does not always correlate with the patient’s true travel origin.23 Furthermore, this study assumed that a patient’s home address represented their primary location during treatment, which may not have always been the case. Finally, although this study adjusted for demographic and clinical confounding variables, there are potentially other unknown confounders associated with travel distance and rurality for which adjustment was not possible. Subsequent studies would benefit from an expanded rural cohort to pressure-test whether these differences in outcome and survival persist, and among which patients.
Despite these limitations, the findings from our study reinforce the criticality of appropriate operative intervention for ACC. They also, however, highlight the disparities in care access inherent in regionalization of care, and further suggest that long travel distance may be an independent variable that affects overall survival for ACC even when adjusted for cofounding variables. Collectively, the findings from this study identify the need for high- quality surgical care for all patients, while simultaneously expanding access to care for rural residents to mitigate the effects of long-distance travel. High-volume academic centers may therefore benefit from implementing more robust patient outreach programs designed for distance-travelers, as well as resources aimed towards facilitating follow-up care and adjuvant therapy for those patients who must travel long-distances.
5
CONCLUSIONS
Surgery was associated with improved overall survival compared to nonsurgical management for both localized and metastatic adrenocortical carcinoma. However, few rural residents who sought care close to home were treated surgically. Most rural residents treated surgically traveled long distances for care. Unfortunately, among those treated surgically, increased travel distance was associated with lower likelihood of receipt of adjuvant therapies and decreased overall survival. Continued efforts to understand the reasons for rural and travel distance disparities in access to oncological services and patient survival may yield targets for future improvement initiatives.
Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
ACKNOWLEDGMENTS
The data used are derived from a deidentified NCDB file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology employed, or the conclusions drawn from these data by the investigator. Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number T37MD014248 (CDL), and the National Cancer Institute under Award Number K07 CA216330 (DDO). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
DATA AVAILABILITY STATEMENT
NA.
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National Cancer Database Adrenal PUF: 2004-2018 n=6,684
Total Excluded (n=3,192):
<1 year of outcomes available: n=546
Histology other than ACC: n=2,097
Missing rurality or travel distance: n=420
Travel >250 miles: n=83
Received neoadjuvant therapy: n=46
Stage I-IV Adrenocortical Carcinoma: 2004-2017 n=3,492
Stage I-III n=2,642
Stage IV n=850
100%
75%
Survival
50%
25%
Short Distance (<42.2 miles)
Long Distance (≥42.2 miles)
0%
0
1
3
5
| Risk Table | Years | Median Survival | ||
|---|---|---|---|---|
| Parameter | Number at Risk | Months (95% CI) | ||
| Short Distance (<42.2 mi), n=1,590 | 1,223 | 761 | 510 | 53.2 (45.9 - 60.5) |
| Long Distance (≥42.2 mi), n=478 | 359 | 202 | 127 | 36.5 (31.3 - 47.0) |
FIGURE 2. Kaplan-Meier curve evaluating the association between long travel distance (≥42.2 miles) and overall survival for surgically treated patients with adrenocortical carcinoma. Log-Rank p= 0.004. CI, confidence interval.
| N Parameter | Patient travel distance | |||
|---|---|---|---|---|
| Total 3492 % | <42.2 miles 2774 % | ≥42.2 miles 718 % | p Value | |
| Travel distance, median (IQR) | 12.5 (5.3-33.3) | 8.8 (4.3-18.0) | 74 (53.8-105.4) | <0.001 |
| Age, median (IQR) | 56 (45-67) | 57 (45-68) | 54 (44-65) | <0.001 ª |
| Sex | 0.06 | |||
| Female | 59.4 | 58.6 | 62.4 | |
| Male | 40.6 | 41.4 | 37.6 | |
| Race and ethnicity | <0.001 | |||
| Non-Hispanic White | 74.5 | 72.1 | 83.8 | |
| Non-Hispanic Black | 9.6 | 10.5 | 6.3 | |
| Hispanic | 6.7 | 7.4 | 4.0 | |
| Asian and Pacific Islander (AAPI) | 2.5 | 3.0 | 0.7 | |
| Other or unknown | 6.7 | 7.1 | 5.2 | |
| Income quartiles | <0.001 | |||
| Lowest | 15.4 | 13.1 | 24.5 | |
| Second | 21.1 | 18.3 | 31.8 | |
| Third | 26.2 | 26.5 | 25.1 | |
| Highest | 36.3 | 41.1 | 17.8 | |
| Missing | 1.0 | 1.1 | 0.8 | |
| Education quartiles | <0.001 | |||
| Lowest | 18.7 | 17.8 | 22.1 | |
| 2 | 24.5 | 23.1 | 30.1 | |
| 3 | 28.4 | 28.1 | 29.7 | |
| Highest | 27.4 | 30.0 | 17.4 | |
| Missing | 1.0 | 1.0 | 0.7 | |
| Insurance status | <0.001 | |||
| Medicare or private | 82.7 | 83.2 | 80.5 | |
| Medicaid or uninsured | 12.8 | 13.1 | 11.4 | |
| Other | 4.6 | 3.7 | 8.1 | |
Author Manuscript
Author Manuscript
Author Manuscript
J Surg Oncol. Author manuscript; available in PMC 2024 October 01.
| N Parameter | Patient travel distance | |||
|---|---|---|---|---|
| Total 3492 % | <42.2 miles | 2774 % ≥42.2 miles 718 % | p Value | |
| Medicaid expansion state | <0.001 | |||
| Yes | 68.7 | 70.0 | 63.8 | |
| No | 31.3 | 30.0 | 36.2 | |
| Year of diagnosis | <0.001 | |||
| 2004 | 5.5 | 5.4 | 5.7 | |
| 2005 | 6.0 | 6.3 | 4.9 | |
| 2006 | 6.3 | 6.5 | 5.9 | |
| 2007 | 6.8 | 6.5 | 7.8 | |
| 2008 | 7.7 | 7.5 | 8.2 | |
| 2009 | 6.7 | 7.2 | 4.9 | |
| 2010 | 7.7 | 7.3 | 9.3 | |
| 2011 | 7.1 | 6.9 | 7.9 | |
| 2012 | 7.2 | 7.2 | 7.4 | |
| 2013 | 7.9 | 7.6 | 8.9 | |
| 2014 | 8.4 | 8.3 | 8.9 | |
| 2015 | 7.5 | 7.9 | 5.6 | |
| 2016 | 7.0 | 7.4 | 5.4 | |
| 2017 | 8.3 | 8.0 | 9.2 | |
| Rurality | <0.001 | |||
| Rural | 15.0 | 7.2 | 45.1 | |
| Nonrural | 85.0 | 92.8 | 54.9 | |
| Facility program | <0.001 | |||
| Community | 3.9 | 4.7 | 0.7 | |
| Comprehensive | 25.0 | 28.1 | 13.1 | |
| Academic | 40.6 | 36.1 | 57.8 | |
| Integrated | 14.5 | 15.7 | 9.9 | |
| Other | 16.1 | 15.4 | 18.5 | |
| Charlson-Deyo score | 0.86 | |||
| 0 | 72.9 | 72.6 | 74.1 | |
| 1 | 19.3 | 19.5 | 18.7 | |
Logan et al.
| N Parameter | Patient travel distance | |||
|---|---|---|---|---|
| Total 3492 % | <42.2 miles 2774 % | ≥42.2 miles 718 % | p Value | |
| 2 | 5.1 | 5.2 | 4.7 | |
| ≥3 | 2.7 | 2.8 | 2.5 | |
| Pathological stage | 0.08 | |||
| I | 4.2 | 4.4 | 3.3 | |
| II | 33.5 | 34.1 | 31.3 | |
| III | 30.6 | 29.5 | 34.7 | |
| IV | 24.3 | 24.6 | 23.3 | |
| Missing | 7.4 | 7.4 | 7.4 | |
| Tumor grade | 0.24 | |||
| Well differentiated | 2.6 | 2.7 | 2.0 | |
| Moderately differentiated | 2.8 | 2.5 | 3.8 | |
| Poorly differentiated | 10.4 | 10.6 | 9.5 | |
| Undifferentiated | 4.0 | 4.1 | 3.8 | |
| Missing | 80.3 | 80.1 | 81.1 | |
| Treatment | <0.001 | |||
| Observation | 15.2 | 16.3 | 11.1 | |
| Surgical resection | 43.8 | 42.5 | 49.0 | |
| Surgery with adjuvant therapy | 23.1 | 22.9 | 23.8 | |
| Chemotherapy without surgery | 15.7 | 16.0 | 14.6 | |
| Radiation only | 2.1 | 2.3 | 1.4 | |
Abbreviation: IQR, interquartile range.
“Mann-Whitney test of patients who traveled >42.2 miles vs. < 42.2 miles.
| N Parameter | Patient travel distance to surgery | |||
|---|---|---|---|---|
| Total 2072 % | <42.2 miles 1593 % | ≥42.2 miles 479 % | p Value | |
| Travel distance, median (IQR) | 14 (6-38) | 10 (5-19) | 73 (53-105) | <0.001 |
| Age, median (IQR) | 55 (44-66) | 55 (44-66) | 54 (44-64) | 0.54 |
| Sex | 0.48 | |||
| Female | 39.6 | 40.0 | 38.2 | |
| Male | 60.4 | 60.0 | 61.8 | |
| Race and ethnicity | <0.001 | |||
| Non-Hispanic White | 76.1 | 73.4 | 85.2 | |
| Non-Hispanic Black | 8.8 | 9.7 | 5.6 | |
| Hispanic | 6.4 | 7.2 | 3.6 | |
| Asian and Pacific Islander (AAPI) | 2.5 | 3.0 | 0.6 | |
| Other or unknown | 6.3 | 6.7 | 5.0 | |
| Income quartiles | <0.001 | |||
| Lowest | 14.1 | 11.7 | 22.3 | |
| Second | 21.5 | 18.1 | 32.6 | |
| Third | 27.6 | 27.7 | 27.4 | |
| Highest | 36.0 | 41.6 | 17.3 | |
| Missing | 0.8 | 0.9 | 0.4 | |
| Education quartiles | <0.001 | |||
| Lowest | 17.9 | 16.7 | 21.9 | |
| 2 | 25.5 | 23.7 | 31.3 | |
| 3 | 28.4 | 28.0 | 29.7 | |
| Highest | 27.5 | 30.7 | 16.9 | |
| Missing | 0.7 | 0.9 | 0.2 | |
| Insurance status | <0.001 | |||
| Medicare or private | 84.4 | 84.6 | 83.7 | |
| Medicaid or uninsured | 12.0 | 12.7 | 9.8 | |
| Other | 3.6 | 2.7 | 6.5 | |
Author Manuscript
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J Surg Oncol. Author manuscript; available in PMC 2024 October 01.
| N Parameter | Patient travel distance to surgery | ||||
|---|---|---|---|---|---|
| Total 2072 % | <42.2 miles 1593 % | ≥42.2 miles 479 % | p Value | ||
| Medicaid expansion state | 0.009 | Logan | |||
| Yes | 70.3 | 71.8 | 65.6 | et al. | |
| No | 29.7 | 28.3 | 34.5 | ||
| Year of diagnosis | 0.54 | ||||
| 2004 | 6.0 | 6.0 | 5.9 | ||
| 2005 | 6.5 | 6.8 | 5.2 | ||
| 2006 | 6.7 | 6.6 | 6.9 | ||
| 2007 | 6.5 | 6.5 | 6.5 | ||
| 2008 | 8.2 | 8.2 | 8.1 | ||
| 2009 | 6.9 | 7.0 | 6.3 | ||
| 2010 | 8.1 | 7.5 | 10.0 | ||
| 2011 | 7.1 | 6.6 | 8.8 | ||
| 2012 | 7.1 | 7.0 | 7.1 | ||
| 2013 | 7.5 | 7.5 | 7.5 | ||
| 2014 | 8.4 | 8.3 | 8.8 | ||
| 2015 | 6.7 | 7.2 | 4.8 | ||
| 2016 | 6.7 | 7.0 | 5.6 | ||
| 2017 | 7.9 | 7.7 | 8.6 | ||
| Rurality | <0.001 | ||||
| Rural | 15.1 | 6.7 | 43.0 | ||
| Nonrural | 84.9 | 93.3 | 57.0 | ||
| Facility program | <0.001 | ||||
| Community | 2.5 | 3.1 | 0.6 | ||
| Comprehensive | 22.4 | 26.1 | 10.0 | ||
| Academic | 44.0 | 38.1 | 63.5 | ||
| Integrated | 13.9 | 15.3 | 9.2 | ||
| Other | 17.3 | 17.5 | 16.7 | ||
| Charlson-Deyo score | 0.79 | ||||
| 0 | 73.2 | 72.8 | 74.3 | ||
| 1 | 19.7 | 20.0 | 19.0 | ||
Author Manuscript
Author Manuscript
Author Manuscript
J Surg Oncol. Author manuscript; available in PMC 2024 October 01.
| N Parameter | Patient travel distance to surgery | |||
|---|---|---|---|---|
| Total 2072 % | <42.2 miles 1593 % | ≥42.2 miles 479 % p Value | ||
| 2 | 4.6 | 4.8 | 4.0 | |
| ≥3 | 2.5 | 2.4 | 2.7 | |
| Pathological stage | 0.03 | |||
| I | 5.2 | 5.5 | 4.0 | |
| II | 39.5 | 40.9 | 34.9 | |
| III | 33.1 | 31.5 | 38.4 | |
| IV | 18.7 | 18.5 | 19.4 | |
| Missing | ||||
| Tumor grade | 0.35 | |||
| Well differentiated | 3.2 | 3.5 | 2.3 | |
| Moderately differentiated | 3.6 | 3.3 | 4.6 | |
| Poorly differentiated | 10.1 | 10.2 | 9.6 | |
| Undifferentiated | 5.1 | 5.3 | 4.4 | |
| Missing | 78.0 | 77.7 | 79.1 | |
| Resection margin | 0.01 | |||
| R1, R2, or unspecified residual | 30.2 | 31.6 | 25.5 | |
| R0, no residual | 69.8 | 68.4 | 74.5 | |
| Treatment | 0.21 | |||
| Surgical resection | 68.7 | 68.0 | 71.0 | |
| Surgery with adjuvant therapy | 31.3 | 32.0 | 29.0 | |
Abbreviation: IQR, interquartile range.
| N Parameter | Rurality | |||
|---|---|---|---|---|
| Total 2072 % | Nonrural 1759 % | Rural 313 % | p Value | |
| Travel distance, median (IQR) | 14 (6-38) | 11 (5-26) | 54 (33-87) | <0.001 |
| Age, median (IQR) | 55 (44-66) | 55 (44-66) | 56 (46-66) | |
| Sex | 0.44 | |||
| Female | 39.6 | 39.2 | 41.5 | |
| Male | 60.4 | 60.8 | 58.5 | |
| Race and ethnicity | <0.001 | |||
| Non-Hispanic White | 76.1 | 74.3 | 86.3 | |
| Non-Hispanic Black | 8.8 | 9.4 | 5.1 | |
| Hispanic | 6.4 | 7.1 | 2.2 | |
| Asian and Pacific Islander (AAPI) | 2.5 | 2.8 | 0.3 | |
| Other or unknown | 6.3 | 6.3 | 6.1 | |
| Income quartiles | <0.001 | |||
| Lowest | 14.1 | 11.1 | 31.0 | |
| Second | 21.5 | 17.9 | 41.9 | |
| Third | 27.6 | 28.5 | 22.7 | |
| Highest | 36.0 | 41.7 | 3.8 | |
| Missing | 0.8 | 0.9 | 0.6 | |
| Education quartiles | <0.001 | |||
| Lowest | 17.9 | 16.8 | 24.3 | |
| 2 | 25.5 | 23.1 | 39.0 | |
| 3 | 28.4 | 28.1 | 30.0 | |
| Highest | 27.5 | 31.3 | 6.4 | |
| Missing | 0.7 | 0.8 | 0.3 | |
| Insurance status | 0.46 | |||
| Medicare or private | 84.4 | 84.7 | 82.8 | |
| Medicaid or uninsured | 12.0 | 11.7 | 14.1 | |
| Other | 3.6 | 3.6 | 3.2 | |
Author Manuscript
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J Surg Oncol. Author manuscript; available in PMC 2024 October 01.
| N Parameter | Rurality | ||||
|---|---|---|---|---|---|
| Total 2072 % | Nonrural 1759 % | Rural 313 % | p Value | ||
| Medicaid expansion state | <0.001 | Logan | |||
| Yes | 70.3 | 72.5 | 58.2 | et al. | |
| No | 29.7 | 27.5 | 41.9 | ||
| Year of diagnosis | 0.41 | ||||
| 2004 | 6.0 | 6.1 | 5.4 | ||
| 2005 | 6.5 | 6.8 | 4.8 | ||
| 2006 | 6.7 | 6.4 | 8.0 | ||
| 2007 | 6.5 | 6.3 | 7.7 | ||
| 2008 | 8.2 | 8.1 | 8.6 | ||
| 2009 | 6.9 | 6.9 | 6.4 | ||
| 2010 | 8.1 | 7.8 | 9.9 | ||
| 2011 | 7.1 | 6.7 | 9.6 | ||
| 2012 | 7.1 | 7.4 | 5.1 | ||
| 2013 | 7.5 | 7.6 | 7.0 | ||
| 2014 | 8.4 | 8.3 | 9.0 | ||
| 2015 | 6.7 | 7.1 | 4.5 | ||
| 2016 | 6.7 | 6.8 | 6.1 | ||
| 2017 | 7.9 | 7.9 | 8.0 | ||
| Travel distance (miles) | <0.001 | ||||
| <42.2 | 76.9 | 84.5 | 34.2 | ||
| ≥42.2 | 23.1 | 15.5 | 65.8 | ||
| Facility program | 0.007 | ||||
| Community | 2.5 | 2.3 | 3.5 | ||
| Comprehensive | 22.4 | 21.7 | 26.2 | ||
| Academic | 44.0 | 43.4 | 47.0 | ||
| Integrated | 13.9 | 14.9 | 8.3 | ||
| Other | 17.3 | 17.7 | 15.0 | ||
| Charlson-Deyo score | 0.69 | ||||
| 0 | 73.2 | 73.5 | 71.3 | ||
| 1 | 19.7 | 19.7 | 20.1 | ||
Author Manuscript
Author Manuscript
Author Manuscript
J Surg Oncol. Author manuscript; available in PMC 2024 October 01.
| N Parameter | Rurality | |||
|---|---|---|---|---|
| Total 2072 % | Nonrural 1759 % | Rural 313 % | p Value | |
| 2 | 4.6 | 4.4 | 5.8 | |
| ≥3 | 2.5 | 2.4 | 2.9 | |
| Pathological stage | 0.97 | |||
| I | 5.2 | 5.1 | 5.4 | |
| II | 39.5 | 39.4 | 39.9 | |
| III | 33.1 | 33.0 | 33.9 | |
| IV | 18.7 | 18.9 | 17.6 | |
| Missing | 3.6 | 3.6 | 3.2 | |
| Tumor grade | 0.30 | |||
| Well differentiated | 3.2 | 3.4 | 2.6 | |
| Moderately differentiated | 3.6 | 3.3 | 5.1 | |
| Poorly differentiated | 10.1 | 10.0 | 10.5 | |
| Undifferentiated | 5.1 | 5.4 | 3.5 | |
| Missing | 78.0 | 77.9 | 78.3 | |
| Resection margin | 0.07 | |||
| R1, R2, or unspecified residual | 30.2 | 30.9 | 25.9 | |
| R0, no residual | 69.8 | 69.1 | 74.1 | |
| Treatment | 0.08 | |||
| Surgical resection | 68.7 | 67.9 | 72.8 | |
| Surgery with adjuvant therapy | 31.3 | 32.1 | 27.2 | |
Abbreviation: IQR, interquartile range.
| N Parameter | Receipt of adjuvant therapy | |||
|---|---|---|---|---|
| Total 2072 % | Adjuvant 649 % | No adjuvant 1423 % | p Value | |
| Travel distance, median (IQR) | 14 (6-38) | 15 (6-35) | 14 (6-40) | |
| Age, median (IQR) | 55 (44-66) | 52 (41-62) | 56 (45-67) | |
| Sex | 0.03 | |||
| Female | 39.6 | 36.1 | 41.2 | |
| Male | 60.4 | 63.9 | 58.8 | |
| Race and ethnicity | 0.61 | |||
| Non-Hispanic White | 76.1 | 78.0 | 75.3 | |
| Non-Hispanic Black | 8.8 | 7.9 | 9.2 | |
| Hispanic | 6.4 | 6.2 | 6.5 | |
| Asian and Pacific Islander (AAPI) | 2.5 | 2.6 | 2.4 | |
| Other or unknown | 6.3 | 5.4 | 6.7 | |
| Income quartiles | 0.18 | |||
| Lowest | 14.1 | 13.9 | 14.3 | |
| Second | 21.5 | 21.6 | 21.4 | |
| Third | 27.6 | 26.7 | 28.0 | |
| Highest | 36.0 | 37.8 | 35.1 | |
| Missing | 0.8 | 0.2 | 1.1 | |
| Education quartiles | 0.09 | |||
| Lowest | 17.9 | 16.5 | 18.6 | |
| 2 | 25.5 | 24.0 | 26.1 | |
| 3 | 28.4 | 30.2 | 27.6 | |
| Highest | 27.5 | 29.1 | 26.8 | |
| Missing | 0.7 | 0.2 | 1.0 | |
| Insurance status | 0.85 | |||
| Medicare or private | 84.4 | 83.8 | 84.7 | |
| Medicaid or uninsured | 12.0 | 12.3 | 11.9 | |
| Other | 3.6 | 3.9 | 3.4 | |
Author Manuscript
J Surg Oncol. Author manuscript; available in PMC 2024 October 01.
Author Manuscript
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| N Parameter | Receipt of adjuvant therapy | |||
|---|---|---|---|---|
| Total 2072 | % Adjuvant 649 % | No adjuvant 1423 % | p Value | |
| Medicaid expansion state | 0.63 | |||
| Yes | 70.3 | 71.0 | 70.0 | |
| No | 29.7 | 29.0 | 30.0 | |
| Year of diagnosis | <0.001 | |||
| 2004 | 6.0 | 4.0 | 6.9 | |
| 2005 | 6.5 | 3.1 | 8.0 | |
| 2006 | 6.7 | 3.1 | 8.3 | |
| 2007 | 6.5 | 4.9 | 7.2 | |
| 2008 | 8.2 | 8.2 | 8.2 | |
| 2009 | 6.9 | 7.7 | 6.5 | |
| 2010 | 8.1 | 9.1 | 7.7 | |
| 2011 | 7.1 | 7.6 | 6.9 | |
| 2012 | 7.1 | 9.1 | 6.1 | |
| 2013 | 7.5 | 9.6 | 6.6 | |
| 2014 | 8.4 | 8.8 | 8.2 | |
| 2015 | 6.7 | 7.1 | 6.5 | |
| 2016 | 6.7 | 8.5 | 5.8 | |
| 2017 | 7.9 | 9.4 | 7.2 | |
| Travel distance (miles) | 0.21 | |||
| <42.2 | 76.9 | 78.6 | 76.1 | |
| ≥42.2 | 23.1 | 21.4 | 23.9 | |
| Facility program | <0.001 | |||
| Community | 2.5 | 1.5 | 3.0 | |
| Comprehensive | 22.4 | 21.1 | 22.9 | |
| Academic | 44.0 | 43.6 | 44.1 | |
| Integrated | 13.9 | 11.1 | 15.2 | |
| Other | 17.3 | 22.7 | 14.8 | |
| Charlson-Deyo score | 0.28 | |||
| 0 | 73.2 | 73.5 | 73.0 | |
| 1 | 19.7 | 20.8 | 19.3 | |
Logan et al.
Author Manuscript
Author Manuscript
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J Surg Oncol. Author manuscript; available in PMC 2024 October 01.
| N Parameter | Receipt of adjuvant therapy | |||
|---|---|---|---|---|
| Total 2072 % | Adjuvant 649 % | No adjuvant | 1423 % p Value | |
| 2 | 4.6 | 3.4 | 5.2 | |
| ≥3 | 2.5 | 2.3 | 2.5 | |
| Pathological stage | <0.001 | |||
| I | 5.2 | 2.8 | 6.3 | |
| II | 39.5 | 30.7 | 43.5 | |
| III | 33.1 | 39.0 | 30.4 | |
| IV | 18.7 | 25.3 | 15.7 | |
| Missing | 3.6 | 2.3 | 4.2 | |
| Tumor grade | <0.001 | |||
| Well differentiated | 3.2 | 1.2 | 4.2 | |
| Moderately differentiated | 3.6 | 2.8 | 3.9 | |
| Poorly differentiated | 10.1 | 10.3 | 10.0 | |
| Undifferentiated | 5.1 | 6.8 | 4.4 | |
| Missing | 78.0 | 78.9 | 77.6 | |
| Resection margin | <0.001 | |||
| R1, R2, or unspecified residual | 30.2 | 37.9 | 26.6 | |
| R0, no residual | 69.8 | 62.1 | 73.4 | |
Abbreviation: IQR, interquartile range.