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Central Surgical Association

49th Annual Meeting

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Regionalization Blind Spot? The Association Between Travel Distance, Hospital Surgical Volume, and Survival for Patients with Resectable Lung Cancer
Charles D. Logan1, Ryan J. Ellis1, Joe Feinglass2, Amy L. Halverson1, Kalvin Lung3, *Samuel Kim3, Ankit Bharat3, Ryan P. Merkow1, David J. Bentrem1, David D. Odell1
1Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States, 2Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States, 3Canning Thoracic Institute, Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States

Objective: Patients who undergo complex surgery at high-volume centers have been shown to have improved outcomes. This has led to a trend towards regionalization, which has increased patient travel distance to care. Though research has demonstrated long distance travel to high-volume centers is beneficial for patients with early stage non-small-cell lung cancer (NSCLC), distance is also associated with decreased rates of receiving adjuvant chemotherapy (AC). However, the relationship between travel distance, surgical volume, receipt of AC, and patient outcomes is unknown. The purpose of this study is to evaluate the association between travel distance, surgical volume, and receipt of AC on survival for patients with resectable NSCLC.
Methods: Patients diagnosed with NSCLC between 2004-2018 were identified using the National Cancer Database. Patients were included if they underwent surgery at the reporting center with intact geographic and surgical volume data without prior neoadjuvant chemotherapy. Travel distance was categorized into quartiles (Q1 <6.4, Q2 6.4 to <14.7, Q3 14.7 to <35.1, Q4 ≥35.1 miles), and high versus low-volume centers (HVC vs LVC) were defined with a cutoff of ≥40 annual resections. Stage I and stage II-IIIa patients were analyzed separately. Patient characteristics were evaluated, and odds of receiving AC at any center were determined by multivariable logistic regression for the stage II-IIIa cohort. Survival analysis was performed using Kaplan-Meier curves and adjusted Cox proportional hazards models.
Results: Of the 174,560 patients included in this study, 53,044 (32.6%) were stage II-IIIa. Of the stage II-IIIa cohort, 42.0% were treated at LVCs, 52.9% received AC, 16.8% traveled short distances (Q1 <6.4 miles) to LVCs, and 15.3% traveled long distances (Q4 ≥35.1 miles) to HVCs (p<0.001; Table 1). Also, 47.2% of stage II-IIIa patients who traveled long distances to HVCs received AC (aOR 0.65, 95% CI 0.57-0.73) versus 55.4% of patients who traveled short distances to LVCs (p<0.001, reference). Stage II-IIIa patients who traveled long distances for treatment at HVCs and failed to receive AC had worse five-year survival (aHR 1.32, 95% CI 1.24-1.41) than patients who traveled short distances and were treated at LVCs but received AC (Table 2). Survival disparities were evident at stage II and stage IIIa, but not stage I (Figures 1-3).
Conclusions: Patients with stage II-IIIa NSCLC who travel long distances to high-volume centers and fail to receive adjuvant chemotherapy have worse survival compared to patients who travel short distances to low-volume centers but receive adjuvant chemotherapy. Understanding the reason for lack of receipt of adjuvant chemotherapy is necessary to improve delivery and maximize the benefit of travel to high-volume centers for surgery.





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