M. Cerullo1, M. Turner1, M. A. Adam1, Z. Sun1, J. Migaly1, C. Mantyh1 1Duke University Medical Center,Department Of Surgery,Durham, NC, USA
Introduction: Though the relationship between surgical volume and outcomes has been well studied, travel to higher-volume centers remains a significant barrier for patients. Though travel to higher-volume centers is associated with improved outcomes for other cancers, it remains unclear whether travel to higher volume centers is associated with improved 30- and 90-day mortality, better long-term survival, or a higher likelihood of undergoing appropriate surgery in patients with rectal cancer.
Methods: Patients with rectal adenocarcinoma (stages I-III) with a single primary tumor were identified in the 2011-2014 National Cancer Database (NCDB). Patients were further categorized into quartiles by distance traveled, while centers were categorized into volume quartiles. Multivariable logistic regression and Cox proportional hazards regression models were used to compare outcomes between patients in the highest quartile of travel distance treated at the highest volume centers (travel) with patients in the lowest quartile of travel distance treated at the lowest volume centers (local).
Results: Exactly 3,088 patients in the lowest quartile of travel distance treated at low-volume centers and 3,071 patients in the highest quartile of travel distance treated at high-volume centers were identified. Overall, 38.2% of patients had stage III disease (35.3% of short-distance/low-volume patients vs. 41.1% of greater-distance/high-volume patients, p<0.001), and 63.6% received neoadjuvant radiation (57.7% of short-distance/low-volume patients vs. 69.6% of greater-distance/high-volume patients, p<0.001). After adjustment for disease severity and receipt of adjuvant therapy, patients who traveled greater distances to high-volume centers had a 71% lower 30- and 61% lower 90-day mortality (30-day: OR=0.29, 95% CI: 0.15–0.57, p<0.001; 90-day: OR=0.39, 95% CI: 0.24–0.62, p<0.001), as well as lower risk of overall mortality (Hazard ratio=0.78, 95% CI: 0.68–0.88, p<0.001). These patients also were more likely to have adequate lymph node harvest (OR=1.83, 95% CI: 1.64–2.05, p<0.001) and less likely to have positive margins (OR=0.76, 95% CI: 0.59–0.96, p=0.02). However, these patients also had 42% greater odds of being readmitted after surgery (OR: 1.42, 95% CI: 1.14–1.75, p=0.001).
Conclusion: Traveling greater distances to high-volume centers improves 30- and 90-day mortality, overall risk of death, and pathologic surrogates for appropriate surgery in rectal cancer patients. As patients may often be faced with choosing to obtain care at local lower-volume centers or traveling to higher-volume centers, these findings provide an impetus for facilitating travel for patients to higher-volume centers.
