By Shira Klapper, Senior Writer/Editor

Mention the phrase “health disparities in cancer” and most people’s thoughts will turn to the recent debate about insurance coverage. But in a country as large as the United States, a major barrier to accessing care can quite simply be where you live.

A team of researchers from MD Anderson has penned a study that correlates travel distance with stage at diagnosis for the third most common cancer in the U.S.—colon cancer. Their conclusion, as reported in the Journal of Clinical Oncology (JCO) online ahead of print, February 10^th, was that travel distance of over 50 miles was significantly associated with having metastatic disease at the time of diagnosis.

The study, “Association Between Travel Distance and Metastatic Disease at Diagnosis Among Patients with Colon Cancer,” Massarweh et al., differs from previous studies in that it used the National Cancer Database to gather information on a sample of 296,474 patients, ages 18 to 90 years. Similar, previous studies have typically used Surveillance, Epidemiology, and End Results data linked to Medicare claims (SEER-Medicare). But the MD Anderson team realized that focusing solely on people age 65 and older posed a methodological problem: at baseline, older patients, and in particular those living further away from hospitals, have a greater likelihood of presenting with more advanced stage cancer at diagnosis.  And the travel distance may not necessarily be the only explanation.

	Nader N. Massarweh,  MD, MPH

“Often, older people don’t drive, have comorbidities that may limit their mobility, or they require help getting around,” said first author, Nader N. Massarweh, MD, MPH. “We weren’t restricting ourselves to elderly patients who may already at baseline have a problem with traveling for medical care. Using SEER-Medicare data might magnify the effect of travel distance.”

According to the researchers, the connection between travel distance and stage of diagnosis might be explained by a well-known phenomenon: the shortage of specialists in rural and remote areas who can perform colonoscopies, which are considered the gold-standard of colon cancer screening and early detection. Colonoscopies not only detect cancer, but allow the doctor to remove any polyps he or she may find.

“I think many providers out there in the community think, ‘Okay, a patient is 50, they should go get a colonoscopy,’” said Dr. Massarweh. “But the closest colonoscopy center for that patient, who may or may not be socioeconomically disadvantaged, could be 150 miles away. That may, in and of itself, be a barrier.”

Given the scarcity of gastroenterologists and surgeons in certain areas of the country, how best to increase screening in medically underserved areas? The answer, the study suggests, might lie in a procedure already used by Kaiser Permanente and Veterans Affairs as their primary colon cancer screening modality: fecal occult blood tests (FOBT). Unlike colonoscopies, FOBT can be performed by local general practitioners. The procedure cannot detect cancer, but can detect traces of blood in the stool—an indication that the patient should proceed to a colonoscopy.

 “Randomized data show that FOBT is an effective screening modality and can decrease the risk of death,” said Dr. Massarweh.

And in areas where colonoscopies are difficult to come by, wider use of FOBT may be able to address health inequities whose roots go beyond medical coverage.

“The distance or time a patient has to travel to medical care is effectively a nonmodifiable factor that you have to account for,” said Dr. Massarweh. “Patient insurance is one thing, but if a patient lives 250 miles away from the closest medical care, you haven’t done anything to address that disparity.”

Nader Massarweh, MD, MPH, is a Surgical Oncology fellow in the Department of Surgical Oncology at the University of Texas MD Anderson Cancer Center. He has been an ASCO member since 2012.

References

Click here to read the abstract

Click here to view a PDF of the full article

Massarweh NN, Chiang Y, Xing Y, et al. Association between travel distance and metastatic disease at diagnosis among patients with colon cancer. J Clin Oncol. 2014; Published online ahead of print 2.10.2014.
 

The Exclusive Coverage series on ASCO.org highlights selected research from JCO with additional perspective provided by the lead or corresponding author.

@ 2014 American Society of Clinical Oncology