Oncologist. 2015 Dec;20(12):1378-85.

Distance as a Barrier to Cancer Diagnosis and Treatment: Review of the Literature.

Ambroggi M1, Biasini C1, Del Giovane C2, Fornari F3, Cavanna L4.
  • 1Department of Oncology-Hematology, G. da Saliceto Hospital, Piacenza, Italy.
  • 2Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy.
  • 3Department of Medicine, G. da Saliceto Hospital, Piacenza, Italy.
  • 4Department of Oncology-Hematology, G. da Saliceto Hospital, Piacenza, Italy l.cavanna@ausl.pc.it.

 

Abstract

The burden of travel from a patient’s residence to health care providers is an important issue that can influence access to diagnosis and treatment of cancer. Although several studies have shown that the travel burden can result in delays in diagnosis and treatment of many common cancers, its role appears underestimated in the treatment of patients in clinical practice. Therefore, we performed a review of the published data on the role of travel burden influencing four items: delay of diagnosis, adequate treatment of cancer, outcome, and quality of life of cancer patients. Forty-seven studies published up to December 2014 were initially identified. Twenty studies were excluded because they did not regard specifically the four items of our review. Twenty-seven studies formed the basis of our study and involved 716,153 patients. The associations between travel burden and (a) cancer stage at diagnosis (12 studies), (b) appropriate treatment (8 studies), (c) outcome (4 studies), and (d) quality of life (1 study) are reported. In addition, in two studies, the relation between travel burden and compliance with treatment was examined. The results of our review show that increasing travel requirements are associated with more advanced disease at diagnosis, inappropriate treatment, a worse prognosis, and a worse quality of life. These results suggest that clinical oncologists should remember the specific travel burden problem for cancer patients, who often need health care services every week or every month for many years.

IMPLICATIONS FOR PRACTICE: The influence of travel burden on cancer patients has been previously studied, but this is the first comprehensive review of the available literature. This review shows that travel burden negatively influences stage at diagnosis, appropriate treatment, outcome, and quality of life in cancer patients. The results demonstrate that clinical oncologists should keep in mind the specific travel burden problem for cancer patients who often need health care services every week or every month for many years.

KEYWORDS: Cancer diagnosis and treatment; Cancer patients; Distance from hospitals; Outcome; Quality of life; Travel burden

PMID: 26512045

 

Supplements:

Cancer is one of the most widespread, and one of the most lethal, diseases. 8.2 milion of people die each year from cancer, an estimated 13% of all deaths worldwide, and an increase by 70% in new cases of cancer is expected over the next 2 decades (from the observatory of WHO).

Diagnostic imaging and therapies improved over the past years for many tumors, but prognosis is still poor in the majority of the cases. In some cases, especially for breast and colon cancer, less frequently for other tumors, patients can be cured and they will not relapse. It is very important, however, that tumor is diagnosed at an early stage and that patients undergo correct and encoded treatments. In these cases, the time factor is very important.

It is well known also that patients with cancer must overcome many psychological, social, economic and also family barriers to obtain the diagnosis and treatment needed. In addition, the burden of travel from a patient’s residence to his or her health care provider can be an important issue that can influence access to diagnosis and treatment services for cancer needs. In fact, the necessity for repeated visits for cancer diagnosis and treatment on an outpatient or an inpatient basis makes distance an important issue which the patient with cancer has to deal with during the course of the disease.

The development of screening programs significantly prolonged survival by diagnosing some tumors at a very early stage, and consequently allowing less invasive surgery and oncological therapies. Health services invite people of certain sex and age to participate to these programs and offer them diagnostic examinations. Not all people, however, accept the invitation: some forget the appointment, others don’t want to accept because they are afraid. Other people, instead, would like to participate but they have some difficulties, because they live far from the hospital, or they don’t drive and so have to ask to their relatives or friends to accompany them, or they find it difficult to move (for example for comorbidities or in general for their clinical conditions). These people, who can’t participate in screening programs, if they get cancer, have more probabilities to have diagnosis at a more advanced stage.

Sometimes oncologists see cancer patients for the first time when the disease is at an advanced stage for other reasons: someone didn’t want to go to the doctor before, may be because they denied the problem, someone had no symptoms before, someone were not able to go to the visit before. In the majority of these situations, oncological therapies can only reduce tumor mass and prolong survival, in a very few cases they can cure. So, it is crucial that oncologists can visit cancer patients at an early stage.

Travel time also can be considered a direct cost of cancer treatment that is usually borne solely by patients and their families. As such, time costs associated with travel are an important component of the full economic burden of cancer. Travel may be of particular importance for socioeconomically disadvantaged persons, because time costs associated with care may strain limited resources, and lower provider accessibility or transportation barriers may result in longer travel times for low-income individuals

We thought that patients living far from health care providers had more probabilities to have cancer diagnosis at a more advanced stage and, consequently, less chances to be definitively cured, with a  worse prognosis. And, in fact, our literature research confirmed this hypothesis. Patients living far from hospitals have more problems to go early to the visits, so the diagnosis was made later than for people living closer.

It is also reasonable, how we’ve said before, to surmise that differences in stage at diagnosis, for example in Breslow thickness for melanoma patients, could translate into differences in overall survival, even if these studies do not provide survival data

However, the worse prognosis of cancer patients living far from health care providers were confirmed by other studies, that evaluated specifically the relationship between distance and disease free-survival and overall survival.

The worse prognosis for patients living farther from treating hospitals could be due to the fact that compliance to treatment or to follow-up program is suboptimal. In addition, it was observed that transportation to the health care provider can be perceived as a barrier to care, and can limit compliance to treatment, often because patients didn’t want to embarrass their relatives or because public transport were missing or not efficient. In addition, socially disadvantaged people had more difficulties to go to the hospital.

It is well known that participation in randomized controlled trials is associated with improved cancer survival; however, many trials require frequent examination, and the travel burden can exclude patients from trials due to the distance of their residence from the trial center. However, there is a lack of literature in this area and farther studies are required to explore this issue.

Patients living far from the hospital have also more probabilities not to adhere to adequate treatments. A typical example is the omission of radiotherapy after breast conserving surgery, or the choice by patients to undergo mastectomy so that they had not to do radiotherapy. In addition, we found that in Australia, patients with localized non-small cell lung cancer (a potentially curable tumor) who lived 100 Km or more from the nearest accessible specialist hospital were more likely to have no surgery (the only intervention potentially curable) than those living 0-39 Km away.

In our town, Piacenza, in Italy, we had some patients who stopped chemotherapy early because they had to travel 50 or more kilometers to come to our hospital and they didn’t want that their sons lose working days to accompany them.

So, in our region, we have developed a provincial oncological network, and rural oncologic patients can have ready access to oncological services, having to travel a maximum of 30 Km, at a unit of internal medicine and can be treated under the supervision of a medical oncologist who goes out to the peripheral units. This network hosts a centralized unit for the preparation of anticancer drugs with a computerized system. A preliminary report shows that oncologic patients can be treated minimizing travel discomfort, achieving also a cost-containment policy for the delivery of cancer care.

In Australia, someone tried to find a solution to this problem with telemedicine. By using telemedicine facilities, rural patients can have immediate access to specialist services without having to travel long distances. Chemotherapy can also be supervised with the use of this technology.

In addition, for all cancer patients, quality of life is a milestone. We found one study that evaluated the relationship between travel burden and quality of life: the results suggested that remote colorectal cancer survivors, women in particular, have more trouble with daily activities and may feel unable to work, or they are limited in their work, as evidenced by their lower physical functioning scores.

The main limitations of the studies we found are: the use principally of cancer registry as data source, with a consequent risk of incomplete data; the methods to calculate travel time/distance; all studies but the one regarding quality of life were retrospective.

Despite these limitations, we believe that travel distance/travel burden is an important issue for many patients: it is an important factor conditioning the access to appropriate and current cancer diagnosis and treatment, and it can worsen the achievement of universal high-quality care for cancer patients.

Consequently, the implication of increasing distance should not be ignored, especially by the oncologists treating cancer patients.

 

 

 

 

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