Prostate Cancer Treatment: It’s Who You Are, Not How Far You Need to Travel
—Which patients with high-risk prostate cancer are less likely to receive evidence-based care?
A team led by Ajay Aggarwal, MD, PhD, professor of Cancer Services & Systems Research at London School of Hygiene and Tropical Medicine and Consultant Clinical Oncologist at Guy’s & St Thomas’ NHS Trust, London. and colleagues designed a study to determine whether increased travel time associated with a trend toward centralization of cancer services was responsible for a lack of evidence-based care among men with prostate cancer.
“Our study revealed that approximately 30% to 35% of nearly 16,000 men in the United Kingdom with high-risk localized or locally advanced prostate cancer did not receive potentially curative treatment with either radiation or surgery,” Professor Aggarwal told 鶹ý.
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“I was surprised to find that travel time did not impact receipt of care. Instead, our findings showed that to improve rates of access/utilization, we need to focus on addressing underlying socio-demographic determinants of treatment variation.,“ Professor Aggarwal added.
In a large cohort
To analyze whether travel time to cancer treatment centers was associated with undertreatment of patients, the investigators used the English National Health Service’s registry to identify all men diagnosed with high risk localized or locally advance prostate cancer over a one-year (2019 to 2020) period.
The cohort comprised 15,971 men with a mean age of 71.1 years (standard deviation [SD]=8.3). Most of the men were White (86.2%, n=13,772), and approximately half (51.2%) lived in socioeconomically deprived areas. Median travel time to a hospital providing appropriate surgery or radiation therapy was 18.0 minutes (interquartile range [IQR]: 10.7 to 29.6) by car or 53 minutes (IQR: 37 to 71) via public transportation.
Undertreatment was common but not related to travel time
The investigators found that only 67% (n=10,693) of the men had radical surgery or radiation treatment within one year of diagnosis.
They did not find any association between travel time and likelihood of receiving evidence-based care. Average travel time to the nearest hospital by car for men who received treatment was 23.1 minutes (SD=18.3) and 23.3 minutes (SD=19.2) for those who were not treated. For public transport, average travel time to the nearest hospital was 58.2 minutes (SD=31.7) for the treated group and 58.1 minutes (SD=32.3) for the untreated group.
Age and social disparities were significantly associated with undertreatment
In sharp contrast to the above findings, age, socioeconomic factors, ethnicity, and comorbidities played a significant role in determining who received appropriate care and who did not.
Men who received appropriate treatment were younger: mean age 68.9 vs 75.5 years. Only 18.5% of men >80 years of age had evidence-based care.
The probability of appropriate treatment in different age groups was:
- 7% lower for men aged 70 to 74 than for those < 70 (adjusted risk ratio [ARR]: 0.93; 95% *C I: 0.91 to 0.95]
- 24% lower for men aged 75–79 (ARR: 0.76; 95% CI: 073 to 0.79)
- 77% lower for men > age 80 (ARR: 0.23;95% CI: 0.20 to 0.26
Lower socioeconomic status was associated with decreased likelihood of appropriate treatment:
- Men in the lowest fifth of the national distribution: [ARR: 0.91; 95% CI: 0.87 to 0.94
Non-white men were less likely to receive treatment:
- Black men: ARR: 0.88; 95% CI: 0.80 to 0.96
- Other non-White men: ARR: 0.89; 95% CI: 0.81 to 0.97
Probability of treatment was lower for those with 2 or more comorbidities:
- Compared to no comorbidities: ARR: 0.73; 95% CI: 0.67 to 0.78
Study limitations
Since the study was designed to analyze the impact of travel time on treatment choice, we asked Prof Aggarwal if he thought the UK findings regarding travel time were applicable to other countries: “It should be noted that these findings may be unique to the structure and organization of prostate cancer services in the UK, and we would recommend repeating the analysis in other health systems to see to what extent centralization and additional travel burden for some is an independent driver of under-treatment.”
In the paper’s discussion, the co-authors cite a national US study showing a negative impact of travel time on choice of radiation treatment rather than surgery for prostate cancer and a state-wide study that failed to demonstrate an impact for travel time on choice of radiotherapy.2,3
The co-authors point out other limitations. They note that utilization of resources might have been impacted by the fact that the study period (April 2019 to March 2020) covered the beginning of the pandemic. They also acknowledge that the data available to them did not include some factors that could influence treatment choice, such as patient preferences.
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