Distance from a Comprehensive Cancer Center: A proxy for poor cervical cancer outcomes?: Beyond the Abstract

Although the burden of cervical cancer in the United States pales in comparison to that in low- and middle-income countries, there are populations and geographic areas in this country that are disproportionately affected by this disease. Furthermore, these populations are often those who end up with poorer outcomes. It has been established that geographic distance from a provider who specializes in gynecologic cancer care can negatively impact outcomes for women with gynecologic malignancies, however this has been less well described in cervical cancer specifically. [1] [2]

Given that an estimated 14.8 million women live in counties that are >50miles away from a gynecologic oncologist, it is important to better describe and focus on improving care for this high-risk subpopulation. [3]

We aimed to identify geographic risk factors for poor cervical cancer outcomes in Alabama, a state with high cervical cancer rates, in order to improve our understanding of how to better serve these populations. Using a large retrospective cohort of patients treated at our institution, we initially stratified patients into two groups (<100 miles away and ≥100 miles) based on distance from our Comprehensive Cancer Center (CCC), and compared the progression free (PFS) and overall survival (OS) between these groups.  Women in our population who live ≥100 miles away from our CCC had a significantly lower overall survival by 34 months when compared to women who lived <100 miles away.  Although not statistically significant, median PFS for patients living ≥100 miles was 20 months less than those living <100 miles away. 

All women in our cohort received some of their care in a CCC, so why were outcomes worse for those who lived further away? One hypothesis is that patients who lived further away may have received part of their care at low-volume facilities or with non-gynecologic oncology specialists who were closer to their home. It is also possible that patients who lived further away did not complete all of their recommend treatment (i.e. fewer than the recommended radiation treatments or longer total treatment time or chemotherapy doses), or did not comply with surveillance recommendations due to the inconvenience of driving >1 hour to our CCC. Unfortunately due to limitations of our data, we were unable to control for important variables such as medical comorbidities or socioeconomic status that may have contributed to these differences.   

Our data point toward the importance of both accessibility and quality of cervical cancer care. While all of our patients received a portion of their care at a high volume CCC, those who lived further away progressed sooner and died more often. Data in ovarian cancer literature has demonstrated that being treated at high-volume centers confers better outcomes, and some in the gynecologic oncology community have pushed for centralization of care for ovarian cancer.[4, 5] However, because cervical cancer tends to affect patients with lower health literacy, socioeconomic status and in minority groups in disproportionate rates, the approach to improving outcomes for cervical cancer patients may be different. We need to improve not just access to any care, but access to high quality care. Our results are compelling, but are far from complete. More research is warranted to further describe the multifactorial risk factors for poor outcomes and the complex way that patients interact with the healthcare system. Interventions to improve access to quality care need to be studied, including the role of partnering with primary care and advanced practice providers to improve gynecologic care in rural communities, and creating satellite cancer centers for oncologists to provide care in more geographically diverse areas.

Written by: Sarah Dilley, MD, MPH, Gynecologic Oncology Fellow 

1. Temkin, S.M., et al., Geographic disparities amongst patients with gynecologic malignancies at an urban NCI-designated cancer center. Gynecologic Oncology, 2015. 137(3): p. 497-502.

2. Bristow, R.E., et al., Spatial analysis of adherence to treatment guidelines for advanced-stage ovarian cancer and the impact of race and socioeconomic status. Gynecologic Oncology, 2014. 134(1): p. 60-67.

3. Shalowitz, D.I., A.M. Vinograd, and R.L. Giuntoli, II, Geographic access to gynecologic cancer care in the United States. Gynecologic Oncology. 138(1): p. 115-120.

4. Bristow, R.E., et al., High-volume ovarian cancer care: Survival impact and disparities in access for advanced-stage disease. Gynecologic Oncology, 2014. 132(2): p. 403-410.

5. Aletti, G.D. and W.A. Cliby, Time for centralizing patients with ovarian cancer: what are we waiting for? Gynecologic Oncology. 142(2): p. 209-210.