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Restoring the home-field advantage
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In team sports, home-field advantage appears to be a real phenomenon. Although the exact causes are not clear — despite having been extensively investigated — there seem to be intangible, difficult-to-define reasons why teams do better in familiar surroundings with a strong support system.
Most data suggest patients with cancer and their families benefit from home-field advantage — most want to have access to their treatment close to home, where they tend to have the optimal support. For those living in rural and frontier locations, and even for those living more than 50 miles from a cancer treatment center, accessing cancer care can be problematic.
This is a problem that may get worse before it gets better.
State of cancer care
ASCO’s “State of Cancer Care in America: 2016” report, as in previous years, provides many valuable insights into the successes of cancer care and the challenges that continue to confront us as oncology providers, as well as our patients and their families.
The report includes data on the oncology practice landscape and the oncology workforce, reinforcing previous reports from ASCO and others that show we have a looming shortage of providers. The 20% to 30% increase in the number of patients with cancer projected for the next 20 years or so will be met by a 2% to 3% increase in medical and radiation oncologists.
In addition, the report highlights the geographic distribution of oncologists across the United States and identifies some disturbing data. For example, 50% of all medical oncologists and hematologists practicing in the United States are based in only eight states, which account for 40 million people aged 55 years and older.
Oncologists are concentrated in urban areas, and the 11% of Americans who live in communities defined as rural are served by 5.6% of the medical oncology/hematology workforce.
The radiation oncology workforce is similarly skewed in its distribution. Another study reports that most radiation oncologists are based in metropolitan areas and that 66% of all U.S. counties have no radiation oncologists. These data confirm the well-documented observations that those who live in rural and remote communities have problems accessing high-quality cancer care.
Distance and outcomes
Many studies have described these access problems and the effect of geography on cancer treatment and outcomes.
Vargo and colleagues evaluated data from the National Cancer Data Base (NCDB) and demonstrated that, for patients with limited-stage diffuse large B-cell lymphoma (DLBCL), distance from the treatment center was a factor in treatment choice. Patients who lived farther from a treatment facility were less likely to undergo radiation therapy. This is not surprising in view of the time and travel commitment required to complete a 3- to 4-week course of radiation; however, it is concerning, given that the decision is being influenced by factors other than the optimal treatment regimen.
Lin and colleagues made similar observations in their exploration of the relationship between geographic access to cancer care and the receipt of radiation therapy for rectal cancer. In their analysis using the NCDB —which is quite difficult to interpret — there appear to be two primary conclusions. The first is that living more than 50 miles from a radiation oncology facility is associated with a lower likelihood of receiving radiation therapy, generally regarded as a standard therapy for stage II to stage III rectal carcinoma.
The second is that patients who actually made the journey to a treatment facility were as likely to receive radiation therapy as those who lived close by, regardless of whether they went to the facility. Thus, getting there from a distance seems to be the problem.
Although these data are concerning, they do not show a direct relationship between geographic access and outcome. However, other data may suggest this.
In a population-based study conducted in Canada, Tao and colleagues reported survival data for patients with DLBCL based on geographic location. Patients who lived in rural communities appeared to have similar outcomes to those who lived in and were treated in large metropolitan areas. Whether this is because those patients tended to travel to large cities for their care is not clear from this study.
By contrast, those treated in small- to medium-sized communities had lower survival rates. In view of the population-based nature of these data, the researchers do not speculate on potential explanations for these apparent geographic disparities, but they appear to be real.
If these differences are real, the reasons for this are likely to be multifactorial, and some may be easier to overcome than others.
For example, Boero and colleagues showed access to high-volume cancer specialists at larger centers was associated with improved outcomes for Medicare beneficiaries with head and neck cancer treated with intensity-modulated radiation therapy.
A population-based study comparing outcomes across multiple tumor types suggested that outcomes are better for patients treated at NCI-designated cancer centers than those treated at other facilities.
Delay in initiation of adjuvant therapy for breast cancer has been associated with rural location. In an analysis using data from the California Cancer Registry, Chavez-MacGregor and colleagues showed delays in adjuvant therapy were associated with inferior outcomes.
Restoring the home-field advantage
More complex than these treatment-related factors are the social, cultural and demographic factors that play into geographic disparities. These are complicated and challenging.
Further, most of the data that have uncovered these apparent disparities can only take us so far. These “big-data” analyses do not have the granularity to address the reasons for inferior access and outcomes in detail — an issue addressed very effectively in the April 25 editorial by HemOnc Today Chief Medical Editor for Oncology Derek Raghavan, MD, PhD.
Despite the lack of robust data, few would dispute that it is more difficult to access high-quality cancer care from rural and frontier locations. The current trends in the oncology workforce suggest that the disparities faced by these folks are not going to self-correct. In addition to the financial, volume and quality challenges of trying to operate a cancer treatment facility in a small community, it appears that most oncologists choose to work in larger, metropolitan areas, and there are no clear incentives for them to do otherwise.
Improving access to cancer care for these communities and allowing these patients to benefit from home-field advantage — particularly as the number of cancer survivors requiring care continues to increase — is likely to be dependent upon changing the workforce and increasing use of technology.
Advanced-practice clinicians with training in cancer care may be part of the answer. Partnerships and affiliations between small community hospitals and larger cancer treatment centers also may address some of the access problems. Increasing the level of support that large treatment centers give to primary health care providers in rural communities will be an essential component of care.
The growing use of telemedicine in oncology is one example of how effective care can be delivered remotely with appropriate collaboration between health care providers across long distances. Breaking down some of the licensure barriers that limit the use of telemedicine across state lines would make this approach more effective. The support and education given through novel programs such as Project Extension for Community Health Care Outcomes (ECHO), a kind of “virtual tumor board,” is another example of a very effective outreach effort in oncology and other specialties.
Remote monitoring of, and intervention for, cancer-related symptoms and collection of patient-reported outcomes by electronic methods, including smartphone apps, are additional examples of new strategies being investigated to overcome the challenge of long-distance travel.
The increased focus on cancer care inspired by President Obama’s moonshot initiative will hopefully allow many disparities in cancer care to be addressed. Let’s hope that restoring home-field advantage to those affected by cancer in rural and frontier communities is recognized as a priority for funding.
References:
ASCO. J Oncol Pract. 2016;doi:10.2100/JOP.2015.01062.
Boero IJ, et al. J Clin Oncol. 2016;doi:10.1200/JCO.2015.63.9898.
Chavez-MacGregor M, et al. JAMA Oncol. 2016; doi: 10.1001/jamaoncol.2015.3856.
Lin CC, et al. Int J Rad Onc Biol Phys. 2016;doi:10.1016/j.ijrobp.2015.12.012.
Tao L, et al. Blood. 2014;doi:10.1182/blood-2013-07-517110.
Vargo JA, et al. J Clin Oncol. 2015;doi:10.1200/JCO.2015.61.7654.
Wolfson JA, et al. Cancer. 2015;doi:10.1002/cncr.29576.
For more information:
John Sweetenham, MD, is HemOnc Today’s Chief Medical Editor for Hematology. He also is senior director of clinical affairs and executive medical director at Huntsman Cancer Institute at University of Utah. He can be reached at john.sweetenham@hci.utah.edu.
Disclosure: Sweetenham reports no relevant financial disclosures.