Number of U.S. radiotherapy facilities rises, but many Americans still lack close access
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Although the percentage of U.S. radiation facilities has increased in the past 15 years, urban areas already dense with these facilities have been disproportionately favored, according to a presenter at the virtual ASTRO Annual Meeting.
Approximately 5% of the U.S. population still reside more than 50 miles from the nearest radiation facility, Sean Maroongroge, MD, MBA, resident in the department of radiation oncology at The University of Texas MD Anderson Cancer Center, said during a press conference.
“Radiation therapy is a key part of the treatment paradigm for most patients with cancer. It is also unique among treatment modalities in that patients often have to come back for multiple treatments,” Maroongroge said. “The distance from radiation facilities is correlated with the receipt of radiation therapy, and this has been recorded in the literature. For example, patients make the decision to undergo breast-conserving surgery and radiation therapy vs. mastectomy for breast cancer or to undergo definitive radiation therapy vs. surgical management of prostate cancer. Participation in clinical trials is also affected. However, most of these older studies rely on different measures of where patients can get their radiation treatment, such as billing data or where the physicians themselves are located.”
Maroongroge and colleagues took another approach, gathering data from state regulatory agencies, such as health departments and national dosimetry monitoring organizations, to update a 2005 database of radiation therapy clinic locations. They used a web-based program to map facilities that were active between 2018 and 2020 and compared those with information on 2005 facilities.
Results showed that approximately 70% of the U.S. population lives within 12.5 miles of a radiation therapy facility, whereas 4.5% of the U.S. population lives more than 50 miles from the nearest facility.
The overall number of radiation facilities increased from 1,987 in 2005 to 2,332 in 2020, for a growth rate of 17%. However, the percentage of the population residing within 12.5 miles of a facility increased from 65% in 2005 to 70% in 2020, whereas the percentage of those residing within 50 miles of a radiation facility increased from 95% to 96%.
“We also surprisingly found that 33% of [radiation facilities] in the initial 2005 database did not exist in our updated database, but this may reflect methodological circumstances rather than rapid movement of facilities,” Maroongroge said.
“Overall, we found that the growth in radiation treatment facilities during the past 15 years roughly mirrors the growth in treated cases during this time period, for an approximate 1.2% annual growth rate,” Maroongroge said. “Our findings raise the question of whether our resources are being allocated appropriately or if we need to do more to increase access for patients farthest away from treatment facilities. Our findings are consistent with recent reports looking at where radiation oncologists are located, which suggests that there is substantial variation in access to radiation therapy depending upon where one resides in the United States.”
Perspective
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Geraldine M. Jacobson, MD, MPH, MBA, FACR, FASTRO
This abstract describes the current distribution of radiation centers across the U.S. in relation to population distribution and compares contemporary geographic access to radiation therapy facilities with data from 2005. Factors that may contribute to the clustering of radiation facilities in more populated areas include the preference of radiation oncology physicians to work in urban areas and the economic vulnerability of opening a center with high fixed costs in a less populated area. Radiation therapy centers in rural areas with low patient volumes are at higher risk from the continuous pressure on radiation oncology reimbursement.
The researchers estimated distance based on straight lines from the center of populated areas to the nearest radiation therapy facility, which may underestimate the actual distance and travel time for patients in congested urban areas or mountainous and rural areas.
Radiation is a primary cancer treatment used by at least 50% of patients with cancer. It requires multiple, often daily, visits to a center with the appropriate technology. The cost, distance and travel time can be substantial barriers to patients obtaining radiation treatments. Numerous studies have shown worse outcomes for patients with cancer who live far from a radiation therapy facility. The trend for increasing radiation therapy facilities in urban areas leaves a significant portion of the U.S. population beyond convenient access to radiation treatment and at risk for worse cancer outcomes.
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Cathy J. Bradley, PhD
The availability of radiation services has grown considerably during the past 15 years, potentially improving the convenience of life-saving therapies for the majority of Americans who live in urban areas, particularly those who are insured and, most likely, already have access to care. The extent to which these facilities were needed or if they added capacity to treat disparate populations is unclear.
Equitable access to care remains a national shortfall, despite the growth in facilities. Just like studies from more than a decade ago, studies published within the last 2 years report that disparities in radiation treatment initiation and completion persist among patients who live in low-income urban neighborhoods, patients who are from racial/ethnic minority groups, and patients who are either uninsured or insured by Medicaid. In addition, rural residence in the U.S. has emerged as another potential detriment to cancer outcomes. Racial/ethnic minority groups account for much of the rural population growth and strikingly, over 80% of rural counties where the majority of residents are Black or Hispanic are designated as Health Professional Shortage Areas. The confluence of minority race/ethnicity and rural residence can further exacerbate disparities. Thus far, evidence is lacking on whether the growth in the number of radiation facilities has improved access, particularly for populations who are historically underserved and less likely to receive equitable care. This is an important topic for future research and a consideration for whether and where additional facilities are constructed.
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Maroongroge S, et al. Abstract 203. Presented at: American Society for Radiation Oncology Annual Meeting (virtual); Oct. 25-28, 2020.
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