Abstract
Given growing specialization in medical care, optimal care may require regionalization, which may create access barriers. We tested this within a large prostate cancer (PC) screening program in Brazil. In 2004–2007, Barretos Cancer Hospital prospectively screened men for PC throughout rural Brazil. Men with abnormal screen were referred for follow-up and possible biopsy. We tested the link between distance from screening site to Barretos Cancer Hospital and risk of noncompliance with showing up for biopsy, PC on biopsy and, among those with PC, PC grade using crude and multivariable logistic regression analysis. Among 10,467 men undergoing initial screen, median distance was 257 km (IQR: 135–718 km). On crude and multivariable analyses, farther distance was significantly linked with biopsy noncompliance (OR/100 km: 0.83, P < 0.001). Among men who lived within 150 km of Barretos Cancer Hospital, distance was unrelated to compliance (OR/100 km: 1.09, P=0.87). There was no association between distance and PC risk or PC grade (all P > 0.25). In Brazil, where distances to referral centers can be large, greater distance was related to reduced biopsy compliance in a PC screening cohort. Among men who lived within 150 km, distance was unrelated to compliance. Care regionalization may reduce access when distances are large.
Highlights
A 2011 study of overall cancer mortality in Brazilian state capitals vs. outlying municipalities from 1980 to 2006 found a mortality increase of more than 100% for all cancer types [1]
Of the 1,131 men who presented to Barretos Cancer Hospital (BCH), all underwent a confirmation screening. 273 had normal screenings and were no longer recommended for biopsy and eight were excluded from analysis due to inconclusive biopsy pathology. erefore, for secondary analyses, we examined 850 men for prostate cancer (PC) on biopsy and PC grade (Figure 1)
We found no association between distance and PC detection or grade on biopsy. ese data suggest that while regionalization of care may in theory improve quality, it comes at the cost of reduced compliance and reduced access. is represents a significant barrier to optimal care if distances are large
Summary
A 2011 study of overall cancer mortality in Brazilian state capitals (urban areas) vs. outlying municipalities (rural areas) from 1980 to 2006 found a mortality increase of more than 100% for all cancer types [1]. Given the growing number of aging people with varied health needs and growing specialization in medical care [2,3,4], there is increasing realization that optimal care for certain procedures may require regionalization [5, 6]. While this comes with the benefit of creating high-volume centers to drive optimal outcomes, this comes at the cost of increased burden to travel, including obtaining transportation [7], loss of wages, and being away from home [6, 8]. The nature of the medical condition and the distance to the care facility may dictate whether the benefits of regionalization outweigh the barriers this creates for access
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