Patterns of Care and Outcomes for Hepatocellular Carcinoma and Pancreatic Cancer Based on Rurality of Patient’s Residence in a Rural Midwestern State

Abstract

BackgroundAlthough advancements in surgical planning and multidisciplinary care have improved the survival of patients with hepatopancreatic cancers in recent years, the impact of the rurality of patient residence on care received and survival is not well known. We aimed to assess the association between the rurality of patient’s residence and cancer-specific survival outcomes among patients with hepatocellular carcinoma (HCC) and pancreatic cancer (PC) in Iowa, hypothesizing that patients in rural areas would experience lower survival. MethodsAdult patients diagnosed with HCC or PC between 2010-2020 were identified using the Iowa Cancer Registry. Chi-square tests were used to compare categorical variables by rural/urban status. Logistic regression was used to examine factors associated with receiving surgery. Multivariable-adjusted Cox proportional hazards regression was used to determine associations with cancer-specific mortality. ResultsOf 1,877 patients with HCC, 58%, 27%, and 16% resided in metropolitan, micropolitan, and rural areas, respectively. Nearly 70% of patients in rural areas traveled≥50 miles for definitive care. Additionally, those residing in rural areas had the highest proportion of patients receiving definitive care at non-Commission on Cancer (CoC) centers (12.6% Metro vs. 14% Micro vs. 22.2% Rural, P<0.001). In multivariable-adjusted analysis of patients with stage I-III disease, definitive care at a non-CoC center was independently associated with lower odds of surgery (95% CI: 0.23 [0.12-0.45], P<0.0001) and higher mortality risk (1.39 [95% CI: 1.07-1.79], P=0.01), though rural residence was not. For PC, 5,465 patients were diagnosed, and 51%, 28%, and 20% resided in metropolitan, micropolitan, and rural areas, respectively. Similar to HCC, although rural residence was neither associated with odds of surgery nor with mortality risk, receiving definitive care at non-CoC accredited centers was associated with significantly lower odds of receiving surgery (95% CI: 0.17 [0.11-0.26], P<0.0001) and higher mortality risk (1.48 [95% CI: 1.23-1.77], P<0.0001). ConclusionRural residents with hepatopancreatic cancer have the highest proportion of patients receiving definitive care at non-CoC centers, which is associated with lower odds of receiving surgery and higher odds of mortality. This highlights the importance of standardizing complex cancer care and the need to foster collaboration between specialized and non-specialized centers.