Rural Pediatric Radiation Oncology in the Era of COVID-19: A Single Institution Analysis

Abstract

Health inequities have recently gained prominence in public consciousness as a result of the COVID-19 pandemic. Rural access to care was particularly impacted regarding delays in cancer screening, diagnosis, and treatment. The fractionated nature of radiotherapy creates transportation burdens in this population. We reviewed our institutional experience with pediatric radiotherapy at a tertiary academic center serving a primarily rural population over a large geographic area. The financial burden of radiotherapy in pediatric patients in our database was modeled using cost-analysis. The cost of transportation using distance to our facility and the IRS-assessed tax value per mile was calculated. Correlative analyses were conducted to evaluate the association of radiotherapy delivered pre- vs. post-COVID with patient race, age at diagnosis, and distance from our institution. Analyses were conducted with two-tailed Pearson correlations for transportation cost vs. age at diagnosis. Mann-Whitney U testing was used to analyze transportation cost vs. patient race. Fisher's Exact Test was used to analyze the trends between tumor primary sites pre- and post-COVID. There was a statistically significant increase in brain tumors vs. all others from 9.1% to 66.7% post-COVID (p = 0.029). When comparing patients treated prior to the onset of the COVID-19 pandemic in 2020 to those treated during the peak years of the pandemic in 2020-2021, there was no difference in the average distance traveled for treatment. However, the mean cost of transportation for pediatric patients undergoing radiotherapy prior to COVID-19 was $266 USD (median = $331), vs. a mean of $535 (median = $378) for patients treated during 2020-2021. For patients treated in 2022, after the height of COVID-19, the mean cost of transportation was $501 (median = $432). No statistically significant differences were found between the cost of transportation and patient race or age at diagnosis before vs. after the onset of COVID-19. Our results highlight the importance of understanding barriers to care and what type of resources are most impactful to rural pediatric patients at our center. The rise of transportation costs for radiotherapy following the COVID-19 pandemic may indicate an additional barrier to care, potentially associated with increasing inflation, for rural pediatric patients that is underreported in the literature. The rise in the relative prevalence of brain tumors at our institution during this period warrants further investigation.