Travel distance is associated with improved survival in hepatocellular carcinoma

Abstract

Background: An association between travel distance and survival measures has been been demonstrated across gastrointestinal malignancies but thus far has not been examined in patients newly diagnosed with hepatocellular carcinoma (HCC). We aimed to determine the association of travel distance with time to treatment (TTT) and overall survival (OS) in patients newly diagnosed with HCC. Methods: Newly diagnosed HCC patients who received treatment were identified in the Texas Cancer Registry from 2004 to 2015. We compared system- and patient-level factors among patients who traveled short (<12.5 miles), intermediate (12.5–49.9 miles), and long (≥50 miles) travel distances for initial treatment. Anova and Chi-square analyses were used to compare clinicopathologic variables, and Kaplan-Meier with log rank and cox regression models were used to compare survival. Results: 4,329 patients were identified: 2,136 (49.3%) short, 1,380 (31.9%) intermediate, and 813 (18.9%) long distance patients. Patients who traveled intermediate and long distances were more likely to be Non-Hispanic White (59% for intermediate and 60% for long vs 33% for short, p<0.001) and a higher proportion of privately insured patients (29% for intermediate and 24% for long vs 16% for short, p < 0.001). Short distance patients were more often Hispanic White (43% vs 24% for intermediate and 31% for long) or Non-Hispanic Black (18% vs 8% for intermediate and long, p < 0.001). Long distance travelers were more often initially treated at ACS accredited hospitals (95% vs 73% for short and 89% for intermediate, p < 0.001), non-safety net hospitals (53% vs 40% for short and 52% for intermediate, p < 0.001), academic centers (80% vs 57% for short and 73% for intermediate,p < 0.001), and high volume hospitals (85% vs 63% for short and 78% for intermediate, p < 0.001). Long distance travelers had smaller tumors, more localized disease, and were more likely to undergo ablation. Patients who traveled short distances were more likely to undergo surgical resection or transplantation. Long distance travelers had the shortest median TTT (4 weeks vs 5 weeks for short and intermediate, p = 0.003). Non-Hispanic Black and Hispanic White races were independently associated with decreased odds of intermediate (OR 0.27, 95%CI 0.2–0.4, and OR 0.40, 95%CI 0.3–0.5) and long (0.27, 95%CI 0.2–0.4, and OR 0.58, 95%CI 0.5–0.7) driving distance compared to short distance. Intermediate distance was associated with the highest median OS of 32 months vs 31 (long) and 22 months (short) (p < 0.001). Intermediate distance was independently associated with improved OS (HR 0.89, 95%CI 0.81–0.98) compared to short, but long distance was associated with similar survival. Conclusion: Racial/ethnic minority patients have decreased odds of traveling longer distances for HCC care. Intermediate travel distance (12.5–49.9 miles) is associated with decreased TTT and improved OS compared to other travel distances.