Originally published as JCO Early Release 10.1200/JCO.2008.20.1715 on August 31 2009

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Centralization of Cancer Surgery: Implications for Patient Access to Optimal Care

From the Departments of Surgical Oncology, Biostatistics, and Medical Oncology; Fox Chase Cancer Center Partners, Fox Chase Cancer Center; and the Leonard Davis Institute of Health Economics, and Center for Bioethics, University of Pennsylvania, Philadelphia, PA.

Corresponding author: Karyn B. Stitzenberg, MD, MPH, Department of Surgery, University of North Carolina, 170 Manning Dr, 1150 POB, CB# 7213, Chapel Hill, NC 27599-7213; e-mail: kbstitz{at}msn.com.

Purpose The volume-outcomes relationship has led many to advocate centralization of cancer procedures at high volume hospitals (HVH). We hypothesized that in response cancer surgery has become increasingly centralized and that this centralization has resulted in increased travel burden for patients.

Patients and Methods Using 1996 to 2006 discharge data from NY, NJ, PA, all patients 18 years old treated with extirpative surgery for colorectal, esophageal, or pancreatic cancer were examined. Patients and hospitals were geocoded. Annual hospital procedure volume for each tumor site was examined, and multiple quantile and logistic regressions were used to compare changes in centralization and distance traveled.

Results Five thousand two hundred seventy-three esophageal, 13,472 pancreatic, 202,879 colon, and 51,262 rectal procedures were included. A shift to HVH occurred to varying degrees for all tumor types. The odds of surgery at a low volume hospital decreased for esophagus, pancreas and colon: per year odds ratios (ORs) were 0.87 (95% CI, 0.85 to 0.90), 0.85 (95% CI, 0.84 to 0.87), and 0.97 (95% CI, 0.97 to 0.98). Median travel distance increased for all sites: esophagus 72%, pancreas 40%, colon 17%, and rectum 28% (P < .0001). Travel distance was proportional to procedure volume (P < .0001). The majority of the increase in distance was attributable to centralization.

Conclusion There has been extensive centralization of complex cancer surgery over the past decade. While this process should result in population-level improvements in cancer outcomes, centralization is increasing patient travel. For some subsets of the population, increasing travel requirements may pose a significant barrier to access to quality cancer care.

Supported by the John A. Ridge, MD, PhD, Surgical Oncology Fellowship at Fox Chase Cancer Center (K.B.S.); and by Grant No. P30 CA 06927 from the National Institutes of Health (B.L.E.). These funding sources had no role in the design and conduct of the study nor the collection, management, analysis, and interpretation of the data, nor the preparation, review, or approval of the manuscript.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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