Effect of rurality and travel distance on contralateral prophylactic mastectomy for unilateral breast cancer.

PURPOSE: Despite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been demonstrated in Midwestern rural women. Greater travel distance for surgical treatment is associated with CPM. Our objective was to examine the relationship between rurality and travel distance to surgery with CPM. METHODS: Women diagnosed with stages I-III unilateral breast cancer between 2007 and 2017 were identified using the National Cancer Database. Logistic regression was used to model likelihood of CPM based on rurality, proximity to metropolitan centers, and travel distance. A multinomial logistic regression model compared factors associated with CPM with reconstruction versus other surgical options. RESULTS: Both rurality (OR 1.10, 95% CI 1.06-1.15 for non-metro/rural vs. metro) and travel distance (OR 1.37, 95% CI 1.33-1.41 for those who traveled 50 + miles vs. < 30 miles) were independently associated with CPM. For women who traveled 30 + miles, odds of receiving CPM were highest for non-metro/rural women (OR 1.33 for 30-49 miles, OR 1.57 for 50 + miles; reference: metro women traveling < 30 miles). Non-metro/rural women who received reconstruction were more likely to undergo CPM regardless of travel distance (ORs 1.11-1.21). Both metro and metro-adjacent women who received reconstruction were more likely to undergo CPM only if they traveled 30 + miles (ORs 1.24-1.30). CONCLUSION: The impact of travel distance on likelihood of CPM varies by patient rurality and receipt of reconstruction. Further research is needed to understand how patient residence, travel burden, and geographic access to comprehensive cancer care services, including reconstruction, influence patient decisions regarding surgery.

Comparing COVID-19 Response Behaviors between a Cancer Patient Sample and a Population-Based Cancer-Free Sample in a Rural Midwestern State.

INTRODUCTION: The COVID-19 pandemic caused an increase in fear, anxiety, and depressive symptoms globally. For populations at increased risk for adverse outcomes due to illness, such as cancer patients, these worries may have been exacerbated. Understanding how the pandemic impacted cancer patients will inform better preparation for future events that cause disturbances to cancer care delivery. METHODS: This study analyzed data from two surveys to determine whether cancer patients' responses differed from a cancer-free population-based sample in terms of concerns, preventive behaviors, and thoughts on their healthcare provider's communication regarding COVID-19 in a US Midwestern state. In August 2020, a survey was sent to 10,009 Iowans aged 18 and older, randomly selected from the 2018 Iowa voter registration file. In September 2020, a survey was emailed to 2,954 cancer patients aged 18 and older who opted into the University of Iowa Holden Comprehensive Cancer Center's Patients Enhancing Research Collaborations at Holden program. Previously validated and pretested Likert-type and multiple-choice items assessed concern regarding COVID-19, social distancing perception and behaviors, and demographic characteristics of respondents. We used χ2 tests and logistic regression to examine differences between the cancer patient and general population survey responses. RESULTS: We included 3,622 responses from the general population survey and 780 responses from the cancer patient survey in this analysis. Cancer patient survey respondents were more frequently older, lived in urban areas, had Medicare insurance coverage, had a college degree or higher, and were married. Cancer patients were more likely to report engaging in social distancing behaviors and greater concern regarding the pandemic. CONCLUSION: This study suggests differences in the impact of the COVID-19 pandemic on cancer patients compared to cancer-free members of the general population. These results indicate the need for consideration of cancer patients' physical and mental health during large-scale disruptions to cancer care.

The Impact of Commission on Cancer Accreditation Status, Hospital Rurality and Hospital Size on Quality Measure Performance Rates.

BACKGROUND: Rural cancer patients receive lower-quality care and experience worse outcomes than urban patients. Commission on Cancer (CoC) accreditation requires hospitals to monitor performance on evidence-based quality measuresPlease confirm the list of authors is correc, but the impact of accreditation is not clear due to lack of data from non-accredited facilities and confounding between patient rurality and hospital accreditation, rurality, and size. METHODS: This retrospective, observational study assessed associations between rurality, accreditation, size, and performance rates for four CoC quality measures (breast radiation, breast chemotherapy, colon chemotherapy, colon nodal yield). Iowa Cancer Registry data were queried to identify all eligible patients diagnosed between 2011 and 2017. Cases were assigned to the surgery hospital to calculate performance rates. Univariate and multivariate regression models were fitted to identify patient- and hospital-level predictors and assess trends. RESULTS: The study cohort included 10,381 patients; 46% were rural. Compared with urban patients, rural patients more often received treatment at small, rural, and non-accredited facilities (p < 0.001 for all). Rural hospitals had fewer beds and were far less likely to be CoC-accredited than urban hospitals (p < 0.001 for all). On multivariate analysis, CoC accreditation was the strongest, independent predictor of higher hospital performance for all quality measures evaluated (p < 0.05 in each model). Performance rates significantly improved over time only for the colon nodal yield quality measure, and only in urban hospitals. CONCLUSIONS: CoC accreditation requires monitoring and evaluating performance on quality measures, which likely contributes to better performance on these measures. Efforts to support rural hospital accreditation may improve existing disparities in rural cancer treatment and outcomes.

Referrals and Decision-Making Considerations Involved in Selecting a Surgeon for Rectal Cancer Treatment in the Midwestern United States.

BACKGROUND: Despite evidence of superior outcomes for rectal cancer at high-volume, multidisciplinary cancer centers, many patients undergo surgery in low-volume hospitals. OBJECTIVE: This study aimed to examine considerations of former patients with rectal cancer when selecting their surgeon and to evaluate which considerations were associated with surgery at high-volume hospitals. DESIGN: In this retrospective cohort study, patients were surveyed about what they considered when selecting a cancer surgeon. SETTINGS: Study data were obtained via survey and the statewide Iowa Cancer Registry. PATIENTS: All eligible individuals diagnosed with invasive stages II/III rectal cancer from 2013 to 2017 identified through the registry were invited to participate. MAIN OUTCOME MEASURES: The primary outcomes were the characteristics of the hospital where they received surgery (ie, National Cancer Institute designation, Commission on Cancer accreditation, and rectal cancer surgery volume). RESULTS: Among respondents, 318 of 417 (76%) completed surveys. Sixty-nine percent of patients selected their surgeon based on their physician's referral/recommendation, 20% based on surgeon/hospital reputation, and 11% based on personal connections to the surgeon. Participants who chose their surgeon based on reputation had significantly higher odds of surgery at National Cancer Institute-designated (OR 7.5; 95% CI, 3.8-15.0) or high-volume (OR 2.6; 95% CI, 1.2-5.7) hospitals than those who relied on referral. LIMITATIONS: This study took place in a Midwestern state with a predominantly white population, which limited our ability to evaluate racial/ethnic associations. CONCLUSION: Most patients with rectal cancer relied on referrals in selecting their surgeon, and those who did were less likely to receive surgery at a National Cancer Institute-designated or high-volume hospitals compared to those who considered reputation. Future research is needed to determine the impact of these decision factors on clinical outcomes, patient satisfaction, and quality of life. In addition, patients should be aware that relying on physician referral may not result in treatment from the most experienced or comprehensive care setting in their area. See Video Abstract at http://links.lww.com/DCR/B897.REMISIONES Y CONSIDERACIONES PARA LA TOMA DE DECISIONES RELACIONADAS CON LA SELECCIÓN DE UN CIRUJANO PARA EL TRATAMIENTO DEL CÁNCER DE RECTO EN EL MEDIO OESTE DE LOS ESTADOS UNIDOSANTECEDENTES:A pesar de la evidencia de resultados superiores para el tratamiento del cáncer de recto en centros oncológicos de gran volumen y multidisciplinarios, muchos pacientes se someten a cirugía en hospitales de bajo volumen.OBJETIVOS:Examinar las consideraciones de los antiguos pacientes con cáncer de recto al momento de seleccionar a su cirujano y evaluar qué consideraciones se asociaron con la cirugía en hospitales de gran volumen.DISEÑO:Encuestamos a los pacientes sobre qué aspectos consideraron al elegir un cirujano oncológico para completar este estudio de cohorte retrospectivo.AJUSTE:Los datos del estudio se obtuvieron mediante una encuesta y el Registro de Cáncer del estado de Iowa.PACIENTES:Se invitó a participar a todas las personas elegibles diagnosticadas con cáncer de recto invasivo en estadios II/III entre 2013 y 2017 identificadas a través del registro.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados principales fueron las características del hospital donde fue realizada la cirugía (es decir, designación del Instituto Nacional del Cáncer, acreditación de la Comisión de Cáncer y volumen de cirugía del cáncer de recto).RESULTADOS:Hubo 318 de 417 (76%) encuestas completadas. El sesenta y nueve por ciento seleccionó a su cirujano en función de la referencia / recomendación de su médico, el 20% por la reputación del cirujano/hospital, y el 11% por sus conexiones personales con el cirujano. Los participantes que eligieron a su cirujano en función a la reputación tuvieron probabilidades significativamente más altas de cirugía en el Instituto Nacional del Cáncer designado (OR = 7,5, IC del 95%: 3,8-15,0) o en hospitales de alto volumen (OR = 2,6, IC del 95%: 1,2-5,7) que aquellos que dependían de la derivación.LIMITACIONES:Este estudio se llevó a cabo en un estado del medio oeste con una población predominantemente blanca, lo que limitó nuestra capacidad para evaluar las asociaciones raciales/étnicas.CONCLUSIONES:La mayoría de los pacientes con cáncer de recto dependían de las derivaciones para seleccionar a su cirujano, y los que lo hacían tenían menos probabilidades de recibir cirugía en un hospital designado por el Instituto Nacional del Cáncer o en hospitales de gran volumen en comparación con los que consideraban la reputación. Se necesitan investigaciones a futuro para determinar el impacto de estos factores de decisión en los resultados clínicos, la satisfacción del paciente y la calidad de vida. Además, los pacientes deben ser conscientes de que depender de la remisión de un médico puede no resultar en el tratamiento más experimentado o integral en su área. Consulte Video Resumen en http://links.lww.com/DCR/B897. (Traducción-Dr Osvaldo Gauto).

Impact of age, rurality and distance in predicting contralateral prophylactic mastectomy for breast cancer in a Midwestern state: a population-based study.

PURPOSE: Iowa is among several rural Midwestern states with the highest proportions of contralateral prophylactic mastectomy (CPM) in women < 45 years of age. We evaluated the role of rurality and travel distance in these surgical patterns. METHODS: Women with unilateral breast cancer (2007-2017) were identified using Iowa Cancer Registry records. Patients and treating hospitals were classified as metro, nonmetro, and rural based on Rural-Urban Continuum Codes. Differences in patient, tumor, and treatment characteristics and median travel distance (MTD) were compared. Characteristics associated with CPM were evaluated with multivariate logistic regression. RESULTS: 22,158 women were identified: 57% metro, 26% nonmetro and 18% rural. Young rural women had the highest proportion of CPM (52%, 39% and 40% for rural, metro, nonmetro women < 40 years). Half of all rural women had surgery at metro hospitals; these women had the longest MTD (62 miles). Among all women treated at metro hospitals, rural women had the highest proportion of CPM (17% rural vs 14% metro/nonmetro, p = 0.007). On multivariate analysis, traveling ≥ 50 miles (ORs 1.43-2.34) and rural residence (OR = 1.29) were independently predictive of CPM. Other risk factors were young age (< 40 years: OR = 7.28, 95% CI 5.97-8.88) and surgery at a metro hospital that offers reconstruction (OR = 2.30, 95% CI 1.65-3.21) and is not NCI-designated (OR = 2.34, 95% CI 1.92-2.86). CONCLUSION: There is an unexpectedly high proportion of CPM in young rural women in Iowa, and travel distance and availability of reconstructive services likely influence decision-making. Improving access to multidisciplinary care in rural states may help optimize decision-making.

Presentation, Management, and Prognosis of Primary Gastrointestinal Melanoma: A Population-Based Study.

BACKGROUND: Primary gastrointestinal (GI) melanomas, compared with cutaneous melanomas, have a much lower incidence. As a result, there is a paucity of data regarding their presentation, treatment, and prognosis. The aim of this study was to analyze the incidence, patient characteristics, treatment patterns, and survival of primary GI melanomas in comparison with cutaneous melanomas using a population-based cohort. METHODS: Patients diagnosed with primary GI and cutaneous melanomas were identified from Surveillance, Epidemiology, and End Results 1973-2016 data. RESULTS: A total of 872 primary GI melanomas and 319,327 cutaneous melanomas were identified. GI melanoma incidence increased by an annual percent change of 1.82 (P < 0.05) during the study period. The most common sites for GI melanoma were the anus (50%) and rectum (34%). Compared to cutaneous melanoma, patients diagnosed with GI melanomas were older, women (58% versus 45%), non-White (16% versus 6%), and presented with a higher stage (36% versus 4% distant stage, all P < 0.001). GI melanomas had significantly worse cancer-specific survival (CSS) than cutaneous melanoma. Despite the poor prognosis, the CSS has increased in recent years. Among patients with anorectal melanomas, local excision with chemotherapy and/or radiation had a similar CSS compared with those with major surgery only. CONCLUSIONS: Despite a steady increasing incidence since 1975, GI melanomas are rare, present with advanced stages, and have worse outcomes than cutaneous melanomas. The improved prognosis of these tumors in recent years might reflect the impact of novel targeted treatments and the more common use of local tumor excision over major resections.

Treatment of Stage IV Colon Cancer in the United States: A Patterns-of-Care Analysis.

BACKGROUND: National guidelines recommend chemotherapy as the mainstay of treatment for stage IV colon cancer, with primary tumor resection (PTR) reserved for patients with symptomatic primary or curable disease. The aims of this study were to characterize the treatment modalities received by patients with stage IV colon cancer and to determine the patient-, tumor-, and hospital-level factors associated with those treatments. METHODS: Patients diagnosed with stage IV colon cancer in 2014 were extracted from the SEER Patterns of Care initiative. Treatments were categorized into chemotherapy only, PTR only, PTR + chemotherapy, and none/unknown. RESULTS: The total weighted number of cases was 3,336; 17% of patients received PTR only, 23% received chemotherapy only, 41% received PTR + chemotherapy, and 17% received no treatment. In multivariable analyses, compared with chemotherapy only, PTR + chemotherapy was associated with being married (odds ratio [OR], 1.9), having bowel obstruction (OR, 2.55), and having perforation (OR, 2.29), whereas older age (OR, 5.95), Medicaid coverage (OR, 2.46), higher T stage (OR, 3.51), and higher N stage (OR, 6.77) were associated with PTR only. Patients who received no treatment did not have more comorbidities or more severe disease burden but were more likely to be older (OR, 3.91) and non-Hispanic African American (OR, 2.92; all P<.05). Treatment at smaller, nonacademic hospitals was associated with PTR (± chemotherapy). CONCLUSIONS: PTR was included in the treatment regimen for most patients with stage IV colon cancer and was associated with smaller, nonacademic hospitals. Efforts to improve guideline implementation may be beneficial in these hospitals and also in non-Hispanic African American and older populations.

Guideline-Recommended Chemoradiation for Patients With Rectal Cancer at Large Hospitals: A Trend in the Right Direction.

BACKGROUND: Many patients with rectal cancer are treated at small, low-volume hospitals despite evidence that better outcomes are associated with larger, high-volume hospitals. OBJECTIVES: This study aims to examine trends of patients with rectal cancer who are receiving care at large hospitals, to determine the patient characteristics associated with treatment at large hospitals, and to assess the relationships between treatment at large hospitals and guideline-recommended therapy. DESIGN: This study was a retrospective cohort analysis to assess trends in rectal cancer treatment. SETTINGS: Data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Patterns of Care studies were used. PATIENTS: The study population consisted of adults diagnosed with stages II/III rectal cancer in 1990/1991, 1995, 2000, 2005, 2010, and 2015. MAIN OUTCOME MEASURES: The primary outcome was treatment at large hospitals (≥500 beds). The receipt of guideline-recommended preoperative chemoradiation therapy and postoperative chemotherapy was assessed for patients diagnosed in 2005+. RESULTS: Two thousand two hundred thirty-one patients were included. The proportion treated at large hospitals increased from 19% in 1990/1991 to 27% in 2015 (ptrend < 0.0001). Black race was associated with treatment at large hospitals (vs white) (OR, 1.73; 95% CI, 1.30-2.31), as was being 55 to 64 years of age (vs 75+), and diagnosis in 2015 (vs 1990/1991). Treatment in large hospitals was associated with twice the odds of preoperative chemoradiation, as well as younger age and diagnosis in 2010 or 2015 (vs 2005). LIMITATIONS: The study did not account for the change in the number of large hospitals over time. CONCLUSIONS: Results suggest that patients with rectal cancer are increasingly being treated in large hospitals where they receive more guideline-recommended therapy. Although this trend is promising, patients receiving care at larger, higher-volume facilities are still the minority. Initiatives increasing patient and provider awareness of benefits of specialized care, as well as increasing referrals to large centers may improve the use of recommended treatment and ultimately improve outcomes. See Video Abstract at http://links.lww.com/DCR/A994. QUIMIORRADIACIÓN RECOMENDADA EN GUÍAS PARA PACIENTES CON CÁNCER RECTAL EN HOSPITALES DE GRAN TAMAÑO: UNA TENDENCIA EN LA DIRECCIÓN CORRECTA: Muchos pacientes con cáncer rectal se tratan en hospitales pequeños y de bajo volumen a pesar de evidencia de que los mejores resultados se asocian con hospitales más grandes y de gran volumen. OBJETIVOS: Examinar las tendencias en los pacientes con cáncer rectal que reciben atención en hospitales de gran tamaño, determinar las características de los pacientes asociadas con el tratamiento en hospitales grandes y evaluar la relación entre el tratamiento en hospitales grandes y la terapia recomendada en guías. DISEÑO:: Este estudio fue un análisis de cohorte retrospectivo para evaluar las tendencias en el tratamiento del cáncer de recto. ESCENARIO: Se utilizaron datos de los estudios del programa Patrones de Atención, Vigilancia, Epidemiología y Resultados Finales (SEER) del Instituto Nacional de Cáncer (NIH). PACIENTES: La población de estudio consistió en adultos diagnosticados con cáncer rectal en estadio II / III en 1990/1991, 1995, 2000, 2005, 2010 y 2015. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue el tratamiento en hospitales grandes (≥500 camas). La recepción de quimiorradiación preoperatoria recomendada según las guías y la quimioterapia posoperatoria se evaluaron para los pacientes diagnosticados en 2005 y posteriormente. RESULTADOS: Se incluyeron 2,231 pacientes. La proporción tratada en los hospitales grandes aumentó del 19% en 1990/1991 al 27% en 2015 (ptrend < 0.0001). La raza afroamericana se asoció con el tratamiento en hospitales grandes (vs. blanca) (OR, 1.73; IC 95%, 1.30-2.31), al igual que 55-64 años de edad (vs ≥75) y diagnóstico en 2015 (vs 1990/1991). El tratamiento en los hospitales grandes se asoció con el doble de probabilidad de quimiorradiación preoperatoria, así como con una edad más temprana y diagnóstico en 2010 o 2015 (vs 2005). LIMITACIONES: El estudio no tomó en cuenta el cambio en el número de hospitales grandes a lo largo del tiempo. CONCLUSIONES: Los resultados sugieren que los pacientes con cáncer rectal reciben cada vez más tratamiento en hospitales grandes donde reciben terapia recomendada por las guías mas frecuentemente. Aunque esta tendencia es prometedora, los pacientes que reciben atención en hospitales más grandes y de mayor volumen siguen siendo una minoría. Las iniciativas que aumenten la concientización del paciente y del proveedor de servicios médicos sobre los beneficios de la atención especializada, así como el aumento de las referencias a centros grandes podrían mejorar el uso del tratamiento recomendado y, en última instancia, mejorar los resultados. Vea el Resumen en video en http://links.lww.com/DCR/A994.

Racial/ethnic differences in thyroid cancer incidence in the United States, 2007-2014.

BACKGROUND: Small tumor diagnostic tools including ultrasound-guided fine needle aspiration (FNA) and computed tomography (CT) could be causing rising and racially/ethnically different thyroid cancer incidence rates due to variable overdiagnosis of indolent tumors. Papillary tumors and <40 mm tumors are most likely to be overdiagnosed as indolent tumors by FNA and CT. METHODS: Age-adjusted incidence rates (AAIRs) for the years 2007-2014 were calculated for race/ethnicity (white, Hispanic, Asian, African American, Native American) by patient/tumor characteristics for microscopically confirmed malignant thyroid cancer cases in the Surveillance, Epidemiology, and End Results Program 18 database (SEER 18; N = 93,607). Multivariate analysis determined cancer patients' odds ratios of diagnosis with papillary thyroid carcinoma (vs other histologies) and tumors <40 mm (vs ≥40 mm). RESULTS: For both males and females, there were statistically significant differences in incidence rates between race/ethnicity, with whites having the highest AAIRs and African Americans the lowest AAIRs. Among thyroid cancer patients, tumor size and histology differed significantly by race and insurance coverage after controlling for age, sex, stage, and tumor sequence. Non-whites with thyroid cancer (vs whites) were less associated with small tumors (odds ratio [OR], 0.51-0.79; P < .0001). Medicaid and uninsured patients with thyroid cancer were less associated with tumors <40 mm (OR, 0.55-0.71; 95% confidence interval [CI], 0.49-0.76) and papillary carcinoma (OR, 0.86; 95% CI, 0.80-0.93). CONCLUSION: The diagnosis of small tumors is occurring at greater rates in whites (vs non-whites) and insured (vs Medicaid and uninsured) patients; consequently, these groups may be vulnerable to unnecessary tests and treatments or potentially aided by early detection. Guidelines that define postdetection interventions may be needed to limit the overtreatment of indolent and small papillary carcinomas. Cancer 2018;124:1483-91. © 2018 American Cancer Society.

KRAS Testing, Tumor Location, and Survival in Patients With Stage IV Colorectal Cancer: SEER 2010-2013.

Purpose:KRAS mutations and tumor location have been associated with response to targeted therapy among patients with stage IV colorectal cancer (CRC) in various trials. This study performed the first population-based examination of associations between KRAS mutations, tumor location, and survival, and assessed factors associated with documented KRAS testing. Methods: Patients with stage IV adenocarcinoma of the colon/rectum diagnosed from 2010 to 2013 were extracted from SEER data. Analyses of patient characteristics, KRAS testing, and tumor location were conducted using logistic regression. Cox proportional hazards models assessed relationships between KRAS mutations, tumor location, and risk of all-cause death. Results: Of 22,542 patients, 30% received KRAS testing, and 44% of these had mutations. Those tested tended to be younger, married, and metropolitan area residents, and have private insurance or Medicare. Rates of KRAS testing also varied by registry (range, 20%-46%). Patients with right-sided colon cancer (vs left-sided) tended to be older, female, and black; have mucinous, KRAS-mutant tumors; and have a greater risk of death (hazard ratio [HR], 1.27; 95% CI, 1.22-1.32). KRAS mutations were not associated with greater risk of death in the overall population; however, they were associated with greater risk of death among patients with left-sided colon cancer (HR, 1.19; 95% CI, 1.05-1.33). Conclusions: This large population-based study showed that among patients initially diagnosed with stage IV CRC, right-sided colon cancer was associated with greater risk of death compared with left-sided cancer, and KRAS mutations were only associated with risk of death in left-sided colon cancer. An unexpected finding was that among patients with stage IV disease, right-sided cancer was more commonly seen in black patients versus whites. Future studies should further explore these associations and determine the role of biology versus treatment differences. In addition, use of KRAS testing is increasing, but there is wide geographic variation wherein disparities related to insurance coverage and rurality may warrant further study.

Perspectives on Referring for Rectal Cancer Surgery: a Survey Study of Gastroenterologist and General Surgeons in Iowa.

PURPOSE: To understand referral practices for rectal cancer surgical care and to secondarily determine differences in referral practices by two main hypothesized drivers of referral: the rurality of the community endoscopists' practice and their affiliation with a colorectal surgeon. METHODS: Community gastroenterologists and general surgeons in Iowa completed a mailed questionnaire on practice demographics, volume, and referral practices for rectal cancer patients. Rurality was operationalized with RUCA codes. RESULTS: Twenty-two of 53 gastroenterologists (42%) and 120 of 188 general surgeons (64%) (total 144/241, 60%) in Iowa responded. Most performed colonoscopies, including 22 gastroenterologists (100%) and 96 general surgeons (80%). Regular referral of rectal cancer patients to colorectal surgeons was reported for 57% of urban physicians affiliated with a colorectal surgeon, 33% of urban physicians not affiliated with a colorectal surgeon, and 57% and 72% of physicians in large and small rural areas, respectively, who were not affiliated with a colorectal surgeon. High surgeon volume, high hospital volume, and colorectal surgeon specialty were important factors in the referral decisions for over half the physicians. 69% of diagnosing urban general surgeons reported performing rectal cancer surgery about half the time or more, while 85% of small rural and 60% of large rural diagnosing general surgeons reported never or rarely performing rectal cancer surgery. CONCLUSIONS: Diagnosing physicians have variable rectal cancer referral practices, including consistency in referred to surgeon and prioritization of volume and specialization. Prioritizing specialized or high-volume rectal cancer surgical care would require changing existing referring patterns.

Geographic distance to Commission on Cancer-accredited and nonaccredited hospitals in the United States.

PURPOSE: The Commission on Cancer (CoC) establishes standards to support multidisciplinary, comprehensive cancer care. CoC-accredited cancer programs diagnose and/or treat 73% of patients in the United States. However, rural patients may experience diminished access to CoC-accredited cancer programs. Our study evaluated distance to hospitals by CoC accreditation status, rurality, and Census Division. METHODS: All US hospitals were identified from public-use Homeland Infrastructure Foundation-Level Data, then merged with CoC-accreditation data. Rural-Urban Continuum Codes (RUCC) were used to categorize counties as metro (RUCC 1-3), large rural (RUCC 4-6), or small rural (RUCC 7-9). Distance from each county centroid to the nearest CoC and non-CoC hospital was calculated using the Great Circle Distance method in ArcGIS. FINDINGS: Of 1,382 CoC-accredited hospitals, 89% were in metro counties. Small rural counties contained a total of 30 CoC and 794 non-CoC hospitals. CoC hospitals were located 4.0, 10.1, and 11.5 times farther away than non-CoC hospitals for residents of metro, large rural, and small rural counties, respectively, while the average distance to non-CoC hospitals was similar across groups (9.4-13.6 miles). Distance to CoC-accredited facilities was greatest west of the Mississippi River, in particular the Mountain Division (99.2 miles). CONCLUSIONS: Despite similar proximity to non-CoC hospitals across groups, CoC hospitals are located farther from large and small rural counties than metro counties, suggesting rural patients have diminished access to multidisciplinary, comprehensive cancer care afforded by CoC-accredited hospitals. Addressing distance-based access barriers to high-quality, comprehensive cancer treatment in rural US communities will require a multisectoral approach.

Identifying predictors of COVID-related delays in cancer-specific medical care.

PURPOSE: Evidence of the impact of the COVID-19 pandemic on cancer prevention and control is growing, but little is known about patient-level factors associated with delayed care. We analyzed data from a survey focused on Iowan cancer patients' COVID-19 experiences in the early part of the pandemic. METHODS: Participants were recruited from the University of Iowa Holden Comprehensive Cancer Center's Patients Enhancing Research Collaborations at Holden (PERCH) program. We surveyed respondents on demographic characteristics, COVID-19 experiences and reactions, and delays in any cancer-related health care appointment, or cancer-related treatment appointments. Two-sided significance tests assessed differences in COVID-19 experiences and reactions between those who experienced delays and those who did not. RESULTS: There were 780 respondents (26% response), with breast, prostate, kidney, skin, and colorectal cancers representing the majority of respondents. Delays in cancer care were reported by 29% of respondents. In multivariable-adjusted models, rural residents (OR 1.47; 95% CI 1.03, 2.11) and those experiencing feelings of isolation (OR 2.18; 95% CI 1.37, 3.47) were more likely to report any delay, where experiencing financial difficulties predicted delays in treatment appointments (OR 5.72; 95% CI 1.96, 16.67). Health insurance coverage and concern about the pandemic were not statistically significantly associated with delays. CONCLUSION: These findings may inform cancer care delivery during periods of instability when treatment may be disrupted by informing clinicians about concerns that patients have during the treatment process. Future research should assess whether delays in cancer care impact long-term cancer outcomes and whether delays exacerbate existing disparities in cancer outcomes.

Locations of COVID-19 vaccination provision: Urban-rural differences.

PURPOSE: Our goal was to compare locations of COVID-19 vaccine provision in urban and rural communities over the course of the pandemic. METHODS: We used the Iowa Immunization Registry Information System (IRIS) to identify the organizations providing COVID-19 vaccines (eg, pharmacies, public health departments, and medical providers). Proportions of first-dose vaccines by organization type and patient census-based statistical area were generated. We calculated Chi-square tests to assess differences among metropolitan, micropolitan, and noncore communities. FINDINGS: IRIS data revealed that 64% (n = 2,043,251) of Iowans received their first COVID-19 vaccine between December 14, 2020, and December 31, 2022. For metropolitan-dwelling individuals, most first doses were administered at pharmacies (53%), with similar trends observed for micropolitan (49%) and noncore (42%) individuals. The second most common location for metropolitan individuals was medical practices (17%); public health clinics and departments were the second most common provider for micropolitan (26%) and noncore (33%) individuals. These trends shifted over time. In December 2020, hospitals were the most common vaccine provider for everyone, but by December 2022, medical providers were the most common source for metropolitan individuals, and pharmacies were most common for micropolitan and noncore individuals. CONCLUSIONS: Trends in the type of vaccine provider differentiated metropolitan residents from micropolitan and noncore residents. For the latter groups, local public health departments played a more significant role. Across all groups, pharmacists emerged as a critical vaccine provider. Our findings can be used to plan for seasonal vaccine campaigns as well as potential future mass vaccination campaigns.

Diagnosing Provider, Referral Patterns, Facility Type, and Patient Satisfaction Among Iowa Rectal Cancer Patients.

PURPOSE: Rectal cancer treatment at high-volume centers is associated with higher likelihood of guideline-concordant care and improved outcomes. Whether rectal cancer patients are referred for treatment at high-volume hospitals may depend on diagnosing provider specialty. We aimed to determine associations of diagnosing provider specialty with treating provider specialty and characteristics of the treating facility for rectal cancer patients in Iowa. METHODS: Rectal cancer patients identified using the Iowa Cancer Registry completed a mailed survey on their treatment experience and decision-making process. Provider type was defined by provider specialty and whether the provider referred patients elsewhere for surgery. Multivariable-adjusted logistic regression models were used to examine predictors of being diagnosed by a general surgeon who also performed the subsequent surgery. RESULTS: Of 417 patients contacted, 381 (76%) completed the survey; our final analytical sample size was 267. Half of respondents were diagnosed by a gastroenterologist who referred them elsewhere; 30% were diagnosed by a general surgeon who referred them elsewhere, and 20% were diagnosed by a general surgeon who performed the surgery. Respondents who were ≥ 65 years old, had less than a college education, and who made < $50,000 per year were more likely to be diagnosed by a general surgeon who performed surgery. In multivariable-adjusted models, respondents diagnosed and treated by the same general surgeon were more likely to have surgery at hospitals with low annual colorectal cancer surgery volume and less likely to be satisfied with their care. CONCLUSIONS: Among rectal cancer patients in Iowa, respondents who were diagnosed and treated by the same provider were less likely to get treatment at a high-volume facility. This study informs the importance of provider referral in centralization of rectal cancer care.

Assessing Completeness of Cancer Treatment Data from an Academic Medical Center's Tumor Registry Through Comparison to the Central Registry.

Background: Researchers often rely on hospital tumor registry data to provide comprehensive cancer therapy information. The purpose of this study was to determine the completeness of treatment information found in the abstracted records of patients seen at an academic medical center located in a rural Midwestern state. Approach: The cohort included 846 Iowa residents diagnosed with a single malignant tumor of the female breast, colon/rectum, lung, pancreas, or prostate in 2017-2018 with an abstract recorded by the academic medical center and at least 1 other hospital. Treatment/no treatment agreement between the academic medical center's abstract and the central registry's consolidated abstract was examined for the following summary variables of the North American Association of Central Cancer Registries (NAACCR): surgery of the primary site, chemotherapy, radiation therapy, immunotherapy, and hormone therapy. Treatment summary variables from the academic medical center abstract that agreed with the corresponding variables from the central registry abstract were classified as concordant. The proportion of concordance for each treatment modality was the outcome measure, and 95% confidence intervals were calculated with the Agresti-Coull method. Concordance was also examined at the specific treatment level. Results: There was high concordance between the treatment information recorded in the academic medical center and the central registry records. The average proportion of treatment/no treatment agreement across all treatment modalities and cancer sites was 0.97 (SD, 0.02). Concordance remained high even when examining specific treatments (average concordance, 0.95; SD, 0.04). The lowest treatment/no treatment concordance proportion was 0.92 (95% CI, 0.86-0.96) for chemotherapeutic treatment of pancreatic cancer. We also found that the academic medical center's summary variables captured most treatments given at other facilities, ranging from 74.4% capture of immunotherapy to 88.2% capture of surgery of the primary site. Conclusions: These results indicate that NAACCR-formatted, summary variables from the academic medical center's tumor registry are likely to provide comprehensive treatment information for those individuals diagnosed or treated in this setting. Analyses of either the academic medical record registry records or consolidated records from the central registry should yield similar results. Future research should establish whether similar findings are obtained at other medical centers.

Rural and urban differences in perceptions, behaviors, and health care disruptions during the COVID-19 pandemic.

PURPOSE: The objective of this study was to assess perceptions, health behaviors, and disruptions related to the COVID-19 pandemic in a largely rural, Midwestern state, and to examine differences between rural and urban respondents. METHODS: A questionnaire was mailed August 2020 to a sample of 10,009 registered voters in Iowa ages 18-100 years, with oversampling from 6 select rural counties. Previously validated and tested items assessed COVID-19 precautions, health care disruptions, emotional reactions, health behavior changes, telehealth and experiences with the internet, and demographic characteristics. FINDINGS: There were 4,048 respondents (40% response rate); 65% were rural and 35% were urban residents. The average age of respondents was 58.3 years and 45% of respondents identified as female. Rural respondents reported less concern about COVID-19 in their community (29% vs 40%, P<.001) and lower perceived importance of social distancing (51% vs 64%, P<.001). Urban respondents more often reported experiencing disruption to daily living, stronger negative emotional reactions, and displayed more pronounced behavior change compared to their rural counterparts. For example, urban respondents reported more pandemic-related job losses (6% vs 4%, P = .05), disruptions to daily activities (48% vs 35%, P<.001), and use of telehealth services during the pandemic (24% vs 16%, P<.001). CONCLUSIONS: The majority of respondents reported disruptions to normal activities, medical appointment cancellations, and emotional distress during the first 6 months of the pandemic. The impact of the pandemic on urban residents appeared to be greater than for rural respondents. Timing of pandemic spread and varying beliefs are potential explanations.

Cancer Registry Data Linkage of Electronic Health Record Data From ASCO's CancerLinQ: Evaluation of Advantages, Limitations, and Lessons Learned.

PURPOSE: To evaluate the completeness of information for research and quality assessment through a linkage between cancer registry data and electronic health record (EHR) data refined by ASCO's health technology platform CancerLinQ. METHODS: A probabilistic data linkage between Iowa Cancer Registry (ICR) and an Iowa oncology clinic through CancerLinQ data was conducted for cases diagnosed between 2009 and 2018. Demographic, cancer, and treatment variables were compared between data sources for the same patients, all of whom were diagnosed with one primary cancer. Treatment data and compliance with quality measures were compared among those with breast or prostate cancer; SEER-Medicare data served as a comparison. Variables captured only in CancerLinQ data (smoking, pain, and height/weight) were evaluated for completeness. RESULTS: There were 6,175 patients whose data were linked between ICR and CancerLinQ data sets. Of those, 4,291 (70%) were diagnosed with one primary cancer and were included in analyses. Demographic variables were comparable between data sets. Proportions of people receiving hormone therapy (30% v 26%, P < .0001) or immunotherapy (22% v 12%, P < .0001) were significantly higher in CancerLinQ data compared with ICR data. ICR data contained more complete TNM stage, human epidermal growth factor receptor 2 testing, and Gleason score information. Compliance with quality measures was generally highest in SEER-Medicare data followed by the combined ICR-CancerLinQ data. CancerLinQ data contained smoking, pain, and height/weight information within one month of diagnosis for 88%, 52%, and 76% of patients, respectively. CONCLUSION: Linking CancerLinQ EHR data with cancer registry data led to more complete data for each source respectively, as registry data provides definitive diagnosis and more complete stage information and laboratory results, whereas EHR data provide more detailed treatment data and additional variables not captured by registries.

Presentation, treatment, and prognosis of colorectal adenosquamous carcinoma: A contemporary analysis of the surveillance, epidemiology, and end results database.

INTRODUCTION: Colorectal adenosquamous carcinoma (ASC) represents <0.1% of colorectal cancers. Due to its rarity, there is paucity of data regarding its prognosis and treatment compared to other colorectal cancers. The aim of the study was to evaluate presentation, treatment and prognosis of colorectal ASC in comparison to adenocarcinoma (AC) and squamous cell carcinoma (SCC). METHODS: Adult patients diagnosed with colorectal AC, SCC, and ASC between 2000 and 2017 were identified using Surveillance, Epidemiology, and End Results database. RESULTS: Among the 446,132 patients diagnosed with colorectal cancer, 0.06% had ASC and were more likely to present with higher T stage and distant metastases compared to AC and SCC (p < 0.001). Major surgery was the primary treatment for colonic ASC, while for rectal ASC, chemotherapy and/or radiation were mainly utilized. Localized and distant colonic ASC had an unadjusted 5-year cause-specific survival that was worse than AC, while rectal ASC had the worst survival across all stages. CONCLUSION: Colorectal ASC usually present with advanced stage and have overall worse prognosis. Standardization of treatment strategies may improve survival in colorectal ASC.

Differences in Travel Time to Cancer Surgery for Colon versus Rectal Cancer in a Rural State: A New Method for Analyzing Time-to-Place Data Using Survival Analysis.

PURPOSE: Rectal cancer is rarer than colon cancer and is a technically more difficult tumor for surgeons to remove, thus rectal cancer patients may travel longer for specialized treatment compared to colon cancer patients. The purpose of this study was to evaluate whether travel time for surgery was different for colon versus rectal cancer patients. METHODS: A secondary data analysis of colorectal cancer (CRC) incidence data from the Iowa Cancer Registry data was conducted. Travel times along a street network from all residential ZIP Codes to all cancer surgery facilities were calculated using a geographic information system. A new method for analyzing "time-to-place" data using the same type of survival analysis method commonly used to analyze "time-to-event" data is introduced. Cox proportional hazard model was used to analyze travel time differences for colon versus rectal cancer patients. RESULTS: A total of 5,844 CRC patients met inclusion criteria. Median travel time to the nearest surgical facility was 9 minutes, median travel time to the actual cancer surgery facilities was 22 minutes, and the median number of facilities bypassed was 3. Although travel times to the nearest surgery facilities were not significantly different for colon versus rectal cancer patients, rectal cancer patients on average traveled 15 minutes longer to their actual surgery facility and bypassed 2 more facilities to obtain surgery. DISCUSSION: In general, the survival analysis method used to analyze the time-to-place data as described here could be applied to a wide variety of health services and used to compare travel patterns among different groups.