Association of Travel Burden with Definitive Prostate Cancer Treatment: A United States Registry Cohort Study

Purpose Prostate cancer (PCa) mortality disparities are partly driven by unequal access to care. Transportation barriers may limit access to definitive treatment. We studied how driving travel time affects receipt of definitive PCa treatment.

We conducted a cohort study of men with non-metastatic PCa (2000 - 2015; follow-up through 2018) across the metropolitan area cancer registries of seven US states. Travel burden was estimated using Google Maps isochrones representing driving time thresholds to reach the hospital appended to geomasked residential addresses. Outcomes were “no treatment, “ “radical surgery,” or “radiotherapy”. Covariate-adjusted multinomial logistic regression with interaction terms assessed modification by sociodemographic factors.

The study included 132,939 men, of whom 37.0% received no treatment, 41.0% underwent surgery, and 22.0% received radiotherapy. Longer driving time (≥90 min vs <30 min) was associated with higher radical prostatectomy (aOR: 1.07, 95% CI: 1.03, 1.12), but lower radiotherapy (0.72, 95% CI: 0.69 - 0.76). Subgroup analyses revealed higher surgery associated with longer driving times among those in nSES Q1 (aOR: 1.33, 95% CI: 1.21-1.45) vs Q5 (aOR: 0.94, 95% CI: 0.86-1.04), those in low (aOR: 1.16, 95% CI: 1.09-1.24) vs high (aOR: 1.03, 95% CI: 0.98-1.09) population density areas, and those with regional (aOR: 1.30, 95% CI: 1.14-1.48) vs localized (aOR: 1.05, 95% CI: 1.00 -1.09) disease. Longer driving time was mostly associated with lower odds of radiotherapy across sociodemographic subgroups.

Higher travel burden was associated with lower radiotherapy receipt, but greater surgery use in deprived and rural patients, which warrants further investigation. Competing Interest Statement QDT: reports consulting fees from Astellas, Bayer, Intuitive Surgical, Janssen, Novartis, Pfizer, and research funding from the American Cancer Society, Pfizer Global Medical Grants (Prostate Cancer Disparities #63354905), and a Health Disparity Research Award from the Department of Defense Congressionally Directed Medical Research Program (#PC220551). APC: reports research funding from the Bruce A Beal and Robert L Beal surgical fellowship of the BWH Department of Surgery, from the Prostate Cancer Foundation and American Cancer Society (#23YOUN25) and from a Physician Research Award from the Department of Defense Congressionally Directed Medical Research Program (#PC220342). The other co-authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. HSI: reports research funding from Prostate Cancer Research, UK and the National Institutes of Health (K01ES035734). Funding Statement This research was funded through a Health Disparity Research Award from the Department of Defense Congressionally Directed Medical Research Program (#PC220551) and Prostate Cancer Research, UK. This project was supported by contract HHSN261201800014I, task order HHSN26100001 from the National Cancer Institute, the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program (75N91021D00009, HHSN261201800007I/HHSN26100002), the Centers for Disease Control and Prevention (CDC) National Program of Cancer Registries (5NU58DP006279, NU58DP006332) with additional support from the State of New Jersey and the Rutgers Cancer Institute of New Jersey and the State of Louisiana. This study includes data provide by the Ohio Department of Health which should not be considered an endorsement of this study or its conclusions. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The institutional review boards of the Brigham and Women's Hospital, Dana-Farber Cancer Institute and Rutgers University, The State University of New Jersey, approved this study and determined that, because existing data sources were used, no written consent was required for participation in the study. Access to cancer registry data additionally required state institutional review board approval for Hawaii, Massachusetts and New Jersey. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Footnotes f.dagnino97{at}gmail.com stephan.korn{at}meduniwien.ac.at danesha.kaye.d{at}gmail.com zhiyu.qian.jason{at}gmail.com danielrobert.stelzl{at}gmail.com hanna.zurl{at}medunigraz.at klara.pohl{at}medunigraz.at mhsieh{at}lsuhsc.edu brenda{at}cc.hawaii.edu andrea.piccolini{at}humanitas.it giovanni.lughezzani{at}hunimed.eu nicolo.buffi{at}hunimed.eu slipsitz{at}bwh.harvard.edu ajreich{at}bwh.harvard.edu jweisman{at}partners.org alexander.p.cole{at}gmail.com trinh.qd{at}gmail.com Key Message: Higher travel burden was associated with lower radiotherapy receipt for prostate cancer. Among socioeconomically deprived patients, travel burden was linked to differing outcomes of surgery and radiotherapy receipt, highlighting potential disparities in access to prostate cancer treatment. DECLARATION OF COMPETING INTERESTS: The authors declare not to have any conflicts of interests. ETHICAL APPROVAL: The institutional review boards of the Brigham and Women’s Hospital, Dana-Farber Cancer Institute and Rutgers University, The State University of New Jersey, approved this study and determined that, because existing data sources were used, no written consent was required for participation in the study. Access to cancer registry data additionally required state institutional review board approval for Hawaii, Massachusetts and New Jersey. DATA AVAILABILITY STATEMENT: The data that support the findings of this study are available from the corresponding author upon reasonable request. Data for this study were requested from each registry for the purposes of this research, and Institutional Review Board and Data Use Agreements between Rutgers, Dana-Farber, and each registry prohibit sharing of these data outside of the research team. Inquiries can be directed to: hi97{at}cinj.rutgers.edu Declaration of generative AI and AI-assisted technologies in the writing process: During the preparation of this work the author used ChatGPT 3.5 in order to correct syntax and grammar during the drafting of the manuscript. After using this tool, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication. FUNDING STATEMENT: This research was funded through a Health Disparity Research Award from the Department of Defense Congressionally Directed Medical Research Program (#PC220551) and Prostate Cancer Research, UK. This project was supported by contract HHSN261201800014I, task order HHSN26100001 from the National Cancer Institute, the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program (75N91021D00009, HHSN261201800007I/HHSN26100002), the Centers for Disease Control and Prevention (CDC) National Program of Cancer Registries (5NU58DP006279, NU58DP006332) with additional support from the State of New Jersey and the Rutgers Cancer Institute of New Jersey and the State of Louisiana. This study includes data provide by the Ohio Department of Health which should not be considered an endorsement of this study or its conclusions. Data Availability The data that support the findings of this study are available from the corresponding author upon reasonable request. Data for this study were requested from each registry for the purposes of this research, and Institutional Review Board and Data Use Agreements between Rutgers, Dana-Farber, and each registry prohibit sharing of these data outside of the research team. Inquiries can be directed to: hi97{at}cinj.rutgers.edu