Impact of Geography on Care Delivery and Survival for Noncurable Pancreatic Adenocarcinoma: A Population-Based Analysis

Authors: Elliott K. Yee B.Arts Sc.1,2, Natalie G. Coburn MD, MPH2,3,4,5, Laura E. Davis MSc6, Alyson L. Mahar PhD7, Victoria Zuk MSc2, Vaibhav Gupta MD, PhD2,4, Ying Liu MSc4, Craig C. Earle MD, MSc2,5,8, and Julie Hallet MD, MSc2,3,4,5
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  • 1 Faculty of Medicine, University of Toronto, Toronto, Ontario;
  • | 2 Cancer Program – Evaluative Clinical Sciences, and
  • | 3 Department of Surgery, Odette Cancer Centre – Sunnybrook Health Sciences Centre, Toronto, Ontario;
  • | 4 Department of Surgery, University of Toronto, Toronto, Ontario;
  • | 5 ICES, Toronto, Ontario;
  • | 6 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec;
  • | 7 Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba; and
  • | 8 Division of Medical Oncology, Odette Cancer Centre – Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Background: Little is known about how the geographic distribution of cancer services may influence disparities in outcomes for noncurable pancreatic adenocarcinoma. We therefore examined the geographic distribution of outcomes for this disease in relation to distance to cancer centers. Methods: We conducted a retrospective population-based analysis of adults in Ontario, Canada, diagnosed with noncurable pancreatic adenocarcinoma from 2004 through 2017 using linked administrative healthcare datasets. The exposure was distance from place of residence to the nearest cancer center providing medical oncology assessment and systemic therapy. Outcomes were medical oncology consultation, receipt of cancer-directed therapy, and overall survival. We examined the relationship between distance and outcomes using adjusted multivariable regression models. Results: Of 15,970 patients surviving a median of 3.3 months, 65.6% consulted medical oncology and 38.5% received systemic therapy. Regions with comparable outcomes were clustered throughout Ontario. Mapping revealed regional discordances between outcomes. Increasing distance (reference, ≤10 km) was independently associated with lower likelihood of medical oncology consultation (relative risks [95% CI] for 11–50, 51–100, and ≥101 km were 0.90 [0.83–0.98], 0.78 [0.62–0.99], and 0.77 [0.55–1.08], respectively) and worse survival (hazard ratios [95% CI] for 11–50, 51–100, and ≥101 km were 1.08 [1.04–1.12], 1.17 [1.10–1.25], and 1.10 [1.02–1.18], respectively), but not with likelihood of receiving therapy. Receipt of therapy seems less sensitive to distance, suggesting that distance limits entry into the cancer care system via oncology consultation. Regional outcome discordances suggest inefficiencies within and protective factors outside of the cancer care system. Conclusions: These findings provide a basis for clinicians to optimize their practices for patients with noncurable pancreatic adenocarcinoma, for future studies investigating geographic barriers to care, and for regional interventions to improve access.

Submitted March 5, 2020; accepted for publication June 18, 2020.

Previous presentation: Part of this work was presented at the GeoHealth Conference, April 30, 2019, Toronto, Ontario; the University of Toronto Department of Surgery Gallie Day, May 3, 2019, Toronto; the University of Toronto Department of Surgery Annual Assembly, May 16, 2019, Toronto; the annual meeting of the Canadian Society of Surgical Oncology, May 3, 2019, Toronto; and the Canadian Surgery Forum, September 5–7, 2019, Montreal, Quebec, Canada.

Author contributions: Statistical analysis: Liu. Study design and analysis: Coburn, Davis, Mahar, Zuk, Gupta, Earle. Manuscript preparation: Yee, Hallet. Suggestions for final manuscript: Coburn, Davis, Mahar, Zuk, Gupta, Earle.

Disclosures: Dr. Coburn has disclosed that she receives salary support from Cancer Care Ontario. Dr. Hallet has disclosed that she has received honoraria from Ipsen Biopharmaceuticals Canada and Novartis Oncology. The remaining authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: This study was supported by the Institute of Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). This study was supported by an operating grant from the Canadian Institutes of Health Research (FRN #154131).

Disclaimer: The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions, and statements expressed herein are those of the authors and not necessarily those of CIHI. Parts of this material are based on data and information provided by Cancer Care Ontario (CCO). The opinions, results, views, and conclusions reported in this paper are those of the authors and do not necessarily reflect those of CCO. No endorsement by CCO is intended or should be inferred.

Correspondence: Julie Hallet, MD, MSc, Department of Surgery, Odette Cancer Centre – Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. Email: julie.hallet@sunnybrook.ca

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