Introduction: High-volume centers are associated with improved outcomes across both surgical and nonsurgical care. The extent to which this has led to centralized care for bladder cancer patients is unknown. We sought to examine trends in centralization among surgical and nonsurgical care and its associations with increased travel distances for bladder cancer patients.
Methods: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified all patients diagnosed with at least muscle-invasive bladder cancer between 2004-2013. To assess centralization, we examined the proportion of patients treated at a high-volume center (i.e., top quintile) over time. This calculation was performed for both surgical (cystectomy) and nonsurgical (radiation, chemotherapy) care. We also assessed patient travel distances for each treatment over this time period by calculating the straight-line distance from the patient’s ZIP code to the treating hospital’s ZIP code. Multilevel linear probability models with hospital-level random effects and median regression were used to examine trends in proportion treated in high volume centers and patient travel distance, respectively.
Results: We identified all patients who underwent radical cystectomy (n=6,756), radiation (n=5,832), and chemotherapy (n=7,730). Cystectomy became more centralized over time, with 50.8% of patients undergoing surgery in a high-volume center in 2004 versus 68.8% in 2013 (p<0.05). This pattern was less pronounced for radiation and chemotherapy (both p>0.05). For all 3 treatments, the median distance travelled increased significantly over time (all p<0.05) (Figure 1). Median travel distances increased by 12.42, 1.06, and 2.89 miles for cystectomy, radiation, and chemotherapy, between 2004 and 2013 respectively, despite stable proportions of patients living in rural areas over this time period.
Conclusions: The increasing centralization of bladder cancer care in terms of percent treated at high volume centers has been striking for surgery and less so for radiation and chemotherapy. However, increasing travel distances for all patients suggests that some form of centralization is likely occurring for nonsurgical care. Source of
Funding: Supported in part by P30CA047904 from the National Cancer Institute, the Henry L. Hillman Foundation, and the Shadyside Hospital Foundation.