title: Centralization of cancer surgery: implications for patient access to optimal care.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Using 1996 to 2006 discharge data from NY, NJ, PA, all patients > or = 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of SurgicalOncology, University of North Carolina, Chapel Hill, NC 27599-7213, USA. kbstitz@msn.com
authors.forename: Karyn B
authors.initials: KB
authors.lastname: Stitzenberg
authors.forename: Elin R
authors.initials: ER
authors.lastname: Sigurdson
authors.forename: Brian L
authors.initials: BL
authors.lastname: Egleston
authors.forename: Russell B
authors.initials: RB
authors.lastname: Starkey
authors.forename: Neal J
authors.initials: NJ
authors.lastname: Meropol
mesh_terms: D002497:Centralized Hospital Services / Q000706:statistics & numerical data*; D015179:Colorectal Neoplasms / Q000401:mortality / Q000601:surgery; D004938:Esophageal Neoplasms / Q000401:mortality / Q000601:surgery; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006751:Hospital Information Systems / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D016015:Logistic Models; D008297:Male; D009369:Neoplasms / Q000401:mortality / Q000601:surgery*; D009515:New Jersey; D009518:New York; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000601:surgery; D010351:Patient Discharge / Q000706:statistics & numerical data; D010414:Pennsylvania; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*