title: The effect of distance traveled on disease outcomes in gestational trophoblastic neoplasia.
abstract: Gestational trophoblastic neoplasia is a rare gynecological malignancy often treated at tertiary referral centers. Patients frequently travel long distances to obtain care for gestational trophoblastic neoplasia, which may affect cancer outcomes in these patients.
  
  
  
  We examined the association between distance traveled to obtain care and disease burden at time of presentation as well as recurrence.
  
  
  
  We performed a retrospective cohort analysis of all patients diagnosed with gestational trophoblastic neoplasia from January 1995 to June 2015 at a high-volume tertiary referral center. Patients were included if they met International Federation of Gynecology and Obstetrics 2000 criteria for postmolar gestational trophoblastic neoplasia or had choriocarcinoma, placental-site trophoblastic tumor, or epithelioid trophoblastic tumor. Sixty patients were identified. Disease burden at presentation was examined using both the World Health Organization prognostic score and International Federation of Gynecology and Obstetrics. Patients who traveled more than 50 miles were considered long-distance travelers based on previous literature on the effect of distance traveled on cancer outcomes. Demographic, clinical, and pathological data were obtained by chart review. Bivariable comparisons were performed using the χ(2) test or Fisher exact test for categorical variables. The t test or Wilcoxon rank-sum test was used to compare continuous variables when normally or not normally distributed.
  
  
  
  Most patients presented at stage I (61%) with low-risk gestational trophoblastic neoplasia (70%). Median distance to care was 40 miles (range, 4-384). Eighteen patients (30%) had no insurance and 42 (70%) had either private or public insurance. Patients traveling more than 50 miles for care were more likely to have high-risk gestational trophoblastic neoplasia (46% vs 19%, P = .03), but there was no difference in recurrence (13% vs 11%, P = .89). Patients with high-risk gestational trophoblastic neoplasia lived 63 miles farther (92 vs 28 miles, P < .001) than patients with low-risk gestational trophoblastic neoplasia. Long-distance travelers had a longer period between antecedent pregnancy and gestational trophoblastic neoplasia diagnosis (10 weeks vs 4.5 weeks, P = .009) and were more likely to receive multiagent chemotherapy (86% vs 61%, P = .03).
  
  
  
  In this cohort, long distance traveled to obtain care for gestational trophoblastic neoplasia was associated with an increased risk of presenting with high-risk disease and requiring multiagent chemotherapy for treatment. Patients with high-risk gestational trophoblastic neoplasia traveled nearly 100 miles to obtain care. There may be a delay in diagnosis in women traveling more than 50 miles to obtain care; however, we found no difference in recurrence risk for long-distance travelers.
authors.affiliation: Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Division of Gynecologic Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC. Electronic address: leslie.clark@unchealth.unc.edu.
authors.forename: Leslie H
authors.initials: LH
authors.lastname: Clark
authors.affiliation: Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: S Allison
authors.initials: SA
authors.lastname: Staley
authors.affiliation: Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Division of Gynecologic Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: Emma L
authors.initials: EL
authors.lastname: Barber
authors.affiliation: Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Division of Gynecologic Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: Weiya Z
authors.initials: WZ
authors.lastname: Wysham
authors.affiliation: Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Division of Gynecologic Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: Kenneth H
authors.initials: KH
authors.lastname: Kim
authors.affiliation: Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Division of Gynecologic Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: John T
authors.initials: JT
authors.lastname: Soper
mesh_terms: D000328:Adult; D017281:Cost of Illness; D005260:Female; D031901:Gestational Trophoblastic Disease / Q000188:drug therapy*; D006801:Humans; D011247:Pregnancy; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D062606:Tertiary Care Centers; D055815:Young Adult
keywords: gestational trophoblastic neoplasia; recurrence; survival; travel distance