title: Going the Extra Mile: Improved Survival for Pancreatic Cancer Patients Traveling to High-volume Centers.
abstract: This study compares outcomes following pancreaticoduodenectomy (PD) for patients treated at local, low-volume centers and those traveling to high-volume centers.
  
  
  
  Although outcomes for PD are superior at high-volume institutions, not all patients live in proximity to major medical centers. Theoretical advantages for undergoing surgery locally exist.
  
  
  
  The 1998 to 2012 National Cancer Data Base was queried for T1-3N0-1M0 pancreatic adenocarcinoma patients who underwent PD. Travel distances to treatment centers were calculated. Overlaying the upper and lower quartiles of travel distance with institutional volume established short travel/low-volume (ST/LV) and long travel/high-volume (LT/HV) cohorts. Overall survival was evaluated.
  
  
  
  Of 7086 patients, 773 ST/LV patients traveled ≤6.3 (median 3.2) miles to centers performing ≤3.3 PDs yearly, and 758 LT/HV patients traveled ≥45 (median 97.3) miles to centers performing ≥16 PDs yearly. LT/HV patients had higher stage disease (P < 0.001), but lower margin positivity (20.5% vs 25.9%, P = 0.01) and improved lymphadenectomy (16 vs 11 nodes, P < 0.01). Moreover, LT/HV patients had shorter hospitalizations (9 vs 12 days, P < 0.01) and lower 30-day mortality (2.0% vs 6.3%, P < 0.01) with similar 30-day readmission rates (10.1% vs 9.8%, P = 0.83). Despite more advanced disease, LT/HV patients had superior unadjusted survival (20.3 vs 15.7 months). After adjustment, travel to a high-volume center remained associated with reduced long-term mortality (hazard ratio 0.75, P < 0.01).
  
  
  
  Despite an increased travel burden, patients treated at high-volume centers had improved perioperative outcomes, short-term mortality, and overall survival. These data support ongoing efforts to centralize care for patients undergoing PD.
authors.affiliation: Duke University Medical Center, Department of Surgery, Durham, NC.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Lidsky
authors.forename: Zhifei
authors.initials: Z
authors.lastname: Sun
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Nussbaum
authors.forename: Mohamed A
authors.initials: MA
authors.lastname: Adam
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Speicher
authors.forename: Dan G
authors.initials: DG
authors.lastname: Blazer
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D000368:Aged; D005260:Female; D017052:Hospital Mortality; D061847:Hospitals, High-Volume; D061846:Hospitals, Low-Volume; D006801:Humans; D007902:Length of Stay; D008197:Lymph Node Excision; D008297:Male; D009367:Neoplasm Staging; D010190:Pancreatic Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy; D012189:Retrospective Studies; D012307:Risk Factors; D014195:Travel; D016896:Treatment Outcome