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Is the Distance Worth It? Patients With Rectal Cancer Traveling to High-Volume Centers Experience Improved Outcomes

Xu, Zhaomin M.D.1; Becerra, Adan Z. B.A.1,2; Justiniano, Carla F. M.D.1; Boodry, Courtney I. M.D.1; Aquina, Christopher T. M.D., M.P.H.1; Swanger, Alex A. B.A.1; Temple, Larissa K. M.D., M.Sc.1; Fleming, Fergal J. M.D.1

doi: 10.1097/DCR.0000000000000924
Original Contributions: Colorectal Cancer
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BACKGROUND: It is unclear whether traveling long distances to high-volume centers would compensate for travel burden among patients undergoing rectal cancer resection.

OBJECTIVE: The purpose of this study was to determine whether operative volume outweighs the advantages of being treated locally by comparing the outcomes of patients with rectal cancer treated at local, low-volume centers versus far, high-volume centers.

DESIGN: This was a population-based study.

SETTINGS: The National Cancer Database was queried for patients with rectal cancer.

PATIENTS: Patients with stage II or III rectal cancer who underwent surgical resection between 2006 and 2012 were included.

MAIN OUTCOME MEASURES: The outcomes of interest were margins, lymph node yield, receipt of neoadjuvant chemoradiation, adjuvant chemotherapy, readmission within 30 days, 30-day and 90-day mortality, and 5-year overall survival.

RESULTS: A total of 18,605 patients met inclusion criteria; 2067 patients were in the long-distance/high-volume group and 1362 in the short-distance/low-volume group. The median travel distance was 62.6 miles for the long-distance/high-volume group and 2.3 miles for the short-distance/low-volume group. Patients who were younger, white, privately insured, and stage III were more likely to have traveled to a high-volume center. When controlled for patient factors, stage, and hospital factors, patients in the short-distance/low-volume group had lower odds of a lymph node yield ≥12 (OR = 0.51) and neoadjuvant chemoradiation (OR = 0.67) and higher 30-day (OR = 3.38) and 90-day mortality (OR = 2.07) compared with those in the long-distance/high-volume group. The short-distance/low-volume group had a 34% high risk of overall mortality at 5 years compared with the long-distance/high-volume group.

LIMITATIONS: We lacked data regarding patient and physician decision making and surgeon-specific factors.

CONCLUSIONS: Our results indicate that when controlled for patient, tumor, and hospital factors, patients who traveled a long distance to a high-volume center had improved lymph node yield, neoadjuvant chemoradiation receipt, and 30- and 90-day mortality compared with those who traveled a short distance to a low-volume center. They also had improved 5-year survival. See Video Abstract at

1 Department of Surgery, University of Rochester Medical Center, Rochester, New York

2 Division of Epidemiology, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York

Funding/Support: None reported.

Financial Disclosure: None reported.

Podium presentation at the scientific and tripartite meeting of The American Society of Colon and Rectal Surgeons, Seattle, WA, June 10 to 14, 2017.

Correspondence: Zhaomin Xu, M.D., Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave, Box SURG, Rochester, NY 14642. E-mail:

© 2017 The American Society of Colon and Rectal Surgeons