Introduction:

Radical Cystectomy (RC) is the standard of care for patients with non-metastatic muscle invasive bladder cancer and is known to be a complex procedure with high morbidity and mortality, frequently requiring readmission post-operatively. The majority of radical cystectomies are performed at high volume centers, which may lead to patients traveling farther distances for care. Over 80% of all cystectomies in Maine are performed at a single institution, with 25% traveling >50 miles for surgery. Numerous processes are in place to ensure adequate support for patients traveling for care. We sought to exam the impact of travel distance on important clinical outcomes.

Methods:

A prospectively maintained database of RC patients from 2015-2021 was retrospectively reviewed. We identified 220 patients who underwent RC. Distance traveled to treatment center was determined by the centroid of patient zip codes and classified as <12.5 mi, 12.5-49.9 mi, and >50 mi. Complications were graded and classified according to the MSKCC system. Outcomes, time to treatment, and readmission to outside hospital (OSH) by distance traveled was compared. For patients with muscle invasive bladder cancer (MIBC) ultimately undergoing RC, the time to initial treatment with neoadjuvant or surgery was determined and compared based on travel distance.

Results:

Zip code was available for all 220 patients. There were no differences in overall complications, high grade complication, readmission, or 90d mortality based on distance traveled to treatment center. For readmitted patients, 38 had high grade complications, 58.8% for those who traveled <12.5 mi to treatment institution, 33.3% for 12.5-49.9 mi traveled, and 56.5% for >50 mi traveled (p=0.08, Table 1). 32 patients were admitted to an OSH, of these patients 0%, 42.4%, and 56.5% traveled <12.5 miles, 12.5-49.9 mi, or >50 mi to treatment, respectively (p<0.001).

114 patients with MIBC underwent neoadjuvant treatment. There was no difference in time to initiation of neoadjuvant treatment (p=0.99) or time to consolidative surgery (p=0.23) based on distance traveled (Figure 1). For the 49 MIBC patients who went directly to surgery, however, there was a statistically significant difference in time from diagnosis to RC based on the distance traveled (p=0.04).

Conclusion:

Existing processes of care, including institutional collaboration, nurse navigation and multidisciplinary care appear to ameliorate the challenges associated with travel distance in a rural state. We noted that with increased travel distance there was increased likelihood of readmission to OSH, most of which are likely to be at smaller community hospitals throughout the state. This was not true for high grade complications. One possibility is that patients who live <12.5 mi from our institution can be seen urgently in our outpatient office for low grade complications and avoid readmission. We also noted a statistically significant increase in time to surgery with increasing travel distance that was not seen for time to neoadjuvant initiation. This speaks to the complex nature of the surgery being performed at one institution, as compared to chemotherapy, which is available at multiple sites.

Funding: N/A