Is patient travel distance associated with survival on phase II clinical trials in oncology?
Is patient travel distance associated with survival on phase II clinical trials in oncology?
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DOI：
10.1093/jnci/djg035
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发表时间：
2003-09-17
影响因子：
10.3
通讯作者：
Vokes, EE
中科院分区：
文献类型：
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作者：
Lamont, EB;Hayreh, D;Vokes, EE
背景：先前的研究表明，从专业医疗中心寻求选择性治疗且来自社区之外的患者，可能比在相同中心接受治疗的患有相同疾病的本地患者有更好的治疗效果。我们假设这种通常被称为“转诊偏倚”或“距离偏倚”的现象，在专业癌症中心的根治性癌症试验中也可能很明显。
方法：我们评估了110名患者的总生存期和无进展生存期与从患者住所到治疗机构的距离之间的关联，这些患者在芝加哥大学7年多的时间里参与了四项针对局部晚期头颈部鳞状细胞癌的Ⅱ期根治性放化疗方案中的一项。
结果：通过对标准的患者层面的疾病和人口统计学因素以及社区层面的经济因素进行调整的考克斯回归分析，我们发现患者从住所到治疗中心的距离与生存期之间存在正相关。居住在距离治疗机构15英里以上的患者死亡风险仅为居住较近患者的三分之一（风险比[HR]=0.32，95%置信区间[CI]=0.12 - 0.84）。此外，患者每为就医多出行10英里，死亡风险就降低3.2%（HR = 0.97，95%CI = 0.94 - 0.99）。无进展生存期也得到了类似的结果。
结论：在专业癌症中心进行的肿瘤学Ⅱ期根治性临床试验的结果可能会因患者的出行距离而产生混淆，出行距离具有超出癌症分期、体能状态和财富的预后意义。需要更多的工作来确定出行距离所介导的未测量因素。
Background: Prior research has suggested that patients who travel out of their neighborhood for elective care from specialized medical centers may have better outcomes than local patients with the same illnesses who are treated at the same centers. We hypothesized that this phenomenon, often called "referral bias" or "distance bias," may also be evident in curative-intent cancer trials at specialized cancer centers. Methods: We evaluated associations between overall survival and progression-free survival and the distance from the patient residence to the treating institution for 110 patients treated on one of four phase 11 curative-intent chemoradiotherapy protocols for locoregionally advanced squamous cell cancer of the head and neck conducted at the University of Chicago over 7 years. Results: Using Cox regression that adjusted for standard patient-level disease and demographic factors and neighborhood-level economic factors, we found a positive association between the distance patients traveled from their residence to the treatment center and survival. Patients who lived more than 15 miles from the treating institution had only one-third the hazard of death of those living closer (hazard ratio [HR] = 0.32, 95% confidence interval [CI] = 0.12 to 0.84). Moreover, with every 10 miles that a patient traveled for care, the hazard of death decreased by 3.2% (HR = 0.97,95% CI = 0.94 to 0.99). Similar results were obtained for progression-free survival. Conclusion: Results of phase 11 curative-intent clinical trials in oncology that are conducted at specialized cancer centers may be confounded by patient travel distance, which captures prognostic significance beyond cancer stage, performance status, and wealth. More work is needed to determine what unmeasured factors travel distance is mediating.