Centralization of Cancer Care: Implications for Access, Outcomes, and Disparities

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Project Summary In recent years, cancer treatment has dramatically shifted towards a centralized model of care, whereby patients with cancer selectively receive complex treatment at regional referral centers, which tend to be tertiary cancer centers. Centralization is associated with improved outcomes for the patients who receive care at regional referral centers for a variety of reasons, including better resources and personnel who treat high volumes of patients. However, the broader impact of centralization on outcomes at the population level remains unknown. Of specific concern are the patients who do not receive care at these centers, but instead continue to receive care at non-regional referral centers, which generally treat lower volumes of patients. These “left behind” patients may suffer poor outcomes due to decreased access to high-quality care. Moreover, to the degree these patients represent traditionally underserved patients (i.e., sociodemographic groups that have long experienced health disparities such as racial and ethnic minorities, low-income individuals, and rural residents), the trend towards centralized cancer care may inadvertently widen disparities in outcomes, worsening care for those patients left behind. The overall goal of this project is to critically examine the impact of cancer treatment centralization at the population level, with a specific focus on whether the trend toward centralization is inadvertently widening sociodemographic disparities in cancer outcomes. We will use a mixed-methods approach as well as an innovative dataset linking cancer registry and administrative data in two large states (New York and Pennsylvania) over an 11-year period. We will focus on patients with the most prevalent (i.e., bladder, breast, colorectal, lung, prostate) and lethal (i.e., brain, esophageal, liver, lung, pancreatic) cancers—these cancers frequently require complex treatments and have improved outcomes at regional referral centers. In Aim 1, we will determine the patient characteristics associated with not receiving care at a regional referral center. In Aim 2, we will examine whether receipt of care at a regional referral center mediates the relationship between being a traditionally underserved patient (racial/ethnic minority, low-income individual, rural resident) and quality of care. In Aim 3, we will identify strategies to minimize cancer disparities in the context of centralization through interviews with key stakeholders. This study is important because it will provide hospitals, providers, and policymakers with actionable new data on the ways centralization may be both helping and harming patients, leading to new strategies to minimize health disparities with implications for interventions and policy changes at multiple levels.