Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
J Bone Joint Surg Am. 2022 Aug 17;104(16):1426-1437. doi: 10.2106/JBJS.21.01140. Epub 2022 Jun 21.
Clinical practice guidelines recommend centralized care for patients with bone sarcoma. However, the relationship between the distance that patients travel to obtain care, institutional treatment volume, and survival is unknown.
We used the National Cancer Database to examine associations between travel distance and survival among 8,432 patients with bone sarcoma diagnosed from 2004 to 2015. Associations were identified using multivariable Cox regression analyses that controlled for sociodemographic, clinical, and hospital-level factors; subgroup analyses stratified patients by histological diagnosis, tumor stage, and pediatric or adult status.
Mortality risk was lower among patients who traveled ≥50 miles (≥80.5 km) than among patients who traveled ≤10 miles (≤16.1 km) (hazard ratio [HR], 0.69 [95% confidence interval (CI), 0.63 to 0.76]). Among hospital-level factors, facility volume independently affected survival: mortality risk was lower among patients at high-volume facilities (≥20 cases per year) than at low-volume facilities (≤5 cases per year), with an HR of 0.72 (95% CI, 0.66 to 0.80). The proportion of patients who received care at high-volume facilities varied by distance traveled (p < 0.001); it was highest among patients who traveled ≥50 miles (53%) and lower among those who traveled 11 to 49 miles (17.7 to 78.9 km) (32%) or ≤10 miles (18%). Patients who traveled ≥50 miles to a high-volume facility had a lower risk of mortality (HR, 0.65 [95% CI, 0.56 to 0.77]) than those who traveled ≤10 miles to a low-volume facility. In subgroup analyses, this association was evident among patients with all 3 major histological subtypes; those with stage-I, II, and IV tumors; and adults.
This national study showed that greater travel burden was associated with higher survival rates in adults, a finding attributable to patients traveling to receive care at high-volume facilities. Despite the burdens associated with travel, modification of referral pathways to specialized centers may improve survival for patients with bone sarcoma.
Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
临床实践指南建议对骨肉瘤患者进行集中治疗。然而，患者就医的路程远近、机构治疗量与生存率之间的关系尚不清楚。
我们利用国家癌症数据库，对 2004 年至 2015 年间确诊的 8432 例骨肉瘤患者的就诊距离与生存情况之间的关系进行了研究。采用多变量 Cox 回归分析控制了社会人口统计学、临床和医院水平因素；并对组织学诊断、肿瘤分期以及儿童或成人患者进行了亚组分析。
与就诊距离≤10 英里（≤16.1 公里）的患者相比，就诊距离≥50 英里（≥80.5 公里）的患者死亡风险更低（风险比[HR]，0.69[95%置信区间[CI]，0.63 至 0.76]）。在医院水平因素中，机构治疗量独立影响生存率：与低治疗量机构（≤5 例/年）相比，高治疗量机构（≥20 例/年）的患者死亡风险更低，HR 为 0.72（95%CI，0.66 至 0.80）。接受高治疗量机构治疗的患者比例随就诊距离的不同而变化（p＜0.001）：就诊距离≥50 英里的患者比例最高（53%），就诊距离 11 至 49 英里（78.9 公里）或≤10 英里的患者比例较低（分别为 17.7%和 18%）。与就诊距离≤10 英里且到低治疗量机构就诊的患者相比，就诊距离≥50 英里且到高治疗量机构就诊的患者死亡风险更低（HR，0.65[95%CI，0.56 至 0.77]）。在亚组分析中，这种关联在所有 3 种主要组织学亚型、Ⅰ期、Ⅱ期和Ⅳ期肿瘤以及成人患者中均有体现。
本项全国性研究表明，成人患者的就诊路程越远，生存率越高，这归因于患者前往高治疗量机构接受治疗。尽管就诊过程中存在诸多不便，但对转诊途径进行修改以转诊至专门中心可能会提高骨肉瘤患者的生存率。
预后 III 级。有关证据水平的完整描述，请参见《作者须知》。
