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Disparities in Access to Radiation Therapy by Race and Ethnicity in the United States With Focus on American Indian/Alaska Native People

      Objectives

      Striking disparities in access to radiation therapy (RT) exist, especially among racial and ethnic–minority patients. We analyzed census block group data to evaluate differences in travel distance to RT as a function of race and ethnicity, socioeconomic status, and rurality.

      Methods

      The Directory of Radiotherapy Centers provided the addresses of facilities containing linear accelerators for RT. We classified block groups as majority (≥ 50%) American Indian/Alaska Native (AI/AN), black, white, Asian, no single racial majority, or Hispanic regardless of race. We used the Area Deprivation Index to classify deprivation and Rural-Urban Commuting Area codes to classify rurality. Generalized linear mixed models tested associations between these factors and distance to nearest RT facility.

      Results

      Median distance to nearest RT facility was 72 miles in AI/AN–majority block groups, but 4 to 7 miles in block groups with non-AI/AN majorities. Multivariable models estimated that travel distances in AI/AN–majority block groups were 39 to 41 miles longer than in areas with non-AI/AN majorities. Travel distance was 1.3 miles longer in the more deprived areas versus less deprived areas and 16 to 32 miles longer in micropolitan, small town, and rural areas versus metropolitan areas.

      Conclusions

      Cancer patients in block groups with AI/AN–majority populations, nonmetropolitan location, and low socioeconomic status experience substantial travel disparities in access to RT. Future research with more granular community- and individual-level data should explore the many other known barriers to access to cancer care and their relationship to the barriers posed by distance to RT care.

      Keywords

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      References

        • Heron M.
        Deaths: leading causes for 2017.
        Natl Vital Stat Rep. 2019; 68: 1-77
        • Jaffray D.A.
        • Knaul F.M.
        • Atun R.
        • et al.
        Global task force on radiotherapy for cancer control.
        Lancet Oncol. 2015; 16: 1144-1146
        • Medenwald D.
        • Vordermark D.
        • Dietzel C.T.
        Number of radiotherapy treatment machines in the population and cancer mortality: an ecological study.
        Clin Epidemiol. 2018; 10: 1249-1273
        • Royce T.J.
        • Qureshi M.M.
        • Truong M.T.
        Radiotherapy utilization and fractionation patterns during the first course of cancer treatment in the United States from 2004 to 2014.
        J Am Coll Rad. 2018; 15: 1558-1564
        • Delaney G.
        • Jacob S.
        • Featherstone C.
        • Barton M.
        The role of radiotherapy in cancer treatment: estimating optimal utilization from a review of evidence-based clinical guidelines.
        Cancer. 2005; 104: 1129-1137
        • Barton M.B.
        • Jacob S.
        • Shafiq J.
        • et al.
        Estimating the demand for radiotherapy from the evidence: a review of changes from 2003 to 2012.
        Radiother Oncol. 2014; 112: 140-144
        • Delaney G.P.
        • Barton M.B.
        Evidence-based estimates of the demand for radiotherapy.
        Clin Oncol (R Coll Radiol). 2015; 27: 70-76
        • Gelband H.
        • Jha P.
        • Sankaranarayanan R.
        • Horton S.
        3rd ed. Cancer: Disease Control Priorities. Vol. 3. World Bank, Washington, DC2015
        • White K.
        • Haas J.S.
        • Williams D.R.
        Elucidating the role of place in health care disparities: the example of racial/ethnic residential segregation.
        Health Serv Res. 2012; 47: 1278-1299
        • Rosenblatt E.
        Planning national radiotherapy services.
        Front Oncol. 2014; 4: 315
        • Ballas L.K.
        • Elkin E.B.
        • Schrag D.
        • Minsky B.D.
        • Bach P.B.
        Radiation therapy facilities in the United States.
        Int J Radiat Oncol Biol Phys. 2006; 66: 1204-1211
        • Herb J.N.
        • Wolff R.T.
        • McDaniel P.M.
        • Holmes G.M.
        • Royce T.J.
        • Stitzenberg K.B.
        Travel time to radiation oncology facilities in the United States and the influence of certificate of need policies.
        Int J Radiat Oncol Biol Phys. 2021; 109: 344-351
        • Bates J.E.
        • Parekh A.D.
        • Chowdhary M.
        • Amdur R.J.
        Geographic distribution of radiation oncologists in the United States.
        Pract Radiat Oncol. 2020; 10: e436-e443
        • Acharya S.
        • Hsieh S.
        • Michalski J.M.
        • Shinohara E.T.
        • Perkins S.M.
        Distance to radiation facility and treatment choice in early-stage breast cancer.
        Int J Radiat Oncol Biol Phys. 2016; 94: 691-699
        • Baade P.D.
        • Dasgupta P.
        • Aitken J.F.
        • Turrell G.
        Distance to the closest radiotherapy facility and survival after a diagnosis of rectal cancer in Queensland.
        Med J Aust. 2011; 195: 350-354
        • Aneja S.
        • Yu J.B.
        The impact of county-level radiation oncologist density on prostate cancer mortality in the United States.
        Prostate Cancer Prostatic Dis. 2012; 15: 391-396
        • Peipins L.A.
        • Graham S.
        • Young R.
        • Lewis B.
        • Flanagan B.
        Racial disparities in travel time to radiotherapy facilities in the Atlanta metropolitan area.
        Soc Sci Med. 2013; 89: 32-38
        • Burnette C.E.
        • Roh S.
        • Liddell J.
        • Lee Y.S.
        American Indian women cancer survivor’s needs and preferences: community support for cancer experiences.
        J Cancer Educ. 2019; 34: 592-599
        • Hohl S.
        • Molina Y.
        • Koepl L.
        • et al.
        Satisfaction with cancer care among American Indian and Alaska Natives in Oregon and Washington State: a qualitative study of survivor and caregiver perspectives.
        Support Care Cancer. 2016; 24: 2437-2444
        • White M.C.
        • Espey D.K.
        • Swan J.
        • Wiggins C.L.
        • Eheman C.
        • Kaur J.S.
        Disparities in cancer mortality and incidence among American Indians and Alaska natives in the United States.
        Am J Public Health. 2014; 104: S377-S387
        • Charlton M.
        • Schlichting J.
        • Chioreso C.
        • Ward M.
        • Vikas P.
        Challenges of rural cancer care in the United States [Review].
        Oncology. 2015; 29: 633-640
        • O’Connor J.M.
        • Sedghi T.
        • Dhodapkar M.
        • Kane M.J.
        • Gross C.P.
        Factors associated with cancer disparities among low-, medium-, and high-income US counties.
        JAMA Netw Open. 2018; 1e183146
        • Park J.
        • Look K.A.
        Health care expenditure burden of cancer care in the United States.
        Inquiry. 2019; 5646958019880696
        • Monsivais P.
        • Amiri S.
        • Denney J.T.
        • Amram O.
        Area deprivation amplifies racial inequities in premature mortality: analysis of 242,667 deaths in Washington State, USA 2011-15.
        Health Place. 2020; 61102261
        • Sancar F.
        • Abbasi J.
        • Bucher K.
        Mortality among American Indians and Alaska natives.
        JAMA. 2018; 319: 112
      1. Cancer incidence among American Indian and Alaska native populations in urban Indian health organization service areas 2008-2017. Centers for Disease Control and Prevention.
        • Herne M.A.
        • Bartholomew M.L.
        • Weahkee R.L.
        Suicide mortality among American Indians and Alaska Natives, 1999-2009.
        Am J Public Health. 2014; 104: S336-S342
      2. American Community survey 5-year estimates. US Census Bureau.
        https://data.census.gov/
        Date accessed: March 1, 2021
      3. Quick facts: Washington. US Census Bureau.
        https://www.census.gov/quickfacts/WA
        Date accessed: June 8, 2020
        • Koeze E.
        • Patel J.K.
        • Singhvi A.
        Where Americans live far from the emergency room. The New York Times. April 26, 2020.
        • Wenger H.
        • Henderson-Frost J.
        Can Indian Health Service referrals for nonemergent care be allocated equitably?.
        AMA J Ethics. 2021; 23: E215-E222
        • Patel S.H.
        • Ebrahimi S.
        • Northfelt D.W.
        • et al.
        Understanding American Indian perceptions toward radiation therapy.
        Cancer Control. 2020; 271073274820945991
        • Greer M.D.
        • Amiri S.
        • Denney J.T.
        • Amram O.
        • Halasz L.M.
        • Buchwald D.
        Disparities in access to radiation therapy facilities among American Indians/Alaska natives and Hispanics in Washington State.
        Int J Radiat Oncol Biol Phys. 2022; 112: 285-293
      4. Directory of radiotherapy centers. IAEA.
        https://dirac.iaea.org/
        Date accessed: February 24, 2022
      5. GIS software. Environmental Systems Research Institute.
        https://www.esri.com/en-us/home
        Date accessed: February 24, 2022
        • Tung E.L.
        • Hampton D.A.
        • Kolak M.
        • Rogers S.O.
        • Yang J.P.
        • Peek M.E.
        Race/ethnicity and geographic access to urban trauma care.
        JAMA Netw Open. 2019; 2e190138
        • Singh G.K.
        Area deprivation and widening inequalities in US mortality, 1969-1998.
        Am J Public Health. 2003; 93: 1137-1143
        • Knighton A.J.
        • Savitz L.
        • Belnap T.
        • Stephenson B.
        • VanDerslice J.
        Introduction of an area deprivation index measuring patient socioeconomic status in an integrated health system: implications for population health.
        eGEMs (Wash DC). 2016; 4: 1238
        • Hunt J.F.V.
        • Buckingham W.
        • Kim A.J.
        • et al.
        Association of neighborhood-level disadvantage with cerebral and hippocampal volume.
        JAMA Neurol. 2020; 77: 451-460
      6. Rural-Urban Commuting Area Codes (RUCAs). WWAMI Rural Health Research Center.
        http://depts.washington.edu/uwruca/
        Date accessed: February 24, 2022
      7. Rural-Urban Commuting Area Codes. USDA.
      8. The Federal Health Program for American Indians and Alaska Natives. IHS, Indian Health Service.
        https://www.ihs.gov/locations/
        Date accessed: June 20, 2021
      9. R: a language and environment for statistical computing. R Core Team.
        http://www.R-project.org/
        Date accessed: February 24, 2022
        • Epstein D.H.
        • Tyburski M.
        • Craig I.M.
        • et al.
        Real-time tracking of neighborhood surroundings and mood in urban drug misusers: application of a new method to study behavior in its geographical context.
        Drug Alcohol Depend. 2014; 134: 22-29
        • Getis A.
        • Ord J.K.
        The analysis of spatial association by use of distance statistics.
        in: Perspectives on Spatial Data Analysis. Springer, Berlin, Germany2010: 127-145
        • Maroongroge S.
        • Wallington D.G.
        • Taylor P.A.
        • et al.
        Geographic access to radiation therapy facilities in the United States.
        Int J Radiat Oncol Biol Phys. 2022; 112: 600-610
        • Hall I.J.
        • Tangka F.K.L.
        • Sabatino S.A.
        • Thompson T.D.
        • Graubard B.I.
        • Breen N.
        Patterns and trends in cancer screening in the United States.
        Prev Chronic Dis. 2018; 15: E97
        • Mokhtech M.
        • Laird Jr., J.H.
        • Maroongroge S.
        • et al.
        Drivers of Medicare spending: a 15-year review of radiation oncology charges allowed by the Medicare physician/supplier fee-for-service program compared with other specialties.
        Int J Radiat Oncol Biol Phys. 2021; 110: 322-327
      10. Maroongroge S. 203 Geographic access to radiation therapy in the United States. ASTRO.
        • Onega T.
        • Duell E.J.
        • Shi X.
        • Wang D.
        • Demidenko E.
        • Goodman D.
        Geographic access to cancer care in the.
        U.S. Cancer. 2008; 112: 909-918
        • Hung P.
        • Deng S.
        • Zahnd W.E.
        • et al.
        Geographic disparities in residential proximity to colorectal and cervical cancer care providers.
        Cancer. 2020; 126: 1068-1076
        • Carlson M.D.
        • Bradley E.H.
        • Du Q.
        • Morrison R.S.
        Geographic access to hospice in the United States.
        J Palliat Med. 2010; 13: 1331-1338
        • Smigielska M.
        • Milecki P.
        Investment in radiotherapy infrastructure positively affected the economic status of an oncology hospital.
        Rep Pract Oncol Radiother. 2012; 17: 151-156
        • Fung C.Y.
        • Chen E.
        • Vapiwala N.
        • et al.
        Radiation oncologist workforce study.
        Int J Radiat Oncol Biol Phys. 2019; 103: 547-556
        • Douthit N.
        • Kiv S.
        • Dwolatzky T.
        • Biswas S.
        Exposing some important barriers to health care access in the rural USA.
        Public Health. 2015; 129: 611-620
        • Chan J.
        • Friborg J.
        • Zubizarreta E.
        • et al.
        Examining geographic accessibility to radiotherapy in Canada and Greenland for indigenous populations: measuring inequities to inform solutions.
        Radiother Oncol. 2020; 146: 1-8
        • Shakespeare T.P.
        • Turner M.
        • Chapman A.
        Is rural radiation oncology practice quality as good as the big smoke? Results of the Australian radiotherapy single machine unit trial.
        Australas Rad. 2007; 51: 381-385
      11. AACR cancer disparities progress REPORT 2020. American Association for Cancer Research.
        (Accessed 2021)
        • Unger J.M.
        • Moseley A.
        • Symington B.
        • Chavez-MacGregor M.
        • Ramsey S.D.
        • Hershman D.L.
        Geographic distribution and survival outcomes for rural patients with cancer treated in clinical trials.
        JAMA Netw Open. 2018; 1e181235
        • Javid S.H.
        • Varghese T.K.
        • Morris A.M.
        • et al.
        Guideline-concordant cancer care and survival among American Indian/Alaskan Native patients.
        Cancer. 2014; 120: 2183-2190
        • Patel C.G.
        • Stavas M.
        • Perkins S.
        • Shinohara E.T.
        Central nervous system disease, education, and race impact radiation refusal in pediatric cancer patients.
        J Pediatr Hematol Oncol. 2017; 39: 382-387
        • Warner E.T.
        • Tamimi R.M.
        • Hughes M.E.
        • et al.
        Racial and ethnic differences in breast cancer survival: mediating effect of tumor characteristics and sociodemographic and treatment factors.
        J Clin Oncol. 2015; 33: 2254-2261
        • Miller K.D.
        • Goding Sauer A.
        • Ortiz A.P.
        • et al.
        Cancer statistics for Hispanics/Latinos, 2018.
        CA Cancer J Clin. 2018; 68: 425-445
        • Velasco-Mondragon E.
        • Jimenez A.
        • Palladino-Davis A.G.
        • Davis D.
        • Escamilla-Cejudo J.A.
        Hispanic health in the USA: a scoping review of the literature.
        Public Health Rev. 2016; 37: 31
        • Fedewa S.A.
        • Sauer A.G.
        • DeSantis C.
        • Siegel R.L.
        • Jemal A.
        Disparities in cancer screening by occupational characteristics.
        Prev Med. 2017; 105: 311-318
        • Scheppers E.
        • van Dongen E.
        • Dekker J.
        • Geertzen J.
        • Dekker J.
        Potential barriers to the use of health services among ethnic minorities: a review.
        Fam Pract. 2006; 23: 325-348
      12. Medicare and State Health Care Programs: fraud and abuse; revisions to safe harbors under the anti-Kickback Statute, and Civil Monetary Penalty Rules regarding beneficiary inducements. Federal Register.
      13. Sweeping new Medicare regs support value-based arrangements, local transportation access. ASTRO.
        • Kanekar S.
        • Petereit D.
        Walking forward: a program designed to lower cancer mortality rates among American Indians in western South Dakota.
        S D Med. 2009; 62: 151-159
        • Petereit D.G.
        • Ashleigh Guadagnolo B.
        • Wong R.
        • Norman Coleman C.
        Addressing cancer disparities among American Indians through innovative technologies and patient navigation: the walking forward experience.
        Front Oncol. 2011; 1: 11
        • Jim M.A.
        • Arias E.
        • Seneca D.S.
        • et al.
        Racial misclassification of American Indians and Alaska Natives by Indian Health Service Contract Health Service Delivery Area.
        Am J Public Health. 2014; 104: S295-S302
        • Espey D.K.
        • Jim M.A.
        • Richards T.B.
        • Begay C.
        • Haverkamp D.
        • Roberts D.
        Methods for improving the quality and completeness of mortality data for American Indians and Alaska natives.
        Am J Public Health. 2014; 104: S286-S294