Are Access Costs and Income Associated With Treatment Decision-Making and Clinical Outcomes in Rural Patients Presenting With Upper Gastrointestinal Malignancy?

Background and objective(s): Few studies evaluate the price elasticity of demand or the relationships between costs of access, patient income, treatment decision making and outcome in rural patients with upper gastrointestinal malignancy.

Methods: We queried the National Cancer Database to identify rural patients presenting with clinical stages I-III esophagus, stomach, pancreas, hepatocellular (HCC) and cholangiocarcinoma between 2004 and 2020. Access cost was defined as (distance to treating center) × (regional gas price)/(regional vehicle fuel efficiency). Patients within the highest (HAC) and lowest (LAC) cost quintiles were selected for analysis. These were subcategorized based on income quartile: High income/High Access Cost (HI/HAC), High Income/Low Access Cost (HI/LAC), Low Income/High Access Cost (LI/HAC), Low Income/Low Access Cost (LI/LAC).

Results: A total of 9582 patients met inclusion criteria. Median access cost was $26.61 (IQR: [$10.57-$73.70]). Patients in the HI/HAC cohort were more likely to undergo treatment at academic centers (79.5%, HI/HAC, 49.6%, HI/LAC, 78.5%, LI/HAC, 38.0%, LI/LAC), undergo neoadjuvant chemotherapy (23.8%, 12.6%, 17.7%, 10.4%) undergo surgery (46.6%, 29.6%, 39.7%, 20.8%), undergo liver transplantation for HCC (30.2%, 5.86%, 18.1%, 2.04%) and demonstrated higher rates of 5-year overall survival (42.4%, 25.6%, 32.2%, 19.0%) than those with HI/LAC, LI/HAC, and LI/LAC cohorts (all p < 0.01).

Conclusions: Among rural patients undergoing treatment for upper gastrointestinal malignancy elasticity of demand for service varies. Patients willing and able to pay for travel are more likely to receive neoadjuvant chemotherapy, undergo resection and demonstrate improved overall survival.