Introduction
The recently updated UK Multidisciplinary Guidelines for Head and Neck CancerReference Paleri and Roland 1 are essential reading for all those involved in treating head and neck cancer nationally. They provide an important update in the evidence-based approach to head and neck cancer management. We read with interest the radiotherapy (RT) guidelines stating that intensity-modulated RT ‘should be offered to all appropriate patients’.Reference Nutting 2 This recommendation is based on the ‘PARSPORT’ trial findings. This phase 3, multi-centre, randomised controlled trial compared parotid-sparing intensity-modulated RT with conventional RT in patients with head and neck cancer, and found reduced xerostomia rates following parotid-sparing treatment.Reference Nutting, Morden, Harrington, Urbano, Bhide and Clark 3
However, intensity-modulated RT is not available in all centres. In 2014, NHS England commissioned intensity-modulated RT from Newcastle hospitals for head and neck cancer care for patients resident in North Cumbria. Hence, some patients live more than 100 miles away from the Freeman Hospital where this treatment is offered, despite the NHS England service specification for radiotherapy stating that treatment should be ‘as close to home as practicable’. 4 Multidisciplinary team (MDT) members were concerned that these long travel distances could lead to the reduced uptake of intensity-modulated RT in patients living in North Cumbria. We have recently evaluated our service in the region, focusing specifically on whether travel distance or deprivation affect decisions to travel to Newcastle for treatment.
Materials and methods
This study was registered with the Cumberland Infirmary audit department.
Patients for whom the MDT felt that intensity-modulated RT was indicated, between December 2013 and January 2016, were included in the study. Patients were excluded if IMRT was not indicated and the MDT felt that three-dimensional conformal RT, conducted in Carlisle, was appropriate.
Distance to the Freeman Hospital and the English Index of Multiple Deprivation deciles (calculated by ranking 32 844 small areas in England from most to least deprived, and dividing them into 10 equal groups) were taken from publically available data, 5 and calculated using postcodes and google maps. We established whether patients received conformal RT treatment in Carlisle or intensity-modulated RT at the Freeman Hospital, Newcastle. Patients were also asked prospectively by our chief clinical technologist (NA) why they made, or did not make, the decision to travel to Newcastle for intensity-modulated RT. Statistical analysis was performed using SPSS statistical software.
Results
Sixty-nine patients were included in this study. Patients’ average age was 60 years, and 75 per cent were male (based on the 53 patients with full demographic data).
The average distance of travel from home to the Cumberland Infirmary and the Freeman Hospital was 22.7 miles (range, 0.2–52.1 miles) and 78.8 miles (range, 58.6–108 miles), respectively. For all 69 patients, there was no significant difference in travel distance (independent samples t-test p = 0.53) or index of multiple deprivation scores (binary logistic regression p = 0.47) between patients opting for treatment in Carlisle or Newcastle.
The reasons patients gave for choosing their location for treatment are shown in Table I. Of note, 29 of the 33 patients who chose not to travel to Newcastle for treatment told us that travelling distance was their main reason for not doing so. Of those opting for treatment in Newcastle, most chose to travel for the increased benefit of intensity-modulated RT regarding the reduced side effect profile. Interestingly, in the first quarter of patients we collected data from, only 4 out of 17 (24 per cent) opted for treatment in Newcastle. In subsequent quarters, 60 per cent of patients consistently chose to travel to Newcastle for treatment.
Table I Reasons for choosing location of treatment
*n = 33; † n = 36. ‡Percentages do not add up to 100 per cent because of rounding
Discussion
Level I evidence suggests that although head and neck cancer survival is equivalent with intensity-modulated RT and conformal RT, patients receiving parotid-sparing intensity-modulated RT experience significantly less xerostomia,Reference Nutting, Morden, Harrington, Urbano, Bhide and Clark 3 which has a positive effect on their quality of life. Although patients in North Cumbria have access to this treatment in Newcastle, there is a significant travel distance associated with this. This is often compounded by the acute toxicities of RT.
Whilst there are options for the provision of travel and accommodation arrangements, informal feedback from some of our patients indicates that volunteers providing travel often pick up a number of people and there is a significant wait post-treatment for their return journey. Furthermore, staying in Newcastle for treatment can add to the stress experienced by these vulnerable patients, as they are away from their support network of family and friends. It is therefore understandable that many patients opt for treatment in Carlisle.
Our quantitative data suggest that deprivation and travel distance have no effect on the decision to travel to Newcastle for intensity-modulated RT. However, this finding is based on a relatively small sample of patients and thus could be subject to type II errors. Nevertheless, the reasons given by patients for choosing their treating centre clearly indicate that distance is important. It also seems that we are now sending more patients for treatment than when the service was first offered. We suspect that this is because of increased confidence that referral pathways and communication between local support teams provide effective care for patients throughout their journey.
Previous work has investigated the role of travel distances on uptake for different cancer treatments. In 2005, Lightfoot and colleagues found that around 15 per cent of respondents, when given a choice of cancer treatment centres, stated that travel distance played a role in their decision-making process.Reference Lightfoot, Steggles, Gauthier-Frohlick, Arbour-Gagnon, Conlon and Innes 6 However, more than half of those surveyed stated that they were not given a choice, or felt like they had no choice but to travel for treatment. Furthermore, that same study found that more than half of their patients reported physical symptoms directly resulting from travelling for treatment. The study also highlighted significant financial and psychological effects associated with travelling. When combined with our data, this has important implications for planning the centralisation of head and neck cancer services.
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• Intensity-modulated radiotherapy (RT) is superior to conformal RT for head and neck cancers because of reduced xerostomia rates
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• Intensity-modulated RT is not readily available in all treating centres
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• Travel distance may play an important role in access to cancer treatments
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• Patients report that travel distance is the major reason they opt for conformal RT over intensity-modulated RT
In 2004, Patel et al. calculated that the centralisation of services from South Devon to Bristol would lead to an increase in travel distance of over 5000 miles.Reference Patel, Hewett and Hickey 7 In addition to the physical transportation effects, a recent Cancer Research UK report on national cancer services highlighted that we need a greater understanding of how centralisation will affect patients in terms of their care co-ordination and out-of-pocket costs. 8 Careful attention needs to be paid to ensuring that local support networks are able to provide high-quality rehabilitative and supportive care if and when services are centralised.
Conclusion
Travel distance affects patients’ decisions to travel to Newcastle for intensity-modulated RT treatment. Future research needs to focus on how to reduce the travel burden for patients so they can better access this treatment, which includes commissioning intensity-modulated RT as close to patients’ homes as possible. It is also of critical importance to investigate and reduce the impact on patients, and their families and support networks should head and neck cancer services be further centralised.
