Going the Extra Mile Improved Survival for Pancreatic Cancer Patients Traveling to High-volume Centers

Objective: This study compares outcomes following pancreaticoduodenectomy (PD) for patients treated at local, low-volume centers and those traveling to high-volume centers. Background: Although outcomes for PD are superior at high-volume institutions, not all patients live in proximity to major medical centers. Theoretical advantages for undergoing surgery locally exist. Methods: The 1998 to 2012 National Cancer Data Base was queried for T1-3N0-1M0 pancreatic adenocarcinoma patients who underwent PD. Travel distances to treatment centers were calculated. Overlaying the upper and lower quartiles of travel distance with institutional volume established short travel/low-volume (ST/LV) and long travel/high-volume (LT/HV) cohorts. Overall survival was evaluated. Results: Of 7086 patients, 773 ST/LV patients traveled <= 6.3 (median 3.2) miles to centers performing <= 3.3 PDs yearly, and 758 LT/HV patients traveled >= 45 (median 97.3) miles to centers performing >= 16 PDs yearly. LT/HV patients had higher stage disease (P < 0.001), but lower margin positivity (20.5% vs 25.9%, P = 0.01) and improved lymphadenectomy (16 vs 11 nodes, P < 0.01). Moreover, LT/HV patients had shorter hospitalizations (9 vs 12 days, P < 0.01) and lower 30-day mortality (2.0% vs 6.3%, P < 0.01) with similar 30-day readmission rates (10.1% vs 9.8%, P = 0.83). Despite more advanced disease, LT/HV patients had superior unadjusted survival (20.3 vs 15.7 months). After adjustment, travel to a high-volume center remained associated with reduced long-term mortality (hazard ratio 0.75, P < 0.01). Conclusions: Despite an increased travel burden, patients treated at highvolume centers had improved perioperative outcomes, short-term mortality, and overall survival. These data support ongoing efforts to centralize care for patients undergoing PD.