Research suggests that transportation insecurity may affect 1 in 4 adults in the United States, and transportation barriers have been shown to disrupt medical care.^1,2

A survey of US adults published earlier this year showed that 1 in 5 respondents without access to a vehicle or public transportation went without needed medical care.²

Cancer patients may be particularly susceptible to transportation-related disruptions in care because cancer care typically requires frequent health care visits over a prolonged period, the need for specialized care may require greater travel burdens, public transportation may be unsafe or logistically difficult for cancer patients, and the financial toxicity of cancer treatment may amplify transportation insecurity.³

Quantifying Transportation Insecurity

The prevalence of transportation insecurity among patients with cancer varies widely in the published literature, in part because there are no evidence-based guidelines for screening.³ A recent survey of 25 National Comprehensive Cancer Network (NCCN) member institutions revealed that only 33% routinely screened patients for transportation insecurity.⁴

To quantify the impact of transportation insecurity on cancer patients, researchers evaluated 25,317 cancer survivors and 422,797 adults without cancer from the National Health Interview Survey.⁵ After adjusting for sociodemographic factors and comorbidities, the researchers found that transportation barriers were significantly more common among cancer survivors than among patients without cancer (2.1% vs 1.6%; adjusted odds ratio [OR], 1.22; 95% CI, 1.10-1.35; P =.001).

In addition, the highest adjusted mortality risk was seen in the cancer survivors with transportation barriers (hazard ratio [HR], 2.12; 95% CI, 1.81-2.49), followed by cancer survivors without transportation barriers (HR, 1.53; 95% CI, 1.42-1.65) and patients without cancer who had transportation barriers (HR, 1.50; 95% CI; 1.45-1.55).

Another analysis of data from the National Health Interview Survey included 28,606 cancer survivors and 469,860 patients without a cancer history.⁶ This analysis showed that cancer survivors with transportation barriers were more likely to use the emergency department for routine care (OR, 5.07; 95% CI, 3.20-8.04) than cancer survivors without transportation barriers (OR, 2.69; 95% CI, 1.77-4.08), cancer-free patients with transportation barriers (OR, 2.00; 95% CI, 1.89-2.12), or cancer-free patients without transportation barriers (reference group).

In addition, cancer survivors with transportation barriers had a higher risk of all-cause mortality (OR, 2.60; 95% CI, 1.71-3.95) than cancer survivors without these barriers (OR, 1.86; 95% CI, 1.26-2.76). The cancer survivors with transportation barriers also had a higher risk of cancer-specific mortality (OR, 1.38; 95% CI, 1.10-1.75) than cancer survivors without these barriers (reference group). The risks of all-cause and cancer-specific mortality remained higher for cancer survivors with transportation barriers even after adjusting for insurance status.

Geography Plays a Role

Research has suggested that patients living in rural areas are disproportionately affected by transportation insecurity.³

Rural areas have a lower density of health care providers, and patients often need to travel longer distances to access care, noted Elisa Rodriguez, PhD, of Roswell Park Comprehensive Cancer Center in Buffalo, New York, who was the keynote speaker at a recent NCCN summit on how geography impacts cancer outcomes.⁷

“A substantial number of rural patients often prefer or need to receive cancer care locally, yet many community hospitals are too under-resourced to offer the continuum of comprehensive and supportive cancer services included in evidence-based standards of care,” Mary Charlton, PhD, of the University of Iowa in Iowa City, a panelist at the NCCN summit, said in a statement.

“In order to provide quality care across varying locales, we must develop a multi-faceted, collaborative cancer network approach that extends the resources and expertise from larger cancer centers out to rural hospitals and providers,” Dr Charlton added. “This must be done in a way that capitalizes on everyone’s strengths while fostering trust and engagement between providers.”Resources and Research

Experts say more research is needed to determine the scope of transportation insecurity among patients with cancer, develop guidelines for screening, and evaluate the effect of policy changes on patient outcomes.³

In the meantime, there are resources that can help patients overcome transportation-related barriers to care.

The Nonemergency Medical Transportation service is the largest federal and state program addressing health care-related transportation barriers.³ The program provides rides to health care appointments for eligible Medicaid beneficiaries.

Another program — the Repetitive Scheduled Non-Emergency Ambulance Transport program — provides transportation for Medicare beneficiaries who require at least 1 round trip weekly for at least 3 weeks. Patients are also eligible for this program if their Medicare Advantage plan adopts transportation as a supplemental benefit.

In addition, the American Cancer Society offers programs targeting transportation barriers, including:

The Road to Recovery Program, in which volunteer drivers provide health care-related transportation for cancer patients
Grants to hospitals for cancer patients who require transportation from rural or unsafe urban areas
Hope Lodge, which offers cancer patients and caregivers free lodging in areas that provide specialized treatment not available in the patient’s home community.

Disclosures: Drs Charlton and Rodriguez have no relevant disclosures.

References

1. Murphy AK, McDonald-Lopez K, Pilkauskas N, Gould-Werth A. Transportation insecurity in the United States: A descriptive portrait. Socius. 2022;8. https://doi.org/10.1177/23780231221121060

2. Smith LB, Karpman M, Gonzalez D, Morriss S. More than one in five adults with limited public transit access forgo health care because of transportation barriers. Urban Institute. Published April 27, 2023. Accessed July 25, 2023.

3. Graboyes EM, Chaiyachati KH, Sisto Gall J, et al. Addressing transportation insecurity among patients with cancer. J Natl Cancer Inst. 2022;114(12):1593-1600. doi:10.1093/jnci/djac134

4. Chaiyachati KH, Krause D, Sugalski J, et al. A survey of the National Comprehensive Cancer Network on approaches toward addressing patients’ transportation insecurity. J Natl Compr Canc Netw. Published online January 2023. doi:10.6004/jnccn.2022.7073

5. Jiang C, Deng L, Wang Q, Perimbeti S, Han X. Transportation barriers to health care and mortality risk among the U.S. adults with history of cancer. J Clin Oncol. 2021;39:28_suppl, 121-121. doi:10.1200/JCO.2020.39.28_suppl.121

6. Jiang C, Deng L, Perimbeti S, et al. Associations of delays in care due to transportation barriers and care utilization, and cause-specific mortality risk among the US adults with a cancer history. J Clin Oncol. 2022;40:28_suppl, 70-70. doi:10.1200/JCO.2022.40.28_suppl.070

7. NCCN convenes policy summit assessing impact of geography on cancer outcomes, examining rural and urban divide. News release. Published June 15, 2023. Accessed July 25, 2023.

This article originally appeared on Cancer Therapy Advisor