There's been a lot of work recently looking at outcomes and disparities for patients with cancer who live in rural environments. We know that probably due to a number of socioeconomic factors-- lower education, lower income, and lower access to care-- that they experience worse outcomes and worse survival, particularly in earlier-stage cancers. We published some data about, particularly in early stage breast cancer, colon and lung cancer as well, the outcomes are worse for people who are living in rural environments.
We've also published that time-to-treatment may actually have a big impact on survival as well, again, in earlier-stage cancers in particular. That's been a big initiative here at Cleveland Clinic recently to bring down time-to-treatment by shortening appointment times, coordinating care with other specialists to be on the same day, and things of that nature. We're really curious basically to see if those same types of findings could apply to a much larger data set. And so we looked at the National Cancer Database, which in the study period of 2004 to 2012 included a little over 1.2 million women with early stage breast cancer, so stages 1 to 3.
And basically we wanted to see if we divided the group between the rural patients versus more urban patients, were there differences in terms of the socioeconomic status, and then also the time-to-treatment, and then do any of those things have a relationship with overall survival. And what we found actually was rather surprising. We found that patients that were in rural settings actually had better survival overall compared to those who lived in urban environments. And that was contrary to, I think, what we would have expected.
I think the data sort of pointed to why that might be the case. So we did find that rural patients had lower median income, lower education levels, and also tended to be older and have more comorbidities. So you would think all of those factors are really pushing towards worse overall survival. The only really positive factor we found was that the time-to-treatment was significantly shorter in rural patients versus the urban patients. So it was 3.75 weeks time-to-treatment for the rural patients versus 4.35 for the urban patients. It's about five days, basically, is what that amounts to.
And when we in fact looked at each of those variables, time-to-treatment, the various economic factors, and age, all of the other things, as you would expect, portended worse overall survival. But the time-to-treatment, so we divided that by less than four weeks versus greater than eight weeks, or four to eight weeks versus greater than eight weeks. Both of those had a significant relationship with overall survival. So both were around a 15% to 20% improvement in overall survival.
Why might rural patients have a shorter time to treatment than those living in suburban areas or cities?
Our study didn't specifically address that, but my thinking on that, just from my anecdotal experience, is that a number of rural patients-- and there's some literature on this as well-- they tend to go directly from their rural setting to an academic center with a higher level of care, more multidisciplinary care immediately. So there's a sort of a U-shaped curve in terms of distance, where patients that live close to academic centers or closer to oncologic care have good outcomes. Those who were around 50 miles or so may have the worst because they sort of stay in their community setting. And those who live quite far immediately decide very quickly that, I've been diagnosed with cancer. I'm going directly downtown to the center that I know that will give me the best care.
The study included hospitals with Commission on Cancer accreditation - what does this mean for our results?
The Commission on Cancer is an excellent organization and set of guidelines that require oncologic centers to have basically multidisciplinary-type care that you would see at a larger academic or university setting. So they require institutions to have tumor boards, to have registries where they track all of their data and all of their outcomes. They're required to have appropriate supportive care for managing the side effects of chemotherapy and things like that. Ensuring that they have radiation oncology, a surgical oncologist that specializes in that disease area.
So I think it really is a set of strong guidelines that ensures that there's true multidisciplinary and subspecialized care specialized to the patient. And I think that's another factor. So these patients in this database are not your usual patients that are receiving care in a rural setting where it might be an oncologist or a few oncologists in the group practice who are managing things mostly on their own. These tend to be larger group practices and also regional hospitals affiliated with academic places where they do have the full gamut of care available.
And I hope that when people read this abstract and then subsequent manuscript as well, I hope that it spurs more interest and more evaluation and development of new initiatives basically to try to improve time-to-treatment. Because I think if that were rolled out really on a national scale, I think that would really make a big difference for a lot of our patients in the rural setting and then otherwise as well.