Introduction
Pancreatic ductal adenocarcinoma is a cancer with poor clinical outcomes that benefits from treatment at dedicated, high-volume cancer centers. As a result, patients from different geographical backgrounds travel to receive treatment at these institutions. Amongst these diverse groups of patients, patients from distant, rural areas are found to be associated with poor outcomes. However, there is limited data that specifically investigates surgical outcomes and postoperative management for these patients.
Methods
This is a retrospective cohort study of patients who underwent the Whipple procedure at a non-university tertiary care center from 2019 to 2021. A cutoff population of less than 10,000 was utilized to label “at-risk” rural zip codes, which was derived from the Office of Management and Budget’s definition of rural. Distance traveled was estimated from the patient’s zip code to the hospital. Various outcomes were investigated, including postoperative complications, adjuvant chemotherapy rate, radiation rate, and survival. Mann-Whitney U test and ANOVA were utilized for quantitative variables, whereas Pearson’s Chi-square was utilized for qualitative variables. P-value of <0.05 was deemed statistically significant.
Results
A total of 78 patients were included in this study. The median distance traveled was 55 miles. “At-risk” rural patients, when compared to the low-risk rural/urban patients, had similar operative outcomes, including length of stay (10.8 versus 10.2 days; p = 0864), 30-day readmission (15% versus 23%; p = 0.523), and 30-day postoperative complication rate (31% versus 30%; p = 0.938) following surgery. However, patients from “at-risk” rural areas were less likely to undergo postoperative chemotherapy (46% versus 75%; p = 0.04) even though there was no statistical difference in their TNM staging compared to their low-risk rural or urban counterparts. Postoperative radiation was also visibly lower for the “at-risk” rural patients, even though it did not meet the statistical significance cutoff (8.3% versus 33%; p = 0.083). Interestingly, the “at-risk” rural status did not impact overall survival.
Conclusions
“At risk” rural patients are less likely to undergo postoperative chemotherapy and possibly radiation, suggesting that these patients may become lost to follow-up postoperatively. While this did not impact overall survival in this study, the importance of adjuvant chemotherapy and radiation in regards to optimizing pancreatic cancer treatment and survival is well established in current literature. Clinicians need to be mindful when attending to this subset of patients and strive to address this issue via a multidisciplinary approach.
