Journal of General Internal Medicine

, Volume 24, Issue 2, pp 205–210 | Cite as

Determinants of NCI Cancer Center Attendance in Medicare Patients with Lung, Breast, Colorectal, or Prostate Cancer

  • Tracy OnegaEmail author
  • Eric J. Duell
  • Xun Shi
  • Eugene Demidenko
  • David Goodman
Original Article



Geographic access to NCI-Cancer Centers varies by region, race/ethnicity, and place of residence, but utilization of these specialized centers has not been examined at the national level in the U.S. This study identified determinants of NCI-Cancer Center attendance in Medicare cancer patients.


SEER-Medicare (Surveillance Epidemiology and End Results) data were used to identify individuals with an incident cancer of the breast, lung, colon/rectum, or prostate from 1998–2002. NCI-Cancer Center attendance was determined based on utilization claims from 1998–2003. Demographic, clinical, and geographic factors were examined in multilevel models. We performed sensitivity analyses for the NCI-Cancer Center attendance definition.


Overall, 7.3% of this SEER-Medicare cohort (N = 211,048) attended an NCI-Cancer Center. Travel-time to the nearest NCI-Cancer Center was inversely related to attendance, showing 11% decreased likelihood of attendance for every 10 minutes of additional travel-time (OR = 0.89, 95%CI 0.88–0.90). Receiving predominantly generalist care prior to diagnosis was associated with a lower likelihood of attendance (OR = 0.79, 95%CI 0.77–0.82). The other factors associated with greater NCI-Cancer attendance were later stage at diagnosis, fewer comorbidities, and urban residence in conjunction with African-American race.


Attendance at NCI-Cancer Centers is low among Medicare beneficiaries, but is strongly influenced by proximity and general provider care prior to diagnosis. Other patient factors are predictive of NCI-Cancer Center attendance and may be important in better understanding cancer care utilization.

Key Words

attendance  determinants cancer centers Medicare 



We would like to thank Dan Gottlieb, M.S. for his invaluable assistance with creation of the analytic dataset and keen advice.

This work was supported in part by NIH Grant Number 1 P20 RR018787 and by the Agency for Healthcare Research and Quality under Ruth L. Kirschstein National Research Service Award number T32HS000070.

This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.

Conflict of Interest statement

The authors deny any conflicts of interest.


  1. 1.
    Jemal A, Ward E, Hao Y, Thun M. Trends in the leading causes of death in the United States, 1970–2002. Jama. 2005;294101255–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Birkmeyer NJ, Goodney PP, Stukel TA, Hillner BE, Birkmeyer JD. Do cancer centers designated by the National Cancer Institute have better surgical outcomes? Cancer. 2005;1033435–41.CrossRefPubMedGoogle Scholar
  3. 3.
    Carney ME, Lancaster JM, Ford C, Tsodikov A, Wiggins CL. A population-based study of patterns of care for ovarian cancer: who is seen by a gynecologic oncologist and who is not? Gynecol Oncol. 2002;84136–42.CrossRefPubMedGoogle Scholar
  4. 4.
    Gillis CR, Hole DJ. Survival outcome of care by specialist surgeons in breast cancer: a study of 3786 patients in the west of Scotland. Bmj. 1996;3127024145–8.PubMedGoogle Scholar
  5. 5.
    Grilli R, Minozzi S, Tinazzi A, Labianca R, Sheldon TA, Liberati A. Do specialists do it better? The impact of specialization on the processes and outcomes of care for cancer patients. Ann Oncol. 1998;94365–74.CrossRefPubMedGoogle Scholar
  6. 6.
  7. 7.
    Bach PB, Cramer LD, Warren JL, Begg CB. Racial differences in the treatment of early-stage lung cancer. N Engl J Med. 1999;341161198–205.CrossRefPubMedGoogle Scholar
  8. 8.
    Celaya MO, Rees JR, Gibson JJ, Riddle BL, Greenberg ER. Travel distance and season of diagnosis affect treatment choices for women with early-stage breast cancer in a predominantly rural population (United States). Cancer Causes Control. 2006;176851–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Cooper GS, Yuan Z, Chak A, Rimm AA. Geographic and patient variation among Medicare beneficiaries in the use of follow-up testing after surgery for nonmetastatic colorectal carcinoma. Cancer. 1999;85102124–31.CrossRefPubMedGoogle Scholar
  10. 10.
    Demissie K, Oluwole OO, Balasubramanian BA, Osinubi OO, August D, Rhoads GG. Racial differences in the treatment of colorectal cancer: a comparison of surgical and radiation therapy between Whites and Blacks. Ann Epidemiol. 2004;143215–21.CrossRefPubMedGoogle Scholar
  11. 11.
    Elliott TE, Elliott BA, Renier CM, Haller IV. Rural-urban differences in cancer care: results from the Lake Superior Rural Cancer Care Project. Minn Med. 2004;87944–50.PubMedGoogle Scholar
  12. 12.
    Greenberg ER, Dain B, Freeman D, Yates J, Korson R. Referral of lung cancer patients to university hospital cancer centers. A population-based study in two rural states. Cancer. 1988;6281647–52.CrossRefPubMedGoogle Scholar
  13. 13.
    Iwashyna TJ, Curlin FA, Christakis NA. Racial, ethnic, and affluence differences in elderly patients’ use of teaching hospitals. J Gen Intern Med. 2002;179696–703.CrossRefPubMedGoogle Scholar
  14. 14. (accessed 10.29/08).
  15. 15.
    Potosky AL, Riley GF, Lubitz JD, Mentnech RM, Kessler LG. Potential for cancer related health services research using a linked Medicare-tumor registry database. Med Care. 1993;318732–48.CrossRefPubMedGoogle Scholar
  16. 16.
  17. 17.
    Onega TDE, Shi X, Demidenko E, Goodman D. Geographic access to cancer care in the United States. Cancer. 2008;1124909–18.CrossRefPubMedGoogle Scholar
  18. 18.
  19. 19.
    Birkmeyer JD, Siewers AE, Marth NJ, Goodman DC. Regionalization of high-risk surgery and implications for patient travel times. Jama. 2003;290202703–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Schrag D, Bach PB, Dahlman C, Warren JL. Identifying and measuring hospital characteristics using the SEER-Medicare data and other claims-based sources. Med Care. 2002;40(8 Suppl):IV-96–103.Google Scholar
  21. 21.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;405373–83.CrossRefPubMedGoogle Scholar
  22. 22.
    Iezzoni LI, Foley SM, Daley J, Hughes J, Fisher ES, Heeren T. Comorbidities, complications, and coding bias. Does the number of diagnosis codes matter in predicting in-hospital mortality? Jama. 1992;267162197–203.CrossRefPubMedGoogle Scholar
  23. 23.
    Klabunde CN, Potosky AL, Legler JM, Warren JL. Development of a comorbidity index using physician claims data. J Clin Epidemiol. 2000;53121258–67.CrossRefPubMedGoogle Scholar
  24. 24.
    Rabe-Hesketh SaS, A. Multilevel and Longitudinal Modeling Using Stata. College Station Texas: Stata Press; 2005.Google Scholar
  25. 25.
    Chan L, Hart LG, Goodman DC. Geographic access to health care for rural Medicare beneficiaries. J Rural Health. 2006;222140–6.CrossRefPubMedGoogle Scholar
  26. 26.
    Goodman DC, Fisher ES, Stukel TA, et al. The distance to community medical care and the likelihood of hospitalization. Am J Public Health. 1997;87:1144–1150.CrossRefPubMedGoogle Scholar
  27. 27.
    Gumpertz ML, Pickle LW, Miller BA, Bell BS. Geographic patterns of advanced breast cancer in Los Angeles: associations with biological and sociodemographic factors (United States). Cancer Causes Control. 2006;173325–39.CrossRefPubMedGoogle Scholar
  28. 28.
    Schroen AT, Brenin DR, Kelly MD, Knaus WA, Slingluff CL, Jr. Impact of patient distance to radiation therapy on mastectomy use in early-stage breast cancer patients. J Clin Oncol. 2005;23287074–80.CrossRefPubMedGoogle Scholar
  29. 29.
    Cooper GS, Koroukian SM. Racial disparities in the use of and indications for colorectal procedures in Medicare beneficiaries. Cancer. 2004;1002418–24.CrossRefPubMedGoogle Scholar
  30. 30.
    Hodgson DC, Fuchs CS, Ayanian JZ. Impact of patient and provider characteristics on the treatment and outcomes of colorectal cancer. J Natl Cancer Inst. 2001;937501–15.CrossRefPubMedGoogle Scholar
  31. 31.
    Morris AM, Billingsley KG, Baxter NN, Baldwin LM. Racial disparities in rectal cancer treatment: a population-based analysis. Arch Surg. 2004;1392151–5; discussion 156.CrossRefPubMedGoogle Scholar
  32. 32.
    Baicker K, Chandra A, Skinner JS, Wennberg JE. Who You Are And Where You Live: How Race And Geography Affect The Treatment Of Medicare Beneficiaries. Health Aff (Millwood). 2004.Google Scholar
  33. 33.
    Shavers VL, Harlan LC, Stevens JL. Racial/ethnic variation in clinical presentation, treatment, and survival among breast cancer patients under age 35. Cancer. 2003;971134–47.CrossRefPubMedGoogle Scholar
  34. 34.
    Velanovich V, Yood MU, Bawle U, et al. Racial differences in the presentation and surgical management of breast cancer. Surgery. 1999;1254375–9.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Tracy Onega
    • 1
    • 2
    • 3
    Email author
  • Eric J. Duell
    • 1
    • 2
    • 3
    • 5
  • Xun Shi
    • 4
  • Eugene Demidenko
    • 2
    • 3
  • David Goodman
    • 1
    • 2
  1. 1.The Dartmouth Institute for Health Policy and Clinical PracticeDartmouth Medical SchoolHanoverUSA
  2. 2.Department of Community and Family MedicineDartmouth Medical SchoolHanoverUSA
  3. 3.Norris Cotton Cancer CenterDartmouth Medical SchoolLebanonUSA
  4. 4.Department of Geography Dartmouth CollegeHanoverUSA
  5. 5.International Agency for Research on Cancer (IARC)LyonFrance

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