Rural patients are at risk for increased stage at presentation and diminished overall survival in osteosarcoma

Background: There is an undefined relationship between access to regional referral centers and whether the eventual oncologic outcomes are influenced by distance, travel time, or residence in a rural community.

Methods: We used the Surveillance, Epidemiology and End Results (SEER) Program Database to capture all cases of high-grade osteosarcoma from 1990 to 2014 in Iowa, Utah, and New Mexico. Using univariate, Kaplan Meier survival analysis, and multivariate Cox proportional hazards modeling we analyzed patient and tumor characteristics.

Results: A total of 476 patients met the study criteria. There was an increased incidence of metastases for patients residing in a county with a greater than 2 -h drive to the nearest comprehensive cancer center (p = 0.021). Individuals residing in "rural" counties and "very rural" counties showed decreased 5-year survival (p = 0.007 and 0.003, respectively) when compared to those living in areas of higher population density. A multivariate regression analysis showed that the presence of metastasis (HR = 2.78 [95% CI: 1.88-4.10], p < 0.0001) and rural status (HR = 1.58 [95% CI: 1.03-2.43], p = 0.037) were risk factors for mortality when controlling for size of the tumor.

Conclusion: The travel time to the nearest comprehensive center was associated with an increased incidence of metastasis on presentation in patients with osteosarcoma. Metastasis and rural status were independent risk factors for mortality. This investigation suggests that individuals living in rural counties may experience barriers to presentation, treatment, or surveillance that are not present in areas with a higher population density.