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Beyond Distance: Travel Burden in Cancer Care- A Scoping Review

Background

Methods

Conclusions

Future Directions

• Radiation therapy—an essential component of cancer care—requires frequent visits over several weeks to months, creating a substantial transportation burden for patients and caregivers.^3,4
• This burden is amplified in rural regions, where access to cancer care is more limited and patients must travel longer distances for treatment.^5,6
• Prior work has emphasized geographic access and per-visit distance.¹⁻² However, cumulative travel burden across the cancer care continuum—and its environmental impact—remain poorly characterized.^4,7
• The cancer care continuum encompasses the full patient journey, from initial screening and diagnosis through acute treatment (surgery, chemotherapy, radiation) to long-term survivorship and surveillance.

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• Primary: To quantify the longitudinal burden of care from diagnosis through five years of follow-up, including medical, surgical, and radiation oncology appointments, imaging, laboratory testing, and symptom management encounters.
• Secondary: To evaluate the intersection of travel with secondary burdens, including time toxicity (hours spent in transit and waiting), financial toxicity, and environmental toxicity (CO₂ emissions).

• Scoping review of peer-reviewed and grey literature (January–April 2026)
• Sources: PubMed, Journal of Rural Health, ASCO, TSJ, ESTRO
• Included studies addressing travel burden and geographic barriers in cancer care
• Thematic analysis focused on geospatial methods, rural populations, and environmental impact

• Current research focuses on single-visit distance,¹⁻² failing to capture the cumulative travel burden experienced by rural patients over time.
• The true extent of patient time toxicity and the associated carbon footprint across the five-year cancer care continuum remains unclear.
• Oncology research has historically relied on geographically oriented access metrics.³⁻⁶
• Transportation burden is often measured in simplified ways, potentially underestimating the real-world strain of repeated treatment visits.

• Quantify cumulative travel burden across the full cancer care continuum using longitudinal, patient-level data
• Integrate time, financial, and environmental toxicity into comprehensive access metrics
• Develop geospatial models to identify high-burden regions and inform targeted interventions
• Evaluate strategies to reduce travel burden, including care decentralization, hypofractionation, and telehealth
• Future study workflow: Link patient cohorts, treatment episodes, and geospatial data to quantify cumulative travel burden (distance, time) and carbon emissions across the cancer care continuum

Figure 1: Components of Travel Burden

Figure 2: Catchment areas of comprehensive cancer centers in Northern New England (NCI.gov)

Figure 3: Population distribution in New Hampshire, (ArcGIS)

¹ Silverwood, S., Lichter, K., Conway, A., Drew, T., McComas, K. N., Zhang, S., Gopakumar, G. M., Abdulbaki, H., Smolen, K. A., Mohamad, O., & Grover, S. (2024). Distance traveled by patients globally to access radiation therapy: A systematic review. *International Journal of Radiation Oncology, Biology, Physics*, 118(4), 891–899. https://doi.org/10.1016/j.ijrobp.2023.10.030

² Silverwood, S. M., Waeldner, K., Demeulenaere, S. K., Keren, S., To, J., Chen, J. J., El Kouzi, Z., Ayoub, A., Grover, S., Lichter, K. E., & Mohamad, O. (2024). The relationship between travel distance for treatment and outcomes in patients undergoing radiation therapy: A systematic review. *Advances in Radiation Oncology*, 9(12), 101652. https://doi.org/10.1016/j.adro.2024.101652

³ Smith, G. L., Xu, Y., Shih, Y. C. T., Giordano, S. H., Smith, B. D., Hunt, K. K., & Buchholz, T. A. (2019). Travel distance and receipt of radiation therapy after breast-conserving surgery. *Cancer*, 125(1), 75–82. https://doi.org/10.1002/cncr.31723

⁴ Patel, M. I., Ma, Y., Mitchell, B. S., & Rhoads, K. F. (2020). Transportation barriers among cancer patients: Patterns and implications for care delivery. *Journal of Clinical Oncology*, 38(22), 2604–2613. https://doi.org/10.1200/JCO.19.02863

⁵ Baldwin, L. M., Patel, S., Andrilla, C. H. A., Rosenblatt, R. A., & Doescher, M. P. (2008). Receipt of recommended radiation therapy among rural and urban cancer patients. *Cancer*, 113(11), 3191–3198. https://doi.org/10.1002/cncr.23964

⁶ Onega, T., Duell, E. J., Shi, X., Demidenko, E., & Goodman, D. (2017). Geographic access to cancer care and outcomes in the United States. *Medical Care Research and Review*, 74(5), 542–560. https://doi.org/10.1177/1077558716650797

⁷ Sherman, J. D., Thiel, C., MacNeill, A., Eckelman, M. J., Dubrow, R., Hopf, H., & Bilec, M. (2020). The green print: Advancement of environmental sustainability in healthcare. *The Lancet Planetary Health*, 4(7), e271–e273. https://doi.org/10.1016/S2542-5196(20)30119-1

Christian Meredith¹, Caroline Walsh, MD¹, Heather Carlos, MS², and Katie E. Lichter, MD, MPH^3-5

The Lichter (GreenHealth) Lab at Dartmouth Geisel School of Medicine¹; Dartmouth Cancer Center, Community Outreach and Engagement Team²; Department of Radiation Oncology and Applied Sciences at Dartmouth Hitchcock Medical Center³; Dartmouth Cancer Center, Lebanon, NH⁴; The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Geisel School of Medicine⁵

Results

Figure 4: Research Findings Thematically

The Gap: Measuring distance by the trip, not the entire patient journey

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The Impact: Failing to track longitudinal travel , which underestimates both time toxicity for rural patients and total environmental burden of cancer care delivery

• Existing evidence is heavily skewed toward per-visit metrics (n=28), with limited studies addressing longitudinal travel burden or environmental impact

Together, these figures demonstrate the disproportionate travel burden for rural patients seeking comprehensive cancer care.

Objective