Quantifying financial toxicity from cancer care travel in a geographically isolated U.S. health system.

Abstract

e13543 Background: Geographic isolation and limited availability of subspecialty oncology services can force patients to travel long distances for cancer care, disrupting continuity and contributing to financial toxicity. Hawaiʻi, the most geographically isolated health system in the United States, provides a natural model for examining how structural constraints drive out-of-state (OOS) cancer care utilization and costs—challenges shared by many rural and medically underserved regions nationwide. Objectives: To quantify OOS cancer care spending in Hawaiʻi from 2021–2023 and to identify cancer types and services most associated with OOS treatment, informing oncology capacity planning in geographically constrained settings. Methods: We conducted a retrospective analysis of administrative claims from commercially insured adults with cancer in Hawaiʻi, identified using Episode Treatment Groups (ETGs). For each year (2021–2023), we quantified the paid amounts for cancer-related services delivered outside Hawaiʻi and identified patients who received any OOS care. For 2023, we summarized member-level utilization by tumor type, including proportions of patients with OOS costs and high-cost OOS episodes (≥$100K). Spending and utilization patterns were examined by cancer type and service category. Results: Total OOS cancer spending increased from $58M in 2021 to $94M in 2022, before declining to $79M in 2023. In 2023, over 3,000 commercially insured cancer patients incurred OOS costs. The highest OOS utilization was observed in breast (953/6,199; 15% of patients, 13% of total costs), pulmonary (241/839; 29%, 9%), leukemia (144/594; 24%, 48%), multiple myeloma (65/249; 26%, 28% ), lymphoma (141/897; 16%, 21%) and central nervous system tumors (46/195; 23%, 27%). OOS utilization was most strongly associated with systemic therapy delivery, specialized diagnostics, and complex surgical care. Conclusions: OOS cancer care represents a substantial and persistent source of economic toxicity for patients and payers in geographically isolated systems and reflects structural gaps in oncology capacity in the State of Hawaiʻi. For instance, hematological malignancies and CNS tumor patients departing Hawaiʻi suggest limited in-state availability of subspecialty expertise, advanced diagnostics, and complex systemic therapies. Although the data are derived from Hawaiʻi, these patterns are broadly applicable to other regions facing geographic and oncology workforce constraints. Targeted expansion of high-impact subspecialty services, earlier multidisciplinary care planning, integration of tele-oncology, and expansion of the clinical trial portfolio may reduce avoidable travel, improve continuity of care, and support more equitable cancer treatment delivery.