Community Hospitals May Leave Breast Cancer Patients Feeling Better Heard Than Regional Centers

For decades, cancer policy has pushed patients toward bigger hospitals. High surgical volumes, the argument goes, translate into better survival, fewer complications, and more guideline-concordant treatment. But a new study published in Breast Cancer Research and Treatment adds a surprising wrinkle to that narrative: when researchers asked breast cancer patients themselves how their care actually felt, those operated on at smaller community facilities reported better experiences with getting needed care than those treated at large regional centers.

The study, led by Savannah R. Gonzales and Erika L. Moen at Dartmouth’s Geisel School of Medicine with collaborators at Columbia University and the University of Utah, drew on a uniquely rich federal data resource called SEER-CAHPS. This dataset links the National Cancer Institute’s Surveillance, Epidemiology, and End Results cancer registry with Medicare administrative claims and the Consumer Assessment of Healthcare Providers and Systems survey, which measures how Medicare beneficiaries rate their interactions with the health care system. The cohort consisted of 3,327 female Medicare beneficiaries diagnosed with stage I to III breast cancer between 2009 and 2019 who received surgical treatment and survived at least nine months after diagnosis.

The central question was whether regionalization, the deliberate steering of surgical procedures toward high-volume hospitals, shapes not just clinical outcomes but the entire multidisciplinary care journey and the patient’s lived experience of it. Prior research has documented compelling survival benefits at high-volume centers, and policies promoting regionalization of breast cancer surgery have followed. Yet the same literature reveals stark geographic inequities: 55 percent of the United States population lives more than one hour from the nearest National Cancer Institute-designated cancer center, and rural patients with common cancers travel a median of 89 minutes for surgical care compared with 36 minutes for urban residents. Regionalization, in other words, is not a free lunch.

To capture the full arc of treatment, the researchers employed a technique called state sequence analysis, a method borrowed from studies of chronic disease care pathways. Each patient’s nine-month trajectory following diagnosis was encoded as a two-dimensional state combining physician specialty, surgery, medical oncology, or radiation oncology, with facility classification. Patients remained in a state for seven days after each encounter or until the next cancer care visit, whichever came first. The team then used a dynamic Hamming distance alignment algorithm, which allows substitution costs to vary with observed transition rates, to calculate dissimilarity scores between every pair of sequences, followed by agglomerative clustering to identify distinct trajectory patterns.

The results revealed a striking stickiness in where patients receive care. Those who had their initial surgery at a regional facility spent an average of 52 days in regional care states versus 16 days in community states, while community surgery patients showed the mirror image, 54 days in community states versus 16 in regional ones. Among regional surgery patients who received chemotherapy, 48 percent obtained it exclusively at regional facilities, while 65.8 percent of community surgery patients received chemotherapy only at community facilities. Radiation therapy followed the same pattern. The surgical facility, it appears, anchors the entire adjuvant treatment journey.

Within each surgery cohort, the clustering algorithm identified three distinct trajectory clusters that were largely complementary across the two groups. One cluster in each cohort was dominated by lumpectomy patients who went on to receive adjuvant radiation, another by older patients with fewer oncologist visits and minimal chemotherapy or radiation, and a third by stage III patients almost universally treated with chemotherapy. But the predominant cluster differed dramatically. Among regional surgery patients, 59 percent fell into a cluster spending 233 of their trajectory days without any cancer care visit, a pattern in which only one-third of lumpectomy patients received adjuvant radiation. Among community surgery patients, the largest cluster, 49 percent, was characterized by lumpectomy followed by radiation in roughly 81 percent of cases.

The authors offer two competing interpretations of this divergence. Regional facilities may be better positioned to identify low-risk cases, particularly women over 70, in whom clinical guidelines support safely omitting radiation after breast-conserving surgery. Alternatively, the higher radiation rates at community facilities may reflect improved access through reduced travel burden and greater colocation of services. Prior work has shown that patients facing longer travel distances are more likely to receive mastectomy over breast-conserving surgery and less likely to receive guideline-concordant adjuvant radiation, even after accounting for cancer stage.

On the experience measures themselves, the findings were subtle but significant. In a linear mixed-effects model with surgical facility as a random intercept, community surgery was associated with a 3.5-point higher score on the composite measure for getting needed care, which includes questions about ease of accessing specialty appointments, with a 95 percent confidence interval of 0.10 to 6.9 and a p-value of 0.043. No significant differences emerged for getting care quickly, care coordination, or doctor communication. Notably, rural residence did not modify the effect of facility classification, meaning the community-facility advantage held for both rural and urban patients. Intriguingly, rural residence itself was associated with higher scores for getting care quickly, 8.8 points, and doctor communication, 6.3 points, as a main effect, echoing prior findings that rural patients sometimes report better care experiences than urban counterparts, possibly due to lower expectations or reduced travel burden at familiar home facilities.

The authors caution that their data cannot discern the mechanisms behind the access gap. One possibility is selection bias: referral to regional facilities may concentrate more complex patients whose care needs are harder to address. Another is fragmentation: regional surgery patients were more likely to receive adjuvant treatment across both regional and community facilities, potentially splitting their care across settings and creating barriers to accessing specialty appointments. The authors suggest that patient navigation services, which have demonstrated benefits across the cancer care continuum, could be targeted toward patients requiring multidisciplinary treatment plans or travel between multiple facilities.

The study has important limitations. The SEER-CAHPS cohort is restricted to women over 65 enrolled in Traditional Medicare within SEER regions, and the analytic sample of 652 patients who completed a survey within two years of diagnosis is smaller than typical SEER-Medicare studies. The median age of breast cancer diagnosis in the United States is 62, meaning over half of all cases are not represented. Encrypted ZIP codes prevented direct calculation of travel distance, and Medicare claims capture only a fraction of each facility’s total surgical volume, forcing the researchers to use HCUP-based hospital size criteria as a proxy rather than true procedure-volume thresholds. Still, the core message stands: the benefits of regionalization must be weighed against the patient’s experience of the journey itself, and for many women, the closer, smaller hospital may deliver something the regional center cannot, a sense that care is truly within reach.

Subject of Research: A retrospective cohort study linking Medicare claims, cancer registry data and CAHPS surveys to compare breast cancer care trajectories and patient experiences by surgical facility type.

Article Title: Associations of surgical breast cancer treatment at regional or community hospitals with patient-reported experience measures

Article References: Gonzales, S. R., Ramesh, U., O’Malley, A. J., Brooks, G. A., Onega, T., & Moen, E. L. (2026). Associations of surgical breast cancer treatment at regional or community hospitals with patient-reported experience measures. Breast Cancer Research and Treatment, 220(1), Article 4. https://doi.org/10.1007/s10549-026-08105-1

Image Credits: AI Generated

DOI: 10.1007/s10549-026-08105-1

Keywords: breast cancer, regionalization of care, patient-reported experience measures, SEER-CAHPS, community hospitals, high-volume hospitals, state sequence analysis, adjuvant therapy, rural health, care trajectories, surgical oncology, health services research