Background: A growing body of evidence supports that the built environment, including access to public transportation, affects the quality of life and survivorship of cancer patients. Cancer patients may be especially vulnerable to the impact of decreased public transit access due to the need for frequent healthcare appointments and the cumulative physical and financial toxicity associated with cancer treatment.

Objectives: To investigate the impact of public transit access on quality of life (QoL), pain, and fatigue among cancer patients, and to examine associations between sociodemographic characteristics and transportation-related healthcare delays in this population.

Methods: Participants (N=31,126) were adults diagnosed with cancer enrolled in the NIH All of Us cohort, which uses a purposive sampling method to improve representation of participants who have been historically underrepresented in biomedical research. Cancer cases were identified using ICD and SNOMED codes. We used multivariable, ordinal logistic regression to analyze the association between increased distance from public transit and self-reported QoL, pain, and fatigue among cancer patients. Models were adjusted for age, sex, race/ethnicity, income, education, and insurance status. Similar models were used to investigate the association between sociodemographic factors and self-reported healthcare delays resulting from a lack of transportation.

Results: Decreased public transit access was associated with worse quality of life (aOR=1.09, p=0.04), pain (aOR=1.12, p<0.001), and fatigue (aOR=1.14, p<0.001) among cancer patients. Further, participants who were older (aOR=0.30, p=0.0208), female (aOR=1.13, p=0.0271), unemployed (aOR=1.13, p<0.001), or lower income (aOR=7.60, p<0.001) were more likely to report delays in care due to transportation barriers. Participants who identified as Black (aOR=1.65, p<0.001), Hispanic (aOR=1.27, p<0.0096), or multiracial (aOR=1.73, p<0.001) were also more likely to report transportation-related care delays.

Implications: This study is unique in identifying the relationship between public transit and key patient-centered markers in cancer patients using a large, diverse sample, with robust adjustment for potential confounders. The mechanisms behind this relationship are likely multifactorial, encompassing not only the impact of public transit access on healthcare utilization but also effects on preventive health behaviors. Accessible public transit is linked to increased aerobic physical activity and social participation, contributing to broader health benefits, especially for cancer patients experiencing fatigue, pain, and functional limitations.
Our findings add to the evidence that public transportation acts as a structural determinant of cancer disparities among vulnerable populations. Addressing transportation barriers may therefore enable healthcare systems to improve patient-centered cancer outcomes. Consideration for transportation should be integrated into treatment plans for all cancer patients to reduce financial toxicity and treatment costs while improving outcomes. Further, policymakers should identify and address gaps in public transit access from historically underserved neighborhoods to healthcare facilities as part of equitable public transportation planning, yielding downstream benefits for population health, quality of life, and survivorship among cancer patients.