Background
Cancer incidence is increasing globally, with a disproportionate burden borne by low- and middle-income countries (LMICs). Achieving Universal Health Coverage requires equitable access to cancer care. In India, specialised cancer services are largely concentrated in tertiary centres, creating geographic and financial access barriers. While the health system has focused on clinical cancer outcomes, evidence on travel distance, travel time, and non-medical costs associated with accessing care remains limited.
Objectives
- To assess travel distance from place of residence to a tertiary cancer care centre in Southern India using Geographic Information System (GIS)–based analysis of hospital-based cancer registry data.
- To examine travel time and associated non-medical costs, identify access-related challenges, and explore factors influencing healthcare facility selection among individuals receiving cancer treatment.
Objective 1 employed a cross-sectional GIS-based spatial analysis of 1,306 adults aged 18–65 years with common cancers (breast, oral, cervix uteri, lung, and upper gastrointestinal) registered between January and December 2022 at a tertiary care centre in Southern India. Residential locations were obtained from the hospital-based cancer registry, and data on nearby public cancer care facilities were sourced from the National Health Mission. Spatial analyses were conducted using ArcGIS Pro.
Objective 2 used a sequential mixed-methods design. Quantitative data were collected from 192 individuals undergoing active chemotherapy or radiation therapy between November 2023 and January 2024 using systematic random sampling and analysed using STATA v14. Qualitative data were obtained through 10 in-depth interviews with individuals and caregivers travelling more than three hours, and analysed using manual content and thematic analysis.
Results
Among the 1,306 individuals included (mean age 51.7 ± 8.8 years; 73.6% female; 65.3% rural), the median travel distance to the tertiary care centre was 96.2 km (interquartile range [IQR]: 36.4–155.7). Although 77.8% resided within 25 km of a public cancer care facility (medical college or district hospitals), substantial bypassing of peripheral services was observed.
Among the 192 surveyed, the median travel time was 4.3 hours (IQR: 2.07–7.3). Median non-medical expenditure per visit was INR 453 (IQR: 200–987), equivalent to approximately USD 5.44 (1 USD = 83.25 INR). Travel costs accounted for INR 200 (IQR: 123–400), and food costs for INR 360 (IQR: 150–613). Most individuals (76%) were diagnosed outside the tertiary centre; however, only 33% were formally referred, while others were influenced by peer networks. Notably, 76% were unaware of nearby cancer care facilities.
Qualitative findings revealed severe physical, financial, and psychosocial hardship due to long and unsafe travel, travel pass rejections, food insecurity, wage loss, stigma, and caregiver burnout. Transport barriers, disrespectful treatment, and weak referral and care coordination further delayed care and intensified household distress.
Conclusion
More than three-fourths of individuals with cancer travelled long distances despite the availability of nearby care facilities. Prolonged travel time and associated costs imposed substantial financial strain on cancer-affected households. Improving awareness of available services, strengthening travel and accommodation support, and decentralising cancer care delivery may enhance access and reduce economic burden.
Spatial distribution of residential areas and the nearest public cancer care facilities of persons with cancer attending a tertiary care facility, Puducherry (N=1306).