Geographic disparities in the distribution of the U.S. gynecologic oncology workforce: A Society of Gynecologic Oncology study

Utilization and Surgical Outcomes of Sentinel Lymph Node Biopsy for Endometrial Intraepithelial Neoplasia

OBJECTIVE

To describe the rate and surgical outcomes of sentinel lymph node (SLN) biopsy in patients with endometrial intraepithelial neoplasia (EIN).

METHODS

We conducted a cohort study that used the prospective American College of Surgeons National Surgical Quality Improvement Program database. Women with EIN on postoperative pathology who underwent minimally invasive hysterectomy from 2012 to 2020 were included. The cohort was dichotomized based on the performance of SLN biopsy. Patients' characteristics, perioperative morbidity, and mortality were compared between patients who underwent SLN biopsy and those who did not. Postoperative complications were defined using the Clavien-Dindo classification system.

RESULTS

Overall, 4,447 patients were included; of those, 586 (13.2%) underwent SLN biopsy. The proportion of SLN biopsy has increased steadily from 0.6% in 2012 to 26.1% in 2020 ( P <.001), with a rate of 16% increase per year. In a multivariable regression that included age, body mass index (BMI), and year of surgery, a more recent year of surgery was independently associated with an increased adjusted odds ratio of undergoing SLN biopsy (1.51, 95% CI, 1.43-1.59). The mean total operative time was longer in the SLN biopsy group (139.50±50.34 minutes vs 131.64±55.95 minutes, P =.001). The rate of any complication was 5.9% compared with 6.7%, the rate of major complications was 2.3% compared with 2.4%, and the rate of minor complications was 4.1% compared with 4.9% for no SLN biopsy and SLN biopsy, respectively. In a single complications analysis, the rate of venous thromboembolism was higher in the SLN biopsy group (four [0.7%] vs four [0.1%], P =.013). In a multivariable regression analysis adjusted for age, BMI, American Society of Anesthesiologists classification, uterus weight, and preoperative hematocrit, the performance of SLN biopsy was not associated with any complications, major complications, or minor complications.

CONCLUSION

The performance of SLN biopsy in EIN is increasing. Sentinel lymph node biopsy for EIN is associated with an increased risk of venous thromboembolism and a negligible increased surgical time.

Geographic distance to Commission on Cancer-accredited and nonaccredited hospitals in the United States

PURPOSE

The Commission on Cancer (CoC) establishes standards to support multidisciplinary, comprehensive cancer care. CoC-accredited cancer programs diagnose and/or treat 73% of patients in the United States. However, rural patients may experience diminished access to CoC-accredited cancer programs. Our study evaluated distance to hospitals by CoC accreditation status, rurality, and Census Division.

METHODS

All US hospitals were identified from public-use Homeland Infrastructure Foundation-Level Data, then merged with CoC-accreditation data. Rural-Urban Continuum Codes (RUCC) were used to categorize counties as metro (RUCC 1-3), large rural (RUCC 4-6), or small rural (RUCC 7-9). Distance from each county centroid to the nearest CoC and non-CoC hospital was calculated using the Great Circle Distance method in ArcGIS.

FINDINGS

Of 1,382 CoC-accredited hospitals, 89% were in metro counties. Small rural counties contained a total of 30 CoC and 794 non-CoC hospitals. CoC hospitals were located 4.0, 10.1, and 11.5 times farther away than non-CoC hospitals for residents of metro, large rural, and small rural counties, respectively, while the average distance to non-CoC hospitals was similar across groups (9.4-13.6 miles). Distance to CoC-accredited facilities was greatest west of the Mississippi River, in particular the Mountain Division (99.2 miles).

CONCLUSIONS

Despite similar proximity to non-CoC hospitals across groups, CoC hospitals are located farther from large and small rural counties than metro counties, suggesting rural patients have diminished access to multidisciplinary, comprehensive cancer care afforded by CoC-accredited hospitals. Addressing distance-based access barriers to high-quality, comprehensive cancer treatment in rural US communities will require a multisectoral approach.

Rural-urban disparities in psychosocial functioning in epithelial ovarian cancer patients

OBJECTIVE

Although rural residence has been related to health disparities in cancer patients, little is known about how rural residence impacts mental health and quality of life (QOL) in ovarian cancer patients over time. This prospective longitudinal study investigated mental health and QOL of ovarian cancer patients in the first-year post-diagnosis.

METHOD

Women with suspected ovarian cancer completed psychosocial surveys pre-surgery, at 6 months and one-year; clinical data were obtained from medical records. Histologically confirmed high grade epithelial ovarian cancer patients were eligible. Rural/urban residence was categorized from patient counties using the USDA Rural-Urban Continuum Codes. Linear mixed effects models examined differences in psychosocial measures over time, adjusting for covariates.

RESULTS

Although disparities were not observed at study entry for any psychosocial variable (all p-values >0.22), urban patients showed greater improvement in total distress over the year following diagnosis than rural patients (p = 0.025) and were significantly less distressed at one year (p = 0.03). Urban patients had a more consistent QOL improvement than their rural counterparts (p = 0.006). There were no differences in the course of depressive symptoms over the year (p = 0.17). Social support of urban patients at 12 months was significantly higher than that of rural patients (p = 0.04).

CONCLUSION

Rural patients reported less improvement in psychological functioning in the year following diagnosis than their urban counterparts. Clinicians should be aware of rurality as a potential risk factor for ongoing distress. Future studies should examine causes of these health disparities and potential long-term inequities and develop interventions to address these issues.

Making Sense of Gynecologic Cancer: A Relational Dialectics Approach

This study used the relational dialectics theory (RDT) as a theoretical lens to examine how the interplay of competing discourses shaped meaning making about gynecologic cancer. A reflexive thematic analysis of the narratives of 12 survivors of cervical cancer, ovarian cancer, and uterine cancer in Arkansas showed two discursive struggles at play, including continuity of care versus change, and voicing versus repressing of feelings. The findings showed that long history of care with physicians contributed to how participants privileged the discourse of continuity of care when faced with a decision to travel for care or receive care locally. We also found that cultural discourses about concealing women's cancer-afflicted bodies, lack of supportive spaces for women to discuss side effects of cancer treatments, and appropriate communication behavior between patients and physicians shaped the interplay of the discursive struggle of voicing versus repressing. The findings extend the RDT by showing that geographic location, disease characteristics, history of care between patients and physicians, and prevailing cultural discourses can contribute to the interplay of discursive struggles in the gynecologic cancer context. Further, the findings suggest to healthcare professionals to address harmful discourses about gynecologic cancer to help create support avenues for survivors.

Geographic Disparities in Potential Accessibility to Gynecologic Oncologists in the United States From 2001 to 2020

OBJECTIVE

To use a spatial modeling approach to capture potential disparities of gynecologic oncologist accessibility in the United States at the county level between 2001 and 2020.

METHODS

Physician registries identified the 2001-2020 gynecologic oncology workforce and were aggregated to each county. The at-risk cohort (women aged 18 years or older) was stratified by race and ethnicity and rurality demographics. We computed the distance from at-risk women to physicians. Relative access scores were computed by a spatial model for each contiguous county. Access scores were compared across urban or rural status and racial and ethnic groups.

RESULTS

Between 2001 and 2020, the gynecologic oncologist workforce increased. By 2020, there were 1,178 active physicians and 98.3% practiced in urban areas (37.3% of all counties). Geographic disparities were identified, with 1.09 physicians per 100,000 women in urban areas compared with 0.1 physicians per 100,000 women in rural areas. In total, 2,862 counties (57.4 million at-risk women) lacked an active physician. Additionally, there was no increase in rural physicians, with only 1.7% practicing in rural areas in 2016-2020 relative to 2.2% in 2001-2005 ( P =.35). Women in racial and ethnic minority populations, such as American Indian or Alaska Native and Hispanic women, exhibited the lowest level of access to physicians across all time periods. For example, 23.7% of American Indian or Alaska Native women did not have access to a physician within 100 miles between 2016 and 2020, which did not improve over time. Non-Hispanic Black women experienced an increase in relative accessibility, with a 26.2% increase by 2016-2020. However, Asian or Pacific Islander women exhibited significantly better access than non-Hispanic White, non-Hispanic Black, Hispanic, and American Indian or Alaska Native women across all time periods.

CONCLUSION

Although the U.S. gynecologic oncologist workforce increased steadily over 20 years, this has not translated into evidence of improved access for many women from rural and underrepresented areas. However, health care utilization and cancer outcomes may not be influenced only by distance and availability. Policies and pipeline programs are needed to address these inequities in gynecologic cancer care.

Factors associated with receipt of second-line recurrent or metastatic cervical cancer treatment in the United States: A retrospective administrative claims analysis

Purpose

Contemporary, real-world data on eligible patients receiving treatment following progression on first-line (1L) recurrent or metastatic cervical cancer (r/mCC) therapy are needed to inform treatment algorithms and identify potential gaps in the r/mCC care continuum.

Methods

This study estimated the prevalence and predictors of second-line (2L) r/mCC therapy among 1L-treated patients using the 2015-2020 IBM MarketScan® commercial claims database. Women ≥ 18 years diagnosed with cervical cancer and treated with first-line systemic therapies were identified and followed for 12 months from their 1L therapy end date. Women with claims for a new therapy after 60 days but no later than 365 days from the end of 1L treatment were identified as those who progressed and received 2L therapy for r/mCC. Descriptive statistics examined baseline cohort characteristics and multivariable logistic regression model examined the factors associated with receiving 2L treatment.

Results

We identified 384 1L-treated patients with r/mCC with ≥ 12 months of follow-up post-1L treatment. During follow-up, over half (51.0 %) of the 1L-treated r/mCC patients received 2L treatment. Patients from the South and Midwest had a lower likelihood of receiving 2L treatment compared with those living in the Northeast (adjusted odds ratio [aOR] = 0.43; 0.23-0.84) and (aOR = 0.52; 0.28-0.95, respectively). Patients not treated with bevacizumab in 1L were also less likely to receive 2L therapy (aOR = 0.65; 0.43-0.99).

Conclusion

Additional research and targeted outreach efforts are needed to understand geography-, population-, or practice-specific barriers impacting access to 2L therapy among patients with r/mCC.

Factors associated with receipt of second-line recurrent or metastatic cervical cancer treatment in the United States: A retrospective administrative claims analysis

Purpose

Contemporary, real-world data on eligible patients receiving treatment following progression on first-line (1L) recurrent or metastatic cervical cancer (r/mCC) therapy are needed to inform treatment algorithms and identify potential gaps in the r/mCC care continuum.

Methods

This study estimated the prevalence and predictors of second-line (2L) r/mCC therapy among 1L-treated patients using the 2015-2020 IBM MarketScan® commercial claims database. Women ≥ 18 years diagnosed with cervical cancer and treated with first-line systemic therapies were identified and followed for 12 months from their 1L therapy end date. Women with claims for a new therapy after 60 days but no later than 365 days from the end of 1L treatment were identified as those who progressed and received 2L therapy for r/mCC. Descriptive statistics examined baseline cohort characteristics and multivariable logistic regression model examined the factors associated with receiving 2L treatment.

Results

We identified 384 1L-treated patients with r/mCC with ≥ 12 months of follow-up post-1L treatment. During follow-up, over half (51.0 %) of the 1L-treated r/mCC patients received 2L treatment. Patients from the South and Midwest had a lower likelihood of receiving 2L treatment compared with those living in the Northeast (adjusted odds ratio [aOR] = 0.43; 0.23-0.84) and (aOR = 0.52; 0.28-0.95, respectively). Patients not treated with bevacizumab in 1L were also less likely to receive 2L therapy (aOR = 0.65; 0.43-0.99).

Conclusion

Additional research and targeted outreach efforts are needed to understand geography-, population-, or practice-specific barriers impacting access to 2L therapy among patients with r/mCC.

Geographic Distribution of Cancer Care Providers in the Philippines

PURPOSE

In the Philippines, a lower middle-income country in Southeast Asia, 6 of 10 Filipinos die without seeing a doctor. To ensure universal access to cancer care, providers must be equitably distributed. Therefore, we evaluated the distribution of oncologists across all 17 regions in the Philippines.

METHODS

We gathered data from the official websites of national medical societies on their members' regional area of practice: Philippine Society of Medical Oncology, Philippine Radiation Oncology Society, Surgical Oncology Society of the Philippines, Society of Gynecologic Oncologists of the Philippines, and Philippine Society of Hospice and Palliative Medicine. We compared this with the regional census to determine the number of board-certified oncologists per 100,000 Filipinos.

RESULTS

For a population of almost 110 million, the Philippines has a total of 348 medical oncologists, 164 surgical oncologists, 99 radiation oncologists, 142 gynecologic oncologists, and 35 hospice and palliative medicine (HPM) specialists. This translates to 0.32 medical oncologists, 0.15 surgical oncologists, 0.09 radiation oncologists, 0.13 gynecologic oncologists, and 0.03 HPM specialists for every 100,000 Filipinos. The number of oncologists is highest in the National Capital Region in Luzon and lowest in the Bangsamoro Autonomous Region in Muslim Mindanao. All regions have at least one medical and gynecologic oncologist. Two regions (12%) have no surgical oncologists, five regions (29%) have no radiation oncologists, and eight regions (47%) have no HPM specialists.

CONCLUSION

Efforts are needed to increase the number of oncologists and improve equity in their distribution to ensure universal access to cancer care in the Philippines.

Community access to primary care is an important geographic disparity among ovarian cancer patients undergoing cytoreductive surgery

Objective

Given the importance of understanding neighborhood context and geographic access to care on individual health outcomes, we sought to investigate the association of community primary care (PC) access on postoperative outcomes and survival in ovarian cancer patients.

Methods

This was a retrospective cohort study of Stage III-IV ovarian cancer patients who underwent surgery at a single academic, tertiary care hospital between 2012 and 2015. PC access was determined using a Health Resources and Services Administration designation. Outcomes included 30-day surgical and medical complications, extended hospital stay, ICU admission, hospital readmission, progression-free and overall survival. Descriptive statistics and chi-squared analyses were used to analyze differences between patients from PC-shortage vs not PC-shortage areas.

Results

Among 217 ovarian cancer patients, 54.4 % lived in PC-shortage areas. They were more likely to have Medicaid or no insurance and live in rural areas with higher poverty rates, significantly further from the treating cancer center and its affiliated hospital. Nevertheless, 49.2 % of patients from PC-shortage areas lived in urban communities. Residing in a PC-shortage area was not associated with increased surgical or medical complications, ICU admission, or hospital readmission, but was linked to more frequent prolonged hospitalization (26.3 % vs 14.1 %, p = 0.04). PC-shortage did not impact progression-free or overall survival.

Conclusions

Patients from PC-shortage areas may require longer inpatient perioperative care in order to achieve the same 30-day postoperative outcomes as patients who live in non-PC shortage areas. Community access to PC is a critical factor to better understanding and reducing disparities among ovarian cancer patients.

Collaborative centralization of gynaecological cancer care

PURPOSE OF REVIEW

To discuss the benefits of centralization of gynaecological cancer care on patients and the healthcare system and how to overcome its barriers.

RECENT FINDINGS

Evidence demonstrates that adherence to clinical practice management guidelines is more likely; the risk of adverse events is lower; survival is improved; in young women fertility preservation is higher; and cost effectiveness is higher; in systems that employ centralized care for women with gynaecological cancer. Barriers to the uptake of centralized models include knowledge, attitude as well as deficient systems and processes, including a lack of governance and leadership. Collaborative centralization refers to a model that sees both elements (centralization and treatment closer to home) utilized at the patient level that addresses some of the barriers of centralized gynaecological cancer care.

SUMMARY

Evidence supports centralized gynaecological cancer care, as it results in reduced risks of adverse events, improved survival and higher fertility rates at lower cost to funders. Collaborative centralization is a process that considers both the value of centralization and collaboration amongst healthcare professionals at primary, secondary and tertiary levels of healthcare to benefit patient outcomes.

Management of the Adnexal Mass: Considerations for the Family Medicine Physician

Ovarian cancer is the most deadly gynecological cancer, so proper assessment of a pelvic mass is necessary in order to determine which are at high risk for malignancy and should be referred to a gynecologic oncologist. However, in a family medicine setting, evaluation and treatment of these masses can be challenging due to a lack of resources. A number of risk assessment tools are available to family medicine physicians, including imaging techniques, imaging systems, and blood-based biomarker assays each with their respective pros and cons, and varying ability to detect malignancy in pelvic masses. Effective utilization of these assessment tools can inform the care pathway for patients which present with an adnexal mass, such as expectant management for those with a low risk of malignancy, or referral to a gynecologic oncologist for surgery and staging, for those at high risk of malignancy. Triaging patients to the appropriate care pathway improves patient outcomes and satisfaction, and family medicine physicians can play a key role in this decision-making process.

Disparity of ovarian cancer survival between urban and rural settings

Objective

To determine if there is a difference in overall survival of patients with epithelial ovarian cancer in rural, urban, and metropolitan settings in the United States.

Methods

We performed a retrospective cohort study using 2004–2016 National Cancer Database (NCDB) data including high and low grade, stage I-IV disease. Bivariate analyses used Student’s t-test for continuous variables and χ² test for dichotomous variables. Kaplan-Meier curves estimated survival of patients based on location of residence, and univariate analyses using Cox proportional HR assessed survival based on baseline characteristics. Multivariate analysis was performed to account for significant covariates. Propensity score matching was used to validate the multivariate survival model. For all tests, p<0.05 was considered statistically significant.

Results

A total of 111 627 patients were included with a mean age of 62.5 years for metroolitan (range 18–90), 64.0 years for rural (range 19–90) and 63.2 years for urban areas (range 18–90). Of all patients included, 94 290 were in a metropolitan area (counties >1 million population or 50 000–999 999), 15 386 were in an urban area (population of 10 000–49 999), and 1951 were in a rural area (non-metropolitan/non-core population). Univariate Cox proportional hazards models showed clinically significant differences in survival in patients from metropolitan, urban, and rural areas. Multivariate Cox proportional hazards models showed a clinically significant increase in HRs for patients in rural settings (HR 1.17; 95% CI 1.06 to 1.29). Increasing age and stage, non-insured status, non-white race, and comorbidity were also significant for poorer survival.

Conclusion

Patients with ovarian cancer who live in rural settings with small populations and greater distance to tertiary care centers have poorer survival. These differences hold after controlling for stage, age, and other significant risk factors related to poorer outcomes. To improve clinical outcomes, we need further studies to identify which of these factors are actionable.

Gynecologic oncologist impact on adjuvant chemotherapy care for stage II-IV ovarian cancer patients

OBJECTIVE

We aim to evaluate the impact gynecologic oncologists have on ovarian cancer adjuvant chemotherapy care from their role as surgeons recommending adjuvant chemotherapy care and their role as adjuvant chemotherapy providers while considering rural-urban differences.

METHODS

Multivariable adjusted logistic regressions and Cox proportional hazards models were developed using a population-based, retrospective cohort of stage II-IV and unknown stage ovarian cancer patients diagnosed in Iowa, Kansas, and Missouri in 2010-2012 whose medical records were abstracted in 2017-2018.

RESULTS

Gynecologic oncologist surgeons (versus other type of surgeon) were associated with increased odds of adjuvant chemotherapy initiation (adjusted odds ratio (OR) 2.18; 95% confidence interval (CI) 1.10-4.33) and having a gynecologic oncologist adjuvant chemotherapy provider (OR 10.0; 95% CI 4.58-21.8). Independent of type of surgeon, rural patients were less likely to have a gynecologic oncologist chemotherapy provider (OR 0.52; 95% CI 0.30-0.91). Gynecologic oncologist adjuvant chemotherapy providers (versus other providers) were associated with decreased surgery-to-chemotherapy time (rural: 6 days; urban: 8 days) and increased distance to chemotherapy (rural: 22 miles; urban: 11 miles). Rural women (versus urban) traveled 38 miles farther when their chemotherapy provider was a gynecologic oncologist and 27 miles farther when it was not.

CONCLUSION

Gynecologic oncologist surgeons may impact adjuvant chemotherapy initiation. Gynecologic oncologists serving as adjuvant chemotherapy providers were associated with some care benefits, such as reduced time from surgery-to-chemotherapy, and some care barriers, such as travel distance. The barriers and benefits of having a gynecologic oncologist involved in adjuvant chemotherapy care, including rural-urban differences, warrant further research in other populations.

Improving the quality of care for patients with advanced epithelial ovarian cancer: Program components, implementation barriers, and recommendations

The high lethality of ovarian cancer in the United States and associated complexities of the patient journey across the cancer care continuum warrant an assessment of current practices and barriers to quality care in the United States. The objectives of this study were to identify and assess key components in the provision of high‐quality care delivery for patients with ovarian cancer, identify challenges in the implementation of best practices, and develop corresponding quality‐related recommendations to guide multidisciplinary ovarian cancer programs and practices. This multiphase ovarian cancer quality‐care initiative was guided by a multidisciplinary expert steering committee, including gynecologic oncologists, pathologists, a genetic counselor, a nurse navigator, social workers, and cancer center administrators. Key partnerships were also established. A collaborative approach was adopted to develop comprehensive recommendations by identifying ideal quality‐of‐care program components in advanced epithelial ovarian cancer management. The core program components included: care coordination and patient education, prevention and screening, diagnosis and initial management, treatment planning, disease surveillance, equity in care, and quality of life. Quality‐directed recommendations were developed across 7 core program components, with a focus on ensuring high‐quality ovarian cancer care delivery for patients through improved patient education and engagement by addressing unmet medical and supportive care needs. Implementation challenges were described, and key recommendations to overcome barriers were provided. The recommendations emerging from this initiative can serve as a comprehensive resource guide for multidisciplinary cancer practices, providers, and other stakeholders working to provide quality‐directed cancer care for patients diagnosed with ovarian cancer and their families.

Quality‐directed recommendations for ovarian cancer care delivery are developed across 7 core program components, with a focus on ensuring high‐quality care delivery by addressing unmet medical and supportive care needs. These recommendations can serve as a comprehensive resource guide for multidisciplinary cancer practices, providers, and other stakeholders working to provide quality‐directed cancer care for patients diagnosed with ovarian cancer and their families.

Rural residence is related to shorter survival in epithelial ovarian cancer patients

OBJECTIVE

Rural residence has been related to health disparities and greater mortality risk in cancer patients, including gynecologic cancer patients. Lower survival rates for rural cancer survivors have been attributed to limited access to specialized healthcare, including surgery. Here, we examined whether a rural/urban survival gap existed in ovarian cancer patients receiving surgery at tertiary-care facilities, and potential causes for this gap, including educational attainment.

METHODS

Rural and urban patients with high grade invasive ovarian cancer (n = 342) seeking treatment at two midwestern tertiary-care university hospitals were recruited pre-surgery and followed until death or censoring date. Rural/urban residence was categorized using the USDA Rural-Urban Continuum Codes. Stratified Cox proportional hazards regression analyses, with clinical site as strata, adjusting for clinical and demographic covariates, were used to examine the effect of rurality on survival.

RESULTS

Despite specialized surgical care, rural cancer survivors showed a higher likelihood of death compared to their urban counterparts, HR = 1.39 (95% CI: 1.04, 1.85) p = 0.026, adjusted for covariates. A rurality by education interaction was observed (p = 0.027), indicating significantly poorer survival in rural vs. urban patients among those with trade school/some college education, adjusted HR = 2.49 (95% CI: 1.44, 4.30), p = 0.001; there was no rurality survival disparity for the other 2 levels of education.

CONCLUSIONS

Differences in ovarian cancer survival are impacted by rurality, which is moderated by educational attainment even in patients receiving initial care in tertiary settings. Clinicians should be aware of rurality and education as potential risk factors for adverse outcomes and develop approaches to address these possible risks.

Health Care Access Measures and Palliative Care Use by Race/Ethnicity among Metastatic Gynecological Cancer Patients in the United States

Palliative care improves quality-of-life and extends survival, however, is underutilized among gynecological cancer patients in the United States (U.S.). Our objective was to evaluate associations between healthcare access (HCA) measures and palliative care utilization among U.S. gynecological cancer patients overall and by race/ethnicity. We used 2004-2016 data from the U.S. National Cancer Database and included patients with metastatic (stage III-IV at-diagnosis) ovarian, cervical, and uterine cancer (n = 176,899). Palliative care was defined as non-curative treatment and could include surgery, radiation, chemotherapy, and pain management, or any combination. HCA measures included insurance type, area-level socioeconomic measures, distance-to-care, and cancer treatment facility type. We evaluated associations of HCA measures with palliative care use overall and by race/ethnicity using multivariable logistic regression. Our population was mostly non-Hispanic White (72%), had ovarian cancer (72%), and 24% survived <6 months. Five percent of metastatic gynecological cancer patients utilized palliative care. Compared to those with private insurance, uninsured patients with ovarian (aOR: 1.80,95% CI: 1.53-2.12), and cervical (aOR: 1.45,95% CI: 1.26-1.67) cancer were more likely to use palliative care. Patients with ovarian (aOR: 0.58,95% CI: 0.48-0.70) or cervical cancer (aOR: 0.74,95% CI: 0.60-0.88) who reside >45 miles from their provider were less likely to utilize palliative care than those within <2 miles. Ovarian cancer patients treated at academic/research programs were less likely to utilize palliative care compared to those treated at community cancer programs (aOR: 0.70, 95%CI: 0.58-0.84). Associations between HCA measures and palliative care utilization were largely consistent across U.S. racial-ethnic groups. Insurance type, cancer treatment facility type, and distance-to-care may influence palliative care use among metastatic gynecological cancer patients in the U.S.

Assessment of Cancer Survivorship Training and Knowledge Among Resident Physicians in Obstetrics and Gynecology

The number of gynecologic cancer survivors in the USA is expected to grow to nearly 2 million by 2029. Gynecologic oncologists alone will not be able to care for all of these women. Thus, preparation of general obstetrician/gynecologists (OBGYNs) to deliver this care is crucial. Our objective was to assess cancer survivorship training (CST) among OB/GYN residents and to evaluate knowledge in basic gynecologic cancer survivorship. OB/GYN residents were recruited nationally to complete a de novo questionnaire, querying demographics, hours of CST received, teaching methods used, and efficacy of those methods. Survivorship knowledge was assessed by ten questions based on the 2017 Society of Gynecologic Oncology recommendations on post-treatment surveillance, which includes topics appropriate for generalists. Analyses were done using t tests and ANOVA, with significance set at p = 0.05. In total, 128 residents responded to the survey. Observation was the most common method of CST (53%), with patient contact reported as the most effective method (42.6%). The mean score of correct responses (MSCRs) among all respondents was 61.5%. MSCR significantly improved with increasing post-graduate year (PGY) (p = 0.003). Survivorship training method was not associated with improved MSCR. Improvements in MSCR were observed with an increasing number of CST hours (p = 0.011). A total of 13.9% of residents reported feeling "very comfortable" with survivorship care, yet 88.5% of respondents indicated they did not want additional CST. More hours of CST are associated with improved resident in knowledge in cancer survivorship care, though deficits still remain. Further investigation into optimizing CST is warranted.

Potential Strategies to Increase Gynecologic Oncologist Treatment for Ovarian Cancer

Evidence shows that treatment by gynecologic oncologists (GOs) increases overall survival among women with ovarian cancer. However, specific strategies for institutions and community-based public health programs to promote treatment by GOs are lacking. To address this, we conducted a literature review to identify evidence-based and promising system- and environmental-change strategies for increasing treatment by GOs, in effort to ensure that all women with ovarian cancer receive the standard of care. We searched for English-language literature published from 2008 to 2018. We used PubMed, PubMed Central, OVID, and EBSCO for peer-reviewed literature and Google and Google Scholar for gray literature related to increasing receipt of care by GOs among ovarian cancer patients. Numerous suggested and proposed strategies that have potential to increase treatment by GOs were discussed in several articles. We grouped these approaches into five strategic categories: increasing knowledge/awareness of role and importance of GOs, improving models of care, improving payment structures, improving/increasing insurance coverage for GO care, and expanding or enhancing the GO workforce. We identified several strategies with the potential for increasing GO care among ovarian cancer patients, although currently there is little evidence regarding their effectiveness across US populations. Public health programs and entities that measure delivery of quality health care may pilot the strategies in their populations. Certain strategies may work better in certain environments and a combination of strategies may be necessary for any one entity to increase GO ovarian cancer care. Findings, lessons learned, and recommendations from implementation projects would inform community and public health practice.

The impact of expanding gynecologic oncology care to ovarian cancer patients in small cities and rural communities

OBJECTIVE

Patients with ovarian cancer from smaller cities and rural communities face unique challenges in accessing comprehensive care. This study compares management strategies, outcomes, and access to care for patients in a small city and surrounding rural communities before and after establishing a full-time gynecologic oncology (GO) office.

METHODS

A local tumor registry was used to identify patients diagnosed with ovarian cancer before and after a full-time GO office was established. Quantitative analyses were used to compare disease characteristics, management strategies, overall survival, and distance traveled for care between cohorts.

RESULTS

Out of 381 patients, 171 women were diagnosed prior to establishing a full-time GO office (pre-GO) and 210 after (post-GO). Post-GO patients were more likely to undergo surgery by a GO specialist (97.1% versus 53.2%, p < 0.01), receive surgery locally (79.0% versus 43.3%, p < 0.01), and undergo complete lymph node dissection (63.3% versus 38.6%, p < 0.01). Patients treated with chemotherapy by GO increased from 10.3% pre-GO to 76.9% post-GO. 5-year survival rates were 33.8% versus 49.5% in the pre-GO and post-GO groups, respectively (p < 0.01). Median survival time increased from 30.8 months to 52.5 months from pre-GO to post-GO time periods. Distance patients traveled for surgery decreased from a mean of 47.9 miles pre-GO to 26.8 miles post-GO.

CONCLUSION

After establishing a full-time GO office within a small city, local patients had significantly improved overall survival and access to care. These results highlight the benefit of expanding GO care into small cities with surrounding rural communities and may be used to address public health discrepancies for women across the country.

Rural disparities in surgical care from gynecologic oncologists among Midwestern ovarian cancer patients

OBJECTIVE

Up to one-third of women with ovarian cancer in the United States do not receive surgical care from a gynecologic oncologist specialist despite guideline recommendations. We aim to investigate the impact of rurality on receiving surgical care from a specialist, referral to a specialist, and specialist surgery after referral, and the consequences of specialist care.

METHODS

We utilized a retrospective cohort created through an extension of standard cancer surveillance in three Midwestern states. Multivariable adjusted logistic regression was utilized to assess gynecologic oncologist treatment of women 18-89 years old, who were diagnosed with primary, histologically confirmed, malignant ovarian cancer in 2010-2012 in Kansas, Missouri and Iowa by rurality.

RESULTS

Rural women were significantly less likely to receive surgical care from a gynecologic oncologist specialist (adjusted odds ratio (OR) 0.37, 95% confidence interval (CI) 0.24-0.58) and referral to a specialist (OR 0.37, 95% CI 0.23-0.59) compared to urban women. There was no significant difference in specialist surgery after a referral (OR 0.56, 95% CI 0.26-1.20). Rural women treated surgically by a gynecologic oncologist versus non-specialist were more likely to receive cytoreduction and more complete tumor removal to ≤1 cm.

CONCLUSION

There is a large rural-urban difference in receipt of ovarian cancer surgery from a gynecologic oncologist specialist (versus a non-specialist). Disparities in referral rates contribute to the rural-urban difference. Further research will help define the causes of referral disparities, as well as promising strategies to address them.

Underrepresented minority representation trends in gynecologic oncology fellowships in the United States

OBJECTIVE

To evaluate representation trends of historically underrepresented minority (URM) groups in gynecologic oncology fellowships in the United States using a nationwide database collected by the Accreditation Council for Graduate Medical Education (ACGME).

METHODS

Data on self-reported ethnicity/race of filled residency positions was collected from ACGME Database Books across three academic years from 2016 to 2019. Primary chi-square analysis compared URM representation in gynecologic oncology to obstetrics and gynecology, other surgical specialties, and other medical specialties. Secondary analysis examined representation of two URM subgroups: 1) Asian/Pacific Islander, and 2) Hispanic, Black, Native American, Other (HBNO), across specialty groups.

RESULTS

A total of 528 gynecologic oncology positions, 12,559 obstetrics and gynecology positions, 52,733 other surgical positions, and 240,690 other medical positions from ACGME accredited medical specialties were included in analysis. Primary comparative analysis showed a statistically significant lower proportion (P < 0.05) of URM trainees in gynecologic oncology in comparison to each of obstetrics and gynecology, other surgical fields, and other medical fields. Secondary analysis also demonstrated a significantly lower proportion (P < 0.05) of HBNO physicians in gynecologic oncology in comparison to obstetrics and gynecology, as well as all other medical and surgical specialties.

CONCLUSIONS

This study illustrates the disparities in URM representation, especially those who identify as HBNO, in gynecologic oncology fellowship training in comparison to obstetrics and gynecology as well as other medical and surgical fields. Improvements to the current recruitment and selection practices in gynecologic oncology fellowships in the United States are necessary in order to ensure a diverse and representative workforce.

Low-risk multivariate index assay scores, physician referral and surgical choices in women with adnexal masses

OBJECTIVE

To assess the use of Multivariate Index Assay (MIA OVA1) by gynecologists and determine referral practices and surgical decision making for women with adnexal masses and low-risk MIA OVA1 scores.

METHODS

Information on patients who received an OVA1 test was collected retrospectively from 22 gynecologic practices through a chart review. Referral patterns were examined for patients with low-risk OVA1 results prior to first surgical intervention. Chart reviews were from a variety of practice and hospital settings representing major geographic regions within the United States.

RESULTS

A total of 282 independent patient charts were reviewed. Low-risk results were found for 146 patients (52%). Surgery was performed on 82 (56%) patients with low-risk scores. The referral rate to specialty care was 21% (17/82) for low-risk OVA1 patients. Three low-malignant potential tumors were identified in the low-risk patients, with no cases of invasive malignancy. Eighty-six percent of the surgeries performed on low-risk OVA1 patients were minimally invasive. In 44% of the low-risk OVA1 patients, no surgical intervention was performed.

CONCLUSIONS

A high proportion of low-risk OVA1 patients were not referred to a gynecologic oncologist prior to surgery, indicating gynecologists may use MIA OVA1 along with clinical and radiographic findings to appropriately retain patients for their care. This practice is safe and may be cost-saving, with patient satisfaction implications.

An increase in multi-site practices: The shifting paradigm for gynecologic cancer care delivery

OBJECTIVE

To assess whether the number of practice sites per gynecologic oncologist (GO) and geographic access to GOs has changed over time.

METHODS

This is a retrospective repeated cross-sectional study using the 2015-2019 Physician Compare National File. All GOs in the 50 United States and Washington, DC, who had completed at least one year of practice were included in the study. All practice sites with complete addresses were included. Linear regression analyses estimated trends in GOs' number of practice sites and geographic dispersion of practice sites. Secondary analyses assessed temporal trends in the number of geographic areas served by at least one GO.

RESULTS

Although there was no significant change in the number of GOs from 2015 to 2019 (n = 1328), there was a significant increase in the number of practice sites (881 to 1416, p = 0.03), zip codes (642 to 984, p = 0.03), HSAs (404 to 536, p = 0.04), and HRRs (218 to 230, p = 0.03) containing a GO practice. The mean number of practice sites (1.64 versus 2.13, p < 0.001) and dispersion of practice sites (0.03 versus 0.43 miles, p = 0.049) per GO increased significantly.

CONCLUSIONS

Between 2015 and 2019, an increasing number of GOs have multi-site practices, and more geographic regions contain a GO practice. Improvements in geographic access to GOs may represent improved access to care for many women in the US, but its effect on patients, physicians, and geographic disparities is unknown.

Impact of geography and travel distance on outcomes in epithelial ovarian cancer: a national cancer database analysis

Background

As ovarian cancer treatment shifts to provide more complex aspects of care at high-volume centers, almost a quarter of patients, many of whom reside in rural counties, will not have access to those centers or receive guideline-based care.

Objective

To explore the association between proximity of residential zip code to a high-volume cancer center with mortality and survival for patients with ovarian cancer.

Methods

The National Cancer Database was queried for cases of newly diagnosed ovarian cancer between January 2004 and December 2015. Our predictor of interest was distance traveled for treatment. Our primary outcomes were 30-day mortality, 90-day mortality, and overall survival. The effect of treatment on survival was analyzed with the Kaplan-Meier method. Multiple logistic regression for binary outcomes and Cox proportional hazards regression for overall survival were used to assess the effect of distance on outcome, controlling for potential confounding variables.

Results

A total of 115 540 patients were included. There was no statistically significant difference in 30- or 90-day mortality among any of the travel distance categories. A statistically significant decrease in 30-day re-admission was found among patients who lived further away from the treating facility. A total of 105 529 patients were available for survival analysis, and survival curves significantly differed between distance strata (p<0.0001). The adjusted regression models demonstrated increased long-term mortality in patients who lived farther away from the treating facility after controlling for potential confounding.

Conclusion

Although 30- and 90-day mortality do not differ by travel distance, worse survival is observed among women living >50 miles from a high-volume treatment facility. With a national policy shift toward centralization of complex care, a better understanding of the impact of distance on survival in patients with ovarian cancer is crucial. Our findings inform the practice of healthcare delivery, especially in rural settings.

Fragmentation of postoperative care after surgical management of ovarian cancer at 30 days and 90 days

BACKGROUND

Fragmentation of care, wherein a patient is discharged from an index hospital and undergoes an unexpected readmission to a nonindex hospital, is associated with increased risk of adverse outcomes. Fragmentation has not been well-characterized in ovarian cancer.

OBJECTIVE

The objective of this study was to assess risk factors and outcomes that are associated with fragmentation of care among women who undergo surgical treatment of ovarian cancer.

STUDY DESIGN

The Nationwide Readmission Database was used to identify all-cause 30-day and 90-day postoperative readmissions after surgical management of ovarian cancer from 2010-2014. Postoperative fragmentation was defined as readmission to a hospital other than the index hospital of the initial surgery. Multivariable regression analyses were used to identify predictors of fragmentation in both 30-day and 90-day readmissions. Similarly, multivariable models were developed to determine the association between fragmentation and death among women who were readmitted.

RESULTS

A total of 10,445 patients (13.3%) were readmitted at 30 days, and 14,124 patients (18.0%) were readmitted at 90 days. Of these, there was a 20.8% and 25.7% rate of postoperative care fragmentation for 30-day and 90-day readmissions, respectively. Patient risk factors that were associated with fragmented postoperative care included Medicare insurance, lower income quartiles, and nonroutine discharge to facility. Hospital factors that were associated with decreased risk of fragmentation included operation at a metropolitan teaching hospital and performance of extended procedures. Cost and length of stay for the readmission were similar among those who had fragmented and nonfragmented readmissions at both 30 and 90 days. Although there was no association between death and fragmentation for patients who were readmitted within 30 days (odds ratio, 1.19; 95% confidence interval, 0.93-1.51), patients who had a fragmented readmission at 90 days were 22% more likely to die than those who were readmitted at 90 days to their index hospital (odds ratio, 1.22; 95% confidence interval, 1.00-1.49).

CONCLUSION

Fragmentation of care is common in women with ovarian cancer who require postoperative readmission. Fragmented postoperative care is associated with an increased risk of death among women who are readmitted within 90 days of surgery.

Caring for Patients With Uterine Cancer in Rural and Public Hospitals in New York State

OBJECTIVE

To evaluate perioperative outcomes for women with uterine cancer undergoing hysterectomy at rural and public hospitals in New York State.

METHODS

The New York Statewide Planning And Research Cooperative System database was used to identify women with uterine cancer who underwent hysterectomy from 2000 to 2015. Perioperative complications, inpatient mortality, and resource utilization were compared at rural, public and private hospitals. Multilevel mixed effect log-linear models were developed to evaluate the association between hospital type and outcomes of interest. Patient characteristics, hospital and surgeon clustering were accounted for within the model.

RESULTS

Over the years studied, there were 193 hospitals that cared for 46,298 women with uterine cancer. Of these, 9.8% were public, 15.0% were rural, and 75.1% were private metropolitan. They cared for 11.0%, 2.2% and 86.8% of patients, respectively. The proportion of patients cared for at rural hospitals decreased significantly from 5.2% in 2000 to 0.6% in 2014 (P<.001). There was no change in the volume of patients cared for at public hospitals (11.3 to 10.3%, P>.05). In a multivariable model adjusting for patient risk, there were no significant differences in perioperative morbidity, transfusion and length of stay across the three hospital types (P>.05). Compared with private hospitals, treatment at a rural hospital was associated with increased inpatient mortality (adjusted risk ratio 4.03, 95% CI 1.02-15.97).

CONCLUSION

In New York State, operative uterine cancer care is shifting away from rural hospitals. Public hospitals have similar risk-adjusted outcomes compared with private metropolitan facilities.

Rural-Urban Differences in Access to Thoracic Surgery in the United States, 2010 to 2014

BACKGROUND

Because of recent lung cancer screening recommendations and corresponding insurance coverage, it is expected that more early stage cases will be identified that require thoracic surgery. However, these services may not be equally available in all regions. Our objective is to describe the availability of thoracic surgeons by examining geographic variation, rural-urban differences, and temporal changes before and after screening recommendation and insurance coverage policy changes.

METHODS

We examined the U.S. thoracic surgery workforce using the 2010 and 2014 Area Health Resource Files. We calculated the density of thoracic surgeons per 100,000 persons for each year at the state and county level. We performed descriptive statistics and developed maps highlighting changes over time and geographic regions.

RESULTS

Despite an overall increase in thoracic surgeons from 2010 to 2014, we observed declining density nationwide (1.5% change) and in sparsely populated states. The difference in thoracic surgeon density widened slightly between 2010 from 0.80 per 100,000 compared with 0.84 per 100,000 in 2014 in all rural counties compared with urban counties (P < .001 for both years). The difference in thoracic surgeon density was most pronounced between small adjacent rural and urban counties (0.95 and 0.96 per 100,000 for 2010 and 2014, respectively; P < .001 for both years). The Northeast held a disproportionate share of the thoracic surgery workforce.

CONCLUSIONS

Limited access to thoracic surgeons in rural areas is a concern, given an older and retiring surgical workforce, the higher burden of lung cancer in rural areas, and recent policy changes for screening reimbursement.