Patient and Provider Perspectives on Barriers to Accessing Gynecologic Oncologists for Ovarian Cancer Surgical Care

Collaborating with the Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program to Increase Receipt of Ovarian Cancer Care from a Gynecologic Oncologist

Background: Treatment by a gynecologic oncologist is an important part of ovarian cancer care; however, implementation strategies are needed to increase care by these specialists. We partnered with National Comprehensive Cancer Control Programs in Iowa, Michigan, and Rhode Island in a demonstration project to deepen the evidence base for promising strategies that would facilitate care for ovarian cancer by gynecologic oncologists. Methods: Five main implementation strategies (increase knowledge/awareness; improve models of care; improve payment structures; increase insurance coverage; enhance workforce) were identified in the literature and used to develop initiatives. Specific activities were chosen by state programs according to feasibility and needs. Results: Activities included: (1) qualitative interviews with patients to determine barriers to receipt of specialized care; (2) development of patient/provider educational materials; (3) creation of patient/provider checklists to facilitate appropriate referrals; (4) expansion of a toll-free patient navigation hotline for ovarian cancer patients; (5) training of the health care workforce. The programs developed resources (educational handouts, toolkits, 2 webinars, 2 podcasts); trained 167 medical and nursing students during 8 Survivors Teaching Students® workshops; and conducted 3 provider education sessions reaching 362 providers in 45 states. Evaluations showed increases in providers' knowledge, awareness, abilities, and intentions to refer ovarian cancer patients to a gynecologic oncologist. Conclusion: The state program resources we discussed are available for other cancer control programs interested in initiating or expanding activities to improve access/referrals to gynecologic oncologists for ovarian cancer care. They serve as a valuable repository for public health professionals seeking to implement similar interventions.

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.

Impact of Surgeon Type and Rurality on Treatment and Survival of Ovarian Cancer Patients

BACKGROUND

National Comprehensive Cancer Network guidelines recommend ovarian cancer patients receive cancer-directed surgery from a gynecologic oncologist surgeon. We aimed to determine if rurality impacts type of surgeon and estimate if the interaction between rurality and type of surgeon impacts cytoreductive surgery, chemotherapy initiation, and survival.

METHODS

Our population-based cohort of Iowan (N=675) ovarian cancer patients included women diagnosed with histologically confirmed stages IB-IV cancer in 2010 to 2016 at the ages of 18 to 89 years old and who received cancer-directed surgery in Iowa. Multivariable logistic regression analysis and Cox proportional hazards models were used.

RESULTS

Rural (vs. urban) patients were less likely to receive surgery from a gynecologic oncologist (adjusted odds ratio [OR]: 0.48; 95% confidence interval [CI]: 0.30-0.78). Rural patients with a gynecologic oncologist (vs. nongynecologic oncologist) surgeon were more likely to receive cytoreduction (OR: 2.84; 95% CI: 1.31-6.14) and chemotherapy (OR: 4.22; 95% CI: 1.82-9.78). Gynecologic oncologist-provided surgery conferred a 3-year cause-specific survival advantage among rural patients (adjusted hazard ratio: 0.57; 95% CI: 0.33-0.97) and disadvantage among urban patients (hazard ratio: 1.77; 95% CI: 1.02-3.06) in the model without treatment covariates. Significance dissipated in models with treatment variables.

DISCUSSION

The variation in the gynecologic oncologist survival advantage may be because of treatment, referral, volume, or nongynecologic oncologist surgeons' specialty difference by rurality. This is the first study to investigate the ovarian cancer survival advantage of having a gynecologic oncologist surgeon by rurality.