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Both community outreach and engagement with obstetrician-gynecologists can help improve referral times for patients with gynecological cancers. High-quality care depends on ensuring that consultation with a gynecologic oncologist occurs in a timely manner, yet little is known about patients' specific interactions with the healthcare system before such evaluation.

In a study in , David I. Shalowitz, MD, MSHP, of West Michigan Cancer Center in Kalamazoo, and colleagues investigated the interactions with the healthcare system of 300 patients before referral to a gynecologic oncologist. Patients came from six different cancer centers in the U.S. that serve geographically diverse populations.

None of the authors were available for comment, and the answers here are from the text of the report.

What does the study add to the literature?

This study is the first, to our knowledge, to review in detail the interactions with the healthcare system before evaluation by gynecologic oncologists by a diverse, national patient population.

Studies have shown worse survival outcomes among specific subsets of gynecologic cancers because of surgical delays. We focus on time to referral to highlight the practices of referring clinicians. Time from referral to evaluation and treatment will be reported in a subsequent analysis; if any patient population experiences delays in evaluation by gynecologic oncology, we will be able to separately account for delay in referral as a cause of delays in care.

We believe this detail is critically important to interventional research designed to improve care pathways and has not been previously reported.

The medical records of 50 consecutive new patients seen in gynecologic oncology clinics at each of six referral centers across the United States were reviewed. Patient and disease characteristics were collected, along with referral indication, evaluation and referral dates, diagnostic procedures, provider specialties, and ZIP code of up to 3 referring providers per patient.

On average, patients were referred to a gynecologic oncologist approximately 5 weeks after initial presentation with signs or symptoms concerning malignancy. After control for other relevant variables, shorter time to referral was significantly associated with lack of insurance and evaluation by an emergency medicine clinician.

Referral times in the longest quartile of our cohort were associated with younger age, residence in a metropolitan ZIP code, increasing distance from residence to a gynecologic oncologist, and evaluation by an obstetrician-gynecologist before referral. Neither race nor disease site was associated with time to referral.

Were rural patients more vulnerable to prolonged times to referral?

Interestingly, patients with a non-metropolitan residence were less likely than metropolitan residents to have a prolonged time to referral, although increasing distance from patient residence to a gynecologic oncologist was associated with a slightly increased likelihood of prolonged time to referral.

These findings suggest that (1) non-metropolitan residence cannot be equated with distance to care, (2) recognition and triage of conditions meriting gynecologic oncologist consultation may not overall be worse for non-metropolitan populations compared with metropolitan populations, and (3) delays in referral for patients living the farthest away from gynecologic oncologists are an independent contributor to delays in presentation and treatment of gynecologic cancers.

Which patients experienced the least time to referral?

We found that patients eventually diagnosed with ovarian cancer were least likely to experience prolonged time to referral, compared with patients with uterine or cervical disease -- potentially due to the predominance of advanced-stage disease in this population.

Why was there a prolonged time to referral among obstetrician-gynecologists?

The most common referrers for gynecologic oncology care were obstetrician-gynecologists, including in settings where patients saw multiple clinicians before gynecologic oncologist referral; likewise, evaluation by an obstetrician-gynecologist was associated with a prolonged time to referral.

We were unable to determine if prolonged time to referral was due to a more complete workup being performed by the obstetrician-gynecologist before referral, a symptom of unnecessary triage to an obstetrician-gynecologist before eventual gynecologic oncologist referral, or related to long-term gynecologic care before gynecologic oncologist referral.

Interventions tailored toward strengthening relationships between gynecologic oncologist providers and general gynecologists have the potential to improve referral processes and streamline care. Additional research is needed to clarify the optimal workflow for these patients.

What is your main message for practicing oncologists?

Interactions with the healthcare system before referral are driven by different personnel and behaviors compared with the processes at referral centers and require distinct interventions to improve access to gynecologic cancer care.

Efforts to optimize referral for gynecologic cancer care need to be tailored through community outreach and engagement. We recommend that cancer centers invest in determining local barriers to care, optimal intervals for referral, and scalable solutions that can improve cancer care delivery.

Read the study here.