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

Abstract

Objective: National Comprehensive Cancer Network (NCCN) guidelines recommend that patients with ovarian cancer receive surgical care from a gynecologic oncologist. However, 15%–30% of patients with ovarian cancer do not receive surgical care from this specialist. The reasons for this remain unknown. We aim at assessing the barriers and attitudes perceived by patients with ovarian cancer who did not receive their primary surgery from a gynecologic oncologist and by diagnosing providers in an exploratory qualitative study. Materials and Methods: Patients and providers were sampled through the Iowa Cancer Registry. Participants were interviewed by telephone about barriers that patients face receiving surgical care from a specialist. Interviews were transcribed verbatim, and thematic analysis was completed by two team members. Findings: Providers ( n = 10, 13% participation rate) identified many system-level barriers, including poor provider-to-provider communication, long time-to-surgery wait times, and a limited number of gynecologic oncologists working in their referral range. Patients ( n = 16, 38% participation rate) denied system-level barriers; however, no patients reported receiving a referral to a gynecologic oncologist. This, in and of itself, constitutes a system-level barrier. Providers identified many barriers that their patients face, whereas patients failed to identify these barriers and denied facing them. Patients described the shock that they experienced after diagnosis and its limitations on their decision-making process. Both providers and patients agreed that the providers were influential in determining care decisions. Discussion: There is a divergence in the perceptions of barriers to care between providers and patients. Open discussions are needed about options and clinical guidelines for surgical ovarian cancer care. Further research is needed to develop and evaluate mechanisms to improve provider-to-patient discussions about surgical recommendations.

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

“…Rural patients had lower odds of receiving surgery from a gynecologic oncologist. This rural-urban difference is consistent with findings of patients diagnosed in the 2010s 13 and 1990s. 5 Recent studies suggest differences in receipt of surgery from a gynecologic oncologist by rurality may be driven by referral rates.…”

“…12 Further, a lack of knowledge of the importance of gynecologic oncologist surgeons, shock at time of diagnosis, trust in providers to refer when guideline-recommended, and limited independent research have been identified as patientlevel barriers to receiving surgery by gynecologic oncologists in the Midwestern United States. 13 Provider-level barriers that have been identified in the Midwestern United States include unclear referral mechanisms and difficulty getting referred patients a surgical appointment in a short timeframe. 13 Further investigations are needed to identify barriers in other regions and to identify additional reasons rural patients may be less likely to receive care from a gynecologic oncologist, such as viewpoints on specialists and large medical centers.…”

“…13 Provider-level barriers that have been identified in the Midwestern United States include unclear referral mechanisms and difficulty getting referred patients a surgical appointment in a short timeframe. 13 Further investigations are needed to identify barriers in other regions and to identify additional reasons rural patients may be less likely to receive care from a gynecologic oncologist, such as viewpoints on specialists and large medical centers. As barriers are identified, regional interventions are needed to improve rural women's access to gynecologic oncologist surgeons.…”

“…However, a qualitative study of ovarian cancer patients in Iowa who had a nongynecologic oncologist surgeon suggested patients made decisions aligning with physician recommendations. 13 Other explanations could include knowledge/skill or patient-provider communication differences. Future studies could consider investigating other factors that might have led to outcome differences between rural and urban women, such as differences in breast cancer gene testing, adjuvant chemotherapy agents, surveillance, and treatment after recurrence or progression.…”

Association of Distance to Gynecologic Oncologist and Survival in a Rural Midwestern State

“… 10 , 12 , 13 Rural patients are also less likely to receive surgery from a gynecologic oncologist, which leads to poorer outcomes, despite this being the guideline recommendations of the National Comprehensive Cancer Network (NCCN). 7 , 8 , 14–18 …”