Persistent inequities in access to and continuity of gynecologic oncology care during the COVID-19 pandemic (052)

Abstract

Objectives: Access to health care was jeopardized during the COVID-19 pandemic due to the unforeseen increase in unmet social needs and financial strain. The pandemic exacerbated social determinants of health that impact systemic health disparities. Furthermore, fear of COVID-19 may have prompted patients with cancer symptoms to delay seeking care. We aimed to assess the impact of race, ethnicity, and insurance status on access to and continuity of gynecologic oncology (GO) care before and during the COVID-19 pandemic.Methods: This was a retrospective cohort study of women newly referred to an NCI-designated cancer center for evaluation by GO during the five months prior to COVID-19 (Oct 2019-Feb 2020) compared to the first five months of the pandemic (Apr 2020-Aug 2020). Descriptive statistics were used to report proportions of new referrals based on race, ethnicity, and insurance, and comparisons between time periods were made using Chi-square tests. Among confirmed cancer patients, time to initial GO visit as well as treatment initiation (time from GO evaluation to treatment) were compared between groups using the student’s t-test.Results: Among 884 new referrals, the mean age was 56.5 years, and 416 (47%) had confirmed gynecologic cancer. The majority were White (81.0%), non-Hispanic (96.5%), and privately insured (52.5%). Overall, new referrals decreased by 32% between the two time periods (526 pre-COVID-19 vs 358 during COVID-19) with no differences by race, ethnicity, or insurance status. Among cancer patients, referrals decreased by 18%, and disproportionately affected under-represented racial and ethnic groups (Black, Asian, Hispanic) (22.0% pre-COVID vs 13.6% during the pandemic, p=0.03), while the proportion of Medicaid patients remained stable (12.9% vs 12.5%). During the ten-month study period, the mean time from referral to GO evaluation was significantly longer for Black patients compared to White patients (17.9 days vs 13.6 days, p<0.01), and those with Medicaid compared to patients with private insurance (17.3 days vs 13.2 days, p=0.03). However, cancer treatment initiation differed by race, ethnicity, and insurance. During the five months preceding COVID-19, delays in treatment initiation were significantly longer for Black compared to White patients (43.5 vs 31.6 days, p=0.001), and those with Medicaid than private insurance (44.0 vs 31.1 days, p<0.01). These disparities were not observed during the first five months of the pandemic.Conclusions: These findings demonstrate that social determinants of health (race, ethnicity, and insurance status) influence how quickly women gain access to GO care and initiate cancer treatment. The COVID-19 pandemic seemed to exacerbate pre-existing barriers to accessing GO care, especially for Black patients. Interventions to mitigate social determinants of health and assist patients with unmet social needs are urgently needed to achieve equitable access and delivery of GO care.