Gynecologic Cancer Care Research Articles

Differential utilization of the online patient portal for completion of health-related social needs screening during routine gynecologic cancer care.

Telehealth technologies offer efficient ways to deliver health-related social needs (HRSN) screening in cancer care, but these methods may not reach all populations. The authors examined patient characteristics associated with using an online patient portal (OPP) to complete HRSN screening as part of gynecologic cancer care. From June 2021 to June 2023, patients in a gynecologic oncology clinic completed validated HRSN screening questions either (1) using the OPP (independently before the visit) or (2) in person (verbally administered by clinic staff). The authors examined the prevalence of HRSN according to activated OPP status and, in a restricted subgroup, used stepwise multivariate Poisson regression to identify associations between patient and visit characteristics and using the OPP. Of 1616 patients, 87.4% (n=1413) had an activated OPP. Patients with inactive OPPs (vs. activated OPPs) more frequently reported two or more needs (10% vs 5%; p<.01). Of 986 patients in the restricted cohort, 52% used the OPP to complete screening. The final multivariable model indicated that patients were less likely to use the OPP if they were Black (vs. White; adjusted relative risk [aRR], 0.70; 95% confidence interval [CI], 0.59-0.83); not employed (vs. employed; aRR, 0.81; 95% CI, 0.68-0.97), or had low measures of OPP engagement (aRR, 0.80; 95% CI, 0.68-0.92). New versus established patients were 21% more likely to use the OPP (aRR, 1.21; 95% CI, 1.06-1.38). Differential use of the OPP suggested that over-reliance on digital technologies could limit the ability to reach those populations that have social factors already associated with cancer outcome disparities. Cancer centers should consider using multiple delivery methods for HRSN screening to maximize reach to all populations.

COVID-19 pandemic impact on gynecologic cancer treatment pathways in a Finnish tertiary center.

COVID-19 and new guidelines during the pandemic affected the gynecologic cancer treatment pathways, resulting in recorded delays and modifications in the treatment protocols. The aim of this study was to determine the impact of the COVID-19 pandemic in one of the major gynecologic cancer care centers in Finland, Tampere University Hospital. Our retrospective register study included 909 patients that were new gynecologic cancer cases (uterine, cervical, vulvar, vaginal, or ovarian) referred to the Tampere University Hospital Gynecologic Oncology Outpatient Clinic between March 17th, 2018, and March 15th, 2022. The patients were divided into two separate groups depending on their time of referral: time before COVID (March 17th, 2018, to March 15th, 2020), and during COVID (March 16th, 2020, to March 15th, 2022). These groups were compared in terms of patient characteristics, different cancer types and stages, symptoms, and treatment methods. During the COVID-19 pandemic, patients generally suffered from cancer symptoms longer (p < 0.003) and were more likely to be overweight (p = 0.035). The improved multidisciplinary team meeting gave the patients a faster route to their first intervention during COVID (p < 0.05). An insignificant shift toward nonsurgical first interventions and non-curative intent was seen during COVID, but the multidisciplinary team treatment plans were mostly implemented accordingly on both eras. No decrease was seen in the number of new gynecologic cancer cases, and the one-year overall survival remained the same in both groups. Overall, the COVID-19 pandemic did not significantly alter treatment pathways in gynecologic cancer care at Tampere University Hospital. The number of new patients and given treatments remained relatively stable. During COVID, access from referral to cancer treatment was significantly accelerated, which is likely confounded by changes to the multidisciplinary team protocol made in early 2021.

Efficacy, safety, and patient-reported outcome of immune checkpoint inhibitor in gynecologic cancers: A systematic review and meta-analysis of randomized controlled trials.

Over the past decades, immune checkpoint inhibitors (ICIs) have shown dramatic efficacy in improving survival rates in multiple malignancies. Recently, gynecological cancer patients also showed to respond favorably to ICI treatment. This study aimed to evaluate the efficacy, safety, and patient-reported outcomes of ICI therapy in gynecological cancers. We conducted a systematic review and meta-analysis by retrieving literature from multiple electronic databases, such as MEDLINE, ScienceDirect, EBSCO, ProQuest, and Google Scholar. The protocol used in this study has been registered in PROSPERO (CRD42022369529). We included a total of 12 trials involving 8 therapies and 8,034 patients. ICI group demonstrated a longer OS (HR: 0.807; 95% CI: 0.719, 0.907; p = 0.000) and greater PFS improvement (HR: 0.809; 95% CI: 0.673, 0.973; p = 0.024) compared to the control group. There was no significant difference in the incidence of treatment-related adverse events [RR: 0.968; 95%CI: 0.936, 1.001; p = 0.061], but a higher incidence of immune-related adverse events (IRAEs) was observed in the ICI group (RR: 3.093; 95%CI: 1.933, 4.798; p = 0.000). Although the mean changes of QOL score from baseline was not significantly different between both groups (SMD: 0.048; 95% CI: -0.106, 0.202; p = 0.542), the time to definitive QOL deterioration was longer in the ICI group (HR: 0.508; 95% CI: 0.461, 0.560; p = 0.000). Despite having a higher incidence of IRAE, ICI was shown to improve survival rates and QOL of patients. Thus, it should be considered as a new standard of care for gynecologic cancers, especially in advanced stages.

Physician perspectives on clinician-to-clinician telemedical consultation for gynecologic cancers: A qualitative study

ObjectiveApproximately fifteen million women in the United States live > 50 miles from a gynecologic oncologist. Telemedical technology allows patients’ local physicians to consult with subspecialist gynecologic oncologists without burdening patients with unnecessary in-person visits. Although critical to adoption of this technology, physicians’ input into implementation of clinician-to-clinician consultation has not been sought. We therefore gathered feedback about experiences with referrals, communication, and openness to telemedical consultation from gynecologic oncologists, gynecologists, and medical oncologists. MethodsWe recruited gynecologic oncologists, gynecologists, and medical oncologists from practices serving rural patients to participate in semi-structured interviews. The Consolidated Framework for Implementation Research and the Theoretical Domains Framework guided the interviews. Questions focused on factors influencing adoption and implementation of clinician-to-clinician telemedicine. Interviews were conducted via WebEx, recorded, and transcribed. Two investigators coded interviews using the combined frameworks and identified salient themes. ResultsWe conducted 11 interviews (6 gynecologic oncologists, 3 gynecologists, 2 medical oncologists) and identified themes encompassing communication burnout, barriers to sharing patient information, need for further logistical information, and potential benefits to patients. ConclusionsClinician-to-clinician telemedicine may improve access to gynecologic cancer care by decreasing barriers to subspecialty expertise while simultaneously benefiting referring and consultant clinicians through improved identification and workup of patients who may need in-person consultation. To optimize desired outcomes, telemedical consultation must allow for communication of relevant patient information and records and easy integration into clinical workflow. Importantly, clinicians must perceive the consultation as improving patients’ access to specialty care.

Predictive modeling of postoperative gastrointestinal dysfunction: the role of serum bilirubin, sodium levels, and surgical duration in gynecological cancer care.

To elucidate the role of preoperative serum bilirubin and sodium levels, along with the duration of surgery, in predicting postoperative gastrointestinal dysfunction (POGD) following gynecological cancer surgery, informing tailored perioperative strategies. We conducted a retrospective analysis of 281 patients undergoing gynecological cancer surgery between 2018 and 2023. This analysis focused on preoperative serum bilirubin and sodium levels and intraoperative factors (surgical duration) as potential predictors of POGD. Logistic regression models were utilized for analysis, controlling for relevant confounders. Elevated preoperative serum bilirubin was associated with a reduced risk of POGD (mean level in non-POGD cases: 14.172 ± 4.0701, vs. POGD cases: 9.6429 ± 3.5351; p< 0.001), suggesting a protective role. Lower preoperative sodium levels were identified in the POGD group (136.26 mEq/L [IQR: 135.2-137.63]) compared to the non-POGD group (139.32 mEq/L [IQR: 137.7-140.75]; p< 0.001), highlighting its predictive value. Additionally, longer surgical duration was associated with increased POGD incidence, with POGD cases experiencing surgeries lasting 6.1547 ± 1.9426 hours compared to 4.5959 ± 1.5475 hours in non-POGD cases (p< 0.001). Our findings underscore the importance of serum bilirubin, sodium levels, and surgical duration as significant predictors of POGD in patients undergoing gynecological cancer surgery. These indicators should be integrated into a predictive model, aiding clinicians in identifying high-risk patients, allowing for personalized perioperative care adjustments, potentially mitigating POGD risks.

Improving access to safe, quality surgical care for gynecologic cancers through capacity-building interventions in low- and middle-income countries: A scoping review.

Following the launch of the World Health Organization's Strategy to accelerate the elimination of cervical cancer, diagnosis is expected to increase, especially in low- and middle-income countries (LMICs). A well-integrated surgical system is critical to treat cervical cancer. Two major approaches have been employed to build human capacity: task-sharing and training of gynecologic oncologists (GynOncs). This review aimed to explore existing literature on capacity-building for surgical management of early-stage gynecologic cancers. The search strategy was registered on Open Science Framework (doi 10.17605/OSF.IO/GTRCB) and conducted on OVID Medline, Embase, Global Index Medicus, and Web of Science. Search results were exported and screened in COVIDENCE. Studies published in English, Spanish, French, and/or Portuguese conducted in LMIC settings evaluating capacity building, task-sharing, or outcomes following operation by subspecialists compared to specialists were included. Results were synthesized using narrative synthesis approach with emergence of key themes by frequency. The scoping review identified 18 studies spanning our themes of interest: capacity building, subspecialized versus non-subspecialized care, and task-shifting/-sharing. A multilayered approach is critical to achieve the WHO Strategy to Eliminate Cervical Cancer. Capacity-building and task-sharing programs demonstrate encouraging results to meet this need; nevertheless, a standardized methodology is needed to evaluate these programs, their outcomes, and cost-effectiveness.

Transportation assistance in gynecologic oncology: A pilot study.

206 Background: Patients who experience transportation barriers to cancer care are less likely to receive optimal treatment and more likely to have delays in care. Our objective was to assess the prevalence of transportation barriers and the impact of a transportation intervention in gynecologic cancer care. Methods: We prospectively screen patients seen at new visits and at clinical trial enrollment in the 5 University of Pennsylvania gynecologic oncology practices for transportation barriers to cancer care. Patients who screen positive are referred to the intervention program, a ride-sharing service through RideHealth. Rides are available to and from clinic visits, to and from chemotherapy or radiation sessions, or to surgical procedures. There are no income or insurance restrictions on transportation assistance; per federal regulation, patients had to live within 40 miles of their oncology practice to receive transportation. Results: From June 2022 to April 2023, 1200 patients were screened. Of these, 34 screened positive for transportation barriers. All of those who screened positive accepted ride-sharing services. Two patients who screened positive were not eligible for ridesharing as they lived greater than 40 miles from our practices. Two patients who screened positive had transportation benefits available through their health insurance and were redirected to those services. We have provided 193 rides for 30 identified patients. The average length of ride was 9.2 miles (range 2.4-14), and the average cost per month was $1,200. Evaluation of clinical impact is ongoing. Conclusions: Transportation assistance is highly acceptable to patients and can facilitate access to cancer care.

"Care needs to be integrated" Patient and provider perspectives on a cancer shared-care model.

Current early-stage breast and gynecological cancer care models often begin with a referral from a primary care provider (PCP) or gynecologist (OB/Gyn) and end with a patient being transitioned back to the referring provider at the completion of treatment. There is frequently little communication between oncologists and the referring provider during treatment, and this pattern continues after the patient completes their treatment. We convened a diverse Patient Advisory Board (PAB) to identify areas where breast or gynecological cancer patients felt they could benefit from additional support during and after their cancer care. PAB members attended five Zoom meetings and completed four online surveys. Semi-structured interviews were conducted with primary care or OB/Gyn physicians to collect information on current practices. Patients identified multiple areas in which they needed additional support from their PCP. Providers also identified topics on which they could use additional training. However, there was little overlap between patient and provider priority topics. Both patients and providers agreed that there was inadequate communication between the cancer center and PCPs before, during, and after cancer treatment. A shared-care model that emphasizes communication between primary care providers, the oncology care team, and patients is urgently needed. Patients indicated the need for additional support from their PCP on specific topics, and PCPs were interested in continuing their education to better serve their patients with cancer. The importance of consistent communication among all parties during the entire cancer journey was emphasized as a key area for improvement.

Gynecologic cancer care in the first year of the COVID-19 pandemic

ObjectiveTo analyze the impact of the early COVID-19 pandemic on the diagnosis and initiation of treatment for patients with gynecologic cancer. MethodsPatients diagnosed with gynecologic cancer in the National Cancer Database during 2017–2020 were included. For the first aim, incidence rate ratios were calculated to compare gynecologic cancer diagnosis in the first year of the COVID-19 pandemic to the three years prior, and factors associated with a reduction in diagnosis were identified. For the second aim, patients who experienced an 8-week delay in cancer treatment were compared to those who did not. Multivariate logistic regression was used to identify factors associated with treatment delay. Propensity score analysis was utilized to compare the rate of cancer treatment delay in patients who were diagnosed with COVID-19 to those who were not. ResultsThe incidence rate ratio of being diagnosed with gynecologic cancer in 2020 versus 2017–2019 was 0.90 (95%CI 0.90–0.91). Factors associated with increased risk of missed or delayed diagnosis in 2020 included cervical cancer, earlier cancer stage, younger age, lower levels of medical comorbidity, and lack of health insurance. In 2020, factors associated with treatment delay included COVID-19 diagnosis (aOR 1.50, 95%CI 1.35–1.67), in addition to race and ethnicity, insurance type, comorbidity, cancer stage, and primary site. The risk of treatment delay remained significantly elevated in patients diagnosed with COVID-19 after propensity-score matching. ConclusionsGynecologic cancer diagnosis and timely provision of care were negatively impacted during the first year of the COVID-19 pandemic, with certain subgroups at elevated risk.

Analysis of Racial Disparity among U.S. Patients with Gynecologic Cancers and COVID-19 Infection

Gynecologic cancer care has been affected by the COVID-19 pandemic. We studied the association of racial disparity and COVID infection in the care of patients with gynecologic cancers. To assess the association of racial disparity and COVID infection in gynecologic cancers the National Cancer Database (NCDB) was queried for the year 2020 for patients with histologically confirmed diagnosis of cervical, endometrial and ovarian cancers. Patients were divided into two cohorts based on COVID test result status and subsequently stratified based on race. Race/ethnicity was categorized as 1) non-Hispanic White (NHW), 2) non-Hispanic Black (NHB), and 3) Hispanic. Subjects with missing race/ethnicity information were excluded. Outcome variables were time from diagnosis to initiation of treatment (surgery, radiation therapy versus chemotherapy). Continuous and categorical variables were reported as median [interquartile range] and number [rate] and were compared using Mann-Whitney U test and Chi-Square test, respectively. Statistical software was used and the level of significance was set at 0.05. A total of 36,863 subjects with newly diagnosed gynecologic cancers in 2020 underwent had available COVID testing information (4,827 with cervical, 23,935 with endometrial, and 8,101 with ovarian cancer). 31,516 (85.5%), 4,735 (12.8%), and 612 (1.7%) of the population were NHW, NHB, and Hispanic, respectively. The overall rate of COVID infection was the highest in NHB (6.9%), followed by Hispanic (5.6%) and NHW (5.4%), p < 0.001. Patients with cervical cancer had the highest rate of COVID infection (7.3%), followed by ovarian (5.6%) and endometrial (5.2%), p < 0.001. Non-Hispanic Black women with cervical cancer had the highest rate of infection (8.6%). Median time from diagnosis to first surgical procedure was highest in COVID positive NHB subjects (52 [IQR 20-91] in NHB, 41 [IQR 12-67] in NHW, and 40 [IQR 9-58] in Hispanics, p = 0.02). Median time from diagnosis to first radiation treatment was also highest in COVID positive NHB subjects (83 [IQR 29-107] in NHB, 52 [IQR 17-67] in NHW, and 39 [IQR 9-51] in Hispanics, p = 0.04). There was not racial or ethnic disparity in time from diagnosis to the first systemic therapy. COVID pandemic has substantially impacted gynecologic cancer care in the United States and exacerbated existing healthcare disparities. Members of African American community with gynecologic cancers have been affected the most compared to other racial groups, both in terms of COVID infection rates and delays in receiving care. Further study is warranted to understand impact on long-term cancer related outcomes.

Racial Disparities in Brachytherapy Treatment among Women with Cervical and Endometrial Cancers: A United States Cohort Study between 2004 and 2017

Brachytherapy (BT) improves clinical outcomes among women with cervical and endometrial cancers. Recent trends found decreasing BT rates in the United States; however, racial/ethnic differences have not been investigated completely. Here we aim to analyze 1) variations in BT practice patterns, 2) racial differences of BT, and 3) predictors of BT by race among women with cervical and endometrial cancers in the United States. A retrospective cohort of women with endometrial and cervical cancers in the US was evaluated using the National Cancer Database, between 2004 and 2017. Primary endpoint was treatment with BT. Women ≥18 years of age were included for FIGO Stage IA-IVA, non-surgically treated cervical cancers and high intermediate risk (PORTEC-2 and GOG-99 definition) or FIGO Stage II-IVA endometrial cancers. Racial groups were in accordance with federal guidelines including Asian, American Indian and Alaska Native (AIAN), Black, Native Hawaiian and other Pacific Islander (NHPI), and White. BT practice patterns and trends over time were evaluated by race. To identify predictors of BT by race, logistic regression calculated adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) after assessing for multicollinearity. A total of 13,857 women with cervical cancer and 140,942 women with endometrial cancer were included. Median follow-up was 69 months. Median (IQR) age was 53 (43-63) years for cervical cancer and 64 (57-72) years for endometrial cancer. Most cervical cancers were Stage III (44%), squamous cell carcinoma (88%), and lymphovascular space invasion (LVSI) positive (49%). Most endometrial cancers were Stage IB (45%), endometrioid histology (82%), and LVSI-positive (50%). Between 2004 and 2017, endometrial cancer BT increased (34% to 57%). BT rates for cervical cancer ranged from 65% NHPI, 63% Asian, 62% White, 59% AIAN, and 57% Black. BT rates for endometrial cancer ranged from 26% Black, 25% White, 25% Asian, 21% AIAN, and 20% NHPI. By race, only Black women with cervical cancer were significantly less likely to receive BT (aOR = 0.8; 95% CI = 0.7-0.9), compared to White women. Only NHPI women with endometrial cancer were less likely to receive BT (aOR = 0.7; 95% CI = 0.5-1.0), compared to White women. Community cancer center treatment was the only factor associated with a decreased odds of BT for both Black women with cervical cancer (aOR = 0.7; 95% CI = 0.6-0.9) and NHPI women with endometrial cancer (aOR = 0.3; 95% CI = 0.1-0.8), compared to academic centers. In this study of women diagnosed with endometrial and cervical cancers with stages known to benefit from BT, NHPI women with endometrial cancer and Black women with cervical cancer were less likely to receive brachytherapy compared to White women. Community engagement is needed to increase BT access for patients treated at community cancer centers to ensure equitable gynecologic cancer care.

Frequency and content of cost conversations about gynecologic cancer care (2249)

Frequency and content of cost conversations about gynecologic cancer care (2249)

Optimizing equitable social needs screening with digital and in-person modalities in routine gynecologic cancer care (170)

Optimizing equitable social needs screening with digital and in-person modalities in routine gynecologic cancer care (170)

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

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. 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. 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. 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.

Fractured and delayed: A qualitative analysis of disruptions in care for gynecologic malignancies during incarceration

ObjectiveWomen are experiencing growing rates of incarceration at twice the pace of that for men. Additionally, one-third will be older than 55 years of age by the end of the decade. Women who are incarcerated experience a higher prevalence of gynecologic malignancies and present with higher stage disease, which may be contributing to the greater mortality from cancer than the age-adjusted US population. Limited access to guideline-recommended screening and prevention and resource limitations across correctional facilities may result in gynecologic cancer disparities. Reasons for delayed gynecologic cancer care in prisons remain underexplored. Therefore, we sought to identify contributors to delayed gynecologic cancer care among women experiencing incarceration. MethodsWomen at a single tertiary center in the Southeastern U.S. who were incarcerated and were diagnosed with a gynecologic cancer during 2014–2021 were identified in the electronic medical record. Note text was extracted and contributors to delay were identified and categorized using the RADaR method. Descriptive statistics were used to assess quantitative data. Results14 patients were identified with a total of 14,879 text excerpts. Data reduction was performed to identify excerpts that were relevant to the central research question resulting in 175 relevant note excerpts. Delays prior to the tertiary care visit included patient and institutional contributors. Delays during transition from the tertiary center to prison included discharge planning and loss to follow-up during/after incarceration. Transportation, authorization, and restraints were concrete contributors. Abstract contributors included communication, and the patient's emotional experience. ConclusionsWe identify myriad contributors to delayed or fractured gynecologic cancer care in women experiencing incarceration. The impact of these issues warrants further study and intervention to improve care.

Black voices on gynecologic cancer: Understanding experiences.

e18680 Background: Structural racism and bias affects care of Black gynecologic cancer patients. Factors associated with disparities in Black cancer death rates have been associated with structural racism which has systematically limited the standard of living (wealth, housing, education, healthy food and healthcare) for Black people. Recent studies point to implicit bias, and lack of cultural sensitivity playing a significant role in the health outcomes of Black cancer patients. For instance, despite NCCN guidelines, oncologists underprescribe chemotherapy for older Black women with ovarian cancer and underdose chemotherapy for Black women with cervical cancer. Moreover, Black women dying from advanced uterine cancer are given pain medication at lower rates &amp; there are disparities in palliative care utilization amongst Black patients with metastatic gynecologic cancer. The voices of Black patient advocates are frequently missing from research studies. By centering the voices of Black patient advocates, we can identify new means of addressing &amp; positively impacting disparities within the clinical care spectrum (from diagnosis to survivorship). Our study group, Black Voices on Gynecologic Cancer: Understanding Experiences, aimed to identify common and unique scenarios of racism and bias in the experiences of Black patients with gynecologic cancer seeking medical attention. Methods: Focus groups were advertised using social media and partner patient advocacy organizations. We conducted five focus groups of 24 Black gynecologic cancer survivors using a Zoom platform. Key themes were identified through individual and group review of transcripts. Results: The themes that emerged from the focus groups included: (1) lack of communication and/or clarity in patient/provider communication - “… my first appointment with my gyn I did…share that…I'm having these hot flashes, night sweats…so he gave me some medicine, but… they´d never really addressed and had a conversation about like this is what your body will be experiencing…So, I really have been dependent on other women that have gone through this.”, (2) insufficient mental health support throughout and after treatment, (3) experiences with misdiagnosis (4) provider’s inadequate management of patient pain, (5) failure to mention clinical trials and (6) difficulty navigating insurance. Conclusions: Our study identified gaps in the care of Black gynecologic cancer patients. The second phase of BVOGUE will reduce structural barriers that prohibit authentic patient and community engagement around gynecologic cancer care and participation in academic research for Black cancer patients. We will pilot modules for both cancer education and research advocacy. This model will serve as a roadmap for all cancer centers creating action plans for engagement, inclusion, and participation.

An implementation science approach to the systematic study of access to gynecologic cancer care

IntroductionBarriers to access to cancer care are profoundly threatening to patients with gynecologic malignancies. Implementation science focuses on empirical investigation of factors influencing delivery of clinical best practices, as well as interventions designed to improve delivery of evidence-based care. We outline one prominent framework for conducting implementation research and discuss its application to improving access to gynecologic cancer care. MethodsLiterature on the use of the Consolidated Framework for Implementation Research (CFIR) was reviewed. Delivery of cytoreductive surgery for advanced ovarian carcinoma was selected as an illustrative case of an evidence-based intervention (EBI) in gynecologic oncology. CFIR domains were applied to the context of cytoreductive surgical care, highlighting examples of empirically-assessable determinants of care delivery. ResultsCFIR domains include Innovation, Inner Setting, Outer Setting, Individuals, and Implementation Process. “Innovation” relates to characteristics of the surgical intervention itself; “Inner Setting” relates to the environment in which surgery is delivered. “Outer Setting” refers to the broader care environment influencing the Inner Setting. “Individuals” highlights attributes of persons directly involved in care delivery, and “Implementation Process” focuses on integration of the Innovation within the Inner Setting. ConclusionsPrioritization of implementation science methods in the study of access to gynecologic cancer care will help ensure that patients are able to utilize interventions with the greatest prospect of benefiting them.

Insurance and racial disparities in prior authorization in gynecologic oncology

While prior authorization aims to reduce unnecessary care, it may limit or delay medically necessary care. Delays in cancer care can impact survival and are more common in historically-marginalized populations. Our objective was to examine to what extent disparities occurred in prior authorizations for gynecologic oncology. Using electronic medical records, we performed a retrospective review of prior authorization occurrence during gynecologic oncology care and analyzed the association with patient race and insurance in a multivariate regression model. In this cohort of 1,406 patients treated at an academic gynecologic oncology practice, patients with Medicare Advantage and patients of Asian descent were more likely to experience prior authorization. Addressing insurance-mediate disparities, such as in the occurrence of prior authorization, may help reduce disparities in gynecologic cancer care.

Evaluating the impact of the COVID-19 pandemic on tertiary gynaecological cancer care delivery: a population based study

During the COVID-19 pandemic, reports of delays and alterations in cancer treatment pathways have emerged. We aim to evaluate the proportional impact of the pandemic over time on standard care delivery in a large tertiary gynaecological cancer centre. Consecutive patient records from weekly multidisciplinary team meetings were collected prospectively between 6 March 2020 and 26 March 2021. In total, 1943 patient discussions were held in our multidisciplinary team meetings during the study period, with 2.1% standard management decisions being altered due to the pandemic, the majority of which occurred during the first wave. Amongst alterations, 87.5% were deferral of surgery, and, in 62.5% of cases, were due to reduced critical care capacity. The majority of patients were offered alternative treatment, and surgery once resources permitted. During subsequent waves of COVID-19, with similar reductions in critical care capacity, we demonstrate avoidance of a second major increase in standard care pathway alterations. IMPACT STATEMENT What is already known about the subject? Recent evidence has demonstrated significant delays to cancer surgery during the COVID-19 pandemic. However, few studies have objectively evaluated the quantity and nature of deviations from both surgical and non-surgical standard gynaecological cancer care pathways. What the results of this study add? We examined in detail the effects of the pandemic on tertiary gynaecological cancer service delivery in our centre. The main impact was in the ability to perform major surgery due to reduced critical care capacity. However, with the majority of standard care alterations clustered during the first wave of the pandemic, we demonstrate how the implementation of a COVID-19 mitigation plan minimised service disruption during subsequent waves. What the implications are of these findings for clinical practice and/or further research? This study reinforces the importance of protecting gynaecological cancer services during situations where resources are limited. Having identified several key factors affected by the pandemic, we hope that our results will support others in coordinating responses to similar scenarios in future. Having not examined the effects of the pandemic on primary and secondary level cancer services, further research will be needed to evaluate the overall impact on long term patient outcomes.

Disparities in prior authorization for gynecologic cancer care (137)

<b>Objectives:</b> Significant insurance, age, and race disparities exist in gynecologic cancer care. It remains unknown whether insurer-based prior authorization requirements may exacerbate disparities. Our objective was to examine whether the frequency of prior authorization differed by insurance type or race in gynecologic cancer care. <b>Methods:</b> We performed a retrospective review of electronic medical records of patients seen in the University of Pennsylvania gynecologic oncology practice from January 1 to March 31, 2021. Our academic practice consists of eight gynecologic oncology attendings and three nurse practitioners across four clinical sites associated with two hospitals. Race was self-reported, and insurance type was assessed from patients' scanned insurance cards. We used univariate and multivariate log-binomial models to estimate the association of insurance type and race with the likelihood of prior authorization during cancer care. <b>Results:</b> There were 2,112 clinic visits of 1,403 unique patients from January to March 2021. Eighteen percent of visits occurred via telemedicine; 23% (95% CI: 20.7-25.1) of patients had experienced a prior authorization during their gynecologic oncology care, and 4.4% (95% CI: 3.3-5.5) experienced 2+ prior authorizations. Of the prior authorizations, the majority were requested by private payers (56.2%, 95% CI: 53.5-58.8), followed by 20.9% (95% CI: 18.8-23.0) for Medicare fee-for-service, and 11.5% (95% CI: 9.8-13.1) for Medicare Advantage. In univariate analysis, having Medicare Advantage and being of Asian descent was associated with an increased risk of prior authorization, and having traditional Medicare was associated with a decreased risk. In multivariate analyses, having Medicare Advantage had an association with a 76% increased risk of experiencing prior authorization (95% CI: 1.27-2.44). Being of Asian descent was associated with a 60% increased risk of experiencing prior authorization (95% CI: 1.16-2.21). <b>Conclusions:</b> Prior authorization disproportionately impacted patients with Medicare Advantage and women of Asian descent in our study of gynecologic oncology patients. Addressing insurance barriers to care may help reduce disparities in gynecologic cancer care, especially for elderly patients.