Compounding or confounding?—addressing context-specific disparities in access to outpatient specialty palliative care

Introduction

Background

A best practice in cancer care according to the American Society of Clinical Oncology (ASCO) is a patient-centered, multidisciplinary approach to treatment, including surgery, chemotherapy, radiotherapy, psychosocial support, and palliative care at all stages of a patient’s disease course (1,2). The Center to Advance Palliative Care (CAPC) defines specialty palliative care as assistance in navigating serious illness and transitions in care, as well as provision of care to manage symptoms for patients and their support systems. ASCO recommends patients with late-stage and/or recurrent cancer with a prognosis of 6–24 months of life be referred to outpatient specialty palliative care within eight weeks of diagnosis, as this is one of the few evidence-based interventions proven to improve quality-of-life in cancer patients (2,3).

Rationale and knowledge gap

A large, randomized trial including gynecologic cancer patients demonstrated that early outpatient palliative care was associated with improved quality-of-life, satisfaction with care, and symptom control (4). A retrospective study including patients with gynecologic cancers found that engagement with outpatient specialty palliative care was associated with significant improvement in sleep quality, pain scores, symptom burden, and overall wellbeing (5). Another study specifically examining patients with gynecologic cancers showed that outpatient palliative care referral was associated with significant improvement in pain, fatigue, nausea, anorexia, and depression and anxiety in a mean follow-up time of only 36 days (6). However, even in high resource healthcare settings, only about 30% of patients with gynecologic cancers that meet ASCO criteria for referral are referred to outpatient specialty palliative care, and even fewer of those patients are seen by a palliative care provider (7,8).

Another best practice in cancer care according to ASCO is to promote access to quality care for socially disadvantaged groups (1). Lack of access to palliative care may lead to increased pain, financial distress, and caregiver burden, especially among women, lower-income populations, and racial/ethnic minorities with advanced serious illnesses (9). Disadvantaged populations have been shown to receive goal-concordant cancer care less often than higher-resourced patients (10). Disparities have also been observed in access to palliative care when comparing rural communities to urban communities (11). In general, increased travel time to National Cancer Institute (NCI)-designated cancer centers is negatively associated with presentation for appointments and with receipt of recommended chemotherapy (12,13).

Objective

The Centers for Disease Control (CDC) defines social determinants of health (SDOH) as “social or economic statuses, geographic locations, and environments that lead to differences in disease burden, injury, violence, or opportunities for patients to achieve optimal health” (14). The purpose of this study is to evaluate SDOH associated with a lack of referral to outpatient specialty palliative care among eligible gynecologic cancer patients at an NCI-designated cancer center. This quality improvement exercise can serve as a model for interdisciplinary work to increase outpatient specialty palliative care uptake at other cancer centers. We present this article in accordance with the STROBE reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-109/rc) (15).

Methods

Overview, data sources, and study population

We conducted a retrospective cohort study of adult patients with gynecologic cancers who were seen in a midwestern NCI-designated cancer center’s gynecologic oncology clinic from January 2019 through December 2022. Patients included had advanced stage [stage III or IV by American Joint Committee on Cancer (AJCC) staging] at time of diagnosis or disease recurrence during the study period, corresponding to ASCO’s definition of advanced cancer meeting criteria for early, integrated palliative care (2). The Institutional Review Board of the University of Kansas Medical Center (Institutional Organization #IORG0000100) determined that the study was exempt from the need for review due to the study’s retrospective nature and primary purpose of quality improvement. Due to this exemption, informed consent was waived for this study. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Patients who received care at this midwestern NCI-designated cancer center during the study period were sourced from an automated report generated in the electronic medical record (EMR report) as well as from an internal outpatient specialty palliative care referral tracking database (PC database) maintained by our institution’s division of palliative medicine (16). The EMR report identified patients with a gynecologic cancer diagnosis seen in outpatient gynecologic oncology clinic during the study period using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes for the following cancer sites: ovarian, fallopian tube, primary peritoneal/Mullerian origin, uterine, endometrial, cervical, vulvar, and vaginal (16). Disease stage according to the AJCC at the time of diagnosis and whether disease was primary versus recurrent during the study period were recorded (16). The EMR report identified 322 gynecologic cancer patients as meeting ASCO criteria for outpatient specialty palliative care referral from January 2019 to December 2022. The true positive rate of the EMR report was 100%, as all patients in the EMR report were correctly identified as meeting ASCO criteria for referral to outpatient specialty palliative care on secondary data review (16).

The PC database tracks outpatient specialty palliative care referrals of oncologic patients. From this database, we identified gynecologic cancer patients by the same previously listed cancer sites referred during the study period. An additional 110 patients meeting ASCO criteria for outpatient specialty palliative care referral were identified from the PC database that were not included in the EMR report (16). Charts of gynecologic cancer patients identified to have an outpatient specialty palliative care referral in the PC database were reviewed to assess cancer site, cancer stage, and primary versus recurrent disease status to determine if they met ASCO criteria for referral (16). All unique patients meeting ASCO criteria identified in the EMR report and in the PC database were summed to determine the total population of gynecologic cancer patients eligible for outpatient specialty palliative care referral (16). Though there are limitations inherent in evaluating a study population assembled from multiple sources, all data were manually reviewed for accuracy and cross-referenced by multiple study team members (R.R., E.P., S.F.W.) to ensure validity (16).

We defined study cohorts as patients who were referred to palliative care versus patients who were not referred to outpatient specialty palliative care, and further subdivided patients who were referred based on whether or not they completed a consultation with an outpatient specialty palliative care provider.

Measures

We performed a retrospective chart review of each patient meeting study inclusion criteria and collected demographic, clinical, and SDOH data for each patient:

Demographic factors

Patient age, race, ethnicity, and primary language were recorded based on patient-reported information listed in the EMR.

Clinical factors

Cancer site and AJCC stage were collected. To determine primary versus recurrent disease status, we used a combination of methods and considered patients to have recurrent disease if we found any of the following: documentation of cancer recurrence in the EMR, recurrence noted in the oncology timeline based on exam and/or imaging findings, initiation of a chemotherapy plan for second-line or recurrent disease, or updated tumor-node-metastasis (TNM) staging for recurrent disease (rTNM). The body mass index (BMI) of each patient was obtained in a standardized fashion, recording the calculated BMI listed in the most recent gynecologic oncology clinic visit during the study period.

SDOH

We assessed individual-level SDOH that may affect access to care including insurance status, insurance type, having a primary care provider (PCP), and distance from the cancer center. Each patient’s insurance status was recorded as their primary insurance type listed in the EMR and was classified as private, Medicare, Medicaid, consolidated billing (for patients in hospice care), or none/self-pay. Patients were recorded as having a PCP if there was PCP listed in their EMR chart and were recorded as not having a PCP if this field reported none or was blank. The distance between patient’s primary address and the medical center was reported as the shortest driving route in miles. We evaluated area-level indicators of rurality and socioeconomic disadvantage based on each patient’s home address. We used patients’ listed home addresses and geospatially joined them to their respective counties and census block groups using ArcGIS Pro Version 3.0 (ESRI, Redlands, CA, USA). 2010 Rural-Urban Continuum Codes (RUCC) were used to classify patients as living in urban (RUCC codes 1–3) versus rural (RUCC codes 4–9) counties (17). The 2020 Area Deprivation Index (ADI) was used to classify patients as living in block groups characterized by higher (National ADI ≥70th percentile) versus lower (ADI <70th percentile) levels of disadvantage (18).

Palliative care

Patients who had a documented referral to palliative care in the EMR were coded as having received a referral to palliative care. Patients were documented as having completed a visit with an outpatient specialty palliative care provider if a clinic visit encounter with a signed and completed visit note was present in the EMR.

Statistical analysis

Differences in referral to outpatient specialty palliative care by demographic factors, clinical factors, and SDOH were assessed using chi-square tests for categorical variables and Wilcoxon Rank Sum tests for continuous variables. Univariable logistic regression evaluated the independent associations between demographic, clinical, and SDOH factors and referral to palliative care. All SDOH found to be statistically significantly associated with referral to palliative care in univariable analyses were included in a multivariable logistic regression model. Statistical significance was set at P value <0.05. All analyses were completed using SAS Version 9.4 (SAS Institute, Cary, NC, USA).

Results

During the study period, 432 gynecologic cancer patients met ASCO criteria for referral to outpatient specialty palliative care. Fewer than half (n=191, 44.2%) were referred to outpatient specialty palliative care; of these patients, 146 (76.4%) were seen for consultation, while 45 (23.6%) were not seen. A previous study performed at our institution identified reasons that patients referred to specialty palliative care did not complete a consultation with a provider including enrollment in hospice care, patient preference, palliative care needs already being met, and inability to contact the patient (16,19). The remaining 241 (55.8%) patients who met ASCO criteria for referral to outpatient specialty palliative care were not referred to a palliative care provider (Figure 1).

Figure 1 Sankey flow diagram illustrating the study population and breakdown of study cohorts. Nodes demonstrate the sub-populations who were or were not referred to outpatient specialty palliative care among gynecologic cancer patients meeting ASCO criteria for referral. Referred patients were further subdivided based on whether or not they completed a visit with a palliative care provider. ASCO, American Society of Clinical Oncology.

Demographic, clinical, and SDOH factors assessed for the study cohorts are shown in Table 1. Most of our cohort was White (84.3%), non-Hispanic (95.1%), and spoke English as their primary language (97.7%). There were no statistically significant differences in referral based on any demographic factors. Ovarian cancer was the most common cancer type (48.6%, n=210) in our patient population, with 32.9% (n=142) having uterine cancer, 13.4% (n=58) having cervical cancer, and 5.1% (n=22) having vulvovaginal cancer. Most patients (93.5%, n=404) had stage III or stage IV disease. There was a statistically significant difference in referral to outpatient specialty palliative care by cancer stage, with patients with lower stage (I and II) disease more likely to have been referred (100%, n=28, P<0.001). All stage I and II patients in our study population had recurrent disease. Significantly more patients with recurrent disease (69.6%, n=133) were referred to outpatient specialty palliative care compared to 30.3% (n=58) with primary disease (P<0.001). Patients with a lower mean BMI (26.8 versus 28.7 kg/m²) also were referred more frequently to outpatient specialty palliative care (P=0.03).

Most of our patients were insured (96%, n=418), and a majority of those were insured by Medicare (58.8%, n=254). Fewer than half (n=202, 46.8%) of patients had a PCP listed in their chart. We did not find any statistically significant differences in referral to outpatient specialty palliative care by insurance status or type. The median distance from the medical center was 52.1 miles [interquartile range (IQR), 13–70 miles]. Nearly two-thirds (n=277, 64.1%) of patients lived in urban counties, and 60% (n=266) of patients lived in census block groups characterized by lower levels of area disadvantage. There was a statistically significant difference in referrals by median from our NCI-designated cancer center; those who were referred tended to live closer [38.2 miles, standard deviation (SD) =55.3 miles] than those who were not referred (63.0 miles, SD =69.3 miles; P<0.001). Patients who lived in counties that were urban (RUCC 1–3) were more frequently referred than those who lived in rural counties (76.4% of urban patients referred versus 23.6% of rural patients referred) (P<0.001). Patients who lived in areas of lower disadvantage were referred to outpatient specialty palliative care significantly more often (67.5% of patients at lower social disadvantage referred versus 32.5% of patients at higher social disadvantage) (P=0.006).

Table 2 shows the results of subsequent univariable and multivariable logistic regression, which identified statistically significant associations between having a PCP, distance from the medical center, rurality, area-level disadvantage and being referred to outpatient specialty palliative care. Specifically, compared to patients without a PCP, patients with a PCP were significantly less likely to be referred to outpatient specialty palliative care [odds ratio (OR) 0.40, 95% confidence interval (CI): 0.26–0.64]. Patients living in rural areas were less likely to be referred than their urban counterparts (OR 0.25, 95% CI: 0.16–0.39), and patients living in block groups characterized by higher levels of deprivation were less likely to be referred than those living in areas characterized by lower levels of deprivation (OR 0.65, 95% CI: 0.46–0.97). As distance from the cancer center increased, the odds of referral decreased (OR 0.99, 95% CI: 0.89–0.99). In multivariate analysis, only associations with rurality and lacking a PCP remained statistically significant.

Discussion

Key findings

In this retrospective cohort quality improvement study, we found a higher-than-average but still suboptimal referral rate to outpatient specialty palliative care for eligible gynecologic cancer patients (44% versus 20–30%) (7,8). Multivariate analysis showed that rurality and having a PCP were the strongest predictors of missed referrals.

Strengths and limitations

The strength of this study is the large sample size, which enabled robust statistical analysis, identifying key SDOH driving disparities. Using a quality improvement lens, we identified key areas of focus for future interventions to improve uptake of outpatient specialty palliative care. This project is part of a broader collaboration between palliative care and oncology, involving trainees and showing success in increasing outpatient specialty palliative care utilization (16,19).

Limitations include retrospective design, in which inaccurate or incomplete information in the EMR may affect data collection and analysis, and single-institution scope, which may affect generalizability as well as underestimate the number of patients who consulted with a palliative care provider outside of our institution. Additionally, the structure of the United States’ healthcare system limits the generalizability of this study, as patients’ income impacts access to specialty medical care significantly more than in other countries where universal healthcare coverage is the norm. Still, our findings highlight the need for context-specific SDOH analysis. Future studies should explore more diverse populations and assess differences between patients who did versus did not see a palliative care provider after being referred.

Our study population was less diverse than Kansas overall—84% White, 95% non-Hispanic, and 97% English-speaking versus 74%, 87%, and 87% statewide (20). This was unexpected given our urban location. Our catchment area includes 4 million people across Kansas and Missouri, with 1 million living rurally (21). The demographic skew may reflect unmeasured SDOH like income, health literacy, and self-efficacy, which affect access to NCI centers (22).

Patients with stage I and II disease were more often referred to outpatient specialty palliative care than those with stage III and IV, likely because all stage I and II patients had recurrent disease, thereby meeting ASCO criteria. However, recurrence is difficult to identify in EMRs due to fragmented care and lack of coding (23-27), limiting analysis. A prior study done at our institution using this data set found that the EMR report was comprised primarily of advanced primary disease patients, whereas the majority of patients unique to the PC database not captured in the EMR report had recurrent disease (16,19). Every effort was made to mitigate the number of patients with recurrent disease omitted from analysis, but verification of disease recurrence in the EMR based on variables able to be assessed in retrospective chart review has limited sensitivity (23). Often, disease recurrence is not directly documented in the EMR due to providers failing to update cancer stage, omitting adding disease recurrence to a patient’s problem list or oncology timeline, and/or not adding ICD-10-CM or billing codes indicating cancer recurrence. Patients with recurrent gynecologic cancers benefit from palliative care referral, and quality improvement research should work to develop workflows to identify these patients most effectively. This may involve the use of text mining and/or machine learning algorithms or implementing quality improvement initiatives to increase explicit coding of disease recurrence in the EMR (28). This finding also calls into question the clinical utility of the ASCO criteria for specialty palliative care referral in real-world practice as these criteria may not fully capture clinical need, and some patients meeting criteria may not require specialty palliative care (16). Further research is needed to test this hypothesis.

Comparison with similar research

Distance to subspecialty centers affects access and outcomes across cancer types (29-31). For gynecologic cancers, 10–15% of patients face geographic barriers, with 40% of counties over 50 miles from a gynecologic oncologist (32,33). Patients farther from high-volume centers are less likely to receive National Comprehensive Cancer Network (NCCN)-adherent care (32,33). Interestingly, both very close and very distant proximity can correlate with worse outcomes (33-36). While distance affected outpatient specialty palliative care referral in univariable analysis, only rurality remained significant in multivariate modeling. Rurality, defined by RUCC (17), likely encompasses more than geography—such as socioeconomic status, education, health literacy, and internet access. Distance may proxy rurality, but rurality itself is a broader, more impactful factor. This data may also be used in the future to further explore the relationships between rurality, having a PCP, and insurance status of our patient population.

Higher area deprivation (ADI >70th percentile) was also associated with missed referrals in univariable analysis but not in multivariate modeling, suggesting its effects were confounded by rurality and/or PCP access. ADI reflects social risk factors (37), and patients in high-ADI areas face limited clinician density, increased anxiety, and negatively impacted quality of life (38,39). In gynecologic cancers, higher deprivation correlates with delayed treatment and worse survival (40,41). ADI is based on income, education, employment, and housing (42), but may underestimate rural disadvantage due to inflated employment and housing metrics (43,44).

Explanations of findings

Patients with a PCP were less likely to be referred to outpatient specialty palliative care. We hypothesized that having a PCP would facilitate referrals, but rural PCPs may provide primary palliative care directly. A 2023 study found that one-third of oncology patients received palliative care from their PCP, citing convenience and satisfaction (45). In gynecologic cancers, PCP access is linked to earlier diagnosis, better survival, and less aggressive end-of-life care (46-48). PCPs may be serving this population’s needs, obviating the need for specialty palliative care services, or these patients may have lower symptom burden and therefore lesser need for specialty palliative care. Alternatively, patients with PCPs and/or living in rural areas may be declining referrals for that or other reasons. Future research should assess if the absence of referral indicates patients’ declining of palliative care involvement versus oversight or implicit or explicit bias by oncologists.

Implications and actions needed

This study highlights the importance of outpatient specialty palliative care referral, as only 45 patients who were referred did not see a provider. Future research and quality improvement work should explore interventions to increase rates of referral by oncologists. With improved patterns of referral to outpatient specialty palliative care, efforts may also be made to improve outpatient specialty palliative care access, especially for rural patients and those with PCPs. Telehealth expansion is a promising avenue in this setting. In a large multisite comparative effectiveness trial, delivery of early palliative care virtually had equal impact on quality of life in patients with advanced lung cancer as in-person consultations (49). Though barriers such as internet access and technological literacy exist, rural patients should be offered virtual palliative care if their local community lacks access to in-person care. Additionally, programs like Project Extension for Community Healthcare Outcomes (ECHO) train PCPs to deliver specialty care in underserved areas (50-52) with proven success in palliative care in other countries (51).

Conclusions

In conclusion, fewer than half of eligible gynecologic cancer patients at our institution were referred to outpatient specialty palliative care despite the presence of a robust palliative care department well-integrated with our division of gynecologic oncology. Rurality and PCP access were key barriers affecting referral. Understanding system-level factors influencing referrals is essential to integrating timely palliative care into treatment plans (53). This quality improvement project may serve as a model for similar efforts at other institutions.

Acknowledgments

The authors wish to acknowledge Susan Boring Van Unen for her ongoing maintenance of the institutional palliative care referral database and for her assistance in data entry, verification, and export to support data analysis for this project. We also acknowledge Gillian Luevano for her help in editing and reference management for this manuscript.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-109/rc

Data Sharing Statement: Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-109/dss

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-109/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-109/coif). C.T.S. reports that he receives royalties for reviewing articles on UpToDate, and is a member of the Development and Awards committees of the American Academy of Hospice and Palliative Medicine. L.S. reports that she is the Palliative Care Subcommittee Chair for the Society of Gynecologic Oncology, which is an unpaid position. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The Institutional Review Board of the University of Kansas Medical Center (Institutional Organization #IORG0000100) determined that the study was exempt from the need for review due to the study’s retrospective nature and primary purpose of quality improvement. Due to this exemption, informed consent was waived for this study. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Selby P, Popescu R, Lawler M, et al. The Value and Future Developments of Multidisciplinary Team Cancer Care. Am Soc Clin Oncol Educ Book 2019;39:332-40. [Crossref] [PubMed]
2. Ferrell BR, Temel JS, Temin S, et al. Integration of Palliative Care Into Standard Oncology Care: ASCO Clinical Practice Guideline Update Summary. J Oncol Pract 2017;13:119-21. [Crossref] [PubMed]
3. Sanders JJ, Temin S, Ghoshal A, et al. Palliative Care for Patients With Cancer: ASCO Guideline Update. J Clin Oncol 2024;42:2336-57. [Crossref] [PubMed]
4. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014;383:1721-30. [Crossref] [PubMed]
5. Shah R, Georgousopoulou EN, Al-Rubaie Z, et al. Impact of ambulatory palliative care on symptoms and service outcomes in cancer patients: a retrospective cohort study. BMC Palliat Care 2022;21:28. [Crossref] [PubMed]
6. Ruskin R, Rabow M, Allen IE, et al. Outpatient Palliative Care Consultation Is Associated with a Decrease in Symptom Burden for Women with Gynecologic Malignancies. Gynecol Oncol 2014;133:45.
7. Lefkowits C, Binstock AB, Courtney-Brooks M, et al. Predictors of palliative care consultation on an inpatient gynecologic oncology service: are we following ASCO recommendations? Gynecol Oncol 2014;133:319-25. [Crossref] [PubMed]
8. Nitecki R, Diver EJ, Kamdar MM, et al. Patterns of palliative care referral in ovarian cancer: A single institution 5 year retrospective analysis. Gynecol Oncol 2018;148:521-6. [Crossref] [PubMed]
9. Wachterman MW, Sommers BD. Dying Poor in the US-Disparities in End-of-Life Care. JAMA 2021;325:423-4. [Crossref] [PubMed]
10. Johnson KS. Racial and ethnic disparities in palliative care. J Palliat Med 2013;16:1329-34. [Crossref] [PubMed]
11. Hoerger M, Perry LM, Korotkin BD, et al. Statewide Differences in Personality Associated with Geographic Disparities in Access to Palliative Care: Findings on Openness. J Palliat Med 2019;22:628-34. [Crossref] [PubMed]
12. Onega T, Duell EJ, Shi X, et al. Determinants of NCI Cancer Center attendance in Medicare patients with lung, breast, colorectal, or prostate cancer. J Gen Intern Med 2009;24:205-10. [Crossref] [PubMed]
13. Lin CC, Bruinooge SS, Kirkwood MK, et al. Association Between Geographic Access to Cancer Care, Insurance, and Receipt of Chemotherapy: Geographic Distribution of Oncologists and Travel Distance. J Clin Oncol 2015;33:3177-85. [Crossref] [PubMed]
14. CDC Restored. What is Health Equity. Available online: https://restoredcdc.org/www.cdc.gov/health-equity/what-is/index.html
15. Cuschieri S. The STROBE guidelines. Saudi J Anaesth 2019;13:S31-4. [Crossref] [PubMed]
16. Ratnaparkhi R, Pope E, Cook I, et al. Outpatient palliative care specialist referral patterns among patients with gynecological cancers. Eur J Gynaecol Oncol 2025;46:26-37.
17. USDA. Rural-Urban Continuum Codes. Available online: https://www.ers.usda.gov/data-products/rural-urban-continuum-codes
18. Maroko AR, Doan TM, Arno PS, et al. Integrating Social Determinants of Health With Treatment and Prevention: A New Tool to Assess Local Area Deprivation. Prev Chronic Dis 2016;13:E128. [Crossref] [PubMed]
19. Petrey L, Ratnaparkhi R, Pope E, et al. Oncologic outpatient specialty palliative care referral uptake: a single institution quality improvement project. Ann Palliat Med 2025;14:332-44. [Crossref] [PubMed]
20. United States Census Bureau. QuickFacts: Kansas. Available online: https://www.census.gov/quickfacts/fact/table/KS/PST045223
21. Mudaranthakam DP, Harlan-Williams LM, Jensen RA, et al. OPTIK: a database for understanding catchment areas to guide mobilization of cancer center assets. Database (Oxford) 2020;2020:baaa054. [Crossref] [PubMed]
22. Xu Y, Fu C, Onega T, et al. Disparities in Geographic Accessibility of National Cancer Institute Cancer Centers in the United States. J Med Syst 2017;41:203. [Crossref] [PubMed]
23. Warren JL, Yabroff KR. Challenges and opportunities in measuring cancer recurrence in the United States. J Natl Cancer Inst 2015;107:djv134. [Crossref] [PubMed]
24. Carroll NM, Ritzwoller DP, Banegas MP, et al. Performance of Cancer Recurrence Algorithms After Coding Scheme Switch From International Classification of Diseases 9th Revision to International Classification of Diseases 10th Revision. JCO Clin Cancer Inform 2019;3:1-9. [Crossref] [PubMed]
25. Kanas G, Morimoto L, Mowat F, et al. Use of electronic medical records in oncology outcomes research. Clinicoecon Outcomes Res 2010;2:1-14. [Crossref] [PubMed]
26. Banerjee I, Bozkurt S, Caswell-Jin JL, et al. Natural Language Processing Approaches to Detect the Timeline of Metastatic Recurrence of Breast Cancer. JCO Clin Cancer Inform 2019;3:1-12. [Crossref] [PubMed]
27. Ritzwoller DP, Hassett MJ, Uno H, et al. Development, Validation, and Dissemination of a Breast Cancer Recurrence Detection and Timing Informatics Algorithm. J Natl Cancer Inst 2018;110:273-81. [Crossref] [PubMed]
28. Warren JL, Mariotto A, Melbert D, et al. Sensitivity of Medicare Claims to Identify Cancer Recurrence in Elderly Colorectal and Breast Cancer Patients. Med Care 2016;54:e47-54. [Crossref] [PubMed]
29. Ambroggi M, Biasini C, Del Giovane C, et al. Distance as a Barrier to Cancer Diagnosis and Treatment: Review of the Literature. Oncologist 2015;20:1378-85. [Crossref] [PubMed]
30. Massarweh NN, Chiang YJ, Xing Y, et al. Association between travel distance and metastatic disease at diagnosis among patients with colon cancer. J Clin Oncol 2014;32:942-8. [Crossref] [PubMed]
31. Onega T, Cook A, Kirlin B, et al. The influence of travel time on breast cancer characteristics, receipt of primary therapy, and surveillance mammography. Breast Cancer Res Treat 2011;129:269-75. [Crossref] [PubMed]
32. Shalowitz DI, Vinograd AM, Giuntoli RL 2nd. Geographic access to gynecologic cancer care in the United States. Gynecol Oncol 2015;138:115-20. [Crossref] [PubMed]
33. Bristow RE, Chang J, Ziogas A, et al. Spatial analysis of adherence to treatment guidelines for advanced-stage ovarian cancer and the impact of race and socioeconomic status. Gynecol Oncol 2014;134:60-7. [Crossref] [PubMed]
34. Petersen S, Shahiri P, Jewell A, et al. Disparities in ovarian cancer survival at the only NCI-designated cancer center in Kansas. Am J Surg 2021;221:712-7. [Crossref] [PubMed]
35. Temkin SM, Fleming SA, Amrane S, et al. Geographic disparities amongst patients with gynecologic malignancies at an urban NCI-designated cancer center. Gynecol Oncol 2015;137:497-502. [Crossref] [PubMed]
36. Lalani N, Cai Y. Palliative care for rural growth and wellbeing: identifying perceived barriers and facilitators in access to palliative care in rural Indiana, USA. BMC Palliat Care 2022;21:25. [Crossref] [PubMed]
37. Hannan EL, Wu Y, Cozzens K, et al. The Neighborhood Atlas Area Deprivation Index For Measuring Socioeconomic Status: An Overemphasis On Home Value. Health Aff (Millwood) 2023;42:702-9. [Crossref] [PubMed]
38. Chen Y, Frydman J, McKendrick K, et al. Disparities in Access to Palliative Care: Geographic Distribution of Palliative Care Specialists in 2022. J Pain Symptom Manag 2024;67:e526.
39. Rosenzweig MQ, Althouse AD, Sabik L, et al. The Association Between Area Deprivation Index and Patient-Reported Outcomes in Patients with Advanced Cancer. Health Equity 2021;5:8-16. [Crossref] [PubMed]
40. Hufnagel DH, Khabele D, Yull FE, et al. Increasing Area Deprivation Index negatively impacts ovarian cancer survival. Cancer Epidemiol 2021;74:102013. [Crossref] [PubMed]
41. Gamble CR, Huang Y, Quinn J, et al. Neighborhood economic vulnerability as a predictor for patterns of care and outcomes for patients with uterine cancer. Gynecol Oncol 2024;190:70-7. [Crossref] [PubMed]
42. NRPA. Data and Mapping Resource Library: Area Deprivation Index. Available online: https://www.nrpa.org/publications-research/data-and-mapping-resource-library/area-deprivation-index/
43. Fecht D, Jones A, Hill T, et al. Inequalities in rural communities: adapting national deprivation indices for rural settings. J Public Health (Oxf) 2018;40:419-25. [Crossref] [PubMed]
44. Bertin M, Chevrier C, Pelé F, et al. Can a deprivation index be used legitimately over both urban and rural areas? Int J Health Geogr 2014;13:22. [Crossref] [PubMed]
45. Moon CC, Mah K, Pope A, et al. Family physicians' involvement in palliative cancer care. Cancer Med 2023;12:6213-24. [Crossref] [PubMed]
46. Smick AH, Holbert M, Neff R. Association of Physician Densities and Gynecologic Cancer Outcomes in the United States. Obstet Gynecol 2022;140:751-7. [Crossref] [PubMed]
47. Zamorano AS, Mazul AL, Marx C, et al. Community access to primary care is an important geographic disparity among ovarian cancer patients undergoing cytoreductive surgery. Gynecol Oncol Rep 2022;44:101075. [Crossref] [PubMed]
48. Mullins MA, Ruterbusch JJ, Clarke P, et al. Continuity of care and receipt of aggressive end of life care among women dying of ovarian cancer. Gynecol Oncol 2021;162:148-53. [Crossref] [PubMed]
49. Greer JA, Temel JS, El-Jawahri A, et al. Telehealth vs In-Person Early Palliative Care for Patients With Advanced Lung Cancer: A Multisite Randomized Clinical Trial. JAMA 2024;332:1153-64. [Crossref] [PubMed]
50. Worster B, Swartz K. Telemedicine and Palliative Care: an Increasing Role in Supportive Oncology. Curr Oncol Rep 2017;19:37. [Crossref] [PubMed]
51. Arora S, Brakey HR, Jones JL, et al. Project ECHO for Cancer Care: a Scoping Review of Provider Outcome Evaluations. J Cancer Educ 2023;38:1509-21. [Crossref] [PubMed]
52. Bhatia S, Landier W, Paskett ED, et al. Rural-Urban Disparities in Cancer Outcomes: Opportunities for Future Research. J Natl Cancer Inst 2022;114:940-52. [Crossref] [PubMed]
53. Yu JA, Ray KN, Park SY, et al. System-Level Factors Associated With Use of Outpatient Specialty Palliative Care Among Patients With Advanced Cancer. J Oncol Pract 2019;15:e10-9. [Crossref] [PubMed]