Social determinants of health, disparities, and outpatient specialty palliative care in patients with gynecologic malignancies

The January 2026 issue of Annals of Palliative Medicine featured 3 Editorials, 3 Original Articles, 2 Study Protocol Articles, 6 Review Articles, and 2 Editorial Commentaries. This Message From the Editor-in-Chief focuses on one of those Original Articles by Nettelblad and colleagues from University of Kansas Medical Center, Kansas City, KS, USA. Those authors assessed how social determinants of health and disparities impact access to outpatient specialty palliative care in a large cohort of patients with gynecologic malignancies (1).

Gynecologic cancers are among the most common malignancies worldwide. Cancer of the cervix uteri is the eighth most common cancer and the ninth leading cause of death from cancer globally (fourth in both incidence and mortality among women), whereas corpus uteri malignancies are the fifteenth most common in incidence and nineteenth most common in mortality and ovarian cancer is the eighteenth most common in incidence and fourteenth most common in mortality. Furthermore, cancers of the vulva and vaginal cancers are both among the top 33 most common in incidence and mortality globally. These malignancies often have geographic and socioeconomic disparities in both incidence and survival (2).

For gynecologic cancers, like other malignancies, prior studies have demonstrated a benefit for outpatient specialty palliative care in improving symptom burden, reducing pain, increasing satisfaction with care, enhancing quality of life, and even extending survival (3,4). As a result, the American Society of Clinical Oncology (ASCO) recommends that patients with late-stage or recurrent cancers who have a prognosis of 6–24 months of life should be referred to outpatient specialty palliative care within eight weeks of diagnosis as an evidence-based intervention to improve quality of life in patients with cancer (5). This is a critical recommendation for which a recent Editorial Commentary was written in Annals of Palliative Medicine (6). Despite this, only approximately one-quarter of patients with gynecologic malignancies receive a referral to outpatient specialty palliative care (7,8).

It has been well described that socioeconomically disadvantaged and/or culturally marginalized patient populations are at risk for inequitable access to specialty palliative care. To date, however, there are little data assessing how social determinants of health and palliative care utilization are related. The authors sought to evaluate the rates of outpatient specialty palliative care referral and assess how social determinants of health are associated with a lack of referral to outpatient specialty palliative care in patients with gynecologic malignancies.

Nettelblad and colleagues conducted a single institution retrospective cohort study evaluating patients with gynecologic malignancies receiving care at their National Cancer Institute (NCI)-designated cancer center from 2019–2022 who met the ASCO criteria for referral to outpatient specialty palliative care. Included patients were stratified according to if they were referred to an outpatient specialty palliative care provider, and the cohorts were compared based on clinical factors, as well as social determinants of health that included race, ethnicity, primary language, insurance status, having a primary care provider, distance from the hospital, rurality, and Area Deprivation Index.

In total, they assessed 432 patients with gynecologic malignancies who were eligible for referral to outpatient specialty palliative care, of whom fewer than half (44%) were actually referred, and only one-third (34%) of whom ultimately saw a palliative care provider. They identified that patients who received a palliative care referral were more likely to have recurrent disease and a lower body mass index. In contrast, patients were less likely to receive a palliative care referral if they lived in a rural or disadvantaged (>70th percentile Area Deprivation Index) county, lived farther away from an NCI-designated cancer center, or had an existing primary care provider.

On multivariable logistic regression, when accounting for rurality, distance, deprivation and primary care access, only rurality and primary care access remained significant, with patients from rural areas notably less likely to be referred to a palliative care provider and patients without a primary care provider significantly more likely to be referred to a palliative care provider. The latter finding is an interesting one and opposite to the a priori hypothesis of the authors that having a primary care provider would facilitate referrals. It is possible, however, that primary care providers who practice in a rural setting may be more likely to provide primary palliative care themselves (9), potentially obviating the need for specialty palliative care referral. The primary care providers for this patient cohort may have also been more attentive to symptom management in their patients, making the need to refer to specialty palliative care to help with symptom burden less applicable.

The authors should be commended for adding to the literature on how social determinants of health are associated with referrals to outpatient specialty palliative care, and for conducting one of the few studies on this important topic in patients with gynecologic malignancies. Their analysis included a large sample size, albeit in a relatively homogenous patient population in a single nation’s health system, and it used rigorous statistical methods to make associations.

The analysis by Nettelblad and colleagues underscores the importance of understanding the effects of social determinants of health in order to optimize and individualize quality improvement interventions that can prioritize the greatest needs of a given patient population in a context-dependent manner. These findings can serve as a model for interdisciplinary care to increase outpatient specialty palliative care uptake well beyond gynecologic malignancies and are an important finding from which all can learn. The authors also raise important questions about the clinical utility of the ASCO criteria for specialty palliative care referral (5), as some patients with advanced disease and clear clinic need may be omitted from current referral recommendations (10).

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-2026-02/coif). C.B.S. II, serves as the co-Editor-in-Chief of Annals of Palliative Medicine from April 2014 to April 2027. The author has no other conflicts of interest to declare.

Ethical Statement: The author is 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.

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/.

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