Enhancing Access in Pancreatic Cancer: Examining Facilitators and Barriers to Tertiary Referral for Complex Oncologic Surgical Care. - Pancreatic cancer continues to represent a significant burden of cancer-related mortality both in the United States and globally, with 5-year survival only 12.8% despite recent treatment advances. For patients with early-stage disease, multi-modal treatment including surgery is the only potentially curative therapy. Nevertheless, surgical intervention remains underutilized nationally – fewer than 50% of eligible patients with non-metastatic disease proceed with resection. Furthermore, significant barriers persist in the diagnosis and treatment of pancreatic cancer, which limits access to advanced surgical care and specialized oncologic therapies. Notably, prior studies have largely focused on patient characteristics such as age, education level, and socioeconomic status, many of which are non-modifiable. Provider- and system-level factors that affect surgical referral patterns have not been thoroughly studied but are likely more amenable to policy and quality improvement interventions. The central objective of this mixed methods research study is to examine the etiology of the underutilization of surgical resection in early-stage pancreatic cancer by analyzing the facilitators and barriers to tertiary referral, focusing on provider and system factors that impact referral to complex cancer surgeons at multidisciplinary centers. First, a quantitative analysis of a national cancer database will be performed to create an explanatory model for referral patterns, highlighting relevant provider-, practice-, and system-level factors. A sub-analysis will be performed, stratifying by patient demographic factors in the multivariable models, to identify factors that may be differentially associated with referral or receipt of surgery between patient groups. Next, qualitative analysis employing semi-structured interviews of various stakeholders across the pancreatic cancer care continuum will be completed to identify facilitators and barriers to referral. Interviews will include both physician and non-physician providers from both academic and community centers across Massachusetts in order to capture comprehensive perspectives regarding relevant factors upstream of the surgical encounter. The project’s focus on provider- and system-level factors, rather than patient characteristics, will better enable identification of potential causal pathways and illuminate modifiable targets for health system and quality improvement interventions. The knowledge gained from this work will therefore help enhance surgical access, optimize cancer care, and improve patient outcomes.
