Referral Times and Time-to-Treat Gynecological Cancer Prior to and During the COVID-19 Pandemic

Introduction/Purpose: Considering the significant impact of gynecological cancers on women’s health, timely treatment plays a crucial role in minimizing morbidity and mortality. Endometrial cancer (EC) stands as the most prevalent gynecologic cancer, while ovarian cancer (OC), although less common, carries a higher fatality rate. The referral process from primary care practitioners (i.e., Ob/Gyn and family medicine physicians) and emergency medicine physicians to gynecologic oncologists (Gyn/Onc) serves as a vital link in the healthcare system, ensuring prompt care. Delays in referrals, particularly for EC and OC, result in assessment and treatment delays and ultimately lead to suboptimal outcomes. The coronavirus disease (COVID-19) pandemic prompted alterations in healthcare practices to reduce exposure risks. Although some changes have persisted post stay-at-home orders and mask mandates, the full impact of resource triaging during the pandemic on gynecologic cancer care remains uncertain. This study aims to investigate referral times and the time-to-treat EC and OC. Our hypothesis posits that during-COVID-19, delays in treatment for EC and OC patients occurred. Our specific focus was to assess the influence of COVID-19 on time from transfer of care and time to surgery. Methods: This retrospective chart review included women undergoing surgical management for EC or suspicion of OC at SIU School of Medicine, Department of Ob/Gyn, Division of Gynecologic Oncology (IRB# 23-343). Subjects seen by the Gyn/Onc between January 1, 2019 and March 11, 2020 were categorized as ‘pre-COVID-19’ and those presenting between March 12, 2020 and May 30, 2021 were considered ‘during-COVID-19’. Patients attending any appointments for their cancer work-up, including surgery, that spanned both the pre- and during-COVID-19 timeframes were excluded. Date of presentation to the referring physician, date of referral to the Gyn/Onc, date of surgery, insurance status, race, age, BMI, gravidity, parity, comorbidities and cancer grade were extracted from the Electronic Health Record. Rural-urban commuting area (RUCA) codes were utilized to determine subjects’ geolocation in order to establish potential delays due to differences in access to transportation or commute time. Chi-square (for categorical variables) and T-test or Mann-Whitney U-test (for numerical variables) were utilized for comparisons. Results: A total 151 patients were included in this study. Of these, 58% presented for surgical evaluation pre-COVID-19 and 42% were during-COVID-19. There were no significant differences (all p-values ≥ 0.05) between the pre- and during-COVID-19 groups, respectively, in regards to: Age at time of surgery (62.3 ± 12.0 vs. 60.0 ± 12.6 years); Insurance type (Medicare: 51% vs. 39%, Medicaid: 19% vs 23%, Commercial: 27% vs. 32%, Uninsured: 2% vs. 6%); RUCA codes (Metro: 51% vs. 49%, Micro: 18% vs. 25%, Rural/Small: 31% vs. 26%); Race (White: 90% vs. 79%, African American: 5% vs. 5%, Asian: 0% vs. 3%, American Indian/Alaskan Native: 1% vs. 0%, Other/declined: 5% vs. 13%); BMI (37.0 ± 10.1 vs. 36.2 ± 10.0); Comorbidities at time of presentation (95% vs. 94%), Gravidity (2.5 ± 2.2 vs. 2.1 ± 1.7) or Parity (2.0 ± 1.6 vs. 1.9 ± 1.6). The cohort during-COVID-19 was found to have significantly shorter ‘time from symptom onset to referral’ compared to the pre-COVID-19 group (median [range]: 34 [7 – 111] days vs. 42 [6 – 298] days, respectively, p=0.009). In addition, there was a significantly shorter time period from the time of referral to surgery (8 [2 – 123] days vs.13 [2 – 125] days, respectively, p=0.006). Conclusions: Despite homogeneous patient populations prior to and during the pandemic era, these findings indicate a noteworthy reduction in both the time to transfer care and the duration from referral to surgery during the COVID-19 pandemic period. Although various factors may contribute to this outcome (i.e., elective surgeries were cancelled allowing more operating room access for cancer cases), our findings suggest that the challenges posed by the COVID-19 pandemic compelled the medical field to enhance efficiency in the health care delivery system. Further investigation is necessary to understand the specific modifications in the referral and time-to-treat processes that have resulted in shorter wait times. A thorough exploration of these changes has the potential to unveil strategies pertinent to improving timeliness of care and enhancing outcomes in the surgical treatment of gynecologic cancers, specifically EC and OC.