Strengthening the referral pathway: Community oncology clinician perspectives on referring to academic cancer centers

Abstract Introduction: Cancer clinical trials (CCTs) are essential to advancing treatment options for patients with hematologic malignancies. Academic cancer centers often lead early-phase and investigator-initiated trials exploring novel agents or mechanisms. Referrals from community oncology sites play a critical role in connecting patients to these CCT opportunities. Strengthening referral pathways between community and academic settings may support improved trial accrual and access. As part of formative work for a multi-level implementation trial aimed at improving equitable access to CCTs, we explored community oncology clinicians' experiences with referrals and identified opportunities to strengthen referral-related communication and coordination. Findings are informing two implementation strategies: Enhanced Connection (focused on reducing barriers to referral) and Enhanced Communication (a clinician training intervention to support referral and trial-related conversations). This formative research is supported by The Leukemia & Lymphoma Society's Equity in Access Research Program as part of its broader mission to improve clinical trial access for patients with hematologic malignancies and other cancer types. Methods: We conducted semi-structured interviews with 10 cancer clinicians (n = 8 oncologists, n = 2 physician assistants) at community oncology sites in Florida between November 2024 and May 2025. Interviews focused on referral experiences, perceived barriers and facilitators to referrals, and suggested strategies or tools to better support referral to academic cancer centers. A thematic analysis approach was used to identify and synthesize themes across interviews. Results: Five key themes were identified. (1) Clinicians described motivators of referral to academic cancer centers, including the need for therapies that are not locally available (e.g., cellular therapies, bone marrow transplant), second opinions for rare or complex cases, or when standard therapy options had been exhausted. (2) Clinicians also discussed clinical reasons for not referring, such as standard treatment options, locally available trials, or when they anticipated patient-level barriers (e.g., frailty, travel burden, insurance limitations). (3) Clinicians reported multiple barriers to referral, including clinician-level challenges (e.g., limited awareness of trial offerings, time constraints, and lack of established relationships with academic oncologists), patient-level challenges (e.g., urgency to initiate treatment, travel burden, insurance limitations, financial concerns), and system-level challenges (e.g., slow intake processes at academic cancer centers). (4) Clinicians highlighted several facilitators of referral, including direct communication with academic oncologists and/or study staff, internal support from staff to identify trials and expedite referrals, and having a dedicated liaison to streamline coordination. (5) Clinicians suggested strategies and tools to enhance referral effectiveness, including centralized contact lists, regularly updated trial summaries, referral guidelines and decision aids, and searchable trial databases or applications. When prompted, many endorsed the option of consultation for a clinical trial via telehealth, citing convenience and a timely trial feasibility assessment. Notably, we also found that nearly all participating interviewees reported that their community sites are participating in clinical trials and offer them to patients within their clinic. Conclusions: Findings from this formative research are informing the design of a multi-level implementation trial aimed at improving accrual to CCTs, including those for hematologic malignancies. Planned strategies will target modifiable determinants at the institutional, clinician, and patient levels. Early engagement with community oncology stakeholders has been vital for understanding real-world referral processes and challenges, and fundamental for shaping pragmatic, context-specific interventions that support referral pathways between community and academic settings.