Referrals and Decision-Making Considerations Involved in Selecting a Surgeon for Rectal Cancer Treatment in the Midwestern United States

Abstract

BACKGROUND: Despite evidence of superior outcomes for rectal cancer at high-volume, multidisciplinary cancer centers, many patients undergo surgery in low-volume hospitals.OBJECTIVE: This study aimed to examine considerations of former patients with rectal cancer when selecting their surgeon and to evaluate which considerations were associated with surgery at high-volume hospitals. DESIGN: In this retrospective cohort study, patients were surveyed about what they considered when selecting a cancer surgeon. SETTINGS: Study data were obtained via survey and the statewide Iowa Cancer Registry. PATIENTS: All eligible individuals diagnosed with invasive stages II/III rectal cancer from 2013 to 2017 identified through the registry were invited to participate. MAIN OUTCOME MEASURES:The primary outcomes were the characteristics of the hospital where they received surgery (ie, National Cancer Institute designation, Commission on Cancer accreditation, and rectal cancer surgery volume).RESULTS: Among respondents, 318 of 417 (76%) completed surveys. Sixty-nine percent of patients selected their surgeon based on their physician's referral/ recommendation, 20% based on surgeon/hospital reputation, and 11% based on personal connections to the surgeon. Participants who chose their surgeon based on reputation had significantly higher odds of surgery at National Cancer Institute-designated (OR 7.5; 95% CI, 3.8-15.0) or high-volume (OR 2.6; 95% CI, 1.2-5.7) hospitals than those who relied on referral.LIMITATIONS: This study took place in a Midwestern state with a predominantly white population, which limited our ability to evaluate racial/ethnic associations.CONCLUSION: Most patients with rectal cancer relied on referrals in selecting their surgeon, and those who did were less likely to receive surgery at a National Cancer Institute-designated or high-volume hospitals compared to those who considered reputation. Future research is needed to determine the impact of these decision factors on clinical outcomes, patient satisfaction, and quality of life. In addition, patients should be aware that relying on physician referral may not result in treatment from the most experienced or comprehensive care setting in their area. See

Availability of hospital‐based cancer services before and after rural hospital closure, 2008‐2017

“…Some studies show that rural patients may bypass the closest source of cancer care to receive treatment at urban clinics further away 28,29 . Other studies show that most patients choose their cancer surgeon based upon referral, but those who instead choose based upon reputation are more likely to choose a larger hospital (ie, more likely to be urban) for their treatment 30 . Rural populations have higher cancer mortality rates, so it is important to ensure they have appropriate access to treatment services and resources to access those services, and that hospital closures do not have a negative impact on access to those services.…”

Policy Recommendations for Improving Rural Cancer Services in the United States

“…Even when services are available, some patients still bypass the closest rural hospital, seeking care from reputable hospitals known for quality in urban areas. 30,33…”

Which Direction to Turn to Resolve the Debate on How to Improve Rectal Cancer Care: Centralize Versus Standardize? North!

“…Del Vecchio and associates’ report of a retrospective survey of Iowa Cancer Registry patients, who were simply asked how they were connected with their surgeon, veers into a discussion that implies that patients with rectal cancer have complete freedom to choose their surgeon/institution. 1 The study further suggests that patients should defy the surgeon recommendation of their primary care physician in favor of a surgeon based on “reputation” or “internet research,” and be prepared to travel for optimal care. 1 In the United States, patients with commercial insurance do not have complete freedom of choice in these matters; they must abide by their insurance carriers, which have contracts with participating surgeons and medical centers across a network.…”

“…1 The study further suggests that patients should defy the surgeon recommendation of their primary care physician in favor of a surgeon based on “reputation” or “internet research,” and be prepared to travel for optimal care. 1 In the United States, patients with commercial insurance do not have complete freedom of choice in these matters; they must abide by their insurance carriers, which have contracts with participating surgeons and medical centers across a network. Choosing a surgeon in another city may be denied if like services can be provided locally.…”

“…The authors are fixated on branding, marketing, logos, and reputation as a proxy for expertise, but given the questionable veracity of “internet research” (eg, marketing and advertising), these searches do not guarantee surgical competence. 1 For instance, my current place of employment is a cancer center branded by a well-known, gigantic logo attached to the building. However, before my arrival as the first American Board of Colon and Rectal Surgery–certified surgeon on campus, a rectal cancer patient’s best chance of avoiding local recurrence (LR), permanent stoma, and diminished disease-free survival would have been a referral to any of the American Board of Colon and Rectal Surgery–certified colorectal specialists practicing elsewhere.…”