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PRIMARY CARE AND PANCREATIC CANCER. THE MISSING LINK?
Jaspinder S. Sanghera
*1, Ioannis Liapis
1, Michelle Holland
1, Omar Ahmed
1, Rida Ahmad
2, Krisha Amin
2, Ahmed Abdalla
2, Smita Bhatia
1, Martin Heslin
1, Annabelle L. Fonseca
11Surgical Oncology, The University of Alabama at Birmingham, Birmingham, AL; 2University of South Alabama Health System, Mobile, AL
Introduction: Guideline-concordant treatment (GCT) is associated with improved outcomes in pancreatic cancer. However, only an estimated 30-45% of patients receive GCT. A pre-existing relationship with the healthcare system, particularly having a primary care provider (PCP), may improve receipt of GCT. This study evaluates whether the presence of a PCP and PCP-initiated diagnostic work-up influences receipt of GCT and time to first treatment in pancreatic cancer.
Methods: A retrospective review of electronic health records (EHR) was conducted for patients presenting with pancreatic adenocarcinoma at two tertiary care hospitals in the Deep South between 2018-2022. The primary outcome was receipt of GCT, and the secondary outcome was the time from diagnosis to first treatment (chemotherapy or surgery). Multivariate logistic regression modelling was used to identify whether the presence of a PCP and diagnostic workup initiated by the PCP or in the Emergency Department (ED) predicts the receipt of GCT. Bivariate analysis and adjusted COX proportional hazards models were used to assess cause-specific hazards for time to first treatment. Marginal cumulative incidence graphs using inverse probability weighting were demonstrated for the presence of PCP and work-up initiated by the PCP/ED.
Results: Of 891 pancreatic cancer patients, 789 (89%) received treatment during the study period. Most patients were male (52%), white (71%) and initiated treatment ?4 weeks after diagnosis (69%). Of note, of the 662 (74%) patients with a PCP, 262 (40%) had their work-up initiated by the ED, and these patients had lower odds of receiving GCT on univariate analyses (p<0.004). Overall, in multivariate analyses, ED-initiated work-up was significantly associated with decreased receipt of GCT (OR 0.71, p=0.05).
On bivariate analysis, black race (p=0.006), living in an area of high deprivation (p<0.001), and greater number of ED visits (p=0.04) were significantly associated with increased time to treatment. ED-initiated work-up and lack of a PCP led to a 19% and 18% decrease, respectively, in the cause-specific hazard for receiving treatment after adjusting for sociodemographic variables (Figure 1).
Discussion: Patients who have their diagnostic work-up initiated in the ED are less likely to receive GCT. Furthermore, patients without a PCP and those diagnosed in the ED have longer times from diagnosis to first treatment. A pre-existing relationship with the healthcare system in the form of a PCP appears to contribute to the timely delivery of pancreatic cancer care. Moreover, the patient-provider relationship also impacts treatment; patients with PCPs but ED-initiated work-up were less likely to receive GCT. Increasing access to PCPs, strengthening patient-provider and primary-specialty care relationships are crucial to delivering GCT.
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