Patterns of Referral for Common Cancer Surgery in the United States

Shifts in healthcare delivery have resulted in most U.S. hospitals participating in integrated health systems, many of which selectively refer complex cancer surgery to high-volume centers. However, this centralization may exacerbate barriers to access and may not be necessary for all cancer types. This study describes the prevalence and pattern of referral for surgery for common cancers and evaluate associated factors.

The National Cancer Database was used to identify adult patients who underwent curative-intent surgical resection between 2010 and 2020 for 12 common cancers (bladder, breast, colon, kidney, lung, melanoma, oral cavity, pancreas, prostate, rectum, thyroid, and uterus). The primary outcome was receipt of referred surgical cancer care.

Overall, 5,406,813 patients underwent surgical resection for common cancers, with 33.7% referred for surgery after diagnosis elsewhere. Rates of referred surgery varied by disease site, ranging from 13.7% (bladder) to 58.2% (melanoma). On multivariable analysis, patients with melanoma, oral cavity, prostate, rectal, and uterine cancers (referent = breast), higher clinical stages, and increasing year of diagnosis had higher adjusted odds of referred surgical care. Nonacademic facility types, lower facility volume, higher comorbidity burden, and nonprivate insurance were associated with reduced odds of referred surgical care.

Likelihood of referred surgical cancer care increased over time for 11 of 12 common cancers, with the prevalence of referred care varying significantly based on disease site and sociodemographic factors. Future work evaluating associated clinical outcomes will aid in decisions regarding allocation of referral of surgical cancer care within health systems.