Fragmented Care and Guideline-Concordant Treatment in Locally Advanced Cervical Cancer

To characterize and estimate rates of fragmented care, to investigate its association with the receipt of guideline-concordant treatment, and to evaluate treatment components at risk with fragmented care.

This is a single-institution retrospective study of patients with locally advanced cervical cancer (stage IB3-IVA) from January 2003 to September 2023. We stratified patients into fragmented and nonfragmented care groups based on receipt of all care at our institution or if they received any component of care outside of our institution. The primary outcome, receipt of guideline-concordant treatment , was defined as a composite of 1) completion of treatment within 56 days, 2) completion of brachytherapy, and 3) receipt of concurrent chemotherapy. Demographic and treatment data were collected, including the Social Vulnerability Index (SVI), a census tract-based measure of disadvantage. Univariate and multivariate analyses were performed.

Two hundred eighty-six patients were identified; 75.5% received fragmented care. Those receiving nonfragmented care were significantly more likely to receive guideline-concordant treatment than those receiving fragmented care (71.4% vs 50.9%, P =.003). This was driven primarily by rates of timely completion (81.4% vs 60.6%, P =.001). Univariate analysis indicated that fragmented care (odds ratio [OR] 0.42, 95% CI, 0.23-0.74) and Medicaid insurance (OR 0.40, 95% CI, 0.20-0.78) were significantly associated with lower odds of guideline-concordant treatment. Multivariate analyses controlling for a priori confounders of insurance type and SVI showed that fragmented care (OR 0.45, 95% CI, 0.23-0.90) and Medicaid insurance (OR 0.42, 95% CI, 0.19-0.89) were independently associated with lower odds of guideline-concordant treatment. Multivariate analysis controlling for demographic covariates found even lower odds of receiving guideline-concordant treatment in those who received fragmented care (OR 0.39, 95% CI, 0.18-0.84) and who had Medicaid insurance (OR 0.35, 95% CI, 0.16-0.78).

More than 75% of patients received fragmented care, which had a significant clinical effect and was associated with significantly lower rates of guideline-concordant treatment.