Physicians' Perspectives on Access to Innovative Oncology Therapies: A Cross-Sectional Survey in Bulgaria

Despite major advances in precision medicine, equitable and timely access to innovative oncology therapies remains challenging because of differences in reimbursement systems, health technology assessment (HTA), and healthcare organization. Physicians are well positioned to identify barriers affecting the implementation of these therapies in routine practice. This study evaluated Bulgarian physicians' perceptions of innovative oncology therapies, assessed patient access, identified barriers to timely availability, and examined factors perceived as associated with these perceptions.

A cross-sectional web-based survey was conducted between March and May 2025 among physicians involved in oncology care in Bulgaria. The questionnaire comprised six domains addressing professional characteristics, self-perceived knowledge, clinical implementation, perceptions of patient access, barriers to implementation, and policy priorities. Descriptive statistics, Pearson's chi-square tests, Cramér's V, and multivariable ordinal logistic regression were used to analyze the data.

A total of 114 physicians participated. Respondents generally reported moderate-to-high levels of self-perceived knowledge regarding innovative oncology therapies. Self-perceived knowledge was higher among medical oncologists (adjusted p < 0.001) and physicians treating at least 100 patients with cancer per month (adjusted p = 0.003). Overall, 57.9% of respondents (95% CI: 48.7-66.6%) rated the perceived timeliness of access as good or very good, while 68.4% (95% CI: 59.4-76.2%) reported encountering patients who sought treatment abroad because innovative therapies were perceived as unavailable or insufficiently accessible in Bulgaria. Professional experience (aOR = 0.68, 95% CI: 0.50-0.93; p = 0.014) and higher monthly patient volume (aOR = 0.45, 95% CI: 0.21-0.96; p = 0.039) were independently associated with more favorable perceptions of access. Financial constraints, regulatory and HTA-related delays, and perceived delays in pharmaceutical-company submissions were the principal perceived barriers.

Bulgarian oncology specialists demonstrate high self-reported professional readiness for innovative oncology therapies; however, the perceived timely patient access remains constrained primarily by financial, organizational, and reimbursement-related factors. Although, these findings reflect physicians' perceptions and do not establish causal determinants of access, strengthening reimbursement pathways, HTA implementation, molecular diagnostic capacity, and clinical research infrastructure may improve equitable access to innovative oncology therapies within the evolving European HTA framework.