Musculoskeletal Tumor Care Disparities Prior to Initiation of Treatment Among Newly Diagnosed Adult Patients

Abstract

Purpose: We investigated care disparities and associated factors along the segments of adult musculoskeletal tumor (MST) care prior to initiation of treatment. Patients and Methods: This cohort included newly diagnosed MST patients who were referred to Stanford Medical Center for establishing care from July 2020 to April 2024. We investigated the interval from the onset of symptoms to the first appointment with a primary care provider (PCP wait-time), and the interval from first PCP appointment to obtaining the first imaging study (imaging wait-time) and to obtaining biopsy results (biopsy wait-time). Sarcoma consult wait-time was defined as the interval between referral date and consult date. We performed a survey among sarcoma physicians and non-physician staff on the perception of wait-time. Results: Among 402 eligible patients, approximately 38.5% had PCP a wait-time longer than 5 weeks, with young adults and Hispanic patients having the highest rate of such long wait-times. Approximately 20.6% of patients had an imaging wait-time longer than 5 weeks, with young adults having the highest proportion of such long wait-times. In addition, Hispanic (p = 0.02), Black (p = 0.05) and Caucasian (p = 0.02) patients had significantly higher percentages of patients with an imaging wait-time of more than 5 weeks compared to Asians. Approximately 79.3% of patients had a biopsy wait-time longer than 5 weeks, with Black and Hispanic patients having the highest percent of such long wait-times. In addition, compared to public insurance, private insurance was associated with a higher proportion of patients with PCP wait-times, imaging wait-times, sarcoma consult wait-times and biopsy wait-times longer than 5 weeks. The survey responses overwhelmingly indicated that a wait-time of more than 5 weeks was not acceptable. Conclusions: Substantial disparities in MST care related to age group, ethnicity and insurance type existed in multiple segments of the care journey prior to the initiation of treatment. Our study provides insights for practice, research and policy considerations for narrowing sarcoma care disparities.

Keywords: biopsy; consult; disparity; imaging; musculoskeletal tumor; sarcoma; wait-time.

Figure 1

(A). Illustration of the segments of MST care prior to initiation of treatment. The interval from the onset of MST symptoms (pain and/or a palpable mass) to the initial visit with a primary care provider (PCP) was defined as PCP wait-time. The interval from the initial PCP visit to obtaining the first imaging study (MRI, PET/CT or CT scan, etc.) was defined as imaging wait-time. The interval from the PCP visit to the biopsy date was defined as biopsy wait-time. The interval between the sarcoma referral date and the consult date was defined as sarcoma consult wait-time. (B). Survey results on acceptability of wait-time >5 weeks. Questionnaires included the following: 1. Is waiting for more than 5 weeks to see a Primary Care Provider (PCP) after the onset of sarcoma symptoms (pain and/or palpable mass) acceptable? 2. Is waiting for more than 5 weeks to obtain an Imaging Study (MRI, CT, or PET/CT, etc.) acceptable? 3. Is waiting for more than 5 weeks to obtain a Biopsy acceptable? 4. Is waiting for more than 5 weeks to see Sarcoma Oncologist for Consult acceptable? The options for response were “Yes” or “No”.

Figure 2

PCP wait-time. (A) PCP wait-time of the full cohort. (B), PCP wait-time by age group. Young adults (age 18–30 years) had a significantly high proportion of patients with wait-times of more than 5 weeks compared to patients older than 70 years (p = 0.03). (C) PCP wait-time by ethnicity. Hispanic patients had significantly higher proportion of patients with wait-times of more than 5 weeks compared to Caucasians (p = 0.01) and Asians (p = 0.03). (D) PCP wait-time by distance. Distances were measured from patients’ residence to Stanford Medical Center. (E) PCP wait-times of more than 5 weeks by insurance type, high-grade or Other, and sex.

Figure 3

Imaging wait-time. (A) Imaging wait-time of the full cohort. (B) Imaging wait-time by age group. Young adults (age 18–30 years) had a significantly high proportion of patients with wait-times of more than 5 weeks compared to patients older than 70 years (p = 0.03). (C) Imaging wait-time by ethnicity. Hispanic (p = 0.02), Black (p = 0.05) and Caucasian (p = 0.02) patients had significantly higher proportions of patients with wait-times of more than 5 weeks compared to Asian patients. (D) Imaging wait-time by distance. Distances were measured from patient residence to Stanford Medical Center. (E) Imaging wait-times of more than 5 weeks by insurance type, high-grade or Other, and sex. A significantly higher proportion of patients with private insurance had wait-times of more than 5 weeks compared to patients with public insurance (p = 0.05).

Figure 4

Sarcoma consult wait-time. (A) Sarcoma consult wait-time of the full cohort. (B) Sarcoma consult wait-time by age group. (C) Sarcoma consult wait-time by ethnicity. (D) Sarcoma consult wait-time by distance. (E) Sarcoma consult wait-time of more than 5 weeks by insurance type, high-grade or Other, and sex. A significantly higher proportion of female patients had wait-times of more than 5 weeks compared to male patients (p = 0.03).

Figure 5

Biopsy wait-time. (A) Biopsy wait-time of the full cohort. Nearly 80% of all patients had wait-times of more than 5 weeks. (B) Biopsy wait-time by age group. No significant differences among age groups. (C). Biopsy wait-time by ethnicity. Hispanic patients had significantly higher proportion of patients with wait-time more than 5 weeks compared to Asians (p = 0.05) and borderline significantly higher proportion of patients with wait-time more than 5 weeks compared to Caucasians (p = 0.08). (D) Biopsy wait-time by distances. Distances were measured from patient residence to Stanford Medical Center. (E). Biopsy wait-times of more than 5 weeks by insurance type, high-grade or Other, and sex.