Bridging Gaps in Gynecologic Cancer Care: An Interview With Stakeholders From Texas Oncology

Texas Oncology is an independent oncology practice with more than 550 physicians and 300 sites of service across Texas and southeastern Oklahoma; these include 50 comprehensive cancer centers.¹ Editors from AJMC spoke with Texas Oncology physicians Joseph de la Garza, MD, FACOG, a gynecologic oncologist located in San Antonio, and Kathryn E. Hudson, MD, a medical oncologist and Director of Survivorship, located in Austin, on the practice’s program and processes for addressing disparities and advancing access to treatment for appropriate patients with endometrial cancer.

AJMC: Please describe the gynecological cancer program at Texas Oncology. How do patients with endometrial cancer come to the practice center to be treated?

de la Garza: At Texas Oncology, our gynecologic cancer program operates on a referral-based model. We work closely with hospitals, where patients may enter our care through consultations—often after arriving at the emergency department (ED) as unassigned cases. In addition, we cultivate relationships with community providers (eg, primary care providers [PCPs] and community oncologists) to ensure they are aware of our specialized gynecologic oncology services and successful patient outcomes. Our goal is to be the first resource that providers consider for their patients with gynecologic cancer, including those with endometrial cancer. This reputation-based referral system is key to connecting patients to our center for specialized care.

Hudson: We also support through partnerships with nonprofit organizations. In Austin, for instance, we provide financial support to breast cancer screening initiatives such as the Big Pink Bus,² a mobile mammography unit that travels to underserved communities. Additionally, the Texas Oncology Foundation³ conducts health screenings in various regions, and our team collaborates with the National Ovarian Cancer Coalition⁴ and with local organizations such as the Breast Cancer Resource Center⁵ to enhance outreach.

AJMC: What does the patient journey look like for patients with endometrial cancer?

de la Garza: For patients with endometrial cancer who are treated at Texas Oncology, the journey begins with timely recognition and referral. Patients are typically sent to us after receiving a diagnosis or when symptoms—such as abnormal ultrasounds or postmenopausal bleeding—raise sufficient suspicion. Once referred, we prioritize rapid clinic access and evaluation, aiming to move the majority of patients quickly to surgery. In cases in which pre-surgical treatment with chemotherapy or radiation therapy would be beneficial, we tailor the treatment plan accordingly.

Our coordinated approach includes focused efforts to reduce time-to-appointment, an important metric linked with treatment success and care accessibility. To expedite care, we partner with advanced practice providers (APPs) who are available 5 days a week, whereas surgeons and oncologists have more limited clinic days. New patient referrals often are seen by an APP within 1 to 3 days, allowing preliminary workups—including imaging and biopsy review—to be initiated promptly, expediting treatment decisions and surgical scheduling. This streamlined approach ensures timely, comprehensive care from initial referral through posttreatment surveillance.

AJMC: Please describe the demographics of patients with endometrial cancer at your practice and the gaps in care seen with the patients in your program.

de la Garza: At Texas Oncology, we care for a diverse patient population with endometrial cancer across various demographics and financial backgrounds. As a private practice, we have many patients with insurance who are referred to us after diagnosis by gynecologists or PCPs. Additionally, we work with hospitals to treat uninsured or underinsured patients who enter through the ED, enabling us to serve a full spectrum of financial backgrounds.

Our San Antonio location sees a high volume of Hispanic and Black patients, reflecting the region’s demographics. The team also receives many referrals from areas such as Corpus Christi and Laredo. One of the most common characteristics across all groups is obesity, which can substantially impact gynecologic cancer care and outcomes. Gaps remain in managing obesity effectively, often due to limited insurance coverage and the high cost of surgical and/or pharmacological treatments and support. Addressing these barriers is critical to improving outcomes in this patient population.

AJMC: What strategies are used by your organization to address barriers to care, especially for underserved populations?

Hudson: As an example, our program minimizes transportation barriers by bringing care closer to patients. We have over 300 sites across Texas, so most patients live within an hour of a clinic. For those in remote areas, we leverage telemedicine, enabling specialists from larger hubs to consult with patients and providers in smaller hub areas that are rural.

The cost of oncology care still poses a major hurdle for many patients, especially among those who are uninsured and underinsured. Our team will work to find financial solutions for these patients—often with the help of social workers who assist with financial support programs. The demand for social workers remains high, and many practices lack the resources and support. We also advocate for broader legislative efforts to address gaps in health care funding and insurance coverage.

AJMC: Who are the key stakeholders involved in the patient’s care team?

de la Garza: At Texas Oncology, a dedicated care team ensures timely, effective treatment across each stage of the patient journey. New patient coordinators play a vital role by receiving and reviewing referrals, contacting patients, and coordinating initial visits. APPs facilitate first-touch appointments within 1 to 3 days to expedite the initial workup and to manage surveillance visits, chemotherapy, and even genetic testing, which is now offered to all women with endometrial cancer. The broader treatment team also includes other providers, such as nurses and radiation oncologists.

AJMC: How did your organization develop an institutional care pathway for optimizing care decisions for patients with endometrial cancer?

Hudson: Texas Oncology developed its institutional care pathway for endometrial cancer based on National Comprehensive Cancer Network guidelines, with additional focus on being cost effective and minimizing toxicity. The pathway integrates directly with our electronic health record (EHR), allowing providers to access detailed information on treatment options, including clinical data supporting each regimen. Providers can request off-pathway treatments if they are warranted by new research; these requests go to a committee for approval, ensuring flexibility without compromising quality.

To support financial transparency, each patient meets with a financial counselor before starting treatment. If necessary, financial assistance can be explored with a social worker. Pathway costs are not adjusted individually by insurance type, but preferred regimens are generally aligned with Medicare.

Patients without coverage are typically referred to safety-net programs that are usually affiliated with other hospitals or federally funded clinics. Aspects of social determinants of health (SDOH) also influence care decisions—for example, if indicated, consideration of oral regimens (vs intravenous [IV]) for patients experiencing transportation challenges or consideration of options that require fewer visits for those with limited access to care. This comprehensive approach enables providers to deliver optimized, patient-centered care across all stages of treatment.

AJMC: What innovative and personalized disease management approaches are you currently exploring for patients with endometrial cancer?

de la Garza: A key innovation in our approach is the extensive use of robotic surgery, which has transformed treatment options for patients with endometrial cancer, especially those with obesity or comorbidities in whom surgery is considered high risk. With the robotic platform, we can perform minimally invasive surgeries that offer faster recovery, reduced hospital stays, and fewer complications in cases in which patients have been advised that surgery is not possible due to high body mass index, elevated hemoglobin A1C, or prior surgical history. Our success with robotic surgery has been a momentous advancement, ensuring that more women—regardless of location or complexity of care—can access effective, personalized treatment.

AJMC: How does Texas Oncology partner with community oncologists to advocate for and facilitate access to cutting-edge treatments for patients with endometrial cancer?

de la Garza: Community oncologists play a vital role in advocating for and facilitating access to advanced treatments for patients with endometrial cancer, especially by partnering with our program. With the rapid emergence of new guidelines for immunotherapies, for example, these partnerships are crucial. Community oncologists provide care close to patients’ homes in more remote areas, but they may not have the latest gynecologic oncology–specific insights due to their broad focus across cancer types. Through collaboration, we can share current recommendations garnered from recent conferences, journal clubs, and other avenues to ensure that patients receive the most current, high-quality care within their communities.

AJMC: How does Texas Oncology ensure that all providers are up to date on the latest advancements in treatment for endometrial cancer?

Hudson: Texas Oncology is part of The US Oncology Network, which offers regular educational webinars to keep providers informed about the latest advancements in endometrial cancer treatment. In addition, the clinical pathways incorporated into our EHR system (iKnowMed),⁶ are reviewed and updated every 6 months by a dedicated committee to ensure that they reflect the latest evidence-based regimens. This integrated system helps keep oncologists informed of the most current treatment options across all US Oncology practices.

AJMC: How do you educate patients about endometrial cancer care options to promote optimal treatment outcomes?

Hudson: Patient education is prioritized through the Texas Oncology Foundation. A key initiative is the annual Survive and Thrive Symposium,⁷ to which all of our patients with cancer from across all the state of Texas are invited for educational workshops. These sessions cover vital topics, including cancer treatment, long-term adverse effects, financial toxicity, and overall wellness.

Additionally, the Foundation hosts a virtual survivorship boot camp that offers support and educational resources and features expert-led discussions on various subjects. Many of our centers also conduct educational sessions led by social workers and dietitians. These sessions focus on nutrition, caregiving, and other important areas. In my role focused on survivorship, I strive to enhance our supportive care offerings. We have developed a nutrition program accessible to all patients that includes virtual consultations with bilingual dietitians. Monthly webinars provide further education. Additionally, before starting treatment, each patient receives an hourlong educational session with an APP to ensure that they understand their specific treatment plan.

Not all sites have social workers, but a social work director is available to assist practices with urgent needs and connect patients with resources. A mental health crisis professional is available to support those experiencing immediate mental health challenges. Palliative care providers are also available. We aim to support our patients holistically throughout their cancer journey.

AJMC: Please expand on how Texas Oncology addresses gaps in care to minimize the health care disparities among patients with endometrial cancer.

de la Garza: Our approach emphasizes education and outreach, informing both patients and referring providers that we are willing to conduct evaluations, including procedures like pelvic examinations, dilation and curettage, or biopsies, without requiring a prior diagnosis. By making our services known and accessible, we aim to alleviate the burden on patients who may lack the understanding or resources to navigate their symptoms. For example, we encourage patients experiencing symptoms such as postmenopausal bleeding to consult with us directly.

In our efforts to expand access to gynecologic oncology care, Texas Oncology has prioritized providing services to underserved and remote areas. Texas Oncology works closely with hospitals and referral networks to offer surgical and oncology services to both funded and unfunded patients across these regions.

Hudson: We also are advancing our personalized approach to endometrial cancer management by integrating SDOH screening into our EHR. Currently, each visit includes a paper-based screening using a distress thermometer and questions about SDOH. High scores on the distress thermometer automatically trigger a social worker referral, ensuring timely support for patients experiencing substantial stressors. This process will be moving to an electronic format soon, which will streamline SDOH data collection and make it accessible in the EHR for more comprehensive, individualized care.

In addition, to minimize disparities in cancer care, we also are focusing on enhancing access to clinical trials, which are critical for delivering innovative treatments. Texas Oncology offers clinical trials through Sarah Cannon Research Institute, one of the world’s leading oncology research organizations conducting community-based clinical trials.⁸ Unlike traditional academic centers, which often require patients to travel for trial participation, we open trials at multiple community sites throughout the state. This approach has been shown to reduce travel burdens and increase access for underrepresented populations.

Recently, we collaborated on a study to increase participation of underrepresented groups in clinical trials. By opening sites at locations convenient to these patients, we achieved the highest representation of Black and Hispanic patients in the trial. Through innovative strategies like this, we are committed to bringing clinical trials to all patients.

AJMC: How do you collaborate with patients to navigate and manage their preferences and expectations for treatment?

de la Garza: Effective collaboration with patients begins with building trust. From the first visit to the last, it’s essential to communicate honestly in a language they understand and to ensure that they feel comfortable and confident. Once trust is established, patients are more likely to fully commit to their treatment plans.

Additionally, it’s crucial to meet patients halfway by adapting to their needs. For instance, if a medical oncologist can provide treatment closer to home, or if an APP can offer chemotherapy on a day when I am in surgery, these options can enhance the patient experience. Ultimately, the foundation of a successful partnership lies in developing a strong partnership based on trust, adaptability, and a shared commitment to the patient’s well-being.

Hudson: Patient preferences substantially influence oncology treatment decisions. During discussions about treatment options, I assess patients’ priorities. For example, some patients undergoing chemotherapy may prefer oral medications (if possible) for convenience, whereas others may choose IV treatment based on efficacy or personal comfort.

As oncologists, it is essential to engage patients in these conversations and to consider their preferences alongside clinical data, financial implications, and potential adverse events. This collaborative approach not only respects patient autonomy but also ensures that treatment plans align with patients’ priorities and lifestyle.

AJMC: How does Texas Oncology use patient-reported outcomes to improve care, and how do you make these tools accessible to all patients?

Hudson: At Texas Oncology, we utilize the Navigating Cancer platform,⁹ a patient-reported outcomes (PRO) tool in which all patients undergoing active treatment are enrolled. This platform allows patients to enter their symptoms and receive tailored educational materials regarding their specific cancer and treatment regimen. Our dedicated committee reviews these materials (developed by the platform) to ensure that they are appropriate and beneficial before distribution.

We have found that PRO programs can enhance quality of life for patients with cancer. Since initiating the PRO program in 2020, we have enrolled thousands of patients, aiming to effectively manage symptoms, reduce hospitalizations, and potentially extend survival. Our PRO program enables patients to receive real-time responses to their reported symptoms. Patients complete weekly questionnaires, and if any symptoms reach a certain severity, triage nurses promptly address their concerns, often within hours. This approach has been successful in reducing ED visits and hospital admissions,¹⁰ demonstrating the program’s value. One of the reasons it has been successful is that we have really invested in our nurses, hiring more triage nurses to address the patients’ responses and investing in provider education.

To accommodate patients who may not have smartphones or those living in rural areas with limited internet access, we plan to implement alternative communication methods such as telephone calls and in-office assessments. We also aim to develop an audio program that allows patients to report symptoms via recorded messages on landlines. These enhancements will ensure that all patients can participate in our PRO program regardless of their technological access.

AJMC: What advice would you give to another organization looking to ensure that all patients with endometrial cancer have access to the most innovative and appropriate treatments?

de la Garza: To implement a successful program, organizations should focus on leveraging their strengths and establishing a robust business model. A high-volume, efficient practice that provides value-based care not only improves service quality but also opens opportunities to support underfunded patients.

Understanding patient needs also is essential. For example, a single physician will not be able provide the needed care for a large, underserved population. Instead, integrating with successful, resource-rich systems can enhance care coordination and support for patients lacking coverage. The key is to create a hybrid model that allows high-functioning clinics to incorporate unfunded patients.

Our success in ensuring access to innovative treatments stems from a strong foundation: a dedicated team of hardworking providers and a sustainable clinic model. By building a high-functioning, patient-centered program, we’re able to serve diverse patient groups, expand access, and deliver the best care to all patients.

AJMC: What are some low-cost initiatives that centers could implement to address the disparities in care among their patient populations?

Hudson: To address disparities in care, community outreach is essential. Many communities harbor distrust toward health care providers and systems, so it’s vital for oncology professionals to engage directly with patients in their local settings. For example, offering screenings at community centers not only demonstrates available resources but also helps to build trust and rapport.

Additionally, fostering strong relationships with PCPs and facilities that serve underserved populations can improve care access. By collaborating with these providers, oncology centers can create a more integrated approach to health care that effectively addresses the needs of these communities.

REFERENCES

1. Who we are. Texas Oncology. Accessed November 4, 2024. https://www.texasoncology.com/who-we-are

2. Mobile mammography. Lone Start Circle of Care. Accessed November 4, 2024. https://lonestarcares.org/service/mobile-mammography-big-pink-bus/

3. Texas Oncology Foundation. Accessed November 4, 2024. https://texasoncologyfoundation.org/

4. Partners. National Ovarian Cancer Coalition. Accessed November 4, 2024. https://ovarian.org/aboutnocc/partners/Community Education and Outreach Program. Breast Cancer Resource Center. Accessed

5. November 4, 2024. https://bcrc.org/community-education-and-outreach/

6. About us. HCA Healthcare, Sarah Cannon Cancer Network. Accessed November 4, 2024. https://sarahcannon.com/about/

7. iKnowMed. Ontada. Accessed November 4, 2024. https://www.ontada.com/providers-solutions/iknowmed/

8. Survive and Thrive Conference. Texas Oncology Foundation. Accessed November 4, 2024. https://texasoncologyfoundation.org/programs/survive-thrive-symposium/

9. Digital health solutions that improve the lives of cancer patients. Navigating Cancer. Accessed November 4, 2024. https://www.navigatingcancer.com/

10. Patt DA, Patel AM, Bhardwaj A, et al. Impact of remote symptom monitoring with electronic patient-reported outcomes on hospitalization, survival, and cost in community oncology practice: the Texas Two-Step Study. JCO Clin Cancer Inform. 2023;7:e2300182. doi:10.1200/CCI.23.00182