Surgical Cancer Care in Safety-Net Hospitals: a Systematic Review

INTRODUCTION: Care delivery in quaternary medical centers in the United States has been developed to provide quality, high-volume surgical cancer care. For the most vulnerable populations, however, safety-net hospitals (SNHs) remain their home for both complex and routine healthcare needs. The objective of this study was to assess the access to and quality of surgical oncology care in SNHs. METHODS: A comprehensive and systematic review of the literature was conducted using the PubMed, EMBASE, and Cochrane Library databases to identify all studies (2000 to present) describing the delivery of surgical cancer care at SNHs in the United States (PROSPERO #CRD42021290092). These studies described the process and/or outcomes of surgical care for gastrointestinal, hepatopancreatobiliary, or breast cancer patients seeking treatment at SNHs. RESULTS: Of 4,530 records, 37 studies met inclusion criteria. Surgical care for breast cancer (43%) was the most represented, followed by colorectal (30%) and hepatopancreatobiliary cancers (16%). Financial constraints, cultural and language barriers, and limitations to insurance coverage were cited as common reasons for disparities in care within SNHs. Advanced disease at presentation was common among cancer patients seeking care at SNHs (range 24% to 61% of patients). Although reports comparing overall survival between SNHs and non-SNHs were few, results were mixed, underscoring the variability in care across SNHs. CONCLUSION: These findings highlight barriers in care facing many cancer patients. Continued efforts should address improved access and quality of care for SNH patients. Future models include a transition away from a two-tiered system of resourced and under-resourced hospitals, toward an integrated cancer system.