Multilevel Barriers Continue to Limit Guideline-Concordant Care in Foregut Cancers, Stakeholder Study Finds

A qualitative study examining care delivery for foregut cancers highlights persistent, multilevel barriers that prevent up to half of patients from receiving guideline-concordant treatment, while offering pragmatic, stakeholder-driven strategies to improve outcomes—particularly in resource-constrained and rural settings.

Foregut malignancies—including cancers of the esophagus, stomach, pancreas, and biliary tract—require complex, multidisciplinary management. Yet, despite established clinical pathways, an estimated 30% to 55% of patients fail to receive recommended care. To better understand why, researchers conducted 12 semi-structured interviews with health system stakeholders across a safety-net hospital and its surrounding rural catchment area in the Southeastern US.

The findings reveal that barriers are not isolated but instead span 4 interconnected levels: individual, provider, institutional, and policy.

At the individual level, stakeholders pointed to financial toxicity, transportation limitations, and psychosocial distress as major impediments to treatment adherence. These challenges often intersect, compounding delays or preventing patients from accessing specialty care altogether.

The provider-level barriers identified in the study are centered on communication gaps. Participants described both inadequate physician-patient communication and limited coordination among providers, particularly between community clinicians and specialists. These disconnects can delay decision-making and disrupt care continuity. Institutional barriers further complicate care delivery. Stakeholders cited delays in accessing specialty services, inefficient scheduling systems, and limited institutional resources as key obstacles. These issues are particularly acute in safety-net settings, where demand often exceeds capacity.

At the policy level, structural challenges—including fragmented care systems, insufficient subspecialty coverage in rural areas, and inadequate reimbursement—were identified as critical drivers of inequity. These systemic issues contribute to disparities in access and limit the scalability of high-quality cancer care models.

Importantly, the study moves beyond identifying barriers to propose actionable solutions informed directly by stakeholders. These strategies emphasize care coordination, communication, and system-level integration.

Proposed interventions include strengthening institutional psychiatric and supportive care programs to address psychosocial burdens, enhancing inter-provider communication through more structured engagement, and streamlining referral pathways to reduce delays in specialty access. Stakeholders also highlighted the need for targeted recruitment of rural physicians to expand subspecialty capacity and called for reimbursement reform to better support complex cancer care delivery.

As one participant noted, “interventions emphasizing communication, navigation, and system-level integration” are essential to improving care delivery in these environments.

For oncology leaders and pathway developers, the study underscores the importance of designing clinical pathways that account for real-world delivery constraints—not just clinical efficacy. Pathways that fail to integrate navigation support, referral efficiency, and cross-provider communication risk limited adoption and suboptimal outcomes.

Key Takeaways:

• Embed navigation into pathways: Financial, transportation, and psychosocial barriers directly impact adherence; navigation services should be a core component of pathway design.
• Prioritize communication infrastructure: Standardized communication protocols between community providers and specialists can reduce delays and improve coordination.
• Streamline referral systems: Efficient, transparent referral pathways are critical to ensuring timely access to multidisciplinary care.
• Address rural access gaps: Workforce strategies, including targeted subspecialist recruitment, are essential to expanding access in underserved regions.
• Align reimbursement with complexity: Payment models must reflect the resource intensity of multidisciplinary foregut cancer care to support sustainable delivery.

The study reinforces that improving guideline-concordant care in foregut cancers will require more than clinical guidance alone. Instead, coordinated, multilevel interventions—grounded in the realities of frontline care delivery—are necessary to close persistent gaps and optimize outcomes.

Reference

Sanghera J, et al. Examining health system stakeholder-reported barriers and solutions to foregut cancer care. J AM J Surg. 254(116824);2026. doi:10.1016/j.amjsurg.2026.116824