Navigating Choices: A Qualitative Exploration of Treatment Location Decisions and Referral Processes in Metastatic Breast Cancer Care

Background: Rurality is a risk factor for metastatic breast cancer (MBC), mediated by factors such as distance to treatment centers and screening access. Coordinating optimal timing of genetic, genomic, and other advanced testing to identify next-line therapies and expand access to clinical trials is crucial. This qualitative study explored factors that patients with MBC consider when choosing a treatment location, and barriers and facilitators to referral between facilities. Materials and Methods: Thirteen patients and four clinicians from rural settings completed semistructured interviews. Transcripts were analyzed using NVivo software and deductive coding guided by the Health Equity Implementation Framework. Codes from transcripts were analyzed for themes or barriers and facilitators to referral. Results: We identified five themes describing factors involved in treatment location decision-making: distinctive features shaping rural care experiences, care preferences formed across multiple levels of influence, decisions based on position within cancer survivorship, splitting care between facilities based on care type, and differing priorities for those receiving local care vs. traveling to a comprehensive cancer center. We identified seven barriers to referral: incomplete communication, outdated/incompatible medical record systems, lack of awareness of options, military insurance requirements, procedural requirements of referral institutions, timeliness, and travel. Facilitators included formal/informal collaboration between institutions, support from clinicians, common electronic medical record systems, and patient self-advocacy. Conclusions: This study sets the foundation for characterizing factors that influence where rural patients receive care and works toward providing patient-centered care, focusing on decreasing travel burden and optimizing referral between local and distant options.