Disparities in Gynecological Malignancies

open access

Introduction

The Institute of Medicine released a landmark report in 2003 titled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” which demonstrated disparities in the U.S. health care system between treatment of racial and ethnic minorities and Whites, subsequently resulting in poorer health outcomes for millions of Americans (1).

Since that time, the National Cancer Institute (NCI) through the Center to Reduce Cancer Health Disparities (CRCHD), the American Cancer Society, the American Society of Clinical Oncology, and the Society of Gynecologic Oncology has committed to the goals of eliminating disparities in cancer-related outcomes (2–4). The NCI defines cancer health disparities as “differences in the incidence, prevalence, mortality, and burden of cancer and adverse related conditions that exist among specific population groups in the United States (2).”.....

Geographic Access and Hospital-Based Discrepancies

Research-Based Discrepancies

Socioeconomic Status and Health Insurance Status

Race

 Ovarian Cancer

Epithelial ovarian cancer (EOC) is the fifth cause of cancer death among women in the United States, accounting for an estimated 21,290 new cases and 14,180 cancer deaths in the US in 2015 (31). With aggressive surgical and chemotherapeutic management, overall survival has improved from 36% during the period of 1975–1977 to 45% during the period 2004–2010 (p < 0.05). However, the survival rate over the same time period for Black women has actually decreased from 42 to 36% (46). From 2002 to 2011, the mortality rate associated with ovarian cancer decreased significantly by 2% per year among White women, 1.4% per year among Hispanic women, but remained unchanged among Black women (47).

Several studies have demonstrated that worse survival outcomes among the Black population results from barriers that impede access to quality care and standardized evidence-based surgical and adjuvant treatment (32, 36, 48). Although the incidence of ovarian cancer is higher among White women (12.8 new cases per 100,000) compared to Black women (9.8 new cases per 100,0000), Black women tend to present with more advanced stage ovarian cancer compared to White women (49, 50). Black women have a higher incidence of medical comorbidities compared to White women that may influence treatment decisions (51, 52). However, several studies evaluating large nationally representative databases have demonstrated that Black patients are less likely to receive treatment consistent with evidence-based guidelines and have worse survival outcomes even after accounting for stage and comorbidities (32, 36, 37, 53). Parham et al. found that Black patients were less likely to receive combined surgery and chemotherapy treatment (48). In an analysis of a state specific database, Bristow et al. found that compared to White patients, Black race was associated with a statistically significant and independent lower likelihood of hysterectomy, lymphadenectomy, bowel resection, and surgery by a high-volume surgeon (54). Goff et al. also found that Black and Hispanic patients were also less likely to receive comprehensive staging compared to White patients (14). A SEER analysis by Wright et al. demonstrated delayed administration of adjuvant chemotherapy in Black patients, which was associated with an increased mortality rate (55). Importantly, the difference in survival outcomes among races is reduced or eliminated after accounting for access issues, socioeconomic status, stage, and treatment (4). The similarity in survival outcomes is highlighted in several GOG clinical trials where Black and White women receive similar treatments (56, 57). After review of available literature, it appears that equal treatment yields equivalent survival outcomes for both Black and White patients with ovarian cancer (4).

  
Conclusion

Health care disparities in the incidence and outcome of gynecologic cancers persist and, in some cases, are worsening. The explanation for these disparities is complex and involves racial, economic, geographic, and biologic factors that influence treatment and survival. Much of the information available outlining these disparities have focused on disparities between Black and White women, with limited studies available regarding other minority populations. Additionally, as most of the studies investigating health disparities evaluated large nationally representative databases with limited detailed clinical information, it is not possible to account for other confounding factors that may have influenced treatment decisions or deviations from evidence-based guidelines. Despite diagnostic and therapeutic advances that have resulted in improved survival among American women in general, significant barriers exist in providing optimal care to millions of women in the US with gynecologic cancer. While not all factors involved in healthcare disparities are modifiable, identification and elimination of those that are must be a considered a top priority in a country that considers access to quality healthcare a basic human right.