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Lee MW, Vallejo A, Furey KB, Woll SM, Klar M, Roman LD, Wright JD, Matsuo K. Racial and ethnic differences in early death among gynecologic malignancy. Am J Obstet Gynecol 2024; 231:231.e1-231.e11. [PMID: 38460831 DOI: 10.1016/j.ajog.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Racial and ethnic differences in early death after cancer diagnosis have not been well studied in gynecologic malignancy. OBJECTIVE This study aimed to assess population-level trends and characteristics of early death among patients with gynecologic malignancy based on race and ethnicity in the United States. STUDY DESIGN The National Cancer Institute's Surveillance, Epidemiology, and End Results Program was queried to examine 461,300 patients with gynecologic malignancies from 2000 to 2020, including uterine (n=242,709), tubo-ovarian (n=119,989), cervical (n=68,768), vulvar (n=22,991), and vaginal (n=6843) cancers. Early death, defined as a mortality event within 2 months of the index cancer diagnosis, was evaluated per race and ethnicity. RESULTS At the cohort level, early death occurred in 21,569 patients (4.7%), including 10.5%, 5.5%, 2.9%, 2.5%, and 2.4% for tubo-ovarian, vaginal, cervical, uterine, and vulvar cancers, respectively (P<.001). In a race- and ethnicity-specific analysis, non-Hispanic Black patients with tubo-ovarian cancer had the highest early death rate (14.5%). Early death racial and ethnic differences were the largest in tubo-ovarian cancer (6.4% for Asian vs 14.5% for non-Hispanic Black), followed by uterine (1.6% for Asian vs 4.9% for non-Hispanic Black) and cervical (1.8% for Hispanic vs 3.8% to non-Hispanic Black) cancers (all, P<.001). In tubo-ovarian cancer, the early death rate decreased over time by 33% in non-Hispanic Black patients from 17.4% to 11.8% (adjusted odds ratio, 0.67; 95% confidence interval, 0.53-0.85) and 23% in non-Hispanic White patients from 12.3% to 9.5% (adjusted odds ratio, 0.77; 95% confidence interval, 0.71-0.85), respectively. The early death between-group difference diminished only modestly (12.3% vs 17.4% for 2000-2002 [adjusted odds ratio for non-Hispanic White vs non-Hispanic Black, 0.54; 95% confidence interval, 0.45-0.65] and 9.5% vs 11.8% for 2018-2020 [adjusted odds ratio, 0.65; 95% confidence interval, 0.54-0.78]). CONCLUSION Overall, approximately 5% of patients with gynecologic malignancy died within the first 2 months from cancer diagnosis, and the early death rate exceeded 10% in non-Hispanic Black individuals with tubo-ovarian cancer. Although improving early death rates is encouraging, the difference among racial and ethnic groups remains significant, calling for further evaluation.
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Affiliation(s)
- Matthew W Lee
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Andrew Vallejo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Katelyn B Furey
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Sabrina M Woll
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
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LaRaja A, Connor Y, Poulson MR. The effect of urban racial residential segregation on ovarian cancer diagnosis, treatment, and survival. Gynecol Oncol 2024; 187:163-169. [PMID: 38788513 DOI: 10.1016/j.ygyno.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/01/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE To investigate the effect of racial residential segregation on disparities between Black and White patients in stage at diagnosis, receipt of surgery, and survival. METHODS Subjects included Black and White patients diagnosed with ovarian cancer between 2005 and 2015 obtained from the Surveillance, Epidemiology, and End Results Program. Demographic data were obtained from the 2010 decennial census and 2013 American Community Survey. The exposure of interest was the index of dissimilarity (IOD), a validated measure of segregation. The outcomes of interest included relative risk of advanced stage at diagnosis and surgery for localized disease, 5-year overall and cancer-specific survival. RESULTS Black women were more likely to present with Stage IV ovarian cancer when compared to White (32% vs 25%, p < 0.001) and less often underwent surgical resection overall (64% vs 75%, p < 0.001). Increasing IOD was associated with a 25% increased risk of presenting at advanced stage for Black patients (RR 1.25, 95% CI 1.08, 1.45), and a 15% decrease for White patients (RR 0.85, 95% CI 0.73, 0.99). Increasing IOD was associated with an 18% decreased likelihood of undergoing surgical resection for black patients (RR 0.82, 95% CI 0.77, 0.87), but had no significant association for White patients (RR 1.01, 95% CI 0.96, 1.08). When compared to White patients in the lowest level of segregation, Black patients in the highest level of segregation had a 17% higher subhazard of death (HR 1.17, 95% CI 1.07, 1.27), while Black patients in the lowest level of segregation had no significant difference (HR 1.13, 95% CI 0.99, 1.29). CONCLUSION Our findings demonstrate the direct harm of historical government mandated segregation on Black women with ovarian cancer.
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Affiliation(s)
- Alexander LaRaja
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States.
| | - Yamicia Connor
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Michael R Poulson
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States.
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Antony M, Putnam E, Peltzer C, Levy A. A Scoping Review of Medical Mistrust Among Racial, Ethnic, and Gender Minorities With Breast and Ovarian Cancer. Cureus 2024; 16:e62410. [PMID: 39011181 PMCID: PMC11248488 DOI: 10.7759/cureus.62410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 06/14/2024] [Indexed: 07/17/2024] Open
Abstract
An overarching theme in clinical literature suggests an inherent mistrust among populations of color within the healthcare system and the importance of healthcare professionals to bridge this gap in care. This is especially true when addressing cancer care in underserved populations due to mistrust in providers, diagnostic tools, and treatments. Ovarian cancer is difficult to diagnose early in all populations; however, women of color who have an intrinsic mistrust of the medical community will delay or refuse screenings or treatments that could be greatly beneficial. Similarly, although breast cancer rates are high in women of color, many are reluctant to utilize genetic screenings or counseling services due to bad experiences with healthcare, both personally and within their community. Moreover, transgender patients are at a unique disadvantage, as they face barriers to accessing culturally competent care while also being at a higher risk for developing cancer. The objective of this study was to conduct a scoping review of the literature in order to synthesize knowledge about the climate of mistrust between medical providers and racial, ethnic, and gender minorities with breast cancer and ovarian cancer. It is imperative for healthcare workers to acknowledge medical mistrust and strive to reduce internalized bias, increase their availability to patients, and ensure patients feel heard, respected, and well cared for during visits. Improving care by physicians can enhance trust between underserved communities and healthcare workers, encouraging all people to actively seek proper medical care and cancer screening, potentially resulting in a reduction of mortality and morbidity rates.
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Affiliation(s)
- Manisha Antony
- Medical Education, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Emma Putnam
- Medical Education, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Cadynce Peltzer
- Medical Education, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Arkene Levy
- Medical Education (Pharmacology), Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
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4
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Washington CJ, Karanth SD, Wheeler M, Aduse-Poku L, Braithwaite D, Akinyemiju TF. Racial and socioeconomic disparities in survival among women with advanced-stage ovarian cancer who received systemic therapy. Cancer Causes Control 2024; 35:487-496. [PMID: 37874478 PMCID: PMC10838826 DOI: 10.1007/s10552-023-01810-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/29/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE The purpose of this study was to assess the association between race/ethnicity and all-cause mortality among women with advanced-stage ovarian cancer who received systemic therapy. METHODS We analyzed data from the National Cancer Database on women diagnosed with advanced-stage ovarian cancer from 2004 to 2015 who received systemic therapy. Race/ethnicity was categorized as Non-Hispanic (NH) White, NH-Black, Hispanic, NH-Asian/Pacific Islander, and Other. Income and education were combined to form a composite measure of socioeconomic status (SES) and categorized into low-, mid-, and high-SES. Multivariable Cox proportional hazards models were used to assess whether race/ethnicity was associated with the risk of death after adjusting for sociodemographic, clinical, and treatment factors. Additionally, subgroup analyses were conducted by SES, age, and surgery receipt. RESULTS The study population comprised 53,367 women (52.4% ages ≥ 65 years, 82% NH-White, 8.7% NH-Black, 5.7% Hispanic, and 2.7% NH-Asian/Pacific Islander) in the analysis. After adjusting for covariates, the NH-Black race was associated with a higher risk of death versus NH-White race (aHR: 1.12; 95% CI: 1.07,1.18), while Hispanic ethnicity was associated with a lower risk of death compared to NH-White women (aHR: 0.87; 95% CI: 0.80, 0.95). Furthermore, NH-Black women versus NH-White women had an increased risk of mortality among those with low-SES characteristics (aHR:1.12; 95% CI:1.03-1.22) and mid-SES groups (aHR: 1.13; 95% CI:1.05-1.21). CONCLUSIONS Among women with advanced-stage ovarian cancer who received systemic therapy, NH-Black women experienced poorer survival compared to NH-White women. Future studies should be directed to identify drivers of ovarian cancer disparities, particularly racial differences in treatment response and surveillance.
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Affiliation(s)
- Caretia J Washington
- Department of Epidemiology, University of Florida College of Public Health and Health Professions, Gainesville, FL, USA
| | - Shama D Karanth
- University of Florida Health Cancer Center, Gainesville, FL, USA
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Meghann Wheeler
- Department of Epidemiology, University of Florida College of Public Health and Health Professions, Gainesville, FL, USA
| | - Livingstone Aduse-Poku
- Department of Epidemiology, University of Florida College of Public Health and Health Professions, Gainesville, FL, USA
| | - Dejana Braithwaite
- Department of Epidemiology, University of Florida College of Public Health and Health Professions, Gainesville, FL, USA
- University of Florida Health Cancer Center, Gainesville, FL, USA
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Tomi F Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, 27708, USA.
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA.
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Algera MD, Morton R, Sundar SS, Farrell R, van Driel WJ, Brennan D, Rijken MJ, Sfeir S, Allen L, Eiken M, Coleman RL. Exploring international differences in ovarian cancer care: a survey report on global patterns of care, current practices, and barriers. Int J Gynecol Cancer 2023; 33:1612-1620. [PMID: 37591611 PMCID: PMC10579489 DOI: 10.1136/ijgc-2023-004563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/24/2023] [Indexed: 08/19/2023] Open
Abstract
OBJECTIVE Although global disparities in survival rates for patients with ovarian cancer have been described, variation in care has not been assessed globally. This study aimed to evaluate global ovarian cancer care and barriers to care. METHODS A survey was developed by international ovarian cancer specialists and was distributed through networks and organizational partners of the International Gynecologic Cancer Society, the Society of Gynecologic Oncology, and the European Society of Gynecological Oncology. Respondents received questions about care organization. Outcomes were stratified by World Bank Income category and analyzed using descriptive statistics and logistic regressions. RESULTS A total of 1059 responses were received from 115 countries. Respondents were gynecological cancer surgeons (83%, n=887), obstetricians/gynecologists (8%, n=80), and other specialists (9%, n=92). Income category breakdown was as follows: high-income countries (46%), upper-middle-income countries (29%), and lower-middle/low-income countries (25%). Variation in care organization was observed across income categories. Respondents from lower-middle/low-income countries reported significantly less frequently that extensive resections were routinely performed during cytoreductive surgery. Furthermore, these countries had significantly fewer regional networks, cancer registries, quality registries, and patient advocacy groups. However, there is also scope for improvement in these components in upper-middle/high-income countries. The main barriers to optimal care for the entire group were patient co-morbidities, advanced presentation, and social factors (travel distance, support systems). High-income respondents stated that the main barriers were lack of surgical time/staff and patient preferences. Middle/low-income respondents additionally experienced treatment costs and lack of access to radiology/pathology/genetic services as main barriers. Lack of access to systemic agents was reported by one-third of lower-middle/low-income respondents. CONCLUSIONS The current survey report highlights global disparities in the organization of ovarian cancer care. The main barriers to optimal care are experienced across all income categories, while additional barriers are specific to income levels. Taking action is crucial to improve global care and strive towards diminishing survival disparities and closing the care gap.
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Affiliation(s)
- Marc Daniël Algera
- Gynecology Oncology, Maastricht UMC+, Maastricht, The Netherlands
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
- GROW- School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Rhett Morton
- Obstetrics and Gynaecology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Sudha S Sundar
- Department of Gynaecology Oncology, University of Birmingham, West Midlands, UK
| | - Rhonda Farrell
- Gynaecology, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Willemien J van Driel
- Gynecologic Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Donal Brennan
- Gynaecology Oncology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Marcus J Rijken
- Gynecologic Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Selina Sfeir
- Department of Gynaecology Oncology, University of Birmingham, Birmingham, UK
| | - Lucy Allen
- Department of Gynaecology Oncology, University of Birmingham, Birmingham, UK
| | - Mary Eiken
- International Gynecologic Cancer Society, Austin, Texas, USA
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Gelissen JH, Adjei NN, McNamara B, Mutlu L, Harold JA, Clark M, Altwerger G, Dottino PR, Huang GS, Santin AD, Azodi M, Ratner E, Schwartz PE, Andikyan V. Hyperthermic Intraperitoneal Chemotherapy in Ovarian Cancer. Ann Surg Oncol 2023; 30:5597-5609. [PMID: 37358686 DOI: 10.1245/s10434-023-13757-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/04/2023] [Indexed: 06/27/2023]
Abstract
Hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment modality that aims to target the main site of tumor dissemination in ovarian cancer, the peritoneum, by combining the benefits of intraperitoneal chemotherapy with the synergistic effects of hyperthermia all during a single administration at the time of cytoreductive surgery. High-quality evidence currently only supports the use of HIPEC with cisplatin at the time of interval cytoreduction after neoadjuvant chemotherapy for stage III epithelial ovarian cancer. Many questions remain, including HIPEC's role at other timepoints in ovarian cancer treatment, who are optimal candidates, and specifics of HIPEC protocols. This article reviews the history of normothermic and hyperthermic intraperitoneal chemotherapy in ovarian cancer and evidence regarding HIPEC implementation and patient outcomes. Additionally, this review explores details of HIPEC technique and perioperative care, cost considerations, complication and quality of life data, disparities in HIPEC use, and unresolved issues.
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Affiliation(s)
- Julia H Gelissen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA.
| | - Naomi N Adjei
- Gynecologic Oncology and Reproductive Medicine Department, MD Anderson Cancer Center, Houston, TX, USA
| | - Blair McNamara
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Levent Mutlu
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Justin A Harold
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Mitchell Clark
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Gary Altwerger
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Peter R Dottino
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Gloria S Huang
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Alessandro D Santin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Masoud Azodi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Elena Ratner
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Peter E Schwartz
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Vaagn Andikyan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
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Montes de Oca MK, Chen Q, Howell E, Wilson LE, Meernik C, Previs RA, Huang B, Pisu M, Liang MI, Ward KC, Schymura MJ, Berchuck A, Akinyemiju T. Health-care access dimensions and ovarian cancer survival: SEER-Medicare analysis of the ORCHiD study. JNCI Cancer Spectr 2023; 7:pkad011. [PMID: 36794910 PMCID: PMC10066801 DOI: 10.1093/jncics/pkad011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/07/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities in ovarian cancer (OC) survival are well-documented. However, few studies have investigated how health-care access (HCA) contributes to these disparities. METHODS To evaluate the influence of HCA on OC mortality, we analyzed 2008-2015 Surveillance, Epidemiology, and End Results-Medicare data. Multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between HCA dimensions (affordability, availability, accessibility) and OC-specific and all-cause mortality, adjusting for patient characteristics and treatment receipt. RESULTS The study cohort included 7590 OC patients: 454 (6.0%) Hispanic, 501 (6.6%) Non-Hispanic (NH) Black, and 6635 (87.4%) NH White. Higher affordability (HR = 0.90, 95% CI = 0.87 to 0.94), availability (HR = 0.95, 95% CI = 0.92 to 0.99), and accessibility scores (HR = 0.93, 95% CI = 0.87 to 0.99) were associated with lower risk of OC mortality after adjusting for demographic and clinical factors. Racial disparities were observed after additional adjustment for these HCA dimensions: NH Black patients experienced a 26% higher risk of OC mortality compared with NH White patients (HR = 1.26, 95% CI = 1.11 to 1.43) and a 45% higher risk among patients who survived at least 12 months (HR = 1.45, 95% CI = 1.16 to 1.81). CONCLUSIONS HCA dimensions are statistically significantly associated with mortality after OC and explain some, but not all, of the observed racial disparity in survival of patients with OC. Although equalizing access to quality health care remains critical, research on other HCA dimensions is needed to determine additional factors contributing to disparate OC outcomes by race and ethnicity and advance the field toward health equity.
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Affiliation(s)
| | - Quan Chen
- Division of Cancer Biostatistics and Kentucky Cancer Registry, University of Kentucky, Lexington, KY, USA
| | - Elizabeth Howell
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Clare Meernik
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Rebecca A Previs
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Bin Huang
- Division of Cancer Biostatistics and Kentucky Cancer Registry, University of Kentucky, Lexington, KY, USA
| | - Maria Pisu
- Division of Preventive Medicine and O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Margaret I Liang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Maria J Schymura
- New York State Department of Health, New York State Cancer Registry, Albany, NY, USA
| | - Andrew Berchuck
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Tomi Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
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Adebayo N, Dunne W, Dean JR, O'Brian C, Dahdouh R, Simon MA. Tackling Gynecologic Cancer Disparities: An Assessment of 2 Interventions for Improving Information Exchange With Racial/Ethnic Communities. Clin Obstet Gynecol 2023; 66:43-52. [PMID: 36162097 PMCID: PMC9851936 DOI: 10.1097/grf.0000000000000742] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Racial health disparities continue to greatly impact the incidence and mortality rates of gynecologic cancers. Although there are many drivers for these disparities, limited inclusion of vulnerable populations in clinical research and narrowed medical knowledge of patients are large contributors that disproportionately affect racial/ethnic communities. To mitigate these disparities, we must look for avenues that connect patients from these communities to cancer researchers. In this review, we summarize 2 projects that can serve as models for future interventions that promote education and engagement in clinical research for populations most impacted by gynecologic cancer disparities.
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Affiliation(s)
- Nihmotallahi Adebayo
- Center for Health Equity Transformation, Department of Obstetrics and Gynecology
| | - Will Dunne
- Center for Health Equity Transformation, Department of Obstetrics and Gynecology
| | - Julie Robin Dean
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Catherine O'Brian
- Center for Health Equity Transformation, Department of Obstetrics and Gynecology
| | - Rabih Dahdouh
- Center for Health Equity Transformation, Department of Obstetrics and Gynecology
| | - Melissa A Simon
- Center for Health Equity Transformation, Department of Obstetrics and Gynecology
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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9
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Amin SA, Collin LJ, Setoguchi S, Satagopan JM, Buckley de Meritens A, Bandera EV. Neoadjuvant Chemotherapy in Ovarian Cancer: Are There Racial Disparities in Use and Survival? Cancer Epidemiol Biomarkers Prev 2023; 32:175-182. [PMID: 36409506 PMCID: PMC9905268 DOI: 10.1158/1055-9965.epi-22-0758] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND We investigated racial and ethnic disparities in treatment sequence [i.e., neoadjuvant chemotherapy (NACT) plus interval debulking surgery (IDS) versus primary debulking surgery (PDS) plus adjuvant chemotherapy] among patients with ovarian cancer and its contribution to disparities in mortality. METHODS Study included 37,566 women ages ≥18 years, diagnosed with stage III/IV ovarian cancer from the National Cancer Database (2004-2017). Logistic regression was used to compute ORs and 95% confidence intervals (CI) for racial and ethnic disparities in treatment sequence. Cox proportional hazards regression was used to estimate HRs and 95% CI for racial and ethnic disparities in all-cause mortality. RESULTS Non-Hispanic Black (NHB) and Asian women were more likely to receive NACT plus IDS relative to PDS plus adjuvant chemotherapy than non-Hispanic White (NHW) women (OR: 1.12; 95% CI: 1.02-1.22 and OR: 1.12; 95% CI: 0.99-1.28, respectively). Compared with NHW women, NHB women had increased hazard of all-cause mortality (HR: 1.14; 95% CI: 1.09-1.20), whereas Asian and Hispanic women had a lower hazard of all-cause mortality (HR: 0.81; 95% CI: 0.74-0.88 and HR: 0.83; 95% CI: 0.77-0.88, respectively), which did not change after accounting for treatment sequence. CONCLUSIONS NHB women were more likely to receive NACT plus IDS and experience a higher all-cause mortality rates than NHW women. IMPACT Differences in treatment sequence did not explain racial disparities in all-cause mortality. Further evaluation of racial and ethnic differences in treatment and survival in a cohort of patients with detailed treatment information is warranted.
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Affiliation(s)
- Saber A Amin
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Lindsay J Collin
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Soko Setoguchi
- Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jaya M Satagopan
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.,Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
| | - Alexandre Buckley de Meritens
- Division of Gynecologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.,Department of Obstetrics and Gynecology and Reproductive Sciences, Division of Gynecologic Oncology, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Elisa V Bandera
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
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Gupta A, Chen Q, Wilson LE, Huang B, Pisu M, Liang M, Previs RA, Moss HA, Ward KC, Schymura MJ, Berchuck A, Akinyemiju TF. Factor Analysis of Health Care Access With Ovarian Cancer Surgery and Gynecologic Oncologist Consultation. JAMA Netw Open 2023; 6:e2254595. [PMID: 36723938 PMCID: PMC9892953 DOI: 10.1001/jamanetworkopen.2022.54595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Poor health care access (HCA) is associated with racial and ethnic disparities in ovarian cancer (OC) survival. OBJECTIVE To generate composite scores representing health care affordability, availability, and accessibility via factor analysis and to evaluate the association between each score and key indicators of guideline-adherent care. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from patients with OC diagnosed between 2008 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) Medicare database. The SEER Medicare database uses cancer registry data and linked Medicare claims from 12 US states. Included patients were Hispanic, non-Hispanic Black, and non-Hispanic White individuals aged 65 years or older diagnosed from 2008 to 2015 with first or second primary OC of any histologic type (International Classification of Diseases for Oncology, 3rd Edition [ICD-O-3] code C569). Data were analyzed from June 2020 to June 2022. EXPOSURES The SEER-Medicare data set was linked with publicly available data sets to obtain 35 variables representing health care affordability, availability, and accessibility. A composite score was created for each dimension using confirmatory factor analysis followed by a promax (oblique) rotation on multiple component variables. MAIN OUTCOMES AND MEASURES The main outcomes were consultation with a gynecologic oncologist for OC and receipt of OC-related surgery in the 2 months prior to or 6 months after diagnosis. RESULTS The cohort included 8987 patients, with a mean (SD) age of 76.8 (7.3) years and 612 Black patients (6.8%), 553 Hispanic patients (6.2%), and 7822 White patients (87.0%). Black patients (adjusted odds ratio [aOR], 0.75; 95% CI, 0.62-0.91) and Hispanic patients (aOR, 0.81; 95% CI, 0.67-0.99) were less likely to consult a gynecologic oncologist compared with White patients, and Black patients were less likely to receive surgery after adjusting for demographic and clinical characteristics (aOR, 0.76; 95% CI, 0.62-0.94). HCA availability and affordability were each associated with gynecologic oncologist consultation (availability: aOR, 1.16; 95% CI, 1.09-1.24; affordability: aOR, 1.13; 95% CI, 1.07-1.20), while affordability was associated with receipt of OC surgery (aOR, 1.08; 95% CI, 1.01-1.15). In models mutually adjusted for availability, affordability, and accessibility, Black patients remained less likely to consult a gynecologic oncologist (aOR, 0.80; 95% CI, 0.66-0.97) and receive surgery (aOR, 0.80; 95% CI, 0.65-0.99). CONCLUSIONS AND RELEVANCE In this cohort study of Hispanic, non-Hispanic Black, and non-Hispanic White patients with OC, HCA affordability and availability were significantly associated with receiving surgery and consulting a gynecologic oncologist. However, these dimensions did not fully explain racial and ethnic disparities.
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Affiliation(s)
- Anjali Gupta
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Quan Chen
- Department of Biostatistics and Kentucky Cancer Registry, University of Kentucky, Lexington
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Bin Huang
- Department of Biostatistics and Kentucky Cancer Registry, University of Kentucky, Lexington
| | - Maria Pisu
- O'Neal Comprehensive Cancer Center, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham
| | - Margaret Liang
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham
| | - Rebecca A Previs
- Duke Cancer Institute, Division of Gynecologic Oncology, Duke University School of Medicine, Durham, North Carolina
- Labcorp Oncology, Durham, North Carolina
| | - Haley A Moss
- Duke Cancer Institute, Division of Gynecologic Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Kevin C Ward
- Georgia Cancer Registry, Emory University, Atlanta
| | - Maria J Schymura
- New York State Cancer Registry, New York State Department of Health, Albany
| | - Andrew Berchuck
- Duke Cancer Institute, Division of Gynecologic Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Tomi F Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
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11
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Shingala K, Stavros S, Parag S, Tercek A, Makhani SS, Bouz A, Galbo A, Chung-Bridges K. Racial Disparities in Survival Outcomes of Patients With Serous Epithelial Ovarian Cancer: A Retrospective Cohort Analysis. Cureus 2023; 15:e34389. [PMID: 36874646 PMCID: PMC9977206 DOI: 10.7759/cureus.34389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/30/2023] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To identify racial disparities in five-year survival rates in women affected by serous epithelial ovarian carcinoma in the United States (US). METHODS This retrospective cohort study analyzed data from the 2010 to 2016 Surveillance, Epidemiology, and End Results (SEER) program database. Women with a primary malignancy of serous epithelial ovarian carcinoma, using International Classification of Diseases for Oncology (ICD-O) Topography Coding and ICD-O-3 Histology Coding, were included in this study. Race and ethnicity were combined into the following groups: Non-Hispanic White (NHW), Non-Hispanic Black (NHB), Non-Hispanic Asian/Pacific Islander (NHAPI), Non-Hispanic Other (NHO), and Hispanics. Cancer-specific survival was measured at five years post-diagnosis. A comparison of baseline characteristics was assessed using Chi-squared tests. Unadjusted and adjusted Cox regression models were used to calculate hazard ratios (HR) and corresponding 95% confidence intervals (CI). RESULTS From 2010 to 2016, there were 9,630 women with a primary diagnosis of serous ovarian carcinoma identified in the SEER database. A higher proportion of Asian/PI women (90.7%) were diagnosed with high-grade malignancy (poorly differentiated/undifferentiated) compared to NHW women (85.4%). NHB women (9.7%) were less likely to undergo surgery when compared to NHW women (6.7%). Hispanic women had the highest proportion of uninsured women (5.9%), while NHW and NHAPI had the lowest (2.2% each). A higher proportion of NHB (74.2%) and Asian/PI (71.3%) women presented with the distant disease compared to NHW women (70.2%). After adjustment for age, insurance, marital status, stage, metastases, and surgical resection, NHB women had the highest hazard of death within five years compared to NHW women (adjusted (adj) HR 1.22, 95% CI 1.09-1.36, p<0.001). Hispanic women also had lower five-year survival probabilities compared to NHW women (adj HR 1.21, 95% CI 1.12-1.30, p<0.001). Patients undergoing surgery had significantly increased survival probability compared to those who did not (p<0.001). As expected, women with Grade III and Grade IV disease both had significantly lower five-year survival probabilities compared to Grade I (p<0.001). CONCLUSION This study reveals that there is an association between race and overall survival in patients with serous ovarian carcinoma, with NHB and Hispanic women having the highest hazards of death compared to NHW women. This adds to the existing body of literature as survival outcomes in Hispanic patients relative to NHW patients are not well documented. Because of the potential interplay between overall survival and several factors including race, future studies should aim to investigate other socioeconomic factors that may be impacting survival.
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Affiliation(s)
- Kishan Shingala
- College of Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Davie, USA
| | - Sarah Stavros
- Medical and Population Health Sciences Research, Florida International University (FIU) Herbert Wertheim College of Medicine, Miami, USA
| | - Sonam Parag
- College of Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Davie, USA
| | - Abigail Tercek
- Medical and Population Health Sciences Research, Florida International University (FIU) Herbert Wertheim College of Medicine, Miami, USA
| | - Sarah S Makhani
- Medical and Population Health Sciences Research, Florida International University (FIU) Herbert Wertheim College of Medicine, Miami, USA
| | - Antoun Bouz
- Medical and Population Health Sciences Research, Florida International University (FIU) Herbert Wertheim College of Medicine, Miami, USA
| | - Alexandra Galbo
- Medical and Population Health Sciences Research, Florida International University (FIU) Herbert Wertheim College of Medicine, Miami, USA
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12
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Harris HR, Guertin KA, Camacho TF, Johnson CE, Wu AH, Moorman PG, Myers E, Bethea TN, Bandera EV, Joslin CE, Ochs-Balcom HM, Peres LC, Rosenow WT, Setiawan VW, Beeghly-Fadiel A, Dempsey LF, Rosenberg L, Schildkraut JM. Racial disparities in epithelial ovarian cancer survival: An examination of contributing factors in the Ovarian Cancer in Women of African Ancestry consortium. Int J Cancer 2022; 151:1228-1239. [PMID: 35633315 PMCID: PMC9420829 DOI: 10.1002/ijc.34141] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 11/07/2022]
Abstract
Black women diagnosed with epithelial ovarian cancer have poorer survival compared to white women. Factors that contribute to this disparity, aside from socioeconomic status and guideline-adherent treatment, have not yet been clearly identified. We examined data from the Ovarian Cancer in Women of African Ancestry (OCWAA) consortium which harmonized data on 1074 Black women and 3263 white women with ovarian cancer from seven US studies. We selected potential mediators and confounders by examining associations between each variable with race and survival. We then conducted a sequential mediation analysis using an imputation method to estimate total, direct, and indirect effects of race on ovarian cancer survival. Black women had worse survival than white women (HR = 1.30; 95% CI 1.16-1.47) during study follow-up; 67.9% of Black women and 69.8% of white women died. In our final model, mediators of this disparity include college education, nulliparity, smoking status, body mass index, diabetes, diabetes/race interaction, postmenopausal hormone (PMH) therapy duration, PMH duration/race interaction, PMH duration/age interaction, histotype, and stage. These mediators explained 48.8% (SE = 12.1%) of the overall disparity; histotype/stage and PMH duration accounted for the largest fraction. In summary, nearly half of the disparity in ovarian cancer survival between Black and white women in the OCWAA consortium is explained by education, lifestyle factors, diabetes, PMH use, and tumor characteristics. Our findings suggest that several potentially modifiable factors play a role. Further research to uncover additional mediators, incorporate data on social determinants of health, and identify potential avenues of intervention to reduce this disparity is urgently needed.
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Affiliation(s)
- Holly R. Harris
- Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - Kristin A. Guertin
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Tareq F Camacho
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Courtney E. Johnson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Anna H. Wu
- University of Southern California Norris Comprehensive Cancer Center and Department of Preventive Medicine, Keck School of Medicine, Los Angeles, California, USA
| | - Patricia G. Moorman
- Department of Family Medicine and Community Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Evan Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Traci N. Bethea
- Office of Minority Health and Health Disparities Research, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Campus, Washington, D.C., USA
| | - Elisa V. Bandera
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Charlotte E. Joslin
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago School of Medicine and Division of Epidemiology and Biostatistics, School of Public Health, Chicago, Illinois, USA
| | - Heather M. Ochs-Balcom
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Lauren C. Peres
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Will T. Rosenow
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Veronica W. Setiawan
- University of Southern California Norris Comprehensive Cancer Center and Department of Preventive Medicine, Keck School of Medicine, Los Angeles, California, USA
| | - Alicia Beeghly-Fadiel
- Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lauren F. Dempsey
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lynn Rosenberg
- Slone Epidemiology Center at Boston University, Boston, Massachusetts, USA
| | - Joellen M. Schildkraut
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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13
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Akinyemiju TF, Wilson LE, Diaz N, Gupta A, Huang B, Pisu M, Deveaux A, Liang M, Previs RA, Moss HA, Joshi A, Ward KC, Schymura MJ, Berchuck A, Potosky AL. Associations of Healthcare Affordability, Availability, and Accessibility with Quality Treatment Metrics in Patients with Ovarian Cancer. Cancer Epidemiol Biomarkers Prev 2022; 31:1383-1393. [PMID: 35477150 PMCID: PMC9250633 DOI: 10.1158/1055-9965.epi-21-1227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/02/2022] [Accepted: 04/18/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Differential access to quality care is associated with racial disparities in ovarian cancer survival. Few studies have examined the association of multiple healthcare access (HCA) dimensions with racial disparities in quality treatment metrics, that is, primary debulking surgery performed by a gynecologic oncologist and initiation of guideline-recommended systemic therapy. METHODS We analyzed data for patients with ovarian cancer diagnosed from 2008 to 2015 in the Surveillance, Epidemiology, and End Results-Medicare database. We defined HCA dimensions as affordability, availability, and accessibility. Modified Poisson regressions with sandwich error estimation were used to estimate the relative risk (RR) for quality treatment. RESULTS The study cohort was 7% NH-Black, 6% Hispanic, and 87% NH-White. Overall, 29% of patients received surgery and 68% initiated systemic therapy. After adjusting for clinical variables, NH-Black patients were less likely to receive surgery [RR, 0.83; 95% confidence interval (CI), 0.70-0.98]; the observed association was attenuated after adjusting for healthcare affordability, accessibility, and availability (RR, 0.91; 95% CI, 0.77-1.08). Dual enrollment in Medicaid and Medicare compared with Medicare only was associated with lower likelihood of receiving surgery (RR, 0.86; 95% CI, 0.76-0.97) and systemic therapy (RR, 0.94; 95% CI, 0.92-0.97). Receiving treatment at a facility in the highest quartile of ovarian cancer surgical volume was associated with higher likelihood of surgery (RR, 1.12; 95% CI, 1.04-1.21). CONCLUSIONS Racial differences were observed in ovarian cancer treatment quality and were partly explained by multiple HCA dimensions. IMPACT Strategies to mitigate racial disparities in ovarian cancer treatment quality must focus on multiple HCA dimensions. Additional dimensions, acceptability and accommodation, may also be key to addressing disparities.
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Affiliation(s)
- Tomi F. Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
- Duke Cancer Institute, Duke University School of Medicine, Durham NC
| | - Lauren E. Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
| | - Nicole Diaz
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
| | - Anjali Gupta
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
| | - Bin Huang
- Department of Biostatistics and Kentucky Cancer Registry, Univ of Kentucky, Lexington KY
| | - Maria Pisu
- Division of Preventive Medicine and O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - April Deveaux
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
| | - Margaret Liang
- Division of Preventive Medicine and O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Rebecca A. Previs
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham NC
| | - Haley A. Moss
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham NC
| | - Ashwini Joshi
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
| | - Kevin C. Ward
- Georgia Cancer Registry, Emory University, Atlanta GA
| | - Maria J. Schymura
- New York State Cancer Registry, New York State Department of Health, Albany NY
| | - Andrew Berchuck
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham NC
| | - Arnold L. Potosky
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington DC
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14
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Understanding the Experience of Canadian Women Living with Ovarian Cancer through the Every Woman Study TM. Curr Oncol 2022; 29:3318-3340. [PMID: 35621661 PMCID: PMC9139742 DOI: 10.3390/curroncol29050271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/30/2022] [Accepted: 05/03/2022] [Indexed: 11/17/2022] Open
Abstract
The Every Woman StudyTM: Canadian Edition is the most comprehensive study to date exploring patient-reported experiences of ovarian cancer (OC) on a national scale. An online survey conducted in Fall 2020 included individuals diagnosed with OC in Canada, reporting responses from 557 women from 11 Canadian provinces/territories. Median age at diagnosis was 54 (11−80), 61% were diagnosed between 2016−2020, 59% were stage III/IV and all subtypes of OC were represented. Overall, 23% had a family history of OC, 75% had genetic testing and 19% reported having a BRCA1/2 mutation. Most (87%) had symptoms prior to diagnosis. A timely diagnosis of OC (≤3 months from first presentation with symptoms) was predicted by age (>50) or abdominal pain/persistent bloating as the primary symptom. Predictors of an acute diagnosis (<1 month) included region, ER/urgent care doctor as first healthcare provider or stage III/IV disease. Regional differences in genetic testing, treatments and clinical trial participation were also noted. Respondents cited substantial physical, emotional, practical and financial impacts of an OC diagnosis. Our national survey has revealed differences in the pathway to diagnosis and post-diagnostic care among Canadian women with OC, with region, initial healthcare provider, specific symptoms and age playing key roles. We have identified many opportunities to improve both clinical and supportive care of OC patients across the country.
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15
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Peres LC, Colin-Leitzinger C, Sinha S, Marks JR, Conejo-Garcia JR, Alberg AJ, Bandera EV, Berchuck A, Bondy ML, Christensen BC, Cote ML, Doherty JA, Moorman PG, Peters ES, Segura CM, Nguyen JV, Schwartz AG, Terry PD, Wilson CM, Fridley BL, Schildkraut JM. Racial Differences in the Tumor Immune Landscape and Survival of Women with High-Grade Serous Ovarian Carcinoma. Cancer Epidemiol Biomarkers Prev 2022; 31:1006-1016. [PMID: 35244678 PMCID: PMC9081269 DOI: 10.1158/1055-9965.epi-21-1334] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/24/2022] [Accepted: 02/22/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Tumor-infiltrating lymphocytes (TIL) confer a survival benefit among patients with ovarian cancer; however, little work has been conducted in racially diverse cohorts. METHODS The current study investigated racial differences in the tumor immune landscape and survival of age- and stage-matched non-Hispanic Black and non-Hispanic White women with high-grade serous ovarian carcinoma (HGSOC) enrolled in two population-based studies (n = 121 in each racial group). We measured TILs (CD3+), cytotoxic T cells (CD3+CD8+), regulatory T cells (CD3+FoxP3+), myeloid cells (CD11b+), and neutrophils (CD11b+CD15+) via multiplex immunofluorescence. Multivariable Cox proportional hazard regression was used to estimate the association between immune cell abundance and survival overall and by race. RESULTS Overall, higher levels of TILs, cytotoxic T cells, myeloid cells, and neutrophils were associated with better survival in the intratumoral and peritumoral region, irrespective of tissue compartment (tumor, stroma). Improved survival was noted for T-regulatory cells in the peritumoral region and in the stroma of the intratumoral region, but no association for intratumoral T-regulatory cells. Despite similar abundance of immune cells across racial groups, associations with survival among non-Hispanic White women were consistent with the overall findings, but among non-Hispanic Black women, most associations were attenuated and not statistically significant. CONCLUSIONS Our results add to the existing evidence that a robust immune infiltrate confers a survival advantage among women with HGSOC; however, non-Hispanic Black women may not experience the same survival benefit as non-Hispanic White women with HGSOC. IMPACT This study contributes to our understanding of the immunoepidemiology of HGSOC in diverse populations.
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Affiliation(s)
- Lauren C. Peres
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | | | - Sweta Sinha
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jeffrey R. Marks
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Jose R. Conejo-Garcia
- Department of Immunology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Anthony J. Alberg
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Elisa V. Bandera
- Department of Population Science, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Andrew Berchuck
- Department of Gynecologic Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Melissa L. Bondy
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - Brock C. Christensen
- Department of Epidemiology, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Community and Family Medicine, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Molecular and Systems Biology, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Michele L. Cote
- Population Studies and Disparities Research Program, Barbara Ann Karmanos Cancer Institute, Detroit, Michigan
- Department of Oncology, Wayne State University School of Medicine, Detroit, Michigan
| | - Jennifer Anne Doherty
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
- Huntsman Cancer Institute, Salt Lake City, Utah
| | - Patricia G. Moorman
- Department of Community and Family Medicine, Duke University Medical Center, Durham, North Carolina
| | - Edward S. Peters
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Carlos Moran Segura
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jonathan V. Nguyen
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ann G. Schwartz
- Population Studies and Disparities Research Program, Barbara Ann Karmanos Cancer Institute, Detroit, Michigan
- Department of Oncology, Wayne State University School of Medicine, Detroit, Michigan
| | - Paul D. Terry
- Department of Medicine, University of Tennessee Medical Center – Knoxville, Knoxville, Tennessee
| | - Christopher M. Wilson
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Brooke L. Fridley
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Joellen M. Schildkraut
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Grubbs A, Barber EL, Roque DR. Healthcare Disparities in Gynecologic Oncology. ADVANCES IN ONCOLOGY 2022; 2:119-128. [PMID: 35669851 PMCID: PMC9165691 DOI: 10.1016/j.yao.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Affiliation(s)
- Allison Grubbs
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Emma L Barber
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Robert H Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Dario R Roque
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Robert H Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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17
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Bowers RR, Jones CM, Paz EA, Barrows JK, Armeson K, Long D, Delaney J. SWAN pathway-network identification of common aneuploidy-based oncogenic drivers. Nucleic Acids Res 2022; 50:3673-3692. [PMID: 35380699 PMCID: PMC9023287 DOI: 10.1093/nar/gkac200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 02/26/2022] [Accepted: 03/14/2022] [Indexed: 02/07/2023] Open
Abstract
Haploinsufficiency drives Darwinian evolution. Siblings, while alike in many aspects, differ due to monoallelic differences inherited from each parent. In cancer, solid tumors exhibit aneuploid genetics resulting in hundreds to thousands of monoallelic gene-level copy-number alterations (CNAs) in each tumor. Aneuploidy patterns are heterogeneous, posing a challenge to identify drivers in this high-noise genetic environment. Here, we developed Shifted Weighted Annotation Network (SWAN) analysis to assess biology impacted by cumulative monoallelic changes. SWAN enables an integrated pathway-network analysis of CNAs, RNA expression, and mutations via a simple web platform. SWAN is optimized to best prioritize known and novel tumor suppressors and oncogenes, thereby identifying drivers and potential druggable vulnerabilities within cancer CNAs. Protein homeostasis, phospholipid dephosphorylation, and ion transport pathways are commonly suppressed. An atlas of CNA pathways altered in each cancer type is released. These CNA network shifts highlight new, attractive targets to exploit in solid tumors.
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Affiliation(s)
- Robert R Bowers
- Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Christian M Jones
- Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Edwin A Paz
- Departments of Neurology, Neurobiology, and Cell Biology, and the Duke Center for Neurodegeneration & Neurotherapeutics, Duke University School of Medicine, Durham, NC, USA
| | - John K Barrows
- Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Kent E Armeson
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - David T Long
- Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Joe R Delaney
- Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC, USA
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18
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An Integrated Approach for Cancer Survival Prediction Using Data Mining Techniques. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2021:6342226. [PMID: 34992648 PMCID: PMC8727098 DOI: 10.1155/2021/6342226] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/27/2021] [Indexed: 12/31/2022]
Abstract
Ovarian cancer is the third most common gynecologic cancers worldwide. Advanced ovarian cancer patients bear a significant mortality rate. Survival estimation is essential for clinicians and patients to understand better and tolerate future outcomes. The present study intends to investigate different survival predictors available for cancer prognosis using data mining techniques. Dataset of 140 advanced ovarian cancer patients containing data from different data profiles (clinical, treatment, and overall life quality) has been collected and used to foresee cancer patients' survival. Attributes from each data profile have been processed accordingly. Clinical data has been prepared corresponding to missing values and outliers. Treatment data including varying time periods were created using sequence mining techniques to identify the treatments given to the patients. And lastly, different comorbidities were combined into a single factor by computing Charlson Comorbidity Index for each patient. After appropriate preprocessing, the integrated dataset is classified using appropriate machine learning algorithms. The proposed integrated model approach gave the highest accuracy of 76.4% using ensemble technique with sequential pattern mining including time intervals of 2 months between treatments. Thus, the treatment sequences and, most importantly, life quality attributes significantly contribute to the survival prediction of cancer patients.
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Huepenbecker SP, Sun CC, Fu S, Zhao H, Primm K, Giordano SH, Meyer LA. Factors impacting the time to ovarian cancer diagnosis based on classic symptom presentation in the United States. Cancer 2021; 127:4151-4160. [PMID: 34347287 DOI: 10.1002/cncr.33829] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/02/2021] [Accepted: 07/07/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients with ovarian cancer often present with late-stage disease and nonspecific symptoms, but little is known about factors affecting the time to diagnosis (TTD) in the United States. METHODS A retrospective, population-based study of the Surveillance, Epidemiology, and End Results-Medicare database was conducted. It included women 66 years old or older with stage II to IV epithelial ovarian cancer with at least 1 code for abdominal/pelvic pain, bloating, difficulty eating, or urinary symptoms within 1 year of the cancer diagnosis. TTD was defined from the first claim with a prespecified symptom to the ovarian cancer diagnosis. Kruskal-Wallis tests were used to assess for differences in TTD by group medians. Univariate and generalized linear models with a log-link function evaluated TTD by covariables. RESULTS For the 13,872 women analyzed, the mean and median times to diagnosis were 2.9 and 1.1 months, respectively. The median TTD differed significantly by first symptom (P < .001), number of symptoms (P < .001), and first physician specialty seen (P < .001). In a multivariable analysis, TTD differed significantly according to race/ethnicity (P < .001), geographic region (P = .001), urban-rural location (P = .031), emergency room presentation (P < .001), and number of specialties seen (P < .001). A shorter TTD was associated with a diagnosis in 2006-2010 (relative risk [RR], 0.92; 95% confidence interval [CI], 0.87-0.98) or 2011-2015 (RR, 0.87; 95% CI, 0.81-0.93) in comparison with 1992-1999. CONCLUSIONS The time from a symptomatic presentation to care to a diagnosis of ovarian cancer is influenced by clinical and demographic variables. This study's findings reinforce the importance of educating all physicians on ovarian cancer symptoms to aid in diagnosis. LAY SUMMARY Ovarian cancer is often diagnosed once disease has spread because the classic symptoms of ovarian cancer-abdominal or pelvic pain, bloating, difficulty eating, and urinary issues-can be mistaken for other problems. This study examined the time between when women with classic ovarian cancer symptoms went to a physician and when they received a cancer diagnosis in a large database population. The authors found that the time to diagnosis differed according to the type and number of symptoms and what type of physician a woman saw as well as factors such as race, geographic location, and year of diagnosis.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shuangshuang Fu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristin Primm
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Sutton AL, Felix AS, Bandyopadhyay D, Retnam R, Hundley WG, Sheppard VB. Cardioprotective medication use in Black and white breast cancer survivors. Breast Cancer Res Treat 2021; 188:769-778. [PMID: 33797652 PMCID: PMC8277673 DOI: 10.1007/s10549-021-06202-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/16/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Racial disparities in cardiovascular disease and cardiac dysfunction exist amongst breast cancer survivors. This study examined the prevalence of cardioprotective medication use in survivors and identified factors associated with use by race. METHODS The analysis included women enrolled in the Women's Hormonal Initiation and Persistence study, a longitudinal observational trial of breast cancer survivors. The study outcome, angiotensin converting enzyme inhibitor (ACEi) or ß-Blocker (BB) use, were ascertained from pharmacy records. Demographic, psychosocial, healthcare, and quality of life factors were collected from surveys and clinical data were abstracted from medical records. Bivariate associations by race and ACEi/BB use were tested using chi square and t tests; logistic regression evaluated multivariable-adjusted associations. RESULTS Of the 246 survivors in the sample, 33.3% were Black and most were < 65 years of age (58.4%). Most survivors were hypertensive (57.6%) and one-third received ACEi/BBs. In unadjusted analysis, White women (vs. Black) (OR 0.33, 95% 0.19-0.58) and women with higher ratings of functional wellbeing (OR 0.94, 95% 0.89-0.99) were less likely to use ACEi/BBs. Satisfaction with provider communication was only significant for White women. In multivariable-adjusted analysis, ACEi/BB use did not differ by race. Correlates of ACEi/BB use included hypertension among all women and older age for Black women only. CONCLUSIONS After adjusting for age and comorbidities, no differences by race in ACEi/BB use were observed. Hypertension was a major contributor of ACEi/BB use in BC survivors.
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Affiliation(s)
- Arnethea L Sutton
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, P.O. Box 980149, Richmond, VA, 23219, USA.
| | - Ashley S Felix
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Dipankar Bandyopadhyay
- Department of Biostatistics, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Reuben Retnam
- Department of Biostatistics, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - William G Hundley
- Department of Internal Medicine, Division of Cardiovascular Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Vanessa B Sheppard
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, P.O. Box 980149, Richmond, VA, 23219, USA
- Office of Health Equity and Disparities Research, Massey Cancer Center, Richmond, VA, USA
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Villanueva C, Chang J, Ziogas A, Bristow RE, Vieira VM. Ambient air pollution and ovarian cancer survival in California. Gynecol Oncol 2021; 163:155-161. [PMID: 34330535 DOI: 10.1016/j.ygyno.2021.07.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/21/2021] [Accepted: 07/24/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To examine whether exposure to ambient ozone, particulate matter with diameter less than 2.5 μm (PM2.5), nitrogen dioxide (NO2), and distance to major roadways (DTR) impact ovarian cancer-specific survival, while considering differences by stage, race/ethnicity, and socioeconomic status. METHODS Women diagnosed with epithelial ovarian cancer from 1996 to 2014 were identified through the California Cancer Registry and followed through 2016. Women's geocoded addresses were linked to pollutant exposure data and averaged over the follow-up period. Pollutants were considered independently and in multi-pollutant models. Cox proportional hazards models assessed hazards of disease-specific death due to environmental exposures, controlling for important covariates, with additional models stratified by stage at diagnosis, race/ethnicity and socioeconomic status. RESULTS PM2.5 and NO2, but not ozone or DTR, were significantly associated with survival in univariate models. In a multi-pollutant model for PM2.5, ozone, and DTR, an interquartile range increase in PM2.5 (Hazard Ratio [HR], 1.45; 95% Confidence Interval [CI], 1.41-1.49) was associated with worse prognosis. Similarly, in the multi-pollutant model with NO2, ozone, and DTR, women with higher NO2 exposures (HR for 20.0-30.0 ppb, 1.30; 95% CI, 1.25-1.36 and HR for >30.0 ppb, 2.48; 95% CI, 2.32-2.66) had greater mortality compared to the lowest exposed (<20.0 ppb). Stratified results show the effects of the pollutants differed by race/ethnicity and were magnified among women diagnosed in early stages. CONCLUSIONS Our analyses suggest that greater exposure to NO2 and PM2.5 may adversely impact ovarian cancer-specific survival, independent of sociodemographic and treatment factors. These findings warrant further study.
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Affiliation(s)
- Carolina Villanueva
- Program in Public Health, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, CA, United States of America.
| | - Jenny Chang
- Department of Medicine, School of Medicine, University of California, Irvine, Irvine, CA, United States of America
| | - Argyrios Ziogas
- Department of Medicine, School of Medicine, University of California, Irvine, Irvine, CA, United States of America
| | - Robert E Bristow
- Chao Family Comprehensive Cancer Center, Orange, CA, United States of America; Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine School of Medicine, Orange, CA, United States of America
| | - Verónica M Vieira
- Program in Public Health, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, CA, United States of America; Chao Family Comprehensive Cancer Center, Orange, CA, United States of America
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22
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Huffman DL, Jayakrishnan TT, Shankar K, Peterson CE, Wegner RE. Disparities in ovarian cancer treatment and overall survival according to race: An update. Gynecol Oncol 2021; 162:674-678. [PMID: 34261593 DOI: 10.1016/j.ygyno.2021.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/01/2021] [Accepted: 07/05/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether guideline non-adherence is associated with Black race. METHODS A retrospective review of National Cancer Database records of women diagnosed with epithelial ovarian cancer from 2012 to 2016 who identified as "White" or "Black" was performed. Exposure was adherence or non-adherence to National Comprehensive Cancer Network guidelines for treatment. Outcomes were differences in disease characteristics and overall survival in months. RESULTS Of the 29,948 eligible patients, 93% (n = 27,744) were White and 7% (n = 2204) were Black. Having stage IV disease (OR 1.45, 95% CI 1.23-1.70; P < 0.001) and treatment in a comprehensive (OR 1.58, 95% CI 1.16-2.15; P = 0.0039) or academic (OR 2.30, 95% CI 1.70-3.12; P < 0.001) treatment facility were associated with Black race. Adherence to guidelines did not predict Black race (OR for adherence 1.0021, 95% CI 0.89-1.13; P = 0.97). Median survival for White patients with adherent care was 63.4 months and 51.4 months for Black patients (P = 0.0001). Median survival for White patients with non-adherent care was 60.5 months and 47.2 months for Black patients (P < 0.0001). Median overall survival was 61.1 months in White patients and 49.3 months in Black patients (P < 0.0001). CONCLUSIONS Our data suggest that while Black patients and patients who receive non-NCCN guideline directed care have worse survival outcomes, guideline adherence is not independently associated with Black race. We must consider other socioeconomic, environmental and system factors that are contributing to the survival discrepancy in Black patients with ovarian cancer.
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Affiliation(s)
- Deanna L Huffman
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Thejus Thayyil Jayakrishnan
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA; Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Karthik Shankar
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Chelsea E Peterson
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA.
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Adherence to treatment guidelines as a major determinant of survival disparities between black and white patients with ovarian cancer. Gynecol Oncol 2020; 160:10-15. [PMID: 33208254 DOI: 10.1016/j.ygyno.2020.10.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/31/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To evaluate whether non-adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines and other factors related to treatment access contribute to racial disparities in ovarian cancer survival. METHODS This large cohort study included patients from the National Cancer Database who were diagnosed with ovarian cancer between 2004 and 2014, with follow-up data up to 2017. The multivariable Cox regression was used to assess the effect of study variables on five-year overall survival. The proportion contributions of prognostic factors to the survival disparities were estimated using individual and sequential adjustment of these factors based on the Cox proportional hazards models. RESULTS Of the 120,712 patients eligible for this study, 110,032 (91.1%) were whites and 10,680 (8.9%) were blacks. Black patients, compared with their white counterparts, had a lower adherence to NCCN guidelines (60.8% vs. 70.4%, respectively, P < 0.001), and a higher five-year mortality after cancer diagnosis (age- and tumor characteristics- adjusted hazard ratio: 1.22, 95% confidence interval: 1.19-1.25). Non-adherence to NCCN treatment guidelines was the most significant contributor to racial disparity in ovarian cancer survival, followed by access to care and comorbidity, each explaining 36.4%, 22.7%, and 18.2% of the racial differences in five-year overall survival, respectively. These factors combined explain 59.1% of racial survival disparities. Risk factors identified for non-adherence to treatment guidelines among blacks include insurance status, treatment facility type, educational attainment, age, and comorbidity. CONCLUSIONS Adherence status to NCCN treatment guidelines is the most important contributor to the survival disparities between black and white patients with ovarian cancer. Our findings call for measures to promote equitable access to guideline-adherence care to improve the survival of black women with ovarian cancer.
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Villanueva C, Chang J, Ziogas A, Bristow RE, Vieira VM. Ovarian cancer in California: Guideline adherence, survival, and the impact of geographic location, 1996-2014. Cancer Epidemiol 2020; 69:101825. [PMID: 33022472 DOI: 10.1016/j.canep.2020.101825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/12/2020] [Accepted: 09/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Evidence suggests that geographic location may independently contribute to ovarian cancer survival. We aimed to investigate how the association between residential location and ovarian cancer-specific survival in California varies by race/ethnicity and socioeconomic status. METHODS Additive Cox proportional hazard models were used to predict hazard ratios (HRs) and 95% confidence intervals (CI) for the association between geographic location throughout California and survival among 29,844 women diagnosed with epithelial ovarian cancer between 1996 and 2014. We conducted permutation tests to determine a global P-value for significance of location. Adjusted analyses considered distance traveled for care, distance to closest high-quality-of-care hospital, and receipt of National Comprehensive Cancer Network guideline care. Models were also stratified by stage, race/ethnicity, and socioeconomic status. RESULTS Location was significant in unadjusted models (P = 0.009 among all stages) but not in adjusted models (P = 0.20). HRs ranged from 0.81 (95% CI: 0.70, 0.93) in Southern Central Valley to 1.41 (95% CI: 1.15, 1.73) in Northern California but were attenuated after adjustment (maximum HR = 1.17, 95% CI: 1.08, 1.27). Better survival was generally observed for patients traveling longer distances for care. Associations between survival and proximity to closest high-quality-of-care hospitals were null except for women of lowest socioeconomic status living furthest away (HR = 1.22, 95% CI: 1.03, 1.43). CONCLUSIONS Overall, geographic variations observed in ovarian cancer-specific survival were due to important predictors such as receiving guideline-adherent care. Improving access to expert care and ensuring receipt of guideline-adherent treatment should be priorities in optimizing ovarian cancer survival.
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Affiliation(s)
- Carolina Villanueva
- Program in Public Health, Susan and Henry Samueli College of Health Sciences, University of California, Anteater Instruction & Research Building, 653 East Peltason Drive, Irvine, CA, 92697, USA.
| | - Jenny Chang
- Department of Medicine, School of Medicine, University of California, 205 Irvine Hall, Irvine, CA, 92697, USA.
| | - Argyrios Ziogas
- Department of Medicine, School of Medicine, University of California, 205 Irvine Hall, Irvine, CA, 92697, USA.
| | - Robert E Bristow
- Chao Family Comprehensive Cancer Center, Orange, CA, USA; Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine School of Medicine, 333 City Boulevard West, Ste 1400, Orange, CA, 92868, USA.
| | - Verónica M Vieira
- Program in Public Health, Susan and Henry Samueli College of Health Sciences, University of California, Anteater Instruction & Research Building, 653 East Peltason Drive, Irvine, CA, 92697, USA; Chao Family Comprehensive Cancer Center, Orange, CA, USA.
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Gardner AB, Sanders BE, Mann AK, Liao CI, Eskander RN, Kapp DS, Chan JK. Relationship status and other demographic influences on survival in patients with ovarian cancer. Int J Gynecol Cancer 2020; 30:1922-1927. [PMID: 32920535 DOI: 10.1136/ijgc-2020-001512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/18/2020] [Accepted: 07/21/2020] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To evaluate the influence of marital status and other demographic factors on survival of patients with ovarian cancer. STUDY DESIGN Data were obtained from the Surveillance, Epidemiology, and End Results database from 2010 to 2015. Analyses were performed using Kaplan-Meier and multivariate Cox proportional hazard methods. RESULTS Of 19 643 patients with ovarian cancer (median age 60 years, range 18-99), 16 278 (83%), 1381 (7%), 1856 (9%), and 128 (1%) were White, Black, Asian, and Native American, respectively. The majority of patients (10 769, 55%) were married while 4155 (21%) were single, 2278 (12%) were divorced, and 2441 (12%) were widowed. Patients were more likely to be married if they were Asian (65%) or White (56%) than if they were Black (31%) or Native American (39%) (p<0.001). Most married patients were insured (n=9760 (91%), non-Medicaid) compared with 3002 (72%) of single, 1777 (78%) divorced, and 2102 (86%) of widowed patients (p<0.001). Married patients were more likely to receive chemotherapy than single, divorced, and widowed patients (8515 (79%) vs 3000 (72%), 1747 (77%), and 1650 (68%), respectively; p<0.001). The 5-year disease-specific survival of the overall group was 58%. Married patients had improved survival of 60% compared with divorced (52%) and widowed (44%) patients (p<0.001). On multivariate analysis, older age (HR 1.02, 95% CI 1.016 to 1.021, p<0.001), Black race (HR 1.24, 95% CI 1.11 to 1.38, p<0.001), and Medicaid (HR 1.19, 95% CI 1.09 to 1.30, p<0.001) or uninsured status (HR 1.23, 95% CI 1.05 to 1.44, p<0.01) carried a worse prognosis. Single (HR 1.17, 95% CI 1.08 to 1.26, p<0.001), divorced (HR 1.14, 95% CI 1.04 to 1.25, p<0.01), and widowed (HR 1.16, 95% CI 1.06 to 1.26, p<0.001) patients had decreased survival. CONCLUSION Married patients with ovarian cancer were more likely to undergo chemotherapy with better survival rates. Black, uninsured, or patients with Medicaid insurance had poorer outcomes.
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Affiliation(s)
- Austin B Gardner
- Obstetrics and Gynecology, University of California Irvine School of Medicine, Irvine, California, USA.,Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brooke E Sanders
- Obstetrics and Gynecology, University of California San Diego School of Medicine, La Jolla, California, USA
| | | | - Cheng-I Liao
- Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ramez Nassef Eskander
- Obstetrics and Gynecology, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Daniel S Kapp
- Stanford University School of Medicine, Stanford, California, USA
| | - John K Chan
- California Pacific Medical Center, San Francisco, California, USA
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Westrick AC, Bailey ZD, Schlumbrecht M, Hlaing WM, Kobetz EE, Feaster DJ, Balise RR. Residential segregation and overall survival of women with epithelial ovarian cancer. Cancer 2020; 126:3698-3707. [PMID: 32484923 DOI: 10.1002/cncr.32989] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND To the authors' knowledge, the etiology of survival disparities in patients with epithelial ovarian cancer (EOC) is not fully understood. Residential segregation, both economic and racial, remains a problem within the United States. The objective of the current study was to analyze the effect of residential segregation as measured by the Index of Concentration at the Extremes (ICE) on EOC survival in Florida by race and/or ethnicity. METHODS All malignant EOC cases were identified from 2001 through 2015 using the Florida Cancer Data System (FCDS). Census-defined places were used as proxies for neighborhoods. Using 5-year estimates from the American Community Survey, 5 ICE variables were computed: economic (high vs low), race and/or ethnicity (non-Hispanic white [NHW] vs non-Hispanic black [NHB] and NHW vs Hispanic), and racialized economic segregation (low-income NHB vs high-income NHW and low-income Hispanic vs high-income NHW). Random effects frailty models were conducted. RESULTS A total of 16,431 malignant EOC cases were diagnosed in Florida among women living in an assigned census-defined place within the time period. The authors found that economic and racialized economic residential segregations influenced EOC survival more than race and/or ethnic segregation alone in both NHB and Hispanic women. NHB women continued to have an increased hazard of death compared with NHW women after controlling for multiple covariates, whereas Hispanic women were found to have either a similar or decreased hazard of death compared with NHW women in multivariable Cox models. CONCLUSIONS The results of the current study indicated that racial and economic residential segregation influences survival among patients with EOC. Research is needed to develop more robust segregation measures that capture the complexities of neighborhoods to fully understand the survival disparities in EOC.
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Affiliation(s)
- Ashly C Westrick
- Department of Public Health Sciences, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Zinzi D Bailey
- Jay Weiss Institute for Health Equity, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Matthew Schlumbrecht
- Jay Weiss Institute for Health Equity, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA.,Department of Obstetrics and Gynecology, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - WayWay M Hlaing
- Department of Public Health Sciences, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Erin E Kobetz
- Jay Weiss Institute for Health Equity, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Daniel J Feaster
- Department of Public Health Sciences, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Raymond R Balise
- Department of Public Health Sciences, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
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Knisely A, Huang Y, Melamed A, Tergas AI, St Clair CM, Hou JY, Khoury-Collado F, Ananth CV, Neugut AI, Hershman DL, Wright JD. Travel distance, hospital volume and their association with ovarian cancer short- and long-term outcomes. Gynecol Oncol 2020; 158:415-423. [PMID: 32456990 DOI: 10.1016/j.ygyno.2020.05.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/12/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine patterns of patient travel among women with ovarian cancer and to explore the association between travel distance and short and long-term outcomes. METHODS Women with stage II-IV epithelial ovarian cancer diagnosed from 2004 to 2016 who underwent primary surgery were identified in the National Cancer Database. Mixed-effect log-linear models and proportional hazards models were developed to evaluate the association between travel distance and short and long-term outcomes after propensity score weighting. A further analysis was performed to compare patients who traveled a short distance to a low volume center (Local) to patients who traveled farther to a high volume hospital (Travel). RESULTS We identified 56,834 patients treated in 1201 hospitals. Hispanic women were 58% and black women 64% less likely than white women to travel to a center in the greatest distance quartile for care. Similarly, Medicaid recipients (vs. commercially insured) were less likely to travel to a quartile four hospital (compared to Q1 of distance traveled). Of all patients, 90-day mortality was significantly lower in patients who traveled farther (Q4 vs. Q1; P < 0.0001). Compared to women in the Local group, patients in the Travel group had a decreased 30-day readmission rate. There was no difference in 30-day, 90-day, or 5-year mortality when comparing the Local to the Travel group. CONCLUSIONS Travel distance for ovarian cancer surgery has increased over time. While there may be some short-term benefits in traveling to a regional center for care, there was little difference in long term outcomes based on travel distance.
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Affiliation(s)
- Anne Knisely
- Columbia University College of Physicians and Surgeons, United States of America; New York Presbyterian Hospital, United States of America
| | - Yongmei Huang
- Columbia University College of Physicians and Surgeons, United States of America
| | - Alexander Melamed
- Columbia University College of Physicians and Surgeons, United States of America; New York Presbyterian Hospital, United States of America
| | - Ana I Tergas
- Columbia University College of Physicians and Surgeons, United States of America; Joseph L. Mailman School of Public Health, Columbia University, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Caryn M St Clair
- Columbia University College of Physicians and Surgeons, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - June Y Hou
- Columbia University College of Physicians and Surgeons, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Fady Khoury-Collado
- Columbia University College of Physicians and Surgeons, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Cande V Ananth
- Joseph L. Mailman School of Public Health, Columbia University, United States of America; Rutgers Robert Wood Johnson Medical School, United States of America; Environmental and Occupational Health Sciences Institute (EOHSI), United States of America
| | - Alfred I Neugut
- Columbia University College of Physicians and Surgeons, United States of America; Joseph L. Mailman School of Public Health, Columbia University, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Dawn L Hershman
- Columbia University College of Physicians and Surgeons, United States of America; Joseph L. Mailman School of Public Health, Columbia University, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; New York Presbyterian Hospital, United States of America.
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Westrick A, Schlumbrecht M, Hlaing WM, Kobetz EK, Feaster D, Balise R. Racial and ethnic disparities in the overall survival of women with epithelial ovarian cancer in Florida, 2001-2015. Cancer Causes Control 2020; 31:333-340. [PMID: 32052218 DOI: 10.1007/s10552-020-01276-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/10/2020] [Indexed: 12/19/2022]
Abstract
Many studies have focused on white and black disparities in epithelial ovarian cancer (EOC) but fewer include Hispanics. Florida presents a unique opportunity to study racial/ethnic disparities. This study examined racial/ethnic disparities in the overall survival of women with EOC in Florida by histology. All EOC cases from 2001 through 2015 were identified in the Florida Cancer Database System (FCDS). Survival curves by race/ethnicity and histology were generated by Kaplan-Meier methods. Cox regression evaluated the associations between race/ethnicity, histology, and survival. Eligible EOC cases (n = 21,721) identified in the 2001-2015 FCDS were included in the study. The median survival for non-Hispanic whites (NHWs), non-Hispanic blacks (NHBs), and Hispanics was 31, 21, and 35 months, respectively (p < 0.001). NHB had an increased [AHR 1.23 (95% CI 1.15, 1.30)] and Hispanics a nonsignificant decreased hazard [AHR 0.96 (95% CI 0.91, 1.02)] of death compared to NHW after controlling for other demographic, treatment, and tumor characteristics. Relative to NHWs, NBH had worse survival while Hispanics had equivalent survival. Future research should consider evaluating genetic and epigenetic modifications, and prevalence of cancer syndromes to further elucidate the etiologies of disease in these disparate populations.
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Affiliation(s)
- Ashly Westrick
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th St, Miami, FL, 33136, USA.
| | - Matthew Schlumbrecht
- Department of Obstetrics and Gynecology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - WayWay M Hlaing
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th St, Miami, FL, 33136, USA
| | - Erin K Kobetz
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Daniel Feaster
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th St, Miami, FL, 33136, USA
| | - Raymond Balise
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th St, Miami, FL, 33136, USA
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Ellis RJ, Schlick CJR, Feinglass J, Mulcahy MF, Benson AB, Kircher SM, Yang TD, Odell DD, Bilimoria K, Merkow RP. Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot? BMJ Qual Saf 2020; 29:103-112. [PMID: 31366576 PMCID: PMC7382916 DOI: 10.1136/bmjqs-2019-009742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/02/2019] [Accepted: 07/09/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Chemotherapy quality measures consider hospitals compliant when chemotherapy is recommended, even if it is not received. This may mask shortcomings in cancer care delivery. Objectives of this study were to (1) identify patient factors associated with failure to receive recommended chemotherapy without a documented contraindication and (2) assess hospital variation in failure to administer recommended chemotherapy. METHODS Patients from 2005 to 2015 with breast, colon and lung cancers who failed to receive recommended chemotherapy were identified using the National Cancer Database. Hospital-level rates of failure to administer recommended chemotherapy were calculated, and patient and hospital factors associated with failure to receive recommended chemotherapy were identified by multivariable logistic regression. RESULTS A total of 183 148 patients at 1281 hospitals were analysed. Overall, 3.5% of patients with breast, 6.6% with colon and 10.7% with lung cancers failed to receive recommended chemotherapy. Patients were less likely to receive recommended chemotherapy in all cancers if uninsured or on Medicaid (p<0.05), as were non-Hispanic black patients with both breast and colon cancer (p<0.001). Significant hospital variation was observed, with hospital-level rates of failure to administer recommended chemotherapy as high as 21.8% in breast, 40.2% in colon and 40.0% in lung cancers. CONCLUSIONS AND RELEVANCE Though overall rates are low, failure to receive recommended chemotherapy is associated with sociodemographic factors. Hospital variation in failure to administer recommended chemotherapy is masked by current quality measure definitions and may define a significant and unmeasured difference in hospital quality.
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Affiliation(s)
- Ryan J Ellis
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
| | - Cary Jo R Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Joe Feinglass
- Division of General Internal Medicine and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mary F Mulcahy
- Robert H Lurie Comprehensive Cancer Center, Chicago, Illinois, USA
- Department of Medicine, Northwestern University Division of Hematology/Oncology, Chicago, Illinois, USA
| | - Al B Benson
- Robert H Lurie Comprehensive Cancer Center, Chicago, Illinois, USA
- Department of Medicine, Northwestern University Division of Hematology/Oncology, Chicago, Illinois, USA
| | - Sheetal M Kircher
- Robert H Lurie Comprehensive Cancer Center, Chicago, Illinois, USA
- Department of Medicine, Northwestern University Division of Hematology/Oncology, Chicago, Illinois, USA
| | - Tony D Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Robert H Lurie Comprehensive Cancer Center, Chicago, Illinois, USA
| | - David D Odell
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Robert H Lurie Comprehensive Cancer Center, Chicago, Illinois, USA
| | - Karl Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
- Robert H Lurie Comprehensive Cancer Center, Chicago, Illinois, USA
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
- Robert H Lurie Comprehensive Cancer Center, Chicago, Illinois, USA
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