Racial disparities in brachytherapy administration and survival in women with locally advanced cervical cancer

Fragmented Care and Guideline-Concordant Treatment in Locally Advanced Cervical Cancer

OBJECTIVE

To characterize and estimate rates of fragmented care, to investigate its association with the receipt of guideline-concordant treatment, and to evaluate treatment components at risk with fragmented care.

METHODS

This is a single-institution retrospective study of patients with locally advanced cervical cancer (stage IB3-IVA) from January 2003 to September 2023. We stratified patients into fragmented and nonfragmented care groups based on receipt of all care at our institution or if they received any component of care outside of our institution. The primary outcome, receipt of guideline-concordant treatment, was defined as a composite of 1) completion of treatment within 56 days, 2) completion of brachytherapy, and 3) receipt of concurrent chemotherapy. Demographic and treatment data were collected, including the Social Vulnerability Index (SVI), a census tract-based measure of disadvantage. Univariate and multivariate analyses were performed.

RESULTS

Two hundred eighty-six patients were identified; 75.5% received fragmented care. Those receiving nonfragmented care were significantly more likely to receive guideline-concordant treatment than those receiving fragmented care (71.4% vs 50.9%, P=.003). This was driven primarily by rates of timely completion (81.4% vs 60.6%, P=.001). Univariate analysis indicated that fragmented care (odds ratio [OR] 0.42, 95% CI, 0.23-0.74) and Medicaid insurance (OR 0.40, 95% CI, 0.20-0.78) were significantly associated with lower odds of guideline-concordant treatment. Multivariate analyses controlling for a priori confounders of insurance type and SVI showed that fragmented care (OR 0.45, 95% CI, 0.23-0.90) and Medicaid insurance (OR 0.42, 95% CI, 0.19-0.89) were independently associated with lower odds of guideline-concordant treatment. Multivariate analysis controlling for demographic covariates found even lower odds of receiving guideline-concordant treatment in those who received fragmented care (OR 0.39, 95% CI, 0.18-0.84) and who had Medicaid insurance (OR 0.35, 95% CI, 0.16-0.78).

CONCLUSION

More than 75% of patients received fragmented care, which had a significant clinical effect and was associated with significantly lower rates of guideline-concordant treatment.

Racial and ethnic disparities in reproductive medicine in the United States: a narrative review of contemporary high-quality evidence

There has been increasing debate around how or if race and ethnicity should be used in medical research-including the conceptualization of race as a biological entity, a social construct, or a proxy for racism. The objectives of this narrative review are to identify and synthesize reported racial and ethnic inequalities in obstetrics and gynecology (ob/gyn) and develop informed recommendations for racial and ethnic inequity research in ob/gyn. A reproducible search of the 8 highest impact ob/gyn journals was conducted. Articles published between January 1, 2010 and June 30, 2023 containing keywords related to racial and ethnic disparities, bias, prejudice, inequalities, and inequities were included (n=318). Data were abstracted and summarized into 4 themes: 1) access to care, 2) adherence to national guidelines, 3) clinical outcomes, and 4) clinical trial diversity. Research related to each theme was organized topically under the headings i) obstetrics, ii) reproductive medicine, iii) gynecologic cancer, and iv) other. Additionally, interactive tables were developed. These include data on study timeline, population, location, and results for every article. The tables enable readers to filter by journal, publication year, race and ethnicity, and topic. Numerous studies identified adverse reproductive outcomes among racial and ethnic minorities as compared to white patients, which persist despite adjusting for differential access to care, socioeconomic or lifestyle factors, and clinical characteristics. These include higher maternal morbidity and mortality among Black and Hispanic/Latinx patients; reduced success during fertility treatments for Black, Hispanic/Latinx, and Asian patients; and lower survival rates and lower likelihood of receiving guideline concordant care for gynecological cancers for non-White patients. We conclude that many racial and ethnic inequities in ob/gyn cannot be fully attributed to patient characteristics or access to care. Research focused on explaining these disparities based on biological differences incorrectly reinforces the notion of race as a biological trait. More research that deconstructs race and assesses efficacy of interventions to reduce these disparities is needed.

Analgesia and Anesthesia Practice Patterns for Gynecologic Brachytherapy Procedures and Potential Impact on Women's Procedural Experience: A National Survey

PURPOSE

The purpose of this study was to determine the current U.S. practice patterns of analgesia (AG) and anesthesia (AS) for gynecologic brachytherapy (BT) procedures.

METHODS AND MATERIALS

A 27-item survey created with expertise from 5 brachytherapists was distributed electronically to 90 U.S. radiation oncology academic programs and publicized on social media and at 2 national meetings from June to October 2023.

RESULTS

Forty-one responses were received (46%). Fifty-four percent identified as female, 66% as Caucasian, and 85% as non-Hispanic/Latino ethnicity. Forty-nine percent use a BT suite ± computed tomography (CT) simulator alone, 39% the operating room ± BT suite or CT simulator or other location, 10% CT simulation room alone, and 2% clinic examination room. Thirty-four percent use general anesthesia alone (GA) for intracavitary BT (n = 41), 20% conscious sedation (CS) alone, 10% oral analgesia (OA) alone, 9% spinal or epidural AS alone, and 27% combination. Among those performing hybrid BT (n = 25), 40% use GA alone, 16% use CS alone, 12% epidural or spinal AS alone, 4% OA alone, and 28% combination. For template interstitial BT (n = 25), 44% use GA alone, 48% epidural alone or in combination with other AS, and 8% CS alone. Twenty-two percent of respondents provide AG or AS during applicator placement only, whereas 32% provide it during placement, planning, treatment, and removal. The most common reasons for not using CS or GA were the lack of AS resources and clinician preference. Seventy-three percent reported the belief that patients suffer from post-traumatic stress disorder symptoms after BT. However, 68% reported not using techniques to alleviate BT-related emotional distress.

CONCLUSIONS

Many U.S. brachytherapists report using GA, CS, or epidural AS; however, 10% are using only OA, and 22% offer AG/AS only during applicator placement. Furthermore, a majority of respondents believe post-traumatic stress disorder symptoms can occur after BT, but few offer any intervention. AS resources and clinician preferences should be targeted for the expansion of higher-quality care.

Prognostic nomograms for locally advanced cervical cancer based on the SEER database: Integrating Cox regression and competing risk analysis

Locally advanced cervical carcinoma (LACC) remains a significant global health challenge owing to its high recurrence rates and poor outcomes, despite current treatments. This study aimed to develop a comprehensive risk stratification model for LACC by integrating Cox regression and competing risk analyses. This was done to improve clinical decision making. We analyzed data from 3428 patients with LACC registered in the Surveillance, Epidemiology, and End Results program and diagnosed them between 2010 and 2015. Cox regression and competing risk analyses were used to identify the prognostic factors. We constructed and validated nomograms for overall survival (OS) and disease-specific survival (DSS). Multivariate Cox regression identified key prognostic factors for OS, including advanced International Federation of Gynecology and Obstetrics stage, age, marital status, ethnicity, and tumor size. Notably, International Federation of Gynecology and Obstetrics stages IIIA, IIIB, and IVA had hazard ratios of 2.227, 2.451, and 4.852, respectively, significantly increasing the mortality risk compared to stage IB2. Ethnic disparities were evident, with African Americans facing a 39.8% higher risk than Caucasians did. Competing risk analyses confirmed the significance of these factors in DSS, particularly tumor size. Our nomogram demonstrated high predictive accuracy, with area under the curve values ranging from 0.706 to 0.784 for DSS and 0.717 to 0.781 for OS. Calibration plots and decision curve analyses further validated the clinical utility of this nomogram. We present effective nomograms for LACC risk stratification that incorporate multiple prognostic factors. These models provide a refined approach for individualized patient management and have the potential to significantly enhance therapeutic strategies for LACC.

Racial disparities in receipt of radiation and brachytherapy in cervical cancer patients: Do they exist in a SEER-Medicare population?

Objectives

To evaluate if race is associated with disparities in receipt of radiation (RT) and outcomes for Medicare patients with cervical cancer who are candidates for primary radiation-chemotherapy.

Methods

This SEER-Medicare retrospective study included White and Black patients with stage IB1 through IVA squamous cell carcinoma or adenocarcinoma diagnosed 2000-2017 who were candidates for primary radiation-chemotherapy. Receipt of treatment by race and associated cancer specific (CSS) and overall survival (OS) outcomes were analyzed using frequency distributions, chi squared, log rank, multivariable Cox proportional-hazards models, and multivariable logistic models.

Results

1038 patients (84.9 % White and 15.1 % Black) were included. 825 (79.5 %) received RT, and 601 (57.9 %) received brachytherapy (BT). Blacks were more likely to undergo RT than Whites (86.0 % vs. 78.3 %, p = 0.028) and had similar rates of BT (58.0 % vs. 57.9 %, p = 0.986). Median RT duration was 64.0 days (IQR 52.0, 75.0), and 276 (33.5 %) completed treatment in ≤ 56 days, with no differences by race (p = 0.488, 0.303, respectively). BT was more frequently provided at larger hospitals, National Cancer Institute-designated cancer centers, and teaching hospitals. When adjusted for covariates, no significant differences in RT, BT, or RT duration by race were identified. Median unadjusted OS was 3.58 years (95 % CI 2.92, 4.42) for White patients and 2.50 years (95 % CI 2.0, 5.25) for Black patients, with no differences in OS (HR 0.93, 95 % CI 0.75, 1.13) or CSS (HR 1.13, 95 %CI 0.86, 1.43).

Conclusions

Black Medicare patients with cervical cancer had greater receipt of RT than White patients, similar rates of BT, and no difference in survival.

Updated Trends in Cervical Cancer Brachytherapy Utilization and Disparities in the United States From 2004 to 2020

PURPOSE

Lower brachytherapy utilization for cervical cancer patients is associated with decreased survival. This study examines more recent trends in brachytherapy utilization from 2004 to 2020 to assess any trend reversal after awareness increased regarding the importance of brachytherapy.

METHODS AND MATERIALS

This study analyzed data from the National Cancer Database of patients with Federation of Gynecology and Obstetrics (FIGO) IB to IVA cervical cancer treated with radiation therapy between 2004 and 2020. To compare brachytherapy utilization over time, 2- to 3-year categories were created to account for potential variation seen in individual years. A multivariate log binomial regression with robust variance was used to estimate the incidence rate ratio (IRR) of brachytherapy utilization in each year category in reference to the 2004-2006 category. Additionally, risk factors for brachytherapy utilization were identified.

RESULTS

Overall brachytherapy utilization for cervical cancer increased from 54.9% in 2004 to 75.7% in 2020. Compared with 2004 to 2006 when rates of utilization totaled 55.2%, brachytherapy utilization significantly increased to 63.4% in 2011 to 2014 (IRR, 1.15; 95% CI, 1.11-1.19), 66.0% in 2015 to 2017 (1.20 [1.16-1.23]), and 76.0% in 2018 to 2020 (1.38 [1.34-1.42]). Sociodemographic factors associated with lower brachytherapy utilization included Black race (0.94 [0.92-0.97]), Hispanic ethnicity (0.92 [0.90-0.95]), and age >59 years (age ≥60-69: 0.96 [0.94-0.98]; age ≥70-79: 0.89 [0.87-0.92]; age ≥80: 0.73 [0.69-0.77]). Positive predictors of brachytherapy utilization included having insurance (IRR, 1.11; 95% CI, 1.07-1.14).

CONCLUSIONS

In patients with FIGO IB-IVA cervical cancer treated with radiation therapy from 2004 to 2020, brachytherapy utilization has increased during the past decade. These results are encouraging given the known benefit to cause-specific survival and overall survival provided by brachytherapy treatment and indicate a reversal in the trend of declining brachytherapy noted previously. Concerns related to disparities by race, ethnicity, and insurance status require further interventions.

Guideline concordant care for patients with locally advanced cervical cancer by disaggregated Asian American and Native Hawaiian/Pacific Islander groups: A National Cancer Database Analysis

OBJECTIVE

Despite the within-group heterogeneity, Asian American (AA) and Native Hawaiian and Pacific Islander (NH/PI) patients are often grouped together. We compared the patterns of guideline-concordant care for locally advanced cervical cancer for disaggregated AA and NH/PI patients.

METHODS

Patients with stage II-IVA cervical cancer between 2004 and 2020 were identified from the National Cancer Database. AA patients were disaggregated as East Asian (EA), South Asian (SA), and Southeast Asian (SEA). NH/PI patients were classified as a distinct racial subgroup. The primary outcome was the proportion undergoing guideline-concordant care, defined by radiation therapy with concurrent chemotherapy, brachytherapy, and completion of treatment within eight weeks.

RESULTS

Of 48,116 patients, 2107 (4%) were AA and 171 (<1%) were NH/PI. Of the AA patients, 36% were SEA, 31% were EA, 12% were SA, and 21% could not be further disaggregated due to missing or unknown data. NH/PI patients were more likely to be diagnosed at an early age (53% NH/PI vs. 30% AA, p < 0.001) and have higher rates of comorbidities (18% NH/PI vs. 14% AA, p < 0.001). Within the AA subgroups, only 82% of SEA patients received concurrent chemotherapy compared to 91% of SA patients (p = 0.026). SA patients had the longest median OS (158 months) within the AA subgroups compared to SEA patients (113 months, p < 0.001).

CONCLUSION

Disparities exist in the receipt of standard of care treatment for cervical cancer by racial and ethnic subgroups. It is imperative to disaggregate race and ethnicity data to understand potential differences in care and tailor interventions to achieve health equity.

Dose and fractionation regimen for brachytherapy boost in cervical cancer in the US

PURPOSE

Curative-intent radiotherapy for locally advanced and select early stage cervical cancer in the US includes external beam radiotherapy (EBRT) with brachytherapy. Although there are guidelines for brachytherapy dose and fractionation regimens, there are limited data on practice patterns. This study aims to evaluate the contemporary utilization of cervical cancer brachytherapy in the US and its association with patient demographics and facility characteristics.

METHODS

We retrospectively analyzed clinical covariates of cervical cancer patients diagnosed and treated in 2018-2020 with curative-intent radiotherapy from the 2020 National Cancer Database. Associations between patient and institutional factors with the number of brachytherapy fractions were identified with logistic regression. Factors with association (p < 0.10) were then included in a multivariable logistic regression model. All tests were two-sided with significance <0.05 unless specified otherwise.

RESULTS

Among the eligible 2517 patients, 97.3% received HDR or LDR and is further analyzed. More patients received HDR than LDR brachytherapy (98.9% vs 1.1%) and intracavitary than interstitial brachytherapy (86.4% vs 13.6%). The most common number of HDR fractions prescribed were 5 (51.0%), 4 (32.9%), and 3 (8.6%). After adjusting for the other variables in the model, ethnicity, private insurance status, overall insurance status, and facility type were the only factors that were significantly associated with the number of brachytherapy factions (p < 0.0001, p = 0.028, p = 0.001, and p < 0.0001, respectively, n = 2184).

CONCLUSIONS

In the US, various HDR brachytherapy regimens are utilized depending on patient and institutional factors. Future research may optimize cervical cancer brachytherapy by correlating specific dose and fractionation regimens with patient outcomes.

Disparities in brachytherapy utilization in cervical cancer in the United States: A comprehensive literature review

Brachytherapy (BT) is an integral component of treatment for patients with locally advanced cervical cancer, significantly improving local control and overall survival. There is an overall trend of decreased utilization of BT in United States (US) in the last few decades with around 50% of patients being treated without BT. The cause of decreased utilization is multifactorial including physician comfort, facility volume, low reimbursements rates and costs of starting and maintaining a brachytherapy program. This decrease coincides with an increase in the use of newer advanced techniques like intensity modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT) boost resulting in inferior oncological outcomes and increased toxicity. Moreover, racial and socioeconomic disparities in BT utilization have been widely reported in the US. Various factors including age, race, socio-economic status, location, facility type, facility volume and insurance status result in limited access to brachytherapy, which jeopardizes oncologic outcomes. This comprehensive review discusses the BT utilization in the US, examines the impact of race and socioeconomic factors on BT utilization, and highlights its impact on outcomes.

Adapting a model of cervical carcinogenesis to self-identified Black women to evaluate racial disparities in the United States

BACKGROUND

Self-identified Black women in the United States have higher cervical cancer incidence and mortality than the general population, but these differences have not been clearly attributed across described cancer care inequities.

METHODS

A previously established microsimulation model of cervical cancer was adapted to reflect demographic, screening, and survival data for Black US women and compared with a model reflecting data for all US women. Each model input with stratified data (all-cause mortality, hysterectomy rates, screening frequency, screening modality, follow-up, and cancer survival) was sequentially replaced with Black-race specific data to arrive at a fully specified model reflecting Black women. At each step, we estimated the relative contribution of inputs to observed disparities.

RESULTS

Estimated (hysterectomy-adjusted) cervical cancer incidence was 8.6 per 100 000 in the all-race model vs 10.8 per 100 000 in the Black-race model (relative risk [RR] = 1.24, range = 1.23-1.27). Estimated all-race cervical cancer mortality was 2.9 per 100 000 vs 5.5 per 100 000 in the Black-race model (RR = 1.92, range = 1.85-2.00). We found the largest contributors of incidence disparities were follow-up from positive screening results (47.3% of the total disparity) and screening frequency (32.7%). For mortality disparities, the largest contributor was cancer survival differences (70.1%) followed by screening follow-up (12.7%).

CONCLUSION

To reduce disparities in cervical cancer incidence and mortality, it is important to understand and address differences in care access and quality across the continuum of care. Focusing on the practices and policies that drive differences in treatment and follow-up from cervical abnormalities may have the highest impact.

Disparities in Gynecologic Cancers

ABSTRACT

Gynecologic cancer disparities have different trends by cancer type and by sociodemographic/economic factors. We highlight disparities in the United States arising due to poor delivery of cancer care across the continuum from primary prevention, detection, and diagnosis through treatment and identify opportunities to eliminate/reduce disparities to achieve cancer health equity. Our review documents the persistent racial and ethnic disparities in cervical, ovarian, and uterine cancer outcomes, with Black patients experiencing the worst outcomes, and notes literature investigating social determinants of health, particularly access to care. Although timely delivery of screening and diagnostic evaluation is of paramount importance for cervical cancer, efforts for ovarian and uterine cancer need to focus on timely recognition of symptoms, diagnostic evaluation, and delivery of guideline-concordant cancer treatment, including tumor biomarker and somatic/germline genetic testing.

Racial Disparities in Brachytherapy Treatment among Women with Cervical and Endometrial Cancer in the United States

Brachytherapy improves clinical outcomes among women diagnosed with cervical and endometrial cancers. Recent evidence demonstrates that declining brachytherapy boosts for women with cervical cancer were associated with higher mortality. In this retrospective cohort study, women diagnosed with endometrial or cervical cancer in the United States between 2004 and 2017 were selected from the National Cancer Database for evaluation. Women ≥18 years of age were included for high intermediate risk (PORTEC-2 and GOG-99 definition) or FIGO Stage II-IVA endometrial cancers and FIGO Stage IA-IVA-non-surgically treated cervical cancers. The aims were to (1) evaluate brachytherapy treatment practice patterns for cervical and endometrial cancers in the United States; (2) calculate rates of brachytherapy treatment by race; and (3) determine factors associated with not receiving brachytherapy. Treatment practice patterns were evaluated over time and by race. Multivariable logistic regression assessed predictors of brachytherapy. The data show increasing rates of brachytherapy for endometrial cancers. Compared to non-Hispanic White women; Native Hawaiian and other Pacific Islander (NHPI) women with endometrial cancer and Black women with cervical cancer were significantly less likely to receive brachytherapy. For both NHPI and Black women, treatment at community cancer centers was associated with a decreased likelihood of brachytherapy. The data suggest racial disparities among Black women with cervical cancer and NHPI women with endometrial cancer and emphasize an unmet need for brachytherapy access within community hospitals.

Comparison of Enhanced Recovery After Surgery (ERAS) metrics by race among gynecologic oncology patients: Ensuring equitable outcomes

OBJECTIVES

Race and ethnicity are not routinely audited in Enhanced Recovery After Surgery (ERAS) pathways. Given known racial disparities in outcomes in gynecologic oncology, the purpose of this study was to compare differences in ERAS implementation and outcomes by race.

METHODS

A cohort study was performed among gynecologic oncology patients enrolled in an ERAS pathway at one academic institution from March 2017 to December 2021. Compliance with ERAS metrics, postoperative complications, 30-day survival, reoperations, intensive care unit (ICU) transfers, and readmissions within 30 days were compared by race.

RESULTS

Of 1083 patients (17.0% non-white), non-white women were younger (54.2 years ±13.1 vs. 60.7 years ±13.6, p < 0.001) and proportionally fewer spoke English (75.0% vs. 97.8%, p < 0.001). Fewer non-white women received preadmission ERAS education (73.4% vs. 79.9%, p = 0.05). There were no differences in ERAS implementation by race, including similar rates of preoperative nutritional assessment, carbohydrate loading, antibiotic and thrombosis prophylaxis, and unplanned surgeries by race. There were no differences in complications, reoperations, ICU transfers, or readmissions by race on univariate and multivariate analysis. Four non-white (2.2%) and two white women (0.2%, p = 0.009) died within 30 days of surgery.

CONCLUSIONS

Fewer non-white women received preadmission education, possibly due to language barriers. ERAS compliance, postoperative complications, readmissions, reoperations, and ICU transfers did not differ by race. There were two additional deaths within 30 days postoperatively among non-white women compared to white women - which is difficult to interpret given the rarity of perioperative mortality - but appeared unlikely to be related to differences in ERAS protocol implementation. ERAS programs should ensure educational materials are translated into various languages and audit metrics by race to ensure equitable outcomes.

Underserved Pacific Islanders With Locally Advanced Cervical Cancer Receive Higher Rates of Standard-of-Care Radiation Treatment Through the Pacific Island Health Care Project and Military Health System Compared to the Average U.S. Population

INTRODUCTION

Brachytherapy, with external beam radiation, increases survival in the treatment of locally advanced cervical cancer (LACC). In 2016, Robin et al. reported only 44% of patients received standard-of-care (SOC) brachytherapy in the USA. The Pacific Island Health Care Project has provided humanitarian medical care to women from the U.S. Associated Pacific Islands (USAPI) for three decades at Tripler Army Medical Center (TAMC), a military health care system (MHS) facility. We evaluated whether this underserved and understudied patient population received SOC treatment for LACC at TAMC.

MATERIALS AND METHODS

The TAMC tumor registry was searched for all cervical cancer cases from 1997 to 2019. Subjects were excluded if they did not have stage IB2-IVA disease and were not from USAPI. The primary outcome was the overall utilization of brachytherapy, and statistical analysis was performed using the chi-square test.

RESULTS

We identified 214 women with cervical cancer treated at TAMC, of which 67 met the study criteria. Ninety-two percent had squamous cell carcinoma on histology. Of the patients identified, 48 (71.6%, P < .001) were treated with brachytherapy. Fifteen (22.4%) patients received external radiation alone, and four (6.0%) received chemoradiation without brachytherapy. A post-hoc power analysis was conducted with a power of 91.3%.

CONCLUSIONS

Women with cervical cancer from USAPI in the PIHCP program treated at TAMC received significantly higher rates of SOC radiation treatment than the U.S. population on average. This highlights the ability of PIHCP, through the MHS, to deliver SOC treatment for cervical cancer to an otherwise underserved patient population.

Equity, Diversity, and Inclusion in Radiation Oncology: A Bibliometric Analysis and Critical Review

The promotion of equity, diversity, and inclusion (EDI) is being increasingly pursued in health care, both in general and within radiation oncology. Because bibliometrics is a powerful tool to reveal the scientific literature on a specific topic during a certain timespan, a systematic bibliometric analysis of the documents published on EDI in radiation oncology was performed, aiming at exploring common patterns in research and emerging trends, tracking collaborations and networks, and anticipating future directions in clinical research. Standard descriptive statistics and bibliometric techniques were used in the analysis. A collaboration network and thematic map were generated from the data. Four domains were represented: (1) motor themes, including themes well developed and important for the structuring of the research field; (2) niche themes, representing the isolated topics that do not share important external links with other themes; (3) emerging themes, referring to still weakly developed topics; and (4) basic themes, including the essential topics. EDI in the profession of radiation oncology is essential to ensure that the workforce delivering radiation oncology care both draws from the full talent pool of human capital and delivers the highest quality science and clinical care to all patients. The burgeoning literature on EDI in radiation oncology suggests that a large and growing cohort of scholars within radiation oncology are dedicated to addressing these important challenges.

Guideline-Discordant Care in Early-Stage Vulvar Cancer

OBJECTIVE

To describe the use of National Comprehensive Cancer Network guideline-concordant inguinofemoral lymph node (LN) evaluation in individuals with early-stage vulvar cancer.

METHODS

This retrospective cohort study identified patients with T1b and T2 vulvar squamous cell carcinoma diagnosed between 2012 and 2018 using the National Cancer Database. Factors associated with LN evaluation were examined using logistic regression analyses, adjusting for patient, disease, and facility-level characteristics. Kaplan-Meier survival analysis using log rank test and Cox regression was performed for the entire cohort and a subgroup of older patients , defined as individuals aged 80 years or older.

RESULTS

Of the 5,685 patients with vulvar cancer, 3,756 (66.1%) underwent guideline-concordant LN evaluation. In our adjusted model, age 80 years or older (odds ratio [OR], 0.30; 95% CI 0.22-0.42) and Black race (OR 0.72; 95% CI 0.54-0.95) were associated with lower odds of LN evaluation. High-volume hospitals were associated with increased odds of LN evaluation compared with low-volume hospitals (OR 1.62; 95% CI 1.28-2.05). Older individuals who did not undergo LN evaluation had significantly worse overall survival than those with pathologically negative LNs (hazard ratio [HR] 0.45; 95% CI 0.37-0.55) and similar overall survival as those with pathologically positive LNs (HR 1.05; 95% CI 0.77-1.43).

CONCLUSION

Guideline-concordant LN evaluation for early-stage vulvar squamous cell carcinoma is low. Lower utilization is associated with older age, Black race, and care at a low-volume hospital.

Regional Variation in Access to Oncologic Care and Racial Disparities Among Cervical Cancer Patients

OBJECTIVES

The goal of this study was to determine whether access to gynecologic oncologists is correlated with disparate outcomes among cervical cancer patients, especially among Black women.

MATERIALS AND METHODS

An ecological study was performed using the National Cancer Database among stage I-IVA cervical cancer patients from 2004 to 2014. Data from the National Cancer Institute, the Society of Gynecologic Oncology, and the United States Census were compiled to describe access to care by region. Factors associated with receipt of optimal treatment (defined as surgery and/or radiation for stage IA-IB1 and IIA1; radiation and chemotherapy for stage IB2, IIA2, IIB-IVA or node positive disease) were identified using multivariate logistic regressions stratified by region, controlling for confounding factors including the number of gynecologic oncologists per states in each subregion. Cox multivariate survival analyses stratified by region were also performed.

RESULTS

Of 42,213 women, 17.0% were Black. On multivariate analysis controlling for confounders, all Southern women were less likely to receive optimal treatment (adjusted odds ratio [aOR]: 0.80, 95% confidence interval [95% CI]: 0.75-0.85, P <0.001) compared with Northeastern women. Black women in the South (aOR: 0.76, 95% CI: 0.70-0.83, P <0.001) and Midwest (aOR: 0.78, 95% CI: 0.68-0.90, P <0.001) were less likely to receive optimal treatment compared with non-Black women in those regions. Black women in the South (adjusted hazard ratio [aHR]: 1.11, 95% CI: 1.04-1.18, P <0.001) and West (aHR: 1.34, 95% CI: 1.11-1.62, P =0.002) had worse mortality compared with non-Black women in those regions, despite controlling for access to gynecologic oncologists. The South, Midwest, and West had proportionally fewer cancer centers and gynecologic oncologists compared with the Northeast.

CONCLUSIONS

Southern women are at risk of inadequate treatment for cervical cancer, and Black Southern women are at even higher risk of inadequate treatment and worse overall survival despite controlling for access to gynecologic oncologists. Social determinants of health and other barriers besides access to oncologists likely contribute to observed regional and racial disparities among cervical cancer patients.

Survival, treatment pattern, and treatment outcome in patients with cervical cancer metastatic to distant lymph nodes

Background

Cervical cancer with nodal involvement beyond the pelvis was considered as distant nodal metastasis in the previous International Federation of Gynecology and Obstetrics staging system. With the improvement of cancer-directed therapies, some of these patients can receive curative treatment. Classifying them as distant metastasis may result in underestimation of their prognosis as well as undertreatment. However, limited research has been conducted on the survival and treatment pattern in distant lymphatic metastatic cervical cancer.

Objective

To investigate the survival, treatment pattern, and treatment outcome of patients with cervical cancer metastasized to distant lymph nodes (DLN) beyond the pelvis.

Methods

Patients with stage III-IV cervical cancer from 1988 to 2016 were identified using the Surveillance, Epidemiology, and End Results program. The cancer cause-specific survival (CSS) was analyzed using the Kaplan-Meier method, log-rank test, multivariable Cox proportional hazard regression, subgroup analysis, and propensity score-matched analysis.

Results

Of 17783 patients with stage III-IV cervical cancer, patients with distant nodal disease beyond the pelvis (n=1883; included para-aortic lymph nodes metastasis) had superior survival compared to those with pelvic organ invasion or with distant organ(s) metastasis (5-year CSS, 32.3%, 26.3%, and 11.5%, respectively; adjusted P<0.001). The T stage significantly affected the survival of patients with positive DLN (5-year CSS for T1, T2, and T3: 47.3%, 37.0%, and 19.8%, respectively, adjusted P<0.01). For patients with positive DLN, combination radiotherapy (external beam radiotherapy [EBRT] with brachytherapy) prolonged CSS compared to EBRT alone (5-year CSS, 38.0% vs 21.7%; propensity score-adjusted HR, 0.60; 95% CI 0.51-0.72; P<0.001). Despite the superiority of combination radiotherapy, EBRT was the most frequently used treatment after 2004 (483/1214, 39.8%), while the utilization of combination radiotherapy declined from 37.8% (253/669) during 1988 through 2003 to 25.2% (306/1214) during 2004 through 2016.

Conclusion

Patients with cervical cancer metastasized to DLN have favorable survival compared to those with pelvic organ invasion or with distant organ(s) metastasis. Their prognosis is significantly affected by local tumor burden and local treatment. Adequate and aggressive local radiotherapy, such as image-guided brachytherapy, can be considered for these patients to achieve better outcomes.

Improved survival in cervical cancer patients receiving care at National Cancer Institute-designated cancer centers

Background

Locally advanced cervical cancer (CC) remains lethal in the United States. We investigate the effect of receiving care at an National Cancer Institute–designated cancer center (NCICC) on survival.

Methods

Data for women diagnosed with CC from 2004 to 2016 who received radiation treatment were extracted from the California Cancer Registry (n = 4250). Cox proportional hazards regression models assessed whether (1) receiving care at NCICCs was associated with risk of CC‐specific death, (2) this association remained after multivariable adjustment for age, race/ethnicity, and insurance status, and (3) this association was explained by receipt of guideline‐concordant treatment.

Results

Median age was 50 years (interquartile range [IQR] 41–61 years), with median follow‐up of 2.7 years (IQR 1.3–6.0 years). One‐third of patients were seen at an NCICC, and 29% died of CC. The hazard of CC‐specific death was reduced by 20% for those receiving care at NCICCs compared with patients receiving care elsewhere (HR = .80; 95% CI, 0.70–0.90). Adjustment for guideline‐concordant treatment and other covariates minimally attenuated the association to 0.83 (95% CI, 0.74–0.95), suggesting that the survival advantage associated with care at NCICCs may not be due to receipt of guideline‐concordant treatment.

Conclusions

This study demonstrates survival benefit for patients receiving care at NCICCs compared with those receiving care elsewhere that is not explained by differences in guideline‐concordant care. Structural, organizational, or provider characteristics and differences in patients receiving care at centers with and without NCI designation could explain observed associations. Further understanding of these factors will promote equality across oncology care facilities and survival equity for patients with CC.

This study demonstrates survival benefit for patients receiving care for cervical cancer at National Cancer Institute–designated cancer centers that is not explained by receipt of guideline‐concordant treatment. Further understanding of these factors will promote equality across oncology care facilities resulting in survival equity for patients with cervical cancer.

[Impact of multi-leaf collimator positioning accuracy on quality control of volumetric modulation arc therapy plan for cervical cancer treated with Elekta linear accelerator]

OBJECTIVE

To investigate the influence of positioning accuracy of the multi-leaf collimators (MLC) on the passing rate of the plan dose verification for volumetric modulation arc therapy (VMAT) of cervical cancer using an Elekta linear accelerator.

METHODS

The dose distributions were measured using Sun Nuclear's Mapcheck and Arccheck semiconductors matrix before and after MLC calibration in30 cervical cancer patients undergoing VMAT. Dosimetric comparisons were performed with 2D and 3D gamma passing rates of 3%, 3 mm and 2%, and 2 mm. The 3D gamma distribution was reconstructed with respect to the patient's anatomy using 3DVH software to evaluate the possible influence of MLC positioning accuracy.

RESULTS

Before and after MLC calibration, the gamma passing rates of Mapcheck were (88.80±1.81)% and (99.25 ± 0.53)% under 3% and 3 mm standard, respectively, with an average increase of 10.45%. The corresponding gamma passing rates of Arccheck were (87.61±1.98)% and (98.13±0.99)%, respectively, with an average increase of 10.52%. The gamma passing rates of 3DVH were (89.87±2.28)% and (98.3±1.15)%, respectively, with an average increase of 8.43%.

CONCLUSION

The MLC positioning accuracy is one of the main factors influencing dosimetric accuracy of VMAT for cervical cancer. The application of Autocal software facilitates MLC calibration and improves the accuracy and safety of VMAT delivery for cervical cancer.

Disparities in gynecologic cancer incidence, treatment, and survival: a narrative review of outcomes among black and white women in the United States

For patients diagnosed with ovarian, uterine, or cervical cancer, race impacts expected outcome, with black women suffering worse survival than white women for all three malignancies. Moreover, outcomes for black women have largely worsened since the 1970s. In this narrative review, we first provide an updated summary of the incidence and survival of ovarian, uterine, and cervical cancer, with attention paid to differences between white and black patients. We then offer a theoretical framework detailing how racial disparities in outcomes for each of the gynecologic malignancies can be explained as the sum result of smaller white-black differences in experience of preventive strategies, implementation of screening efforts, early detection of symptomatic disease, and appropriate treatment. Much research has been published regarding racial disparities in each of these domains, and with this review, we seek to curate the relevant literature and present an updated understanding of disparities between black and white women with gynecologic malignancies.

The vaginal microbiome: A complex milieu affecting risk of human papillomavirus persistence and cervical cancer

The purpose of this review is to describe the existing literature regarding the relationship between the vaginal microbiome, human papillomavirus persistence, and cervical cancer risk, as well as to discuss factors that mediate these relationships. Data suggest that alterations in the vaginal microbiome affect the risk of human papillomavirus infection and persistence, which has downstream effects on cervical dysplasia and cancer risk. The homeostatic Lactobillus species L. crispatus, L. gasseri, L. jensenii act to promote a healthy vaginal environment, while L. iners and pathogens causing bacterial vaginosis are associated with increased inflammation, human papillomavirus infection, cervical dysplasia, and potentially cancer. There are, however, still several large gaps in the literature, particularly related to the modifiable and non-modifiable factors that affect the vaginal microbiome and ensuing risk of pre-cancerous and cancerous lesions. Evidence currently suggests that endogenous and exogenous hormones, tobacco products, and sexual practices influence vaginal microbiome composition, but the nuances of these relationships and how changes in these factors affect dysplasia risk are yet to be delineated. Other studies examining how diet, exercise, race, socioeconomic status, and genetic factors influence the vaginal microbiome are difficult to interpret in the setting of multiple confounders. Future studies should focus on how changes in these modulatory factors might promote a healthy vaginal microbiome to prevent or treat dysplasia in the lower female genital tract.

Sociodemographic characteristics and cervical cancer survival in different regions of the United States: a National Cancer Database study

OBJECTIVE

To determine how sociodemographic factors impact cervical cancer survival in different geographic locations in the USA.

METHODS

A retrospective cohort of patients with cervical cancer from January 1, 2004 to December 31, 2015 in the National Cancer Database (NCDB) was identified. Tumor characteristics as well as race, income, insurance type, and treating facility types were compared among nine geographic regions. χ2 tests and Cox regression were used to compare differences between regions; p values <0.05 were considered significant.

RESULTS

A total of 48 787 patients were included. Survival was inferior in seven of nine regions for underinsured patients. In six regions survival was inferior for Medicaid and Medicare patients, respectively: Middle Atlantic: hazard ratio (HR) 1.25 and 1.22; South Atlantic: HR 1.41 and HR 1.22; East North Central: HR 1.36 and HR 1.25; East South Central: HR 1.37 and HR 1.25; West North Central: HR 1.67 and HR 1.42; West South Central: HR 1.44 and HR 1.46. In the Pacific region survival was inferior for Medicare patients (HR 1.35) but not inferior for Medicaid patients. Being uninsured was associated with worse survival in the South Atlantic (HR 1.23), East North Central (HR 1.23), East South Central (HR 1.56), and West South Central (HR 1.31) regions. Annual income level under $38 000 was associated with worse survival in the Middle Atlantic (HR 1.24), South Atlantic (HR 1.35), and East North Central (HR 1.49) regions. Lastly, when compared with academic research institutions, comprehensive community cancer centers had significantly worse survival in four of the nine regions.

CONCLUSIONS

Cervical cancer mortality is higher for women with a low income, underinsured (Medicaid or Medicare) or uninsured status, and decreased access to academic institutions in most US regions. An increase in cervical cancer mortality was associated with underinsured or uninsured populations in regions mainly located in the South and Midwest.

Evolution of patterns of care for women with cervical cancer in Morocco over a decade

BACKGROUND

We conducted a Pattern-of-care (POC) study at two premier-most public-funded oncology centers in Morocco to evaluate delays in care continuum and adherence to internationally accepted treatment guidelines of cervical cancer.

METHOD

Following a systematic sampling method, cervical cancer patients registered at Centre Mohammed VI (Casablanca) and Institut National d'Oncologie (Rabat) during 2 months of every year from 2008 to 2017, were included in this retrospective study. Relevant information was abstracted from the medical records.

RESULTS

A total of 886 patients was included in the analysis; 59.5% were at stage I/II. No appreciable change in stage distribution was observed over time. Median access and treatment delays were 5.0 months and 2.3 months, respectively without any significant temporal change. Concurrent chemotherapy was administered to 57.7% of the patients receiving radiotherapy. Surgery was performed on 81.2 and 34.8% of stage I and II patients, respectively. A very high proportion (85.7%) of operated patients received post-operative radiation therapy. Median interval between surgery and initiation of radiotherapy was 3.1 months. Only 45.3% of the patients treated with external beam radiation received brachytherapy. Radiotherapy was completed within 10 weeks in 77.4% patients. An overall 5-year disease-free survival (DFS) was observed in 57.5% of the patients - ranging from 66.1% for stage I to 31.1% for stage IV. Addition of brachytherapy to radiation significantly improved survival at all stages. The study has the usual limitations of retrospective record-based studies, which is data incompleteness.

CONCLUSION

Delays in care continuum need to be further reduced. Increased use of chemoradiation and brachytherapy will improve survival further.

Treatment of cervical cancer: overcoming challenges in access to brachytherapy

INTRODUCTION

Brachytherapy is an essential component of the cervical cancer treatment paradigm as it contributes to improved clinical outcomes and overall survival. Yet brachytherapy remains globally underutilized, with disparities in access at both national and international levels.

AREAS COVERED

The review explores current brachytherapy utilization practices and efforts being undertaken to address barriers to implementation in low-, middle-, and high-income countries, and how these efforts are projected to impact future brachytherapy access. The content presented is based on a review of published literature and the authors' collective clinical experiences.

EXPERT OPINION

There exists a tremendous opportunity to expand access to essential brachytherapy services for women with cervical cancer. Many national and international brachytherapy efforts exist; yet it remains imperative that such focused efforts continue to grow and provide further access to this critical treatment modality for women in need worldwide.

Better late than never: Brachytherapy is more important than timing in treatment of locally advanced cervical cancer

PURPOSE

To evaluate the utilization of brachytherapy and duration of treatment on overall survival for locally advanced cervical cancer.

METHODS

The National Cancer Database (NCDB) was queried to identify stage II-IVA cervical cancer patients diagnosed in the United States between 2004 and 2015 who were treated with definitive chemoradiation therapy. We defined standard of care (SOC) treatment as receiving external beam radiation therapy (EBRT) and concurrent chemotherapy, brachytherapy (BT), and completing treatment within 8 weeks, and compared SOC treatment to non-SOC. The primary outcome was overall survival (OS). We also evaluated the effect of sociodemographic and clinical variables on receiving SOC.

RESULTS

We identified 10,172 women with locally advanced cervical cancer primarily treated with chemotherapy and concurrent EBRT of which 6047 (59.4%) patients received brachytherapy, and only 2978 (29.3%) completed treatment within 8 weeks (SOC). Receipt of SOC was associated with significantly improved overall survival (median OS 131.0 mos vs 95.5 mos, 78.1 mos, 49.2 mos; p < 0.0001). Furthemore, in patients whose treatment extended beyond 8 weeks, brachytherapy was still associated with an improved survival (median OS 95.5 vs 49.2 mos, p < 0.0001). More advanced stage, Non-Hispanic Black race, lower income, lack of insurance or government insurance, less education, and rural residence were associated with decreased likelihood of receiving SOC.

CONCLUSIONS

Completing standard of care concurrent chemoradiation therapy and brachytherapy in the recommended 8 weeks was associated with a superior overall survival. Patients who received brachytherapy boost show superior survival to patients receiving EBRT alone, regardless of treatment duration. Disparities in care for vulnerable populations highlight the challenges and importance of care coordination for patients with cervical cancer.

Socioeconomic and Racial Determinants of Brachytherapy Utilization for Cervical Cancer: Concerns for Widening Disparities

PURPOSE

Cervical cancer (CC) disproportionately affects minorities who have higher incidence and mortality rates. Standard of care for locally advanced CC involves a multimodality approach including brachytherapy (BT), which independently improves oncologic outcomes. Here, we examine the impact of insurance status and race on BT utilization with the SEER database.

MATERIALS AND METHODS

In total, 7,266 patients with stage I-IV CC diagnosed from 2007 to 2015 were included. BT utilization, overall survival (OS), and disease-specific survival (DSS) were compared.

RESULTS

Overall, 3,832 (52.7%) received combined external beam radiation therapy (EBRT) + BT, whereas 3,434 (47.3%) received EBRT alone. On multivariate logistic regression analysis, increasing age (OR, 0.98; 95% CI, 0.98 to 0.99; P < .001); Medicaid (OR, 0.80; 95% CI, 0.72 to 0.88; P < .001), uninsured (OR, 0.67; 95% CI, 0.56 to 0.80; P < .001), and unknown versus private insurance (OR, 0.61; 95% CI, 0.43 to 0.86; P < .001); Black (OR, 0.68; 95% CI, 0.60 to 0.77; P < .001) and unknown versus White race (OR, 0.30; 95% CI, 0.13 to 0.77; P = .047); and American Joint Committee on Cancer stage II (OR, 1.07; 95% CI, 0.93 to 1.24; P = .36), stage III (OR, 0.82; 95% CI, 0.71 to 0.94; P = .006), stage IV (OR, 0.30; 95% CI, 0.23 to 0.40; P < .001), and unknown stage versus stage I (OR, 0.36; 95% CI, 0.28 to 0.45; P < .001) were associated with decreased BT utilization. When comparing racial survival differences, the 5-year OS was 44.2% versus 50.9% (P < .0001) and the 5-year DSS was 55.6% versus 60.5% (P < .0001) for Black and White patients, respectively. Importantly, the racial survival disparities resolved when examining patients who received combined EBRT + BT, with the 5-year OS of 57.3% versus58.5% (P = .24) and the 5-year DSS of 66.3% versus 66.6% (P = .53) for Black and White patients, respectively.

CONCLUSION

This work demonstrates notable inequities in BT utilization for CC that particularly affects patients of lower insurance status and Black race, which translates into inferior oncologic outcomes. Importantly, the use of BT was able to overcome racial survival differences, thus highlighting its essential value.

Brachytherapy utilization rate and effect on survival in cervical cancer patients in Korea

OBJECTIVE

External beam radiation therapy (EBRT) with concurrent chemotherapy followed by intracavitary brachytherapy is the standard treatment in locally advanced cervical cancer. This study examined the brachytherapy utilization rate and evaluated the effect of brachytherapy on survival in cervical cancer patients in Korea.

METHODS

In this study, data from the Korea Central Cancer Registry and Korean National Health Insurance Service and data on mortality from Statistics Korea were linked and used. Patients with other cancers, distant metastasis at diagnosis, or unknown stage or who underwent hysterectomy were excluded. A total of 12,721 cervical cancer patients were analyzed in this study.

RESULTS

The brachytherapy utilization rate (%) was calculated as the proportion of patients who received brachytherapy among those who received curative EBRT. The brachytherapy utilization rate decreased from 84% in 2005 to 78% in 2013 (p<0.001). Brachytherapy utilization rates varied by region, ranging from 72% to 100% except for in Jeju Island, where the rate was 56%. The brachytherapy utilization rate was lower in patients older than 80 years; patients with localized disease, non-squamous cell carcinoma, or Charlson comorbidity index 3 or more; patients diagnosed after 2010; patients from certain regions; patients receiving medical aid; and patients who underwent gynecologic procedures. Multivariable Cox regression analysis showed that brachytherapy when added to curative EBRT was independently associated with better cancer-specific survival (CSS) and overall survival (OS) than curative EBRT only.

CONCLUSION

The brachytherapy utilization rate decreased from 2005 to 2013 and varied by region in Korea. Brachytherapy use is independently associated with significantly higher CSS and OS in cervical cancer.

Age, racial, and ethnic disparities in reported clinical studies involving brachytherapy

PURPOSE

The purpose of this study was to evaluate for age, racial, and ethnic disparities among clinical studies where patients can potentially receive brachytherapy treatment.

METHODS AND MATERIALS

Trials involving brachytherapy for breast, cervical, prostate, and uterine cancers were identified using ClinicalTrials.gov. The age, racial, and ethnic breakdown of the identified trials were compared to US population-estimates derived from the Surveillance, Epidemiology, and End Results (SEER) Program. Primary outcomes were gaps between gaps between mean age and race and ethnic proportions in trials and the US population. Secondary outcomes included proportions of racial and ethnic data reporting. Descriptive statistics, t-tests, χ2 tests, and univariate analysis were used to analyze the data.

RESULTS

A total of 77 trials with reported data were identified, representing 13,580 patients. The overall difference in mean age in the identified trials compared to US population estimates was -2.29 years (p < 0.001), with the largest difference occurring in prostate cancer at -2.72 years (p < 0.001). With the exception of ethnicity in cervical cancer (p = 0.18), all racial and ethnic distributions were statistically significantly different. Overall, the largest disparity was among Asian (-2.65%) and Hispanic patients (-1.05%). Of the 77 trials, 76 (98.7%) reported age, 36 (46.8%) reported race, and 24 (31.2%) reported ethnicity.

CONCLUSIONS

Diversity data is underreported among clinical studies where brachytherapy is a potential treatment component. However, among reported trials, disparities are present albeit relatively small compared to previous studies reporting on disparities in clinical trials. Future efforts should emphasize increased reporting of racial and ethnicity data as well as ensuring inclusion of older patients and minorities.

Identify Function of WASL in Prognosis of Cervical Cancer Based on Omics Data

Objective

To clarify the clinical relevance of WASP like actin nucleation promoting factor (WASL) in patients with cervical cancer and associated mechanisms.

Methods and Materials

We obtained high prediction accuracy and determined the correlation between the expression of WASL and the clinical characteristics of cervical cancer patients. Differentially expressed genes (DEGs) were identified using microarray. Gene ontology (GO) enrichment analysis and gene set enrichment analysis (GSEA) were performed to determine potentially relevant mechanisms related to the prognostication ability of WASL expression.

Results

Chi-square test and multivariable logistic regression analysis suggested that lower expression of WASL was associated with lower pathological stage (chi-square test: p = 0.022, chi-square = 9.613; logistic regression: OR = 0.869, 95% CI: 0.756-0.991, p = 0.041). Patients in the WASL high expression group have worse overall survival (OS) [hazard ratio (HR): 0.555, 95% CI: 0.348-0.884, log-rank p = 0.012] and recurrence-free survival (RFS) (HR = 0.449, 95% CI: 0.215-0.934, log-rank p = 0.028) compared with those in the WASL low expression group. Univariate and multivariable Cox proportional hazards regression model suggested that WASL expression was an independent prognostic factor for predicting OS and RFS in cervical cancer. DEGs were mostly enriched GO terms related to DNA replication or the proliferation of tumor cells. The results of GSEA suggested samples in the WASL knockdown group were enriched in glycolysis, TNF-α signaling via NFkB, mTORC1 signaling, and Wnt/β-catenin signaling.

Conclusions

WASL expression was associated with the pathological stage, and it might be an independent prognostication factor in patients with cervical cancer. Knockdown of WASL might be correlated with biological processes such as glycolysis, TNFα signaling, mTOR signaling, and Wnt/β-catenin signaling.

Assessing Inequities in Cervical Cancer Quality of Care and Survival Related to Ethnicity and Socioeconomic Factors

OBJECTIVE

This study aimed to assess the effect that race and socioeconomic factors have on the provision of care to cervical cancer patients based on National Comprehensive Cancer Network (NCCN) recommended treatment guidelines.

MATERIALS AND METHODS

To do this, we completed a retrospective cohort study using the American College of Surgeon's Nation Cancer Database from 2004 to 2016. We identified all reported cases of cervical cancer in that period. Two cohorts were created using self-reported racial demographic data, Hispanic- and White, non-Hispanic-identified patients. Our primary outcome variables were adherence to NCCN-recommended treatment and 5-year overall survival. Adherence to NCCN-recommended treatment was determined by the provision of surgical and/or radiation and/or chemotherapy treatment based on the clinical stage at time of diagnosis and the presence or absence of lymphovascular space invasion. We used bivariate analyses to compare baseline characteristics between the 2 cohorts, multivariable logistic regression to identify independent predictors of 5-year survival, and Cox proportional hazards models to compute survival by group.

RESULTS

The difference in NCCN-adherent care between the 2 cohorts was found to be not statistically significant (p = .880). A log rank (Mantel-Cox) χ2 test showed that there was a statistically significant difference between the 2 groups in overall survival with the Hispanic-identified patients living longer (p < .001). Our study is limited by the effect large databases confer on finding statistical significance.

CONCLUSIONS

Hispanic-identified women with cervical cancer receive NCCN-compliant care and live longer than their White, non-Hispanic counterparts.

Race- and Age-Related Disparities in Cervical Cancer Mortality

BACKGROUND

Although the incidence of cervical cancer among younger Black women is now equivalent to that of White women, it is unknown whether the reduced incidence has affected survival rates among younger Black women. The goal of this study was to assess differences in survival by age and race.

PATIENTS AND METHODS

A retrospective cohort study was performed using the National Cancer Database to analyze women with nonmetastatic cervical cancer diagnosed between 2004 and 2014. Women with unknown survival data and those who died within 3 months of diagnosis were excluded. Multivariable logistic regression models evaluated interactions between age and race (Black vs non-Black) for presentation with stage I disease and receipt of optimal treatment. A multivariable Cox regression model was used to evaluate survival differences by age and race.

RESULTS

Of 55,659 women included, 16.4% were Black. Compared with their non-Black counterparts, fewer Black women presented with stage I disease (37.8% vs 47.8%; P<.01) and received optimal treatment (46.2% vs 58.3%; P<.01). Fewer Black women had private insurance if they were aged <65 years (39.6% vs 55.7%; P<.01), but not if they were aged ≥65 years (11.7% vs 12.4%; P=.43). According to multivariable logistic regression, Black women aged ≤39 years were less likely to present with stage I disease, with a significant interaction term between age and race (P<.01 for interaction). Disparities in overall survival by race were greatest for Black women aged ≤39 years (adjusted hazard ratio, 1.32; 95% CI, 1.20-1.46; P<.01) but decreased with increasing age interval until no disparity was noted for women aged ≥65 years (P<.01 for interaction).

CONCLUSIONS

Younger Black women with cervical cancer are at risk for presenting with higher-stage disease and having worse overall survival. These findings may be related to insurance-related disparities and inadequate follow-up for abnormal Papanicolaou test results. Younger Black women with cervical cancer may be a particularly vulnerable population.

An Analysis of the Racial Disparities Among Cervical Cancer Patients Treated at an Academic Medical Center in the Southeastern United States

Objective

The purpose of this study was to identify racial disparities in treatment outcomes, if any, among patients with carcinoma of the cervix treated at a tertiary care institution in the state of Mississippi.

Methods

A retrospective review of patients with carcinoma of the cervix treated in the Department of Radiation Oncology at our institution between 2010 and 2018 was performed. Data regarding demographics, disease stage, treatments administered, and follow-up were collected. Patient outcomes, including median survival and overall survival, were analyzed using the Kaplan-Meier method. All analyses were performed using SPSS Statistics version 24 (IBM, Armonk, NY).

Results

Between January 2010 and December 2018, a total of 165 patients with carcinoma of the cervix were treated at our institution. We had a significantly higher proportion of African American (AA) compared to Caucasian American (CA) patients (59.4 vs. 36.4%; p=0.03). There was a significant difference in the disease stage at the time of presentation between AA and CA in that compared to AA women, a higher number of CA patients presented with locally advanced disease [Federation of Gynecology and Obstetrics (FIGO) stages IB2 to IVA] (78.6 vs. 86.7%; p<0.001). However, a higher number of AA patients presented with metastatic disease at diagnosis compared to CA women (13.3 vs. 8.3%; p<0.001).

Regarding their treatment, 157 (95.2%) underwent definitive chemoradiotherapy, while three (1.8%) had definitive surgery followed by adjuvant radiation or chemoradiation, depending on the risk factors identified operatively. The treatment details of five patients were not available. The median follow-up and the median survival of the entire cohort were 16 months and 79 months, respectively. In our cohort, there was no significant difference in overall survival between AA and CA patients at either three years (80 vs. 68%; p=0.883) or five years (77 vs. 68%; p=0.883). As expected, patients with locally advanced disease showed a significantly better median survival of 79 months compared to only 11 months for those with metastatic disease at their presentation (p<0.001).

Conclusions

Our study revealed that more AA women presented with metastatic disease compared to CA women. However, our analysis did not identify any racial disparities in the prognosis of the entire cohort.

Outcomes by Race Among Women Referred to an Academic Colposcopy Clinic with a Patient Navigation Program

Background: Although minority women are at higher risk of cervical cancer in the United States, little is known about differences in rates of colposcopy and loop electrosurgical excision procedure (LEEP) by race once patients present for care. Materials and Methods: A prospective registry of patients presenting to an academic colposcopy clinic was queried from 2008 to 2018. Women with missing race or cytology results, prior hysterectomy, or prior history of cervical, vulvar, or vaginal cancer were excluded. Poisson and logistic regression models were performed to evaluate the associations between race and colposcopy, LEEP, and cancer rates, adjusting for referral Papanicolaou (Pap), human papillomavirus (HPV) result, year of visit, age, insurance, pregnancy, number of sexual partners, and smoking status. Results: A total of 4506 women were included (56.1% white and 43.9% non-white). Referral for high-grade cytology was more likely among white compared to non-white women (22.5% vs. 17.5%, p < 0.001), as well as positive HPV testing (white 7.8% vs. non-white 6.0%, p < 0.001). The colposcopy rate was slightly higher among black (incidence rate ratio [IRR]_adjusted 1.11, 95% confidence interval [CI] 1.03-1.19, p = 0.006) and Hispanic women (IRR_adjusted 1.13, 95% CI 1.06-1.21, p = 0.0003) compared to white women. Hispanic women were significantly more likely to undergo LEEP (odds ratio_adjusted 1.26, 95% CI 1.01-1.58, p = 0.04). However, no significant difference in cancer, adenocarcinoma in situ, or high-grade histology was noted by race. Conclusions: Black and Hispanic women referred for abnormal Pap or HPV results underwent a greater number of colposcopies compared to white women, and Hispanic women underwent a greater number of LEEPs. Although cancer is rare in our cohort, there was no statistical difference in rate of cancer by race.