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Ganz EM, Brown B, Smith H, Wellisch L, Gupta M, Wagner SM. The association between affordable care act implementation and the prevalence of women having ever received a Pap smear. J OBSTET GYNAECOL 2024; 44:2393359. [PMID: 39176454 DOI: 10.1080/01443615.2024.2393359] [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: 05/13/2024] [Accepted: 08/12/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND To assess if implementation of the 2010 Patient Protection and Affordable Care Act (ACA) was associated with changes in the prevalence of women having ever received a pap smear. METHODS This study utilised the publicly available Centre for Disease Control National Survey of Family Growth (NSFG) data set. This was a serial cross-sectional study. The comparison groups were defined as women who received cancer screening and prevention interventions prior to full implementation of the ACA (2011-2013) and post full implementation (2017-2019). The primary outcome was self-reporting receipt of a Papanicolaou (Pap) smear. Secondary outcomes included HPV vaccination and mammogram rates. Anonymized patient information was collected from the nationally representative dataset, and analyses were performed utilising STATA 18. RESULTS The two study cohorts obtained from the NSFG included women who responded in 2011-2013 (n = 5601), deemed to be 'Pre-ACA implementation' (Pre ACA), and those who responded in 2017-2019 (n = 6141) 'Post-ACA implementation' (Post ACA). The proportion of women who were 21 years and older and ever had a Pap smear in the Pre ACA group (96.0%) was higher than that of the Post ACA group (94.1%) (OR 0.66 (0.49-0.91)). In contrast, HPV vaccination rates rose, and mammogram rates remained stable in the Post ACA period. CONCLUSION A decrease in proportion of women ever having had a Pap smear despite implementation of health policies to increase access to preventive measures suggests further interventions to improve access to cervical cancer screening are warranted.
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Affiliation(s)
- Eric M Ganz
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | - Benjamin Brown
- Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Heather Smith
- Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Lawren Wellisch
- Brown University School of Public Health, Providence, RI, USA
| | - Megha Gupta
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | - Stephen M Wagner
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, USA
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Frej KBH, Hardy N, Whitcomb B. A National Survey of Obstetrics and Gynecology Resident Perspectives on Their Preparedness to Provide Care for Underserved Patients with Gynecologic Malignancies. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2024:10.1007/s13187-024-02510-0. [PMID: 39313627 DOI: 10.1007/s13187-024-02510-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/14/2024] [Indexed: 09/25/2024]
Abstract
Obstetrics and Gynecology (Ob/Gyn) residents will encounter, screen for, and diagnose gynecologic malignancies. This survey assessed residents' confidence in providing NCCN Guidelines-based care to Gynecologic Oncology patients of differing racial/ethnic backgrounds and insurance statuses while accounting for residents' backgrounds. An anonymous, novel Qualtrics survey was disseminated to current US Ob/Gyn residents, with multiple-choice questions about subject demographics and Likert scale questions about their readiness to care for diverse patients. Differences in responses between racial groups were analyzed using the Kruskal-Wallis Rank Sum test. Differences in responses between ethnic groups were evaluated using the Wilcoxon Rank Sum test. Regardless of their backgrounds, residents feel "somewhat prepared" to care for diverse patients. There was no statistical between ethnic groups regarding confidence in caring for racial minorities or insurance types. Similarly, there was no statistical difference between racial groups regarding caring for racial minorities, but a difference did exist for insurance types (p = 0.027). No significant racial/ethnic differences were found in opinions on trial enrollment or chemotherapy delays, though most residents agreed that racial/ethnic minorities face delays in chemotherapy. Finally, resident ethnicity and race both impacted resident perceptions of difficulties for Medicaid and minority patients in obtaining non-operative gynecologic care (p = 0.044; p = 0.017) and scheduling outpatient appointments (p = 0.016; p = 0.032). Ob/Gyn residents feel prepared to provide NCCN Guidelines-based care to socioeconomically diverse patients with gynecologic malignancies, though differences exist when accounting for residents' racial/ethnic backgrounds. These results reflect the importance of emphasizing on culturally competent care in residency, particularly for patients with cancer.
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Affiliation(s)
- Khaoula Ben Haj Frej
- University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT, 06030, USA.
| | - Nicole Hardy
- University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - Bradford Whitcomb
- Division of Gynecologic Oncology, John Dempsey Hospital, Farmington, CT, USA
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3
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Smith AJ, Sharma MH, Powell K, Doherty M, Hinkle SN, Ko EM. Financial toxicity in gynecologic oncology: a multi-practice survey. Int J Gynecol Cancer 2024; 34:919-925. [PMID: 38346844 DOI: 10.1136/ijgc-2023-005054] [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] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Financial toxicity is associated with worse cancer outcomes, including lower survival. OBJECTIVE To characterize the prevalence of, and patient risk factors for, financial toxicity among gynecologic oncology patients in a multi-site health system. METHODS We identified patients seen in University of Pennsylvania gynecologic oncology practices between January 2020 and February 2022 with a patient portal account. We sent a survey to all alive patients twice between March and April 2022, including the 11-item Comprehensive Score for Financial Toxicity (COST) tool. We compared differences between patients reporting high (COST score <26) and low financial toxicity (COST score ≥26) in Χ2 and regression analyses. RESULTS Of 8239 patients, 6925 had a portal account, and 498 completed the survey for 7.2% response rate. 44% had a COST score <26, indicating financial toxicity. Patients with high financial toxicity were more likely to be younger (mean age 54 vs 60), have cervical cancer (10% vs 4%; p=0.008), be privately insured (71% vs 57%; p=0.003) or have Medicaid (7% vs 3%; p=0.03), or be unemployed (18% vs 3%; p=<0.001), and less likely to be white (79% vs 90%, p=0.003) than those with low financial toxicity. Patients with Medicare were less likely to experience financial toxicity than privately insured patients (RR=0.59, 95% CI 0.37 to 0.95). CONCLUSION In this study of patients with gynecologic cancer or pre-cancer, 44% had financial toxicity. Financial toxicity was higher in patients who were younger, did not identify as White, and had private insurance. Targeted measures to address financial toxicity are needed to minimize disparities in patient burden of cancer treatment.
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Affiliation(s)
- Anna Jo Smith
- Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania, USA
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maya H Sharma
- University of Pennsylvania, Philadelphia, Philadelphia, USA
| | - Kristina Powell
- Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania, USA
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Meredith Doherty
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stefanie N Hinkle
- Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Meichun Ko
- Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania, USA
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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4
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Gamble C, Woodard TJ, Yakubu AI, Chapman-Davis E. An Intervention-Based Approach to Achieve Racial Equity in Gynecologic Oncology. Obstet Gynecol 2023; 142:957-966. [PMID: 37678907 PMCID: PMC10510810 DOI: 10.1097/aog.0000000000005348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 09/09/2023]
Abstract
Racial inequities within gynecologic oncology exist at every step of the cancer continuum. Although the disparities have been well described, there is a significant gap in the literature focused on eliminating inequities in gynecologic cancer outcomes. The goal of this narrative review is to highlight successful, evidence-based interventions from within and outside of gynecologic oncology that alleviate disparity, providing a call to action for further research and implementation efforts within the field. These solutions are organized in the socioecologic framework, where multiple levels of influence-societal, community, organizational, interpersonal, and individual-affect health outcomes.
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Affiliation(s)
- Charlotte Gamble
- Division of Gynecologic Oncology, MedStar Washington Hospital Center, and Georgetown University, Washington, DC; the Division of Gynecologic Oncology, Washington University School of Medicine in St. Louis, St. Louis, Missouri; the Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, Virginia; and the Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, New York
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Smith AJB, Mulugeta-Gordon L, Pena D, Kanter GP, Bekelman JE, Haggerty A, Ko EM. Insurance and racial disparities in prior authorization in gynecologic oncology. Gynecol Oncol Rep 2023; 46:101159. [PMID: 36942280 PMCID: PMC10024078 DOI: 10.1016/j.gore.2023.101159] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/03/2023] [Accepted: 03/05/2023] [Indexed: 03/12/2023] Open
Abstract
While prior authorization aims to reduce unnecessary care, it may limit or delay medically necessary care. Delays in cancer care can impact survival and are more common in historically-marginalized populations. Our objective was to examine to what extent disparities occurred in prior authorizations for gynecologic oncology. Using electronic medical records, we performed a retrospective review of prior authorization occurrence during gynecologic oncology care and analyzed the association with patient race and insurance in a multivariate regression model. In this cohort of 1,406 patients treated at an academic gynecologic oncology practice, patients with Medicare Advantage and patients of Asian descent were more likely to experience prior authorization. Addressing insurance-mediate disparities, such as in the occurrence of prior authorization, may help reduce disparities in gynecologic cancer care.
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Affiliation(s)
- Anna Jo Bodurtha Smith
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, Philadelphia, PA, United States
- Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, Philadelphia, PA, United States
- University of Pennsylvania, Leonard Davis Institute of Health Economics, University of Pennsylvania Health Systems, Philadelphia, PA, United States
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania Health Systems, Philadelphia, PA, United States
| | - Lakeisha Mulugeta-Gordon
- Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, Philadelphia, PA, United States
| | | | - Genevieve P. Kanter
- Department of Medicine, University of Pennsylvania Health Systems, Philadelphia, PA, United States
- Department of Medical Ethics and Health Policy, University of Pennsylvania Health Systems, Philadelphia, PA, United States
- University of Pennsylvania, Leonard Davis Institute of Health Economics, University of Pennsylvania Health Systems, Philadelphia, PA, United States
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania Health Systems, Philadelphia, PA, United States
| | - Justin E. Bekelman
- Department of Radiation Oncology, University of Pennsylvania Health Systems, Philadelphia, PA, United States
- University of Pennsylvania, Leonard Davis Institute of Health Economics, University of Pennsylvania Health Systems, Philadelphia, PA, United States
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania Health Systems, Philadelphia, PA, United States
| | - Ashley Haggerty
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, Philadelphia, PA, United States
- Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, Philadelphia, PA, United States
| | - Emily M. Ko
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, Philadelphia, PA, United States
- Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, Philadelphia, PA, United States
- University of Pennsylvania, Leonard Davis Institute of Health Economics, University of Pennsylvania Health Systems, Philadelphia, PA, United States
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania Health Systems, Philadelphia, PA, United States
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Lee SS, Karpel HC, Oh C, Smith J, Pothuri B. Beyond BRCA: Patterns of risk-reducing surgery for non-BRCA, homologous recombination repair pathway gene variant carriers. Gynecol Oncol 2023; 170:234-240. [PMID: 36724586 DOI: 10.1016/j.ygyno.2022.12.012] [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: 10/22/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The real-world management of patients with non-BRCA, homologous recombination repair pathway variants with increased or uncertain risks of ovarian cancer is unknown. The objective was to determine the adoption of risk-reducing salpingo-oophorectomy (RRSO) for carriers of variants with increased or uncertain risks of ovarian cancer beyond BRCA. METHODS This was a retrospective cohort study of patients at three hospitals with non-BRCA, homologous recombination repair pathway variants with increased risk (BRIP1, RAD51C, RAD51D) and uncertain risk (ATM, BARD1, NBN, PALB2) of ovarian cancer. Outcomes of interest were adoption of RRSO and factors associated with adoption of RRSO. Wilcoxon rank-sum, chi-square, and logistic regression were performed with p < 0.05. RESULTS Of 318 patients, 76 (24%) had pathogenic variants with increased risks of ovarian cancer (BRIP1, 45; RAD51C, 20; RAD51D, 11), and 242 (76%) had variants with uncertain risks of ovarian cancer (ATM, 145; PALB2, 69; NBN, 23; BARD1, 5). Of 64 patients eligible for RRSO by National Comprehensive Cancer Network (NCCN) criteria or family history, 31 (48%) underwent RRSO. Among eligible patients who did not undergo RRSO, 24 (73%) were not referred for gynecologic oncology consultation. Older age at testing (adjusted odds ratio [aOR] 1.08, 95% confidence interval [CI] 1.03-1.13) and referral to gynecologic oncology (aOR 33.48, CI 8.10-138.39) were associated with increased adoption of RRSO when adjusting for personal and family history of breast and ovarian cancer. CONCLUSION Half of RRSO-eligible patients by NCCN criteria beyond BRCA did not undergo RRSO. Opportunities exist for improving education to increase referrals to facilitate RRSO for these patients.
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Affiliation(s)
- Sarah S Lee
- New York University Langone Health, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, New York, NY, United States of America
| | - Hannah C Karpel
- New York University Grossman School of Medicine, New York, NY, United States of America
| | - Cheongeun Oh
- New York University Langone Health, Department of Population Health, Division of Biostatistics, New York, NY, United States of America
| | - Julia Smith
- New York University Langone Health, Department of Medicine, Division of Medical Oncology, New York, NY, United States of America
| | - Bhavana Pothuri
- New York University Langone Health, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, New York, NY, United States of America; New York University Langone Health, Department of Medicine, Division of Medical Oncology, New York, NY, United States of America.
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7
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Talbott J, Khurana A, Wasson M. Supply of obstetrician-gynecologists and gynecologic oncologists to the US Medicare population: a state-by-state analysis. Am J Obstet Gynecol 2023; 228:203.e1-203.e9. [PMID: 36088988 DOI: 10.1016/j.ajog.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND The supply of obstetrician-gynecologists and gynecologic oncologists across the United States has been described. However, these studies focused on reproductive-age patients and did not assess the growing demand for services to the advanced-age female population. OBJECTIVE This study aimed to evaluate the supply of obstetrician-gynecologists and gynecologic oncologists who serve the US Medicare population per 100,000 female Medicare beneficiaries, over time and by state and region. STUDY DESIGN The supply of obstetrician-gynecologists and gynecologic oncologists was extracted from the Physician and Other Supplier Public Use File database of Medicare Part B claims submitted to the US Centers for Medicare & Medicaid Services. Data were only available from 2012 to 2019. The supply of providers was divided by the number of original female Medicare beneficiaries obtained from the Kaiser Family Foundation; all values reported are providers per 100,000 female beneficiaries by state. Trends over time were assessed as the difference in provider-to-beneficiary ratio and the percentage change from 2012 to 2019. All data were collected in 2021. All analyses were performed with SAS, version 9.4. This study was exempt from institutional review board approval. RESULTS In 2019, the average number of obstetrician-gynecologists per 100,000 female beneficiaries across all states was 121.32 (standard deviation±33.03). The 3 states with the highest obstetrician-gynecologist-to-beneficiary ratio were the District of Columbia (268.85), Connecticut (204.62), and Minnesota (171.60), and the 3 states with the lowest were Montana (78.37), West Virginia (82.28), and Iowa (83.92). The average number of gynecologic oncologists was 4.48 (standard deviation±2.08). The 3 states with the highest gynecologic oncologist-to-beneficiary ratio were the District of Columbia (11.30), Rhode Island (10.58), and Connecticut (9.24), and the 3 states with the lowest were Kansas (0.82), Vermont (1.41), and Mississippi (1.47). The number of obstetrician-gynecologists per 100,000 female beneficiaries decreased nationally by 8.4% from 2012 to 2019; the difference in provider-to-beneficiary ratio from 2012 to 2019 ranged from +29.97 (CT) to -82.62 (AK). Regionally, the Northeast had the smallest decrease in the number of obstetrician-gynecologists per 100,000 female beneficiaries (-3.8%) and the West had the largest (-18.2%). The number of gynecologic oncologists per 100,000 female beneficiaries increased by 7.0% nationally during the study period; this difference ranged from +8.96 (DC) to -3.39 (SD). Overall, the West had the smallest increase (4.7%) and the Midwest had the largest (15.4%). CONCLUSION There is wide geographic variation in the supply and growth rate of obstetrician-gynecologists and gynecologic oncologists for the female Medicare population. This analysis provides insight into areas of the country where the supply of obstetrician-gynecologists and gynecologic oncologists may not meet current and future demand. The national decrease in the number of obstetrician-gynecologists is alarming, especially because population projections estimate that the proportion of elderly female patients will grow. Future work is needed to determine why fewer providers are available to see Medicare patients and what minimum provider-to-enrollee ratios are needed for gynecologic and cancer care. Once such ratios are established, our results can help determine whether specific states and regions are meeting demand. Additional research is needed to assess the effect of the COVID-19 pandemic on the supply of women's health providers.
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Affiliation(s)
| | | | - Megan Wasson
- Department of Medical and Surgical Gynecology, Mayo Clinic, Phoenix, AZ
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Jorgensen K, Meernik C, Wu CF, Murphy CC, Baker VL, Jarmon P, Brady PC, Nitecki R, Nichols HB, Rauh-Hain JA. Disparities in Fertility-Sparing Treatment and Use of Assisted Reproductive Technology After a Diagnosis of Cervical, Ovarian, or Endometrial Cancer. Obstet Gynecol 2023; 141:341-353. [PMID: 36649345 PMCID: PMC9858239 DOI: 10.1097/aog.0000000000005044] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/07/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To assess the presence of sociodemographic and clinical disparities in fertility-sparing treatment and assisted reproductive technology (ART) use among patients with a history of cervical, endometrial, or ovarian cancer. METHODS We conducted a population-based cohort study of patients aged 18-45 years who were diagnosed with cervical cancer (stage IA, IB), endometrial cancer (grade 1, stage IA, IB), or ovarian cancer (stage IA, IC) between January 1, 2000, and December 31, 2015, using linked data from the CCR (California Cancer Registry), the California Office of Statewide Health Planning and Development, and the Society for Assisted Reproductive Technology. The primary outcome was receipt of fertility-sparing treatment , defined as surgical or medical treatment to preserve the uterus and at least one ovary. The secondary outcome was fertility preservation , defined as ART use after cancer diagnosis. Multivariable logistic regression analysis was used to estimate odds ratios and 95% CIs for the association between fertility-sparing treatment and exposures of interest: age at diagnosis, race and ethnicity, health insurance, socioeconomic status, rurality, and parity. RESULTS We identified 7,736 patients who were diagnosed with cervical, endometrial, or ovarian cancer with eligible histology. There were 850 (18.8%) fertility-sparing procedures among 4,521 cases of cervical cancer, 108 (7.2%) among 1,504 cases of endometrial cancer, and 741 (43.3%) among 1,711 cases of ovarian cancer. Analyses demonstrated nonuniform patterns of sociodemographic disparities by cancer type for fertility-sparing treatment, and ART. Fertility-sparing treatment was more likely among young patients, overall, and of those in racial and ethnic minority groups among survivors of cervical and ovarian cancer. Use of ART was low (n=52) and was associated with a non-Hispanic White race and ethnicity designation, being of younger age (18-35 years), and having private insurance. CONCLUSION This study demonstrates that clinical and sociodemographic disparities exist in the receipt of fertility-sparing treatment and ART use among patients with a history of cervical, endometrial, or ovarian cancer.
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Affiliation(s)
- Kirsten Jorgensen
- Department of Gynecologic Oncology and Reproductive Medicine and the Department of Health Services Research, University of Texas MD Anderson Cancer Center, and the Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas; the Department of Public Health Sciences, Duke University School of Medicine, Durham, North Carolina; the Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; Tulane University School of Medicine, New Orleans, Louisiana; the Columbia University Irving Medical Center, Columbia University Fertility Center, New York, New York; and the Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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9
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Gonzalez-Bosquet J, Cardillo ND, Reyes HD, Smith BJ, Leslie KK, Bender DP, Goodheart MJ, Devor EJ. Using Genomic Variation to Distinguish Ovarian High-Grade Serous Carcinoma from Benign Fallopian Tubes. Int J Mol Sci 2022; 23:ijms232314814. [PMID: 36499142 PMCID: PMC9738935 DOI: 10.3390/ijms232314814] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/04/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022] Open
Abstract
The preoperative diagnosis of pelvic masses has been elusive to date. Methods for characterization such as CA-125 have had limited specificity. We hypothesize that genomic variation can be used to create prediction models which accurately distinguish high grade serous ovarian cancer (HGSC) from benign tissue. METHODS In this retrospective, pilot study, we extracted DNA and RNA from HGSC specimens and from benign fallopian tubes. Then, we performed whole exome sequencing and RNA sequencing, and identified single nucleotide variants (SNV), copy number variants (CNV) and structural variants (SV). We used these variants to create prediction models to distinguish cancer from benign tissue. The models were then validated in independent datasets and with a machine learning platform. RESULTS The prediction model with SNV had an AUC of 1.00 (95% CI 1.00-1.00). The models with CNV and SV had AUC of 0.87 and 0.73, respectively. Validated models also had excellent performances. CONCLUSIONS Genomic variation of HGSC can be used to create prediction models which accurately discriminate cancer from benign tissue. Further refining of these models (early-stage samples, other tumor types) has the potential to lead to detection of ovarian cancer in blood with cell free DNA, even in early stage.
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Affiliation(s)
- Jesus Gonzalez-Bosquet
- Department of Obstetrics and Gynecology, University of Iowa, 200 Hawkins Dr., Iowa City, IA 52242, USA
- Correspondence: ; Tel.: +1-(319)-356-2160; Fax: +1-(319)-353-8363
| | - Nicholas D. Cardillo
- Hanjani Institute of Gynecologic Oncology, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Henry D. Reyes
- Department of Obstetrics and Gynecology, University of Buffalo, Buffalo, NY 14203, USA
| | - Brian J. Smith
- Department of Biostatistics, University of Iowa, 145 N Riverside Dr., Iowa City, IA 52242, USA
| | - Kimberly K. Leslie
- Division of Molecular Medicine, Departments of Internal Medicine and Obstetrics and Gynecology, The University of New Mexico Comprehensive Cancer Center, 915 Camino de Salud, CRF 117, Albuquerque, NM 87131, USA
| | - David P. Bender
- Department of Obstetrics and Gynecology, University of Iowa, 200 Hawkins Dr., Iowa City, IA 52242, USA
| | - Michael J. Goodheart
- Department of Obstetrics and Gynecology, University of Iowa, 200 Hawkins Dr., Iowa City, IA 52242, USA
| | - Eric J. Devor
- Department of Obstetrics and Gynecology, University of Iowa, 200 Hawkins Dr., Iowa City, IA 52242, USA
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10
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Huepenbecker SP, Fu S, Sun CC, Zhao H, Primm KM, Giordano SH, Meyer LA. Medicaid expansion and 2-year survival in women with gynecologic cancer: a difference-in-difference analysis. Am J Obstet Gynecol 2022; 227:482.e1-482.e15. [PMID: 35500609 PMCID: PMC9420833 DOI: 10.1016/j.ajog.2022.04.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 04/15/2022] [Accepted: 04/23/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The Affordable Care Act implemented optional Medicaid expansion starting in 2014, but the association between Medicaid expansion and gynecologic cancer survival is unknown. OBJECTIVE To evaluate the impact of Medicaid expansion by comparing 2-year survival among gynecologic cancers before and after 2014 in states that did and did not expand Medicaid using a difference-in-difference analysis. STUDY DESIGN We searched the National Cancer Database for women aged 40 to 64 years, diagnosed with a primary gynecologic malignancy (endometrial, ovarian, cervical, vulvar, and vaginal) between 2010 and 2016. We used a quasiexperimental difference-in-difference multivariable Cox regression analysis to compare 2-year survival between states that expanded Medicaid in January 2014 and states that did not expand Medicaid as of 2016. We performed univariable subgroup difference-in-difference Cox regression analyses on the basis of stage, income, race, ethnicity, and geographic location. Adjusted linear difference-in-difference regressions evaluated the proportion of uninsured patients on the basis of expansion status after 2014. We evaluated adjusted Kaplan-Meier curves to examine differences on the basis of study period and expansion status. RESULTS Our sample included 169,731 women, including 78,669 (46.3%) in expansion states and 91,062 (53.7%) in nonexpansion states. There was improved 2-year survival on adjusted difference-in-difference Cox regressions for women with ovarian cancer in expansion than in nonexpansion states after 2014 (hazard ratio, 0.88; 95% confidence interval, 0.82-0.94; P<.001) with no differences in endometrial, cervical, vaginal, vulvar, or combined gynecologic cancer sites on the basis of expansion status. On univariable subgroup difference-in-difference Cox analyses, women with ovarian cancer with stage III-IV disease (P=.008), non-Hispanic ethnicity (P=.042), those in the South (P=.016), and women with vulvar cancer in the Northeast (P=.022), had improved 2-year survival in expansion than in nonexpansion states after 2014. In contrast, women with cervical cancer in the South (P=.018) had worse 2-year survival in expansion than in nonexpansion states after 2014. All cancer sites had lower proportions of uninsured patients in expansion than in nonexpansion states after 2014. CONCLUSION There was a significant association between Medicaid expansion and improved 2-year survival for women with ovarian cancer in states that expanded Medicaid after 2014. Despite improved insurance coverage, racial, ethnic, and regional survival differences exist between expansion and nonexpansion states.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Shuangshuang Fu
- Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Hui Zhao
- Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Kristin M Primm
- Department of Epidemiology, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Sharon H Giordano
- Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX.
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Cherston C, Yoh K, Huang Y, Melamed A, Gamble CR, Prabhu VS, Li Y, Hershman DL, Wright JD. Relative importance of individual insurance status and hospital payer mix on survival for women with cervical cancer. Gynecol Oncol 2022; 166:552-560. [PMID: 35787803 DOI: 10.1016/j.ygyno.2022.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the relative contributions of individual insurance status and hospital payer mix (safety net status) to quality of care and survival for patients with cervical cancer. METHODS We used the National Cancer Database to identify patients with cervical cancer diagnosed from 2004 to 2017. Patients were classified by insurance (uninsured/Medicaid/private/Medicare/other) and hospitals were grouped into quartiles based on the proportion of uninsured/Medicaid patients (payer mix) (top quartile defined as safety-net hospital (SNHs) and lowest as Q1 hospitals). Quality-of-care was assessed by adherence to evidence-based metrics. Individual contributions of insurance status and payer mix to survival was assessed with a proportional hazards Cox model. RESULTS A total of 124,339 patients including 11,338 uninsured (9.1%) and 27,281 Medicaid (21.9%) recipients treated at 1156 hospitals were identified. Quality-of-care was not significantly different across hospital quartiles. Adjusting for patients' clinical/demographic characteristics, treatment at a SNH was associated with a 14% higher mortality (HR = 1.14; 95% CL, 1.08-1.20) than at Q1 hospitals. Testing for individual insurance, uninsured patients had 32% increased mortality (HR = 1.32; 95% CI,1.26-1.38) and Medicaid recipients 40% increased (HR = 1.40; 95%CI,1.35-1.44) compared to privately insured patients. Examining both payer mix and insurance, only individual insurance retained a significant impact on mortality. CONCLUSIONS Individual insurance may be a more important predictor of survival than site-of-care and hospital payer mix for women with cervical cancer. There is substantial variation in outcomes within hospitals based on individual insurance, regardless of hospital payer mix.
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Affiliation(s)
- Caroline Cherston
- Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Katherine Yoh
- Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Yongmei Huang
- Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Alexander Melamed
- Columbia University, College of Physicians and Surgeons, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, USA; New York Presbyterian Hospital, USA
| | - Charlotte R Gamble
- Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | | | - Yeran Li
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - Dawn L Hershman
- Columbia University, College of Physicians and Surgeons, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, USA; New York Presbyterian Hospital, USA
| | - Jason D Wright
- Columbia University, College of Physicians and Surgeons, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, USA; New York Presbyterian Hospital, USA.
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