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Papatla K, Orfanelli T, Stoffels G, Layne T, Baldwin E, Leibold A, Blank SV, Cohen S. Mitigating disparity?: Treatment patterns, survival, and recurrence rates by race, ethnicity, and hospital site across a large urban health system. Gynecol Oncol Rep 2024; 53:101372. [PMID: 38584803 PMCID: PMC10997945 DOI: 10.1016/j.gore.2024.101372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/11/2024] [Accepted: 03/17/2024] [Indexed: 04/09/2024] Open
Abstract
Objective National data have shown worse endometrial cancer (EC) outcomes among racial and ethnic minorities. We aimed to analyze EC patient outcomes within a large urban academic health system, with a focus on patterns of care and recurrence rates. Methods This was a retrospective chart review of EC patients at three system hospitals from 1/1/07-12/31/17. Demographic and clinical factors, including time from EMB to surgery, rate of chemotherapy completion, persistent or recurrent disease, and palliative care referrals were extracted. Descriptive statistics and survival curves were generated. Analysis was done using SAS version 9.4. Results Black patients had lower overall survival compared to all others on univariate analysis only (p < 0.0001). Hospital site was associated with OS, with the academic anchor and satellite 1 having higher rates of all-cause mortality compared to satellite 2 (HR 4.68 academic anchor, 95 % CI 1.72-12.76, HR 5.36 satellite 1, 95 % CI 1.85-15.52). Time from EMB to surgery and rates of persistent disease following primary treatment were higher in Black patients. After adjusting for stage and grade, chemotherapy completion rate was significantly associated with race. Palliative care was utilized more for Black than White patients after adjusting for stage and grade (p = 0.005). Conclusions Racial disparities in EC are caused by a complex web of interconnected factors that ultimately lead to worse outcomes in Black women. While precision medicine has helped to close the gap, social determinants of health should be addressed, and models focusing on the complex interactions between biologic, genetic, and social factors should be utilized.
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Affiliation(s)
- Katyayani Papatla
- Icahn School of Medicine at the Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science, Division of Gynecologic Oncology, New York, NY, United States
| | - Theofano Orfanelli
- Stony Brook Medicine, Department of Obstetrics, Gynecology, and Reproductive Medicine, Division of Gynecologic Oncology, Stony Brook, NY, United States
| | | | - Tracy Layne
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Elena Baldwin
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Aurora Leibold
- Mount Sinai West, Department of Obstetrics, Gynecology, and Reproductive Science New York, NY, United States
| | - Stephanie V. Blank
- Icahn School of Medicine at the Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science, Division of Gynecologic Oncology, New York, NY, United States
| | - Samantha Cohen
- Icahn School of Medicine at the Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science, Division of Gynecologic Oncology, New York, NY, United States
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Hicks ML, Hicks MM, Mathews RP, Khabele D, Clare CA, Balogun O, Lawson YR, Tillman RH, Butler R, Spann CO, Parham GP. Racial disparities in endometrial cancer: Where are we after 26 years? Gynecol Oncol 2024; 184:236-242. [PMID: 38382150 DOI: 10.1016/j.ygyno.2024.01.054] [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: 11/03/2023] [Revised: 01/27/2024] [Accepted: 01/30/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Endometrial cancer is the most commonly diagnosed female genital tract malignancy in the United States of America. Racial disparities surrounding this particular disease have been extensively investigated for over 26-years. We sought to determine if research in this area has led to any significant improvements in this disparity. METHODS We performed a rapid systematic review of English language publications on racial disparities in endometrial cancer among African American (AAW) and white American women (WAW), from 1997 to 2023. We looked at trends in incidence and survival; impact of known poor prognostic factors (stage at diagnosis, histological subtypes, grade); co-morbidities; differences in treatment (surgery, radiation and chemotherapy); socioeconomic factors; differences in biological and genetic markers; and policies/declarations. RESULTS During the period under review (1997-2023), there was a notable increase in both disease incidence (39%) and mortality (26%) rates for AAW, in comparison to WAW among whom the incidence rates increased by 2% and mortality rates rose, but 9% less than for AAW. It should be noted that the current incidence rate of 29.4% in AAW represent a reversal of what is was 26-years ago, when the incidence rate was 17.8%. In comparison to WAW, AAW had a higher prevalence of poor prognostic variables, more co-morbidities, lower income levels, less insurance coverage, and were more frequently under treated with surgery, chemotherapy and radiation. To date no actionable molecular/genetic markers have been identified. We were unable to locate any published recommendations or active programs of implementation strategies/policies designed to effectively mitigate the documented racial disparity. CONCLUSION Racial disparities in disease incidence and mortality in endometrial cancer rates between WAW and AAW have widened during a 26-year period of robust research, suggesting that current research alone is not enough to eliminate this disparity. Based on this rapid systematic review we have identified and analyzed the impact of causation variables on this disparity. Additionally, we have made strong and pertinent recommendations for the benefit of mitigating this escalating racial disparity.
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Affiliation(s)
- Michael L Hicks
- St. Joseph Mercy Oakland Cancer Center, Michigan Cancer Institute, 44405 Woodward Ave, Suite 202, Pontiac, MI 48324, USA; University of North Carolina at Chapel Hill, Department of Obstetrics & Gynecology, Chapel Hill, 101 Manning Dr. Chapel Hill, NC 27514, USA.
| | - Maya M Hicks
- Anne Arundel Medical Center, Department of Obstetrics and Gynecology, 2000 Medical Pkwy, Belcher Pavilion, Ste 309, Annapolis, MD 21401, USA
| | - Roland P Mathews
- Morehouse School of Medicine, Department of Obstetrics and Gynecology, 720 Westview Drive, Atlanta, GA 30310, USA
| | - Dineo Khabele
- Washington University, School of Medicine Department of Obstetrics and Gynecology, 660 S. Euclid Ave, Mailstop 86064-37-1005, Saint Louis, MO 63110, USA.
| | - Camille A Clare
- SUNY Downstate Health Science University, Department of Obstetric and Gynecology, 450 Clarkson Ave, MSC-24, Brooklyn, NY 11203, USA.
| | - Onyinye Balogun
- Weill Cornell Medicine, Radiation Oncology, 525 East Street, Stich Radiation Center, New York, NY 10065, USA
| | - Yolanda R Lawson
- Made Well Obstetrics and Gynecology, 2509 Thomas Ave, Dallas, TX 75201, USA
| | - Ronda Henry Tillman
- University of Arkansas Medical Center, Winthrop P. Rockerfeller Cancer Institute, 449 Jack Stephens Drive, Little Rock, AR 72205, USA
| | - Raleigh Butler
- Princess Margaret Hospital, Department of Obstetrics and Gynaecology, 102 Thompson Blvd Nassau, Bahamas
| | - Cyril O Spann
- Piedmont Hospital, 1800 Howell Mill Road Northwest, suite 300, Atlanta, GA 30318, USA
| | - Groesbeck P Parham
- Charles Drew University of Medicine and Science, Department of Obstetrics and Gynecology, 1731 E 120th St., Los Angeles, CA 90059, USA
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Kopelman ZA, Tian C, Tumas J, Phippen NT, Tarney CM, Hope ER, Winkler SS, Jokajtys S, Kucera CW, Chan JK, Richardson MT, Kapp DS, Hamilton CA, Leath CA, Jones NL, Rocconi RP, Farley JH, Secord AA, Cosgrove CM, Powell MA, Klopp A, Walker JL, Fleming GF, Bateman NW, Conrads TP, Maxwell GL, Darcy KM. Disease progression, survival, and molecular disparities in Black and White patients with endometrioid endometrial carcinoma in real-world registries and GOG/NRG oncology randomized phase III clinical trials. Gynecol Oncol 2024; 183:103-114. [PMID: 38593674 DOI: 10.1016/j.ygyno.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Investigate racial disparities in outcomes and molecular features in Black and White patients with endometrioid endometrial carcinoma (EEC). METHODS Black and White patients diagnosed with EEC who underwent hysterectomy ± adjuvant treatment in SEER, National Cancer Database (NCDB), the Genomics Evidence Neoplasia Information Exchange (GENIE) project (v.13.0), and eight NCI-sponsored randomized phase III clinical trials (RCTs) were studied. Hazard ratio (HR) and 95% confidence interval (CI) were estimated for cancer-related death (CRD), non-cancer death (NCD), and all-cause death. RESULTS Black (n = 4397) vs. White (n = 47,959) patients in SEER had a HR (95% CI) of 2.04 (1.87-2.23) for CRD and 1.22 (1.09-1.36) for NCD. In NCDB, the HR (95% CI) for death in Black (n = 13,468) vs. White (n = 155,706) patients was 1.52 (1.46-1.58) dropping to 1.29 (1.23-1.36) after propensity-score matching for age, comorbidity, income, insurance, grade, stage, LVSI, and treatment. In GENIE, Black (n = 109) vs. White (n = 1780) patients had fewer PTEN, PIK3R1, FBXW7, NF1, mTOR, CCND1, and PI3K-pathway-related gene mutations. In contrast, TP53 and DNA-repair-related gene mutation frequency as well as tumor mutational burden-high status were similar in Black and White patients. In RCTs, Black (n = 187) vs. White (n = 2877) patients were more likely to have advanced or recurrent disease, higher grade, worse performance status and progressive disease. Risk of death in Black vs. White patients in RCTs was 2.19 (1.77-2.71) persisting to 1.32 (1.09-1.61) after matching for grade, stage, and treatment arm while balancing age and performance status. CONCLUSIONS Differences exist in clinical presentation, outcomes, and molecular features in Black vs. White patients with EEC in real-world registries and RCTs. Targeted-drug development, strategies to modify social determinants, and diverse inclusion in RCTs are approaches to reduce disparities.
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Affiliation(s)
- Zachary A Kopelman
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Chunqiao Tian
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; The Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Jordyn Tumas
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Neil T Phippen
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Christopher M Tarney
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Erica R Hope
- Division of Gynecologic Oncology, Department of Gynecologic Surgery and Obstetrics, Brooke Army Medical Center, San Antonio, TX, USA
| | - Stuart S Winkler
- Division of Gynecologic Oncology, Department of Gynecologic Surgery and Obstetrics, Brooke Army Medical Center, San Antonio, TX, USA
| | - Suzanne Jokajtys
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Calen W Kucera
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - John K Chan
- Palo Alto Medical Foundation, California Pacific Medical Center, Sutter Health, San Francisco, CA, USA
| | - Michael T Richardson
- Department of Obstetrics and Gynecology, University of California, Los Angeles School of Medicine, Los Angeles, CA, USA
| | - Daniel S Kapp
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Chad A Hamilton
- Gynecologic Oncology Section, Women's Services and The Ochsner Cancer Institute, Ochsner Health, New Orleans, LA, USA
| | - Charles A Leath
- Division of Gynecologic Oncology, University of Alabama at Birmingham, O'Neal Comprehensive Cancer Center, Birmingham, AL, USA
| | - Nathaniel L Jones
- Division of Gynecologic Oncology, Mitchell Cancer Institute, University of South Alabama, Mobile, AL, USA
| | - Rodney P Rocconi
- Division of Gynecologic Oncology, Cancer Center & Research Institute, the University of Mississippi Medical Center, Jackson, MS, USA
| | - John H Farley
- Division of Gynecologic Oncology, Center for Women's Health, Cancer Institute, Dignity Health St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | | | - Casey M Cosgrove
- Division of Gynecologic Oncology, The Ohio State University, Columbus, OH, USA
| | - Matthew A Powell
- Division of Gynecologic Oncology, Siteman Cancer Center, Washington University, St Louis, MO, USA
| | - Ann Klopp
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joan L Walker
- Gynecologic Oncology Division, Stephenson Cancer Center, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | - Gini F Fleming
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Nicholas W Bateman
- Division of Gynecologic Oncology, Center for Women's Health, Cancer Institute, Dignity Health St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; The Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Thomas P Conrads
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; The Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA; Women's Health Integrated Research Center, Inova Women's Service Line, Inova Health System, Falls Church, VA, USA
| | - G Larry Maxwell
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; The Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA; Women's Health Integrated Research Center, Inova Women's Service Line, Inova Health System, Falls Church, VA, USA.
| | - Kathleen M Darcy
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; The Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA.
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Illah O, Adeeko D, Olaitan A, Gentry-Maharaj A. Racioethnic Disparities in Endometrial Cancer Outcomes. Diagnostics (Basel) 2024; 14:417. [PMID: 38396458 PMCID: PMC10887632 DOI: 10.3390/diagnostics14040417] [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: 12/28/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
Black women are twice as likely to die from endometrial cancer (EC) compared with white women. This represents one of the worst racioethnic disparities amongst all cancers globally. Compared with white women, black women are more likely to be diagnosed with advanced EC, have more barriers to accessing care and experience increased delays in obtaining an EC diagnosis and commencing treatment. Histological and molecular differences place black women at higher risk of being diagnosed with more aggressive EC subtypes that carry less favourable outcomes. Furthermore, EC diagnostic pathways are less reliable in black women, and black women are less likely to receive evidence-based treatment for EC. This racioethnic disparity in EC outcomes exists both in the UK and US, despite differences in healthcare systems. This review methodically describes the key factors along the patient journey that contribute to the disparity in black women and proposes multifaceted approaches to lessen these gaps.
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Affiliation(s)
- Ojone Illah
- Department of Women’s Cancer, Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London WC1E 6DD, UK
| | - Deborah Adeeko
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London WC1E 6AU, UK
| | - Adeola Olaitan
- Department of Women’s Cancer, Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London WC1E 6DD, UK
| | - Aleksandra Gentry-Maharaj
- Department of Women’s Cancer, Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London WC1E 6DD, UK
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London WC1V 6LJ, UK
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Istl AC, Desravines N, Nudotor R, Stone R, Greer JB, Meyer CF, Johnston FM. Treatment patterns and outcomes for primary uterine leiomyosarcoma with synchronous isolated lung metastases: A National Cancer Database study of primary resection and metastasectomy. Gynecol Oncol Rep 2024; 51:101308. [PMID: 38174328 PMCID: PMC10758710 DOI: 10.1016/j.gore.2023.101308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 01/05/2024] Open
Abstract
Background One third of patients with uterine leiomyosarcomas (uLMS) present with distant metastases. Current guidelines do not include recommendations around surgery for metastatic uLMS. Patients with distant metastases commonly receive primary tumor resection for symptoms and so oncologic outcomes after surgery warrant exploration. We describe treatment patterns and outcomes for uLMS patients with synchronous isolated lung metastases (SILM). Methods This retrospective analysis of the National Cancer Database identified patients with uLMS and SILM. Patients with non-pulmonary metastases were excluded. We collected demographic, disease, and treatment characteristics and assessed clinicopathologic factors associated with the receipt of surgery on multivariate regression. Median, 1-year, and 5-year overall survival (OS) across treatment approaches were compared using Kaplan-Meier curves and log-rank tests. Multivariate Cox proportional hazard regressions identified independent predictors of survival. Results We identified 905 patients with uLMS and SILM between 2004 and 2017. 600 patients had primary tumor resection; 63 also had curative intent surgery with metastasectomy. Patients who did not receive chemotherapy were older (p<0.01) with a higher comorbidity index (p<0.05). Women with private health insurance were more likely to receive chemotherapy (p<0.01) and primary tumor resection (p<0.01). Patients who underwent curative intent surgery had 1-year OS of 71.2% and 5-year survival of 18% compared to 1-year survival of 35.6 % and 5-year survival of 5.16 % for patients who had no surgery. Black women had poorer survival on multivariate regression. Conclusions Primary tumor resection and curative intent surgery are associated with improved OS in uLMS with SILM and may be a reasonable treatment option in appropriately selected patients.
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Affiliation(s)
- Alexandra C. Istl
- Division of Surgical Oncology, Medical College of Wisconsin, United States
| | | | - Richard Nudotor
- Department of Surgery, Anne Arundel Medical Center, United States
| | - Rebecca Stone
- Division of Gynecologic Oncology, Johns Hopkins Hospital, United States
| | - Jonathan B. Greer
- Division of Surgical Oncology, Johns Hopkins Hospital, United States
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Akinsola O, Klausner AP, Vince R, Scarpato KR. The Other Pandemic, Racism, in Urology. Urol Clin North Am 2023; 50:525-530. [PMID: 37775211 DOI: 10.1016/j.ucl.2023.06.012] [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] [Indexed: 10/01/2023]
Abstract
Racism is deeply ingrained in our society with lasting effects within medicine. The COVID-19 pandemic further highlighted racial disparities in the medical field, including in the field of Urology. This has led to investigation regarding the effects of racism on education, patient care, and research within Urology. This article aims to review current literature on the "other pandemic," structural racism, within medicine and specifically urology and provide ways to combat its impact.
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Affiliation(s)
- Olutiwa Akinsola
- Department of Urology, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA.
| | - Adam P Klausner
- Division of Urology, Department of Surgery, Virginia Commonwealth University School of Medicine, 1200 East Broad Street, 7th Floor East Wing, Richmond, VA 23298, USA
| | - Randy Vince
- Case Western Reserve University, University Hospital Urology Institute, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Kristen R Scarpato
- Department of Urology, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
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7
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Taylor KN, Li A, Manuel M, Rimel BJ, Kim KH. The association of black race with receipt of hysterectomy and survival in low-risk endometrial cancer. Gynecol Oncol 2023; 175:156-162. [PMID: 37390596 DOI: 10.1016/j.ygyno.2023.06.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVE To determine whether Black race is associated with treatment and survival among women with low-risk endometrial cancer. METHODS Black and White women with Stage IA grade 1-2 endometrioid endometrial carcinoma diagnosed from 2010 to 2016 in the SEER 18 dataset were identified (n = 23,431), and clinical and socioeconomic attributes obtained. Five-year cancer-specific survival (CSS) and relative survival (RS) were calculated using SEER*Stat 8.3.9. Cox proportional hazards model was used to determine predictors of overall survival (OS) and CSS. RESULTS There was a significantly higher proportion of Black women who did not have surgery compared to White women (3% vs 1%, respectively; p < 0.0001). Residing in the South, being insured with Medicaid, and residing in a county with low median income were also associated with non-receipt of surgery. Black women remained less likely to undergo hysterectomy on multivariable analysis (OR 0.44, 95% CI 0.32-0.60). Non-receipt of hysterectomy was predictive of decreased CSS (HR 0.14, 95% CI 0.09-0.21) and OS (HR 0.18, 95% 0.14-0.23) on adjusted analysis. Black race was also an independent predictor of increased cancer-specific death (HR 2.07, 95% CI 1.50-2.86) as well as death from any cause (HR 1.74, 95% CI 1.44-2.09) on adjusted analysis. CONCLUSIONS Black women with low-risk endometrial cancer were less likely to undergo hysterectomy and experienced decreased survival relative to White women. Further investigation is warranted to better understand the socioeconomic, geographic, and biologic factors that influence this disparity.
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Affiliation(s)
- Kristin N Taylor
- Cedars-Sinai Medical Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samuel Oschin Cancer Center, 127 South San Vicente Blvd, Los Angeles, CA 90048, USA.
| | - Andrew Li
- Cedars-Sinai Medical Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samuel Oschin Cancer Center, 127 South San Vicente Blvd, Los Angeles, CA 90048, USA
| | - Michael Manuel
- Cedars-Sinai Medical Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samuel Oschin Cancer Center, 127 South San Vicente Blvd, Los Angeles, CA 90048, USA
| | - Bobbie Jo Rimel
- Cedars-Sinai Medical Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samuel Oschin Cancer Center, 127 South San Vicente Blvd, Los Angeles, CA 90048, USA
| | - Kenneth H Kim
- Cedars-Sinai Medical Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samuel Oschin Cancer Center, 127 South San Vicente Blvd, Los Angeles, CA 90048, USA
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8
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Kucera CW, Tian C, Tarney CM, Presti C, Jokajtys S, Winkler SS, Casablanca Y, Bateman NW, Mhawech-Fauceglia P, Wenzel L, Hamilton CA, Chan JK, Jones NL, Rocconi RP, O’Connor TD, Farley JH, Shriver CD, Conrads TP, Phippen NT, Maxwell GL, Darcy KM. Factors Associated With Survival Disparities Between Non-Hispanic Black and White Patients With Uterine Cancer. JAMA Netw Open 2023; 6:e238437. [PMID: 37067801 PMCID: PMC10111180 DOI: 10.1001/jamanetworkopen.2023.8437] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/02/2023] [Indexed: 04/18/2023] Open
Abstract
Importance Disparities in survival exist between non-Hispanic Black (hereafter, Black) and non-Hispanic White (hereafter, White) patients with uterine cancer. Objective To investigate factors associated with racial disparities in survival between Black and White patients with uterine cancer. Design, Setting, and Patients This cohort study used data from the National Cancer Database on 274 838 Black and White patients who received a diagnosis of uterine cancer from January 1, 2004, to December 31, 2017, with follow-up through December 2020. Statistical analysis was performed in July 2022. Main Outcomes and Measures Overall survival by self-reported race and evaluation of explanatory study factors associated with hazard ratio (HR) reduction for Black vs White patients. A propensity scoring approach was applied sequentially to balance racial differences in demographic characteristics, comorbidity score, neighborhood income, insurance status, histologic subtype, disease stage, and treatment. Results The study included 32 230 Black female patients (mean [SD] age at diagnosis, 63.8 [10.0] years) and 242 608 White female patients (mean [SD] age at diagnosis, 63.5 [10.5] years) and had a median follow-up of 74.0 months (range, 43.5-113.8 months). Black patients were more likely than White patients to have low income (44.1% vs 14.0%), be uninsured (5.7% vs 2.6%), present with nonendometrioid histologic characteristics (46.1% vs 21.6%), have an advanced disease stage (34.1% vs 19.8%), receive first-line chemotherapy (33.8% vs 18.2%), and have worse 5-year survival (58.6% vs 78.5%). Among patients who received a diagnosis at younger than 65 years of age, the HR for death for Black vs White patients was 2.43 (95% CI, 2.34-2.52) in a baseline demographic-adjusted model and 1.29 (95% CI, 1.23-1.35) after balancing other factors. Comorbidity score, neighborhood income, insurance status, histologic subtype, disease stage, treatment, and unexplained factors accounted for 0.8%, 7.2%, 11.5%, 53.1%, 5.8%, 1.2%, and 20.4%, respectively, of the excess relative risk (ERR) among the younger Black vs White patients. Among patients 65 years or older, the HR for death for Black vs White patients was 1.87 (95% CI, 1.81-1.93) in the baseline model and 1.14 (95% CI, 1.09-1.19) after balancing other factors. Comorbidity score, neighborhood income, insurance status, histologic subtype, disease stage, treatment, and unexplained factors accounted for 3.0%, 7.5%, 0.0%, 56.2%, 10.6%, 6.9%, and 15.8%, respectively, of the ERR among Black vs White patients aged 65 years or older. Conclusions and Relevance This study suggests that histologic subtype was the dominant factor associated with racial survival disparity among patients with uterine cancer, while insurance status represented the main modifiable factor for women younger than 65 years. Additional studies of interactions between biology and social determinants of health are merited.
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Affiliation(s)
- Calen W. Kucera
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Chunqiao Tian
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- The Henry M Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland
| | - Christopher M. Tarney
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Cassandra Presti
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia
| | - Suzanne Jokajtys
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Stuart S. Winkler
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Yovanni Casablanca
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Nicholas W. Bateman
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- The Henry M Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland
| | - Paulette Mhawech-Fauceglia
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- Aurora Diagnostics, LMC Pathology Services, Las Vegas, Nevada
| | - Lari Wenzel
- Department of Medicine, School of Medicine, University of California, Irvine
- Department of Public Health, School of Medicine, University of California, Irvine
| | - Chad A. Hamilton
- Gynecologic Oncology Section, Women’s Services and The Ochsner Cancer Institute, Ochsner Health, New Orleans, Louisiana
| | - John K. Chan
- Gynecologic Oncology Division, Palo Alto Medical Foundation/California Pacific Medical Center/Sutter Health, San Francisco
| | - Nathaniel L. Jones
- Division of Gynecologic Oncology, the Mitchell Cancer Institute, University of South Alabama, Mobile
| | - Rodney P. Rocconi
- Division of Gynecologic Oncology, the University of Alabama at Birmingham, Infirmary Cancer Care, Infirmary Health, Mobile
| | - Timothy D. O’Connor
- Institute for Genome Sciences, Department of Medicine, Program in Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore
- Program in Health Equity and Population Health, University of Maryland School of Medicine, Baltimore
- The University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore
| | - John H. Farley
- Division of Gynecologic Oncology, Dignity Health Cancer Institute, Dignity Health St Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Craig D. Shriver
- John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Thomas P. Conrads
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- Women’s Health Integrated Research Center, Inova Women’s Service Line, Inova Health System, Falls Church, Virginia
| | - Neil T. Phippen
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - G. Larry Maxwell
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- Women’s Health Integrated Research Center, Inova Women’s Service Line, Inova Health System, Falls Church, Virginia
| | - Kathleen M. Darcy
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
- The Henry M Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland
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9
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Kwolek DG, Gerstberger S, Tait S, Qiu JM. Ovarian, Uterine, and Vulvovaginal Cancers: Screening, Treatment Overview, and Prognosis. Med Clin North Am 2023; 107:329-355. [PMID: 36759101 DOI: 10.1016/j.mcna.2022.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Ovarian, uterine, and vulvovaginal cancers affect approximately 96,000 women per year in the United States, resulting in approximately 29,000 deaths annually. Routine screening protocols do not detect these malignancies; thus, the recognition of risk factors and evaluation of worrisome symptoms are essential for early detection and improved prognoses. Treatment is managed by gynecologic oncologists, and often involves a combination of surgery, chemotherapy, and possible radiation treatments. Survivor care is managed by the primary-care clinician: expert attention to the mental, physical, and sexual health of each patient will ensure the best outcomes and quality of life.
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Affiliation(s)
- Deborah Gomez Kwolek
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | - Stefanie Gerstberger
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Sarah Tait
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Jeanna M Qiu
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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10
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Ran X, Yang H, Yu XQ, Lu L, Wang Y, Ji JS, Xu M, Wei W, Li B, Zeng H. Patterns and trends in the cause of death for patients with endometrial cancer. JNCI Cancer Spectr 2023; 7:pkac082. [PMID: 36420983 PMCID: PMC9808774 DOI: 10.1093/jncics/pkac082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/27/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Racial disparities in endometrial cancer have been reported in the United States, but trends and the underlying causes are not well understood. We aimed to examine the trends and contributing factors in racial disparities for causes of death among endometrial cancer patients. METHOD In this population-based cohort study, we identified 139 473 women diagnosed with first, primary endometrial cancer between 1992 to 2018 from the Surveillance, Epidemiology, and End Results Program. We used the "Fine and Gray" method to calculate the cumulative incidence of all-cause and specific-cause death. We used proportional subdistribution hazard (PSH) and cause-specific hazard (CSH) models to quantify the relative risk of Black-White disparities. We performed a mediation analysis to assess the contribution of potential factors to disparities. RESULTS The cumulative incidence of all-cause death decreased in endometrial cancer patients, with estimates at 5 years of 26.72% in 1992-1996 and 22.59% in 2007-2011. Compared with White patients, Black patients persistently had an increased risk of death due to endometrial cancer (PSH hazard ratio [HR] = 2.05, 95% confidence interval [CI] = 1.90 to 2.22; CSH HR = 2.19, 95% CI = 2.00 to 2.40) and causes other than endometrial cancer (PSH HR = 1.23, 95% CI = 1.10 to 1.37; CSH HR = 1.46, 95% CI = 1.31 to 1.63). Grade, histological subtype, surgery utilization, and stage at diagnosis explained 24.4%, 20.1%, 18.4%, and 16.6% of the Black-White disparity in all-cause death, respectively. CONCLUSIONS Although the cumulative incidence of all-cause death decreased, the Black-White gaps persisted in patients with endometrial cancer. Grade and histological subtype had the greatest influence. More efforts are needed to address the disparities.
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Affiliation(s)
- Xianhui Ran
- National Central Cancer Registry, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huansong Yang
- Department of Gynecologic Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Thoracic Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xue Qin Yu
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, Sydney, NSW, Australia
| | - Lingeng Lu
- Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale Cancer Center, Yale University, New Haven, CT, USA
| | - Yixin Wang
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - John S Ji
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Mengyuan Xu
- Department of Epidemiology and Statistics, Hebei Medical University/Hebei Province Key Laboratory of Environment and Human Health, Shijiazhuang, China
| | - Wenqiang Wei
- National Central Cancer Registry, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Li
- Department of Gynecologic Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongmei Zeng
- National Central Cancer Registry, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Nutrition, Harvard School of Public Health, Boston, MA, USA
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11
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Chapman-Davis E, Webster EM, Balogun OD, Frey MK, Holcomb K. Landmark Series on Disparities: Uterine Cancer and Strategies for Mitigation. Ann Surg Oncol 2023; 30:48-57. [PMID: 36376567 DOI: 10.1245/s10434-022-12765-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022]
Abstract
Longstanding racial disparities exist in uterine cancer. There is a growing body of literature documenting differences in the prevalence, diagnosis, treatment, and tumor characteristics of uterine cancer in Black women compared with White women that significantly contribute to the outcome disparity seen between the groups. This article seeks to provide an overview of racial disparities present in uterine cancer, with attention on Black women in the USA, as well as offer a review on the multifactorial etiology of the disparities described.
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Affiliation(s)
- Eloise Chapman-Davis
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA.
| | - Emily M Webster
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Onyinye D Balogun
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, USA.,NewYork-Presbyterian Brooklyn Methodist Hospital, New York, NY, USA
| | - Melissa K Frey
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Kevin Holcomb
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
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12
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Karia PS, Huang Y, Tehranifar P, Wright JD, Genkinger JM. Racial and ethnic differences in type II endometrial cancer mortality outcomes: The contribution of sociodemographic, clinicopathologic, and treatment factors. Gynecol Oncol 2023; 168:119-126. [PMID: 36434946 PMCID: PMC9797437 DOI: 10.1016/j.ygyno.2022.11.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/09/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The burden of type II endometrial cancer (EC) is rising dramatically in the U.S. Although type II EC disproportionately affects Black women, the magnitude of racial/ethnic differences in type II EC mortality outcomes and factors underlying these differences remain understudied. We examined racial/ethnic differences in cancer-specific and overall mortality in women with type II EC and quantified the extent to which mortality differences are mediated by sociodemographic, clinicopathologic, and treatment factors. METHODS 14,710 women ≥18 years with type II EC from 2007 to 2016 were identified from the Surveillance, Epidemiology, and End Results database. The association between race/ethnicity (non-Hispanic White [NHW], non-Hispanic Black [NHB], Hispanic, and non-Hispanic Asian/Pacific Islander [NHAPI]) and cancer-specific and overall mortality was examined. Mediation analysis was used to identify factors underlying differences in mortality outcomes. RESULTS NHB women had a higher risk of cancer-specific mortality than NHW women (hazard ratio [HR]: 1.22, 95% CI: 1.12-1.33), whereas NHAPI (HR: 0.88, 95% CI: 0.78-0.99) and Hispanic women (HR: 0.91, 95% CI: 0.81-1.01) had a lower risk of cancer-specific mortality than NHW women. Differences in clinicopathologic (stage, grade, histologic subtype), sociodemographic (insurance type, geographic region and location, neighborhood socioeconomic status), and treatment factors (treatment type, lymphadenectomy) explained 43.5%, 8.1%, and 7.3% of the difference in cancer-specific mortality between NHB and NHW women, respectively. Similar results were noted for overall mortality. CONCLUSIONS Multidisciplinary and multilevel approaches that integrate and address social and biological factors are needed to reduce the disproportionate burden of type II EC mortality in NHB women.
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Affiliation(s)
- Pritesh S Karia
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States of America
| | - Yongmei Huang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America
| | - Parisa Tehranifar
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, United States of America
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, United States of America
| | - Jeanine M Genkinger
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, United States of America.
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13
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Disparities in the survival of endometrial cancer patients in a public healthcare system: A population-based cohort study. Gynecol Oncol 2022; 167:532-539. [PMID: 36192238 DOI: 10.1016/j.ygyno.2022.09.015] [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: 07/30/2022] [Revised: 09/10/2022] [Accepted: 09/12/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Social determinants of health (SDH) have been shown to correlate with adverse cancer outcomes. It is unclear if their impact goes beyond behavioral risk or healthcare access. We aimed to evaluate the association of SDH with endometrial cancer outcomes in a public healthcare system. METHODS A retrospective cohort study of endometrial cancer patients diagnosed between 2009 and 2017 in Ontario, Canada. Clinical and sociodemographic variables were extracted from administrative databases. Validated multifactorial marginalization scores for domains of material deprivation, residential instability and ethnic concentration were used. Associations between marginalization and survival were evaluated using log-rank testing and Cox proportional hazards regression. RESULTS 20228 women with endometrial cancer were identified. Fewer patients in marginalized communities presented with early disease (70% vs. 76%, p < 0.001) and received surgery (89% vs. 93%, p < 0.001). Overall survival was shorter among marginalized patients (p < 0.001). On multivariable analysis adjusted for patient and disease factors, overall marginalization (HR = 1.22, 95% CI 1.03-1.08), material deprivation (HR = 1.22, 95% CI 1.10-1.35) and residential instability (HR = 1.32, 95% CI 1.19-1.46) were associated with increased risk of death (p < 0.001). CONCLUSIONS Socioeconomic marginalization is associated with an increased risk of death in endometrial cancer patients. Targetable events in the cancer care pathway should be identified to improve health equity. FUNDING This study was supported by a grant (#RD-196) from the Hamilton Health Sciences Juravinski Hospital and Cancer Center Foundation.
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14
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Barriers and Promotors to Health Service Utilization for Pelvic Floor Disorders in the United States: Systematic Review and Meta-analysis of Qualitative and Quantitative Studies. Female Pelvic Med Reconstr Surg 2022; 28:574-581. [PMID: 35649239 DOI: 10.1097/spv.0000000000001215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE We need a systematic approach to understanding health service utilization behavior in women with pelvic floor symptoms in the United States. OBJECTIVES The aim of this study was to determine the prevalence of pelvic floor care utilization and identify its barriers and promotors using Andersen's model, which theorizes care-seeking behavior with individual care needs, resources, predispositions, and macrostructures. DESIGN This was a systematic search of studies on care-seeking patterns in women with symptomatic pelvic floor disorders, which included pelvic organ prolapse, lower urinary tract symptoms, and anal incontinence. We then performed meta-analyses with random-effects models and descriptive analysis to determine utilization rate and the impact of each identified determinant. RESULTS The pooled utilization rate was 37% (95% confidence interval [CI], 30%-45%). Determinants were identified across all domains except at the macrostructure level. For individual care needs, increased symptom severity or duration and a history of depression (odds ratio [OR], 1.27; 95% CI, 1.07-1.51) were associated with higher utilization. In the resources domain, having social support and established primary/secondary care were promotors, whereas higher income and employed status trended as barriers. Under predispositions, age ≥50 years (OR, 1.29; 95% CI, 1.05-1.60), and pelvic floor awareness were associated with utilization, whereas Asian (OR, 0.60; 95% CI, 0.51-0.72) and Black (OR, 0.77; 95% CI, 0.55-1.08) women as well as women experiencing fear, misinformation, or normalization of pelvic floor disorders had decreased utilization. CONCLUSIONS This review identified a low utilization rate for pelvic floor care and revealed multilayered, actionable items affecting care-seeking behavior. It highlights the need for more inclusive and multifaceted approaches in future pelvic floor disparity research and equity interventions.
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15
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Barrington DA, Meade CE, Cosgrove CM, Cohn DE, Felix AS. Racial and ethnic disparities in readmission risk following the surgical management of endometrial cancer. Gynecol Oncol 2022; 166:543-551. [PMID: 35882610 DOI: 10.1016/j.ygyno.2022.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/12/2022] [Accepted: 07/15/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Most women diagnosed with endometrial cancer undergo primary surgical management with hysterectomy. Although racial disparities in readmission risk following hysterectomy for non-cancerous conditions have been reported, data among women with endometrial cancer are absent. This study evaluates racial differences in readmission risk among women undergoing endometrial cancer-related hysterectomy. METHODS In the National Cancer Database, women who underwent surgical management for endometrial cancer from 2004 to 2018 were identified. Readmission and minimally invasive hysterectomy (MIH) proportions were plotted according to year of diagnosis and race/ethnicity. Multivariable logistic regression models were used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for associations between readmission risk and epidemiological, facility, tumor, and surgical characteristics. A base model was sequentially adjusted to incorporate significant covariates. RESULTS There were 350,631 patients included in the study. The proportion of MIH increased among all race/ethnicities over the study period; however, MIH rates were lower among Black women. Readmission proportions were 2.7% among White, 4.2% among Black, 2.9% among Hispanic, 2.4% among Asian, 2.1% among American Indian/Alaska Native, and 3.1% among Native Hawaiian/Pacific Islander women. In the fully adjusted model incorporating surgical approach, Black women (OR: 1.20, 95% CI = 1.13, 1.28) and Native Hawaiian/Pacific Islander women (OR: 1.54, 95% CI = 1.09, 2.18) were more commonly readmitted compared to White women. CONCLUSIONS In this study, Black and Native Hawaiian/Pacific Islander women with endometrial cancer had significantly higher readmission risk than White women. Optimizing perioperative care for minority women is an essential component of overcoming racially disparate endometrial cancer outcomes.
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Affiliation(s)
- David A Barrington
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, The Ohio State University Wexner Medical Center, Arthur G James Cancer Center, Columbus, OH, USA
| | - Caitlin E Meade
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Casey M Cosgrove
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, The Ohio State University Wexner Medical Center, Arthur G James Cancer Center, Columbus, OH, USA
| | - David E Cohn
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, The Ohio State University Wexner Medical Center, Arthur G James Cancer Center, Columbus, OH, USA
| | - Ashley S Felix
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA.
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16
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Towner M, Kim JJ, Simon MA, Matei D, Roque D. Disparities in gynecologic cancer incidence, treatment, and survival: a narrative review of outcomes among black and white women in the United States. Int J Gynecol Cancer 2022; 32:931-938. [PMID: 35523443 PMCID: PMC9509411 DOI: 10.1136/ijgc-2022-003476] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Mary Towner
- Obstetrics and Gynecology, Division of Gynecologic Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - J Julie Kim
- Obstetrics and Gynecology, Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois, USA
| | - Melissa A Simon
- Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniela Matei
- Obstetrics and Gynecology, Division of Gynecologic Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dario Roque
- Obstetrics and Gynecology, Division of Gynecologic Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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17
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Health Disparities in Uterine Cancer: Report From the Uterine Cancer Evidence Review Conference. Obstet Gynecol 2022; 139:645-659. [PMID: 35272301 PMCID: PMC8936152 DOI: 10.1097/aog.0000000000004710] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/02/2021] [Indexed: 12/27/2022]
Abstract
The Centers for Disease Control and Prevention recognized the need for educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. The American College of Obstetricians and Gynecologists convened a panel of experts in evidence review from the Society for Academic Specialists in General Obstetrics and Gynecology and content experts from the Society of Gynecologic Oncology to review relevant literature, best practices, and existing practice guidelines for the development of evidence-based educational materials for women's health care clinicians about uterine cancer. This article is the evidence summary of the literature review of health disparities and inequities related to uterine cancer. Substantive knowledge gaps are noted and summarized to provide guidance for future research.
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18
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Barrington DA, Sinnott JA, Nixon D, Padamsee TJ, Cohn DE, Doll KM, Donneyong MM, Felix AS. More than treatment refusal: a National Cancer Database analysis of adjuvant treatment refusal and racial survival disparities among women with endometrial cancer. Am J Obstet Gynecol 2022; 227:244.e1-244.e17. [PMID: 35283091 PMCID: PMC9308654 DOI: 10.1016/j.ajog.2022.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/18/2022] [Accepted: 03/05/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Disparities in adjuvant treatment between Black and White women with endometrial cancer exist and contribute to worse outcomes among Black women. However, factors leading to disparate treatment receipt are understudied. OBJECTIVE We examined whether patient refusal of adjuvant treatment (chemotherapy or radiation) differed between Black and White women and whether treatment refusal mediated racial disparities in survival among women with endometrial cancer. STUDY DESIGN We used the National Cancer Database, a hospital-based cancer registry, to identify non-Hispanic Black and non-Hispanic White women diagnosed with endometrial cancer from 2004 to 2016 who either received or refused recommended radiation or chemotherapy. We used logistic regression to estimate multivariable-adjusted odds ratios and 95% confidence intervals for associations between race and treatment refusal. We also examined predictors of treatment refusal in race-specific models. Accelerated failure time models were used to estimate absolute differences in overall survival by race. We used causal mediation analysis to estimate the proportion of racial differences in overall survival attributable to racial differences in adjuvant treatment refusal. We considered the overall study population and strata defined by histology, and adjusted for sociodemographic, tumor, and facility characteristics. RESULTS Our analysis included 75,447 endometrial cancer patients recommended to receive radiation and 60,187 endometrial cancer patients recommended to receive chemotherapy, among which 6.4% and 11.4% refused treatment, respectively. Among Black women recommended for radiation or chemotherapy, 6.4% and 9.6% refused, respectively. Among White women recommended for radiation or chemotherapy, 6.4% and 11.8% refused, respectively. After adjusting for sociodemographic variables, facility characteristics, and tumor characteristics, Black women were more likely to refuse chemotherapy than White women (adjusted odds ratio, 1.26; 95% confidence interval, 1.15-1.37), but no difference in radiation refusal was observed (adjusted odds ratio, 1.00; 95% confidence interval, 0.91-1.11). Some predictors of radiation refusal varied by race, namely income, education, histology, stage, and chemotherapy receipt (P interactions<.05), whereas predictors of chemotherapy refusal were generally similar between Black and White women. Among women recommended for radiation, Black women survived an average of 4.3 years shorter than White women, which did not seem attributable to differences in radiation refusal. Among women recommended for chemotherapy, Black women survived an average of 3.2 years shorter than White women of which 1.9 months (4.9%) could potentially be attributed to differences in chemotherapy refusal. CONCLUSION We observed differences in chemotherapy refusal by race, and those differences may be responsible for up to about 2 months of the overall 3.2-year survival disparity between White and Black women. Radiation refusal did not explain any of the 4.3-year disparity among women recommended for radiation. Treatment refusal accounts for, at most, a small fraction of the total racial disparity in endometrial cancer survival. Although a better understanding of the reasons for patient treatment refusal and subsequent intervention may help improve outcomes for some women, other causes of disparate outcomes, particularly those reflecting the social determinants of health, must be investigated.
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Affiliation(s)
- David A Barrington
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, The Ohio State University Wexner Medical Center, Arthur G James Cancer Center, Columbus, OH
| | | | - Danaye Nixon
- Department of Statistics, The Ohio State University, Columbus, OH
| | - Tasleem J Padamsee
- Division of Health Services, Management, and Policy, College of Public Health, The Ohio State University, Columbus, OH
| | - David E Cohn
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, The Ohio State University Wexner Medical Center, Arthur G James Cancer Center, Columbus, OH
| | - Kemi M Doll
- Department of Obstetrics and Gynecology, School of Medicine, University of Washington, Seattle, WA
| | - Macarius M Donneyong
- Division of Health Services, Management, and Policy, College of Public Health, The Ohio State University, Columbus, OH; Division of Outcomes and Translational Sciences, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Ashley S Felix
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH.
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MicroRNA profiling in a case-control study of African American women with uterine serous carcinoma. Gynecol Oncol 2021; 163:453-458. [PMID: 34607711 DOI: 10.1016/j.ygyno.2021.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/18/2021] [Accepted: 09/21/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Uterine serous carcinoma (USC) is an aggressive subtype of endometrial cancer associated with worse survival outcomes in African American (AA) patients. This study evaluated tumor miRNA expression by race, clinical and tumor characteristics, and survival outcomes. METHODS FFPE tumor tissue from hysterectomy specimens was identified for 29 AA cases. Case matching was performed by computer-based random assignment in a 1:1 ratio with Caucasian controls based on age, stage and histologic subtype (pure vs. mixed). RNA was extracted from 77 specimens (54 tumors and 23 matched normal endometrium). MicroRNA array profiling was performed by microRNA Hi-Power Labeling (Hy3/Hy5) and hybridization to miRCURY LNA microRNA Array 7th Gen. RESULTS Clinical and treatment characteristics were similar for cases and controls, although use of adjuvant radiation was less common in African Americans (p = 0.03). Of 968 miRNAs analyzed, 649 were differentially expressed in normal endometrium vs. tumor. When compared by race, histologic subtype, stage or presence of LVI, no differentially expressed miRNAs were identified. In patients with disease recurrence at 3 years, the three most upregulated miRNAs were miR-1, miR-21-5p and miR-223. Of these, increased miR-223 expression (>median) was associated with worse OS (p = 0.0496) in an independent dataset (TCGA dataset) comprising of 140 patients with USC (mixed or pure serous). After adjusting for age, ethnicity and BMI, upregulation of miR-223 remained risk factor for death (adjusted HR 2.87, 95% CI 1.00-8.27). CONCLUSIONS MiRNA profiling did not identify biological differences between AA and Caucasian patients with USC. Upregulation of miR-223 may be a prognostic factor in USC.
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Rodriguez AM, Polychronopoulou E, Hsu E, Shah R, Lamiman K, Kuo YF. Factors associated with endometrial cancer and hyperplasia among middle-aged and older Hispanics. Gynecol Oncol 2020; 160:16-23. [PMID: 33221024 DOI: 10.1016/j.ygyno.2020.10.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 10/25/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE While disparities in endometrial hyperplasia and endometrial cancer are well documented in Blacks and Whites, limited information exists for Hispanics. The objective is to describe the patient characteristics associated with endometrial hyperplasia symptoms, endometrial hyperplasia with atypia and endometrial cancer, and assess factors contributing to racial/ethnic differences in disease outcomes. METHODS This single-center, retrospective study included women aged ≥50 years with ≥ two encounters for endometrial hyperplasia symptoms, endometrial hyperplasia with atypia and endometrial cancer between 2012 and 2016. Multivariate logistic regression models evaluated the predictors of endometrial cancer and hyperplasia. RESULTS We included 19,865 women (4749 endometrial hyperplasia symptoms, 71 endometrial hyperplasias with atypia, 201 endometrial cancers) with mean age of 60.45 years (SD 9.94). The odds of endometrial hyperplasia symptoms were higher in non-Hispanic Blacks (Odds Ratio [OR] 1.56, 95% Confidence Interval [CI] 1.20-1.72), Hispanics (OR 1.35, 95% CI 1.22-1.49), family history of female cancer (OR 1.25, 95% CI 1.12-1.39), hypertension (OR 1.24, 95% CI 1.14-1.35), and birth control use (OR 1.29, 95% CI 1.15-1.43). Odds of endometrial cancer and atypical hyperplasia increased for ages 60-64 (OR 7.95, 95% CI 3.26-19.37; OR 3.66, 95% 1.01-13.22) and being obese (OR 1.61, 95% CI 1.08-2.41; OR: 6.60, 95% CI 2.32-18.83). Odds of endometrial cancer increased with diabetes (OR 1.68, 95% CI 1.22-2.32). CONCLUSION(S) Patients with obesity and diabetes had increased odds of endometrial cancer and hyperplasia with atypia. Further study is needed to understand the exogenous estrogen effect contributing to the increased incidence among Hispanics.
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Affiliation(s)
- Ana M Rodriguez
- Department of Obstetrics & Gynecology, USA; Sealy Institute for Vaccine Sciences, USA.
| | | | - Enshuo Hsu
- Department of Preventive Medicine and Population Health, USA
| | - Rahul Shah
- School of Medicine, The University of Texas Medical Branch at Galveston, TX, USA
| | | | - Yong-Fang Kuo
- Department of Preventive Medicine and Population Health, USA
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Huang AB, Huang Y, Hur C, Tergas AI, Khoury-Collado F, Melamed A, St Clair CM, Hou JY, Ananth CV, Neugut AI, Hershman DL, Wright JD. Impact of quality of care on racial disparities in survival for endometrial cancer. Am J Obstet Gynecol 2020; 223:396.e1-396.e13. [PMID: 32109459 DOI: 10.1016/j.ajog.2020.02.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/30/2020] [Accepted: 02/18/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Black women experience poorer survival compared with white women across all endometrial cancer stages and histologies. The incidence of endometrial cancer is 30% lower in black women compared with white women, yet mortality is 80% higher in black women. Differences in adherence to evidence-based guidelines have been proposed to be major contributors to this disparity. OBJECTIVES We examined whether adherence to evidence-based treatment recommendations for endometrial cancer could mitigate survival disparities between black and white women. STUDY DESIGN The National Cancer Database was used to identify women with endometrial cancer treated from 2004 through 2016. We established 5 evidence-based quality metrics based on review of primary literature and accepted guidelines: surgical treatment within 6 weeks of diagnosis (Q1), use of minimally invasive surgery (stage I-IIIC; Q2), pelvic nodal assessment (high-risk tumors; Q3), adjuvant radiation (high intermediate risk; Q4), and systemic chemotherapy (stage III-IV; Q5). The rates of 30 and 90 day mortality and 5 year survival were compared between black and white women. To determine the influence of quality on outcomes, we compared outcomes among perfectly adherent black and white women with stage I and III endometrial cancer. RESULTS We identified 310,208 women including 35,035 (11.3%) black women and 275,173 (88.3%) white women. Black women were less likely than white women to receive Q1 (65.8 vs 75.6%), Q2 (58.5 vs 72.9%), Q3 (71.3 vs 74.2%), and Q5 (72.7 vs 73.2%) (P < .05 for all). Adherence to each quality metrics was associated with improved survival. Among women with stage I disease, perfect adherence to the relative quality metrics was seen in 53.1% of white and 41.5% of black women. Among perfectly adherent stage I patients, outcomes in black women improved relative to unselected black women; however, they still experienced higher risk of 30 day (adjusted relative risk, 2.25; 95% confidence interval, 1.30-3.90), 90 day (adjusted relative risk, 1.84; 95% confidence interval, 1.23-2.76), and 5 year mortality (adjusted hazard ratio, 1.42; 95% confidence interval, 1.26-1.59) compared with similar white women. Among women with stage III tumors, perfect adherence to the relative quality metrics was seen in 56.6% of white and 44.1% of black women. Perfectly adherent black women with stage III disease had improved outcomes but remained at increased risk of 30 day (adjusted relative risk, 1.86; 95% confidence interval, 1.01-3.44) and 5 year mortality (adjusted hazard ratio, 1.35; 95% confidence interval, 1.22-1.50) compared with white women. CONCLUSION Black women are less likely than white women with endometrial cancer to receive evidence-based care. However, receipt of evidence-based care mitigates but does not eliminate racial disparities in outcomes and black women remain at greater risk of death from endometrial cancer.
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Black and Hispanic women are less likely than white women to receive guideline-concordant endometrial cancer treatment. Am J Obstet Gynecol 2020; 223:398.e1-398.e18. [PMID: 32142825 DOI: 10.1016/j.ajog.2020.02.041] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/05/2020] [Accepted: 02/22/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Differences in receipt of guideline-concordant treatment might underlie well-established racial disparities in endometrial cancer mortality. OBJECTIVE Using the National Cancer Database, we assessed the hypothesis that among women with endometrioid endometrial cancer, racial/ethnic minority women would have lower odds of receiving guideline-concordant treatment than white women. In addition, we hypothesized that lack of guideline-concordant treatment was linked with worse survival. STUDY DESIGN We defined receipt of guideline-concordant treatment using the National Comprehensive Cancer Network guidelines. Multivariable logistic regression models were used to compute odds ratios and 95% confidence intervals for associations between race and guideline-concordant treatment. We used multivariable Cox proportional hazards regression models to estimate hazards ratios and 95% confidence intervals for relationships between guideline-concordant treatment and overall survival in the overall study population and stratified by race/ethnicity. RESULTS This analysis was restricted to the 89,319 women diagnosed with an invasive, endometrioid endometrial cancer between 2004 and 2014. Overall, 74.7% of the cohort received guideline-concordant treatment (n = 66,699). Analyses stratified by race showed that 75.3% of non-Hispanic white (n = 57,442), 70.1% of non-Hispanic black (n = 4334), 71.0% of Hispanic (n = 3263), and 72.5% of Asian/Pacific Islander patients (n = 1660) received treatment in concordance with guidelines. In multivariable-adjusted models, non-Hispanic black (odds ratio, 0.92, 95% confidence interval, 0.86-0.98) and Hispanic women (odds ratio, 0.90, 95% confidence internal, 0.83-0.97) had lower odds of receiving guideline-concordant treatment compared with non-Hispanic white women, while Asian/Pacific Islander women had a higher odds of receiving guideline-concordant treatment (odds ratio, 1.11, 95% confidence interval, 1.00-1.23). Lack of guideline-concordant treatment was associated with lower overall survival in the overall study population (hazard ratio, 1.12, 95% confidence interval, 1.08-1.15) but was not significantly associated with overall survival among non-Hispanic black (hazard ratio, 1.09, 95% confidence interval, 0.98-1.21), Hispanic (hazard ratio, 0.92, 95% confidence interval=0.78-1.09), or Asian/Pacific Islander (hazard ratio, 0.90, 95% confidence interval, 0.70-1.16) women. CONCLUSION Non-Hispanic black and Hispanic women were less likely than non-Hispanic white women to receive guideline-concordant treatment, while Asian/Pacific Islander women more commonly received treatment in line with guidelines. Furthermore, in the overall study population, overall survival was worse among those not receiving guideline-concordant treatment, although low power may have had an impact on the race-stratified models. Future studies should evaluate reasons underlying disparate endometrial cancer treatment.
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Barrington DA, Sinnott JA, Calo C, Cohn DE, Cosgrove CM, Felix AS. Where you live matters: A National Cancer Database study of Medicaid expansion and endometrial cancer outcomes. Gynecol Oncol 2020; 158:407-414. [PMID: 32527568 DOI: 10.1016/j.ygyno.2020.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine associations between adoption of Medicaid expansion (ME) and changes in insurance status, early stage diagnosis, and cancer survival among women with endometrial carcinoma (EC). METHODS The National Cancer Database (NCDB) was queried for patients diagnosed with EC between the age 40-64 from 2004 to 2015. Difference-in-differences analysis quantified the impact of ME on the proportion of new EC diagnoses with insurance (vs. uninsured), the proportion diagnosed with stage I (vs. II-IV), and overall survival. RESULTS 156,253 patients were included. Among 65,019 women living in ME states, ME is associated with an increase in the percent of EC cases who are insured of 1.4% (95% CI 0.9-2.0%, p < 0.0001), with strongest effects among Hispanic women, women in the lowest income quartile, and women in the second age quartile (age 53-57). There was no overall impact of ME on stage, though an increase of early stage diagnoses by 2.4% (95% CI 0.3-4.5%, p = 0.022) was observed among women age 53-57. There was a trend towards improved overall survival with ME, which was strongest in women age 53-57 (HR = 0.83, 95% CI 0.70-0.99, p = 0.037). CONCLUSIONS Among women with EC, ME positively impacted insurance coverage, an important hurdle in accessing health care. In women aged 53-57, ME was associated with earlier stage at diagnosis and improved survival, suggesting that the magnitude of the improvement in insurance coverage may correlate with important clinical outcomes. Efforts should continue to understand the complexity of barriers to health care access and to develop effective strategies to surmount them.
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Affiliation(s)
- David A Barrington
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America.
| | - Jennifer A Sinnott
- Department of Statistics, The Ohio State University, Columbus, OH, United States of America; Huntsman Cancer Institute, The University of Utah, Salt Lake City, UT, United States of America; Department of Pediatrics, University of Utah, Salt Lake City, UT, United States of America; Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Corinne Calo
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - David E Cohn
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Casey M Cosgrove
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Ashley S Felix
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, United States of America
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Clarke MA, Devesa SS, Harvey SV, Wentzensen N. Hysterectomy-Corrected Uterine Corpus Cancer Incidence Trends and Differences in Relative Survival Reveal Racial Disparities and Rising Rates of Nonendometrioid Cancers. J Clin Oncol 2019; 37:1895-1908. [PMID: 31116674 PMCID: PMC6675596 DOI: 10.1200/jco.19.00151] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
PURPOSE Uterine corpus cancer incidence rates have been projected to increase, a prediction often attributed to the obesity epidemic. However, correct estimation of these rates requires accounting for hysterectomy prevalence, which varies by race, ethnicity, and region. Here, we evaluated recent trends in hysterectomy-corrected rates by race and ethnicity and histologic subtype and estimated differences in relative survival by race and ethnicity, subtype, and stage. METHODS We estimated hysterectomy prevalence from the Behavioral Risk Factor Surveillance System. Hysterectomy-corrected age-standardized uterine corpus cancer incidence rates from 2000 to 2015 were calculated from the SEER 18 registries. Incidence rates and trends were estimated separately by race and ethnicity, region, and histologic subtype. Five-year relative survival rates were estimated by race and ethnicity, histologic subtype, and stage. RESULTS Hysterectomy-corrected incidence rates of uterine corpus cancer were similar among non-Hispanic whites and blacks and lower among Hispanics and Asians/Pacific Islanders. Endometrioid carcinoma rates were highest in non-Hispanic whites, whereas nonendometrioid carcinoma and sarcoma rates were highest in non-Hispanic blacks. Hysterectomy-corrected uterine corpus cancer incidence increased among non-Hispanic whites from 2003 to 2015 and among non-Hispanic blacks, Hispanics, and Asians/Pacific Islanders from 2000 to 2015. Overall incidence rates among non-Hispanic blacks surpassed those of non-Hispanic whites in 2007. Endometrioid carcinoma rates rose among non-Hispanic blacks, Hispanics, and Asians/Pacific Islanders but were stable among non-Hispanic whites; however, nonendometrioid carcinoma rates rose significantly among all women. Non-Hispanic blacks had the lowest survival rates, irrespective of stage at diagnosis or histologic subtype. CONCLUSION Among all women, rates of nonendometrioid subtypes have been rising rapidly. Our analysis shows profound racial differences and disparities indicated by higher rates of nonendometrioid subtypes and poorer survival among non-Hispanic black women.
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High-grade Endometrial Carcinomas: Morphologic and Immunohistochemical Features, Diagnostic Challenges and Recommendations. Int J Gynecol Pathol 2019; 38 Suppl 1:S40-S63. [PMID: 30550483 PMCID: PMC6296248 DOI: 10.1097/pgp.0000000000000491] [Citation(s) in RCA: 144] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This review of challenging diagnostic issues concerning high-grade endometrial carcinomas is derived from the authors' review of the literature followed by discussions at the Endometrial Cancer Workshop sponsored by the International Society of Gynecological Pathologists in 2016. Recommendations presented are evidence-based, insofar as this is possible, given that the levels of evidence are weak or moderate due to small sample sizes and nonuniform diagnostic criteria used in many studies. High-grade endometrioid carcinomas include FIGO grade 3 endometrioid carcinomas, serous carcinomas, clear cell carcinomas, undifferentiated carcinomas, and carcinosarcomas. FIGO grade 3 endometrioid carcinoma is diagnosed when an endometrioid carcinoma exhibits >50% solid architecture (excluding squamous areas), or when an architecturally FIGO grade 2 endometrioid carcinoma exhibits marked cytologic atypia, provided that a glandular variant of serous carcinoma has been excluded. The most useful immunohistochemical studies to make the distinction between these 2 histotypes are p53, p16, DNA mismatch repair proteins, PTEN, and ARID1A. Endometrial clear cell carcinomas must display prototypical architectural and cytologic features for diagnosis. Immunohistochemical stains, including, Napsin A and p504s can be used as ancillary diagnostic tools; p53 expression is aberrant in a minority of clear cell carcinomas. Of note, clear cells are found in all types of high-grade endometrial carcinomas, leading to a tendency to overdiagnose clear cell carcinoma. Undifferentiated carcinoma (which when associated with a component of low-grade endometrioid carcinoma is termed "dedifferentiated carcinoma") is composed of sheets of monotonous, typically dyscohesive cells, which can have a rhabdoid appearance; they often exhibit limited expression of cytokeratins and epithelial membrane antigen, are usually negative for PAX8 and hormone receptors, lack membranous e-cadherin and commonly demonstrate loss of expression of DNA mismatch repair proteins and SWI-SNF chromatin remodeling proteins. Carcinosarcomas must show unequivocal morphologic evidence of malignant epithelial and mesenchymal differentiation.
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Felix AS, Cohn DE, Brasky TM, Zaino R, Park K, Mutch DG, Creasman WT, Thaker PH, Walker JL, Moore RG, Lele SB, Guntupalli SR, Downs LS, Nagel CI, Boggess JF, Pearl ML, Ioffe OB, Randall ME, Brinton LA. Receipt of adjuvant endometrial cancer treatment according to race: an NRG Oncology/Gynecologic Oncology Group 210 Study. Am J Obstet Gynecol 2018; 219:459.e1-459.e11. [PMID: 30096321 DOI: 10.1016/j.ajog.2018.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/30/2018] [Accepted: 08/01/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Black women with endometrial cancer are more likely to die of their disease compared with white women with endometrial cancer. These survival disparities persist even when disproportionately worse tumor characteristics among black women are accounted. Receipt of less complete adjuvant treatment among black patients with endometrial cancer could contribute to this disparity. OBJECTIVE We assessed the hypothesis that black women with endometrial cancer are less likely than their white counterparts to receive adjuvant treatment within subgroups defined by tumor characteristics in the NRG Oncology/Gynecology Oncology Group 210 Study. STUDY DESIGN Our analysis included 615 black and 4283 white women with endometrial cancer who underwent hysterectomy. Women completed a questionnaire that assessed race and endometrial cancer risk factors. Tumor characteristics were available from pathology reports and central review. We categorized women as low-, intermediate-, or high-risk based on the European Society for Medical Oncology definition. Adjuvant treatment was documented during postoperative visits and was categorized as no adjuvant treatment (54.3%), radiotherapy only (16.5%), chemotherapy only (15.2%), and radiotherapy plus chemotherapy (14.0%). We used polytomous logistic regression to estimate odds ratios and 95% confidence intervals for multivariable-adjusted associations between race and adjuvant treatment in the overall study population and stratified by tumor subtype, stage, or European Society for Medical Oncology risk category. RESULTS Overall, black women were more likely to have received chemotherapy only (odds ratio, 1.40; 95% confidence interval, 1.04-1.86) or radiotherapy plus chemotherapy (odds ratio, 2.01; 95% confidence interval, 1.54-2.62) compared with white women in multivariable-adjusted models. No racial difference in the receipt of radiotherapy only was observed. In tumor subtype-stratified models, black women had higher odds of receiving radiotherapy plus chemotherapy than white women when diagnosed with low-grade endometrioid (odds ratio, 2.04; 95% confidence interval, 1.06-3.93) or serous tumors (odds ratio, 1.81; 95% confidence interval, 1.07-3.08). Race was not associated with adjuvant treatment among women who had been diagnosed with other tumor subtypes. In stage-stratified models, we observed no racial differences in the receipt of adjuvant treatment. In models that were stratified by European Society for Medical Oncology risk group, black women with high-risk cancer were more likely to receive radiotherapy plus chemotherapy compared with white women (odds ratio, 1.41; 95% confidence interval, 1.03-1.94). CONCLUSION Contrary to our hypothesis, we observed higher odds of specific adjuvant treatment regimens among black women as compared with white women within specific subgroups of endometrial cancer characteristics.
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Temkin SM, Rimel BJ, Bruegl AS, Gunderson CC, Beavis AL, Doll KM. A contemporary framework of health equity applied to gynecologic cancer care: A Society of Gynecologic Oncology evidenced-based review. Gynecol Oncol 2018; 149:70-77. [PMID: 29605053 DOI: 10.1016/j.ygyno.2017.11.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/19/2017] [Accepted: 11/07/2017] [Indexed: 01/21/2023]
Abstract
Health disparities are defined as the preventable difference in the burden of disease, injury, and violence, or opportunity to achieve optimal health that socially disadvantaged populations experience compared to the population as a whole. Disparities in incidence and cancer outcomes for women with gynecologic malignancies have been well described particularly for American women of Black race. The etiology of these disparities has been tied to socio-economics, cultural, educational and genetic factors. While access to high quality treatment has been primarily linked to survival from cervical and ovarian cancer, innate biologic distinctions have been principally cited as reasons for differences in incidence and mortality in cancers of the uterine corpus. This article will update the framework of disparities to incorporate a broader understanding of the social determinants of health and how they affect health equity by addressing the root causes of disparities within the health care system. Special populations are identified who are at risk for health inequities which include but are not limited to Black race, underserved racial and ethnic minorities (e.g. indigenous peoples, low English fluency), trans/gender nonconforming people and rural populations. Each of these populations at risk have unique structural barriers within the healthcare system impacting gynecologic cancer outcomes. The authors provide practical recommendations for practitioners aimed at eliminating cancer related outcome disparities.
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Affiliation(s)
- Sarah M Temkin
- Virginia Commonwealth University, Massey Cancer Center, Richmond, VA, USA
| | - B J Rimel
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Camille C Gunderson
- Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma city, OK, USA
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Racial and ethnic disparities over time in the treatment and mortality of women with gynecological malignancies. Gynecol Oncol 2018; 149:4-11. [PMID: 29605048 DOI: 10.1016/j.ygyno.2017.12.006] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/27/2017] [Accepted: 12/05/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To examine temporal trends in treatment and survival among black, Asian, Hispanic, and white women diagnosed with endometrial, ovarian, cervical, and vulvar cancer. METHODS Using the National Cancer Database (2004-2014), we identified women diagnosed with endometrial, ovarian, cervical, and vulvar cancer. For each disease site, we analyzed race/ethnicity-specific trends in receipt of evidence-based practices. Professional societies' recommendations were used to define these practices. Using data from the Surveillance, Epidemiology, and End Results Program (2000-2009) we analyzed trends in 5-year survival. RESULTS Throughout the study period black (64.8%) and Hispanic (68.3%) women were less likely to undergo lymphadenectomy for stage I ovarian cancer compared to Asian (79.5%) and white patients (74.6%). Black women were the least likely group to undergo lymphadenectomy in all periods. Among patients with stage II-IV ovarian cancer, 76.6% of white and Asian women received both surgery and chemotherapy, compared to 70.8% of black and 73.9% Hispanic women. Hispanic women with deeply invasive or high-grade stage I endometrial cancer underwent lymphadenectomy less frequently (74.5%) than all other groups (80.7%). Black women were less likely to have chemo-radiotherapy for stage IIB-IVA cervical cancer (75.6% versus 80.4% of all others). Black women were also less likely to have a surgical lymph node evaluation for vulvar cancer (58.8% versus 63.5% of all others). Among women diagnosed with ovarian, endometrial, and cervical cancer, black women had lower five-year survival than other groups. CONCLUSION Significant racial disparities persist in the delivery of evidence-based care. Black women with ovarian, endometrial, and cervical cancer continue to experience higher cancer-specific mortality than other groups.
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Doll KM, Snyder CR, Ford CL. Endometrial cancer disparities: a race-conscious critique of the literature. Am J Obstet Gynecol 2018; 218:474-482.e2. [PMID: 28964822 DOI: 10.1016/j.ajog.2017.09.016] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/17/2017] [Accepted: 09/18/2017] [Indexed: 12/31/2022]
Abstract
Racial disparities in endometrial cancer are stark and have increased over the past decade. While the disparities are well documented, intervention work to address the mortality gap is nonexistent. This review critiques how race has been conceptualized to explain the causes of endometrial cancer disparities, assesses gaps in knowledge production, and proposes new research priorities. Using public health critical race praxis, a research approach for examining racial disparities and knowledge production processes, we reviewed the endometrial cancer disparities literature from 1995 through 2016. Using systematic search methods, 133 unique records were identified and 48 studies critiqued. We found that a narrow definition of race as a purely biological construct is common throughout the literature. This appears to result in an underemphasis on the role of modifiable, nonbiological contributors to racial disparities and a lack of follow-up work to address these contributors. Key knowledge gaps identified were the role of health care systems in early diagnosis, a lack of intervention studies to address persistent treatment inequity by race, and the near absence of qualitative work to understand the perspectives of Black women diagnosed with endometrial cancer. We conclude with an iterative demonstration of the public health critical race praxis and suggest new routes of inquiry to broaden the scope of research priorities to understand and improve the outcomes of Black women with endometrial cancer.
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Tarney CM, Tian C, Wang G, Dubil EA, Bateman NW, Chan JK, Elshaikh MA, Cote ML, Schildkraut JM, Shriver CD, Conrads TP, Hamilton CA, Maxwell GL, Darcy KM. Impact of age at diagnosis on racial disparities in endometrial cancer patients. Gynecol Oncol 2018; 149:12-21. [PMID: 28800945 PMCID: PMC6863162 DOI: 10.1016/j.ygyno.2017.07.145] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 07/29/2017] [Accepted: 07/31/2017] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Although black patients with endometrial cancer (EC) have worse survival compared with white patients, the interaction between age/race has not been examined. The primary objective was to evaluate the impact of age at diagnosis on racial disparities in disease presentation and outcome in EC. METHODS We evaluated women diagnosed with EC between 1991 and 2010 from the Surveillance, Epidemiology, and End Results. Mutation status for TP53 or PTEN, or with the aggressive integrative, transcript-based, or somatic copy number alteration-based molecular subtype were acquired from the Cancer Genome Atlas. Logistic regression model was used to estimate the interaction between age and race on histology. Cox regression model was used to estimate the interaction between age and race on survival. RESULTS 78,184 white and 8518 black patients with EC were analyzed. Median age at diagnosis was 3-years younger for black vs. white patients with serous cancer and carcinosarcoma (P<0.0001). The increased presentation of non-endometrioid histology with age was larger in black vs. white patients (P<0.0001). The racial disparity in survival and cancer-related mortality was more prevalent in black vs. white patients, and in younger vs. older patients (P<0.0001). Mutations in TP53, PTEN and the three aggressive molecular subtypes each varied by race, age and histology. CONCLUSIONS Aggressive histology and molecular features were more common in black patients and older age, with greater impact of age on poor tumor characteristics in black vs. white patients. Racial disparities in outcome were larger in younger patients. Intervention at early ages may mitigate racial disparities in EC.
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Affiliation(s)
- Christopher M Tarney
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States; John P Murtha Cancer Center, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Chunqiao Tian
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Guisong Wang
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Elizabeth A Dubil
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States; John P Murtha Cancer Center, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States; Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Naval Medical Center Portsmouth, VA, United States
| | - Nicholas W Bateman
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States; John P Murtha Cancer Center, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - John K Chan
- Palo Alto Medical Foundation, California Pacific Medical Center, Sutter Health, San Francisco, CA, United States
| | - Mohamed A Elshaikh
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI, United States
| | - Michele L Cote
- Oncology, Wayne State University, Karmanos Cancer Institute, Detroit, MI, United States
| | - Joellen M Schildkraut
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Craig D Shriver
- John P Murtha Cancer Center, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Thomas P Conrads
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States; John P Murtha Cancer Center, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States; Inova Schar Cancer Institute, Inova Center for Personalized Health, Falls Church, VA, United States
| | - Chad A Hamilton
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States; John P Murtha Cancer Center, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - G Larry Maxwell
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States; John P Murtha Cancer Center, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States; Inova Schar Cancer Institute, Inova Center for Personalized Health, Falls Church, VA, United States; Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, VA, United States.
| | - Kathleen M Darcy
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States; John P Murtha Cancer Center, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.
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Sud S, Holmes J, Eblan M, Chen R, Jones E. Clinical characteristics associated with racial disparities in endometrial cancer outcomes: A surveillance, epidemiology and end results analysis. Gynecol Oncol 2018; 148:349-356. [DOI: 10.1016/j.ygyno.2017.12.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/14/2017] [Accepted: 12/16/2017] [Indexed: 11/28/2022]
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Mukerji B, Baptiste C, Chen L, Tergas AI, Hou JY, Ananth CV, Neugut AI, Hershman DL, Wright JD. Racial disparities in young women with endometrial cancer. Gynecol Oncol 2018; 148:527-534. [PMID: 29307452 DOI: 10.1016/j.ygyno.2017.12.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/29/2017] [Accepted: 12/31/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Although racial disparities in treatment and outcome for endometrial cancer are well recognized, little work has explored disparities in young women. We performed a population-based analysis to compare survival between black and white women with endometrial cancer at <50years of age. METHODS We used the National Cancer Data Base to identify women <50years of age with endometrial cancer from 1998 to 2012. Clinical and demographic characteristics were compared between black and white women and survival by race analyzed using Kaplan-Meier curves and multivariable Cox proportional hazards models. RESULTS We identified a total of 35,850 women <50years of age including 31,947 (89.1%) white and 3903 (10.9%) black patients. Black women were more likely to have advanced stage, poorly differentiated, and non-endometrioid histology neoplasms (P<0.05 for all). In a multivariable model, survival was 19% worse for black patients than white patients (HR=1.19; 95% CI, 1.08-1.32). A similar effect was seen when limited to women with early-stage tumors (HR=1.24; 95% CI, 1.04-1.49), while among patients with advanced stage tumors, no association between race and survival was seen (HR=1.12; 95% CI, 0.89-1.41). Five-year survival rates were 90.6% (95% CI, 88.6-92.3%) for white and 81.5% (95% CI, 73.0-87.5%) for black women with stage IB tumors, and 75.1% (95% CI, 72.5-77.5%) and 63.3% (95% CI, 54.1-71.2%) for white and black women with stage III tumors, respectively. CONCLUSIONS Young black women are more likely to present with pathologically aggressive, advanced stage tumors. Even after adjusting for these pathologic differences, young black women with endometrial cancer have higher mortality than white women.
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Affiliation(s)
- Barenya Mukerji
- Department of Obstetrics and Gynecology, Monmouth Medical Center, United States
| | - Caitlin Baptiste
- Columbia University College of Physicians and Surgeons, United States
| | - Ling Chen
- Columbia University College of Physicians and Surgeons, United States
| | - Ana I Tergas
- Columbia University College of Physicians and Surgeons, United States; Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, United States; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, United States; New York Presbyterian Hospital, United States
| | - June Y Hou
- Columbia University College of Physicians and Surgeons, United States; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, United States; New York Presbyterian Hospital, United States
| | - Cande V Ananth
- Columbia University College of Physicians and Surgeons, United States; Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, United States
| | - Alfred I Neugut
- Columbia University College of Physicians and Surgeons, United States; Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, United States; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, United States; New York Presbyterian Hospital, United States
| | - Dawn L Hershman
- Columbia University College of Physicians and Surgeons, United States; Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, United States; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, United States; New York Presbyterian Hospital, United States
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons, United States; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, United States; New York Presbyterian Hospital, United States.
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Felix AS, Brasky TM, Cohn DE, Mutch DG, Creasman WT, Thaker PH, Walker JL, Moore RG, Lele SB, Guntupalli SR, Downs LS, Nagel C, Boggess JF, Pearl ML, Ioffe OB, Deng W, Miller DS, Brinton LA. Endometrial carcinoma recurrence according to race and ethnicity: An NRG Oncology/Gynecologic Oncology Group 210 Study. Int J Cancer 2017; 142:1102-1115. [PMID: 29063589 DOI: 10.1002/ijc.31127] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 09/20/2017] [Accepted: 10/04/2017] [Indexed: 01/21/2023]
Abstract
Non-Hispanic black (NHB) women are more likely to experience an endometrial carcinoma (EC) recurrence compared to non-Hispanic white (NHW) women. The extent to which tumor characteristics, socioeconomic status (SES) and treatment contribute to this observation is not well defined. In the NRG Oncology/Gynecology Oncology Group (GOG) 210 Study we evaluated associations between race/ethnicity and EC recurrence according to tumor characteristics with adjustment for potential confounders. Our analysis included 3,199 NHW, 532 NHB and 232 Hispanic women with EC. Recurrence was documented during follow-up. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between race/ethnicity and EC recurrence in models stratified by histologic subtype (low-grade endometrioid, high-grade endometrioid, serous, mixed cell, carcinosarcoma, clear cell) or stage (I, II, III) and adjusted for age, SES, body mass index, smoking status and treatment. In histologic subtype-stratified models, higher EC recurrence was noted in NHB women with low-grade endometrioid (HR = 1.94, 95% CI = 1.21-3.10) or carcinosarcomas (HR = 1.66, 95% CI = 0.99-2.79) compared to NHWs. In stage-stratified models, higher EC recurrence was noted among NHB women with stage I (HR = 1.48, 95% CI = 1.06-2.05) and Hispanic women with stage III disease (HR = 1.81, 95% CI = 1.11-2.95). Our observations of higher EC recurrence risk among NHB and Hispanic women, as compared to NHW women, were not explained by tumor characteristics, SES, treatment or other confounders. Other factors, such as racial differences in tumor biology or other patient factors, should be explored as contributors to racial disparities in EC recurrence.
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Affiliation(s)
- A S Felix
- Division of Epidemiology, Ohio State University College of Public Health, Columbus, OH
| | - T M Brasky
- Division of Cancer Prevention and Control, Ohio State University College of Medicine, Columbus, OH
| | - D E Cohn
- Division of Gynecologic Oncology, Ohio State University College of Medicine, Columbus, OH
| | - D G Mutch
- Washington University School of Medicine, St. Louis, MO
| | - W T Creasman
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
| | - P H Thaker
- Washington University School of Medicine, St. Louis, MO
| | - J L Walker
- Department of Obstetrics and Gynecology, University of Oklahoma, Oklahoma, OK
| | - R G Moore
- Program in Women's Oncology, Department of Obstetrics and Gynecology, Women and Infants Hospital/Brown University, Providence, RI
| | - S B Lele
- Gynecologic Oncology [SBL] & NRG Statistics and Data Management Center [WD], Roswell Park Cancer Institute, Buffalo, NY
| | - S R Guntupalli
- Gynecologic Oncology, University of Colorado Cancer Center, Aurora, CO
| | - L S Downs
- Gynecologic Oncology, University of Minnesota, Minneapolis, MN
| | - Ci Nagel
- Gynecologic Oncology, Case Western Reserve University, Cleveland, OH
| | - J F Boggess
- Gynecologic Oncology Program, University of North Carolina, Chapel Hill, NC
| | - M L Pearl
- Gynecologic Oncology, State University of New York at Stony Brook, Stony Brook, NY
| | - O B Ioffe
- Anatomical Pathology, University of Maryland, College Park, MD
| | - W Deng
- Gynecologic Oncology [SBL] & NRG Statistics and Data Management Center [WD], Roswell Park Cancer Institute, Buffalo, NY
| | - D S Miller
- Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - L A Brinton
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
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Foote JR, Gaillard S, Broadwater G, Sosa JA, Davidson B, Adam MA, Secord AA, Jones MB, Chino J, Havrilesky LJ. Disparities in the surgical staging of high-grade endometrial cancer in the United States. GYNECOLOGIC ONCOLOGY RESEARCH AND PRACTICE 2017; 4:1. [PMID: 28116108 PMCID: PMC5247803 DOI: 10.1186/s40661-016-0036-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 12/28/2016] [Indexed: 11/25/2022]
Abstract
Background The National Comprehensive Cancer Network (NCCN) and the Society of Gynecologic Oncology (SGO) recommend lymph node sampling (LNS) as a key component in the surgical staging of high-grade endometrial cancer. Our goal was to examine surgical staging patterns for high-grade endometrial cancer in the United States. Methods The National Cancer Data Base (NCDB) was searched for patients who underwent surgery for serous, clear cell, or grade 3 endometrioid endometrial cancer. Outcomes were receipt of LNS and overall survival (OS). Multivariate logistic regression was used to examine receipt of LNS in Stage I–III disease based on race (White vs. Black), income, surgical volume, and distance traveled to care. Multivariate Cox proportional hazards regression modeling was used to assess OS based on stage, race, income, LNS, surgical volume, and distance traveled. Results Forty-two thousand nine hundred seventy-three patients were identified: 76% White, 53% insured by Medicare/Medicaid, 24% traveled >30 miles, and 33% stage III disease. LNS was similar among White and Black women (81% vs 82%). LNS was more common among >30 miles traveled (84% vs 81%, p < 0.001), higher surgical volume (83% vs 80%, p < 0.001), and academic centers (84% vs 80%, p < 0.001). In multivariate analysis, higher income, higher surgical volume, Charlson-Deyo score, and distance traveled were predictors of LNS. Stage III disease (HR 3.39, 95% CI 3.28–3.50), age (10-year increase; HR 1.63, 95% CI 1.61–1.66), lack of LNS (HR 1.64, 95% CI 1.56–1.69), and low income (HR 1.20, 95% CI 1.14–1.27) were predictors of lower survival. Conclusions Surgical care for high-grade endometrial cancer in the United States is not uniform. Improved access to high quality care at high volume centers is needed to improve rates of recommended LNS.
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Affiliation(s)
- Jonathan R Foote
- Division of Gynecologic Oncology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710 USA
| | - Stephanie Gaillard
- Division of Gynecologic Oncology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710 USA
| | - Gloria Broadwater
- Biostatistics, Duke Cancer Institute, Duke University, 2301 Erwin Rd, Durham, NC 27710 USA
| | - Julie A Sosa
- Department of Surgery, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710 USA.,Duke Clinical Research Institute, Durham, USA
| | - Brittany Davidson
- Division of Gynecologic Oncology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710 USA
| | - Mohamed A Adam
- Department of Surgery, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710 USA
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710 USA
| | - Monica B Jones
- Division of Gynecologic Oncology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710 USA
| | - Junzo Chino
- Division of Radiation Oncology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710 USA
| | - Laura J Havrilesky
- Division of Gynecologic Oncology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710 USA
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Pennington M, Gentry-Maharaj A, Karpinskyj C, Miners A, Taylor J, Manchanda R, Iyer R, Griffin M, Ryan A, Jacobs I, Menon U, Legood R. Long-Term Secondary Care Costs of Endometrial Cancer: A Prospective Cohort Study Nested within the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). PLoS One 2016; 11:e0165539. [PMID: 27829038 PMCID: PMC5102347 DOI: 10.1371/journal.pone.0165539] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 10/13/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND There is limited evidence on the costs of Endometrial Cancer (EC) by stage of disease. We estimated the long-term secondary care costs of EC according to stage at diagnosis in an English population-based cohort. METHODS Women participating in UKCTOCS and diagnosed with EC following enrolment (2001-2005) and prior to 31st Dec 2009 were identified to have EC through multiple sources. Survival was calculated through data linkage to death registry. Costs estimates were derived from hospital records accessed from Hospital Episode Statistics (HES) with additional patient level covariates derived from case notes and patient questionnaires. Missing and censored data was imputed using Multiple Imputation. Regression analysis of cost and survival was undertaken. RESULTS 491 of 641 women with EC were included. Five year total costs were strongly dependent on stage, ranging from £9,475 (diagnosis at stage IA/IB) to £26,080 (diagnosis at stage III). Stage, grade and BMI were the strongest predictors of costs. The majority of costs for stage I/II EC were incurred in the first six months after diagnosis while for stage III / IV considerable costs accrued after the first six months. CONCLUSIONS In addition to survival advantages, there are significant cost savings if patients with EC are detected earlier.
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Affiliation(s)
- Mark Pennington
- King’s Health Economics, David Goldberg Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Aleksandra Gentry-Maharaj
- Department of Women’s Cancer, Institute for Women’s Health, University College London, London, United Kingdom
| | - Chloe Karpinskyj
- Department of Women’s Cancer, Institute for Women’s Health, University College London, London, United Kingdom
| | - Alec Miners
- Department of Health Services Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Julie Taylor
- Department of Women’s Cancer, Institute for Women’s Health, University College London, London, United Kingdom
| | - Ranjit Manchanda
- Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Rema Iyer
- Department of Women’s Cancer, Institute for Women’s Health, University College London, London, United Kingdom
| | - Michelle Griffin
- Department of Women’s Cancer, Institute for Women’s Health, University College London, London, United Kingdom
| | - Andy Ryan
- Department of Women’s Cancer, Institute for Women’s Health, University College London, London, United Kingdom
| | - Ian Jacobs
- Department of Women’s Cancer, Institute for Women’s Health, University College London, London, United Kingdom
- University of New South Wales, Sydney, New South Wales, Australia
| | - Usha Menon
- Department of Women’s Cancer, Institute for Women’s Health, University College London, London, United Kingdom
| | - Rosa Legood
- Department of Health Services Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Mahdi H, Han X, Abdul-Karim F, Vargas R. Racial disparity in survival of patients with uterine serous carcinoma: Changes in clinical characteristics, patterns of care and outcomes over time from 1988 to 2011. Gynecol Oncol 2016; 143:334-345. [PMID: 26948694 DOI: 10.1016/j.ygyno.2016.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/29/2016] [Accepted: 03/01/2016] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To determine if the disparities in the outcome between white (W) and African American (AA) patients with uterine serous carcinoma (USC) have changed over time. METHODS Women with USC were identified using the SEER database from 1988 to 2011 (N=7667). Years of the study were divided into three periods (1988-1997, 1998-2004 and 2005-2011). Overall (OS) and disease-specific survivals (DSS) was estimated. RESULTS Over the three time periods, African American patients continued to be younger and less likely to have cancer directed surgery and extensive lymphadenectomy when compared to white patients. In multivariable analysis adjusting for age, race, marital status, stage, cancer-directed surgery, extent of lymphadenectomy, adjuvant radiation, and geographic location, AA was significantly associated with worse DSS and OS in the three time periods compared to white race. African American patients were 29% (95% CI 1.03-1.62, p=0.027) in 1988-1997, 40% in 1998-2004 (95% CI 1.21-1.63, p<0.0001) and 34% in 2005-2011 (95% CI 1.13-1.59, p=0.0008) more likely to die from uterine cancer compared to their white counterparts. A slight improvement in the difference in OS over time was noted comparing African American and white patients. African American patients were 46% (95% CI 1.23-1.73, p<0.0001) in 1988-1997, 39% in 1998-2004 (95% CI 1.23-1.56, p<0.0001) and 26% in 2005-2011 (95% CI 1.10-1.45, p<0.0001) more likely to die from any cause compared to their white counterparts. CONCLUSIONS Significant improvement in outcome was noted in both racial groups over time. However, African American patients continued to have worse outcome than white patients over time.
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Affiliation(s)
- Haider Mahdi
- Gynecologic Oncology Division, Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Xiaozhen Han
- Population Health and Outcomes Research Core, Clinical and Translational Science Collaborative, Cleveland, OH, USA
| | - Fadi Abdul-Karim
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Roberto Vargas
- Gynecologic Oncology Division, Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
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Fader AN, Habermann EB, Hanson KT, Lin JF, Grendys EC, Dowdy SC. Disparities in treatment and survival for women with endometrial cancer: A contemporary national cancer database registry analysis. Gynecol Oncol 2016; 143:98-104. [PMID: 27470998 DOI: 10.1016/j.ygyno.2016.07.107] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/14/2016] [Accepted: 07/19/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE The study aim was to identify contemporary socioeconomic, racial, ethnic, and facility-related factors associated with stage at diagnosis, receipt of cancer treatment, and survival in women with endometrial cancer (EC). PATIENTS AND METHODS Women diagnosed with EC between 1998 and 2010 were identified from the National Cancer Database. Variables associated with the outcomes of interest were assessed using multivariable Cox proportional hazards and logistic regression. RESULTS Among 228,511 women identified, the percentage of blacks with stage IIIC/IV disease at diagnosis was nearly twice that of non-Hispanic whites (17.8% vs 9.8%; P<0.001). Patients with advanced disease who were insured with Medicare were less likely to receive standard-of-care postoperative radiotherapy and/or chemotherapy than those with private insurance (odds ratio: OR 0.80, P<0.001), as were those residing in the South (reference) in comparison to the Northeast, Atlantic, Great Lakes, and Midwest regions (OR 1.3-1.7, all P<0.001). Those residing in the Mountain region were even less likely to receive appropriate treatment (OR 0.7, P<0.001). Five-year stage IIIC/IV survival was 42.8% for non-Hispanic whites vs 24.6% for blacks (hazard ratio 1.3, P<0.001). Other factors associated with inferior 5-year survival included payer status (not insured, Medicaid, Medicare, vs private, ORs 1.2-1.3, all P<0.01), and treatment at low-volume centers (<5 vs ≥30cases/year, HR 1.3, P<0.001). CONCLUSIONS AND RELEVANCE Socioeconomic, geographic and facility-related factors predict advanced endometrial cancer stage, failure to receive cancer care, and shorter survival. Black women had especially poor survival. Nationwide standardization and concentration of treatment at high-volume centers may improve outcomes.
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Affiliation(s)
- Amanda N Fader
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Division of Health Care Policy and Research Division of Surgery Research, Mayo Clinic, Rochester, MN, United States
| | - Kristine T Hanson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Division of Health Care Policy and Research Division of Surgery Research, Mayo Clinic, Rochester, MN, United States
| | - Jeff F Lin
- Division of Gynecologic Oncology, Magee-Women's Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | | | - Sean C Dowdy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Division of Health Care Policy and Research Division of Surgery Research, Mayo Clinic, Rochester, MN, United States; Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States.
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Chatterjee S, Gupta D, Caputo TA, Holcomb K. Disparities in Gynecological Malignancies. Front Oncol 2016; 6:36. [PMID: 26942126 PMCID: PMC4761838 DOI: 10.3389/fonc.2016.00036] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 02/04/2016] [Indexed: 12/31/2022] Open
Abstract
Objectives Health disparities and inequalities in access to care among different socioeconomic, ethnic, and racial groups have been well documented in the U.S. healthcare system. In this review, we aimed to provide an overview of barriers to care contributing to health disparities in gynecological oncology management and to describe site-specific disparities in gynecologic care for endometrial, ovarian, and cervical cancer. Methods We performed a literature review of peer-reviewed academic and governmental publications focusing on disparities in gynecological care in the United States by searching PubMed and Google Scholar electronic databases. Results There are multiple important underlying issues that may contribute to the disparities in gynecological oncology management in the United States, namely geographic access and hospital-based discrepancies, research-based discrepancies, influence of socioeconomic and health insurance status, and finally the influence of race and biological factors. Despite the reduction in overall cancer-related deaths since the 1990s, the 5-year survival for Black women is significantly lower than for White women for each gynecologic cancer type and each stage of diagnosis. For ovarian and endometrial cancer, black patients are less likely to receive treatment consistent with evidence-based guidelines and have worse survival outcomes even after accounting for stage and comorbidities. For cervical and endometrial cancer, the mortality rate for black women remains twice that of White women. Conclusion Health care disparities in the incidence and outcome of gynecologic cancers are complex and involve biologic factors as well as racial, socioeconomic, and geographic barriers that influence treatment and survival. These barriers must be addressed to provide optimal care to women in the U.S. with gynecologic cancer.
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Affiliation(s)
- Sudeshna Chatterjee
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York Presbyterian Hospital , New York, NY , USA
| | - Divya Gupta
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York Presbyterian Hospital , New York, NY , USA
| | - Thomas A Caputo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York Presbyterian Hospital , New York, NY , USA
| | - Kevin Holcomb
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York Presbyterian Hospital , New York, NY , USA
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Lack of a clinically significant impact of race on morbidity and mortality in abdominal surgery: an analysis of 186,466 patients from the American College of Surgeons National Surgical Quality Improvement Program database. Am J Surg 2015; 210:236-42. [DOI: 10.1016/j.amjsurg.2014.12.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 12/12/2014] [Accepted: 12/22/2014] [Indexed: 11/21/2022]
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Doll KM, Meng K, Basch EM, Gehrig PA, Brewster WR, Meyer AM. Gynecologic cancer outcomes in the elderly poor: A population-based study. Cancer 2015; 121:3591-9. [PMID: 26230631 DOI: 10.1002/cncr.29541] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 04/27/2015] [Accepted: 06/02/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Adults aged ≥65 years who are dually enrolled in Medicare and Medicaid are an at-risk group in health care. However, to the best of the authors' knowledge, the outcomes of women with gynecologic cancers in this population are unknown. METHODS The current study was a population-based cohort study of North Carolina state cancer registry cases of uterine, ovarian, cervical, and vulvar/vaginal cancers (2003-2009), with linked enrollment in Medicare and state Medicaid. Outcomes of all-cause mortality and stage of disease at the time of diagnosis were analyzed as a function of enrollment status using multivariate analysis and survival curves. RESULTS Of 4522 women aged ≥65 years (3702 of whom were enrolled in Medicare [82%] and 820 of whom were dually enrolled [18%]), there were 2286 cases of uterine (51%), 1587 cases of ovarian (35%), 302 cases of cervical (7%), and 347 cases of vulvar/vaginal (8%) cancers. Dual enrollees had increased all-cause mortality overall (adjusted hazard ratio [aHR], 1.34; 95% confidence interval [95% CI], 1.19-1.49), and within each cancer site (uterine: aHR, 1.22 [95% CI, 1.02-1.47]; ovarian: aHR, 1.25 [95% CI, 1.05-1.49]; cervical: aHR, 1.34 [95% CI, 0.96-1.87]; and vulvar/vaginal: aHR, 1.93 [95% CI, 1.36-2.72]). Increased odds of advanced-stage disease at the time of diagnosis among dual enrollees was only present in patients with uterine cancer (adjusted odds ratio, 1.38; 95% CI, 1.06-1.79). Stratified survival curves demonstrated the strongest disparities among women with early-stage uterine and early-stage vulvar/vaginal cancers. CONCLUSIONS Women aged ≥65 years who were dually enrolled in Medicare and Medicaid were found to have an overall 34% increase in all-cause mortality after diagnosis with a gynecologic cancer compared with the non-dually enrolled Medicare population. Women with early-stage uterine and vulvar/vaginal cancers appeared to have the most disparate outcomes. Because these malignancies are generally curable, they have the most potential for benefit from targeted interventions.
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Affiliation(s)
- Kemi M Doll
- Division of Gynecologic Oncology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina.,Division of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ke Meng
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ethan M Basch
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paola A Gehrig
- Division of Gynecologic Oncology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Wendy R Brewster
- Division of Gynecologic Oncology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anne-Marie Meyer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Association of specific PTEN/10q haplotypes with endometrial cancer phenotypes in African-American and European American women. Gynecol Oncol 2015; 138:434-40. [PMID: 26026735 DOI: 10.1016/j.ygyno.2015.05.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/22/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Endometrial carcinoma (EC), the most common gynecologic malignancy in the United States, affects European American (EA) women more frequently than African-American (AA) women. Yet, AA women are more likely to die from EC. Proposed etiologies for this racial disparity, such as socioeconomic status, aggressive, non-endometrioid tumor histology, and comorbid conditions, do not account for the entire disparity experienced by AA women, suggesting an unexplored genetic component. Germline mutations in PTEN cause Cowden syndrome (CS), which increases lifetime risk of endometrial cancer. In addition, somatic PTEN silencing is one of the most common initiating events in sporadic EC. Therefore, we hypothesized that specific PTEN haplotypes in the AA population may directly predispose AA women to unfavorable tumor characteristics when diagnosed with EC. METHODS We conducted a case-control association study of germline variations in and around the PTEN/10q region between 53 EA and 51 AA EC cases and ethnic controls. RESULTS Eighteen tag SNPs with minor allele frequency ≥0.1, were genotyped and used to reconstruct haplotypes. Forty-eight ancestry informative markers were genotyped control for population stratification. Two haplotypes were overrepresented in AA, and there was a trend towards tumors with higher stage and grade in patients with these haplotypes. One haplotype was overrepresented in the EA population with a trend towards more endometrioid tumors. CONCLUSIONS We show that specific PTEN/10q haplotypes are significantly different between EA and AA individuals (p≤0.02), and specific haplotypes may increase the risk of unfavorable tumor phenotypes in AA women diagnosed with EC.
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Ozen A, Falchook AD, Varia MA, Gehrig P, Jones EL. Effect of race and histology on patterns of failure in women with early stage endometrial cancer treated with high dose rate brachytherapy. Gynecol Oncol 2015; 138:429-33. [PMID: 26024766 DOI: 10.1016/j.ygyno.2015.05.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 05/19/2015] [Accepted: 05/23/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clinical trials have helped refine management of early stage endometrial cancer (EC). For patients with intermediate risk features, adjuvant radiation is considered, primarily vaginal cuff brachytherapy. For higher risk patients, there may be a role for chemotherapy and radiation. The purpose of this study is to examine patterns of failure for early stage EC patients treated with postoperative high dose rate brachytherapy. METHODS In this single institution retrospective cohort study, 208 women with early stage endometrial cancer who received definitive therapy between January 1, 2000 and January 1, 2013 were identified. RESULTS Median follow-up was 46.4 (range, 6.2-137.3) months. Thirteen (6.3%) patients developed with locoregional recurrent disease and 15 (7.2%) patients developed distant metastasis. Freedom from recurrence at 5 years was 88.6% for white patients and 60.5% for black patients (p=0.0093). Five year recurrence free survival (RFS) for white vs. black patients was 82.9% vs. 48.9% (p=0.0007). Five year overall survival (OS) was 86.8% for white patients and 59.5% for black patients (p=0.0023). Black patients with unfavorable histology treated with chemotherapy and vaginal brachytherapy had a 15% locoregional recurrence rate, more than double the rate of local recurrence compared to AA patients with endometrioid histology and white patients with any histology (6% locoregional recurrence rate). CONCLUSIONS Black women with unfavorable histology early stage EC experience increased rates of recurrence and worse survival compared to white patients. Patterns of failure in this group also indicate a high locoregional failure rate for the black patients with unfavorable histology (type II).
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Affiliation(s)
- Alaattin Ozen
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Radiation Oncology, Eskisehir Osmangazi University Hospital, Eskisehir, Turkey
| | - Aaron D Falchook
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mahesh A Varia
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paola Gehrig
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ellen L Jones
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Racial Disparities in Treatment of High-Grade Endometrial Cancer in the Medicare Population. Obstet Gynecol 2015; 125:843-851. [DOI: 10.1097/aog.0000000000000605] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ruterbusch JJ, Ali-Fehmi R, Olson SH, Sealy-Jefferson S, Rybicki BA, Hensley-Alford S, Elshaikh MA, Gaba AR, Schultz D, Munkarah AR, Cote ML. The influence of comorbid conditions on racial disparities in endometrial cancer survival. Am J Obstet Gynecol 2014; 211:627.e1-9. [PMID: 24954655 DOI: 10.1016/j.ajog.2014.06.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/21/2014] [Accepted: 06/17/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVE There are known disparities in endometrial cancer survival with black women who experience a greater risk of death compared with white women. The purpose of this investigation was to evaluate the role of comorbid conditions as modifiers of endometrial cancer survival by race. STUDY DESIGN Two hundred seventy-one black women and 356 white women who had been diagnosed with endometrial cancer from 1990-2005 were identified from a large urban integrated health center. A retrospective chart review was conducted to gather information on comorbid conditions and other known demographic and clinical predictors of survival. RESULTS Black women experienced a higher hazard of death from any cause (hazard ratio [HR] 1.51; 95% confidence interval [CI], 1.22-1.87) and from endometrial cancer (HR, 2.42; 95% CI, 1.63-3.60). After adjustment for known clinical prognostic factors and comorbid conditions, the hazard of death for black women was elevated but no longer statistically significant for overall survival (HR, 1.22; 95% CI, 0.94-1.57), and the hazard of death from endometrial cancer remained significantly increased (HR, 2.27; 95% CI, 1.39-3.68). Both black and white women with a history of hypertension experienced a lower hazard of death from endometrial cancer (HR, 0.47; 95% CI, 0.23-0.98; and HR, 0.35; 95% CI, 0.19-0.67, respectively). CONCLUSION The higher prevalence of comorbid conditions among black women does not explain fully the racial disparities that are seen in endometrial cancer survival. The association between hypertension and a lower hazard of death from endometrial cancer is intriguing, and further investigation into the underlying mechanism is needed.
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Affiliation(s)
- Julie J Ruterbusch
- Barbara Ann Karmanos Cancer Institute, Detroit, MI; Department of Oncology, Wayne State University, Detroit, MI.
| | - Rouba Ali-Fehmi
- Barbara Ann Karmanos Cancer Institute, Detroit, MI; Department of Pathology, Wayne State University, Detroit, MI
| | - Sara H Olson
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Shawnita Sealy-Jefferson
- Barbara Ann Karmanos Cancer Institute, Detroit, MI; Department of Family Medicine and Public Health Sciences, Wayne State University, Detroit, MI
| | | | - Sharon Hensley-Alford
- Department of Public Health, Henry Ford Health System, Detroit, MI; Department of Women's Health, Henry Ford Health System, Detroit, MI
| | | | - Arthur R Gaba
- Department of Pathology, Henry Ford Health System, Detroit, MI
| | - Daniel Schultz
- Department of Pathology, Henry Ford Health System, Detroit, MI
| | - Adnan R Munkarah
- Department of Women's Health, Henry Ford Health System, Detroit, MI
| | - Michele L Cote
- Barbara Ann Karmanos Cancer Institute, Detroit, MI; Department of Oncology, Wayne State University, Detroit, MI
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Mahdi H, Lockhart D, Moslemi-Kebria M, Rose PG. Racial disparity in the 30-day morbidity and mortality after surgery for endometrial cancer. Gynecol Oncol 2014; 134:510-5. [DOI: 10.1016/j.ygyno.2014.05.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 05/22/2014] [Accepted: 05/24/2014] [Indexed: 10/25/2022]
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Kadakia KC, Hui D, Chisholm GB, Frisbee-Hume SE, Williams JL, Bruera E. Cancer patients' perceptions regarding the value of the physical examination: a survey study. Cancer 2014; 120:2215-21. [PMID: 24899511 DOI: 10.1002/cncr.28680] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 12/30/2013] [Accepted: 01/07/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Despite its clinical utility, progressive reliance on technology can lead to devaluing the physical examination in patients with advanced cancer. The primary objective of this study was to determine whether these patients have a positive or negative perception of the physical examination. A secondary objective was to determine whether these perceptions are related to interpersonal/relational values (symbolic) or diagnostic/objective values (pragmatic). METHODS One hundred fifty patients with cancer who were receiving concurrent oncology and palliative care were administered a 26-item survey regarding their overall perception of the physical examination. The primary outcome-patient responses to "In the last 3 months, I believe my experience while being examined has been overall: very negative (a score of -5) to very positive (a score of +5),"-was analyzed using the Sign test. Other items were predefined as either symbolic or pragmatic statements, and patient responses from strongly disagree (a score of 1) to strongly agree (a score of 5) were further analyzed. Multivariable logistic regression was used to test for associations between baseline characteristics and the primary outcome. RESULTS Most patients (83%) indicated that the overall experience of being examined was highly positive (median score, 4; interquartile range [IQR], 2-5; P ≤ .0001). Patients valued both the pragmatic aspects (median score, 5; IQR, 4-5) and symbolic aspects (median score, 4; IQR, 4-5) of the physical examination. Increasing age was independently associated with a more positive perception of the physical examination (odds ratio, 1.07 per year; 95% confidence interval, 1.02-1.12 per year; P = .01). CONCLUSIONS Patients with advanced cancer indicate that the physical examination is a highly positive aspect of their care. These benefits are perceived as having both symbolic and pragmatic value. The physical examination should remain a cornerstone of clinical encounters.
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Affiliation(s)
- Kunal C Kadakia
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Ko EM, Walter P, Clark L, Jackson A, Franasiak J, Bolac C, Havrilesky L, Secord AA, Moore DT, Gehrig PA, Bae-Jump VL. The complex triad of obesity, diabetes and race in Type I and II endometrial cancers: Prevalence and prognostic significance. Gynecol Oncol 2014; 133:28-32. [DOI: 10.1016/j.ygyno.2014.01.032] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 01/15/2014] [Accepted: 01/18/2014] [Indexed: 01/27/2023]
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Hou JY, McAndrew TC, Goldberg GL, Whitney K, Shahabi S. A clinical and pathologic comparison between stage-matched endometrial intraepithelial carcinoma and uterine serous carcinoma: is there a difference? Reprod Sci 2014; 21:532-7. [PMID: 24023030 PMCID: PMC3960843 DOI: 10.1177/1933719113503414] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endometrial intraepithelial carcinoma (EIC) is a rare pathologic variant of uterine serous carcinoma (USC). Our aim is to distinguish patterns of clinic-pathologic outcomes in patients with EIC and USC for disease limited to the endometrium (stage 1A) as well as with distant metastasis (stage 4B). Surgically staged patients were retrospectively identified and relevant variables were extracted and compared. Kaplan-Meier was used to generate the survival data. More USC (n = 29) exhibited lymphovascular invasion (stage 4, P = .01) and expressed higher levels of estrogen receptor-α than EIC (P = .0009 and .063 for stages 1 and 4, respectively). The survival is comparable, with 1 recurrence in each group for stage 1A disease. For stage 4 EIC and USC, the progression-free survival (14 vs10 months) and overall survival (19 vs 20 months) are similar to what is previously published. In conclusion, EIC, whether limited to the endometrium, or widely metastatic, imparts similar outcomes and should be treated comparably with stage-matched USC.
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MESH Headings
- Aged
- Biomarkers, Tumor/analysis
- Carcinoma in Situ/chemistry
- Carcinoma in Situ/mortality
- Carcinoma in Situ/pathology
- Carcinoma in Situ/surgery
- Disease Progression
- Disease-Free Survival
- Endometrial Neoplasms/chemistry
- Endometrial Neoplasms/mortality
- Endometrial Neoplasms/pathology
- Endometrial Neoplasms/surgery
- Estrogen Receptor alpha/analysis
- Female
- Humans
- Kaplan-Meier Estimate
- Middle Aged
- Neoplasm Invasiveness
- Neoplasm Recurrence, Local
- Neoplasm Staging
- Neoplasms, Cystic, Mucinous, and Serous/chemistry
- Neoplasms, Cystic, Mucinous, and Serous/mortality
- Neoplasms, Cystic, Mucinous, and Serous/secondary
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Retrospective Studies
- Time Factors
- Treatment Outcome
- Uterine Neoplasms/chemistry
- Uterine Neoplasms/mortality
- Uterine Neoplasms/pathology
- Uterine Neoplasms/surgery
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Affiliation(s)
- June Y. Hou
- Division of Gynecology Oncology, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Thomas C. McAndrew
- Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Gary L. Goldberg
- Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Kathleen Whitney
- Department of Pathology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Shohreh Shahabi
- Department of Obstetrics, Gynecology, and Reproductive Biology, Danbury Hospital, Danbury, CT, USA
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Racial Disparities in Uterine Clear Cell Carcinoma: A Multi-Institution Study. Int J Gynecol Cancer 2014; 24:541-8. [DOI: 10.1097/igc.0000000000000068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
ObjectiveThe aim of this study was to evaluate the impact of race on the overall survival (OS) and progression-free survival (PFS) of white and African-American patients with uterine clear cell carcinoma (UCCC).MethodsA retrospective review was conducted of all primary UCCC cases treated at 1 of 4 major gynecologic cancer centers between 1982 and 2012. Patients and tumor characteristics were retrieved from the cancer databases of the respective institutions and based on a retrospective review of the medical records. Differences in the OS and PFS between African-American and white women were compared using the Kaplan-Meier curves and log-rank test for univariate analysis. Cox regression models for the multivariate analyses were built to evaluate the relative impact of the various prognostic factors.ResultsOne hundred seventy women with UCCC were included in the study, including 118 white and 52 African-American women. Both groups were comparable with respect to age (P= 0.9), stage at diagnosis (P= 0.34), angiolymphatic invasion (P= 0.3), and depth of myometrial invasion (P= 0.84). In the multivariate analyses for known prognostic factors, OS and PFS were significantly different between white and African-American patients in the early-stage disease (hazard ratio [HR], 5.4; 95% confidence interval [CI], 1.2–23.2;P= 0.023 and HR, 3.5; 95% CI, 1.60–7.77;P= 0.0016, respectively) but not in the advanced-stage disease (HR, 0.83; 95% CI, 0.40–1.67;P= 0.61 and HR, 1.5; 95% CI, 0.84–2.78;P= 0.15, respectively).ConclusionsIn the current study, African-American patients have a prognosis worse than that of white patients in early-stage UCCC. We could not prove the same difference in advanced-stage disease.
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Abstract
Endometrial cancer is increasingly common in affluent Western countries, largely owing to the growing obesity of those populations. There are two recognized types of endometrial cancer: Type I is more common and is associated with obese postmenopausal women and comprises approximately 80% of all endometrial cancers; Type II describes a woman who is often younger and thinner with a more aggressive histologic type that is nonestrogen dependent, of either serous or clear cell histology, and consists of a more aggressive clinical course and results in poorer prognosis. As the majority of patients with endometrial cancer present with symptoms and have early disease, screening is unlikely to be cost effective or reduce the mortality rate. However, surveillance of high-risk populations is a different proposition. Patients who may benefit from routine surveillance include those with a family history of endometrial cancer, a history of hormone replacement therapy with less than 12-14 days of progestogens, long-term use of tamoxifen, hereditary nonpolyposis colorectal cancer family syndrome, Cowden's syndrome, Peutz-Jeghers syndrome, a history of breast cancer and obesity. Most patients with endometrial cancer are offered surgery as first-line therapy. The standard surgical procedure should be an extrafascial total hysterectomy with bilateral salpingo-oophorectomy. Adnexal removal is also recommended, even if the adnexa appear normal, as they may contain micrometastases. The safety of a laparoscopic approach in the surgical management of uterine cancer has not yet been demonstrated in prospective randomized trials, therefore, the field awaits the Gynaecologic Oncology Group's prospective Lap-2 study. While post-treatment follow-up guidelines vary between institutions and countries, in general, patients at high risk of recurrence are followed closely every 3-4 months for the first year or two, then every 6 months to complete 5 years of follow-up.
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Affiliation(s)
- Jonathan Carter
- Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.
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