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Kanbergs A, Jorgensen K, Agusti N, Viveros-Carreño D, Wu CF, Nitecki R, Harris JA, Woodard T, Ramphul R, Rauh-Hain JA. Patient Location and Disparities in Access to Fertility Preservation for Women With Gynecologic or Breast Cancer. Obstet Gynecol 2024; 143:824-834. [PMID: 38574368 PMCID: PMC11098692 DOI: 10.1097/aog.0000000000005570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/29/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE To assess the effect of geographic factors on fertility-sparing treatment or assisted reproductive technology (ART) utilization among women with gynecologic or breast cancers. METHODS We conducted a cohort study of reproductive-aged patients (18-45 years) with early-stage cervical, endometrial, or ovarian cancer or stage I-III breast cancer diagnosed between January 2000 and December 2015 using linked data from the California Cancer Registry, the California Office of Statewide Health Planning and Development, and the Society for Assisted Reproductive Technology. Generalized linear mixed models were used to evaluate associations between distance from fertility and gynecologic oncology clinics, as well as California Healthy Places Index score (a Census-level composite community health score), and ART or fertility-sparing treatment receipt. RESULTS We identified 7,612 women with gynecologic cancer and 35,992 women with breast cancer. Among all patients, 257 (0.6%) underwent ART. Among patients with gynecologic cancer, 1,676 (22.0%) underwent fertility-sparing treatment. Stratified by quartiles, residents who lived at increasing distances from gynecologic oncology or fertility clinics had decreased odds of undergoing fertility-sparing treatment (gynecologic oncology clinics: Q2, odds ratio [OR] 0.76, 95% CI, 0.63-0.93, P =.007; Q4, OR 0.72, 95% CI, 0.56-0.94, P =.016) (fertility clinics: Q3, OR 0.79, 95% CI, 0.65-0.97, P =.025; Q4, OR 0.67, 95% CI, 0.52-0.88, P =.004), whereas this relationship was not observed among women who resided within other quartiles (gynecologic oncology clinics: Q3, OR 0.81 95% CI, 0.65-1.01, P =.07; fertility clinics: Q2, OR 0.87 95% CI, 0.73-1.05, P =.15). Individuals who lived in communities with the highest (51 st -100 th percentile) California Healthy Places Index scores had greater odds of undergoing fertility-sparing treatment (OR 1.29, 95% CI, 1.06-1.57, P =.01; OR 1.66, 95% CI, 1.35-2.04, P =.001, respectively). The relationship between California Healthy Places Index scores and ART was even more pronounced (Q2 OR 1.9, 95% CI, 0.99-3.64, P =.05; Q3 OR 2.86, 95% CI, 1.54-5.33, P <.001; Q4 OR 3.41, 95% CI, 1.83-6.35, P <.001). CONCLUSION Geographic disparities affect fertility-sparing treatment and ART rates among women with gynecologic or breast cancer. By acknowledging geographic factors, health care systems can ensure equitable access to fertility-preservation services.
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Affiliation(s)
- Alexa Kanbergs
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kirsten Jorgensen
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nuria Agusti
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Viveros-Carreño
- Unidad Ginecología oncológica, Grupo de Investigación GIGA, Centro de Tratamiento e Investigación sobre Cáncer Luis Carlos Sarmiento Angulo (CTIC), Bogotá, Colombia
- Clínica Universitaria Colombia, Bogotá, Colombia
| | - Chi-Fang Wu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Roni Nitecki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - John A. Harris
- Magee-Womens Research Institute, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Terri Woodard
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ryan Ramphul
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jose Alejandro Rauh-Hain
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Pancoe S, Ko EM, Smith AJB. Federal Transportation Regulations Limit Access to Clinical Trials and Oncology Care. JAMA Oncol 2024; 10:425-426. [PMID: 38300547 DOI: 10.1001/jamaoncol.2023.6767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
This Viewpoint discusses how improving accessibility to oncology services will lead to more equitable care for patients with cancer.
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Affiliation(s)
- Sam Pancoe
- Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Emily M Ko
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania Health Systems, Philadelphia
| | - Anna Jo Bodurtha Smith
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania Health Systems, Philadelphia
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Gomez SL, Chirikova E, McGuire V, Collin LJ, Dempsey L, Inamdar PP, Lawson-Michod K, Peters ES, Kushi LH, Kavecansky J, Shariff-Marco S, Peres LC, Terry P, Bandera EV, Schildkraut JM, Doherty JA, Lawson A. Role of neighborhood context in ovarian cancer survival disparities: current research and future directions. Am J Obstet Gynecol 2023; 229:366-376.e8. [PMID: 37116824 PMCID: PMC10538437 DOI: 10.1016/j.ajog.2023.04.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/01/2023] [Accepted: 04/20/2023] [Indexed: 04/30/2023]
Abstract
Ovarian cancer is the fifth leading cause of cancer-associated mortality among US women with survival disparities seen across race, ethnicity, and socioeconomic status, even after accounting for histology, stage, treatment, and other clinical factors. Neighborhood context can play an important role in ovarian cancer survival, and, to the extent to which minority racial and ethnic groups and populations of lower socioeconomic status are more likely to be segregated into neighborhoods with lower quality social, built, and physical environment, these contextual factors may be a critical component of ovarian cancer survival disparities. Understanding factors associated with ovarian cancer outcome disparities will allow clinicians to identify patients at risk for worse outcomes and point to measures, such as social support programs or transportation aid, that can help to ameliorate such disparities. However, research on the impact of neighborhood contextual factors in ovarian cancer survival and in disparities in ovarian cancer survival is limited. This commentary focuses on the following neighborhood contextual domains: structural and institutional context, social context, physical context represented by environmental exposures, built environment, rurality, and healthcare access. The research conducted to date is presented and clinical implications and recommendations for future interventions and studies to address disparities in ovarian cancer outcomes are proposed.
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Affiliation(s)
- Scarlett L Gomez
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA.
| | - Ekaterina Chirikova
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Valerie McGuire
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Lindsay J Collin
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Lauren Dempsey
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Pushkar P Inamdar
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Katherine Lawson-Michod
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Edward S Peters
- Department of Epidemiology, University of Nebraska Medical Center College of Public Health, Omaha, NE
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Juraj Kavecansky
- Department of Hematology and Oncology, Kaiser Permanente Northern California, Antioch, CA
| | - Salma Shariff-Marco
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Lauren C Peres
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Paul Terry
- Department of Medicine, University of Tennessee, Knoxville, TN
| | - Elisa V Bandera
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Joellen M Schildkraut
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jennifer A Doherty
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Andrew Lawson
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC; Usher Institute, School of Medicine, University of Edinburgh, Edinburgh, United Kingdom
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Jorgensen K, Meernik C, Wu CF, Murphy CC, Baker VL, Jarmon P, Brady PC, Nitecki R, Nichols HB, Rauh-Hain JA. Disparities in Fertility-Sparing Treatment and Use of Assisted Reproductive Technology After a Diagnosis of Cervical, Ovarian, or Endometrial Cancer. Obstet Gynecol 2023; 141:341-353. [PMID: 36649345 PMCID: PMC9858239 DOI: 10.1097/aog.0000000000005044] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/07/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To assess the presence of sociodemographic and clinical disparities in fertility-sparing treatment and assisted reproductive technology (ART) use among patients with a history of cervical, endometrial, or ovarian cancer. METHODS We conducted a population-based cohort study of patients aged 18-45 years who were diagnosed with cervical cancer (stage IA, IB), endometrial cancer (grade 1, stage IA, IB), or ovarian cancer (stage IA, IC) between January 1, 2000, and December 31, 2015, using linked data from the CCR (California Cancer Registry), the California Office of Statewide Health Planning and Development, and the Society for Assisted Reproductive Technology. The primary outcome was receipt of fertility-sparing treatment , defined as surgical or medical treatment to preserve the uterus and at least one ovary. The secondary outcome was fertility preservation , defined as ART use after cancer diagnosis. Multivariable logistic regression analysis was used to estimate odds ratios and 95% CIs for the association between fertility-sparing treatment and exposures of interest: age at diagnosis, race and ethnicity, health insurance, socioeconomic status, rurality, and parity. RESULTS We identified 7,736 patients who were diagnosed with cervical, endometrial, or ovarian cancer with eligible histology. There were 850 (18.8%) fertility-sparing procedures among 4,521 cases of cervical cancer, 108 (7.2%) among 1,504 cases of endometrial cancer, and 741 (43.3%) among 1,711 cases of ovarian cancer. Analyses demonstrated nonuniform patterns of sociodemographic disparities by cancer type for fertility-sparing treatment, and ART. Fertility-sparing treatment was more likely among young patients, overall, and of those in racial and ethnic minority groups among survivors of cervical and ovarian cancer. Use of ART was low (n=52) and was associated with a non-Hispanic White race and ethnicity designation, being of younger age (18-35 years), and having private insurance. CONCLUSION This study demonstrates that clinical and sociodemographic disparities exist in the receipt of fertility-sparing treatment and ART use among patients with a history of cervical, endometrial, or ovarian cancer.
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Affiliation(s)
- Kirsten Jorgensen
- Department of Gynecologic Oncology and Reproductive Medicine and the Department of Health Services Research, University of Texas MD Anderson Cancer Center, and the Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas; the Department of Public Health Sciences, Duke University School of Medicine, Durham, North Carolina; the Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; Tulane University School of Medicine, New Orleans, Louisiana; the Columbia University Irving Medical Center, Columbia University Fertility Center, New York, New York; and the Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Zamorano AS, Mazul AL, Marx C, Mullen MM, Greenwade M, Stewart Massad L, McCourt CK, Hagemann AR, Thaker PH, Fuh KC, Powell MA, Mutch DG, Khabele D, Kuroki LM. Community access to primary care is an important geographic disparity among ovarian cancer patients undergoing cytoreductive surgery. Gynecol Oncol Rep 2022; 44:101075. [PMID: 36217326 PMCID: PMC9547182 DOI: 10.1016/j.gore.2022.101075] [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: 09/02/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 10/30/2022] Open
Abstract
Objective Given the importance of understanding neighborhood context and geographic access to care on individual health outcomes, we sought to investigate the association of community primary care (PC) access on postoperative outcomes and survival in ovarian cancer patients. Methods This was a retrospective cohort study of Stage III-IV ovarian cancer patients who underwent surgery at a single academic, tertiary care hospital between 2012 and 2015. PC access was determined using a Health Resources and Services Administration designation. Outcomes included 30-day surgical and medical complications, extended hospital stay, ICU admission, hospital readmission, progression-free and overall survival. Descriptive statistics and chi-squared analyses were used to analyze differences between patients from PC-shortage vs not PC-shortage areas. Results Among 217 ovarian cancer patients, 54.4 % lived in PC-shortage areas. They were more likely to have Medicaid or no insurance and live in rural areas with higher poverty rates, significantly further from the treating cancer center and its affiliated hospital. Nevertheless, 49.2 % of patients from PC-shortage areas lived in urban communities. Residing in a PC-shortage area was not associated with increased surgical or medical complications, ICU admission, or hospital readmission, but was linked to more frequent prolonged hospitalization (26.3 % vs 14.1 %, p = 0.04). PC-shortage did not impact progression-free or overall survival. Conclusions Patients from PC-shortage areas may require longer inpatient perioperative care in order to achieve the same 30-day postoperative outcomes as patients who live in non-PC shortage areas. Community access to PC is a critical factor to better understanding and reducing disparities among ovarian cancer patients.
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Affiliation(s)
- Abigail S. Zamorano
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States,Corresponding author.
| | - Angela L. Mazul
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Christine Marx
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Mary M. Mullen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Molly Greenwade
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - L. Stewart Massad
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Carolyn K. McCourt
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Andrea R. Hagemann
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Premal H. Thaker
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Katherine C. Fuh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Matthew A. Powell
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - David G. Mutch
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Dineo Khabele
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Lindsay M. Kuroki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
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Assessment of Travel Distance for Hyperthermic Intraperitoneal Chemotherapy in Women with Ovarian Cancer. Gynecol Oncol Rep 2022; 40:100951. [PMID: 35392128 PMCID: PMC8980495 DOI: 10.1016/j.gore.2022.100951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 11/24/2022] Open
Abstract
The median travel distance in women with EOC undergoing CRS with HIPEC was 57.0 miles in women with EOC. Over 20% of patients treated at our institution traveled more than 100 miles for HIPEC procedures. No differences were observed in post-operative complications or oncologic outcomes based upon travel distance.
Objective (s) To evaluate travel distance in women with advanced or recurrent epithelial ovarian cancer (OC) undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) and the subsequent impact upon outcomes. Methods An IRB-approved single-institution prospective registry was queried for women with OC who underwent HIPEC from 1/1/2009–12/1/2020. Demographic, oncologic, and surgical data were recorded. The patient's home zip code was compared to the institutional zip code to determine travel distance using Google Maps. Patients were divided into three strata for analysis: 1) local: ≤50 miles, 2) regional: 51–99 miles, and 3) distant: ≥100 miles and univariate analysis was performed. Results Of 127 women, the median distance travelled was 57.0 miles (IQR: 20.6, 84.6). There were no significant differences in mild (28.3% vs. 26.3 vs. 24.1%), moderate (21.7% vs. 15.8% vs. 17.2%) or severe postoperative complications (11.7% vs. 5.3% vs. 17.2%) (p = 0.75) for local, regional and distant patients, respectively. There was no difference in progression-free survival (17.4 vs. 22.2 vs. 12.8 months, p > 0.05) or overall survival (57.3 vs. 61.6 vs. 29.2 months, p > 0.05) for local, regional or distant patients, respectively. Conclusions This study demonstrates that women with OC are willing to travel for HIPEC, with over 50% traveling > 50 miles. Our results suggest that women who travel for HIPEC procedures are not at increased risk for perioperative complications or worse oncologic outcomes than those local to HIPEC centers.
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Weeks KS, Lynch CF, West M, Carnahan R, O'Rorke M, Oleson J, McDonald M, Stewart SL, Charlton M. Gynecologic oncologist impact on adjuvant chemotherapy care for stage II-IV ovarian cancer patients. Gynecol Oncol 2022; 164:3-11. [PMID: 34776243 PMCID: PMC11089835 DOI: 10.1016/j.ygyno.2021.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE We aim to evaluate the impact gynecologic oncologists have on ovarian cancer adjuvant chemotherapy care from their role as surgeons recommending adjuvant chemotherapy care and their role as adjuvant chemotherapy providers while considering rural-urban differences. METHODS Multivariable adjusted logistic regressions and Cox proportional hazards models were developed using a population-based, retrospective cohort of stage II-IV and unknown stage ovarian cancer patients diagnosed in Iowa, Kansas, and Missouri in 2010-2012 whose medical records were abstracted in 2017-2018. RESULTS Gynecologic oncologist surgeons (versus other type of surgeon) were associated with increased odds of adjuvant chemotherapy initiation (adjusted odds ratio (OR) 2.18; 95% confidence interval (CI) 1.10-4.33) and having a gynecologic oncologist adjuvant chemotherapy provider (OR 10.0; 95% CI 4.58-21.8). Independent of type of surgeon, rural patients were less likely to have a gynecologic oncologist chemotherapy provider (OR 0.52; 95% CI 0.30-0.91). Gynecologic oncologist adjuvant chemotherapy providers (versus other providers) were associated with decreased surgery-to-chemotherapy time (rural: 6 days; urban: 8 days) and increased distance to chemotherapy (rural: 22 miles; urban: 11 miles). Rural women (versus urban) traveled 38 miles farther when their chemotherapy provider was a gynecologic oncologist and 27 miles farther when it was not. CONCLUSION Gynecologic oncologist surgeons may impact adjuvant chemotherapy initiation. Gynecologic oncologists serving as adjuvant chemotherapy providers were associated with some care benefits, such as reduced time from surgery-to-chemotherapy, and some care barriers, such as travel distance. The barriers and benefits of having a gynecologic oncologist involved in adjuvant chemotherapy care, including rural-urban differences, warrant further research in other populations.
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Affiliation(s)
- Kristin S Weeks
- Carver College of Medicine, University of Iowa, Iowa City, IA, United States of America; Department of Epidemiology, University of Iowa, Iowa City, IA, United States of America.
| | - Charles F Lynch
- Department of Epidemiology, University of Iowa, Iowa City, IA, United States of America; Iowa Cancer Registry, State Health Registry of Iowa, University of Iowa, Iowa City, IA, United States of America
| | - Michele West
- Iowa Cancer Registry, State Health Registry of Iowa, University of Iowa, Iowa City, IA, United States of America
| | - Ryan Carnahan
- Department of Epidemiology, University of Iowa, Iowa City, IA, United States of America
| | - Michael O'Rorke
- Department of Epidemiology, University of Iowa, Iowa City, IA, United States of America
| | - Jacob Oleson
- Department of Biostatistics, University of Iowa, Iowa City, IA, United States of America
| | - Megan McDonald
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States of America
| | - Sherri L Stewart
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Mary Charlton
- Department of Epidemiology, University of Iowa, Iowa City, IA, United States of America; Iowa Cancer Registry, State Health Registry of Iowa, University of Iowa, Iowa City, IA, United States of America
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Mujumdar V, Butler TR, Shalowitz DI. A qualitative study on the impact of long-distance travel for gynecologic cancer care. Gynecol Oncol Rep 2021; 38:100868. [PMID: 34692967 PMCID: PMC8511836 DOI: 10.1016/j.gore.2021.100868] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/09/2021] [Accepted: 09/21/2021] [Indexed: 11/17/2022] Open
Abstract
Background Women with gynecologic malignancies experience improved clinical outcomes when they are treated by gynecologic oncologists and in high-volume cancer centers. However, geography is a major barrier to high-volume care for patients. This qualitative study was undertaken to identify facilitators and barriers to patients traveling long distances for gynecologic cancer care. Methods Semi-structured interviews were conducted with 19 women with gynecologic malignancies traveling >50 miles for treatment at Wake Forest Comprehensive Cancer Center. Eight interviews included caregivers. Four interview domains focused on personal challenges and coping strategies related to accessing cancer care. Results Mean distance traveled for care was 87 miles (range: 54-218). Most participants reported that recommendations from physicians, friends, and family motivated travel. 10/19 participants were aware of closer sites for cancer care; 5 had unfavorable experiences elsewhere. Barriers to travel included time, cost, childcare, difficulty navigating, and physical discomfort. Social support was an important facilitator of travel for care; some patients utilized loaned money or vehicles. Participants reported significant energy expenditure scheduling travel, coordinating time off work, and arranging overnight stays near the cancer center. Suggestions for care improvement included travel vouchers, transportation assistance, signage and personnel to help with navigation, and appointments later in the day. Participants supported in-person oncologist outreach to rural areas and appointments via telemedicine; few preferred the current infrastructure. Conclusion Patients who travel long distances for gynecologic cancer care encounter significant burdens and rely heavily on social and financial support. Interventions should be developed and evaluated to reduce the burden of long-distance travel and develop efficient methods of outreach, including telemedicine.
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Affiliation(s)
- Vaidehi Mujumdar
- Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Timberly R. Butler
- Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - David I. Shalowitz
- Section on Gynecologic Oncology, Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, NC, United States
- Department of Implementation Sciences, Wake Forest School of Medicine, Winston-Salem, NC, United States
- Corresponding author at: Section on Gynecologic Oncology, 4th Floor Watlington Hall, Medical Center Blvd, Winston-Salem, NC 27157, United States.
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Rural residence is related to shorter survival in epithelial ovarian cancer patients. Gynecol Oncol 2021; 163:22-28. [PMID: 34400004 DOI: 10.1016/j.ygyno.2021.07.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Rural residence has been related to health disparities and greater mortality risk in cancer patients, including gynecologic cancer patients. Lower survival rates for rural cancer survivors have been attributed to limited access to specialized healthcare, including surgery. Here, we examined whether a rural/urban survival gap existed in ovarian cancer patients receiving surgery at tertiary-care facilities, and potential causes for this gap, including educational attainment. METHODS Rural and urban patients with high grade invasive ovarian cancer (n = 342) seeking treatment at two midwestern tertiary-care university hospitals were recruited pre-surgery and followed until death or censoring date. Rural/urban residence was categorized using the USDA Rural-Urban Continuum Codes. Stratified Cox proportional hazards regression analyses, with clinical site as strata, adjusting for clinical and demographic covariates, were used to examine the effect of rurality on survival. RESULTS Despite specialized surgical care, rural cancer survivors showed a higher likelihood of death compared to their urban counterparts, HR = 1.39 (95% CI: 1.04, 1.85) p = 0.026, adjusted for covariates. A rurality by education interaction was observed (p = 0.027), indicating significantly poorer survival in rural vs. urban patients among those with trade school/some college education, adjusted HR = 2.49 (95% CI: 1.44, 4.30), p = 0.001; there was no rurality survival disparity for the other 2 levels of education. CONCLUSIONS Differences in ovarian cancer survival are impacted by rurality, which is moderated by educational attainment even in patients receiving initial care in tertiary settings. Clinicians should be aware of rurality and education as potential risk factors for adverse outcomes and develop approaches to address these possible risks.
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Huepenbecker SP, Sun CC, Fu S, Zhao H, Primm K, Giordano SH, Meyer LA. Factors impacting the time to ovarian cancer diagnosis based on classic symptom presentation in the United States. Cancer 2021; 127:4151-4160. [PMID: 34347287 DOI: 10.1002/cncr.33829] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/02/2021] [Accepted: 07/07/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients with ovarian cancer often present with late-stage disease and nonspecific symptoms, but little is known about factors affecting the time to diagnosis (TTD) in the United States. METHODS A retrospective, population-based study of the Surveillance, Epidemiology, and End Results-Medicare database was conducted. It included women 66 years old or older with stage II to IV epithelial ovarian cancer with at least 1 code for abdominal/pelvic pain, bloating, difficulty eating, or urinary symptoms within 1 year of the cancer diagnosis. TTD was defined from the first claim with a prespecified symptom to the ovarian cancer diagnosis. Kruskal-Wallis tests were used to assess for differences in TTD by group medians. Univariate and generalized linear models with a log-link function evaluated TTD by covariables. RESULTS For the 13,872 women analyzed, the mean and median times to diagnosis were 2.9 and 1.1 months, respectively. The median TTD differed significantly by first symptom (P < .001), number of symptoms (P < .001), and first physician specialty seen (P < .001). In a multivariable analysis, TTD differed significantly according to race/ethnicity (P < .001), geographic region (P = .001), urban-rural location (P = .031), emergency room presentation (P < .001), and number of specialties seen (P < .001). A shorter TTD was associated with a diagnosis in 2006-2010 (relative risk [RR], 0.92; 95% confidence interval [CI], 0.87-0.98) or 2011-2015 (RR, 0.87; 95% CI, 0.81-0.93) in comparison with 1992-1999. CONCLUSIONS The time from a symptomatic presentation to care to a diagnosis of ovarian cancer is influenced by clinical and demographic variables. This study's findings reinforce the importance of educating all physicians on ovarian cancer symptoms to aid in diagnosis. LAY SUMMARY Ovarian cancer is often diagnosed once disease has spread because the classic symptoms of ovarian cancer-abdominal or pelvic pain, bloating, difficulty eating, and urinary issues-can be mistaken for other problems. This study examined the time between when women with classic ovarian cancer symptoms went to a physician and when they received a cancer diagnosis in a large database population. The authors found that the time to diagnosis differed according to the type and number of symptoms and what type of physician a woman saw as well as factors such as race, geographic location, and year of diagnosis.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shuangshuang Fu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristin Primm
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Racial-Ethnic and Socioeconomic Disparities in Guideline-Adherent Treatment for Endometrial Cancer. Obstet Gynecol 2021; 138:21-31. [PMID: 34259460 PMCID: PMC10403994 DOI: 10.1097/aog.0000000000004424] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/04/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate the association of race-ethnicity and neighborhood socioeconomic status with adherence to National Comprehensive Cancer Network guidelines for endometrial carcinoma. METHODS Data are from the SEER (Surveillance, Epidemiology, and End Results) cancer registry of women diagnosed with endometrial carcinoma for the years 2006-2015. The sample included 83,883 women after inclusion and exclusion criteria were applied. Descriptive statistics, bivariate analyses, univariate, and multivariate logistic regression models were performed to evaluate the association between race-ethnicity and neighborhood socioeconomic status with adherence to treatment guidelines. RESULTS After controlling for demographic and clinical covariates, Black (odds ratio [OR] 0.89, P<.001), Latina (OR .92, P<.001), and American Indian or Alaska Native (OR 0.82, P=.034) women had lower odds of receiving adherent treatment and Asian (OR 1.14, P<.001) and Native Hawaiian or Pacific Islander (OR 1.19 P=.012) women had higher odds of receiving adherent treatment compared with White women. After controlling for covariates, there was a gradient by neighborhood socioeconomic status: women in the high-middle (OR 0.89, P<.001), middle (OR 0.84, P<.001), low-middle (OR 0.80, P<.001), and lowest (OR 0.73, P<.001) neighborhood socioeconomic status categories had lower odds of receiving adherent treatment than the those in the highest neighborhood socioeconomic status group. CONCLUSIONS Findings from this study suggest there are racial-ethnic and neighborhood socioeconomic disparities in National Comprehensive Cancer Network treatment adherence for endometrial cancer. Standard treatment therapies should not differ based on sociodemographics. Interventions are needed to ensure that equitable cancer treatment practices are available for all individuals, regardless of racial-ethnic or socioeconomic background.
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12
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Villanueva C, Chang J, Ziogas A, Bristow RE, Vieira VM. Ovarian cancer in California: Guideline adherence, survival, and the impact of geographic location, 1996-2014. Cancer Epidemiol 2020; 69:101825. [PMID: 33022472 DOI: 10.1016/j.canep.2020.101825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/12/2020] [Accepted: 09/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Evidence suggests that geographic location may independently contribute to ovarian cancer survival. We aimed to investigate how the association between residential location and ovarian cancer-specific survival in California varies by race/ethnicity and socioeconomic status. METHODS Additive Cox proportional hazard models were used to predict hazard ratios (HRs) and 95% confidence intervals (CI) for the association between geographic location throughout California and survival among 29,844 women diagnosed with epithelial ovarian cancer between 1996 and 2014. We conducted permutation tests to determine a global P-value for significance of location. Adjusted analyses considered distance traveled for care, distance to closest high-quality-of-care hospital, and receipt of National Comprehensive Cancer Network guideline care. Models were also stratified by stage, race/ethnicity, and socioeconomic status. RESULTS Location was significant in unadjusted models (P = 0.009 among all stages) but not in adjusted models (P = 0.20). HRs ranged from 0.81 (95% CI: 0.70, 0.93) in Southern Central Valley to 1.41 (95% CI: 1.15, 1.73) in Northern California but were attenuated after adjustment (maximum HR = 1.17, 95% CI: 1.08, 1.27). Better survival was generally observed for patients traveling longer distances for care. Associations between survival and proximity to closest high-quality-of-care hospitals were null except for women of lowest socioeconomic status living furthest away (HR = 1.22, 95% CI: 1.03, 1.43). CONCLUSIONS Overall, geographic variations observed in ovarian cancer-specific survival were due to important predictors such as receiving guideline-adherent care. Improving access to expert care and ensuring receipt of guideline-adherent treatment should be priorities in optimizing ovarian cancer survival.
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Affiliation(s)
- Carolina Villanueva
- Program in Public Health, Susan and Henry Samueli College of Health Sciences, University of California, Anteater Instruction & Research Building, 653 East Peltason Drive, Irvine, CA, 92697, USA.
| | - Jenny Chang
- Department of Medicine, School of Medicine, University of California, 205 Irvine Hall, Irvine, CA, 92697, USA.
| | - Argyrios Ziogas
- Department of Medicine, School of Medicine, University of California, 205 Irvine Hall, Irvine, CA, 92697, USA.
| | - Robert E Bristow
- Chao Family Comprehensive Cancer Center, Orange, CA, USA; Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine School of Medicine, 333 City Boulevard West, Ste 1400, Orange, CA, 92868, USA.
| | - Verónica M Vieira
- Program in Public Health, Susan and Henry Samueli College of Health Sciences, University of California, Anteater Instruction & Research Building, 653 East Peltason Drive, Irvine, CA, 92697, USA; Chao Family Comprehensive Cancer Center, Orange, CA, USA.
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13
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Lu VM, Shah AH, Eichberg DG, Quinones-Hinojosa A, Esquenazi Y, Komotar RJ, Ivan ME. Geographic disparities in access to glioblastoma treatment based on Hispanic ethnicity in the United States: Insights from a national database. J Neurooncol 2020; 147:711-720. [PMID: 32236779 DOI: 10.1007/s11060-020-03480-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/26/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Access to treatment for glioblastoma (GBM) can be impacted by multiple demographic parameters. Barriers specific to the Hispanic population of the United States (US) are not fully understood. Therefore, the aim of this study was to elucidate geographic disparities for access to GBM treatment in the US Hispanic population. METHODS All GBM patients with known Hispanic ethnicity status (and Caucasian race) in the US National Cancer Database (NCDB) between the years 2005-2016 were retrospectively reviewed. Treatment statuses of surgical resection, chemotherapy, radiation therapy and triple therapy (resection, chemotherapy and radiation) were summarized, and analyzed by comparison and regression analyses over US Census regions. RESULTS A total cohort size of 40,232 Caucasian GBM patients were included, with 3,111 (8%) identifying as Hispanic. The odds of treatment by chemotherapy (OR 0.78, P < 0.01), radiation therapy (OR 0.82, P < 0.01) and triple therapy (OR 0.84, P < 0.01) were all significantly lower in the Hispanic group versus non-Hispanic group. The odds of being treated in the Hispanic group were significantly lower in multiple Census regions with respect to surgical resection (New England, OR 0.51; Mountain, OR 0.68), chemotherapy (East North Central, OR 0.77; Middle Atlantic, OR 0.71; Pacific, OR 0.77), radiation therapy (Middle Atlantic, OR 0.77) and triple therapy (New England, OR 0.49; Middle Atlantic, OR 0.87; Pacific, OR 0.84). Significant barriers to triple therapy in the Hispanic group within these regions were older age (OR 0.97; P < 0.01), treatment in a community facility (OR 0.85, P = 0.03), lack of insurance (OR 0.71, P = 0.03), yearly income < $40,227 (OR 0.69, P < 0.01), low education levels (OR 0.75, P = 0.03) and presence of co-morbidity (OR 0.82; P < 0.01). CONCLUSIONS Currently in the US, there exists heterogenous geographic disparities for Hispanic GBM patients to access different treatments compared to non-Hispanic patients. Multiple circumstances can influence access to treatment within the Hispanic community of these regions, and greater investigation with more granularity required to reveal mechanisms in which these disparities may be addressed in the future.
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Affiliation(s)
- Victor M Lu
- Department of Neurological Surgery, Lois Pope Life Center, University of Miami Miller School of Medicine, Jackson Health System, Miami, FL, USA. .,Department of Neurologic Surgery, 200 First St. SW, Rochester, MN, 55905, USA.
| | - Ashish H Shah
- Department of Neurological Surgery, Lois Pope Life Center, University of Miami Miller School of Medicine, Jackson Health System, Miami, FL, USA
| | - Daniel G Eichberg
- Department of Neurological Surgery, Lois Pope Life Center, University of Miami Miller School of Medicine, Jackson Health System, Miami, FL, USA
| | | | - Yoshua Esquenazi
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, Lois Pope Life Center, University of Miami Miller School of Medicine, Jackson Health System, Miami, FL, USA
| | - Michael E Ivan
- Department of Neurological Surgery, Lois Pope Life Center, University of Miami Miller School of Medicine, Jackson Health System, Miami, FL, USA
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