In the Journals Plus

Ethnic disparities persist in use of guideline-based care for cervical cancer

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April 17, 2017

Black and Hispanic women with cervical cancer were less likely than white women to receive treatment that follows national guidelines, according to a retrospective study published in Obstetrics & Gynecology.

Overall, 53% of black women and 51% of Hispanic women with cervical cancer received guideline-based care, compared with 58% of white women.

Shitansu Uppal

“This study was from a database, so the reasons for the disparity are unknown,” Shitansu Uppal, MBBS, assistant professor of obstetrics and gynecology at Michigan Medicine at University of Michigan, told HemOnc Today. “However, based on my experience, access to care is a big problem. Even when these women reach high-volume centers, the treatment of advanced cervical cancer needs intense chemotherapy (every week) and radiation (every day for 5 weeks).

“Cervix cancer has a median age of 35, and if you live in a poor neighborhood or have no transportation and two little kids, you are likely to miss appointments and not get the entire care needed. It also is likely that some centers skip chemotherapy to make compliance higher.”

In the United States, cervical cancer is diagnosed in about 13,000 women each year and led to an estimated 4,100 deaths in 2016. Racial and ethnic disparities in cervical cancer mortality have persisted for many decades, and although adherence to guideline-based care has been associated with improved survival in ovarian, colorectal and head and neck squamous cell carcinoma, guideline-based care in cervical cancer is widely understudied.

Researchers used the National Cancer Data Base to gather data from 16,195 women (61% white; 20% black; 13% Hispanic) diagnosed with locally advanced squamous or adenocarcinoma of the cervix between 2004 and 2012.

Among black women, 50% were aged between 40 and 60 years (17% younger than 40 years); 48% were either uninsured or on Medicaid; 40% had an income below $38,000 (14% income above $63,000); and 29% were treated in high-volume hospitals. Among Hispanic women, 52% were aged between 40 and 60 years (22% younger than 40 years); 63% were either uninsured or on Medicaid; 27% had an income below $38,000 (23% income above $63,000); and 38% were treated in high-volume hospitals.

From 2004 to 2012, the overall rate of guideline-based care increased from 49.5% (95% CI, 47.1-51.9) to 59.1% (95% CI, 56.9-61.2; P < .001).

The rate of guideline-based care was 58.4% (95% CI, 57.4-59.4) for white women, 53% (95% CI, 51.4-54.9) for black women and 51.5% (95% CI, 49.4-53.7) for Hispanic women (P < .001).

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“We’re closing the gap, but there’s still a gap,” Uppal said. “Understanding the ‘why’ behind our findings is important, not just for the minority population, but for all. We can do better.”

Overall, patients receiving guideline-based care had a lower risk for mortality (adjusted HR = 0.65; 95% CI, 0.62-0.68). Treatment in high-volume hospitals was associated with greater use of guideline-based care among whites (63% vs. 48%), blacks (53% vs. 47%) and Hispanics (54% vs. 41%).

These adherence rates are far inferior to those observed for breast cancer and colorectal cancer, where guideline adherence is 70% to 75%. Uppal said that, from his clinical experience, adherence rates are lower in patients with cervical cancer because it disproportionately affects women in lower socioeconomic statuses. Further, the number of oncologists specializing in cervical cancers is declining.

The best ways to address the adherence gap are to increase patient awareness on the importance of completing therapy and to include guideline-based care as a quality of care metric, Uppal said.

“Any time a patient — regardless of race, age or income — does not get full guideline-based therapy, there should be an explanation in the chart for reasons for deviation from standard of care,” Uppal said. “Moreover, we should have ways to monitor hospitals if they are on par with other hospitals. One hundred percent adherence is impossible, but 70% would be a good start.” – by Chuck Gormley

For more information:

Shitanshu Uppal, MBBS, can be reached at University of Michigan, 1500 E. Medical Drive, Ann Arbor, MI 48109; email: uppal@med.umich.edu.

Disclosure: Researchers report no relevant financial disclosures.