Ovarian cancer afflicts approximately 204,000 women worldwide, with ∼125,000/year deaths. In the United States more than 22,000 new cases of ovarian cancer diagnosed with over 14,000 disease-related deaths.[1] The standard of care in ovarian cancer includes expedient access to the health care system, consultation with a gynecologic oncologist, surgical intervention, and multiagent platinum-based chemotherapy. Prognostic factors for improved survival in women with ovarian cancer include younger age; early stage; low-grade and serous histology; good performance status; disease biology (BRCA1 and 2 mutation carriers have a better prognosis); and low volume of residual disease at the time of cytoreductive surgery. In contrast, African-American race, low socioeconomic status (SES), geographic location, and insurance status have been associated with worse survival and increased probability of not receiving appropriate standard of care treatment.[2-7] These differences in ovarian cancer outcomes linked to race, social, and economic factors indicate that health care disparities exist in the treatment of this gynecologic cancer.

In this presentation, we will (1) review the standard of care for epithelial ovarian cancer treatment, (2) discuss the variables affecting the outcome for patients with epithelial ovarian cancer, (3) describe the factors contributing to healthcare disparities, and (4) discuss the evidence for clinical disparities in epithelial ovarian cancer care and outcomes. Causes of healthcare disparities are complex and include differences in race/ethnicity, SES, insurance status, education level, geographic location, culture, healthcare system factors (adherence to treatment guidelines, and access to care), and disease biology.[2-7]

The following are highlighted in this presentation:

  • Population-based studies have demonstrated that African-American women are at increased risk of ovarian cancer death compared to non-Hispanic Caucasian women.

  • Population-based studies have demonstrated that African-American women are less likely to undergo site-specific surgery or surgical staging for ovarian cancer compared to Caucasian women.

  • African-American women were less likely to seek care at high-volume hospitals or be operated on by high-volume surgeons.

  • African-American women and those with Medicaid/Medicare payer status are less likely to receive standard of care therapy based on National Comprehensive Cancer Network (NCCN) guidelines.

  • Geographic location away from a high-volume hospital is associated with increased risk of non-adherent ovarian cancer care.

  • Geographic barriers to standard treatment disproportionately affect racial minorities and women of low-SES.

  • In contrast to population-based studies, retrospective single academic institution studies and ancillary analysis of large cooperative group phase III trials in advanced ovarian cancer have demonstrated no difference in overall survival in women of African-American and Caucasian descent.

The reported research in ovarian cancer indicates that unequal delivery of quality care, obstacles to the delivery of recommended care, and limited access to expert care may account for the disparities seen in ovarian cancer care. The U.S. Department of Health and Human Services has targeted disparities in access to health care as the centerpiece of the Healthy People 2020 campaign and the Department of Health and Human Services (HHS) has unveiled an action plan to reduce racial and ethnic Health disparities.[8, 9] The 5 goals of the HHS Disparities Action Plan are: (1) transform health care; (2) strengthen the nation's Health and Human Services infrastructure and workforce; (3) advance the health, safety, and well-being of the American people; (4) advance scientific knowledge and innovation; and (5) increase the efficiency, transparency, and accountability of HHS programs. The HHS Disparities initiative will specifically target programs to increase knowledge of, access to, and utilization of biomedical and behavioral procedures to reduce cancer disparities.[9]

Listed below are future research objectives that will reduce and potentially eliminate health care disparities in ovarian cancer in the United States:

  • Improve our knowledge of the interaction between race, ethnicity, SES, geographic location and ovarian cancer health care disparities across the United States to harmonize existing data and identify opportunities for intervention.

  • Improve our knowledge regarding cultural barriers to care.

  • Promote community-based participatory research to increase ovarian cancer awareness and review standards of care.

  • Develop interventions to provide expedient access to expert care by trained specialists in Gynecology Oncology, cytoreductive surgery, and administration of multiagent platinum-based chemotherapy in order to increase the likelihood of NCCN adherent standard of care therapy.

References:

1. Bristow RE, Chang J, Ziogas A, Anton-Culver H, Vieira VM. Spatial analysis of adherence to treatment guidelines for advanced-stage ovarian cancer and the impact of race and socioeconomic status. Gynecol Oncol. 2014 Jul;134(1):60-7

2. Bristow RE, Powell MA, Al-Hammadi N, Chen L,Miller JP, Roland PY, et al. Disparities in ovarian cancer care quality and survival according to race and socioeconomic status. J Natl Cancer Inst 2013;105:823–32.

3. Harlan LC, Greene AL, Clegg LX, Mooney M, Stevens JL, Brown ML. Insurance status and the use for guideline therapy in the treatment of selected cancers. J Clin Oncol 2005;23:9079–88.

4. Harlan LC, Clegg LX, Trimble EL. Trends in surgery and chemotherapy for women diagnosed with ovarian cancer in the United States. J Clin Oncol 2003;21:3488–94.

5. Parham G, Phillips JL, Hicks ML, Andrews N, Jones WB, Shingleton HM, et al. The National Cancer Data Base report on malignant epithelial ovarian carcinoma in African-American women. Cancer 1997;80:816–26.

6. Barnholtz-Sloan JS, Talnsky MA, Abrams J, Severson RK, Qureshi F, Jacques SM, et al. Ethnic differences in survival among women with ovarian carcinoma. Cancer 2002;94:1886–93.

7. Terplan M, Schluterman N, McNamara EJ, Tracy JK, Temkin SM. Have racial disparities in ovarian cancer increased over time? An analysis of SEER data. Gynecol Oncol 2012;125:19–24.

8.U.S. Department of Health and Human Services. Healthy people 2020: disparities. [cited 2014 Jan 14]. Available from: http://healthypeople.gov/2020/about/disparitiesAbout.aspx.

9. U.S. Department of Health and Human Services. HHS Action Plan to Reduce Racial and Ethnic Health Disparities. A Nation free of disparities in health and health care. [cited 2014 Oct 1]. Available from: http://www.minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf

Citation Format: Angeles A. Secord. Standard of care and clinical disparities in epithelial ovarian cancer. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr IA41.

©2015 American Association for Cancer Research.
2015