No abstract

Adherence to National Comprehensive Cancer Network guidelines for treatment of ovarian cancer is correlated with improved survival and may be a useful process measure of quality cancer care. Ovarian cancer case volume correlates with a higher likelihood of recommended care and improved survival and may be a useful structural quality measure. Increased efforts to concentrate ovarian cancer care are warranted.

Among patients with advanced-stage ovarian cancer, the provider combination of HVH/HVP is an independent predictor of improved disease-specific survival. Access to high-volume ovarian cancer providers is limited, and barriers are more pronounced for patients with low socioeconomic status, Medicaid insurance, and racial minorities.

OBJECTIVE To determine the impact of geographic location on advanced-stage ovarian cancer care adherence to National Comprehensive Cancer Network (NCCN) guidelines in relation to race and socioeconomic status (SES). METHODS Patients diagnosed with Stage IIIC/IV epithelial ovarian cancer (1/1/96-12/31/06) were identified from the California Cancer Registry. Generalized additive models were created to assess the effect of spatial distributions of geographic location, proximity to a high-volume hospital (≥20 cases/year), distance travelled to receive care, race, and SES on adherence to NCCN guidelines, with simultaneous smoothing of geographic location and adjustment for confounding variables. Disparities in geographic predictors of treatment adherence were analyzed with the χ2 test for equality of proportions. RESULTS Of the 11,770 patients identified, 45.4% were treated according to NCCN guidelines. Black race (OR=1.49, 95%CI=1.21-1.83), low-SES (OR=1.46, 95%CI=1.24-1.72), and geographic location ≥80km/50mi from a high-volume hospital (OR=1.88, 95%CI=1.61-2.19) were independently associated with an increased risk of non-adherent care, while high-volume hospital treatment (OR=0.59, 95%CI=0.53-0.66) and travel distance to receive care ≥32km/20mi (OR=0.80, 95%CI=0.69-0.92) were independently protective. SES was inversely associated with location ≥80km/50mi from a high-volume hospital, ranging from 6.3% (high-SES) to 33.0% (low-SES) (p<0.0001). White patients were significantly more likely to travel ≥32km/20mi to receive care (21.8%) compared to Blacks (14.4%), Hispanics (15.9%), and Asian/Pacific Islanders (15.5%) (p<0.0001). CONCLUSION Geographic proximity to a high-volume hospital and travel distance to receive treatment are independently associated with NCCN guideline adherent care for advanced-stage ovarian cancer. Geographic barriers to standard ovarian cancer treatment disproportionately affect racial minorities and women of low-SES.

OBJECTIVE To estimate whether race or ethnic and socioeconomic strata are independently associated with advanced-stage ovarian cancer–specific survival after adjusting for adherence to National Comprehensive Cancer Network treatment guidelines. METHODS The design was a retrospective population-based cohort study of patients with stage IIIC–IV epithelial ovarian cancer identified from the Surveillance, Epidemiology, and End Results–Medicare database (1992–2009). Quartile of census tract median household income was used as the measure of socioeconomic status (quartiles 1–4). A multivariable logistic regression model was used to identify characteristics predictive of adherence to National Comprehensive Cancer Network guidelines for surgery and chemotherapy. Cox proportional hazards models and propensity score matching were used for survival analyses. RESULTS A total of 10,296 patients were identified, and 30.2% received National Comprehensive Cancer Network guideline–adherent care. Among demographic variables, black race (adjusted odds ratio [OR] 1.53, 95% confidence interval [CI] 1.22–1.92) and low socioeconomic status (quartile 1, adjusted OR 1.32, 95% CI 1.14–1.52) were independently associated with nonguideline care. Stratified multivariate survival analysis using the propensity score-matched sample (n55,124) revealed that deviation from treatment guidelines was associated with a comparable risk of disease-related death across race-ethnicity: whites (adjusted hazard ratio [HR] 1.59, 95% CI 1.48–1.71), blacks (adjusted HR 1.66, 95% CI 1.19–2.30), Asian or Pacific Islanders (adjusted HR 1.52, 95% CI 0.99–1.92), and Hispanics (adjusted HR1.91, 95% CI 0.98–3.72). Across socioeconomic status, deviation from treatment guidelines was also associated with a comparable risk of ovarian cancer mortality for quartile 1 (adjusted HR 1.69, 95% CI 1.47–1.95), quartile 2 (adjusted HR 1.63, 95% CI1.42–1.87), quartile 3 (adjusted HR 1.51, 95% CI1.32–1.73), and quartile 4 (adjusted HR 1.57, 95% CI 1.38–1.79). CONCLUSION Adherence to treatment guidelines for advanced-stage ovarian cancer is associated with equivalent survival benefit across racial or ethnic and socioeconomic strata. Ensuring equal access to standard treatment is a viable strategic approach to reduce survival disparities.