Healthcare Access Dimensions and Guideline-Concordant Ovarian Cancer Treatment: SEER-Medicare Analysis of the ORCHiD Study

Abstract

Background: Racial disparities exist in receipt of guideline-concordant treatment of ovarian cancer (OC). However, few studies have evaluated how various dimensions of healthcare access (HCA) contribute to these disparities. Methods: We analyzed data from non-Hispanic (NH)–Black, Hispanic, and NH-White patients with OC diagnosed in 2008 to 2015 from the SEER-Medicare database and defined HCA dimensions as affordability, availability, and accessibility, measured as aggregate scores created with factor analysis. Receipt of guideline-concordant OC surgery and chemotherapy was defined based on the NCCN Guidelines for Ovarian Cancer. Multivariable-adjusted modified Poisson regression models were used to assess the relative risk (RR) for guideline-concordant treatment in relation to HCA. Results: The study cohort included 5,632 patients: 6% NH-Black, 6% Hispanic, and 88% NH-White. Only 23.8% of NH-White patients received guideline-concordant surgery and the full cycles of chemotherapy versus 14.2% of NH-Black patients. Higher affordability (RR, 1.05; 95% CI, 1.01–1.08) and availability (RR, 1.06; 95% CI, 1.02–1.10) were associated with receipt of guideline-concordant surgery, whereas higher affordability was associated with initiation of systemic therapy (hazard ratio, 1.09; 95% CI, 1.05–1.13). After adjusting for all 3 HCA scores and demographic and clinical characteristics, NH-Black patients remained less likely than NH-White patients to initiate systemic therapy (hazard ratio, 0.86; 95% CI, 0.75–0.99). Conclusions: Multiple HCA dimensions predict receipt of guideline-concordant treatment but do not fully explain racial disparities among patients with OC. Acceptability and accommodation are 2 additional HCA dimensions which may be critical to addressing these disparities.

Disparities in Gynecologic Cancers

“…66,67 Black ovarian cancer patients are less likely to receive full NCCN guideline-recommended care than NHW patients. 67 Several single-institution retrospective studies at academic centers have not shown differences in treatment or survival by race or ethnicity as seen in larger data sets, suggesting that equity can be achieved in controlled settings but may be limited by bias of who can get care at these specialized centers. 68,69 Increased geographic distance from a high-volume hospital was also associated with less concordant care.…”

“…High-quality cancer care in ovarian cancer includes adequate cytoreductive and staging surgery, receipt of timely appropriate chemotherapy, and genetic germline and tumor testing. In a large National Cancer Database study, National Comprehensive Cancer Network (NCCN) guideline nonadherence was found to be the single highest contributor to the disparity noted, explaining 36.4% of the 5-year overall survival disparity experienced by Black pateints 66,67 . Black ovarian cancer patients are less likely to receive full NCCN guideline–recommended care than NHW patients 67 .…”

“…In a large National Cancer Database study, National Comprehensive Cancer Network (NCCN) guideline nonadherence was found to be the single highest contributor to the disparity noted, explaining 36.4% of the 5-year overall survival disparity experienced by Black pateints 66,67 . Black ovarian cancer patients are less likely to receive full NCCN guideline–recommended care than NHW patients 67 . Several single-institution retrospective studies at academic centers have not shown differences in treatment or survival by race or ethnicity as seen in larger data sets, suggesting that equity can be achieved in controlled settings but may be limited by bias of who can get care at these specialized centers 68,69 .…”

“…Failure to receive guideline care is multifactorial and likely a complex model of overall health care access that has been articulated by several authors. Montes de Oca et al, 67 in their analysis, review measures of health care access dimensions to include “affordability (ability to pay), availability (service type, quality, volume), accessibility (geographic location), accommodation, and acceptability (quality of patient-provider interaction, patient experience).” An additional important framework (Fig. 5) considers proximal (individual, biologic), intermediate (social and physical environments), and distal structural factors to best explain causes of disparities and their interplay 78 …”

Disparities in Late-Stage Breast and Colorectal Cancer Diagnosis Among Hispanic, Non-Hispanic White, and Non-Hispanic Black Patients: a Retrospective Cohort Study of Texas Medicare Beneficiaries

“…In their SEER-based study of Americans aged < 65, Mobley and Kuo found that Black and other non-White races and those of Hispanic ethnicities have significantly higher odds of late-stage diagnosis for breast cancer compared with their White counterparts, but only Black patients have high odds of late-stage colorectal cancer diagnosis compared to White patients [ 18 ]. A national study based on SEER-Medicare database ( n = 5632) showed that 29.1% of White, 32.4% of Black, and 33% of Hispanic patients had stage 4 ovarian cancer at diagnosis, with NH-Black patients being less likely than White (hazard ratio, 0.86; 95% CI 0.75–0.99) to receive guideline-concordant systemic therapy for ovarian cancer [ 19 ].…”