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Associate Professor of OB/GYN
Department of OB/GYN
Division of Gynecologic Oncology
Weill Cornell Medicine-NewYork Presbyterian Hospital
New York, New York
Eloise Chapman-Davis, MD, FACOG, has no relevant conflicts of interest to report.
Gynecologic cancers remain among the most lethal for women worldwide, causing the deaths of more than 600,000 women globally each year. Disparities in cancer incidence and mortality vary by race and ethnicity, although morbidity and mortality associated with these cancers can be reduced with timely screening, early diagnosis, and adherence to guideline concordant treatment. For example, Black women with endometrial cancer have a 90% higher mortality rate than White women with endometrial cancer. The advanced disease stage at which Black women receive a diagnosis of endometrial cancer (only 53% diagnosed as early stage) is a major factor in this disparity and is not explained by differences in healthcare access. In addition, in the United States, cervical cancer incidence and mortality is higher in underrepresented women of color than in White women.
In this commentary, I unveil key takeaways from a program designed to educate healthcare professionals (HCPs) on health equity and access to care for racial and ethnic minority women with endometrial, ovarian, and cervical cancers, including insights gained from a patient survey and HCPs resources codeveloped by Clinical Care Options (CCO) and Smart Patients, a patient advocacy group.
Health Disparities in Ovarian, Endometrial, and Cervical Cancer
A major disparity in ovarian cancer is suboptimal treatment and poor survival rates in Black women, Hispanic/Latinx women, women with low incomes, and women with public health insurance or no insurance coverage. Patients using Medicare or Medicaid may be less likely than women with private insurance to receive germline and/or somatic molecular testing. In addition, they are less likely than Black, Hispanic/Latinx, and American Indian women to receive testing. Although Black women have a lower incidence of ovarian cancer, they experience worse 5-year survival outcomes compared with other racial and ethnic groups. Racial and ethnic minority women, women with Medicaid insurance, and women of low socioeconomic status also are less likely to receive care from high-volume physicians in high-volume treatment centers associated with better clinical outcomes or standard of care treatment, further increasing the health disparity and increasing mortality.
Similarly, despite having a lower risk of developing endometrial cancer, Black women have a higher mortality rate and a 19% lower 5-year overall survival (OS) rate compared with White women. One of the key causes of racial disparities in postmenopausal women with endometrial cancer is delay in diagnosis, which results in Black women presenting with more advanced disease. To reduce the disparity at the time of diagnosis, patients and HCPs need to better recognize the symptoms of endometrial cancer and address socioeconomic factors that may prevent patients from receiving timely and guideline concordant care.
Black and Hispanic/Latinx patients have a higher overall incidence of cervical cancer and increased mortality compared with White women. Part of the health disparity observed for women with cervical cancer may result from low availability of HCPs, particularly pediatricians in rural areas, which may contribute to lower vaccination rates for human papillomavirus (HPV), an effective preventive measure. Black women also are less likely to receive regular cervical cancer screenings via Pap smears and HPV testing. Besides the disparity in screening, Black women with cervical cancer are less likely to receive surgery compared with White women and are more likely to receive no treatment at all. It has been reported that when Black women receive care that is comparable to that of White women, survival is similar, suggesting that improving access to similar treatments can help mitigate health disparities in this population.
Disparities in Clinical Trial Participation and Molecular Testing
Underrepresented women of color patients with gynecologic cancers are less likely to enroll on clinical trials than White women, with a 14.8-fold difference in ovarian cancer, a 9.8-fold difference in endometrial cancer, and a 4.5-fold difference in cervical cancer. Increasing racial and ethnic minority participation is important for providing insight into objective racial differences in tumor biology, treatment responses, and survival. Racial and ethnic underrepresented women of color in clinical trials also may have better outcomes than patients who were never enrolled. A retrospective study of women with ovarian cancer found that although White women had a higher median OS compared with Black women, if never enrolled on a clinical trial, median OS was similar between the races among patients who had been enrolled on ≥1 trial.
Molecular testing is an important tool across endometrial cancer, cervical cancer, and ovarian cancer because it informs both diagnosis and treatment choices. Genomic testing identifies patients with germline and/or somatic mutations likely to benefit from targeted therapy such as PARP inhibitors. Patients are not always aware that they should ask to be tested or that it can change their clinical outcomes, so it will be important to educate patients to help eliminate disparities regarding molecular testing.
Outcomes of the CCO/Smart Patients Health Equity Program
The health equity program was conducted in collaboration with the patient advocacy group Smart Patients to educate HCPs about health disparities in endometrial, cervical, and ovarian cancer. Short multimedia presentations discussed the disparities using data from clinical trials to show their impact on patient outcomes. Guideline recommendations for testing and treatment, as well as patient preferences, were discussed, as were strategies that care teams can employ to increase health equity across race/ethnicity and socioeconomic status.
With the health equity program education and resources, we aimed to increase HCPs’ knowledge of health disparities affecting underrepresented women of color with gynecologic cancers. A notable educational gain was seen for HCPs caring for women with cervical cancer. Before participating in the program, only 14% of learners knew that Black and Hispanic/Latinx patients have the highest incidence and/or mortality from cervical cancer, compared with 67% following education. Knowledge of patients’ barriers to clinical trial enrollment also increased, with the frequency of learners knowing that assistance for patient psychologic stressors is not helpful increasing from 0% to 50%. The program also was highly successful at increasing learners’ knowledge of optimal guideline-based treatments. Before taking part in the program, approximately 53% of learners knew that lenvatinib plus pembrolizumab is indicated for patients with recurrent non–microsatellite high/mismatch repair proficient status, compared with 100% post education. In addition, approximately 55% of learners initially knew that niraparib is indicated as frontline maintenance for patients with or without BRCA mutations or homologous repair deficiency status, compared with 82% following education.
Final Thoughts and Takeaways
HCPs should reflect on their own biases and become more culturally aware and sensitive in their interactions with patients, realizing that microaggressions may contribute to health disparities. HCPs also can build patients’ trust and confidence by involving them in shared decision-making and increasing communication. Patients should be provided with education about their cancer care, available treatments, molecular testing, and―of most importance―the advantages of participating in clinical trials.
Patients also should be offered testimonials from other trial participants from underrepresented backgrounds. Asking patients about the resources they have access to and what limits their access to care also is helpful, because knowing these barriers allows the care team to better assist patient needs through access to patient navigators, additional education, dependent care, and transportation. When barriers to healthcare access are addressed, it is more likely that patients can address their healthcare needs and receive the appropriate treatment.
How do you plan to address health disparities affecting underrepresented women of color with endometrial, ovarian, and cervical cancers in your own practice? Please leave your thoughts in the comment box below.
To learn about health disparities and improving outcomes for all women with gynecologic cancers, visit the full program on the CCO website, titled “Smarter. Stronger. Together. Education and Resources to Optimize Clinical Outcomes in Gynecologic Cancers,” to view short, CME-certified, expert-authored presentations and free downloadable slidesets associated with this discussion.