Study Finds Racial Disparities in Ovarian Cancer Care

Approximately 1.1 percent of women are diagnosed with ovarian cancer at some point in their lifetimes, according to the National Cancer Institute. Although ovarian cancer is rare, it ranks fifth in cancer deaths among women and causes more deaths than any other gynecological cancer, according to the American Cancer Society.

The relative five-year survival rate for women with ovarian cancer is 49.7 percent. This rate has improved over the years for white women but has worsened for Black women. Research indicates that this disparity is due, in part, to the type of care received.

A study published in November 2022 in the Journal of the National Comprehensive Cancer Network (NCCN) sought to examine the relationship between healthcare access and the receipt of guideline-recommended care. The NCCN creates comprehensive guidelines that are the recognized standard of care for cancer patients.

Black women are less likely to receive recommended care

The researchers discovered racial disparities among people who received care that met NCCN guidelines.

"Black women are less likely to receive care that is concordant with the NCCN Clinical Practice Guidelines in Oncology...and lack of concordance with the NCCN guidelines is an independent predictor of worse survival," the study authors wrote.

"Unfortunately, we know there are racial disparities in gynecologic cancer leading to worse outcomes in Black women," said Heidi Gray, M.D., professor and chief of the gynecologic oncology division in the Department of Obstetrics and Gynecology at UW Medicine, part of the University of Washington. Gray was not involved in the study but is a member of the NCCN Guidelines Panel for Ovarian Cancer.

"There have been multiple studies, particularly in cervical and endometrial cancer, that have demonstrated lower rates of survival in Black women compared to white women," Gray said. "Ovarian cancer research in this area has been lagging despite being the most deadly gynecologic cancer, so this study is very timely and important."

The study's setup

The study was conducted by a research team from Duke University School of Medicine, the University of Kentucky, the University of Alabama, Emory University and the New York State Department of Health.

The study included 5,632 patients, ages 65 and older, with ovarian cancer who were diagnosed from 2008 to 2015.

Of these patients:

• 333 (5.9 percent) were non-Hispanic Black
• 318 (5.6 percent) were Hispanic
• 4,981 (88.4 percent) were non-Hispanic White

The study authors used the Penchansky and Thomas framework to evaluate patients' healthcare access. This framework defines five dimensions of healthcare access:

• Availability. The type, quality and volume of services available.
• Accessibility. The patient's geographic location relative to services.
• Accommodation. The organization of services and patient resources.
• Affordability. The ability to pay.
• Acceptability. The patient experience and the quality of the patient-provider interaction.

This study evaluated the relationship between three of these dimensions—affordability, availability and accessibility—in relation to racial disparities and NCCN-recommended care.

The study's findings

The researchers found Black patients scored lower on affordability and availability dimensions than white patients, meaning the Black patients were more likely to be enrolled in Medicaid and Medicare, live in financially deprived communities and have fewer and poorer-quality healthcare resources.

However, white patients had lower accessibility scores than Black and Hispanic patients, meaning the white patients were more likely to live in less populated, rural areas and, therefore, be farther away from services.

"Although distance and availability of specialists may be a larger issue for white patients who are more likely to live in rural areas, non-Hispanic Black and Hispanic patients who live in urban areas may have other challenges, including transportation to appointments," the study authors explained.

The researchers also found Black patients were less likely to receive surgery. Approximately 45 percent of total patients received guideline-concordant surgery, however, only 37 percent of Black patients received the recommended surgery.

Additionally, the study revealed that Black patients were less likely to initiate guideline-recommended care. For example, of those eligible for chemotherapy, 44 percent of white and Hispanic patients but only 36 percent of Black patients received all recommended cycles. About 24 percent of white and Hispanic patients received both guideline-concordant surgery and completed systemic therapy, such as chemotherapy, compared with only 14 percent of Black patients.

Perhaps unsurprisingly, when the researchers compared who had received guideline-recommended care with patients' healthcare access, they found patients with higher affordability and availability were more likely to receive recommended surgery and start systemic therapy.

However, even after accounting for healthcare access scores, Black patients were still less likely to start systemic therapy than white patients. This indicates that even when access is equal across racial demographics (which it often isn't), Black patients are less likely to seek treatment.

The study's conclusions

"Efforts to equalize access to guideline-concordant treatment are key to eliminating disparities in OC [ovarian cancer] survival; there is an increased mortality risk among those who do not receive guideline-concordant treatment and among Black individuals independent of receipt of guideline-concordant treatment," the study authors stated.

"[However,] simply addressing differences in these [healthcare] dimensions may be insufficient to ameliorate racial disparities in treatment," they concluded.

Previous research on ovarian cancer and other cancers indicates perceived discrimination from healthcare providers is associated with decreased screenings and treatment by patients.

"Studies evaluating oncologists' rates of implicit bias have found they have bias at the same rate as the general population and that oncologists who score higher on implicit bias tests tended to have shorter interactions with Black patients," said Taneal Carter, M.S., M.P.A., manager of the Cancer Care Equity Program at the NCCN.

These factors may explain the current study's findings that Black patients are less likely to initiate treatment even when their healthcare access is equal to that of white patients.

"As the authors point out, this needs to be addressed head-on and we need to be brave enough to have tough conversations within our field about how we are going to change," Gray stated. "I would like to commend the authors on this monumental study. Tackling racial disparities in gynecologic cancers so we can improve the lives of Black women needs to be placed in the highest priority for our society."

Setting the standard for oncology patient care

The NCCN, headquartered in Pennsylvania, is a not-for-profit alliance of 32 cancer centers devoted to patient care, research and education. Its cancer care guidelines are developed by 61 panels composed of clinicians, research volunteers, patient advocates and other relevant professionals who are experts on the subject.

"NCCN guidelines are also updated at least once every year, and often more frequently than that, through a transparent process that informs patients, clinicians and payers of the evidence supporting each treatment recommendation," Carter said.

"As most patients with ovarian cancer are diagnosed at advanced stage, they require complex multidisciplinary care, with surgery and chemotherapy followed by novel targeted therapies as maintenance to reduce risk of recurrence and improve survival," Gray explained.

"NCCN guidelines are thoughtfully developed to provide a detailed road map for physicians to deliver the best and most up-to-date care for patients," Gray continued. "There have been numerous studies, including this one, that have shown adherence to NCCN guidelines is associated with improved survival."

If you or a loved one are receiving cancer treatment, you can find resources written for patients on the NCCN website. There are Guidelines for Patients for numerous cancer types written in easy-to-read formats, including charts, pictures and lists of questions to ask your healthcare provider to make sure you are receiving the recommended standard of care. The guidelines are available in several languages.