New study presents evidence for ‘tough conversations’ around racism in access to cancer care

Lifestyle

New research in the November 2022 issue of JNCCN—Journal of the National Comprehensive Cancer Network has examined whether people with ovarian cancer were being treated based on very specific recommendations regarding comprehensive staging surgery and the recommended minimum cycles of systemic therapy from evidence-based, expert consensus NCCN Guidelines.

The findings showed clear disparities based on patients’ race, ability to pay, and the availability of specialists/cancer centers in their area—significantly impacting treatment course, which can affect survival.

Out of 6,632 patients studied, 23.8% of non-Hispanic white patients received fully guideline-concordant surgery and chemotherapy, compared to only 14.2% of non-Hispanic Black patients. Racial disparities remained after adjusting for the assessed health care access issues, including the ability to pay for care and having access to local specialists.

“While the ability to pay and the number of hospitals and specialists in the area impacts a patient’s cancer care, these do not completely explain racial disparities in ovarian cancer treatment. More work needs to be done to determine what other factors are contributing to these inequities,” said lead author Mary Katherine Montes de Oca, MD, Duke University School of Medicine.

“The reasons are complex and multifaceted,” agreed senior author Tomi F. Akinyemiju, Ph.D., with the Department of Population Health Sciences and the Duke Cancer Institute at Duke University School of Medicine.
“For many reasons, including the legacy of structural racism, Black patients have poorer access to health care. This is related to employment patterns, which predict quality insurance coverage and residential patterns, and in turn, the availability and quality of health care resources in predominantly Black neighborhoods. As our study shows, these are significant contributors to receiving guideline-concordant care. There is also an aspect of the quality of interactions between patients and providers, which is an area of ongoing research by our group—these additional dimensions of accommodation and acceptability need to be further addressed.”

Dr. Akinyemiju continued, “As a society, we need to have tough conversations about access to quality care, and collectively come up with solutions so that having a cancer diagnosis does not become a death sentence for the most vulnerable members of our society.”

The researchers used a SEER-Medicare linked dataset to examine the treatment received by patients who had at least 12 months of continuous enrollment in Medicare fee-for-service before and after being diagnosed with ovarian cancer. The findings also reference previous studies that illustrate worse outcomes, including increased mortality, for ovarian cancer patients who did not receive guideline-concordant treatment—based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Ovarian Cancer recommendations for surgery and chemotherapy cycles. According to their cited research, guideline-adherent treatment has been associated with substantially improved outcomes in both Black and white patients, but some racial disparities in survival still remain, possibly due to later diagnosis or higher comorbidity burden.

“We know that the best outcomes for ovarian cancer are achieved when affected patients are treated according to NCCN Guidelines,” commented Ronald D. Alvarez, MD, MBA, Professor, Chairman, and Clinical Service Chief, Vanderbilt-Ingram Cancer Center, who was not involved in this research. “This study demonstrated, similar to many other studies, that non-Hispanic Black ovarian cancer patients were less likely than non-Hispanic white ovarian cancer patients to receive NCCN Guidelines-based care. This study specifically pointed out that non-Hispanic Black patients were less likely to undergo guideline-based surgery or initiate/complete chemotherapy and that this was predominantly related to lower affordability and availability of quality ovarian cancer services.”

Dr. Alvarez—who serves as Vice-Chair for the NCCN Guidelines Panel for Ovarian Cancer—continued, “Improving the affordability and availability of such services should help improve adherence to guidelines and improve ovarian cancer outcomes in non-Hispanic Black patients. Interestingly, this study suggests that outcomes for this population would still fall short of those achieved for non-Hispanic white patients, even if affordability and availability issues were overcome.”