New research examining whether patients with ovarian cancer were receiving care concordant with the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology (NCCN Guidelines) found clear disparities based on patients’ race, ability to pay, and access to specialists and cancer centers—significantly impacting the treatment course and affecting survival. The findings were published by Montes de Oca in JNCCN–Journal of the National Comprehensive Cancer Network.
Research Highlights Importance of Guideline-Concordant Treatment
The researchers used a Surveillance, Epidemiology, and End Results–Medicare linked data set to examine the treatment received by patients who had at least 12 months of continuous enrollment in Medicare fee-for-service pre– and post–ovarian cancer diagnosis. The findings also referenced previous studies that illustrated worse outcomes—including increased mortality—for patients with ovarian cancer who did not receive guideline-concordant treatment based on the NCCN Guideline recommendations for surgery and chemotherapy cycles. According to the cited research, guideline-adherent treatment has been associated with substantially improved outcomes for both Black and White patients, but some racial disparities in survival still remain, possibly due to later diagnoses or higher comorbidity burdens.
“We know that the best outcomes for [patients with] ovarian cancer are achieved when affected patients are treated according to NCCN Guidelines. This study demonstrated, similar to many other studies, that non-Hispanic Black patients [with ovarian cancer] were less likely than non-Hispanic White patients [with ovarian cancer] to receive NCCN Guidelines–based care,” commented Ronald D. Alvarez, MD, MBA, the Betty and Lonnie S. Burnett Endowed Professor of Obstetrics and Gynecology, and Chairman and Clinical Service Chief of Obstetrics and Gynecology at the Vanderbilt University Medical Center, as well as Vice-Chair for the NCCN Guidelines Panel for Ovarian Cancer, who was not involved in the research. “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.”
Study Findings
Among the 6,632 cases studied, 23.8% of non-Hispanic White patients received fully guideline-concordant surgery and chemotherapy compared with only 14.2% of non-Hispanic Black patients. Racial disparities persisted after adjusting for health-care accessibility, 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 study author Mary Katherine Montes de Oca, MD, a resident at the Duke University School of Medicine.
“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,” Dr. Alvarez underscored.
'Tough Conversations' Needed
“The reasons [for this] are complex and multifaceted. 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,” emphasized senior study author Tomi F. Akinyemiju, PhD, Associate Professor of Population Health and Global Health; Vice-Chair of Diversity and Inclusion in the Department of Population Health Sciences; and Associate Director of Community Outreach, Engagement, and Equity at the Duke Cancer Institute at the Duke University School of Medicine. “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. 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,” Dr. Akinyemiju concluded.
Disclosure: For full disclosures of the study authors, visit jnccn.org.
