Black patients with stage IA low-grade endometrioid endometrial carcinoma may be less likely to undergo a hysterectomy and survive their cancer than White patients with the same type of cancer, according to a recent study published by Taylor et al in Gynecologic Oncology.
Background
“We’ve known for years that Black [patients] with endometrial cancer have lower survival rates than White [patients], largely because they are more likely to have an aggressive subtype and to be diagnosed at an advanced stage. But our study found this disparity persists even when we compare patients with the lowest-risk [type of endometrial cancer] diagnosed at the earliest possible stage,” explained lead study author Kristin Taylor, MD, Assistant Professor of Obstetrics and Gynecology at Cedars-Sinai. “Low-grade endometrioid tumors account for about 80% of endometrial cancers, and most of these are stage I at diagnosis. For these patients, standard treatment is hysterectomy, and many should be cured without the need for radiation or chemotherapy,” she added.
Study Methods and Results
In the new study, investigators analyzed data from over 23,000 Black and White patients with stage IA low-grade endometrioid endometrial carcinoma who participated in the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program. They found that the vast majority of the patients involved in the study were treated with hysterectomy and had high overall survival rates. Just 1% of White patients did not undergo hysterectomies, whereas 3% of Black patients didn’t undergo the life-saving procedure. The investigators noted that patients who resided in the South, lived in counties with low median income, and were insured with Medicaid were less likely to undergo hysterectomies.
“We had hoped that when we looked only at the lowest-risk patients, the disparity between Black and White [patients] would disappear, but it did not,” Dr. Taylor stressed.
The investigators proposed that physicians may advise against hysterectomies for patients, regardless of their race, who have underlying health conditions that increase the risk of surgical complications. Physicians might also offer patients at childbearing age a fertility-sparing hormone treatment that allows them to temporarily postpone the procedure—however, a slightly higher, though statistically insignificant, number of Black patients than White patients refused surgery when their physicians recommended it.
“Although there was no data collected on the reason for refusal, there is likely an element of mistrust of the medical community that contributes to this difference,” Dr. Taylor suggested. The investigators hypothesized that structural racism may be a factor contributing to this disparity. They noted that historical policies may have caused more Black patients to have lower socioeconomic status, to be uninsured or underinsured, and to have less access to quality health care.
Conclusions
“Even though they might not always be in our conscious memory, I think that the downstream effects of those insults from decades ago get passed on culturally, particularly in the South. I see geographical differences in how [patients] perceive their relationships with their [physicians],” Dr. Taylor continued.
“Disparities in survival that persist even among patients with the same stage and subtype of cancer must be investigated and addressed,” underscored Dan Theodorescu, MD, PhD, the PHASE ONE Foundation Distinguished Chair and Director of Cedars-Sinai Cancer. “Dr. Taylor’s work is an example of the many ways investigators at Cedars-Sinai Cancer are working to understand these disparities and bring the highest level of care to all of the diverse patient groups we serve,” he emphasized.
The investigators plan to address the limitations of their study in further evaluations utilizing different datasets.
“One major limitation with the SEER [Program] is that socioeconomic factors are recorded at the county level, which is so broad. We're essentially repeating this study using the California Cancer Registry—which gives information including median income, education level, insurance status, primary language, and immigration status at the neighborhood level. We'll have a much richer, more granular view of the lives of these patients, which should be really informative,” Dr. Taylor detailed. “Some data suggest that there are different genetic pathways, even within this narrow subset of tumors, that could be driving disparities between outcomes in Black and White [patients]. We’re hoping to develop models in the lab derived from the tumors of Black and White [patients] with [low-risk endometrial] cancer to look for biologic differences that could help inform treatments for each population,” she concluded.
The investigators emphasized that more research is needed to uncover the social factors that may be contributing to cancer care disparities among Black patients.
Disclosure: For full disclosures of the study authors, visit gynecologiconcology-online.net.
