Massey's director of gynecologic oncology provides framework for addressing gynecologic cancer disparities
Health disparities are differences in health among certain groups due to social, economic and environmental disadvantages, and they have long contributed to higher incidence rates and lower overall survival for many populations of women diagnosed with gynecologic cancers.
In a paper published in Gynecologic Oncology, Sarah Temkin, M.D., director of gynecologic oncology and member of the Developmental Therapeutics research program at VCU Massey Cancer Center, outlined the health disparities that currently exist among several populations of women diagnosed with gynecologic cancers and conceived a framework for how to reduce these inequities moving forward.
“Health disparity research should provide insight into where and for whom resources are most needed to create equal health in the population,” said Temkin, the Dianne Harris Wright Professor of GYN Oncology Research at Massey. “In addition to the ethical imperative of providing high quality care, increasing health equity is essential to improving population health and reflects a well-functioning and just society.”
Disparities in cervical cancer
More than 13,000 new cases of cervical cancer will be diagnosed and over 4,000 women will die from the disease this year, according to the American Cancer Society (ACS).
Incidence and mortality rates for cervical cancer are twice as high among black, Hispanic and American Indian/Alaskan Native women compared to white women. In addition, low follow-up rates after abnormal screening results are more associated with non-white women, lower literacy rates, medical comorbidities (other diseases present at the time of screening), public health insurance and low socioeconomic status.
Black women with cervical cancer are more likely to be treated with radiation as opposed to surgery, less likely to receive the full course of radiation and less likely to complete the full staging procedure in the event they undergo a minimally invasive surgery.
Older women, women treated at low-volume hospitals and women without Medicaid or any health insurance are less likely to receive the full scope of cervical cancer care.
Disparities in endometrial cancer
Endometrial cancer, or cancer of the uterine body, is the most common cancer of the female reproductive organs in the United States, and is expected to account for more than 63,000 new diagnoses in 2018, as estimated by ACS.
Black women are more often diagnosed at an advanced stage of disease and mortality rates are nearly double that of white women. In 2015, an analytical review found that black women with high-risk endometrial cancer were half as likely to undergo surgical treatment than white women.
Obesity and diabetes, the two largest risk factors for endometrial cancer, are more prevalent among black and Hispanic women, low-income women and women living in rural areas. Obesity also impedes the ability of medical professionals to perform certain surgical treatments and decreases the efficacy of chemotherapy and radiation treatment.
Disparities in ovarian cancer
In 2018, more than 22,000 cases of ovarian cancer will be diagnosed in the United States, according to the National Cancer Institute (NCI).
Access to high-quality care is the most important factor in determining a patient’s overall outcome for ovarian cancer since it is typically detected at an advanced stage. Standard treatment for ovarian cancer involves complex surgical procedures; therefore, adherence to guideline-based care is critical in impacting survival. However, black women, low-income women and women treated at low-volume hospitals by low-volume surgeons are much less likely to receive guideline-based care.
New drugs are constantly being tested through clinical trials to improve care for ovarian cancer patients; however, non-white women, non-English speaking women and women without Medicaid or health insurance are much less likely to enroll in an available trial.
Addressing the disparities
Temkin underlined three key areas in which strategies can be implemented to help reduce health care disparities for women with gynecological cancers:
1. Prevention and screening
Virtually all cases of cervical cancer, about 65 percent of vaginal cancers and half of all vulvar cancers are directly caused by the human papillomavirus (HPV), according to the NCI.
HPV vaccination has the potential to significantly reduce the incidence rate of these cancers, including a more than two-thirds reduction in cervical cancer diagnoses worldwide. However, only 42 percent of girls and 28 percent of boys aged 9 to 26 have completed the vaccine series in the U.S. While racial and ethnic disparities have improved since federal approval of the HPV vaccine in 2006, vaccination rates remain particularly low in southern and rural regions of the U.S.
“Provider recommendation is repeatedly cited as the most important predictor of vaccine uptake, and gynecologic oncologists can champion and promote HPV vaccination,” Temkin said.
As far as screening, Temkin said that controlled trials have demonstrated that mailing self-sampling kits to patients proves to be a much more effective cervical cancer screening method than sending invitations for patients to come in for a Pap test.
“Self-sampling provides an innovative and feasible way to reach women at risk for lack of follow-up or who live in rural, isolated regions. The self-sampling kits are comfortable and convenient, thereby overcoming some of the emotional and practical barriers to Pap screening and social barriers like transportation,” said Temkin, who is also a professor of gynecologic oncology at the VCU School of Medicine.
Massey is also working to improve access to genetic testing to more effectively identify patients who have an inherited risk for gynecologic malignancies regardless of race, ethnicity or income.
2. Patient navigation
Patient navigation is a service that helps guide patients through the health care system and overcome certain barriers that may be present in the process of screening, diagnosis, treatment or scheduling follow-up appointments. Patient navigators also help break down communication barriers between patients and health care providers to ensure that patients are receiving and understanding the necessary information to make decisions about their cancer care.
Because the cancer care continuum has become increasingly more complex with advancements in medical treatment and health care delivery, underserved populations face steeper challenges associated with the course of their treatment. Implementing and sustaining strong patient navigation services can ease the burden for many women undergoing cancer treatment and allow for all patients to receive equitable care. By recruiting patient navigators for all forms of cancer, Massey is a leader in this movement.
3. Improvements to the health care system
Temkin said that there is much work to be done in terms of health care reform specific to cancer care in the United States.
A widening gap in the income levels for upper and middle class citizens is reflected in the nation’s health care system, and higher income is associated with better overall outcomes for cancer patients.
Although reduced health disparities have been observed since the passing of the Affordable Care Act, most health networks included in the federal exchange do not cover care at NCI-designated cancer centers, which offer the greatest resources for specialized care and innovative clinical trials. This limits patients’ ability to receive specialized treatment.
The emergence of accountable care organizations and bundled payment models can provide coverage for health care that more directly meets the needs of socially disadvantaged patients. This approach also supports improved health equity by offering incentives for community-based organizations that create interventions addressing social and environmental determinants of health.
In an effort to enhance the health care system experience, Massey offers services including transportation for patients in need, legal and financial counseling and outpatient social work support.
“There is an urgent need for cancer care delivery research that identifies multilevel interventions that improve the health of disadvantaged groups more rapidly than the rest of the population so that inequities in health can be reduced and ultimately eliminated,” Temkin said.
Temkin collaborated on this paper with Amanda Bruegl, M.D., of the Oregon Health and Science University; Anna Beavis, M.D., of Johns Hopkins University; B.J. Rimel, M.D., of the Cedars-Sinai Medical Center; Camille Gunderson, M.D., of the Stephenson Cancer Center; and Kemi Doll, M.D., of the University of Washington.
The full version of this manuscript is available at: https://www.sciencedirect.com/science/article/pii/S0090825817315081?via=ihub