Racial Disparities Reported With Quality of Care in Endometrial Cancer

Jason D. Wright, MD, chief of the Division of Gynecologic Oncology and vice chair of Academic Affairs in the Department of Obstetrics and Gynecology at Columbia University Irving Medical Center

Jason D. Wright, MD

Retrospective results showed that African-American women with endometrial cancer are less likely to receive evidence-based care compared with white women—1 factor causing significant racial disparities in endometrial cancer care, explained senior study author Jason D. Wright, MD.

Patients with endometrial cancer treated from 2004 to 2016—identified via the National Cancer Database—were evaluated based on 5 evidence-based quality metrics: surgical treatment within 6 weeks of diagnosis (Q1), use of minimally invasive surgery (stage I-IIIc; Q2), pelvic nodal assessment (high-risk tumors; Q3), adjuvant radiation (high/intermediate risk; Q4), and systemic chemotherapy (stage III-IV; Q5). The study also compared 30- and 90-day mortality, as well as 5-year mortality.

Among 310,208 patients with endometrial cancer, 11.3% were African American and 88.3% were white. Results showed that African Americans were less likely than white patients to receive Q1 (65.8% vs 75.6%), Q2 (58.5% vs 72.9%), Q3 (71.3% vs 74.2%), and Q5 (72.7% vs 73.2%; P <.05 for all).

For patients with stage I disease, African Americans compared with white women experienced a higher risk of 30-day (adjusted relative risk [aRR] = 2.25; 95% CI, 1.30-3.90), 90-day (aRR = 1.84; 95% CI, 1.23-2.76), and 5-year mortality (adjusted HR = 1.42; 95% CI, 1.26-1.59). African Americans with stage III disease experienced the same increased mortality risk versus white women at 30-day (aRR = 1.86; 95% CI, 1.01-3.44) and 5-year mortality (aHR = 1.35; 95% CI, 1.22-1.50).

“African-American women are less likely than white women to receive evidence-based care for endometrial cancer,” said Wright. “Even if African-American women receive evidence-based care, it may mitigate but does not completely eliminate the survival disparities that we saw based on race. We still need to work and look at other factors that may be responsible for the survival disparities that we see.”

In an interview with OncLive, Wright, chief of the Division of Gynecologic Oncology and vice chair of Academic Affairs in the Department of Obstetrics and Gynecology at Columbia University Irving Medical Center, discussed the findings of this trial and how practice can shift to decrease the gap between African-American and white patients with endometrial cancer.

OncLive: Could you discuss the rationale and goals of this retrospective study?

Wright: It's long been recognized that African-American women with endometrial cancer are at an increased risk for adverse outcomes, particularly decreased survival compared with white women. We don't completely understand why there is this difference in survival, but there are a number of factors, including delays in diagnosis. African-American women often have more aggressive types of tumors.

Additionally, there are often concerns that African-American women with endometrial cancer don't receive the same quality of care as white women with the disease. The goal of this study was to compare outcomes between African-American and white women with endometrial cancer, and to try to quantify how much high-quality care impacts survival. Specifically, we wanted to determine if African-American women receiving high-quality care would have the same outcomes as white women with the disease.

What were the findings?

Overall, we found that compared with white women, African-American women often did not receive the same level of care. We looked at 5 quality metrics that are fairly well-established standards of care for endometrial cancer. In 4 or 5 of those measures, African-American women were less likely to receive those standards than white women; African-American women did not receive the same quality of care as white women.

Even when you looked at African-American women who received high-quality care, they still had survival outcomes that were inferior to white women. When we correct for poor quality of care, survival improves for [African-American] women with endometrial cancer, but this subgroup still does not have the same survival outcomes as white women. Quality of care may explain a portion of the survival disparities between African-American and white women with endometrial cancer, but not all of them.

How could this information be used to adjust care for African-American women in the future?

This highlights that African-American women with endometrial cancer are clearly at risk for receiving substandard care. We need to have targeted programs to try to improve the quality of care for African-American women as well as focus on and measure their quality of care.

Even if we improve the quality of care for African-American women with endometrial cancer, we're not going to be able to achieve the same results that we see for white women. We still have a lot of work that needs to be done to better understand why there's this discrepancy in survival between [these 2 patient subgroups]. What we have seen is not completely due to the quality of care that African-American women are receiving.

What are some steps that can be taken to increase the level of care for African-American women with endometrial cancer?

We need to make providers ensure that African-American women are receiving care from doctors and hospitals that can provide high-quality care for endometrial cancer. We also need to better track the outcomes in both African-American and white women, therefore measuring the quality of care and reporting that back to providers and patients.

Further, we need to communicate with African-American women to make them aware of this disparity and [convey the] importance of receiving high-quality care. We need to raise awareness among providers and patients to try to improve their quality of care.

What are the next steps in addressing this research in the real-world setting?

There are a number of ongoing steps. Quality of care is probably one reason why African-American women have decreased survival. There are also concerns about timely diagnosis. We know from prior work that African-American women are often diagnosed later [with endometrial cancer] than white women. We're currently doing some additional studies to [focus on] the importance of barriers to early diagnosis.

When African-American women are diagnosed, they often have more aggressive tumors. There is a different biology [within this demographic]; there are certain high-risk endometrial cancers in African-American women [that are not seen in white patients with endometrial cancer]. We're trying to understand why that is and figure out strategies where it can potentially mitigate the difference in biology between African-American and white women.

Why is it important to discuss racial disparities in cancer treatment?

For many cancers, there are disparities in access to care and outcomes. When you look at endometrial cancer, there is a particularly large disparity in outcomes between black and white women. What is even more concerning is that this disparity in outcomes appears to be worsening. We're seeing that this survival differential between African-American and white women is growing, and we need to understand that so we can hopefully close that that survival gap.

Endometrial cancer is typically a cancer that's highly curable with early detection and appropriate treatment. To see the survival disparities [between these 2 patient demographics] with a highly curable cancer is particularly problematic. We need to address that so we can have a higher percentage of women with this cancer who can be treated appropriately, and hopefully cured.

Huang AB, Huang Y, Hur C, et al. Impact of quality of care on racial disparities in survival for endometrial cancer [published online ahead of print February 25, 2020]. Am J Obstet Gynecol. doi: 10.1016/j.ajog.2020.02.021