Disparities in receipt of care for high-grade endometrial cancer: A National Cancer Data Base analysis

Highlights

• White women were most likely to present with early stage disease.

• African American women had lower all-cause survival compared to white women.

• Hispanic women had higher all-cause survival compared to white women.

Abstract

Purpose

To examine patterns of care and survival for Hispanic women compared to white and African American women with high-grade endometrial cancer.

Methods

We utilized the National Cancer Data Base (NCDB) to identify women diagnosed with uterine grade 3 endometrioid adenocarcinoma, carcinosarcoma, clear cell carcinoma and papillary serous carcinoma between 2003 and 2011. The effect of treatment on survival was analyzed using the Kaplan-Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model.

Results

43,950 women were eligible. African American and Hispanic women had higher rates of stage III and IV disease compared to white women (36.5% vs. 36% vs. 33.5%, p < 0.001). African American women were less likely to undergo surgical treatment for their cancer (85.2% vs. 89.8% vs. 87.5%, p < 0.001) and were more likely to receive chemotherapy (36.8% vs. 32.4% vs. 32%, p < 0.001) compared to white and Hispanic women. Over the entire study period, after adjusting for age, time period of diagnosis, region of the country, urban or rural setting, treating facility type, socioeconomic status, education, insurance, comorbidity index, pathologic stage, histology, lymphadenectomy and adjuvant treatment, African American women had lower overall survival compared to white women (Hazard Ratio 1.21, 95% CI 1.16–1.26). Conversely, Hispanic women had improved overall survival compared to white women after controlling for the aforementioned factors (HR 0.87, 95% CI 0.80–0.93).

Conclusions

Among women with high-grade endometrial cancer, African American women have lower all-cause survival while Hispanic women have higher all-cause survival compared to white women after controlling for treatment, sociodemographic, comorbidity and histopathologic variables.

Introduction

In the United States, endometrial cancer is the most common gynecologic malignancy, with 60,050 new cases estimated in 2016 [1]. While the majority of these cases are early stage and of low-grade endometrioid histology, a proportion of women will be diagnosed with an aggressive histologic subtype that confers a greater risk of disease recurrence and increased mortality [2]. African American women have a higher incidence of high-grade histology [3], [4], [5], [6], [7], which may contribute to the well-documented increase in overall mortality among African American women [8], [9], [10], [11], [12]. While the vast majority of research has focused on the comparison between white and African American women with endometrial cancer, a growing yet limited body of literature has examined differences in disease presentation, treatment patterns and outcomes between Hispanic and non-Hispanic women [7], [13], [14], [15], [16].

“Hispanic or Latino” ethnicity is defined by the federal Office of Management and Budget as “a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race” [17]. Hispanics represent the largest ethnic minority group in the United States, and cancer is the leading cause of death among Hispanic women [18]. Hispanic women, similar to African American women, have a higher incidence of high-grade disease [13], [15] and are a vulnerable population disproportionately affected by lower socioeconomic status and barriers to healthcare. While there is substantial racial and cultural diversity within the Hispanic community and significant variation in the literature regarding how Hispanic ethnicity is characterized [19], cancer data are typically presented for Hispanics in aggregate [18]. Despite the heterogeneity within the Hispanic population, there is value in comparing the differences in treatment patterns and clinical outcomes among white women, African American women and Hispanic women with cancer, as such studies are lacking. The objective of this study is to compare the demographics, tumor characteristics, treatment course and overall survival of Hispanic women to non-Hispanic white women and non-Hispanic African American women with high-grade endometrial cancer.