In the USA, Black and Hispanic ovarian cancer patients experience much poorer outcomes than White patients, suggesting they have less access to quality care. But why does this disparity exist, and what can be done to bridge this gap?
Dr Akinyemiju, Associate Professor in Population Health Sciences at Duke University School of Medicine and Duke Cancer Institute, USA, is tackling these questions and more in the Ovarian Cancer Epidemiology, Healthcare Access, and Disparities Study, or simply, ORCHiD.
Read some of their latest work here: http://dx.doi.org/10.1136/bmjopen-2021-052808
Image source: Andrey Popov / Shutterstock
Hello and welcome to Research Pod! Thank you for listening and joining us today.
In this episode, we will be diving into research conducted by Dr Tomi Akinyemiju, an Associate Professor in Population Health Sciences at Duke University School of Medicine and Duke Cancer Institute. Her innovative work probes persistent disparities in ovarian cancer outcomes in the United States. She examines why Black and Hispanic patients frequently experience poorer outcomes than White patients – generating valuable insights that may guide policies to reduce racial disparities.
In 2020, the United States experienced almost 22,000 newly diagnosed cases of ovarian cancer, with 14,000 deaths attributed to the disease. There are no easily recognisable symptoms or effective screening methods for ovarian cancer. As a result, 75% of patients are diagnosed after the cancer has spread regionally or metastasised, meaning the 5-year survival rate is less than 50%.
Importantly, Black patients experience much poorer outcomes than White patients. For example, although five-year cause-specific epithelial ovarian cancer survival among White women has improved from 40% to 47% between 1992 to 1994 and 2007 to 2013, five-year survival among Black women has remained constant at around 35%. These alarming statistics suggest that all racial groups are not benefiting equally from advances in ovarian cancer care. Indeed, lack of access to advanced treatment options is a major contributor to poorer outcomes among Black and Hispanic ovarian cancer patients.
This leads us to two key questions – why are Black and Hispanic ovarian cancer patients less likely to access quality care than White patients? And, perhaps more importantly, what can be done to bridge these disparities?
Dr Akinyemiju is tackling these questions and much more in the Ovarian Cancer Epidemiology, Healthcare Access, and Disparities Study, or simply, ORCHiD. The ORCHiD study utilises the Penchansky and Thomas model of healthcare access, which includes five separate but related dimensions: first, Availability—the type, quality and quantity of healthcare resources; second, Affordability—the ability to pay for healthcare; third, Accessibility—the location of healthcare resources in relation to the patient; fourth, Accommodation—the organisation of healthcare resources in relation to the patient’s constraints and preferences; and fifth, Acceptability—the quality of patient-provider interactions.
Dr Akinyemiju’s goal is to comprehensively characterize these five dimensions of healthcare access among Black, Hispanic, and White patients with ovarian cancer and elucidate how these dimensions influence racial disparities in treatment, supportive care and survival.
The first part of the ORCHiD study includes novel analyses of data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset. The SEER dataset is routinely linked with Medicare insurance claims data for cancer patients who are 65 years or older. It includes sociodemographic variables, cancer stage, treatments, vital status, survival time, and more. It also contains variables that align with three of the five Penchansky and Thomas healthcare access dimensions – Affordability, Availability, and Accessibility. Dr Akinyemiju is using the SEER-Medicare dataset to understand how these three dimensions influence racial disparities in ovarian cancer care.
Among Black, Hispanic and White patients in SEER-Medicare, Dr Akinyemiju and her team found significant racial differences in healthcare Affordability, Availability, and Accessibility. Black and Hispanic patients were more than twice as likely as White patients to live in regions with lower educational attainment, higher poverty, and more residents without health insurance. In other words, Black and Hispanic patients had lower Affordability than White patients. Additionally, while Black patients were more likely to live in metropolitan regions, and therefore reside in neighbourhoods with more healthcare resources, such as hospitals and primary care physicians, those healthcare resources were of lower quality compared with those in neighbourhoods with White patients. Essentially, Black patients had higher Accessibility, but lower Availability than White patients.
The researchers found that these racial differences in healthcare access influence the care that patients received. Black patients were less likely than White and Hispanic patients to receive ovarian cancer surgery performed by a gynecologic oncologist. Black patients also initiated recommended systemic therapy, such as chemotherapy, at lower rates than White patients, though this was explained largely by clinical factors including age at diagnosis, stage at diagnosis, tumour histology, and comorbid conditions.
Dr Akinyemiju’s analyses further revealed that patients living in areas with low educational attainment, representing low healthcare Affordability, were less likely to receive antidepressants than those living in areas with high educational attainment. Strikingly, nearly 1 in 3 White patients received antidepressants, compared to only 1 in 7 Black patients. However, even after accounting for healthcare Affordability, Black and Hispanic patients were still less likely to receive antidepressants. This racial disparity in supportive care reflects lower quality care among minority patients.
To characterize each dimension of healthcare access more comprehensively, Dr Akinyemiju and her team used a method called factor analysis to combine many individual measures related to Affordability, Availability, and Accessibility into composite scores representing each dimension. They then evaluated how these scores affect racial disparities in guideline-adherent treatment and survival.
The researchers found that Black ovarian cancer patients were less likely than their White counterparts to receive surgery or consult a gynecologic oncologist, two important indicators of guideline-adherent treatment. Patients with higher Affordability scores were more likely to receive surgery, and higher Affordability and Availability scores were associated with consulting a gynecologic oncologist. Alarmingly, only 23% of Non Hispanic White patients and 14% of Non Hispanic Black patients received both guideline-adherent surgery and the recommended number of chemotherapy cycles. Patients with higher Affordability and Availability scores were more likely to receive guideline-adherent surgery and initiate systemic therapy. However, after accounting for demographic and clinical characteristics and the healthcare access scores, Black patients were still less likely to initiate systemic therapy than White patients.
These racial disparities in guideline-adherent treatment accompany striking disparities in ovarian cancer survival rates. Dr Akinyemiju’s research found that Black patients had a 46% higher risk of ovarian cancer death than White patients. After accounting for the healthcare access scores, clinical characteristics, and patient demographics, Black patients were still 26% more likely to die of ovarian cancer than White patients.
Ultimately, the SEER-Medicare analyses revealed that differences in healthcare Affordability, Availability, and Accessibility contribute to poorer outcomes among minority ovarian cancer patients. However, these differences do not fully explain disparities. So, what’s the missing link?
This is where the second part of Dr Akinyemiju’s ORCHiD study comes in. The Penchansky and Thomas framework includes five healthcare access dimensions. Two dimensions, Acceptability and Accommodation, were not captured in the SEER-Medicare analyses. However, these dimensions may be the missing link. Structural racism, implicit bias, patient-provider communication and cultural competence are likely major drivers of patient decisions regarding facility choice, adherence to provider recommendations, and quality of care.
To capture all five dimensions of healthcare access, Dr Akinyemiju and her team created a comprehensive patient survey. They are currently interviewing hundreds of Black, Hispanic, and White ovarian cancer patients across the United States, gathering robust data to inform strategies that may improve care for all ovarian cancer patients. Dr Akinyemiju is also collecting saliva and vaginal microbiome samples to examine how biological and genomic factors influence racial differences in ovarian cancer prognosis. Ultimately, the ORCHiD study brings a cell-to-society approach to ovarian cancer disparities.
In conclusion, Dr Akinyemiju’s ORCHiD study uniquely underscores how racial differences in healthcare access produce poorer ovarian cancer outcomes among Black and Hispanic patients than White patients. Her team’s findings suggest that coordinated interventions targeting multiple dimensions of healthcare access – Affordability, Availability, Accessibility, Acceptability, and Accommodation – are urgently needed to bridge racial disparities in ovarian cancer outcomes.
This research was made possible through support from the United States National Institutes of Health. Dr Akinyemiju and her team would also like to thank the many ORCHiD investigators who contributed to the development of this study, the patients who are participating in the study, and the countless staff members and physicians who have played an instrumental role in accomplishing the study goals.
That’s all for today – be sure to check out the links to Dr Akinyemiju’s original ORCHiD research papers, which are included in the notes for this episode. Thanks for listening, and stay subscribed to Research Pod for more of the latest science. See you again soon.