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Disparities in Guideline-Based Cervical Cancer Care Greatest at High-Volume Hospitals

Angelica Welch
Published: Monday, Mar 27, 2017

Shitanshu Uppal, MD

Shitanshu Uppal, MD

A study recently published in Obstetrics & Gynecology evaluated racial and ethnic disparities in guideline-based care for women with locally advanced cervical cancer using the National Cancer Database.

The intent for this study, said lead investigator Shitanshu Uppal, MD, was to understand the disparities of care, mainly, why certain women are not receiving standard of care for cervical cancer. Additionally, if a woman is not given standard of care, the reason is not included in her chart and is therefore excluded from that entry into the National Cancer Database.

“We never document a clear reason as to why a particular therapy was not done, which is a big part of healthcare that is missing right now,” said Uppal.

In a cohort of 16,195 patients, the rate of guideline-based care was 58.4% (95% CI, 57.4-59.4) for non-Hispanic white women, 53% (95% CI, 51.4-54.9) for non-Hispanic black women, and 51.5% (95% CI, 49.4-53.7) for Hispanic women (<.001). As per a propensity score-matched analysis, women who received guideline-based care had a lower risk of mortality than those who did not (adjusted HR, 0.65; 95% CI, 0.62-0.68).

The study found that racial and ethnic disparities in the administration of guideline-based care were highest in high-volume hospitals.

In an interview with OncLive, Uppal, assistant professor of obstetrics and gynecology at Michigan Medicine, discussed the study and the need for a more comprehensive registry process for patients with cervical cancer.

OncLive: Please provide an overview of this study.

Uppal: One of the areas where I am focusing now is at the intersection of disparities and the utilization of standard of care. What I fundamentally believe is that in order to reduce a disparity, [it is necessary to] look at the quality of the monitoring. That means, asking if everyone receives standard of care quality of care. If that is remedied, then maybe we will see a decline in disparity of care.

We used the National Cancer Database. We looked at information from database from 2004 to 2012. The idea was to basically get patients into 2 cohorts—whether they got the care or did not get the care—and the ones who did not get the care we looked at what component of their care was missing.

We started brainstorming how to answer the question of why guideline-based care was so low, and what should we do next. And we kept coming back to the point that not knowing what is going on is such a big problem. You can imagine a scenario where a patient with cervical cancer has to come to the hospital every single day to get radiation for 5 weeks. So, if we got 200 of these women, and 20 of them said, “Well, I didn't have a car to come to the hospital every single day” is different than them saying, “Oh well, we weren't told that coming everyday is as important as we thought it is.” How we design something to fix this problem will depend on what exactly is the problem. Our paper is just processing that there is a problem. 

What do you do think would be viable next steps to remedy these shortcomings?

What is urgently needed based on these data is that whenever the standard of care is not followed, physicians need to actually document the reason. This is not only needed in cervical cancer, but other cancers as well. Every hospital, in my opinion, should have a repository of why certain patients were not given standard of care. In breast and colorectal cancer, for example, single institutions have looked at what is the number of patients if you were dedicated to delivering patients with national comprehensive cancer network guideline–based care, the rates are somewhere in the range of 75% to 90%. The actual rates are extremely low—60% in the best case scenario. Again, what will be the next step? To find out why is it that 40% of the people are not getting what they should be getting. 

What would you like your fellow oncologists to take away from this study?

Two points. One is that we have to be mindful as to why we are not doing guideline-based care and the second is this misperception in the oncology world that patients are not getting the standard of care because they are going to low-volume hospitals. What we found in our study, is that even when you went to a high-volume hospital, even though you got care which was better than low-volume hospitals, not everybody got standard-of-care. Even in the best-case scenario, we are getting to 65% of white women in high-volume hospitals receiving standard of care. So, just because somebody is doing something many times, doesn’t mean that they are doing it correctly.

Is there anything else you’d like to mention?

There is a related story to this that came out in The New York Times based on a study in the journal Cancer that looked at mortality statistics. We look at how many out of 100,000 actually get a particular cancer and how many die. What they did was recalculate that metric by excluding women who already have their uterus taken out. And because of that, the number of patients who had cervical cancer was extremely high compared to what we have the estimates for. One of the facts is that African-American women get hysterectomies more often than white women, and what ended up happening was that by adjusting the rates by excluding women who have had a hysterectomy before, the mortality in some of the African-American women was close to mortalities from cervical cancer in third-world countries. And that is huge, we are sitting in one of the largest economies and we are still having mortality rates in cervical cancer that are comparable to a third-world country, it is pathetic. This is not something we should be able to tolerate in this country. 
Uppal S, Chapman C, Spencer RJ, et al. Association of hospital volume with racial and ethnic disparities in locally advanced cervical cancer treatment. Obstet Gynecol. 2017;129(2):295-304. doi:10.1097/AOG.0000000000001819.





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