Background

Black women experience worse survival effects with high-grade endometrial cancer. Differences in adjuvant treatment have been proposed to be major contributors to this disparity. However, little is known about the differences in type or timing of adjuvant treatment as it relates to race and ethnicity in the Medicare population.

Objective

This study aimed to examine patterns of adjuvant therapy and survival for non-Hispanic Black women vs non-Hispanic White women and Hispanic women who have undergone surgery for high-grade endometrial cancer in the Medicare population.

Study Design

We used the Medicare-linked Surveillance, Epidemiology, and End Results database to identify women who underwent surgery as a primary treatment for uterine grade 3 endometrioid adenocarcinoma, carcinosarcoma, clear-cell carcinoma, or serous carcinoma between the years 2000 and 2015. Women who did not identify as White or Black race or Hispanic ethnicity were excluded. Multinomial logistic regression was used to estimate odds ratios and 95% confidence intervals for receiving a treatment delay or not receiving adjuvant treatment (compared with those who received adjuvant treatment within 12 weeks) adjusted for clinical and demographic characteristics. Overall survival was stratified by race and ethnicity, route of surgery, operative complications, and type and timing of adjuvant therapy, which were analyzed using the Kaplan-Meier method. Cox proportional-hazards regression was used to estimate the hazard ratio of death by race and ethnicity adjusted for known predictors and surgical outcomes and adjuvant therapy patterns.

Results

A total of 12,201 women met the study inclusion criteria. Non-Hispanic Black patients had a significantly worse 5-year overall survival than Hispanic and non-Hispanic White patients (30.9 months vs 51.0 months vs 53.6 months, respectively). Approximately 632 of 7282 patients (8.6%) who received adjuvant treatment experienced a treatment delay. Delay in treatment of ≥12 weeks was significantly different by race and ethnicity (P=.034), with 12% of Hispanic, 9% of non-Hispanic Black, and 8% of non-Hispanic White women experiencing a delay. After adjustment for the number of complications, age, histology (endometrioid vs nonendometroid), International Federation of Gynecology and Obstetrics stage, marital status, comorbidity count, surgical approach, lymph node dissection, and urban-rural code, Hispanic women had a 71% increased risk of treatment delay (odds ratio, 1.71; 95% confidence interval, 1.23–2.38) for all stages of disease. In the same model, non-Hispanic Black race was independently predictive of decreased use of adjuvant treatment for the International Federation of Gynecology and Obstetrics stage II and higher (odds ratio, 1.32; 95% confidence interval, 1.04–1.68). Non-Hispanic Black race, number of perioperative complications, and nonendometrioid histology were predictive of worse survival in univariate models. Treatment delay was not independently predictive of worse 1- or 5-year survival at any stage.

Conclusion

Non-Hispanic Black race was predictive of worse 5-year survival across all stages and was associated with omission of adjuvant treatment in International Federation of Gynecology and Obstetrics stage II or higher high-grade endometrial cancer. In unadjusted analyses, patients who experience treatment omission or delay experienced poorer overall survival, but these factors were not independently associated in multivariate analyses. This study suggests that race and ethnicity are independently associated with the type and timing of adjuvant treatment in patients with high-grade endometrial cancer. Further efforts to identify specific causes of barriers to care and timely treatment are imperative.

中文翻译：

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医疗保险人群中高级别子宫内膜癌辅助治疗的差异

 背景

黑人女性患有高级别子宫内膜癌时生存效果更差。辅助治疗的差异被认为是造成这种差异的主要原因。然而，人们对辅助治疗类型或时间安排的差异知之甚少，因为它与医疗保险人群中的种族和民族有关。

 客观的

本研究旨在研究医疗保险人群中非西班牙裔黑人女性与非西班牙裔白人女性以及接受过高级别子宫内膜癌手术的西班牙裔女性的辅助治疗和生存模式。

 研究设计

我们使用与医疗保险相关的监测、流行病学和最终结果数据库来确定 2000 年至 2015 年间因子宫内膜样腺癌、癌肉瘤、透明细胞癌或浆液性癌接受手术作为主要治疗的女性。不属于白人或黑人种族或西班牙裔的人被排除在外。多项 Logistic 回归用于估计延迟治疗或未接受辅助治疗（与 12 周内接受辅助治疗的患者相比）的比值比和 95% 置信区间，并根据临床和人口统计学特征进行调整。总生存率按种族和民族、手术途径、手术并发症以及辅助治疗的类型和时间进行分层，并使用 Kaplan-Meier 方法进行分析。 Cox比例风险回归用于估计按种族和族裔分类的死亡风险比，并根据已知的预测因素、手术结果和辅助治疗模式进行调整。

 结果

共有 12,201 名女性符合研究纳入标准。非西班牙裔黑人患者的 5 年总生存率明显低于西班牙裔和非西班牙裔白人患者（分别为 30.9 个月 vs 51.0 个月 vs 53.6 个月）。接受辅助治疗的 7282 名患者中约有 632 名 (8.6%) 经历了治疗延迟。治疗延迟 ≥12 周因种族和民族而存在显着差异 ( P =.034)，其中 12% 的西班牙裔女性、9% 的非西班牙裔黑人女性和 8% 的非西班牙裔白人女性经历了延迟治疗。在调整并发症数量、年龄、组织学（子宫内膜样与非子宫内膜样）、国际妇产科联合会分期、婚姻状况、合并症计数、手术方式、淋巴结清扫和城乡编码后，西班牙裔女性的死亡率为 71%所有疾病阶段的治疗延迟风险增加（比值比，1.71；95% 置信区间，1.23-2.38）。在同一模型中，非西班牙裔黑人种族可以独立预测国际妇产科联合会 II 期及以上辅助治疗使用量的减少（比值比，1.32；95% 置信区间，1.04-1.68）。在单变量模型中，非西班牙裔黑人种族、围手术期并发症的数量和非子宫内膜样组织学可预测较差的生存率。治疗延迟并不能独立预测任何阶段的 1 年或 5 年生存率较差。

 结论

非西班牙裔黑人种族在所有阶段的 5 年生存率均较差，并且与国际妇产科联合会 II 期或更高级别子宫内膜癌的辅助治疗的省略有关。在未经调整的分析中，经历治疗遗漏或延迟治疗的患者总体生存率较差，但这些因素在多变量分析中并不独立相关。这项研究表明，种族和族裔与高级别子宫内膜癌患者辅助治疗的类型和时间独立相关。必须进一步努力查明护理和及时治疗障碍的具体原因。