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Pattern of Care, Health Care Disparities, and Their Impact on Survival Outcomes in Stage IVB Cervical Cancer: A Nationwide Retrospective Cohort Study
  1. Randa J. Jalloul, MD*,
  2. Shelly Sharma, MD,
  3. Celestine S. Tung, MD, MPH,
  4. Barrett O’Donnell, BS§ and
  5. Michelle Ludwig, MD, PhD, MPH*
  1. * Department of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School (formerly known as The University of Texas Health in Houston); Departments of
  2. Radiation Oncology and
  3. Obstetrics and Gynecology, Baylor College of Medicine; and
  4. § McGovern Medical School, Houston, TX.
  1. Address correspondence and reprint requests to Randa J. Jalloul, MD, Department of Obstetrics and Gynecology, McGovern Medical School (formerly known as the University of Texas Health in Houston), 5656 Kelley St, Houston, TX 77026. E-mail: randa.j.jalloul{at}


Objective Although locally advanced cervical cancer can be cured, patients with stage IVB disease have poor prognosis with limited treatment options. Our aim was to describe the pattern of care and analyze health disparity variables that may account for differences in treatment modalities and survival in this population.

Methods The National Cancer Database was queried for patients diagnosed between 2004 and 2013 with metastatic squamous cell carcinoma or adenocarcinoma of the cervix. Codes representing parenchymal and lymphatic metastasis (beyond the para-aortic radiation fields) were used to identify the cohort. Variables included age, race, insurance status, comorbidity, treatment modality, and outcomes. We used Kaplan-Meier methods to compare survival curves and Cox proportional hazards to estimate the association between variables and overall survival (OS). Log-rank method was used to compare Kaplan-Meier curves.

Results There were 4576 patients identified. The majority was white (59.7%); 19.5% were Hispanic, and 9.6% were black. Fifty-one percent had Medicare/Medicaid; 33.7% had private, and 12.5% had no insurance. The majority (56.3%) received chemotherapy (CMT) alone or in combination with radiation therapy (RT) and/or surgery. Median follow-up was 7.3 months (0–124.8 months). Median OS was 11.5 months (10.5–12.5 months). Higher probability of receiving CMT and RT was associated with having private insurance (P < 0.001). Significant prognostic values positively affecting survival on multivariate analysis included black and Asian race, private insurance, comorbidity index of 0, metastatic site at initial presentation (lung), and treatment modality. Patients treated with CMT + RT with or without surgery had significantly better median OS (12 months) compared with those treated with CMT alone (8.3 months), RT alone (4.8 months), or those untreated (2.3 months) (P < 0.001).

Conclusions Insurance status influences treatment options in patients with distant metastatic cervical cancer. Race, comorbidity index, metastatic site, and suboptimal treatment appear to affect survival outcomes. Regardless of treatment, survival was extremely limited.

  • Cervical cancer
  • Health disparities
  • Pattern of care
  • Stage IVB

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  • The authors declare no conflicts of interest.