Elsevier

Gynecologic Oncology

Volume 132, Issue 2, February 2014, Pages 403-410
Gynecologic Oncology

High-volume ovarian cancer care: Survival impact and disparities in access for advanced-stage disease

https://doi.org/10.1016/j.ygyno.2013.12.017Get rights and content

Highlights

  • Among patients with advanced-stage ovarian cancer, the provider combination of HVH/HVP is an independent predictor of improved disease-specific survival.

  • Access to high-volume ovarian cancer providers is limited.

  • Barriers are more pronounced for patients with low socioeconomic status, Medicaid insurance, and racial minorities.

Abstract

Objective

To characterize the impact of hospital and physician ovarian cancer case volume on survival for advanced-stage disease and investigate socio-demographic variables associated with access to high-volume providers.

Methods

Consecutive patients with stage IIIC/IV epithelial ovarian cancer (1/1/96–12/31/06) were identified from the California Cancer Registry. Disease-specific survival analysis was performed using Cox-proportional hazards model. Multivariate logistic regression analyses were used to evaluate for differences in access to high-volume hospitals (HVH) (≥ 20 cases/year), high-volume physicians (HVP) (≥ 10 cases/year), and cross-tabulations of high- or low-volume hospital (LVH) and physician (LVP) according to socio-demographic variables.

Results

A total of 11,865 patients were identified. The median ovarian cancer-specific survival for all patients was 28.2 months, and on multivariate analysis the HVH/HVP provider combination (HR = 1.00) was associated with superior ovarian cancer-specific survival compared to LVH/LVP (HR = 1.31, 95%CI = 1.16–1.49). Overall, 2119 patients (17.9%) were cared for at HVHs, and 1791 patients (15.1%) were treated by HVPs. Only 4.3% of patients received care from HVH/HVP, while 53.1% of patients were treated by LVH/LVP. Both race and socio-demographic characteristics were independently associated with an increased likelihood of being cared for by the LVH/LVP combination and included: Hispanic race (OR = 1.72, 95%CI = 1.22–2.42), Asian/Pacific Islander race (OR = 1.57, 95%CI = 1.07–2.32), Medicaid insurance (OR = 2.51, 95%CI = 1.46–4.30), and low socioeconomic status (OR = 2.84, 95%CI = 1.90–4.23).

Conclusions

Among patients with advanced-stage ovarian cancer, the provider combination of HVH/HVP is an independent predictor of improved disease-specific survival. Access to high-volume ovarian cancer providers is limited, and barriers are more pronounced for patients with low socioeconomic status, Medicaid insurance, and racial minorities.

Introduction

The United States accounts for approximately 10% of the world ovarian cancer burden, with an estimated 22,240 new cases being diagnosed in 2013 and 14,030 disease-related deaths [1], [2]. The National Institutes of Health, National Cancer Institute, American College of Obstetricians and Gynecologists, Society of Gynecologic Oncology, and the National Comprehensive Cancer Network (NCCN) have recommended that women with suspected ovarian cancer should be afforded an evaluation and surgical intervention by a qualified gynecologic oncologist, and the Society of Surgical Oncology practice guidelines add that “…optimal treatment of this disease requires the skillful and appropriate integration of cancer surgery and chemotherapy, and is best carried out in centers in which a coordinated and experienced multidisciplinary team is available” [3], [4], [5], [6].

Inadequate access to high-volume providers for disease processes with a demonstrated positive volume–outcome relationship has contributed to widespread racial disparities in cancer care in the United States [7]. For ovarian cancer, the extent to which racial and socioeconomically based differences in access to high-volume providers contribute to disparities in treatment and survival has not been well characterized [8]. The primary objective of the current study was, therefore, to investigate the impact of socio-demographic variables, including race, payer status, and socioeconomic status (SES), on access to high-volume ovarian cancer hospitals and physicians in the most clinically challenging patient population —those with stage IIIC/IV disease. As a secondary objective, we aimed to characterize the combined impact of both hospital and physician case volume on ovarian cancer-specific survival.

Section snippets

Methods

The study design was a retrospective population-based study of invasive epithelial ovarian cancer reported to California Cancer Registry (CCR) and received exempt status by the Institutional Review Board of the University of California, Irvine (HS#2011-8317). CCR case reporting is estimated to be 99% for the entire state of California, with follow-up completion rates exceeding 95% [9]. International Classification of Disease Codes for Oncology (ICD-O) based on World Health Organization's

Population characteristics

The median age at diagnosis was 65.0 years (range = 18–104 years), and 7272 patients (61.3%) had Stage IIIC disease, while 38.7% had Stage IV disease (Table 1). White patients accounted for 71.7% of cases, followed in frequency by Hispanics (15.3%), Asian/Pacific Islanders (8.3%), and Blacks (4.7%). Private insurance was the most common payer category (47.7%), and 32.5% of patients had Medicare.

A total of 400 hospitals provided care to advanced-stage ovarian cancer patients during the 11-year study

Conclusions

Eliminating health disparities and improving the health of all socio-demographic groups have become national priorities [15], [16], [17]. For women with ovarian cancer, racial and ethnic minority populations, the economically disadvantaged, and those with safety-net insurance have worse survival outcomes and are more likely to receive less than the standard of care [18], [19]. For example, data from the National Center for Health Statistics and the National Cancer Institute indicate that from

Conflict of interest statement

No author has a conflict of interest to disclose.

Acknowledgment

Dr. Robert E. Bristow was supported in part by the Queen of Hearts Foundation.

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  • Cited by (0)

    This study was funded in part by the Queen of Hearts Foundation.

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