Racial Disparities in the Ovarian Cancer Care Continuum: from the Symptomatic Period to the End of Life

Abstract

Ovarian cancer is the deadliest gynecologic cancer with less than half of women surviving five years after their diagnosis. At all stages of diagnosis and across histologic subtypes, black women have the poorest survival. Despite survival improvements among white women, survival in black women has declined. Evidence overwhelmingly points to differential care driving this disparity. This dissertation evaluates race and racially driven exposures in two phases of the ovarian cancer care continuum, the symptomatic window prior to diagnosis and end-of-life care. In Aim 1, we evaluated the associations between everyday discrimination and trust in physicians with a prolonged interval between symptom onset and ovarian cancer diagnosis in the African American Cancer Epidemiology Study. Perceived everyday discrimination was associated with prolonged symptom duration whereas more commonly evaluated determinants of access to care and trust in physicians were not. In Aim 2, we evaluated racial disparities in aggressive end-of-life care among older women with ovarian cancer in the Surveillance, Epidemiology and End Results linkage with Medicare. We also explored the association of care characteristics including source of evaluation and management, utilization of hospice/palliative care visits, and continuity of care. We found that nonwhite women were more likely to receive aggressive end-of-life care than white women. While the proportion of management done in oncology, receipt of a hospice or palliative evaluation and management visit and continuity of care were associated with certain outcomes, they did not explain the racial variation that we see in these outcomes. In Aim 3, we investigated physician variation in aggressive end-of-life care. We found substantial clustering in physicians for many aggressive end-of-life care indicators including chemotherapy, not enrolling in hospice, and multiple hospitalizations in the last month of life. Although physician characteristics did not meaningfully explain the racial differences seen in receipt of aggressive end-of-life care, nonwhite women tended to see different types of physicians, and seeing a physician with a more racially diverse patient base was associated with higher odds of not receiving hospice, having a stay in the ICU, receiving a life extending procedure, and having a terminal hospitalization. Overall, this dissertation is one of the first to examine racial disparities across the care continuum for women diagnosed with ovarian carcinoma. Findings suggest that black women tend to receive different care for their ovarian cancer than white women, especially towards the end of life. Future studies must delve further into the effects of racism and patient care practices on ovarian cancer care in order to identify targets for intervention.