Vagelos College of Physicians and Surgeons, New York, NY.
Vagelos College of Physicians and Surgeons, New York, NY; Joseph L. Mailman School of Public Health, New York, NY; Columbia University, the Herbert Irving Comprehensive Cancer Center, New York, NY; NewYork-Presbyterian Hospital, New York, NY.
Am J Obstet Gynecol. 2020 Sep;223(3):396.e1-396.e13. doi: 10.1016/j.ajog.2020.02.021. Epub 2020 Feb 25.
Black women experience poorer survival compared with white women across all endometrial cancer stages and histologies. The incidence of endometrial cancer is 30% lower in black women compared with white women, yet mortality is 80% higher in black women. Differences in adherence to evidence-based guidelines have been proposed to be major contributors to this disparity.
We examined whether adherence to evidence-based treatment recommendations for endometrial cancer could mitigate survival disparities between black and white women.
The National Cancer Database was used to identify women with endometrial cancer treated from 2004 through 2016. We established 5 evidence-based quality metrics based on review of primary literature and accepted guidelines: surgical treatment within 6 weeks of diagnosis (Q1), use of minimally invasive surgery (stage I-IIIC; Q2), pelvic nodal assessment (high-risk tumors; Q3), adjuvant radiation (high intermediate risk; Q4), and systemic chemotherapy (stage III-IV; Q5). The rates of 30 and 90 day mortality and 5 year survival were compared between black and white women. To determine the influence of quality on outcomes, we compared outcomes among perfectly adherent black and white women with stage I and III endometrial cancer.
We identified 310,208 women including 35,035 (11.3%) black women and 275,173 (88.3%) white women. Black women were less likely than white women to receive Q1 (65.8 vs 75.6%), Q2 (58.5 vs 72.9%), Q3 (71.3 vs 74.2%), and Q5 (72.7 vs 73.2%) (P < .05 for all). Adherence to each quality metrics was associated with improved survival. Among women with stage I disease, perfect adherence to the relative quality metrics was seen in 53.1% of white and 41.5% of black women. Among perfectly adherent stage I patients, outcomes in black women improved relative to unselected black women; however, they still experienced higher risk of 30 day (adjusted relative risk, 2.25; 95% confidence interval, 1.30-3.90), 90 day (adjusted relative risk, 1.84; 95% confidence interval, 1.23-2.76), and 5 year mortality (adjusted hazard ratio, 1.42; 95% confidence interval, 1.26-1.59) compared with similar white women. Among women with stage III tumors, perfect adherence to the relative quality metrics was seen in 56.6% of white and 44.1% of black women. Perfectly adherent black women with stage III disease had improved outcomes but remained at increased risk of 30 day (adjusted relative risk, 1.86; 95% confidence interval, 1.01-3.44) and 5 year mortality (adjusted hazard ratio, 1.35; 95% confidence interval, 1.22-1.50) compared with white women.
Black women are less likely than white women with endometrial cancer to receive evidence-based care. However, receipt of evidence-based care mitigates but does not eliminate racial disparities in outcomes and black women remain at greater risk of death from endometrial cancer.
在所有子宫内膜癌阶段和组织学中，黑人女性的生存率均低于白人女性。与白人女性相比，黑人女性的子宫内膜癌发病率低 30%，但死亡率却高 80%。有人提出，对循证指南的依从性差异是造成这种差异的主要原因。
我们研究了遵循子宫内膜癌循证治疗建议是否可以减轻黑人和白人女性之间的生存差距。
使用国家癌症数据库确定了 2004 年至 2016 年间接受治疗的患有子宫内膜癌的女性。我们根据主要文献回顾和公认的指南建立了 5 个基于证据的质量指标：诊断后 6 周内进行手术治疗（Q1）、采用微创手术（I 期-IIIC 期；Q2）、进行盆腔淋巴结评估（高危肿瘤；Q3）、辅助放疗（中高危；Q4）和全身化疗（III 期-IV 期；Q5）。比较了黑人和白人女性的 30 天和 90 天死亡率以及 5 年生存率。为了确定质量对结果的影响，我们比较了 I 期和 III 期子宫内膜癌中完全依从和完全不依从的黑人和白人女性的结局。
我们确定了 310208 名女性，包括 35035 名（11.3%）黑人女性和 275173 名（88.7%）白人女性。与白人女性相比，黑人女性接受 Q1（65.8%比 75.6%）、Q2（58.5%比 72.9%）、Q3（71.3%比 74.2%）和 Q5（72.7%比 73.2%）的可能性较小（所有 P 值均<.05）。每个质量指标的依从性均与生存改善相关。在 I 期疾病的女性中，53.1%的白人女性和 41.5%的黑人女性完全符合相对质量指标。在完全依从 I 期患者中，与未选择的黑人女性相比，黑人女性的预后有所改善；然而，与相似的白人女性相比，她们的 30 天（调整后的相对风险，2.25；95%置信区间，1.30-3.90）、90 天（调整后的相对风险，1.84；95%置信区间，1.23-2.76）和 5 年死亡率（调整后的风险比，1.42；95%置信区间，1.26-1.59）的风险仍然更高。在 III 期肿瘤的女性中，56.6%的白人女性和 44.1%的黑人女性完全符合相对质量指标。III 期疾病的完全依从黑人女性的结局有所改善，但与白人女性相比，她们的 30 天（调整后的相对风险，1.86；95%置信区间，1.01-3.44）和 5 年死亡率（调整后的风险比，1.35；95%置信区间，1.22-1.50）的风险仍然更高。
与白人女性相比，患有子宫内膜癌的黑人女性接受循证治疗的可能性较低。然而，接受循证治疗可以减轻但不能消除结局方面的种族差异，黑人女性死于子宫内膜癌的风险仍然更高。
