Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland.
John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland.
JAMA Netw Open. 2023 Apr 3;6(4):e238437. doi: 10.1001/jamanetworkopen.2023.8437.
Disparities in survival exist between non-Hispanic Black (hereafter, Black) and non-Hispanic White (hereafter, White) patients with uterine cancer.
To investigate factors associated with racial disparities in survival between Black and White patients with uterine cancer.
DESIGN, SETTING, AND PATIENTS: This cohort study used data from the National Cancer Database on 274 838 Black and White patients who received a diagnosis of uterine cancer from January 1, 2004, to December 31, 2017, with follow-up through December 2020. Statistical analysis was performed in July 2022.
Overall survival by self-reported race and evaluation of explanatory study factors associated with hazard ratio (HR) reduction for Black vs White patients. A propensity scoring approach was applied sequentially to balance racial differences in demographic characteristics, comorbidity score, neighborhood income, insurance status, histologic subtype, disease stage, and treatment.
The study included 32 230 Black female patients (mean [SD] age at diagnosis, 63.8 [10.0] years) and 242 608 White female patients (mean [SD] age at diagnosis, 63.5 [10.5] years) and had a median follow-up of 74.0 months (range, 43.5-113.8 months). Black patients were more likely than White patients to have low income (44.1% vs 14.0%), be uninsured (5.7% vs 2.6%), present with nonendometrioid histologic characteristics (46.1% vs 21.6%), have an advanced disease stage (34.1% vs 19.8%), receive first-line chemotherapy (33.8% vs 18.2%), and have worse 5-year survival (58.6% vs 78.5%). Among patients who received a diagnosis at younger than 65 years of age, the HR for death for Black vs White patients was 2.43 (95% CI, 2.34-2.52) in a baseline demographic-adjusted model and 1.29 (95% CI, 1.23-1.35) after balancing other factors. Comorbidity score, neighborhood income, insurance status, histologic subtype, disease stage, treatment, and unexplained factors accounted for 0.8%, 7.2%, 11.5%, 53.1%, 5.8%, 1.2%, and 20.4%, respectively, of the excess relative risk (ERR) among the younger Black vs White patients. Among patients 65 years or older, the HR for death for Black vs White patients was 1.87 (95% CI, 1.81-1.93) in the baseline model and 1.14 (95% CI, 1.09-1.19) after balancing other factors. Comorbidity score, neighborhood income, insurance status, histologic subtype, disease stage, treatment, and unexplained factors accounted for 3.0%, 7.5%, 0.0%, 56.2%, 10.6%, 6.9%, and 15.8%, respectively, of the ERR among Black vs White patients aged 65 years or older.
This study suggests that histologic subtype was the dominant factor associated with racial survival disparity among patients with uterine cancer, while insurance status represented the main modifiable factor for women younger than 65 years. Additional studies of interactions between biology and social determinants of health are merited.
非西班牙裔黑种人（以下简称“黑人”）和非西班牙裔白种人（以下简称“白人”）的子宫癌患者之间存在生存差异。
研究与黑人与白人患者的子宫癌生存差异相关的因素。
设计、设置和患者：本队列研究使用了国家癌症数据库的数据，纳入了 2004 年 1 月 1 日至 2017 年 12 月 31 日期间诊断为子宫癌的 274838 名黑人和白人患者，随访至 2020 年 12 月。统计分析于 2022 年 7 月进行。
根据自我报告的种族和评估与黑人与白人患者的危险比（HR）降低相关的解释性研究因素来评估总生存率。应用倾向评分方法依次平衡了人口统计学特征、合并症评分、社区收入、保险状况、组织学亚型、疾病分期和治疗方面的种族差异。
研究纳入了 32230 名黑人女性患者（诊断时的平均[标准差]年龄为 63.8[10.0]岁）和 242608 名白人女性患者（诊断时的平均[标准差]年龄为 63.5[10.5]岁），中位随访时间为 74.0 个月（范围：43.5-113.8 个月）。与白人患者相比，黑人患者更有可能来自低收入家庭（44.1% vs 14.0%）、没有保险（5.7% vs 2.6%）、表现出非子宫内膜样组织学特征（46.1% vs 21.6%）、疾病分期更晚（34.1% vs 19.8%）、接受一线化疗（33.8% vs 18.2%），并且 5 年生存率更差（58.6% vs 78.5%）。在诊断年龄小于 65 岁的患者中，黑人与白人患者的死亡 HR 在基线人口统计学调整模型中为 2.43（95%CI，2.34-2.52），在平衡其他因素后为 1.29（95%CI，1.23-1.35）。合并症评分、社区收入、保险状况、组织学亚型、疾病分期、治疗和未解释的因素分别解释了年轻黑人与白人患者中 0.8%、7.2%、11.5%、53.1%、5.8%、1.2%和 20.4%的超额相对风险（ERR）。在 65 岁及以上的患者中，黑人与白人患者的死亡 HR 在基线模型中为 1.87（95%CI，1.81-1.93），在平衡其他因素后为 1.14（95%CI，1.09-1.19）。合并症评分、社区收入、保险状况、组织学亚型、疾病分期、治疗和未解释的因素分别解释了 65 岁及以上黑人与白人患者中 3.0%、7.5%、0.0%、56.2%、10.6%、6.9%和 15.8%的 ERR。
本研究表明，组织学亚型是与子宫癌患者种族生存差异相关的主要因素，而保险状况是年轻患者（<65 岁）的主要可调节因素。需要进一步研究生物学和健康社会决定因素之间的相互作用。
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