Socioeconomic and Racial Determinants of Brachytherapy Utilization for Cervical Cancer: Concerns for Widening Disparities

Abstract

QUESTION ASKED: What factors are associated with declining brachytherapy (BT) utilization for cervical cancer (CC) and are racial and socioeconomic ineq-uities in survival outcomes related to BT utilization? SUMMARY ANSWER: Increasing age, Black or unknown race, Medicaid or no insurance, and increasing American Joint Committee on Cancer (AJCC) stage were associated with decreased BT utilization. Significant racial survival differences were noted between Black and White patients; however, these differences were eliminated when our comparison was restricted to patients who received both external beam radiation therapy (EBRT) and BT, suggesting that BT can independently correct racially driven survival inequities. WHAT WE DID: We analyzed 7,266 patients with stage I-IV CC from the SEER database diagnosed between 2007 and 2015. Demographic and disease characteristics were examined for their association with BT use. Overall survival (OS) and disease-specific survival (DSS) were compared between patients who received EBRT alone versus EBRT and BT. Finally, we examined the impact of BT use on racial driven survival differences noted on our multivariate analysis. WHAT WE FOUND: More than 47% of patients did not receive BT as a component of their treatment. Increasing age, Black or unknown race, Medicaid or no insurance, and increasing AJCC stage were associated with decreased BT utilization. EBRT 1 BT demonstrated superior OS and DSS compared with EBRT alone, with the 5-year OS of 58.8% versus 40.5% and the 5-year DSS of 67.0% versus 51.8%, respectively (P , .0001). On multivariate logistic regression analysis, Medicaid versus private insurance (hazard ratio [HR], 1.14; 95% CI, 1.04 to 1.25; P 5 .007), Black versus White race (HR, 1.13; 95% CI, 1.02 to 1.26; P , .001), and increasing AJCC stage (P , .001) were associated with inferior DSS-specific survival, whereas the use of EBRT 1 BT versus EBRT alone (HR, 0.61; 95% CI, 0.56 to 0.66; P , .001) and Other versus White race (HR, 0.84; 95% CI, 0.72 to 0.98; P , .001) was associated with improved DSS. When comparing racial survival differences, the 5-year OS was 44.2% versus 50.9% (P , .0001) and the 5-year DSS was 55.6% versus 60.5% (P , .0001) for Black and White patients, respectively. Importantly, the racial survival disparities resolved when examining patients who received combined EBRT 1 BT, with the 5-year OS of 57.3% versus 58.5% (P 5 .24) and the 5-year DSS of 66.3% versus 66.6% (P 5 .53) for Black and White patients, respectively. BIAS, CONFOUNDING FACTORS, REAL-LIFE IMPLICATIONS: BT is a vital component of standard-of-care therapy for locally advanced CC. Despite its benefits, BT utilization has been declining. CC exhibits notable racial inequities in terms of survival outcomes because of a number of factors including screening rates, vaccination use, and access to appropriate care. Our work confirms notable inequities in terms of utilization of BT for Black and minority women, as well as those with lower insurance status, which unfortunately is directly associated with inferior oncologic outcomes. Importantly, when the use of BT is corrected for, racially driven survival differences no longer exist (Fig). This highlights the importance of BT in the management of CC and demonstrates the need to address access-of-care issues that minority and economically disadvantaged women face. abstract PURPOSE Cervical cancer (CC) disproportionately affects minorities who have higher incidence and mortality rates. Standard of care for locally advanced CC involves a multimodality approach including brachytherapy (BT), which independently improves oncologic outcomes. Here, we examine the impact of insurance status and race on BT utilization with the SEER database. MATERIALS AND METHODS In total, 7,266 patients with stage I-IV CC diagnosed from 2007 to 2015 were included. BT utilization, overall survival (OS), and disease-specific survival (DSS) were compared. RESULTS Overall, 3,832 (52.7%) received combined external beam radiation therapy (EBRT) 1 BT, whereas 3, 434 (47.3%) received EBRT alone. On multivariate logistic regression analysis, increasing age (OR, 0.98; 95% CI, 0.98 to 0.99; P , .001); Medicaid (OR, 0.80; 95% CI, 0.72 to 0.88; P , .001), uninsured (OR, 0.67; 95% CI, 0.56 to 0.80; P , .001), and unknown versus private insurance (OR, 0.61; 95% CI, 0.43 to 0.86; P , .001); Black (OR, 0.68; 95% CI, 0.60 to 0.77; P , .001) and unknown versus White race (OR, 0.30; 95% CI, 0.13 to 0.77; P 5 .047); and American Joint Committee on Cancer stage II (OR, 1.07; 95% CI, 0.93 to 1.24; P 5 .36), stage III (OR, 0.82; 95% CI, 0.71 to 0.94; P 5 .006), stage IV (OR, 0.30; 95% CI, 0.23 to 0.40; P , .001), and unknown stage versus stage I (OR, 0.36; 95% CI, 0.28 to 0.45; P , .001) were associated with decreased BT utilization. When comparing racial survival differences, the 5-year OS was 44.2% versus 50.9% (P , .0001) and the 5-year DSS was 55.6% versus 60.5% (P , .0001) for Black and White patients, respectively. Importantly, the racial survival disparities resolved when examining patients who received combined EBRT 1 BT, with the 5-year OS of 57.3% versus 58.5% (P 5 .24) and the 5-year DSS of 66.3% versus 66.6% (P 5 .53) for Black and White patients, respectively. CONCLUSION This work demonstrates notable inequities in BT utilization for CC that particularly affects patients of lower insurance status and Black race, which translates into inferior oncologic outcomes. Importantly, the use of BT was able to overcome racial survival differences, thus highlighting its essential value.