Searching for Equity in Women’s Cancer Care, Home and Abroad

From Botswana to Bangladesh to Alabama, disparities in care are a worldwide problem in for women with gynecological cancers, whether it’s a delay in starting treatment that allows disease to progress, poverty that puts medication out of reach, or what one speaker called the systemic racism that keeps Black patients from joining clinical trials.

“Equality in Care for All Women: Addressing Disparities in Gynecologic Malignancies,” came on the first day of the 2021 Annual Meeting of the American Society of Clinical Oncology. Health equity will be a theme throughout the 5-day virtual meeting. Moderated by Surbhi Grover, MD, MBA, of the University of Pennsylvania, the session also featured Arunangshu Das, FCPS, MBBS, of Square Hospital in Dhaka, Bangladesh, and Jennifer Young Pierce, MD, MPH, FACOG, of Mitchell Cancer Institute at the University of South Alabama.

Botswana

Grover has developed a practice of global radiation oncology from the Princess Marina Hospital in Gaborone, Botswana, and presented data showing that disparities in care in Africa start with the limited number of machines in the central part of the continent—which leads to delays treatment for women with locally advanced cervical cancer.

Botswana has high HIV rates—about 20% of adults are positive, and rates among women of reproductive age are higher. Most people know their HIV status and are receiving treatment. “More than 95% of the ones that are on treatment are actually virally suppressed,” Grover said.

But that immunosuppression increases the risk of cervical cancer. “These are the patients that will need radiotherapy,” she said. “Overall survival for all patients at 2 years is close to 67%; at 5 years, it’s close to 56%.”

The challenge is getting patients treated in a reasonable time frame. It could take 25 days from a clinic visit to get the pathology report, and by the time the patient gets to the first radiation conference, 40 days have passed. Government-funded care doesn’t mean it’s fast, Grover explained. “During this period, a lot of the patients potentially get lost or get sicker. And that has a huge impact on their outcomes,” she said.

In 2015, work began on a clinic with Grover’s hospital to set up care navigation to speed the process, connect the different physicians and laboratory staff, and cut down the number of days from diagnosis to treatment. “Just with the simple intervention, we were able to reduce the [time] from biopsy to treatment from 120 days to 60 days, and we're re-analyzing this data again, since this was last looked at in 2017,” she said.

Other interventions involve addressing problems with electronic medical records and using phone apps to track patients, which has allowed the hospital to record “every single patient” in an application, which eliminates paper and makes it easier to keep tabs on patients. She said, “90% of the patients as well as the providers found this really useful,” and patients are permitted to send free messages if they need to reschedule.

Other projects include using technology to figure out why some women to not follow up for radiation for their cervical cancer, improving screening rates, and working on adjusting screening guidelines, given what they see of patients in their clinic.

International Disparities

Das said the “striking disparities” in cancer management between rich and poor countries reaches every aspect of care, whether it's surgery, chemotherapy, radiotherapy, or pathological service. “Almost 100% of these components are available in the public sector of high-income countries. But if we look at the low-income countries, we can see that only 40% of these essential components are available in public sector,” he said.

Large numbers of patients with major gynecological cancers—cervical, endometrial, and ovarian—live in Africa and Asia, Das explained. But the global burden of where deaths occur does not align with where the resources are.

Each year, he said, about 300,000 women die of cervical cancer and 207,000 die or ovarian cancer, and 80% of new cervical cancer diagnoses and deaths happened in Asia and Africa. “There are 3 important components of cervical cancer management: vaccination, screening and treatment. HPV vaccination lowers the risk of cervical cancer in person. However, huge disparities persist in the distribution of the HPV vaccine throughout the world,” Das said, pointing to maps and data from the New England Journal of Medicine to show that low- and middle-income countries are not keeping up pace.

Other data show that 19% of eligible women are screened for cervical cancer in low-income countries, compared with 63% of women in high-income countries. Access to the most modern therapies is often limited by price—the cost of bevacizumab, he said, is typically beyond the reach of a wage-earner in a country like Bangladesh. And technologies like next-generation sequencing, which are essential for today’s precision medicine strategies, may not even be available in some parts of the world, or even to some poor patients in developed countries.

Das noted how COVID-19’s revelation of disparities in care had become a political issue. “Collaboration to reduce the gap is needed,” he said. Access to resources and “the commitment of international societies and organizations is needed to ensure equality.”

Disparities at Home

Pierce was direct in taking on the “paradox on ongoing disparities and emerging technology,” showing a map of the United States to highlight how cervical cancer rates vary by states. “Specifically, by race, we see higher rates of mortality in Black, Hispanic and Native American women,” she said, noting that disparities have decreased and access to guideline-based care improved.

“However, race is not the only category where we see ongoing disparities. In each state, there are a multitude of differences each county within a state can have,” she said. Using maps from Alabama, she showed the overlap of HPV-associated cancer incidence and poverty.

“We know that in the US race is just a marker for other social determinants of health due to systemic racism. And yet this can be true in other parts of the world as well,” she said. “Differences in economic stability, housing, education, food, community, and access to the healthcare system all play a role in our access to cancer care and our risk of getting cancer.”

Pierce addressed several realities of vaccination:

• HPV vaccination ranges from 39% to 60%, and Pierce said uptake can be affected by cultural concerns that vaccination of teenagers is an invitation to premarital sex.
• In Alabama, those with public insurance are more likely to get the HPV vaccine than those with private coverage

Guidelines that call for HPV screening, testing, and PAP testing and take into account a patient’s history and near- and long-term risk may help. Such factors “ultimately result in a recommendation that is specific to that patient on that day,” Pierce said, but they may not be helpful in other countries.

Social determinants play a role in everything from lack of transportation, to not having child care that leads to missed appointments, to not being enrolled in clinical trials. “It's important to note that differences in screening do account for differences in mortality with up to 50% of women dying of cervical cancer, not having recent screening. However, these do not account for the disparities,” Pierce said.

Why, she asked, are women of different races with cervical cancer at the same stage given different surgical recommendations? It’s a big problem if patients are receiving guideline-based care and yet even in a high-volume hospital the disparities are not completely eliminated, she said.

“Genetic alterations may contribute to these disparities, and increasingly data supports molecular differences at the tumor level by race and other cancers. This is not to say that one race is good or bad, but rather, these genetic differences may play a role in the treatments that we are offering patients and their response to treatment,” Pierce said.

The problem: White women account for most of the patients in the studies used the develop the guidelines.

“If we want to find different treatments that may work differently, we've got to look harder,” she said.