Disparities in Use of Gynecologic Oncologists for Women with Ovarian Cancer in the United States

One of the most lethal cancers for women in the United States is ovarian cancer. Although it accounts for only 3 percent of all cancers, it is the fifth most common cause of death among women after lung, breast, colorectal, and pancreatic cancer (American Cancer Society 2010). Treatment for ovarian cancer includes surgery, chemotherapy, and radiation therapy; in many instances, two or even all of the treatments are recommended (American Cancer Society 2009). In addition, appropriate staging is important to plan follow-up treatment, that is, chemotherapy and radiation, and debulking to surgically remove as much of the tumor as possible. Surgery is usually followed by chemotherapy, which is important to increase the chance of killing residual tumor cells, and thus improving survival (National Cancer Institute 2010a). Another key component of quality of care for women with ovarian cancer is the care delivered by gynecologic oncologists (GOs). At any stage of disease, patients whose surgery was performed by GOs have been shown to have optimal debulking, smaller residual tumors, and higher survival rates than patients operated on by obstetric gynecologists or general surgeons (Eisenkop et al. 1992; Mayer et al. 1992; Nguyen et al. 1993; Junor, Hole, and Gillis 1994; Kehoe et al. 1994; Woodman et al. 1997; Junor et al. 1999; Carney et al. 2002; Elit et al. 2002; Chan et al. 2007; Vernooij et al. 2009). In addition, GOs provide comprehensive management of ovarian cancer and thus provide continuity of care that is important for women with this disease (Elit et al. 2010). The 2011 Clinical Practice Guidelines for Oncology by the National Comprehensive Cancer Network (NCCN) recommend that GOs should provide the primary assessment, debulking, and follow-up care for women with ovarian cancer (NCCN Clinical Practice Guidelines in Oncology 2011). Despite these national guidelines, not all women diagnosed with ovarian cancer receive care from GOs. Non-Hispanic African American women may be at higher risk of not receiving this care compared to non-Hispanic white women. This may contribute to non-Hispanic African Americans having higher mortality rates despite having lower incidence of ovarian cancer than non-Hispanic white women (Barnholtz-Sloan et al. 2002; Altekruse et al. 2010). Moreover, previous studies have reported that non-Hispanic African American women are diagnosed at later stages of ovarian cancer and are less likely to receive appropriate treatment (Barnholtz-Sloan et al. 2002; Chan et al. 2008). Furthermore, studies in other areas, such as pancreatic cancer, neurology, and cardiovascular disease, documented that non-Hispanic African Americans and other minorities are less likely than non-Hispanic whites to be treated by specialists (McGowan et al. 1985; Kogan, Kotelchuck, and Johnson 1993; Blustein and Weiss 1998; Murphy et al. 2009). In addition, disparities in health care utilization exist by age, education, income, health insurance, English language proficiency, and rural/urban residence (Agency for Healthcare Research and Quality 2010), and it may also exist in the use of GOs among ovarian cancer patients. We currently do not know whether disparities exist in utilization of GO care. The objective of this study was to examine the utilization of GO specialists across sociodemographic variables and, in particular, to test the hypothesis that non-Hispanic African American women were less likely to receive care from a GO compared to non-Hispanic white women. In addition, since GOs provide comprehensive care to women with ovarian cancer, we investigated the utilization of GOs in the different phases of care, that is, the study evaluated the use of GOs not only for initial ovarian cancer treatment but also for longer term care.