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GYN Cancer Equity
Overcoming Barriers and Optimizing Outcomes in Gynecologic Cancer Care Delivery: Thoughts From an Educational Program Focused on Healthcare Equity

Released: October 12, 2023

Ritu Salani
Ritu Salani, MD, MBA
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Key Takeaways
  • Increasing healthcare professionals’ awareness and promoting action to resolve inequities in gynecologic cancer care are critical, particularly for improving outcomes in Black patients who may present with more advanced disease and may not receive guideline-concordant care.
  • Continued education on facilitating patient adherence to standard of care treatments and facilitating resources to empower patients may help support some of the most vulnerable patients.
  • Point-of-care resources are needed to help improve patient‒healthcare professional dialogue on disease education, medication, transportation assistance programs, and molecular testing, particularly in a time- and resource-limited setting.

Despite recent advances in gynecologic cancer care, health disparities and barriers to equitable care delivery remain in clinical practice. Gynecologic cancer incidence and mortality vary by race and ethnicity, but data suggest that morbidity and mortality can potentially be reduced with timely screening, early diagnosis, and adherence to guideline-concordant treatment. For example, Black women with endometrial cancer have a 90% higher mortality rate than White women with endometrial cancer, which is often attributed to delay in diagnosis and not pursuing guideline-concordant care. The advanced disease stage at which Black women receive a diagnosis of endometrial cancer (only 53% diagnosed as early stage) is a major factor in this disparity. In addition, in the United States, HPV-related cervical cancer incidence and mortality is higher in underrepresented women of color when compared with White women—which is thought to be the result of lower HPV vaccination rates among Black and other underserved populations.

In this commentary, I share my thoughts and key strategies from a multidisciplinary program developed for oncology professionals, including MDs, PharmDs, NPs, and PAs, with the goal of raising awareness and providing education on optimal and equitable care delivery for all patients with gynecologic cancers.

Providing Patient Education and Reinforcing Clinical Trial Participation
We know that patients may experience different outcomes based on sociodemographic status, health literacy, and access to care—particularly to the various treatments available for their cancer type (eg, localized treatments and systemic immunotherapy alone or in combination with chemotherapy for advanced endometrial and cervical cancer). We must encourage guideline-concordant care for all of our patients and provide printed or downloadable resources with a focus on addressing healthcare disparities and increasing adherence to guideline-concordant care. We also know that patients of different backgrounds may be equally interested in clinical trials if given the chance to understand the trial objectives and the fact that they can potentially receive the standard of care for their disease. Thus, discussing clinical trials equally with all patients is key in overcoming barriers to care in clinical trial enrolment. Notwithstanding, we recognize that not all patients may feel the same way about participating in clinical trials and some might not understand the goals of a clinical trial. Having discussions with these patients about treatment goals, challenges that might impact their adherence to recommended treatment, and addressing preconceived concerns are key.

I think all patients should be offered a clinical trial if they would benefit from it and there is a center near them with a relevant clinical trial that we might be able to offer. We can empower patients by facilitating access to resources like the Just Ask program, which helps with patient-centered education and promotes clinical trial enrollment of underserved populations by increasing their knowledge of the benefits of participation, including testimonials of patients who have had a similar experience. Based on healthcare professional (HCP) surveys that were part of this educational program, it seems that fewer than 25% of HCPs frequently or always provide like-patient testimonials to underserved populations, which has been demonstrated to improve enrollment on clinical trials (n = 260).

Overall Educational Strategies From the Program
HCP-endorsed education and patient resources were also provided for download to all participants. These resources include strategies to help providers start a conversation with their patients, promote a shift from awareness of health disparities to agreement with best practices, and review recommendations on how to apply best practices. For instance, patient-resource PDFs summarize information on the given gynecologic cancer such as current guidelines for HPV screening and molecular testing in cervical cancer, assessment of microsatellite instability status in endometrial cancer, and when germline or somatic BRCA molecular tests might be appropriate for patients with ovarian cancer. In addition, educational resources cite strategies to increase access to care for vulnerable populations such as facilitating access to patient navigators if available, receipt of treatment at high-volume centers, leveraging community pharmacies to improve HPV vaccination rates, connecting patients with ongoing clinical trials, and sharing financial resources potentially available to patients who qualify based on income status.

Remaining Barriers After the Program
In follow-up surveys, we noted “that lack of time” was a significant barrier from a physician or physician-provider team’s perspective—here we saw that 20% (n = 208) of survey participants lacked sufficient time to implement the recommendations. In my opinion, it may be unreasonable for the healthcare team to be expected to coordinate transportation or childcare needs for patients in addition to their daily responsibilities (medication or treatment administration, follow-up appointments, imaging, etc). However, having resources like these PDFs for patients with information about what resources are available and how to apply for them can potentially make a big difference. Another situation where resources may be helpful is where the care site does not have a budget for a social worker or patient navigator on-site, which can be expensive.

Final Thoughts and Takeaways
This education has taught us that awareness of health disparities is key and that we should all ensure our patients are well educated about their disease, the goal of their treatment, and the importance of remaining adherent to guideline-concordant care—whether it is on a clinical trial or standard-of-care treatment.

As time allows, we also need to help patients identify what resources are available, including grants to cover the cost of care, resources to learn more about their disease—the American Cancer Society website, for example—and other resources like transportation and childcare assistance so they are able to keep and get to their appointment visits.

This will be a dynamic process, but by keeping delivery of equitable gynecologic cancer care top of mind, we can make progress on overcoming the barriers of today and potentially uncover new barriers that have not yet been recognized. Thus, staying current with education like this program and highlighting the issues that our patients face is extremely important. Personally, I can say that I learned a lot from this experience.

I encourage you to learn about health disparities and improving outcomes for all women with gynecologic cancers by visiting the program on the CCO website titled “Smarter. Stronger. Together. Optimizing Outcomes and an Equitable Healthcare Experience for All Patients With Gynecologic Cancers.”

Your Thoughts?
What strategies do you include in your practice to ensure equitable care for all of your patients with gynecologic cancers? Please take a moment to answer the poll and leave a comment below.

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How often do you provide underrepresented women of color with education about the benefits of enrolling on randomized clinical trials for endometrial, ovarian, or cervical cancers?

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