Effect of race and histology on patterns of failure in women with early stage endometrial cancer treated with high dose rate brachytherapy

Health Disparities in Uterine Cancer: Report From the Uterine Cancer Evidence Review Conference

The Centers for Disease Control and Prevention recognized the need for educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. The American College of Obstetricians and Gynecologists convened a panel of experts in evidence review from the Society for Academic Specialists in General Obstetrics and Gynecology and content experts from the Society of Gynecologic Oncology to review relevant literature, best practices, and existing practice guidelines for the development of evidence-based educational materials for women's health care clinicians about uterine cancer. This article is the evidence summary of the literature review of health disparities and inequities related to uterine cancer. Substantive knowledge gaps are noted and summarized to provide guidance for future research.

Black and Hispanic women are less likely than white women to receive guideline-concordant endometrial cancer treatment

BACKGROUND

Differences in receipt of guideline-concordant treatment might underlie well-established racial disparities in endometrial cancer mortality.

OBJECTIVE

Using the National Cancer Database, we assessed the hypothesis that among women with endometrioid endometrial cancer, racial/ethnic minority women would have lower odds of receiving guideline-concordant treatment than white women. In addition, we hypothesized that lack of guideline-concordant treatment was linked with worse survival.

STUDY DESIGN

We defined receipt of guideline-concordant treatment using the National Comprehensive Cancer Network guidelines. Multivariable logistic regression models were used to compute odds ratios and 95% confidence intervals for associations between race and guideline-concordant treatment. We used multivariable Cox proportional hazards regression models to estimate hazards ratios and 95% confidence intervals for relationships between guideline-concordant treatment and overall survival in the overall study population and stratified by race/ethnicity.

RESULTS

This analysis was restricted to the 89,319 women diagnosed with an invasive, endometrioid endometrial cancer between 2004 and 2014. Overall, 74.7% of the cohort received guideline-concordant treatment (n = 66,699). Analyses stratified by race showed that 75.3% of non-Hispanic white (n = 57,442), 70.1% of non-Hispanic black (n = 4334), 71.0% of Hispanic (n = 3263), and 72.5% of Asian/Pacific Islander patients (n = 1660) received treatment in concordance with guidelines. In multivariable-adjusted models, non-Hispanic black (odds ratio, 0.92, 95% confidence interval, 0.86-0.98) and Hispanic women (odds ratio, 0.90, 95% confidence internal, 0.83-0.97) had lower odds of receiving guideline-concordant treatment compared with non-Hispanic white women, while Asian/Pacific Islander women had a higher odds of receiving guideline-concordant treatment (odds ratio, 1.11, 95% confidence interval, 1.00-1.23). Lack of guideline-concordant treatment was associated with lower overall survival in the overall study population (hazard ratio, 1.12, 95% confidence interval, 1.08-1.15) but was not significantly associated with overall survival among non-Hispanic black (hazard ratio, 1.09, 95% confidence interval, 0.98-1.21), Hispanic (hazard ratio, 0.92, 95% confidence interval=0.78-1.09), or Asian/Pacific Islander (hazard ratio, 0.90, 95% confidence interval, 0.70-1.16) women.

CONCLUSION

Non-Hispanic black and Hispanic women were less likely than non-Hispanic white women to receive guideline-concordant treatment, while Asian/Pacific Islander women more commonly received treatment in line with guidelines. Furthermore, in the overall study population, overall survival was worse among those not receiving guideline-concordant treatment, although low power may have had an impact on the race-stratified models. Future studies should evaluate reasons underlying disparate endometrial cancer treatment.

Endometrial cancer disparities: a race-conscious critique of the literature

Racial disparities in endometrial cancer are stark and have increased over the past decade. While the disparities are well documented, intervention work to address the mortality gap is nonexistent. This review critiques how race has been conceptualized to explain the causes of endometrial cancer disparities, assesses gaps in knowledge production, and proposes new research priorities. Using public health critical race praxis, a research approach for examining racial disparities and knowledge production processes, we reviewed the endometrial cancer disparities literature from 1995 through 2016. Using systematic search methods, 133 unique records were identified and 48 studies critiqued. We found that a narrow definition of race as a purely biological construct is common throughout the literature. This appears to result in an underemphasis on the role of modifiable, nonbiological contributors to racial disparities and a lack of follow-up work to address these contributors. Key knowledge gaps identified were the role of health care systems in early diagnosis, a lack of intervention studies to address persistent treatment inequity by race, and the near absence of qualitative work to understand the perspectives of Black women diagnosed with endometrial cancer. We conclude with an iterative demonstration of the public health critical race praxis and suggest new routes of inquiry to broaden the scope of research priorities to understand and improve the outcomes of Black women with endometrial cancer.

Treatment strategies for endometrial cancer: current practice and perspective

PURPOSE OF REVIEW

Endometrial cancer incidence is increasing in North America and is a major cause of morbidity and mortality in women. We review recent literature published on treatment of endometrial cancer and highlight areas of active interest.

RECENT FINDINGS

There has been movement toward minimal invasive surgery at diagnosis; lymph node staging remains controversial and continues to be investigated. Progress has been made to establish consensus on endometrial cancer risk classification to promote consistency for future trial design. Molecular characterization of endometrial cancer and its integration into clinicopathological profiling to develop predictive biomarkers for treatment selection are active areas of research. Optimal adjuvant treatment strategy in high-risk endometrial cancer remains to be defined with recognition of treatment-related toxicity. Despite encouraging results in drug development for treatment of advanced/recurrent endometrial cancer, no targeted therapies beyond hormonal therapy are approved. There is an urgent need for scientifically validated therapy with predictive biomarkers.

SUMMARY

Our understanding of endometrial cancer has evolved through improvements in molecular biology, allowing improved definition of target-specific therapies. The precise role and sequence of conventional and targeted therapies, including immunotherapy, will require careful attention to the design of clinical trials with translational emphasis to allow the discovery, validation, and implementation of predictive biomarkers into clinical care.

Endometrial carcinoma recurrence according to race and ethnicity: An NRG Oncology/Gynecologic Oncology Group 210 Study

Non-Hispanic black (NHB) women are more likely to experience an endometrial carcinoma (EC) recurrence compared to non-Hispanic white (NHW) women. The extent to which tumor characteristics, socioeconomic status (SES) and treatment contribute to this observation is not well defined. In the NRG Oncology/Gynecology Oncology Group (GOG) 210 Study we evaluated associations between race/ethnicity and EC recurrence according to tumor characteristics with adjustment for potential confounders. Our analysis included 3,199 NHW, 532 NHB and 232 Hispanic women with EC. Recurrence was documented during follow-up. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between race/ethnicity and EC recurrence in models stratified by histologic subtype (low-grade endometrioid, high-grade endometrioid, serous, mixed cell, carcinosarcoma, clear cell) or stage (I, II, III) and adjusted for age, SES, body mass index, smoking status and treatment. In histologic subtype-stratified models, higher EC recurrence was noted in NHB women with low-grade endometrioid (HR = 1.94, 95% CI = 1.21-3.10) or carcinosarcomas (HR = 1.66, 95% CI = 0.99-2.79) compared to NHWs. In stage-stratified models, higher EC recurrence was noted among NHB women with stage I (HR = 1.48, 95% CI = 1.06-2.05) and Hispanic women with stage III disease (HR = 1.81, 95% CI = 1.11-2.95). Our observations of higher EC recurrence risk among NHB and Hispanic women, as compared to NHW women, were not explained by tumor characteristics, SES, treatment or other confounders. Other factors, such as racial differences in tumor biology or other patient factors, should be explored as contributors to racial disparities in EC recurrence.

ACR Appropriateness Criteria® Management of Recurrent Endometrial Cancer

OBJECTIVES

In women with endometrial carcinoma (EC), tumor recurrences tend to occur in the 2- to 3-year period following surgical staging. Management of disease recurrence in EC poses significant challenges. These patients represent a heterogenous group where histologic subtypes, previous adjuvant management, interval since completion of adjuvant therapy, and size and site(s) of disease recurrence all have important implications on salvage therapies and prognosis. No randomized controlled trials have been published to determine optimal management in this group of patients. An expert panel was convened to reach consensus on the most appropriate management options in this group of patients.

METHODS

The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

RESULTS

Five clinical variants were developed to address common scenarios in the management of women with recurrent EC. Group members reached consensus on the appropriateness of specific evaluation and treatment approaches with numerical ratings.

CONCLUSIONS

In combining available medical literature and expert opinions, this manuscript may serve as an aid for other practitioners in the appropriate management of women with recurrent EC.

Endometrial cancer associated biomarkers in bariatric surgery candidates: exploration of racial differences

BACKGROUND

Obesity is the main risk factor for endometrial cancer (EC), the most common gynecologic malignancy in the United States. A number of potential risk biomarkers have been associated with EC development, including altered proinflammatory cytokines, chemokines, and adipokines.

OBJECTIVES

The overarching aim of this research is to investigate racial differences in the expression of EC-associated biomarkers among bariatric surgery candidates.

SETTING

Tertiary academic medical center METHODS: Blood samples were collected from 175 women aged 18 to 72 (mean age: 42.93; standard deviation 11.66), before bariatric surgery. Levels of biomarkers associated with obesity and EC risk were measured using xMAP immunoassays. Wilcoxon rank sum and Fisher's exact tests were utilized to compare biomarker and demographic variables between African American and European American women. Linear regression models, adjusted for menopause status and diabetes, were utilized to identify factors associated with biomarker levels.

RESULTS

When the biomarker levels were compared by race, insulin-like growth factor-binding protein 1 and adiponectin were significantly lower in African American women (P<.05), whereas estradiol was significantly higher in African American women (P<.05). Linear regression models found that race significantly predicted insulin-like growth factor binding protein 1, adiponectin, resistin, and interleukin-1 receptor alpha expression levels, menopause status and diabetes status were significantly associated with adiponectin and leptin levels, whereas body mass index was significantly associated with leptin, adiponectin, interleukin-1 receptor alpha, and interleukin-6 levels.

CONCLUSION

As one of the first efforts to explore racial differences in EC-associated biomarkers in a cohort of women with severe obesity, this study found several significant differences that should be further explored in large-scale studies.