Equality in Care for All Women: Addressing Disparities in Gynecologic Malignancies at ASCO 2021

At the 2021 American Society of Clinical Oncology (ASCO) Annual Meeting, a multi-session panel led by Dr. Surbhi Grover, an Assistant Professor of Radiation Oncology at the Hospital of the University of Pennsylvania, explored disparities in the treatment of cervical cancer and other gynecological malignancies in the United States and abroad. Here's a recap of those presentations.

Cervical Cancer Management in Botswana: Challenges & Next Steps

Presented by the session chair, Dr. Grover examined the higher incidence of cervical cancer in low-income countries, specifically in Africa, and how radiotherapy access and unequal distribution contribute to this disparity.

In Botswana, which is a rural country in Africa, clinicians have found a higher rate of HIV. About 380,000 people are living with HIV, and there are approximately 5,000 AIDS-related deaths every year, according to data recorded in 2019.

HIV infection due to immunosuppression can increase the risk of certain cancers, such as Kaposi's sarcoma, Non-Hodgkin lymphoma, and cervical cancer, and due to the lengthy care cascade for cervical cancer radiation, patients are unable to receive treatment when needed.

That’s why Dr. Grover set up an oncology clinic with Botswana-UPENN to help assist with care navigation and eliminate gaps in access. The clinic was developed with a multidisciplinary tumor board with the intention of bringing several specialists together for easy intervention when dealing with OB-GYN cancers, and the clinic utilized the following approaches:

• Evaluate and assess patients with nursing staff
• Discuss the case with patients and explain the treatment plan
• Every patient gets recorded into the database so the clinician can learn from outcomes and patterns of care

With these simple interventions, the clinic was able to reduce delays from biopsy to treatment from 120 days to 60 days.

The clinic also found that HIV status has little to do with oncological outcomes and that factors such as stage of cancer, hemoglobin levels, and age play a bigger role in a patient’s ability to receive treatment and overall outcomes, and the clinic continues to strive for equal treatment for all patients in Botswana.

International Disparities in Gynecologic Malignancies

In the next session, Dr. Arunangshu Das, Associate Consultant of Oncology at Square Hospital in Dhaka, Bangladesh, explored disparities in the management and treatment of cervical cancer and ovarian cancer. Looking at cervical cancer, in particular, a majority of patient deaths are in Asia and Africa, and this could be due to one of the three main components of treatment:

• Vaccination: HPV vaccination significantly lowers the risk of cervical cancer, but a disparity in the distribution of the vaccine globally leads to higher rates of cervical cancer for patients in low-income countries.
• Screening: In low-income and middle-income countries, only 19 percent of eligible women are screened for cervical cancer compared with 63 percent in high-income regions.
• Treatment: Radiotherapy is a critical component of cervical cancer management, and there is a disparity in access to radiotherapy in low- and middle-income regions.

According to an initiative launched by WHO to accelerate the elimination of cervical cancer globally, at least 90 percent of girls need to be fully vaccinated with the HPV vaccine by 15, 70 percent of women need to be screened using a high-performance test by 35 and again at 45, and 90 percent of women identified with cervical disease must receive treatment.

Focusing on ovarian cancer, Dr. Das said that the biggest disparity here comes from a lack of standard of care and that a majority of women are deprived of a standard of care due to a:

• Lack of Expert Healthcare Professional: Surgery is the cornerstone of ovarian cancer management, and there is a shortage of healthcare professionals trained in surgical oncology.
• Lack of Evidence-Based Practice: Guidelines and treatment protocols in the developed world may be difficult in adopt in developing countries due to a limitation of resources.
• Limited Access to Chemotherapeutic Agents: Low- and middle-income countries have limited resources, and many chemotherapeutic agents are expensive.
• Limited Access to Molecular Personalized Medicine: PARP inhibitors are becoming a standard of care in ovarian cancer, and access to PARP inhibitors is very limited due to the high price of medicine and lack of government support.

International disparities are a major challenge to fight gynecological malignancies, specifically in low- and middle-income countries, but international collaboration to reduce care gaps, recourse stratified guidelines, and increased access to molecular techniques could help us ensure equal access and care for all patients.

Cervical Cancer Management in the United States: Challenges & Next Steps

Presented by Dr. Jennifer Young Pierce, a Program Leader in Cancer Control and Prevention at the University of South Alabama Mitchell Cancer Institute, the session covered ongoing disparities due to emerging technologies.

Dr. Pierce began by detailing how social determinants of health, such as race, economic stability, and education can impact patients’ mortality, morbidity, and overall life expectancy.

Health disparities in GYN cancers are multifactorial, and there are five main domains of cervical cancer management in the U.S., including:

• Primary Prevention – Vaccination: The HPV vaccination varies wildly around the country.
• Secondary Prevention – Screening & Treatment: The 2020 ASCCP cervical cancer screening guidelines have evolved to incorporate HPV as primary screening, HPV contesting, and Pap testing. It also considers the patient’s previous history.
• Early Diagnosis – Surgery: Consider conization vs. trachelectomy and consider open vs. laparoscopic or robotic surgery. There’s been less push for parametrectomy.
• Advanced Disease – Chemoradiotherapy: We need to consider whether or not Black and white women are receiving the same treatment. According to research, Black women are most likely to receive radiotherapy or receive no treatment.

And according to a few studies, guideline-based care has increasingly reduced this disparity in care, but the disparity is not entirely eliminated.

• Metastatic Disease – Combination Therapy: A study has shown the Bevacizumab added to chemotherapy has increased survival rates for women with cervical cancer. However, there is a racial difference in tumor mutational therapy when considering the combination of immunotherapy with chemotherapy.

Moving forward, ongoing research, guideline-based care, increasing education, and improving widespread access to clinical trials and clinical care is critical to eliminating racial disparities in the management and treatment of cervical cancer for women in the U.S.