Receipt of Adjuvant Endometrial Cancer Treatment According to Race NRG Oncology/Gynecologic Oncology Group (GOG) 210 Study Ashley Felix, PhD, MPH Assistant Professor of Epidemiology Ohio State University College of Public Health NRG Scientific Session July 19, 2019

Disclosures No disclosures.

Cancer Health Disparities Cancer health disparities are adverse differences between certain population groups in cancer measures, such as: incidence, prevalence, morbidity (cancer-related health complication), mortality, survivorship and quality of life after cancer treatment, burden of cancer or related health conditions, screening rates, and stage at diagnosis Examine differences between Black and White women Residual direct effect: Measures the racial differences NOT mediated by measurable disadvantage (e.g. education differences)

Blacks are more likely to die from EC than whites Black women are 93% more likely to die from endometrial cancer compared to white women Annual Report to the Nation on the Status of Cancer, 1975-2014

Black women have more aggressive EC Stage Distribution for Uterine Cancer by Race, United States, 2008 to 2014 Age-adjusted Uterine Cancer Incidence Rates by Histology and Race, United States, 2000 to 2011 Annual Report to the Nation on the Status of Cancer, 1975-2014 Cote ML et al. CEBP 2014

Is more aggressive disease the whole story? Black women are more likely to have more advanced stage disease and aggressive histology – factors that contribute to their worse survival However, within these subgroups, racial disparities still exist

Is more aggressive disease the whole story? Low-grade endometrioid All histological types High-grade endometrioid Serous Cote ML et al. CEBP 2014

Other factors that might contribute to racial disparities in EC survival Lower socioeconomic status Higher prevalence of comorbid conditions Poor patient-provider interactions Inferior treatment Surgery is less common among Black women with EC compared to White women Adjuvant treatment differences?

Based on poorer survival we hypothesized receipt of adjuvant treatment would be lower among African-American compared to White endometrial cancer patients

NRG Oncology/Gynecologic Oncology Group (GOG) 210 Trial Molecular and pathological staging trial >6,000 endometrial cancer patients enrolled Risk factor questionnaire administered prior to standard treatment Central pathology review

Methods Classified treatment as no adjuvant, radiation only, chemotherapy only, radiation plus chemotherapy No information on radiation type/dose, chemotherapy agent/dose Odds of receiving adjuvant treatment according to race stratified by histology or stage Polytomous logistic regression: ORs and 95% CI

Results N=4,898 (Black, n=615, White, n=4,283) Model adjusted for age at diagnosis, tumor subtype, stage, annual income, educational attainment Results N=4,898 (Black, n=615, White, n=4,283)

Model adjusted for age at diagnosis, tumor subtype, stage, annual income, educational attainment

Results No differences by stage Could not examine race and treatment associations in strata cross-classified by histology and stage

Discussion Findings were in contrast to our hypotheses Lack of information on other factors that guide treatment (e.g. patient preferences, overall health status) Increased clinician awareness of poorer survival among black as compared with white endometrial cancer patients Additional hypotheses of interest Quality of patient-provider interactions Regional variations in treatment patterns

Acknowledgements Grant/Sponsor Acknowledgements Author’s Affiliations Ohio State University, Pennsylvania State University, Memorial Sloan Kettering Cancer Center, Washington University School of Medicine, Medical University of South Carolina, University of Oklahoma, Brown University, Roswell Park Cancer Institute, University of Colorado Cancer Center, University of Minnesota, Case Western Reserve University, University of North Carolina, State University of New York at Stony Brook, University of Maryland, University of Kentucky, National Cancer Institute Grant/Sponsor Acknowledgements This study was supported by National Cancer Institute grants to the Gynecologic Oncology Group Administrative Office (CA 27469), the Gynecologic Oncology Group Statistical and Data Center (CA 37517) and the NRG Oncology Grant number: 1 U10 CA180822 and U10 CA180868 In addition, this research was supported in part by funds provided by the intramural research program of the National Cancer Institute, National Institutes of Health