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Racial Differences in Surgeons and Hospitals for Endometrial Cancer Treatment

Armstrong, Katrina MD, MS*†‡§; Randall, Thomas C. MD§; Polsky, Daniel PhD*†; Moye, Elizabeth BA*; Silber, Jeffrey H. MD, PhD†¶

doi: 10.1097/MLR.0b013e3182019123
Original Article

Purpose: To determine whether (1) black and white women with endometrial cancer were treated by different surgical specialties and in different types of hospitals and (2) differences in specialty and hospital type contributed to racial differences in survival.

Methods: Retrospective cohort study of 12,307 women aged 65 years and older who underwent surgical treatment of endometrial cancer between 1991 and 1999 in the 11 Surveillance Epidemiology and End Results registries.

Results: Black women were more likely to have a gynecologic oncologist to perform their surgery and to be treated at hospitals that were higher volume, larger, teaching, National Cancer Institute centers, urban, and where a greater proportion of the surgeries were performed by a gynecologic oncologist. In unadjusted models, black women were over twice as likely as white women who died because of cancer (hazards ratio [HR]: 2.33), but nearly all of the initial racial difference in survival was explained by differences in cancer stage, and grade as well as age and comorbidities at presentation (adjusted HR: 1.10). Surgical specialty was not associated with survival and, of the hospital characteristics studied, only surgical volume was associated with survival (P < 0.005). Adjusting for hospital characteristics did not change the racial difference in survival (HR: 1.10). Adjustment for the specific hospital where the woman was treated eliminated the association between race and surgeon specialty and slightly widened the residual racial difference in survival (HR: 1.23 vs. 1.10).

Conclusions: In contrast to several studies suggesting that blacks with breast cancer, colon cancer, or cardiovascular disease are treated in hospitals with lower quality indicators, black women diagnosed with endometrial cancer in Surveillance Epidemiology and End Results regions between 1991 and 1999 were more likely to be treated by physicians with advanced training and in high volume, large, urban, teaching hospitals. However, except for a modest association with hospital surgical volume, these provider and hospital characteristics were largely unrelated to survival for women with endometrial cancer. The great majority of the difference in survival was explained by differences in tumor and clinical characteristics at presentation.

From the *Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA; †Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; ‡Abramson Cancer Center, University of Pennsylvania School of Medicine, Philadelphia, PA; §Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, PA; and ¶Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA.

Supported by the National Cancer Institute grant R01 CA 98901–01.

Reprints: Katrina Armstrong, MD, MS, 1204 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104. E-mail: karmstro@mail.med.upenn.edu.

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© 2011 Lippincott Williams & Wilkins, Inc.