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Association of Hospital Volume With Racial and Ethnic Disparities in Locally Advanced Cervical Cancer Treatment

Uppal, Shitanshu MBBS; Chapman, Christina MD; Spencer, Ryan J. MD; Jolly, Shruti MD; Maturen, Kate MD; Rauh-Hain, J. Alejandro MD; delCarmen, Marcela G. MD; Rice, Laurel W. MD

doi: 10.1097/AOG.0000000000001819
Contents: Original Research

OBJECTIVE: To evaluate racial–ethnic disparities in guideline-based care in locally advanced cervical cancer and their relationship to hospital case volume.

METHODS: Using the National Cancer Database, we performed a retrospective cohort study of women diagnosed between 2004 and 2012 with locally advanced squamous or adenocarcinoma of the cervix undergoing definitive primary radiation therapy. The primary outcome was the race–ethnicity-based rates of adherence to the National Comprehensive Cancer Network guideline–based care. The secondary outcome was the effect of guideline-based care on overall survival. Multivariable models and propensity matching were used to compare the hospital risk-adjusted rates of guideline-based adherence and overall survival based on hospital case volume.

RESULTS: The final cohort consisted of 16,195 patients. The rate of guideline-based care was 58.4% (95% confidence interval [CI] 57.4–59.4%) for non-Hispanic white, 53% (95% CI 51.4–54.9%) for non-Hispanic black, and 51.5% (95% CI 49.4–53.7%) for Hispanic women (P<.001). From 2004 to 2012, the rate of guideline-based care increased from 49.5% (95% CI 47.1–51.9%) to 59.1% (95% CI 56.9–61.2%) (P trend<.001). Based on a propensity score-matched analysis, patients receiving guideline-based care had a lower risk of mortality (adjusted hazard ratio 0.65, 95% CI 0.62–0.68). Compared with low-volume hospitals, the increase in adherence to guideline-based care in high-volume hospitals was 48–63% for non-Hispanic white, 47–53% for non-Hispanic black, and 41–54% for Hispanic women.

CONCLUSION: Racial and ethnic disparities in the delivery of guideline-based care are the highest in high-volume hospitals. Guideline-based care in locally advanced cervical cancer is associated with improved survival.

High-volume hospitals have the highest rates of guideline-based care but also the highest racial and ethnic disparities in the management of advanced cervical cancer.

Division of Gynecologic Oncology, the Institute for Healthcare Policy and Innovation, the Department of Radiation Oncology, and the Department of Diagnostic Radiology, University of Michigan, Ann Arbor, Michigan; the Division of Gynecologic Oncology, University of Wisconsin, Madison, Wisconsin; and the Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Corresponding author: Shitanshu Uppal, MBBS, University of Michigan, 1500 E Medical Drive, Ann Arbor, MI 48109; email:

Financial Disclosure The authors did not report any potential conflicts of interest.

The authors thank Sarah Block for her editorial assistance in preparing the manuscript.

Each author has indicated that he or she has met the journal's requirements for authorship.

© 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.