Multilevel determinants of racial disparities in receipt of guideline-concordant endometrial cancer treatment

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PROJECT SUMMARY/ABSTRACT Of all solid tumors, endometrial cancer (EC) exhibits one of the worst racial disparities - the Black-White mor- tality gap has increased from 79.5% in 1992-2001 to 97.8% in 2014-2018. Receipt of treatment in line with na- tional recommendations is an important modifiable factor that influences EC outcomes and contributes to racial disparities in survival. The National Comprehensive Cancer Network recommends surgical staging as the first step of guideline-concordant treatment and pathology factors captured from surgery inform adjuvant treatment recommendations. Our prior work demonstrates that receipt of guideline-concordant EC treatment improves survival among EC patients who are Black or White. Therefore, the lower guideline-concordant EC treatment among Black women that we have observed is concerning and contributes to the marked disparities in disease outcomes. We lack a comprehensive understanding of the determinants that underlie disparate guideline-con- cordant EC treatment, preventing any meaningful progress in evidence-based intervention development. The extant literature has exclusively focused on individual-level factors as predictors of guideline-concordant EC treatment. This work has not led to effective intervention and ignores the multilevel influences that are known to undergird race-based differences in health. In addition, within guideline-concordant paradigms, there can be wide variation in intensity level of recommended treatments, with markedly different impact on quality of life. The impact of race on intensity of treatment within guideline-concordant paradigms is currently unknown. Most important, there are no qualitative data to understand how Black women or their providers make decisions re- garding EC treatment. Absent these critical building blocks, we cannot move forward with evidence-based in- terventions to improve guideline-concordant EC treatment receipt. We propose to identify determinants of guideline-concordant EC treatment disparities by combining analysis of multilevel data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare claims linked dataset (Aims 1-2) with in-depth interviews of Black women with EC and EC providers (Aim 3). Aim 1: Identify multilevel factors that predict Black-White dis- parities in guideline-concordant EC treatment. Aim 2: Quantify racial disparities and underlying predictors of guideline-concordant EC treatment intensity and examine associations between guideline-concordant EC treat- ment intensity and survival. Aim 3: Examine the multilevel dynamics that drive and constrain treatment choices by and for Black women with EC using qualitative methods. By analyzing a high-quality, multilevel dataset with Black and White EC patients, and capturing first-hand accounts of treatment experiences and preferences of Black women and their providers, our team will assess the importance of race-specific barriers to guideline- concordant EC treatment. Our study will identify the set of multilevel modifiable factors that can be targeted to reduce disparities and improve care for all women.