Disparities in Oncofertility: Assisted reproductive technology utilization and fertility-sparing oncology care in women with a history of breast, ovarian, cervical or endometrial cancer (094)

Abstract

Objectives: Few studies have assessed the association between sociodemographic characteristics and the use of assisted reproductive technology (ART) or receipt of fertility-sparing (FS) oncology care in women with a history of gynecologic or breast cancer. This study examined rates of ART and FS oncology care in a population-level database to characterize disparities in oncofertility. Methods: Women aged 18-45 diagnosed with breast (stage I-III), ovarian (stage IA, IC), cervical (stage IA, IB), or endometrial cancer (stage IA, IB) from 2004 to 2015 were identified in the California Cancer Registry (CCR). The data were linked to the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System database. Fertility-sparing oncology care was defined as surgical or medical interventions allowing for preservation of the uterus and at least one ovary for women with gynecologic cancers. The primary outcome was the utilization of ART, defined as an assisted cycle (medical or procedural). The secondary outcome was the receipt of FS oncology care following diagnosis of gynecologic cancer. Results were stratified by race, geography, and insurance. Chi-square tests and logistic regressions were performed to compare outcomes. Results: Of 44,529 women included in the analysis, 236 (0.5% overall, 0.5% of breast, 0.5% of cervical, 0.6% of endometrial, 0.9% of ovarian cancer patients) utilized ART. Among 8,061 patients with a gynecologic malignancy, 1,814 (22.5% overall, 19.7% cervical, 6.9% endometrial, 42.7% of ovarian cancer patients) had FS oncology care. Non-Hispanic Black (NHB) and Hispanic women with a history of breast cancer were less likely to receive ART compared to non-Hispanic White (NHW) women (OR: 0.32, 95% CI: 0.14-0.73 and OR: 0.30, 95% CI: 0.19-0.49, respectively). Hispanic women with a history of cervical cancer were least likely to receive ART compared to NHW women (OR: 0.33, 95% CI: 0.11-0.98). Rural dwellers (OR: 0.13, 95% CI: 0.04-0.39 vs urban dwellers) and Medicaid recipients (OR: 0.28, 95% CI: 0.14-0.56 vs privately insured) with a history of breast cancer were less likely to utilize ART. Similar trends were seen among patients with gynecologic cancers. FS oncology care in women with a diagnosis of ovarian cancer was practiced more commonly for NHB (OR: 1.77, 95% CI: 1.15-2.73) and Hispanic women (OR: 1.48, 95% CI: 1.19-1.84) than NHW women. Women with a diagnosis of endometrial cancer were more likely to have FS oncology care if they were NHB (OR: 2.62, 95% CI: 1.01-6.73) or Asian/Pacific Islander (API) (OR: 2.83, 95% CI: 1.65-4.86) than NHW. Women living in rural areas were less likely to receive FS oncology care for cervical (OR: 0.76, 95% CI: 0.60-0.96) and ovarian cancer (OR: 0.54, 95% CI: 0.36-0.75) than urban dwellers. Conclusions: ART and FS oncology care following a diagnosis of breast or gynecologic cancer are underutilized. In this study, NHW women were more likely to receive ART but less likely to receive FS oncology care. Geography and insurance status demonstrated higher rates in urban and insured populations for both ART utilization and receipt of FS oncology care, regardless of cancer type. Further studies are necessary to understand these differences given overall infrequent outcomes. Objectives: Few studies have assessed the association between sociodemographic characteristics and the use of assisted reproductive technology (ART) or receipt of fertility-sparing (FS) oncology care in women with a history of gynecologic or breast cancer. This study examined rates of ART and FS oncology care in a population-level database to characterize disparities in oncofertility. Methods: Women aged 18-45 diagnosed with breast (stage I-III), ovarian (stage IA, IC), cervical (stage IA, IB), or endometrial cancer (stage IA, IB) from 2004 to 2015 were identified in the California Cancer Registry (CCR). The data were linked to the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System database. Fertility-sparing oncology care was defined as surgical or medical interventions allowing for preservation of the uterus and at least one ovary for women with gynecologic cancers. The primary outcome was the utilization of ART, defined as an assisted cycle (medical or procedural). The secondary outcome was the receipt of FS oncology care following diagnosis of gynecologic cancer. Results were stratified by race, geography, and insurance. Chi-square tests and logistic regressions were performed to compare outcomes. Results: Of 44,529 women included in the analysis, 236 (0.5% overall, 0.5% of breast, 0.5% of cervical, 0.6% of endometrial, 0.9% of ovarian cancer patients) utilized ART. Among 8,061 patients with a gynecologic malignancy, 1,814 (22.5% overall, 19.7% cervical, 6.9% endometrial, 42.7% of ovarian cancer patients) had FS oncology care. Non-Hispanic Black (NHB) and Hispanic women with a history of breast cancer were less likely to receive ART compared to non-Hispanic White (NHW) women (OR: 0.32, 95% CI: 0.14-0.73 and OR: 0.30, 95% CI: 0.19-0.49, respectively). Hispanic women with a history of cervical cancer were least likely to receive ART compared to NHW women (OR: 0.33, 95% CI: 0.11-0.98). Rural dwellers (OR: 0.13, 95% CI: 0.04-0.39 vs urban dwellers) and Medicaid recipients (OR: 0.28, 95% CI: 0.14-0.56 vs privately insured) with a history of breast cancer were less likely to utilize ART. Similar trends were seen among patients with gynecologic cancers. FS oncology care in women with a diagnosis of ovarian cancer was practiced more commonly for NHB (OR: 1.77, 95% CI: 1.15-2.73) and Hispanic women (OR: 1.48, 95% CI: 1.19-1.84) than NHW women. Women with a diagnosis of endometrial cancer were more likely to have FS oncology care if they were NHB (OR: 2.62, 95% CI: 1.01-6.73) or Asian/Pacific Islander (API) (OR: 2.83, 95% CI: 1.65-4.86) than NHW. Women living in rural areas were less likely to receive FS oncology care for cervical (OR: 0.76, 95% CI: 0.60-0.96) and ovarian cancer (OR: 0.54, 95% CI: 0.36-0.75) than urban dwellers. Conclusions: ART and FS oncology care following a diagnosis of breast or gynecologic cancer are underutilized. In this study, NHW women were more likely to receive ART but less likely to receive FS oncology care. Geography and insurance status demonstrated higher rates in urban and insured populations for both ART utilization and receipt of FS oncology care, regardless of cancer type. Further studies are necessary to understand these differences given overall infrequent outcomes.