Delay to timely treatment in locally advanced cervical cancer - insurance inequities in access to gynecologic oncology.

Abstract

Background: Cervical cancer continues to disproportionately affect marginalized populations, with significant disparities in treatment and outcomes. Social determinants of health (SDOH) and insurance status have been associated with delays in treatment initiation, which can adversely affect clinical outcomes.

Objective: To determine the risk factors associated with delays in treatment initiation among patients with locally advanced cervical cancer (LACC) and identify the time period of delay in treatment initiation.

Study design: We conducted a retrospective cohort study of patients with LACC at a single institution between 2003 and 2023. The primary outcome was timely initiation of treatment, defined as treatment initiation within 60 days of diagnosis by biopsy. Multivariate analysis was used to assess the impact of insurance status and other demographic factors on treatment delays.

Results: 280 patients were identified. Median time from biopsy to treatment initiation was 68.5 days (IQR, 52-104). 37.1% of patients received timely treatment initiation. Univariate analyses indicated patients with Medicaid had significantly increased odds of delayed treatment (OR 2.76, 95% CI 1.46-5.23) and living in a geographic location with a higher social vulnerability index (SVI) (quartile 3 OR 2.68 95% CI 1.22-5.85). Multivariate analysis indicated that Medicaid was independently associated with delayed treatment compared to private insurance (OR 2.42, 95% CI 1.18-4.93). When time to treatment was stratified by time from biopsy to staging and time from staging to treatment start, delay was primarily attributable to time from biopsy to staging. In patients within the upper quartile of delay (>104 days), social risk factors including insurance-related issues and unmet social needs (e.g. psychosocial distress, unstable housing, substance abuse) were identified as contributors to significant delays.

Conclusion(s): Medicaid insurance was independently associated with lower odds of timely cervical cancer treatment, driven largely by delays between biopsy and staging. These findings underscore the need for targeted interventions to address insurance-mediated barriers to initiation of care, which may include screening and addressing unmet health-related social needs and social risks.