Racial/ethnic, socioeconomic, and healthcare access disparities in achieving textbook oncologic outcome in advanced ovarian cancer

Objective: Textbook Oncologic Outcome (TOO) is a composite measure that strongly predicts survival after surgery for advanced epithelial ovarian cancer (AEOC), regardless of approach: primary (PDS) or interval debulking surgery (IDS). We aimed to identify risk factors associated with failure to achieve TOO and to receive standard treatment (surgery and chemotherapy) for AEOC. Methods: Patients diagnosed with AEOC between 2008 and 2019 were identified using the National Cancer Database. TOO was defined as achieving complete cytoreduction, hospital stay <10 days, no 30-day readmission, adjuvant chemotherapy initiation <42 days, and 90-day survival. Logistic regression models were used to identify factors associated with TOO and receipt of standard treatment. Results: Among 58,635 AEOC patients, 49% received standard treatment. Of the 21,657 patients who underwent surgery, 51.4% received PDS and 48.6% IDS. For PDS multivariable analysis, factors associated with lower likelihood to achieve TOO included age >75 years (vs <60; OR 0.47, 95% CI 0.38-0.58), Black race (vs White; OR 0.73, 95% CI 0.59-0.90), government insurance (vs private; OR 0.82, 95% CI 0.73-0.92), high surgical complexity (vs low; OR 0.62, 95% CI 0.56-0.68), and median surgical volume ≤5 cases/year (vs ≥20; OR 0.75, 95% CI 0.63-0.89). For IDS, similar associations were observed for government insurance (OR 0.87, 95% CI, 0.80-0.96), high surgical complexity (OR 0.61, 95% CI 0.55-0.66), and median surgical volume ≤5 cases/year (OR 0.60, 95% CI 0.52-0.70). Conclusions: Several factors are associated with lower likelihood of achieving TOO after treatment for AEOC. Some of these factors (age, race, payor type) reflect disparities in care; others (facility volume, surgical complexity) highlight the need for referral to high-volume centers for initial treatment planning.