Socioeconomic Inequalities in the Diagnosis and Treatment of Ovarian Cancer in the United Kingdom: A Systematic Review and Narrative Synthesis

Problem

Survival inequalities exist for patients diagnosed with ovarian cancer living in England's most socioeconomically deprived areas. Delays in diagnosis and treatment can contribute to these inequalities. Studies evaluating delays amongst patients from deprived areas appear limited, but a Danish study demonstrated that women from households with smaller incomes had experienced system delays. Inequalities in treatment received between socioeconomic groups can further exacerbate survival differences, and studies have demonstrated the presence of such inequalities in non-universal healthcare settings. It is thus essential to evaluate socioeconomic inequalities across the cancer care continuum in the United Kingdom (UK). This is the first systematic review to evaluate diagnostic and treatment inequalities for patients diagnosed with ovarian cancer living in the UK.

Approach

MEDLINE, EMBASE, CINAHL, CENTRAL, Web of Science, AMED and PsycINFO were searched from inception to January 2023. The grey literature was extensively searched, including HMIC, BASE, NHS Evidence and Google Advanced Search, hand-searching of relevant websites and forwards/backwards citation searching. Two reviewers independently screened all studies. Previous reviews were used to refine the search terms, and the search strategy was validated using a test set. Observational UK-based studies were included if they reported measures of socioeconomic status and system interval or treatments received. Study risk of bias was assessed using the QUIPS tool, and a narrative synthesis was conducted. The review was reported according to PRISMA 2020 and registered with PROSPERO [CRD42022332071].

Findings

Ten of the 2,876 identified references were included in the review, nine from England and one from Northern Ireland. Two studies evaluated the system interval without evidence of an association between socioeconomic status and system delay. Meanwhile, eight studies evaluated treatments received, demonstrating a reduced likelihood of surgery and chemotherapy for patients from the most deprived area.

Consequences

There were socioeconomic inequalities in treatments received for patients with ovarian cancer, but no evidence of inequalities across the system interval. However, there were limitations across all studies. Notably, the two studies that evaluated time periods across the system interval used data that is now a decade old and waiting times have since deteriorated. Furthermore, not all ovarian cancers were captured, especially those diagnosed by non-managed routes. Ovarian cancer is challenging to suspect; patients are at risk of delays in the patient and primary care intervals, with the potential for further delays across the system interval. We, therefore, need a robust methodology to measure system intervals for all patients diagnosed with ovarian cancer. We need to measure these intervals specifically for patients from deprived communities to ensure policy changes do not exacerbate any existing inequalities. We consequently need a systems approach to tackle delays, with effective partnerships between all stakeholders across the National Health Service to balance timely diagnosis with the finite resources available.