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solutions to bridge health care disparities and understand why they occur.

Keywords: Ovarian cancer, healthcare disparities, public health, racial disparities, epidemiology, literature review

INTRODUCTION
Ovarian cancer (OC) is the most lethal gynecologic malignancy and tends to develop as a result of atypical
[1]
cells in the epithelium of the distal fallopian tubes . Worldwide each year there are an estimated 200,000
[2]
women diagnosed with OC and 125,000 deaths from the disease . In the United States, the American
Cancer Society estimated that in 2017, there would be 22,440 new cases of OC and 14,080 deaths associated
[3]
[2]
with the disease . One in 78 American women will develop OC in their lifetime . Five-year survival
rates vastly differ among early stage and late-stage disease. For instance, with advanced stage III and IV
disease, in which disease has spread beyond the pelvis to lymph nodes or the abdominal cavity or lungs, the
mortality rate is around 70% whereas in early stages when the disease is confined to the ovaries or pelvis
mortality rates are much lower at around 10%-40% [1,4,5] . Early diagnosis of OC when the disease is limited to
the ovaries is difficult because, in early-stages, patients tend to be asymptomatic. This is further complicated
by the lack of screening or diagnostic tests, which aid in early diagnosis [1,4-6] . Early diagnosis is prudent
since the mortality rate after treatment or interventional therapy of early-stage OC is much lower [1,5,6] . By
the time patients develop symptoms, such as abdominal pain or swelling, the vagueness of these symptoms
often complicates and delays diagnosis. These symptoms tend to be attributed to aging, menopause, dietary
changes, stress, depression or gastrointestinal issues. Patients with more apparent symptoms such as a pelvic
mass, abdominal pain, bloating, abdominal swelling, early satiety or urinary symptoms often have a more
[7]
advanced disease, with symptoms usually due to the development of large mass and ascites . This is further
complicated by the fact that screening tests for OC, such as tumor markers or imaging, often lack both
sensitivity and specificity. As a result, a physician’s ability to detect OC in its early-stages is limited by the
[5]
low-performance measures of these currently available screening tests , leaving most patients undiagnosed.
Patients with lack of access to tertiary medical care are more susceptible to late-stage diagnosis, associated
with far higher mortality rates [1,5,8] . The current standard is to test for high levels of cancer antigen 125
[5]
(CA-125), an ovarian cell glycoprotein . However, high levels of CA-125 tend to be correlated with late-
[5]
stage OC . Eighty percent of patients with late-stage OC have elevated values of CA-125, whereas only 10%
[5]
of patients with early-stage OC have elevated values of CA-125 . Furthermore, certain histologic types of
OC, such as mucinous or endometrioid type tumors may not have elevations in CA-125. Another factor
limiting the utility of CA-125 screening is that high levels of CA-125 can be seen in a variety of other benign
gynecologic and non-gynecologic malignant conditions. Non-malevolent conditions such as endometriosis,
[4]
fibroids, and pregnancy can result in elevations in CA-125 . Other malignant conditions, which can result
[4]
in elevations in CA-125, are breast, pancreatic, lung, gastric and colorectal cancers . Additional diagnostic
techniques such as ultrasound evaluation for masses, may aid in diagnostic precision but also lack sensitivity
and specificity. Consideration of other risk factors for OC such as genetic susceptibility, strong family
[1,9]
history, and nulliparity may influence the detection of OC in patients . At present, the standard tests and
techniques to screen for this devastating disease are ineffective, and studies show that routine screenings are
not recommended for the general population [4,8-10] .

[4]
Standard treatment for OC is a combination of surgery and chemotherapy . Surgical exploration is
performed if there is sufficient suspicion for OC based on an initial evaluation. The goal of surgery is to
confirm if malignancy is present and if so to proceed with surgical staging and cytoreduction. Per National
Comprehensive Cancer Network (NCCN) guidelines, adjuvant therapy, which consists of platinum-taxane
[5]
based combination chemotherapy, is necessary in most cases and depends on the stage of the disease .
Women with clinical suspicion of OC should be referred to a gynecologic oncologist for counseling and
surgical treatment. Evidence shows that prognosis is improved when a gynecologic oncologist performs
surgical staging and cytoreduction [1,2,6] . Unfortunately, despite initial therapy, the majority of women with