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the African Americans, and 60% of the Hispanic respondents reported that they had poor access to a
vehicle [16,41,43] . The net result to the underserved communities was geographic and transportation barriers,
greater reschedules, no-shows, delayed care or missed or delayed medication use [16,41] . Hence, these geographic
and transportation factors lead to delivery of substandard care and negatively, impact survival rates [19,29,41] .
[41]
Across 25 different studies, patients reported that transportation was a major barrier to their healthcare .
These data indicate that geographic and travel factors have a negative impact on OC patient outcome.

DIFFERENT OC PATIENTS RECEIVE DIFFERENT TREATMENT
Patients from different socioeconomic backgrounds and cultures experience a difference in quality
treatment. African American women from underserved communities overall have lower 5-year survival rates
[44]
[16]
from OC than their Caucasian counterparts, attributed to treatment delays . Bristow et al. reported that
despite equitable access to healthcare, patients who hailed from lower SES status were less likely to receive
[29]
treatment adhering to the NCCN guidelines . Furthermore, a clear difference exists between populations
regarding access to quality of healthcare, impacting the outcome of an OC patient. To understand the source
of healthcare disparities is the key in order to pursue strategies to correct these disparities and eventually
create initiatives to eliminate them.

An increasing body of literature suggests that patients from a lower SES receive substandard care, in
large part from a general lack of proper facilities and equipment to carry out standard procedures [1,16,29,44] .
Unfortunately, patients from underserved communities, have poorer access than affluent communities to
high-quality healthcare [19,29] . African American and Hispanic patients were less likely to receive accurate
[29]
staging for OC than Caucasian patients . African American patients with OC also tend to receive less
proactive treatment plans than Caucasian patients [16,19] . A study conducted at a large, high volume medical
center showed that African American OC patients were less likely to undergo surgery than Caucasian OC
patients overall, 61% and 77% respectively, and less likely to undergo chemotherapy [16,19,29] . Furthermore,
underserved patients are much less likely to enroll in clinical trials and experimental treatments. In a study
that analyzed over 400 clinical trials from The Gynecologic Oncology Group (GOG) from 1985 to 2013, 83%
of participants were Caucasian, and only 8% African American, and 2.2% Hispanic [29,42,45] . As compared
with the expected Centers for Disease Control projections for minority participation in clinical trials, actual
[45]
African American participation was 15 times lower than expected for ovarian GOG trials . The GOG
also reported that the rate of participation for African American patients has been decreasing over time,
demonstrating that participation from African American communities has decreased 2.8 times from 1994-
[45]
2002 to 2009-2013 . There are many possible explanations for poor participation by minority groups in
clinical trials include lack of access to centers, which offer these trials, lack of understanding regarding
the purpose and potential benefits of these trials, and lack of means such as transportation to effectively
participate in these trials. Due to decreased levels of education, patients may have diminished understanding
of how the treatment works and therefore cannot understand how these treatments are different from
previous ones and might have decreased efficacy. Additionally, cultural and spiritual differences in these
communities could also contribute to the disparity. Members of these communities have been spurned
by healthcare institutions and other institutions in the past, which could result in an overall distrust in
providers or healthcare institutions. All of these aspects stack the odds against minority communities from
receiving proper treatment.

[46]
Armstrong et al. reported that only 37% of patients received genetic counseling prior to testing for the
BRCA1/2 gene, and of those that did receive counseling, most were Caucasian women (69%) who were
married (76%), with high income (55%) and with a college degree (81.4%) [1,46] . African American women
have a much lower rate of testing particularly in limited-resource settings, which is important because
they have a similar or higher incidence of BRCA mutation than their Caucasian counterparts [1,20-23] . It
is estimated that roughly 12.4% of African American patients with breast cancer under 50 carry the