OBJECTIVES: Given rising incidence rates of endometrial cancer and potential for the COVID-19 pandemic to exacerbate inequities due to delayed care, we examined endometrial cancer survival in recent years, focusing on differences before and after the COVID-19 pandemic by race/ethnicity, and the influence of social determinants of health (SDOH).

METHODS: This retrospective study used the nationwide Flatiron Health electronic health record-derived de-identified database, focusing on patients diagnosed with advanced endometrial cancer from January 2017 to December 2022 (follow-up through October 2023). Survival was assessed using Kaplan-Meier methods and Cox proportional-hazards. We estimated separate models in the pre- (2017-2019) and post-COVID (2020-2022) periods that sequentially adjusted for race/ethnicity, age, clinical factors (histology, group stage, treatment history), and SDOH factors (e.g., practice type, household income, vehicle ownership).

RESULTS: The cohort included 3,677 patients (15.2% Black, 7.0% Latinx, 57.4% White, 20.4% Other/Unknown). Overall, Black patients more often presented with later and more aggressive disease (Stage IV: 39% vs. 26%; Serous carcinoma: 40% vs. 21%) and exhibited shorter median survival (26 months vs. 50 months) than White patients. In the pre-COVID period, Black patients experienced an increased risk of death compared to White patients (hazard ratio [HR]=1.70 [95% CI: 1.44-2.01]) with approximately half of this racial gap associated with clinical and SDOH factors: HR=1.38 (95% CI: 1.16-1.65) in clinical-adjusted models and HR=1.31 (95% CI: 1.05-1.64) in SDOH-adjusted models. Similar trends were observed in post-COVID models. Inequities were not observed between Latinx and White patients in crude or adjusted models.

CONCLUSIONS: This study highlights the persistence of Black-White inequities in survival for patients with advanced endometrial cancer before and after the COVID-19 pandemic, driven by both clinical and SDOH factors. Identifying and addressing the drivers of later and more aggressive disease in Black patients with endometrial cancer, including SDOH-focused interventions, is needed to reduce inequities and improve patient outcomes.