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RESEARCH 

Regional Disparities in Ovarian Cancer in 

the United States 
Zhixin Wang1, Sarah Dilley2, HyounKyoung G Park3, Alfred A. Bartolucci4, Chenguang Wang5, Warner K. 

Huh2,6, Sejong Bae1,6 

1 Division of Preventive Medicine, Department of Medicine, School of Medicine, University of Alabama at 

Birmingham, Birmingham, AL 2 Division of Gynecology Oncology, Department of Obstetrics and 

Gynecology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL 3 University of 

Liverpool, UK 4 Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, 

Birmingham, AL 5 Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer 

Center, The Johns Hopkins University, Baltimore, MD 6 Comprehensive Cancer Center, University of 

Alabama at Birmingham, Birmingham, AL 

Corresponding author: sbae@uabmc.edu 

 
 

ABSTRACT 
The aim of this study was to investigate the association between geographic regions and ovarian cancer 

disparities in the United States. Data from the Surveillance, Epidemiology, and End Results (SEER) 

Program was used to identify women diagnosed with ovarian cancer. 18 registries were divided into two 

groups: South region and US14 region. Chi-Square tests were used to compare proportions, the logistic 

regression model to evaluate the association between 5-year survival and other variables, and the Cox 

proportional hazards model to estimate hazard ratios. The South region had a lower incidence rate 

than the US14 region (12.0 vs. 13.4 per 100,000), and a lower 5-year observed survival rate (37.5% vs. 

39.8%). White women living in the US14 region had the best overall survival, compared to white women 

living in the South region, and black women living in both regions. Women in the South region were 

less likely to have insurance (6.6% vs. 2.7%, p<0.0001) and surgery (73.4% vs. 76.2%, p<0.0001). Women 

living in the South were 1.4 times more likely to die after five years of diagnosis than women living in the 

US14 region. The data confirmed regional disparities in ovarian cancer in the United States, showing 

women living in the South region were disadvantaged in ovarian cancer survival regardless of race, 

black or white. Future research focusing on the identification of contributing factors to regional disparity 

in ovarian cancer is necessary to develop practical approaches to improve health outcomes related to 

this lethal disease. 

KEYWORDS: Ovarian Cancer, Geographic Health Disparities, Survival  

 

Citation: Wang Z et al. (2019) Regional Disparities in Ovarian Cancer in the United States. Cancer Health 

Disparities 3:e1-e12. doi:10.9777/chd.2019.1002.



 
 
 
 
 

 

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INTRODUCTION 

Ovarian cancer is the tenth most common cancer 

and the fifth most lethal cancer among women in 

the United States. In 2017, there will be an 

estimated 22,440 new cases and 14,080 cancer 

deaths (ACS, 2014). A woman’s risk of getting 

invasive ovarian cancer during her lifetime is about 

1 in 75, and the risk of dying from invasive ovarian 

cancer is about 1 in 100 (OCRFA). 

Racial disparities in ovarian cancer have been well 

documented in the United States. For example, 

white women had higher incidence rates and 

higher mortality rates compared to black women. 

However, 5-year relative survival rate was lower in 

black women than in white women. The incidence 

of ovarian cancer was 12.2 in white women, and 

9.4 in black women, and the number of deaths 

was 7.7 in white women and 6.4 in black women 

(per 100,000 women, 2010-2014) (OCRFA). The 

five-year relative survival rate in black women was 

38%, compared with 46% in white women (2006-

2012) (ACS, 2014). From 2003 to 2012, the 

incidence rate decreased by 2.1% per year among 

white women, while it only decreased by 1.3% 

among black women (CDC). During the same time 

period, the mortality rate decreased by 2.1% per 

year among white women comparing to 1.6% 

among black women(CDC). The five-year relative 

survival rate of ovarian cancer among white 

women increased from 35% (1975-1977) to 46% 

(2006-2012). However, the survival rate among 

black women decreased from 42% to 38%. 

 

Studies about racial disparities in ovarian cancer 

have shown that the racial difference in survival 

rate is affected by multiple factors, such as 

receiving of guideline care, socioeconomic status, 

medical comorbidities, genetic differences, lifestyle, 

diet and more. It has been reported that black 

women are more likely to be diagnosed at 

advanced stages, less likely to receive guideline 

care (surgery and chemotherapy), and more likely 

to have comorbidities (Bristow et al., 2013), (Long 

et al., 2015), (Howell et al., 2013), (Srivastava et al., 

2017), (Chase et al., 2012). However, after 

controlling for access to quality care, 

socioeconomic status, cancer stage and treatment, 

there was no difference in ovarian cancer survival 

between black and white women (Collins et al., 

2014), (Terplan et al., 2008). 

 

Contrary to well-studied racial disparities, there are 

few studies on regional differences in ovarian 

cancer that may be considered as a critical 

moderator to explain the unequal outcomes of the 

healthcare system. One study reported that 

ovarian cancer incidence rates were different 

among the four regions in the United States 

(Northeast, Midwest, West and South), showing 

the lower incidence rate for all races combined in 

the South than in any of the other 3 regions (Hall 

et al., 2003). Another study reported that the areas 

with the lowest rates of cancer-directed surgery 

were likely to be in more remote locations, 

addressing some relevance of the regional 

disparities to ovarian cancer mortality (Fairfield et 

al., 2010). Also, geographic proximity to high 

volume hospitals and travel distance to receive 

treatment were significantly associated with 

adherence to guideline care for advanced-stage 

ovarian cancer patients (Bristow et al., 2014a). 

Bristow, et al, reported the relationship between 

low SES and more limited access to high volume 

of healthcare and assumed disparities in ovarian 

cancer survival associated with race and SES 

resulted from unequal access to care (Bristow et 

al., 2014a). Hodeib and colleagues (Hodeib et al., 

2015) also found the low SES was a significant and 

independent predictor of deviation from the 

NCCN guidelines for surgery, chemotherapy, and 

overall treatment in their study on patients with 

early-stage ovarian cancer. 

 

Regional and racial/ethnic disparities in health 

outcomes are often associated with 

socioeconomic factors(Long et al., 2015), (Chase et 

al., 2012), (Collins et al., 2014). Black race and low 

SES were independently associated with an 



 
 
 
 
 

 

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increased likelihood of treatment non-adherent to 

guidelines (Bristow et al., 2014b) (Bristow et al., 

2015). The US Census Bureau reported in its 

annual population report on income and poverty 

that the South region continues to have the lowest 

median income and the highest poverty rate 

relative to the other regions (Chase et al., 2012). 

Considering the disproportionate number of 

African Americans in the South, geographic 

variations may be resulted from the combined 

effects of race and region on the outcomes of 

ovarian cancer that specifically living in the South 

is associated with greater racial disparity in ovarian 

cancer incidence and survival. Therefore, this study 

aimed to investigate the association between 

geographic regions and ovarian cancer disparities 

in the United States.  

 

MATERIALS AND METHODS 

Data from the Surveillance, Epidemiology, and End 

Results (SEER) 18 Program (2000-2014) was used 

that covered 28% of the US population. The SEER 

program collects data on patient demographics, 

primary tumor site, tumor morphology and stage 

at diagnosis, first course of treatment, and follow-

up for vital status, supported by the National 

Cancer Institute. SEER 18 registries cover 

approximately 28% of the newly diagnosed cancer 

patients in the United States. 

To compare regional differences, we divided the 

18 registries into two groups: South region and 

US14 region. The registries included in the South 

region are: Louisiana; Metropolitan Atlanta, 

Georgia; Rural Georgia; and Greater Georgia. The 

registries included in the US14 region are: 

Connecticut; Hawaii; Iowa; New Mexico; Utah; 

California excluding San Francisco, San Jose-

Monterey, and Los Angeles; Kentucky; New Jersey; 

San Francisco-Oakland Metropolitan Statistical 

Area, California; Metropolitan Detroit, Michigan; 

Seattle (Puget Sound), Washington; San Jose-

Monterey, California; Los Angeles, California; and 

Alaska Natives. 

Only non-Hispanic white (NHW) and non-Hispanic 

black (NHB) women were included in this analysis. 

Ovarian cancer stages were identified according to 

the 3rd and 6th editions of staging manual of 

American Joint Committee on Cancer (AJCC) and 

compared at stages: 0, I, II, III, IV, and unstaged. 

The stages were also combined into three groups: 

Stage 0-II (non-advanced stage), Stage III-IV 

(advanced stage), and unstaged. Insurance status 

includes two categories: insured (including any 

Medicaid and insured) and uninsured. Age-

adjusted incidence rates and mortality rates were 

calculated by SEER*STAT. Incidence under 25 

cases and mortality under 15 cases are suppressed. 

Five-year survival rates were calculated by SAS 9.2. 

Chi-Square tests were performed when comparing 

proportions. A logistic regression model was built 

to evaluate the association between 5-year survival 

and other variables: age, cancer stage, and health 

insurance. The Sidak adjusted log-rank test was 

applied to compare multiple survival curves. The 

Cox proportional hazards model was used to 

estimate hazard ratios. 

RESULTS 

A total of 43,637 women with ovarian cancer were 

included in this study. 36,182 were in US14 region 

and 7,455 were in the South region (Table 1). 

Among the women in the US14 region, 33,813 

(93.4%) were non-Hispanic white (US14-NHW) and 

2,369 (6.6 %) were non-Hispanic black (US14-

NHB). In the South region, 5,834 (78.3%) were 

non-Hispanic white (South-NHW) and 1,621 

(31.7%) were non-Hispanic black (South-NHB) 

(Table 2). Average age at diagnosis in the US14 

region was 63.4, which was older than 62.5 in the 

South region (p<0.0001). There was no significant 

difference between age at diagnosis for both races 

living in the US14 or the South region (NHW: 

p=0.15 and NHB: p=0.22). 



 
 
 
 
 

 

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Table 1. Patient characteristics by region. 

Characteristics 
Total  

(N=43,637) 
Region 

p-value 

  US14 (N=36,182) South (N=7,455) 

 Age at diagnosis (%)     

Mean (SD) 63.3 (15.8) 63.4 (15.7) 62.5 (15.9) <0.0001 

Median (IQR) 64.0 (53,76) 64 (53, 76) 63 (52, 75) 
 

≥ 65 21,034 (48.2) 48.4% 47.0% 0.03 

< 65 22,603 (51.8) 51.6% 53.0% 

 Cancer stage (%)    <0.0001 

0 81 (0.2) 68 (0.2) 13 (0.2)  

I 8,447 (19.6) 7,062 (19.8) 1,385 (18.9)  

II 3,001 (7.0) 2,441 (6.8) 560 (7.6)  

III 13,008 (30.2) 10,779 (25.3) 2,229 (30.4)  

IV 11,036 (25.7) 9,028 (25.3) 2,008 (27.4)  

Unstaged 7,445 (17.3) 6,302 (17.7) 1,143 (15.6)  

Grouped Cancer stage (%)    <0.0001 

Stage 0-II 11,529 (26.8) 9,571 (26.8) 1,958 (26.7)  

Stage III-IV 24,044 (55.9) 19,807 (55.5) 4,237 (57.7)  

Unstaged 7,445 (17.3) 6,302 (17.7) 1,143 (15.6)  

Surgery    <0.0001 

Yes 32,786 (75.7) 27,347 (76.2) 5,439 (73.4)  

No 10,529 (24.3) 8,558 (23.8) 1,971 (26.6)  

Insurance (%)ⱡ     



 
 
 
 
 

 

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Insured 8,703 (96.6) 7,154 (97.3) 1,549(93.4)  

Uninsured 306 (3.4) 197 (2.7) 109 (6.6)  

5-year survival◊    <0.0001 

Yes 17,331 (39.7) 14,575 (40.3) 2,756 (37.0)  

No 26,306 (60.3) 21,607 (59.7) 4,699 (63.0)  

ⱡ Only available for cases diagnosed after 2007 

 

Table 2. Patient characteristics by region and race (2000-2008). 

Characteristics 
Total  

(N=43,637) 

White (N=39,647)  Black (N=3,990)  

US14  

(N=33,813) 

South  

(N=5,834) 
p-value 

US14 

(N=2,369) 

South 

(N=1,621) 
p-value 

Age at diagnosis (%)        

Mean (SD) 63.3 (15.8) 63.6 (15.6) 63.3 (15.2) 0.15 60.2 (16.8) 59.5 (17.6) 0.22 

Median (IQR) 64.0 (53,76) 64 (53, 76) 64 (54, 75)  61 (49, 73) 60 (49, 73)  

≥ 65 21,034 (48.2) 16,521 (48.9) 2,847 (48.8) 0.93 1,006 (42.5) 660 (40.7) 0.27 

< 65 22,603 (51.8) 17,292 (51.1) 2,987 (51.2)  1,363 (57.5) 961 (59.3)  

Cancer stage (%)    0.0009   0.01 

0 81 (0.2) 65 (0.2) 9 (0.2)  3 (0.1) 4 (0.3)  

I 8,447 (19.6) 6,648 (19.9) 1,104 (19.2)  414 (17.9) 281 (17.7)  

II 3,001 (7.0) 2,298 (6.9) 450 (7.8)  143 (6.2) 110 (6.9)  

III 13,008 (30.2) 10,220 (30.6) 1,795 (31.2)  559 (24.2) 434 (27.4)  

IV 11,036 (25.7) 8,283 (24.8) 1,493 (26.0)  745 (32.3) 515 (32.5)  

Unstaged 7,445 (17.3) 5,856 (17.6) 902 (15.7)  446 (19.3) 241 (15.2)  



 
 
 
 
 

 

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Grouped Cancer stage (%)    0.002   0.004 

Stage 0-II 11,529 (26.8) 9,011 (27.0) 1,563 (27.2)  560 (24.2) 395 (24.9)  

Stage III-IV 24,044 (55.9) 18,503 (55.5) 3,288 (57.2)  1,304 (56.5) 949 (59.9)  

Unstaged 7,445 (17.3) 5,856 (17.6) 902 (15.7)  446 (19.3) 241 (15.2)  

Surgery    0.13   0.51 

Yes 32,786 (75.7) 25,822 (77.0) 4,413 (76.1)  1,525 (64.8) 1,026 (63.8)  

No 10,529 (24.3) 7,731 (23.0) 1,389 (23.9)  827 (35.2) 528 (36.2)  

Insurance (%)ⱡ    <0.0001   0.02 

Insured 8,703 (96.6) 6,654 (97.6) 1,229 (94.6)  500 (93.6) 320 (89.1)  

Uninsured 306 (3.4) 163 (2.4) 70 (5.4)  34 (6.37) 39 (10.9)  

5-year survival◊    0.0004   0.5 

Yes 17,331 (39.7) 13,787 (40.8) 2,235 (38.3)  788 (33.3) 521 (32.1)  

No 26,306 (60.3) 20,026 (59.2) 3,599 (61.7)   1,581 (66.7) 1,100 (67.9)   

ⱡ Only available for cases diagnosed after 2007 

 



 
 
 
 
 

 

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Over half of the women in this data (55.9%) were 

diagnosed with advanced ovarian cancer stage 

(stage III and IV). Women in the South region were 

more likely to be diagnosed at an advanced stage 

(57.7% vs. 55.5%, p<0.0001). This result was 

consistent within each race (57.2% vs. 55.5% for 

NHW, p=0.0002; 59.9% vs. 56.5% for NHB, 

p=0.004). NHW and NHB had different regional 

differences in cancer stage distributions: South- 

NHW had higher proportion in stage IV compared 

to US14-NHW (26.0% vs. 24.8%), whereas South- 

NHB had higher proportion in stage III compared 

to US14-NHB (27.4% vs. 24.2%). In addition, the 

South region had lower proportion of unstaged 

patients (15.7% vs. 17.6 for NHW and 15.2% vs. 

19.3% for NHB). 

Overall, there were 75.7% ovarian cancer patients 

who had any surgery on the primary cancer site. 

Women in the US14 region were more likely to 

have surgery compared to women in south region 

(76.2% vs. 73.4%, p<0.0001). There were no 

significant regional differences comparing the 

US14 region with the South region within each 

race, (NHW: 76.1% vs. 77.0%, p=0.13; NHB: 64.8% 

vs. 63.8%, p=0.51). 

In SEER data, insurance information was only 

available for patients diagnosed in 2007 and after. 

Among a total of 96.6% women who were insured, 

women in the South region were less likely to have 

insurance (93.4% vs. 97.3%, p<0.0001). US14-NHW 

and US14-NHB had a higher proportion of being 

insured than South-NHW and South-NHB (97.6% 

vs. 94.6%, p<0.0001; 93.6% vs. 89.1%, p=0.02, 

respectively). The overall 5-year survival rate was 

39.7% from 2000-2008. The South region had a 

significantly lower 5-year survival rate than the 

US14 region (37.0% vs. 40.3%, p<0.0001). The 5-

year survival rate of South-NHW was significantly 

lower than that of US14-NHW (38.3% vs. 40.8%, 

p=0.0004). South-NHB had the lowest 5-year 

survival rate (32.1%). 

The South region constantly had lower age-

adjusted incidence rates than the US14 region 

during the study period 2000-2014 (2000: 12.7 vs. 

15.4, per 100,000; 2014: 10.6 vs. 11.7, per 100,000) 

(Figure 1). White women (US14-NHW and South-

NHW) had higher incidence rates than black 

women (US14-NHB and South-NHB) (Figure 2). 

While NHW in US14 had higher incidence rates 

than NHW in South, NHB in US14 region and NHB 

in the South region had similar incidence rates 

except for years after 2010, when NHB in the US14 

started to have higher incidence rates than NHB in 

the South region. 

 

Figure 1. Incidence rate comparison between US14 

and South region. 

 

Figure 2. Incidence rate comparison between US14 

and South region by race. 

Regional differences in mortality rates were 

observed in years 2000 to 2004 and years 2010 to 

2014, when the US14 region had higher mortality 

rates than the South region (Figure 3). NHW 

0

2

4

6

8

10

12

14

16

18

2000 2002 2004 2006 2008 2010 2012 2014

In
ci

d
e
n
ce

 (
p

e
r 

10
0
,0

0
0
) 

US14

South

0

2

4

6

8

10

12

14

16

18

2000 2002 2004 2006 2008 2010 2012 2014

In
ci

d
e
n
ce

 (
p

e
r 

10
0
,0

0
0
) 

US14-NHW

US14-NHB

South-NHW

South-NHB



 
 
 
 
 

 

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women had higher mortality rates than NHB 

women over all years (Figure 4). 

 

Figure 3. Mortality rate comparison between US14 

and South region. 

 

Figure 4. Mortality rate comparison between US14 

and South region by race. 

The US14 region had higher 5-year survival than 

the South region (Figure 5). Compared with the 

US14 region, 5-year survival rates in the South 

region were very unsteady. NHW women had 

higher 5-year observed survival rates than NHB 

women (Figure 6). A logistic regression model 

showed that after controlling for surgery, women 

in the South region were still 1.4 times more likely 

to die 5-years after diagnosis (95% CI: 1.2-1.6). 

Controlling for age, race, cancer stage and 

insurance, women in the South region were 1.2 

times less likely to receive surgery (95% CI: 1.03-

1.4). 

 

Figure 5. Five-year survival rate comparison 

between US14 and South region. 

 

Figure 6. Five-year survival rate comparison 

between US14 and South region by race. 

Women in the South region had significantly 

shorter survival times than women in the US14 

region (Figure 7). NHW in the US14 region had 

significantly longer survival time compared to 

NHW in the South region, NHB in the US14 region, 

and NHB in South region (p<0.0001 for all three 

comparisons, Figure 8). After adjusting for surgery, 

compared with the US14 region, the hazard ratio 

of death for the South region was 2.6 times higher 

for age group 20-34 (95% CI: 1.4-4.9), 1.5 times 

higher for age group 45-54 (95% CI: 1.2-1.8), 1.4 

times higher for age group 75-84 (95% CI: 1.2-1.6), 

and 1.3 times higher for women older than 84 

years old (95% CI: 1.1-1.7) (Table 3). 

0

2

4

6

8

10

2000 2002 2004 2006 2008 2010 2012 2014

M
o

rt
a
lit

y 
(p

e
r 

10
0
,0

0
0
) 

US14

South

0

2

4

6

8

10

2000 2002 2004 2006 2008 2010 2012 2014

M
o

rt
a
lit

y 
(p

e
r 

10
0
,0

0
0
) 

US14-NHW

US14-NHB

South-NHW

South-NHB

32%

34%

36%

38%

40%

42%

44%

2000 2001 2002 2003 2004 2005 2006 2007 2008

5
-y

e
a
r 

su
rv

iv
a
l r

a
te

 

US14

South

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

2000 2001 2002 2003 2004 2005 2006 2007 2008

5
-y

e
a
r 

su
rv

iv
a
l r

a
te

 

US14-NHW

US14-NHB

South-NHW

South-NHB



 
 
 
 
 

 

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Figure 7. Overall survival comparison between 

US14 and South region. 

 

Figure 8. Overall survival comparison between 

US14 and South region by race. 

Table 3. Hazard ratio of death comparing the South 

region to the US14 region for patients who had surgery. 

 HR 95% CI 

 Age   

≤ 20 2.076 (0.106, 40.485) 

20-34 2.567* (1.351, 4.879) 

35-44 1.304 (0.945, 1.789) 

45-54 1.472* (1.223, 1.771) 

55-64 1.048 (0.908, 1.208) 

65-74 1.054 (0.911, 1.220) 

75-84 1.363* (1.162, 1.599) 

≥ 84 1.341* (1.052, 1.709) 

* p<0.05 

DISCUSSION 

The racial disparities among women with ovarian 

cancer in the United States are well-known. 

However, not much research has been done on 

the regional differences of this lethal disease. One 

study published in 2003 confirmed that the 

ovarian cancer incidence rate varied among the 

four regions in the United States: Northeast, 

Midwest, West and South (Hall et al., 2003). They 

found that black women in the South region had 

the second lowest incidence rates (10 per 100,000), 

compared with 9.7 for the black women in the 

West region. Their comparisons were limited to 

incidence rates only. 

Results from this study confirmed that regional 

differences existed in incidence rates, with the 

South region having the lower incidence rate (12.0 

vs. 13.4, per 100,000 2000-2014) compared to the 

US14 region (data not shown). Additionally, 

regional variation in 5-year survival (37.5% vs. 

39.8%, 2000-2014) and overall survival (Figure 5) 

was identified. The association between survival 

and age at diagnosis, race, region, cancer stage, 

surgery and health insurance was further analyzed. 

The results indicated that women with ovarian 

cancer in the South region had significantly poorer 

survival compared to the US14 region. Especially, 

among white women, those who live in the South 

region had worse survival outcome. 

Black women were known to have lower incidence 

rates, lower mortality rates, and lower survival than 

white women (Howell et al., 2013; Srivastava et al., 

2017); (Moorman et al., 2009); (Kim et al., 2010); 

(Chan et al., 2008); (Terplan, 2012);(Park et al., 

2017; Stewart et al., 2017). Ross and colleagues 

reported a survival disadvantage was still observed 

in black women with ovarian cancer in the deep 

South after controlling for clinical and 

environmental factors (Ross et al., 2017).  

Rationale behind these racial disparities is 

acknowledged to be multifaceted and intertwined. 

Black women tend to be diagnosed at advanced 

0.2

0.4

0.6

0.8

1.0

0 12 24 36 48 60 72 84 96

Survival time, months

S
u

rv
iv

a
l 
p

ro
b

a
b

il
it

y

South

US14

0.2

0.4

0.6

0.8

1.0

0 12 24 36 48 60 72 84 96

Survival time, months

S
u

rv
iv

a
l p

ro
b

a
b

ili
ty

South-NHB

South-NHW

US14-NHB

US14-NHW



 
 
 
 
 

 

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cancer stages, and were less likely to receive 

standard treatment, including surgery and 

chemotherapy, according to the guideline (Barber 

et al., 2017; Bristow et al., 2013; Howell et al., 2013; 

Kim et al., 2010; Terplan et al., 2012). Disparities in 

ovarian cancer treatment and survival persisted, 

resulting in black women, even among women 

with equal access to care, experiencing poorer 

survival (Bandera et al., 2016).  

Therefore, the higher proportion of black 

population in the South region (21.7% in the 

South, 6.5% in the US14 region) may partially 

contribute to the regional differences in incidence 

and mortality rates, and survival. However, region 

was identified as an independent predictor of 

ovarian cancer survival, too. For example, after 

accounting for race, age, cancer stage, insurance 

and surgery, women in the South region were still 

1.4 times more likely to die 5-years after diagnosis. 

Also women in the South region were 1.2 times 

less likely to receive surgery. 

Socioeconomic status (SES) is also important factor 

which affects health outcomes. According to the 

2014 Report of Income and Poverty in the United 

States from the US Department of Commerce, the 

South region (including Georgia and Louisiana) 

had the lowest income and highest poverty rate 

among the regions in the United States (Northeast, 

Midwest, West and South). Studies have shown 

that lower SES status is associated with lower 

insurance participating rates, limited access to high 

volume hospitals, and poorer survival in ovarian 

cancer (Brewer et al., 2015; Bristow et al., 2015). We 

identified the South region had lower insurance 

participating rate and lower surgery rate, 

compared to the US14 region, which are consistent 

with these findings resulting in worse survival. As 

another factor that may contribute to these 

regional disparities, regional differences in 

numbers and distributions of high volume 

hospitals and surgeons need to be considered. For 

example, density of oncology hospitals could 

affect chemotherapy use (Polsky et al., 2006). 

Further study is needed to identify possible 

reasons for unsteady 5-year survival rates in the 

South region, especially what factors contribute to 

increasing 5-survival rates in this region. This may 

help identify possible solutions to decrease 

regional disparities in Ovarian Cancer in the United 

States.  

This study has some limitations related to data 

used for analysis. The SEER research data did not 

provide the information on insurance and SES, 

thus the analysis in this study was limited and 

could not be done to analyze the impact of 

insurance status in detail and the association 

between SES status and other variables. 

Acknowledgements 

This article was partially supported by the National 

Cancer Institute (P30 CA013148, 2U54 CA118948), 

National Institute on Minority Health and Health 

Disparities (U54MD008176) The contents of this 

article are solely the responsibility of the authors 

and do not necessarily represent the official views 

of the funding agency, NIH. 

 

Conflict of interest statement 
The author has declared that no competing or 

conflict of interests exist. The funders had no role 

in study design, writing of the manuscript and 

decision to publish. 

 

Authors’ contributions 

Conceptualization: SD AB MF WH SB. 

Formal analysis: ZW SB. 

Methodology: ZW AB SB. 

Supervision: AB SB. 

Writing ± original draft: ZW SD AB HP. 

Writing ± review & editing: ZW SD AB HP MF WH 

SB. 

 



 
 
 
 
 

 

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