Understanding treatment outcomes and multi-level determinants of gynecologic cancer treatment: A systematic review.

183 Background: Patients diagnosed with gynecologic cancers experience mortality disparities by race, income, and rurality, driven by differences in treatment receipt and quality of care. The purpose of this systematic review was to identify treatment-related outcomes and the multi-level determinants of these outcomes among patients with gynecologic cancers. Methods: We followed the PRISMA guidelines for systematic reviews and conducted a comprehensive search across PubMed, Scopus, and CINAHL using keywords related to cervical, endometrial, and ovarian cancers, as well as potential determinants of disparate care (e.g., rurality, cost, poverty, race). Included studies focused on individuals diagnosed with cervical, ovarian, and/or endometrial cancer conducted in the U.S. and published in English. Included outcomes were treatment-related and fell into at least one category: 1) receipt, adherence, or completion of treatment; 2) treatment timeliness; 3) treatment or referral delays; 4) treatment quality metrics. We extracted data on study population characteristics, outcomes, and determinants. Study quality was assessed using the Mixed Methods Appraisal Tool. Results: The initial search yielded 4,031 unique citations. Final extraction included 77 articles: 21 on endometrial, 17 on cervical, 34 on ovarian, and 5 covering multiple gynecologic cancers. Most studies were quantitative (74/77, 96%). Articles commonly reported on surgical outcomes (47% (8/17) cervical, 67% (14/ 21) endometrial, 47% (16/34) ovarian). Radiation outcomes were most frequently examined in cervical cancer studies (58%, 10/17) while guideline-concordant care was emphasized in ovarian cancer studies (47%, 16/34). Patient-level determinants such as age, race, and comorbidities, were found to influence treatment outcomes across cancer types. Clinic-level determinants (e.g., hospital type, location) were frequently associated with endometrial cancer treatment outcomes. Provider-level (e.g., gynecologic oncologist involvement, physician volume) and clinic-level (e.g., hospital volume) determinants were associated with treatment in ovarian cancer studies. Conclusions: Patient-level determinants consistently influenced access and care quality, while provider- and clinic-level determinants played larger roles in ovarian and endometrial cancer. Findings underscore the need for multilevel interventions targeting disparities in treatment delivery and outcomes in underserved populations. Future research should explore mechanisms underlying structural barriers and evaluate systems-level solutions to improve equity in gynecologic cancer care.