Cancer is the leading cause of death in Puerto Rico (PR) and the United States Virgin Islands (USVI). Gynecologic (GYN) cancers represent more than 15% of all cancers diagnosed in women in PR. GYN cancer data from USVI is unknown as they recently created a cancer registry. Cancer has been described as one of the conditions of top medical management priority after a natural disaster. In particular, cancer patients are among the people with the greatest risk of death and complications after a disaster, as health care interruptions can negatively affect their health outcomes. On September 2017 Hurricanes Irma and Mara affected PR and USVI, causing all the population to experience major disruptions in essential services (e.g. potable water and electric power, health services, telecommunications, and transportation) and potential environmental health issues (e.g. water sanitation, contaminant exposure, vector borne diseases, and food hygiene). Research has evidenced that extreme events lead to disruptions in health care systems and can have a direct impact in health status of populations. The impact of these hurricanes on oncology care and health outcomes of GYN cancer patients has yet to be documented, particularly knowing that access to care prior to the hurricanes existed, as only 5 trained GYN oncologists provide services in PR and none in USVI, and patients from USVI relocate for oncologic care to the continental US and PR. To address this gap, the proposed study will focus on oncology care and health outcomes of women with GYN cancer from PR and USVI who receive health services in PR and will use a mixed-methods approach to answer the proposed study aims: 1) determine the psychosocial and environmental stressors and 2) the multi-level responses that women with GYN cancers experienced in the aftermath of hurricanes Irma and Mara, and 3) determine the impact of such stressors and multi-level responses on oncology care and health outcomes among women with GYN cancers. Using a qualitative assessment (focus groups and key-informant interviews), we will document the stressors, responses, and experiences of patients and providers/organizations involved in the receipt and delivery of GYN oncology medical services in PR, respectively. Afterwards, a retrospective cohort study design will be used to quantitatively evaluate the impact of stressors and multilevel responses on oncology care and health outcomes in a clinic-based, two-way stratified random sample of 400 women with GYN cancer. The clinics where GYN oncologists provide care in PR will collaborate in the study. Data collection procedures will include an interviewer administered questionnaire, assessment of susceptibility to hurricane-related physical hazards, and medical record review. Bayesian spatio-temporal models with the inclusion of hierarchical structures will be used to capture temporal and spatial trends of our outcomes, given our predictors variables, in several levels and interactions. Study results will be disseminated and used to generate recommendations and guidelines for future disaster planning and response through the creation of a Dissemination Board.
The impact of hurricanes Mara and Irma on oncology care adherence and health outcomes of GYN cancer patients from PR and USVI has yet to be documented, particularly knowing that access to care prior to the hurricanes existed for these patients given lack of enough available GYN oncologists in these territories. Study results and their dissemination will serve 1) as the basis for future studies of longer-term health impacts of hurricanes and other extreme events on cancer patients from PR and the USVI, and 2) will help disaster planners and public health professionals to a) develop and implement effective and evidence-based mitigation strategies in the future, and more specifically, b) an action plan for patient preparedness and resilience-based institutional capacity, to guide timely and adequate disaster responses for both GYN patients and providers, which could later be extrapolated to other populations of cancer patients.
