Ovarian cancer is the fifth leading cause of cancer death among women in the United States with 13,445 deaths in 2019 alone [1]. It remains the most lethal gynecologic malignancy, even after significant progress in treatment strategies over the past few decades. Between 1976 and 2015 the mortality rate dropped 33% from 10 per 100,000 to 6.7 per 100,000 [2], with most of this improvement attributed to aggressive surgical debulking and platinum-based chemotherapies that became standard during the mid-1980s [3]. Concerningly, not all patients appear to benefit equally from these medical advances. Ovarian cancer mortality in Black women remains significantly higher than that of White women [6]. Data the from Surveillance, Epidemiology and End Results (SEER) registry between 1990 and 2010 showed five-year survival rates increased from 33% to 47% among White women, while simultaneously decreasing 44% to 35% among black women [4,5].

These disparate outcomes may at least partially be explained by differences in access to and receipt of appropriate care. Previous work has shown Black patients are more likely to present at a later stage of diagnosis [7,8]. Furthermore, numerous studies have shown that Black patients are less likely than their White counterparts to receive standard of care stage for stage [7,[9], [10], [11], [12],15]. Importantly, disparities in outcomes may be reduced when treatment is similar [6,13,14]. Researchers have attempted to explain racial differences in outcomes through a socioeconomic [18] and genetic lens [19]. In actuality, the observed disparity is likely a complex combination of multiple factors, but given race is a social construct with little genetic basis, it would stand to reason that social factors drive the observed disparities. Recent research has implicated racial residential segregation as a driver of disparate health outcomes for Black Americans [20,21], providing a unifying framework for the previously addressed causes of ovarian cancer disparities.

There is an enduring history of racial segregation in the United States. Starting in early the 19th and 20th Century, the Great Migration led many Black Southerners North as they fled White on Black violence in the South. Arriving in the North, they were often met with zoning ordinances, created by urban planners, to intentionally keep Blacks and Whites separate. These neighborhood divides were further cemented in 1934, with the establishment of the Federal Housing Agency. In a practice now known as redlining, areas with a large share of Black population were deemed too risky an investment, thus disqualifying these residents from accessing federally backed housing loans. This excluded Black families from generational wealth building that was afforded to White families. The effects of these policies have persisted and previously redlined neighborhoods still have lower levels of homeownership and access to credit, as well as higher rates of poverty and crime [22,23].

A recent study associated lower survival in epithelial ovarian cancer with higher levels of racial segregation but was only limited to one state [24]. While insightful, there are marked differences in ovarian cancer treatment and survival by region, and this study may not be generalizable [25]. In our study, we use a large, nationally representative sample to investigate the effect of racial residential segregation on disparities between Black and White patients in stage at diagnosis, receipt of surgery, and 5-year cancer specific survival.