Disparities In Cervical Cancer Mortality Research Articles

Patient perspectives on delays in cervical cancer screening and follow-up care in Botswana: a mixed methods study

BackgroundDelays in screening and timely diagnosis contribute significantly to global disparities in cervical cancer mortality in Botswana and other low- and middle-income countries, particularly those with high rates of HIV. Little is known about the modifiable factors shaping these delays from the perspectives of women themselves and how these perspectives may differ between those living with and without HIV.MethodsFrom March–May 2019, we conducted a concurrent, mixed methods study of women receiving treatment for cervical cancer at a multidisciplinary oncology clinic in Botswana. Enrolled participants completed a one-time, concurrent semi-structured interview and structured questionnaire assessing patient characteristics, screening and HIV-related beliefs and knowledge, and barriers and facilitators to screening and follow-up care. Qualitative data were analyzed using directed content analysis guided by the Model of Pathways to Treatment and triangulated with quantitative questionnaire data to identify areas of convergence and divergence. Fisher’s exact tests were used to explore associations between questionnaire data (e.g., screening knowledge) and HIV status.ResultsForty-two women enrolled in the study, 64% of whom were living with HIV and 26% were diagnosed with stage III cervical cancer. Median age was 45 years (IQR 54–67) in those living with HIV and 64 years (IQR 42–53) in those living without. Overall screening rates before symptomatic disease were low (24%). Median time from most proximal screen to diagnosis was 52 median days (IQR 15–176), with no significant differences by HIV status. General screening knowledge was higher among those living with HIV versus those without (100% vs 73%; p < 0.05), but knowledge about HPV and other risk factors was low in both groups. Similar to questionnaire results, qualitative results indicate limited awareness of the need to be screened prior to symptoms as a central barrier to timely screening. Some participants also noted that delays in the receipt of screening results and fear also contributed to treatment delays. However, many participants also described myriad sources of social and tangible support that helped them to overcome some of these challenges.ConclusionInterventions focused on increasing routine screening and supporting timely awareness and access to care are needed to reduce global disparities in cervical cancer.

Reducing Disparities in Cervical Cancer Mortality Among Young Black Women.

Reducing Disparities in Cervical Cancer Mortality Among Young Black Women.

Race- and Age-Related Disparities in Cervical Cancer Mortality

Background: Although the incidence of cervical cancer among younger Black women is now equivalent to that of White women, it is unknown whether the reduced incidence has affected survival rates among younger Black women. The goal of this study was to assess differences in survival by age and race. Patients and Methods: A retrospective cohort study was performed using the National Cancer Database to analyze women with nonmetastatic cervical cancer diagnosed between 2004 and 2014. Women with unknown survival data and those who died within 3 months of diagnosis were excluded. Multivariable logistic regression models evaluated interactions between age and race (Black vs non-Black) for presentation with stage I disease and receipt of optimal treatment. A multivariable Cox regression model was used to evaluate survival differences by age and race. Results: Of 55,659 women included, 16.4% were Black. Compared with their non-Black counterparts, fewer Black women presented with stage I disease (37.8% vs 47.8%; P&lt;.01) and received optimal treatment (46.2% vs 58.3%; P&lt;.01). Fewer Black women had private insurance if they were aged &lt;65 years (39.6% vs 55.7%; P&lt;.01), but not if they were aged ≥65 years (11.7% vs 12.4%; P=.43). According to multivariable logistic regression, Black women aged ≤39 years were less likely to present with stage I disease, with a significant interaction term between age and race (P&lt;.01 for interaction). Disparities in overall survival by race were greatest for Black women aged ≤39 years (adjusted hazard ratio, 1.32; 95% CI, 1.20–1.46; P&lt;.01) but decreased with increasing age interval until no disparity was noted for women aged ≥65 years (P&lt;.01 for interaction). Conclusions: Younger Black women with cervical cancer are at risk for presenting with higher-stage disease and having worse overall survival. These findings may be related to insurance-related disparities and inadequate follow-up for abnormal Papanicolaou test results. Younger Black women with cervical cancer may be a particularly vulnerable population.

A Comparative Study of Health Disparities in Cervical Cancer Mortality Rates Through Time Between Black and Caucasian Women in Alabama and the US.

Background:The main purpose of this study was to assess changes in cervical cancer mortality rates through time between Black and Caucasian women residing in Alabama and the US.Methods:Alabama cervical cancer mortality rates (MR), percentage differences, percentage changes and annual percentage changes for trends were compared with the US baseline and target rates. The US Baseline data and target objectives of utilization of cervical cancer screening and MR were obtained from Healthy People 2020. The cervical cancer behavioral risk factors and utilization of screening tests data were obtained from CDC’s Behavioral Risk Factor Surveillance System (BRFSS). The cervical cancer MR data were obtained from the Surveillance, Epidemiology, and End Results (SEER). The analysis was done using SEER*Stat and Linear Trendlines analysis.Results:Although Blacks in Alabama had higher cervical cancer MR through times, a decreasing trend was noted for both races. However, in Alabama, there is no significant change in Blacks aged 65 years and older in cervical cancer MR, despite a high screening rate compared to Whites. In contrast, between 2002 and 2012, Whites in Alabama and the US made a significant progress toward the Healthy People 2020 goal.Conclusions:In Alabama, there exists cervical cancer MR disparity in Blacks despite the higher rates of screening for cervical cancer as would otherwise be expected. The state has not yet achieved the Healthy People 2020 goal. Public health officials should monitor progress toward reduction and/or elimination of these disparities by focusing in a follow up of screening.

Abstract D125: Disparities in cervical cancer mortality across the Siberian related ethnic regions: The Republic of Sakha, the Republic of Khakassia, Buryatia, the Altai Republic, and Tuva (2007-2017)

Abstract Introduction. Cervical cancer mortality (CCM) varies throughout Russia, including Siberia. Nevertheless, disparities in CCM of Siberian native ethnic population have not yet been investigated. The objective of this study was to determine the differences of CCM during 2007-2017 in Siberian regions, where gene related ethnic groups live – the Republic of Sakha (Sakha), Buryatia, the Republic of Khakassia (Khakassia), the Altai Republic (Altai) and Tuva. Four out of these five regions, except for Sakha, geographically located in the south of Siberia. Sakha is located in the northern part of Siberia. Methods. Annual mortality rates from cervical cancer were analyzed from 2007 to 2017. This data was obtained from the annual reports entitled “Malignant neoplasms in Russia (incidence and mortality)” of P. Hertzen Moscow Oncology Research Institute - branch of the National Medical Research Radiological Center of the Ministry of Health of the Russian Federation. Age-adjusted mortality rates (per 100,000 populations) were compared for each region - Sakha, Buryatia, Khakassia, Altai and Tuva. Kruskal-Wallis H-test was used to determine the statistically significant differences in CCM variances of three or more regions and Mann-Whitney U test for two regions. T-test was used to determine the statistically significant differences in paired CCM rates. Differences with a probability less than the significance level of 0.05 were considered as a statistically significant. Results. Comparisons showed CCM heterogeneity between all five regions of Siberia. The highest CCM rates from 2007 to 2017 were found in Buryatia - the average value of CCM rates (avCCM) is 11.46. CCM rates in this region from 2007 to 2017 were significantly higher than in all other regions, except for the Tuva. The lowest mortality rates during the observed timeframe were detected in Sakha, avCCM - 5.82. Mortality rates in Sakha during this timeframe were significantly lower compared to the other four regions. CCM rates comparison of Altai (avCCM - 9.85), Tuva (avCCM - 9.62) and Khakassia (avCCM - 7.76) did not reveal the significance of the differences between these three regions (although was close to significance). But when paired comparison of CCM variances was used, the CCM rates in Tuva were significantly higher than in Khakassia. When all regions’ CCM rates in 2007 to 2017 were compared, then no significant changes of four regions, except for Altai, were found. In the Altai, compared to 2007, the mortality rate in 2017 significantly decreased, about 2 times (7.61 vs. 15.97). Conclusion. Despite the genetic relationships of the native ethnic populations of Siberia, CCM in the analyzed regions between 2007 and 2017 differs. The highest CCM were observed in Buryatia. The lowest mortality rates were detected in Sakha. CCM rates for the Altai, Tuva and Khakassia were not significantly different. CCM in the Altai in 2007 compared to 2017 decreased twice. The same comparison in Sakha, Khakassia, Buryatia and Tuva showed no changes. Citation Format: Irina V. Kononova, Sargylana N. Mamaeva, Maria P. Kirillina, Petr V. Nikiforov. Disparities in cervical cancer mortality across the Siberian related ethnic regions: The Republic of Sakha, the Republic of Khakassia, Buryatia, the Altai Republic, and Tuva (2007-2017) [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D125.

Trends in geographical disparities for cervical cancer mortality in China from 1973 to 2013: a subnational spatio-temporal study.

This study was designed to explore the time trends in geographical variations of cervical cancer mortality in mainland China over the period 1973 to 2013, to provide subnational spatio-temporal patterns for targeted promotion of human papillomavirus vaccine in China. Data were extracted from three national retrospective death surveys and cancer registry. The rate ratio (RR) was estimated for the aggregated data for seven geographical regions using generalized linear models to evaluate time trends in geographical disparities of cervical cancer mortality. There was a significant decrease in cervical cancer mortality in China from 1973-1975 to 2004-2005, but leveled off thereafter to 2011-2013. Compared to the period 1973-1975 the RR for the three last time periods were 0.33 [95% confidence interval (95% CI): 0.30-0.37] for 1990-1992, 0.21 (95% CI: 0.19-0.24) for 2004-2005 and 0.24 (95% CI: 0.22-0.26) for 2011-2013. Females living in the Northwest China and Central China have a high risk of mortality from cervical cancer compared to the nationwide, with the RR being 2.09 (95% CI: 1.83-2.38) and 1.26 (95% CI: 1.11-1.44) respectively, while the RRs for South China, Northeast China and Southwest China were below 1.00, indicating the lower death risk. Despite the mortality rate had increased slightly from 2004 to 2013, there was an encouraging sign that the geographical disparities in cervical cancer mortality had gradually narrowed over time across China. Although cervical cancer mortality in China has reduced to very low levels, the high risk of cervical cancer in Northwest China and Central China is still noteworthy. Public health policies including the promotion of vaccine should be targeted to further reduction of geographical disparities in cervical cancer mortality.

Assessment of mediators of racial disparities in cervical cancer survival in the United States.

Cervical cancer (CC) morbidity and mortality have decreased in the United States, but they remain high among black women. We assessed racial disparities in CC mortality, accounting for socioeconomic status (SES). We linked data from the 1988 to 2007 Surveillance Epidemiology and End Results (SEER) database to the US Census. Additional SES information was obtained through linkage with Area Resource Files. We used the Kaplan-Meier method for estimating probabilities following CC diagnosis and Cox proportional hazards regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for CC mortality by race. The models were incrementally adjusted for marital status, registry, period, stage, age at diagnosis, histology, treatment, household income, poverty and unemployment rates. We stratified the analyses by disease stage and American state. A total of 44,554 women with CC were identified. Compared to white women, black women had a higher risk of dying from CC; crude and adjusted HRs were 1.41 (CI: 1.34-1.48) and 1.09 (CI: 1.03-1.15), respectively. Corresponding estimates for Hispanic women were 0.85 (CI: 0.80-0.89) and 0.75 (CI: 0.71-0.80). Black women diagnosed at late disease stages had a higher risk of CC death, whereas Hispanic women diagnosed at early and late stages had significantly lower risks. Black CC patients in California experienced poorer survival relative to white women. Conversely, longer CC survival was seen among Hispanic women in California, Georgia and Utah. While crude estimates indicated an increased CC death risk among black women, risks diminished upon adjustment for clinical and sociodemographic characteristics.

Disparities in cervical cancer mortality rates as determined by the longitudinal hyperbolastic mixed-effects type II model.

BackgroundThe main purpose of this study was to model and analyze the dynamics of cervical cancer mortality rates for African American (Black) and White women residing in 13 states located in the eastern half of the United States of America from 1975 through 2010.MethodsThe cervical cancer mortality rates of the Surveillance, Epidemiology, and End Results (SEER) were used to model and analyze the dynamics of cervical cancer mortality. A longitudinal hyperbolastic mixed-effects type II model was used to model the cervical cancer mortality data and SAS PROC NLMIXED and Mathematica were utilized to perform the computations.ResultsDespite decreasing trends in cervical cancer mortality rates for both races, racial disparities in mortality rates still exist. In all 13 states, Black women had higher mortality rates at all times. The degree of disparities and pace of decline in mortality rates over time differed among these states. Determining the paces of decline over 36 years showed that Tennessee had the most rapid decline in cervical cancer mortality for Black women, and Mississippi had the most rapid decline for White Women. In contrast, slow declines in cervical cancer mortality were noted for Black women in Florida and for White women in Maryland.ConclusionsIn all 13 states, cervical cancer mortality rates for both racial groups have fallen. Disparities in the pace of decline in mortality rates in these states may be due to differences in the rates of screening for cervical cancers. Of note, the gap in cervical cancer mortality rates between Black women and White women is narrowing.

Geographic variations of racial/ethnic disparities in cervical cancer mortality in Texas.

To examine how racial/ethnic disparities of cervical cancer mortality vary geographically and to identify factors contributing to the variation. Using the population-weighted risk difference, the authors investigated geographic patterns of racial/ethnic disparities in cervical cancer mortality in Texas based on data from 1995 to 2008 georeferenced at the census tract level. In addition, we considered the impact of seven factors--stage at diagnosis, spatial access to health care, and five factors that were created from available demographic data: socioeconomic status (SES), the sociodemographic factor, the percentage of African Americans, the health insurance factor, and the behavioral factor--on racial/ethnic disparities in the analysis using multivariate logistic regression. SES, the sociodemographic factor, the percentage of African Americans, and racial/ethnic disparities in late-stage diagnosis in a census tract were independent predictors of a census tract's displaying significant racial/ethnic disparities in cervical cancer mortality. Compared with a census tract with the highest SES, a census tract with the lowest SES was more likely to have higher mortality rates in African Americans (odds ratio 4.19, confidence interval 2.18-8.07) or Hispanics (odds ratio 8.15, confidence interval 5.27-12.61) than non-Hispanic whites after adjusting for covariates. Health insurance expenditures also influenced racial/ethnic disparities in mortality, although this effect was attenuated after adjusting for covariates. Neither our calculated behavioral factor nor spatial analysis of access to health care explained racial/ethnic gaps in mortality. Findings from this study could allow cervical cancer intervention programs to more clearly identify areas that would reduce disparities in cervical cancer outcomes.

Racial disparities in cervical cancer mortality over time.

5604 Background: The aim of this study is to examine changes over time in survival for African-American (AA) and white women diagnosed with cervical cancer (CeCa). Methods: Surveillance, Epidemiology, and End Results (SEER) Program data 9 for 1983-2007 were used for this analysis. Kaplan–Meier and Cox proportional hazards survival methods were used to assess differences in survival by race at 5-year intervals. Results: The study included 23,722 women; including 19,777 whites and 3,945 AA. AAs were older (51.4 vs. 49 years; p&lt;0.001), had a higher rate of regional (38.3% vs. 31.7; p&lt;0.001) and distant metastasis (10.5% vs. 8.5; p&lt;0.001). AAs received less frequently cancer-directed surgery (53.1% vs. 65.7%; p&lt;0.001), and more frequently radiotherapy (56.9% vs. 47.3%; p&lt;0.001). AAs had a hazard ratio (HR) of 1.40 (95% CI, 1.31-1.49) of CeCa mortality compared to whites. Adjusting for SEER registry, marital status, stage, age, surgery, radiotherapy, grade and histology, AA women had a HR of 1.15 (95% CI, 1.07-1.24) of CeCa related mortality. AAs had a higher HR of all cause mortality and CeCa related mortality for all the five-year diagnosis cohorts (Table). After adjusting for the same variables, there was a significant difference in survival in the 1988-1992 group (HR 1.26; 95% CI 1.09-1.47). Conclusions: The present data indicates significant survival differences by race for women with invasive CeCa. After adjusting for SEER registry, marital status, stage, age, surgery, radiotherapy, grade and histology, only between 1988-1992 there was a difference in survival between the groups. [Table: see text]

The potential impact of the Deep South Network for Cancer Control on cervical cancer mortality among black females in historically underserved areas of Alabama.

6559 Background: Racial disparities in cervical cancer mortality are well-documented. The Deep South Network for Cancer Control (DSNCC) was implemented in 2000 to address this disparity by targeting blacks for cervical cancer screening in historically underserved areas of Alabama and Mississippi. We aimed to assess whether the implementation of the DSNCC has improved cervical cancer mortality among black females in Alabama. Methods: We used data from the University of Alabama-Birmingham (UAB) Comprehensive Cancer Center Tumor Registry, which comprises all cancer cases treated in the UAB Health system. We selected all black females diagnosed with cervical cancer in the pre-DSNCC (January 1995-December 1999) and post-DSNCC (January 2001-December 2005) periods. Person time was calculated for up to five years post diagnosis. We estimated hazard ratios (HRs) and corresponding 95% confidence limits (CLs) using Cox proportional hazards models. The cervical cancer mortality rate of black females who resided in DSNCC-targeted Alabama counties was compared to non-DSNCC-targeted Alabama counties before and after implementation of the DSNCC. Results: The study population comprised 129 black females diagnosed with cervical cancer pre-DSNCC and 175 diagnosed post-DSNCC. During the pre-intervention period, black females in DSNCC-targeted counties had a two-fold higher cervical cancer mortality rate than black females in non-DSNCC-targeted counties (HR=2.0; 95%CL: 1.10, 3.72). During the post-intervention period, black females in DSNCC-targeted counties had nearly a two-fold lower cervical cancer mortality rate than black females in non-DSNCC-targeted counties (HR=0.54; 95%CL: 0.35, 0.87). Conclusions: Our results suggest that the DSNCC interventions are improving cervical cancer outcomes among black females in historically underserved areas of Alabama. The current analysis was only able to examine the initial 5 years after implementation of the DSNCC; continued assessment of outcomes would be useful for assessing the long-term impact of the DSNCC.

Widening socioeconomic disparities in cervical cancer mortality among women in 26 states, 1993‐2007

Despite substantial declines in cervical cancer mortality because of widespread screening, socioeconomic status (SES) disparities persist. The authors examined trends in cervical cancer mortality rates and the risk of late-stage diagnoses by SES. Using data from the National Vital Statistics System, trends in age-standardized mortality rates among women ages 25 to 64 years (1993-2007) by education level (≤12 years, 13-15 years, and ≥16 years) and race/ethnicity for non-Hispanic white (NHW) women and non-Hispanic black (NHB) women in 26 states were assessed using log-linear regression. Rate ratios (RRs) and 95% confidence intervals (CIs) were used to assess disparities between those with ≤12 years versus ≥16 years of education during 1993 to 1995 and 2005 to 2007. Avertable deaths were calculated by applying mortality rates from the most educated women to others in 48 states. Trends in the risk of late-stage diagnosis by race/ethnicity and insurance status were evaluated in the National Cancer Data Base. Declines in mortality were steepest for those with the highest education levels (3.2% per year among NHW women and 6.8% per year among NHB women). Consequently, the education disparity widened between the periods 1993 to 1995 and 2005 to 2007 from 3.1 (95% CI, 2.4-3.9) to 4.4 (95% CI, 3.5-5.6) for NHW women and from 3.8 (95% CI, 2.0-7.0) to 5.6 (95% CI, 3.1-10.0) for NHB women. The risk of late-stage diagnosis increased for uninsured versus privately insured women over time. During 2007, 74% of cervical cancer deaths in the United States may have been averted by eliminating SES disparities. SES disparities in cervical cancer mortality and the risk of late-stage diagnosis increased over time. Most deaths in 2007 may have been averted by eliminating SES disparities.

Abstract B13: Widening socioeconomic disparities in cervical cancer mortality among women in 26 states: 1993–2007

Abstract Background: Despite declines in cervical cancer mortality in the U.S. due to widespread Pap testing, mortality disparities persist. Previous studies were limited to area-level determinants of socioeconomic status (SES). We examined recent temporal trends in cervical cancer mortality by individual levels of educational attainment as a proxy for SES. Methods: Data from the National Vital Statistics System were used to calculate age-standardized cervical cancer mortality rates for women aged 25–64 years (1993–2007) by individual levels of education: &amp;lt;12 years (high-school diploma or less), 13–15 years (some college), and 16+ years (college degree or more) and race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic). The following 26 states were included in the analysis as they consistently reported education status: Alabama, Alaska, Arizona, Arkansas, Colorado, Hawaii, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Mississippi, Missouri, Nevada, North Carolina, North Dakota, Pennsylvania, Tennessee, Vermont, Virginia, West Virginia, and Wisconsin. Current Population Survey data were used as population denominators and rates presented are per 100,000 population. Log-linear regression was used to assess changes in mortality rates during 1993–2007. Rate ratios (RRs) and corresponding 95% confidence intervals (CIs) were used to assess education disparities for those with &amp;lt;12 years of education versus those with 16+ years of education during 1993–1995 and 2005–2007. The fraction of avoidable cervical cancer deaths in 2007 (had all women experienced the death rates of the reference group, i.e., the most educated non-Hispanic white women) was calculated by applying mortality rates from the reference group to the population of women aged 25–64 years in the study. Results: A total 6,613 cervical cancer deaths occurred during 1993–2007. Mortality rates declined from 4.18 during 1993–1995 to 3.01 during 2005–2007 (−2.9% per year, P&amp;lt;0.05). Declines were greatest for women with 16+ years of education, regardless of race/ethnicity (−3.9% per year, P&amp;lt;0.05). As a result, the education disparity as measured by the RR, widened between 1993–1995 and 2005–2007, from 3.07 (95%CI 2.40–3.93) to 4.41 (95%CI 3.51–5.55) among non-Hispanic whites, and from 3.77 (95%CI 2.03–7.00) to 5.55 (95%CI 3.07–10.03) among non-Hispanic blacks. For Hispanics the education disparity RR during 2005–2007 was 2.54 (95%CI 0.76–8.48). If the entire population experienced the same mortality as non-Hispanic white women with the highest levels of education, about 70% cervical cancer deaths could have been avoided in 2007. Conclusions: Overall cervical cancer mortality declined among women aged 25–64 during 1993–2007; however, the rate of decline was much slower for women with lower levels of educational attainment, leading to widening of SES disparities in cervical cancer mortality rates. We note that many cervical cancer deaths could be avoided by addressing SES disparities, and that additional research is needed to assess individual determinants of these disparities in cervical cancer mortality as well as interventions to reduce them. Citation Information: Cancer Prev Res 2011;4(10 Suppl):B13.

The roles of social domains, behavioral risk, health care resources, and chlamydia in spatial clusters of US cervical cancer mortality: not all the clusters are the same

While high-risk geographic clusters of cervical cancer mortality have previously been assessed, factors associated with this geographic patterning have not been well studied. Once these factors are identified, etiologic hypotheses and targeted population-based interventions may be developed and lead to a reduction in geographic disparities in cervical cancer mortality. The authors linked multiple data sets at the county level to assess the effects of social domains, behavioral risk factors, local physician and hospital availability, and Chlamydia trachomatis infection on overall spatial clustering and on individual clusters of cervical cancer mortality rates in 2000-2004 among 3,105 US counties in the 48 states and the District of Columbia. During the study period, a total of 19,898 cervical cancer deaths occurred in women aged 20 and older. The distributions of county-level characteristics indicated wide ranges in social domains measured by demographics and socioeconomic status, local health care resources, and the rate of chlamydial infection. We found that overall geographic clustering of increased cervical cancer mortality was related to the high proportion of black population, low socioeconomic status, low Papanicolaou test rate, low health care coverage, and the high chlamydia rate; however, unique characteristics existed for each individual cluster, and the Appalachian cluster was not related to a high proportion of black population or to chlamydia rates. This study indicates that local social domains, behavioral risk, and health care sources are associated with geographic disparities in cervical cancer mortality rates. The association between the chlamydia rate and the cervical cancer mortality rate may be confounded by other factors known to be a risk for cervical cancer mortality, such as the infection with human papillomavirus. The findings will help cancer researchers examine etiologic hypotheses and develop tailored, cluster-specific interventions to reduce cervical cancer disparities.