Social Determinants of Health Linked With Varying Cervical Cancer Rates in the US

Tara Castellano, MD

Social determinants of health, including poverty level, race and ethnicity, and access to modern, early-stage treatment contributed to variations in the rates of cervical cancer in the United States (US); furthermore, the burden of recurrent or metastatic cervical cancer could fuel health care disparities in this patient population, according to findings from geographical analysis.¹

Findings from the analysis, which were presented at the 2024 SGO Annual Meeting on Women’s Cancer, showed that regions with a higher percentage of low-income households were significantly associated with decreased screening (P <.001) and higher cervical cancer burden (P <.001). Additionally, poverty level was significantly associated with recurrent/metastatic cervical cancer burden in the South (P <.003).

“Findings from this study [are] the first step to optimize health care resources allocations, advocate to minimize access barriers, and [tailor] education on modern treatment options to minimize disparities in outcomes for US patients,” presenting study author Tara Castellano, MD, and colleagues, wrote in a presentation of the data.

Castellano is an assistant professor in the Department of Gynecologic Oncology at Louisiana State University in New Orleans.

Investigators developed the Cervical Cancer Geo-Analyzer tool to help researchers, policy makers, and advocacy groups identify geographical areas where cervical cancer education or health care resource needs are high. The open-access, web-based, interactive tool is designed to allow for the visualization of cervical cancer and recurrent/metastatic cervical cancer burden across different regions of the US.²

A previous study utilizing the tool published in Gynecologic Oncology in 2023 analyzed recurrent/metastatic cervical cancer burden across 410 metropolitan statistical areas (MSAs). Findings demonstrated that this burden varied across MSAs (range, 0%-83.3%). Additionally, recurrent/metastatic burden increased in Boston-Cambridge-Newton, Massachusetts, from 41% in 2018 to 50% in 2020, and in Sacramento-Roseville-Arden-Arcade, California, from 33% in 2018 to 50% in 2020. Conversely, this burden decreased in Grand Rapids, Michigan, from 55% in 2018 to 31% in 2020, and in San Francisco-Oakland-Hayward, California, from 40% in 2018 to 26% in 2020.³

The analysis presented at the 2024 SGO Annual Meeting on Women’s Cancer aimed to allow investigators to further understand the factors related to the observed rates of cervical cancer across different geographical regions.¹

Investigators defined cervical cancer burden as prevalent diagnoses per 100,000 enrollees, and recurrent/metastatic burden was defined as the proportion of patients with cervical cancer who initiated systemic therapy. For screening data, women needed to be between 21 and 64 years of age who had cervical cytology performed within the previous 3 years; be between 30 and 64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the previous 5 years; or be between 30 and 64 years of age who had cervical cytology/hrHPV co-testing performed within the previous 5 years.

The study used the administrative claims database to identify more than 165 million US patients, and investigators examined the prevalence of cervical cancer, the incidence of recurrent/metastatic disease, and the number of women screened in different areas based on the first 3 digits of their ZIP code (ZIP-3).

Data from the US Census Bureau American Community Survey were used to classify poverty level and race/ethnicity. Poverty level was defined as households with income less than 200% of the federal poverty limit. Additionally, information from the American Brachytherapy Society was used to identify brachytherapy centers per ZIP-3.

The study aimed to create a visualization of the geographical distribution of cervical cancer and recurrent/metastatic cervical cancer in the US. Additionally, investigators sought to quantify the association between cervical cancer and recurrent/metastatic cervical cancer burden and screening rates, poverty level, race/ethnicity, and brachytherapy access.

Investigators identified 75,521 patients with cervical cancer who had a median age of 53 years (IQR, 42-63). Insurance type included commercial (70%), Medicaid (29%), and other (1%). Twenty-one percent of patients were from the Midwest, 22% were from the Northeast, 37% were from the South, 19% were from the West, and 1% were other/unknown.

Furthermore, 14,033 patients with recurrent/metastatic cervical cancer were identified, and they had a median age of 59 years (IQR, 49-66). Insurance type included commercial (73%), Medicaid (26%), and other (1%). The regional breakdown consisted of Midwest (21%), Northeast (22%), South (37%), West (19%), and other/unknown (1%).

Additional data showed higher screening rates were significantly associated with decreased cervical cancer burden for the South only (P <.001). Higher screening rates were associated with decreased recurrent/metastatic burden in the Midwest (P <.05) and South (P <.05); however, they were linked with higher recurrent/metastatic burden in the West (P <.05).

Regarding the association between race/ethnicity and cervical cancer burden, a significant association between the increasing percentage of race/ethnicity and increasing burden was observed for Hispanic patients in all regions; Black patients in the Midwest; Black patients in the Northeast; and White patients in the South. Conversely, a significant association between the increasing percentage of race/ethnicity and decreasing cervical cancer burden was observed for Asian patients in all regions; White patients in the Midwest; other patients in the Midwest; Black patients in the South; and White patients in the West.

Regarding recurrent/metastatic cervical cancer burden, a significant association between the increasing percentage of race/ethnicity and decreasing burden was observed only for Asian patients in the Midwest.

Additionally, the presence of at least 1 brachytherapy center in a ZIP-3 was associated with a reduction in recurrent or metastatic cervical cancer burden of 2.7% (20.7% vs 23.4%; P <.001). Notably, the reduction was driven by significant associations in the South and Midwest (P <.001).

Disclosures: Dr Castellano reported receiving consulting fees from GSK and Nykode; and receiving grant support from Bristol Myers Squibb.

References

1. Castellano T, ElHabr AK, Washington C, et al. Health disparities in cervical cancer: mapping behavioral and socioeconomic drivers of geographic dispersion of disease burden with the geo-analyzer. Presented at: 2024 SGO Annual Meeting on Women’s Cancer; March 16-18, 2024; San Diego, CA.
2. Cervical Cancer Geo-Analyzer. Accessed March 16, 2024. https://geo-analyzer.org/
3. Castellano T, Moore K, Ting J, et al. Cervical cancer geographical burden analyzer: an interactive, open-access tool for understanding geographical disease burden in patients with recurrent or metastatic cervical cancer. Gynecol Oncol. 2023;169:113-117. doi:10.1016/j.ygyno.2022.12.004