Predictors of Late Stage Cervical Cancer Diagnoses and Disparities in the U.S. (A Closer Look at the Interactions Between Characteristics of Access, Women & Place)

Background: Approximately 51% of women with cervical cancer (CVC) are diagnosed at a late stage (regional or distant), an outcome associated with increased morbidity and mortality.African American, and Hispanic women,and women residing in specific geographic regions of the (US) are among those most heavily burdened by late stage CVC.The cause(s) of these disparities are multifaceted and not well understood. However, the most significant predictor of late stage CVC diagnosis and disparities is current screening, which is largely impacted by access to care. Thus, the goal of this study was to identify access-related predictors of late stage CVC and develop a comprehensive understanding of where and why racial and geographic disparities in late stage CVC occur. Methods: This three-part study examined primary CVC cases diagnosed between the years of 2005-2014, from the United States Cancer Statistics (USCS) database. The final sample included 120,325 CVC cases within 43 states and their 2,357constituent counties. First, Empirical Bayes LISA clustering methods were applied to identify clusters of counties considered to be high risk for late stage CVC “hotspots” during two 5-year time periods (pre- and post-2010). Second, a series of T-tests were conducted to determine whether various contextual and compositional factors were significantly different in hotspots versus other places. Third, two Generalized Linear Mixed Models (GzLMM), using data from person and county levels, were estimated to identify predictors of late stage CVC diagnosis and racial or ethnic disparities among women with CVC in the US. Lastly, a General Linear Mixed Model (GLMM) using data from county- and state –levels was estimated to examine predictors of higher proportions of late stage CVC among counties. Results: Primary care physician shortage areas, Planned Parenthood (PPH) clinics, area-level poverty rates, area-level uninsured rates, percent of immigrants from other countries, state CVC screening mandates and prevalence of self-insured employer health plans were all statistically significant predictors of access to care associated with late stage CVC diagnoses and geographic disparities. We also found that PPH clinics play an important role in reducing the odds of late stage CVC among Hispanic women with CVC. Conclusion: Access to CVC screening plays a significant role in the etiological pathway to late stage CVC diagnoses and disparities. Given that significant access barriers occurred at various ecological and geographical levels, it is recommend that future research and intervention efforts begin to focus on multilevel and/or spatial approaches. Without further exploration of the factors impacting late stage CVC diagnoses, CVC mortality rates will remain high and at a disproportionately higher rate for women in various geographical areas and among African American and Hispanic women

Using residential segregation to predict colorectal cancer stage at diagnosis: two different approaches

Studies have found a variety of evidence regarding the association between residential segregation measures and health outcomes in the US. Some have focused on any individuals living in residentially segregated places, while others have examined whether persons of specific races or ethnicities living in places with high segregation of their own race or ethnicity have differential outcomes. This paper compares and contrasts these two approaches in the study of predictors of late-stage CRC diagnoses in a cross-national study. We argue that it is very important when interpreting results from studies like this to carefully consider the geographic scope of the analysis, which can significantly change the context and meaning of the results

Modeling Geospatial Patterns of Late-Stage Diagnosis of Breast Cancer in the US

In the US, about one-third of new breast cancers (BCs) are diagnosed at a late stage, where morbidity and mortality burdens are higher. Health outcomes research has focused on the contribution of measures of social support, particularly the residential isolation or segregation index, on propensity to utilize mammography and rates of late-stage diagnoses. Although inconsistent, studies have used various approaches and shown that residential segregation may play an important role in cancer morbidities and mortality. Some have focused on any individuals living in residentially segregated places (place-centered), while others have focused on persons of specific races or ethnicities living in places with high segregation of their own race or ethnicity (person-centered). This paper compares and contrasts these two approaches in the study of predictors of late-stage BC diagnoses in a cross-national study. We use 100% of U.S. Cancer Statistics (USCS) Registry data pooled together from 40 states to identify late-stage diagnoses among ~1 million new BC cases diagnosed during 2004–2009. We estimate a multilevel model with person-, county-, and state-level predictors and a random intercept specification to help ensure robust effect estimates. Person-level variables in both models suggest that non-White races or ethnicities have higher odds of late-stage diagnosis, and the odds of late-stage diagnosis decline with age, being highest among the <age 50 group. After controlling statistically for all other factors, we examine place-centered isolation and find for anyone living in an isolated Asian community there is a large beneficial association (suggesting lower odds of late-stage diagnosis) while for anyone living in an isolated White community there is a large detrimental association (suggesting greater odds of late-stage diagnosis). By contrast, living in neighborhoods among others of one’s own race or ethnicity (person-centered isolation) is associated with greater odds of late-stage diagnosis, as this measure is dominated by Whites (the majority). At the state level, living in a state that allows unfettered access to a specialist is associated with a somewhat lower likelihood of being diagnosed at a late stage of BC. Geographic factors help explain the likelihood of late-stage BC diagnosis, which varies considerably across the U.S. as heterogeneous compositional and contextual factors portray very different places and potential for improving information and outcomes. The USCS database is expanding to cover more states and is expected to be a valuable resource for ongoing and future place-based cancer outcomes research

Using residential segregation to predict colorectal cancer stage at diagnosis: two different approaches

PURPOSE: Studies have found a variety of evidence regarding the association between residential segregation measures and health outcomes in the US. Some have focused on any individuals living in residentially segregated places, while others have examined whether persons of specific races or ethnicities living in places with high segregation of their own race or ethnicity have differential outcomes. This paper compares and contrasts these two approaches in the study of predictors of late-stage CRC diagnoses in a cross-national study. We argue that it is very important when interpreting results from studies like this to carefully consider the geographic scope of the analysis, which can significantly change the context and meaning of the results. METHODS: We use US Cancer Statistics Registry data from 40 states to identify late-stage diagnoses among over 500 thousand CRC cases diagnosed during 2004–2009. We pool data over the states and estimate a multilevel model with person, county, and state levels and a random intercepts specification to ensure robust effect estimates. The isolation index of residential segregation is defined for racial and ethnic groups at the county level using Census 2000 data. The association between isolation indices and late stage CRC diagnosis was measured by 1) anyone living in minority segregated areas (place-centered approach), and by 2) individuals living in areas segregated by one’s own racial or ethnic peers (person-centered approach). RESULTS: Findings from the place-centered approach suggest that living in a highly segregated African American community is associated with lower likelihood of late-stage CRC diagnosis, while the opposite is true for people living in highly segregated Asian communities, and living in highly segregated Hispanic communities has no significant association. Using the person-centered approach, we find that living in places segregated by one’s racial or ethnic peers is associated with lower likelihood of late-stage CRC diagnosis. CONCLUSIONS: In a model that covers a large geographic area across the nation, the place-centered approach is most likely picking up geographic disparities that may be deepened by targeted interventions in minority communities. By contrast, the person-centered approach provides a national average estimate suggesting that residential isolation may confer community cohesion or support that is associated with better CRC prevention