Cervical Cancer Disparities In Texas
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As a preventable and curable cancer, cervical cancer incidence and mortality rates have declined due to the adoption of Human papillomavirus (HPV) vaccine as a prevention method, as well as the wide use of Pap smear tests as a screening tool. However, cervical cancer remains one of the most common cancers among females in the United States. Cervical cancer outcome disparities by race/ethnicity, socioeconomic status, and geographic location have been documented. One of the overarching themes of the American Cancer Society’s (ACS) 2015 goals is to eliminate disparities in cancer burdens among different segments of the U.S. population. Despite advances in knowledge about cancer during the last century, identifying factors associated with cervical cancer disparities remains a challenging task. An increasing number of studies revealed that health disparities are attributed to a wide range of factors that exist and operate on different levels (e.g., contextual and individual level). However, there are several research gaps in the literature on cervical cancer disparities. First, no research has taken into consideration individual-level factors (age, race/ethnicity, tumor characteristics, and type of treatment received) in conjunction with contextual-level factors (demographic factors, behavioral factors, health insurance expenditure, urbanization, and spatial access to health care) to study cervical cancer disparities. Second, no work has placed all the above factors in a spatial context and examined how they jointly contribute to geographic disparity in cancer. Third, no work has examined how the racial disparity in cervical cancer varies spatially. Fourth, little work has analyzed geographic disparities in cervical cancer survival and examined impacts of multilevel factors on the geographic disparities. Taking advantage of Geographic information science and spatial analysis techniques, this dissertation investigated cervical cancer disparities of state at diagnosis, survival and mortality in Texas based on data from 1995 to 2008 from three social domains: race/ethnicity, socioeconomic status (SES), and geographic location. Multilevel models were adopted to measure the impact of individual- and contextual-level factors on cervical cancer disparities. Spatial scan statistics were used to measure geographic variations of cervical cancer outcomes. The dissertation also used a population-weighted risk difference to measure geographic variations of racial/ethnic disparities of cervical cancer mortality. This dissertation found statistically significant racial/ethnic and SES disparities of cervical cancer late-stage diagnosis and survival. African-American women had an elevated risk of late-stage diagnosis or mortality compared with their non-Hispanic white counterparts. Compared with women from census tracts with a higher SES, individuals from census tracts with a lower SES experienced elevated risk of late-stage diagnosis or mortality. The study did not observe any significant geographic disparities of late-stage diagnosis. However, it identified statistically significant geographic clusters of longer-than-expected or shorter-than-expected cervical cancer survival. This study also identified significant geographic variations in racial/ethnic disparities. Findings from this study have several important implications for reducing cervical cancer disparities in Texas by providing information for developing effective cervical cancer intervention programs in Texas. This research found that contextual-level factors explained part of cervical cancer disparities. Therefore, it is important to ameliorate contextual effects in order to reduce disparities in cervical cancer survival. Intervention programs should be developed to target socially deprived areas (e.g., areas with lower SES, areas with higher percentage of African Americans, foreign-born women, or linguistic isolated households).