Mediation of Racial and Ethnic Inequities in the Diagnosis of Advanced-Stage Cervical Cancer by Insurance Status

Abstract

ImportanceBlack and Hispanic or Latina women are more likely than White women to receive a diagnosis of and to die of cervical cancer. Health insurance coverage is associated with diagnosis at an earlier stage of cervical cancer.ObjectiveTo evaluate the extent to which racial and ethnic differences in the diagnosis of advanced-stage cervical cancer are mediated by insurance status.Design, Setting, and ParticipantsThis retrospective, cross-sectional population-based study used data from the Surveillance, Epidemiology, and End Results (SEER) program on an analytic cohort of 23 942 women aged 21 to 64 years who received a diagnosis of cervical cancer between January 1, 2007, and December 31, 2016. Statistical analysis was performed from February 24, 2022, to January 18, 2023.ExposuresHealth inusurance status (private or Medicare insurance vs Medicaid or uninsured).Main Outcomes and MeasuresThe primary outcome was a diagnosis of advanced-stage cervical cancer (regional or distant stage). Mediation analyses were performed to assess the proportion of observed racial and ethnic differences in the stage at diagnosis that were mediated by health insurance status.ResultsA total of 23 942 women (median age at diagnosis, 45 years [IQR, 37-54 years]; 12.9% were Black, 24.5% were Hispanic or Latina, and 52.9% were White) were included in the study. A total of 59.4% of the cohort had private or Medicare insurance. Compared with White women, patients of all other racial and ethnic groups had a lower proportion with a diagnosis of early-stage cervical cancer (localized) (American Indian or Alaska Native, 48.7%; Asian or Pacific Islander, 49.9%; Black, 41.7%; Hispanic or Latina, 51.6%; and White, 53.3%). A larger proportion of women with private or Medicare insurance compared with women with Medicaid or uninsured received a diagnosis of an early-stage cancer (57.8% [8082 of 13 964] vs 41.1% [3916 of 9528]). In models adjusting for age, year of diagnosis, histologic type, area-level socioeconomic status, and insurance status, Black women had higher odds of receiving a diagnosis of advanced-stage cervical cancer compared with White women (odds ratio, 1.18 [95% CI, 1.08-1.29]). Health insurance was associated with mediation of more than half (ranging from 51.3% [95% CI, 51.0%-51.6%] for Black women to 55.1% [95% CI, 53.9%-56.3%] for Hispanic or Latina women) the racial and ethnic inequities in the diagnosis of advanced-stage cervical cancer across all racial and ethnic minority groups compared with White women.Conclusions and RelevanceThis cross-sectional study of SEER data suggests that insurance status was a substantial mediator of racial and ethnic inequities in advanced-stage cervical cancer diagnoses. Expanding access to care and improving the quality of services rendered for uninsured patients and those covered by Medicaid may mitigate the known inequities in cervical cancer diagnosis and related outcomes.

Disparities in Gynecologic Cancers

“…Several studies of patterns of care show decreased rates of surgical treatment for Black women, older women, and those with Medicaid or no insurance. 28,29 As shown in Figure 3, non-Hispanic Black women are more likely to have more advanced disease and require chemoradiation. Those lacking insurance, those of older age, and rural patients also present with higher-stage disease.…”

“…Those lacking insurance, those of older age, and rural patients also present with higher-stage disease. 5,11,29 Patients with locally advanced cervical cancer require weekly chemotherapy and radiation with external beam pelvic radiation and intracavitary brachytherapy to achieve cure. 31 Treatment delay beyond 8 weeks is a quality metric and associated with decreased survival and local control of tumor spread.…”

“…Early-stage cervical cancer (tumors <4 cm and limited to the cervix) can be treated and cured surgically with either simple hysterectomy or radical hysterectomy and lymphadenectomy/sentinel lymph node dissection, depending on tumor size. Several studies of patterns of care show decreased rates of surgical treatment for Black women, older women, and those with Medicaid or no insurance 28,29 . As shown in Figure 3, non-Hispanic Black women are more likely to have more advanced disease and require chemoradiation.…”

Overlooked and Damaging Impact of Structural Racism and Implicit Bias on US Health Care

“…6,7 The unfortunate result is disparities in access to preventive services and programs, leading to delayed screening and later-stage diagnosis. [8][9][10][11][12] Further complicated by the lack of representation of racial and ethnic minorities in clinical trials and the high cost of cancer care, many patients often receive lower-quality care because they do not have access to appropriate treatment options or lack the appropriate resources for supportive and palliative care. 13 Finally, equitable quality care has yet to be realized, which is largely linked to a lack of diversity in the oncology workforce and attributable bias, which impacts the provider-patient relationship and decision-making.…”

“…In addition to factors aforementioned, other specific influences on cancer outcomes include work and environmental conditions (related to disproportionate exposure to carcinogens) and how health care is valued and utilized differently by certain groups 6,7 . The unfortunate result is disparities in access to preventive services and programs, leading to delayed screening and later-stage diagnosis 8–12 . Further complicated by the lack of representation of racial and ethnic minorities in clinical trials and the high cost of cancer care, many patients often receive lower-quality care because they do not have access to appropriate treatment options or lack the appropriate resources for supportive and palliative care 13 .…”