TitleNativity and neighborhood characteristics and cervical cancer stage at diagnosis and survival outcomes among hispanic women in California Despite advances in early detection, cervical cancer remains the second most-common cancer worldwide and the third most-common gynecologic malignancy in the United States, 1,2 with an age-adjusted incidence rate of 7.8 per 100 000 and mortality rate of 2.3 per 100 000 from 2007 to 2011. 3 Notably, although the incidence of cervical cancer is higher among Hispanic women (10.2 per 100 000) than among Asian/Pacific Islander (6.4), African American (9.4), and nonHispanic White (7.8) women, mortality rates among Hispanic women are comparable with those of other groups (2.8 per 100 000).
3---5Compared with women of other racial/ethnic groups, studies consistently show a survival advantage for Hispanic women after control for stage at diagnosis and other clinical and sociodemographic characteristics 2,6---13 ; this observation of lower mortality among Hispanics compared with non-Hispanic Whites is consistent with the "Hispanic paradox." 14,15 Previous studies further suggest that the paradox applies in particular to Hispanic immigrants, particularly immigrants born in Mexico. 15 A recent analysis of national data from the Surveillance, Epidemiology, and End Results (SEER) program found that foreignborn Hispanic women had lower survival than US-born Hispanic women for early-stage disease, but better survival for late-stage disease. 16,17 However, this analysis was based on imputed data for women missing place of birth, which is problematic when one considers that SEER birthplace data are not missing at random. 18---20 The observed survival advantage may also reflect higher rates of losses to follow-up among foreign-born Hispanics, causing underreporting of cervical cancer mortality in this group if significant numbers of women return to their native country once diagnosed with later-stage disease. Thus, to date, reasons for the apparent immigrant survival advantage among women with cervical cancer are poorly understood.The "healthy immigrant effect" suggests that the Hispanic mortality advantage is greater among the foreign-born than US-born because immigrants are selected for better health 21 ; this hypothesis may explain the patterns seen for cervical cancer survival. Therefore, neighborhood characteristics including socioeconomic status (SES) and ethnic enclave (geographical areas that are culturally and ethnically concentrated and distinct from the surrounding area) may be important contributors to survival after cervical cancer diagnosis. Low-income residential ethnic enclaves may protect health by increasing residents' ability to maintain positive health behaviors such as a healthy native diet or abstention from smoking, and provide increased social support. Residents of ethnic enclave communities may also receive targeted public health services or perceive fewer barriers to care. However, ethnic enclaves tend to be of low SES and frequently have higher crime rates a...