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The Impact of Racial, Geographic, and Socioeconomic Risk Factors on the Development of Advanced-Stage Cervical Cancer

Powell, T. Clark, MD, MPH1; Dilley, Sarah E., MD, MPH2; Bae, Sejong, PhD3; Straughn, J. Michael Jr, MD2; Kim, Kenneth H., MD2; Leath, Charles A. III, MD, MSPH2

Journal of Lower Genital Tract Disease: October 2018 - Volume 22 - Issue 4 - p 269–273
doi: 10.1097/LGT.0000000000000421
Special Edition: Underserved Populations

Objectives Despite screening, disparities exist in cervical cancer incidence and outcomes. Demographic factors are associated with diagnosis at advanced stage (AS), but less is known about geographic factors. We sought to investigate risk factors for developing AS cervical cancer in Alabama.

Materials and Methods We identified women treated for cervical cancer from 2005 to 2015 at our institution. Stages II–IV were considered AS. ZIP codes were categorized by federal Rural-Urban Commuting Area Codes, and 16 historically underserved counties were categorized as Black Belt rural. Using data from the American College of Obstetricians and Gynecologists, we identified women's health provider locations. We explored associations between stage and multiple factors using logistic regression.

Results Of 934 patients, 29.2% were black, 52.7% had AS cancer, and 63.4% lived in urban areas. Average distance to nearest American College of Obstetricians and Gynecologists Fellow in urban, rural, and Black Belt rural areas was 5.0, 10.6, and 13.7 miles, respectively. Black race, public insurance and age of older than 65 years were associated with increased risk of AS cancer. Living in a rural area trended toward higher risk but was not significant. When stratified by race, insurance status and age were associated with AS cancer in white women only.

Conclusions Living further from a women's health provider or in a rural area was not associated with a higher risk of AS cervical cancer. Black women had a higher risk of AS than white women regardless of age, insurance status, and geography. Disparities in cervical cancer are multifactorial and necessitate further research into socioeconomic, biologic, and systems causes.

1Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL;

2Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL; and

3Division of Preventative Medicine, University of Alabama at Birmingham, Birmingham, AL

Reprint requests to: T. Clark Powell, MD, MPH, University of Alabama at Birmingham, 619 19th St S, 176F Rm 5329, Birmingham AL, 35249. E-mail:

This study was in part supported by NIH 3P30CA013148-43S3 to C.A.L.; P30 CA13148 to S.B.; and P50 CA098252 to S.B. and C.A.L.

C.A.L. serves on an advisory board for Genentech/Roche and previously served on an advisory board for Celsion and Mateon Therapeutics. The authors have declared they have no conflicts of interest.

This work was approved by the University of Alabama at Birmingham Institutional Review Board (Protocol # X160802010).

Copyright © 2018 by the American Society for Colposcopy and Cervical Pathology