Original Article
Disparities in Survival Among Women With Invasive Cervical Cancer A Problem of Access to Care Kathleen F. Brookfield, MD, PhD, MPH1, Michael C. Cheung, MD2, Joseph Lucci, MD1, Lora E. Fleming, MD, PhD3, and Leonidas G. Koniaris, MD2
BACKGROUND: In this study, the authors sought to understand the effects of patient race, ethnicity, and socioeconomic status (SES) on outcomes for cervical cancer. METHOD: The Florida Cancer Data System and the Agency for Health Care Administration data sets (1998-2003) were merged and queried. Survival outcomes for patients with invasive cervical cancer were compared between different races, ethnicities, and community poverty levels. RESULTS: In total, 5367 patients with cervical cancers were identified. The overall median survival was 43 months. Significantly longer survival was observed for Caucasians (47.1 months vs 28.8 months for African Americans [AA]; P < .001), Hispanics (52.8 months vs 41.6 months for non-Hispanics; P < .001), the insured (63 months vs 41.2 months for uninsured; P < .001), and patients from more affluent communities (53.3 months where 15% lived in poverty; P < .001). Surgery was associated with dramatically improved survival. AA women who were diagnosed with cervical cancer were significantly less likely to undergo surgical treatment with curative intent compared with Caucasian women (P < .001). However, on multivariate analysis, independent predictors of poorer outcomes were insurance status, tumor stage, tumor grade, and treatment. Neither race, nor ethnicity, nor SES was an independent predictor of poorer outcome. CONCLUSIONS: Race, ethnic, and SES disparities in cervical cancer survival were explained by late-stage presentation and under-treatment. Earlier diagnosis and greater access to surgery and other treatments would significantly improve the survival of C 2008 American Cancer Society. women with cervical cancer. Cancer 2009;115:166-78. V KEY WORDS: health disparities, poverty, socioeconomic status, women’s health.
Cervical cancer represents the third most common gynecologic malignancy diagnosed in the United States. Approximately 11,070 new cases of invasive cervical cancer will be diagnosed in 2008, with an estimated 3870 deaths.1 Disparities in diagnosis, treatment, and outcome for cancers in African Americans (AA) and Caucasians have been documented over the past 30 years.2 The Annual Report to the Nation on
Corresponding author: Leonidas G. Koniaris, MD, University of Miami School of Medicine, 3550 Sylvester Comprehensive Cancer Center, 1475 NW 12th Avenue, Miami, FL 33136; Fax: (305) 243-7083;
[email protected] 1 Department of Obstetrics and Gynecology, University of Miami Miller School of Medicine; Miami, Florida; 2DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; 3Department of Epidemiology and Public Health, University of Miami Miller School of Medicine, Miami, Florida
Supported in part by the James and Ester King Tobacco Grant from the State of Florida, the Florida Department of Health, and the Centers for Disease Control through the National Program of Cancer Registries to the Florida Cancer Data System. Received: June 26, 2008; Revised: August 2, 2008; Accepted: August 6, 2008 C 2008 American Cancer Society Published online: December 18, 2008, V
DOI: 10.1002/cncr.24007, www.interscience.wiley.com
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Cervical Cancer Outcomes / Brookfield et al
the Status of Cancer (1975-2002) indicated that the incidence of cervical cancer deaths was highest for AA women (6.3 per 100,000), followed by Hispanic women (3.9 per 100,000), and Caucasian women (2.7 per 100,000).3 In the current study, we examined the differences in survival observed among patients with invasive cervical cancer based on race, ethnicity, and socioeconomic status (SES). We used a large state cancer registry with a diverse population and with comorbidity information that allowed for better correction for covariates.
MATERIALS AND METHODS The study dataset consisted of data linked between the Florida Cancer Data System (FCDS), which is Florida’s population-based incidence tumor registry, and the Agency for Healthcare Administration (AHCA), which is Florida’s healthcare facility discharge database. FCDS data were used to identify all incident cases of invasive cervical cancer diagnosed in the state of Florida between 1998 and 2003. The FCDS dataset was enhanced with data linked from the AHCA dataset for the same years for both follow-up and comorbidities. Primary cases that were diagnosed antemortem and treated surgically with curative intent were identified. In addition, nonFlorida residents were not included in the analysis, because follow-up for such patients, particularly survival information, may be inaccurate in up to 10% of such patients.4 AHCA maintains 2 databases (Hospital Patient Discharge Data and Ambulatory Outpatient Data) on all patient encounters within hospitals and freestanding ambulatory surgical and radiation therapy centers in Florida. The AHCA datasets that were used in this study contain diagnoses and procedures performed during every hospitalization or outpatient encounter in the state of Florida for the period from 1998 to 2003. Cases in the FCDS and AHCA datasets were linked on the basis of unique identifiers, birth, and sex. Postal codes listed in the FCDS-AHCA database were used to determine community poverty levels according to the 2007 US Census Bureau report. 5 Insurance and payor status was collected as an FCDS variable. The staging criteria used by the FCDS are consistent with the National Cancer Institute’s Surveillance, EpideCancer
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miology, and End Result summary staging and differ from International Federation of Gynecology and Obstetrics staging guidelines. In this study, ‘local’ staging represented disease that did not extend beyond the primary organ, whereas patients who had positive lymph nodes at the time of resection were classified as having ‘regional’ disease. Documentation of distant metastases during the perioperative period led to the classification of affected patients as having ‘distant’ disease. Statistical analysis was performed with SPSS Statistical Package version 15.0 (SPSS Inc., Chicago, Ill). Comparisons between categorical variables were made by using the chi-square test. Median survival rates were calculated by using the Kaplan-Meier method. Because the FCDS collects only primary cause of death, we analyzed only overall survival and not disease-specific survival. Survival was calculated from the time of the initial diagnosis to the date of last contact (or date of death). The univariate effects of demographic, clinical, and treatment variables on survival were tested by using the log-rank test for categorical values. To estimate the impact of race, ethnicity, and SES on survival outcomes, we used a Cox proportional hazards model and added demographic, clinical, and treatment variables in a stepwise fashion.
RESULTS Patient Demographics and Characteristics Over the 5-year period studied, 5367 Florida residents with invasive tumors of the cervix were identified. Demographics, social characteristics, and tumor characteristics are summarized in Table 1. The majority of the patients were Caucasian (n ¼ 4421 women; 82.4%) and non-Hispanic (n ¼ 4454 women; 83.7%). The majority of women were ages 40 to 64 years (n ¼ 2733 women; 50.9%) and were insured (n ¼ 2567 women; 47.8%). Greater than 66% of tumors were of squamous cell histology (n ¼ 3600 tumors; 67.1%). Localized disease was most common (n ¼ 2442 tumors; 53.1%), followed by regional disease (n ¼ 1679 tumors; 36.5%). Approximately 33.1% of the study population lived in a community where >15% of the area population was living below the poverty line. 167
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Cancer
Squamous Adenocarcinoma Epithelial Other cancer
Histology
Yes No Other
Tobacco use
Insured No insurance Medicare Medicaid Medicare/Medicaid NOS Government Unknown
Insurance
A B C D
Community poverty level
Non-Hispanic Hispanic
Ethnicity
Caucasian AA
Race
