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Cervical Cancer Mortality:
Exploring the Disparity in Appalachia
Debora Geary, MS
East Tennessee State University
Office of Rural and Community Health
RURAL APPALACHIAN CANCER DEMONSTRATION PROGRAM
ABSTRACT
Appalachia is a cervical cancer disparity region, with an elevated level of
mortality compared to national levels. We analyzed the patterns of cervical cancer
mortality at the county level, in order to identify who is at particular risk. The number of
Appalachian counties in the worst 20% of cervical cancer mortality is double the
national rate. Appalachian counties with low socioeconomic status, measured by the
persistently distressed county designation of the Appalachian Regional Commission
(ARC), had almost four times the risk of being in the worst 20% of cervical cancer
mortality. There was no observed relationship between cervical cancer mortality and
Health Provider Shortage Area (HPSA) status, and no relationship between mortality
and whether a county was urban or rural. Our findings suggest that focusing on the
special problems of distressed counties might be a fruitful way to improve cervical
cancer outcomes in Appalachia, and therefore address one of the most prominent
cervical cancer disparities in the nation.
This material is a copy of a program report to the Centers for Disease
Control and Prevention intended for the purposes of dissemination of
results. This report has not been peer reviewed for the purposes of
publication. This Program was supported in whole by grant # H57-CCH420134.
INTRODUCTION
One look at the Atlas of Cancer Mortality’s map of cervical cancer mortality,
1970-94, will tell you that there is a cervical cancer disparity in Appalachia (see figure
1). There is a swath of red through most of the region, red representing the worst rates
of cervical cancer mortality.
Figure 1
Cervical cancer mortality disparities are particularly disturbing because they
represent avoidable deaths. Early detection is available and straightforward, and there
are highly effective treatments for early stage cervical cancer. In spite of this, the
American Cancer Society estimates that 4,100 women will die from cervical cancer in
2002. Appalachia was identified as one of the primary geographic regions of elevated
cervical cancer mortality at a recent NCI conference on this persistent health issue.
Despite the high level of cervical cancer mortality in Appalachia, there is not a lot
of research focused on a better understanding of this disparity within the region as a
whole. Several reasons are likely for this: Appalachia is difficult to describe as a
population group – its poverty levels, racial composition, degree of rurality, etc. differ
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substantially within the region. Data availability is also an issue, especially across state
lines. The Rural Appalachian Cancer Demonstration Program conducted an analysis to
look at the patterns of cervical cancer mortality in the region as a whole, in the hopes of
contributing to a greater understanding of who is at particular risk.
FINDINGS
Appalachian Mortality Disparity
The first step in our analysis was to show, just like the map in figure 1 suggests,
that Appalachia has a disproportionate number of counties with high cervical cancer
mortality. Using use the county decile rankings for cervical cancer mortality 1970-1994,
to identify county level evidence of the Appalachian cervical cancer disparity. Table 1
shows that the 13 states which comprise Appalachia have an elevated number of
counties in the worst two deciles (worst 20%) of cervical cancer mortality (24% vs.
17%). It also shows that when the 13 states are subdivided into their Appalachian and
non-Appalachian components, there is a clear disparity. The non-Appalachian regions
of the 13 states have very similar numbers of counties in the worst two mortality deciles
as compared with national numbers (18% vs. 17%). The number of Appalachian
counties in the worst 2 deciles of cervical cancer mortality is double the national
percentage (34% vs. 17%).
Table 1
Mortality and Economic Distress
Because cervical cancer mortality is often linked with poverty and low economic
status, we then looked at patterns of economic disparity in Appalachia to see if they
were related to cervical cancer mortality patterns. Figure 2 shows a comparison of the
Appalachian region of cervical cancer mortality from figure 1, compared with an
economic indicator developed by the Appalachian Regional Commission (ARC). The
ARC uses a threefold qualification process to designate counties as distressed.
Counties must be over 150% of the US poverty rate, over 150% of the US
unemployment rate AND less than 67% of the US median per capita income. In
addition, the ARC identifies persistently distressed counties as those who have
remained in distressed status for a significant length of time. The other map in figure 2
is the map of counties in Appalachia that were designated as distressed in both 1960
and 1990, taken from the ARC website.
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Figure 2
Cervical Cancer Mortality Rates
Persistently Distressed Counties
Table 2 shows that non-distressed Appalachian counties have more counties in
the worst two deciles than the national average (25% vs. 17%). However, the
difference becomes far more pronounced when looking at the persistently distressed
counties. Of the 95 persistently distressed counties, 59 (62%) have mortality rates that
place them in the worst two deciles. That is almost four times the national average risk.
In fact, half of persistently distressed counties rank in the worst 10% of counties
nationally.
Table 2
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This disparity reflects a very uneven burden of mortality. In non-distressed
Appalachian counties, over 10,000 women died of cervical cancer from 1970-1994.
That is 1584, or 15% more women than would have died if Appalachian mortality rates
were the same as the national average during that time period. In the 95 distressed
counties, 1,640 women died of cervical cancer from 1970-1994. That’s 704, or 42%
more women than would have died if Appalachian mortality rates were the same as
national rates.
Improving Economic Status
Even though cervical cancer mortality is higher in Appalachia, it has been
improving in the past few decades with the availability of better screening and
treatment. Because the economic status of many counties in Appalachia has also been
improving, we looked at what happens to the cervical cancer mortality rates in counties
where economic conditions improve.
In 1960, over 50% of the counties in Appalachia were distressed. By 1990, less
than half of those counties were still distressed (resulting in the persistently distressed
designation). Therefore, there are three groups we can examine for cervical cancer
mortality trends: the persistently distressed counties (distressed in 1960 and 1990), the
historically distressed counties (distressed in 1960, but not in 1990), and the nonhistorically distressed counties (not distressed in 1960 or 1990). Table 3 shows the
change in average mortality rates from 1950-1969 to 1970-1994 for each of these
groups.
Table 3
It is evident from table 3 that historically distressed counties have seen a decline
in cervical cancer mortality rates in line with levels of national improvement. Of the 206
counties which were distressed in 1960, 111 experienced improvements in both their
economic status and their cervical cancer mortality rates. 95 remained economically
distressed and did not experience the same level of decline in mortality rates as the
nation, or as the more economically strong counties in their region.
Measures Not Related to Mortality
Given the strong connection with socio-economic distress and cervical cancer
rates, we wanted to examine factors that are often associated with socio-economic
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distress in Appalachia, and examine their relationship to cervical cancer mortality. The
two factors we examined were level of medical care, and urban-rural distinctions.
We used Health Provider Shortage Area (HPSA) designation as a measure of
availability of medical care. The HPSA designation and persistently distressed
designation of counties did not overlap as tightly as we expected. More distressed
counties are also HPSA than non-distressed counties (33% vs. 16%), but 67% of
distressed counties are not HPSA designated.
Table 4 shows a comparison of numbers of counties in the worst two deciles,
based on HPSA designation. For non-Appalachian counties within the 13 states, there
is a relationship between HPSA designation and number of counties in the worst two
deciles. As one might expect, in counties with a lack of available medical care, they are
more likely to be in the worst two mortality deciles than in counties with adequate
availability of medical care (27% vs. 15%). However, in Appalachia, this relationship
does not hold. The risk of an Appalachian county being in the worst 20% of cervical
cancer mortality does not differ for HPSA and non-HPSA designated counties.
Table 4
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Another characterization of distressed counties is that they are predominantly
rural. We compared USDA urban-rural codes, a scale of 0 (very urban) to 9 (very rural),
against county level mortality rates. We found no relationship between how rural the
county is, and its level of mortality. For each level of USDA urban-rural code, there are
approximately equal numbers of counties above and below the average mortality rate.
This same lack of relationship is observed by running regression analysis on all
Appalachia counties, or all counties nationally.
RECOMMENDATIONS
Distressed Counties as a Useful Indicator
Persistently distressed county designation was found to be a very significant
indicator of a county’s likelihood of being in the worst two deciles of counties in the
nation for cervical cancer mortality. That would suggest that in addressing cervical
cancer disparities, targeting distressed counties might be more fruitful than targeting
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rural counties or HPSA counties. It is recommended that future research, health
policies, and interventions consider distressed status as a useful indicator.
More Geographically Based Research
This county level approach highlights the need to use analysis methods which
give weight to geographic areas with low population densities. In a county based
analysis, where all counties, whether the population is 10,000 or 1,000,000, are
weighted equally, the persistently distressed counties of Appalachia emerge as a
nationally prominent disparity. 28% of the worst 300 counties in the nation for cervical
cancer mortality are within Appalachia, and the majority of those are persistently
distressed counties. Women living in these counties are much ore evident as a
disparity group when geographic patterns are analyzed.
Important to Look at More Detailed Patterns
While previous analyses at the level of the Appalachian region as a whole have
shown small disparities in relation to the rest of the country, the worst two deciles
approach points to a moderate disparity in the region, coupled with a very significant
disparity localized to certain counties. This is important information when targeting
prevention, detection and treatment programs in an era of limited resources. When
targeting interventions and prevention strategies, it is important to consider both which
communities, and which members in the communities, are at highest risk for cervical
cancer.
What We Don’t Know
Our analysis does not establish a causal link between county level
socioeconomic distress and cervical cancer mortality. We believe that cervical cancer
outcomes will not be significantly improved without a better understanding of the factors
which drive this relationship. Possible factors might include community attitudes and
beliefs, physician knowledge, screening services available in a community, distance of a
community from cancer care, socioeconomic distress of individuals and/or communities
and significantly decreased survivorship due to late detection and/or inadequate
treatment. Community participation and community level intervention will be significant
in increasing our understanding of this health disparity.
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