Cervical Cancer Mortality & Screening: Two Analyses using BRFSS Data Open Access

Abstract

BACKGROUND: Cervical cancer is the most preventable cancer through screening yet is still a leading cause of cancer death among young women in the US. Contemporary trends in hysterectomy-corrected cervical cancer mortality were examined by age, race/ethnicity, and state. An updated assessment of cervical cancer screening among LGBTQ+ women is also presented.

METHODS: Annual hysterectomy prevalence was estimated using the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS 1990-2020), with missing data years approximated via two-year averages of adjacent years. Age-specific cervical cancer deaths (20-49, 50-64, ≥65 years) by race/ethnicity were obtained from the National Center for Health Statistics (1990-2019). Age-standardized hysterectomy-corrected mortality rates per 100,000 women were calculated by dividing death counts by the estimated female population with an intact uterus for each stratum. Joinpoint regression quantified the annual and 5-year average annual percent change (AAPC) and 95% confidence intervals (CI). The association between sexual orientation and screening compliance was examined in data from BRFSS female respondents (2014-2020) aged 21-29 and 30-65, and expressed as logistic regression-generated odds ratios adjusted for age, education, relationship status, income, race/ethnicity, smoking and insurance status.

RESULTS: Cervical cancer death rates declined continuously from 1990-2019, with contemporary declines largest among ages ≥65 years (AAPC: -1.7% [95% CI: -2.0%, -1.3%]) and smallest among ages 20-49 years (AAPC: -0.5% [95% CI: -0.8%, -0.2%]). Mortality from 2015-2019 was highest in Alabama, Arkansas, Mississippi, and Oklahoma, where most age groups experienced stable trends. Morality increased among young women in Indiana (4.8% per year 2009-2019 [95% CI: 0.9%, 8.9%]), NHW women in Alabama (1.9% per year 2003-2019 [95% CI: 0.4%, 3.4%]), and NHW young women in Kansas (2.2% per year 1996-2019 (95% CI: 0.5%, 3.9%]). The odd ratios comparing screening adherence non-straight women to straight referents were 0.58 (95% CI: 0.45, 0.75) and 0.80 (95% CI: 0.66, 0.97) in 21-29- and 30-65-year age groups, respectively.

CONCLUSION: Cervical cancer mortality declined for all ages of women in most states, but progress has lagged in states with the highest burden. Non-straight women were less likely than their straight counterparts to be screening compliant.

Table of Contents

Introduction....................................................................................................................................1 Methods..........................................................................................................................................2

Hysterectomy-Correction Analysis...............................................................................................2

Screening Compliance Analysis...................................................................................................4 Results............................................................................................................................................7

Hysterectomy-Correction Analysis..............................................................................................7

Screening Compliance Analysis...................................................................................................9 Discussion......................................................................................................................................11 References......................................................................................................................................18 Tables............................................................................................................................................25

Table 1: Hysterectomy correction impact on death rates &

rate ratios by race/ethnicity (2015-2019)...............................................................................25

Table 2: Trends in cervical cancer mortality by race/ethnicity and age (1990-2019)........................26

Table 3: Population characteristics by screening compliance status (2014-2020)............................27

Table 4: Odds ratios of screening compliance estimated using logistic regression model

including all two-by-two exposure-confounder interaction terms (2014-2020).......................28

Table 5: Population characteristics by screening compliance

status and age group (2014-2020) .......................................................................................29 Figures...........................................................................................................................................30

Figure 1: Hysterectomy prevalence estimates by race/ethnicity and age (1990-2019)......................30

Figure 2: Five-year cervical cancer mortality rate by state over time (1990s vs 2010s) .....................30

Figure 3: Five-year cervical cancer mortality rate ratios by

race/ethnicity, age, and state (2015-2019)............................................................... ..............31

Figure 4: Odds ratios of screening compliance estimated from

stratified logistic regression models (2014-2020)...................................................................32

Supplemental materials..................................................................................................................33

Supplemental Table 1: Trends in corrected cervical cancer

mortality rates by age and state (1990-2019) ........................................................................33

Supplemental Table 2: Trends in non-Hispanic White corrected

cervical cancer mortality rates by age and state (1990-2019)..................................................40 

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.S.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health GLBT Studies Health Sciences, Epidemiology
Keyword	mortality cervical cancer US state screening
Committee Chair / Thesis Advisor	Dr. Michael Goodman, Emory University
Committee Members	Rebecca Siegel, American Cancer Society Kimberly Miller, American Cancer Society

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