Abstract A091: Mediation of racial/ethnic inequities in the diagnosis of early-stage cervical cancer by insurance status
Authors: Holt Hunter K. , Peterson Caryn , MacLaughlan Shannon , Sawaya George F. , Calip Gregory S. 
Published: January 2023

Background: Black and Latina/Hispanic women are more likely to be diagnosed with and die from cervical cancer than White women in the US. Having adequate health insurance, a social and structural determinant of health, may be associated with an earlier stage cervical cancer diagnosis and improved prognosis for racial/ethnic minorities. Objective: To determine whether insurance status among racial/ethnic groups is associated with earlier diagnosis of cervical cancer among a large and diverse population of US women with cervical cancer. Methods: A retrospective, cross-sectional population-based study utilizing data from the Surveillance, Epidemiology, and End Results Census Tract-Level Socioeconomic Status and Rurality Database on 24,945 women aged 21-64 years who were diagnosed with a histologically confirmed invasive cervical cancer between January 1, 2007, to December 31, 2016. The primary outcome was the risk of having a more advanced cervical cancer diagnosis (regional or distant versus localized). Causal mediation analyses were performed using a series of multivariable logistic regression models to determine the association of race/ethnicity with cervical cancer stage and the potential mediator, health insurance status (private insurance versus Medicaid coverage or no insurance). Adjusted odds ratios (OR) and 95% confidence intervals were calculated, and estimates of direct and indirect effects of race/ethnicity and cervical cancer stage were used to calculate the proportion mediated (PM) by health insurance status. Results: 24,945 women (median [IQR] age, 45 [37-54] years) were included in the study. 52% of women were identified as Non-Hispanic (NH) White, 13% as NH Black, and 24% as Hispanic/Latina. Overall, 14,271 women had private insurance, 9,765 women were uninsured or received Medicaid, and 909 women had no documented insurance status. A larger proportion of women who were uninsured or received Medicaid were diagnosed with more advanced stage cancer (regional/distant) compared to women with private health insurance (53.5% versus 42.0%). In models adjusted for age, year of diagnosis and histology type: NH Black (OR 1.38, 95% CI 1.27-1.50), and Hispanic/Latina (OR 1.13, 95% CI 1.06-1.21) women had higher odds of being diagnosed with regional/distant cancer compared to NH White women. After adjustment for insurance status and accounting for co-mediation by area-level socioeconomic status, the association with regional/distant cervical cancer was attenuated toward the null (Black: OR 1.18, 95% CI 1.08-1.29; Hispanic/Latina: OR 0.93, 95% CI 0.87-1.00). Our mediation analysis found that over half (PM 51% to 56%) of the inequities in cervical cancer diagnosis were mediated by health insurance across all racial/ethnic groups. Conclusion: In this population-based sample of US women, insurance status was major mediator of over half the racial/ethnic inequities in late-stage cervical cancer diagnoses. Focused policies making robust health coverage accessible may mitigate the known inequities in cervical cancer diagnosis and outcomes.

Citation Format: Hunter K. Holt, Caryn Peterson, Shannon MacLaughlan, George F. Sawaya, Gregory S. Calip. Mediation of racial/ethnic inequities in the diagnosis of early-stage cervical cancer by insurance status [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A091.