Effect of Insurance Status on Racial and Ethnic Inequities in the Diagnosis of Advanced-Stage Cervical Cancer

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In a study reported in JAMA Network Open, Holt et al found that health insurance status was a substantial mediator in the diagnosis of advanced-stage vs early-stage cervical cancer across ethnicity and race in patients from the United States.

Study Details

The retrospective, cross-sectional, population-based study used data from the Surveillance, Epidemiology, and End Results (SEER) program from 23,942 patients aged 21 to 64 years who were diagnosed with cervical cancer between January 2007 and December 2016. The primary outcome measure was diagnosis of advanced-stage disease (regional or distant stage), with mediation analyses performed to assess the proportion of racial and ethnic differences in the stage at diagnosis that were mediated by health insurance status. Health insurance status was defined as private or Medicare vs Medicaid or uninsured.

Key Findings

In the total cohort (median age at diagnosis = 45 years), 52.9% of patients were White, 24.5% were Hispanic/Latinx, 12.9% were Black, 9.0% were Asian/Pacific Islander, and 0.8% were American Indian/Alaska Native.

A total of 59.4% of the cohort had private/Medicare insurance at diagnosis, including 69.4% of White, 64.3% of Asian/Pacific Islander, 48.7% of American Indian/Alaska Native, 48.2% of Black, and 42.5% of Hispanic/Latinx patients (overall P < .001). Patients with private/Medicare insurance were more likely to be diagnosed with early (localized) disease vs those with Medicaid or no insurance (57.8% vs 41.1%, P < .001). Compared with White patients (53.3%), smaller proportions of Black (41.7%), American Indian/Alaska Native (48.7%), Asian/Pacific Islander (49.9%), and Hispanic/Latinx patients (51.6%) were diagnosed with early-stage disease (overall P < .001).

In a model adjusting for age, year of diagnosis, histologic type, area-level socioeconomic status, and insurance status, Black patients had higher odds of receiving a diagnosis of advanced-stage disease compared with White patients (odds ratio = 1.18, 95% confidence interval = 1.08–1.29).

In the mediation analysis, compared with White patients (reference category), health insurance status was associated with mediation of more than half of the racial and ethnic inequities in the diagnosis of advanced-stage cervical cancer across all other racial and ethnic groups, with values ranging from 51.3% for Black patients to 55.1% for Hispanic/Latinx patients.

The investigators concluded, “This cross-sectional study of SEER data suggests that insurance status was a substantial mediator of racial and ethnic inequities in advanced-stage cervical cancer diagnoses. Expanding access to care and improving the quality of services rendered for uninsured patients and those covered by Medicaid may mitigate the known inequities in cervical cancer diagnosis and related outcomes.”

Hunter K. Holt, MD, MAS, of the Department of Family and Community Medicine, University of Illinois at Chicago, is the corresponding author for the JAMA Network Open article.

Disclosure: The study was supported by the National Institutes of Health Office of Research on Women’s Health. For full disclosures of the study authors, visit

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