Trends in Hysterectomy-Corrected Cervical Cancer Incidence by Texas Public Health Region, 2000-2020
Introduction
Cervical cancer is preventable through human papillomavirus (HPV) vaccination and screening. Largely driven by inequity in access to screening and follow-up care, disparities in cervical cancer incidence and mortality by geography, race/ethnicity, and socioeconomic status have been reported. This study is the first to describe cervical cancer incidence trends within eleven Public Health Regions (PHR) of Texas (a state with one of the highest cervical cancer incidence and burden in the U.S.).
Methods
We identified microscopically confirmed malignant cervical cancer cases diagnosed in Texas from 2000 to 2020 in the Surveillance, Epidemiology, and End Results-22 (SEER-22) dataset. PHRs were those defined by the Department of State Health Services. Annual age-adjusted (to 2000 U.S. Standard Population) incidence rates per 100,000 person-years were estimated for Texas overall and by PHR using SEER*Stat v8.4.1.2. Incidence rates were corrected to account for overall and PHR-specific hysterectomy prevalence, which was calculated using data from the Texas Behavioral Risk Factor Surveillance System. Smoothed survey-weighted hysterectomy prevalence estimates were used to correct the respective population at risk by removing the proportion of women estimated to have had a hysterectomy. Hysterectomy-corrected age-adjusted incidence rates and standard errors were then calculated. JoinPoint Regression v4.9.1.0 was used to estimate piecewise log-linear trends and derive Annual Percent Change (APC) utilizing the empirical quantile method to calculate 95% confidence intervals (CI).
Results
Between 2000-2020, there were 22,894 cervical cancer cases identified in Texas. In Texas overall, hysterectomy-corrected incidence decreased significantly until 2010 (APC2000-2010= -3.1% [95% CI= -4.4% to -2.4%]) and stabilized thereafter (APC2010-2020= -0.4% [95% CI= -1.1% to 0.8%)]. From 2013 to 2020, hysterectomy-corrected cervical cancer incidence increased by 7.1% (95% CI= 1.2% to 25.0%) per year in PHR-2 (Northwest Texas). Additionally, from 2011 to 2020, we observed a statistically non-significant increasing trend in incidence in PHR-9 (West Texas) (APC2011-2020= 3.6% [95% CI= -0.2% to 21.5%]). In the other nine PHRs, incidence either significantly decreased (PHR- 3, 5, 6, 7, 8, 10, 11), trended downward non-significantly (PHR-4), or remained stable (PHR-1). In 2020, the statewide cervical cancer incidence rate was 10.9 per 100,000; the incidence in five PHRs was at least nearly 1.4-fold higher than the statewide average (rates per 100,000: PHR-1= 18.6; PHR-2= 16.7; PHR-4= 15.2; PHR-5= 17.6; PHR-9= 15.0).
Conclusion
Our findings suggest a rise in cervical cancer incidence in PHR-2 (Northwest Texas) and a stabilization of previously declining rates in Texas overall. We also observed a non-significant upward trend in PHR-9 (West Texas). Additionally, in 2020, cervical cancer incidence rates were higher in most PHRs than in Texas overall, indicating that aggregate state-level estimates may mask regional disparities. Targeted efforts to increase access to and utilization of preventive services may help to mitigate increasing cervical cancer incidence in specific PHRs of the state.