Help Wanted: Low Provider Density Is Associated With Advanced-Stage At Presentation For Cervical Cancer

Objectives: Prior studies suggest that geographic disparities exist for patients with cervical cancer, with a higher incidence and a higher rate of advanced stage disease observed in patients living in rural areas. The objective of the current study is to determine the association between provider:patient ratios and incidence and stage at diagnosis in patients with cervical cancer. Methods: The United States Area Health Resource File was utilized to determine the number of primary obstetric-gynecologists (OBGYN) as well as family practice (FP), and internal medicine (IM) providers in each county. Population estimates by county were obtained from census.gov and provider to resident ratios were calculated. Cervical cancer cases by county were retrieved from the 2015 SEER database. Spearman rank correlations were used to compare the number of providers per 100,000 residents to the overall incidence of cervical cancer as well as the percentage of patients diagnosed at an advanced stage (IIA-IVB). Multivariable logistic regression was performed to assess factors independently associated with advanced stage cervical cancer and county of residence was accounted for through robust sandwich standard error estimation. Results: The analysis included 3,505 cases of cervical cancer in 405 counties, with 1422 early stage cancers, 1728 advanced stage cancers, and 355 of unknown stage. The median number of office-based OBGYN providers per county was 5 per 100,000 residents and the median number of OBGYN, FP, and IM providers per county was 40 per 100,000 residents. Spearman correlation demonstrated a significant inverse association between the number of OBGYN providers per 100,000 residents and the incidence of cervical cancer (p<0.0001) as well as the percentage of cases diagnosed at a late stage (p=0.003). When accounting for OBGYN, FP, and IM providers per 100,000 residents there was a significant inverse correlation with the incidence of cervical cancer cases (p<0.0001), but no significant correlation with the percentage of late stage cervical cancer cases (p=0.09). Adjusting for age, race and insurance type, the odds of presenting with advanced disease decreased as the number of OBGYN providers per 100,000 residents increased with an OR of 0.93 (95% CI: 0.77-1.12) for 8-12 providers per 100,000 residents and an OR of 0.78 (95% CI: 0.61-0.99) for >12 providers per 100,000 residents (reference group: <8 providers per 100,000 residents). Conclusions: This study demonstrated a significant inverse correlation between the number of OBGYN providers per 100,000 residents and incidence of cervical cancer. Most notably, the proportion of advanced stage disease was significantly lower in counties with >12 OBGYN providers per 100,000 residents. Increasing provider density in these underserved, high-risk areas may improve timely cancer detection. Efforts should be made to examine barriers and incentives to increasing provider density in these areas. Prior studies suggest that geographic disparities exist for patients with cervical cancer, with a higher incidence and a higher rate of advanced stage disease observed in patients living in rural areas. The objective of the current study is to determine the association between provider:patient ratios and incidence and stage at diagnosis in patients with cervical cancer. The United States Area Health Resource File was utilized to determine the number of primary obstetric-gynecologists (OBGYN) as well as family practice (FP), and internal medicine (IM) providers in each county. Population estimates by county were obtained from census.gov and provider to resident ratios were calculated. Cervical cancer cases by county were retrieved from the 2015 SEER database. Spearman rank correlations were used to compare the number of providers per 100,000 residents to the overall incidence of cervical cancer as well as the percentage of patients diagnosed at an advanced stage (IIA-IVB). Multivariable logistic regression was performed to assess factors independently associated with advanced stage cervical cancer and county of residence was accounted for through robust sandwich standard error estimation. The analysis included 3,505 cases of cervical cancer in 405 counties, with 1422 early stage cancers, 1728 advanced stage cancers, and 355 of unknown stage. The median number of office-based OBGYN providers per county was 5 per 100,000 residents and the median number of OBGYN, FP, and IM providers per county was 40 per 100,000 residents. Spearman correlation demonstrated a significant inverse association between the number of OBGYN providers per 100,000 residents and the incidence of cervical cancer (p<0.0001) as well as the percentage of cases diagnosed at a late stage (p=0.003). When accounting for OBGYN, FP, and IM providers per 100,000 residents there was a significant inverse correlation with the incidence of cervical cancer cases (p<0.0001), but no significant correlation with the percentage of late stage cervical cancer cases (p=0.09). Adjusting for age, race and insurance type, the odds of presenting with advanced disease decreased as the number of OBGYN providers per 100,000 residents increased with an OR of 0.93 (95% CI: 0.77-1.12) for 8-12 providers per 100,000 residents and an OR of 0.78 (95% CI: 0.61-0.99) for >12 providers per 100,000 residents (reference group: <8 providers per 100,000 residents). This study demonstrated a significant inverse correlation between the number of OBGYN providers per 100,000 residents and incidence of cervical cancer. Most notably, the proportion of advanced stage disease was significantly lower in counties with >12 OBGYN providers per 100,000 residents. Increasing provider density in these underserved, high-risk areas may improve timely cancer detection. Efforts should be made to examine barriers and incentives to increasing provider density in these areas.