摘要：Objectives. We examined stage of diagnosis and survival after cervical cancer among Hispanic women, and their associations with Hispanic nativity, and explored whether neighborhood socioeconomic status (SES) and residence in a Hispanic enclave modify the association of nativity with stage and survival. Methods. We used California Cancer Registry data (1994–2009) to identify 7958 Hispanic women aged 21 years and older with invasive cervical cancer. We used logistic and Cox proportional hazards models to estimate the associations between stage and mortality with nativity, neighborhood factors, and other covariates. Results. Foreign-born women had similar adjusted relative odds of being diagnosed with stages II through IV (vs stage I) cervical cancer compared with US-born Hispanic women. However, among foreign-born women, those in low-SES–low-enclave neighborhoods were more likely to have late-stage disease than those in high-SES–low-enclave neighborhoods (adjusted odds ratio = 1.91; 95% confidence interval = 1.18, 3.07). Foreign-born women had lower cervical cancer mortality (adjusted hazard ratio = 0.67; 95% confidence interval = 0.58, 0.76) than US-born women, but only in high enclaves. Conclusions. Among Hispanic women, nativity, neighborhood enclaves, and SES interact in their influence on stage and survival of cervical cancer. Despite advances in early detection, cervical cancer remains the second most-common cancer worldwide and the third most-common gynecologic malignancy in the United States, 1,2 with an age-adjusted incidence rate of 7.8 per 100 000 and mortality rate of 2.3 per 100 000 from 2007 to 2011. 3 Notably, although the incidence of cervical cancer is higher among Hispanic women (10.2 per 100 000) than among Asian/Pacific Islander (6.4), African American (9.4), and non-Hispanic White (7.8) women, mortality rates among Hispanic women are comparable with those of other groups (2.8 per 100 000). 3–5 Compared with women of other racial/ethnic groups, studies consistently show a survival advantage for Hispanic women after control for stage at diagnosis and other clinical and sociodemographic characteristics 2,6–13 ; this observation of lower mortality among Hispanics compared with non-Hispanic Whites is consistent with the “Hispanic paradox.” 14,15 Previous studies further suggest that the paradox applies in particular to Hispanic immigrants, particularly immigrants born in Mexico. 15 A recent analysis of national data from the Surveillance, Epidemiology, and End Results (SEER) program found that foreign-born Hispanic women had lower survival than US-born Hispanic women for early-stage disease, but better survival for late-stage disease. 16,17 However, this analysis was based on imputed data for women missing place of birth, which is problematic when one considers that SEER birthplace data are not missing at random. 18–20 The observed survival advantage may also reflect higher rates of losses to follow-up among foreign-born Hispanics, causing underreporting of cervical cancer mortality in this group if significant numbers of women return to their native country once diagnosed with later-stage disease. Thus, to date, reasons for the apparent immigrant survival advantage among women with cervical cancer are poorly understood. The “healthy immigrant effect” suggests that the Hispanic mortality advantage is greater among the foreign-born than US-born because immigrants are selected for better health 21 and have strong family and community ties that support health behaviors 22,23 and buffer against discrimination 24 ; this hypothesis may explain the patterns seen for cervical cancer survival. Therefore, neighborhood characteristics including socioeconomic status (SES) and ethnic enclave (geographical areas that are culturally and ethnically concentrated and distinct from the surrounding area) may be important contributors to survival after cervical cancer diagnosis. Low-income residential ethnic enclaves may protect health by increasing residents’ ability to maintain positive health behaviors such as a healthy native diet or abstention from smoking, and provide increased social support. Residents of ethnic enclave communities may also receive targeted public health services or perceive fewer barriers to care. However, ethnic enclaves tend to be of low SES and frequently have higher crime rates and may have lower availability of healthy foods, all of which are risk factors for poor health outcomes. The disproportionate burden of cervical cancer among Hispanic women but paradoxical incidence–mortality patterns, coupled with the rapid rate at which this population is growing, underscores the need to examine diagnostic and survival differences within this population. The purpose of this study was to examine stage of diagnosis and survival after cervical cancer, and their associations with Hispanic nativity, and to explore whether neighborhood SES and residence in a Hispanic enclave modify the association of nativity with stage and survival. Understanding how individual- and neighborhood-level factors jointly and independently contribute to survival outcomes after cervical cancer among Hispanic women may help target interventions that can improve survival after cancer diagnosis, despite socioeconomic disadvantage.
