Patterns of cancer incidence among US Hispanics/Latinos, 1995-2000

The association between ethnic background and prostate cancer

Prostate cancer is a complex disease which is more prevalent among men of black and minority ethnic (BME) background than their Caucasian counterparts, with men of African-Caribbean background experiencing higher levels of incidence and mortality than any other ethnic group. The reasons behind this health inequality are poorly understood and likely to be multifactorial. Several theories have been posited, including genetic disposition, poorer access to health care, a lack of understanding of the risks posed by prostate cancer and an unwillingness to access mainstream health care. There is, however, a notable disparity between the amount of literature focusing on prostate cancer as it affects those with a BME background and on prostate cancer in general. This further compounds the difficulties encountered by BME men, who rely on health professionals being aware of the greater risk they face. More knowledge and understanding is required by both the general population and medical practitioners to address this health inequality.

A rising trend in the incidence of advanced gastric cancer in young Hispanic men

BACKGROUND

Although the incidence of gastric cancer has been decreasing, recent reports suggest an increased rate in select populations. We sought to evaluate trends in gastric cancer incidence to identify high-risk populations.

METHODS

Gastric cancer incidence rates from 1992 to 2011 were computed with use of the Surveillance, Epidemiology, and End Results (SEER) registry. We evaluated trends in incidence rates by calculating the annual percent change (APC) across three age groups (20-49 years, 50-64 years, and 65 years or older) and four racial/ethnic groups (Hispanics, non-Hispanic whites, blacks, and Asian/Pacific Islanders).

RESULTS

We identified 41,428 patients with gastric cancer. For the entire cohort during the study period, the APC was decreased. When patients were grouped according to sex, the APC was flat or decreased in women regardless of age or race/ethnicity. The APC was also flat or decreased for all men except young Hispanic men (20-49 years), who had an increased APC of nearly 1.6 % (1.55 %, 95 % confidence interval 0.26-2.86 %). Furthermore, young Hispanic men were the only group to have increased incidence of stage IV disease (APC 4.34 %, 95 % confidence interval 2.76-5.94 %) and poorly differentiated tumors (APC 2.08 %, 95 % confidence interval 0.48-3.70 %).

CONCLUSIONS

The APC of the incidence of gastric cancer in young Hispanic men places it among the top cancers with rising incidence in the USA. This is concomitant with increased incidence of advanced disease at presentation. This major public health concern warrants additional research to determine the cause of the increasing incidence in this group.

Esophageal cancer incidence rates by histological type and overall: Puerto Rico versus the United States Surveillance, Epidemiology, and End Results population, 1992-2005

OBJECTIVE

The aim of our study was to compare the age-standardized incidence of esophageal cancer (EC) in Puerto Ricans (PRs) with that for non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic (USH), groups in the United States (US) as reported by the Surveillance, Epidemiology, and End Results program for the 1992-2005 period.

METHODS

We computed the age-standardized and age-specific incidence (per 100,000 individuals) of EC during 1992-2005 using the World Standard Population as reference. The percent changes for age-standardized rates (ASR), from 1992-1996 to 2001-2005, were calculated. The relative risks (RR) and the standardized rate ratios (SRR) were estimated, along with 95% confidence intervals (CIs).

RESULTS

The ASR of adenocarcinomas (AC) showed increases for most racial/ethnic groups from 1992-1996 to 2001-2005. All racial/ethnic groups showed ASR reductions for squamous cell carcinomas (SCC). For both sexes, PRs had lower AC incidences than NHW and USH but higher than NHB. For those younger than 80 years of age, PR men showed higher SCC incidences than NHW but lower than NHB (P < 0.05). The incidence of SCC was about two times higher in PR men than USH men (SRR: 2.16; 95% CI = 1.65-2.88). Among women, the RR for SCC increased with age when comparing PRs to groups in the US.

CONCLUSION

Incidence disparities were observed between PRs and other racial/ethnic groups in the US. These differences and trends may reflect lifestyles of each racial/ethnic group. Further studies are warranted to explain these disparities.

Descriptive epidemiology of gastric adenocarcinoma in the state of Texas by ethnicity: Hispanic versus White non-Hispanic

BACKGROUND

We aimed to evaluate the clinicopathological and demographic characteristics of gastric adenocarcinoma in Hispanics and compare these trends with those found in non-Hispanic Whites in Texas.

METHODS

Records of patients with gastric adenocarcinoma found in the Texas Cancer Registry from 1995 to 2006 were reviewed. Four ethnic-geographic groups were formed: Hispanics residing in El Paso County (a county on the Texas-Mexico border), White non-Hispanics in El Paso County, Hispanics from the remaining counties of Texas combined, and White non-Hispanics from the remaining counties of Texas combined. Adjusted prevalence ratios (PRs) for the outcome of late stage at diagnosis were calculated.

RESULTS

Of 9949 patients, 561 patients were El Paso County residents, of whom 83% were Hispanics. Among the four ethnic-geographic groups, the age-adjusted incidence was the highest in Hispanics in El Paso County (15.5 cases/100000). Tumor pathobiology varied by ethnicity. White non-Hispanics were more likely than Hispanics to have a proximal tumor and less likely to have a poorly differentiated or undifferentiated tumor. In El Paso County, patients in each of the eight age groups under 75 years compared to patients aged ≥85 years were significantly more likely to be at late stage (adjusted PRs 1.44-1.71).

CONCLUSION

The incidence of gastric adenocarcinoma is higher in Hispanics than in Whites in both El Paso County and the remaining portion of Texas. Hispanics have a higher grade of gastric adenocarcinoma. The prevalence of late stage at the time of diagnosis is higher in younger patients than in older patients.

Gastric cancer incidence among Hispanics in California: patterns by time, nativity, and neighborhood characteristics

BACKGROUND

Better understanding about gastric cancer incidence patterns among Hispanics by birthplace, socioeconomic status (SES), and acculturation can improve preventive strategies and disease models.

METHODS

Incidence rates, rate ratios, and estimated annual percent change (EAPC) in rates of anatomic and histologic subtype-specific gastric cancer were calculated by age, sex, and nativity among Hispanics using California Cancer Registry data from 1988 through 2004. Incidence rates in 1998 to 2002 were compared by neighborhood SES and Hispanic enclave status according to 2000 US Census data.

RESULTS

Incidence rates of diffuse gastric cancer increased from 1988 through 2004 among foreign-born Hispanic men (EAPC: 3.5%, 95% CI: 1.5%-5.5%) and U.S.-born Hispanic women (EAPC: 3.0%, 95% CI: 0.7%-5.3%). During the same time period, incidence rates of intestinal gastric cancer declined significantly and both cardia and noncardia gastric cancer were steady or declined among foreign-born and U.S.-born Hispanic men and women. Noncardia and both intestinal and diffuse gastric cancer were more common in foreign-born than U.S.-born Hispanic men and women, and in those from lower SES, higher enclave neighborhoods. By contrast, among younger and middle-aged Hispanic men, cardia tumors were more common in the U.S.-born than the foreign-born, and in higher SES, lower enclave neighborhoods.

CONCLUSIONS

Varying gastric cancer risk factors among Hispanic subgroups and increasing rates of diffuse gastric cancer in foreign-born Hispanic men and U.S.-born Hispanic women merit further investigation to identify separate disease etiologies.

IMPACT

Age, sex, birthplace, SES, and acculturation modify gastric cancer incidence in Hispanics and should be considered when examining disease risk and prevention.

Developing strategies for reducing cancer disparities via cross-institutional collaboration: outreach efforts for the partnership between the Ponce School of Medicine and the Moffitt Cancer Center

The disproportionate burden of cancer among U.S. Hispanics is well documented. Historically, epidemiologic data on U.S. Hispanics and cancer have aggregated all Hispanics as one homogeneous group without appreciating the diversity of this population with regard to nativity (nationality/geographic origin). The authors report on the initial efforts of a collaborative academic institutional partnership between a minority-serving institution and a National Cancer Institute-designated cancer center to address cancer health disparities in two Hispanic communities in Puerto Rico and Florida. This article outlines the joint Outreach Program's initial collaborative strategies and activities in community outreach, cancer education, and research that mutually benefit both the Ponce (Puerto Rico) and Tampa (Florida) Hispanic communities. This partnership program used innovative multipronged community-engagement strategies in the two communities to reduce cancer health disparities. Specific projects and lessons learned from three outreach/cancer education projects and two pilot research projects are discussed. The challenges of balancing service and research agendas in communities with disparate levels of resources and infrastructure are summarized to inform future initiatives in this partnership, as well as serve as an example for similar minority-serving institution/cancer center partnerships to reduce cancer health disparities.

Racial differences in colorectal cancer incidence and mortality in the Women's Health Initiative

BACKGROUND

Colorectal cancer (CRC) incidence and mortality rates are higher in African-Americans as compared with other racial/ethnic groups. The women's health initiative (WHI) study sample was used to determine whether differences in CRC risk factors explain racial/ethnic differences in incidence and mortality.

METHODS

The WHI is a longitudinal study of postmenopausal women recruited from 40 centers. Baseline questionnaires were used to collect sociodemographic and health status information. All CRC diagnoses were centrally adjudicated. Cox regression models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for invasive CRC by race/ethnicity.

RESULTS

The study sample included 131,481 (83.7%) White, 14,323 (9.1%) African-American, 6,362 (4.1%) Hispanic, 694 (0.4%) Native American and 4,148 (2.6%) Asian/Pacific Islanders. After a mean follow-up of 10.8 years (SD 2.9), CRC incidence was the highest in African-Americans (annualized rate = 0.14%), followed by Whites and Native Americans (0.12% each), Asian/Pacific Islanders (0.10%), and Hispanics (0.08%). After adjustment for age and trial assignment, Hispanics had a lower risk compared with Whites, HR 0.73 (95% CI: 0.54-0.97) (P = 0.03), and African-Americans had a marginally greater risk, HR 1.16 (95% CI: 0.99-1.34), P = 0.06. Multivariable adjustment attenuated the difference in incidence between African-Americans and Whites (HR 0.99, 95% CI: 0.82-1.20), while strengthening the lower HR for Hispanics (HR 0.68, 95% CI: 0.48-0.97).

CONCLUSIONS

African-American/White differences in CRC risk are likely due to sociodemographic/cultural factors other than race.

IMPACT

A number of modifiable exposures could be a focus for reducing CRC risk in African-Americans.

Macronutrient composition influence on breast cancer risk in Hispanic and non-Hispanic white women: the 4-Corners Breast Cancer Study

The association of dietary macronutrient composition with risk of breast cancer is not well understood. We investigated the macronutrient composition of diet in the 4-Corners Breast Cancer Study. Logistic regression models were used for case-control comparisons adjusted for age, center, education, smoking, total activity, calories, dietary fiber, dietary calcium, height, parity, recent hormone exposure, reference year body mass index (BMI), and the interaction of BMI and recent hormone exposure. Breast cancer risk declined with increasing dietary fat and increased with carbohydrates similarly across ethnicity and menopausal status. Associations of carbohydrate (direct) and fat (inverse), particularly saturated and monounsaturated fat, with breast cancer were present among normal and overweight postmenopausal women and absent among obese postmenopausal women. No substantive differences were noted in the association of macronutrients with risk of breast cancer between non-Hispanic white and Hispanic women. Associations of the macronutrients carbohydrate and fat with breast cancer risk were attenuated among postmenopausal obese women.

Patient predictors of colposcopy comprehension of consent among English- and Spanish-speaking women

PURPOSE

patients with limited English proficiency may be at increased risk for diminished understanding of clinical procedures. This study sought to assess patient predictors of comprehension of colposcopy information during informed consent and to assess differences in understanding between English and Spanish speakers.

METHODS

between June and August 2007, English- and Spanish-speaking colposcopy patients at two Boston hospitals were surveyed to assess their understanding of the purpose, risks, benefits, alternatives, and nature of colposcopy. Patient demographic information was collected.

FINDINGS

there were 183 women who consented to participate in the study. We obtained complete data on 111 English speakers and 38 Spanish speakers. English speakers were more likely to have a higher education, greater household income, and private insurance. Subjects correctly answered an average of 7.91 ± 2.16 (72%) of 11 colposcopy survey questions. English speakers answered more questions correctly than Spanish speakers (8.50 ± 1.92 [77%] vs 6.21 ± 1.93 [56%]; p < .001). Using linear regression to adjust for confounding variables, we found that language was not significantly associated with greater understanding (p = .46). Rather, education was the most significant predictor of colposcopy knowledge (p < .001).

CONCLUSION

many colposcopy patients did not understand the procedure well enough to give informed consent. The observed differences in colposcopy comprehension based on language were a proxy for differences in education. Education, not language, predicted subjects' understanding of colposcopy. These results demonstrate the need for greater attention to patients' educational background to ensure adequate understanding of clinical information.

Factors that influence the incidence of breast cancer in Arica, Chile (Review)

Breast cancer is a common disease estimated to occur in 1 in 9 women over their lifetime. Epidemiological research has identified a number of risk factors for breast cancer. Racial and ethnic differences in breast cancer mortality rates have been difficult to ascertain. The present review reports that there was an increase in the incidence of breast cancer in Arica, Chile, from 1997 to 2007, particularly in 2005, reaching 55.1% per 100,000 women, while the percentage decreased in 2006 and 2007. A greater percentage of breast cancer was found in individuals between 46 and 65 years of age when the population was distributed by age. The Indian population, Aymara, had only a 13.9% incidence of the disease. The incidence for breast cancer for patients with no family background reached approximately 88%, with or without Indian ethnicity, and 98.4% of these women did not have prior hormonal therapy. When the stage of the disease and the number of pregnancies were considered, results showed that there was an increase in the progression of the disease from stage I to stage III in women that had 1-3 pregnancies. Results also showed that 20.9 and 33.2% who received prior tamoxifen treatment were in stages I and IIA, respectively. The breast cancer incidence reached 42.4% when patients had a sister with the disease. It can be concluded that important differences in the risk factors of breast cancer should be identified in the future for a comparison with other biological factors, such as genetic and molecular factors. This may provide greater insight into breast cancer aetiology in different populations.

Incidence and mortality rates of selected infection-related cancers in Puerto Rico and in the United States

BACKGROUND

In 2002, 17.8% of the global cancer burden was attributable to infections. This study assessed the age-standardized incidence and mortality rates of stomach, liver, and cervical cancer in Puerto Rico (PR) for the period 1992-2003 and compared them to those of Hispanics (USH), non-Hispanic Whites (NHW), and non-Hispanic Blacks (NHB) in the United States (US).

METHODS

Age-standardized rates [ASR(World)] were calculated based on cancer incidence and mortality data from the PR Cancer Central Registry and SEER, using the direct method and the world population as the standard. Annual percent changes (APC) were calculated using the Poisson regression model from 1992-2003.

RESULTS

The incidence and mortality rates from stomach, liver and cervical cancer were lower in NHW than PR; with the exception of mortality from cervical cancer which was similar in both populations. Meanwhile, the incidence rates of stomach, liver and cervical cancers were similar between NHB and PR; except for NHB women who had a lower incidence rate of liver cancer than women in PR. NHB had a lower mortality from liver cancer than persons in PR, and similar mortality from stomach cancer.

CONCLUSIONS

The burden of liver, stomach, and cervical cancer in PR compares to that of USH and NHB and continues to be a public health priority. Public health efforts are necessary to further decrease the burden of cancers associated to infections in these groups, the largest minority population groups in the US. Future studies need to identify factors that may prevent infections with cancer-related agents in these populations. Strategies to increase the use of preventive strategies, such as vaccination and screening, among minority populations should also be developed.

Uptake of colorectal cancer screening: system, provider and individual factors and strategies to improve participation

Colorectal cancer (CRC) accounts for 9% of all new cancer cases worldwide and affects over 1 million people each year. Screening can reduce the mortality associated with the disease, yet participation rates are suboptimal. Compliers with CRC screening are less deprived; they have higher education than noncompliers and tend to be male, white and married. Likely reasons for nonparticipation encompass several 'modifiable' factors that could be targeted in interventions aimed at increasing participation rates. Successful intervention strategies include organizational changes, such as increasing access to fecal occult blood test (FOBT) kits, providing reminders to healthcare providers or users about screening opportunities, and educational strategies to improve awareness and attitudes towards CRC screening. Multifactor interventions that target more than one level of the screening process are likely to have larger effects. The biggest challenge for future research will be to reduce inequalities related to socio-economic position and ethnicity in the uptake of screening.

Knowledge of HPV among United States Hispanic women: opportunities and challenges for cancer prevention

In the United States, Hispanic women contribute disproportionately to cervical cancer incidence and mortality. This disparity, which primarily reflects lack of access to, and underutilization of, routine Pap smear screening may improve with increased availability of vaccines to prevent Human Papillomavirus (HPV) infection, the principal cause of cervical cancer. However, limited research has explored known determinants of HPV vaccine acceptability among Hispanic women. The current study examines two such determinants, HPV awareness and knowledge, using data from the 2007 Health Interview National Trends Survey (HINTS) and a cross-section of callers to the National Cancer Institute's (NCI) Cancer Information Service (CIS). Study data indicate that HPV awareness was high in both samples (69.5% and 63.8% had heard of the virus) but that knowledge of the virus and its association with cervical cancer varied between the two groups of women. The CIS sample, which was more impoverished and less acculturated than their HINTS counterparts, were less able to correctly identify that HPV causes cervical cancer (67.1% vs. 78.7%) and that it is a prevalent sexually transmitted infection (STI; 66.8% vs. 70.4%). Such findings imply that future research may benefit from disaggregating data collected with Hispanics to reflect important heterogeneity in this population subgroup's ancestries, levels of income, educational attainment, and acculturation. Failing to do so may preclude opportunity to understand, as well as to attenuate, cancer disparity.

Indirect method to estimate specific Hispanic group cancer rates

INTRODUCTION

Several states with large Hispanic populations have historically served as the source for US Hispanic cancer incidence rates, with aggregation of data across all states limited by different methodologies to identify Hispanic persons. Now with data available for more than 85% of the US Hispanic population, state rates suggest regional diversity in their Hispanic cancer profiles.

METHOD

We tested an approach of using a surrogate indicator of county residential homogeneity for Hispanic groups based on the 2000 US Census. The indicator used the counts of specific Hispanic residents compared to the total Hispanic population in the county to define counties with homogenous Hispanic populations. From these data, we aggregated counties into homogeneity categories for each Hispanic group and defined thresholds and rules for allocating Hispanic persons to a specific Hispanic group.

RESULTS

We found that it was possible to use county demographic data in many counties to meaningfully attribute a specific Hispanic ethnicity to incident cancer cases based on homogeneity thresholds. Cancer rates for the US Hispanic population describe a profile of high rates of cancers of the liver, gallbladder, cervix (in female), stomach, and lower rates of the cancers of the lung, female breast, and prostate compared with the non-Hispanic white population. In general, rates among US Mexicans are lower than the US Hispanic rates, while rates for Puerto Ricans and Cubans are higher than the US Hispanic rates. Additional variations among the three Hispanic groups were also evident.

CONCLUSION

The approach yielded reasonable and useful information to explore etiologic differences among the populations, as well as to develop relevant cancer control interventions. However, direct identification of specific Hispanic ethnicity in medical records and annual Census estimates of these populations would be preferable if they ever became available.

Perceived risk of breast cancer among Latinas attending community clinics: risk comprehension and relationship with mammography adherence

OBJECTIVE

To describe breast cancer risk perceptions, determine risk comprehension, and evaluate mammography adherence among Latinas.

METHODS

Latina women age >or=35, primarily from Central and South America, were recruited from community-based clinics to complete in-person interviews (n = 450). Risk comprehension was calculated as the difference between numeric perceived risk and Gail risk score. Based on recommended guidelines from the year data were collected (2002), mammography adherence was defined as having a mammogram every one to two years for women >or=40 years of age.

RESULTS

Breast cancer risk comprehension was low, as 81% of women overestimated their risk and only 6.9% of women were high risk based on Gail risk scores. Greater cancer worry and younger age were significantly associated with greater perceived risk and risk overestimation. Of women age eligible for mammography (n = 328), 29.0% were non-adherent to screening guidelines. Adherence was associated with older age, (OR = 2.99, 95% CI = 1.76-5.09), having insurance (OR = 1.81, 95% CI = 1.03-3.17), greater acculturation (OR = 1.18, 95% CI = 1.02-1.36), and higher breast cancer knowledge (OR = 2.03, 95% CI = 1.21-3.40).

CONCLUSIONS

While most Latinas over-estimated their breast cancer risk, older age, having insurance, being more acculturated, and having greater knowledge were associated with greater screening adherence in this Latino population. Perceived risk, risk comprehension, and cancer worry were not associated with adherence. In Latinas, screening interventions should emphasize knowledge and target education efforts at younger, uninsured, and less acculturated mammography-eligible women.

Latinos and chronic hepatitis C: a singular population

Latinos are the largest minority in the USA and have higher rates of HCV infection. The course of chronic hepatitis C in Latinos is more aggressive, with higher risk to develop cirrhosis than any other ethnic group or race. Available information suggests that more rapid progression of liver disease is aggravated by decreased efficacy to treatment with available therapies. The causes for more aggressive progression and decreased efficacy of treatment are complex. Factors related to metabolic syndrome, insulin resistance, and hepatic steatosis are important, as well as genetic differences, not only for metabolic syndrome but for immune responses to interferon. In addition, there are substantial barriers for Latinos to access medical care. Language, cultural differences, and socioeconomic factors, including lack of medical insurance, more frequent use of alcohol, and possible medical care provider bias, are significant obstacles to diagnosis and treatment. The severity of the liver disease and the association to metabolic syndrome medical conditions justify that Latinos be considered a special population with urgent need of intervention strategies. In this article we present all the available evidence on epidemiology, natural history of chronic hepatitis C, and efficacy of anti-HCV therapy in Latinos infected with HCV.

Diet patterns and breast cancer risk in Hispanic and non-Hispanic white women: the Four-Corners Breast Cancer Study

BACKGROUND

There is a lower incidence of breast cancer among Hispanic women than among non-Hispanic white women. Little is known about the role of diet in this difference.

OBJECTIVE

We examined the associations of dietary patterns (Western, Prudent, Native Mexican, Mediterranean, and Dieter) with risk for breast cancer in Hispanic women (757 cases, 867 controls) and non-Hispanic white women (1524 cases, 1598 controls) from the Four-Corners Breast Cancer Study.

DESIGN

Dietary intake, physical activity, and other exposures were assessed by using interviews. Dietary patterns were defined via factor analysis. Risk was assessed by using logistic regression with adjustment for age, center, education, smoking, total activity, calories, dietary fiber, dietary calcium, height, parity, recent hormone exposure, family history of breast cancer, menopausal status, and body mass index x recent hormone exposure.

RESULTS

The Western (odds ratio for highest versus lowest quartile: 1.32; 95% CI: 1.04, 168; P for trend < 0.01) and Prudent (1.42; 1.14, 1.77; P for trend < 0.01) dietary patterns were associated with greater risk, and the Native Mexican (0.68; 0.55, 0.85; P for trend < 0.01) and Mediterranean (0.76; 0.63, 0.92; P for trend < 0.01) dietary patterns were associated with lower risk of breast cancer. Body mass index modified the associations of the Western diet and breast cancer among postmenopausal women and those of the Native Mexican diet among premenopausal women.

CONCLUSIONS

Associations of dietary patterns with breast cancer risk varied by menopausal and body mass index status, but there was little difference in associations between non-Hispanic white and Hispanic women.

Racial and ethnic disparities in cervical cancer incidence rates in the United States, 1992-2003

OBJECTIVE

Differences in cervical cancer incidence rates by race/ethnicity persist in the United States. We examined these differences by histologic type and by various patient and socioeconomic characteristics.

METHODS

Thirteen U.S. cancer registries were used to identify women 20-79 years of age diagnosed from 1992 to 2003 with invasive cervical cancer. Age-adjusted incidence rates and annual percent changes were calculated for four different races/ethnicities (Non-Hispanic whites, Hispanic whites, African-Americans, and Asians/Pacific Islanders) for cervical cancer overall, squamous cell carcinoma (SCC), and adenocarcinoma (AC).

RESULTS

Hispanic whites had the highest incidence rate of cervical cancer overall (24.2/100,000), SCC (18.3/100,000), and AC (4.6/100,000). Non-Hispanic whites had the lowest rates of cervical cancer overall (10.8/100,000) and SCC (7.2/100,000), while African-Americans had the lowest rate of AC (2.3/100,000). Incidence rates of cervical cancer overall and SCC declined across all racial/ethnic groups. Numerous variations in incidence rates and annual percent changes were observed when analyses were stratified by county level socioeconomic characteristics.

CONCLUSIONS

Variations in screening utilization and socioeconomic status may account for the majority of racial/ethnic disparities in cervical cancer incidence. Targeting groups with the greatest burdens of cervical cancer is of public health importance, particularly as we enter the human papillomavirus vaccine era.