title: Geographic disparities in cervical cancer mortality: what are the roles of risk factor prevalence, screening, and use of recommended treatment?
abstract: BACKGROUND
  Despite advances in early detection and prevention of cervical cancer, women living in rural areas, and particularly in Appalachia, the rural South, the Texas/Mexico border, and the central valley of California, have had consistently higher rates of cervical cancer mortality than their counterparts in other areas during the past several decades.
  
  
  METHODS
  This paper reviews the published literature from 1966 to July 2002 to assess three potential pathways underlying this excess mortality--high human papilloma virus (HPV) prevalence, lack of or infrequent screening and advanced disease at diagnosis, and under-use of recommended treatment and shorter survival.
  
  
  RESULTS
  Living in rural areas may impose barriers to cervical cancer control, including lack of transportation and medical care infrastructures. Population characteristics that place women at greater risk for developing and dying from cervical cancer, such as low income, lack of health insurance, and physician availability, are concentrated in rural areas. Published data, however, are insufficient to identify the key reasons for the observed mortality patterns.
  
  
  CONCLUSIONS
  At this time, given the lack of definitive evidence in the published literature, decisions about priorities in areas with high rates of cervical cancer mortality will depend on knowledge of current levels of screening, incidence, and stage distribution; and service delivery infrastructures, resources, and acceptability of interventions to the target population.
authors.affiliation: Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD 20892-7344, USA. yabroffr@mail.nih.gov
authors.forename: K Robin
authors.initials: KR
authors.lastname: Yabroff
authors.forename: William F
authors.initials: WF
authors.lastname: Lawrence
authors.forename: Jason C
authors.initials: JC
authors.lastname: King
authors.forename: Patricia
authors.initials: P
authors.lastname: Mangan
authors.forename: Kathleen Shakira
authors.initials: KS
authors.lastname: Washington
authors.forename: Bin
authors.initials: B
authors.lastname: Yi
authors.forename: Jon F
authors.initials: JF
authors.lastname: Kerner
authors.forename: Jeanne S
authors.initials: JS
authors.lastname: Mandelblatt
mesh_terms: D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D030361:Papillomavirus Infections / Q000175:diagnosis / Q000453:epidemiology; D010342:Patient Acceptance of Health Care; D018570:Risk Assessment; D012307:Risk Factors; D012423:Rural Health / Q000706:statistics & numerical data*; D019035:Rural Health Services / Q000706:statistics & numerical data* / Q000600:supply & distribution; D014481:United States / Q000453:epidemiology; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy / Q000821:virology; D014626:Vaginal Smears / Q000706:statistics & numerical data