Trends in U.S. Gynecologic Cancers (2001-2019): Influence of Social Determinants, Geographic Disparities, and Specialist Access on Stage at Diagnosis.
BACKGROUND Disparities in gynecologic cancer stage at diagnosis, driven by race/ethnicity, socioeconomic disadvantage, and geographic barriers to specialty care, contribute to worse outcomes in marginalized populations. The combined influence of social vulnerability and access to gynecologic oncologists on stage at diagnosis remains incompletely characterized at the national level. OBJECTIVE(S) To examine trends in gynecologic cancer stage at diagnosis from 2001 to 2019 and evaluate the effects of race/ethnicity, social vulnerability, and geographic access to gynecologic oncologists on late-stage diagnosis. STUDY DESIGN Population-based cross-sectional study using the United States Cancer Statistics restricted-use database. A total of 1,398,959 individuals diagnosed with endometrial cancer, ovarian cancer, cervical cancer, or uterine sarcoma from 2001 to 2019 were included. Exposures included race/ethnicity, age, and calendar period at the individual level, and Social Vulnerability Index quartile (low, low-medium, medium-high, high) and geographic access to gynecologic oncologists categorized into quintiles via the two-step floating catchment area method at the county level. The primary outcome was late- versus early-stage diagnosis per International Federation of Gynecology and Obstetrics criteria. Multilevel logistic regression estimated adjusted odds ratios and 95% confidence intervals for each cancer type. RESULTS Late-stage diagnosis was significantly more likely among Non-Hispanic Black women across all cancer types (adjusted odds ratio range: 3.22-6.80; all p<0.05) compared to Non-Hispanic White women, as well as among Hispanic women (adjusted odds ratio range: 2.89-3.50) and Asian/Pacific Islander women (adjusted odds ratio range: 2.71-3.22). Residence in high social vulnerability counties was associated with increased odds of late-stage diagnosis (adjusted odds ratio range: 2.64-3.11; all p<0.05) relative to low vulnerability counties. Women in the lowest geographic access quintile, representing counties with no gynecologic oncologist within 100 miles, had higher odds of late-stage diagnosis than those in the highest quintile (adjusted odds ratio range: 2.23-2.86; all p<0.05). Race/ethnicity and social vulnerability interactions were identified for endometrial and cervical cancers, indicating that race/ethnicity associations with late-stage diagnosis were further elevated in higher versus low vulnerability counties. Late-stage cervical cancer diagnoses declined over the study period, while late-stage endometrial cancer and uterine sarcoma diagnoses increased. CONCLUSION(S) Disparities in gynecologic cancer stage at diagnosis are driven by race/ethnicity, social vulnerability, and poor geographic access to specialty care. Targeted strategies, including gynecologic oncology workforce expansion in underserved areas and culturally tailored early detection programs, are needed to reduce late-stage diagnosis and improve outcomes in marginalized communities.