Background: Violence against women (VAW) is defined by the United Nations as "any act of gender based violence that results in physical, sexual, or psychological harm or suffering to women." In Kentucky almost 40% of women had experienced some form of VAW in their lifetime. The frequency of VAW poses a serious public health challenge not only due to the prevalence but also the long term impact on women's health, documented in an impressive body of literature. However, very little research has explored the effect of lifetime VAW on cancer prevention and control. Kentucky has a high cancer burden with the highest cancer mortality rate of all US states. Incidence rates of cancer and the proportion of women diagnosed at a later stage are higher in the Appalachian region of Kentucky. VAW frequently co-occurs with social factors leading to health disparities including unemployment, less education and minority race. Overall objectives of this project are to determine the extent to which VAW may explain noted disparities in cancer care based on women's race/ethnicity, socioeconomic status, access to health insurance, or residence in high poverty and rural areas of Kentucky.
Specific aims : To determine whether VAW is associated with disparities in breast cancer (aim 1), colorectal cancer (aim 2) and cervical cancer (aim 3) care outcomes to include not receiving cancer screening at recommended intervals, being diagnosed with cancer at a later stage, not receiving recommended cancer treatment including supportive/palliative care, and poorer cancer specific survival among women diagnosed with these cancers in Kentucky and adjusting for relevant confounders including race, socioeconomic status, having health insurance, rural residence, and specific regions of high poverty (e.g., living in the Appalachian region of eastern Kentucky or the Delta region of western Kentucky). Methods: We propose a prospective cohort using the Kentucky Cancer Registry (KCR) as the source of 3150 breast cancer cases, 1575 colorectal cancer cases and 525 cervical cancer cases. These 5250 women will be interviewed by phone to determine their lifetime exposure to VAW and comorbid conditions. These data will be linked with state level Medicare claims data for women completing phone surveys who are 65 or older. The Medicare claims data, administered by the Center for Medicare and Medicaid Services, include comprehensive coverage of medical services regardless of where the patients seek care in the nation, which would allow the detailed examination of the proposed cancer care continuum: cancer screening, stage at diagnosis, treatment, supportive or palliative care and survivorship. Both logistic regression and Cox proportional hazards modeling will be used to determine the role of VAW (by frequency, duration, severity, recency and type) and socioeconomic attributes influencing disparities in cancer care. These associations will be investigated for each of the hypothesized five cancer care outcomes and by specific cancer. The mediating or moderating role of socioeconomic factors will also be explored using structural equation modeling. Relevance: This will be the first population-based cohort of the influence of VAW on the life course of cancer care in a state with high cancer burden and regions of extreme poverty. Findings will have significant public health impact in reducing disparities and improving cancer prevention and control in women.
Determining whether violence against women influences the life course of cancer prevention and control for women with breast, cervical or colorectal cancer can result in an important opportunity to understand reasons for and potential solutions to cancer care disparities. If VAW does influence cancer care interventions can be developed to identify VAW in women with cancer and provide appropriate support to ensure receipt of recommended care.