Structural determinants of diagnosis and prognosis in cervical cancer: Associations between care setting, comorbidity burden, and sociodemographic factors.

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Background: Cervical cancer remains a significant public health issue, with approximately 13,000 new cases and over 4,000 deaths annually in the United States. Understanding how healthcare setting and sociodemographic factors influence diagnostic and presentation pathways is critical to addressing inequities. Methods: A retrospective cohort study at a large, urban, tertiary care safety-net academic medical center was conducted. Patients with a new diagnosis of cervical cancer between January 1, 2016, and December 31, 2023, were included. Socio-demographics, diagnosis location, Carlson Comorbidity Index (CCI), FIGO cancer stage and clinical factors were obtained. Multivariate logistic regression analysis was performed. Results: 126 patients met inclusion; 20 diagnosed inpatient and 106 diagnosed outpatient. Mean age was 52.6 years old, and most were non-white (60.3%), non-Hispanic (72.2%) non-English speaking (59.5%), had a primary care physician (PCP) (68%) and had public insurance (82.3%). The mean number of Papanicolaou (pap) smear screenings prior to diagnosis was 1.89, and 20 patients had 0 pap smears. Inpatient setting at diagnosis was strongly associated with advanced stage (stage 3 vs 1: OR 3.86; stage 4 vs 1: OR 11.85; both p < 0.0001) and higher CCI (OR 1.27, p < 0.0001), while having insurance (OR 0.26, p < 0.0001) and college education (OR 0.37, p = 0.0036) were associated with lower odds of inpatient diagnosis. Having a PCP was associated with lower odds of advanced stage (stage 4 vs 1: OR 0.42; p≤0.0002) and American nationality (OR 0.55; p < 0.0001), but higher odds among English proficiency (OR 2.11, p < 0.0001), insurance (OR 2.12, p < 0.0001), and college education (OR 1.98, p = 0.018). Mortality was independently associated with advanced stage (stage 3 vs 1: OR 1.76; stage 4 vs 1: OR 5.24; both p≤0.0004) and higher comorbidity burden (OR 1.27, p < 0.0001), while demographic factors were not independently associated with death. Conclusions: Inpatient diagnosis and lack of an established PCP were significantly associated with advanced stage at presentation, higher CCI and markers of socioeconomic instability. Although most patients had insurance and a PCP, gaps in preventive care were evident, with a low mean number of prior pap smears or never screened. Advanced stage at diagnosis was independently associated with mortality, highlighting missed opportunities for access to screening, continuity of care, and early detection. Findings suggest that inequities in preventive access and longitudinal care may shift diagnostic pathways toward more frequent, higher acuity inpatient presentations with overall higher mortality outcomes, for structurally vulnerable populations. Efforts to improve equitable access should focus on disparities related to insurance status, educational attainment, nationality, and language access.