Does Violence Against Women result in disparities in cancer care for women with b

描述（由申请人提供）：对妇女的暴力行为（VAW）被联合国定义为“对妇女造成身体、性或心理伤害或痛苦的任何基于性别的暴力行为”。在肯塔基州，近40%的妇女在其一生中经历过某种形式的暴力侵害。对妇女的暴力行为频繁发生对公共卫生构成严重挑战，这不仅是因为其普遍性，而且还因为对妇女健康的长期影响，这在大量文献中都有记载。然而，很少有研究探讨终身VAW对癌症预防和控制的影响。肯塔基州的癌症负担很高，癌症死亡率在美国所有州中最高。在肯塔基州的阿巴拉契亚地区，癌症发病率和晚期确诊的妇女比例较高。对妇女的暴力行为往往与导致健康差异的社会因素同时发生，包括失业、受教育程度低和少数族裔。这个项目的总体目标是确定妇女歧视在多大程度上可以解释因妇女的种族/民族、社会经济地位、获得医疗保险的机会或居住在肯塔基州高度贫困和农村地区而在癌症治疗方面存在的明显差异。具体目标:为了确定VAW是否与乳腺癌（目标1）、结直肠癌（目标2）和宫颈癌（目标3）护理结果的差异有关，包括未按推荐间隔接受癌症筛查、晚期被诊断为癌症、未接受推荐的癌症治疗（包括支持性/姑息治疗）以及肯塔基州诊断为这些癌症的妇女中较差的癌症特异性生存率，并调整相关混杂因素，包括种族。社会经济地位，有医疗保险，居住在农村，以及特定的高度贫困地区（例如，居住在肯塔基州东部的阿巴拉契亚地区或肯塔基州西部的三角洲地区）。方法：我们采用肯塔基州癌症登记处（KCR）作为3150例乳腺癌病例、1575例结直肠癌病例和525例宫颈癌病例的来源，提出一项前瞻性队列研究。将对这5250名妇女进行电话访谈，以确定她们终生暴露于VAW和合并症的情况。这些数据将与完成电话调查的65岁或以上妇女的州一级医疗保险索赔数据联系起来。医疗保险索赔数据由医疗保险和医疗补助服务中心管理，包括全面覆盖医疗服务，无论患者在全国何处寻求治疗，这将允许对拟议的癌症护理连续体进行详细检查：癌症筛查，诊断阶段，治疗，支持或姑息治疗和幸存者。将使用逻辑回归和Cox比例风险模型来确定VAW（按频率、持续时间、严重程度和类型）和社会经济属性对癌症治疗差异的影响。这些关联将根据假设的五种癌症护理结果和特定癌症进行调查。社会经济因素的中介或调节作用也将使用结构方程模型进行探讨。相关性：这将是首个基于人群的队列研究，研究在癌症负担高的国家和极端贫困地区，VAW对癌症治疗生命过程的影响。研究结果将对缩小差距和改善妇女癌症预防和控制产生重大的公共卫生影响。

DESCRIPTION (provided by the applicant): 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, 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.