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RESEARCH 

Hysterectomy-corrected Cervical Cancer 
Incidence Reveal Larger Racial Disparities 
in Texas 2012-2014 
Isela De La Cerda1; Miryoung Lee1; Kathleen M. Schmeler2; Joseph B. McCormick1; Susan P Fisher-Hoch1 

 
1 Department of Epidemiology, Human Genetics, & Environmental Sciences, University of Texas Health 
Science Center at Houston, School of Public Health, Brownsville, Texas, USA, 2 Department of Gynecologic 
Oncology and Reproductive Medicine, Division of Surgery, University of Texas MD Anderson Cancer 
Center, Houston, Texas, USA.  

*Corresponding author email: Isela.DeLaCerda@uth.tmc.edu 

ABSTRACT 
The purpose of this study was to determine the race specific age-standardized and age-specific annual 
Texas cervical cancer incidence after correcting for hysterectomy prevalence. A registry-based cross-
sectional study design using Texas State level data for the years 2012-2014 was used to evaluate cervical 
cancer incidence after applying a correction for hysterectomy and examined racial disparities by age 
and race. We merged into a single database annual age- and race-stratified hysterectomy prevalence, 
cervical cancer incident case counts, population at-risk denominators and US Census 2000 population 
weights using the Behavioral Risk Factor Surveillance System (BRFSS) and Texas Cancer Registry (TCR), 
and used these data to estimate hysterectomy-corrected, age-standardized and age-specific cervical 
cancer incidence. Significant differences in hysterectomy prevalence by race were seen. For women 
aged 35-44 years, hysterectomy rates were highest in non-Hispanic whites. Among non-Hispanic blacks 
and Hispanics, the prevalence of hysterectomy peaked between the ages of 55 and 64 years, but 
thereafter continued to increase dramatically with age but only in non-Hispanic whites. The largest 
adjustment between corrected and uncorrected cervical cancer rates (17.1%) was in non-Hispanic white 
women followed by Hispanics (4.1%) and non-Hispanic blacks (3.6%). Failing to correct reported cervical 
cancer rates underestimates the true burden of disease. Hysterectomy prevalence in Texas also suggest 
disparities in access to care based on race. These findings provide further evidence-based information 
to develop more effective region and ethnic specific cervical cancer prevention programs using 
unbiased estimates of disease burden. 

KEYWORDS: Disparities, Racial, Cervical, Cancer 

Citation: De La Cerda I et al (2021) Hysterectomy-corrected Cervical Cancer Incidence Reveal Larger Racial 
Disparities in Texas 2012-2014. Cancer Health Disparities 5:e1-e7. doi:10.9777/chd.2020.1003 
 



 
 
 
 
 

 
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RESEARCH 

Introduction 

The Centers for Disease Control and Prevention 
(CDC) United States (US) Cancer Statistics Data 
Visualization Tool shows that for the years 2011-
2015, the incidence of cervical cancer was the 
highest for Hispanic females between the age of 
40-45 residing in Southern states [1]. Though 
ostensibly valid, this conclusion is subject to 
underlying bias. Women who have undergone 
surgical removal of the cervix and uterus 
(hysterectomy) are no longer at risk for developing 
cancers in these organs and should therefore be 
excluded from the denominator when estimating 
incidence [2]. Yet current reports of cervical cancer 
incidence in the US use uncorrected rates, 
potentially masking cervical cancer disparities [3]. 
Similar studies in some states and in other 
countries show underestimation of cervical cancer 
burden among whites and blacks using this 
correction but were unable to evaluate the effect 
in Hispanics due to insufficient sample sizes [4]. A 
study using Massachusetts state level data 
reported that age standardized, corrected cervical 
cancer incidence among Hispanics resulted in a 
28.3% increase from uncorrected rates compared 
to a 17.1% increase in non-Hispanic whites [5,6]. 
Furthermore, geographic setting in the US, 
regardless of race, points to women in Southern 
regions having both higher cervical cancer 
incidence and mortality rates than their 
counterparts in other US regions [7]. Thus, Texas 
state-level data provides the opportunity to 
evaluate the effect of correction on cervical cancer 
incidence among a large Hispanic population in a 
Southern region of the US. The purpose of this 
paper is to determine the age-standardized and 
age-specific annual hysterectomy corrected-
cervical cancer incidence using Texas State level 

data for the years 2012-2014 and evaluate 
disparities by age and race. 

Materials and Methods 

A registry-based cross-sectional design using the 
Texas Cancer Registry (TCR) cervical cancer 
incidence data and the Behavioral Risk Factor 
Surveillance System (BRFSS) data was used to 
arrive at age-specific and age-standardized 
hysterectomy corrected cervical cancer incidence. 
At the time of data access, the only complete and 
valid years with both cervical cancer incidence and 
hysterectomy prevalence data limited our analysis 
to only 2012-2014. The TCR Institutional Review 
Board deemed this study exempt from review 
since it did not involve human subjects and only 
used publicly available de-identified information. 

Data Sources and Linkage 
Cervical Cancer incidence 

State cancer registries are passive surveillance 
systems to which all state health care facilities that 
diagnose or treat cancer patients must report their 
cases to. For this study we obtained a limited-use 
cancer incidence dataset from the Texas Cancer 
Registry (TCR). Using the proprietary software 
SEER*Stat version 8.3.5 to open the limited-use 
dataset, we extracted the crude and adjusted 
cervical cancer incidence, counts, population at 
risk, and US 2000 Standard Population age- and 
race- stratified for the years 2012-2014 [8]. Only 
women 18 years or older with primary ICD-O-3 
site codes C53.0 Cervix Uteri excluding 9050-9055, 
9140, 9590-9992 (morphological codes related to 
lymphoma and leukemias) were included in this 
analysis. The samples obtained for all three years 
had their own sample sizes and weights. 



 
 
 
 
 

 
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RESEARCH 

Hysterectomy prevalence 

The Behavioral Risk Factor Surveillance System 
(BRFSS) established in 1984, is an annual 
population-based health-related telephone survey 
performed in all 50 states [9]. Each state randomly 
samples their area and collects information 
regarding health-related risk behaviors, chronic 
health conditions and use of preventive services in 
non-institutionalized adults. In 1988 the question 
“Have you ever had a hysterectomy?” was added 
and administered for the Texas survey of every 
even numbered year [9]. After obtaining access to 
the SAS datasets for the Texas BRFSS surveys for 
the years 2012 and 2014, we extracted survey-
weighted, stratum-equivalent age- and race-
stratified hysterectomy prevalence for each year 
using SAS 9.4. Hysterectomy prevalence estimates 
for the year 2013 were calculated using the 
weighted average of the flanking years. 

Data Merge 

The annual age- and race-stratified hysterectomy 
prevalence (hx) from BRFSS, cervical cancer 
incident case counts (n), population at risk 
denominator (p) and US Census 2000 population 
weights from TCR were merged into an Excel 
worksheet. The hysterectomy corrected population 
at risk denominator (𝑝𝑝𝑐𝑐) was calculated in Excel 
using the following formula: 

𝑝𝑝𝑐𝑐 = 𝑝𝑝 ∗ (1− ℎ𝑥𝑥) 

Statistical Analysis 
Hysterectomy prevalence estimates were obtained 
using STATA 15 and graphs and trends created 
using R Studio. Age-standardized and age-specific 
corrected and uncorrected incidence, 95% 
confidence intervals (95%CI), rate ratios and p-
values were produced using PROC STDRATE 
command in SAS 9.4. Direct standardization using 

the US Census 2000 population weights for both 
corrected and uncorrected estimates. Tiwari, Cleg 
and Zou methodology for efficient interval 
estimation for cancer rates used in SEER*Stat was 
used to produce our estimates using SAS [10]. 

Results 

Hysterectomy Prevalence 

For 2014, 7,933 women answered the survey’s 
hysterectomy question, 28.1% were Hispanic, 
63.7% non-Hispanic white, and 8.2% were non-
Hispanic black. 

Overall the prevalence of hysterectomy for women 
≥18 years of age was 22.74 per 100,00 (95% CI, 
21.2%-23.3%). Figure 1 shows the age-specific 
estimates of hysterectomy prevalence by three 
races (NH white; NH black; and Hispanic). 
Hysterectomy prevalence increased with age for all 
races but diverged markedly beginning at the 45-
54 year age category and older. In women over 
age 65, the hysterectomy prevalence rates were 
significantly higher among non-Hispanic white 
women, compared with non-Hispanic black (p = 
0.021) and Hispanics (p = 0.035). 

 

Figure 1. Line plot of Texan women hysterectomy 
prevalence per 100 by age group and race in 
2012-2014. There is a marked difference in women 
with hysterectomies depending on their race and 



 
 
 
 
 

 
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RESEARCH 

age. NH white women have higher hysterectomy 
prevalence than Hispanic and NH black women 
and is most distinctly observed in age groups 
older than 35. (NH: non-Hispanic) 

Age-specific and age-standardized Cervical Cancer 
Incidence 
For the year 2012, 12,509,180 women consisted of 
39.6% Hispanic, 47.6% non-Hispanic whites and 
12.8% non-Hispanic blacks similar to 2013. For the 
12,890,550 women in 2014, 40.2% were Hispanic, 
46.8% non-Hispanic white and 13.0% non-Hispanic 
black. 

Age-specific cervical cancer (CC) incidence was 
highest for Hispanics for most excluding 18-24 and 
65+ age categories, followed by non-Hispanic 
blacks and then non-Hispanic whites, even after 
correction for hysterectomy. Table 1 shows that 
correction for hysterectomy increased CC 
incidence in all three categories. The most 
noteworthy change after correction was in non-
Hispanic white women 65+ with a 46% increase in 
CC incidence.  

Table 1. Uncorrected and Corrected Age-specific cervical cancer incidence and percentage increase 
(Rate per 100,000) 

 Non-Hispanic white Non-Hispanic black Hispanic 

 Uncorrected 
Rate 

Corrected 
Rate 

% 
Increase 

Uncorrected 
Rate 

Corrected 
Rate 

% 
Increase 

Uncorrected 
Rate 

Corrected 
Rate 

% 
Increase 

18-24 1.1 1.1 0 0.8 0.8 0 0.6 0.6 0 

25-34 9.4 9.5 1 6.1 6.1 0 10.5 10.6 1 

35-44 14.6 15.2 4 10.4 10.6 2 15.4 15.9 3.2 

45-54 10.2 11.4 10.5 14.5 15.0 3.4 16.6 17.4 4.8 

55-64 9.4 11.2 19 16.5 17.3 4.8 16.6 17.8 7.2 

65+ 6.3 9.2 46 20.8 21.8 4.8 14.5 15.4 6.2 

Age-standardized cervical cancer incidence increased in all races after correction for hysterectomy and 
was highest among Hispanics overall, both before and after correction. Table 2 shows the age-
standardized cervical cancer incidence and 95% confidence intervals by race before and after the 
correction. 

Table 2. Age-standardized Cervical Cancer Incidence, Uncorrected and Corrected for the Prevalence of 
Hysterectomy for NH white, NH black, and Hispanic 2012-2014 (Rate per 100,000) 

 UNCORRECTED CORRECTED 

 NH white NH black Hispanic NH white NH black Hispanic 

 Rate 95% CI Rate 95% CI Rate 95% CI Rate 95% CI Rate 95% CI Rate 95% CI 

2012 8.7 [7.9,9.6] 12.1 [10.8,15.0] 11.8 [10.6,13.0] 9.7 [8.8,10.7] 13.3 [11.1,15.5] 12.3 [11.0,13.6] 

2013 8.5 [7.6,9.3] 9.9 [8.1,11.7] 12.4 [11.2,13.6] 9.4 [8.5,10.3] 10.2 [8.4,12.0] 12.9 [11.6,14.2] 

2014 8.7 [7.9,9.6] 10.3 [8.5,12.2] 12.3 [11.1,13.5] 9.9 [8.9,10.8] 10.7 [8.8,12.6] 12.8 [11.6,14.0] 

Overall 8.2 [8.2,9.2] 11.0 [9.9,12.1] 12.2 [11.5,12.9] 9.6 [9.1,10.2] 11.4 [10.2,12.5] 12.7 [11.9,13.4] 

 



 
 
 
 
 

 
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RESEARCH 

Corrected rate ratio comparing rates between 
overall Hispanics and NH whites (reference group) 
was 1.31 (p <0.0001) and uncorrected was 1.40 (p 
<0.0001). The difference between NH whites and 
Hispanic incidence decreased after correction but 
remained significant. For NH blacks the rate ratio 
increased after correction (1.27; p<0.0001) 
compared with the uncorrected rate ratio (1.17; 
p=0.0049). Figure 2 shows the percent increase 
between corrected and uncorrected age-
standardized cervical cancer incidence in each 
race. NH white rates increased the most overall 
with a 17.1% increase compared to 4.1% in 
Hispanics and 3.6% in NH blacks. 

 

Figure 2. Bar chart of percent increase between 
corrected and uncorrected cervical cancer rates for 
each race. Although NH White had the biggest 
changes among the corrected and uncorrected 
rates Hispanics remained having the highest age-
specific and age-standardized cervical cancer rates. 

Discussion 

Integration of national surveillance databases 
provide the means for correcting reported biased 
gynecological cancer rates. Our study revealed 
greater cervical cancer incidence and marked 
racial disparity than currently reported in Texas. 
Hysterectomy correction on the Texas 
demographic uncovered that although correction 

increases incidence across all races, NH whites and 
Hispanic women have a higher burden of cervical 
cancer and discrepancies in hysterectomy 
prevalence. Hysterectomy prevalence trends in 
Texas differ among NH white, NH black and 
Hispanic women with a higher prevalence among 
NH whites, among whom there is high frequency 
in older age groups. The difference in 
hysterectomy prevalence also reveals racial 
disparities in access to care, primarily surgery 
which may be elective. Cervical cancer incidence 
after correction increased for all races but had the 
highest impact on NH white women with an 
increase of 17.1% compared to 4.1% and 3.6% for 
Hispanics and NH blacks respectively. Correction 
of age-specific cervical cancer rates also retained 
the same significant differences but showed a 
marked increase in NH white women 65 years and 
older. 

Cervical cancer screening and prevention has 
ameliorated its incidence and mortality through 
outreach programs. These initiatives reach out to 
all women considered at risk for developing 
cervical cancer. These women are then referred to 
clinics or programs that provide low-cost or free 
screening but fail to consider if these women have 
had a hysterectomy. Implementing this question in 
routine screening and outreach efforts can 
decrease the amount of unnecessary pap smears 
and vaccines administered as well as allowing 
clinics and programs to correct the gynecological 
cancer rates reported by them. Hysterectomy 
surveillance data collection in the US is ongoing 
but generally under-utilized and undervalued [11]. 
The American Congress of Obstetricians and 
Gynecologists (ACOG) reports hysterectomy as the 
second most frequently performed surgical 
procedure among US. women of reproductive age 
second only to Cesarean section [12]. This report 



 
 
 
 
 

 
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RESEARCH 

used National Hospital Discharge Data to arrive at 
hysterectomy prevalence of 33 per 100,000 in 2008 
and to demonstrate a steady decrease since 1980 
(55.6 per 100,000). Another source of 
hysterectomy surveillance is BRFSS. This annual 
population-based surveillance system collects 
hysterectomy status for women over the age of 18, 
every even numbered year. This provides a source 
for continuous hysterectomy prevalence 
monitoring by races and states every other year 
that could be integrated with national or state level 
cancer registries to produce corrected cervical and 
uterine cancer rates. While adjustment of 
hysterectomy prevalence from BRFSS is a good 
approach to correct the biased rate, there are 
limitations in using BRFSS hysterectomy 
prevalence. One is that there is no specificity to 
the type of hysterectomy, age at surgery or reason 
for why the hysterectomy was performed, since it 
is self-reported without any surgical or medical 
details. The racial differences reveal bias probably 
due to access to care, however, this procedure 
may be elective and reflect social pressure as well 
as medical indications. The type of hysterectomy 
will determine whether a woman should be 
removed from the denominator for estimation of 
cervical cancer rate, as not all hysterectomies 
include the removal of the cervix (supracervical 
hysterectomy). 

The strength in our method of cervical cancer 
hysterectomy corrected rates is contingent on the 
databases used. TCR and BRFSS, are samples 
representative of the Texas population, and 
provide a direct comparison. As opposed to 
another indirect method used for these types of 
analysis where they use National Hospital 
Discharge Data for national hysterectomy 
prevalence estimates and use the same prevalence 
to correct rates for all states [13]. 

Our results concur with findings of similar studies 
that revealed current cervical cancer incidence 
rates are an underestimation of disease burden 
especially among NH whites. The social 
determinant of access to health services is seen in 
effect in hysterectomy corrected cervical rates. 
Unequal access to healthcare by these races in 
Texas, in this case access to a physician trained to 
perform hysterectomies could cause the marked 
differences between hysterectomy prevalence’s by 
race. Accurate, unbiased, assessment of both 
cervical cancer rates and racial disparities require 
the correction we report here. Efforts between 
national surveillance systems, outreach programs, 
and health care providers can improve screening 
programs by targeting women who truly are at risk 
as well as providing for more accurate depictions 
of geographical disparities of access to health care 
for women. 

Acknowledgements 

This project received no financial support. We 
would like to thank Cassie Fox, BRFSS 
epidemiologist who guided us through the 
process to retrieve the Texas hysterectomy 
prevalence data. As well as Dr. Paige Miller-
Gianturco for guiding us through the process to 
access the Texas cancer registiry incidence data. 
The cancer data was provided by the Texas Cancer 
Registry, Cancer Epidemiology and Surveillance 
Branch, Texas Department of State Health 
Services, 1100 West 49th Street, Austin, TX 78756, 
https://www.dshs.texas.gov/tcr/. 

Conflict of interest 
The authors declare that no competing or conflict of 
interests exist. The funders had no role in study 
design, writing of the manuscript, or decision to 
publish. 



 
 
 
 
 

 
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RESEARCH 

Authors’ contributions 
Conceptualization: Isela De La Cerda and Susan P. 
Fisher-Hoch. Development of methodology: Isela De 
La Cerda and Miryoung Lee. Acquisition of Data: 
Isela De La Cerda. Analysis and interpretation of 
data: Isela De La Cerda and Miryoung Lee. Writing, 
review, and/or revision of the manuscript: Isela De La 
Cerda, Miryoung Lee, Susan P Fisher-Hoch, Kathleen 
Schmeler, Joseph B. McCormick. Administrative, 
technical, or material support: Miryoung Lee, 
Kathleen Schmeler, Susan P. Fisher-Hoch, Joseph B. 
McCormick. 

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