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Breast and Cervical cancer disparities in 
Alabama: current scenario, ongoing 
efforts to reduce the disparity gaps, and 
what more we could be doing 
Kiley Caroline Brady1#, Claudia Paige Stephens1#, Sarabjeet Kour Sudan2,3, Ajay Pratap Singh2,3,4, Santanu 
Dasgupta2,3,4, Seema Singh2,3,4* 

1Frederick P. Whiddon, College of Medicine, University of South Alabama, Mobile, Alabama, 36688; 
2Mitchell Cancer Institute, University of South Alabama, Mobile, AL 36604, USA; 3Department of Pathology, 
College of Medicine, University of South Alabama, Mobile, AL 36617, USA; 4Department of Biochemistry 
and Molecular Biology, University of South Alabama, Mobile, AL 36688 

#Equal contribution 

*Corresponding author: Seema Singh, Ph.D. Email: seemasingh@southalabama.edu 

ABSTRACT 
Over the years, we have made considerable progress in our understanding of the biology of various 
cancers leading to advancements in their management strategies. Consequently, we have witnessed 
steady improvements in survival rates of cancer patients post-diagnosis. The progress; however, has been 
slow for some cancer types and the advances in cancer care have not benefited all the communities 
equally in the United States. The state of Alabama has one of the most diverse demographics in the 
country and as a result, we witness significant health disparities among our populations. Breast and 
cervical cancers are the two major cancer types that disparately affect the women in our state. Here, we 
describe the extent of disparities in the diagnosis and death rates from these cancers in the state of 
Alabama and discuss potential underlying causes affecting the health outcomes. We also discuss ongoing 
efforts undertaken to reduce the disparity gaps and provide a perspective for addressing these disparities 
more effectively. 

KEYWORDS: Breast Cancer, Cervical Cancer, Cancer Health Disparities, African American, Caucasian 
American. 

Citation: Brady KC et al (2022) Breast and Cervical cancer disparities in Alabama: current scenario, ongoing 
efforts to reduce the disparity gaps, and what more we could be doing. Cancer Health Disparities 6: e1-e10. 
doi:10.9777/chd.2022.1004. 
  



 
 
 
 
 

 
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Introduction 
Cancer is the second leading cause of death in the 
nation, following only behind heart disease (Nagai 
and Kim, 2017). This year, nearly 1.9 million new 
cancer diagnoses and about 609,360 cancer-
related deaths are expected to occur in the United 
States (Siegel et al., 2022). This number is 0.9% and 
1% higher than the last year for overall cancer 
incidence and mortality, respectively (Siegel et al., 
2021, Siegel et al., 2022). Among the multiple 
cancers affecting women, breast cancer (BC) is the 
most common, with an overall annual incidence of 
287,850 nationwide and an estimated death of 
43,250 women (Siegel et al., 2022). Cervical cancer 
(CC) is another common malignancy that affects 
women with an expected 14,100 diagnoses this year 
alone in the United States and an estimated death 
of 4280 women according to the American Cancer 
Society (ACS). While these statistics might be 
startling, the state of Alabama has even higher all-
site cancer incidence and mortality rates than the 
national average. From the years 2014-2018, the 
cancer incidence rate in Alabama was 450.8 
compared to 448.6 nationwide per 100,000 
persons, and from 2015-2019 the mortality rate was 
170.0 for Alabama, compared to 152.4 per 100,000 
in all states combined (Profiles, 2014-2018). More 
importantly, significant health disparities are 
observed in these two cancer types in terms of 
disease incidence, aggressiveness, and mortality 
based on racial background, lifestyle, 
socioeconomic status (SES), and genetic 
background (Yedjou et al., 2019). BC incidence has 
been lower among black women as compared to 
white women (SEER, 2022a). In contrast, the 
mortality rate has been observed to be high in black 
women as compared to white women (SEER, 
2022a). In addition to racial background, BC 
disparity also exists due to SES and insurance status 
(Newman and Martin, 2007, Bigby and Holmes, 
2005). Similarly, CC disparity has been observed 

among different races in incidence and mortality 
rates between white and black women. The 
incidence and mortality rate of CC is found to be 
high in black women as compared to the white 
population (SEER, 2022b). Besides, women in rural 
areas have a higher incidence of CC as compared 
to women in urban areas (Yu et al., 2019). 

In the sections below, we focus on the extent of BC 
and CC disparities in Alabama and discuss possible 
underlying causes and the efforts that have been 
made to reduce the disparity gaps. We anticipate 
that our analysis will provide guidance in 
developing effective and collective approaches to 
address this significant clinical and social problem 
affecting women’s health in the state of Alabama 
and nationwide. 

BREAST AND CERVICAL CANCER 
DISPARITIES IN ALABAMA 
Alabama is one of the southeastern states in the 
United States with diverse demographics. As per the 
most recent American community survey, Alabama 
state has a diverse racial composition, as given in 
Table 1 (Worldpopulation, 2022). Among gender 
distribution, there are 51.5% female and 48.5% male 
in Alabama. In Alabama only, there is an estimated 
30,210 new cancer cases with a mortality of 10,520 
in 2022 (Siegel et al., 2022). As per state cancer 
profiles, BC is the most commonly diagnosed 
cancer in Alabama after colorectal cancer and the 
second leading cause of cancer-related death in the 
state. From 2009-2018 the Alabama Statewide 
Cancer Registry (ASCR) showed that the incidence 
of BC was higher for black women than for white 
women (126.5 vs. 118.1 per 100,000) (Figure 1A). It is 
interesting since BC incidence is generally higher in 
white women than in black women. The incidence 
rate per 100,000 persons is 137.6 cases in white 
women as compared to 129.6 cases in women of 
black ethnicity (SEER, 2022a). The mortality rates 
due to BC were also higher among black women 



 
 
 
 
 

 
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than white women (28.0 vs. 19.9 per 100,000) (Figure 
1B). This difference in mortality rate is also greater 
compared to that observed in a nationwide 
comparison. As per the Surveillance, Epidemiology, 
and End Results (SEER) program, the mortality of 
black women is 28.0 compared to 19.9 in the white 
population. Besides, black women have a low 5-
year survival rate compared to white women 
(Moormeier, 1996). 

Table 1. Distribution of race in the state of Alabama 

Race Percentage (%) 

White 67.50 

Black or African American 26.59 

Two or more races 2.44 

Some other races 1.53 

Asian 1.39 

American Indian and Alaska native 0.51 

Native Hawaiian or Pacific Islander 0.04 

Source: World population review. 

CC is the third most common women cancer 
globally and the second leading cause of cancer-
related mortalities in women between 20 to 39 
years of age (Abdalla et al., 2021, Siegel et al., 2022). 
CC disparity has also been observed in incidence 
and mortality rates between white and black 
women. Nationwide, the incidence of CC in black 
women is 9.0 cases per 100,000 women compared 
to 7.1 cases per 100,000 in women of white ethnicity. 
In addition, the death rate is different between 
white (2.0 cases per 100,000) and black women (3.4 
cases per 100,000) (SEER, 2022b). Notably, the 
incidence of CC is significantly higher in Alabama 
than in the United States average, with a rate of 9.0 
versus 7.5, respectively. Besides, the mortality rate 
of CC has also been significantly higher in Alabama 
than in the USA, with a rate of 3.3 versus 2.3 (ASCR, 
2021). Between black and white women, the 

incidence rate of CC in black women (10.2) is high 
as compared to white women (8.7) (Figure 1A). 
Additionally, black women have an approximately 
1.5 times higher mortality rate due to CC than white 
women in the state of Alabama (Figure 1B) (ASCR, 
2021, Abdalla et al., 2021). This disparity is of 
particular attention since CC is almost entirely 
preventable and treatable with proper vaccination, 
screening, and available treatments. Human 
Papillomavirus (HPV) infection is a significant cause 
of cervical carcinogenesis, and this malignancy is 
virtually ubiquitous in sexually active individuals 
(Braaten and Laufer, 2008, Burd, 2003). Vaccines 
are available to prevent HPV infection, and with 
timely screening, CC can be detected early at a 
more manageable stage (Safaeian et al., 2007, 
Thomas, 2016). Thus, it becomes essential to 
understand the underlying reasons behind the 
unequal distribution of cancer among different 
races. 

 

Figure1. Incidence and mortality of breast and 
cervical cancer in Alabama. (A) Rate of incidence 
per 100,000 women with black and white racial 
background (B) Rate of mortality per 100,000 
women with black and white racial background. 

Underlying causes of Cervical and 
Breast cancer disparities in Alabama 
When discussing BC and CC, early detection and 
access to care are critical to decreasing the 
mortality rate. Among various causes, lack of 
medical insurance is one of the reasons behind the 
disparity. About 31.6 million people in the US were 
uninsured as of 2020 (Cha and Cohen, 2022). To 



 
 
 
 
 

 
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qualify for Medicaid in Alabama, you must be 
characterized in the low-income or very low-
income category, pregnant or responsible for a 
person under 18, disabled or have a disabled family 
member, blind, or over 65 years of age (Alabama 
Medicaid, https://www.benefits.gov 
/benefit/1618). Although with the help of the 
Affordable Care Act, there has been an increase in 
the availability of reasonable insurance options via 
Medicaid expansion among Black Americans 
however, Alabama is among the states that have 
chosen not to expand Medicaid coverage following 
the ACS, 2010 even though it has some of the 
lowest eligibility rates in the country (Insurance, 
2021) (Health insurance.org). Another important 
cause for the disparity is accessibility to health care 
facilities. Even if low-income women in Alabama 
could get Medicaid coverage, healthcare access 
becomes the second hurdle in the way. The Black 
belt describes a series of 17 counties in Alabama 
that lack access to social and medical services, 
whose economy depends predominantly on 
agriculture, and have populations that are at least 
50% black and a per capita income of around 
$13,000. As per 2021 poverty guidelines, the 
national poverty line for one individual in 2021 is 
$12,880 and $21,960 for a family of three. Of the 17 
counties that fall into the Black belt, only 4 have at 
least one obstetrician-gynecologist as of 2018, as 
per the human rights watch report. Proper 
gynecological care and screening for CC have five-
year survival rates of 93% (Flannery, 2018). 

Limited screening of black women is also a factor 
contributing to the health disparities. Mammogram 
screening has been shown to decrease 10-year 
mortality by 41% in BC patients (Duffy et al., 2020). 
The HPV vaccine is the best way to prevent women 
from developing CC. Still, black women who are 
statistically less likely to have a primary care 
provider have reduced access to this preventative 
measure. According to the KFF analysis of the 

Centers for Disease Control and Prevention (CDC)'s 
2020 Behavioral Risk Factor Surveillance System, in 
Alabama, 15% of black women were reported to 
have no personal healthcare provider compared to 
12% in the case of women with white racial 
backgrounds. 

The increased incidence of poverty in Alabama’s 
Black Belt also contributes to the increase in 
incidence. While a pap smear is routine for many 
women, an alarming number of lower-income 
women, a larger percentage of whom are in this 
region are black, are unable to take time off work 
to receive this essential standard of care. As per the 
Center for Health Journalism, 2016, the poverty rate 
was 32.7% for black individuals compared to 8.1% 
for white people in the region (Barry-Jester, 2016). 
While it cannot be doubted that income, insurance 
status, access, and other heavily economic reasons 
account for differences in care, even when black 
women are diagnosed, they are still more likely to 
die from CC even when compared to white women 
in their same socioeconomic class (Abdalla et al., 
2021). 

Another issue that is particular to Alabama is 
abstinence-only teaching in schools. Education can 
empower the women with the understanding to go 
for screening and vaccinations when required to 
decrease the burden of cancer. In many Alabama 
counties, a Black belt, in particular, there is no fund 
in public schools due to state constitution 
restrictions. Sexual health education has no 
importance, and it is left unregulated and 
unmonitored, which further increases the spread of 
CC (Flannery, 2018). Hence, it becomes imperative 
to provide education regarding sexually transmitted 
infections and strategies for their prevention and 
also provide sufficient funds for their 
implementation in the curriculum without any 
biasing (Figure 2). 



 
 
 
 
 

 
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Figure 2. Schematic diagram showing different 
factors involved in cancer health disparities in 
Alabama. 

CLOSING THE DISPARITY GAPS: WHAT 
WE ARE DOING AND WHAT MORE WE 
COULD DO 
Ongoing remediation efforts: Although the 
incidence and mortality rates for both BC and CC 
are alarming, they have not gone entirely unnoticed 
by the state. One measure to offset the cost and 
thereby increase diagnosis and treatment is the 
Alabama Breast and CC Early Detection Program 
(ABCCEDP). The ABCCEDP provides free breast and 
CC screenings for women ages 40-64 at or below 
250% of the federal poverty line, or an annual 
income of $33,975 for one individual. There are also 
certain instances where women of this income level 
can qualify at younger ages, such as a first-degree 
family history of BC or previous tubal ligation for CC 
screening (Medicaid). This program helps bridge 
the gap for those who would not usually qualify for 
Medicaid, thus allowing women of all races to 
receive necessary care. However, a program like 
ABCCEDP is only helpful if women know about it. 
This is where the Community Health Advisor 
Program based at the University of Alabama at 
Birmingham (UAB) has the potential to be more 
beneficial. As part of the Deep South Network for 
Cancer Control (DSN), this program trains 
individuals that are already leaders in their 
community to become Community Health Advisors 

(CHAs) and Community Health Advisors as 
Research Partners (CHARPs). The DSN works to 
spread information regarding breast and CC 
screening and treatment. Funded by the National 
Cancer Institute, this program helps build 
infrastructure, partners with state organizations and 
coalitions, and implements interventions in target 
communities where cancer disparities are 
disproportionately high (Lisovicz et al., 2008). The 
thought process behind this model is that 
information will be more trusted and highly 
regarded if it comes from community pillars to 
whom people are already looking for information. 
The goal is to build a volunteer, grassroots 
community infrastructure that provides individuals 
in that community the opportunity to take control 
of their health and lessen healthcare disparities 
(UAB, 2022). In the first three years of the programs, 
from 2001 to 2004, Alabama CHARPs reported a 
greater than 700% increase in referral screenings in 
targeted communities. It is evident that the 
program is working, and people are receptive to the 
work being done by the DSN and CHARPs. More 
such programs need to be developed and federally 
or state-supported to reach and benefit 
communities across the state. Moreover, the 
involvement of advocates from different 
communities, including minority groups, should be 
sought to enhance engagement and develop ways 
to maximize the reach and benefits. 

Lessons from the parallel public health efforts: 
Currently, the patterns of racial disparity, inequality, 
and exclusion all contribute to minority women 
being less likely to receive the reproductive health 
care services and follow-up they need. While efforts 
are in place to help combat these problems, more 
work is still required. The Human Rights Watch 
identified four critical interventions that can be used 
to prevent, treat, and cure CC and the same could 
be applied to BC as well. These include i) 
vaccination ii) screening, iii) timely follow-up after 



 
 
 
 
 

 
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abnormal test results, and iv) early treatment 
(Flannery, 2018). The HPV vaccine is highly effective 
at reducing the incidence of CC compared to 
unvaccinated women (Lei et al., 2020). Currently, 
the national average for HPV vaccination in 
adolescents in this age group is 58.6%, and the 
Alabama average is 52.9% (Vaccination, 2022). 
Working with systems already in place, such as the 
DSN and CHARP, and implementing new strategies 
to help remind patients and make access to 
vaccines easier will help increase vaccination rates 
across the state. CC screening is essential to detect 
cancer at an initial stage with high chances of 
cancer treatment. Tests for HPV infection need to 
be done for screening for CC, and we should make 
every effort to increase the participation of minority 
women in the screening process. Moreover, we 
should also develop ways to provide timely follow-
up to the minority women, who come up with 
abnormal screening. Finally, the women who are 
diagnosed with malignancy should be provided 
early and optimal treatment to enhance clinical 
outcomes. 

Implementation hurdles and awareness issues: 
Despite medical advances and recognition of 
cancer health disparities, multiple hurdles restrict 
the efforts targeted at reducing the existing 
disparities. The problem lies in rural communities 
where there is a lack of medical facilities. 
Additionally, the cost of a visit is also high for those 
without insurance and for those living at or below 
the poverty line. For these people, choosing to take 
care of health problems that may not currently be 
causing issues may be trumped by basic needs such 
as food, shelter, and clothing. 

Besides, it is essential to inform the public regarding 
their sexual and reproductive health. The CDC 
identified that fewer than 43% of high schools and 
18% of middle schools teach the key topics for 
sexual health education in their curriculum (CDC, 

2020). This population of adolescents and young 
adults make up a quarter of the world’s population 
and is the largest cohort of young people in history 
(Nguyen et al., 2019). Alabama’s current laws do not 
mandate that sex education be taught in schools. If 
it is introduced, the state approaches the 
conversation from a largely pure culture mindset, 
emphasizing abstinence-only teaching. While the 
state mandates that students receive HIV/AIDS 
education through a school program between the 
grades of 5-12, and efforts are currently being made 
to remove anti-homosexuality language in the laws, 
there is still no requirement for schools to cover 
these topics in their curriculum. 

CDC data suggests that nearly one-third of high 
school students in the state of Alabama are sexually 
active, and these students are the most at risk for 
engaging in risky sexual behaviors that can lead to 
HIV infections, sexually transmitted diseases, and 
unintended pregnancies, which all have long-term 
effects on their health (Profiles, 2016). By changing 
the beliefs, attitudes, and behaviors of this 
population regarding sexual and reproductive 
health, a shift can be made to change the culture 
around these topics. Recent guidance from the 
American College of Obstetrics and Gynecologists 
suggests that taking a more holistic approach to 
sexual education may be a first step in overcoming 
social, economic, and political factors that have 
negative sexual, psychological, and social influences 
on reproductive health. While the state is making an 
effort to be more inclusive and encourage 
conversations regarding sexual health, future 
revisions should take a more biological approach 
and focus on setting clear health goals, 
reproductive development, consent, 
communication, recognizing and preventing sexual 
violence, human rights about LGBTQ+ community 
and others (Profiles, 2016). Schools can use 
resources such as the CDC’s Health Education 
Curriculum Analysis Tool to engage in more 



 
 
 
 
 

 
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comprehensive conversations with their students 
and provide valuable information regarding sexual 
and reproductive health. By shifting away from the 
purist mindset and focusing on a research-based 
curriculum that addresses social pressures and 
influences and increases personal perceptions of 
the risks and harms of engaging in certain 
behaviors, the culture, and mindset around sexual 
and reproductive health will shift. 

Moving forward: With this in mind, there are three 
critical areas that the state can focus on to increase 
access to care and decrease the burden among 
populations at the highest risk. By expanding the 
Medicaid eligibility to cover adults earning 138% of 
the federal poverty line, Medicaid enrollment would 
increase by 283,636 patients. While this would cost 
the state an average of $225.4 million per year 
above current expenditures, the state could see 
savings of up to $397.8 million (PARCALABAMA, 
2022). This increase in federal revenue would not 
only help alleviate the financial burden placed on 
low-income families but also reduces racial and 
ethnic disparities gaps, strengthens rural health care 
provider institutions, and would help the state 
economy. 

Expanding Medicaid eligibility would also create an 
estimated average of 20,083 new jobs annually for 
the following six years (PARCALABAMA, 2022). This 
would seem to be a promising work opportunity for 
the growing number of medical students 
graduating each year. However, with the average 
medical student graduating with $194,280 in debt 
from a public institution, working in a rural 
community can be daunting, knowing the pay could 
be significantly reduced (Calonia, 2022). That is why 
programs such as the University of Alabama’s 
College of Community Health Sciences Rural 
Medical Scholars and Rural Community Health 
Scholars programs and the Blue Cross Blue Shield 
of Alabama Primary Care Physician Network 

scholarship are being created to help offset the 
costs of medical education and encourage students 
to seek our rural positions (BCBS, 2018, Zganjar, 
2021). These programs target medical students 
from the four medical schools within the state who 
desire to work in underserved communities, such as 
the Black belt, and provide better scholarship 
funding and specialized training to prepare these 
students for their work in these fields. By funding 
programs and rural medicine loan forgiveness 
programs, graduating medical students are 
incentivized to care for these populations in need 
without the fear of being unable to pay back the 
money used for their initial education. 

Moreover, increasing the available obstetrician-
gynecologists in rural areas will help. Transportation 
to these offices can still be a major issue for women 
seeking care. Alabama is one of only three states 
that does not provide state funding for public 
transportation. Many seniors, people with 
disabilities, and low-income families suffer from the 
lack of this facility. In 2018, the Alabama state 
legislature created the Public Transportation Trust 
Fund to combat the lack of available transportation. 
However, no state funds had been allocated to the 
fund until February 2022. This initial transit funding 
is designed to help update current bus fleets and 
facilities and build new rail cars, tracks, and stations 
throughout the state. While this is a great first step, 
we must continue advocating for funding to be 
allocated to the state to improve transportation 
throughout the state. 

Conclusion 
Drastic differences in care between black and white 
women because of socioeconomic and geographic 
factors largely contribute to the racial cancer health 
disparities throughout the state of Alabama. 
Moreover, lack of information available to the 
public has made the mindset of many fall into the 
category of “If I don’t have to go, I won’t go”. In 



 
 
 
 
 

 
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addition, the cost of missing work, traveling 
throughout the state, or expenses of the care itself 
far outweigh the perceived benefits. While efforts 
are being made throughout the state to increase 
access to care, alleviate financial burdens, and raise 
awareness regarding sexual and reproductive 
health, more work is still needed. There is also a 
need to understand the causes of health disparities 
beyond socioeconomic and geographical aspects. 
It is being increasingly recognized that there are 
significant differences in the tumor biology of 
minority patients. We all know that African 
American women are more likely to be diagnosed 
with an aggressive triple-negative breast tumor 
subtype, compared to Caucasian American women, 
which likely also contributes to their greater 
mortality as per ACS, 2022. There are other 
biological differences that have been reported 
between AA and CA women (Deshmukh et al., 2017, 
Deshmukh et al., 2015, Olusola et al., 2019). Clearly, 
we need to precisely characterize these differences 
in tumor biology and genetics and study their 
impact on patient outcomes. Clinical trials testing 
new drugs should also enroll minority patients to 
determine if the drug efficacy is similar or different 
among diverse racial populations. Altogether, by 
developing more awareness, developing ways to 
provide equal healthcare to all, and providing the 
right treatment based on the genetic makeup of the 
tumors, the state and the country at large, can 
succeed in reducing the prevalent health disparities 
in cancer. 

Conflict of interest 
The authors declare that they have no conflict of 
interest. 

Author contribution 
Study design and oversight: SS, APS; Data 
acquisition: CPS, KCB, SKS; Writing original draft: 

CPS, KCB, SKS; Review and Supervision: SKS, APS, 
SD, SS. 

Acknowledgment 
This work was supported, in part, by funding from 
the NIH/NCI [R01CA231925 (SS), Medical Student 
Summer Research program of the Whiddon 
College of Medicine, (KCB, CPS), and Mitchell 
Cancer Institute, University of South Alabama.  

References 
Abdalla, E., Habtemariam, T., Fall, S., Troy, R., Tameru, B. & 

Nganwa, D. 2021. A Comparative Study of Health 
Disparities in Cervical Cancer Mortality Rates Through 
Time Between Black and Caucasian Women in Alabama 
and the US. Int J Stud Nurs, 6, 9-23. 

ASCR, 2021. Alabama Cancer Statistics [Online]. Available: 
https://www.alabamapublichealth.gov/ASCR/assets/acs20
21.pdf [Accessed 2022]. 

Barry-Jester, A. M. 2016. In Alabama’s Black Belt, a lasting 
legacy of racial disparities and deep poverty [Online]. 
Available: https://centerforhealthjournalism.org/2016/07/ 
14/alabama%E2%80%99s-black-belt-lasting-legacy-
racial-disparities-and-deep-poverty [Accessed 2022]. 

BCBS. 2018. Blue Cross And Blue Shield Of Alabama Expands 
Initiative To Further Improve Access To Primary Care 
Physicians And Advance Quality Of Care For Alabamians 
[Online]. Available: https://www.bcbs.com/press-
releases/blue-cross-and-blue-shield-of-alabama-
expands-initiative-further-improve-access [Accessed 
2022]. 

Bigby, J. & Holmes, M. D. 2005. Disparities across the breast 
cancer continuum. Cancer Causes Control, 16, 35-44. 

Braaten, K. P. & Laufer, M. R. 2008. Human Papillomavirus 
(HPV), HPV-Related Disease, and the HPV Vaccine. Rev 
Obstet Gynecol, 1, 2-10. 

Burd, E. M. 2003. Human papillomavirus and cervical cancer. 
Clin Microbiol Rev, 16, 1-17. 

Calonia, J. 2022. What’s The Average Medical School Debt In 
2022? [Online]. Available: https://www.forbes.com 
/advisor/student-loans/average-medical-school-debt/ 
[Accessed 2022]. 

CDC. 2020. Adolescent Health: What Works in Schools [Online]. 
Available: https://www.cdc.gov/healthyyouth 
/whatworks/pdf/what-works-sexual-health-education.pdf 
[Accessed 2022]. 

https://www.alabamapublichealth.gov/ASCR/assets/acs2021.pdf
https://www.alabamapublichealth.gov/ASCR/assets/acs2021.pdf


 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e9 Cancer Health Disparities 

RESEARCH 

Cha, A. E. & Cohen, R. A. 2022. Demographic Variation in 
Health Insurance Coverage:United States, 2020. Natl 
Health Stat Report, 1-15. 

Deshmukh, S. K., Srivastava, S. K., Bhardwaj, A., Singh, A. P., 
Tyagi, N., Marimuthu, S., Dyess, D. L., Dal Zotto, V., Carter, 
J. E. & Singh, S. 2015. Resistin and interleukin-6 exhibit 
racially-disparate expression in breast cancer patients, 
display molecular association and promote growth and 
aggressiveness of tumor cells through STAT3 activation. 
Oncotarget, 6, 11231-41. 

Deshmukh, S. K., Srivastava, S. K., Tyagi, N., Ahmad, A., Singh, 
A. P., Ghadhban, A. A. L., Dyess, D. L., Carter, J. E., Dugger, 
K. & Singh, S. 2017. Emerging evidence for the role of 
differential tumor microenvironment in breast cancer 
racial disparity: a closer look at the surroundings. 
Carcinogenesis, 38, 757-765. 

Duffy, S. W., Tabar, L., Yen, A. M., Dean, P. B., Smith, R. A., 
Jonsson, H., Tornberg, S., Chen, S. L., Chiu, S. Y., Fann, J. 
C., Ku, M. M., Wu, W. Y., Hsu, C. Y., Chen, Y. C., Svane, G., 
Azavedo, E., Grundstrom, H., Sunden, P., Leifland, K., 
Frodis, E., Ramos, J., Epstein, B., Akerlund, A., Sundbom, 
A., Bordas, P., Wallin, H., Starck, L., Bjorkgren, A., Carlson, 
S., Fredriksson, I., Ahlgren, J., Ohman, D., Holmberg, L. & 
Chen, T. H. 2020. Mammography screening reduces rates 
of advanced and fatal breast cancers: Results in 549,091 
women. Cancer, 126, 2971-2979. 

Flannery, K. 2018. It Should Not Happen, Alabama’s Failure to 
Prevent Cervical Cancer Death in the Black Belt [Online]. 
Available: https://www.hrw.org/report/2018/11/29/it-
should-not-happen/alabamas-failure-prevent-cervical-
cancer-death-black-belt#_ftn2 [Accessed 2022]. 

Insurance, H. 2021. Alabama and the ACA’s Medicaid 
expansion [Online]. Available: 
https://www.healthinsurance.org/medicaid/alabama 
[Accessed 2022]. 

Lei, J., Ploner, A., Elfstrom, K. M., Wang, J., Roth, A., Fang, F., 
Sundstrom, K., Dillner, J. & Sparen, P. 2020. HPV 
Vaccination and the Risk of Invasive Cervical Cancer. N 
Engl J Med, 383, 1340-1348. 

Lisovicz, N., Wynn, T., Fouad, M. & Partridge, E. E. 2008. Cancer 
health disparities: what we have done. Am J Med Sci, 335, 
254-9. 

Medicaid, A. Breast and Cervical Cancer Program [Online]. 
Available: https://medicaid.alabama.gov/content/ 
3.0_Apply/3.2_Qualifying/3.2.7_Breast_Cervical_Cancer.as
px [Accessed 2022]. 

Moormeier, J. 1996. Breast cancer in black women. Ann Intern 
Med, 124, 897-905. 

Nagai, H. & Kim, Y. H. 2017. Cancer prevention from the 
perspective of global cancer burden patterns. J Thorac Dis, 
9, 448-451. 

Newman, L. A. & Martin, I. K. 2007. Disparities in breast cancer. 
Curr Probl Cancer, 31, 134-56. 

Nguyen, G., Costenbader, E., Plourde, K. F., Kerner, B. & Igras, 
S. 2019. Scaling-up Normative Change Interventions for 
Adolescent and Youth Reproductive Health: An 
Examination of the Evidence. J Adolesc Health, 64, S16-
S30. 

Olusola, P., Banerjee, H. N., Philley, J. V. & Dasgupta, S. 2019. 
Human Papilloma Virus-Associated Cervical Cancer and 
Health Disparities. Cells, 8. 

Parcalabama. 2022. The Economic Impact of Expanding 
Medicaid in Alabama [Online]. Available: 
https://parcalabama.org/wp-
content/uploads/2022/01/Economic-Analysis-of-
Alabama-Medicaid-Expansion.pdf [Accessed 2022]. 

Profiles. 2016. Analysis of State Health Education Laws [Online]. 
Available: https://www.cdc.gov/healthyyouth/ 
policy/pdf/summary_report_factsheets/Alabama.pdf 
[Accessed]. 

Profiles, S. C. 2014-2018. Dynamic views of cancer statistics for 
prioritizing cancer control efforts across the nation 
[Online]. Available: https://statecancerprofiles.cancer.gov/ 
[Accessed 2022]. 

Safaeian, M., Solomon, D. & Castle, P. E. 2007. Cervical cancer 
prevention--cervical screening: science in evolution. 
Obstet Gynecol Clin North Am, 34, 739-60, ix. 

SEER. 2022a. Cancer Stat Facts: Female Breast Cancer [Online]. 
Available: https://seer.cancer.gov/statfacts/html/ 
breast.html [Accessed 2022]. 

SEER. 2022b. Cancer Stat Facts: Female Cervical Cancer 
[Online]. Available: https://seer.cancer.gov/statfacts/html/ 
cervix.html [Accessed 2022]. 

Siegel, R. L., Miller, K. D., Fuchs, H. E. & Jemal, A. 2021. Cancer 
Statistics, 2021. CA Cancer J Clin, 71, 7-33. 

Siegel, R. L., Miller, K. D., Fuchs, H. E. & Jemal, A. 2022. Cancer 
statistics, 2022. CA Cancer J Clin, 72, 7-33. 

Thomas, T. L. 2016. Cancer Prevention: HPV Vaccination. Semin 
Oncol Nurs, 32, 273-80. 

UAB. 2022. Community Health Advisor Program [Online]. 
Available: 
https://www.uab.edu/onealcancercenter/outreach/comm
unity-health-advisor-program [Accessed 2022]. 

Vaccination, H. 2022. America's Health Rankings analysis of 
CDC, National Immunization Survey-Teen, United Health 
Foundation [Online]. Available: 
https://www.americashealthrankings.org/explore/annual/
measure/Immunize_HPV/state/AL [Accessed 2022]. 

World population. 2022. Alabama Population [Online]. 
Available: https://worldpopulationreview.com/states/ 
alabama-population [Accessed 2022]. 

https://www.hrw.org/report/2018/11/29/it-should-not-happen/alabamas-failure-prevent-cervical-cancer-death-black-belt#_ftn2
https://www.hrw.org/report/2018/11/29/it-should-not-happen/alabamas-failure-prevent-cervical-cancer-death-black-belt#_ftn2
https://www.hrw.org/report/2018/11/29/it-should-not-happen/alabamas-failure-prevent-cervical-cancer-death-black-belt#_ftn2
https://parcalabama.org/wp-content/uploads/2022/01/Economic-Analysis-of-Alabama-Medicaid-Expansion.pdf
https://parcalabama.org/wp-content/uploads/2022/01/Economic-Analysis-of-Alabama-Medicaid-Expansion.pdf
https://parcalabama.org/wp-content/uploads/2022/01/Economic-Analysis-of-Alabama-Medicaid-Expansion.pdf
https://www.cdc.gov/healthyyouth/policy/pdf/summary_report_factsheets/Alabama.pdf
https://www.cdc.gov/healthyyouth/policy/pdf/summary_report_factsheets/Alabama.pdf
https://statecancerprofiles.cancer.gov/
https://seer.cancer.gov/statfacts/html/cervix.html
https://seer.cancer.gov/statfacts/html/cervix.html
https://www.uab.edu/onealcancercenter/outreach/community-health-advisor-program
https://www.uab.edu/onealcancercenter/outreach/community-health-advisor-program
https://www.americashealthrankings.org/explore/annual/measure/Immunize_HPV/state/AL
https://www.americashealthrankings.org/explore/annual/measure/Immunize_HPV/state/AL


 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e10 Cancer Health Disparities 

RESEARCH 

Yedjou, C. G., Sims, J. N., Miele, L., Noubissi, F., Lowe, L., 
Fonseca, D. D., Alo, R. A., Payton, M. & Tchounwou, P. B. 
2019. Health and Racial Disparity in Breast Cancer. Adv Exp 
Med Biol, 1152, 31-49. 

Yu, L., Sabatino, S. A. & White, M. C. 2019. Rural-Urban and 
Racial/Ethnic Disparities in Invasive Cervical Cancer 
Incidence in the United States, 2010-2014. Prev Chronic 
Dis, 16, E70. 

Zganjar, L. 2021. UA Programs Welcome Students Studying 
Rural Health Care [Online]. Available: 
https://news.ua.edu/2021/10/ua-programs-welcome-
students-studying-rural-health-care [Accessed 2022]. 

 


	Introduction
	BREAST AND CERVICAL CANCER DISPARITIES IN ALABAMA
	Underlying causes of Cervical and Breast cancer disparities in Alabama
	CLOSING THE DISPARITY GAPS: WHAT WE ARE DOING AND WHAT MORE WE COULD DO
	Conclusion
	Conflict of interest
	Author contribution
	Acknowledgment

