2974
Assessing the Burden of HPV-Associated Cancers
in the United States
Supplement to Cancer
Variability of Cervical Cancer Rates Across 5
Appalachian States, 1998-2003
Claudia Hopenhayn, PhD, MPH1,2
Jessica B. King, MPH3
Amy Christian, MSPH1
Bin Huang, MS1
W. Jay Christian, MPH1
BACKGROUND. Although the rates of invasive cervical cancer (ICC) have
decreased substantially in the US since the advent of the Papanicolaou (Pap) test,
Appalachian women remain at increased risk compared with the nation as a
whole. The ICC incidence rates were compared in 5 Appalachian states with
population-based cancer registries to investigate variability within the Appalachian region.
1
METHODS. Alabama, Kentucky, Ohio, Pennsylvania, and West Virginia were
Markey Cancer Control Program, Lexington,
Kentucky.
selected for the analysis on the basis of their having high-quality cancer registry
2
College of Public Health, University of Kentucky,
Lexington, Kentucky.
data for 1998 through 2003. Incidence rates were calculated by state and by
Appalachia/non-Appalachia, urban/rural, and black/nonblack within each state,
3
following the standard case definition and inclusion criteria used in this supple-
National Center for Chronic Disease Prevention
and Health Promotion, Coordinating Center for
Health Promotion, Centers for Disease Control
and Prevention, Atlanta, Georgia.
ment. Data from the Behavioral Risk Factor Surveillance System (BRFSS) were
used to characterize the prevalence of Pap testing and smoking.
RESULTS. The ICC incidence rates varied among the 5 states, being highest in
West Virginia (10.9 of 100,000) and Kentucky (10.7 of 100,000), and lowest in
Ohio (8.2 of 100,000). The Appalachian regions of Kentucky, West Virginia, and
Ohio had considerably higher rates than those of Alabama and Pennsylvania.
These variations reflected patterns in the rates of poverty, education, smoking,
and Pap testing.
CONCLUSIONS. The variability in ICC risk across subgroups of Appalachia should
This supplement to Cancer was supported by Cooperative Agreement Number U50 DP424071-04
from the Centers for Disease Control and Prevention (CDC).
be considered in the planning of preventive strategies, including reduction in risk
factors and promotion of screening and vaccination. Cancer 2008;113(10 suppl):
2974–80. Published 2008 by the American Cancer Society.*
The findings and conclusions in this report are
those of the authors and do not necessarily
represent the views of the Centers for Disease
Control and Prevention.
KEYWORDS: Appalachia, cervical cancer, Papanicolaou testing, rural, women’s
health.
Address for reprints: Claudia Hopenhayn, PhD,
MPH, Markey Cancer Control Program and College of Public Health, University of Kentucky,
2365 Harrodsburg Road, Suite B100, Lexington,
KY 40504-3381; Fax: (859) 219-0548; E-mail:
[email protected]
T
Received April 14, 2008; revision received June
2, 2008; accepted June 18, 2008.
*This article is a U.S. Government work and, as
such, is in the public domain in the United States
of America.
he Papanicolaou (Pap) test has been an extremely effective
screening tool in detecting abnormal cervical cells that can lead
to cervical cancer. Because of the widespread use of the Pap test,
the rate of invasive cervical cancer (ICC) has decreased substantially
in the last several decades in the US.1 Nevertheless, cervical cancer
mortality rates have been consistently higher among subgroups of
the population, including Appalachian women.2-4 The Appalachian
area is generally characterized as being white, rural, poor, and
poorly educated.5 However, the Appalachian area is quite extensive
and diverse, spanning 13 states ranging from New York in the north
to Mississippi in the south.6 Previous research has shown that rates
Published 2008 by the American Cancer Society*
DOI 10.1002/cncr.23749
Published online 3 November 2008 in Wiley InterScience (www.interscience.wiley.com).
Cervical CA in Appalachia/Hopenhayn et al
2975
of cervical cancer incidence and mortality vary considerably across the Appalachian states.2,3,7 An analysis of cervical cancer incidence data from 3
Appalachian states (Kentucky, Pennsylvania, and
West Virginia) demonstrated that rural status, education, and race were significant predictors of higher
rates of cervical cancer.7
The purpose of the current study was to expand
and update the previous research7 to include 5 Appalachian states, using the most current 6-year incidence data available from the National Program of
Cancer Registries (NPCR). This article complements
another article included in this supplement featuring
a regional analysis of incidence rates across another
area of the US, namely, the US-Mexico border
region.8 Both regions cross state lines, and state-level
analyses may not reveal the high incidence rates
across the affected area, in this case, Appalachia.
MATERIALS AND METHODS
The calculations of age-adjusted ICC rates for the 5
states included in this study were based on 1998
through 2003 NPCR data coded C53.0-C53.9 (cervix
uteri), as described in detail in the article by Watson
et al in this supplement.9 Briefly, NPCR data from 5
population-based cancer registries were used: Alabama (AL), Kentucky (KY), Ohio (OH), Pennsylvania
(PA), and West Virginia (WV). Each of these tumor
registries meets high-quality standards for the study
period, including 90% case ascertainment and 3%
missing data regarding age, race, and sex.9 These 5
Appalachian states were selected on the basis of the
availability of complete cancer registry data for 1998
through 2003. Of the remaining 8 Appalachian states,
only New York and South Carolina met the criteria
for inclusion. However, those 2 states were excluded
from the analysis for the following reasons: New York
City has such a large population that it overwhelms
any analysis of non-Appalachian New York (Appalachian counties comprised 5.2% of New York State’s
population during the study period, whereas New
York City comprised 42.2%); South Carolina, conversely, has only 6 of its 46 counties in Appalachia
(13%). The 5 selected states represent different population distributions across demographic factors such
as race, income, and education; range geographically
from north to south; and include 57% of the Appalachian population, thus constituting a good cross-section of the region. The study area is depicted in
Figure 1.
To characterize the burden of ICC across the
study region, we classified subregions within and
across the 5 states as Appalachian/non-Appalachian
FIGURE 1. Map of Appalachian states and areas included in the current
study.
and rural/urban, based on their county-level classification. Each county was classified as Appalachian/
non-Appalachian using the Appalachian Regional
Commission (ARC) classification,6 and as either rural
or urban, according to the Department of Agriculture’s 2003 Rural-Urban Continuum Codes10; codes 03 were grouped as urban, and codes 4-9 as rural, as
done previously.7 Only 16 cases meeting the inclusion
criteria were missing county of residence and therefore were excluded from these analyses. Rates were
also calculated by race, dichotomized as black and
nonblack because of the small number of nonblack
minorities in much of the study region. Cases missing
a designation for race (n 5 179) were excluded from
the calculations of rates by race.
Census 2000 data were used to characterize the
study region by the proportion of residents living in
poverty and their educational level across each of the
states, and for each of the subgroups of analysis (Appalachian status, urban/rural, race groups), based on
the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program-modified
population estimates. SEER*Stat software11 was used
2976
CANCER Supplement
November 15, 2008 / Volume 113 / Number 10
TABLE 1
General Characteristics of the 5-State Study Area
US
All 5 states
Appalachian
Non-Appalachian
Alabama
Appalachian
Non-Appalachian
Kentucky
Appalachian
Non-Appalachian
Ohio
Appalachian
Non-Appalachian
Pennsylvania
Appalachian
Non-Appalachian
West Virginia (Appalachian)
No. of Counties*
No. of Rural Countiesy
Female Population{
Black Population{
<High School Education{
Below Poverty{
397
224 (56%)
173 (44%)
67
37 (55%)
30 (45%)
120
51 (43%)
69 (57%)
88
29 (33%)
59 (67%)
67
52 (78%)
15 (22%)
55
241
155
86
39
19
20
85
47
38
48
22
26
35
33
2
34
17,510,191
6,719,146
10,791,046
2,303,605
1,467,508
836,097
2,071,969
583,644
1,488,325
5,848,984
742,734
5,106,250
6,357,019
2,996,646
3,360,373
928,614
12.3%
11.8%
7.5%
11.3%
25.9%
21.4%
34.0%
7.3%
1.6%
9.5%
11.4%
2.1%
12.7%
9.9%
4.6%
14.6%
3.1%
19.6%
19.9%
22.1%
18.5%
24.7%
24.6%
25.1%
25.9%
37.5%
21.3%
17.0%
21.9%
16.3%
18.1%
17.3%
18.9%
24.8%
12.4%
12.5%
14.3%
14.5%
16.1%
14.4%
19.2%
15.8%
24.4%
12.4%
10.6%
13.6%
10.2%
11.0%
11.4%
10.6%
17.9%
*Classified as Appalachian according to the Appalachian Regional Commission.6
y
Rural-Urban Continuum Codes, 2003.10
{
Data from US Census 2000. Available at: http://www.census.gov/main/www/cen2000.html. Accessed on July 1, 2007.
to calculate the age-adjusted rates and 95% confidence intervals (using the method of Tiwari et al12)
across the same categories.
To further explore some of the observed contrasts across the different states using available secondary data sources, we used 2004 data from the
Behavioral Risk Factor Surveillance System (BRFSS)
on smoking and Pap test usage, 2 behavioral variables strongly associated with the risk of ICC
(smoking as a biologic factor, and Pap test usage as a
screening-related factor). Smokers have been consistently found to have approximately twice the risk of
ICC as nonsmokers.13-15 Although it has now been
established that infection with an oncogenic human
papillomavirus (HPV) type is a necessary condition
for the development of ICC, it is not a sufficient
cause, and smoking is clearly a contributing factor.
In fact, women who test positive for HPV and smoke
have approximately 5 times the risk of ICC as nonsmokers who test positive.16 We categorized female
survey respondents as smokers if they reported being
current smokers, and we classified them as having
had a recent Pap test if they had received 1 within
the last 3 years. Women were excluded from the
analysis if they reported having undergone a hysterectomy and if data were missing for both the smoking and screening questions. The BRFSS data used in
this descriptive analysis are publicly available,17 but
the county of residence is excluded if there are <50
respondents in any given county. For the 5 states of
our analysis, the county variable was missing for 14%
of respondents in PA and OH, and for 25% to 30% in
the remaining 3 states. Given this sizeable proportion
of counties, we did not stratify the analysis by Appalachian/non-Appalachian or by rural/urban status,
because both classifications are at the county level.
However, we were able to calculate the prevalence of
smoking and of recent Pap tests by race, income,
education, and age groups. The BRFSS data were analyzed using Stata 10.0 statistical software (StataCorp,
College Station, Tex).18
RESULTS
Given the well-established relation between lower
education, lower income, and black race and the
increased risk of ICC, it is relevant to present in
some detail the demographic composition of the
study population, as shown in Table 1. Overall, the
general characteristics of the population in the study
region are quite similar to those of the US as a
whole, particularly in terms of education and poverty
but also with respect to the percentage of blacks in
the population. However, there is a wide range of
variability within the study area, both among states
and among the Appalachian regions within each
state. For example, the 2 states with the largest populations, OH and PA, have higher rates of education,
Cervical CA in Appalachia/Hopenhayn et al
as measured by the percentage of the adult population who did not complete high school, than the
other 3 states. A similar pattern was observed for
poverty levels, with lower rates of poverty found in
OH (10.6%) and PA (11.0%) than in the other 3 states
(15.8%-17.9%). With respect to race, the percentage
of blacks ranged from 3.1% in WV to 25.9% in AL,
with the other 3 states distributed in between (7.3%
in KY, 9.9% in PA, and 11.4% in OH).
The data in Table 1 also demonstrate variability
within the states. Overall, there is clear disparity
between Appalachian and non-Appalachian KY with
regard to education (37.5% vs 21.3% who did not
complete high school) and poverty levels (24.4% vs
12.4%), and to a lesser extent in OH, whereas in PA
the rates do not differ much by Appalachian status.
In AL, the reverse was observed for poverty (14.4%
for Appalachia and 19.2% in non-Appalachia), with
no differences noted with regard to education. This
comparison could not be assessed in WV, because
the entire state is Appalachian, but its indices of education and poverty fall between those of Appalachian
KY and Appalachian OH. With respect to race, all the
states have a higher proportion of blacks in their nonAppalachian regions, and except for Appalachian AL,
the other states have <5% total blacks across their respective, combined Appalachian counties (with KY
having the lowest at 1.6%). KY and WV have the largest
percentage of rural counties (71% and 62%, respectively) compared with the other 3 states (52%-58%).
The ICC age-adjusted incidence rates for the
study period (1998-2003), stratified by race, urban/
rural, and Appalachian status, are presented in Table
2. All rates are shown per 100,000 women. The rate
for the entire study area was 8.8; however, state-specific rates varied, with WV and KY having the highest
rates (10.9 and 10.7, respectively), followed by AL
(9.0), PA (8.5), and OH (8.2).
The comparisons by Appalachian status demonstrated variability across the region. In the study area
as a whole, the rates were somewhat higher in Appalachia than in non-Appalachia (9.5 vs 8.4), and this
difference reached statistical significance, as determined by the lack of overlap of the 95% confidence
intervals. However, there was no consistent trend
noted across all the states. The highest incidence rate
of ICC was found in Appalachian KY (12.5), a rate that
was 25% higher than in the non-Appalachian part of
the state. The greatest contrast was observed in OH,
in which the Appalachian rates were 36% higher than
in non-Appalachia. Conversely, there was no difference noted in AL or PA with respect to Appalachian
status. As previously stated, WV is entirely Appalachian, and therefore this factor could not be assessed.
2977
TABLE 2
Incidence Rates (Per 100,000 Women) of ICC in Selected Appalachian
States by Race, Rural/Urban Area, and Appalachian Status, 1998-2003
All 5 states
Appalachia
Non-Appalachia
Urban
Rural
Black
Nonblack
Alabama
Appalachia
Non-Appalachia
Urban
Rural
Black
Nonblack
Kentucky
Appalachia
Non-Appalachia
Urban
Rural
Black
Nonblack
Ohio
Appalachia
Non-Appalachia
Urban
Rural
Black
Nonblack
Pennsylvania
Appalachia
Non-Appalachia
Urban
Rural
Black
Nonblack
West Virginia
Appalachia
Non-Appalachia
Urban
Rural
Black
Nonblack
No. of ICC Cases
Rate*
95% CI
9682
4034
5648
7048
2634
1363
8140
1285
821
464
871
414
426
846
1378
453
925
719
659
128
1224
2955
486
2469
2262
693
344
2541
3407
1617
1790
2863
544
447
2890
657
657
—
333
324
18
639
8.8
9.5
8.4
8.4
10.2
11.3
8.4
9.0
9.0
9.1
8.7
9.8
12.5
8.0
10.7
12.5
10.0
10.0
11.6
15.1
10.2
8.2
10.6
7.8
7.7
10.1
8.9
7.9
8.5
8.4
8.5
8.4
8.5
11.8
7.9
10.9
10.9
—
10.2
11.7
10.4
10.9
8.7–9.0
9.2–9.8
8.2–8.7
8.2–8.6
9.8–10.6
10.7–11.9
8.2–8.6
8.5–9.5
8.4–9.6
8.3–10.0
8.1–9.3
8.9–10.8
11.4–13.8
7.5–8.6
10.2–11.3
11.4–13.7
9.4–10.7
9.3–10.8
10.8–12.6
12.6–18.0
9.7–10.8
7.9–8.5
9.7–11.6
7.5–8.1
7.4–8.0
9.4–10.9
8.0–9.9
7.6–8.2
8.2–8.7
8.0–8.8
8.1–8.9
8.1–8.8
7.8–9.3
10.7–12.9
7.6–8.2
10.1–11.8
10.1–11.8
—
9.1–11.4
10.4–13.1
6.1–16.4
10.1–11.8
ICC indicates invasive cervical cancer; 95% CI, 95% confidence interval.
*Rates are per 100,000 population and are age-adjusted to the 2000 US standard population (19 age
groups [Census P25-1130]). Data were obtained from 5 population-based cancer registries that participate in the National Program of Cancer Registries (NPCR) and/or the National Cancer Institute’s
Surveillance, Epidemiology, and End Results (SEER) Program and meet high-quality data criteria.
These registries cover approximately 57% of the US population in Appalachia.
The findings across urban-rural classification
were similar. Overall, the rates were significantly
higher in rural counties than in urban counties (10.2
vs 8.4). This contrasting trend was observed across
all the study states except PA, and it reached statisti-
2978
CANCER Supplement
November 15, 2008 / Volume 113 / Number 10
cal significance in OH (10.1 vs 7.7), as evidenced by
the lack of overlap of the 95% confidence intervals.
With respect to race, we compared only blacks
and nonblacks because the number of cases of other
ethnic and/or minority groups was too small in
some of the regions to yield stable rates. The rates of
ICC were approximately 35% higher among blacks
across the study region (11.3 vs 8.4). This contrast
persisted across each of the states in this study,
except for WV, in which the estimates were unstable
because of the low number of cases among blacks
(N 5 18 over the 6-year study period). The racial difference was significant in AL (56% higher among
blacks), followed by PA (49% higher) and KY (48%
higher), but lower in OH (13%) with overlap of the
95% confidence intervals.
The analysis of the 2004 BRFSS data with respect
to 2 salient ICC risk factors—smoking and lack of frequent Pap testing—demonstrated variability across
states and also across demographic groups within
each state (Table 3). The self-reported prevalence of
current female smoking was highest in WV (28.1%),
followed by KY (27.0%) and OH (26.0%), and lowest
in PA (23.4%) and AL (22.3%). In addition, AL was
the only state in which smoking rates across all levels
of income were lower than the combined rates of the
5 states. Black women were less likely than nonblacks to be smokers in OH and AL than in the other
3 states. The negative effects of lower educational
attainment and lower income level on the frequency
of Pap testing were found to be similar across all the
5 states, as was the decreasing gradient observed
with age. It is interesting to note that OH and AL had
the greatest proportion of women aged 65 years
who had recently been screened.
DISCUSSION
The results of the analysis presented herein are consistent with those reported previously, showing that
the rates of ICC are higher among populations that
are rural,7,19-22 are poor,22,23 and have a low educational attainment.7,23 In addition, each year the ARC
designates certain counties in Appalachia as distressed, a term used to denote the most economically depressed counties based on poverty,
unemployment, and income. The proportion of
counties that are distressed in each of the 5 study
states, as projected by ARC for 2008, are: 1 of 52 or
1.9% in PA; 2 of 37 or 5.4% in AL; 4 of 29 or 13.8% in
OH; 13 of 55 or 23.6% in WV; and 37 of 51 or 72.6%
in KY.6 It is noteworthy that the proportion of distressed Appalachian counties by state closely follows
the relative rates of ICC across the Appalachian
regions of the 5 states. This pattern is also consistent
with the notion that although Appalachia as a whole
is often regarded as a disadvantaged region with
respect to economic and social factors as well as
health risks,5,24,25 it encompasses a large and heterogeneous area of the country. This has been documented particularly for cancer, as reflected by the
variations in cancer incidence rates noted across
Appalachia,26 including marked differences in the
rates of ICC.7 This was also evident in the current
analysis, with distinct patterns of risk observed
across the northern, central, and southern regions of
Appalachia, as described also in the study by Wingo
et al.26
The higher rates of poverty and lower levels of
education, in turn, reflect other underlying factors
that contribute to the increased risk of ICC. In addition to the well-established necessary role of HPV
infection in the development of ICC, smoking has
been clearly identified as a contributory factor, conferring approximately double the risk of ICC among
women who smoke. In general, there is a pattern of
increased smoking prevalence with decreased
income and educational levels,27,28 also suggested in
the results of the current analysis. Pap test usage for
the early detection of suspicious or precancerous
lesions in the cervix, or the detection of early-stage
ICC, follows similar patterns across income and educational groups. A lower prevalence of Pap testing
also tends to occur among rural populations.19,29-32
However, the interplay between socioeconomic
factors, smoking, and Pap testing is complex because
women who smoke, as a whole, may be more likely
to engage in risky behavior, including a higher risk of
exposure to HPV infection through a larger number
of sexual partners.33-36 The census data presented in
Table 1 shows that KY, WV, and AL have similar rates
of education and poverty, yet the rates of ICC are
considerably lower in AL. This may be explained at
least in part by the finding that AL has lower smoking rates than KY and WV, as well as higher rates of
Pap testing, and this contrast is greatest among the
low-income, low-education groups. This may reflect
public health intervention practices that may have
been more common or more effective in AL, as well
as possible cultural differences in the Deep South,
but further work is needed to elucidate these stateregional differences.
With respect to race, black women in KY had the
highest ICC rate (15.1); however, the racial contrast
between black and nonblack women peaked in AL,
in which the ICC rate was 56% higher in black
women. This is somewhat puzzling, given that blacks
in AL had much lower rates of smoking than non-
Cervical CA in Appalachia/Hopenhayn et al
2979
TABLE 3
Distribution of Current Smoking Rates and Recent Papanicolaou Testing* by State and by Race, Income, and Education Based on BRFSS 2004
Data, Selected Appalachian States16
Alabama
Total
Race
Black
Nonblack
Age, y
18-24
25-34
35-44
45-54
55-64
651
Income
<$25,000
$25,000-49,999
$50,0001
Education
<High school
High school graduate
Some college
College graduate
Kentucky
Ohio
Pennsylvania
West Virginia
All 5 States
Current
Smoker, %
Recent
Pap, %
Current
Smoker, %
Recent
Pap, %
Current
Smoker, %
Recent
Pap, %
Current
Smoker, %
Recent
Pap, %
Current
Smoker, %
Recent
Pap, %
Current
Smoker, %
Recent
Pap, %
22.3
87.2
27.0
84.4
26.0
86.2
23.4
84.2
28.1
82.1
24.8
85.1
14.9
25.0
89.3
86.3
33.7
26.5
79.5
84.7
25.4
26.1
89.5
86.0
29.8
22.8
85.2
84.2
27.8
28.1
79.5
82.2
24.4
24.9
87.2
85.0
20.8
22.5
26.7
27.6
19.6
12.9
87.8
92.5
88.2
91.4
84.9
72.7
31.6
30.9
25.5
31.0
23.3
14.9
80.5
92.9
88.4
84.0
85.6
66.7
30.7
31.9
31.4
29.5
18.1
6.8
88.8
91.5
90.0
83.6
87.1
73.8
30.5
26.1
28.2
24.7
21.6
7.5
80.7
92.4
89.2
87.8
83.7
67.5
38.8
33.0
33.4
26.4
20.6
12.6
81.9
90.8
86.1
86.9
78.8
64.6
29.8
28.6
29.0
27.5
20.4
8.9
84.5
92.1
89.1
86.2
84.9
69.9
30.5
22.5
14.6
81.9
88.8
95.6
36.7
30.9
13.0
80.1
87.3
95.4
40.4
31.3
16.8
76.1
88.1
91.2
34.2
24.7
17.0
77.1
87.4
91.7
39.1
29.4
13.6
73.6
87.4
91.6
36.1
27.6
16.1
77.6
87.8
92.2
42.6
23.8
22.4
9.7
76.6
83.5
90.6
93.8
43.6
32.7
24.9
13.3
66.8
83.3
86.4
93.2
55.8
29.4
28.2
11.3
75.3
83.6
87.7
91.2
42.5
29.1
23.7
10.3
68.8
80.4
88.8
89.8
41.6
32.8
24.8
14.8
63.6
81.7
85.5
92.1
46.5
29.2
25.2
11.1
71.1
82.2
88.2
91.2
BRFSS indicates Behavioral Risk Factor Surveillance System; Pap, Papanicolaou test.
*The most recent Pap test was <3 years previously.
Women were excluded from the analysis if they reported having undergone a hysterectomy or if data were missing from either the smoking or screening question.
blacks and blacks in the other states. They also had
higher rates of Pap testing. The contrast could be at
least partially explained by the limitations of the
BRFSS, which may not accurately represent all subgroups of the population, either by the relative proportion of women who have landline telephones or
by differences between respondents and nonrespondents, given the national 2004 median BRFSS
response rate of only 52.7% (range, 45.1%-61%
among the 5 states in our analysis).37 The accuracy
of responding to the questions regarding Pap testing
also may introduce bias, either by social desirability
pressure or poor knowledge of Pap testing.38 Other
factors not accounted for in this analysis may also
contribute to some of the differences observed in the
current study, such as rates of follow-up for abnormal Pap results, exposure to other ICC risk factors,
or interaction effects not revealed by this analysis.39-41
Finally, the distribution of the black population
across the study area differed, suggesting there may
be other socioeconomic, lifestyle, or health access
factors underlying the observed differences in ICC
rates. AL as a whole has a higher poverty level than
KY, PA, and OH, and it has a much greater percent-
age of blacks than the other 4 states, particularly
when compared with KY and WV. This contrast in
race distribution is even greater across the state-specific Appalachian regions.
In conclusion, we found variability in the risk of
ICC across the 5 Appalachian states included in the
current analysis, which stretched from PA in the
north to AL in the south, with rates found to be substantially higher in KY and WV and lower in OH, PA,
and AL. We also observed variations across the Appalachian-only counties, with the highest rate found in
KY and the lowest in PA. The variations across the
subregions appeared to reflect the socioeconomic
differences of their population, which in turn may be
at least partly explained by differing prevalence of
ICC risk factors, such as smoking and screening
practices.
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