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Widening of Socioeconomic Disparities in U. S. Mortality from Major Cancers Ahmedin Jemal, Ph. Widening of Socioeconomic Disparities in U. S. Mortality from Major Cancers Ahmedin Jemal, Ph. D Elizabeth Ward, Ph. D June 10, 2008 Kinsey T, Jemal A, Liff J, Ward E, Thun MJ, JNCI 2008 (in press)

“Poverty Is a Carcinogen” Dr. Samuel Broder, 1991 “Poverty Is a Carcinogen” Dr. Samuel Broder, 1991

Background • Death rates have decreased for the 4 major cancer sites (lung, colon Background • Death rates have decreased for the 4 major cancer sites (lung, colon and rectum, female breast, and prostate) among U. S. men and women aged 25– 64 years since at least the early 1990 s. • Factors that have contributed to these trends include reduction in risk factors (tobacco use for lung cancer) and improvements in early detection and treatment for the other major cancers. • However, the extent to which these favorable mortality trends vary by socioeconomic status (SES) has not been examined using national data with individual measures of SES.

Background (contd. ) Previous Published studies have either used: • Area-level measures of SES Background (contd. ) Previous Published studies have either used: • Area-level measures of SES Singh et al. , JNCI 2002; 94: 916 -25; 2002; 94: 904 -15 • Studied cohorts with higher SES than the general population Steenland et al. , Amer J of Epi 2002; 156: 11 -21 • Or were restricted to employed persons Steenland et al. , Amer J of Public Health 2004; 94: 1037 -42

Background Albano et al. Cancer Mortality in the United States by Education and Race. Background Albano et al. Cancer Mortality in the United States by Education and Race. JNCI 2007; 99: 1384 -1394.

Objective Examine variation in cancer mortality trends from 1993 through 2001 for the 4 Objective Examine variation in cancer mortality trends from 1993 through 2001 for the 4 major cancers by educational attainment among non-Hispanic white and non-Hispanic black men and women aged 25– 64 years, using individual-level educational attainment data from death certificates that cover approximately 85% of the U. S. population. Deaths from the four major cancers (lung, colon and rectum, prostate and female breast) account for about 50% of the total cancer deaths.

Data Sources & Analyses • 1993 -2001 Mortality Data from NCHS • Educational attainment Data Sources & Analyses • 1993 -2001 Mortality Data from NCHS • Educational attainment (number of years of schooling) as marker of socioeconomic position was obtained from death certificates. This was typically provided by surviving family member to the funeral director.

Data Sources and Analyses (contd. ) Educational attainment was categorized by 4 levels: • Data Sources and Analyses (contd. ) Educational attainment was categorized by 4 levels: • Less than 12 years (did not finish high school) • 12 years (high school graduate) • 13– 15 years (some college) • 16 or more years (college graduate or higher)

Data Sources and Analyses (contd. ) Population data by educational attainment was obtained from Data Sources and Analyses (contd. ) Population data by educational attainment was obtained from the U. S. Bureau of Census based on the Current Population Survey, a nationally representative sample of about 50, 000 households. (Carbaugh CS, U. S. Bureau of Census, personal communication)

Data Sources and Analyses- Restrictions 1) Age 25 -64 years • • Individuals who Data Sources and Analyses- Restrictions 1) Age 25 -64 years • • Individuals who died before age 25 may not have completed their education. Educational attainment information is recorded more accurately on death certificates and better predicts SES for individuals younger than age 65 than for older individuals. 2) Non-Hispanic Whites & Non-Hispanic Blacks 3) Time Interval: 1993 -2001 • • 4) Both cancer risk and demographic characteristics differ by Hispanic ethnicity. Most states did not collect death certificate information on education systematically until 1993. Beginning in 2002, race/ethnicity information collected by the Current Population Survey is not consistent with that of death certificates. Beginning with mortality data from 2003, the question about educational attainment on the death certificate changed from a highest grade of school completed to collegiate track education, (i. e. , the ability to identify degree status). 43 States and DC • Seven states (Georgia, Rhode Island, Oklahoma, South Dakota, New York, Kentucky, and West Virginia) were excluded because recording of educational level on the death certificates was not at least 80% complete for all years from 1993 through 2001.

Data Sources and Analyses (contd. ) • The final analysis included 546, 703 cancer Data Sources and Analyses (contd. ) • The final analysis included 546, 703 cancer deaths • Accounting for approximately - 86% of the total cancer deaths recorded among whites and blacks of the same age in the entire US during 1993 -2001, and - 97% of deaths recorded in the 43 states and DC.

Statistical Analyses (Measured Outcomes) • Temporal trends in death rates from 1993 through 2001 Statistical Analyses (Measured Outcomes) • Temporal trends in death rates from 1993 through 2001 (APCs) by educational attainment within each race/sex/cancer site stratum using weighted linear regression. • Linear trends in the APCs (i. e. , changes in slope) over increasing levels of education within each race/sex/cancer site stratum using weighted linear regression. • Rate ratios comparing the lowest with the highest educational categories and 95% confidence intervals for the years 1993 and 2001 to summarize the changes in educational disparities in cancer mortality over the 9 years (1993 -2001).

Results Results

Lung Cancer: Trends in Age-Adjusted Death Rates by Educational Attainment, Ages 25 -64, 1993 Lung Cancer: Trends in Age-Adjusted Death Rates by Educational Attainment, Ages 25 -64, 1993 -2001

Trends in Lung Cancer Death Rates Among Men, by Race and Educational Attainment, Ages Trends in Lung Cancer Death Rates Among Men, by Race and Educational Attainment, Ages 25 -64, 1993 -2001 White Non-Hispanic Men Education 1993 Rate 2001 Rate All education 46. 9 <12 yrs Black Non-Hispanic Men APC 1993 Rate 2001 Rate APC 35. 7 -3. 3* 81. 4 57. 9 -4. 0* 88. 1 87. 3 -0. 1 98. 3 90. 4 -0. 2 12 yrs 59. 5 53. 2 -1. 5* 98. 6 73. 7 -3. 2* 13 -15 yrs 32. 7 24. 2 -3. 5* 45. 6 32. 2 -4. 7* 16+ yrs 20. 7 13. 7 -4. 9* 38. 3 21. 0 -6. 8* P value trend Rate ratio (<12 vs. 16+) 0. 001 4. 2 6. 4 (4. 1 -4. 4) (6. 2 -6. 6) 0. 004 2. 6 4. 3 (2. 5 -2. 8) (3. 9 -4. 8) *Annual percent change is statistically significant for difference from zero at two-sided p<. 05. Source: Kinsey T, Jemal A, Ward E, et al. Trends in mortality from four major cancers by education, United States, 1993 -2001. JNCI (in press).

Trends in Lung Cancer Death Rates Among Women, by Race and Educational Attainment, Ages Trends in Lung Cancer Death Rates Among Women, by Race and Educational Attainment, Ages 25 -64, 1993 -2001 White Non-Hispanic Women 1993 Rate 27. 6 2001 Rate 24. 7 <12 yrs 45. 5 12 yrs Black Non-Hispanic Women APC -1. 4* 1993 Rate 28. 7 2001 Rate 26. 3 APC -1. 0 55. 4 2. 4* 32. 7 30. 4 0. 8 32. 1 33. 1 0. 1 37. 3 35. 7 -0. 7 13 -15 yrs 19. 8 16. 6 -1. 7* 20. 1 19. 3 -1. 3 16+ yrs 13. 9 11. 6 -2. 9* 14. 8 16. 7 -2. 2 Education All education P value trend Rate ratio (<12 vs. 16+) 0. 009 3. 3 4. 8 (3. 1 -3. 5) (4. 5 -5. 0) 0. 059 2. 2 1. 8 (1. 8 -2. 7) (1. 6 -2. 1) *Annual percent change is statistically significant for difference from zero at two-sided p<. 05. Source: Kinsey T, Jemal A, Ward E, et al. Trends in mortality from four major cancers by education, United States, 1993 -2001. JNCI (in press).

Colorectal Cancer: Trends in Age-Adjusted Death Rates, by Educational Attainment, Ages 25 -64, 1993 Colorectal Cancer: Trends in Age-Adjusted Death Rates, by Educational Attainment, Ages 25 -64, 1993 -2001

Trends in Colorectal Cancer Death Rates Among Men, by Race and Educational Attainment, Ages Trends in Colorectal Cancer Death Rates Among Men, by Race and Educational Attainment, Ages 25 -64, 1993 -2001 White Non-Hispanic Men Education 1993 Rate 2001 Rate All education 11. 7 <12 yrs Black Non-Hispanic Men APC 1993 Rate 2001 Rate APC 10. 6 -1. 5* 18. 0 17. 9 0. 0 14. 1 16. 0 0. 9 17. 4 20. 9 2. 7* 12 yrs 14. 6 13. 9 -0. 9 21. 9 23. 9 1. 0 13 -15 yrs 9. 2 8. 1 -1. 1* 15. 4 11. 7 -2. 7 16+ yrs 9. 3 7. 9 -2. 4* 16. 3 11. 5 -4. 8* P value trend Rate ratio (<12 vs. 16+) 0. 039 1. 5 2. 0 (1. 4 -1. 6) (1. 9 -2. 2) 0. 010 1. 1 1. 8 (0. 9 -1. 3) (1. 5 -2. 2) *Annual percent change is statistically significant for difference from zero at two-sided p<. 05. Source: Kinsey T, Jemal A, Ward E, et al. Trends in mortality from four major cancers by education, United States, 1993 -2001. JNCI (in press).

Trends in Colorectal Cancer Death Rates Among Women, by Race and Educational Attainment, Ages Trends in Colorectal Cancer Death Rates Among Women, by Race and Educational Attainment, Ages 25 -64, 1993 -2001 White Non-Hispanic Women Black Non-Hispanic Women 1993 Rate 2001 Rate APC 8. 3 7. 2 -1. 7* 13. 0 -0. 3 <12 yrs 9. 5 10. 4 11. 0 10. 3 -0. 3 12 yrs 9. 7 9. 2 -1. 0* 16. 1 17. 8 -0. 3 13 -15 yrs 6. 4 5. 5 -1. 6* 9. 4 10. 0 0. 7 16+ yrs 6. 8 5. 4 -3. 0* 15. 6 12. 2 -2. 6* Education All education P value trend Rate ratio (<12 vs. 16+) 0. 063 1. 4 1. 9 (1. 3 -1. 6) (1. 7 -2. 1) 0. 288 0. 7 0. 8 (0. 6 -0. 9) (0. 7 -1. 0) *Annual percent change is statistically significant for difference from zero at two-sided p<. 05. Source: Kinsey T, Jemal A, Ward E, et al. Trends in mortality from four major cancers by education, United States, 1993 -2001. JNCI (in press).

Female Breast and Prostate Cancer: Trends in Age-Adjusted Death Rates by Educational Attainment, Ages Female Breast and Prostate Cancer: Trends in Age-Adjusted Death Rates by Educational Attainment, Ages 25 -64, 1993 -2001

Trends in Female Breast Cancer Death Rates by Race and Educational Attainment, Ages 25 Trends in Female Breast Cancer Death Rates by Race and Educational Attainment, Ages 25 -64, 1993 -2001 White Non-Hispanic Women Black Non-Hispanic Women Education 1993 Rate 2001 Rate APC All education 27. 4 21. 4 -3. 4* 38. 0 34. 9 -1. 1* <12 yrs 27. 4 24. 1 -1. 4* 30. 0 28. 7 0. 1 12 yrs 30. 6 25. 4 -2. 9* 45. 3 43. 4 -1. 5 13 -15 yrs 23. 2 17. 3 -3. 6* 35. 3 30. 0 -0. 9 16+ yrs 27. 4 20. 1 -4. 3* 45. 7 35. 8 -3. 8* P value trend Rate ratio (<12 vs. 16+) 0. 025 1. 0 1. 2 (1. 0 -1. 1) (1. 1 -1. 3) 0. 046 0. 7 0. 8 (0. 6 -0. 7) (0. 7 -0. 9) *Annual percent change is statistically significant for difference from zero at two-sided p<. 05. Source: Kinsey T, Jemal A, Ward E, et al. Trends in mortality from four major cancers by education, United States, 1993 -2001. JNCI (in press).

Trends in Prostate Cancer Death Rates by Race and Educational Attainment, Ages 25 -64, Trends in Prostate Cancer Death Rates by Race and Educational Attainment, Ages 25 -64, 1993 -2001 White Non-Hispanic Men Education 1993 Rate 2001 Rate All education (incl. missing) 3. 9 (4. 0) <12 yrs Black Non-Hispanic Men APC 1993 Rate 2001 Rate APC 2. 7 (2. 8) -4. 6* (-4. 7*) 11. 8 (12. 7) 8. 8 (9. 1) -3. 3* (-3. 6*) 4. 0 3. 4 -1. 6 10. 4 9. 6 -1. 6 12 yrs 4. 3 3. 3 -3. 5* 16. 2 12. 7 -1. 6 13 -15 yrs 3. 4 2. 3 -5. 5* 10. 3 5. 3 -7. 4* 16+ yrs 3. 8 2. 3 -6. 3* 7. 6 4. 8 -5. 9 P value trend Rate ratio (<12 vs. 16+) 0. 022 1. 1 1. 5 (0. 9 -1. 2) (1. 3 -1. 7) 0. 211 1. 4 2. 0 (1. 0 -1. 8) (1. 5 -2. 7) *Annual percent change is statistically significant for difference from zero at two-sided p<. 05. Source: Kinsey T, Jemal A, Ward E, et al. Trends in mortality from four major cancers by education, United States, 1993 -2001. JNCI (in press).

Conclusions Recent declines in death rates from major cancers in the U. S. mainly Conclusions Recent declines in death rates from major cancers in the U. S. mainly reflect declines in more highly educated persons.

Factors That May Have Contributed to These Trends • Trends in screening rates by Factors That May Have Contributed to These Trends • Trends in screening rates by education • Trends in smoking prevalence by education • Survival by insurance status (access to care)

Prevalence (%) Prevalence of Mammography Screening* Among Women Ages ≥ 40 years, by Educational Prevalence (%) Prevalence of Mammography Screening* Among Women Ages ≥ 40 years, by Educational Attainment, NHIS Education (years) *Percent of women having a mammogram within the past 2 years. NHIS= National Health Interview Survey Source: 2005 data: Breen N, Cronin KA, Meissner HI, et al. Reported drop in mammography: Is this cause for concern? Cancer 2007; 109: 2405 -9. 1987 & 2000 data: Swan J, Breen N, Coates RJ, et al. Progress in cancer screening practices in the United States. Cancer 2003; 97: 1528 -40.

Prevalence (%) Prevalence of Colorectal Screening* Among Adults Aged ≥ 50 years, by Educational Prevalence (%) Prevalence of Colorectal Screening* Among Adults Aged ≥ 50 years, by Educational Attainment, NHIS Education (years) *Percent of persons having a fecal occult blood test in past year or colorectal endoscopy within the last 3 years. NHIS= National Health Interview Survey Source: Swan J, Breen N, Coates RJ, et al. Progress in cancer screening practices in the United States. Cancer 2003; 97: 1528 -40.

Prevalence (%) Prevalence of Prostate Cancer Screening* Among Men Ages ≥ 50 years, by Prevalence (%) Prevalence of Prostate Cancer Screening* Among Men Ages ≥ 50 years, by Educational Attainment, NHIS Education (years) *Percent of persons having a fecal occult blood test in past year or colorectal endoscopy within the last 3 years. NHIS= National Health Interview Survey Source: 2000 data: Swan J, Breen N, Coates RJ, et al. Progress in cancer screening practices in the United States. Cancer 2003; 97: 1528 -40. 2005 data: American Cancer Society, Cancer Prevention and Early Detection Facts & Figures 2008.

Trends in Smoking Prevalence Among US Adults, Ages ≥ 25 years, by Educational Attainment, Trends in Smoking Prevalence Among US Adults, Ages ≥ 25 years, by Educational Attainment, 1974 -2004 Men Women 0 -11 yrs 12 yrs 0 -11 yrs 13 -15 yrs 16+ yrs 12 yrs 13 -15 yrs 16+ yrs *Source: National Center for Health Statistics, Health, United States, 2006 with Chartbook on Trends in the Health of Americans.

Colorectal Cancer Survival Among Whites by Stage and Insurance Status* Stage 1, Private Stage Colorectal Cancer Survival Among Whites by Stage and Insurance Status* Stage 1, Private Stage 2, Private Stage 1, Uninsured/Medicaid Stage 2, Uninsured/Medicaid Stage 3, Private Stage 3, Uninsured/Medicaid Stage 4, Private Stage 4, Uninsured/Medicaid Survival Time in Months *Patients aged 18 to 64 years diagnosed from 1999 to 2000; excluded from the analysis: unknown stage; race/ethnicity other than White, African American, or Hispanic; missing information on stage, race/ethnicity, or zip code. Source: Ward, E. et al. CA Cancer J Clin 2008; 58: 9 -31.

Colorectal Cancer Survival Among African Americans by Stage and Insurance Status* Stage 1, Private Colorectal Cancer Survival Among African Americans by Stage and Insurance Status* Stage 1, Private Stage 2, Private Stage 1, Uninsured/Medicaid Stage 3, Private Stage 2, Uninsured/Medicaid Stage 3, Uninsured/Medicaid Stage 4, Private Stage 4, Uninsured/Medicaid Survival Time in Months *Patients aged 18 to 64 years diagnosed from 1999 to 2000; excluded from the analysis: unknown stage; race/ethnicity other than White, African American, or Hispanic; missing information on stage, race/ethnicity, or zip code. Source: Ward, E. et al. CA Cancer J Clin 2008; 58: 9 -31.

Approaches to Reduce Disparity in Cancer Mortality • Eliminate social and economic barriers to Approaches to Reduce Disparity in Cancer Mortality • Eliminate social and economic barriers to access to care and healthy behaviors • Promote public education on primary and secondary disease prevention targeted to the disadvantaged populations • Engage health care providers at all levels (primary care, HMOs, community)