Journal of the National Cancer Institute Advance Access originally published online on July 8, 2008
JNCI Journal of the National Cancer Institute 2008 100(14):1003-1012; doi:10.1093/jnci/djn207
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Secular Trends in Mortality From Common Cancers in the United States by Educational Attainment, 1993–2001
Affiliations of authors: Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (TK, JL); Department of Epidemiology and Surveillance Research, American Cancer Society, Atlanta, GA (AJ, EW, MT)
Correspondence to: Ahmedin Jemal, DVM, PhD, Epidemiology and Surveillance Research, American Cancer Society, 250 Williams St, NW, Atlanta, GA 30303-1002 (e-mail: ahmedin.jemal{at}cancer.org).
Background: Death rates for the four major cancer sites (lung, breast, prostate, and colon and rectum) have declined steadily in the United States among persons aged 25–64 years since the early 1990s. We used national data to examine these trends in relation to educational attainment.
Methods: We calculated age-standardized death rates for each of the four cancers by level of education among 25- to 64-year-old non-Hispanic white and non-Hispanic black men and women for 1993 through 2001 using data on approximately 86% of US deaths from the National Center for Health Statistics, education level as recorded on the death certificate, and population data from the US Bureau of Census Current Population Survey. Annual percent changes in age-adjusted death rates were estimated using weighted log-linear regression models. All statistical tests were two-sided.
Results: Death rates for each cancer decreased statistically significantly from 1993 to 2001 in people with at least 16 years of education in every sex and race stratum except lung cancer in black women, for whom death rates were stable. For example, colorectal cancer death rates among white men, black men, white women, and black women with at least 16 years of education decreased by 2.4% (P < .001), 4.8% (P = .011), 3.0% (P < .001), and 2.6% (P = .030) annually, respectively. By contrast, among people with less than 12 years of education, a statistically significant decrease in death rates from 1993 through 2001 was seen only for breast cancer in white women (1.4% per year; P = .029). Death rates among persons with less than 12 years of education over the same time interval increased for lung cancer in white women (2.4% per year; P < .001) and for colon cancer in black men (2.7% per year; P < .001) and were stable for the remaining race/sex/site strata. Temporal trends generally followed an educational gradient in which the slopes of the decreases in death rate became steeper with higher educational attainment.
Conclusion: The recent declines in death rates from major cancers in the United States mainly reflect declines in more highly educated individuals.
| CONTEXT AND CAVEATS Prior knowledge Rates of death from the four major cancers (lung, colorectal, female breast, and prostate) in the United States have declined since the early 1990s. Previous studies have indicated that the fall in death rates may be distributed unequally among groups of different socioeconomic status, but the association had not been studied in a national sample with individual-level data. Study design Population study in which death certificates covering 86% of US deaths in 1993–2001 were analyzed for cause of death and level of education of the decedent. Annual percent changes from 1993 through 2001 in age-standardized death rates for 25- to 64-year-olds who had died from one of the four major cancers were computed by educational level, race (non-Hispanic white and non-Hispanic black), and sex. Contributions Death rates for each cancer decreased from 1993 to 2001 in people with at least 16 years of education in every sex/race group except lung cancer in black women, for whom death rates were stable. Among people with less than 12 years of education, by contrast, a decrease in death rates was seen only for breast cancer in white women; death rates increased for lung cancer in white women and for colon cancer in black men and were stable for the remaining race/sex/cancer site groups. Implications The decreases in rates of death from the four major cancers have been limited mainly to those with higher educational attainment. Limitations Educational attainment is an imperfect measure of socioeconomic status. Whether the findings would generalize to the elderly, in whom most cancer deaths occur, is not known. Misclassification of educational level on death certificates could have affected the results. From the Editors
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The authors wish to acknowledge the valuable assistance of Taylor Murray with the management and analyses of these data.
Manuscript received January 2, 2008; revised May 2, 2008; accepted May 21, 2008.
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