Journal of the National Cancer Institute Advance Access originally published online on September 11, 2007
JNCI Journal of the National Cancer Institute 2007 99(18):1384-1394; doi:10.1093/jnci/djm127
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Cancer Mortality in the United States by Education Level and Race
Affiliations of authors: Epidemiology and Surveillance Research, American Cancer Society, Atlanta, GA (JDA, EW, AJ, VEC, TM, JH, MJT); Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA (JDA); National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD (RA); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (JL)
Correspondence to: Elizabeth Ward, PhD, Epidemiology and Surveillance Research, American Cancer Society, 1599 Clifton Rd, Atlanta, GA 30329 (e-mail: elizabeth.ward{at}cancer.org).
Background: Although both race and socioeconomic status are well known to influence mortality patterns in the United States, few studies have examined the simultaneous influence of these factors on cancer incidence and mortality. We examined relationships among race, education level, and mortality from cancers of the lung, breast, prostate, colon and rectum, and all sites combined in contemporary US vital statistics.
Methods: Age-adjusted cancer death rates (with 95% confidence intervals [CIs]) were calculated for 137708 deaths among 119376196 individuals aged 25–64 years, using race and education information from death certificates and population denominator data from the US Bureau of the Census, for 47 states and Washington, DC, in 2001. Relative risk (RR) estimates were used to compare cancer death rates in persons with 12 or fewer years of education with those in persons with more than 12 years of education.
Results: Educational attainment was strongly and inversely associated with mortality from all cancers combined in black and white men and in white women. The all-cancer death rates were nearly identical for black men and white men with 0–8 years of education (224.2 and 223.6 per 100000, respectively). The estimated relative risk for all-cancer mortality comparing the three lowest (
12 years) with the three highest (>12 years) education categories was 2.38 (95% CI = 2.33 to 2.43) for black men, 2.24 (95% CI = 2.23 to 2.26) for white men, 1.43 (95% CI = 1.41 to 1.46) for black women, and 1.76 (95% CI = 1.75 to 1.78) for white women. For both men and women, the magnitude of the relative risks comparing the three lowest educational levels with the three highest within each race for all cancers combined and for lung and colorectal cancers was higher than the magnitude of the relative risks associated with race within each level of education, whereas for breast and prostate cancer the magnitude of the relative risks associated with race was higher than the magnitude of the relative risks associated with level of education within each racial group. Among the most important and novel findings were that black men who completed 12 or fewer years of education had a prostate cancer death rate that was more than double that of black men with more schooling (10.5 versus 4.8 per 100000 men; RR = 2.17, 95% CI = 1.82 to 2.58) and that, in contrast with studies of mortality rates in earlier time periods, breast cancer mortality rates were higher among women with less education than among women with more education (37.0 and 31.1 per 100000, respectively, for black women and 25.2 versus 18.6 per 100000, respectively, for white women).
Conclusion: Cancer death rates vary considerably by level of education. Identifying groups at high risk of death from cancer by level of education as well as by race may be useful in targeting interventions and tracking cancer disparities.
| CONTEXT AND CAVEATS Prior knowledge Both race and socioeconomic factors influence mortality patterns and life expectancy in the United States, but few studies have examined the simultaneous influence of these factors on cancer incidence and mortality in the United States. Study design Death certificate data from 2001 and population data from the 2001 Current Population Survey of the US Bureau of the Census were used to examine associations between educational level and age-standardized mortality rates for lung, breast, prostate, and colorectal cancers, individually and combined, by sex and by race. Contribution Education level was inversely associated with the rate of death from all cancers combined for black men, white men, and white women. The difference in cancer mortality was most pronounced between those with 12 or fewer years of education and those with more than 12 years of education. Implications Identifying groups at high risk of death from cancer by level of education as well as by race may be useful in targeting interventions and tracking cancer disparities. Limitations Educational attainment was the only indicator of individual socioeconomic status used. This study was restricted to individuals who were 25–64 years old at death and to blacks and whites, which limits the generalizability of the results to older individuals and to individuals of other races and ethnicities.
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Manuscript received February 13, 2007; revised July 9, 2007; accepted July 24, 2007.
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