Cancer screening in the United States, 2014: a review of current American Cancer Society guidelines and current issues in cancer screening.

Answer questions and earn CME/CNE Each year the American Cancer Society publishes a summary of its guidelines for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, we summarize current American Cancer Society cancer screening guidelines. In addition, the latest data on the use of cancer screening from the National Health Interview Survey is described, as are several issues related to screening coverage under the Patient Protection and Affordable Care Act, including the expansion of the Medicaid program.

Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening.

Each year the American Cancer Society (ACS) publishes a summary of its recommendations for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, current ACS cancer screening guidelines are summarized, as are updated guidelines on cervical cancer screening and lung cancer screening with low-dose helical computed tomography. The latest data on the use of cancer screening from the National Health Interview Survey also are described, as are several issues related to screening coverage under the Patient Protection and Affordable Care Act of 2010.

Cancer-related risk factors and preventive measures in US Hispanics/Latinos.

In this article, we provide prevalence data on major cancer-related risk factors, early detection testing, and vaccination among Hispanics using nationally representative surveys. Compared with non-Hispanic whites, Hispanic adults are less likely to be current smokers (13% vs 22%) or frequent alcohol drinkers, but they are more likely to be obese (32% vs 26%) and to have lower levels of mammography use within the past year (46% vs 51%), colorectal screening as per recommended intervals (47% vs 61%), and Papanicolaou (Pap) test use within the past 3 years (74% vs 79%). Within the Hispanic population, the prevalence of these risk factors and early detection methods substantially vary by country of origin. For example, Cuban men (20.7%) and Puerto Rican men (19%) had the highest levels of current smoking than any other Hispanic subgroups, while Mexican women had the lowest levels of mammogram use (44%) and Pap test use (71%). Hispanic migrants have a higher prevalence of hepatitis B virus and Helicobacter pylori, which cause liver and stomach cancer, respectively. Among Hispanic adolescents, tobacco use (eg, 20.8% use of any tobacco products), alcohol use (42.9%), and obesity (23.2%) remain highly prevalent risk factors. Although 56% of Hispanic adolescents initiate human papillomavirus vaccination, only 56% of them completed the 3-dose series. Differences in risk factors and early detection testing among Hispanic groups should be considered in clinical settings and for cancer control planning.

Cancer screening in the United States, 2012: A review of current American Cancer Society guidelines and current issues in cancer screening.

Each year the American Cancer Society (ACS) publishes a summary of its recommendations for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, current ACS cancer screening guidelines are summarized, as are the latest data on the use of cancer screening from the National Health Interview Survey.

Cancer screening in the United States, 2011: A review of current American Cancer Society guidelines and issues in cancer screening.

Each year the American Cancer Society (ACS) publishes a summary of its recommendations for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. This article summarizes the current ACS guidelines, describes the anticipated impact of new health care reform legislation on cancer screening, and discusses recent public debates over the comparative effectiveness of different colorectal cancer screening tests. The latest data on the utilization of cancer screening from the National Health Interview Survey is described, as well as several recent reports on the role of health care professionals in adult utilization of cancer screening.

Cancer screening in the United States, 2010: a review of current American Cancer Society guidelines and issues in cancer screening.

Each year the American Cancer Society (ACS) publishes a summary of its recommendations for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. In 2010, the ACS updated its guidelines for testing for early prostate cancer detection, and during 2009 there were several newsworthy updates in the cancer screening guidelines from other organizations. In this article, the current ACS guidelines and recent issues are summarized, updates of guidelines for testing for early breast cancer detection by the US Preventive Services Task Force and for prevention and early detection of cervical cancer from the American College of Obstetricians and Gynecologists are addressed, and the most recent data from the National Health Interview Survey pertaining to participation rates in cancer screening are described.

Tobacco control in the United States--recent progress and opportunities.

Effective tobacco control efforts have resulted in substantial declines in tobacco use and tobacco-related cancer deaths in the United States. Nearly 40% of reductions in male lung cancer deaths between 1991 and 2003 can be attributed to smoking declines in the last half century. Nevertheless, tobacco use still remains the single, largest preventable cause of disease and premature death in the United States. Each year, smoking and exposure to secondhand smoke result in nearly half a million premature deaths of which nearly one-third are due to cancer. In a previous report, we described youth and adult smoking prevalence and patterns and discussed policy measures that had proven effective in comprehensive tobacco control. In this report, we update trends in youth and adult smoking prevalence. We find that while adult smoking prevalence has declined overall, socioeconomic gradients in smoking still persist within race and ethnic subgroups. In addition, we describe the diffusion of tobacco-control strategies at the national, state, and community level. Although recent developments, such as the Food and Drug Administration's (FDA) regulation of tobacco products, hold promise for tobacco control, there continues to be a need for broader dissemination of sustainably funded comprehensive national and state tobacco-control programs.

Cigarette affordability in the United States.

INTRODUCTION: Cigarette excise tax and price increases reduce smoking consumption and prevalence. Studies have previously defined cigarette affordability internationally and have discussed its relevance as a tobacco control policy measure. This study provides the first estimates on cigarette affordability in the United States. METHODS: Cigarette affordability was defined as cigarette price in relation to individuals' income level. Three measures of cigarette affordability were estimated for U.S. states and nationally between 1970 and 2010. RESULTS: In 2010, on average, it took 1.62% of an individual's annual personal disposable income to purchase 100 packs of cigarettes in a U.S. state (relative income price). An individual who earned the equivalent of the hourly median wage in a U.S. state needed to work 21.4min in an hour to purchase a pack of cigarettes (minutes of labor, MoL50), whereas a relatively poorer individual earning the hourly 25th percentile wage needed to work 32.7min (MoL25). Cigarettes were most affordable in parts of the South and West and were least affordable in Northeastern states. While cigarette prices increased significantly between 1970 and 2008, affordability remained unchanged during this time and cigarettes may have become more affordable since the early 2000s in many states. CONCLUSIONS: Cigarette affordability in 2010 varied widely across U.S. states, a result of cigarette price increases not keeping pace with income increases in some parts of the United States, especially in Southern and Western states. In order to maximize the public health gains from cigarette tax increases, state taxation policies may consider affordability in benchmarking excise tax increases.

Trends in colorectal cancer screening with home-based fecal occult blood tests in adults ages 50 to 64 years, 2000-2008.

BACKGROUND: National surveys have reported declines in rates of home-based fecal occult blood test (FOBT) screening for colorectal cancer (CRC) in the last decade. However, socioeconomic status (SES) and racial/ethnic differences in FOBT trends and their changes relative to endoscopic CRC screening have not been evaluated. METHODS: Data on adults ages 50 to 64 years from the 2000, 2005, and 2008 National Health Interview Surveys were used. Weighted analyses and multivariate logistic regression were used to study trends in the use of FOBT and endoscopic CRC screening during this period. RESULTS: Between 2000 and 2008, significant declines in FOBT prevalence occurred in higher SES groups, but not in lower SES groups (uninsured and publicly insured, those without a usual source of care, lower educated, lower income, and immigrants to the United States) or Hispanics. Endoscopic CRC screening during the period studied consistently increased in all higher SES subgroups. In contrast, few lower SES subgroups (publicly insured, lower educated, near poor individuals, long-term immigrants) and Hispanics experienced increases in CRC endoscopic screening, and these increases were smaller than those observed in higher SES subgroups. CONCLUSIONS: Socially and economically disadvantaged groups experienced little or no change in FOBT prevalence, and few of these groups experienced contemporaneous increases in CRC endoscopic screening. These trends suggest the continued availability and acceptance of FOBT in these groups. If national CRC screening goals are to be achieved in populations with lower access to colonoscopy, then annual high-sensitivity FOBT should be promoted as an immediately accessible and viable alternative.

Association of insurance status and age with cervical cancer stage at diagnosis: National Cancer Database, 2000-2007.

OBJECTIVES: We examined the relationship of age at diagnosis and insurance status with stage among cervical cancer patients aged 21 to 85 years. METHODS: We selected data on women (n = 69 739) diagnosed with invasive cervical cancer between 2000 and 2007 from the National Cancer Database. We evaluated the association between late stage (stage III/IV) and both insurance and age, with adjustment for race/ethnicity and other sociodemographic and clinical factors. We used multivariable log binomial models to estimate risk ratios (RRs) and 95% confidence intervals (CIs). RESULTS: The proportion of late-stage disease increased with age: from 16.53% (21-34 years) to 42.44% (≥ 70 years). The adjusted relative risk of advanced-stage disease among women aged 50 years and older was 2.2 to 2.5 times that of patients aged 21 to 34 years. Uninsured (RR = 1.44; 95% CI = 1.40, 1.49), Medicaid (RR = 1.37, 95% CI = 1.34, 1.41), younger Medicare (RR = 1.12, 95% CI = 1.06, 1.19), and older Medicare (RR = 1.20, 95% CI = 1.15, 1.26) patients had a higher risk of late-stage disease than did privately insured patients. CONCLUSIONS: Screening should be encouraged for women at high risk for advanced-stage disease.

A profile of skin cancer prevention media coverage in 2009.

BACKGROUND: Little is known about the coverage of skin cancer prevention messages in news print media. OBJECTIVE: To perform a content analysis of mass-media articles from newspaper and magazines pertaining to skin cancer prevention in 4 specific months (January, May, July, and October) in 2009 and assess the extent of coverage of skin cancer prevention messages. METHODS: We conducted a content analysis of 144 articles related to skin cancer prevention extracted from strategic media scans of selected months in 2009. We sought to provide the frequency of mass-media content categorized by theme and focus related to ultraviolet radiation (UVR) protection and risk-reducing behaviors. RESULTS: The audience for the vast majority (78%) of the articles was the general public. Among the assessed articles, more were published in May (49%) and July (35%) than in the remaining other months. The two most frequent themes focused on 'protection of the skin' (32%) and on 'skin cancer prevention' (23%) via risk reduction behavioral practices. Analysis of message content regarding UVR reduction practices showed that many mentioned 'use of sunscreen' (65% of messages) with the least-often mentioned behaviors being 'seek shade' (6.3%) and 'do not burn' (1.4%). In addition, a quarter of the articles lacked any content mentioning recommended UVR reduction behaviors. LIMITATIONS: This study was limited to the narrow scope of articles published in 2009 and for selected months. CONCLUSIONS: This profile of mass-media content regarding skin cancer prevention revealed gaps in coverage of UVR reduction behaviors with possible room for improvement. Strategies for improving and comprehensiveness of coverage of recommended skin cancer prevention behaviors in the media are discussed.

Prevalence of sunburn, sun protection, and indoor tanning behaviors among Americans: review from national surveys and case studies of 3 states.

BACKGROUND: Exposure to ultraviolet radiation (from solar and nonsolar sources) is a risk factor for skin cancer. OBJECTIVE: We sought to summarize recent estimates on sunburns, sun-protection behaviors, and indoor tanning available from national and selected statewide behavioral surveys. METHODS: Estimates of the prevalence of sunburn, sun-protection behaviors, and indoor tanning by US adults, adolescents, and children collected in national surveys in 1992, 2004 to 2005, and 2007 to 2009 were identified and extracted from searches of computerized databases (ie, MEDLINE and PsychINFO), reference lists, and survey World Wide Web sites. Sunburn estimates from 3 state Behavioral Risk Factors Surveillance Systems were also analyzed. RESULTS: Latest published estimates (2005) showed that 34.4% of US adults were sunburned in the past year. Incidence of sunburns was highest among men, non-Hispanic whites, young adults, and high-income groups in national surveys. About 3 in 10 adults routinely practiced sun-protection behaviors, and women and older adults took the most precautions. Among adolescents, 69% were sunburned in the previous summer and less than 40% practiced sun protection. Approximately 60% of parents applied sunscreen and a quarter used shade to protect children. Indoor tanning was prevalent among younger adults and females. LIMITATIONS: Limitations include potential recall errors and social desirability in self-report measures, and lack of current data on children. CONCLUSION: Many Americans experienced sunburns and a minority engaged in protective behaviors. Females and older adults were most vigilant about sun protection. Substantial proportions of young women and adolescents recently used indoor tanning. Future efforts should promote protective hats, clothing, and shade; motivate males and younger populations to take precautions; and convince women and adolescents to reduce indoor tanning.

Racial and ethnic variations in incidence and survival of cutaneous melanoma in the United States, 1999-2006.

BACKGROUND: Most melanoma studies use data from the National Cancer Institute Surveillance, Epidemiology, and End Results Program or individual cancer registries. Small numbers of melanoma cases have limited in-depth analyses for all racial and ethnic groups. OBJECTIVE: We sought to describe racial and ethnic variations in melanoma incidence and survival. METHODS: Incidence for invasive melanoma and 5-year melanoma-specific survival were calculated for whites, blacks, American Indians/Alaskan Natives, Asians/Pacific Islanders (API), and Hispanics using data from 38 population-based cancer registries. RESULTS: Incidence rates of melanoma were significantly higher for females than males among whites and Hispanics under 50 years of age and APIs under 40 years of age. White and black patients were older (median age: 59-63 years) compared with Hispanics, American Indians/Alaskan Natives, and API (median age: 52-56 years). The most common histologic type was acral lentiginous melanoma among blacks and superficial spreading melanoma among all other racial and ethnic groups. Hispanics had the highest incidence rate of acral lentiginous melanoma, significantly higher than whites and API. Nonwhites were more likely to have advanced and thicker melanomas at diagnosis and lower melanoma-specific survival compared with whites. LIMITATIONS: Over 50% of melanoma cases did not have specified histology. The numbers of nonwhite patients were still relatively small despite broad population coverage (67% of United States). CONCLUSIONS: Racial and ethnic differences in age at melanoma diagnosis, anatomic sites, and histologic types suggest variations in etiologic pathways. The high percentages of advanced and thicker melanomas among nonwhites highlight the need to improve melanoma awareness for all race and ethnicity in the United States.

Melanoma in adolescents and young adults (ages 15-39 years): United States, 1999-2006.

BACKGROUND: Invasive melanoma of the skin is the third most common cancer diagnosed among adolescents and young adults (aged 15-39 years) in the United States. Understanding the burden of melanoma in this age group is important to identifying areas for etiologic research and in developing effective prevention approaches aimed at reducing melanoma risk. METHODS: Melanoma incidence data reported from 38 National Program of Cancer Registries and/or Surveillance Epidemiology and End Results statewide cancer registries covering nearly 67.2% of the US population were used to estimate age-adjusted incidence rates for persons 15-39 years of age. Incidence rate ratios were calculated to compare rates between demographic groups. RESULTS: Melanoma incidence was higher among females (age-adjusted incidence rates = 9.74; 95% confidence interval 9.62-9.86) compared with males (age-adjusted incidence rates = 5.77; 95% confidence interval 5.68-5.86), increased with age, and was higher in non-Hispanic white compared with Hispanic white and black, American Indians/Alaskan Natives, and Asian and Pacific Islanders populations. Melanoma incidence rates increased with year of diagnosis in females but not males. The majority of melanomas were diagnosed on the trunk in all racial and ethnic groups among males but only in non-Hispanic whites among females. Most melanomas were diagnosed at localized stage, and among those melanomas with known histology, the majority were superficial spreading. LIMITATIONS: Accuracy of melanoma cases reporting was limited because of some incompleteness (delayed reporting) or nonspecific reporting including large proportion of unspecified histology. CONCLUSIONS: Differences in incidence rates by anatomic site, histology, and stage among adolescents and young adults by race, ethnicity, and sex suggest that both host characteristics and behaviors influence risk. These data suggest areas for etiologic research around gene-environment interactions and the need for targeted cancer control activities specific to adolescents and young adult populations.

Changes in smoking prevalence among U.S. adults by state and region: Estimates from the Tobacco Use Supplement to the Current Population Survey, 1992-2007.

BACKGROUND: Tobacco control policies at the state level have been a critical impetus for reduction in smoking prevalence. We examine the association between recent changes in smoking prevalence and state-specific tobacco control policies and activities in the entire U.S. METHODS: We analyzed the 1992-93, 1998-99, and 2006-07 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) by state and two indices of state tobacco control policies or activities [initial outcome index (IOI) and the strength of tobacco control (SOTC) index] measured in 1998-1999. The IOI reflects cigarette excise taxes and indoor air legislation, whereas the SOTC reflects tobacco control program resources and capacity. Pearson Correlation coefficient between the proportionate change in smoking prevalence from 1992-93 to 2006-07 and indices of tobacco control activities or programs was the main outcome measure. RESULTS: Smoking prevalence decreased from 1992-93 to 2006-07 in both men and women in all states except Wyoming, where no reduction was observed among men, and only a 6.9% relative reduction among women. The percentage reductions in smoking in men and women respectively were the largest in the West (average decrease of 28.5% and 33.3%) and the smallest in the Midwest (18.6% and 20.3%), although there were notable exceptions to this pattern. The decline in smoking prevalence by state was correlated with the state's IOI in both women and men (r = -0.49, p < 0.001; r = -0.31, p = 0.03; respectively) and with state's SOTC index in women(r = -0.30, p = 0.03 0), but not men (r = -0.21, p = 0.14). CONCLUSION: State level policies on cigarette excise taxes and indoor air legislation correlate strongly with reductions in smoking prevalence since 1992. Strengthening and systematically implementing these policies could greatly accelerate further reductions in smoking.

The association between state mandates of colorectal cancer screening coverage and colorectal cancer screening utilization among US adults aged 50 to 64 years with health insurance.

BACKGROUND: Several states in the US have passed laws mandating coverage of colorectal cancer (CRC) screening tests by health insurance plans. The impact of these state mandates on the use of colorectal cancer screening has not been evaluated among an age-eligible target population with access to care (i.e., health care insurance coverage). METHODS: We collected information on state mandates implemented by December 31, 2008 and used data on insured adults aged 50 and 64 years from the Behavioral Risk Factor Surveillance System between 2002 and 2008 to classify individual-level exposure to state mandates for at least 1 year. Multivariate logistic regression models (with state- and year- fixed effects, and patient demographic and socioeconomic characteristics) were used to estimate the effect of state mandates on recent endoscopy screening (either flexible sigmoidoscopy or colonoscopy during the past year). RESULTS: From 1999-2008, twenty-two states in the US, including the District of Columbia passed comprehensive laws requiring health insurance coverage of CRC screening including endoscopy tests. Residence in states with CRC screening coverage mandates in place for at least 1 year was associated with a 1.4 percentage point increase in the probability of utilization of recent endoscopy (i.e., 17.5% screening rates in those with mandates versus 16.1% in those without, Adjusted OR = 1.10, 95% CI: 1.02-1.20, p = 0.02). CONCLUSIONS: The findings suggest a positive, albeit small, impact of state mandates on the use of recent CRC screening endoscopy among the target eligible population with health insurance. However, more research is needed to evaluate potential effects of mandates across health insurance types while including controls for other system-level factors (e.g. endoscopy and primary care capacity). National health insurance reform should strive towards a system that expands access to recommended CRC screening tests.

Physician sun protection counseling: prevalence, correlates, and association with sun protection practices among US adolescents and their parents, 2004.

OBJECTIVE: To assess the population prevalence and correlates of ever receiving physician advice to practice sun protection (i.e. sun protection counseling) and whether such counseling is associated with sun protection behaviors in adolescents and their parents. METHOD: Analysis of a nationally representative cross-sectional telephone survey of ultraviolet radiation exposure behaviors among US adolescents ages 11 to 18 and their parents, conducted between August and November 2004. RESULTS: Forty-four percent of US adolescents and their parents reported physician sun protection counseling. Counseling was more frequently reported by adolescents whose parents were also counseled, reported other sun protection information sources (skin cancer prevention media messages and school sun safety messages), had first degree relatives with skin cancer, and were white, non-Hispanic. Counseling was positively associated with regular sunscreen use, appropriate sunscreen application practices, and intermittent hat use, but not with other recommended behaviors. Sunscreen use rates were generally higher among adolescents reporting several sun protection information sources (counseling, media and school messages) than those with combinations of two or fewer of these sources. CONCLUSIONS: The role of physicians, either independently or in concert with other information sources, should be explored in strategies promoting primary skin cancer prevention behaviors among adolescents and parents.

Sunburns, sun protection and indoor tanning behaviors, and attitudes regarding sun protection benefits and tan appeal among parents of U.S. adolescents-1998 compared to 2004.

This study presents nationally representative trends (1998-2004) and patterns in skin cancer risk behaviors, including sunburns, sun protection, and indoor tanning behaviors, and attitudes regarding ultraviolet radiation exposure among parents of U.S. adolescents. Data were from the American Cancer Society Sun Surveys I and II, telephone-based random digit dialed cross-sectional surveys of U.S. adolescents and their parents conducted in the summers of 1998 and 2004. Between 1998 and 2004, use of sunscreen, wide-brimmed hats and composite use of three to five behaviors increased significantly; concurrently, indoor tanning use increased significantly and sunburn prevalence changed a little. In 2004, 47% reported summer sunburns and more than half of those received painful sunburns. Parents continued to report low compliance with recommended behaviors; sunscreen use was most frequently reported, but many followed inappropriate application practices. About 13% practiced indoor tanning in the past year. Parents reported high levels of positive attitudes toward sun protection benefit, but at the same time, significant proportions reported positive tan appeal and outdoor sun exposure attitudes. The low rates and mixed progress in safe ultraviolet radiation exposure behaviors demand more attention for primary skin cancer prevention among parents of adolescents that focuses on changing beliefs about tanning appeal and promotes comprehensive ultraviolet radiation exposure protection.

Racial and ethnic disparities in smoking-cessation interventions: analysis of the 2005 National Health Interview Survey.

BACKGROUND: Recent national surveys document racial and ethnic disparities in receipt of smoking-cessation advice. This study updates and expands prior analyses using survey data for 2005, and evaluates the association between smokers' race and ethnicity and three separate measures of healthcare-encounter-based tobacco interventions: screening, smoking-cessation advice, and use of smoking-cessation aids. METHODS: Analyses are based on 4756 smokers (aged 18 and older) reporting a healthcare encounter within the past year who participated in the 2005 National Health Interview Survey (NHIS). Multivariate-adjusted OR and 95% CI for receipt of tobacco interventions in non-Hispanic black and Hispanic smokers were compared to those of non-Hispanic white smokers, adjusted for smokers' characteristics (sociodemographics, health status, and healthcare-utilization factors, and smoking-related characteristics). Analyses were done in 2006. RESULTS: Results show that compared to white smokers, black and Hispanic smokers had significantly lower odds of (1) being asked about tobacco use (AOR=0.70 and AOR=0.69, respectively); (2) being advised to quit (AOR=0.72 and AOR=0.64, respectively); or (3) having used tobacco-cessation aids during the past year in a quit attempt (AOR=0.60 and AOR=0.59, respectively). Compared to 2000 NHIS published data, the prevalence of receipt of advice to quit from a healthcare provider increased from 52.9% in 2000 to 61.2% in 2005, with increases across racial and ethnic groups. CONCLUSIONS: Despite progress in smokers' being advised to quit during healthcare encounters in the past 5 years, black and Hispanic smokers continue to be less likely than whites to receive and use tobacco-cessation interventions, even after control for socioeconomic and healthcare factors. Further actions are needed to understand and eliminate this disparity.

Mortality from leading causes by education and race in the United States, 2001.

BACKGROUND: Low educational attainment is a marker of socioeconomic status that correlates strongly with higher death rates from many conditions. No previous studies have analyzed national data to measure the number of deaths associated with lower education among working-aged adults (25-64 years) by race or ethnicity. Furthermore, no previous studies have examined comprehensively the relationship of education to cause-specific and all-cause mortality in the three largest racial or ethnic groups in the United States using national data. METHODS: Age-standardized, race/ethnicity-specific death rates from all causes and the 15 leading causes were measured among men and women aged 25-64 years by level of education based on U.S. national mortality data in 2001. The total number of deaths that potentially could be avoided among people aged 25-64 years was estimated by applying the mortality rates among college graduates (within each 5-year category of age, gender, and race/ethnicity) to each of the less-educated subpopulations. All analyses were performed in 2007. RESULTS: Nearly half (48%) of all deaths among men aged 25-64 years (white, black, and Hispanic), and 38% of all deaths in women would not have occurred in this age range if all segments of the population experienced the death rates of college graduates. Black men and women had the highest death rates from all causes combined and from many specific causes at nearly all levels of education, and the largest average life years lost before age 65 years. However, the total number of deaths associated with low education status was not confined to any single racial group. About 161,280 deaths in whites, 40,840 deaths in blacks, and 13,162 deaths in Hispanics in this age range were associated with educational disparity. CONCLUSIONS: Potentially avoidable factors associated with lower educational status account for almost half of all deaths among working-aged adults in the U.S.; these deaths are not confined to any single racial or ethnic group. These findings highlight the need for greater attention to social determinants of health.