Impact of socioeconomic status on cancer incidence and stage at diagnosis: selected findings from the surveillance, epidemiology, and end results: National Longitudinal Mortality Study.

BACKGROUND: Population-based cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute (NCI) are mainly based on medical records and administrative information. Individual-level socioeconomic data are not routinely reported by cancer registries in the United States because they are not available in patient hospital records. The U.S. representative National Longitudinal Mortality Study (NLMS) data provide self-reported, detailed demographic and socioeconomic data from the Social and Economic Supplement to the Census Bureau's Current Population Survey (CPS). In 1999, the NCI initiated the SEER-NLMS study, linking the population-based SEER cancer registry data to NLMS data. The SEER-NLMS data provide a new unique research resource that is valuable for health disparity research on cancer burden. We describe the design, methods, and limitations of this data set. We also present findings on cancer-related health disparities according to individual-level socioeconomic status (SES) and demographic characteristics for all cancers combined and for cancers of the lung, breast, prostate, cervix, and melanoma. METHODS: Records of cancer patients diagnosed in 1973-2001 when residing 1 of 11 SEER registries were linked with 26 NLMS cohorts. The total number of SEER matched cancer patients that were also members of an NLMS cohort was 26,844. Of these 26,844 matched patients, 11,464 were included in the incidence analyses and 15,357 in the late-stage diagnosis analyses. Matched patients (used in the incidence analyses) and unmatched patients were compared by age group, sex, race, ethnicity, residence area, year of diagnosis, and cancer anatomic site. Cohort-based age-adjusted cancer incidence rates were computed. The impact of socioeconomic status on cancer incidence and stage of diagnosis was evaluated. RESULTS: Men and women with less than a high school education had elevated lung cancer rate ratios of 3.01 and 2.02, respectively, relative to their college educated counterparts. Those with family annual incomes less than $12,500 had incidence rates that were more than 1.7 times the lung cancer incidence rate of those with incomes $50,000 or higher. Lower income was also associated with a statistically significantly increased risk of distant-stage breast cancer among women and distant-stage prostate cancer among men. CONCLUSIONS: Socioeconomic patterns in incidence varied for specific cancers, while such patterns for stage were generally consistent across cancers, with late-stage diagnoses being associated with lower SES. These findings illustrate the potential for analyzing disparities in cancer outcomes according to a variety of individual-level socioeconomic, demographic, and health care characteristics, as well as by area measures available in the linked database.

U.S. Latino population composition change and comprehensive cancer centers.

BACKGROUND: We describe a typology characterizing population trends of U.S. Latinos/Hispanics from 1990 to 2000 with respect to National Cancer Institute-designated comprehensive cancer centers (CCCs) and corresponding consolidated metropolitan statistical or metropolitan statistical areas (CMSA/MSAs). METHODS: Using U.S. Census Bureau data, we constructed population pyramids to analyze population growth and composition for each CMSA/MSA with a CCC. RESULTS: We identified four types of population growth and composition: Type I--Very Fast and Unstable; Type II--Fast and Unstable; Type III--Somewhat Fast and Stable; Type IV--Slow and Stable. CONCLUSIONS: The CCCs in areas with Types I and II population growth face the greatest challenges because of the lack of infrastructure for reaching medically underserved Latinos. In contrast, CCCs in areas with Types III and IV population growth may have significant infrastructure but must quickly develop interventions to reach and provide access to aging Latinos to reduce health disparities in cancer mortality and morbidity.

Measures of racial/ethnic health disparities in cancer mortality rates and the influence of socioeconomic status.

OBJECTIVES: In the 1990s, U.S. cancer mortality rates declined due to reductions in tobacco use among men and beneficial cancer interventions, such as mammography and Pap smears. We examined the cancer rates by racial/ethnic group, socioeconomic status and time period to identify disparities underlying the overall mortality trend. METHODS: We examined racial/ethnic disparities by measuring excess cancer burden [rate ratio (RR) and ratio differences (RD)] and trends in their cancer rates for nine cancer sites. The trend (T) is calculated as a ratio of the average annual cancer mortality rate for 1995-2000 relative to the rate for 1990-1994 for three levels of poverty (counties with <10% living below the poverty level, 10% - <20% and > or =20%) for the major racial/ethnic populations. We also compared the trend for each racial/ethnic SES group to the trend for lowest SES white group (TD). RESULTS: Blacks have RR disparities relative to whites for each cancer site examined, except for female lung cancer, while the other minorities had RR disparities for cervical cancer (RR>1). There are increases in RR disparities from 1990-1994 to 1995-2000 (RD>0) for colorectal cancer, prostate cancer and breast cancer for each racial/ethnic minority. Whites and blacks had declining trends for every SES group (T<1) and positive high SES gradients (the highest SES group had the best trend and the lowest SES group had the worst trend) at each cancer site, except female lung cancer (T>1). In contrast, American Indians/Alaska natives, Hispanics and Asians/ Pacific Islanders had increasing trends for some of their cancer sites, and their trends did not have the SES gradients. CONCLUSIONS: Increases in racial/ethnic disparities (RD>0) for colorectal, breast and prostate cancer were largest in the lowest SES groups. At some cancer sites, the highest SES group for minorities had worse trend results than the trends for the lowest SES white group (TD>0).

Changing area socioeconomic patterns in U.S. cancer mortality, 1950-1998: Part II--Lung and colorectal cancers.

BACKGROUND: Lung cancer and colorectal cancer are leading causes of U.S. cancer mortality. Because mortality rates for many cancers vary by socioeconomic characteristics, we used area socioeconomic indices to examine patterns in U.S. lung and colorectal cancer mortality between 1950 and 1998. METHODS: A factor-based area socioeconomic index was linked to 1950-1998 county mortality data to generate annual lung and colorectal cancer mortality rates for each area socioeconomic group. Joinpoint regression analysis was used to model and identify statistically significant changes in the mortality trends. RESULTS: Area socioeconomic patterns in U.S. lung cancer mortality changed dramatically between 1950 and 1998. Men aged 25-64 years and those aged 65 years or older in higher socioeconomic areas generally had higher lung cancer mortality than did those in lower socioeconomic areas during 1950-1964 and 1950-1980, respectively. Area socioeconomic differences in lung cancer mortality began to reverse and widen by the early 1970s for younger men and by the mid-1980s for older men. In 1998, lung cancer mortality was 56% (95% confidence interval [CI] = 49% to 64%) higher for younger men and 38% higher (95% CI = 34% to 43%) for older men in the lowest area socioeconomic group than for the same age groups in the highest area socioeconomic group. Lung cancer mortality among older women in all socioeconomic groups increased sevenfold to eightfold between 1950 and 1998, with higher mortality in higher area socioeconomic groups. The positive socioeconomic gradient in colorectal cancer mortality diminished substantially over time. Although colorectal cancer mortality among women in all area socioeconomic groups showed a consistent downward trend, colorectal cancer mortality among men in low area socioeconomic groups, but not in high area socioeconomic groups, showed an upward trend. CONCLUSIONS: Socioeconomic gradients in male lung cancer mortality reversed between 1950 and 1998, and those in colorectal cancer mortality narrowed over that time. Area measures may be useful for monitoring socioeconomic disparities in cancer mortality and for identifying areas for potential cancer control interventions.

Changing area socioeconomic patterns in U.S. cancer mortality, 1950-1998: Part I--All cancers among men.

BACKGROUND: Area socioeconomic deprivation indices are widely used to monitor health disparities in Europe. However, such indices have not been used in cancer surveillance in the United States. We developed an area socioeconomic index to examine area socioeconomic patterns in all-cancer mortality among U.S. men between 1950 and 1998. METHODS: Principal components analysis on 11 census variables was used to develop an area socioeconomic index that was then used to stratify all U.S. counties into one of five socioeconomic categories. The index was linked to 1950-1998 county mortality data to generate annual mortality rates for each area socioeconomic group. Joinpoint regression analysis was used to model mortality trends, and Poisson regression analysis was used to estimate socioeconomic gradients in mortality over time. RESULTS: Area socioeconomic patterns in U.S. male cancer mortality changed dramatically between 1950 and 1998. Throughout the 1950s and 1960s, there was a positive socioeconomic gradient, with higher cancer mortality rates in high area socioeconomic groups than in low area socioeconomic groups. For example, in 1950-1952, cancer mortality was 49% (95% confidence interval [CI] = 41% to 59%) greater in the highest area socioeconomic group than in the lowest. The positive gradient narrowed in the 1970s, and by the late 1980s, socioeconomic differences in cancer mortality began to reverse and widen. In 1997-1998, cancer mortality was 19% (95% CI = 11% to 28%) higher in the lowest area socioeconomic group than in the highest. Gradients were steeper for men aged 25-64 years than for men aged 65 years or older. CONCLUSIONS: Socioeconomic patterns in male cancer mortality have reversed over time in the United States. Area socioeconomic indices could serve as a powerful surveillance tool for monitoring health disparities in cancer outcomes.

Height and the survival of prostate cancer patients.

We investigated the associations between height and other anthropometric factors and the survival of 584 prostate cancer patients, initially recruited for a population-based, case-control study. During a median of 6.6 years of follow-up, 129 prostate cancer deaths and 153 deaths because of other causes were identified. After adjusting for age, cancer stage, and grade, the relative risk and 95% confident intervals for prostate cancer death were 1.0 (reference), 0.9 (0.6-1.4), 0.5 (0.3-0.9), and 0.6 (0.3-1.0) for patients whose heights were <1.75 m, 1.75-1.79 m, 1.80-1.84 m, and > or =1.85 m, respectively (P for trend = 0.01). Similar associations were found in subgroup analyses by cancer stage, cancer grade, age, race, and occupation-based socioeconomic status. However, height was not associated with death because of other causes. In addition, no significant associations were found between body mass index or weight and either prostate cancer death or death because of other causes. Our results suggest that greater height may be associated with better survival of prostate cancer patients.

Health, life expectancy, and mortality patterns among immigrant populations in the United States.

BACKGROUND: The US immigrant population has grown considerably in the last three decades, from 9.6 million in 1970 to 32.5 million in 2002. However, this unprecedented population rise has not been accompanied by increased immigrant health monitoring. In this study, we examined the extent to which US- and foreign-born blacks, whites, Asians, and Hispanics differ in their health, life expectancy, and mortality patterns across the life course. METHODS: We used National Vital Statistics System (1986-2000) and National Health Interview Survey (1992-1995) data to examine nativity differentials in health outcomes. Logistic regression and age-adjusted death rates were used to examine differentials. RESULTS: Male and female immigrants had, respectively, 3.4 and 2.5 years longer life expectancy than the US-born. Compared to their US-born counterparts, black immigrant men and women had, respectively, 9.4 and 7.8 years longer life expectancy, but Chinese, Japanese, and Filipino immigrants had lower life expectancy. Most immigrant groups had lower risks of infant mortality and low birthweight than the US-born. Consistent with the acculturation hypothesis, immigrants' risks of disability and chronic disease morbidity increased with increasing length of residence. Cancer and other chronic disease mortality patterns for immigrants and natives varied considerably, with Asian Immigrants experiencing substantially higher stomach, liver and cervical cancer mortality than the US-born. Immigrants, however, had significantly lower mortality from lung, colorectal, breast, prostate and esophageal cancer, cardiovascular disease, cirrhosis, diabetes, respiratory diseases, HIV/AIDS, and suicide. INTERPRETATION: Migration selectivity, social support, socio-economic, and behavioural characteristics may account for health differentials between immigrants and the US-born.

Cancer incidence trends among Asian American populations in the United States, 1990-2008.

BACKGROUND: National cancer incidence trends are presented for eight Asian American groups: Asian Indians/Pakistanis, Chinese, Filipinos, Japanese, Kampucheans, Koreans, Laotians, and Vietnamese. METHODS: Cancer incidence data from 1990 through 2008 were obtained from 13 Surveillance, Epidemiology, End Results (SEER) registries. Incidence rates from 1990 through 2008 and average percentage change were computed using SEER*Stat and Joinpoint software. The annual percentage change (APC) in incidence rates was estimated with 95% confidence intervals (95% CIs) calculated for both the rate and APC estimates. Rates for non-Hispanic whites are presented for comparison. RESULTS: Prostate cancer was the most common malignancy among most groups, followed by lung, colorectal, liver, and stomach cancers. Breast cancer was generally the most common cancer in women, followed by colorectal and lung cancers; liver, cervix, thyroid, and stomach cancers also ranked highly. Among men, increasing trends were observed for prostate (Asian Indians and Pakistanis: APC 1990-2003 = 2.2, 95% CI = 0.3 to 4.1; Filipinos: APC 1990-1994 = 19.0, 95% CI = 4.5 to 35.4; Koreans: APC 1990-2008 = 2.9, 95% CI = 1.8 to 4.0), colorectal (Koreans: APC 1990-2008 = 2.2, 95% CI = 0.9 to 3.5), and liver cancers (Filipinos: APC 1990-2008 = 1.6, 95% CI = 0.4 to 2.7; Koreans: APC 1990-2006 = 2.1, 95% CI = 0.4 to 3.7; Vietnamese: APC 1990-2008 = 1.6, 95% CI = 0.3 to 2.8), whereas lung and stomach cancers generally remained stable or decreased. Among women, increases were observed for uterine cancer (Asian Indians: APC 1990-2008 = 3.0, 95% CI = 0.3 to 5.8; Chinese: APC 2004-2008 = 7.0, 95% CI = 1.4 to 12.9; Filipina: APC 1990-2008 = 3.0, 95% CI = 2.4 to 3.7; Japanese: APC 1990-2008 = 1.1, 95% CI = 0.1 to 2.0), colorectal cancer (Koreans: APC 1990-2008 = 2.8, 95% CI = 1.7 to 3.9; Laotians: APC: 1990-2008 = 5.9, 95% CI = 4.0 to 7.7), lung cancer (Filipinas: APC 1990-2008 = 2.1, 95% CI = 1.4 to 2.8; Koreans: APC 1990-2008 = 2.1, 95% CI = 0.6 to 3.6), thyroid cancer (Filipinas: APC 1990-2008 = 2.5, 95% CI = 1.7 to 3.3), and breast cancer in most groups (APC 1990-2008 from 1.2 among Vietnamese and Chinese to 4.7 among Koreans). Decreases were observed for stomach (Chinese and Japanese), colorectal (Chinese), and cervical cancers (Laotians and Vietnamese). CONCLUSIONS: These data fill a critical knowledge gap concerning the cancer experience of Asian American groups and highlight where increased preventive, screening, and surveillance efforts are needed-in particular, lung cancer among Filipina and Korean women and Asian Indian/Pakistani men, breast cancer among all women, and liver cancer among Vietnamese, Laotian, and Kampuchean women and Filipino, Kampuchean, and Vietnamese men.

Cancer incidence trends among native Hawaiians and other Pacific Islanders in the United States, 1990-2008.

BACKGROUND: Lack of annual population estimates for disaggregated Native Hawaiian and Other Pacific Islander (NHOPI) populations limits the ability to examine cancer incidence rates and trends to understand the cancer burdens among NHOPIs. METHODS: Utilizing 1990 and 2000 population census data, we estimated the annual populations by age and sex for Native Hawaiians, Samoans, and Guamanians/Chamorros for 1990-2008 in regions covered by 13 of the National Cancer Institute's SEER registries. Cancer diagnoses during 1990-2008 from these registries were used to calculate the age-adjusted (2000 US Standard) incidence rates by sex, calendar year/period, and cancer type for each population. The annual percentage change (APC) in incidence rates was estimated with the 95% confidence intervals (95% CIs) calculated for both the rate and APC estimates. RESULTS: Statistically significant declining trends were found in Native Hawaiians, in men for lung and stomach cancers (APC = -2.3%; 95% CI = -3.3 to -1.3; and APC = -3.8%; 95% CI = -6.0 to -1.6, respectively), and in women for breast cancer (APC = -4.1%; 95% CI = -5.7 to -2.5) since 1998 and lung cancer (APC = -6.4%; 95% CI = -10.7 to -1.8) since 2001. Rising incidence trends were experienced by Samoans, especially by Samoan women for breast (APC = 2.7%; 95% CI = 0.9 to 4.5) and uterus (APC = 7.3%; 95% CI = 6.2 to 8.4) cancers. With limited data, Guamanians/Chamorros demonstrated lower, but increasing, incidence rates than other NHOPIs. CONCLUSIONS: Population-based cancer incidence rates for disaggregated NHOPI populations help identify disparities in cancer burden and provide valuable information to improve cancer control efforts among NHOPIs.

Methods for improving cancer surveillance data in American Indian and Alaska Native populations.

BACKGROUND: The misclassification of race decreases the accuracy of cancer incidence data for American Indians and Alaska Natives (AI/ANs) in some central cancer registries. This article describes the data sources and methods that were used to address this misclassification and to produce the cancer statistics used by most of the articles in this supplement. METHODS: Records from United States cancer registries were linked with Indian Health Service (IHS) records to identify AI/AN cases that were misclassified as non-AI/AN. Data were available from 47 registries that linked their data with IHS, met quality criteria, and agreed to participate. Analyses focused on cases among AI/AN residents in IHS Contract Health Service Delivery Area (CHSDA) counties in 33 states. Cancer incidence and stage data were compiled for non-Hispanic whites (NHWs) and AI/ANs across 6 IHS regions of the United States for 1999 through 2004. RESULTS: Misclassification of AI/AN race as nonnative in central cancer registries ranged from 85 individuals in Alaska (3.4%) to 5297 individuals in the Southern Plains (44.5%). Cancer incidence rates among AI/ANs for all cancers combined were lower than for NHWs, but incidence rates varied by geographic region for AI/ANs. Restricting the rate calculations to CHSDA counties generally resulted in higher rates than those obtained for all counties combined. CONCLUSIONS: The classification of race for AI/AN cases in cancer registries can be improved by linking records to the IHS and stratifying by CHSDA counties. Cancer in the AI/AN population is clarified further by describing incidence rates by geographic region. Improved cancer surveillance data for AI/AN communities should aid in the planning, implementation, and evaluation of more effective cancer control and should reduce health disparities in this population.

Cancer incidence and mortality patterns among specific Asian and Pacific Islander populations in the U.S.

OBJECTIVES: We report cancer incidence, mortality, and stage distributions among Asians and Pacific Islanders (API) residing in the U.S. and note health disparities, using the cancer experience of the non-Hispanic white population as the referent group. New databases added to publicly available SEER*Stat software will enable public health researchers to further investigate cancer patterns among API groups. METHODS: Cancer diagnoses among API groups occurring from 1 January 1998 to 31 December 2002 were included from 14 Surveillance, Epidemiology, and End Results (SEER) Program state and regional population-based cancer registries covering 54% of the U.S. API population. Cancer deaths were included from the seven states that report death information for detailed API groups and which cover over 68% of the total U.S. API population. Using detailed racial/ethnic population data from the 2000 decennial census, we produced incidence rates centered on the census year for Asian Indians/Pakistanis, Chinese, Filipinos, Guamanians, Native Hawaiians, Japanese, Kampucheans, Koreans, Laotians, Samoans, Tongans, and Vietnamese. State vital records offices do not report API deaths separately for Kampucheans, Laotians, Pakistanis, and Tongans, so mortality rates were analyzed only for the remaining API groups. RESULTS: Overall cancer incidence rates for the API groups tended be lower than overall rates for non-Hispanic whites, with the exception of Native Hawaiian women (All cancers rate = 488.5 per 100,000 vs. 448.5 for non-Hispanic white women). Among the API groups, overall cancer incidence and death rates were highest for Native Hawaiian and Samoan men and women due to high rates for cancers of the prostate, lung, and colorectum among Native Hawaiian men; cancers of the prostate, lung, liver, and stomach among Samoan men; and cancers of the breast and lung among Native Hawaiian and Samoan women. Incidence and death rates for cancers of the liver, stomach, and nasopharynx were notably high in several of the API groups and exceeded rates generally seen for non-Hispanic white men and women. Incidence rates were lowest among Asian Indian/Pakistani and Guamanian men and women and Kampuchean women. Asian Indian and Guamanian men and women also had the lowest cancer death rates. Selected API groups had less favorable distributions of stage at diagnosis for certain cancers than non-Hispanic whites. CONCLUSIONS: Possible disparities in cancer incidence or mortality between specific API groups in our study and non-Hispanic whites (referent group) were identified for several cancers. Unfavorable patterns of stage at diagnosis for cancers of the colon and rectum, breast, cervix uteri, and prostate suggest a need for cancer control interventions in selected groups. The observed variation in cancer patterns among API groups indicates the importance of monitoring these groups separately, as these patterns may provide etiologic clues that could be investigated by analytic epidemiological studies.

Cancer among American Indians and Alaska Natives in the United States, 1999-2004.

BACKGROUND: Cancer incidence rates vary among American Indian and Alaska Native (AI/AN) populations and often differ from rates among non-Hispanic whites (NHWs). However, the misclassification of race for AI/AN cancer cases in central cancer registries may have led to underestimates of the AI/AN cancer burden in previous reports. METHODS: Cases diagnosed during 1999 through 2004 were identified from population-based cancer registries in the United States. Age-adjusted rates were calculated for the 25 most common sites for AI/ANs and NHWs. To minimize the misclassification of race, cancer registry records were linked with patient registration files from the Indian Health Service (IHS). Analyses were restricted to Contract Health Service Delivery Area (CHSDA) counties and were stratified by IHS region. RESULTS: In CHSDA counties, cancer incidence rates among AI/ANs varied widely by region, whereas rates among NHWs did not. For all cancer sites combined, AI/AN rates were higher than NHW rates among both males and females in the Northern and Southern Plains, and among Alaska Native Females; AI/AN rates were lower than NHW rates in the Southwest, the Pacific Coast, and the East. Lung cancer and colorectal cancer rates for AI/ANs exceeded rates for NHWs in Alaska and the Northern Plains. Rates for stomach, gallbladder, kidney, and liver cancer were higher among AI/ANs than among NHWs overall, in Alaska, in the Plains regions, and in the Southwest. CONCLUSIONS: Regional differences in cancer incidence rates among AI/AN populations were not obvious from nationwide data and highlighted opportunities for cancer control and prevention. It is unlikely that such differences are explained by race misclassification.

Annual report to the nation on the status of cancer, 1975-2004, featuring cancer in American Indians and Alaska Natives.

BACKGROUND: The American Cancer Society, the Centers for Disease Control and Prevention, the National Cancer Institute, and the North American Association of Central Cancer Registries collaborate annually to provide updated information on cancer occurrence and trends in the U.S. The 2007 report features a comprehensive compilation of cancer information for American Indians and Alaska Natives (AI/AN). METHODS: Cancer incidence data were available for up to 82% of the U.S. population. Cancer deaths were available for the entire U.S. population. Long-term (1975 through 2004) and fixed-interval (1995 through 2004) incidence and mortality trends were evaluated by annual percent change using regression analyses (2-sided P < .05). Cancer screening, risk factors, socioeconomic characteristics, incidence data, and stage were compiled for non-Hispanic whites (NHW) and AI/AN across 6 regions of the U.S. RESULTS: Overall cancer death rates decreased by 2.1% per year from 2002 through 2004, nearly twice the annual decrease of 1.1% per year from 1993 through 2002. Among men and women, death rates declined for most cancers. Among women, lung cancer incidence rates no longer were increasing and death rates, although they still were increasing slightly, were increasing at a much slower rate than in the past. Breast cancer incidence rates in women decreased 3.5% per year from 2001 to 2004, the first decrease observed in 20 years. Colorectal cancer incidence and death rates and prostate cancer death rates declined, with colorectal cancer death rates dropping more sharply from 2002 through 2004. Overall, rates for AI/AN were lower than for NHW from 1999 through 2004 for most cancers, but they were higher for cancers of the stomach, liver, cervix, kidney, and gallbladder. Regional analyses, however, revealed high rates for AI/AN in the Northern and Southern Plains and Alaska. For cancers of the breast, colon and rectum, prostate, and cervix, AI/AN were less likely than NHW to be diagnosed at localized stages. CONCLUSIONS: For all races/ethnicities combined in the U.S., favorable trends in incidence and mortality were noted for lung and colorectal cancer in men and women and for breast cancer in women. For the AI/AN population, lower overall cancer incidence and death rates obscured important variations by geographic regions and less favorable healthcare access and socioeconomic status. Enhanced tobacco control and cancer screening, especially in the Northern and Southern Plains and Alaska, emerged as clear priorities.

Quality of race, Hispanic ethnicity, and immigrant status in population-based cancer registry data: implications for health disparity studies.

Population-based cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute are based on medical records and administrative information. Although SEER data have been used extensively in health disparities research, the quality of information concerning race, Hispanic ethnicity, and immigrant status has not been systematically evaluated. The quality of this information was determined by comparing SEER data with self-reported data among 13,538 cancer patients diagnosed between 1973-2001 in the SEER--National Longitudinal Mortality Study linked database. The overall agreement was excellent on race (kappa = 0.90, 95% CI = 0.88-0.91), moderate to substantial on Hispanic ethnicity (kappa = 0.61, 95% CI = 0.58-0.64), and low on immigrant status (kappa = 0.21. 95% CI = 0.10, 0.23). The effect of these disagreements was that SEER data tended to under-classify patient numbers when compared to self-identifications, except for the non-Hispanic group which was slightly over-classified. These disagreements translated into varying racial-, ethnic-, and immigrant status-specific cancer statistics, depending on whether self-reported or SEER data were used. In particular, the 5-year Kaplan-Meier survival and the median survival time from all causes for American Indians/Alaska Natives were substantially higher when based on self-classification (59% and 140 months, respectively) than when based on SEER classification (44% and 53 months, respectively), although the number of patients is small. These results can serve as a useful guide to researchers contemplating the use of population-based registry data to ascertain disparities in cancer burden. In particular, the study results caution against evaluating health disparities by using birthplace as a measure of immigrant status and race information for American Indians/Alaska Natives.

Racial/ethnic patterns in lifetime and age-conditional risk estimates for selected cancers.

BACKGROUND: Estimates of the probability of developing or dying from cancer, either over a lifetime or over a specified number of years, are useful summary measures of the burden of cancer in a population. METHODS: The authors used publicly available DevCan software and new, detailed, racial/ethnic data bases that were developed in the Surveillance Research Program of the National Cancer Institute to produce risk estimates for selected major cancers among American Indian/Aleut/Eskimo, black, Chinese, Filipino, native Hawaiian, Japanese, white (total, non-Hispanic), and Hispanic populations. RESULTS: Japanese and non-Hispanic white men had the highest lifetime risk for developing cancer (47.94% and 47.41%, respectively), and the American Indian/Eskimo/Aleut population (excluding Alaska) had the lowest lifetime risk among men (24.30%). Among women, white and American Indian/Eskimo/Aleut (in Alaska) populations had higher lifetime risks than Japanese women, whereas American Indian/Eskimo/Aleut (excluding Alaska) women had the lowest risk. The age-conditional probabilities of developing cancer within the next 10 years among men and women age 60 years and the lifetime probabilities of dying from cancer also were reported by racial/ethnic group. CONCLUSIONS: Racial/ethnic disparities in the lifetime risk of cancer may be because of differences in cancer incidence rates, but they also may reflect differential mortality rates from causes other than the cancer of interest. Furthermore, because cross-sectional incidence and mortality rates are used in calculating the DevCan lifetime risk estimates, results must be interpreted with caution when events, such as the widespread and rapid implementation of a new screening test, are known to have influenced disease rates.

Geographic patterns of advanced breast cancer in Los Angeles: associations with biological and sociodemographic factors (United States).

OBJECTIVE: Examination of patterns of advanced breast cancer may provide evidence needed to direct health care resources to those communities or population groups in greatest need. We assessed to what degree biologic, ethnic, and sociodemographic factors could explain such patterns within Los Angeles County. METHODS: The proportion of cases of advanced disease among all breast cancer cases identified during 1992-1996 were analyzed using generalized linear mixed models with random census tract effects. Models included characteristics of the individual and her tumor, census tract of residence, and aggregated health districts. RESULTS: Approximately 6% of cases, ranging from 4% for Asian to 10% for Black women, were diagnosed as advanced, exhibiting striking geographic patterns. Tumor histology and hormone receptor status were most predictive of advanced disease. Sociodemographic variables such as marital status, median income, and distance to nearest mammography unit showed additional association with risk. CONCLUSIONS: These models explain most of the geographical patterns and eliminate differences between White and Hispanic but not Asian or Black women, identify subpopulations at high risk of advanced disease, and suggest cancer control opportunities.

Rural/nonrural differences in colorectal cancer incidence in the United States, 1998-2001.

BACKGROUND: Few studies of colorectal cancer incidence by rural, suburban, and metropolitan residence have been published. METHODS: The authors examined colorectal cancer incidence among men and women in U.S. counties classified as rural, suburban, and metropolitan for the period 1998-2001. They examined rural/suburban/metropolitan differences in incidence by age, race, Hispanic ethnicity, stage at diagnosis, histology, and percentage of the total county population below the poverty level, using data from the CDC's National Program of Cancer Registries, the NCI's Surveillance, Epidemiology, and End Results Program, and the 2000 U.S. Census. RESULTS: A total of 495,770 newly diagnosed or incident cases of colorectal cancer were included in this analysis (249,919 among men and 245,851 among women). Over the period 1998-2001, the colorectal cancer incidence rates among men tended to be lower among those who resided in rural areas, for each of the subgroups examined, with the exception of Asians and Pacific Islanders and those living in more affluent counties. Among women aged 75 years and older, the colorectal cancer incidence rates tended to be lower among rural than metropolitan or suburban residents, though the differences were slight. In multivariate analysis, the incidence of colorectal cancer was higher in metropolitan, suburban, and rural areas for blacks than that for whites (incidence rate ratios [RR] = 1.12, 1.07, and 1.06, respectively, all P < 0.015). CONCLUSIONS: This study suggests that black men who reside in metropolitan areas have a higher risk of colorectal cancer than black men who reside in rural areas. This finding suggests the need for diverse approaches for reducing colorectal cancer when targeting rural compared with metropolitan areas.

Impact of sociodemographic factors, hormone receptor status, and tumor grade on ethnic differences in tumor stage and size for breast cancer in US women.

The importance of sociodemographic factors and tumor biomarkers in explaining ethnic differences in tumor stage and size at diagnosis was investigated in over 106,000 female breast cancer patients reported during 1992-1996 from 11 US population-based cancer registries. Japanese and non-Hispanic White women tended to be diagnosed at an earlier stage, with smaller diameter tumors and with a lower tumor grade than women from seven other ethnic groups. Statistical adjustment for individual- and group-level sociodemographic factors produced 50-80% reductions in the odds ratios for distant (vs. localized) stage and larger (vs. <1 cm) tumor size among Black women and Hispanic women. These factors also helped to account for tumor stage and size variation among most other ethnic groups. Consideration of hormone receptor status and tumor grade had little effect on the ethnic patterns. Although small, elevated odds ratios remained for some groups, our results suggest that sociodemographic factors accounted for many of the observed ethnic differences in breast cancer stage and tumor size at the time of diagnosis. Because most of the sociodemographic variables were aggregate measures, it is possible that residual confounding by socioeconomic position could explain the persistence of slightly elevated odds ratios in some ethnic groups.

Persistent area socioeconomic disparities in U.S. incidence of cervical cancer, mortality, stage, and survival, 1975-2000.

BACKGROUND: Temporal cervical cancer incidence and mortality patterns and ethnic disparities in patient survival and stage at diagnosis in relation to socioeconomic deprivation measures have not been well studied in the United States. The current article analyzed temporal area socioeconomic inequalities in U.S. cervical cancer incidence, mortality, stage, and survival. METHODS: County and census tract poverty and education variables from the 1990 census were linked to U.S. mortality and Surveillance, Epidemiology, and End Results cancer incidence data from 1975 to 2000. Age-adjusted incidence and mortality rates and 5-year cause-specific survival rates were calculated for each socioeconomic group and differences in rates were tested for statistical significance at the 0.05 level. RESULTS: Substantial area socioeconomic gradients in both incidence and mortality were observed, with inequalities in cervical cancer persisting against a backdrop of declining rates. Cervical cancer incidence and mortality rates increased with increasing poverty and decreasing education levels for the total population as well as for non-Hispanic white, black, American Indian, Asian/Pacific Islander, and Hispanic women. Patients in lower socioeconomic census tracts had significantly higher rates of late-stage cancer diagnosis and lower rates of cancer survival. Even after controlling for stage, significant differences in survival remained. The 5-year survival rate among women diagnosed with distant-stage cervical cancer was approximately 30% lower in low than in high socioeconomic census tracts. CONCLUSIONS: Census-based socioeconomic measures such as area poverty and education levels could serve as important surveillance tools for monitoring temporal trends in cancer-related health inequalities and targeting interventions.