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Disparities in cancer incidence and mortality by area-level socioeconomic status: a multilevel analysis
  1. Theresa A Hastert1,2,3,
  2. Shirley A A Beresford1,2,
  3. Lianne Sheppard4,5,
  4. Emily White1,2
  1. 1Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
  2. 2Department of Epidemiology, University of Washington, Seattle, Washington, USA
  3. 3University of Michigan Center for Social Epidemiology and Population Health, Ann Arbor, Michigan, USA
  4. 4Department of Biostatistics, University of Washington, Seattle, Washington, USA
  5. 5Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
  1. Correspondence to Dr Theresa Hastert, Wayne State University Department of Oncology, Karmanos Cancer Institute, 4100 John R Street, MM04EP, Detroit, MI 48201, USA; hastertt{at}


Background Disparities in cancer incidence and mortality have been observed by measures of area-level socioeconomic status (SES); however, the extent to which these disparities are explained by individual SES is unclear.

Methods Participants included 60 756 men and women in the VITamins And Lifestyle (VITAL) study cohort, aged 50–76 years at baseline (2000–2002) and followed through 2010. We constructed a block group SES index using the 2000 US Census and fit Cox proportional hazards models to estimate the association between area-level SES (by quintile) and total and site-specific cancer incidence and total cancer mortality, with and without household income and individual education in the models.

Results Lower area-level SES was weakly associated with higher total cancer incidence and lower prostate cancer risk, but was not associated with risk of breast cancer. Compared with the highest-SES areas, living in the lowest-SES areas was associated with higher lung (HR: 2.21, 95% CI 1.69 to 2.90) and colorectal cancer incidence (HR: 1.52, 95% CI 1.11 to 2.09) and total cancer mortality (HR: 1.68, 95% CI 1.47 to 1.93). Controlling for individual education and household income weakened the observed associations, but did not eliminate them (lung cancer HR: 1.43, 95% CI 1.07 to 1.91; colorectal cancer HR: 1.35, 95% CI 0.97 to 1.88; cancer mortality HR: 1.28, 95% CI 1.11 to 1.48).

Conclusions Area-level socioeconomic disparities exist for several cancer outcomes. These differences are not fully explained by individual SES, suggesting area-level factors may play a role.

  • Neighborhood/place
  • Cohort studies
  • Health inequalities

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