title: Cancer mortality rates in Appalachia: descriptive epidemiology and an approach to explaining differences in outcomes.
abstract: Cancer is a leading cause of death in the Appalachian region of the United States. Existing studies compare regional mortality rates to those of the entire nation. We compare cancer mortality rates in Appalachia to those of the nation, with additional comparisons of Appalachian and non-Appalachian counties within the 13 states that contain the Appalachian region. Lung/bronchus, colorectal, female breast and cervical cancers, as well as all cancers combined, are included in analysis. Linear regression is used to identify independent associations between ecological socioeconomic and demographic variables and county-level cancer mortality outcomes. There is a pattern of high cancer mortality rates in the 13 states containing Appalachia compared to the rest of the United States. Mortality rate differences exist between Appalachian and non-Appalachian counties within the 13 states, but these are not consistent. Lung cancer is a major problem in Appalachia; most Appalachian counties within the 13 states have significantly higher mortality rates than in-state, non-Appalachian counterparts. Mortality rates from all cancers combined also appear to be worse overall within Appalachia, but part of this disparity is likely driven by lung cancer. Education and income are generally associated with cancer mortality, but differences in the strength and direction of these associations exist depending on location and cancer type. Improving high school graduation rates in Appalachia could result in a meaningful long term reduction in lung cancer mortality. The relative importance of household income level to cancer outcomes may be greater outside the Appalachian regions within these states.
authors.affiliation: Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, TN 37614, USA. blackley@goldmail.etsu.edu
authors.forename: David
authors.initials: D
authors.lastname: Blackley
authors.forename: Bruce
authors.initials: B
authors.lastname: Behringer
authors.forename: Shimin
authors.initials: S
authors.lastname: Zheng
mesh_terms: D000328:Adult; D001061:Appalachian Region / Q000453:epidemiology; D001943:Breast Neoplasms / Q000401:mortality; D015179:Colorectal Neoplasms / Q000401:mortality; D004522:Educational Status; D005260:Female; D006801:Humans; D007182:Income / Q000706:statistics & numerical data; D016014:Linear Models; D008175:Lung Neoplasms / Q000401:mortality; D008297:Male; D008913:Minority Groups / Q000706:statistics & numerical data; D009369:Neoplasms / Q000401:mortality*; D012423:Rural Health; D014481:United States / Q000453:epidemiology; D002583:Uterine Cervical Neoplasms / Q000401:mortality
references.citation: Cancer. 2003 Mar 1;97(5):1303-11
references.pmid: 12599239
references.citation: Cancer. 2008 Jan 1;112(1):181-92
references.pmid: 18000806
references.citation: J Rural Health. 2005 Spring;21(2):149-57
references.pmid: 15859052
references.citation: South Med J. 2000 Apr;93(4):386-91
references.pmid: 10798507
references.citation: J Natl Cancer Inst. 2007 Sep 19;99(18):1384-94
references.pmid: 17848670
references.citation: CA Cancer J Clin. 2004 Mar-Apr;54(2):72-7
references.pmid: 15061597
references.citation: CA Cancer J Clin. 2004 Mar-Apr;54(2):78-93
references.pmid: 15061598
references.citation: Health Aff (Millwood). 2008 Mar-Apr;27(2):350-60
references.pmid: 18332489
references.citation: PLoS Med. 2006 Sep;3(9):e260
references.pmid: 16968116
references.citation: J Epidemiol Community Health. 2001 Dec;55(12):913-20
references.pmid: 11707486
references.citation: J Rural Health. 2008 Winter;24(1):67-74
references.pmid: 18257873
references.citation: Appl Nurs Res. 2003 May;16(2):93-102
references.pmid: 12764720
references.citation: Health Serv Res. 2011 Aug;46(4):1082-103
references.pmid: 21413980
references.citation: Oncol Nurs Forum. 2007 Nov;34(6):1133-9
references.pmid: 18024340
references.citation: MMWR Morb Mortal Wkly Rep. 2002 Jun 21;51(24):527-9
references.pmid: 12088143
references.citation: Int J Epidemiol. 2003 Oct;32(5):830-7
references.pmid: 14559760
references.citation: J Rural Health. 2008 Fall;24(4):390-9
references.pmid: 19007394
references.citation: Am J Public Health. 2007 Dec;97(12):2148-50
references.pmid: 17538052
references.citation: PLoS Med. 2008 Apr 22;5(4):e66
references.pmid: 18433290
references.citation: Lung Cancer. 2008 Oct;62(1):1-7
references.pmid: 18353487
references.citation: Int J Epidemiol. 2001 Aug;30(4):809-17
references.pmid: 11511609
references.citation: Am J Public Health. 2010 Jul;100(7):1313-8
references.pmid: 20466957
references.citation: Prev Chronic Dis. 2006 Oct;3(4):A113
references.pmid: 16978488
references.citation: J Rural Health. 2004 Spring;20(2):181-7
references.pmid: 15085633
references.citation: J Thorac Imaging. 1999 Oct;14(4):228-34
references.pmid: 10524803
references.citation: Cancer. 2001 Jan 1;91(1):178-88
references.pmid: 11148575
references.citation: Bull World Health Organ. 2002;80(1):9-15
references.pmid: 11884968
references.citation: Am J Public Health. 2004 Oct;94(10):1682-6
references.pmid: 15451731
references.citation: Cancer Causes Control. 2001 Oct;12(8):703-11
references.pmid: 11562110