title: Disparities in cancer incidence and mortality by area-level socioeconomic status: a multilevel analysis.
abstract: 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.
authors.affiliation: Fred Hutchinson Cancer Research Center, Seattle, Washington, USA Department of Epidemiology, University of Washington, Seattle, Washington, USA University of Michigan Center for Social Epidemiology and Population Health, Ann Arbor, Michigan, USA.
authors.forename: Theresa A
authors.initials: TA
authors.lastname: Hastert
authors.affiliation: Fred Hutchinson Cancer Research Center, Seattle, Washington, USA Department of Epidemiology, University of Washington, Seattle, Washington, USA.
authors.forename: Shirley A A
authors.initials: SA
authors.lastname: Beresford
authors.affiliation: Department of Biostatistics, University of Washington, Seattle, Washington, USA Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA.
authors.forename: Lianne
authors.initials: L
authors.lastname: Sheppard
authors.affiliation: Fred Hutchinson Cancer Research Center, Seattle, Washington, USA Department of Epidemiology, University of Washington, Seattle, Washington, USA.
authors.forename: Emily
authors.initials: E
authors.lastname: White
mesh_terms: D000368:Aged; D005260:Female; D062305:Geographic Mapping; D054624:Health Status Disparities; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D055361:Multilevel Analysis; D009369:Neoplasms / Q000145:classification / Q000453:epidemiology* / Q000401:mortality; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D018426:SEER Program / Q000706:statistics & numerical data; D012923:Social Class; D014861:Washington / Q000453:epidemiology
keywords: CANCER; Cohort studies; Health inequalities; Neighborhood/place; SOCIO-ECONOMIC