title: Contribution of health behaviors to the association between area-level socioeconomic status and cancer mortality.
abstract: Cancer mortality is higher among residents of low-socioeconomic status (SES) areas than those of high-SES areas; however, the contribution of modifiable risk factors to this disparity is not known. We used data from 54,737 participants in the VITamins And Lifestyle (VITAL) Study, aged 50-76 with no history of cancer at baseline (2000-2002). Of these, 1488 died of cancer over an average of 7.7 years of follow-up. Data on modifiable risk factors including body mass index (BMI), physical activity, diet, alcohol, smoking and screening were taken from baseline questionnaires. We constructed a block group-level SES index using data from the 2000 United States Census and fit Cox proportional hazards models estimating the association between area-level SES and total cancer mortality with and without control for modifiable risk factors. All statistical tests are 2-sided. Cancer mortality was 77% (95% CI: 50%, 111%) higher in the lowest-SES areas compared with the highest. Modifiable risk factors accounted for 45% (95% CI: 34%, 62%) of this association. Smoking explained the greatest proportion (29%; 95% CI: 22%, 40%) of the observed association, followed by diet (11%; 95% CI: 7%, 17%), physical activity (10%; 95% CI: 7%, 16%), screening (9%; 6%, 13%), and BMI (5%; 95% CI: 1%, 10%). Results were similar in models controlling for individual education and income. The association between area-level SES and cancer mortality is partially explained by modifiable risk factors, which could suggest the appropriate targets to reduce socioeconomic disparities.
authors.affiliation: Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA; Population Studies and Disparities Research Program, Karmanos Cancer Institute, Detroit, MI, USA; Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA; Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA. Electronic address: hastertt@karmanos.org.
authors.forename: Theresa A
authors.initials: TA
authors.lastname: Hastert
authors.affiliation: Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA; Population Studies and Disparities Research Program, Karmanos Cancer Institute, Detroit, MI, USA.
authors.forename: Julie J
authors.initials: JJ
authors.lastname: Ruterbusch
authors.affiliation: Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA; Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
authors.forename: Shirley A A
authors.initials: SA
authors.lastname: Beresford
authors.affiliation: Department of Biostatistics, University of Washington School of Public Health, Seattle, WA, USA; Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, WA, USA.
authors.forename: Lianne
authors.initials: L
authors.lastname: Sheppard
authors.affiliation: Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA; Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
authors.forename: Emily
authors.initials: E
authors.lastname: White
mesh_terms: D000368:Aged; D000428:Alcohol Drinking; D015992:Body Mass Index; D004032:Diet; D055088:Early Detection of Cancer; D005260:Female; D015438:Health Behavior; D054624:Health Status Disparities; D006801:Humans; D008297:Male; D008875:Middle Aged; D009043:Motor Activity; D009369:Neoplasms / Q000401:mortality*; D011446:Prospective Studies; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D012307:Risk Factors; D012907:Smoking; D012923:Social Class; D014481:United States / Q000453:epidemiology
keywords: Behavior; Cancer mortality; Diet; Neighborhood; Physical activity; Screening; Smoking; Socioeconomic status