Cancer Causes & Control

, Volume 20, Issue 6, pp 989–1000 | Cite as

County-level poverty and distant stage cancer in the United States

  • Robert T. GreenleeEmail author
  • Holly L. Howe
Original Paper



Late stage cancer at diagnosis increases the likelihood of cancer death. We evaluated the relation of county-level poverty with late stage cancer for 18 anatomic sites using data from the North American Association of Central Cancer Registries.


Stratified analysis and logistic regression were applied to 2 million incident cancers (1997–2000) from 32 states representing 57% of the United States.


For 12 sites, higher county poverty significantly increased the odds of late stage, [adjusted odds ratio (95% confidence interval) comparing highest to lowest county poverty: larynx 2.4 (1.8–3.2), oral cavity 2.2 (1.8–2.7), melanoma 2.0 (1.5–2.8), female breast 1.9 (1.7–2.2), prostate 1.7 (1.5–1.9), corpus uteri 1.6 (1.3–1.9), cervix 1.6 (1.3–2.1), bladder 1.6 (1.2–2.1), colorectum 1.4 (1.3–1.5), esophagus 1.3 (1.1–1.7), stomach 1.3 (1.1–1.5), and kidney 1.3 (1.1–1.5)]. With some exceptions, county poverty associations with stage were comparable across gender and race, but stronger among metropolitan cases. A few differences by age may reflect screening patterns.


In this large population-based study, higher county poverty independently predicted distant stage cancer. This held for several non-screenable cancers, suggesting improved area economic deprivation, including access to and utilization of good medical care might facilitate earlier diagnosis and longer survival even for cancers without practical screening approaches.


Neoplasms Poverty Social class Early diagnosis 



Confidence interval


Cancer in North America


North American Association of Central Cancer Registries, Inc


National Cancer Institute


Not otherwise specified


Odds ratio


Surveillance, Epidemiology, and End Results



The authors would like to thank the staff of NAACCR, Inc. and IMS, Inc. for their work in generating CINA analytic files and the NAACCR scientific editorial board for their helpful suggestions.


  1. 1.
    Ries LAG, Eisner MP, Kosary CL et al (eds) (2004) SEER cancer statistics review, 1975–2001, National Cancer Institute. Bethesda, MD.
  2. 2.
    Oluwole SF, Ali AO, Adu A et al (2003) Impact of a cancer screening program on breast cancer stage at diagnosis in a medically underserved urban community. J Am Coll Surg 196(2):180–188. doi: 10.1016/S1072-7515(02)01765-9 PubMedCrossRefGoogle Scholar
  3. 3.
    National Program of Cancer Registries (2003) Cancer Registries: The Foundation for Cancer Prevention and Control. Cancer Registries Fact Sheet (2003) Centers for Disease Control and PreventionGoogle Scholar
  4. 4.
    Glaser SL, Clarke CA, Gomez SL, O’Malley CD, Purdie DM, West DW (2005) Cancer surveillance research: a vital subdiscipline of cancer epidemiology. Cancer Causes Control 16(9):1009–1019. doi: 10.1007/s10552-005-4501-2 PubMedCrossRefGoogle Scholar
  5. 5.
    Krieger N, Chen JT, Waterman PD, Soobader M, Subramanian SV, Carson R (2002) Geocoding and monitoring of US socioeconomic inequalities in mortality and cancer incidence: does the choice of area-based measures and geographic level matter? Am J Epidemiol 156:471–482. doi: 10.1093/aje/kwf068 PubMedCrossRefGoogle Scholar
  6. 6.
    Krieger N (1992) Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology. Am J Public Health 92:703–710. doi: 10.2105/AJPH.82.5.703 CrossRefGoogle Scholar
  7. 7.
    Singh GK, Miller BA, Hankey BF, Edwards BK (2003) Area socioeconomic variations in U.S. cancer incidence, mortality, stage, treatment, and survival, 1975–1999. NCI Cancer Surveillance Monograph Series, Number 4. National Cancer Institute, Bethesda, MD. NIH Publication No. 03–5417Google Scholar
  8. 8.
    Schwartz KL, Crossley-May H, Vigneau FD, Brown K, Banerjee M (2003) Race, socioeconomic status and stage at diagnosis for five common malignancies. Cancer Causes Control 14(8):761–766. doi: 10.1023/A:1026321923883 PubMedCrossRefGoogle Scholar
  9. 9.
    Howe HL, Wu X, Ries LAG et al (2006) Annual report to the nation on the status of cancer, 1975–2003, featuring cancer among U.S. Hispanic/Latino populations. Cancer 107(8):1711–1742. doi: 10.1002/cncr.22193 PubMedCrossRefGoogle Scholar
  10. 10.
    Yabroff KR, Gordis L (2003) Does stage at diagnosis influence the observed relationship between socioeconomic status and breast cancer incidence, case-fatality, and mortality? Soc Sci Med 57(12):2265–2279. doi: 10.1016/S0277-9536(03)00100-X PubMedCrossRefGoogle Scholar
  11. 11.
    Ward E, Jemal A, Cokkinides V et al (2004) Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin 54(2):78–93PubMedCrossRefGoogle Scholar
  12. 12.
    Ellison JH, Wu XC, McLaughlin CC et al (eds) (2006) Cancer in North America, 1999–2003. Volume one: incidence. North American Association of Central Cancer Registries Inc., Springfield, ILGoogle Scholar
  13. 13.
    Surveillance Research Program, National Cancer Institute SEER*Stat software version 6.2.4.
  14. 14.
    Havener L, Hulstrom D (eds) (2004) Standards for Cancer Registries Volume II: data standards and data dictionary, Version 1.1, 10th edn. North American Association of Central Cancer Registries, Springfield, IL, November 2004.
  15. 15.
    Phillips JL (ed) (2003) Summary stage: data effects of the changes in 2000. North American Association of Central Cancer Registries, Springfield, IL, December 2003.
  16. 16.
    U.S. Census Bureau (2007) Poverty Definitions. Accessed Dec 2007
  17. 17.
    Economic Research Service (2007) USDA. Rural-Urban Continuum Codes. Accessed Dec 2007
  18. 18.
    SPSS for Windows, Rel. 10.0.5 (1999). SPSS Inc, ChicagoGoogle Scholar
  19. 19.
    Rebbek TR (2006) Conquering cancer disparities: new opportunities for cancer epidemiology, biomarker, and prevention research. Cancer Epidemiol Biomark Prev 15(9):1569–1571. doi: 10.1158/1055-9965.EPI-06-0613 CrossRefGoogle Scholar
  20. 20.
    Woolf SH, Johnson RE, Fryer GE Jr, Rust G, Satcher D (2004) The health impact of resolving racial disparities: an analysis of US mortality data. Am J Public Health 94:2078–2081. doi: 10.2105/AJPH.94.12.2078 PubMedCrossRefGoogle Scholar
  21. 21.
    Singh GK, Miller BA, Hankey BF, Edwards BK (2004) Persistent area socioeconomic disparities in U.S. incidence of cervical cancer, mortality, stage, and survival, 1975–2000. Cancer 101(5):1051–1057. doi: 10.1002/cncr.20467 PubMedCrossRefGoogle Scholar
  22. 22.
    Mandelblatt J, Andrews H, Kao R, Wallace R, Kerner J (1996) The late-stage diagnosis of colorectal cancer: demographic and socioeconomic factors. Am J Public Health 86(12):1794–1797. doi: 10.2105/AJPH.86.12.1794 PubMedCrossRefGoogle Scholar
  23. 23.
    Mandelblatt J, Andrews H, Kao R, Wallace R, Kerner J (1995) Impact of access and social context on breast cancer stage at diagnosis. J Health Care Poor Underserved 6(3):342–351PubMedGoogle Scholar
  24. 24.
    Stitzenberg KB, Thomas NE, Dalton K et al (2007) Distance to diagnosing provider as a measure of access for patients with melanoma. Arch Dermatol 143(8):991–998. doi: 10.1001/archderm.143.8.991 PubMedCrossRefGoogle Scholar
  25. 25.
    MacKinnon JA, Duncan RC, Huang Y et al (2007) Detecting an association between socioeconomic status and late stage breast cancer using spatial analysis and area-based measures. Cancer Epidemiol Biomarkers Prev 16(4):756–762. doi: 10.1158/1055-9965.EPI-06-0392 PubMedCrossRefGoogle Scholar
  26. 26.
    Parikh-Patel A, Bates JH, Campleman S (2006) Colorectal cancer stage at diagnosis by socioeconomic and urban/rural status in California, 1988–2000. Cancer 107(Suppl 5):1189–1195. doi: 10.1002/cncr.22016 PubMedCrossRefGoogle Scholar
  27. 27.
    Shipp MP, Desmond R, Accortt N, Wilson RJ, Fouad M, Eloubeidi MA (2005) Population-based study of the geographic variation in colorectal cancer incidence in Alabama: relationship to socioeconomic status indicators and physician density. South Med J 98(11):1076–1082. doi: 10.1097/01.smj.0000184844.01148.10 PubMedCrossRefGoogle Scholar
  28. 28.
    Wu X, Cokkinides V, Chen VW et al (2006) Associations of subsite-specific colorectal cancer incidence rates and stage of disease at diagnosis with county-level poverty by race and sex. Cancer 107(Suppl 5):1121–1127. doi: 10.1002/cncr.22009 PubMedCrossRefGoogle Scholar
  29. 29.
    Miller AB (1996) Fundamental issues in screening for cancer. In: Schottenfeld D, Fraumeni JF Jr (eds) Cancer epidemiology and prevention, 2nd edn. Oxford University Press, New York, pp 1434–1435Google Scholar
  30. 30.
    Groome PA, Schulze KM, Keller S et al (2006) Explaining socioeconomic status effects in laryngeal cancer. Clin Oncol (R Coll Radiol) 18(4):283–292. doi: 10.1016/j.clon.2005.12.010 Google Scholar
  31. 31.
    Gornick ME, Eggers PW, Riley GF (2004) Associations of race, education, and patterns of preventive service use with stage of cancer at time of diagnosis. Health Serv Res 39(5):1403–1427. doi: 10.1111/j.1475-6773.2004.00296.x PubMedCrossRefGoogle Scholar
  32. 32.
    Woolf SH, Johnson RE, Geiger HJ (2006) The rising prevalence of severe poverty in America: a growing threat to public health. Am J Prev Med 31(4):332–341. doi: 10.1016/j.amepre.2006.06.022 PubMedCrossRefGoogle Scholar
  33. 33.
    McCracken M, Olsen M, Chen MS Jr et al (2007) Cancer incidence, mortality, and associated risk factors among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese ethnicities. CA Cancer J Clin 57(4):190–195PubMedCrossRefGoogle Scholar
  34. 34.
    Lengerich EJ, Tucker TC, Powell RK et al (2005) Cancer incidence in Kentucky, Pennsylvania, and West Virginia: disparities in Appalachia. J Rural Health 21(1):39–47. doi: 10.1111/j.1748-0361.2005.tb00060.x PubMedCrossRefGoogle Scholar
  35. 35.
    Smith RA, Cokkinides V, Eyre HJ (2006) American Cancer Society guidelines for the early detection of cancer, 2006. CA Cancer J Clin 56:11–25PubMedCrossRefGoogle Scholar
  36. 36.
    Walter LC, Bertenthal D, Lindquist K, Konety BR (2006) PSA screening among elderly men with limited life expectancies. JAMA 296(19):2336–2342. doi: 10.1001/jama.296.19.2336 PubMedCrossRefGoogle Scholar
  37. 37.
    Barnett S, Roderick P, Martin D, Diamond I, Wrigley H (2002) Interrelations between three proxies of health care need at the small area level: an urban/rural comparison. J Epidemiol Community Health 56(10):754–761. doi: 10.1136/jech.56.10.754 PubMedCrossRefGoogle Scholar
  38. 38.
    Swerlick RA, Chen S (1996) The melanoma epidemic. Is increased surveillance the solution or the problem? Arch Dermatol 132(8):881–884. doi: 10.1001/archderm.132.8.881 PubMedCrossRefGoogle Scholar
  39. 39.
    Pan SY, Desmeules M (2009) Energy intake, physical activity, energy balance, and cancer: epidemiologic evidence. Methods Mol Biol 472:191–215. doi: 10.1007/978-1-60327-492-0_8 PubMedCrossRefGoogle Scholar
  40. 40.
    Parker A, Lohse C, Cheville J, Leibovich B, Igel T, Blute M (2008) Evaluation of the association of current cigarette smoking and outcome for patients with clear cell renal cell carcinoma. Int J Urol 15(4):304–308. doi: 10.1111/j.1442-2042.2008.01994.x PubMedCrossRefGoogle Scholar
  41. 41.
    Morris CR, Snipes KP, Schlag R, Wright WE (1999) Sociodemographic factors associated with prostatectomy utilization and concordance with the physician data query for prostate cancer. Cancer Causes Control 10(6):503–511. doi: 10.1023/A:1008951009959 PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2009

Authors and Affiliations

  1. 1.Marshfield Clinic Research FoundationMarshfieldUSA
  2. 2.North American Association of Central Cancer Registries, IncSpringfieldUSA

Personalised recommendations