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Association of Community Economic Distress and Breast and Colorectal Cancer Screening, Incidence, and Mortality Rates Among US Counties

  • Global Health Services Research
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Abstract

Introduction

Not all Americans may benefit equally from current improvements in breast and colorectal cancer screening and mortality rates.

Methods

We performed a cross-sectional retrospective review of county-level screening, incidence, and mortality rates for breast and colon cancer utilizing three publicly available data sources from the Centers for Disease Control and Prevention (CDC), and their association with the Distressed Communities Index (DCI), a measure of local economic prosperity across communities.

Results

After controlling for other factors, DCI was associated with county-level screening, incidence, and death rates per 100,000 for breast and colorectal cancer. There was an absolute increase of 0.77 (95% confidence interval [CI] 0.67–0.85, p < 0.001) in the proportion of women aged 40 years or older who had a screening mammogram for every 10-point decrease in DCI, which in turn correlated with an increase in the age-adjusted incidence by 1.68 per 100,000 (95% CI 1.37–2.00, p < 0.001). While the age-adjusted death rate for breast cancer was highest in the most distressed communities, the overall incidence of age-adjusted death decreased by 0.28 per 100,000 (95% CI −0.37 to −0.19, p < 0.001) with every 10-point decrease in DCI. For colorectal cancer, every 10-point decrease in DCI was similarly associated with an absolute 0.60 (95% CI 0.52–0.69, p < 0.001) increase in the proportion of individuals who had screening endoscopy. Increased colorectal screening in low-DCI counties was associated with a lower age-adjusted incidence rate (−0.80 per 100,000; 95% CI −0.94 to −0.65) and age-adjusted death rate (−0.55 per 100,000; 95% CI −0.62 to −0.49) of colorectal cancer per every 10-point decrease in DCI (p < 0.001).

Conclusion

The association of county-level socioeconomic and healthcare factors with breast and colorectal cancer outcomes was notable, with level of community distress impacting cancer screening, incidence, and mortality rates.

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Fig. 1

Source: Maps are based on the authors’ analysis of DCI and CDC cancer statistics data for breast and colorectal cancer. a US county DCI by tertiles. b US county breast cancer screening estimates by tertiles. c US county colorectal cancer screening estimates by tertiles. DCI Distressed Communities Index, CDC Centers for Disease Control and Prevention

Fig. 2

Source: Figures are based on the authors’ analysis of DCI and CDC cancer statistics data for breast and colorectal cancer. a County-level estimates of the percentage of individuals who had breast and colorectal screening across the DCI. b County-level estimates of the breast and colorectal incidence rate across the DCI. c County-level estimates of breast and colorectal death rates across the DCI. Models are adjusted for percentage of females, percentage of Black subjects, percentage of Hispanic subjects, percentage of individuals without health insurance, primary care provider per 100K, and hospital beds per 100K. Random effects for states were included to account for clustering of counties within states. DCI Distressed Communities Index, CDC Centers for Disease Control and Prevention

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References

  1. Kochanek KD, Xu J, Arias E. Mortality in the United States, 2019. NCHS Data Brief. 2020;395:1–8.

    Google Scholar 

  2. US Cancer Statistics Working Group. US Cancer Statistics Data Visualizations Tool, based on 2019 submission data (1999–2017). US Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2020.

  3. Cancer Facts and Figures 2021. American Cancer Society, NY, 2021.

  4. Centers for Disease Control and Prevention. Health, United States, 2019 – Data Finder. Available at: https://www.cdc.gov/nchs/hus/contents2019.htm. Accessed 26 Apr 2021.

  5. Centers for Disease Control and Prevention. Colorectal Cancer Screening Rates. 26 June 2020. Available at: https://www.cdc.gov/cancer/ncccp/screening-rates/. Accessed 26 Apr 2021.

  6. Goel MS, Wee CC, McCarthy EP, et al. Racial and ethnic disparities in cancer screening: the importance of foreign birth as a barrier to care. J Gen Intern Med. 2003;18(12):1028–35.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Goding Sauer A, Siegel RL, Jemal A, et al. Current Prevalence of Major Cancer Risk Factors and Screening Test Use in the United States: Disparities by Education and Race/Ethnicity. Cancer Epidemiol Biomarkers Prev. 2019;28(4):629–42.

    Article  PubMed  Google Scholar 

  8. National Cancer Institute. Cancer Disparities. 17 November 2020. Available at: https://www.cancer.gov/about-cancer/understanding/disparities. Accessed 3 May 2021.

  9. Zeng C, Wen W, Morgans AK, et al. Disparities by Race, Age, and Sex in the Improvement of Survival for Major Cancers: Results From the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program in the United States, 1990 to 2010. JAMA Oncol. 2015;1(1):88–96.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Warren Andersen S, Blot WJ, Lipworth L, et al. Association of Race and Socioeconomic Status With Colorectal Cancer Screening, Colorectal Cancer Risk, and Mortality in Southern US Adults. JAMA Netw Open. 2019;2(12):e1917995.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Freeman HP, Alshafie TA. Colorectal carcinoma in poor blacks. Cancer. 2002;94(9):2327–32.

    Article  PubMed  Google Scholar 

  12. Clegg LX, Reichman ME, Miller BA, et al. Impact of socioeconomic status on cancer incidence and stage at diagnosis: selected findings from the surveillance, epidemiology, and end results: National Longitudinal Mortality Study. Cancer Causes Control. 2009;20(4):417–35.

    Article  PubMed  Google Scholar 

  13. O’Connor JM, Sedghi T, Dhodapkar M, et al. Factors associated with cancer disparities among low-, medium-, and high-income US counties. JAMA Netw Open. 2018;1(6):e183146.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Reames BN, Birkmeyer NJ, Dimick JB, et al. Socioeconomic disparities in mortality after cancer surgery: failure to rescue. JAMA Surg. 2014;149(5):475–81.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Singh GK, Jemal A. Socioeconomic and Racial/Ethnic Disparities in Cancer Mortality, Incidence, and Survival in the United States, 1950–2014: Over Six Decades of Changing Patterns and Widening Inequalities. J Environ Public Health. 2017;2017:2819372.

    Article  PubMed  PubMed Central  Google Scholar 

  16. State Cancer Profiles. Available at: https://www.statecancerprofiles.cancer.gov/index.html. Accessed April 20, 2021.

  17. State Cancer Profiles. Data Types—Screening and Risk Factors Data Types. 16 May 2017. Available at: https://statecancerprofiles.cancer.gov/screening_risk_datatypes.html. Accessed 11 May 2021.

  18. Liu B, Parsons V, Feuer EJ, et al. Small Area Estimation of Cancer Risk Factors and Screening Behaviors in US Counties by Combining Two Large National Health Surveys. Prev Chronic Dis. 2019;16:E119.

    Article  PubMed  PubMed Central  Google Scholar 

  19. National Institutes of Health, National Cancer Institute. Methodology for the Model-based Small Area Estimates of Cancer Risk Factors and Screening Behaviors. Small Area Estimates for Cancer-Related Measures. 19 August 2019. Available at: https://sae.cancer.gov/nhis-brfss/methodology.html. Accessed 20 Apr 2021.

  20. National Institutes of Health, National Cancer Institute. State Cancer Profiles. Breast cancer incidence rates table. Available at: https://www.statecancerprofiles.cancer.gov/incidencerates/index.php?stateFIPS=00&areatype=county&cancer=055&race=00&sex=2&age=001&stage=999&year=0&type=incd&sortVariableName=rate&sortOrder=default&output=0#results. Accessed 20 Apr 2021.

  21. National Institutes of Health, National Cancer Institute. State Cancer Profiles. Colon and rectal cancer incidence rates table. Available at: https://www.statecancerprofiles.cancer.gov/incidencerates/index.php?stateFIPS=00&areatype=county&cancer=020&race=00&sex=0&age=001&stage=999&year=0&type=incd&sortVariableName=rate&sortOrder=default&output=0#results. Accessed 20 April 2021.

  22. National Institutes of Health, National Cancer Institute. State Cancer Profiles. Breast cancer death rates table. Available at: https://www.statecancerprofiles.cancer.gov/deathrates/index.php?stateFIPS=00&areatype=county&cancer=055&race=00&sex=2&age=001&year=0&type=death&sortVariableName=rate&sortOrder=default#results. Accessed 20 Apr 2021.

  23. National Institutes of Health, National Cancer Institute. State Cancer Profiles. Colon and rectal cancer death rates table. Available at: https://www.statecancerprofiles.cancer.gov/deathrates/index.php?stateFIPS=00&areatype=county&cancer=020&race=00&sex=0&age=001&year=0&type=death&sortVariableName=rate&sortOrder=default#results. Accessed 20 Apr 2021.

  24. Economic Innovation Group. Distressed Communities Index: methodology. Available at: https://eig.org/dci/methodology. Accessed 20 Apr 2021.

  25. US Census Bureau. Explore Census data. Available at: https://data.census.gov/cedsci/. Accessed 20 Apr 2021.

  26. Health Resources and Services Information. Area health resources file. Available at: https://data.hrsa.gov/topics/health-workforce/ahrf. Accessed 20 Apr 2021.

  27. Sommeiller E, Price M 2018 The new gilded age. Income inequality in the U.S. by state, metropolitan area, and county. Economic Policy Institute

  28. Benzow A, Fikri K, et al. 2020 The Spaces Between Us. The Evolution of American Communities in the New Century. Economic Innovation Group

  29. Shambaugh J, Nunn R et al. Place-based Policies for Shared Economic Growth. The Hamilton Project; 2018.

  30. Florida R. America’s Worsening Geographic Inequality. 16 October 2018. Available at: https://www.bloomberg.com/news/articles/2018-10-16/geographic-economic-inequality-is-growing-in-the-u-s. Accessed 22 Apr 2021.

  31. Siu AL, US Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(4):279–96.

    Article  PubMed  Google Scholar 

  32. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2016; 315(23):2564-2575.

  33. State Health Facts. Health Insurance Coverage of the Total Population. 2021. Available at: https://www.kff.org/other/state-indicator/total-population/?dataView=1&currentTimeframe=0&selectedDistributions=employer&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed 26 Apr 2021.

  34. SHADAC analysis of the American Community Survey (ACS) Public Use Microdata Sample (PUMS) files. 2021. Available at: statehealthcompare.shadac.org. Accessed 26 Apr 2021.

  35. Kirby JB, Yabroff KR. Rural-Urban Differences in Access to Primary Care: Beyond the Usual Source of Care Provider. Am J Prev Med. 2020;58(1):89–96.

    Article  PubMed  Google Scholar 

  36. Stone LC, Boursaw B, Bettez SP, et al. Place as a predictor of health insurance coverage: a multivariate analysis of counties in the United States. Health Place. 2015;34:207–14.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Institute of Medicine (US) Committee on Health Insurance Status and its Consequences. America’s Uninsured Crisis: Consequences for Health and Health Care. Washington (DC); National Academies Press (US);2009.

  38. Ellis L, Canchola AJ, Spiegel D, et al. Trends in cancer survival by health insurance status in California from 1997 to 2014. JAMA Oncol. 2018;4(3):317–23.

    Article  PubMed  Google Scholar 

  39. Sun W, Cheng M, Zhuang S, et al. Impact of Insurance Status on Stage, Treatment, and Survival in Patients with Colorectal Cancer: A Population-Based Analysis. Med Sci Monit. 2019;25:2397–418.

    Article  PubMed  PubMed Central  Google Scholar 

  40. de Moor JS, Cohen RA, Shapiro JA, et al. Colorectal cancer screening in the United States: Trends from 2008 to 2015 and variation by health insurance coverage. Prev Med. 2018;112:199–206.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Freeman VL, Naylor KB, Boylan EE, et al. Spatial access to primary care providers and colorectal cancer-specific survival in Cook County Illinois. Cancer Med. 2020;9(9):3211–23.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Chien LC, Deshpande AD, Jeffe DB, et al. Influence of primary care physician availability and socioeconomic deprivation on breast cancer from 1988 to 2008: a spatio-temporal analysis. PLoS One. 2012;7(4):35737.

    Article  Google Scholar 

  43. Donohoe J, Marshall V, Tan X, et al. predicting Late-stage breast cancer diagnosis and receipt of adjuvant therapy: Applying current spatial access to care methods in Appalachia. Med Care. 2015;53(11):980–8.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Edwards BK, Ward E, Kohler BA, et al. Annual report to the nation on the status of cancer, 1975–2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer. 2010;116(3):544–73.

    Article  PubMed  Google Scholar 

  45. Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012;366(8):687–96.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Ladabaum U, Dominitz JA, Kahi C, et al. Strategies for colorectal cancer screening. Gastroenterology. 2020;158(2):418–32.

    Article  CAS  PubMed  Google Scholar 

  47. White A, Thompson TD, White MC, et al. Cancer Screening Test Use—United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(8):201–6.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Meester RG, Doubeni CA, Lansdorp-Vogelaar I, et al. Colorectal cancer deaths attributable to nonuse of screening in the United States. Ann Epidemiol. 2015;25(3):208-213e1.

    Article  PubMed  Google Scholar 

  49. Behavioral Risk Factor Surveillance System. 2010 Codebook Report. Centers for Disease Control and Prevention 2011.

  50. Schneider KL, Clark MA, Rakowski W, et al. Evaluating the impact of non-response bias in the behavioral risk factor surveillance system (BRFSS). J Epidemiol Community Health. 2012;66(4):290–5.

    Article  PubMed  Google Scholar 

  51. Doubeni CA, Laiyemo AO, Reed G, et al. Socioeconomic and racial patterns of colorectal cancer screening among Medicare enrollees in 2000 to 2005. Cancer Epidemiol Biomarkers Prev. 2009;18(8):2170–5.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Carethers JM, Doubeni CA. Causes of socioeconomic disparities in colorectal cancer and intervention framework and strategies. Gastroenterology. 2020;158(2):354–67.

    Article  PubMed  Google Scholar 

  53. Mohan G, Chattopadhyay S. Cost-effectiveness of leveraging social determinants of health to improve breast, cervical, and colorectal cancer screening: a systematic review. JAMA Oncol. 2020;6(9):1434–44.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Kurani SS, McCoy RG, Lampman MA, et al. Association of neighborhood measures of social determinants of health with breast, cervical, and colorectal cancer screening rates in the US Midwest. JAMA Netw Open. 2020;3(3):200618.

    Article  Google Scholar 

  55. Cole AM, Jackson JE, Doescher M. Urban-rural disparities in colorectal cancer screening: cross-sectional analysis of 1998–2005 data from the Centers for Disease Control’s Behavioral Risk Factor Surveillance Study. Cancer Med. 2012;1(3):350–6.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993;329(27):1977–81.

    Article  CAS  PubMed  Google Scholar 

  57. Siegel RL, Sahar L, Robbins A, et al. Where can colorectal cancer screening interventions have the most impact? Cancer Epidemiol Biomarkers Prev. 2015;24(8):1151–6.

    Article  PubMed  Google Scholar 

  58. Mandelblatt JS, Stout NK, Schechter CB, et al. Collaborative modeling of the benefits and harms associated with different us breast cancer screening strategies. Ann Intern Med. 2016;164(4):215–25.

    Article  PubMed  PubMed Central  Google Scholar 

  59. National Institutes of Health, National Cancer Institute. Cancer Stat Facts: Female Breast Cancer. 2021. Available at: https://seer.cancer.gov/statfacts/html/breast.html. Accessed 26 Apr 2021.

  60. Blumen H, Fitch K, Polkus V. Comparison of treatment costs for breast cancer, by Tumor Stage and type of service. Am Health Drug Benefits. 2016;9(1):23–32.

    PubMed  PubMed Central  Google Scholar 

  61. Subramanian S, Trogdon J, Ekwueme DU, et al. Cost of breast cancer treatment in Medicaid: implications for state programs providing coverage for low-income women. Med Care. 2011;49(1):89–95.

    Article  PubMed  Google Scholar 

  62. Hall IJ, Tangka FKL, Sabatino SA, et al. Patterns and trends in cancer screening in the United States. Prev Chronic Dis. 2018;15:E97.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Tatalovich Z, Zhu L, Rolin A, et al. Geographic disparities in late stage breast cancer incidence: results from eight states in the United States. Int J Health Geogr. 2015;14:31.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Verdial FC, Etzioni R, Duggan C, et al. Demographic changes in breast cancer incidence, stage at diagnosis and age associated with population-based mammographic screening. J Surg Oncol. 2017;115(5):517–22.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Harding C, Pompei F, Burmistrov D, et al. Breast cancer screening, incidence, and mortality across US counties. JAMA Intern Med. 2015;175(9):1483–9.

    Article  PubMed  Google Scholar 

  66. Obeng-Gyasi S, Timsina L, Bhattacharyya O, et al. Breast cancer presentation, surgical management and mortality across the rural-urban continuum in the national cancer database. Ann Surg Oncol. 2020;27(6):1805–15.

    Article  PubMed  Google Scholar 

  67. Elmore JG, Etzioni R. Effect of Screening Mammography on Cancer Incidence and Mortality. JAMA Intern Med. 2015;175(9):1490–1.

    Article  PubMed  Google Scholar 

  68. Das B, Feuer EJ, Mariotto A. Geographic association between mammography use and mortality reduction in the US. Cancer Causes Control. 2005;16(6):691–9.

    Article  PubMed  Google Scholar 

  69. Cooper GS, Yuan Z, Bowlin SJ, et al. An ecological study of the effectiveness of mammography in reducing breast cancer mortality. Am J Public Health. 1998;88(2):281–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Funding

Adrian Diaz receives funding from the University of Michigan Institute for Healthcare Policy and Innovation Clinician Scholars Program, and received salary support from the Veterans Affairs Office of Academic Affiliations during the conduct of this study/

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Authors and Affiliations

  1. Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA

    Chelsea Herbert BS

  2. Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA

    Chelsea Herbert BS, Alessandro Paro MD, Adrian Diaz MD, MPH & Timothy M. Pawlik MD, MPH, MTS, PhD

  3. National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA

    Adrian Diaz MD, MPH

  4. Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA

    Adrian Diaz MD, MPH

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  1. Chelsea Herbert BS
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Correspondence to Adrian Diaz MD, MPH.

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Chelsea Herbert, Alessandro Paro, Adrian Diaz, and Timothy M. Pawlik have no disclosures to declare.

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Herbert, C., Paro, A., Diaz, A. et al. Association of Community Economic Distress and Breast and Colorectal Cancer Screening, Incidence, and Mortality Rates Among US Counties. Ann Surg Oncol 29, 837–848 (2022). https://doi.org/10.1245/s10434-021-10849-7

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