This publication was prepared by:

Gopal K. Singh, Ph.D.

Barry A. Miller, Dr.P.H.

Benjamin F. Hankey, Sc.D.

Brenda K. Edwards, Ph.D.

Surveillance Research Program

Division of Cancer Control and Population Sciences

National Cancer Institute

6116 Executive Blvd., Suite 504

Bethesda, Maryland 20892-8316

Fax: 301-496-9949

Suggested citation for the monograph:

Singh GK, Miller BA, Hankey BF, Edwards BK. Area Socioeconomic Variations in U.S. Cancer Incidence,

Mortality, Stage, Treatment, and Survival, 1975–1999. NCI Cancer Surveillance Monograph Series,

Number 4. Bethesda, MD: National Cancer Institute, 2003. NIH Publication No. 03-0000. 

This publication is available on the SEER web site: http://seer.cancer.gov

Copyright information:

All material in this report is in the public domain and may be reproduced or copied without

permission; citation as to source, however, is appreciated.

Area Socioeconomic Variations in 

U.S. Cancer Incidence, Mortality, Stage,

Treatment, and Survival, 1975–1999

Acknowledgments

The authors wish to thank the Principal Investigators and the staffs of the SEER contract

organizations who provided the cancer incidence data for this report. These organizations, funded

through National Cancer Institute (NCI) contracts, include:

Contracting Organization Principal Investigator

Northern California Cancer Center Dr. Dee W. West

Connecticut State Department of Dr. Anthony P. Polednak

Health Mr. Daniel Savino

Emory University Dr. John L. Young, Jr.

Dr. Jonathan M. Liff

University of Hawaii Dr. Marc T. Goodman

Dr. Laurence N. Kolonel

The Fred Hutchinson Cancer Dr. Thomas L. Vaughan

Research Center Dr. Steve Schwartz

University of Iowa Dr. Charles F. Lynch

Dr. Charles E. Platz

Wayne State University Dr. Ann Schwartz

Dr. Kendra Schwartz

University of New Mexico Dr. Charles R. Key

University of Southern California Dr. Ronald K. Ross

Dr. Dennis Deapen

Dr. Leslie Bernstein

University of Utah Dr. Charles L. Wiggins

The production of this report would not have been possible without the efforts of the NCI staff who

ensure the quality and completeness of the SEER data: Benjamin Hankey, Margaret Adamo, Limin

Clegg, Milton Eisner, April Fritz, Carol Johnson, Carol Kosary, Denise Lewis, Barry Miller, Lynn Ries,

Gopal Singh, and Elliott Ware of the Cancer Statistics Branch, and Brenda Edwards of the Surveillance

Research Program.

Acknowledgments
Computer support services were provided by Information Management Services (IMS), Inc.

Special appreciation for database creation and programming support is given to Scott Depuy, Todd

Gibson, and Steve Scoppa of IMS, Inc. Thanks are owed to Dr. Frank Boscoe for developing county

maps.

Dr. Lihua Liu of the University of Southern California and Drs. Marsha E. Reichman and B. Sue Bell of

NCI provided the peer review. Their thoughtful comments and critique are greatly appreciated.
Table of Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Data and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Selecting an Area Socioeconomic Measure—The Poverty Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Socioeconomic and Demographic Characteristics of Area Poverty Groups . . . . . . . . . . . . . . . . . . . . . . . 16

Computing Incidence and Mortality Rates for Area Poverty Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Computing Five-Year Cause-Specific Survival Rates for Area Poverty Groups . . . . . . . . . . . . . . . . . . . . . 18

Statistical Significance and Suppression of Rates and Counts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Use of County Versus Census Tract Poverty Rates for U.S. Mortality and SEER Databases . . . . . . . . . . 19

Incidence and Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

All Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Trends in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Cross-Sectional Patterns in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Trends in Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Cross-Sectional Patterns in Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Trends in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Cross-Sectional Patterns in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Trends in Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Cross-Sectional Patterns in Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Table of Contents
Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Trends in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Cross-Sectional Patterns in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Trends and Cross-Sectional Patterns in Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Trends in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Cross-Sectional Patterns in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Trends and Cross-Sectional Patterns in Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Female Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Trends in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Cross-Sectional Patterns in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Trends in Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Cross-Sectional Patterns in Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Cervical Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Trends in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Cross-Sectional Patterns in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Trends in Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Cross-Sectional Patterns in Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Melanoma of the Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Trends in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Cross-Sectional Patterns in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Trends in Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Cross-Sectional Patterns in Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

The Area Poverty and Cancer Incidence and Mortality Continuum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Stage of Disease at Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

The Summary Staging Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Area Socioeconomic and Racial/Ethnic Patterns in Early- and Late-Stage Cancer Diagnoses . . . . . . . 69

Trends in Area Socioeconomic Gradients in the Stage Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Treatment (Cancer-Directed Surgery) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Non-Small-Cell Lung Cancer, Stages I or II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Prostate Cancer, Localized or Regional Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Breast Cancer, Stages I or II, <= 2 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Area Socioeconomic and Racial/Ethnic Patterns in Survival, the 1988–1994 Patient Cohort . . . . . . . 95

Trends in Survival from Cancers of the Prostate and Female Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Summary and Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Tables 

Table 2.1. Selected Socioeconomic and Demographic Characteristics of Area (Census Tract and

County) Poverty Groups, 1990: United States and 11 SEER Registration Areas . . . . . . . . . . . . . . . . . . . . 24

Table 3.1. U.S. Site-Specific Cancer Deaths and Age-Adjusted Mortality Rates and 95% Confidence

Intervals by Sex, Race/Ethnicity, and County Poverty Rate, 1995–1999 . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Table 3.2. SEER Site-Specific Cancer Incidence (Invasive) Cases and Age-Adjusted Incidence Rates 

and 95% Confidence Intervals by Sex, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1992: 

11 SEER Registration Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Table 4.1. Distribution of SEER Site-Specific Cancer (Invasive) Cases by Stage, Sex, Race/Ethnicity, 

and Census Tract Poverty Rate, 1995–1999: 11 SEER Registration Areas . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Table 5.1. Number and Percentage of AJCC Stages I and II Non-Small-Cell Lung Cancer Patients

Receiving Surgical Treatment by Sex, Race/Ethnicity, and Census Tract Poverty Rate, 1995–1999: 

11 SEER Registration Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Table 5.2. Number and Percentage of Localized- and Regional-Stage Prostate Cancer Patients

Undergoing Radical Prostatectomy by Age, Race/Ethnicity and Census Tract Poverty Rate, 

1995–1999: 11 SEER Registration Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Table 5.3. Number and Percentage of AJCC Stages I and II Female Breast Cancer Patients With 

Tumor Size <= 2 cm Undergoing Breast-Conserving Surgery by Race/Ethnicity and Census Tract

Poverty Rate, 1995–1998: 11 SEER Registration Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Table 6.1. SEER Site-Specific Five-Year Cause-Specific Cancer Survival Rates (%) and Standard Errors

(SE) by Sex, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994 Patient Cohort: 

11 SEER Registration Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

Table 6.2. SEER Site-Specific Five-Year Cause-Specific Cancer Survival Rates (%) and Standard Errors

(SE) for Localized-Stage Cancers by Sex, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994

Patient Cohort: 11 SEER Registration Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Table 6.3. SEER Site-Specific Five-Year Cause-Specific Cancer Survival Rates (%) and Standard Errors

(SE) for Regional-Stage Cancers by Sex, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994

Patient Cohort: 11 SEER Registration Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Table 6.4. SEER Site-Specific Five-Year Cause-Specific Cancer Survival Rates (%) and Standard Errors

(SE) for Distant-Stage Cancers by Sex, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994

Patient Cohort: 11 SEER Registration Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Table 7.1. Correlations Among Poverty, Behavioral Factors, Cancer Screening, and Age-Adjusted

Cancer Mortality Rates Using State-Level Data: United States, 1990–1999 (N = 51) . . . . . . . . . . . . . . 129
Foreword

1

This monograph presents one of the most comprehensive analyses yet on socioeconomic patterns in

cancer incidence and outcomes in the United States. The extensive amount of data assembled in this

report will be extremely useful in furthering our understanding of the relationship of socioeconomic

status to the overall cancer burden as well as to the magnitude and causes of current social

inequalities in cancer between major racial and ethnic groups in the United States. Documenting and

monitoring the extent of socioeconomic inequalities in cancer incidence, mortality, disease stage,

treatment, and survival remain central to cancer surveillance research in terms of generating

hypotheses for population health research and the evidence for comprehensive population-based

strategies for cancer prevention and control. This monograph is an excellent example of how linkage

of census-based area measures with the national mortality and SEER databases can be used to track

socioeconomic trends in cancer rates and to improve our capacity to monitor progress toward

reducing the cancer burden among various segments of the U.S. population.

Disparities documented here are not necessarily the experience of each individual. Rather, they

indicate differences in cancer incidence and outcomes among population groups or geographic areas

that are stratified with respect to key social and economic resources, such as education, income, or

poverty level. These group- or area-based differences in cancer may be related to a variety of factors,

including the social and physical environment, health behaviors (smoking and diet being two main

cancer-related behaviors), and health care.

This monograph also makes a significant contribution to the burgeoning literature on social

determinants of health. Although the role of socioeconomic factors as determinants of such major

chronic diseases as heart disease, stroke, diabetes, and respiratory diseases are well established, their

relationship with cancer is less well studied. As shown here, the relationship between socioeconomic

position and cancer is a complex one and varies according to cancer type and secular time. Despite

overall improvements in mortality and patient survival, socioeconomic inequalities in cancer persist,

but in some instances they may be changing direction, lessening or widening over time. Like other

diseases and health outcomes, differences in cancer incidence, mortality, disease stage, and survival

are shown to exist across the entire range of social hierarchy, not just between rich and poor,

privileged and disadvantaged. It is hoped that the data and findings of this report will stimulate

future research aimed at identifying major social, environmental, health care, behavioral, and

biologic determinants underlying these cancer disparities.

Foreword
I would like to congratulate my former colleagues at the National Cancer Institute for

completing this important work, which highlights the value of the SEER program as a national

resource. It is an exciting example of the kinds of results we can expect from an expanded perspective

on what can be accomplished by surveillance research. I, with the authors, hope that this publication

will be a major stimulus for innovative work by cancer researchers, novel insights by policy makers,

and ultimately improvement of the public health.

Robert A. Hiatt, M.D., Ph.D.

Director of Population Sciences

UCSF Comprehensive Cancer Center

Professor of Epidemiology

UCSF School of Medicine

University of California, San Francisco

2
Abstract

3

Objectives. This report analyzes area

socioeconomic differentials and trends in

incidence, mortality, stage of disease, treatment,

and survival for all cancers combined and for

six major cancers (lung, colon/rectum, prostate,

breast, uterine cervix, and melanoma of the

skin) by sex and race/ethnicity in the United

States.

Methods. County and census tract poverty rates

from the 1990 census were linked to U.S.

mortality, SEER cancer incidence, stage,

treatment, and survival data from 1975 to 1999.

Age-adjusted incidence and mortality rates were

calculated for each area poverty group, and

differences in rates were tested for statistical

significance at the 0.05 level. 

Results. Substantial area socioeconomic

gradients in both incidence and mortality were

observed for various cancers. The association

between area socioeconomic position and

cancer mortality changed markedly over the

past 25 years. Socioeconomic inequalities in

male lung and prostate cancer mortality

widened, while those in colorectal and breast

cancer mortality narrowed over time and even

appear to have reversed in the late 1990s. There

was a marked increase in incidence for breast

cancer and melanoma of the skin in all

socioeconomic groups, with a positive gradient

remaining throughout the study period.

Socioeconomic inequalities in cervical cancer

also persisted against a backdrop of declining

incidence and mortality rates. For each of the

cancers considered, regardless of race/ethnicity,

both men and women in high poverty areas

(poverty rates 20% or higher) had substantially

higher rates of late-stage cancer diagnosis and

lower rates of cancer survival than those in low

poverty areas (poverty rates less than 10%).

Cancer survival rates for residents of higher

poverty areas remained lower even after

controlling for differences in stage. Residents of

higher poverty areas were also less likely to

receive preferred treatment for lung and breast

cancers and to undergo radical prostatectomy.

Conclusions. Area socioeconomic differentials

in cancer incidence and mortality vary

substantially by sex, race/ethnicity, and time

period. Area socioeconomic disparities may be

associated with similar disparities in the

distribution of smoking, diet, physical activity,

cancer screening, and treatment. Area

socioeconomic measures, when linked to cancer

registration and vital statistics data, enhance

cancer surveillance research and monitoring.

Key Words. SEER, cancer, incidence, mortality,

survival, stage of disease, treatment, area-based

measure, socioeconomic status, poverty,

deprivation, health disparities, race/ethnicity. 

Abstract

Highlights 

5

The Surveillance Research Program of the

National Cancer Institute is pleased to release

this monograph on area socioeconomic

variations in cancer in the United States from

1975 through 1999. Cancer is the second

leading cause of death after heart disease and is

responsible for more estimated years of life lost

than any other cause of death in the United

States. Cancer as a disease also exacts an

enormous toll in terms of financial costs of

cancer care and emotional and psychological

distress among people affected by it. As shown

in this monograph, the cancer burden varies

greatly among various ethnic and

socioeconomic groups in the United States, and

the magnitude of socioeconomic inequalities for

some cancers may be widening over time. This

monograph focuses on six major cancers—lung,

colorectum, breast, prostate, uterine cervix, and

melanoma of the skin—the cancers for which

cancer control interventions have been

introduced into the general population. The

analysis of cancer rates and trends by

socioeconomic characteristics may shed

important light on the potential contribution of

major cancer control efforts such as smoking

reduction and cancer screening on reducing the

cancer burden among the various segments of

the U.S. population. Some of the highlights

from the monograph are listed herein:

Monograph Data

• Incidence, stage, treatment, and survival data

are from the 11 population-based SEER cancer

registries that cover 14% of the U.S. population.

• For incidence trend analysis, 2.4 million

newly diagnosed invasive cancer cases between

1975 and 1999 were used. Stage of disease

analyses included 1.8 million invasive cancer

cases diagnosed between 1988 and 1999. 

• The analysis of patient survival included

442,415 men and 398,147 women who were

diagnosed with primary invasive cancers during

1988–1994 and were followed for vital status

through December 31, 1999.

• Mortality data are presented both for the

SEER areas and the entire U.S. population. 

• For mortality trend analysis, 6.3 million male

cancer deaths and 5.5 million female cancer

deaths occurring between 1975 and 1999 were

used.

• The poverty rate, the percentage of the

population below the poverty level, was used as

the area socioeconomic measure and was

derived from the 1990 decennial census at

either the county or census tract level.

Highlights
Incidence and Mortality

All Cancers

• Area socioeconomic gradients in all-cancer

mortality among U.S. men widened between

1975 and 1999. In 1975, total male cancer

mortality was only 2% greater in high poverty

areas (county poverty rate of 20% or higher)

than in low poverty areas (county poverty rate

less than 10%). But in 1999, total cancer

mortality among men was 13% greater in high

poverty areas than in low poverty areas.

• Area socioeconomic patterns in all-cancer

mortality among U.S. women reversed between

1975 and 1999. Compared to the rate for

women in low poverty counties, the total cancer

mortality rate for U.S. women in high poverty

counties was 3% lower in 1975 but was 3%

greater in 1999.

Lung Cancer

• The higher the county poverty rate, the

greater the lung cancer mortality rate among

U.S. men. However, area socioeconomic

gradients in lung cancer mortality among U.S.

men widened between 1975 and 1999.

Compared to the rate for men in low poverty

counties, the lung cancer mortality rate for U.S.

men in high poverty counties was 7% greater in

1975 and 25% greater in 1999.

• Lung cancer incidence during 1988–1992

increased with increasing census tract poverty

rate for non-Hispanic white and black men and

women and Asian/Pacific Islander (API) men. 

In contrast, for Hispanic men and women, lung

cancer incidence rates were higher in low

poverty census tracts than in high poverty

census tracts.

Colorectal Cancer

• Area socioeconomic patterns in colorectal

cancer mortality among U.S. men and women

reversed between 1975 and 1999. Compared to

the rates in low poverty counties, the colorectal

cancer mortality rates in high poverty counties

were 12% lower in 1975 but at least 5% higher

in 1999. Although colorectal cancer mortality

showed a downward trend in all poverty groups,

the reversal in patterns occurred largely as a

result of a faster decline in mortality among

men and women in low poverty counties.

• Colorectal cancer incidence was only weakly

or inconsistently related to census tract poverty

rate. 

Prostate Cancer

• Prostate cancer mortality did not vary much

by area poverty rates from 1975 through 1989.

However, since 1990 there has been a widening

of the area socioeconomic gradient, with men in

high poverty counties in 1999 experiencing a

22% higher prostate cancer mortality rate than

men in low poverty counties.

• The higher the census tract poverty rate, the

lower the prostate cancer incidence during

1988–1992. Compared to the rates for their

counterparts in high poverty census tracts, the

prostate cancer incidence rates for non-Hispanic

white, black, American Indian, API, and

6
Hispanic men were respectively 20%, 17%, 16%,

46%, and 48% higher in low poverty census

tracts.

Female Breast Cancer

• Socioeconomic differences in U.S. female

breast cancer mortality have narrowed over time

and appear to have reversed in the late 1990s.

Compared to the rate for women in low poverty

counties, breast cancer mortality for women in

high poverty counties was 15% lower in 1976

but 4% greater in 1999.

• Time trends in SEER female breast cancer

incidence from 1975 to 1999 indicate

consistently higher rates among lower poverty

groups, with incidence rates increasing more

rapidly in low poverty counties than in high

poverty counties.

• The higher the census tract poverty rate, the

lower the breast cancer incidence during

1988–1992. Compared to the rates for their

counterparts in high poverty areas, the breast

cancer incidence rates for non-Hispanic white,

black, API, and Hispanic women were

respectively 10%, 16%, 49%, and 50% higher in

low poverty areas.

Cervical Cancer

• Although cervical cancer mortality decreased

consistently for all county poverty groups

between 1975 and 1999, socioeconomic

inequalities in U.S. cervical cancer mortality did

not diminish during this time period. In the

1990s, U.S. women experienced at least 71%

higher cervical cancer mortality in high poverty

counties than in low poverty counties.

• U.S. cervical cancer mortality increased with

increasing area poverty for women in all

racial/ethnic groups. During 1995–1999,

American Indian and Hispanic women in high

poverty counties had almost twice the cervical

cancer mortality of their counterparts in low

poverty counties. The cervical cancer mortality

rates were respectively 45% and 37% higher for

non-Hispanic white women and black women

in high poverty counties than in low poverty

counties.

• The SEER cervical cancer incidence rates also

showed a downward trend for all county

poverty groups during 1975–1999. However, a

substantial socioeconomic gradient in cervical

cancer incidence remained, with women in high

poverty counties having at least a one-third

higher incidence rate than those in low poverty

counties throughout the study period.

• The higher the census tract poverty rate, the

greater the cervical cancer incidence during

1988–1992. Compared to the rates for their

counterparts in low poverty census tracts, the

cervical cancer incidence rates for non-Hispanic

white, black, American Indian, API, and

Hispanic women were respectively 97%, 30%,

292%, 44%, and 83% higher in high poverty

census tracts. 

7
Melanoma of the Skin

• The higher the county poverty rate, the lower

the U.S. mortality from melanoma of the skin.

While mortality from melanoma of the skin

showed an increasing trend between 1975 and

1999 for men in all county poverty groups, the

trend was relatively stable for women.

• Between 1975 and 1999, the SEER incidence

rates for melanoma of the skin increased two- to

three-fold for men and women in all county

poverty groups, with low poverty counties

maintaining substantially higher incidence rates

than high poverty counties throughout the

study period.

• The higher the census tract poverty rate, the

lower the incidence for melanoma of the skin

during 1988–1992. The rates were respectively

2.7 and 3 times higher for men and women in

low poverty census tracts than in high poverty

census tracts.

Stage of Disease at Diagnosis

• For each of the cancers considered, men and

women in high poverty areas (census tracts with

poverty rates 20% or higher) had a higher

percentage of late-stage cancer diagnoses than

those in low poverty areas (census tracts with

poverty rates less than 10%). Conversely,

patients in low poverty areas were generally

more likely to be diagnosed with early-stage

(localized) cancers. These patterns generally held

for each racial/ethnic group.

• The largest socioeconomic gradients occurred

for patients diagnosed with distant-stage

melanoma of the skin, distant-stage prostate

cancer, and distant-stage female breast cancer.

Compared to their counterparts in low poverty

areas, men and women in high poverty areas

were respectively 2.5 and 2.2 times more likely

to be diagnosed with distant-stage melanoma of

the skin. Patients in high poverty areas were

respectively 1.9 and 1.7 times more likely to be

diagnosed with distant-stage cancers of the

prostate and female breast.

• The percentage of prostate cancers diagnosed

at local or regional stage increased from 1988

through 1999 in all socioeconomic groups. 

A socioeconomic gradient persisted over the

time period, with the lowest poverty group

having the largest percentage of local/regionalstage cancers. This pattern coincides with the

rising utilization of the prostate-specific antigen

(PSA) test for prostate cancer screening since the

late 1980s.

• The stage distribution of female breast cancer

cases remained stable from 1988 to 1999. A

consistent socioeconomic gradient is also

apparent over this time period.

• Socioeconomic differences in the stage

distribution for cervical cancer cases were large

and consistent throughout the 1990s.

• The percentage of regional- or distant-stage

melanoma diagnoses appeared to have increased

during 1995–1999 among men in high poverty

areas.

8
Treatment 

(Cancer-Directed Surgery)

• Men with stage I or II non-small-cell lung

cancer showed a consistent area socioeconomic

gradient in surgery rates for each racial/ethnic

group; those in the lowest census tract poverty

group (the highest SES group) had the highest

likelihood of undergoing surgery. Among

women, the socioeconomic gradient was

apparent only for non-Hispanic whites.

• The lack of a consensus on the therapeutic

management of prostate cancer leads to

variations in practice that may be linked to both

clinical and nonclinical factors. There were clear

socioeconomic gradients in the frequency of

prostatectomy for non-Hispanic white and black

men aged under 70 years, with the highest

surgery frequency occurring in the lowest

poverty group.

• The percentage of black patients receiving

radical prostatectomy was the lowest among the

four racial/ethnic groups within each area

poverty group. There was no clear

socioeconomic pattern in the frequency of

surgery for Asian/Pacific Islander men. 

• Among women diagnosed during 1995–1999

with stage I or II breast cancers, 2 cm or less in

diameter, there was a consistent socioeconomic

gradient in the percentage receiving breastconserving surgery (BCS). BCS was most

commonly performed in low poverty census

tracts (high SES areas), and this relationship

held for each racial/ethnic group.

• The percentage of women receiving BCS

increased steadily in each socioeconomic group

over the period 1988–1998, although women in

the lowest poverty group consistently showed

the highest levels of BCS.

Survival

• For all cancers combined as well as for the

individual cancers considered, both men and

women in high poverty areas (census tracts with

poverty rates 20% or higher) generally had

lower rates of cancer survival than those in low

poverty areas (census tracts with poverty rates

less than 10%).

• Among men diagnosed with cancer between

1988 and 1994, the five-year survival rate for all

cancers combined was 61% in low poverty areas

but only 49% in high poverty areas.

• Among women diagnosed with cancer

between 1988 and 1994, the five-year survival

rate for all cancers combined was 63% in low

poverty areas and only 53% in high poverty

areas.

• The pattern of lower cancer survival

associated with higher poverty levels held for

each racial/ethnic group except American

Indians/Alaska natives. For example, for black

men diagnosed with cancer between 1988 and

1994, the five-year survival rate for all cancers

combined was 58% in low poverty areas and

only 45% in high poverty areas.

9
• Among women diagnosed with breast cancer

between 1988 and 1994, five-year survival was

86% for those in low poverty areas and only

78% for those in high poverty areas. Large

socioeconomic differentials in survival were also

observed for melanoma of the skin and for

colorectal, prostate, and cervical cancers.

• For all cancers combined and for many types

of cancer, significant racial/ethnic differences in

cancer survival remained within each area

poverty group. However, racial/ethnic

differences in survival were substantially

reduced after controlling for stage of disease at

diagnosis. For example, for non-Hispanic white

and black women diagnosed with breast cancer

(all stages combined) between 1988 and 1994 in

high poverty census tracts, the five-year survival

rates were 82% and 72% respectively. However,

among women diagnosed with localized-stage

breast cancer in high poverty census tracts, the

five-year survival rate was 94% for non-Hispanic

white women and 90% for black women.

• Socioeconomic gradients in cancer survival

were generally most pronounced for regionalstage disease. For example, the five-year survival

rates for women diagnosed with regional-stage

breast cancer were 80% among those living in

low poverty census tracts and 71% for those in

high poverty census tracts. Socioeconomic

differences in survival were also substantial for

localized-stage lung cancer and distant-stage

cervical cancer.

• Five-year survival rates for all cancers

combined improved between 1988 and 1994 for

men in all area poverty groups, although

substantial socioeconomic differences remained.

Trends in overall cancer survival among women

remained stable between 1988 and 1994, with

women in higher poverty areas experiencing

significantly lower cancer survival throughout

the period. 

• Prostate cancer survival improved between

1988 and 1994 for men in all area poverty

groups, with socioeconomic inequalities

diminishing slightly because of somewhat larger

gains in survival among men in high poverty

areas.

• Socioeconomic differentials in female breast

cancer survival appear to be relatively

unchanged between 1988 and 1994, with little

or no improvement in survival among women

in each area group.

10
Introduction

11

Since the launching of the national initiative in

disease prevention and health promotion

Healthy People 2000 more than a decade ago,

socioeconomic inequalities in health and

disease in the United States have been

documented with increasing frequency. This

health initiative presented a national strategy

for reducing health disparities among

Americans. The current initiative, Healthy People

2010, has taken an even bolder step, calling for

the elimination of health disparities among

racial/ethnic and socioeconomic groups during

this decade (1).

Socioeconomic characteristics have long

been studied in relation to health, disease, and

mortality differentials in the United States as

well as in other industrialized countries (2–12).

Individuals of lower socioeconomic status (SES)

or geographic areas with higher levels of

socioeconomic disadvantage have generally

been associated with poorer health than their

more advantaged counterparts (2–14). The

relationship between SES and health, both at

the individual and area levels, is not simply

confined to the difference between the most

and least disadvantaged strata. Rather, a social

gradient exists, implying that as we move along

the socioeconomic continuum or the

deprivation scale, we tend to observe a

corresponding improvement or deterioration in

health (4,5,13,14). Cancer incidence and

mortality have also been associated with both

individual- and area-level socioeconomic

position, although the pattern of association

varies for specific cancers (15–38). Moreover,

socioeconomic patterns for some cancers can

change substantially over time (16–17).

Contemporary data indicate that higher SES is

consistently associated with lower incidence or

mortality rates of lung, stomach, cervical,

esophageal, oropharyngeal, and liver cancer and

higher rates of breast cancer and melanoma

(18,20–23,25,27,31,34–36). Current research

also indicates consistently higher rates of

advanced stage of cancer at diagnosis (39–42)

and lower rates of survival among cancer

patients of lower socioeconomic position or

among patients residing in more disadvantaged

areas (43–44). Furthermore, the major

behavioral, environmental, and health care

determinants of cancer, such as smoking, diet,

alcohol use, reproductive behavior, occupational

and environmental exposures, and cancer

screening are themselves substantially

influenced by individual- and area-level

socioeconomic factors (7,18,45–51).

Documenting socioeconomic disparities in

cancer is important for several reasons

(13,52,53). First, estimating the cancer-related

health disparities between the least and most

advantaged socioeconomic groups can tell us

about the extent to which improvements in

specific cancer outcomes can be achieved in a

given population. Second, presenting cancer

statistics according to socioeconomic factors can

help identify socioeconomic groups or areas

Introduction
that are at greatest risk of cancer morbidity,

mortality, or poor survival and that may

therefore benefit from focused social and

medical interventions. Third, analysis of such

data may provide important insights into cancer

rates and trends, particularly with regard to the

impact of cancer control interventions that are

known to vary by socioeconomic characteristics

(16,17). Fourth, although socioeconomic factors

may not be direct determinants of cancer, they

may represent underlying factors that (1) create

conditions that give rise to risk factors such as

smoking, alcohol use, fatty diet, lack of physical

activity, and environmental exposures to

carcinogens, and (2) influence health care

accessibility and use (such as cancer screening

and treatment) that may be more directly linked

to cancer mortality and survival (13,53). An

understanding of the extent and causes of

socioeconomic inequalities in cancer incidence,

mortality, and survival is therefore crucial to the

development and implementation of a

comprehensive and effective strategy for cancer

control and prevention and for general health

improvement (13,18).

Individual-level data on key socioeconomic

variables, such as educational attainment,

occupation, and income, are not available for

cancer patients in the National Cancer

Institute’s Surveillance, Epidemiology, and End

Results (SEER) database (16,54–56). Reliable

socioeconomic data are also lacking on U.S.

death certificates, which provide the basis for

computing cancer mortality rates for various

demographic groups and geographic areas

(16,17,57). Consequently, population-based

surveillance studies of cancer incidence,

mortality, and patient survival in the U.S. have

mostly relied on ecological SES data linked to

both individual- and aggregate-level cancer data.

In this report, we focus on all cancers

combined and six major cancers: lung and

bronchus, colon/rectum, breast, prostate,

uterine cervix, and melanoma of the skin. These

are not only among the most commonly

diagnosed cancers, but most are also leading

causes of cancer mortality in the United States

(55,57–59). Taken together, these six cancers

accounted for 53% of all cancer deaths in the

U.S. in 1999 and 62% of all new cancer cases

diagnosed in 1999 in the 11 SEER registration

areas (55,57). These are also the cancers for

which cancer control interventions have been

introduced into the general population (16).

In this report, we use “the percentage of

population below the poverty level” as the area

socioeconomic measure, our primary covariate

of interest. We link this area measure to the U.S.

cancer mortality data using the county of

residence of the decedent and to the cancer

incidence data from the 11 population-based

SEER cancer registries using the county and

census tract residence of the cancer patient at

the time of diagnosis. We examine the extent to

which socioeconomic differentials in cancer

outcomes vary by race/ethnicity and sex. Where

possible, we present socioeconomic differentials

separately for specific racial/ethnic groups. This

allows one to assess how the impact of area

socioeconomic position on cancer varies

according to race/ethnicity and the extent to

which racial/ethnic differences in cancer may be

accounted for by differences in area SES. 

12
The results in this report have been

organized into four sections: incidence and

mortality, stage of disease at diagnosis,

treatment (cancer-directed surgery), and

survival. These sections contain interpretive and

analytic text and graphical presentations of the

most important data and findings, followed by

detailed tables. Wherever possible, both

temporal patterns and recent cross-sectional

data are presented. Data are first analyzed for

mortality and incidence rates because variations

in cancer mortality rates could logically be

interpreted in terms of variations in incidence

rates, stage distribution, treatment, and survival

rates.

13

Data and Methods

15

Selecting an Area Socioeconomic

Measure—The Poverty Rate 

A variety of socioeconomic variables at the

ecological level, such as poverty rate, median

family income, percentage of population with at

least a high school education, percentage

employed in white collar occupations,

unemployment rate, housing tenure, household

crowding, and automobile ownership, as well as

composite indices that combine some or all of

these variables, have been used to analyze area

socioeconomic inequalities in cancer outcomes

(16,17,21–23,25,26,28,30,34,36,39–42). These

single and composite area measures are

generally taken to represent important aspects

of the social environment—such as economic

deprivation, social inequality, resource

availability, opportunity structure, or living

conditions (6,16,17,34,60).

Although all of the above variables are

useful in describing socioeconomic inequalities

in cancer, the poverty rate (the percentage of

population below the poverty level) was chosen

as the preferred area measure for a variety of

reasons. In the United States, the poverty rate

refers to the percentage of families or

individuals classified as being below the official

poverty threshold. The poverty thresholds are

updated annually by the U.S. Bureau of the

Census to reflect changes in the Consumer Price

Index. In the 1990 decennial census, the official

poverty threshold for a family of four was

$12,674, and 12.8% of the U.S. population was

below this poverty threshold (61,62). The

poverty rate is a measure of economic

deprivation and an uneven distribution of

economic resources in a given population. It

also correlates highly with other measures of

socioeconomic position and deprivation, such

as educational attainment, unemployment rate,

and occupational composition. For example, for

the U.S. as a whole, the weighted correlation

coefficients of the 1990 county poverty rate

with other socioeconomic variables were as

follows: percentage of population with at least a

high school education (–0.73), median family

income (–0.77), percentage of population in

white collar occupations (–0.43), and

unemployment rate (0.78). The corresponding

national correlations at the census tract level

were –0.67, –0.66, –0.51, and 0.72. Similar

county- and census tract-level correlations were

also observed for the combined 11 SEER

registration areas. Moreover, poverty rate had

one of the largest relative weights in generating

a composite area socioeconomic index for the

U.S. (16,17).

Yet another advantage for choosing

poverty rate as an area measure is that a priori

cutpoints may be specified based on prior

empirical research and policy relevance (21).

The following cutpoints for poverty rate were

selected: < 10%, 10%–19.99%, ≥ 20%. Areas

Data and Methods
with a poverty rate of 20% or higher are often

considered to be distressed or severely

disadvantaged areas. For other area variables,

quintiles or quartiles of a distribution that

classify an equal number of areas or an equal

amount of population into the given categories

are measures generally used to denote cutpoints.

Although quintiles and quartiles are useful

statistical categories, they are intrinsically less

meaningful from a programmatic and policy

standpoint than the aforementioned poverty

categories.

In all of the analyses, the poverty rate is

measured at either the county or census tract

level and is derived from the 1990 decennial

census. Figures 2.1–2.3, pages 20–22, show

respectively the county-level distribution of

poverty rate, median family income, and

percentage of population with at least a high

school diploma in 1990, indicating a fairly

similar geographic distribution of

socioeconomic disadvantage in the U.S. The

socioeconomic classification of counties based

on the 1990 poverty rate is also temporally

stable for the study period 1975–1999 in that

the 1990 poverty rate is highly correlated with

the 1980 rate (r = 0.91 for the U.S. and 0.90 for

the SEER regions). Similar associations were

observed when the three-category poverty

variable was compared in 1990 and 1980 

(γ = 0.94 for the U.S. and 0.91 for the SEER

regions; Figures 2.1 and 2.4, pages 20 and 23).

Socioeconomic and Demographic

Characteristics of Area Poverty Groups

Table 2.1, page 24, shows the distribution of

selected sociodemographic characteristics across

the three area poverty groups in 1990. For the

U.S. as a whole, 13% of the population lived in

counties with poverty rates of 20% or more and

31% of the population lived in counties with a

poverty rate of less than 10%. However, the

population distribution varied substantially by

race/ethnicity. Whereas 27% of blacks, 31% of

American Indians/Alaska natives, and 21% of

the Hispanic population lived in counties with

poverty rates of 20% or more, only 7% of Asians

and Pacific Islanders and 10% of non-Hispanic

whites were represented in the highest poverty

county group. The three poverty groups also

varied substantially in terms of median family

income, concentration of high school and

college graduates, white collar employment, and

unemployment rate. Also, the high poverty

county group had a higher proportion of rural

population than the low poverty county group.

Taken together, the 11 SEER registration

areas were somewhat more well off than the

total U.S. population. Eight percent of the SEER

population lived in high poverty counties and

43% of the SEER population lived in low

poverty counties, as compared with 13% and

31% respectively of the U.S. population.

Moreover, the SEER county poverty groups did

not differ much in their urbanization levels.

The area poverty groups for the 11 SEER

registries based on census tracts differed from

those based on counties in that a higher

16
proportion of the population was concentrated

in the high poverty census tract group than in

the high poverty county group (18% vs. 8%).

Moreover, more than 40% of the black,

American Indian/Alaska native, and Hispanic

population lived in census tracts with a poverty

rate of 20% or higher, as compared with 23%,

32%, and 6% respectively of the black,

American Indian/Alaska native, and Hispanic

populations living in counties with a poverty

rate of 20% or higher. Income, education,

occupation, and unemployment differentials

between area poverty groups were also greater

for census tracts than for counties. 

Computing Incidence and Mortality Rates

for Area Poverty Groups

To compute cancer incidence and mortality

rates, three categories of area poverty rate were

used to classify all U.S. counties, SEER counties,

and SEER census tracts into three population

groups, which ranged from being the least

disadvantaged (richest) to the most

disadvantaged (poorest) area group. While the

county geocode in the national mortality

database refers to the residence of the decedent

at the time of cancer death (57), the county or

census tract geocode in SEER relates to the place

of residence at the time of cancer diagnosis (63).

The analysis of census tract-level

socioeconomic patterns in incidence were based

on 379,070 men and 347,245 women newly

diagnosed with invasive cancers between

January 1, 1988, and December 31, 1992, in 11

population-based SEER cancer registries (55).

The analysis of census tract-level socioeconomic

patterns in stage of disease were based on

942,839 men and 881,216 women diagnosed

with invasive cancers between January 1, 1988,

and December 31, 1999. The 11 SEER registries

cover about 14% of the total U.S. population

and include the states of Connecticut, Hawaii,

Iowa, New Mexico, and Utah, and the

metropolitan areas of Atlanta, Detroit, Los

Angeles, San Francisco and Oakland, San Jose

and Monterey, and Seattle. For the analysis of

temporal county-level socioeconomic patterns

in cancer incidence, data from 9 SEER registries

(excluding Los Angeles and San Jose/Monterey

from the above list) were used, which consisted

of 1,210,279 male and 1,153,028 female

incidence cases during the 1975–1999 time

period. All analyses of SEER data were based on

the November 2001 data submission (55).

Demographic and medical variables from the

SEER database used in this report included age

at diagnosis, sex, race/ethnicity, county and

census tract of residence, stage of disease at

diagnosis, therapy/treatment (cancer surgery),

survival time (months) and vital status, and year

of diagnosis (63).

The analysis of mortality trends was based

on 6,277,958 male and 5,516,968 female cancer

deaths drawn from the annual national

mortality data files from 1975 through 1999.

Age-sex-race-county-specific population

estimates from 1975 to 1999 served as

denominators for computing cancer mortality

rates and county-based poverty-specific

incidence rates over time (64). Age-sex-racecensus tract-specific decennial census

populations in 1990, multiplied by 5, served as

denominators for computing average annual

17
cancer incidence rates for the 1988–1992 time

period (65). Of the 11.8 million U.S. cancer

deaths and 2.36 million newly diagnosed

cancers cases from 9 SEER registries between

1975 and 1999, 12 cancer deaths and 231

cancer incidence cases could not be matched

with the county poverty rate because of missing

or invalid county geocode. Of the 1.82 million

invasive cancer cases diagnosed in 11 SEER

registries during 1988–1999, 2.57% (46,904) had

missing census tract information and hence

could not be linked to the area poverty rate. The

proportion of cancer cases with missing census

tract data was somewhat higher among men

than among women (2.81% vs. 2.32%) and

among American Indians/Alaska natives

(6.37%), Asian and Pacific Islanders (4.76%),

Hispanics (3.17%), and non-Hispanic whites

(2.17%) than among blacks (1.32%). The higher

proportion of American Indian/Alaska native

and API cases with missing data was due to a

higher proportion of cases with unknown

census tracts in the New Mexico, San

Jose/Monterey, and Hawaii registries, which

have a substantially higher concentration of the

American Indian and API populations

respectively. However, the cancer cases with and

without census tract codes were similar in their

age distribution, nativity and marital status

composition, stage, and year of diagnosis.

Incidence and mortality rates for each area

poverty group were age-adjusted by the direct

method using the age composition of the 2000

U.S. standard population and five-year agespecific cancer incidence and mortality rates

(55). While trends in mortality rates for the U.S.

are presented on an annual basis, trends in SEER

incidence and mortality are analyzed as threeyear moving average rates. The moving average

smoothing technique allows the identification

of a trend more clearly by reducing some of the

variability associated with the small populations

represented in the SEER annual rates. 

Computing Five-Year Cause-Specific

Survival Rates for Area Poverty Groups

The analysis of patient survival included

442,415 men and 398,147 women (with known

census tract poverty rates) in 11 SEER registries

who were diagnosed with primary invasive

cancers during 1988–1994 and were followed for

vital status through December 31, 1999. Fiveyear cause-specific survival rates were computed

for each poverty group. Survival times were

measured in months. The patients lost to

follow-up, those alive at the end of the five-year

follow-up, and those dying of causes other than

the underlying cancer during the follow-up

period were treated as censored observations

(66). Cancer patients who died of unknown

causes, those whose initial diagnosis was found

on the death certificate or at autopsy, and those

who were not being actively followed were

excluded from the analysis.

Statistical Significance and Suppression of

Rates and Counts

Socioeconomic gradients were generally

described in terms of relative incidence and

mortality rate ratios. Rate ratios and differences

in rates were tested for statistical significance at

18
the 0.05 level (54,55). In all analyses, the lowest

area poverty group was selected as the reference

category. When the number of incidence cases

or deaths used to compute incidence or

mortality rates are small, those rates tend to

have poor reliability. Therefore, to discourage

misinterpretation and misuse of rates or counts

that are unstable and to protect confidentiality

of cancer patients and decedents because of the

small numbers of cases or deaths, incidence and

mortality rates as well as case and death counts

are not shown in tables and figures if the case or

death counts are fewer than 16. A case or a

death count of less than approximately 16

results in a standard error of the incidence or

mortality rate that is approximately 25% or

more as large as the rate itself. Equivalently, a

case or death count of less than approximately

16 results in the width of the 95% confidence

interval around the rate being at least as large as

the rate itself. These relationships were derived

under the assumption of a Poisson process and

with the standard population age distribution

close to the observed population age

distribution (67). Because of the small numbers

of cases and the above criteria for rate reliability,

stage, treatment, and survival analyses for

American Indians/Alaska natives are deemed

unreliable and are generally not presented in

this report.

Use of County Versus Census Tract Poverty

Rates for U.S. Mortality and SEER Databases

Counties are far more heterogeneous in their

socioeconomic and demographic composition

than smaller geographic areas such as census

tracts, zip codes, or block groups (16). As such,

census tracts are preferable to counties for the

purposes of classifying areas into socioeconomic

groups and for examining area socioeconomic

patterns in health outcomes, especially over a

relatively short time horizon. For confidentiality

protection of individual information on death

certificates, however, the national mortality

database does not include data for geographic

areas smaller than counties. Therefore, for all

analyses of temporal and cross-sectional

mortality data, the county-level poverty rate was

used.

The SEER database, on the other hand,

contained the county geocode from 1975 to

1999 and the census tract geocode from 1988 to

1999. Therefore, for the SEER incidence trend

analyses from 1975 through 1999, the county

poverty rate was used. However, for crosssectional racial/ethnic and socioeconomic

patterns in cancer incidence for the 1988–1992

period, the census tract poverty rate was used.

Socioeconomic patterns in SEER cancer

incidence, using the census tract poverty rate,

could not be assessed for a more recent time

period or in a temporal fashion because of a lack

of relevant population denominator data at the

census tract level. All stage, treatment, and

survival analyses in this report involved the use

of numerator-based SEER data; hence, for both

temporal and cross-sectional analyses, the

census tract poverty rate was used.

19
Figure 2.1. Percentage of County Population Below Poverty Level, United States, 1990

20

Source: U.S. Bureau of the Census. Data for Alaska and Hawaii are shown at the state level.

20% or higher 10% to 19.9% less than 10%
Figure 2.2. Median Family Income by County, United States, 1990

21

Source: U.S. Bureau of the Census. Data for Alaska and Hawaii are shown at the state level.

less than $22,870 (bottom quintile)$22,870 to $32,620 $32,630 or higher (top quintile)
Figure 2.3. Percentage of Population With at Least a High School Diploma, United States, 1990

22

Source: U.S. Bureau of the Census. Data for Alaska and Hawaii are shown at the state level.

less than 59.78% (bottom quintile)59.78% to 78.33% 78.34% or higher (top quintile)
Figure 2.4. Percentage of County Population Below Poverty Level, United States, 1980

23

20% or higher 10% to 19.9% less than 10%

Source: U.S. Bureau of the Census. Data for Alaska and Hawaii are shown at the state level.
24

Table 2.1. Selected Socioeconomic and Demographic Characteristics of Area (Census Tract and County) Poverty Groups, 1990:United States and 11 SEER Registration Areas

Area Poverty Rate % Non- % Asian & % High

(% Population Hispanic % American Pacific % Population % Population School % White Median Unemployment

Below % Total White % Black Indian Islander % Hispanic Age Group Age Group Diploma % College Collar Family Rate % Urban

Poverty Level) Population Population Population Population Population Population < 25 Years 65+ Years or More Graduates Occupation Income ($) (%) Population

United StatesCounty Poverty Rate

Less than 10% 31.17 35.08 16.72 18.69 40.82 17.54 34.99 11.87 81.42 24.90 62.41 44,555 4.63 78.3910% to 19.99% 55.76 54.70 56.15 49.94 51.86 61.80 36.51 12.84 74.44 18.94 56.10 33,765 6.56 76.0420% or higher 13.06 10.22 27.13 31.37 7.32 20.66 38.74 13.04 63.43 14.92 51.41 25,447 9.71 64.07Total 100.00 100.00 100.00 100.00 100.00 100.00 36.12 12.54 75.20 20.30 58.10 35,338 6.30 75.20

11 SEER Registration AreasCounty Poverty Rate

Less than 10% 43.44 52.14 27.83 23.55 49.81 18.72 35.09 11.01 83.06 27.42 64.91 46,058 4.70 88.5010% to 19.99% 48.30 40.97 49.00 44.40 49.36 75.37 37.75 10.93 74.78 22.90 59.18 39,035 6.66 90.2020% or higher 8.27 6.89 23.17 32.25 0.83 5.91 38.73 12.17 69.39 13.91 53.76 34,099 11.75 87.39Total 100.00 100.00 100.00 100.00 100.00 100.00 36.99 11.04 78.00 24.30 61.70 39,035 6.20 89.20

11 SEER Registration AreasCensus Tract Poverty Rate

Less than 10% 59.28 72.55 24.96 29.42 60.22 28.31 33.72 11.42 85.03 29.32 67.13 48,077 4.27 86.6510% to 19.99% 22.90 20.41 25.58 23.03 23.75 31.06 38.46 11.48 73.53 17.39 52.50 32,041 7.01 80.8220% or higher 17.82 7.04 49.46 47.54 16.03 40.66 45.69 9.02 56.31 11.05 43.50 21,458 14.85 91.20

Total 100.00 100.00 100.00 100.00 100.00 100.00 36.99 11.04 78.00 24.30 61.70 40,112 6.20 89.20

Notes: The 11 SEER registries include the states of Connecticut, Hawaii, Iowa, New Mexico, and Utah, and the metropolitan areas of Atlanta, Detroit, Los Angeles, San Francisco and Oakland, San Jose and

Monterey, and Seattle. Median family income for each area group is the weighted median of the county or census tract median family income values.
Incidence and Mortality

25

Incidence and mortality rates are the two most

commonly used measures for assessing the

cancer burden in the general population. As

shown below, the association between area

socioeconomic position and cancer mortality in

particular has changed markedly over the past

25 years, and the relationship between area

socioeconomic position and incidence or

mortality varies among the major racial/ethnic

groups in terms of magnitude and sometimes in

direction. While variations in cancer incidence

may occur primarily through behavioral and

environmental mechanisms, differences in

mortality rates may represent the cumulative

effects of health-risk behaviors, social and

environmental factors, health care access, and

medical care services. Data are first presented for

mortality and then for incidence because

mortality data pertain both to the entire U.S.

and SEER regions, whereas incidence data are

limited to the SEER regions.

All Cancers

Trends in Mortality

Area socioeconomic gradients in all-cancer

mortality among U.S. men widened between

1975 and 1999 (Figure 3.1, page 33). In 1975,

total male cancer mortality was only 2% greater

in high poverty areas (county poverty rate of

20% or higher) than in low poverty areas

(county poverty rate less than 10%). But in

1999, total cancer mortality among men was

13% greater in high poverty areas than in low

poverty areas. Although temporal

socioeconomic gradients in all-cancer mortality

among men in the SEER regions were less

consistent than those for the U.S. as a whole,

all-cancer mortality among men in the SEER

regions was at least 9% greater in high poverty

areas than in low poverty areas throughout the

study period (Figure 3.2, page 33).

Area socioeconomic patterns in all-cancer

mortality among U.S. women reversed between

1975 and 1999 (Figure 3.3, page 34). Compared

to the rate for women in low poverty areas, the

total cancer mortality rate for U.S. women in

high poverty areas was 3% lower in 1975 but

3% greater in 1999. Temporal socioeconomic

patterns in all-cancer female mortality in the

SEER regions differed from those for the U.S. as

a whole. The differential in the mortality rates

between the low and high poverty areas in the

SEER regions remained stable throughout the

1980s and 1990s, with women in high poverty

areas experiencing at least 4% higher mortality

than those in low poverty areas (Figure 3.4,

page 34).

Cross-Sectional Patterns in Mortality

During 1995–1999, area socioeconomic

gradients in total cancer mortality among U.S.

men were most pronounced for Hispanics 

Incidence and Mortality
(Table 3.1, page 64, and Figure 3.5, page 35).

Total cancer mortality was 45% higher for

Hispanic men in high poverty areas than in low

poverty areas. The rates for non-Hispanic white

men, black men, and for the total U.S. male

population were respectively 9%, 10%, and 15%

higher in high poverty areas than in low

poverty areas. The gradient was in the opposite

direction for API men, whose cancer mortality

rate was 13% lower in high poverty areas than

in low poverty areas.

During 1995–1999, area socioeconomic

gradients in total cancer mortality among U.S.

women were most pronounced for Hispanics

(Table 3.1, page 64, and Figure 3.6, page 35).

Total cancer mortality was 35% higher for

Hispanic women in high poverty areas than in

low poverty areas. For non-Hispanic white

women and for the total U.S. female population,

the rates were respectively 2% and 3% higher in

high poverty areas than in low poverty areas.

The gradient was in the opposite direction for

API women, whose cancer mortality rate was

14% lower in high poverty areas than in low

poverty areas.

Trends in Incidence

Trends in SEER male cancer incidence did not

reveal consistent socioeconomic gradients.

However, during the 1980s and 1990s, the

incidence rate for men in high poverty counties

was at least 3% greater than the rate for men in

low poverty counties (Figure 3.7, page 36). As

for trends in SEER female cancer incidence by

county poverty levels, the patterns were less

consistent during the 1980s. However, in the

mid-1970s and late 1990s, higher female cancer

incidence rates were associated with lower

poverty levels (Figure 3.8, page 36).

Cross-Sectional Patterns in Incidence

During 1988–1992, when census tract-level

poverty information could be used, SEER total

cancer incidence rates increased with increasing

area (census tract) poverty rate for non-Hispanic

white and black men but decreased for Hispanic

men (Table 3.2, page 66, and Figure 3.9, page

37). The total cancer incidence rates for nonHispanic white and black men were respectively

11% and 7% higher in high poverty areas

(census tracts) than in low poverty areas. The

total cancer incidence rate for Hispanic men was

28% higher in low poverty areas than in high

poverty areas.

During 1988–1992, SEER total cancer

incidence rates decreased with increasing area

(census tract) poverty rate for all women and for

API and Hispanic women (Table 3.2, page 66,

and Figure 3.10, page 37). The cancer incidence

rates for the total female population and for API

and Hispanic women were respectively 10%,

14%, and 22% higher in low poverty areas

(census tracts) than in high poverty areas.

Lung Cancer

Trends in Mortality

Area socioeconomic gradients in lung cancer

mortality among U.S. men increased between

1975 and 1999 (Figure 3.11, page 38).

Compared to the rate for men in low poverty

26
areas, the lung cancer mortality rate for U.S.

men in high poverty areas was 7% greater in

1975 and 25% greater in 1999. Temporal

socioeconomic patterns in male lung cancer

mortality in the SEER regions differed from

those for the U.S. as a whole. The differential in

the mortality rates between the low and high

poverty areas in the SEER regions remained

stable throughout 1975–1999, with men in high

poverty areas experiencing at least 18% higher

mortality than men in low poverty areas (Figure

3.12, page 38).

In 1975, U.S. women in high poverty areas

had a 7% lower lung cancer mortality rate than

those in low poverty areas. But the area

socioeconomic differences diminished in the

1990s, and the 1999 data indicate no

statistically significant differentials between the

area poverty groups (Figure 3.13, page 39).

Temporal socioeconomic patterns in female

lung cancer mortality in the SEER regions,

however, differed from those for the U.S. as a

whole. The rate was highest in the counties with

poverty rates exceeding 20%, followed by

counties with poverty rates less than 10%, with

counties with poverty levels between 10% and

20% having the lowest rates (Figure 3.14, page

39).

Cross-Sectional Patterns in Mortality

During 1995–1999, lung cancer mortality

among U.S. men increased with increasing area

poverty rates for non-Hispanic whites, blacks,

and Hispanics, but did not change significantly

with poverty rates for APIs (Table 3.1, page 64,

and Figure 3.15, page 40). The lung cancer

mortality rates were respectively 16%, 29%, and

56% higher for black, non-Hispanic white, and

Hispanic men in high poverty areas than in low

poverty areas.

During 1995–1999, area socioeconomic

gradients in U.S. lung cancer mortality among

women differed by race/ethnicity (Table 3.1,

page 64, and Figure 3.16, page 40). Compared to

the rates for their counterparts in low poverty

areas, the lung cancer mortality rates for nonHispanic white women and Hispanic women

were respectively 6% and 29% higher in high

poverty areas. The rates for API and American

Indian/Alaska native women were respectively

26% and 24% lower in high poverty areas than

in low poverty areas.

Trends in Incidence

Trends in male lung cancer incidence were

similar to the SEER mortality trends, with the

incidence rate for men in high poverty counties

during 1975–1999 being at least 12% greater

than the rate for men in low poverty counties

(Figure 3.17, page 41). Trends in female lung

cancer incidence were also similar to the SEER

mortality trends, with the incidence rate for

women in high poverty counties during

1975–1999 being at least 11% greater than the

rate for women in counties with poverty levels

between 10% and 20% (Figure 3.18, page 41).

Cross-Sectional Patterns in Incidence

The area socioeconomic gradient in SEER lung

cancer incidence during 1988–1992 was steeper

for men than for women (Table 3.2, page 66).

27
The lung cancer incidence rate increased with

increasing area (census tract) poverty rate for

non-Hispanic white and black men and women

and API men (Figures 3.19 and 3.20, page 42).

Compared to the rates for their counterparts in

low poverty areas, the lung cancer incidence

rates for non-Hispanic white, black, and API

men were respectively 45%, 46%, and 23%

higher in high poverty areas. The incidence

rates for non-Hispanic white and black women

were respectively 23% and 19% higher in high

poverty areas than in low poverty areas. In

contrast, for Hispanic men and women, lung

cancer incidence rates were respectively 21%

and 34% higher in low poverty areas than in

high poverty areas.

Colorectal Cancer

Trends in Mortality

Area socioeconomic patterns in colorectal

cancer mortality among U.S. men reversed

between 1975 and 1999 (Figure 3.21, page 43).

Compared to the rate for men in low poverty

areas, the colorectal cancer mortality rate for

men in high poverty areas was 12% lower in

1975 but 5% higher in 1999. Although

colorectal cancer mortality showed a downward

trend for men in all poverty groups, the reversal

in patterns occurred largely as a result of a faster

decline in colorectal cancer mortality among

men in low poverty areas. No consistent pattern

in the SEER male colorectal cancer mortality

trends was found prior to the mid-1980s. In the

late 1990s, however, higher male mortality was

associated with higher poverty levels. During

1997–1999, for example, the male colorectal

cancer mortality rate was 12% higher in high

poverty areas than in low poverty areas of the

SEER regions (Figure 3.22, page 43).

Temporal area socioeconomic patterns in

colorectal cancer mortality among U.S. women

were similar to those for U.S. men. Area

socioeconomic patterns in colorectal cancer

mortality reversed between 1975 and 1999, with

women in low poverty areas experiencing a

faster decline in mortality than those in high

poverty areas (Figure 3.23, page 44). Compared

to the rate for women in low poverty areas, the

colorectal cancer mortality rate for women in

high poverty areas was 12% lower in 1975 but

7% higher in 1999. No consistent pattern in the

SEER female colorectal cancer mortality trends

was found until the late 1980s. From the 1988

to 1990 period onwards, however, higher female

mortality was generally associated with higher

poverty levels. During 1997–1999, for example,

the female colorectal cancer mortality rate was

8% higher in high poverty areas than in low

poverty areas of the SEER regions (Figure 3.24,

page 44).

Cross-Sectional Patterns in Mortality

During 1995–1999, the colorectal cancer

mortality rate increased with increasing area

(county) poverty rate for the total male

population and for Hispanic men (Table 3.1,

page 64, and Figure 3.25, page 45). The

mortality rate for Hispanic men was 33% higher

in high poverty areas than in low poverty areas.

A consistent gradient in mortality was also

observed for Hispanic women, with the rate

being 39% higher in high poverty areas than in

low poverty areas (Figure 3.26, page 45).

28
Trends and Cross-Sectional Patterns in Incidence

Regarding the SEER colorectal cancer incidence

trends by county poverty levels, no consistent

pattern was found for either men or women

(Figures 3.27 and 3.28, page 46). During

1988–1992, the SEER colorectal cancer incidence

rate was 9% higher for men in low poverty areas

(census tracts) than in high poverty areas (Table

3.2, page 66, and Figure 3.29, page 47). The

gradient was most pronounced for Hispanic

men and women, whose colorectal cancer

incidence rates were respectively 37% and 48%

higher in low poverty areas (census tracts) than

in high poverty areas (Figures 3.29 and 3.30,

page 47).

Prostate Cancer

Trends in Mortality

U.S. prostate cancer mortality rates did not vary

much by area poverty rates from 1975 through

1989. However, since 1990 there has been a

widening of the area socioeconomic gradient,

with men in the two highest poverty groups in

1999 experiencing respectively 7% and 22%

higher prostate cancer mortality rates than men

in the lowest poverty group (Figure 3.31, page

48). Similar patterns were observed in SEER

prostate cancer mortality during the 1990s.

During 1997–1999, for example, men in the two

highest poverty groups in the SEER regions

experienced respectively 6% and 23% higher

prostate cancer mortality rates than men in the

lowest poverty group (Figure 3.32, page 48).

Moreover, men in the highest poverty group in 

the SEER regions had significantly higher

mortality rates than those in the lowest poverty

group throughout the 1975–1999 period. 

Cross-Sectional Patterns in Mortality

During 1995–1999, U.S. prostate cancer

mortality increased with increasing poverty rates

for the total population and for Hispanic and

American Indian men, but decreased with

increasing poverty rates for API men (Table 3.1,

page 64, and Figure 3.33, page 49). Compared to

the rates for their counterparts in low poverty

areas, the prostate cancer mortality rates for

Hispanic and American Indian/Alaska native

men were respectively 51% and 58% higher in

high poverty areas. The rate for API men was

38% lower in high poverty areas than in low

poverty areas.

Trends and Cross-Sectional Patterns in Incidence

During the 1990s, the prostate cancer incidence

rate for men in high poverty counties in the

SEER regions was at least 12% higher than the

rate for men in low poverty counties (Figure

3.34, page 50). During 1988–1992, SEER prostate

cancer incidence rates were higher in lower

poverty areas (census tracts) for the total

population and for all racial/ethnic groups

(Table 3.2, page 66 and Figure 3.35, page 50).

Compared to the rates for their counterparts in

high poverty areas, the prostate cancer

incidence rates for non-Hispanic white, black,

American Indian/Alaska native, API, and

Hispanic men were respectively 20%, 17%, 16%,

46%, and 48% higher in low poverty areas.

29
Female Breast Cancer

Trends in Mortality

Socioeconomic differences in U.S. female breast

cancer mortality have narrowed over time, and

appear to have reversed in the late 1990s (Figure

3.36, page 51). In 1976, breast cancer mortality

was 15% lower in high poverty areas than in

low poverty areas. In the early 1990s, no

significant differences in breast cancer mortality

between area poverty groups were found. In

1999, breast cancer mortality was 4% higher in

high poverty areas than in low poverty areas.

The SEER breast cancer mortality trends differed

from the national trends. In the 1990s, breast

cancer mortality was higher in high poverty

areas than in low poverty areas. During

1995–1997, for example, breast cancer mortality

was 17% greater in high poverty areas than in

low poverty areas of the SEER regions (Figure

3.37, page 51).

Cross-Sectional Patterns in Mortality

During 1997–1999, U.S. breast cancer mortality

was 3% lower for non-Hispanic white women in

high poverty areas than in low poverty areas

(Table 3.1, page 64, and Figure 3.38, page 52).

However, breast cancer mortality was 41%

higher for Hispanic women in high poverty

areas than in low poverty areas.

Trends in Incidence

During 1975–1999, SEER female breast cancer

incidence rates were higher in lower poverty

areas (counties), with incidence rates increasing

more rapidly in lower poverty groups than in

higher poverty groups (Figure 3.39, page 53).

During 1997–1999, compared to the rate for

women in the lowest poverty county group, the

breast cancer incidence rates were respectively

6% and 18% lower among women in the two

highest poverty groups. 

Cross-Sectional Patterns in Incidence

During 1988–1992, SEER breast cancer incidence

rates were higher in lower poverty areas (census

tracts) for the total population and for all

racial/ethnic groups except American

Indians/Alaska natives (Table 3.2, page 66, and

Figure 3.40, page 53). Compared to the rates for

their counterparts in high poverty areas, the

breast cancer incidence rates for all women and

for non-Hispanic white, black, API, and

Hispanic women were respectively 31%, 10%,

16%, 49%, and 50% higher in low poverty

areas.

Cervical Cancer

Trends in Mortality

Although cervical cancer mortality rates

decreased consistently for all area poverty

groups between 1975 and 1999, the area

socioeconomic gradient in U.S. cervical cancer

mortality did not diminish during this period

(Figure 3.41, page 54). In the 1990s, U.S. women

experienced at least 71% higher cervical cancer

mortality in high poverty counties than in low

poverty counties. Similar temporal

socioeconomic patterns were observed in SEER

cervical cancer mortality (Figure 3.42, page 54).

30
Cross-Sectional Patterns in Mortality

U.S. cervical cancer mortality increased with

increasing area poverty for women in all

racial/ethnic groups (Table 3.1, page 64, and

Figure 3.43, page 55). During 1995–1999,

American Indian/Alaska native and Hispanic

women in high poverty areas had almost twice

the cervical cancer mortality of their

counterparts in low poverty areas. The cervical

cancer mortality rates were respectively 45% and

37% higher for non-Hispanic white women and

black women in high poverty areas than in low

poverty areas.

Trends in Incidence

The SEER cervical cancer incidence rates also

showed a downward trend for all county

poverty groups during 1975–1999 (Figure 3.44,

page 56). However, a substantial area

socioeconomic gradient in cervical cancer

incidence remained, with women in high

poverty counties having at least a one-third

higher incidence rate than those in low poverty

counties throughout the study period.

Cross-Sectional Patterns in Incidence

The higher the census tract poverty rate, the

greater the cervical cancer incidence during

1988–1992. Compared to the rates for their

counterparts in low poverty census tracts, the

cervical cancer incidence rates for all women

and for non-Hispanic white, black, American

Indian, API, and Hispanic women were

respectively 119%, 97%, 30%, 292%, 44%, and

83% higher in high poverty census tracts (Table

3.2, page 66, and Figure 3.45, page 56). 

Melanoma of the Skin

Trends in Mortality

Mortality from melanoma of the skin showed

an increasing trend between 1975 and 1999 for

U.S. men in all area (county) poverty groups,

with higher mortality rates observed in lower

poverty areas (Figure 3.46, page 57). Mortality

from melanoma of the skin was 19% higher in

1975 and 32% higher in 1999 among U.S. men

in low poverty counties than among men in

high poverty counties. Trends in male mortality

for the SEER regions were similar (Figure 3.47,

page 57).

The trend in mortality from melanoma of

the skin remained stable between 1975 and

1999 among U.S. women in all area poverty

groups (Figure 3.48, page 58). Although

mortality from melanoma of the skin did not

vary by county poverty levels in 1975, the

mortality rate was 25% higher in low poverty

counties than in high poverty counties in 1999.

Trends in mortality were less consistent for the

SEER regions, although in the 1990s, the

mortality rate for women in the SEER regions

was higher in low poverty counties than in high

poverty counties (Figure 3.49, page 58).

Cross-Sectional Patterns in Mortality

During 1995–1999, mortality from melanoma of

the skin among U.S. men was 27% higher and

among U.S. women 24% higher in low poverty

counties than in high poverty counties (Figures

3.50 and 3.51, page 59). However, mortality

rates did not vary significantly by county 

31
poverty levels for any of the racial/ethnic groups

(Table 3.1, page 64).

Trends in Incidence

Between 1975 and 1999, the SEER incidence

rates for melanoma of the skin increased two- to

three-fold for men and women in all county

poverty groups (Figures 3.52 and 3.53, page 60).

The skin melanoma incidence rate was 117%

higher during 1975–1977 and 69% higher

during 1997–1999 among men in low poverty

counties than among men in high poverty

counties. The skin melanoma incidence rate was

85% higher in 1975–1977 and 82% higher in

1997–1999 among women in low poverty

counties than among women in high poverty

counties. 

Cross-Sectional Patterns in Incidence

During 1988–1992, SEER skin melanoma

incidence rates were respectively 2.7 and 3 times

higher for men and women in low poverty areas

(census tracts) than in high poverty areas (Table

3.2, page 66). The skin melanoma incidence

rates for non-Hispanic white and Hispanic men

were respectively 30% and 89% higher in low

poverty areas (census tracts) than in high

poverty areas (Figure 3.54, page 61). The skin

melanoma incidence rates for non-Hispanic

white and Hispanic women were respectively

33% and 99% higher in low poverty areas

(census tracts) than in high poverty areas (Figure

3.55, page 61).

The Area Poverty and Cancer Incidence and

Mortality Continuum

The relationship between area poverty and

cancer mortality and incidence is not confined

to the difference between the low and high

poverty areas. Rather, as we move along the

poverty continuum, we might expect to see a

corresponding increase or decrease in the

incidence and/or mortality rates. For instance,

the scatter plots in Figures 3.56 and 3.57, page

62, appear to indicate increasing U.S. male lung

cancer and cervical cancer mortality rates at

higher county poverty rates during the

1990–1999 time period. The weighted linear

regression models, with weights being the

number of deaths in each county, were fitted to

the data, yielding the correlation between

county poverty and male lung cancer mortality

to be 0.42 and that between county poverty and

cervical cancer mortality to be 0.56.

The weighted linear regression models

applied to the SEER incidence data during the

1988–1992 period, with weights being the

number of incidence cases in each census tract,

yielded a correlation of 0.49 between census

tract poverty rate and male lung cancer

incidence and 0.36 between census tract poverty

and cervical cancer incidence (Figures 3.58 and

3.59, page 63).

32
Figure 3.1. Trends in All-Cancer Mortality Among U.S. Men, 1975–1999

33

Figure 3.2. Trends in SEER All-Cancer Mortality Among Men (Three-Year Moving Averages),

1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. SEER mortality rates are based on data for 9 SEER registries. 

See “Data and Methods” for a list of SEER registries. Age-Adjusted Death Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975197719791981198319851987198919911993199519971999

350

300

250

200

150

100

50

0

Age-Adjusted Death Rate per 100,000 Population

1975–77

1977–791979–811981–83

1983–85

1985–87

1987–891989–911991–93

1993–951995–97

1997–99

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

350

300

250

200

150

100

50

0
Figure 3.4. Trends in SEER All-Cancer Mortality Among Women (Three-Year Moving Averages),

1975–1999

Figure 3.3. Trends in All-Cancer Mortality Among U.S. Women, 1975–1999

34

Age-Adjusted Death Rate per 100,000 Population

200

175

150

125

100

75

50

25

0

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975197719791981198319851987198919911993199519971999

Note: Rates are age-adjusted to the 2000 U.S. standard population. SEER mortality rates are based on data for 9 SEER registries. 

See “Data and Methods” for a list of SEER registries. Age-Adjusted Death Rate per 100,000 Population

200

175

150

125

100

75

50

25

0

1975–77

1977–791979–81

1981–83

1983–85

1985–87

1987–891989–911991–93

1993–95

1995–97

1997–99

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher
35

Figure 3.5. All-Cancer Mortality Among U.S. Men, 1995–1999

Figure 3.6. All-Cancer Mortality Among U.S. Women, 1995–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates for Hispanics and non-Hispanic whites are based on

1997–1999 data. Average Annual Age-Adjusted Death Rate per 100,000 Population

< 10% 10% to 19.99% 20% or higher

400

300

200

100

0

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

246.3

261.4

282.1

244.1

256.3

269.5

337.1

362.6 366.3

168.5

133.6

185.8

162.0 155.4

140.8

124.2

156.6

179.9

Percent of County Population Below Poverty Level in 1990

Average Annual Age-Adjusted Death Rate

per 100,000 Population

400

300

200

100

0

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

170.1 171.3 175.3 171.2 171.5 173.9

202.3 206.0 200.6

120.8

132.4

96.6

108.2 101.2 93.2 102.6

113.6

84.1

< 10% 10% to 19.99% 20% or higher

Percent of County Population Below Poverty Level in 1990
Figure 3.7. Trends in SEER Cancer (All Sites Combined) Incidence Among Men (Three-Year Moving

Averages), 1975–1999

36

Figure 3.8. Trends in SEER Cancer (All Sites Combined) Incidence Among Women (Three-Year Moving

Averages), 1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates are based on data from 9 SEER registries. 

See “Data and Methods” for a list of SEER registries. Age-Adjusted Incidence Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

750

600

450

300

150

0

1975–77

1977–791979–81

1981–83

1983–85

1985–87

1987–891989–911991–93

1993–951995–97

1997–99

Age-Adjusted Incidence Rate per 100,000 Population

1975–77

1977–791979–81

1981–83

1983–851985–87

1987–891989–911991–93

1993–95

1995–97

1997–99

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

750

600

450

300

150

0
Figure 3.9. SEER Cancer (All Sites Combined) Incidence Among Men, 1988–1992

37

Figure 3.10. SEER Cancer (All Sites Combined) Incidence Among Women, 1988–1992

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates are based on data from 11 SEER registries. 

See “Data and Methods” for a list of SEER registries. Average Annual Age-Adjusted Incidence Rate per 100,000 Population

< 10% 10% to 19.99% 20% or higher

800

600

400

200

0

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

Percent of Census Tract Population Below Poverty Level in 1990

589.0 578.5 595.6 601.6 610.7

666.9 681.9 687.3

732.8

245.1

199.5 182.3

396.7

374.2 384.8

458.5

393.9

356.8

Average Annual Age-Adjusted Incidence Rate

per 100,000 Population

800

600

400

200

0

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of Census Tract Population Below Poverty Level in 1990

417.7

396.4 379.6

427.2 420.7

443.3

411.5

392.6 402.7

134.3

167.2 167.1

304.8 290.3

268.0

332.1

292.9 272.6
Figure 3.11. Trends in Lung Cancer Mortality Among U.S. Men, 1975–1999

38

Figure 3.12. Trends in SEER Lung Cancer Mortality Among Men (Three-Year Moving Averages),

1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. SEER mortality rates are based on data for 9 SEER registries.

See “Data and Methods” for a list of SEER registries. Age-Adjusted Death Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975197719791981198319851987198919911993199519971999

120

100

80

60

40

20

0

Age-Adjusted Death Rate per 100,000 Population

1975–77

1977–791979–81

1981–83

1983–85

1985–87

1987–891989–911991–93

1993–95

1995–97

1997–99

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

120

100

80

60

40

20

0
Figure 3.13. Trends in Lung Cancer Mortality Among U.S. Women, 1975–1999

39

Figure 3.14. Trends in SEER Lung Cancer Mortality Among Women (Three-Year Moving Averages),

1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. SEER mortality rates are based on data for 9 SEER registries.

See “Data and Methods” for a list of SEER registries. Age-Adjusted Death Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975197719791981198319851987198919911993199519971999

50

40

30

20

10

0

Age-Adjusted Death Rate per 100,000 Population

1975–77

1977–791979–81

1981–83

1983–851985–87

1987–891989–911991–93

1993–95

1995–97

1997–99

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

50

40

30

20

10

0
Figure 3.15. Lung Cancer Mortality Among U.S. Men, 1995–1999

40

Figure 3.16. Lung Cancer Mortality Among U.S. Women, 1995–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates for Hispanics and non-Hispanic whites are based on

1997–1999 data. Average Annual Age-Adjusted Death Rate per 100,000 Population

< 10% 10% to 19.99% 20% or higher

120

90

60

30

0

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

Percent of County Population Below Poverty Level in 1990

73.1

83.0

93.5

73.0

82.8

93.9 96.8

111.4 112.2

61.9

43.3

55.5

41.6 41.1 38.6 35.9

42.6

27.3

Average Annual Age-Adjusted Death Rate

per 100,000 Population

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of County Population Below Poverty Level in 1990

50

40

30

20

10

0

40.9 41.3

39.8

42.7 43.9

45.3

40.5

41.7

37.5

29.7

25.6

22.5

20.9

19.3

15.4

12.0

13.3

15.5
Figure 3.17. Trends in SEER Lung Cancer Incidence Among Men (Three-Year Moving Averages),

1975–1999

41

Figure 3.18. Trends in SEER Lung Cancer Incidence Among Women (Three-Year Moving Averages),

1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates are based on data from 9 SEER registries. See “Data and

Methods” for a list of SEER registries. Age-Adjusted Incidence Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975–77

1977–791979–81

1981–83

1983–851985–87

1987–891989–911991–93

1993–951995–97

1997–99

140

120

100

80

60

40

20

0

Age-Adjusted Incidence Rate per 100,000 Population

1975–77

1977–79

1979–811981–83

1983–85

1985–87

1987–891989–91

1991–93

1993–95

1995–97

1997–99

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

60

50

40

30

20

10

0
Figure 3.19. SEER Lung Cancer Incidence Among Men, 1988–1992

42

Figure 3.20. SEER Lung Cancer Incidence Among Women, 1988–1992

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates are based on data from 11 SEER registries. 

See “Data and Methods” for a list of SEER registries. Average Annual Age-Adjusted Incidence Rate per 100,000 Population

< 10% 10% to 19.99% 20% or higher

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

Percent of Census Tract Population Below Poverty Level in 1990

175

150

125

100

75

50

25

0

87.4

99.2

116.2

89.9

105.6

130.8

108.4

129.3

157.7

38.5

45.6

58.5

68.8 71.8

59.9

50.1 49.4

18.9

Average Annual Age-Adjusted Incidence Rate

per 100,000 Population

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of Census Tract Population Below Poverty Level in 1990

70

60

50

40

30

20

10

0

47.1 46.6 47.3

52.1

61.1

49.5

46.9 48.2

55.7

24.1

27.7

5.6

27.3 27.1 27.1

23.5

21.2

28.5
Figure 3.21. Trends in Colorectal Cancer Mortality Among U.S. Men, 1975–1999

43

Figure 3.22. Trends in SEER Colorectal Cancer Mortality Among Men (Three-Year Moving Averages),

1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. SEER mortality rates are based on data for 9 SEER registries. 

See “Data and Methods” for a list of SEER registries. Age-Adjusted Death Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975197719791981198319851987198919911993199519971999

40

35

30

25

20

15

10

5

0

Age-Adjusted Death Rate per 100,000 Population

1975–77

1977–791979–81

1981–83

1983–851985–87

1987–891989–911991–93

1993–95

1995–97

1997–99

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

40

35

30

25

20

15

10

5

0
Figure 3.23. Trends in Colorectal Cancer Mortality Among U.S. Women, 1975–1999

44

Figure 3.24. Trends in SEER Colorectal Cancer Mortality Among Women (Three-Year Moving

Averages), 1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. SEER mortality rates are based on data for 9 SEER registries. 

See “Data and Methods” for a list of SEER registries. Age-Adjusted Death Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975197719791981198319851987198919911993199519971999

40

35

30

25

20

15

10

5

0

Age-Adjusted Death Rate per 100,000 Population

1975–77

1977–79

1979–81

1981–83

1983–85

1985–87

1987–891989–91

1991–93

1993–95

1995–97

1997–99

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

40

35

30

25

20

15

10

5

0
Figure 3.25. Colorectal Cancer Mortality Among U.S. Men, 1995–1999

45

Figure 3.26. Colorectal Cancer Mortality Among U.S. Women, 1995–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates for Hispanics and non-Hispanic whites are based on

1997–1999 data. Average Annual Age-Adjusted Death Rate per 100,000 Population

< 10% 10% to 19.99% 20% or higher

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

Percent of County Population Below Poverty Level in 1990

40

30

20

10

0

25.9 26.4 27.0

25.5 25.7 26.2

32.9

35.2

33.7

13.6

17.6

19.4

16.1 16.0

15.0

13.0

16.5 17.3

Average Annual Age-Adjusted Death Rate

per 100,000 Population

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of County Population Below Poverty Level in 1990

40

30

20

10

0

18.5 18.4 19.1 18.1 17.9 17.8

25.6 25.6 24.8

16.1

13.0

9.5

11.5 11.3

10.1

8.1

10.6 11.3
Figure 3.27. Trends in SEER Colorectal Cancer Incidence Among Men (Three-Year Moving Averages),

1975–1999

46

Figure 3.28. Trends in SEER Colorectal Cancer Incidence Among Women (Three-Year Moving

Averages), 1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates are based on data from 9 SEER registries. 

See “Data and Methods” for a list of SEER registries. Age-Adjusted Incidence Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975–77

1977–791979–81

1981–83

1983–85

1985–87

1987–891989–911991–93

1993–951995–97

1997–99

90

75

60

45

30

15

0

Age-Adjusted Incidence Rate per 100,000 Population

1975–77

1977–79

1979–811981–83

1983–85

1985–87

1987–891989–911991–93

1993–95

1995–97

1997–99

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

90

75

60

45

30

15

0
Figure 3.29. SEER Colorectal Cancer Incidence Among Men, 1988–1992

47

Figure 3.30. SEER Colorectal Cancer Incidence Among Women, 1988–1992

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates are based on data from 11 SEER registries. 

See “Data and Methods” for a list of SEER registries. Average Annual Age-Adjusted Incidence Rate per 100,000 Population

< 10% 10% to 19.99% 20% or higher

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

Percent of Census Tract Population Below Poverty Level in 1990

80

60

40

20

0

73.1

69.7

66.8

73.6 73.2 74.4 75.8 78.9 77.0

28.1

30.6

20.2

64.3

52.5

55.1 55.8

45.3

40.8

Average Annual Age-Adjusted Incidence Rate

per 100,000 Population

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of Census Tract Population Below Poverty Level in 1990

80

60

40

20

0

49.7 49.9

48.0 49.8 51.3 52.2

60.4

56.5

59.7

14.4

20.0

14.8

42.2

40.0

31.5

25.8

37.0 38.2
Figure 3.31. Trends in U.S. Prostate Cancer Mortality, 1975–1999

48

Figure 3.32. Trends in SEER Prostate Cancer Mortality (Three-Year Moving Averages), 1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. SEER mortality rates are based on data for 9 SEER registries. 

See “Data and Methods” for a list of SEER registries. Age-Adjusted Death Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975197719791981198319851987198919911993199519971999

50

40

30

20

10

0

Age-Adjusted Death Rate per 100,000 Population

1975–77

1977–791979–81

1981–83

1983–85

1985–87

1987–891989–911991–93

1993–95

1995–97

1997–99

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

50

40

30

20

10

0
Figure 3.33. U.S. Prostate Cancer Mortality, 1995–1999

49

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates for Hispanics and non-Hispanic whites are based on

1997–1999 data. Average Annual Age-Adjusted Death Rate per 100,000 Population

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of County Population Below Poverty Level in 1990

80

60

40

20

0

32.1 33.9

38.3

29.9 30.4 29.6

71.9 71.6

75.3

14.1 15.6

22.2

16.4

13.1

10.1

15.7

20.3

23.7
Figure 3.34. Trends in SEER Prostate Cancer Incidence (Three-Year Moving Averages), 1975–1999

50

Figure 3.35. SEER Prostate Cancer Incidence, 1988–1992

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates in Figures 3.34 and 3.35 are based on data from 9 and 11

SEER registries, respectively. See “Data and Methods” for a list of SEER registries. Age-Adjusted Incidence Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975–77

1977–791979–81

1981–83

1983–851985–87

1987–891989–911991–93

1993–951995–97

1997–99

300

250

200

150

100

50

0

Average Annual Age-Adjusted Incidence Rate

per 100,000 Population

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of Census Tract Population Below Poverty Level in 1990

300

250

200

150

100

50

0

183.7

164.5 160.1

186.8

169.3

155.5

268.4

229.0

242.3

64.8 64.4

55.8

104.9

82.2

71.9

112.5

139.8

94.2
Figure 3.36. Trends in U.S. Female Breast Cancer Mortality, 1975–1999

51

Figure 3.37. Trends in SEER Female Breast Cancer Mortality (Three-Year Moving Averages),

1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. SEER mortality rates are based on data for 9 SEER registries. 

See “Data and Methods” for a list of SEER registries. Age-Adjusted Death Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975197719791981198319851987198919911993199519971999

40

32

24

16

8

0

Age-Adjusted Death Rate per 100,000 Population

1975–77

1977–79

1979–81

1981–83

1983–85

1985–87

1987–891989–91

1991–93

1993–95

1995–97

1997–99

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

40

32

24

16

8

0
Figure 3.38. Breast Cancer Mortality Among U.S. Women, 1995–1999

52

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates for Hispanics and non-Hispanic whites are based on

1997–1999 data. Average Annual Age-Adjusted Death Rate per 100,000 Population

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of County Population Below Poverty Level in 1990

40

30

20

10

0

28.9 28.5

29.6

28.2 27.5 27.4

36.9 37.3 37.1

16.2

13.3

17.4

13.7

12.5 12.1

13.5

16.7

19.0
Figure 3.39. Trends in SEER Female Breast Cancer Incidence (Three-Year Moving Averages),

1975–1999

53

Figure 3.40. SEER Female Breast Cancer Incidence, 1988–1992

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates in Figures 3.39 and 3.40 are based on data from 9 and 11

SEER registries, respectively. See “Data and Methods” for a list of SEER registries. Age-Adjusted Incidence Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975–77

1977–791979–81

1981–83

1983–851985–87

1987–891989–911991–93

1993–95

1995–97

1997–99

150

125

100

75

50

25

0

Average Annual Age-Adjusted Incidence Rate

per 100,000 Population

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of Census Tract Population Below Poverty Level in 1990

150

125

100

75

50

25

0

136.3

103.9

120.3

140.5

129.7 127.5 129.6

114.7 111.4

37.5 40.6

32.8

91.7

76.7

61.4

101.6

82.6

67.6
Figure 3.41. Trends in U.S. Cervical Cancer Mortality, 1975–1999

54

Figure 3.42. Trends in SEER Cervical Cancer Mortality (Three-Year Moving Averages), 1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. SEER mortality rates are based on data for 9 SEER registries. 

See “Data and Methods” for a list of SEER registries. Age-Adjusted Death Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

8

6

4

2

0

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975–77

1977–79

1979–81

1981–83

1983–85

1985–87

1987–89

1989–91

1991–93

1993–95

1995–97

1997–99

Age-Adjusted Death Rate per 100,000 Population

8

6

4

2

0
Figure 3.43. U.S. Cervical Cancer Mortality, 1995–1999

55

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates for Hispanics and non-Hispanic whites are based on

1997–1999 data. Average Annual Age-Adjusted Death Rate per 100,000 Population

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of County Population Below Poverty Level in 1990

8

6

4

2

0

2.4

3.2

4.3

2.2

2.7

3.2

5.0

6.3

6.9

2.2

2.7

4.4

2.7

3.3

3.7

2.4

3.4

4.5
Figure 3.44. Trends in SEER Cervical Cancer Incidence (Three-Year Moving Averages), 1975–1999

56

Figure 3.45. SEER Cervical Cancer Incidence, 1988–1992

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates in Figures 3.44 and 3.45 are based on data from 9 and 11

SEER registries, respectively. See “Data and Methods” for a list of SEER registries. Age-Adjusted Incidence Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975–77

1977–791979–81

1981–83

1983–851985–87

1987–891989–91

1991–93

1993–951995–97

1997–99

21

18

15

12

9

6

3

0

Average Annual Age-Adjusted Incidence Rate

per 100,000 Population

American Indian/

Alaska Native

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of Census Tract Population Below Poverty Level in 1990

30

25

20

15

10

5

0

8.8

12.4

19.2

8.0

10.6

15.8

13.9 14.3

18.1

3.1

7.2

12.0

10.5

15.1

14.1

25.2

18.8

13.7
Figure 3.46. Trends in Mortality from Melanoma of the Skin Among U.S. Men, 1975–1999

57

Figure 3.47. Trends in SEER Mortality from Melanoma of the Skin Among Men (Three-Year Moving

Averages), 1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. SEER mortality rates are based on data for 9 SEER registries. 

See “Data and Methods” for a list of SEER registries. Age-Adjusted Death Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975

5

4

3

2

1

0

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975–77

1977–79

1979–81

1981–83

1983–85

1985–87

1987–89

1989–91

1991–93

1993–95

1995–97

1997–99

Age-Adjusted Death Rate per 100,000 Population

5

4

3

2

1

0
Figure 3.48. Trends in Mortality from Melanoma of the Skin Among U.S. Women, 1975–1999

58

Figure 3.49. Trends in SEER Mortality from Melanoma of the Skin Among Women (Three-Year

Moving Averages), 1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. SEER mortality rates are based on data for 9 SEER registries. 

See “Data and Methods” for a list of SEER registries. Age-Adjusted Death Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975

5

4

3

2

1

0

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975–77

1977–79

1979–81

1981–83

1983–85

1985–87

1987–89

1989–91

1991–93

1993–95

1995–97

1997–99

Age-Adjusted Death Rate per 100,000 Population

5

4

3

2

1

0
Figure 3.50. Mortality from Melanoma of the Skin, U.S. Men, 1995–1999

59

Figure 3.51. Mortality from Melanoma of the Skin, U.S. Women, 1995–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates for Hispanics and non-Hispanic whites are based on

1997–1999 data. Average Annual Age-Adjusted Death Rate per 100,000 Population

< 10% 10% to 19.99% 20% or higher

Non-Hispanic Hispanic

White

All Races

Percent of County Population Below Poverty Level in 1990

Black

5

4

3

2

1

0

4.2

3.3

4.0

4.7 4.7

4.5

0.5 0.5 0.5

0.9

1.1 1.2

< 10% 10% to 19.99% 20% or higher

Percent of County Population Below Poverty Level in 1990

Non-Hispanic Hispanic

White

All Races Black

Average Annual Age-Adjusted Death Rate

per 100,000 Population

5

4

3

2

1

0

2.0

1.8

1.6

2.2 2.1 2.2

0.4 0.5 0.5 0.6 0.6 0.6
Figure 3.52. Trends in SEER Incidence, Melanoma of the Skin Among Men (Three-Year Moving

Averages), 1975–1999

60

Figure 3.53. Trends in SEER Incidence, Melanoma of the Skin Among Women (Three-Year Moving

Averages), 1975–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates are based on data from 9 registries. 

See “Data and Methods” for a list of SEER registries. Age-Adjusted Incidence Rate per 100,000 Population

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975–77

1977–79

1979–81

1981–83

1983–85

1985–87

1987–89

1989–91

1991–93

1993–95

1995–97

1997–99

25

20

15

10

5

0

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1975–77

1977–79

1979–81

1981–83

1983–85

1985–87

1987–89

1989–91

1991–93

1993–95

1995–97

1997–99

Age-Adjusted Incidence Rate per 100,000 Population

25

20

15

10

5

0
Figure 3.54. SEER Incidence of Melanoma of the Skin (Invasive) Among Men, 1988–1992

61

Figure 3.55. SEER Incidence of Melanoma of the Skin (Invasive) Among Women, 1988–1992

Note: Rates are age-adjusted to the 2000 U.S. standard population. Rates are based on data from 11 SEER registries. 

See “Data and Methods” for a list of SEER registries Average Annual Age-Adjusted Incidence Rate per 100,000 Population

< 10% 10% to 19.99% 20% or higher

Non-Hispanic Hispanic

White

All Races

Percent of Census Tract Population Below Poverty Level in 1990

Black

25

20

15

10

5

0

19.4

12.6

7.2

21.7

17.0 16.6

1.4 0.9 1.3

3.3

2.2

4.2

< 10% 10% to 19.99% 20% or higher

Percent of Census Tract Population Below Poverty Level in 1990

Non-Hispanic Hispanic

White

All Races Black

Average Annual Age-Adjusted Incidence Rate

per 100,000 Population

25

20

15

10

5

0

13.5

9.1

4.6

15.0

12.6

11.3

1.7

0.8 0.7

5.3

3.8

2.6
Figure 3.56. Relationship Between County Poverty Rate and Lung Cancer Mortality Among U.S. Men,

1990–1999

62

Figure 3.57. Relationship Between County Poverty Rate and U.S. Cervical Cancer Mortality,

1990–1999

Note: Rates are age-adjusted to the 2000 U.S. standard population. Age-Adjusted Death Rate per 100,000 Population

Percentage of County Population Below Poverty Level, 1990

0 10 20 30 40 50 60 70

250

200

150

100

50

0

Observed Fitted (weighted linear model)

Rate = 71.822 + 1.302 Poverty

Standard Error of Slope = 0.051

Correlation Coefficient = 0.421; P < 0.0001

Percentage of County Population Below Poverty Level, 1990

0 10 20 30 40 50 60 70

Age-Adjusted Death Rate per 100,000 Population

40

30

20

10

0

Observed Fitted (weighted linear model)

Rate = 1.950 + 0.134 Poverty

Standard Error of Slope = 0.004

Correlation Coefficient = 0.556; P < 0.0001
Figure 3.58. Relationship Between Census Tract Poverty Rate and SEER Male Lung Cancer Incidence

Rate, 1988–1992

63

Figure 3.59. Relationship Between Census Tract Poverty Rate and SEER Cervical Cancer Incidence

Rate, 1988–1992

Note: Rates are age-adjusted to the 2000 U.S. standard population. Age-Adjusted Incidence Rate per 100,000 Population

Percentage of Census Tract Population Below Poverty Level, 1990

0 10 20 30 40 50 60 100

600

500

400

300

200

100

0

70 80 90

Observed Fitted (weighted linear model)

Rate = 82.144 + 2.256 Poverty

Standard Error of Slope = 0.074

Correlation Coefficient = 0.494; P < 0.0001

Percentage of Census Tract Population Below Poverty Level, 1990

Age-Adjusted Incidence Rate per 100,000 Population

0 10 20 30 40 50 60 100 70 80 90

500

400

300

200

100

0

Observed Fitted (weighted linear model)

Rate = 54.202 + 1.117 Poverty

Standard Error of Slope = 0.055

Correlation Coefficient = 0.356; P < 0.0001
64

Table 3.1. U.S. Site-Specific Cancer Deaths and Age-Adjusted Mortality Rates and 95% Confidence Intervals by Sex, Race/Ethnicity,and County Poverty Rate, 1995–1999

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

# Deaths Rate SE Lower CI Upper CI # Deaths Rate SE Lower CI Upper CI # Deaths Rate SE Lower CI Upper CI

All Cancers, Male

All Races 419,470 246.32 0.39 245.56 247.09 797,659 261.35 0.30 260.77 261.94 195,455 282.10 0.65 280.83 283.37Non-Hispanic White 227,970 244.07 0.52 243.05 245.09 395,887 256.32 0.41 255.52 257.13 78,559 269.52 0.97 267.62 271.43Black 23,663 337.08 2.39 332.42 341.81 93,141 362.56 1.25 360.12 365.01 47,134 366.29 1.72 362.92 369.69American Indian 893 168.46 6.09 156.73 180.96 2,008 133.57 3.13 127.51 139.88 1,651 185.81 4.73 176.66 195.37Asian/Pacific Islander 9,502 162.03 1.76 158.60 165.52 10,426 155.43 1.63 152.24 158.67 1,442 140.80 3.93 133.20 148.77Hispanic 4,178 124.19 2.11 120.10 128.41 18,957 156.59 1.22 154.20 159.01 7,865 179.86 2.13 175.70 184.10

All Cancers, Female

All Races 401,329 170.10 0.27 169.57 170.63 723,847 171.33 0.20 170.93 171.73 171,297 175.30 0.43 174.46 176.14Non-Hispanic White 220,484 171.18 0.37 170.46 171.90 362,719 171.52 0.29 170.96 172.09 69,371 173.93 0.67 172.61 175.26Black 20,818 202.30 1.43 199.50 205.13 79,939 205.95 0.73 204.52 207.40 41,148 200.55 0.99 198.61 202.50American Indian 835 120.81 4.30 112.52 129.59 1,892 96.59 2.26 92.22 101.14 1,574 132.38 3.37 125.85 139.18Asian/Pacific Islander 8,194 108.21 1.25 105.78 110.69 9,324 101.17 1.10 99.02 103.36 1,147 93.22 2.88 87.66 99.09Hispanic 3,845 84.06 1.41 81.32 86.87 16,734 102.61 0.81 101.02 104.22 6,820 113.63 1.40 110.90 116.41

Lung, Male

All Races 128,060 73.13 0.21 72.72 73.54 260,867 83.01 0.16 82.69 83.34 66,498 93.49 0.37 92.77 94.21Non-Hispanic White 69,969 72.95 0.28 72.40 73.50 131,534 82.77 0.23 82.31 83.22 28,133 93.94 0.56 92.84 95.06Black 7,059 96.82 1.24 94.41 99.29 29,777 111.37 0.67 110.06 112.69 14,872 112.16 0.94 110.34 114.02American Indian 324 61.87 3.66 54.89 69.62 659 43.32 1.75 39.96 46.93 489 55.49 2.56 50.58 60.80Asian/Pacific Islander 2,437 41.62 0.88 39.91 43.39 2,658 41.14 0.84 39.50 42.83 381 38.55 2.07 34.59 42.88Hispanic 867 27.27 0.99 25.37 29.30 4,189 35.94 0.58 34.81 37.11 1,800 42.64 1.05 40.61 44.75

Lung, Female

All Races 95,189 40.88 0.13 40.62 41.14 173,396 41.29 0.10 41.09 41.49 38,723 39.78 0.20 39.38 40.18Non-Hispanic White 54,058 42.67 0.18 42.31 43.03 91,876 43.87 0.15 43.58 44.16 17,858 45.33 0.34 44.66 46.01Black 4,103 40.53 0.64 39.28 41.82 16,149 41.72 0.33 41.08 42.37 7,668 37.51 0.43 36.68 38.37American Indian 194 29.65 2.17 25.54 34.27 480 25.64 1.18 23.37 28.08 263 22.49 1.40 19.84 25.42Asian/Pacific Islander 1,523 20.87 0.55 19.80 21.99 1,679 19.32 0.49 18.36 20.31 181 15.38 1.19 13.13 17.94Hispanic 512 12.02 0.54 10.98 13.14 2,057 13.33 0.30 12.75 13.93 887 15.49 0.53 14.47 16.56

Colorectal, Male

All Races 43,275 25.87 0.13 25.62 26.12 79,103 26.36 0.10 26.18 26.55 18,431 27.01 0.20 26.62 27.41Non-Hispanic White 23,491 25.54 0.17 25.21 25.88 39,115 25.66 0.13 25.41 25.92 7,533 26.16 0.30 25.56 26.76Black 2,284 32.93 0.75 31.48 34.45 8,877 35.18 0.39 34.42 35.96 4,270 33.69 0.53 32.66 34.74American Indian 95 19.41 2.15 15.43 24.25 203 13.62 1.00 11.73 15.78 157 17.62 1.45 14.89 20.77Asian/Pacific Islander 951 16.09 0.55 15.03 17.22 1,044 15.96 0.53 14.94 17.04 136 15.01 1.35 12.48 17.93Hispanic 423 12.95 0.68 11.65 14.39 1,949 16.53 0.40 15.76 17.33 753 17.27 0.66 16.00 18.62

Colorectal, Female

All Races 44,878 18.47 0.09 18.30 18.64 80,357 18.41 0.07 18.28 18.54 19,243 19.07 0.14 18.80 19.35Non-Hispanic White 24,372 18.14 0.12 17.91 18.37 39,783 17.91 0.09 17.73 18.09 7,540 17.82 0.21 17.42 18.24Black 2,506 25.63 0.52 24.62 26.68 9,698 25.64 0.26 25.13 26.16 5,063 24.76 0.35 24.08 25.46American Indian 104 16.12 1.61 13.11 19.65 185 9.53 0.71 8.19 11.05 152 12.98 1.06 10.98 15.26Asian/Pacific Islander 834 11.49 0.42 10.68 12.34 973 11.32 0.38 10.58 12.10 117 10.14 0.98 8.31 12.29

Hispanic 351 8.11 0.44 7.26 9.03 1,636 10.64 0.27 10.13 11.18 656 11.29 0.45 10.43 12.20

Continued on page 65
65

Table 3.1. U.S. Site-Specific Cancer Deaths and Age-Adjusted Mortality Rates and 95% Confidence Intervals by Sex, Race/Ethnicity,and County Poverty Rate, 1995–1999 (continued)

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

# Deaths Rate SE Lower CI Upper CI # Deaths Rate SE Lower CI Upper CI # Deaths Rate SE Lower CI Upper CI

Prostate

All Races 48,383 32.14 0.15 31.85 32.43 92,916 33.89 0.11 33.66 34.11 24,118 38.30 0.25 37.81 38.80Non-Hispanic White 25,139 29.93 0.19 29.55 30.31 43,085 30.38 0.15 30.09 30.67 8,025 29.61 0.34 28.96 30.28Black 3,855 71.89 1.22 69.50 74.33 15,157 71.61 0.60 70.43 72.81 8,554 75.33 0.83 73.71 76.97American Indian 58 14.08 1.94 10.53 18.53 186 15.57 1.18 13.35 18.08 168 22.24 1.75 18.95 25.98Asian/Pacific Islander 730 16.40 0.62 15.20 17.68 643 13.09 0.54 12.06 14.19 79 10.12 1.17 7.96 12.72Hispanic 397 15.73 0.82 14.16 17.45 1,888 20.31 0.49 19.37 21.28 850 23.71 0.84 22.09 25.42

Breast, Female

All Races 66,923 28.86 0.11 28.64 29.08 116,897 28.54 0.08 28.38 28.71 27,936 29.62 0.18 29.27 29.98Non-Hispanic White 35,493 28.18 0.15 27.89 28.48 55,927 27.50 0.12 27.27 27.73 10,408 27.41 0.27 26.87 27.95Black 4,108 36.91 0.59 35.76 38.09 14,872 37.26 0.31 36.66 37.87 7,602 37.08 0.43 36.25 37.92American Indian 120 16.22 1.53 13.37 19.57 270 13.26 0.82 11.70 14.99 215 17.44 1.20 15.17 19.98Asian/Pacific Islander 1,178 13.74 0.41 12.94 14.58 1,345 12.50 0.36 11.82 13.23 161 12.08 1.00 10.21 14.25Hispanic 661 13.45 0.54 12.41 14.57 2,884 16.69 0.32 16.07 17.32 1,200 19.02 0.56 17.94 20.15

Cervix 

All Races 5,518 2.43 0.03 2.36 2.49 12,648 3.23 0.03 3.18 3.29 3,920 4.34 0.07 4.20 4.48Non-Hispanic White 2,640 2.20 0.04 2.12 2.29 5,027 2.73 0.04 2.65 2.81 1,087 3.20 0.10 3.01 3.40Black 584 5.04 0.22 4.63 5.49 2,598 6.30 0.12 6.05 6.55 1,432 6.90 0.18 6.55 7.27American Indian 19 2.16 0.52 1.27 3.56 60 2.69 0.36 2.03 3.51 55 4.39 0.60 3.30 5.76Asian/Pacific Islander 230 2.68 0.18 2.34 3.08 351 3.32 0.19 2.96 3.71 49 3.66 0.55 2.67 4.95Hispanic 137 2.40 0.22 2.00 2.88 662 3.43 0.14 3.17 3.71 299 4.51 0.27 4.01 5.07

Melanoma of the Skin, Male

All Races 7,670 4.24 0.05 4.14 4.34 12,511 3.96 0.04 3.89 4.03 2,368 3.34 0.07 3.20 3.47Non-Hispanic White 4,606 4.70 0.07 4.56 4.84 7,382 4.71 0.06 4.60 4.82 1,312 4.51 0.13 4.27 4.76Black 39 0.49 0.09 0.33 0.72 125 0.48 0.05 0.40 0.58 68 0.51 0.06 0.39 0.65American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~Asian/Pacific Islander 30 0.49 0.09 0.33 0.73 37 0.53 0.09 0.36 0.77 ~ ~ ~ ~ ~Hispanic 31 0.88 0.17 0.57 1.33 148 1.09 0.10 0.91 1.31 60 1.18 0.16 0.89 1.57

Melanoma of the Skin, Female

All Races 4,563 1.96 0.03 1.91 2.02 7,447 1.82 0.02 1.78 1.86 1,509 1.58 0.04 1.50 1.66Non-Hispanic White 2,673 2.16 0.04 2.07 2.24 4,189 2.11 0.03 2.05 2.18 821 2.20 0.08 2.05 2.36Black 41 0.42 0.07 0.30 0.57 184 0.47 0.04 0.41 0.55 93 0.45 0.05 0.37 0.56American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~Asian/Pacific Islander 25 0.30 0.06 0.19 0.46 36 0.37 0.06 0.26 0.53 ~ ~ ~ ~ ~

Hispanic 28 0.61 0.12 0.40 0.90 96 0.56 0.06 0.45 0.69 34 0.56 0.10 0.38 0.79

Notes: Rates are per 100,000 and are age-adjusted to the 2000 U.S. standard population by the direct method. Data for Hispanics and non-Hispanic whites are provided for 1997–1999. SE = standard error of

the rate. CI = confidence interval. ~ Counts or rates are suppressed if based on fewer than 16 deaths.
66

Table 3.2. SEER Site-Specific Cancer Incidence (Invasive) Cases and Age-Adjusted Incidence Rates and 95% Confidence Intervals bySex, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1992: 11 SEER Registration Areas

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

# Cases Rate SE Lower CI Upper CI # Cases Rate SE Lower CI Upper CI # Cases Rate SE Lower CI Upper CI

All Cancers, Male

All Races 232,653 588.99 1.29 586.47 591.52 83,244 578.46 2.06 574.43 582.52 54,510 595.56 2.64 590.39 600.77Non-Hispanic White 204,999 601.58 1.39 598.86 604.32 63,807 610.69 2.46 605.87 615.54 23,801 666.87 4.41 658.25 675.59Black 6,316 681.93 10.33 661.84 702.69 7,984 687.29 8.56 670.62 704.41 20,042 732.75 5.40 722.21 743.45American Indian 187 182.30 16.08 152.15 218.93 195 245.09 19.43 208.49 287.64 367 199.45 11.17 178.17 222.87Asian/Pacific Islander 11,209 396.73 4.05 388.84 404.79 4,313 374.22 6.02 362.51 386.29 2,981 384.81 7.31 370.61 399.50Hispanic 7,715 458.50 6.07 446.68 470.64 6,421 393.88 5.63 382.92 405.14 7,144 356.83 4.79 347.49 366.39

All Cancers, Female

All Races 216,894 417.74 0.90 415.97 419.52 76,807 396.42 1.46 393.56 399.29 46,869 379.62 1.79 376.13 383.14Non-Hispanic White 190,103 427.19 0.99 425.25 429.14 58,551 420.74 1.82 417.18 424.33 20,170 443.29 3.35 436.75 449.93Black 5,504 411.47 6.04 399.73 423.52 6,781 392.57 4.92 383.00 402.36 16,148 402.67 3.22 396.37 409.04American Indian 198 134.27 10.46 114.55 157.10 184 167.16 13.25 142.20 196.16 415 167.06 8.54 150.73 184.86Asian/Pacific Islander 11,110 304.76 3.09 298.74 310.90 4,136 290.34 4.75 281.11 299.85 2,566 267.97 5.42 257.45 278.84Hispanic 8,108 332.13 3.91 324.50 339.92 6,692 292.90 3.79 285.52 300.46 7,455 272.62 3.37 266.05 279.33

Lung, Male

All Races 34,895 87.43 0.49 86.47 88.40 14,230 99.20 0.85 97.55 100.88 10,569 116.17 1.15 113.92 118.46Non-Hispanic White 31,096 89.91 0.53 88.87 90.96 11,100 105.56 1.02 103.57 107.58 4,692 130.80 1.94 127.01 134.67Black 1,047 108.39 3.91 100.86 116.57 1,534 129.31 3.59 122.36 136.70 4,428 157.73 2.44 152.98 162.63American Indian 42 38.47 7.04 25.94 58.07 34 45.60 8.31 30.79 66.82 33 18.85 3.38 12.82 27.14Asian/Pacific Islander 1,684 58.47 1.51 55.55 61.56 809 68.81 2.51 63.97 74.02 552 71.77 3.14 65.74 78.31Hispanic 879 59.94 2.26 55.60 64.61 715 50.12 2.05 46.18 54.37 851 49.40 1.81 45.91 53.12

Lung, Female

All Races 24,704 47.14 0.30 46.55 47.74 9,051 46.62 0.50 45.65 47.61 5,768 47.27 0.63 46.04 48.53Non-Hispanic White 22,455 49.51 0.33 48.86 50.17 7,310 52.08 0.63 50.84 53.34 2,772 61.06 1.24 58.66 63.55Black 568 46.93 2.07 42.95 51.22 828 48.24 1.71 44.95 51.74 2,242 55.71 1.20 53.39 58.11American Indian 33 24.13 4.52 16.09 35.59 29 27.72 5.31 18.30 41.48 13 5.59 1.58 2.92 9.93Asian/Pacific Islander 910 27.34 0.96 25.48 29.32 366 27.06 1.48 24.24 30.18 260 27.08 1.71 23.83 30.68Hispanic 614 28.46 1.19 26.18 30.92 478 23.50 1.11 21.39 25.80 483 21.21 0.99 19.32 23.26

Colorectal, Male

All Races 27,530 73.06 0.47 72.15 73.98 9,681 69.71 0.73 68.29 71.15 5,822 66.81 0.90 65.06 68.61Non-Hispanic White 23,981 73.58 0.50 72.60 74.57 7,504 73.18 0.86 71.51 74.89 2,617 74.39 1.48 71.52 77.36Black 690 78.86 3.61 71.93 86.49 839 75.84 2.89 70.28 81.87 2,029 77.02 1.79 73.56 80.63American Indian 25 28.05 6.78 16.38 47.49 22 30.59 7.14 18.24 49.79 37 20.18 3.53 13.86 28.77Asian/Pacific Islander 1,803 64.30 1.63 61.15 67.61 596 52.48 2.26 48.14 57.21 423 55.13 2.77 49.82 60.94Hispanic 865 55.81 2.15 51.69 60.26 684 45.30 1.89 41.67 49.24 708 40.82 1.65 37.64 44.24

Colorectal, Female

All Races 25,818 49.71 0.31 49.10 50.32 10,104 49.86 0.50 48.88 50.86 6,009 48.00 0.63 46.78 49.24Non-Hispanic White 22,771 49.80 0.33 49.15 50.46 7,977 51.29 0.60 50.13 52.48 2,742 52.17 1.05 50.12 54.30Black 686 59.70 2.42 55.04 64.68 957 60.44 2.00 56.58 64.51 2,255 56.45 1.20 54.11 58.87American Indian 19 14.35 3.50 8.33 23.94 18 19.95 4.92 11.49 33.17 33 14.80 2.62 10.11 21.11Asian/Pacific Islander 1,390 42.22 1.21 39.88 44.69 488 37.04 1.77 33.65 40.72 374 39.99 2.11 35.96 44.38

Hispanic 806 38.23 1.41 35.52 41.12 610 31.51 1.32 28.98 34.23 592 25.79 1.10 23.69 28.05

Continued on page 67
67

Table 3.2. SEER Site-Specific Cancer Incidence (Invasive) Cases and Age-Adjusted Incidence Rates and 95% Confidence Intervals bySex, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1992: 11 SEER Registration Areas (continued)

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

# Cases Rate SE Lower CI Upper CI # Cases Rate SE Lower CI Upper CI # Cases Rate SE Lower CI Upper CI

Prostate

All Races 69,032 183.72 0.74 182.28 185.17 22,738 164.48 1.12 162.30 166.69 13,592 160.09 1.41 157.33 162.88Non-Hispanic White 61,596 186.75 0.79 185.20 188.30 17,751 169.33 1.29 166.80 171.88 5,566 155.54 2.12 151.42 159.75Black 2,052 268.41 6.79 255.26 282.26 2,477 242.34 5.34 231.98 253.17 5,922 228.97 3.11 222.91 235.19American Indian 52 64.84 10.33 46.20 90.74 43 64.37 10.36 45.70 89.57 83 55.78 6.30 44.12 69.80Asian/Pacific Islander 2,569 104.91 2.21 100.63 109.36 831 82.23 3.01 76.44 88.41 518 71.87 3.26 65.62 78.64Hispanic 1,893 139.81 3.53 132.97 146.98 1,434 112.52 3.17 106.39 118.98 1,415 94.20 2.63 89.12 99.53

Breast, Female

All Races 69,948 136.33 0.52 135.31 137.35 22,420 120.34 0.82 118.74 121.97 12,348 103.85 0.95 101.99 105.73Non-Hispanic White 61,344 140.53 0.57 139.41 141.66 17,115 129.67 1.04 127.63 131.73 5,431 127.47 1.86 123.85 131.19Black 1,908 129.62 3.23 123.38 136.16 2,061 114.68 2.60 109.64 119.91 4,372 111.42 1.71 108.08 114.84American Indian 61 37.45 5.22 27.93 50.12 49 40.56 6.12 29.46 55.74 84 32.77 3.65 26.01 41.01Asian/Pacific Islander 3,578 91.67 1.61 88.55 94.91 1,146 76.70 2.35 72.16 81.50 577 61.36 2.61 56.35 66.73Hispanic 2,535 101.58 2.11 97.49 105.83 1,914 82.62 1.97 78.81 86.59 1,850 67.55 1.64 64.37 70.87

Cervix 

All Races 4,665 8.78 0.13 8.53 9.04 2,300 12.38 0.27 11.87 12.92 2,381 19.19 0.41 18.40 20.00Non-Hispanic White 3,489 8.00 0.14 7.74 8.28 1,263 10.59 0.31 10.00 11.22 583 15.76 0.69 14.43 17.19Black 244 13.86 0.99 11.98 16.02 273 14.32 0.91 12.60 16.26 742 18.06 0.68 16.76 19.46American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 30 11.96 2.28 7.92 17.59Asian/Pacific Islander 441 10.47 0.52 9.47 11.58 217 14.12 0.99 12.24 16.28 147 15.06 1.27 12.67 17.81Hispanic 427 13.74 0.71 12.38 15.25 519 18.80 0.88 17.11 20.65 868 25.21 0.93 23.43 27.13

Melanoma of the Skin, Male

All Races 8,530 19.36 0.22 18.94 19.80 1,927 12.55 0.30 11.98 13.15 713 7.18 0.28 6.64 7.77Non-Hispanic White 8,023 21.66 0.25 21.17 22.16 1,777 16.97 0.41 16.17 17.80 593 16.60 0.70 15.25 18.04Black 18 1.42 0.43 0.71 3.03 ~ ~ ~ ~ ~ 35 1.27 0.22 0.86 1.83American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~Asian/Pacific Islander 33 1.01 0.19 0.67 1.54 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~Hispanic 96 4.19 0.48 3.30 5.38 71 3.25 0.45 2.43 4.38 55 2.22 0.36 1.58 3.11

Melanoma of the Skin, Female

All Races 7,142 13.52 0.16 13.21 13.84 1,743 9.05 0.22 8.62 9.50 593 4.57 0.19 4.20 4.97Non-Hispanic White 6,518 15.01 0.19 14.64 15.38 1,564 12.55 0.33 11.91 13.22 459 11.31 0.57 10.23 12.50Black 22 1.69 0.41 0.99 2.77 ~ ~ ~ ~ ~ 28 0.72 0.14 0.47 1.05American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~Asian/Pacific Islander 46 1.11 0.18 0.79 1.55 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

Hispanic 158 5.25 0.45 4.40 6.25 95 3.75 0.42 2.97 4.69 81 2.64 0.33 2.04 3.39

Notes: Rates are per 100,000 and are age-adjusted to the 2000 U.S. standard population by the direct method. SE = standard error of the rate. CI = confidence interval. ~ Counts or rates are suppressed if

based on fewer than 16 cases.

Stage of Disease at Diagnosis

69

Cancer staging is a method for grouping

patients based on the extent of the spread of

their cancer from its site of origin. Detecting

cancers at an early, more treatable stage is a

major goal of cancer control efforts, and

knowledge of the stage of disease at the time of

diagnosis is essential for determining the choice

of therapy and in assessing prognosis.

Numerous studies have documented the

association of an early cancer stage at diagnosis

with higher socioeconomic position (39–42,68).

The Summary Staging Classification

The localized-regional-distant summary staging

scheme has been used for many years in

descriptive and statistical analyses of tumor

registry data (69) and is defined below:

Localized: An invasive malignant neoplasm

confined entirely to the organ of origin with no

lymph node involvement.

Regional: A malignant neoplasm that (1) has

extended beyond the limits of the organ of

origin directly into surrounding organs or

tissues; or (2) involves regional lymph nodes by

way of the lymphatic system; or (3) has both

regional extension and involvement of regional

lymph nodes.

Distant: A malignant neoplasm that has spread

to parts of the body remote from the primary

tumor either by direct extension or by

discontinuous metastasis (e.g., implantation or

seeding) to distant organs, tissues, or via the

lymphatic system to distant lymph nodes.

The best available information on stage of

disease, as it appears in the medical record

within two months of diagnosis, was used to

classify the cancers. Thus, staging is based on a

combination of clinical and operative/

pathological assessment. Since many surgically

treated prostate cancer cases undergoing radical

prostatectomy are reclassified from clinically

localized- to regional-stage disease based on the

more accurate information obtained from the

operative or pathology report (70), localizedand regional-stage prostate cancers are

combined for the analyses by stage in this

report.

Area Socioeconomic and Racial/Ethnic

Patterns in Early- and Late-Stage Cancer

Diagnoses

During 1988–1999, for each of the cancers

considered, men and women in high poverty

census tracts had a higher percentage of latestage cancer diagnoses than those in low

Stage of Disease at Diagnosis
poverty census tracts (Figures 4.1–4.18, pages

72–85; Table 4.1, page 86). This was also

generally true for each racial/ethnic group. The

largest socioeconomic gradients occurred for

patients diagnosed during 1995–1999 with

distant-stage melanoma of the skin (ratio of

percent diagnosed with distant-stage disease in

highest:lowest poverty areas = 9.17:3.73 = 2.5

for men and 5.42:2.52 = 2.2 for women),

distant-stage prostate cancer (highest:lowest

poverty areas = 9.06:4.76 = 1.9), and distantstage female breast cancer (highest:lowest

poverty areas = 8.59:5.04 = 1.7). The socioeconomic gradients for distant-stage colorectal

cancer in men and women and for cervical

cancer were similar (highest:lowest poverty areas

= 9.77:8.22 = 1.2). The majority of lung cancer

cases are diagnosed at distant stage, and a

socioeconomic gradient, with persons in the

highest poverty areas more likely to be

diagnosed at distant stage, consistently appears

for men and women in each racial/ethnic group

with the exception of black women.

Patients in low poverty areas were generally

more likely to be diagnosed with early-stage

(localized) cancers. The largest socioeconomic

gradient for localized diagnoses occurred for

male patients with melanoma of the skin

(lowest:highest poverty areas = 1.2 for men and

1.1 for women). Sixty-seven percent of female

breast cancer patients in the lowest poverty

areas were diagnosed with localized-stage

disease, whereas only 59% of those in the high

poverty areas were diagnosed at this stage. 

A similar difference was seen for cervical cancer,

with nearly 60% of the diagnoses in low poverty

areas being at the localized stage while only

52% of the diagnoses in high poverty areas were

localized.

Trends in Area Socioeconomic Gradients in

the Stage Distribution

Time trends in the stage of disease distribution

for each of the specific cancers are included in

Figures 4.10–4.18, pages 81–85. The socioeconomic gradients noted in the cross-sectional

data above persisted throughout the 1988–1999

time period and, with the exception of prostate

cancer, were generally stable. The percentage of

prostate cancers diagnosed at local or regional

stage increased from 1988 through 1999 in all

socioeconomic groups. A socioeconomic

gradient persisted over the time period, with the

lowest poverty group having the largest

percentage of local/regional-stage cancers. As

expected, the rise in local/regional-stage cancers

was accompanied by a decline in the percentage

of distant-stage cancers over the time period. A

socioeconomic gradient was also evident among

the distant-stage prostate cancers; however, the

association was reversed, with the highest

poverty group having the highest percentage of

distant-stage cancers. These patterns coincide

with the rising utilization of the prostate-specific

antigen (PSA) test for prostate cancer screening

since the late 1980s (71). The stage distribution

of female breast cancer cases remained stable

from 1988 to 1999. A consistent socioeconomic

70
gradient was also apparent over this time

period. Data are grouped into three-year moving

average categories for cancers of the lung,

colorectum, uterine cervix, and melanoma of

the skin to help visualize patterns by stage of

disease when the data are sparse. Trends in the

stage distribution for cervical cancer diagnoses

indicate persistent and substantial socioeconomic differences in the percentage of

localized- or regional/distant-stage cancers, with

little or no change in the gradient in the 1990s.

For melanoma of the skin, the percentage of

cases diagnosed at regional or distant stage

appeared to be increasing during 1995–1999

among men in the high poverty group. This is a

disturbing finding that deserves further study.

71
Figure 4.1. Distribution of SEER Lung Cancer Cases Among Men by Stage, Race/Ethnicity, and Census Tract Poverty Rate, 1995–1999

72

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

17.7

16.4 15.7

18.0

16.9 16.7

14.2 14.9 16.0 16.2 16.6 15.2 15.0 13.3

10.7

Regional Stage

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

27.7 27.7

25.3

27.7 27.8 26.7 26.6

24.3

29.1

27.8

25.5

28.9

27.3

26.1

23.4

Distant Stage

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

54.6

56.0

59.0

54.3

55.3

56.6 56.7

58.5

59.7

56.0

54.5

59.3

57.8

60.7

65.9
Figure 4.2. Distribution of SEER Lung Cancer Cases Among Women by Stage, Race/Ethnicity, and Census Tract Poverty Rate, 1995–199

9

73

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

21.5

20.0

18.8

22.0

20.8

19.1

16.1

19.2 18.7 17.6

16.0

18.2

16.8

15.5

18.6

Regional Stage

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

26.5

24.9 24.4

26.7

25.0 25.3

27.3 26.6

24.9

23.5

22.1 21.0

24.9

23.7

20.6

Distant Stage

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

52.0

55.0

56.8

51.4

54.2

55.7 56.6 54.8 55.9

60.3

63.0

60.8 60.8

58.3 58.3
Figure 4.3. Distribution of SEER Colorectal Cancer Cases Among Men by Stage, Race/Ethnicity, and Census Tract Poverty Rate,

1995–1999

74

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

5040302010

0

43.2

40.8

40.0

43.0

41.4 41.4 41.4

38.3 38.9

45.2

41.1

38.2

41.6

37.0

41.2

Regional Stage

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

5040302010

0

37.8

36.3

39.1

37.8

35.4

39.3

34.6

36.9

35.4

38.9 39.1 39.3

40.2

38.2 38.6

Distant Stage

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

5040302010

0

20.1

23.7

19.1

23.2

19.2 19.3

24.1 24.3

26.3

15.9

22.6

19.8 19.8

22.8

20.6
Figure 4.4. Distribution of SEER Colorectal Cancer Cases Among Women by Stage, Race/Ethnicity, and Census Tract Poverty Rate,

1995–1999

75

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

5040302010

0

41.5

39.9

38.7

41.6

40.1 39.5 39.2 38.6 38.7

43.3

41.3

38.8

35.8

37.8

36.4

Regional Stage

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

5040302010

0

40.0 39.8 39.2 40.1 40.0 40.4

37.6 38.1 37.2

41.3

43.2

39.4

43.6

39.6 39.7

Distant Stage

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

5040302010

0

18.5

20.3

22.1

18.3

20.0 20.2

23.2 23.2

24.0

17.4 17.3 18.0

20.6

22.6

23.9
Figure 4.5. Distribution of SEER Prostate Cancer Cases by Stage, Race/Ethnicity, and Census Tract Poverty Rate, 1995–1999

76

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized/Regional Stage

< 10% 10% to 19.99% 20% or higher

100

Percent of Cases

80604020

0

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

95.2 93.3

90.9

95.4 93.6 92.4 95.2 92.8 90.1 92.4 91.8 89.0 93.9 92.0 90.6

Distant Stage

Percent of Cases

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

100

80604020

0

4.8 6.7

9.1

4.6 6.4 7.6 4.8 7.3 9.9 7.6 8.2 11.0 6.2 8.0 9.4
Figure 4.6. Distribution of SEER Female Breast Cancer Cases by Stage, Race/Ethnicity, and Census Tract Poverty Rate, 1995–1999

77

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

67.0

64.3

59.0

67.6

65.9

63.4

55.9

66.8 66.3

61.0 61.2

54.7

57.9 58.3 58.2

28.0

32.4

27.4 27.8

35.1

33.2 33.9 33.2 33.0 34.2

35.7

29.1

Regional Stage

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

29.3 28.8 29.1

Distant Stage

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

5.0

6.5

5.0

6.3

7.3 7.0

10.2

4.4 4.6

5.8 5.8

7.6

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

8.6 8.4 9.6
Figure 4.7. Distribution of SEER Cervical Cancer Cases by Stage, Race/Ethnicity, and Census Tract Poverty Rate, 1995–1999

78

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

57.1

52.3

59.6 59.3

57.6

54.0

57.1

52.9

49.5

56.2

53.8 54.0

61.9

59.2

53.4

Regional Stage

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

32.2

34.1

37.9

32.0

33.6

35.5

32.8

35.4

40.3

36.9

40.0

38.1

31.4

32.8

37.0

Distant Stage

Percent of Cases

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

8.2 8.8 9.8 8.7 8.8 10.6 10.1

11.8

10.2

6.9 8.1 6.0 6.8 8.1

9.7
Figure 4.8. Distribution of SEER Skin Melanoma Cases Among Men by Stage, Race/Ethnicity, and Census Tract Poverty Rate, 1995–199

9

79

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Percent of Cases

All Races Non-Hispanic

White

Hispanic

907560453015

0

86.0

80.4

74.2

85.6

81.1

77.0

73.9

63.9

55.4

Regional Stage

Percent of Cases

All Races Non-Hispanic

White

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

3025201510

50

10.3

16.7

14.2

10.5

13.6

15.5

28.6

26.8

18.1

Distant Stage

Percent of Cases

All Races Non-Hispanic

White

Hispanic

201510

50

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

3.7

5.4

9.2

3.9

5.3

7.5

8.0

9.3

16.1
Figure 4.9. Distribution of SEER Skin Melanoma Cases Among Women by Stage, Race/Ethnicity, and Census Tract Poverty Rate,

1995–1999

80

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Percent of Cases

All Races Non-Hispanic

White

Hispanic

100

80604020

0

89.1

85.5

79.2

89.0

85.7

82.4 83.9

77.0

74.4

Regional Stage

Percent of Cases

All Races Non-Hispanic

White

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

201612

840

8.4

15.3

11.3

8.5

13.8

11.3 11.7

16.0

18.6

Distant Stage

Percent of Cases

All Races Non-Hispanic

White

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

10

86420

2.5

3.3

5.4

2.6

3.0

3.9

4.5

7.0 7.0
Figure 4.10. Trends in Lung Cancer Diagnoses Among Men by Stage (Three-Year Moving Averages),

1988–1999

81

Figure 4.11. Trends in Lung Cancer Diagnoses Among Women by Stage (Three-Year Moving

Averages), 1988–1999

Note: Based on data from 11 SEER registries. Los Angeles registry data from 1988 to 1991 were not available. 

See “Data and Methods” for a list of SEER registries. Percent

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1988– 90

1989– 91

1990– 92

1991– 93

1992– 94

1993– 95

1994– 96

1995– 97

1996– 98

1997– 99

60

50

40

30

20

10

0

Localized+Regional Stage

Distant Stage

Percent

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1988– 90

1989– 91

1990– 92

1991– 93

1992– 94

1993– 95

1994– 96

1995– 97

1996– 98

1997– 99

60

50

40

30

20

10

0

Distant Stage

Localized+Regional Stage
Figure 4.12. Trends in Colorectal Cancer Diagnoses Among Men by Stage (Three-Year Moving

Averages), 1988–1999

82

Figure 4.13. Trends in Colorectal Cancer Diagnoses Among Women by Stage (Three-Year Moving

Averages), 1988–1999

Note: Based on data from 11 SEER registries. Los Angeles registry data from 1988 to 1991 were not available. 

See “Data and Methods” for a list of SEER registries. Percent

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1988– 90

1989– 91

1990– 92

1991– 93

1992– 94

1993– 95

1994– 96

1995– 97

1996– 98

1997– 99

90

80

70

60

50

40

30

20

10

0

Localized+Regional Stage

Distant Stage

Percent

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1988– 90

1989– 91

1990– 92

1991– 93

1992– 94

1993– 95

1994– 96

1995– 97

1996– 98

1997– 99

90

80

70

60

50

40

30

20

10

0

Localized+Regional Stage

Distant Stage
Figure 4.14. Trends in Prostate Cancer Diagnoses by Stage, 1988–1999

83

Figure 4.15. Trends in Female Breast Cancer Diagnoses by Stage, 1988–1999

Note: Based on data from 11 SEER registries. Los Angeles registry data from 1988 to 1991 were not available. 

See “Data and Methods” for a list of SEER registries. Percent

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1988

1990

1992

1993

1995

1998

1999

100

90

80

70

60

50

40

30

20

10

0

Localized+Regional Stage

Distant Stage

1989

1991

1994

1996

1997

Percent

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

70

60

50

40

30

20

10

0

Localized Stage

Regional Stage

Distant Stage

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999
Figure 4.16. Trends in Cervical Cancer Diagnoses by Stage (Three-Year Moving Averages), 1988–1999

84

Note: Based on data from 11 SEER registries. Los Angeles registry data from 1988 to 1991 were not available. 

See “Data and Methods” for a list of SEER registries. Percent

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1988– 90

1989– 91

1990– 92

1991– 93

1992– 94

1993– 95

1994– 96

1995– 97

1996– 98

1997– 99

70

60

50

40

30

20

10

0

Localized Stage

Regional+Distant Stage
Figure 4.17. Trends in Melanoma of the Skin Diagnoses Among Men by Stage (Three-Year Moving

Averages), 1988–1999

85

Note: Based on data from 11 SEER registries. Los Angeles registry data from 1988 to 1991 were not available. 

See “Data and Methods” for a list of SEER registries.

Figure 4.18. Trends in Melanoma of the Skin Diagnoses Among Women by Stage (Three-Year Moving

Averages), 1988–1999 Percent

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1988– 90

1989– 91

1990– 92

1991– 93

1992– 94

1993– 95

1994– 96

1995– 97

1996– 98

1997– 99

100

80

60

40

20

0

Localized Stage

Regional+Distant Stage

Percent

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1988– 90

1989– 91

1990– 92

1991– 93

1992– 94

1993– 95

1994– 96

1995– 97

1996– 98

1997– 99

100

80

60

40

20

0

Localized Stage

Regional+Distant Stage
86

Table 4.1. Distribution of SEER Site-Specific Cancer (Invasive) Cases by Stage, Sex, Race/Ethnicity, and Census Tract Poverty Rate,1995–1999: 11 SEER Registration Areas

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

Localized Stage Regional Stage Distant Stage Localized Stage Regional Stage Distant Stage Localized Stage Regional Stage Distant Stage

Count % Count % Count % Count % Count % Count % Count % Count % Count %

Lung, Male

All Races 5,350 17.69 8,383 27.71 16,518 54.60 1,851 16.35 3,136 27.70 6,336 55.96 1,230 15.68 1,984 25.29 4,630 59.03Non-Hispanic White 4,708 18.04 7,225 27.68 14,168 54.28 1,412 16.89 2,328 27.84 4,621 55.27 507 16.67 813 26.73 1,721 56.59Black 169 14.21 346 29.10 674 56.69 201 14.89 359 26.59 790 58.52 545 15.97 830 24.32 2,038 59.71American Indian ~ ~ ~ ~ 26 70.27 ~ ~ ~ ~ 24 72.73 ~ ~ ~ ~ 26 61.90Asian/Pacific Islander 336 16.16 578 27.80 1,165 56.04 141 16.57 246 28.91 464 54.52 93 15.22 156 25.53 362 59.25Hispanic 118 14.96 215 27.25 456 57.79 94 13.26 185 26.09 430 60.65 79 10.73 172 23.37 485 65.90

Lung, Female

All Races 5,498 21.53 6,753 26.45 13,283 52.02 1,691 20.09 2,099 24.94 4,627 54.97 909 18.83 1,178 24.40 2,740 56.76Non-Hispanic White 4,979 21.97 6,045 26.67 11,641 51.36 1,351 20.79 1,624 24.99 3,524 54.22 395 19.07 523 25.25 1,153 55.67Black 122 16.14 206 27.25 428 56.61 169 18.69 240 26.55 495 54.76 380 19.24 491 24.86 1,104 55.90American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~Asian/Pacific Islander 240 18.17 311 23.54 770 58.29 87 17.61 109 22.06 298 60.32 48 16.00 63 21.00 189 63.00Hispanic 115 16.84 170 24.89 398 58.27 77 15.46 118 23.69 303 60.84 84 18.58 93 20.58 275 60.84

Colorectal, Male

All Races 11,661 43.19 10,197 37.76 5,144 19.05 3,706 40.79 3,554 39.12 1,826 20.10 1,983 39.95 1,803 36.32 1,178 23.73Non-Hispanic White 9,669 42.95 8,520 37.84 4,325 19.21 2,709 41.38 2,574 39.32 1,263 19.29 797 41.36 683 35.44 447 23.20Black 359 41.36 300 34.56 209 24.08 353 38.83 335 36.85 221 24.31 665 38.26 616 35.44 457 26.29American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 26 50.98 ~ ~Asian/Pacific Islander 1,055 45.22 908 38.92 370 15.86 306 41.13 291 39.11 147 19.76 176 38.18 181 39.26 104 22.56Hispanic 458 41.60 425 38.60 218 19.80 314 37.03 341 40.21 193 22.76 316 41.20 293 38.20 158 20.60

Colorectal, Female

All Races 10,835 41.51 10,441 40.00 4,824 18.48 3,699 39.92 3,686 39.78 1,882 20.31 1,977 38.69 2,003 39.20 1,130 22.11Non-Hispanic White 9,146 41.60 8,810 40.08 4,027 18.32 2,744 40.07 2,738 39.98 1,366 19.95 803 39.48 821 40.36 410 20.16Black 374 39.20 359 37.63 221 23.17 384 38.63 379 38.13 231 23.24 769 38.74 739 37.23 477 24.03American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 20 42.55 17 36.17Asian/Pacific Islander 855 43.25 778 39.35 344 17.40 260 41.34 260 41.34 109 17.33 149 38.80 166 43.23 69 17.97Hispanic 359 35.83 437 43.61 206 20.56 281 37.82 294 39.57 168 22.61 240 36.36 262 39.70 158 23.94

Prostate

All Races 67,773 95.24 3,388 4.76 20,125 93.27 1,452 6.73 12,053 90.94 1,201 9.06Non-Hispanic White 56,467 95.44 2,698 4.56 13,734 93.59 940 6.41 4,011 92.38 331 7.62Black 3,457 95.18 175 4.82 3,070 92.75 240 7.25 5,450 90.13 597 9.87American Indian 39 92.86 ~ ~ 40 93.02 ~ ~ 90 84.91 16 15.09Asian/Pacific Islander 3,488 92.37 288 7.63 1,097 91.80 98 8.20 566 88.99 70 11.01Hispanic 2,596 93.85 170 6.15 1,839 92.00 160 8.00 1,736 90.61 180 9.39

Breast, Female

All Races 54,058 66.95 22,619 28.01 4,072 5.04 15,051 64.33 6,817 29.14 1,527 6.53 7,189 59.01 3,946 32.39 1,047 8.59Non-Hispanic White 45,891 67.60 18,613 27.42 3,380 4.98 10,995 65.94 4,632 27.78 1,046 6.27 2,967 63.40 1,372 29.32 341 7.29Black 1,682 57.92 1,020 35.12 202 6.96 1,493 58.32 851 33.24 216 8.44 2,386 55.92 1,448 33.93 433 10.15American Indian 42 51.85 30 37.04 ~ ~ 32 49.23 27 41.54 ~ ~ 62 54.87 41 36.28 ~ ~Asian/Pacific Islander 3,902 66.82 1,681 28.78 257 4.40 1,099 66.28 483 29.13 76 4.58 544 60.99 296 33.18 52 5.83Hispanic 2,093 61.20 1,130 33.04 197 5.76 1,360 58.24 798 34.18 177 7.58 1,206 54.72 787 35.71 211 9.57

Cervix 

All Races 2,560 59.59 1,383 32.19 353 8.22 1,162 57.07 695 34.14 179 8.79 1,055 52.31 765 37.93 197 9.77Non-Hispanic White 1,756 59.32 946 31.96 258 8.72 572 57.60 334 33.64 87 8.76 228 53.90 150 35.46 45 10.64Black 136 57.14 78 32.77 24 10.08 130 52.85 87 35.37 29 11.79 291 49.49 237 40.31 60 10.20American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~Asian/Pacific Islander 318 56.18 209 36.93 39 6.89 127 53.81 90 38.14 19 8.05 81 54.00 60 40.00 9 6.00Hispanic 284 61.87 144 31.37 31 6.75 323 59.16 179 32.78 44 8.06 437 53.36 303 37.00 79 9.65

Melanoma of the Skin, Male

All Races 9,625 85.98 1,152 10.29 417 3.73 1,900 80.41 335 14.18 128 5.42 534 74.17 120 16.67 66 9.17Non-Hispanic White 8,907 85.61 1,096 10.53 401 3.85 1,742 81.10 293 13.64 113 5.26 472 77.00 95 15.50 46 7.50Black 32 76.19 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~Asian/Pacific Islander 62 83.78 11 14.86 1 1.35 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~Hispanic 102 73.91 25 18.12 11 7.97 62 63.92 26 26.80 ~ ~ 31 55.36 16 28.57 ~ ~

Melanoma of the Skin, Female

All Races 7,890 89.07 745 8.41 223 2.52 1,678 85.48 221 11.26 64 3.26 439 79.24 85 15.34 30 5.42Non-Hispanic White 7,185 88.95 683 8.46 210 2.60 1,510 85.70 199 11.29 53 3.01 341 82.37 57 13.77 16 3.86Black 26 86.67 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~Asian/Pacific Islander 55 79.71 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

Hispanic 187 83.86 26 11.66 10 4.48 77 77.00 16 16.00 ~ ~ 64 74.42 16 18.60 ~ ~

Notes: Stage distribution data for prostate cancer cases are presented for distant stage and the combined category of localized/regional stage. ~ Counts or percentages are suppressed if based on fewer than 16 cases.
Treatment (Cancer-Directed Surgery)

87

Several studies have reported associations

between the type of medical treatment given to

cancer patients and socioeconomic and

demographic factors, even after controlling for

differences in clinical presentation (72–86). Age

(72,75,76,81,82,86), race (74,77,78), marital

status (84,85), geographic location (83), type of

medical insurance (73), education

(75,76,78,80,82), and income (75,79,80) have all

been found to play a role. In this section, we

describe socioeconomic patterns (as measured

by the census tract poverty variable) in the

surgical treatment given to patients with three

types of cancer. Since published treatment

recommendations (87) often refer to the

American Joint Committee on Cancer 0–IV

staging classification scheme (88), we present

some of the results using this scheme instead of

the localized-regional-distant summary staging

scheme used elsewhere.

Non-Small-Cell Lung Cancer,

Stages I or II

Surgical resection has been shown to confer a

definitive benefit to patients with stage I or II

non-small-cell lung cancer (89). Among men

diagnosed with this type and stage of lung

cancer, there was a consistent area

socioeconomic gradient in surgery rates for each

racial/ethnic group; those in the lowest census

tract poverty group (highest SES group) had the

highest likelihood of undergoing surgery (Table

5.1, page 92, and Figure 5.1, page 89). Among

women, the socioeconomic gradient was

apparent only for non-Hispanic whites. Black

women tended to be less likely to undergo

surgery than other racial/ethnic groups (Figure

5.2, page 89).

Prostate Cancer, Localized or

Regional Stage 

The optimal course of treatment for

nonmetastatic prostate cancer is controversial

given the paucity of definitive evidence on the

efficacy of aggressive therapies (radical

prostatectomy or radiation therapy) compared

to conservative management (hormonal therapy

or observation) (90). This lack of a consensus on

the therapeutic management of prostate cancer

leads to variations in practice that may be

linked to both clinical and nonclinical factors

(78,91). Since radical prostatectomy is

infrequently performed in older men, Figure 5.3,

page 90, only shows surgery patterns among

men under age 70 by race/ethnicity and area

socioeconomic status. Table 5.2, page 93,

however, contains surgery data for men aged

under 70 as well as those aged 70 years or older.

There were clear socioeconomic gradients in the

frequency of prostatectomy for non-Hispanic

white and black men aged under 70 years, with

Treatment (Cancer-Directed Surgery)
the highest surgery frequency occurring in the

lowest poverty group. The percentage of black

patients receiving radical prostatectomy was the

lowest among the four racial/ethnic groups

within each area socioeconomic group. Radical

prostatectomy was most common among

Hispanic men, with only a slight drop in the

frequency in the highest poverty group. There

was no clear socioeconomic pattern in the

frequency of surgery for Asian and Pacific

Islanders. 

Breast Cancer, Stages I or II, 

<= 2 cm

Breast-conserving surgery has become the

preferred method of treatment for many

patients with stage I or II breast cancers (92).

Among women diagnosed during 1995–1998

with stage I or II breast cancers, 2 cm or less in

diameter, there was a consistent socioeconomic

gradient in the percentage receiving breastconserving surgery (BCS). For this analysis, BCS

was defined to include partial or segmental

mastectomy, quadrantectomy, tylectomy, wedge

resection, nipple resection, lumpectomy, and

excisional biopsy with or without dissection of

axillary lymph nodes. BCS was most commonly

performed in low poverty census tracts (high

SES areas), and this relationship held for each

racial/ethnic group (Table 5.3, page 93, and

Figure 5.4, page 90). The percentage of black

patients receiving BCS was somewhat higher

than other racial/ethnic groups within each

socioeconomic group. BCS was performed less

frequently among API women, however, than

among other racial/ethnic groups. This was due

to the greater likelihood of API women to

undergo mastectomies (data not shown). These

findings are similar to those reported in other,

smaller studies (93–96). The percentage of

women receiving BCS increased steadily in each

socioeconomic group over the time period

1988–1998, though women in the lowest

poverty group consistently showed the highest

levels of BCS (Figure 5.5, page 91).

88
Figure 5.1. Percentage of Stages I and II Non-Small-Cell Male Lung Cancer Patients Undergoing

Surgery, 1995–1999

89

Figure 5.2. Percentage of Stages I and II Non-Small-Cell Female Lung Cancer Patients Undergoing

Surgery, 1995–1999

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries. Percent Receiving Surgical Treatment

< 10% 10% to 19.99% 20% or higher

Non-Hispanic Hispanic

White

All Races

Percent of Census Tract Population Below Poverty Level in 1990

Black Asian/Pacific

Islander

90

80

70

60

50

40

30

20

10

0

72.6

66.8

57.8

72.6

61.2

66.6

74.6

52.4

68.0

71.5

63.2

66.3

75.3

69.5

66.4

< 10% 10% to 19.99% 20% or higher

Percent of Census Tract Population Below Poverty Level in 1990

Non-Hispanic Hispanic

White

All Races Black Asian/Pacific

Islander

Percent Receiving Surgical Treatment

90

80

70

60

50

40

30

20

10

0

73.2

70.0

63.0

73.2

69.7

66.0 68.1 68.6

58.6

81.0

76.2 76.5

71.0 71.1

57.7
Figure 5.3. Percentage of SEER Localized- and Regional-Stage Prostate Cancer Patients Aged Less

Than 70 Years Undergoing Radical Prostatectomy, 1995–1999

90

Figure 5.4. Percentage of Stages I and II Female Breast Cancer Patients With Tumor Size <= 2 cm

Undergoing Breast-Conserving Surgery, 1995–1998

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries. Percent

< 10% 10% to 19.99% 20% or higher

Non-Hispanic Hispanic

White

All Races

Percent of Census Tract Population Below Poverty Level in 1990

Black Asian/Pacific

Islander

60

50

40

30

20

10

0

56.2

53.0

44.0

57.3

55.3

46.4

51.1

44.6

39.4

52.4 53.3

48.2

59.4 59.9

54.2

< 10% 10% to 19.99% 20% or higher

Percent of Census Tract Population Below Poverty Level in 1990

Percent of Women

Non-Hispanic Hispanic

White

All Races Black Asian/Pacific

Islander

70

60

50

40

30

20

10

0

62.9

56.6 56.4

63.4

55.7 54.7

65.8

63.1

60.3

56.4

51.8

47.4

61.5 60.9

57.3
Figure 5.5. Percentage of Stages I and II Female Breast Cancer Patients With Tumor Size <= 2 cm

Undergoing Breast-Conserving Surgery, 1988–1998

91

Note: Based on data from 11 SEER registries. Los Angeles registry data from 1988 to 1991 were not available. 

See “Data and Methods” for a list of SEER registries. Percent

70

60

50

40

30

20

10

0

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

19881989199019911992199319941995199619971998
92

Table 5.1. Number and Percentage of AJCC Stages I and II Non-Small-Cell Lung Cancer Patients

Receiving Surgical Treatment by Sex, Race/Ethnicity, and Census Tract Poverty Rate, 1995–1999: 

11 SEER Registration Areas

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

Number Percent Number Percent Number Percent

Male

All Races 5,316 72.63 1,697 66.76 928 57.75

Non-Hispanic White 4,647 72.62 1,297 66.55 407 61.20

Black 188 74.60 189 67.99 365 52.37

Asian/Pacific Islander 343 71.46 126 66.32 79 63.20

Hispanic 125 75.30 82 69.49 73 66.36

Female

All Races 4,925 73.15 1,428 70.00 672 62.98

Non-Hispanic White 4,439 73.17 1,107 69.67 301 66.01

Black 111 68.10 164 68.62 269 58.61

Asian/Pacific Islander 249 76.15 88 76.52 51 80.95

Hispanic 98 71.01 64 71.11 49 57.65
93

Table 5.2. Number and Percentage of Localized- and Regional-Stage Prostate Cancer Patients

Undergoing Radical Prostatectomy by Age, Race/Ethnicity, and Census Tract Poverty Rate,

1995–1999: 11 SEER Registration Areas

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

Number Percent Number Percent Number Percent

Age Under 70 Years

All Races 20,844 56.16 5,461 52.97 2,787 43.95

Non-Hispanic White 17,537 57.31 3,646 55.27 922 46.42

Black 1,336 51.07 888 44.56 1,222 39.38

Asian/Pacific Islander 837 52.44 219 48.24 106 53.27

Hispanic 924 59.38 655 59.93 500 54.17

Age 70 Years or Older

All Races 3,903 12.76 1,269 12.95 520 9.12

Non-Hispanic White 3,382 13.09 942 13.22 202 10.00

Black 85 10.14 103 9.56 150 6.39

Asian/Pacific Islander 233 12.36 70 10.94 45 12.33

Hispanic 175 16.84 148 19.84 120 14.76

Table 5.3. Number and Percentage of AJCC Stages I and II Female Breast Cancer Patients With

Tumor Size <= 2 cm Undergoing Breast-Conserving Surgery by Race/Ethnicity and Census Tract

Poverty Rate, 1995–1998: 11 SEER Registration Areas

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

Number Percent Number Percent Number Percent

All Races 24,081 62.88 5,831 56.61 2,593 56.36

Non-Hispanic White 20,756 63.37 4,286 55.69 1,101 54.72

Black 730 65.77 598 63.08 893 60.34

Asian/Pacific Islander 1527 56.41 381 51.77 162 47.37

Hispanic 876 61.47 514 60.90 406 57.26

Survival 

95

Stage of disease at diagnosis is the most

important factor affecting cancer patient

survival (20,96). Many studies have also shown

consistently poorer survival among cancer

patients of lower socioeconomic status

(43,44,68,93,98–102). Patients of lower

socioeconomic status or those living in more

disadvantaged areas have substantially higher

rates of late-stage diagnoses of breast, prostate,

and colorectal cancers than their higher SES

counterparts (39–42,103–105). Since a late-stage

diagnosis is associated with reduced survival,

cancer survival would be expected to be lower

among low SES than high SES patients, all else

being equal. However, stage at diagnosis does

not fully account for the socioeconomic

differences in survival (68).

Area Socioeconomic and Racial/Ethnic

Patterns in Survival, the 1988–1994 Patient

Cohort

The survival measure used in this report

represents the percentage of patients diagnosed

with cancer between 1988 and 1994 who did

not die of the neoplasm within five years from

the time of diagnosis. For all cancers combined

as well as for the individual cancers considered,

both men and women in high poverty census 

tracts generally had lower rates of cancer

survival than those in low poverty census tracts

(Tables 6.1–6.4, pages 114–117; Figures 6.1–6.24,

pages 97–113). Among men, the five-year

survival rate for all cancers combined was about

61% in low poverty areas but only 49% in high

poverty areas (Table 6.1, page 114; Figure 6.3,

page 98). The pattern among women was

similar, with five-year survival for all cancers at

63.4% in low poverty areas and only 53.1% in

high poverty areas. Socioeconomic differentials

in cancer survival were apparent within each

racial/ethnic group with the exception of

American Indians/Alaska natives.

Among women with breast cancer, fiveyear survival was 86.4% for those in census

tracts with a poverty rate of less than 10% and

only 77.5% for those in census tracts with a

20% or higher poverty rate. Socioeconomic

differentials in survival were also large among

men and women with melanoma of the skin

and colorectal cancers. Moderate socioeconomic

differentials in survival were seen for cancers of

the cervix uteri and prostate. Even though fiveyear survival rates for lung cancer patients are

consistently low, a socioeconomic gradient is

apparent.

Survival
For many types of cancer, ethnic

differentials in cancer survival were apparent

within each area socioeconomic group. These

racial/ethnic differences in cancer survival were

substantially reduced, however, after controlling

for stage of disease at diagnosis (Tables 6.2–6.4,

pages 115–117). Socioeconomic gradients in

survival were generally most pronounced for

regional-stage disease (Table 6.3, page 116). For

example, five-year cause-specific survival rates

for women diagnosed with regional-stage breast

cancer were 79.6% among those living in low

poverty census tracts and 71.2% for those in

high poverty census tracts. Socioeconomic

differences in survival were also substantial for

localized-stage lung cancer (Table 6.2, page 115)

and distant-stage cancer of the cervix uteri

(Table 6.4, page 117).

Trends in Survival from Cancers of the

Prostate and Female Breast

Trends in the survival rates from 1988 through

1994 are shown for the two most frequently

diagnosed cancers: male prostate and female

breast (Figures 6.13 and 6.16, pages 105 and

107, respectively). Area socioeconomic

differences persisted throughout the time period

for both cancers. Prostate cancer survival

improved between 1988 and 1994 for men in all

area poverty groups, with socioeconomic

inequalities diminishing slightly because of

somewhat larger gains in survival among men

in high poverty areas. Socioeconomic

differentials in female breast cancer survival

appear to be relatively unchanged between 1988

and 1994, with little or no improvement in

survival among women in each area group.

96
Figure 6.1. Trends in SEER Cancer (All Sites Combined) Survival Among Men, 1988–1994

97

Figure 6.2. Trends in SEER Cancer (All Sites Combined) Survival Among Women, 1988–1994

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries. Five-Year Cause-Specific Survival Rate (%)

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1988

1989

1990

1991

1992

1993

1994

70

60

50

40

30

20

10

0

Five-Year Cause-Specific Survival Rate (%)

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1988

1989

1990

1991

1992

1993

1994

70

60

50

40

30

20

10

0
Figure 6.3. SEER Cancer (All Sites Combined) Survival Among Men, 1988–1994 Patient Cohort

98

Figure 6.4. SEER Cancer (All Sites Combined) Survival Among Women, 1988–1994 Patient Cohort

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries. Five-Year Cause-Specific Survival Rate (%)

< 10% 10% to 19.99% 20% or higher

Non-Hispanic Hispanic

White

All Races Black Asian/Pacific

Islander

70

60

50

40

30

20

10

0

61.0

55.0

49.0

61.5

56.0

51.7

57.5

51.2

45.3

54.9

47.9

43.7

59.9

55.4 53.8

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

Five-Year Cause-Specific Survival Rate (%)

Non-Hispanic Hispanic

White

All Races Black Asian/Pacific

Islander

70

60

50

40

30

20

10

0

63.4

58.2

53.1

63.3

54.5

58.4

56.1

65.8

60.7

64.7

60.8 59.6

52.0

47.8

58.5

Percent of Census Tract Population Below Poverty Level in 1990
Figure 6.5. SEER Lung Cancer Survival Among Men, 1988–1994 Patient Cohort

99

Figure 6.6. SEER Lung Cancer Survival Among Women, 1988–1994 Patient Cohort

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries. Five-Year Cause-Specific Survival Rate (%)

< 10% 10% to 19.99% 20% or higher

Non-Hispanic Hispanic

White

All Races Black Asian/Pacific

Islander

25

20

15

10

5

0

16.8

14.1

12.1

16.8

12.1

14.1

15.5

11.9

13.9

17.8

11.8

14.3

16.4

14.8 14.3

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

Five-Year Cause-Specific Survival Rate (%)

Non-Hispanic Hispanic

White

All Races Black Asian/Pacific

Islander

25

20

15

10

5

0

20.8

17.7

16.4

20.7

17.7

16.5

24.8

18.2

15.8

20.7

15.8 15.8

18.7 19.0 19.4

Percent of Census Tract Population Below Poverty Level in 1990
Figure 6.7. SEER Lung Cancer Survival Among Men by Stage, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994 Patient Cohort

100

Note: Based on data from 11 SEER registries. Stage data for the Los Angeles registry from 1988 to 1991 were not available. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Five-Year Cause-Specific Survival Rate (%)

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

52.2

47.4

39.3

52.3

47.6

40.2

46.1

39.9

49.7

54.4

50.3

43.8

46.1 45.9

26.4

Regional Stage

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

Five-Year Cause-Specific Survival Rate (%) 23.1 16.0 19.6 23.2 17.2 19.8 22.6 15.3 18.4 23.2 18.8

8.6

20.6

22.6

18.8

Distant Stage

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

70605040302010

0

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

Five-Year Cause-Specific Survival Rate (%)

3.1 2.6 3.1 2.9 2.2 2.2 3.4 3.5 3.2

5.3 5.0 4.4 5.1

3.1

7.8
Figure 6.8. SEER Lung Cancer Survival Among Women by Stage, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994 Patient

Cohort

101

Note: Based on data from 11 SEER registries. Stage data for the Los Angeles registry from 1988 to 1991 were not available. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

70605040302010

0

60.3

53.5

49.6

60.1

53.9

50.8

64.7

52.4

60.3

54.8

52.1

Hispanic

48.9

63.7

45.8

42.8

Five-Year Cause-Specific Survival Rate (%)

Regional Stage

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

70605040302010

0

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

Hispanic

27.6

23.1 23.2

27.5

22.3

24.3

30.3

24.1

21.5

32.1

23.5

19.6 20.1

32.9

26.5

Five-Year Cause-Specific Survival Rate (%)

Distant Stage

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

70605040302010

0

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

4.3 4.1 3.0 4.2 4.0 2.2

6.1 5.9

3.9

5.8

1.6 1.3

4.8 4.8 5.8

Hispanic

Five-Year Cause-Specific Survival Rate (%)
Figure 6.9. SEER Colorectal Cancer Survival Among Men, 1988–1994 Patient Cohort

102

Figure 6.10. SEER Colorectal Cancer Survival Among Women, 1988–1994 Patient Cohort

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries. Five-Year Cause-Specific Survival Rate (%)

< 10% 10% to 19.99% 20% or higher

Non-Hispanic Hispanic

White

All Races Black Asian/Pacific

Islander

70

60

50

40

30

20

10

0

63.9

60.1

56.1

63.9

60.4

57.6 57.6

55.4

52.5

67.4 64.9

58.8 60.3

58.3 58.4

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

Five-Year Cause-Specific Survival Rate (%)

70

60

50

40

30

20

10

0

Non-Hispanic Hispanic

White

All Races Black Asian/Pacific

Islander

63.7

59.5

57.5

63.7

59.5 58.9

56.7 57.6

55.3

68.2 64.9

62.7 61.0

58.1 56.8

Percent of Census Tract Population Below Poverty Level in 1990
Figure 6.11. SEER Colorectal Cancer Survival Among Men by Stage, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994 Patient

Cohort

103

Note: Based on data from 11 SEER registries. Stage data for the Los Angeles registry from 1988 to 1991 were not available. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Five-Year Cause-Specific Survival Rate (%)

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

100

80604020

0

90.1

88.0

85.3

90.3

88.2

84.6 85.8 85.4 84.1

91.3

89.0 89.3

86.4 85.8

89.0

Regional Stage

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

100

Five-Year Cause-Specific Survival Rate (%)80604020

0

64.8

62.4

64.8

62.2 61.5

58.8

62.1

60.3

54.5

67.0 67.9

55.7

62.1 61.0 62.9

Distant Stage

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

100

Five-Year Cause-Specific Survival Rate (%)80604020

0

9.5

7.5

9.2 9.6

7.1 8.4 7.8 6.8 8.8

10.8 9.9 9.8

7.8

9.5

14.1
Note: Based on data from 11 SEER registries. Stage data for the Los Angeles registry from 1988 to 1991 were not available. See “Data and Methods” for a list of SEER registries.

104

Figure 6.12. SEER Colorectal Cancer Survival Among Women by Stage, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994Patient Cohort

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Five-Year Cause-Specific Survival Rate (%)

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

100

80604020

0

90.3

88.1

86.2

90.4

88.2

86.6

89.5

84.8 86.0

92.1

90.6 90.0

85.5

90.8

83.3

Regional Stage

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

100

Five-Year Cause-Specific Survival Rate (%)80604020

0

66.4

63.1

60.9

66.3

63.2

61.1 62.0 63.4 59.9

68.8 69.4 68.4 68.7

54.6

58.8

Distant Stage

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

100

Five-Year Cause-Specific Survival Rate (%)80604020

0

10.5 9.5 10.7 10.6 8.9 11.8

5.3

11.0

8.5

12.5

8.7 8.6

13.9 13.8

17.6
Figure 6.13. Trends in SEER Prostate Cancer Survival, 1988–1994

105

Figure 6.14. SEER Prostate Cancer Survival, 1988–1994 Patient Cohort

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries. Five-Year Cause-Specific Survival Rate (%)

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1988

1989

1990

1991

1992

1993

1994

100

80

60

40

20

0

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of Census Tract Population Below Poverty Level in 1990

100

80

60

40

20

0

Five-Year Cause-Specific Survival Rate (%)

89.1

86.0

82.2

89.3

86.6 85.0 85.8

82.9

79.5

89.6

86.4 85.3 87.6

84.9 83.8
Figure 6.15. SEER Prostate Cancer Survival by Stage, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994 Patient Cohort

106

Note: Based on data from 11 SEER registries. Stage data for the Los Angeles registry from 1988 to 1991 were not available. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized/Regional Stage

< 10% 10% to 19.99% 20% or higher

100

Five-Year Cause-Specific Survival Rate (%) 806040

20

0

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

94.8 93.5 92.1 94.8 93.5 93.3 93.7 92.8 90.4 95.3 94.7 95.6 95.3 93.8 93.9

Distant Stage

Five-Year Cause-Specific Survival Rate (%)

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

100

80604020

0

34.7

31.2

37.8 36.4 35.2

29.6

41.4

29.0 30.7

52.2

45.4

40.6

32.5

35.4

38.6
Figure 6.16. Trends in SEER Female Breast Cancer Survival, 1988–1994

107

Figure 6.17. SEER Female Breast Cancer Survival, 1988–1994 Patient Cohort

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries. Five-Year Cause-Specific Survival Rate (%)

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

1988

1989

1990

1991

1992

1993

1994

100

80

60

40

20

0

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of Census Tract Population Below Poverty Level in 1990

100

80

60

40

20

0

Five-Year Cause-Specific Survival Rate (%)

86.4

83.0

77.5

86.7 84.6 81.9

73.2 71.7

76.4

87.8 86.9

81.1

84.5

79.4 78.0
Figure 6.18. SEER Female Breast Cancer Survival by Stage, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994 Patient Cohort

108

Note: Based on data from 11 SEER registries. Stage data for the Los Angeles registry from 1988 to 1991 were not available. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Five-Year Cause-Specific Survival Rate (%)

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

100

80604020

0

95.4 94.0 92.7 95.5 94.5 94.4

90.2

88.5 90.2

96.8 96.4

94.1 93.6 92.4 93.1

Regional Stage

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

100

Five-Year Cause-Specific Survival Rate (%)80604020

0

76.3

71.2

79.6 80.0

69.4

66.0

64.1

78.1 77.3

80.3

70.1

80.1

73.4 74.3

78.9

Distant Stage

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

100

Five-Year Cause-Specific Survival Rate (%)80604020

0

24.8 24.7

21.1

24.9 25.4 23.5

16.6

21.2

17.4

25.8

24.0

15.9

29.5

27.1 26.7
Figure 6.19. SEER Cervical Cancer Survival, 1988–1994 Patient Cohort

109

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries. Five-Year Cause-Specific Survival Rate (%)

Asian/Pacific

Islander

Non-Hispanic Black Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of Census Tract Population Below Poverty Level in 1990

100

80

60

40

20

0

79.1

72.6 75.6

70.0

79.2

74.8 71.9

67.0 65.2

79.6 81.2

71.5

80.6 79.3 81.0
Figure 6.20. SEER Cervical Cancer Survival by Stage, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994 Patient Cohort

110

Note: Based on data from 11 SEER registries. Stage data for the Los Angeles registry from 1988 to 1991 were not available. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Five-Year Cause-Specific Survival Rate (%)

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

100

80604020

0

94.2 93.1 92.6 94.4 93.5 94.5

91.0 92.2

88.7

93.0 94.5 93.4 95.4

91.4

94.2

Regional Stage

All Races Non-Hispanic

White

Black Asian/Pacific

Islander

Hispanic

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

100

Five-Year Cause-Specific Survival Rate (%)80604020

0

60.6

56.1

59.9

57.2

47.9

59.0

50.3

45.8

52.5

67.2

70.3

58.6

63.6

66.2

70.2

Distant Stage

All Races Non-Hispanic

White

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

100

Five-Year Cause-Specific Survival Rate (%)80604020

0

22.8

16.1 15.8

25.1

15.7

13.4
Figure 6.21. SEER Cancer Survival Among Men, Melanoma of the Skin, 1988–1994 Patient Cohort

111

Figure 6.22. SEER Cancer Survival Among Women, Melanoma of the Skin, 1988–1994 Patient Cohort Five-Year Cause-Specific Survival Rate (%)

< 10% 10% to 19.99% 20% or higher

Non-Hispanic Hispanic

White

All Races

Percent of Census Tract Population Below Poverty Level in 1990

100

80

60

40

20

0

86.0

82.2

74.6

86.1

82.7

76.9

81.9

71.2 69.5

Note: Based on data from 11 SEER registries. See “Data and Methods” for a list of SEER registries.

Non-Hispanic Hispanic

White

All Races

< 10% 10% to 19.99% 20% or higher

Percent of Census Tract Population Below Poverty Level in 1990

100

80

60

40

20

0

Five-Year Cause-Specific Survival Rate (%)

91.7

88.1

84.1

91.8 88.7

85.4 85.5

80.4

85.1
Figure 6.23. SEER Cancer Survival Among Men, Melanoma of the Skin, by Stage, Race/Ethnicity, and Census Tract Poverty Rate,

1988–1994 Patient Cohort

112

Note: Based on data from 11 SEER registries. Stage data for the Los Angeles registry from 1988 to 1991 were not available. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Five-Year Cause-Specific Survival Rate (%)

All Races Non-Hispanic

White

100

80604020

0

93.2 92.8

88.3

93.2 93.1

89.6

Regional Stage

All Races Non-Hispanic

White

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

100

Five-Year Cause-Specific Survival Rate (%) 806040

20

0

61.0

54.3

51.7

60.9

52.5

55.1

Distant Stage

All Races Non-Hispanic

White

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

100

Five-Year Cause-Specific Survival Rate (%) 806040

20

0

10.8

21.4 19.1 19.1 19.8

7.9
Figure 6.24. SEER Cancer Survival Among Women, Melanoma of the Skin, by Stage, Race/Ethnicity, and Census Tract Poverty Rate,

1988–1994 Patient Cohort

113

Note: Based on data from 11 SEER registries. Stage data for the Los Angeles registry from 1988 to 1991 were not available. See “Data and Methods” for a list of SEER registries.

Percent of Census Tract Population Below Poverty

Level in 1990

Localized Stage

< 10% 10% to 19.99% 20% or higher

Five-Year Cause-Specific Survival Rate (%)

All Races Non-Hispanic

White

100

80604020

0

96.4

95.4

92.4 96.4

95.6 93.4

Regional Stage

All Races Non-Hispanic

White

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

100

Five-Year Cause-Specific Survival Rate (%)80604020

0

69.7

64.4

58.3

69.7

63.6

57.9

Distant Stage

All Races Non-Hispanic

White

Percent of Census Tract Population Below Poverty

Level in 1990

< 10% 10% to 19.99% 20% or higher

100

Five-Year Cause-Specific Survival Rate (%)80604020

0

22.9

17.6 19.6 16.7

27.0

17.9
114

Table 6.1. SEER Site-Specific Five-Year Cause-Specific Cancer Survival Rates (%) and Standard Errors

(SE) by Sex, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994 Patient Cohort: 11 SEER

Registration Areas

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

# Cases Rate (%) SE # Cases Rate (%) SE # Cases Rate (%) SE

All Cancers, Male

All Races 279,061 60.95 0.10 98,473 54.95 0.17 64,881 48.98 0.21

Non-Hispanic White 244,994 61.48 0.10 74,143 55.98 0.20 27,025 51.70 0.33

Black 8,487 57.54 0.56 10,155 51.15 0.53 24,552 45.28 0.34

American Indian 243 38.03 3.37 242 46.17 3.41 508 42.06 2.34

Asian/Pacific Islander 14,619 54.85 0.43 5,600 47.85 0.70 3,794 43.68 0.85

Hispanic 9,933 59.92 0.52 8,209 55.35 0.59 9,063 53.84 0.57

All Cancers, Female

All Races 254,798 63.39 0.10 88,955 58.16 0.17 54,394 53.11 0.23

Non-Hispanic White 222,281 63.31 0.11 66,709 58.43 0.20 22,196 54.50 0.35

Black 7,068 58.49 0.61 8,303 51.97 0.57 19,190 47.79 0.38

American Indian 221 44.13 3.46 231 46.40 3.42 543 53.17 2.21

Asian/Pacific Islander 14,528 65.84 0.40 5,225 60.65 0.70 3,280 56.12 0.90

Hispanic 9,963 64.69 0.49 8,357 60.79 0.55 9,250 59.58 0.53

Lung, Male

All Races 39,387 16.77 0.21 15,994 14.14 0.31 11,860 12.14 0.35

Non-Hispanic White 34,853 16.80 0.22 12,304 14.14 0.35 5,138 12.10 0.53

Black 1,266 15.47 1.12 1,795 13.88 0.91 5,059 11.90 0.53

American Indian 51 9.77 4.52 40 6.96 4.50 43 13.97 5.90

Asian/Pacific Islander 2,104 17.75 0.91 972 14.30 1.24 661 11.78 1.37

Hispanic 1,011 16.36 1.30 868 14.81 1.37 967 14.33 1.31

Lung, Female

All Races 28,067 20.75 0.26 10,162 17.71 0.42 6,446 16.37 0.51

Non-Hispanic White 25,399 20.72 0.28 8,087 17.65 0.47 2,980 16.45 0.75

Black 696 24.83 1.79 1,010 18.15 1.36 2,594 15.80 0.81

American Indian 33 6.82 4.63 29 11.18 6.25 20 30.45 10.94

Asian/Pacific Islander 1,144 20.72 1.30 470 15.84 1.83 309 15.84 2.26

Hispanic 712 19.03 1.59 548 19.35 1.82 548 18.71 1.85

Colorectal, Male

All Races 30,943 63.85 0.29 10,739 60.09 0.50 6,399 56.09 0.67

Non-Hispanic White 26,716 63.92 0.31 8,171 60.35 0.58 2,753 57.64 1.02

Black 837 57.60 1.78 999 55.43 1.66 2,246 52.52 1.13

American Indian 32 52.12 9.01 29 57.27 9.37 50 65.72 7.00

Asian/Pacific Islander 2,243 67.43 1.04 730 64.86 1.86 515 58.83 2.29

Hispanic 1,035 60.28 1.58 803 58.25 1.84 844 58.35 1.82

Colorectal, Female

All Races 28,632 63.68 0.30 11,103 59.46 0.49 6,624 57.50 0.65

Non-Hispanic White 24,975 63.69 0.32 8,623 59.46 0.56 2,857 58.91 0.99

Black 869 56.66 1.76 1,110 57.61 1.57 2,552 55.26 1.05

American Indian ~ ~ ~ 20 46.27 11.69 35 57.18 8.71

Asian/Pacific Islander 1,743 68.18 1.15 580 64.87 2.07 464 62.68 2.36

Hispanic 948 61.04 1.65 748 58.13 1.89 720 56.78 1.96

Prostate

All Races 88,589 89.11 0.11 28,768 85.98 0.22 18,008 82.23 0.31

Non-Hispanic White 85,457 89.17 0.11 26,619 86.05 0.23 15,854 82.02 0.33

Black 3,142 85.77 0.65 3,530 82.90 0.67 8,274 79.45 0.48

American Indian 53 67.87 6.92 55 75.54 6.21 123 71.94 4.42

Asian/Pacific Islander 3,655 89.57 0.53 1,193 86.42 1.05 743 85.29 1.38

Hispanic 2,722 87.64 0.66 2,029 84.89 0.84 2,079 83.81 0.86

Breast, Female

All Races 83,704 86.37 0.12 26,130 83.03 0.24 14,446 77.51 0.36

Non-Hispanic White 73,078 86.68 0.13 19,522 84.55 0.27 6,001 81.92 0.52

Black 2,475 76.41 0.88 2,587 73.17 0.90 5,293 71.66 0.65

American Indian 73 70.03 5.65 57 70.88 6.38 130 80.31 3.53

Asian/Pacific Islander 4,725 87.83 0.49 1,500 86.90 0.89 740 81.10 1.49

Hispanic 3,112 84.51 0.67 2,436 79.40 0.85 2,295 77.97 0.89

Cervix 

All Races 5,782 79.07 0.56 2,875 75.58 0.84 2,969 72.56 0.87

Non-Hispanic White 4,298 79.26 0.65 1,577 74.76 1.15 700 69.96 1.81

Black 307 71.91 2.70 341 67.02 2.66 907 65.16 1.70

American Indian ~ ~ ~ ~ ~ ~ 35 55.15 9.08

Asian/Pacific Islander 612 79.57 1.71 282 81.17 2.41 211 71.52 3.20

Hispanic 547 80.60 1.77 662 79.28 1.68 1,130 81.04 1.25

Melanoma of the Skin, Male

All Races 10,145 86.00 0.36 2,334 82.24 0.83 822 74.56 1.61

Non-Hispanic White 9,884 86.14 0.36 2,211 82.72 0.84 704 76.91 1.68

Black 23 75.42 9.62 ~ ~ ~ 34 55.13 8.95

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 50 71.36 6.49 16 74.75 10.93 ~ ~ ~

Hispanic 127 81.91 3.59 84 71.18 5.22 65 69.48 5.86

Melanoma of the Skin, Female

All Races 8,362 91.73 0.31 2,071 88.13 0.74 702 84.11 1.45

Non-Hispanic White 8,016 91.83 0.32 1,912 88.74 0.75 544 85.36 1.58

Black 25 100.00 0.00 ~ ~ ~ 35 65.61 8.53

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 58 90.95 3.87 15 85.66 9.41 ~ ~ ~

Hispanic 189 85.49 2.64 111 80.44 3.84 103 85.09 3.83

Note: ~ Counts or rates are suppressed if based on fewer than 16 cases.
115

Table 6.2. SEER Site-Specific Five-Year Cause-Specific Cancer Survival Rates (%) and Standard Errors

(SE) for Localized-Stage Cancers by Sex, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994

Patient Cohort: 11 SEER Registration Areas

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

# Cases Rate (%) SE # Cases Rate (%) SE # Cases Rate (%) SE

Lung, Male

All Races 5,009 52.18 1.51 1,804 47.38 2.53 1,179 39.31 3.14

Non-Hispanic White 4,487 52.27 1.60 1,441 47.55 2.84 560 40.20 4.61

Black 140 49.72 9.11 193 46.05 7.63 476 39.93 4.96

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 270 54.44 6.50 91 50.28 11.43 53 43.76 14.21

Hispanic 105 46.09 10.30 68 45.93 13.11 85 26.36 10.71

Lung, Female

All Races 4,048 60.25 1.61 1,305 53.46 2.94 766 49.59 3.84

Non-Hispanic White 3,703 60.07 1.68 1,091 53.89 3.21 397 50.79 5.30

Black 108 64.74 9.36 114 52.39 10.13 285 48.91 6.32

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 137 60.34 8.71 46 54.81 15.05 29 52.08 19.22

Hispanic 94 63.72 10.47 51 45.78 15.39 53 42.83 14.98

Colorectal, Male

All Races 10,828 90.14 0.61 3,436 87.97 1.19 1,832 85.30 1.77

Non-Hispanic White 9,430 90.26 0.65 2,728 88.22 1.33 877 84.60 2.63

Black 230 85.83 4.81 264 85.41 4.65 615 84.05 3.16

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 849 91.28 2.04 241 89.03 4.24 128 89.29 5.88

Hispanic 296 86.37 4.12 198 85.78 5.30 199 89.00 4.66

Colorectal, Female

All Races 9,556 90.33 0.63 3,252 88.11 1.19 1,895 86.21 1.68

Non-Hispanic White 8,393 90.37 0.68 2,626 88.16 1.32 898 86.63 2.42

Black 248 89.46 4.08 287 84.84 4.43 706 85.97 2.77

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 626 92.10 2.21 150 90.60 4.97 125 89.96 5.51

Hispanic 267 85.47 4.42 180 90.79 4.55 156 83.33 6.23

Prostate (Localized+Regional)

All Races 63,651 94.79 0.18 19,554 93.46 0.38 11,347 92.13 0.54

Non-Hispanic White 56,947 94.82 0.19 15,298 93.51 0.42 4,636 93.27 0.79

Black 2,075 93.67 1.12 2,158 92.82 1.17 4,933 90.38 0.90

American Indian 33 85.78 13.23 45 82.45 12.12 87 87.61 7.80

Asian/Pacific Islander 2,716 95.28 0.85 803 94.70 1.66 417 95.62 2.15

Hispanic 1,767 95.34 1.04 1,239 93.82 1.44 1,290 93.87 1.41

Breast, Female

All Races 46,723 95.37 0.20 13,130 93.98 0.43 6,363 92.73 0.68

Non-Hispanic White 41,456 95.47 0.21 10,394 94.52 0.46 3,030 94.35 0.87

Black 1,101 90.22 1.85 1,084 88.52 1.99 2,198 90.16 1.32

American Indian 35 87.63 11.59 25 91.38 11.67 63 95.19 5.42

Asian/Pacific Islander 2,681 96.78 0.70 719 96.39 1.42 314 94.10 2.78

Hispanic 1,394 93.61 1.35 905 92.43 1.81 763 93.08 1.89

Cervix 

All Races 2,922 94.18 0.89 1,235 93.12 1.49 1,004 92.62 1.71

Non-Hispanic White 2,264 94.41 0.99 766 93.53 1.83 297 94.54 2.75

Black 141 90.96 4.99 122 92.19 5.00 286 88.67 3.91

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 285 92.99 3.10 113 94.49 4.38 61 93.36 6.42

Hispanic 231 95.40 2.84 229 91.36 3.90 353 94.17 2.60

Melanoma of the Skin, Male

All Races 7,213 93.22 0.61 1,497 92.81 1.39 509 88.28 3.01

Non-Hispanic White 7,075 93.24 0.62 1,440 93.13 1.39 459 89.59 3.01

Black ~ ~ ~ ~ ~ ~ ~ ~ ~

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander ~ ~ ~ ~ ~ ~ ~ ~ ~

Hispanic 63 91.39 7.37 34 79.96 14.71 35 85.10 12.33

Melanoma of the Skin, Female

All Races 6,369 96.41 0.48 1,486 95.40 1.13 470 92.38 2.56

Non-Hispanic White 6,151 96.44 0.49 1,403 95.58 1.14 387 93.37 2.62

Black ~ ~ ~ ~ ~ ~ ~ ~ ~

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander ~ ~ ~ ~ ~ ~ ~ ~ ~

Hispanic 122 93.81 4.54 60 93.23 6.53 54 87.50 9.56

Note: ~ Counts or rates are suppressed if based on fewer than 16 cases.
116

Table 6.3. SEER Site-Specific Five-Year Cause-Specific Cancer Survival Rates (%) and Standard Errors

(SE) for Regional-Stage Cancers by Sex, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994

Patient Cohort: 11 SEER Registration Areas

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

# Cases Rate (%) SE # Cases Rate (%) SE # Cases Rate (%) SE

Lung, Male

All Races 8,757 23.11 0.97 3,096 19.64 1.56 2,276 15.95 1.70

Non-Hispanic White 7,787 23.19 1.04 2,423 19.79 1.78 1,000 17.19 2.61

Black 255 22.59 5.52 356 18.37 4.39 1,022 15.34 2.54

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 505 23.20 3.99 196 18.84 6.09 113 8.60 5.64

Hispanic 195 20.64 6.41 114 22.60 8.51 132 18.77 7.48

Lung, Female

All Races 5,706 27.55 1.26 1,860 23.12 2.08 1,149 23.22 2.71

Non-Hispanic White 5,162 27.45 1.32 1,500 22.30 2.29 518 24.31 4.06

Black 149 30.30 8.29 180 24.06 6.79 502 21.47 4.03

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 244 32.12 6.30 86 23.52 9.70 40 19.55 13.94

Hispanic 138 20.07 7.13 90 32.90 10.27 87 26.49 10.17

Colorectal, Male

All Races 10,058 64.75 1.01 3,380 62.41 1.77 1,815 58.77 2.47

Non-Hispanic White 8,738 64.79 1.08 2,664 62.17 2.00 826 61.47 3.64

Black 265 62.05 6.25 285 60.25 6.10 603 54.45 4.32

American Indian ~ ~ ~ ~ ~ ~ 19 68.97 23.41

Asian/Pacific Islander 737 67.03 3.65 222 67.90 6.49 156 55.74 8.35

Hispanic 301 62.11 5.79 200 61.01 7.23 214 62.89 6.98

Colorectal, Female

All Races 9,783 66.39 1.00 3,750 63.09 1.66 1,946 60.93 2.36

Non-Hispanic White 8,594 66.30 1.07 3,002 63.22 1.86 891 61.11 3.51

Black 261 62.04 6.31 328 63.43 5.60 712 59.93 3.90

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 644 68.78 3.76 202 69.42 6.72 129 68.41 8.65

Hispanic 278 68.69 5.79 207 54.56 7.28 204 58.78 7.32

Breast, Female

All Races 21,848 79.58 0.56 6,831 76.32 1.07 3,972 71.22 1.50

Non-Hispanic White 19,026 79.97 0.60 5,065 78.06 1.21 1,612 77.25 2.20

Black 736 69.38 3.50 732 65.98 3.62 1,589 64.10 2.52

American Indian 31 50.86 18.84 17 60.74 25.11 50 69.89 13.01

Asian/Pacific Islander 1,226 80.27 2.33 398 78.91 4.23 159 70.08 7.49

Hispanic 813 80.07 2.87 628 73.36 3.63 567 74.33 3.80

Cervix 

All Races 1,548 60.55 2.65 781 58.95 3.75 824 56.14 3.75

Non-Hispanic White 1,141 59.86 3.08 441 57.17 5.04 218 47.93 7.18

Black 88 50.30 11.45 99 45.82 10.51 296 52.47 6.46

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 188 67.21 7.31 96 70.27 9.81 74 58.62 12.32

Hispanic 128 63.61 9.18 142 66.15 8.49 224 70.20 6.65

Melanoma of the Skin, Male

All Races 797 60.99 3.63 243 54.28 6.83 93 51.71 11.10

Non-Hispanic White 775 60.89 3.69 229 55.13 7.04 72 52.48 12.95

Black ~ ~ ~ ~ ~ ~ ~ ~ ~

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander ~ ~ ~ ~ ~ ~ ~ ~ ~

Hispanic ~ ~ ~ ~ ~ ~ ~ ~ ~

Melanoma of the Skin, Female

All Races 494 69.71 4.35 158 64.38 8.20 68 58.28 13.20

Non-Hispanic White 472 69.72 4.45 145 63.56 8.60 48 57.91 15.33

Black ~ ~ ~ ~ ~ ~ ~ ~ ~

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander ~ ~ ~ ~ ~ ~ ~ ~ ~

Hispanic 16 64.65 25.68 ~ ~ ~ ~ ~ ~

Note: ~ Counts or rates are suppressed if based on fewer than 16 cases.
117

Table 6.4. SEER Site-Specific Five-Year Cause-Specific Cancer Survival Rates (%) and Standard Errors

(SE) for Distant-Stage Cancers by Sex, Race/Ethnicity, and Census Tract Poverty Rate, 1988–1994 

Patient Cohort: 11 SEER Registration Areas

Percent of Census Tract Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

# Cases Rate (%) SE # Cases Rate (%) SE # Cases Rate (%) SE

Lung, Male

All Races 16,618 3.12 0.33 6,701 2.56 0.48 4,977 3.13 0.63

Non-Hispanic White 14,735 2.92 0.34 5,263 2.20 0.51 2,173 2.17 0.85

Black 552 3.35 1.86 747 3.52 1.64 2,235 3.20 0.96

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 904 5.31 1.76 381 4.97 2.61 234 4.36 2.97

Hispanic 383 5.05 2.67 304 3.13 2.60 325 7.83 3.51

Lung, Female

All Races 11,508 4.34 0.45 4,098 4.06 0.74 2,740 3.04 0.83

Non-Hispanic White 10,420 4.23 0.46 3,278 4.00 0.82 1,267 2.18 1.02

Black 274 6.06 3.54 406 5.87 2.84 1,157 3.87 1.44

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 515 5.77 2.46 221 1.64 2.20 127 1.25 2.45

Hispanic 270 4.79 3.01 179 4.84 3.86 181 5.81 4.37

Colorectal, Male

All Races 5,363 9.54 0.89 1,876 7.48 1.35 1,273 9.16 1.89

Non-Hispanic White 4,676 9.56 0.95 1,439 7.05 1.50 552 8.42 2.79

Black 160 7.78 4.80 196 6.78 4.02 497 8.80 2.93

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 355 10.78 3.63 117 9.91 6.15 76 9.81 7.67

Hispanic 165 7.77 4.69 119 9.45 6.11 143 14.11 6.81

Colorectal, Female

All Races 4,795 10.51 0.98 1,872 9.46 1.52 1,193 10.73 2.05

Non-Hispanic White 4,232 10.55 1.04 1,479 8.88 1.66 495 11.82 3.30

Black 181 5.26 3.58 200 11.03 5.22 523 8.49 2.82

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 229 12.53 4.86 90 8.74 7.11 63 8.63 8.30

Hispanic 144 13.90 6.35 99 13.77 7.27 110 17.58 8.18

Prostate

All Races 6,564 37.76 1.33 2,583 34.68 2.11 2,146 31.20 2.28

Non-Hispanic White 5,619 36.43 1.43 1,880 35.15 2.49 663 29.58 4.04

Black 323 41.43 5.99 386 28.96 5.10 1,167 30.74 3.12

American Indian ~ ~ ~ ~ ~ ~ 23 21.30 20.02

Asian/Pacific Islander 405 52.21 5.41 146 45.43 9.15 89 40.60 11.44

Hispanic 197 38.61 7.66 164 32.50 8.17 204 35.42 7.39

Breast, Female

All Races 3,843 24.79 1.49 1,369 24.73 2.52 1,045 21.11 2.71

Non-Hispanic White 3,352 24.91 1.60 1,009 25.36 2.97 417 23.46 4.52

Black 161 16.61 6.47 188 21.15 6.28 458 17.40 3.77

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 196 25.79 6.62 56 24.00 12.73 38 15.85 12.61

Hispanic 122 29.52 8.70 115 27.12 8.94 124 26.71 8.48

Cervix

All Races 350 22.75 5.19 171 16.06 6.88 171 15.75 6.44

Non-Hispanic White 268 25.08 6.13 115 15.74 7.83 46 13.44 11.41

Black 21 8.64 15.77 ~ ~ ~ 73 7.90 7.44

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander 27 14.61 15.14 ~ ~ ~ ~ ~ ~

Hispanic 33 21.37 16.15 21 20.40 25.94 34 33.92 18.84

Melanoma of the Skin, Male

All Races 349 19.09 4.68 113 21.39 8.82 53 10.78 9.72

Non-Hispanic White 333 19.08 4.78 101 19.79 8.92 41 7.87 9.91

Black ~ ~ ~ ~ ~ ~ ~ ~ ~

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander ~ ~ ~ ~ ~ ~ ~ ~ ~

Hispanic ~ ~ ~ ~ ~ ~ ~ ~ ~

Melanoma of the Skin, Female

All Races 195 17.60 6.08 65 19.56 11.67 30 22.91 17.61

Non-Hispanic White 180 17.92 6.38 60 16.71 11.77 21 27.00 20.91

Black ~ ~ ~ ~ ~ ~ ~ ~ ~

American Indian ~ ~ ~ ~ ~ ~ ~ ~ ~

Asian/Pacific Islander ~ ~ ~ ~ ~ ~ ~ ~ ~

Hispanic ~ ~ ~ ~ ~ ~ ~ ~ ~

Note: ~ Counts or rates are suppressed if based on fewer than 16 cases.

Summary and Discussion

119

Although socioeconomic disparities in cancer

have been noted previously, this report provides

one of the most comprehensive analyses yet of

area socioeconomic variations in cancer

incidence, mortality, stage, treatment and

survival in the United States, using populationbased SEER incidence and national mortality

data. The results provide important insights into

the extent of area socioeconomic disparities in

cancer for the total population as well as for the

major racial and ethnic groups in the United

States and are generally consistent with the

findings of previous studies.

One of the most important findings of this

report concerns the dynamic nature of the

association between area socioeconomic

position and cancer mortality. The association

changed markedly over the past 25 years for all

cancers combined and for lung, colorectal,

prostate, and breast cancers. While

socioeconomic inequalities in male lung and

prostate cancer mortality have been widening,

those in colorectal and breast cancer mortality

narrowed over time and even appear to have

reversed in the late 1990s. Against the backdrop

of falling mortality rates, substantial

socioeconomic inequalities in cervical cancer

have persisted. 

Temporal changes in area socioeconomic

patterns in cancer incidence were less

pronounced than those in cancer mortality.

There was a marked increase in incidence for

breast cancer and melanoma of the skin in all

area SES groups, and a positive socioeconomic

gradient remained throughout the study period.

On the other hand, a negative but somewhat

diminishing socioeconomic gradient in cervical

cancer incidence was observed as incidence rates

declined substantially for all area groups during

1975–1999.

As regards the other cancer outcomes, for

each of the cancers considered, both men and

women in high poverty areas had substantially

higher rates of late-stage cancer diagnosis and

lower rates of cancer survival than those in low

poverty areas. Cancer survival rates for residents

of higher poverty areas remained lower even

after controlling for differences in stage.

Residents of higher poverty areas were also less

likely to receive preferred treatment for lung

and breast cancers and to undergo radical

prostatectomy.

Another important finding of the report

relates to the substantial effect of area

socioeconomic position on cancer risks for each

racial/ethnic group. Poorer survival and smaller

probabilities of early detection and preferred

treatment of cancers were associated with lower

SES for each racial/ethnic group. The

socioeconomic gradients in incidence and

mortality from some cancers, however, varied by

ethnicity not only in magnitude but sometimes

Summary and Discussion
in direction as well. An example of the

differential pattern is lung cancer incidence,

which increased during 1988–1992 with

increasing poverty rate for non-Hispanic white

and black men and women and API men, but

decreased with increasing poverty rate for

Hispanic men and women. Such differences in

pattern may partially reflect the impact of

acculturation on smoking patterns for Hispanics

and to some extent APIs (106). While area SES

does contribute to racial/ethnic differences in

cancer outcomes, ethnic differences remain

within each area poverty group. Residual ethnic

differences may reflect differences in individual

socioeconomic and cultural characteristics as

well as differences in area socioeconomic

position not completely accounted for by

poverty rates. 

Do socioeconomic patterns in cancer based

on poverty rates that are reported here also

apply to other frequently used area measures,

such as median family income and percentage

of population with at least a high school

diploma? To address this question, we compared

differentials in cancer incidence, mortality,

stage, treatment, and survival by area poverty

levels with those based on median family

income and education. Similar patterns in

cancer incidence, mortality, and survival were

observed for all of the area measures, and the

size of the gradients associated with education

and family income corresponded fairly closely

with that based on area poverty levels.

Because of temporal proximity, the 1980

poverty rate is more likely than the 1990

poverty rate to accurately characterize the

socioeconomic characteristics of counties during

1975–1984. Despite a high correlation and

categorical correspondence between the 1980

and 1990 poverty rates, we wanted to examine

the impact on cancer mortality and incidence

trends of any potential area misclassification

that may have arisen from using the 1990

poverty rate throughout the study period. As

shown in Figure 7.1, page 124, for cervical

cancer as an example, the use of the 1980 and

1990 county poverty rates produced essentially

similar trends in mortality and incidence during

1975–1999.

For most of the analyses in this report, we

selected three broad poverty categories for a

simpler presentation of data and for minimizing

the extent of potential misclassification of areas

over time. However, it is important to

emphasize that the impact of socioeconomic

position on cancer is not limited to the

differences between the lowest and highest

poverty areas. Rather, a graded relationship may

be observed for many of the cancers across the

entire range of the social hierarchy, as shown for

lung and cervical cancer incidence and

mortality in Figures 3.56–3.59, pages 62–63.

Moreover, within the broad category of areas

with poverty rates < 10%, the areas with lower

poverty rates generally had a significantly lower

likelihood of a late-stage cancer diagnosis than

those with higher poverty rates (e.g., men in

census tracts with poverty rates < 2% were 34%

less likely to be diagnosed with distant-stage

prostate cancer than men in census tracts with

poverty rates between 8% and 10%). Similarly,

within the broad category of areas with poverty

rates ≥ 20%, the likelihood of late-stage cancer

120
diagnosis increased with increasing poverty rates

(e.g., men in census tracts with poverty rates

exceeding 50% were 38% more likely to be

diagnosed with distant-stage prostate cancer

than men in census tracts with poverty rates

between 20% and 23%). Similar heterogeneity

in survival can be noted within the three broad

poverty categories. For example, for the

1988–1994 patient cohort, 83.9% of men

diagnosed with prostate cancer and living in

census tracts with poverty rates between 20%

and 23% had survived at least five years, as

compared with 79.9% of men in census tracts

with poverty rates exceeding 50%.

While temporal socioeconomic patterns in

cancer rates may be related to increasing

temporal differences in socioeconomic

conditions between areas, such patterns can be

examined in terms of how social patterns in

behavioral and lifestyle factors have changed

over time. Specifically, area socioeconomic

gradients in cancer incidence and mortality may

be related to area differences in smoking rates,

tobacco regulation and advertising, availability

of cigarettes, public awareness of the harmful

health effects of smoking, fatty diet, physical

inactivity, reproductive factors, human

papillomavirus (HPV) infection, sun exposure,

or other factors. Individual-level data on many

of these variables demonstrate a faster rate of

smoking decline or a more rapid adoption of

healthier lifestyles (including the availability of

cancer screening) over time among the members

of higher SES groups (7,16,17). Temporal and

cross-sectional ecological data (especially at the

small area level) on social, environmental,

behavioral, and health care disparities by area

SES are particularly lacking in the U.S. 

To address these data gaps and to help

interpret the above area socioeconomic

gradients in cancer incidence and mortality, we

used a variety of national databases (107–112) to

determine cross-sectional associations between

poverty, tobacco control policy, behavioral

factors, cancer screening, and cancer mortality

at the state level (Table 7.1, page 129, and

Figures 7.2–7.7, pages 125–127). These data

illustrate a high degree of correlation between

poverty and behavioral and health care factors

such as smoking, physical activity, and cancer

screening, as well as between behavioral factors,

policy variables, and cancer mortality at the area

level. Of particular interest is the substantial

association of poverty with current smoking

rates, anti-smoking policy measures, physical

inactivity, obesity, mammography use and

colorectal cancer screening rates, and lack of

health insurance. Several of the behavioral and

policy variables, such as current smoking rates,

obesity and physical inactivity levels, and

workplace and home restrictions on smoking

are, in turn, strongly linked to overall cancer

mortality and mortality from lung, colorectal,

prostate, and breast cancers (Table 7.1, page

129). For example, states with higher rates of

workplace and home restrictions on tobacco use

in 1993 generally had substantially lower

smoking prevalence in 1996 (r = –0.62 and –0.72

respectively) and lung cancer mortality rates

during 1995–1999 (r = –0.58 and –0.64

respectively).

121
Data presented in this report are subject to

several potential limitations. The association

between area socioeconomic position and

cancer incidence, stage, and survival for specific

racial/ethnic groups may be affected by the

degree of ethnic misclassification in patient

records. Information on race/ethnicity in the

SEER cancer registries is routinely obtained from

the patient’s medical record or death certificate

and often reflects a subjective assessment made

by hospital personnel or a funeral director or

coroner (113). Hispanic ethnicity may also be

derived by using the census surname list.

However, not all persons with Hispanic

surnames are Hispanic, and name changes are

especially problematic when classifying women.

Cancer registry data for whites and blacks are

expected to be reasonably accurate, though

published data evaluating this issue are

generally lacking (113). Registry data for

Hispanics were found to be problematic in a

study completed by the Greater Bay Area cancer

registry in California (114). The investigators

determined that the percentage of self-identified

Hispanics who were classified as Hispanic in

registry records was just 68%. A similar study of

misclassification of Vietnamese in the same

cancer registry reported that 74% of patients

that the registry classified as Vietnamese agreed

with this classification during a telephone

interview (115). Misclassification of Asian

ethnicity might be expected to be less of a factor

in this report, however, since the composite

grouping of all Asian and Pacific Islanders was

used.

Caution should also be exercised when

comparing mortality rates among various

racial/ethnic groups. Mortality rates shown in

this report are based on the death certificate

data. Two potential sources of error—the

misclassification of race/ethnicity on the death

certificate (resulting in an underreporting of

deaths for ethnic minority groups such as APIs,

American Indians, and Hispanics) and the

undercoverage of ethnic minority groups in the

census and resultant population estimates—may

affect ethnic comparisons in mortality rates

(116–118). The joint effect of these two sources

of error may result in an underestimation of

mortality for American Indians, APIs, and

Hispanics by 17.1%, 9.7%, and 1.6%

respectively, and an overestimation of mortality

for whites and blacks by 1% and 5% respectively

(116,117). 

The data shown in this report could also be

affected by the extent to which patients in SEER

were incorrectly geocoded or assigned to specific

census tracts. The area socioeconomic effects

would be underestimated if patients in poorer

and rural census tracts were more likely to have

missing census tract information than their

wealthier, urban counterparts. Area effects could

also be biased if the area socioeconomic

category associated with residence at the time of

diagnosis or death differed from that at

exposure. 

122
Area socioeconomic variations in cancer

incidence, mortality, stage, and survival should

not be considered as proxies for socioeconomic

differentials at the individual level. Such

consideration may lead to the ecological fallacy,

implying that the socioeconomic effects at the

aggregate level are being interpreted as those

occurring at the individual level (10,16,17,119).

In this report, area variations in cancer

outcomes, particularly incidence and mortality

rates, were analyzed as a function of an

ecological variable, area poverty rate. Although

area socioeconomic patterns in several of the

cancer outcomes are generally consistent with

those at the individual level, the area-level

effects shown here may be smaller in magnitude

than individual socioeconomic effects

(6,10,15–18,120). This may be partly due to the

compositional heterogeneity of the areas

examined, particularly counties, which, unlike

census tracts, may contain substantial

socioeconomic variability (16,17). 

Census-based area socioeconomic measures,

including the poverty rate, can serve as valuable

surveillance tools for documenting social

inequalities in cancer and monitoring trends in

the extent of cancer-related health inequalities

over time. In the absence of individual-level

socioeconomic data, characterization of patterns

in cancer incidence, stage, treatment, survival,

and mortality by area socioeconomic measures

may be useful in cancer control planning and

resource allocation (16). Area socioeconomic

measures can also be used in conjunction with

other ecological variables, such as rural-urban

continuum or behavioral factors, to examine

differences in cancer outcomes after adjusting

for area socioeconomic position. While policy

interventions (e.g., smoking prevention and

cancer control programs) aimed at reducing

disparities in cancer generally should target

socioeconomically disadvantaged areas, there

may be a need to develop ethnic, cultural, and

gender-specific programs. Obviously, social

policy actions can have a profound effect on the

magnitude of social inequalities in cancer.

Although reducing poverty, improving access to

education and employment opportunities, and

improving working conditions remain the

fundamental social policy measures for reducing

health inequalities (4,53), improving access to

health care and specific cancer screening

programs and cancer control interventions

among the disadvantaged has the potential to

substantially reduce the cancer burden and

cancer disparities among population groups and

geographic areas.

123
Figure 7.1. Comparison of Trends in U.S. Cervical Cancer Mortality and SEER Cervical Cancer

Incidence by 1990 and 1980 County Poverty Rates

124

Note: Rates are age-adjusted to the 2000 U.S. standard population. SEER incidence rates are based on data from 9 SEER registries.

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

SEER Cervical Cancer Incidence

(Three-Year Moving Averages), 1975–1999

Age-Adjusted Incidence Rate per 100,000 Population

1975–77

25

20

15

10

5

0

1977–79

1979–81

1981–83

1983–85

1985–87

1987–89

1989–91

1991–93

1993–95

1995–97

1997–99

Percent of County Population Below Poverty Level in 1980

< 10% 10% to 19.99% 20% or higher

SEER Cervical Cancer Incidence

(Three-Year Moving Averages), 1975–1999

Age-Adjusted Incidence Rate per 100,000 Population

25

20

15

10

5

0

1975–77

1977–79

1979–81

1981–83

1983–85

1985–87

1987–89

1989–91

1991–93

1993–95

1995–97

1997–99

Percent of County Population Below Poverty Level in 1990

< 10% 10% to 19.99% 20% or higher

U.S. Cervical Cancer Mortality, 1975–1999

Age-Adjusted Death Rate per 100,000 Population

1975

8

6

4

2

0

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

Percent of County Population Below Poverty Level in 1980

< 10% 10% to 19.99% 20% or higher

U.S. Cervical Cancer Mortality, 1975–1999

Age-Adjusted Death Rate per 100,000 Population

8

6

4

2

0

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999
Figure 7.2. Relationship Between State-Specific Physical Inactivity Levels and Total Cancer Mortality,

United States, 1995–1999 (N = 51)

125

Figure 7.3. Relationship Between State-Specific Physical Inactivity Levels and Prostate Cancer

Mortality, United States, 1995–1999 (N = 51)

Note: Rates are age-adjusted to the 2000 U.S. standard population. Average Annual Age-Adjusted Death Rate per 100,000 Population

Percentage of Adults 18+ Reporting No Leisure-Time Physical Activity, 1994

15 20 25 30 35 40 45 50

Observed Fitted (linear model)

250

200

150

100

50

0

Rate = 163.662 + 1.462 Physical Inactivity

Standard Error of Slope = 0.241

Correlation Coefficient = 0.655; P < 0.0001

50

40

30

20

10

0

Observed Fitted (linear model)

Rate = 25.592 + 0.319 Physical Inactivity

Standard Error of Slope = 0.078

Correlation Coefficient = 0.505; P < 0.001

Average Annual Age-Adjusted Death Rate

per 100,000 Population

Percentage of Adults 18+ Reporting No Leisure-Time Physical Activity, 1994

15 20 25 30 35 40 45 50
Figure 7.4. Relationship Between State-Level Smoke-Free Workplace Policy and Male Lung Cancer

Mortality, United States, 1995–1999 (N = 51)

126

Note: Rates are age-adjusted to the 2000 U.S. standard population.

Figure 7.5. Relationship Between State-Specific Poverty Rates and Physical Inactivity Levels, United

States, 1994 (N = 51) Average Annual Age-Adjusted Death Rate per 100,000 Population

Percentage of Workers Aged 18+ Who Report Being Covered by a Smoke-Free Workplace Policy, 1993

20 30 40 50 60

Observed Fitted (linear model)

70

125

100

75

50

25

0

Rate = 141.419 – 1.299 Workplace Smoking Ban

Standard Error of Slope = 0.203

Correlation Coefficient = –0.674; P < 0.0001

Percentage of State Population Below Poverty Level, 1990

Percentage of Adults Aged 18+ Reporting No

Leisure-Time Physical Activity, 1994

5 10 15 20 25 30

50

40

30

20

10

0

Observed Fitted (linear model)

Physical Inactivity = 18.052 + 0.864 Poverty

Standard Error of Slope = 0.253

Correlation Coefficient = 0.438; P < 0.01
Figure 7.6. Relationship Between State-Specific Poverty Rates and Recent Mammography Use, United

States, 1995 (N = 51)

127

Percentage of Women Aged 50+ Who Report Having

Had a Mammogram in the Past Two Years, 1995

Percentage of State Population Below Poverty Level, 1990

5 10 15 20 25

Observed Fitted (linear model)

30

100

80

60

40

20

0

Mammography Use = 78.764 – 0.706 Poverty

Standard Error of Slope = 0.172

Correlation Coefficient = –0.507; P < 0.001

Figure 7.7. Relationship Between State-Specific Poverty Rates and Colorectal Cancer Screening,

United States, 1999 (N = 51)

Percentage of State Population Below Poverty Level, 1990

Percentage of Population Aged 50+ Who Reported

Sigmoidoscopy/Colonoscopy Within Five Years, 1999

5 10 15 20 25 30

50

40

30

20

10

0

Observed Fitted (linear model)

Sigmoidoscopy/Colonoscopy = 40.229 – 0.545 Poverty

Standard Error of Slope = 0.140

Correlation Coefficient = –0.485; P < 0.001
Legend for Variables in the Correlation Matrix (Table 7.1)

1. Poverty = Percentage of population below poverty level, 1990. Data source: 1990 Census.

2. Inactive = Percentage of adults aged 18 years or older who reported no leisure-time physical activity, 1994. Data source: 1994 Behavioral Risk Factor Surveillance Survey

(BRFSS).

3. Overweight = Percentage of adults 18 years or older who reported being overweight, 1995. Data source: 1995 Behavioral Risk Factor Surveillance Survey (BRFSS).

4. Current Smoker, 1993 = Percentage of adults 18 years or older who reported cigarette smoking, 1993. Data source: 1992–1993 Current Population Survey—Tobacco Use

Supplement.

5. Current Smoker, 1996 = Percentage of adults 18 years or older who reported cigarette smoking, 1996. Data source: 1995–1996 Current Population Survey—Tobacco Use

Supplement.

6. Cigarette Sales/Capita = Per capita tax paid on sales of cigarette packs, 1997. Data source: The Tobacco Institute; MMWR, Vol. 47, No. 3, November 6, 1998.

7. Workplace Smoking Ban, 1993 = Percentage of indoor workers 18 years or older who reported being covered by a smoke-free workplace policy, 1993. Data source:

1992–1993 Current Population Survey—Tobacco Use Supplement.

8. Workplace Smoking Ban, 1996 = Percentage of indoor workers 18 years or older who reported being covered by a smoke-free workplace policy, 1996. Data source:

1995–1996 Current Population Survey—Tobacco Use Supplement.

9. Home Smoking Ban, 1993 = Percentage of adults 18 years or older who reported no smoking allowed anywhere in the home, 1993. Data source: 1992–1993 Current

Population Survey—Tobacco Use Supplement.

10. Home Smoking Ban, 1996 = Percentage of adults 18 years or older who reported no smoking allowed anywhere in the home, 1996. Data source: 1995–1996 Current

Population Survey—Tobacco Use Supplement.

11. Smoking Advertising Ban, 1993 = Percentage of adults 18 years or older who think advertising of tobacco products should not be allowed at all, 1993. Data source:

1992–1993 Current Population Survey—Tobacco Use Supplement.

12. Smoking Advertising Ban, 1996 = Percentage of adults 18 years or older who think advertising of tobacco products should not be allowed at all, 1996. Data source:

1995–1996 Current Population Survey—Tobacco Use Supplement.

13. Alcohol Consumption = Average alcohol consumption per drinker in gallons, 1991 (based on annual alcoholic beverage sales data). Data source: Alcohol Epidemiologic

Data System; the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

14. Recent Pap Test = Percentage of women 18 years or older with an intact uterine cervix who reported having had a Pap smear in the past three years, 1995. Data source:

1995 Behavioral Risk Factor Surveillance Survey (BRFSS).

15. Pap Test Ever = Percentage of women 18 years or older with an intact uterine cervix who reported ever having had a Pap smear, 1995. Data source: 1995 Behavioral

Risk Factor Surveillance Survey (BRFSS).

16. Recent Mammography Use = Percentage of women aged 50 years or older who reported having had a mammogram in the past 2 years, 1995. Data source: 1995

Behavioral Risk Factor Surveillance Survey (BRFSS).

17. Mammography Ever Use = Percentage of women aged 40 years or older who reported ever having had a mammogram, 1995. Data source: 1995 Behavioral Risk Factor

Surveillance Survey (BRFSS).

18. Colonoscopy/Sigmoidoscopy = Percentage of population aged 50 years or older who reported having colonoscopy/sigmoidoscopy within the past 5 years, 1999. Data

source: 1999 Behavioral Risk Factor Surveillance Survey (BRFSS).

19. FOBT = Percentage of population aged 50 years or older who reported having a fecal occult blood test (FOBT) within the past 1 year, 1999. Data source: 1999

Behavioral Risk Factor Surveillance Survey (BRFSS).

20. No Health Insurance = Percentage of population without health insurance, 1994. Data source: 1994 Current Population Survey—March Supplement.

21. Total Cancer Mortality = Average annual age-adjusted death rate for all cancers and both sexes combined per 100,000 2000 U.S. standard population, 1995–1999.

22. Male Cancer Mortality = Average annual age-adjusted death rate for men from all cancers combined per 100,000 2000 U.S. standard population, 1995–1999.

23. Female Cancer Mortality = Average annual age-adjusted death rate for women from all cancers combined per 100,000 2000 U.S. standard population, 1995–1999.

24. Total Lung Cancer Mortality = Average annual age-adjusted death rate for lung cancer (both sexes combined) per 100,000 2000 U.S. standard population, 1995–1999.

25. Male Lung Cancer Mortality = Average annual age-adjusted death rate for male lung cancer per 100,000 2000 U.S. standard population, 1995–1999.

26. Female Lung Cancer Mortality = Average annual age-adjusted death rate for female lung cancer per 100,000 2000 U.S. standard population, 1995–1999.

27. Total Colorectal Cancer Mortality = Average annual age-adjusted death rate for colorectal cancer (both sexes combined) per 100,000 2000 U.S. standard population,

1995–1999.

28. Male Colorectal Cancer Mortality = Average annual age-adjusted death rate for male colorectal cancer per 100,000 2000 U.S. standard population, 1995–1999.

29. Female Colorectal Cancer Mortality = Average annual age-adjusted death rate for female colorectal cancer per 100,000 2000 U.S. standard population, 1995–1999.

30. Total Mortality from Melanoma of the Skin = Average annual age-adjusted death rate for melanoma of the skin (both sexes combined) per 100,000 2000 U.S. standard

population, 1995–1999.

31. Male Mortality from Melanoma of the Skin = Average annual age-adjusted death rate for men from melanoma of the skin per 100,000 2000 U.S. standard population,

1995–1999.

32. Female Mortality from Melanoma of the Skin = Average annual age-adjusted death rate for women from melanoma of the skin per 100,000 2000 U.S. standard

population, 1995–1999.

33. Prostate Cancer Mortality = Average annual age-adjusted death rate for prostate cancer per 100,000 2000 U.S. standard population, 1995–1999.

34. Female Breast Cancer Mortality = Average annual age-adjusted death rate for female breast cancer per 100,000 2000 U.S. standard population, 1995–1999.

35. Cervical Cancer Mortality = Average annual age-adjusted death rate for cervical cancer per 100,000 2000 U.S. standard population, 1995–1999. Data source for

Variables 21 through 35: National Mortality Database, 1995–1999.

128
See “Page 129.pdf” for Table 7.1.

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