Impact of state health disparity on lung, breast, and prostate cancer incidence and mortality in the United States.
Authors: Muthusamy Kumarasamy Vasanthan , Lee Yu-Che , Roy Arya Mariam , Jatwani Karan , Chang Ko-Yun , Lee Yi , Chan Shu-Yen , Li Cheng-Chen , Jain Prantesh 
Published: June 2023

e18639 Background: Lung cancer is the second most common cancer and the leading cause of cancer deaths in both sex in the United States (US). Prostate cancer is the most common in men, while in women being breast cancer. America’s Health Rankings (AHR) is a comprehensive assessment of the nation's health on a state-by-state basis to determine state health rankings annually. We aimed to evaluate the association, which has not been investigated, between state-level health disparity as measured by AHR and lung, breast, and prostate cancer incidence and mortality in the US. Methods: We examined lung, breast and prostate cancer incidence and mortality data for 2015-2019 from the United States Cancer Statistics (USCS) database provided by the Centers for Disease Control and Prevention (CDC). Overall state health rankings were obtained from AHR and calculated by an equation using weighted measures in five different categories: 25% Behaviors, 22.5% Community & Environment, 12.5% Policy, 15% Clinical Care, and 25% Outcomes. We extracted 2015-2019 AHR data and further classified state health rankings into quartiles (1st [the healthiest] = rank 1 to 13; 4th [the least healthy] = rank 38 to 50). Associations of cancer incidence and mortality with overall state health rankings were analyzed by negative binomial regressions. Results: From 2015 to 2019, age-adjusted incidence rate per 100,000 population for lung, breast, and prostate cancer were 56.3, 128.0 and 109.8, respectively. Age-adjusted mortality rate per 100,000 population for lung, breast, and prostate cancer were 36.7, 19.9 and 18.9, respectively. Among 50 states we included for analysis, AHR indicated that Hawaii was the healthiest state (No.1) whereas Mississippi was the least healthy state (No. 50) for overall health rankings. States in the 4th quartile of health ranking were significantly associated with greater lung cancer incidence (Rate Ratio [RR]: 1.34 [95% CI, 1.18-1.52]) and mortality (1.50 [1.32-1.71]) than those in the 1st quartile. This was pronounced for age < 65 (Incidence [I]: 1.63 [1.36-1.96]; Mortality [M]: 1.93 [1.51-2.48]), Male (I: 1.48 [1.30-1.67]); M: 1.66 [1.47-1.87]), and Black (I: 1.43 [1.22-1.66]; M: 1.54 [1.32-1.79]). Black women living in states with worse health rankings had higher relative risks of breast cancer incidence (1.14 [1.03-1.26]) and mortality (1.27 [1.05-1.53]). There was no significant association between state health rankings and prostate cancer incidence and mortality in the US. Conclusions: There are significant differences in lung, breast, and prostate cancer incidence and mortality within the US. States with worse health rankings had higher cancer incidence and mortality, and varied by different demographics. Our findings suggests that advanced cancer screening and targeted public health interventions should be prioritized in areas with health disadvantages to improve cancer disparity.