Counties eliminating racial disparities in colorectal cancer mortality

Abstract

BACKGROUND: Although colorectal cancer (CRC) mortality rates are declining, racial-ethnic disparities in CRC mortality nationally are widening. Herein, the authors attempted to identify county-level variations in this pattern, and to characterize counties with improving disparity trends. METHODS: The authors examined 20-year trends in US county-level black-white disparities in CRC ageadjusted mortality rates during the study period between 1989 and 2010. Using a mixed linear model, counties were grouped into mutually exclusive patterns of black-white racial disparity trends in age-adjusted CRC mortality across 20 three-year rolling average data points. County-level characteristics from census data and from the Area Health Resources File were normalized and entered into a principal component analysis. Multinomial logistic regression models were used to test the relation between these factors (clusters of related contextual variables) and the disparity trend pattern group for each county. RESULTS: Counties were grouped into 4 disparity trend pattern groups: 1) persistent disparity (parallel black and white trend lines); 2) diverging (widening disparity); 3) sustained equality; and 4) converging (moving from disparate outcomes toward equality). The initial principal component analysis clustered the 82 independent variables into a smaller number of components, 6 of which explained 47% of the county-level variation in disparity trend patterns. CONCLUSIONS: County-level variation in social determinants, health care workforce, and health systems all were found to contribute to variations in cancer mortality disparity trend patterns from 1990 through 2010. Counties sustaining equality over time or moving from disparities to equality in cancer mortality suggest that disparities are not inevitable, and provide hope that more communities can achieve optimal and equitable cancer outcomes for all. Cancer 2016;122:1735-48. V C 2016 American Cancer Society.KEYWORDS: African American, black, cancer mortality, colorectal cancer, disparities, geographic variation, health equity, local-area variation, race, trends. INTRODUCTIONColorectal cancer (CRC) is the third most common cancer and the third leading cause of cancer death in the United States, 1 and is expected to account for >8% of US cancer deaths in men and women in 2015, although death rates are on the decline. 1-4 On average, since 1990 there has been an annual average percentage decrease in CRC mortality of 2.6% for men and 3.0% for women. 5 Unfortunately, the benefits of decreasing mortality have not accrued equally to all segments of the population. Indeed, the racial (black-white) gap in CRC mortality has been increasing since the 1990s. 6,7 Black or African American individuals have higher CRC mortality rates than whites, with sex-specific black mortality rates from 2007 to 2011 of 28.4 (male) and 18.9 (female) per 100,000 individuals, compared with white rates of 18.7 and 13.2 per 100,000 men and women, respectively. 1,2 As with other conditions for which lifesaving ...

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