Poverty and Cancer Disparities in Ohio

John Kollman, MS; Holly L. Sobotka, MS

Disclosures

Prev Chronic Dis. 2018;15(12):E152 

In This Article

Discussion

Similar to results based on US census-tract data,[3] the results of our study found that cancers with the greatest disparity in incidence rates between the poorest and most affluent counties in Ohio were cancers of the cervix and larynx. Also similar to other national data, our data showed that the most affluent counties had higher incidence rates than the poorest counties for female breast cancer, melanoma of the skin, prostate cancer, and thyroid cancer. Nationally, poverty is associated with higher cancer mortality rates.[1] Similarly, our study found that the poorest counties in Ohio had higher cancer mortality rates for all cancers combined, with cancers of the cervix and larynx showing the greatest disparity between the poorest and most affluent counties in Ohio in 2011–2015.

Poverty is also associated with some cancer risk factors such as tobacco use, obesity, and lack of access to cancer screening and treatment.[1] Tobacco use is associated with 12 types of cancer and is estimated to cause more than 30% of all cancer deaths in the United States, including 80% of lung cancer deaths among men and women.[18] Obesity is the second leading cause of preventable cancer in the United States. Overweight and obesity are associated with increased risk for developing many cancers, including adenocarcinoma of the esophagus and cancers of the breast (in postmenopausal women), colon and rectum, endometrium, kidney, liver, and pancreas.[19] Higher levels of physical activity are linked to lower risks of several cancers, including colon, breast, and endometrial cancers.[20] Heavy alcohol consumption is a risk factor for cancers of the oral cavity and pharynx (excluding the lips), larynx, esophagus, liver, and breast and is associated with an increased risk of cancers of the colon and rectum.[21] People who use both alcohol and tobacco have a greater risk of developing cancers of the oral cavity and pharynx, larynx, and esophagus than people who use either alcohol or tobacco alone.[21] Virtually all cervical cancer cases are caused by infection with human papillomavirus (HPV).[22] Women who do not regularly have Pap tests to detect abnormal cells in the cervix or tests to detect HPV are at increased risk for cervical cancer.[22] Among women infected with HPV, those who smoke have twice the risk of nonsmokers of developing cervical cancer.[23] Our study found that the prevalence of current tobacco smoking, obesity, and physical inactivity was significantly higher in Ohio's poorest counties, which also had higher rates of cervical cancer and tobacco-related cancers. In addition, residents in the poorest counties in Ohio were more likely to be diagnosed at a later stage for cervical cancer, and to a lesser extent, other smoking-related cancers.

Health insurance status plays a role in cancer disparities. People who are uninsured or underinsured are less likely to have adequate cancer treatment and care. Furthermore, unequal access to screening may lead to a later stage at diagnosis and a lower chance of survival.[2] In our analysis, Ohio's poorest counties had a significantly higher percentage of people who were uninsured at the time of cancer diagnosis and were less likely to have received treatment. Other barriers to health care access may play a role in cancer health disparities. For example, all of the poorest counties, except Lucas County, are in Appalachia. These counties have fewer specialty physicians (61 per 100,000) than counties not in Appalachia (175 per 100,000) and in Ohio as a whole (155 per 100,000).[24]

This study has several limitations. First, incidence rates are affected by completeness of reporting. "Completeness" is the percentage of cancer cases diagnosed among Ohio residents that are reported to OCISS within 24 months of diagnosis. It is based on Ohio mortality rates and the SEER Program incidence to mortality rate ratio. Overall, completeness of case reporting to OCISS was an estimated 97% for 2011–2015. However, the estimated completeness of reporting for the poorest counties was 91% for all cancers combined in 2011–2015, whereas the most affluent counties had an estimated completeness of 100%. Therefore, incidence rates may be higher than indicated in the poorest counties, and higher incidence rates in the poorest counties would result in even greater differences between the 2 groups of counties. Cancer mortality rates are not affected by delayed reporting or underreporting; therefore, an analysis of cancer mortality rates may provide a more accurate comparison of the cancer burden between these 2 groups of counties. Second, BRFSS estimates have limitations. The BRFSS surveys adults living in households only. Therefore, people living in group settings such as nursing homes, military facilities, or prisons are not surveyed. In addition, adults who live in households without telephones are not included in the BRFSS sample. BRFSS prevalence estimates are based solely on respondents' self-reported answers to survey questions. Respondents may be uncomfortable sharing private health information, or conversely, may exaggerate particular feelings or experiences, or may be tempted to provide responses that are more socially desirable. In some cases, information provided by respondents may be subject to recall bias. Finally, because it was not possible to know the poverty status and risk factors of each person with cancer in Ohio, we could not examine direct causal associations.

Our study identifies cancer disparities between Ohio's poorest counties and most affluent counties and may help target public health interventions for cancer prevention, early detection, and control. In Ohio, the poorest counties had higher cancer incidence and mortality rates than the most affluent counties, especially for cancers of the cervix and larynx and other smoking-related cancers. Several cancers were diagnosed more often at a late stage in the poorest counties than in the most affluent counties. Targeted public health interventions such as smoking cessation programs and screening programs in poor and underserved geographic areas in Ohio may lead to a reduction in cancer disparities. Social determinants of health such as lack of health insurance and access to cancer treatment must also be addressed to reduce the burden of cancer and improve patient outcomes in this state.

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