Education Statistics of the United States 2001 (Education Statistics of the United States)
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Among black men, colorectal cancer death rates were approximately 1. Among black women, the colorectal cancer death rates were highest among those with 12 years of education and 17 or more years of education, and again there was no consistent trend in death rates by level of education Fig. Nonetheless, relative risk estimates comparing the death rates in the three lowest with the three highest educational levels were statistically significantly different from 1. Colorectal cancer mortality rates, by education level, sex, and race, for persons aged 25—64 years in the United States, Colorectal cancer mortality rates were substantially higher in black men than in white men in all educational categories presented Fig.
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Among men in the lowest three levels of education, the relative risk of colorectal cancer mortality for black men compared with white men was 1. Colorectal cancer death rates were higher among black women than among white women in four of six categories of education Fig. Among women in the lowest three levels of education, the relative risk of colorectal cancer mortality for black women compared with white women was 1. Thus, in both men and women, the magnitude of the relative risks for colorectal cancer mortality comparing the three lowest with the three highest educational levels within each race was higher than the relative risks associated with race within each level of education Table 2.
Prostate cancer mortality varied with education level to a greater extent among black men than among white men Fig. Among black men, the highest prostate cancer death rate was among those in the 12 years of education group The relative risk of prostate cancer mortality for the three lowest compared with the three highest levels of educational attainment among black men was 2.
Among white men, prostate cancer death rates varied from 2. Prostate cancer mortality rates, by education level and race, for men aged 25—64 years in the United States, Prostate cancer mortality rates in black men were higher than those among white men in all six educational categories Fig.
Among men in the lowest three levels of education, the relative risk of prostate cancer mortality for black men compared with white men was 3.
Thus, despite the substantial variability in prostate cancer mortality by level of education, especially among black men, the magnitude of the relative risks associated with race within the three lowest compared with the three highest education levels was substantially higher than the magnitude of the relative risks for level of education within race Table 2. Breast cancer mortality varied with level of education among both black and white women Fig. Among black women, the highest breast cancer death rates were observed in the 12 years of education group Among black women, the relative risk of death from breast cancer for women in the three lowest levels of education compared with those in the three highest levels of education was 1.
Among white women, breast cancer death rates varied from The relative risk of death from breast cancer for white women in the three lowest levels of education compared with the three highest levels of education was 1. Breast cancer mortality rates, by education level and race, for women aged 25—64 years in the United States, Breast cancer death rates were substantially higher among black women than among white women in five of the six education level categories Fig.
Elementary & Secondary Education General Information Survey (ELSEGIS) Series
Among women in the three lowest levels of education, the relative risk of breast cancer mortality in black women compared with white women was 1. Thus, the magnitude of the relative risks of breast cancer mortality associated with race within the population of women in the three lowest education levels compared with those in the three highest education levels was substantially higher than the magnitude of the relative risks for level of education within race Table 2.
A number of factors could influence the association between education level and cancer death rate, including access to medical care associated with lack of health insurance; the prevalence of exposure to important cancer risk factors, such as cigarette smoking and obesity; and the likelihood of cancer screening utilization. The contribution of these factors to the variations in cancer mortality observed in this study could not be assessed because information about these factors is not available on death certificates.
Instead, we examined the relationship between educational attainment and various factors that may increase or decrease risk of cancer death using data from the NHIS, a national population-based survey that was conducted in Within each race and sex group, the percentage of individuals without health insurance generally declined as education level increased Table 3.
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The percentage of individuals reporting that they currently smoked cigarettes also declined with increasing level of education Table 3. The percentage of black women who reported having had a mammogram during the previous 2 years was lowest among those with 0—11 years of education i.
Among white women, The prevalence of colorectal cancer screening did not vary in a consistent fashion by level of education Table 3. Restricted to women 40—64 years old. The 0—8 and 9—12 years-of-education categories were combined because of small numbers; the 16 and 17 or more years-of-education categories were also combined because of small numbers. Restricted to adults 50—64 years old. Includes fecal occult blood testing during the previous year and endoscopy during the previous 5 years.
We found an inverse relationship between education level and the rate of death from all cancers combined for black men, white men, and white women. For all cancers combined and for lung and colorectal cancers, the relative risks of death among individuals in the lowest three compared with the highest three levels of education within each race and sex group were larger than the relative risks of death among black men compared to white men and black women compared to white women within the three lowest versus the three highest education categories.
This pattern was not observed for prostate cancer or breast cancer, for which the relative risks of death associated with race within the three lowest versus the three highest levels of education were larger than the relative risks of death associated with the level of education within race. Death rates for all cancers combined and the four cancer sites studied were generally higher among blacks than among whites with similar levels of education. Higher cancer mortality among blacks compared with whites at similar levels of education likely reflects socioeconomic disparities in work, wealth, income, housing, overall standard of living, and access to medical care that are not fully captured by the single measure of SES available for our analysis i.
A novel finding of our study was the large difference in prostate cancer mortality in relation to education in both black and white men. Black men who completed 12 or fewer years of education had a prostate cancer death rate that was more than double that of black men with further schooling. Although the relationship between education level and prostate cancer mortality was weaker in white men than in black men and was not linear in men of either race, the observed associations between prostate cancer mortality and level of education suggests that modifiable factors associated with lower levels of education may play an important role in the uniquely high mortality from prostate cancer among black men.
No prior study, to our knowledge, has examined the relationship between educational attainment and prostate cancer mortality in blacks and whites separately using a nationally representative sample, although several studies have examined the association between SES and prostate cancer incidence or mortality 5 , 7 , 8 , 28—34 with inconsistent results.
Some studies 28 , 34 have shown a positive association between prostate cancer incidence and SES, but others 35 have not. Studies of this association have varied with respect to the time period studied, geographic locations, and SES measures used in the studies. The reasons for the inverse relationship that we observed between education level and prostate cancer mortality are not known.
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A second novel finding of our study was an apparent change in the direction of the relationship between educational attainment and breast cancer mortality compared with previous studies. Historically, studies in the United States and Europe have found that women with higher levels of education or other characteristics related to higher SES have higher risks of developing breast cancer 36 , 37 and of dying from breast cancer 9 , 37 than women with lower levels of education.
Our study found that among women who died in , the most recent time period to be analyzed in any study, the risk of dying of breast cancer is lower among more highly educated women than in less highly educated women. The positive association between SES and breast cancer incidence and mortality in earlier studies has been attributed to a higher prevalence of reproductive risk factors, including later age at first birth among women of higher compared with lower SES 9 , 36 , Changing patterns of breast cancer mortality by SES may be related to a number of factors.
Differences in reproductive patterns by SES that resulted in increased breast cancer risk among higher SES women have diminished over time, while differences in survival related to earlier detection and timely, high-quality treatment among higher SES women have increased The positive association between education and breast cancer mortality has been previously reported to be diminishing or disappearing in the United States 16 , 39 , France 40 , and Finland However, to our knowledge, this is the first study to document an actual reversal in the association, such that in the United States in a recent time period, higher education is associated with lower breast cancer death rates among both black and white women.
An important strength of this study is its use of contemporary national vital statistics data, which provided nearly complete ascertainment of deaths in the US population. The deaths included in this study represent The associations between educational attainment and all-cancer mortality for black and white men and for white women observed in this study are, in general, stronger than those observed in previous US studies 7 , 9 , 10 , 32 and in studies of level of education and cancer incidence or mortality in other countries 1 , These differences may reflect the broader representation of all socioeconomic strata in the general population in our study, as well as the increasing differences in morbidity and mortality by race and SES for many chronic conditions observed in the past several decades in the United States and Europe 1 , 2 , 43— Several studies 43 , 46 have documented that declines in mortality rates for many causes of death that are associated with improvements in disease prevention and treatment have had a much greater impact on whites than on blacks and in higher SES areas than in lower SES areas.
The collection of level-of-education information on death certificates provides a potentially important opportunity to identify and monitor disparities in population health, which could potentially lead to effective public health interventions.
However, the usefulness of vital statistics data to analyze the relationship between individual educational attainment and mortality depends on the validity of individual-level information on death certificates. Sorlie and Johnson 19 assessed the validity of the education information on death certificates by comparing it with data previously self-reported by participants in the National Longitudinal Mortality Study NLMS. Although such misclassification of individuals with less than a high school education may produce an underestimate of death rates for individuals with fewer than 12 years of education and a corresponding overestimate of death rates for individuals with 12 years of education, it does not bias the comparison of death rates between those who are educated beyond high school and those who are not Associations between lower educational attainment and higher risks of developing or dying from many cancers are likely to be influenced by a number of risk factors that are associated with SES.
For example, historical patterns in the prevalence and intensity of cigarette smoking by SES 47 clearly account for much of the associations we observed between education level and lung cancer mortality among black and white men and the smaller associations we observed in women. The variation in lung cancer mortality with education accounts for a substantial portion of the variation in all-cancer death rates with education in men, as reported from other studies in the United States 3—5 and Europe 1.
Lung cancer mortality rates are also influenced by stage at diagnosis and survival from lung cancer, which have also been found to vary by SES and race 48 , The relationships between education level and the mortality rates for colorectal, prostate, and breast cancers are more complex than that for lung cancer. For those cancers, no single risk factor accounts for as much of the variation in cancer mortality as does smoking in lung cancer mortality. The inverse association that we observed between colorectal cancer mortality and educational attainment is stronger than that observed in two earlier US studies 7 , 9 that did not report data separately for blacks and whites.
SES-associated factors that influence the risk of developing or dying from colorectal cancer include obesity 29 , physical inactivity, diet, and use of hormone replacement therapy, anti-inflammatory drugs, and colorectal cancer screening Greater use of colorectal cancer screening among individuals with higher levels of education 51 , 52 is likely to have contributed to the lower colorectal cancer mortality rates observed in this and in previous studies 7 , 9 , although this trend was not apparent for black men in our analysis of the NHIS survey, when screening rates were low in all groups Table 3.
Our study considered only mortality, and we did not attempt to differentiate variations attributable to colorectal cancer incidence from those affecting survival. However, more advanced stage at diagnosis and lower rates of receipt of appropriate treatment have been found for black compared with white colorectal cancer patients Our study has several limitations.
First, we relied on only one indicator of individual SES, namely, educational attainment. Level of education has been used as an indicator of individual SES in many studies because it is a stable indicator of lifetime SES, it is associated with other indicators of SES such as income, and the data are relatively easy to collect However, spousal SES can have as strong an influence on income and other characteristics as personal SES, especially for women; thus, our inability to account for a spouse's SES may have contributed, in part, to the weaker association between educational attainment and overall cancer mortality we observed in women than in men.
It is widely recognized that SES is a complex concept that reflects a combination of individual- and geographic area—level influences and that, when possible, it is desirable to consider multiple indices of SES in analyzing relationships between SES and health outcomes 54 , We were unable to do so in this study because the data available for analysis of mortality by individual level of education could not be linked to geographic area—level SES indicators and because level of education is the only indicator of SES available in vital statistics records.
Second, this study was restricted to individuals who were 25—64 years old at death, which limits the generalizability of the results to older individuals. It is possible that differences in mortality by level of education may be attenuated in individuals older than 65 years because such individuals may have better access to health care through Medicare.
Restriction of the current analysis to black and non-Hispanic whites also limits the generalizability of the results to other racial and ethnic population groups. It is widely recognized that cancer death rates provide a meaningful composite index of the success of cancer control measures throughout the cancer continuum, which ranges from prevention and early diagnosis to treatment and survival. Studies of trends in cancer mortality by race and geographic region have historically been an important resource for identifying high-risk populations.
This study demonstrates the utility of examining mortality rates by level of education using national vital statistics data to identify and monitor health disparities in the United States. This information would be even more valuable if it could be augmented by routine collection of data on level of education in a broad array of administrative health record systems. Information on education is routinely collected in surveys of behavioral risk factors and is used to examine socioeconomic gradients in relation to those risk factors and to selected measures of self-reported health care utilization and outcomes but is not available in medical records that are used as the basis for cancer registries and health services research studies.
Collecting data on individual level of education would allow researchers to examine the contribution of variations in cancer incidence, stage at diagnosis, and survival to differences in cancer mortality by level of education. In conclusion, we have found that cancer death rates vary substantially by race, level of education, and sex in a recent time period in the United States.
Our findings provide a baseline against which efforts to reduce cancer disparities can be measured. Funding to pay the Open Access publication charges for this article was provided by the American Cancer Society. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation.
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Google Scholar. Elizabeth Ward. Ahmedin Jemal. Robert Anderson. Vilma E. Taylor Murray. Jane Henley. Jonathan Liff. Michael J. Cite Citation. Permissions Icon Permissions. Abstract Background. Table 1. Open in new tab.