Abstract
Background and Objective: Appalachia is a large geographic area in all or part of 13 eastern states, characterized by limited health care access, poverty, and a low level of health insurance which are risks for elevated breast cancer mortality rates. The mammogram rates for Appalachian women were significant lower than those for women living elsewhere in the U.S., but Appalachia had experienced lower incidence and death rates of breast cancer than the rest of the U.S. This study examined if Appalachia has maintained comparative low death rates of breast cancer during 1990-2006 in a situation where public health system in Appalachia are disproportionately poor compared with those in the rest of the nation.
Data and Method: Mortality data of white women in 13 Appalachian states were collected by CDC's National Center for Health Statistics. We used mortality data from 1990 through 2006 and SEER∗Stat to calculate the Appalachian/non-Appalachian ratio of the age-adjusted cancer death rates, by rural/urban status and by age group. We limited analysis to whites to reduce confounding by race. Six-year aggregate rates during 1990-1995 and 1996-2001 and five-year aggregate rates during 2002-2006 were calculated by taking the sum of death counts for the 5-year period and dividing by the population totals for the same 5-year period to produce stable estimates. The resulting rates were age-adjusted to the 2000 U.S. standard population by 5-year age groups. GeoDa& ArcGIS were used to conduct the spatial exploratory data analysis.
Findings: Rates in Appalachia declined more slowly than did rates in non-Appalachia (19.1% versus 24.8%). The ratio of Appalachian/non-Appalachian rates increased steadily overtime (0.9310∗∗∗, 0.9458∗∗∗, and 1.0028), in both rural and urban areas (urban: 0.9355∗∗∗, 0.9411∗∗∗, 0.9982; rural: 1.0273, 1.0309, 1.0610∗), and among both age groups (65 and older: 0.8891∗∗∗, 0.9175∗∗∗, 0.9794; 64 and younger: 0.9793, 0.9821, 1.0343∗). Appalachian/non-Appalachian rate ratios increased in 10 states except in Mississippi and Georgia. The ratios of Appalachian/non-Appalachian rates in Kentucky, South Carolina, and Virginia have increased from 0.95-0.98 during 1990-1995 to 1.10-1.11 during 2002-2006. The spatial pattern of high breast cancer mortality was more clustered in Appalachia than in non-Appalachia during 2002-2006, especially in West Virginia and Appalachian Kentucky.
Conclusions: Breast cancer mortality rates among Appalachian women, especially younger women, women in rural areas, Women from Appalachian Kentucky, South Carolina, and Virginia, are not decreasing as fast as rates for women in non-Appalachian areas during 1990-2006. High breast cancer mortality was clustered in Central Appalachia.
Implications: These results provide valuable information for identifying who to focus and where to enhance public health systems in Appalachia regarding cancer screening efforts, increasing access to health care, for assessing the quality of health care, and for developing research plans.
Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B70.
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