Association of Educational Attainment with Cancer Mortality in a National Cohort Study of Black and White Adults: A Mediation Analysis

Overview

Journal SSM Popul Health

Date 2023 Nov 13

PMID 37954012

Authors

Anjali Gupta

Lauren E Wilson

Laura C Pinheiro

Amy H Herring

Tyson Brown

Virginia J Howard

Tomi F Akinyemiju

Affiliations

Soon will be listed here.

Abstract

Background: Low educational attainment is associated with excess cancer mortality. However, the mechanisms driving this association remain unknown.

Methods: Using data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, we evaluated the associations of participant and parental/caregiver education with cancer mortality using Cox proportional hazards models, adjusting for socio-demographic characteristics and health conditions. We used principal components analysis to generate indices of measures representing the social determinants of health (SDOH) and health behaviors. We used structural equation modeling to determine if the association between educational attainment and cancer mortality was mediated by these domains.

Results: Among 30,177 REGARDS participants included in this analysis, 3798 (12.6%) had less than a high school degree. In fully adjusted models, those without a high school education experienced about 50% greater risk of death than high school graduates and higher (White participants HR: 1.47; 95% CI: 1.23, 1.76 and Black HR: 1.54; 95% CI: 1.33, 1.79). There was evidence of a modest mediation effect for the association between education and cancer mortality by the SDOH domain score (White total effect HR: 1.25; 95% CI: 1.18, 1.33, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.21; 95% CI: 1.14, 1.28 and Black total effect HR: 1.24; 95% CI: 1.18, 1.29, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.19; 95% CI: 1.14, 1.24). There was no evidence of mediation by the health behaviors score. No significant associations were found for female caregiver/mother's or male caregiver/father's education (N = 13,209).

Conclusions: In conclusion, participant education was strongly associated with cancer mortality, and this association was partially mediated by the SDOH domain score.

Citing Articles

An Interdisciplinary Perspective on Improving Cancer Care in the State of Mississippi as an Example of Cancer Care Improvements in the Global South.

Jones M, Vijayakumar S, Nittala M, Brunson C Cureus. 2025; 17(1):e76865.

PMID: 39758867 PMC: 11698381. DOI: 10.7759/cureus.76865.

Addressing knowledge and behavior gaps in breast cancer risks: implications for health promotion and intervention strategies.

Effiong M, Afolabi I, Chinedu S Front Oncol. 2024; 14:1456080.

PMID: 39610935 PMC: 11602397. DOI: 10.3389/fonc.2024.1456080.

References

Rogers R, Hummer R, Everett B . Educational differentials in US adult mortality: An examination of mediating factors. Soc Sci Res. 2013; 42(2):465-81. PMC: 4874513. DOI: 10.1016/j.ssresearch.2012.09.003. View

Greenup R, Obeng-Gyasi S, Thomas S, Houck K, Lane W, Blitzblau R . The Effect of Hospital Volume on Breast Cancer Mortality. Ann Surg. 2016; 267(2):375-381. PMC: 5994238. DOI: 10.1097/SLA.0000000000002095. View

Gupta A, Jones K, Deveaux A, Bevel M, Salako O, Daramola A . Association of Life-Course Educational Attainment and Breast Cancer Grade in the MEND Study. Ann Glob Health. 2021; 87(1):59. PMC: 8269775. DOI: 10.5334/aogh.3142. View

Zajacova A, Lawrence E . The Relationship Between Education and Health: Reducing Disparities Through a Contextual Approach. Annu Rev Public Health. 2018; 39:273-289. PMC: 5880718. DOI: 10.1146/annurev-publhealth-031816-044628. View

OConnor J, Sedghi T, Dhodapkar M, Kane M, Gross C . Factors Associated With Cancer Disparities Among Low-, Medium-, and High-Income US Counties. JAMA Netw Open. 2019; 1(6):e183146. PMC: 6324449. DOI: 10.1001/jamanetworkopen.2018.3146. View

Sterling M, Ringel J, Pinheiro L, Safford M, Levitan E, Phillips E . Social Determinants of Health and 90-Day Mortality After Hospitalization for Heart Failure in the REGARDS Study. J Am Heart Assoc. 2020; 9(9):e014836. PMC: 7428585. DOI: 10.1161/JAHA.119.014836. View

Jaiswal J, Halkitis P . Towards a More Inclusive and Dynamic Understanding of Medical Mistrust Informed by Science. Behav Med. 2019; 45(2):79-85. PMC: 7808310. DOI: 10.1080/08964289.2019.1619511. View

Meader N, King K, Moe-Byrne T, Wright K, Graham H, Petticrew M . A systematic review on the clustering and co-occurrence of multiple risk behaviours. BMC Public Health. 2016; 16:657. PMC: 4966774. DOI: 10.1186/s12889-016-3373-6. View

Reshetnyak E, Ntamatungiro M, Pinheiro L, Howard V, Carson A, Martin K . Impact of Multiple Social Determinants of Health on Incident Stroke. Stroke. 2020; 51(8):2445-2453. PMC: 9264323. DOI: 10.1161/STROKEAHA.120.028530. View

10.

Rogers R, Everett B, Zajacova A, Hummer R . Educational degrees and adult mortality risk in the United States. Biodemography Soc Biol. 2010; 56(1):80-99. PMC: 3184464. DOI: 10.1080/19485561003727372. View

11.

Taghizadeh N, Vonk J, Boezen H . Lifetime Smoking History and Cause-Specific Mortality in a Cohort Study with 43 Years of Follow-Up. PLoS One. 2016; 11(4):e0153310. PMC: 4824471. DOI: 10.1371/journal.pone.0153310. View

12.

Kunzmann A, Coleman H, Huang W, Berndt S . The association of lifetime alcohol use with mortality and cancer risk in older adults: A cohort study. PLoS Med. 2018; 15(6):e1002585. PMC: 6007830. DOI: 10.1371/journal.pmed.1002585. View

13.

Singh G, Jemal A . Socioeconomic and Racial/Ethnic Disparities in Cancer Mortality, Incidence, and Survival in the United States, 1950-2014: Over Six Decades of Changing Patterns and Widening Inequalities. J Environ Public Health. 2017; 2017:2819372. PMC: 5376950. DOI: 10.1155/2017/2819372. View

14.

Brown T, Parmar G, Durant R, Halanych J, Hovater M, Muntner P . Health Professional Shortage Areas, insurance status, and cardiovascular disease prevention in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. J Health Care Poor Underserved. 2011; 22(4):1179-89. PMC: 3586412. DOI: 10.1353/hpu.2011.0127. View

15.

Cormie P, Zopf E, Zhang X, Schmitz K . The Impact of Exercise on Cancer Mortality, Recurrence, and Treatment-Related Adverse Effects. Epidemiol Rev. 2017; 39(1):71-92. DOI: 10.1093/epirev/mxx007. View

16.

Vohra J, Marmot M, Bauld L, Hiatt R . Socioeconomic position in childhood and cancer in adulthood: a rapid-review. J Epidemiol Community Health. 2015; 70(6):629-34. PMC: 4893135. DOI: 10.1136/jech-2015-206274. View

17.

Albano J, Ward E, Jemal A, Anderson R, Cokkinides V, Murray T . Cancer mortality in the United States by education level and race. J Natl Cancer Inst. 2007; 99(18):1384-94. DOI: 10.1093/jnci/djm127. View

18.

Martin K, Beckles G, Wu C, McClure L, Carson A, Bennett A . Lifecourse socioeconomic position and diabetes incidence in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, 2003 to 2016. Prev Med. 2021; 153:106848. PMC: 8658048. DOI: 10.1016/j.ypmed.2021.106848. View

19.

Halanych J, Shuaib F, Parmar G, Tanikella R, Howard V, Roth D . Agreement on cause of death between proxies, death certificates, and clinician adjudicators in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Am J Epidemiol. 2011; 173(11):1319-26. PMC: 3101067. DOI: 10.1093/aje/kwr033. View

20.

Cole A, Lu C, Krimphove M, Szymaniak J, Sun M, Fletcher S . Comparing the Association Between Insurance and Mortality in Ovarian, Pancreatic, Lung, Colorectal, Prostate, and Breast Cancers. J Natl Compr Canc Netw. 2019; 17(9):1049-1058. DOI: 10.6004/jnccn.2019.7296. View