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University of Southern California Dissertations and Theses
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Socioeconomic status and cancer risk among diverse populations in Los Angeles County, 1972-1992
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Socioeconomic status and cancer risk among diverse populations in Los Angeles County, 1972-1992
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INFORMATION TO USERS This manuscript has been reproduced from the microfilm master. UMI films the text directly from the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter face, while others may be from any type of computer printer. The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleedthrough, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left-hand comer and continuing from left to right in equal sections with small overlaps. Each original is also photographed in one exposure and is included in reduced form at the back of the book. Photographs included in the original manuscript have been reproduced xerographically in this copy. Higher quality 6” x 9” black and white photographic prints are available for any photographs or illustrations appearing in this copy for an additional charge. Contact UMI directly to order. UMI A Bell & Howell Information C om pany 300 North Zeeb R oad, Ann A rbor M I 48106-1346 USA 313/761-4700 800/521-0600 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. SOCIOECONOMIC STATUS AND CANCER RISK AMONG DIVERSE POPULATIONS IN LOS ANGELES COUNTY 1972-1992 by Lihua Liu A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (Sociology) December 1996 Copyright 1996 Lihua Liu Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UMI N um ber: 9720258 Copyright 1996 by Liu, Lihua All rights reserved. UMI Microform 9720258 Copyright 1997, by UMI Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. UMI 300 North Zeeb Road Ann Arbor, MI 48103 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UNIVERSITY OF SOUTHERN CALIFORNIA THE GRADUATE SCHOOL UNIVERSITY PARK LOS ANGELES. CALIFORNIA 90007 This dissertation, written by ..........................L ihuaLiu............................................ under the direction of h e x. Dissertation Committee; and approved by all its members, has been presented to and accepted by The Graduate School in partial fulfillment of re quirements for the degree of DOCTOR OF PHILOSOPHY i c r v ’ L Dean of Graduate Studies / -Date.S9.KMVI3 . >..I.?.9 .6# DISSERTATION COMMITTEE ........................................................ ^ * 7 A _ < erson Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Lihua Liu David M. Heer SOCIOECONOMIC STATUS AND CANCER RISK AMONG DIVERSE POPULATIONS IN LOS ANGELES COUNTY 1972-1992 Using data from the Los Angeles County Cancer Surveillance Program, this study was designed to investigate the relationship between SES and cancer risk among the racially/ ethnically diversified residents in Los Angeles County during 1972-1992. Nineteen cancers were included in this study. A SES index was developed based on census tract level socioeconomic data. Annual population by age, sex, race/ethnicity, and SES were estimated for the intercensal and postcensal years. Age-specific and age- adjusted incidence rates were examined by SES and race/ethnicity. Poisson regression models were used to evaluate the effect of SES with adjustment for age and race/ethnicity and the effect of race/ethnicity with adjustment for age and SES. The most important findings of this study are that for some cancers (e.g., cancers of the female breast cancer, central nervous system, colon, corpus uteri, melanoma, ovary, prostate, testis, and thyroid) the increasing risk is associated with increasing socioeconomic status (SES), for other cancers the relationship is reversed (e.g., cancers of cervix uteri, esophagus, larynx, liver, lung, and stomach), and for still other forms of cancer no relationship with SES is apparent (e.g., cancers of bladder, kidney, pancreas, and rectum). These results support the hypothesis that the association with SES depends on the risk factors involved in a particular cancer. The heterogeneity in the relationships between specific cancers and socioeconomic status also suggests that no single factor can account for these associations. History has shown that when changes happen in diseases, treatments, risks, and/or knowledge about risks, people of high SES always eventually come out ahead. As health-related situations change, those with the most resources are best able to avoid diseases and their consequences. The positive SES associations with so many cancers indicate that the public as well as the health service providers do not have adequate information in order to take preventive measures against cancer. They point to the lack of understanding of cancer and the need for research. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. PREFACE This dissertation was supported in part by the American Cancer Society, California Division Fellowship #3-4-96 and by the Los Angeles County Cancer Surveillance Program. The ideas and opinions expressed herein are those of the author and do not necessarily represent those of the above institutions. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ACKNOWLEDGMENTS I am grateful to the members of my dissertation committee: Dr. David Heer, Professor of Sociology and Director of the Population Research Laboratory (Pop Lab), USC, Dr. Leslie Bernstein, Professor of Preventive Medicine, Senior Associate Dean for Faculty Affairs of the School of Medicine, USC, and Scientific Director of the Los Angeles County Cancer Surveillance Program (CSP), and Dr. Edward Ransford, professor of Sociology, USC. As chairman of the committee, Dr. Heer extended to me his continued support and enthusiasm. He was always there available to help me. His able guidance was crucial to the completion of this dissertation. I feel extremely lucky to have had Dr. Bernstein in my committee. Without her expertise as a renowned cancer epidemiologist this study would not be possible. Her warmth, sincerity, and incredible proficiency and efficiency have made her my inspiration. Dr. Ransford was the professor who first taught me medical sociology. He agreed to join this committee at a very critical time. His scholarship in sociological issues have helped me in better writing the dissertation. It has been a long but worthy process to complete the Ph.D training. I am very fortunate to have met many special people at USC who had trust in me and helped me through the years. I would like to take this opportunity to name a few of them. Dr. Maurice D. Van Arsdol, Jr., Professor of Sociology and former Director of the Pop Lab, USC, recruited me to USC Pop Lab from China and introduced me to world demography. Like a caring parent he taught me a lot, more than I have realized. Dr. Herman Turk, the late professor of Sociology, strongly recommended me for the Ph.D program while I was studying for my M.S. degree. His belief in me had led me to self-discovery and the Ph.D degree. Dr. Jon Miller, Professor of Sociology and former graduate advisor, at many critical occasions, extended me his support Ms. Frances Fitzgerald, Student Sen/ice Advisor at the Department of Sociology, whose experience and care have made my student life enjoyable. iii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I am deeply indebted to Dr. Dennis Deapen, Associate Professor at the Department of Preventive Medicine, School of Medicine, USC, and Executive Director of the CSP. Many times when I was discouraged and in difficult situations, it was Dr. Deapen who went out his way to help me and encouraged me to complete the doctoral training. His wise advice and deep understanding have made the dissertation project a valuable experience for me. Furthermore, I would like to thank my sponsors: the Los Angeles County Cancer Surveillance Program and the American Cancer Society, California Division, whose financial support is truly appreciated. I also wish to extend special thanks to Mr. Ed Sharpe for the great support in computer-related matters, to Frances Wang, M.S. and Angela Miu, M.S. for their help in SAS programming, and to the hospital cancer registrars and the CSP staff members whose dedication and hard work provided the foundation for this study. Finally, I want to say “ Thank you" to my dear husband, Yang Chai, and my lovely two- year old daughter, Audrey, for their understanding, support, and love. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TABLE OF CONTENTS Page Preface...................................................................................................................................................... ii Acknowledgment......................................................................................................................................iii List of Tables...........................................................................................................................................vii List of Figures...........................................................................................................................................ix List of Maps............................................................................................................................................xxi Chapter 1. Introduction.............................................................................................................................1 Chapter 2. Socio-demographic Factors in Health.................................................................................9 2.1 - Age......................................................................................................................10 2.2 - Gender................................................................................................................ 11 2.3 - Race/Ethnicity................................................................................................... 12 2.4 - Socioeconomic Status (SES)...........................................................................16 2.5 - Interaction between Race/Ethnicity and SES................................................. 22 2.6 - The Enduring Relationship between Social Conditions and Disease........... 25 Chapter 3. Socioeconomic Status....................................................................................................... 28 3.1 - Theories of Social Class................................................................................... 29 3.2 - Measures of Socioeconomic Status (SES).....................................................31 3.2.1 - Occupation As An Indicator.............................................................31 3.2.2 - Education As An Indicator...............................................................34 3.2.3 - Income As An Indicator................................................................... 36 3.2.4 - Composite Measures...................................................................... 37 3.2.5.- Ecological Approach........................................................................ 41 Chapter 4. Cancer Epidemiology......................................................................................................... 43 4.1 - Terminology and Measurements in Cancer Study.........................................45 4.2 - Causes of Cancer..............................................................................................48 4.3 - Cancer Risk Factors..........................................................................................50 4.4 - Selected cancers...............................................................................................54 4.4.1 - Cancer of the Bladder....................................................................54 4.4.2 - Cancer of the Breast..................................................................... 56 4.4.3 - Cancer of the Central Nervous System........................................58 4.4.4 - Cancer of the Cervix Uteri.............................................................59 4.4.5 - Cancer of the Colon....................................................................... 60 4.4.6 - Cancer of the Corpus Uteri............................................................63 4.4.7 - Cancer of the Esophagus..............................................................64 4.4.8 - Cancer of the Kidney..................................................................... 65 4.4.9 - Cancer of the Larynx.....................................................................67 4.4.10 - Cancer of the Liver........................................................................ 68 4.4.11 - Cancer of the Lung........................................................................ 69 4.4.12-Melanoma ..................................................................................... 70 4.4.13 - Cancer of the Ovary...................................................................... 72 4.4.14 - Cancer of the Pancreas.................................................................73 4.4.15 - Cancer of the Prostate..................................................................74 4.4.16 - Cancer of the Rectum...................................................................76 4.4.17 - Cancer of the Stomach..................................................................77 4.4.18 - Cancer of the Testis......................................................................78 4.4.19 - Cancer of the Thyroid....................................................................80 v Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 5. Study Design and Materials...............................................................................................82 5.1 - The Study Design..............................................................................................84 5.2 - The Study Area.................................................................................................86 5.2.1 - The Diverse Population....................................................................86 5.2.2 - The Cancer Surveillance Program................................................. 88 5.3 - The Materials..................................................................................................... 89 5.3.1 - The Case Data................................................................................. 90 5.3.2 - The Population Data......................................................................... 91 5.3.3 - The 1970-80-90 Census Tract Correspondence File................... 91 Chapter 6. Methodology........................................................................................................................93 6.1 - Developing the SES Index................................................................................ 93 6.2 - Population Estimates for Intercensal Years.....................................................96 6.3 - The Age-specific and Age-adjusted Incidence Rates...................................100 6.3.1 - Age-specific Incidence Rates........................................................100 6.3.2 - Age-adjusted Incidence Rates......................................................101 6.4 - The Poisson Regression Model......................................................................101 Chapter 7. Results and Findings........................................................................................................105 7.1 - The SES and Population Structure.................................................................105 7.2 - The Age-adjusted Cancer Incidence Rates...................................................113 7.3 - The Age-specific Cancer Incidence Rates....................................................134 7.4 - The Poisson Regression Analysis................................................................. 268 Chapter 8. Discussion and Implications.............................................................................................275 8.1 - Positive SES Associations with Some Cancers...........................................276 8.1.1 - Explanations and Speculations for the Positive Relationships.................................................................................. 276 8.1.2 - Positive SES Association in Predicting Survival..........................279 8.1.3 - Implications of the Positive Association........................................281 8.2 - Comparisons with Other Studies....................................................................282 8.3 - Cancer Risk by SES among Racial/Ethnic Populations.............................. 284 8.4 - Cancer Risk by SES at Different Age............................................................287 8.5 - Limitation of This Study.................................................................................. 289 8.6 - Recommendations for Future Studies........................................................... 290 References.......................................................................................................................................... 293 Appendix A. SES Designation for Census Tracts in Los Angeles County, 1970,1980, and 1990.................................................................................................315 Appendix B. SEER Site Recode for ICD-O-2 Incidence Data...................................................... 332 Appendix C. Standard Population....................................................................................................336 vi Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF TABLES Table 1. Population Structure by Race/Ethnicity and SES, Los Angeles County, 1970, 1980, and 1990.....................................................................................................108 Table 2. Number of Cancer Cases for People 15 Years of Age and Older, by Site and Sex, All Races/Ethnicities Combined, Los Angeles County, 1972-1992.................... 119 Table 3. Age-adjusted Incidence Rates by Sex, Race/Ethnicity, SES, and Cancer Site, Los Angeles County, 1972-1992.................................................................................... 120 Table 4. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Bladder Cancer.............................................................................135 Table 5. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Breast Cancer...............................................................................143 Table 6. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Cancer of the Central Nervous System..................................... 148 Table 7. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Cervical Cancer........................................................................... 156 Table 8. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Colon Cancer.................................................................................161 Table 9. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Cancer of the Corpus Uteri.......................................................... 169 Table 10. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Esophageal Cancer...................................................................... 174 Table 11. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Kidney Cancer...............................................................................182 Table 12. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Larynx Cancer...............................................................................190 Table 13. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Liver Cancer..................................................................................198 Table 14. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Lung Cancer................................................................................. 206 Table 15. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Melanoma......................................................................................214 Table 16. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Ovarian Cancer............................................................................ 222 Table 17. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Pancreatic Cancer........................................................................227 vii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 18. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Prostate Cancer............................................................................ 235 Table 19. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Rectal Cancer...............................................................................240 Table 20. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Stomach Cancer...........................................................................248 Table 21. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Testis Cancer............................................................................... 256 Table 22. Age-specific Incidence Rates by Sex, Race/Ethnicity, and SES, Los Angeles County, 1972-1992, Thyroid Cancer.............................................................................261 Table 23 Relative Risk (R.R.) by SES with 95% Confidence Interval (C.l.) and Test for Trend Adjusting for Race/Ethnicity and Age for Selected Cancers, Los Angeles County, 1972-1992................................................................................... 269 Table 24 Relative Risk (R.R.) by Race/Ethnicity with 95% Confidence Interval (C.l.) and Test for Trend Adjusting for SES and Age for Selected Cancers, Los Angeles County, 1972-1992................................................................................... 272 Table 25 Summary of Epidemiological Studies of Prostatic Cancer Risk and Socioeconomic Status (SES).........................................................................................292 viii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF FIGURES Figure 1. Average Education by SES, Los Angeles County, 1970,1980, and 1990................. 107 Figure 2. Average Income by SES, Los Angeles County, 1970,1980, and 1990......................107 Figure 3. Population Distribution by SES among Racial/Ethnic Groups, Los Angeles County, 1990.....................................................................................................................109 Figure 4. Population Distribution by SES among Racial/Ethnic Groups, Los Angeles County, 1980.....................................................................................................................109 Figure 5. Population Distribution by SES among Racial/Ethnic Groups, Los Angeles County, 1970.....................................................................................................................109 Figure 6. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Bladder, Males............................................................................... 124 Figure 7. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Bladder, Females.......................................................................... 124 Figure 8. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Breast, Females............................................................................ 124 Figure 9. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Central Nervous System, Males.................................................. 125 Figure 10. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Central Nervous System, Females..............................................125 Figure 11. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Cervix Uteri, Females....................................................................125 Figure 12. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Colon, Males.................................................................................. 126 Figure 13. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Colon, Females............................................................................. 126 Figure 14. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Corpus Uteri, Females...................................................................126 Figure 15. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Esophagus, Males.........................................................................127 Figure 16. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Esophagus, Females.....................................................................127 Figure 17. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Kidney, Males................................................................................ 127 ix Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 18. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Kidney, Females........................................................................... 127 Figure 19. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Larynx, Males................................................................................128 Figure 20. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Larynx, Females........................................................................... 128 Figure 21. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Liver, Males...................................................................................128 Figure 22. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Liver, Females...............................................................................128 Figure 23. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Lung, Males...................................................................................129 Figure 24. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Lung, Females..............................................................................129 Figure 25. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Melanoma, Males........................................................................ 129 Figure 26. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Melanoma, Females....................................................................129 Figure 27. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Ovary, Females........................................................................... 130 Figure 28. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Pancreas, Males.......................................................................... 130 Figure 29. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Pancreas, Females......................................................................130 Figure 30. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Prostate, Males............................................................................ 131 Figure 31. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Rectum, Males............................................................................. 131 Figure 32. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Rectum, Females........................................................................131 Figure 33. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Stomach, Males...........................................................................132 Figure 34. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Stomach, Females.......................................................................132 x Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 35. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Testis, Males.................................................................................132 Figure 36. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Thyroid, Males...............................................................................133 Figure 37. Age-adjusted Incidence Rates by Race/Ethnicity and SES, Los Angeles County, 1972-1992, Thyroid, Females.......................................................................... 133 Figure 38. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Bladder Cancer, White Males.................................................................... 137 Figure 39. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Bladder Cancer, White Females................................................................137 Figure 40. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Bladder Cancer, Black Males..................................................................... 138 Figure 41. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Bladder Cancer, Black Females................................................................138 Figure 42. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Bladder Cancer, Hispanic Males................................................................139 Figure 43. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Bladder Cancer, Hispanic Females...........................................................139 Figure 44. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Bladder Cancer, Asian Males.................................................................... 140 Figure 45. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Bladder Cancer, Asian Females................................................................140 Figure 46. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Bladder Cancer, All Males.......................................................................... 141 Figure 47. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Bladder Cancer, All Females..................................................................... 141 Figure 48. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Breast Cancer, White Females..................................................................144 Figure 49. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Breast Cancer, Black Females..................................................................144 Figure 50. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Breast Cancer, Hispanic Females.............................................................145 Figure 51. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Breast Cancer, Asian Females..................................................................145 xi Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 52. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Breast Cancer, All Females....................................................................... 146 Figure 53. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Central Nervous System, White Males..............................150 Figure 54. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Central Nervous System, White Females........................ 150 Figure 55. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Central Nervous System, Black Males..............................151 Figure 56. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Central Nervous System, Black Females......................... 151 Figure 57. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Central Nervous System, Hispanic Males........................ 152 Figure 58. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Central Nervous System, Hispanic Females....................152 Figure 59. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Central Nervous System, Asian Males............................ 153 Figure 60. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Central Nervous System, Asian Females........................153 Figure 61. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Central Nervous System, All Males..................................154 Figure 62. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Central Nervous System, All Females............................. 154 Figure 63. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cervical Cancer, White Females.............................................................. 157 Figure 64. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cervical Cancer, Black Females............................................................... 157 Figure 65. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cervical Cancer, Hispanic Females.......................................................... 158 Figure 66. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cervical Cancer, Asian Females................................................................158 Figure 67. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cervical Cancer, All Females.....................................................................159 Figure 68. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Colon Cancer, White Males....................................................................... 163 xii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 69. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Colon Cancer, White Females...................................................................163 Figure 70. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Colon Cancer, Black Males........................................................................164 Figure 71. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Colon Cancer, Black Females...................................................................164 Figure 72. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Colon Cancer, Hispanic Males...................................................................165 Figure 73. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Colon Cancer, Hispanic Females..............................................................165 Figure 74. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Colon Cancer, Asian Males.......................................................................166 Figure 75. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Colon Cancer, Asian Females...................................................................166 Figure 76. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Colon Cancer, All Males............................................................................. 167 Figure 77. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Colon Cancer, All Females........................................................................167 Figure 78. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Corpus Uteri, White Females.............................................170 Figure 79. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Corpus Uteri, Black Females.............................................170 Figure 80. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Corpus Uteri, Hispanic Females........................................171 Figure 81. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Corpus Uteri, Asian Females........................................... 171 Figure 82. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Cancer of the Corpus Uteri, All Females.................................................172 Figure 83. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Esophageal Cancer, White Males..............................................................176 Figure 84. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Esophageal Cancer, White Females........................................................ 176 Figure 85. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Esophageal Cancer, Black Males..............................................................177 xiii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 86. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Esophageal Cancer, Black Females......................................................... 177 Figure 87. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Esophageal Cancer, Hispanic Males........................................................ 178 Figure 88. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Esophageal Cancer, Hispanic Females.................................................... 178 Figure 89. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Esophageal Cancer, Asian Males............................................................. 179 Figure 90. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Esophageal Cancer, Asian Females......................................................... 179 Figure 91. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Esophageal Cancer, All Males...................................................................180 Figure 92. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Esophageal Cancer, All Females...............................................................180 Figure 93. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Kidney Cancer, White Males...................................................................... 184 Figure 94. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Kidney Cancer, White Females.................................................................184 Figure 95. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Kidney Cancer, Black Males...................................................................... 185 Figure 96. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Kidney Cancer, Black Females..................................................................185 Figure 97. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Kidney Cancer, Hispanic Males.................................................................186 Figure 98. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Kidney Cancer, Hispanic Females............................................................ 186 Figure 99. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Kidney Cancer, Asian Males...................................................................... 187 Figure 100. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Kidney Cancer, Asian Females..................................................................187 Figure 101. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Kidney Cancer, All Males........................................................................... 188 Figure 102. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Kidney Cancer, All Females.......................................................................188 xiv Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 103. Age-specific incidence Rates by SES, Los Angeles County, 1972-1992, Larynx Cancer, White Males......................................................................192 Figure 104. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Larynx Cancer, White Females..................................................................192 Figure 105. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Larynx Cancer, Black Males......................................................................193 Figure 106. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Larynx Cancer, Black Females..................................................................193 Figure 107. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Larynx Cancer, Hispanic Males.................................................................194 Figure 108. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Larynx Cancer, Hispanic Females............................................................ 194 Figure 109. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Larynx Cancer, Asian Males......................................................................195 Figure 110. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Larynx Cancer, Asian Females..................................................................195 Figure 111. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Larynx Cancer, All Males........................................................................... 196 Figure 112. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Larynx Cancer, All Females....................................................................... 196 Figure 113. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Liver Cancer, White Males............................................. 200 Figure 114. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Liver Cancer, White Females.....................................................................200 Figure 115. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Liver Cancer, Black Males.........................................................................201 Figure 116. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Liver Cancer, Black Females.................................................................... 201 Figure 117. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Liver Cancer, Hispanic Males................................................................... 202 Figure 118. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Liver Cancer, Hispanic Females............................................................... 202 Figure 119. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Liver Cancer, Asian Males.........................................................................203 xv Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 120. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Liver Cancer, Asian Females..................................................................... 203 Figure 121. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Liver Cancer, All Males...............................................................................204 Figure 122. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Liver Cancer, All Females...........................................................................204 Figure 123. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Lung Cancer, White Males......................................................................... 208 Rgure 124. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Lung Cancer, White Females.................................................................... 208 Figure 125. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Lung Cancer, Black Males......................................................................... 209 Figure 126. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Lung Cancer, Black Females..................................................................... 209 Figure 127. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Lung Cancer, Hispanic Males.................................................................... 210 Figure 128. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Lung Cancer, Hispanic Females................................................................210 Figure 129. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Lung Cancer, Asian Males..........................................................................211 Figure 130. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Lung Cancer, Asian Females..................................................................... 211 Figure 131. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Lung Cancer, All Males...............................................................................212 Figure 132. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Lung Cancer, All Females.......................................................................... 212 Figure 133. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Melanoma, White Males..............................................................................216 Figure 134. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Melanoma, White Females........................................................................ 216 Figure 135. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Melanoma, Black Males..............................................................................217 Figure 136. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Melanoma, Black Females......................................................................... 217 xvi Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 137. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Melanoma, Hispanic Males........................................................................ 218 Figure 138. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Melanoma, Hispanic Females.................................................................... 218 Figure 139. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Melanoma, Asian Males..............................................................................219 Figure 140. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Melanoma, Asian Females......................................................................... 219 Figure 141. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Melanoma, All Males................................................................................... 220 Figure 142. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Melanoma, All Females............................................................................... 220 Figure 143. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Ovarian Cancer, White Females................................................................223 Figure 144. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Ovarian Cancer, Black Females...............................................................223 Figure 145. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Ovarian Cancer, Hispanic Females..........................................................224 Figure 146. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Ovarian Cancer, Asian Females...............................................................224 Figure 147. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Ovarian Cancer, All Females....................................................................225 Figure 148. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Pancreatic Cancer, White Males................................................................229 Figure 149. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Pancreatic Cancer, White Females.......................................................... 229 Figure 150. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Pancreatic Cancer, Black Males................................................................230 Figure 151. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Pancreatic Cancer, Black Females............................................................230 Figure 152. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Pancreatic Cancer, Hispanic Males...........................................................231 Figure 153. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Pancreatic Cancer, Hispanic Females...................................................... 231 xvii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 154. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Pancreatic Cancer, Asian Males............................................................... 232 Rgure 155. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Pancreatic Cancer, Asian Females.......................................................... 232 Figure 156. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Pancreatic Cancer, All Males................................................................... 233 Figure 157. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Pancreatic Cancer, All Females............................................................... 233 Figure 158. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Prostate Cancer, White Males...................................................................236 Figure 159. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Prostate Cancer, Black Males.................................................................. 236 Figure 160. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Prostate Cancer, Hispanic Males................... 237 Figure 161. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Prostate Cancer, Asian Males................................................................. 237 Figure 162. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Prostate Cancer, All Males...................................................................... 238 Figure 163. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Rectal Cancer, White Males......................................................................242 Figure 164. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Rectal Cancer, White Females................................................................. 242 Figure 165. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Rectal Cancer, Black Males.......................................................................243 Figure 166. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Rectal Cancer, Black Females.................................................................. 243 Figure 167. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Rectal Cancer, Hispanic Males................................................................. 244 Figure 168. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Rectal Cancer, Hispanic Females............................................................. 244 Figure 169. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Rectal Cancer, Asian Males.......................................................................245 Figure 170. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Rectal Cancer, Asian Females................................................................. 245 xviii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 171. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Rectal Cancer, All Males............................................................................ 246 Figure 172. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Rectal Cancer, All Females....................................................................... 246 Figure 173. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Stomach Cancer, White Males..................................................................250 Figure 174. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Stomach Cancer, White Females..............................................................250 Figure 175. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Stomach Cancer, Black Males...................................................................251 Figure 176. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Stomach Cancer, Black Females...............................................................251 Figure 177. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Stomach Cancer, Hispanic Males..............................................................252 Figure 178. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Stomach Cancer, Hispanic Females......................................................... 252 Figure 179. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Stomach Cancer, Asian Males...................................................................253 Figure 180. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Stomach Cancer, Asian Females..............................................................253 Figure 181. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Stomach Cancer, All Males........................................................................ 254 Figure 182. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Stomach Cancer, All Females...................................................................254 Figure 183. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Testis Cancer, White Males....................................................................... 257 Figure 184. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Testis Cancer, Black Males......................................................................257 Figure 185. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Testis Cancer, Hispanic Males................................................................ 258 Figure 186. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Testis Cancer, Asian Males......................................................................258 Figure 187. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Testis Cancer, All Males...........................................................................259 xix Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 188. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Thyroid Cancer, White Males..................................................................... 263 Figure 189. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Thyroid Cancer, White Females................................................................263 Figure 190. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Thyroid Cancer, Black Males..................................................................... 264 Figure 191. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Thyroid Cancer, Black Females.................................................................264 Figure 192. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Thyroid Cancer, Hispanic Males................................................................265 Figure 193. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Thyroid Cancer, Hispanic Females........................................................... 265 Figure 194. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Thyroid Cancer, Asian Males..................................................................... 266 Figure 195. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Thyroid Cancer, Asian Females.................................................................266 Figure 196. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Thyroid Cancer, All Males...........................................................................267 Figure 197. Age-specific Incidence Rates by SES, Los Angeles County, 1972-1992, Thyroid Cancer, All Females...................................................................... 267 xx Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF MAPS Map 1. Population Distribution by SES at 1990 Census Tract Level, Los Angeles County, 1990.................................................................................................110 Map 2. Population Distribution by SES at 1990 Census Tract Level, Los Angeles County, 1980.................................................................................................111 Map 3. Population Distribution by SES at 1990 Census Tract Level, Los Angeles County, 1970.................................................................................................112 xxi Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 1 INTRODUCTION In the long history of mankind, the relationship between social factors and conditions that influence health and the development of disease has been a major interest of human beings. Throughout history, people responded to the issue of health and disease from the perspective of their own particular societies and cultures. Knowledge about norms, values, beliefs, social structures, and lifestyles has provided insight not only about the social organization which was designed to cope with health hazards, but also about the nature and causes of illness. Health is a facet of the social system. Social factors are important in disease occurrence. In order to make the serious attempt to prevent disease in populations, scientists must search out the disparities in health among populations and seek to comprehend the social factors that create them. In this dissertation, the relationship between socioeconomic status and cancer incidence rates is studied. As a Ph.D student in Sociology, my major specialty is demography and my minor is medical sociology. I chose this topic because I thought it perfectly combined demography, medical sociology, and epidemiology. Demography is the science of population. Like most other sciences, demography may be defined narrowly or broadly. The narrowest sense is that of “ formal demography". Formal 1 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. demography is concerned with the size, distribution, structure, and change of populations. A broader sense includes additional characteristics of the population. These include ethnic characteristics, social characteristics, and economic characteristics. The widest sense of demography extends to applications of its data and findings in a number of fields including the study of problems that are related to demographic processes. Population studies are concerned not only with population variables but also with relationships between population changes and other variables— social, economic, political, biological, genetic, geographical, and the like (Shryock and Siegel, 1976). Medical sociology studies the social factors of health and disease and their consequences on a person's physical and mental well-being (Cockerham, 1995). The interplay of factors affecting people's lifestyle and level of health, such as social values, politics, history, philosophy, patterns of social stratification, quality and availability of health services, and individual participation, constitute the domain of medial sociology. Medical sociology came of age after World War II in an intellectual climate far different from sociology's more traditional specialties which have direct roots in 19th and early 20th century social thought Consequently, medical sociology faces a set of circumstances in its development different from that of most other sociological subdisciplines. The circumstance that most affects medical sociology is the pressure to produce work that can be applied to medical practice and the formulation of health policy. This pressure originated from public and medical sources, both of which have considerable influence and power with respect to the conduct of sociomedical research and little or no interest in purely theoretical sociology. Medical sociology is an interdisciplinary field that benefits not only from the work of social scientists, but also from that of researchers in medicine and public health. It distinguishes itself by connecting social processes and medical phenomena and health issues. Many medical sociologists are working in the field of epidemiology and identify themselves as social epidemiologists. 2 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Epidemiology is the study of the distribution and determinants of disease frequency in human populations (MacMahon and Pugh, 1970; Friedman, 1994). Two main areas of investigation are indicated in this definition-the study of the distribution of disease and the search for the determinants of the observed distribution. The first area, describing the distribution of health status in terms of age, sex, race, geography, etc., might be considered an extension of the discipline of demography to health and disease. The second area involves explanation of the patterns of distribution of a disease in terms of causal factors. Many disciplines seek to learn about the determinants of disease; the special contribution of epidemiology is its use of knowledge of the frequency and distribution of disease in populations (MacMahon and Pugh, 1970). The epidemiological perspective views disease in its larger socio-ecological context in which disease agents (such as viral or bacterial agents, noxious environmental substances, and dangerous technologies) have different effects depending on the characteristics of the host (biological, genetic, psychological, and social capacities and characteristics) and on the larger socio-cultural and physical environment (Hollingshead, 1961). It argues that disease is a consequence of no single agent by itself, but results from the complicated interplay among aspects of the person and agents in his environment The epidemiologist is concerned with exploring human ecology as it relates to the health of human beings and their environment The primary focus of the epidemiologist is not on the individual but on the health problems of social aggregates or large groups of people. The epidemiologist attempts to determine what group of people in a particular population develops a disease, on what occasions, and under what influences. The epidemiologist is looking for the common denominator that links all the victims of a health problem together so that the cause of the problem can be identified and eliminated or controlled. By learning something about whom the disease strikes in the population-whether young or old, male or female, rich or poor-various ideas are suggested that lead to more focused investigation. It helps researchers to trace out, step by step, the interdependence between individuals' lifestyles and the 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. appearance and nonappearance of a specific disease in a population. Typically, the epidemiological approach is used in attempting to gain increased understanding of a disease whose causes are unknown. Epidemiology is an applied discipline— that is, one concerned with the solution of practical problems. The epidemiologist needs the contributions of many other disciplines in order to pursue his own. Cancer is a disease that deserves special attention. It is the second leading cause of death in the United States next to heart disease. In fact, for people under age 75, cancer is the No. 1 cause of death exceeding heart disease (Gardner and Hudson, 1996). The human and economic effects of cancer are powerful, measured each year in millions of productive life-years lost and billions of health dollars spent The causes of cancer are multiple and not clear-cut The assessment of causal relationships is a never-ending process of hypothesis formulation, testing, and interpretation. In general, there is a striking consistency in the distribution of mortality and morbidity between social groups. The more advantaged groups, whether expressed in terms of income, education, social class, or ethnicity, tend to have better health than the other members of their societies. The distribution is not bipolar (advantaged vs. the rest) but graded, so that each change in the level of advantage or disadvantage is in general associated with a change in health (Blane, 1995). The relationship between cancer incidence rates and socioeconomic status (SES) has been investigated for many years, primarily as a source of etiological hypotheses. The SES differentials displayed by a particular cancer have profound meanings for both cancer research and public health services. They would greatly enhance our understanding of cancer and may provide clues to the environmental risk factors that may have important bearings on the causes of 4 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. cancer. The life styles that characterize various social groups may expose them to different cancer risks. The investigation of the cause of a particular cancer can benefit from consideration of the SES relationships which it displays and any complete etiologic explanation should be consistent with the existence of such relationships. By recognizing populations that are at higher risk, such study may further have policy implications and may lead to more effective intervention strategies. It may point to the target population for programs oriented toward early detection and prevention of cancer. The gap between the most and least advantaged groups in terms of cancer risk shows the potential for the reduction in cancer incidence. The contribution of SES to cancer research, however, is complicated by its association with race/ethnicity and other risk factors that may also be associated with both race/ethnicity and SES (e.g. dietary, lifestyle, and environmental and occupational exposures). Minorities tend to be equated with the underprivileged, although there are exceptions to this generalization. Minorities and the underprivileged share common features generally termed socioeconomic, which include such highly interrelated factors as education, income, occupation, cultural habits, ethnicity, place of residence, and degree of industrialization of their home community. These factors, taken collectively, are related to the prevalence of exposure to risk factors that cause cancer and perhaps to genetic composition that determines resistance to these exposures. They also relate to the accessibility and use of medical facilities and to the knowledge, attitudes, and beliefs concerning health and illness. Our understanding of the SES association with cancer is further complicated by the following facts: 1) The absence of SES information in most health data bases and cancer registry data bases. Since cancer is a relatively rare disease, the data source for most cancer studies is the regional or national cancer registry. The cancer data in these registries come from hospital charts which do not include information on SES. 2) The lack of agreement on the “ best Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. measurement" of SES. Like most other sociological notions, the concept of social class is many- sided. The phenomenon it describes is real enough, but its fundamental nature is hard to agree upon among even sociologists. Poor measurement can lead to misclassification which in turn may dilute any association or mar any relationship. The systematic monotonically graded association with SES has been established for some cancer sites, e.g., female breast cancer is positively associated with SES while lung cancer and cancer of the cervix uteri are negatively associated with SES (see Chapter 5 for review of the literature). For other cancers the SES association is not that clear. Prostate cancer, for example, shows changing and varying relationships with SES from one study to another. Some studies claim the racial differences between whites and blacks in cancer incidence are due to the different SES distribution in each population (Baquet et al., 1991). If this were true, then, once the SES effect was controlled for, the significant racial difference in cancer incidence should disappear. Previous studies on the relationship between SES and cancer incidence rates in the U.S. have been limited to white and black populations, although the US population as a whole has gained more diversity with the continuing immigration of other racial/ethnic groups. The method of measuring SES in health studies, especially cancer studies, have been based on investigator's understanding and interpretation of the concept of SES and on the availability of data. As a result, a variety of SES indicators have been used making it difficult to compare results across studies. This study is designed to combine the knowledge base of medical sociology and that of epidemiology and utilize the expertise of demography in order to study the relationship between SES and cancer risk. This study examines the relationship between SES and cancer incidence rates among different racial/ethnic groups, not only whites and blacks but also Asians and Hispanics. To do this, first, a measure of SES was developed that could be applied to the cancer 6 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. cases and to the population. Secondly, SES-specific population estimates by age, sex, and ethnicity for the years under study were developed. Because of its large and diverse population and the availability of cancer registry data, Los Angeles County serves as an ideal study area for this project Complete population-based cancer registry data from 1972 to 1992 were obtained from the Los Angeles County Cancer Surveillance Program. Nineteen types of cancer were included in the analysis: cancers of the lung, larynx, esophagus, female breast, cervix uteri, corpus uteri, ovary, prostate, testis, colon, rectum, stomach, liver, pancreas, bladder, kidney, central nervous system, and thyroid and melanoma of the skin. This is the first effort of its kind using one method to examine the SES association with so many cancers among diverse population groups. The study intends to provide a method which will achieve the following goals: 1) provide an SES indicator for cancer registry data, 2) provide appropriate population estimates of the different socioeconomic status strata in Los Angeles County over time, and 3) provide a method that can be easily replicated by other researchers providing cross-study comparability. The following questions will be answered by this study: 1) After controlling for the confounding factors race/ethnicity and age, is the risk of specific types of cancer associated with SES? 2) Are the patterns of association between SES for a specific types of cancer consistent across different racial/ethnic groups? 3) Are the patterns of association between SES for a specific type of cancer consistent across age categories? 4) Will the racial/ethnic differences in cancer incidence rates disappear after adjustment is made for SES and age? The social and demographic variables in relation to health status are reviewed in general in chapter 2. The methods of measuring socioeconomic status are examined in Chapter 3. A brief 7 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. summary of the current state of knowledge of the epidemiology of the 19 types of cancer is presented in Chapter 4, as are results from studies on the relationship between cancer incidence and SES. The design of this study and its materials are provided in Chapter 5. Chapter 6 contains discussions on the methodological issues. The results of the analysis are provided along with tables and graphics in chapter 7. Discussions on the findings, their implications, limitations of this study, and suggested future study topics are presented in chapter 8. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 2 SOCIO-DEMOGRAPHIC FACTORS IN HEALTH Health is a facet of the social system. Most health professionals nowadays agree that social factors are important in disease. In order to make the serious attempt to prevent disease in populations, the disparities in health among populations must be searched out and the social factors that create them must be comprehended. Medicine has three tasks (Mechanic, 1978): (1) to understand how particular symptoms, syndromes, or diseases occur either in individuals or among groups of individuals; (2) to recognize and cure these or to shorten their course and minimize any residual impairment; and (3) to promote living conditions in human populations that eliminate hazards to health and thus prevent disease. Each of these tasks can be pursued with maximal effectiveness only if the importance of social and physical, as well as biological, factors is appreciated. Much of medical activity, whether in research, clinical practice, or preventive work, requires an understanding of the cultural and social backgrounds that influence an individual's behavior and life style, and his recognition and response to the disease. Basic social and demographic characteristics of persons constitute the attributes of greatest concern. Four of the most important socio-demographic variables employed in epidemiological research are age, gender, race/ethnicity, and social class or socioeconomic status (SES). It has been found that each of these four variables represents important differences 9 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. between people that can be correlated with disease prevalence, behavioral patterns, and life expectancy. 2 r1 Age Age is a description specific to the state of the individual at a particular point in time. It tells that the person is young or old. It is a statement of the duration of an individual’s exposure to life experience. It quantifies the weathering caused by environment It is a mark of membership in a particular historical generation or birth cohort Age identifies the specific historical experience to which the individual has been exposed (Susseretal., 1985). Age is one of the most important factors in disease occurrence. Some diseases occur almost exclusively in one particular age group, such as retinoblastoma in children. Other diseases occur over a much wider age span but tend to be more prevalent at certain ages than at others. Susceptibility to certain infectious diseases and the duration of the immunity developed after infection vary with age. In childhood the bulk of illnesses are acute infections and exanthemata (eruption of the skin accompanied by inflammation, such as measles, scarlatina, erysipelas). The incidence of acute illness declines rapidly in adolescence, and then more gradually in old age. Many chronic and degenerative diseases such as coronary heart disease show a progressive increase in prevalence with increasing age and markedly at middle age. It is tempting to regard a disease with this age pattern as being due merely to aging itself. It should be remembered, however, that increasing age also marks the passage of time, during which the body is accumulating exposures to harmful environmental influences. One of the great contributions of epidemiology in the past few decades has been to show that aging is not the primary cause of atherosclerosis and its 10 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. consequences, as was previously thought, but that a person’s habits and manner of living may contribute significantly to this disease process. The steady geometric increase in breast cancer incidence before age 40 and its lesser continuing increase afterwards suggested the hypothesis that the hormonal changes of the menopause tend to decrease susceptibility to breast cancer (Lilienfeld, 1956). This hypothesis continues to be of great interest to scientists studying the causes of breast cancer. It must be noted that useful generalization about the health status at different ages is limited by marked variations in health status by sex, race/ethnicity, and socioeconomic status, and by the heterogeneity in the causes of similar diseases. 2.2 Gender Women tend to have a distinct advantage in life expectancy over men. More women survive into old age than men. Some diseases occur more frequently in males, others more frequently in females. About 92% of all breast cancers are diagnosed in females (Young and Pollack, 1982). The sex difference in disease incidence initially brings to mind the possibility of hormonal or reproductive factors that either predispose or protect For example, the greater risk of coronary heart disease in young men than that in young women cannot be explained entirely by sex differences in the so-called coronary risk factors such as blood lipid concentrations, blood pressure, cigarette smoking, diabetes mellitus, and obesity. It may be that some important hormonal factors contribute to the male-female difference - perhaps protection of the female by estrogens before menopause. Similarly, the greater prevalence of gallstones in women than in men is probably attributable, in part, to the effects of repeated pregnancies and, in addition, to hormonal effects on bile composition (Friedman, 1994). But men and women differ in many other ways, including habits, social relations, environmental exposures, and other aspects of day-to-day Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. living. The higher prevalence of cirrhosis of the liver and chronic bronchitis in men is at least partly related to the feet that, on average, men drink more alcohol and smoke more than women. Women generally know more about health matters than men and take better care of themselves (Dean 1989). Females exhibit a lifelong pattern of visiting doctors more often than do males. Pregnancy and associated conditions do result in especially high rates of visits to physicians during the childbearing years, but the female reproductive role accounts for less than 20% of all women’s doctor visits. More frequent utilization of physicians may have a substantial benefit for women in that they receive, on the average, more earlier diagnosis and treatment for illness than men (Verbrugge, 1989). The disparities in morbidity and mortality between men and women reflect both the constitutional and the role differences between men and women. Environmental hazards expose the sexes unequally by virtue of their different occupations and recreations. In addition, the differing demands of the social roles ascribed to men and women, and even boys and girls, set different environmental exposures. Sex differences in disease occurrence are important descriptive findings and often suggest avenues for further research. No disease can be considered to have a well-understood etiology if its male-female difference is not explained. 2.3 Race/Ethnicity People vary in such obvious physical matters as skin color, hair form, and head shape, as well as in less obvious characteristics such as susceptibility to disease. Race is an operational term based on skin color, that in fact specifies group membership. Biologically, race can be no 12 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. more than an indicator of the distribution of gene frequencies across populations. The human species show genetic diversity. The frequency of certain genes varies between populations, although few if any genes are confined to a single race (Susser et al., 1985). The distributions of genes across population groups are conflated with geographic, social class, and cultural distinctions (Cooperand David, 1986). If a population designated by race has common ancestors, similar social and physical environment and a shared communication system, its members will tend to have a similar tradition, value system, belief system, and world view. These shared elements lead to common lifestyle, attitudes, and behavior. Such cultural factors deeply influence health status (Freeman, 1991). Race is only one type of genetic configuration among many sources of cultural variation. Race may be seen as a gross variable for culture. Society provides a culture pervaded by expressive symbols, faiths, and emotional attitudes. Society provides a structure of social relations that rests on the distinctive positions and statuses accorded individuals of different sex, age, power, and prestige. Society provides a value system with moral and legal sanctions. At the same time these elements of society are learned and internalized by individuals. This cycle of successive social transmission and individual internalization produces a self-perpetuating system of belief and behavior, and a recognizable patterning of the personalities within each culture (Susser et al., 1985). Ethnicity refers to a shared heritage. This heritage includes a common geographical origin and history, a distinctive language (in the past if not actively maintained), and a characteristic culture. Ethnicity designates group membership, but membership may be assigned by others or declared by the individual (Susser etal., 1985).. 13 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In societies influenced by legacies of slavery or colonialism or both, racial and ethnic divisions tend to coincide with those of the class structure. But racial and ethnic divisions can cut across class divisions. Thus, distinctions of race or ethnicity are complex, and the health status of a minority group does not necessarily correspond to that characteristic of its class position. However, where racial disadvantage is present, it can be largely explained by the close association of minority status. The influence of race/ethnicity on health status is not universal, but particular and dictated by special circumstances. As categorizations, race/ethnicity directly influence the epidemiology of certain disorders. Their main influence, however, is an indirect one exercised through the consequences of race/ethnicity for social position and opportunity, including access to health care and experience within health facilities. In most multi-racial/ethnic societies, racial/ethnic groups are found in a hierarchy of power, wealth, and prestige. Differences in health status are the reflections of inequalities in the society. Historically, White Anglo Saxon Protestants (WASP) were the dominant group in the early American colonies. English language, law, and literature prevailed. Later arriving groups were judged according to their fit with this WASP model. White ethnics (e.g., Italians, Jews, Poles, Greeks) arrived in the U.S. during the later waves of immigration from 1880 to 1920. These groups faced a moderate amount of prejudice and discrimination. White ethnics were often judged as backwards and boorish because of their lack of urban-industrial skills, their differences in religion, and their inability to speak English well. Despite these handicaps, white ethnics had major advantages over racial minorities because: 1) they entered this country voluntarily, they were not conquered groups; 2) they were able to set up communities in which they could practice their traditions and religion; and 3) they were white and blended in physically with the majority group, allowing for more rapid acculturation and assimilation (Ransford, 1994). 14 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Asian Americans represent an interesting intermediate stratum between the WASP and the most oppressed minorities. Though they are certainly physically different their cultural stress on personal achievement duty to the community, emphasis on long-range goals, etc., is highly compatible with that of the dominant culture. Asian Americans have not remained in a highly dependent paternalistic relationship for a long period of time. Though legal controls against them have often been harsh, Asian Americans have not experienced the long-range powerlessness of the three “ conquered minorities” , i.e., blacks, Latinos, and American Indians (Ransford, 1994). Blacks, Latinos, and American Indians are lowest in the racial/ethnic hierarchy in the U.S. having the least access to power, privilege, and prestige because of a combination of the following factors: 1) Pronounced cultural differences; 2) Physical appearances; 3) Conquered status and long-lasting paternalistic relationship with the white majority; 4) Relatively powerless communities controlled and manipulated by white society; and 5) Highly crystallized ideologies of inferiority or belief held by the majority that they have not invested necessary efforts for achievement (Ransford, 1994). Race/ethnicity represents a social experience that influences how a particular person perceives his or her health situation. The strategies that people employ for seeking health care are socially organized around the opportunities they have for interacting with people in a position to help (Pescosolido, 1992). The influence of race/ethnicity on using medical care appears largely limited to its role in providing a cultural context for decision making within social networks. Research has suggested that under certain conditions, close and ethnically exclusive social relationships tend to channel help-seeking behavior, at least initially, toward the group rather than professional health care delivery systems (Suchman, 1965). 15 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Due to the large diversity of races/ethnicities and cultures, race/ethnicity is a significant health variable in the United States. Differences in health profile and disease prevalence exist among racial/ethnic groups. In the United States, Asian Americans have typically enjoyed high levels of health, with blacks being especially disadvantaged. Hispanics and Native Americans also have health disadvantages relative to whites (Cockerham, 1995). In the case of some diseases (e.g., black-white differences in sickle cell anemia and skin cancer), the racial differences are genetically determined. With other disease, the explanation may not be so simple, especially when racial/ethnic differences are accompanied by differences in socioeconomic status and standing in the social hierarchy. 2.4 Socioeconomic Status (SES) Within most human societies there seem always to have existed groups enjoying different privileges and status. These differences have derived from the division of labor and reflect the different ways in which individuals acquire their means of livelihood. Individuals and families vary in their current access to jobs, earnings, assets, and power. This phenomenon has been labeled by sociologists as social inequality or social stratification, commonly referred to as social class or socioeconomic status (SES). Social stratification in the United States has been characterized by vague boundary lines, at least a moderate amount of social mobility from one stratum to another, and rather low degrees of shared fete, stratum solidarity, and collective action (Ransford, 1994). Modem social scientists tend to view the social order as an arrangement of categories of people with differing levels of access to goods and services. In addition, social stratification has an important subjective dimension as well. It seems to help determine self-perception, lifestyle, and culture (Dahrendorf, 1959). 16 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Americans do not like to think of themselves as members of classes in conflict with each other, but they seem aware that they occupy different levels in society. Generations of Americans have been trained to think of their individual capabilities and achievements-not class solidarity or social revolution-as the most important determinants of success and happiness. American sociologists tend to view social class as an array of distinct resources and characteristics that an individual may possess, rather than as a coherent identity. Even in a society like the United States with its strong belief in equality, which offers significant opportunity for individual achievement, position in the social order-whether it is called class, status, stratum, or some other term -is a major determinant the course of people’s life. It plays a large part in determining the habits, beliefs, and life choices. The class into which one is bom will have much to do with how much money he or she earns and how much deference, respect, honor, and obedience he or she receives from others (Hodge and Treiman, 1968). Moving upward through the class structure allows the individual not just to consume more expensive goods and services, but to associate and communicate with a broader range of people (Sennett and Cobb, 1972). It is natural that social position should affect the individual’s health status. A given socioeconomic stratum refers to a category of people with roughly comparable levels of occupational attainment, education, and income (Ransford, 1994). SES represents distinctions between lifestyles and living environments. It thus has functional meaning for public health, both as a predictive instrument and as an analytic tool. Relationships with SES may express the effects on health and health care of behavioral, economic, environmental and other elements of SES, the influence of other characteristics that happen to be associated with SES, and the effect of health status on social mobility. Epidemiologists frequently consider SES as a 17 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. potentially confounding variable, in view of its association with many potential risk factors and disease. The relation between SES and health status has been observed and assessed since the nineteenth century (Susser et al., 1985; Graham and Reeder, 1979). SES is now clearly an important variable in studies of health and is frequently included in epidemiological studies. (Marmot et al., 1987; Liberates et al., 1988). Sociologists have long recognized and argued the importance of SES in understanding various social phenomena. For social scientists, uneven distribution of disease, illness, and sickness in society are manifestations of social structure and culture that reveal variations in custom, disparities in resources, or differences among subgroups in the conditions of daily life. While traditional sociologists are more concerned with trying to explain the social hierarchy as an end in itself, medical sociologists and epidemiologists often include SES as an explanatory variable in their analysis of health related studies. For epidemiologists, tee discovery of such variations is a starting point; they must elucidate their medical significance, and through preventive medicine attempt to eliminate them (Susser et al., 1985). In the United State and elsewhere in the world, SES is one of the strongest and most consistent predictors of a person’s health status and life expectancy (Williams, 1990; and Winkleby et al., 1992). Upper SES groups are favored in all dimensions of life expectancy (Antonovsky, 1972). As differences between SES groups decline, overall mortality rates of a population may similarly decline (DeWolff and Meerdink, 1954). People of lower SES appear to be especially disadvantaged in regard to health. In tee 19th century, tee founders of social medicine observed a strong association between poverty and indicators of ill health. Mortality and morbidity among the poor of all ages have been greater for epidemic and infectious diseases, bronchitis, pneumonia and tuberculosis, rheumatic heart disease, and for many others (Kitagawa and Hauser, 1973). Naturally these disorders were equated with poverty, and tee high rates were 18 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ascribed to poor living conditions, inadequate diet, bad sanitation, and ignorance. Many people confidently expected if poverty were to be abolished, and medical services made available to all, rates for various disorders would eventually reach a single standard throughout society, irrespective of social standing. However, this equalization did not occur. By the 1960s, many of the factors previously identified as linking SES to disease had been addressed-the grosser forms of poverty disappeared, free social and medical services became available to all, and mortality rates at all ages declined sharply— but large disparities in disease between the SES groups remain. Such fact indicates that the relationship between SES and health is not static but dynamic. Within the general movement of society, each social class changes its way of life and its composition, the borders between classes alter, and members are exchanged between them. Changes take place in social and cultural relations, and these changes can be detected in health patterns. As the burden of infectious disease, morbidity, and mortality has eased in the course of this century and the chronic diseases have come to play the dominate role, the explanation of persisting class differences shift as well. While the grinding poverty of the past has been much alleviated, relative poverty continues in the United States and Britain (Townsend, 1979; Ryan, 1981). This relative deprivation is seen in the quality of the physical environment (crowded homes, lack of playground facilities, lead in the paint of old houses and in old water supply systems), in education, and in cultural amenities. Thus a multiplicity of social and cultural factors is available to contribute to the unfavorable health patterns of the lower social classes (Susser et al., 1985). This dynamic relationship between SES and health and the disadvantage of being in the low social class is demonstrated in the dramatic shifts in the social distribution of coronary heart disease. In the 1930s and 1940s in the United States, coronary heart disease was linked with an affluent way of life— incidence was high in rich and low in poor. By 1960s, the burden of coronary Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. heart disease shifted from people of high SES to people of low SES. The concentration of recognized risk factors for coronary heart disease among low SES people, found by many studies, suggests that people of low social class lack resources to protect themselves against those forces that promote unhealthy practices which the upper classes are learning to avoid (Susser, 1985). Resources like knowledge, money, power, prestige, and social connection strongly influence people's ability to avoid risks. For example, cigarette smoking has declined first among the upper classes in both the United States and Britain (Khosla and Lowe, 1972; Ashwell etal., 1978; Center for Diseases Control, 1990); vigorous leisure exercise is more common among the better-off, and “prudent diets” are less likely to be consciously practiced among the poor (Mom's, 1979; Pratt 1971; Cobum and Pope, 1974). In fact, a newly published study has shown that in 1965, there were large differences among racial and SES groups in the United States in dietary quality, with whites of high SES eating the least healthful diet and blacks of low SES the most healthful. By the 1989-1991, the diet of all groups had improved and were relatively similar (Popkin etal., 1996). This study indicates that as health information becomes available, people of high SES are able to absorb it fester than people of the low SES. Surveys of health knowledge invariably find deficits among the poor and the ill educated. The poor have tended to make less use of preventive health services even in the face of more pressing needs, and even when financial barriers have been removed (Riessman, 1974; Dutton, 1978; Rundall and Wheeler, 1979). In the United States, largely due to the Medicare and Medicaid health insurance programs, the poor have dramatically improved their utilization of physicians since late 1960s. Even though the poor are visiting doctors in greater numbers, this does not mean that they use 20 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the same sources of medical treatment in proportions equal to those of higher SES groups. The poor appear to have more sickness and, despite the significant increase in use of services, still do not obtain as much health care as they actually need (Sudman and Freeman 1989). Attitudes related to the “ culture of poverty" play an important role in the use differences of health services between SES groups, particularly the use of preventive care. The culture of poverty is a phenomenon in which poverty, over time, influences the development of certain social and psychological traits among those trapped within it These traits include dependency, fatalism, inability to delay gratification, and a lower value placed on health (Rundall and Wheeler, 1979). Like education and knowledge about health, self-esteem and the sense of control and autonomy in shaping the course of one’s life, diminish with the social class gradient “ System barrier" is another factor efficiently explains the low use of medical services by the poor (Dutton, 1978). There are organizational barriers inherent in the more “public” system of health care typically used by the poor, such as hospital outpatient clinics and emergency rooms. This type of barrier pertains not just to the difficulty in locating and traveling to a particular source of care, but also includes the general atmosphere of the treatment setting, which in itself may be impersonal and alienating (Strauss, 1970). Regardless of gender, persons living in poverty and reduced socioeconomic circumstances have greater exposure to physical (crowding, poor sanitation, extreme temperatures), chemical and biochemical (diet, pollution, smoking, alcohol and drug abuse), biological (bacteria, viruses), psychological (stress) and social (violence) risk factors that produce ill health. Their limited access to health care further decreases their survival chances than more affluent individuals. 21 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. At the same time, however, low SES also appears to confer protection against some diseases. For example, in the series of annual poliomyelitis epidemics that began in 1947, the higher SES groups were the most severely affected. It is believed that poor sanitary conditions in low SES groups had led to widespread subclinical infection in the first few years of life, resulting in immunity. When “ higher" living standards prevent this early infection, poliomyelitis acquired later in childhood is more likely to cause disabling paralysis (Friedman, 1994). 2.5 Interaction between Race/Ethnicitv and SES Race/ethnicity and socioeconomic status (SES) result in two distinct but interacting hierarchies in social stratification. Although there are significant differences between these two orders, they share a common basis-both determine access to power, economic privilege, and social honor. Until recently, the correlation between minority and low socioeconomic position was so consistent that the two categories were rarely separated. The 1990 census revealed that somewhere between 30 and 40 percent of the employed black and Hispanic populations are either in skilled blue-collar positions or white-collar positions. This emergence of an increased skilled and white-collar class coupled with heightened ethnic consciousness among American ethnic minorities have made the racial/ethnic divisions less hierarchical and reduced the correlation between minority origin and low SES (Ransford, 1994). This means that race/ethnicity and SES increasingly interact in complex and interesting ways. Sociologists have not adequately explored the ways in which race/ethnicity and SES combine. The failure to consider race and class conjointly stems from two kinds of overemphasis: the stress on race/ethnicity to the exclusion of SES and the stress on SES to the exclusion of 22 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. race/ethnicity. Often the minority group is viewed as one homogeneous, impoverished, lower-SES group. Some view SES as being such a powerful steam roller variable that it overrides all racial/ethnic effects (Wilson, 1978). Such perspectives ignore the special effects or complex blends of race/ethnicity and SES discrimination. At lower-SES levels, racial/ethnic and SES discrimination often are combined to produce unique barriers that cannot be explained by either SES or racial/ethnic discrimination alone (Ransford, 1994). There are three theoretical models which explore the interaction between race and class (Ransford, 1994): 1) open marketplace of status interaction, 2) minority subcommunities, and 3) ethclass. In the open marketplace of status interaction model, a number of important things can happen. A relatively high social class position can undermine or considerably offset a low ethnicity position. Although socioeconomic advancement increases the power and the economic life chances of minority persons, there are still likely to remain some racially-associated differentials between majority and minority persons holding the same degree of SES. Majority group’s tendency to dominate racial interaction and to perceive minority people as incompetent is weakened by exposure to conventional role relationships in which the minority person is in superordinate position. The open market model stresses the interaction of race/ethnicity and SES in integrated situations and the common importance in both majority and minority communities of occupation, education, and income. The minority subcommunities model accepts occupation, education, and income as important, but postulates that either there are significant differences in the relative importance of these factors between the racial/ethnic groups or there are more limited ranges in each of these hierarchies in minority communities resulting in evaluations different from those of the majority for the same socioeconomic position. 23 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. According to the ethclass concept, it is fallacious to assume that either class variables or ethnicity variables will alone consistently predict values, interaction, or behavior. Both class and ethnicity are powerful forces that profoundly affect identity, social participation, and cultural behavior. As a determinant of cultural behavior, life style, and taste, social class is likely to be more important than ethnicity. People of the same social class have similar interests, tastes, and occupational experiences, even if they are from different ethnic groups. However, when it comes to collective identity-a sense of peoplehood in which a common sense of destiny and heritage is shared with a large number of people of the same racial or national descent-ethnicity will be more salient than class position. Ethclass perspective retains both race and SES identities, which produces unique joint effects for each distinct race-class combination. The uneven profile of health among racial/ethnic groups in American society repeats itself when the distribution of health among socioeconomic groups (SES) is considered. Patterns of help-seeking behavior for medical care by blacks in American society are not so determined by race or ethnicity perse as they are by conditions of poverty and the limitations of low incomes (Cockerham, 1995). Even though black Americans have made significant progress in obtaining equal opportunity in employment and education, largely as a result of the civil rights movement of the 1960s, the disparity between blacks and whites in regard to social and economic benefits still exists for many black people. This continued socioeconomic disadvantage translates into continued health disadvantage. Blacks have higher death rates than non-Hispanic whites, Hispanics, Asians and Pacific Islanders, and native Americans for heart disease, some forms of cancer, and other major causes of mortality (Braithwaite and Taylor, 1992; and National Center for Health Statistics, 1993). A variable that particularly confounds the effects of ethnicity on help-seeking is socioeconomic status. The higher an individual’s socioeconomic position, the less ethnic the 24 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. person often becomes (Hollingshead and Redlich, 1958). In other words, middle-class Americans of European, African, Hispanic, Asian, and native origin descent tend to reflect the same middle- class norms and values as part of their mutual participation in middle-class society. Included in this pattern are similar perspectives toward the utilization of health services (Welch et al., 1973). This situation suggests that the direct effects of race/ethnicity on decision making concerning health care are largely confined to the lower class (Suchman, 1965). Some Hispanics are prone to use the service of nonprofessionals in health care matters. Some favor the use of “ folk" medicine, which involves treatment by friends, relatives, or neighbors who employ patent medicines and home cures for ailments (Andersen et al., 1981). Low utilization rates of medical services by Mexican-Americans seem to be largely a function of socioeconomic status rather than ethnicity (Roberts and Lee, 1980). Mexican-Americans are among those most likely to report that they could not afford health insurance. Uninsured Hispanics are less likely to have a regular source of health care, to have visited a physician in the past year, had a routine physical examination, and rate their health as excellent or very good in comparison to Hispanics with private health insurance (Trevino et al., 1991). Evidence is mounting that the differences in people's socioeconomic condition and cultural factors lead to the differences in the circumstances of life of different sections of society. Variations in life style have an important bearing on people's health status, lifestyle and general health 2.6 The Enduring Relationship between Social Conditions and Disease For some people, knowledge about socio-demographic patterns of disease is considered useful insofar as it helps us to pinpoint the medically relevant risk factors that explain 25 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the associations between social conditions and disease and that are the true culprits in disease causation. Progress is made when we are able to move our attention away from the social conditions and toward identifying and intervening on the more proximate risk factors. The continuing focus on socio-demographic patterns and the enduring associations between social factors and disease can only suggest that we are stuck in a primitive stage of scientific development and indicate our failure to identify risk factors and intervene effectively (Link and Phelan, 1996). Yet there is an important principle that suggests that we will never be able to, nor should we try to, turn our attention away from the socio-demographic factors themselves. “Societies in part create disease they experience and, further, they materially shape the ways in which diseases are to be experienced” (Susser et al., 1985). These statements are not bound by time or place. They imply that socio-cultural factors are at work in all societies-past, present, and future— and that a direct focus on them is essential. History has shown that social patterns of disease may persist despite effective interventions on potent risk factors. In the case of socioeconomic status (SES) and disease, as some risk factors known to intervene in the association between SES and disease (poor sanitation and lack of immunization) were eradicated, others (smoking, exercise, and diet) emerged, so the association between SES and many disease outcomes has endured (Adler etal., 1994). Such enduring associations between social condition and disease are predictable and perhaps unavoidable, because many social conditions are fundamental social causes of disease (Link and Phelan, 1996). A fundamental social cause involves resources like knowledge, money, power, prestige, and social connections that strongly influence people's ability to avoid risks and to minimize the consequences of disease once it occurs. The resources embodied in fundamental causes can be transported from one situation to another. As health-related situations change, 26 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. those with the most resources are best able to avoid diseases and their consequences. Thus, no matter what the profile of diseases and known risks happens to be at any given time, those who have greater access to important social and economic resources will be less afflicted by disease (Link and Phelan, 1996). Viewed from this perspective, the continuing focus on the relationship between SES and disease is essential and is a vital contribution to public health research and practice. Its impact will be further enhanced with the recognition that societies have always shaped patterns of disease and that they do so in ways that reflect the distribution of advantage and disadvantage in those societies. 27 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 3 SOCIOECONOMIC STATUS Comparisons of health status or disease incidence across levels of SES may point to differential health needs in the population and may yield clues to etiology (Abramson et al., 1982). Examination of the variations in disease rates by SES may lead to a better understanding of the existence of and components of the causal chain between social position and disease risk (Marmot et al., 1987). Frequently, SES is a starting point for providing clues about many etiologic agents. SES scales are convenient devices for analyzing and correlating social and medical phenomena. The difficulty lies in finding objective, measurable criteria by which the complex populations of industrial societies can be accurately and readily classified. Industrial society is a process of social interaction between individuals in time, during which values are constantly modified and relationships change. Like most other sociological notions, the concept of social class is many-sided. The phenomenon it describes is real enough, but how to define and measure its fundamental nature is hard to agree upon. Poor measurement can lead to misclassification which in turn may dilute any association or obscure any relationship. Specialists in social stratification have devoted considerable time and effort toward arriving at reliable and valid measures of social class. Even though some disagreement continues regarding issues in social stratification, there is sufficient agreement on the measurement of social class in order to quantify relative position within society. Following is the background information that has implications for measurement decisions. 28 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 3.1 Theories of Social Class In its modem sense as a term of social division, “ class” is a word that came into currency during the period of social dislocation brought about by the industrial revolution. It signaled in part a growing awareness that social position was created not inherited. In the centuries that followed, the lines of division the term was intended to designate were shifting and ambiguous. “Class” was used to denote sometimes an economic grouping (landowners, laborers), sometimes a social rank (the middle class), or a political self-aware and active formation (the working class). Preferred usage often corresponded with the political disposition of the user, a practice which continues to the present day. In the extreme, the term may be avoided altogether, as in much American sociological inquiry into the particularities of “ socioeconomic status (SES)," rather than “ class” (Williams, 1976). The starting point for the analysis of social class was formulated by Karl Marx (1818- 1883) as part of a general account of the origins, dynamics, and prospects of industrial capitalism. Marx categorized class on the basis of a group's relation to the means of production. He emphasized the economic dimension as the most important The original Marxian theory presents a basic dichotomy between the owners and nonowners of the economic means of production. It argues that the class structure exploits many to the advantage of few. Given this condition, conflict was endemic to modern society. Class struggle might be muted or strident, it might assume new forms as circumstances changed, but it could not disappear so long as the essential inequality in the production process persisted. Thus in Marxian analysis, class is a theoretic term that refers to a complex force in social change. The manifestation of class is a historical phenomenon, however. As such it can be understood only by attending to the particularities of a given social context (Robinson and Kelley, 1979). 29 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. There is much to Marx’s theory of social class than this bald account, but it is in essence a theory based on the structure of relations of production. Other theorists have taken a more multifaceted view of social stratification and its causes. Max Weber (1864-1920), whose late- nineteenth-century ideas have stimulated a great deal of theorizing in modem sociology, took the view that three distinct systems of stratification existed in industrial societies: one system founded on economic interest, a second on prestige or honor, and third on power (Weber, 1947). Weber did not disagree with Marx on the economic stratification of society in terms of property and income. But he observed that certain groups of people derived social prestige or honor from the preindustrial past. Thus the prestige of the nobility and the learned professions was independent of their economic resources in an industrial society, such status groups have proliferated in industrial societies. They take the form of a series of professional and other groups. By virtue of their skilled occupations, their elaborate education and culture, and their whole style of life, they are bound together by common interests. In turn, these status groups link together the two extreme economic classes of owners and unskilled workers along a continuum of prestige (Susser, 1985). Moreover, Weber treated political power as a separate issue independent of the existence of economic classes, thus tempering the idea of discrete classes locked in opposition. He introduced intangible elements of judgment into the analysis of social class, and rather than a dichotomy postulated a series of status groups, not necessarily divided by a fundamental conflict over the question of the ownership of property. Weber did not deny that these three systems of stratification-by prestige, economic class, and power-could and did overlap, as it were, so that there could be a coincidence of status grouping, economic dominance, and access to political power. But he insisted that stratification in contemporary industrial society could be analyzed in at least three distinctive and separate ways. 30 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 3.2 Measures of Socioeconomic Status (SES) Weber's influence on theories of social stratification has been pervasive. The classic Marxian dichotomy of owners and nonowners of the means of production simply is inappropriate for modernized societies. Most measures developed by American sociologists are based on Weber's view of three separate but linked dimensions of social class. In an attempt to reflect this conceptualization, three indicators have been used most often either individually or collectively: occupation, education, and income. Occupation serves as the basis from which salaries and wages are derived, differential status or prestige is attributed to various occupations. Since education often provides the qualifications to acquire certain occupations and income, it is also sometimes used as a proxy measure for variables in the economic domain. Differential amounts of income or wealth may influence opportunities for education, thus education and income provide access to different lifestyles, prestige, or power (Hauser and Featherman, 1977; Nam and Tem'e, 1982). 3.2.1 Occupation As An Indicator For reasons of convenience, occupation has been commonly used as a basis for ranking large populations by social class. Occupation is an objective criterion easy to establish. It can be compared with other occupations within the same ora different community. Occupations are ranked in two ways: those based on public opinion of their level of esteem and those based on educational requirements and monetary payoffs. The first is referred to as a prestige perspective; the second is considered to be a socioeconomic approach. Therefore, many sociologists feel that occupation is a reliable single indicator of relative standing in industrial societies (Blau and Duncan, 1967; Haug, 1977). However, the several elements that enter into social stratification 31 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. make clear that the use of occupation as the sole index for constructing a social class hierarchy must lead to oversimplification. Occupation alone does not reflect the full reality of class conditions (Krieger and Fee, 1994). Job assignments to one or other class are often made for males alone and are insensitive to variations in family status which are not fixed by occupation. Rapid changes in the technology of work cause occupational categories to change in status over time. These changes can result in status inconsistency and make comparisons over time difficult, if the SES is classified according to occupation only. Moreover, assumptions about the nature of social class are easily smuggled in, and the underlying values by which the superiority or inferiority of occupations on the scale are determined may never be explicit (Susser, 1985). To construct a valid unitary scale of the prestige of occupations in a modem industrial society presents undeniable difficulties. The equivalences or differences in prestige of occupations depend on subjective estimates on the part of the respondents, and they are sometimes unable to distinguish between occupations. Nevertheless, despite wide variations in study methods and changes in the economy and labor force, consensus on the prestige ratings of occupations has proved remarkably consistent over time (Otto, 1975). Following are some of the assembled scales based on occupation. British Registrar General's Scale The approach of using occupation as the measure for SES is heavily influenced by the British classification system. The British system, known as the Registrar General's Scale, is the earliest and most widely used classification system in the United Kingdom. It was developed in 1911 to allocate the occupation of the head of household to one of five SES groups: 1) professional, 2) intermediate, 3) skilled, 4) partly skilled, and 5) unskilled (Haug, 1977). Occupations were judged by the Registrar General and ranked on the basis of the degree of skill involved and the social position implied. Revisions are made every 10 years to take into account changes in skills and status attached to occupations. These revisions have resulted in substantial 32 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. changes in the composition of the SES groups and have changed the relative size of each SES group. Thus, one cannot determine whether variation in the association with SES over time reflects the true change or is merely a function of changes in the composition of SES groups. Edwards' Social-Economic Grouping of Occupations Edwards, a statistician for the U. S. Bureau of the Census created a hierarchy of occupations based on his intuition in 1917 (U. S. Bureau of the Census, 1963). His approach was found to be roughly correlated with average income and education. By 1940, occupations derived from decennial census data were ordered into 10 categories on the basis of education and income. Since then, this has become the system used by the Bureau of the Census for grouping occupations. In 1970, the Bureau of the Census expanded the 10 categories to 12 maintaining a division of white-collar and blue-collar occupations. In 1980, the occupational categories were expanded to 13 with a composition somewhat different from prior years (U. S. Bureau of the Census, 1982a). As educational requirements and income level have changed over time, the interrelations with occupation have also changed. The major problem with this approach is the heterogeneity within categories. There were wide variations in education and income within each of the occupation categories (Hodge and Siegel, 1966). Nam-Powers' Occupational Status Scores In 1963, Nam and Powers generated the occupational status scores using a detailed list of occupations and information on income and education from the 1950 census for each occupation (Nam and Powers, 1968). The occupations were ordered by the education and income of the incumbents separately. The final occupational score for each occupation represents the occupation's cumulative percentile in the list of occupations. They have updated it for the 1960,1970 and 1980 censuses (Nam and Tem'e, 1986). Although the Nam- Powers measure has many advantages, it has not been widely used. 33 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Siegel's Prestige Scale The development of the Siegel scale was based on the assumption that the ranking of occupations is socially defined by the general public's estimate of social standing or prestige. The scale was built upon the prestige ratings of census occupations from three random sample surveys of the US population conducted by the National Opinion Research Center in the mid-1960s (Siegel, 1971). It yielded prestige scores for 350 occupational titles which can then be grouped by the 1960 census occupational categories. It has not been updated since then. Since the research on what people take into account in ranking occupations clearly shows a large variety of criteria are employed, its validity as a measure of social prestige has been questioned. (Reiss, 1961) Treiman's Standard International Occupational Prestige Scale Treiman used a procedure similar to that used by Siegel, but attempted to develop a scale that is applicable internationally. He collected information from 55 developed and developing countries where prestige data were available. Occupations were coded into the categories of the International Standard Classification of Occupations, Revised Edition (1969), used by the International Labor Office (1969). Occupational scores from each nation were converted to a standard metric and averaged across countries to produce the scale (Treiman, 1977). The use of prestige rating as a criterion for ranking occupations has several difficulties. It is based on the average judgment made by people who have various degrees of familiarity with each occupation. There is evidence that the prestige of an occupation is biased by the sex of the incumbent (Bose and Rossi, 1983). Thus, some variation in rating may exist which has nothing to do with relative prestige. 3.2.2 Education As An Indicator Education is considered to be more satisfactory than occupation, because it is reliable and generally stable over the course of an adult's lifetime (Ries, 1991). The amount of education 34 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and knowledge that persons acquire can affect their behavior and practices by influencing lifestyle and social networks. Education has become a popular single indicator of SES mostly because of its association with many lifestyle characteristics and the simplicity of collecting education data. The most commonly used measure of education is the number of school years completed. Education is sometimes used directly as a quantitative variable or is categorized into several groups. Fairly accurate information for this variable is usually readily obtainable (Liberates etal., 1988). For most adults, education is more stable over one’s lifetime than either occupation or income. There are problems as well with using education as the single indicator of social class. Being the fixed attribute may be a disadvantage. Unlike occupation that changes over time, an individual's educational attainment is obtained early in life and kept generally unchanged thereafter. It is an inappropriate measure to capture status fluctuations over the adult life span. Besides, there exists considerable heterogeneity in terms of occupational prestige and status within each education category. There are other flaws of using education as a measure of social class. 1) Educational attainment varies by age cohort Many more people have completed high school or college than before (U. S. Bureau of the Census, 1982b). 2) Education is sometimes assumed to be the precursor to SES (Hauser and Featherman, 1977). However high education does not necessarily lead to high income and high occupational standing (Susser et al., 1985). 3) There are regional differences in educational attainment (U. S. the Census, 1982b). 4) There are other aspects to education, besides years of schooling, that have impact on a person's social standing, including public versus private school attended, type of degree earned, and major field of specialty (Hall, 1986). 5) The perceived status of education does not rise monotonically with the number of years 35 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. completed. As years of education increase, equal increments in education produce increasingly larger status gains (Schmitt 1965). Despite these potential problems with the use of education as a single indicator of SES, education is frequently more strongly associated with disease status than are other indicators (MacMahon etal., 1970; Jacobsen and Thelle, 1988). 3.2.3. Income As An Indicator When used as the indicator of SES, income is commonly grouped into categories, since many people are reticent about providing exact income information but feel less uncomfortable if they can place themselves in groups. The categories are often determined on the basis of the income range of respondents within the sample being studied. Income is not desirable as a single best indicator of SES either. The following difficulties associated with using income variable make many people think that it is inappropriate to use income as the single indicator of SES. 1) It varies considerably within occupations. 2) It is often inconsistent with education requirements. 3) The perceived status of income is not monotonically related to income amount. As income increases, equal increments in income produce increasing by smaller gains in status (Schmitt, 1965). 4) Income is relatively unstable over time. Compared with occupation, income is more unstable. 5) Level of current income is age-dependent Earnings tend to increase throughout one's occupational career and then drop off after retirement 6)There is always a problem of comparability of income across households of different sizes, and across years or region with different costs of living. Comparison of income over time or across region requires adjustments for inflation or price and consumption differences. 7) Since not everybody has income, household income usually is used as income indicator. However, household income itself is subject to number of earners in the household and its usefulness as an indicator of living standard depends 36 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. on the number of people living in the household. 8) In addition, response error to income questions is more likely than to questions related to education or occupation (Mueller and Parcel, 1981; Ries, 1991). 3.2.4 Composite Measures Overall, studies have shown that the three SES indicators are distinct but related components measuring the multiple aspects of social class. One indicator by itself does not constitute a good indicator of a multidimensional construct like SES (McQueen and Siegrist, 1982; Abramson etal., 1982). Two approaches are frequently taken to reflect the multidimensionality: 1) to construct an index representing a composite of several indicators, and 2) to use multiple indicators. Some believe that the use of more than one indicator may increase the chance that an existing relationship with social class will be detected, allow the evaluation of independent effects and important interactions between indicators, and improve the predictive power of the model (Abramson et al., 1982). The examples of composite measures of SES are as follows: Duncan's Socioeconomic Index This index is considered to be the most frequently used SES measure in social science research (Cooney et al., 1982). It has also been used in epidemiological studies (Glynn et al., 1985). Similar to what Siegel and Treiman did, but much earlier, Duncan developed his index using public opinion as obtained in a national sample survey conducted by the National Opinion Research Center in 1947 to determine occupational prestige. Since respondents to this sample survey were asked to rate the prestige of only a small number of occupations out of the total possible occupational titles, Duncan estimated the prestige value of the "missing" occupations on the basis of income and education of males in each occupation using 1950 census data (Duncan, 1961). Criticisms of this index are that it bases its data exclusively on males and is outdated. 37 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Nakao-Treas' Socioeconomic Index of Occupations There have been serious efforts by sociologists to overcome the shortcomings in Duncan's index. Stevens and Featherman (1981) revised Duncan’s index using 1970 census information and expanded the ratings of occupations. Later on Stevens and Cho (1985) further updated the index for the 1980 census classification. Among them all, the Nakao and Treas (1992) Socioeconomic Index for Occupations is probably the best amendment for determining status scores from Job codes. It was derived from both educational attainment and income of job incumbents corresponding to the detailed occupational categories in the 1980 census. Actually, they developed two sets of indices. One is based on data from both males and females, the other is based on data for males only. Hollingshead's Index of Social Position Hollingshead's index is another widely used index for social position. It is composed of two scales representing the characteristics of the head of the household. One is occupational rank, the other is educational attainment Each factor is weighted based on a derived prediction equation from a study conducted in 1958 in New Haven, Connecticut. Originally, the measure included a third scale based on area of residence. Since that scale was specific to New Haven, it has been dropped (Hollingshead, 1957). The validity of the index was tested and approved (Hollingshead and Redlich ,1958). Hollingshead's index was criticized later for its use of the head of the household to represent the social class of all family members, its outdated occupational categories, and its development and validation in only one small Connecticut city. In response to some of the criticisms, Hollingshead updated the index in 1975. It was based on a modified occupational categories from the 1970 census. The index scores for working couples were averaged. Even so, it is still not good enough because: 1) the modified occupational groups are beyond the conventional concept of occupation and industry and the index requires additional and specific information in order to classify; 2) The averaged 38 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. score for both working spouses may be misleading, especially in the case of extreme imbalances between the scores of the spouses; and 3) it has not been update since 1975. Nam-Powers’ Socioeconomic Status Scores This is a composite measure consisting of three indicators: the Nam-Powers’ Occupational Status Scores (described above), the person's own educational attainment, and the person's family income. Scores for education and income were calculated similarly to the Occupational Status Scores. The occupation score, education score, and income score were then averaged to produce the Socioeconomic Status Score (Nam and Terrie, 1986b). The authors felt that adding education and income to Occupational Status Scores helped to refine the occupation measure. These scores are fairly normally distributed. Nam and Powers first developed these scores in 1963 based on the 1950 male civilian labor force exclusively. Later, they updated them for the 1960 and 1970 censuses for the male, female, and total labor forces. In 1980 they updated this measure for total labor force only. The question raised about this approach is whether education and income are overly weighted-both through their own contributions to the composite and through their influence on the occupational assessment Since this method has not been widely used, there are few empirical data to evaluate its strengths and weaknesses. Warner's Index of Status Characteristics This index was based on four measures: occupation, source of income, house type, and dwelling area. Each of these measures consists of several ordered categories which are then weighted and summed to produce the index (Miller, 1983). Warner viewed social class as based on the prestige of persons in their community. He developed this index in the 1940s and provided some evidence for its validity based on studies in several small communities. There have been serious questions regarding the applicability of an index validated on the basis of data from small communities in the 1940s to the US population 40 years later (Coover, 1977; Jackson and Curtis 1968). 39 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Green's Scores for Socioeconomic Status In response to inadequacies of the Hollingshead's Index, Green (1970) developed a scoring procedure designed to be used for public health research and evaluation. Urging health researchers to pay attention to sociological variables like socioeconomic status, Green argues that normal preventive health behavior is more highly correlated with income, education, and occupation than other personal attributes. According to Green’s method, ranking scores are assigned separately to the educational level of the female adult in the household, annual family income before taxes, and the main earner's occupation. These three scores are combined according to a set of weights. This measure seems to be accepted by researchers in the health behavior field to replace the once-accepted Hollingshead's Index, but has not been not recommended for use in other fields (Mueller and Parcel, 1981). Indices combining education and income Sometimes only education and income data are available to researchers. There are practices to combine education and income together to provide a measurement for SES. Either to use the average of a person's education and income transformed into standard scores (Lee and Kolonel, 1982), or to order the education and income separately then to produce several class categories (Berkman and Syme, 1979; Andrews and Withey, 1976; Wingard et al., 1982), these approaches do not offer systematic validation of the resulting scales. Since these approaches are tailored to individual studies, it makes cross-study comparisons difficult (Liberates et al., 1988). Although composite indices proved to be useful in some studies (Green, 1970; Campbell and Parker, 1983), others found that they may obscure important differences in associations (Mueller and Parcel, 1981). Recognizing the complexity of the SES context and how difficult it is to operationalize, scholars have suggested the choice of indicators should be determined by practical considerations and by the conceptual framework of the individual study. "It is very 40 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. important to realize that the best measure to use in a research study depends intimately on the nature of the study" (Entwisle and Astone, 1994. p.1522). 3.2.5 Ecological Approach Information obtained directly at the individual level is ideal for studies concerning SES. However, for most studies, these individual level data are not available. The alternative to using SES data on individuals is to use aggregate data and apply these group characteristics to the individual participants. One approach that has been frequently used is based on summary census data for census tracts. The average SES characteristics of the census tracts as a whole are attributed to each individual residing in it Census tracts are small, relatively permanent statistical subdivisions of a county. Census tracts are delineated for all metropolitan areas and other densely populated counties. Census tracts usually have between 2,500 and 8,000 persons and are designed to be homogeneous with respect to population characteristics, economic status, and living conditions. Census tracts do not cross county boundaries. The spatial size of census tracts varies widely depending on the density of settlement Census tract boundaries are delineated with the intention of being maintained over a long time so that statistical comparisons can be made from census to census. However, physical changes in street patterns caused by highway construction, new development, etc., may require occasional revisions; census tracts occasionally are split due to large population growth, or combined as a result of substantial population decline (U. S. Bureau of the Census, 1993a). The advantage of this area-based ecological approach is that it is relatively easy and inexpensive to use. The disadvantage is if the residents in the area are heterogeneous instead of being homogeneous as assumed, the results can be misleading. Despite the concern that defining individual characteristics based on grouped data may cause misclassification which may result in 41 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. erroneous inference of causal relationships (Alker, 1969), such aggregate variables can be beneficial because they also capture some exposures that operate primarily at the census tract or neighborhood level, such as neighborhood peer-group health behaviors, access to health care, or possible local environmental pollution (Krieger and Fee, 1994). The overall validity of this ecological approach has been amply examined (Morgenstem, 1985; Liberatos etal., 1988; Krieger, 1992) and the practice has been widely adopted (Duncan, 1964; Kitagawa and Hauser, 1973; Yeracaris and Kim, 1978; McWhorter et al., 1989; Wells and Horm, 1992; Wagener and Schatzkin, 1994). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 4 CANCER EPIDEMIOLOGY Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells in the body. Normally cells reproduce in an orderly manner, so that worn-out tissues are replaced, injuries are repaired, and the body stays healthy. Occasionally, a cell undergoes a change that is abnormal and begins a process of uncontrolled growth and spread. These cells lose their functional differentiation and begin to reproduce themselves indiscriminately, over-growing their natural boundaries, distorting their surroundings, and destroying the normally ordered structure of the tissues in which they are growing. These cells may grow into masses of tissue called tumors. Some tumors are benign and others are malignant The cancer cells may invade distant or neighboring organs or tissues and cause secondary growths elsewhere in the body. This occurs either by direct extension of growth, or by metastasis whereby cells become detached and are earned through the lymph or blood stream to other parts of the body. Sooner or later the growing masses of cancer cells interfere with the function of a vital organ of the body, or the growth itself outgrows its own blood supply and becomes necrotic. The breakdown of the tissues may then lead to bleeding and secondary infection. Eventually the life of the victim is destroyed by organ failure, or infection, or by massive hemorrhage. Sometimes the sheer inanition caused by the growth leads to exhaustion and death (Rowland and Cooper, 1983). Cancer deserves special attention for several reasons. It is typical of "modem diseases” that constitute the most important health problems in the late twentieth century (Greenwald, 43 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1980). But cancer differs from most other modem diseases in ways that make differences in survival chances especially revealing with respect to health and society. Death from most of the other diseases are decreasing in number - especially death from heart disease (Stem, 1979). Deaths from cancer, on the contrary, are increasing. Malignant neoplasms (the official term for cancer) are today the second most frequent cause of death in many parts of the world. Cancer is a disease that concerns all Americans. It is estimated that over 10 million Americans alive today have a history of cancer, 7 million diagnosed five or more years ago. Most of the 7 million can be considered cured, while others still have evidence of cancer. About 1,359,150 new cancer cases are estimated to be diagnosed in the United States in 1996. This estimate does not include carcinoma in situ and basal and squamous cell skin cancers. The incidence of these skin cancers is estimated to be over 800,000 cases annually. Cancer-caused death in 1996 is estimated at 554,740 - over 1,500 people a day. One of every four deaths in the U.S. is from cancer (American Cancer Society, 1996). The fact that Americans, on the average, are getting older does not explain the increased cancer death rate (Greenwald, 1992). The epidemiology of cancer is the study of the determinants of the frequency of cancer in the population (Hutchison, 1982). Descriptive epidemiology is used to investigate the occurrence of cancer in different population groups (Tomatis et al., 1990). The objective may be simply to enumerate the size of the problem that cancer poses to health (how many cases, how many deaths) or, more often, to investigate how the risk for developing cancer varies in relation to different attributes of the populations studied, such as their place of residence, ethnicity, social status, or occupation. Variations in incidence rates between different population groups, as defined by personal (demographic) variables or by place of residence, may suggest the importance of environmental factors in the causation of a particular cancer. Therefore, descriptive epidemiological data are often described as “hypothesis generating”. 44 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. It may sometimes be possible to obtain quantitative data on the exposure of populations to environmental factors, for example, the level of an atmospheric pollutant or the average intake of a dietary item. Then ecological studies are possible, in which the strength of an association between disease risk and the level of exposure is tested, but always at the level of a population rather than for individuals. The study of exposure in relation to disease risk in individuals is the domain of analytical epidemiology. 4.1 Terminology and Measurements in Cancer Study The methods of epidemiology in general are also the methods of cancer epidemiology. Certain characteristics of cancer in human beings, however, require special emphasis (Hutchison, 1982). Cancer is primarily classified according to the system and anatomical site of the body which is affected. Different sites of origin produce different symptoms and different patterns of occurrence, as well as the different approaches to treatment Within a given anatomic site, cancers are classified as to morphology, as determined by the microscopic appearance of biopsy specimens, as, for example, adenocarcinoma or squamous cell carcinoma. In general, each distinguishable cell type of normal tissue may proliferate to form one or more specific morphologic types of neoplasms. The importance of these morphologic diagnoses is that they are designed to separate cancers of a site into different diseases, diseases that often have different epidemiologies. The recognition of morphologic and functional specificity has important implications for prevention (Berg, 1982). 45 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. It is generally understood, that tumors begin as unicellular changes, or perhaps as multifocal changes in several cells. The natural course thereafter is commonly a progressive increase through local, regional, and distant steps. The word extent is used to refer to any of these successive steps. Cancer staging is defined as the extent of tumor spread at the time of initial diagnosis. The simplest and most widely used system of staging involves a three-way classification of local, regional, and distant spread of tumor. Cancer is also classified into in situ or invasive cancer. In situ cancers are early localized tumors. Traditionally, in situ cancers are counted separately from invasive cancers because it is not certain that they will become invasive. Also, the reporting of in situ cancers is not as reliable as that of invasive cancers. Cancer grading refers to the degree of differentiation of the tumor as determined in microscopic sections. While site and morphology are permanent characteristics of tumors and may be useful in identifying etiologically different types, extent and grade are commonly variable characteristics over time, usually progressing from greater to lesser degrees of differentiation and from lesser to greater extent. Nevertheless, the initial grade and initial extent (the stage) may be indicators of the rate of growth or degree of malignancy of tumors, and the rate of progression of tumors over time may similarly reflect an inherent characteristic. Thus all these descriptive characteristics are useful in epidemiological studies. Although the above characteristics refer to affected individuals, it is fundamental to most epidemiological methods of study to relate affected individuals to a population from which they were derived. The following principal measures are used for the quantitative description of the relation between case and population. The number of new cases of cancer in a specified period of time and in a defined population is the cancer incidence. This frequency of occurrence of new cases may be expressed 46 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. either as a probability or as an instantaneous rate of occurrence. For studies of cancer causation, incidence is commonly the information desired. The number of cases, old and new, present at a point in time in a defined population is the cancer prevalence. Neither cancer incidence nor cancer prevalence is generally available. Population-based incidence is determined from special population-based cancer registries, together with census enumerations of the same populations. Cancer prevalence must be determined by special surveys, and is difficult to define in operational terms that lead to reliable estimates. The difficulty arises from the absence of any generally accepted concepts as to a time at which cancer may be considered to be eradicated in a surveyed population. The number of deaths attributed to cancer in a specified time period and in a defined population is the cancer mortality. Mortality may be expressed as a probability of cancer death in a population or as an instantaneous rate of dying from cancer. Reports of cancer mortality based on the usual national vital statistics suffer from certain deficiencies. Routine reports assign a single cause of death to each reported death. Persons dying with cancer may have death attributed, correctly or not. to some other condition present terminally. Furthermore, with the most satisfactory death reporting, mortality is a reflection of incidence and survival. Mortality and incidence are related by the case fatality rate, the proportion of incident cancer cases that terminate as cancer deaths. For certain malignancies, such as leukemia and lung cancer, the case fatality rate is close to 100 per cent, while for relatively benign cancers, such as nonmelanoma skin cancer, it is 1 to 2 percent (Myers and Hankey, 1982). Patient survival has been considered a useful measure of the end result of cancer treatment. Survival results can indicate whether there has been overall improvement over time in the management of cancer patients. Mortality trends reflect both incidence and survival trends in 47 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ways that are intuitively simple but in fact very difficult to describe analytically. For forms of cancer with poor survival outlook, mortality serves as a useful measure of cancer incidence, for other cancer sites mortality patterns reflect not only incidence trends but also variation over time in patient survival. Over a relatively long period of time, however, one could observe both incidence and mortality trends and infer the patterns of patient survival. Relative risk is a measure of the strength of the relationship between risk factors and a particular cancer. It compares the risk of developing cancer in persons with a certain exposure or trait to the risk in persons who do not have this exposure or trait For example, smokers have a 10-fold relative risk of developing lung cancer compared with nonsmokers. This means that smokers are about 10 times more likely to develop lung cancer than nonsmokers. 4.2 Causes of Cancer The causes of cancer are multiple and not clear-cut The assessment of causal relationships is a never-ending process of hypothesis formulation, testing, and interpretation. Cancer used to be regarded as a chronic degenerative disease that was natural concomitant of the process of aging. As a result of gradual accumulation of evidence, a major conceptual change regarding the nature of cancer occurred. Rather than showing cancer to be a disease that was inevitable, epidemiological studies implicated exogenous agents in the production of many cancers raising the possibility of cancer prevention and control. Cancer is caused by both external (chemicals, radiation, and viruses) and internal (hormones, immune conditions, and inherited mutations) factors. Causal factors may act together or in sequence to initiate or promote carcinogenesis. Ten or more years often pass between exposures or mutations and detectable cancer. 48 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Studies have indicated that 50-80% of human cancer is potentially preventable, because the factors that determine incidence are largely exogenous (Weinstein, 1991; Doll and Peto, 1981; Peacock, 1976; Weisburger and Williams, 1982). Although genetic factors are probably very important in terms of influencing individual susceptibility and that in certain rare forms of human cancer hereditary factors play a more decisive role (Post, 1966; Knudson et al., 1973; McConnell, 1976; Thomas, 1980), the majority of human cancers do not show simple patterns of inheritance. Therefore, the majority of cancers are preventable if the external causative factors can be identified. This, however, constitutes a major challenge, because for several prevalent forms of human cancer (i.e., cancer of the breast prostate, colon, and several other organ sites), the precise causes are still not known with certainty (Weinstein et al., 1995). Known causes of human cancer include specific chemicals or mixtures of chemicals present in various sources (cigarette smoke, various therapeutic agents, diet, the workplace, and the general environment), radiation (both ultraviolet and ionizing radiation), and specific viruses (hepatitis B, Epstein-Barr, papilloma, and certain retroviruses). In addition, oxidative damage to DNA due to endogenous metabolic reactions that generate highly reactive forms of oxygen and certain bacterial or parasitic infections have also been implicated (Brugge et al., 1991; Weinstein, 1991). Within the past few decades, astounding progress has been made in the understanding of the cellular and molecular basis of cancer causation and the molecular genetics of cancer (Brugge et al., 1991). Researchers now understand in minute detail many of the processes that transform a normal cell into a malignant one, and this knowledge will eventually allow us to identify molecular targets and design customized prevention and therapeutic strategies. Without research, our knowledge base will be frozen at its current level. With it, there is a virtual guarantee that many of the cancers that cannot be cured today will be controlled in the future. 49 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4.3 Cancer Risk Factors Age is the most important determinant of risk for cancer. Overall cancer incidence rates among the elderly are ten or even one hundred times higher than those of younger people. The incidence of cancer remains particularly low in children and young adults, although not unknown, but sharply increases with age for most cancers. This can be explained as the older one becomes the longer one is exposed to the factors that, directly or indirectly, increase the risk for developing cancer. The fact is, in the case of cancer, the environmental risk factors to which people can be exposed at "ordinary" levels, which means very low dose, exert their carcinogenic effect after several decades. There is a long latency between the carcinogenic exposure and the onset of cancer. However, the long latent period between what is usually thought to be the first event (often called "initiation") of carcinogenesis and the clinical appearance of cancer can be shortened when the carcinogenic factors interact with predisposing genetic factors, in which case the role of "ordinary" level may be magnified by increased susceptibility. Gender differences in cancer risk produce important etiologic clues. Except the sex- specific cancers affecting the reproductive systems pertain to the specific sex of the population, such as prostate and uterus cancer, for nearly all the cancer sites the age-specific incidence rates are higher in males than in females. Exceptions to this striking and consistent feature of cancer are in the cases of breast, gall-bladder and thyroid, which are generally more common in females, especially breast cancer (Muir et al., 1987). For all cancers combined, women have higher incidence rates than men in the age group 30-54 years for every racial/ethnic group. This is due to the high rates of female breast cancer and cancers of the female genital system (ovary, corpus uteri, and cervix uteri). The male-female difference in the frequency of breast cancer is perhaps one of the most obvious features of its descriptive epidemiology. Lifetime risk refers to the 50 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. probability that an individual, over the course of a lifetime, will develop cancer or die from it In the U.S., men have a 1 in 2 lifetime risk of developing cancer, and for women the risk is 1 in 3 (American Cancer Society, 1996). Besides age and sex, race/ethnicity and SES are the two other significant demographic risk factors for cancer. Race/ethnicity represents the differences in norm, belief, religion, diet, lifestyle, as well as genetic composition of the body. The cancer experience among racial/ethnic groups varies widely across the world as well as in the United States. The racial/ethnic differences in site-specific cancer incidence have long captured the attention of scientific studies. Comparisons between different ethnic groups living in the same country or region reveal substantial variations in cancer incidence and mortality (Muiretal., 1987; Bernstein and Ross, 1991; Miller et al., 1996). In the United States, black men have the highest incidence rate of cancer overall. Non-Hispanic white men have the next highest rate. The overall cancer rate for women is higher in non-Hispanic whites than in blacks. For both sexes, the incidence rates of Hispanic whites, Chinese and Japanese are 30 to 40 percent lower than those of blacks and other whites (Bernstein and Ross, 1991). Cancer incidence rates differ among Hispanic and white populations in the U.S.. However, it presents a paradox because the many risk factors attributed to Hispanics seem to be contradicted by low incidence rates (Montes, 1989). Asian-Americans experience lower cancer rates than blacks and whites for many of the more common malignancies (Goodman, 1989). Research has shown that both cancer incidence and survival are strongly related to SES and the racial/ethnic differences in cancer rates largely reflect socioeconomic factors (American Cancer Society, 1986). However, SES is not a risk factor for cancer per se, but a proxy for other real environmental exposures that are more prevalent in particular groups in the society. Societies are not homogeneous. The differences in people's socioeconomic condition lead to the 51 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. differences in the circumstances of life of different sections of society. Variations in life style have an important bearing on people's health status. Quite dramatic differences in cancer risk are evident according to some measures of "socioeconomic status." Although poor people are regarded to have greater exposure to risk factors which produce ill health, it is increasingly clear that affluent style of life produces vulnerabilities to particular diseases and disorders as well. For instance, the rich diets of higher SES groups and their occupational demands that involve considerable stress but little physical exercise have been linked by some investigators with a high prevalence of coronary heart disease (Mom's, 1964). Studies have found that the women of high SES tend to have higher risk for breast cancer but lower risk for the cancer of cervix uteri compared to their counterparts of low SES (Devesa and Diamond, 1980; Hakama etal., 1982). Although it is reasonable to assume that lower SES and poverty may produce greater disease risks and vulnerability than do the characteristics of the higher class, it must not fail to note that the variability is apparent within particular SES categories. Occupational exposures to physical and chemical agents are usually heavy and extended over a relatively long period of time. Significant relationships have been demonstrated between many categories of job and the risks for different cancers; for example, electrical workers appear to have a higher than average risk for leukemia and butchers have a higher risk for lung cancer (Logan, 1986). Based on direct observations of various occupational groups, quite a few chemical and physical agents or industrial processes have been well recognized as carcinogenic hazards (Decoufle, 1982). Occupational hazards have implications beyond the workforce because many chemical and physical agents are not confined to a workplace but may spread into the general environment. Since the early part of this century, laboratory scientists have known that various nutritional manipulations could influence the occurrence of tumors in animals. Widespread interest 52 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. in the relation of diet to cancer in humans developed more recently when the large international differences in cancer rates were shown to be correlated with variations in dietary factors (Armstrong and Doll, 1975). The observation that migrating populations adopted, sooner or later, the cancer rates of their new host population fortified the evidence that the international differences were the result of noninherited factors including, among other possibilities, diet Diet has been estimated to be responsible for between a quarter and one-third of all cancers that occur in economically developed countries (Willett and Trichopoulos, 1996). Data have demonstrated a beneficial and more or less universal effect of vegetable consumption and, perhaps less definitively, a similar effect of fruit consumption. Animal protein and fat, mostly red meat, is linked closely to the occurrence of cancer in the large bowel, and saturated fat, mostly animal fat, to the occurrence of prostate cancer. Salt intake is a likely component cause of stomach cancer, and intake of salty fish very early in life is linked closely to nasopharyngeal cancer in Southeast Asia. The intake of very hot drinks increases the risk of esophageal cancer in Central Asia and South America. Drinking alcoholic beverages increases the risk of developing cancers of the oral cavity, pharynx, larynx, oesophagus and liver. It is also clear that the risks for these cancers are multiplied in people who also smoke (IARC, 1988). The fact that tobacco smoking causes lung cancer has been recognized ever since the beginning of the 1950s (Doll and Hill, 1950). A considerable number of investigations conducted in different parts of the world, on different subsets of the general population and with different designs have consistently reported an increase in the occurrence of lung cancer among smokers in comparison with nonsmokers (Hammond, 1966; Doll and Peto 1976). Tobacco smoking is causally associated not only with cancer of the lung but also with cancers of the upper respiratory tract, upper digestive tract, pancreas, bladder and renal pelvis (Tuyns et al., 1988; Tuyns et al., 1977; Rebelakos et al., 1985; Mack et al., 1986). There is consistent and strong evidence that consumption of large quantities of alcoholic beverages in conjunction with tobacco smoking 53 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. sharply increases the risk of cancer in the upper respiratory and digestive tract; there is also substantial evidence that intake of small quantities may be linked to the occurrence of breast and colorectal cancer (Willett and Trichopoulos, 1996). Physical activity in the adult life reduces the risk of colorectal cancer (Garbrandt et al., 1984; Vena et ai„ 1985; Giovannucci et al., 1995) and probably breast cancer (Bernstein et al., 1994; Frisch et al., 1985). Limited evidence also suggests a possible reduction in risk of prostate cancer with high levels of activity. Moreover, higher levels of physical activity tend to reduce obesity which is an important cause of endometrial cancer, kidney cancer, and probably postmenopausal breast cancer and cancer of the large bowel (Willett and Trichopoulos, 1996). 4.4 Selected Cancers 4.4.1 Cancer of the Bladder The highest incidence rates for bladder cancer are found in industrialized countries such as the United States, Canada, France, Denmark, Italy, and Spain. Rates are lower in England, Scotland, and Eastern Europe. The lowest rates are in Asian and South America, where the incidence is only about 30% as high as in the United States. In all countries the rates are higher for men than women (Miller et al., 1996). Among men the highest incidence rates for bladder cancer occur among non-Hispanic white. The rates for black men and Hispanic men are similar and are about one-half of the non- Hispanic white rate. The lowest rates are in the Asian populations. For women, the highest incidence rates also occur among non-Hispanic white and are about twice the rate for Hispanics. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Black women, however, have higher rates than Hispanic women. The incidence of bladder cancer increases dramatically with age among men and women in all populations. While incidence rates in the white population exceed those for the black population, such is not the case for mortality where the rates are much closer together. Black women who have a lower incidence of bladder cancer than white women actually die from the disease at a greater rate (Bernstein and Ross, 1991; Miller et al., 1996). This difference in survival between black and white populations reflects the fact that in whites a larger proportion of these cancers are diagnosed at an early more treatable stage. Mortality rates for Hispanics and Asians are only about one-half those for whites and blacks. Bladder cancer mortality rates are low relative to incidence rates because many tumors are detected early and are successfully treated. Cigarette smoking is an established risk factor for bladder cancer. It is estimated that about 50% of these cancers in men and 30% in women are due to smoking. Cigarette smokers have about twice the risk of developing bladder cancer of non-smokers. Yet, some populations who have exceptionally high smoking rates, such as black males, do not have exceptionally high bladder cancer incidence rates. This suggests that there may be some unknown (actor which protects such population groups from developing the disease (Bernstein and Ross, 1991). Occupational exposures may account for up to 25% of all bladder cancers. Most of the occupational accrued risk is due to exposure to a group of chemicals known as arylamines (Howe et al., 1980). Occupations with high exposure to arylamines include dye workers, rubber workers, leather workers, truck drivers, painters, and aluminum workers. Because of the association with bladder cancer, some of the most important arylamines have been greatly reduced or eliminated from occupational settings by federal regulated occupational standards. Coffee, alcohol, and artificial sweeteners have all been studied as risk factors for bladder cancer, but associations, if they exist, are weak (Miller et al., 1996). 55 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. So far, no significant or consistent associations have been found between bladder cancer and SES (Williams etal., 1991; Smith etal., 1991). 4.4.2 Cancer of the Breast * Breast cancer occurs almost exclusively in women everywhere in the world, among whom it ranks first among all the diagnosed cancers. Breast cancer is rare in men. The sex difference in the frequency of breast cancer is perhaps the most obvious feature of its epidemiology. The incidence of female breast cancer has been rising for the past two decades, while mortality has remained relatively stable since the 1950s. Much of the increase in incidence in the past 15 years is associated with increased screening by physical examination and mammography. However, screening alone does not seem to explain all of this increase. The risk of breast cancer varies throughout the world, with high rates seen in Western industrialized countries such as the United States, Canada, and Western Europe, and very low rates seen in Asia, Latin America, and Africa. The age-adjusted incidence rates of invasive female breast cancer reveal that white and black women have the highest rates, with white women have higher incidence rate than black women. In the United States, the lowest rates occur among Korean, American Indian, and Vietnamese women (Miller et al., 1996). The incidence of breast cancer is low among Japanese women in Japan. However, among Japanese women in Los Angeles County, who are relatively Americanized, the rates have been increasing and are similar to those of Hispanic white women (Bernstein and Ross, 1991). Mortality rates are much lower than incidence rates for breast cancer. Racial/ethnic patterns of mortality differ slightly from those observed for incidence. The highest age-adjusted mortality occurs among black women, followed by white women. The higher breast cancer mortality among black women is related to the fact 56 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. that compared to white women, a large percentage of their breast cancers are diagnosed at a later, less treatable stage (Miller et al., 1996). Breast cancer is extremely rare prior to the start of menstruation. The age-specific incidence rates climb steeply from young adulthood until about age 50, around the age of menopause. After this time, rates continue to increase, but at a much lower speed. Early onset of menstruation is associated with higher risk of breast cancer as is later age at menopause. Reproductive experiences also greatly influence risk. Women who have their first child late in life or who never have a child are at higher risk of breast cancer than those who have children at younger ages. Women who breast feed their children for long periods of time appear to be protected (Petrakis etal., 1982). Several other factors are still being evaluated in terms of their effect on a woman’s risk of breast cancer. These include diet, especially dietary fat, alcohol consumption, physical exercise, and the use of birth control pills and hormone replacement therapy (Bernstein and Ross, 1991). A consistent observation is the positive correlation between socioeconomic status and breast cancer incidence, the higher incidence rates occurring in upper SES levels (Williams et al., 1991; Baquetet al., 1991; Petrakis etal., 1982; Hakama etal., 1982; Devesa and Diamond, 1980;). Such a relationship has been found in both white and black women. Strong positive associations with both income and education were found among white women, while among black women a strong positive association with education but not with income was found (Devesa and Diamond, 1980). The Western way of life and a high standard of living as well as individual reproductive characteristics seem to play an important role in the etiology of breast cancer (De Waard, 1969). The most discriminating risk factor was identified as maternal age at first birth (MacMahon et al., 1973). The correlation of breast cancer incidence with education was considered a reflection of postponement of first birth as education is pursued (Devesa and 57 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Diamond, 1980; Hayes, 1987). However, childbearing history is not sufficient to explain the large variations observed in breast cancer risk. Positive associations with SES persist after adjustment for fertility, marital status, or age at first birth (Graham et al., 1960; MacMahon et al., 1970). Environmental factors appear to operate in all age groups. Diet, particularly fat consumption, and physical activity have been suggested as influencing hormone environment and therefore risk; these may be influenced by income and education. Some evidence indicates that the risks for blacks and whites of the same SES group may be similar (Zippin and Petrakis, 1971; Shapiro et al., 1968). The racial difference between white and black women in breast cancer is largely reduced by adjustment for SES factors, with the effect of education being stronger (Devesa and Diamond, 1980; Baquetetal., 1991). 4.4.3 Cancer of the Central Nervous System Cancer of the central nervous system (CNS) includes malignant brain tumors and spinal cord tumors. These tumors are generally more common in men than in women and more common in whites than in blacks (Schoenberg, 1982). For both men and women the majority of these cancers occur in the brain. A general pattern of age-specific incidence has been found for these cancers: a small peak in childhood, followed by a higher peak, reaching a maximum between age 60 and 80 and then declining after those ages. The shape of the age-specific incidence curve resembles that of the age-specific mortality curve. Although cancer of the central nervous system is relatively rare, mortality rates are high relative to incidence rates (Bernstein and Ross, 1991). There are a variety of subtypes of malignant central nervous system tumors. Each appears to have a distinct pattern of age-specific incidence rates, and these subtypes should probably be considered as separate diseases (Tomatis et al., 1990). There are generally too few cases to assess the incidence or mortality rates for racial/ethnic groups other than whites, blacks, 58 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and Hispanics. Among these three population groups, for both men and women, incidence rates are lowest in blacks, slightly higher in Hispanics, and highest in whites. The same pattern occurs in the mortality rates for men. Among women, however, mortality rates for Hispanics and blacks are similar (Miller et al., 1996). Epidemiologic studies have yet to define the causes of the majority of these tumors (Preston-Martin et al., 1993). One apparent risk factor for the cancer of the central nervous system is exposure to radiation. Other possible risk factors, which are currently being studied further, include trauma to the head or spine and certain occupational exposures, and for childhood brain tumors, the occupational exposure of their parents. A few studies looked into the relationship between SES and the risk of developing cancer of CNS. There seems to be a positive association between cancer of the central nervous system and SES. A rising trend in the incidence of children with CNS was strongly linked with increasing levels of affluence in one study (McKinney, et al., 1994). In other studies, strong trends of increasing brain cancer incidence with increasing social class were found (Preston-Martin, 1989; Preston-Martin etal., 1993; Smith et al., 1991). However, one study found no significant association between brain cancer and education; but low income was associated with a significantly reduced risk of brain cancer mortality (Morrison et al., 1992). 4.4.4 Cancer of the Cervix Uteri The body of knowledge on cervical cancer is undoubtedly greater than that for any other solid tissue neoplasm with the possible exception of breast cancer. Despite this, full understanding and complete control of this disease have not yet been achieved, and it remains a frequent cause of death in some groups of women. 59 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. There are racial differences in the incidence rates for cervical cancer. Invasive cervical cancer was diagnosed twice as frequently among black females as among white females (Jones, 1989). Poverty status was considered to account for much or all of the racial differences (McWhother et al., 1989). The incidence rates of invasive cervical cancer have been declining in the U. S. for the past almost 50 years, due primarily to the use of Pap screening test, which results in early detection of cellular changes in the cervix before invasive cancer develops. The risk of dying from cervical cancer is low relative to the incidence of this disease. Cervical cancer is thought to have a viral etiology. Most cases are probably caused by chronic infection with certain types of human papilloma virus, which also causes genital warts. Risk factors for cervical cancer relate to certain aspects of sexual activity such as early age at first intercourse and multiple sexual partners (Cramer, 1982). Negative associations between socioeconomic status and the occurrence of cervical cancer have been reported; high incidence rates are found in women of low SES (Baquet et al., 1991; Williams etal., 1991; McWhother et al., 1989; Devesa and Diamond, 1980). Cervical cancer incidence is higher at lower educational levels and at lower family-income levels (Baquet et al., 1991; Devesa and Diamond, 1980). The negative association is thought to relate both to differential exposure to risk factors, and to a lack of knowledge and use of screening services (Chamberlain, 1984). 4.4.5 Cancer of the Colon Colon cancer is the third most frequently diagnosed cancer in the U.S.. The age-specific incidence rates of colon cancer rise steadily starting at ages 10-14. Blacks, non-Latino whites and 60 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Japanese have similar incidence rates in Los Angeles County (Bernstein and Ross 1991). The high risk of Japanese is surprising since Japanese in Japan have some of the lowest rates of colon cancer found in the world. The risk among Latino whites is nearly half of the high risk groups. Males tend to have slightly higher incidence rates than females within each racial/ethnic group. Racial/ethnic differences in colon cancer rates reinforce the concern that environmental factors play a major role in colon cancer etiology. Studies of migrant populations have shown that the incidence rates for different racial/ethnic groups living in the same area tend to converge over time and migrating groups tend to reflect the rates in the new host country (Schottenfeld and Winawer, 1982; Mack etal., 1985). The patterns of mortality roughly parallel the patterns of incidence for colon cancer, for each sex and racial/ethnic group, but are about 50% lower (Bernstein and Ross, 1991). Differences between whites and blacks in the U.S. with respect to colon cancer mortality were quite marked before 1950, but subsequent years have seen a steady convergence as a result of increasing rates among nonwhites. Mortality rates are higher for men than women. Black women die at a slightly higher rate from colon cancer than white women (Schottenfeld and Winawer, 1982). In general, incidence and mortality rates for cancer of the colon are rising, particularly in areas where the risk was formerly low (Boyle et al., 1985). It is reasonable to assume that the risk of colon cancer is related to diet, and the similarity of male and female incidence rates is consistent with this concept Yet the precise way in which diet alters the risk of colon cancer has not been completely established. Higher consumption of dietary fat, especially fat from animal sources, and low intake of dietary fiber, fruits, and vegetables have frequently been shown in epidemiological studies to be related to higher risk of colon cancer. But not every study has shown such a relationship (Bernstein and Ross, 1991; Wilson, 1989). Obviously, generalities like “high fat” and “low fiber" without more specific Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. information lead to confusion. Fats are not all the same; some may well be protective while others are harmful, as demonstrated by the epidemiology of cardiovascular disease. The same is true for fiber, a category that includes soluble and insoluble components. The insoluble fiber is believed to offer some protection from colon cancer. It is this absence of specificity that may explain why some studies have associated colon cancer with dietary fat and fiber and others have not There are also data which suggest that a high calcium diet is associated with lower risk of cancer of the colon. Colon cancer seems to cluster in families, but it is unclear whether this familial aggregation is the result of common environmental or genetic backgrounds (Wilson, 1989). Persons with certain inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis are also known to be at a higher risk than persons without these conditions (Kirsner, 1980), although these conditions account for only a small proportion of colon cancer. There is a growing body of evidence to suggest that physical exercise may lower risk of this disease (Garbrandt et al., 1984; Vena etal., 1985). Studies have demonstrated higher colon cancer incidence among individuals of the upper social classes (Wynder and Shigematsu, 1967; Haenszel et al., 1975; Lynch et al., 1975; Williams et al., 1991). The increased colon cancer risk in high SES groups is suspected to be related to lifestyle factors, especially ovemutrition and sedentary occupations (Williams et al., 1991). However, some studies found that the colon cancer incidence rates are not related to educational level or median family income (Baquet et al., 1991). 62 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4.4.6 Cancer of the Corpus Uteri Cancer of the corpus uteri or endometrial cancer is a cancer of the inner lining of the uterus. This cancer is the fourth most common cancer among women in the U.S.. Although the incidence rates for cancer of the corpus uteri increase throughout life, like breast cancer the rate of increase is much greater before age 50 than later in life. The mortality rates from corpus uteri cancer have declined steeply for women of all age groups. This cancer is often detected at an early stage, especially in women using estrogen replacement therapy. When diagnosed at an early stage, cancer of the corpus uteri has a very good prognosis. High incidence rates are found in white populations in the U.S. and low rates of incidence are seen in Asian populations. Cancer of the corpus uteri is caused by the female hormone estrogen, whereas the other major female hormone, progesterone, blocks this estrogen effect and prevents endometrial cancer development. Estrogen-related exposures including unopposed estrogen replacement therapy, tamoxifen (which is an “ antiestrogen” with estrogen-like effects on the uterus), early menarche, late menopause, never having children, and a history of infertility or failure to ovulate have all been shown to increase risk. High body weight is a risk factor because, compared to thin women, heavy women produce more estrogen that is not counteracted by progesterone. Pregnancies and the use of birth control pills (which contain both estrogen and progesterone-like hormones) reduce the risk of developing this cancer (Bernstein and Ross, 1991; American Cancer Society, 1996). Studies of migrants suggest that the risk increases in populations who move to areas with “ westernized" life styles (Tomatis et al., 1990). There is a suggestive relationship between affluence and the incidence of cancer of the corpus uteri (De Waard, 1982). Differences in the risks of urban and rural residents and with socioeconomic status are small and inconsistent (de 63 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Waard, 1982; Tomatis etal., 1990; Williams etal., 1991). Insignificant association was reported between poverty level and incidence of cancer of the corpus uteri (McWhorter et al., 1988). 4.4.7 Cancer of the Esophagus Esophageal cancer is characterized by an extreme diversity of rates throughout the world. It is a common cancer in developing countries, but is less common in the United States. There are usually more cases among males, but in areas of very high incidence the rates in females may exceed those in males (Tomatis et al., 1990). Historically, most esophageal cancers were squamous cell tumors. Recently, however, there has been a marked increase in adenocarcinoma of the esophagus, primarily among white men, in developed countries of the world, including the U.S.. In fact, among white men, rates of adenocarcinoma of the esophagus nearly equal those of squamous cell tumors (Miller et al., 1996). In the United States, the incidence of esophagus cancer is about four times higher in black men than in white men, and blacks of both genders are almost three times more likely to die from cancer of the esophagus than are their white counterparts (Bernstein and Ross, 1991; Wilson 1989). Yet, risk of esophageal cancer does vary by histologic subtype so that adenocarcinomas of the esophagus which now comprise 50% of esophagus cancers are 5-7 times greater among whites than blacks. Incidence rates of esophageal cancer generally increase with age. Mortality rates for esophageal cancer are only slightly lower than its incidence rates reflecting the generally poor survival for patients with this cancer. Currently there is no evidence of familial aggregation of this cancer. The major risk factors implicated in the development of esophageal cancer are cigarette smoking (and, possibly, other types of tobacco use) and heavy alcohol consumption. The combination of smoking and alcohol 64 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. use results in large elevations in risk. Diet may play a small role in the development of cancer of the esophagus. Decreased consumption of fruits and vegetables, high salt intake, and drinking very hot beverages have been suggested as risk factors (Keller, 1980; Pottem etal., 1981; Day and Munoz, 1982; Tuyns etal., 1979). Esophageal cancer is a disease of the poor. Higher risk is found among the lower socioeconomic strata (Day, 1975; Wynder and Brass, 1961; Pukkala and Teppo, 1986; Van Loon et al., 1995). Negative association with SES are found for both squamous esophageal cancer (Day and Munoz, 1982; Schottenfeld, 1984) and esophageal adenocarcinomas (Brawn et al., 1994). The SES differences in esophageal cancer is thought likely attributable to differences in alcohol consumption, smoking, dietary factors, and poverty account for substantial risk differences among SES groups. 4.4.8 Cancer of the Kidney Historically, incidence rates for kidney cancer have included cancers of the renal cells (in the main part of the kidney) and the renal pelvis (the lower part of the kidney where urine collects before entering the ureter and continuing to the bladder), although there is evidence that these cancers have different characteristics. About one of four kidney cancers occur in the renal pelvis, Cancer of the kidney, like cancer of the bladder, is a disease for which the highest rate occurs among white males. The second highest incidence rate occurs among black males. The lowest incidence rates occur in Asian population. The incidence rates are nearly identical in white and black populations, but are about twice as high for men as for women (Morrison and Cole, 1982). The excess of kidney cancer in males compared to females is considerably less than that for bladder cancer. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. There is a small peak in kidney cancer incidence in early childhood due to wilm’s tumor, an uncommon tumor of the kidney with a good prognosis. Rates then decline until about age 40. After this age, there is a more or less continued increase in the incidence rates throughout the remainder of life. Although incidence rates for kidney cancer are considerably lower than those of cancer of the bladder, the mortality rates are not substantially different Kidney cancer has a relatively high mortality rate in all racial/ethnic populations. In all racial/ethnic populations the mortality of kidney cancer increases with age. The etiology of cancer of the kidney is poorly understood. Cancer of the kidney and renal pelvis share many risk factors, although the strengths of the associations differ. For both types of cancer the only well-established risk factor for kidney cancer is cigarette smoking (Doll and Peto, 1976). Compared to non-smokers, smokers have between 1.5 to 2 times greater risk of developing renal cell and approximately four times the risk of developing cancer of the renal pelvis cancer than non-smokers (Bernstein and Ross, 1991). Other probable risk factors for kidney cancer include obesity, coffee consumption, occupational exposure to asbestos, and heavy long term use of analgesics (medications used primarily to relieve mild pain of muscular or neurological origin). The relationship between SES and the chance of developing kidney cancer is sporadic and mixed. While some studies found no association between SES and the disease (Williams et al., 1977; Kantor et al., 1976), others observed a trend for increased risk with lower SES (Maclure and Willett, 1990; Asal et al., 1988). The findings on the association between education and risk of kidney cancer is also conflicting (La Vecchia et al., 1992; Krieger et al., 1993). 66 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4.4.9 Cancer of the Larvnx Cancer of the larynx is relatively rare in the United States. Laryngeal cancer is a predominantly a cancer of males. Its male-female ratio is among the highest of all cancers. Blacks have somewhat higher incidence rates than other racial/ethnic groups in the U.S., while Chinese and Japanese have the lowest rates (Bernstein and Ross, 1991). Symptoms of larynx cancer, which often include hoarseness or difficulty breathing, are usually recognized relatively early in the course of the disease, leading to early treatment The average annual age-adjusted mortality rates are about 1/3 of the related incidence rates. Tobacco use is the predominant cause of cancer of the larynx (Wynder et al., 1956; Auerbach et al., 1970; Tuyns, 1982). The risk increases with heavy alcohol use and particularly in heavy smokers who also drink large amounts of alcohol (Jussawalla and Deshpande, 1971). Occupational exposure to some chemicals and dusts (Peterson and Milham, 1980), as well as asbestos (Stell and McGill; 1973), have been reported to increase the risk of cancer of the larynx, although these relationships have not been found consistently in all studies (Austin, 1982). A definite SES relationship has been reported for laryngeal cancer, the incidence rates are lowest in the high SES groups and highest in the low SES groups (Logan, 1982). Lower risk of laryngeal cancer is associated with more educated individuals (La Vecchia et al., 1992). Some of the association could be related to the lower prevalence of smoking and alcohol consumption among educated people (Doll and Peto, 1981; Franceschi etal., 1990). 67 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4.4.10 Cancer of the Liver Liver cancer is more common in Africa and Asia than in the U.S. where liver cancer is a relatively rare cancer. In North America, high incidence rates are found in populations of Asian origin and Eskimos. Non-Hispanic white men and women have the lowest age-adjusted incidence and mortality rates for primary liver cancer. Rates in the black and Hispanic populations are roughly twice as high as the rates in whites. Asian-American groups have liver cancer incidence and mortality rates several times higher than the white population (Miller et al., 1996). Liver cancer occurs more frequently in males than in females. The male excess was observed for every racial/ethnic group. The mortality rates appear to exceed the incidence rates by a small amount. The most likely explanation for this phenomenon is the misclassification on death certification of metastatic cancer from another body site to the liver (Bernstein and Ross, 1991; Miller et al., 1996). The major cause of liver cancer is chronic infection with hepatitis B virus. The prevalence of such infection is highest among Asian populations. Infection with hepatitis B virus may be passed on from generation to generation. There is currently much interest in the possible role of another important hepatitis virus, hepatitis C, in the development of liver cancer. Other risk factors for this cancer include cigarette smoking, excessive alcohol consumption, and possibly, dietary intake of a toxin known as aflatoxin. Aflatoxin is produced by a fungus and is often a contaminant of moldy nuts and grains, especially in tropical settings. Elevated liver cancer risk has been recorded with lower SES groups (Pukkala and Teppo, 1986; Logan, 1982) and people with less education (La Vecchia et al., 1992). 68 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4.4.11 Cancer of the Lung The incidence rates of lung cancer, which had been increasing steadily in men and women for several decades, have declined in men in recent years, while the incidence rates for women continue to increase (American Cancer Society, 1996). Lung cancer is the leading cause of cancer deaths among men and, in the past few years, has surpassed breast cancer to become the leading cause of cancer deaths among women. Greater than 80% of lung cancers are squamous cell carcinoma, adenocarcinoma, small cell carcinoma, or large cell carcinoma. Squamous cell carcinoma is the most common type of lung cancer among men. Among women, however, adenocarcinoma constitutes the highest proportion of diagnosed lung cancers (Travis, etal., 1995). Overall, there exists a substantial male excess of lung cancer among all of the racial/ethnic groups. Men and women have similar lung cancer incidence rates up to age 45. After age 45, it appears that the incidence and mortality rates of lung cancer do not increase as rapidly with age in women as in men. This probably is a result of lower smoking rates among the current group of older women. This is expected to change when women smokers of the past 30 or 40 years reach the older age groups (Bernstein and Ross, 1991). Black males have the highest age- adjusted lung cancer incidence rate of any racial/ethnic group. Age-adjusted mortality rates follow similar racial/ethnic patterns to those for the incidence rates. Cigarettes are well established as the major etiologic factor in lung cancer (Fraumeni and Blot, 1982). Passive smoking also contribute to the development of lung cancer among nonsmokers (Dalager etal., 1986). Tobacco is associated with most of the major histologic types of lung cancer (Morabia and Wynder, 1991). However, the increase in lung cancer risk according to number of cigarettes per day appears stronger for squamous cell carcinoma and small cell 69 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. carcinoma than for adenocarcinoma, and there is no increase for large cell carcinoma (Morabia and Wynder, 1991). A stronger link between squamous cell carcinoma and smoking has been suggested (Lubin and Blot, 1984). Other factors include exposure to certain industrial substances, such as arsenic; some organic chemicals and asbestos, particularly for persons who smoke; radiation exposure from occupational, medical, and environmental sources; air pollution; tuberculosis; radon exposure, especially in cigarette smokers (American Cancer Society, 1996). An inverse association between lung cancer and SES has been observed in several studies (Fraumeni and Blot, 1982; Logan, 1982; Smith et al., 1991; Ashley, 1969; Williams and Horm, 1977). Lung cancer has been reported to occur more frequently among males of lower SES groups (Devesa and Diamond, 1983). The reported patterns among females have been inconsistent (Devesa and Silverman, 1978). Smoking habits, occupational exposure, environmental pollution in general are considered contributing to the to the SES differential of lung cancer (Wynder and Stellman, 1977; Hein etal., 1992; Devesa and Diamond, 1983;). 4.4.12 Melanoma Malignant melanoma incidence rates show substantial international variation. This variation is related to racial/ethnic composition and the intensity of sunlight exposure in different geographic areas. The risk of this disease is strongly related to the latitude of a person’s residence; white populations living near the equator generally have higher incidence and mortality rates than those living near the poles. Rates are low in races with the most skin pigmentation, such as blacks and Asians, and are high in whites (Miller et al., 1996; Bernstein and Ross, 1991; Lee, 1982). Among whites, age-adjusted incidence rates are over five times higher in non- Hispanic men compared to Hispanic men, and over three times higher in non-Hispanic women compared to Hispanic women. In almost every white population, especially in Australia and the 70 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. United States, malignant melanoma incidence rates have been increasing faster than nearly every other cancer. In Los Angeles County, unlike many other parts of the world, the age-adjusted incidence rates of malignant melanoma are higher in men than in women (Bernstein and Ross, 1991). The anatomic distribution of these tumors differs for men and women, with men more likely than women to have melanoma on the head, neck, and trunk and women more likely than men to have melanoma on the lower limbs (Lee, 1982). Among white populations, fair-skinned people, particularly those who lack the ability to tan, have the highest risk (Lee, 1982). Sunlight exposure appears to be associated with melanoma development in a complex way; the precise pattern of exposure conveying the greatest risk is not well established yet. However, the increasing incidence of the disease seems related to increases in voluntary sun exposure and the use of tanning devices. There is also some indication that sever burning or strong intermittent exposure, especially in childhood, may be especially high risk patterns for the disease (Elwood et al., 1985; Holman et al., 1986). An excess of this cancer has been reported in family members of cases, but it is not clear whether this is due to inherited genes or due to common skin type or sun exposure patterns (Miller et al., 1996). There is a strong generalized effect of SES in the occurrence of melanoma-the risk is significantly higher in high-paying than low-paying occupations, in white-collar than blue-collar occupations, in rich than poor, and in more educated than less educated (Pion et al., 1995; Lee and Strickland, 1980; Williams et al., 1991; Kirkpatrick etal., 1990). The SES pattern for women has been inconsistent (Pion et al., 1995; Williams et al., 1991). Lifestyle factors associated with higher levels of education were considered to be more important determinants of melanoma risk than characteristics of the work environment (Goodman et al., 1995). The strong positive SES 71 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. gradient with melanoma incidence is not reflected in the melanoma mortality (MacKie and Hole, 1996; Geller et al., 1996). This apparent mortality benefit enjoyed by people of high SES could be due to better treatment or it might be explained by earlier detection, earlier treatment and subsequently improved prognosis (Williams etal., 1991). 4.4.13 Cancer of the Ovarv Ovarian cancer is an important cause of morbidity and mortality among middle-aged women. Among women in the United States, cancer of the ovary ranks fifth in incidence. Incidence is high in women in the age range 45-64 years, and survival is poor, partly because the disease has often spread widely when diagnosed (Tomatis et al., 1990). Although incidence rates increase throughout life, they increase more rapidly before menopause (which occurs, on average, around 50 years of age) than after menopause. The incidence of ovarian cancer appears to have changed very little over the past 20 or more years (Bernstein and Ross, 1991). Age-adjusted incidence rates are highest in American Indian women, followed by white, Vietnamese, white Hispanic, and Hawaiian women. Rates are lowest among Korean and Chinese women. The ovarian cancer mortality patterns by racial/ethnic group differ from the incidence patterns. The age-adjusted mortality rate is highest among white women, followed by Hawaiian women, and black women. The great majority of ovarian cancers are epithelial carcinomas; germ cell tumors are uncommon, with a peak in incidence in women aged 15-34 years (as for germ-cell tumors of the testis), and follicular tumors (mainly granulosa-cell) are also rare (Weiss, 1982). Risk for ovarian cancer increases with age. Although the epidemiology of ovarian cancer is not well understood, hormonal and reproductive risk factors are implicated in the etiology of this disease. Women who have never had children are more likely to develop ovarian cancer than 72 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. those who have. Pregnancy and the use of oral contraceptives appear to be protective against cancer of the ovary. Women who have had breast cancer or have a family history of ovarian cancer are associated with increased risk. With the exception of Japan, industrialized countries have the highest incidence rates (American Cancer Society, 1996). Results on the relationship between ovarian cancer and SES have been contradictory (Logan, 1982). In most studies incidence and mortality were highest in the higher SES groups and lowest in the lower SES groups (Tavani et al., 1993). However, other studies pointed in the opposite direction or found no clear SES gradient (La Vecchia etal., 1992; Lund, 1992.). 4.4.14 Cancer of the Pancreas Cancer of the pancreas stands out as a highly lethal disease with the poorest likelihood of survival among all major malignancies. It counts for only 2% of all newly diagnosed cancers in the U.S. each year, but 5% of all cancer deaths. While pancreas cancer is not among the ten most frequently diagnosed cancers in the U.S., it ranks fifth in terms of cancer mortality (American Cancer Society, 1996). Cancer of the pancreas is one of the most poorly understood of all the major malignancies, mainly because a majority of patients survive only briefly after diagnosis. The disease is often advanced before the first symptoms are recognized. This disease occurs more frequently in black Americans than in white Americans, more frequently in men than in women. The incidence rates are generally lower in Asian-American groups as compared to whites and blacks. Very little is known about what causes the disease or how to prevent it. Risk increases after age 50, with most cases occurring between ages 65 and 79. Smoking has been identified consistently as an important risk factor for pancreas cancer, incidence rates are more than twice 73 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. as high for smokers as for nonsmokers (Mack, 1982). Although dietary fat, coffee, alcohol, and low intake of fruits and vegetables have been suggested to increase the risk of pancreas cancer in some studies, none of these factors has been found consistently in all studies (Bernstein and Ross, 1991). Some studies have suggested associations with chronic pancreatitis, diabetes, or cirrhosis (American Cancer Society, 1996). Certain occupations, such as those of chemists, radiologists, and metal workers, have also been implicated as having an etiologic role (Wilson, 1989). The relationship between pancreas cancer and SES seems to have changed over the years. Observations from earlier periods suggested either no SES effect or increased rates in the lower SES categories (Logan, 1982). In more recent periods, some have observed no effect (Levin et al., 1981; Pukkala and Teppo, 1986), while others have observed an inconsistent association with high SES (Mack, 1982; La Pukkala and Teppo, 1986; La Vecchia et al., 1992). Moreover, the relationship with SES seemed different between men and women (Pukkala and Teppo, 1986; Faggiano et al., 1995). There is no major consistent SES effect in pancreatic cancer. It appears unlikely that SES related factors are consistently or strongly operating in the causation of this cancer. 4.4.15 Cancer of the Prostate Cancer of the prostate has recently become the most common cancer in men in the U.S., overtaking lung cancer in the total number of patients diagnosed annually. Between 1980 and 1990, prostate cancer incidence rates increased 65% largely due to improved detection. Further increased incidence continued in the early 1990's due to widespread use of prostate serum screening exams (American Cancer Society, 1996), now rates are felling precipitously. Prostate cancer mortality rates are, too, generally increasing, although not as rapidly as those for Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. incidence. However, in U.S. whites, there has been little change in mortality, which might be related to improvement in survival rates (Tomatis et al., 1990). Mortality rates for prostate cancer are much lower than the incidence rates, because survival for men with this cancer is generally quite high. The cause of prostate cancer is not known. The most important risk factor for prostate cancer is age. Prostate cancer is rare prior to age 50, but after this age, the rate of increase is greater than for any other cancer. Blacks have the highest incidence rate of prostate cancer. Although the incidence among whites is quite high, it is distinctly lower than among blacks. Asians and native American men have the lowest rates. Indeed, blacks in the U.S. have the highest rates of this cancer in the world. The reason for the high incidence among blacks is unknown. It has been speculated that high levels of the male hormone testosterone during young adulthood may play a role and that testosterone levels may be influenced by dietary fat consumption. This hypothesis is unproven (Bernstein and Ross, 1991). Men with a family history of prostate cancer are at increased risk, but whether this is genetic or due to shared environmental influences, or both, is not known. It is thought that whatever the causal factors are, they act by altering the balance of male hormones in the body. Previous investigations designed to determine whether an association exists between prostatic cancer and SES reveal little consensus. A variety of approaches has been adopted in these studies. The results showed a wide range of SES association patterns, from positive (Richardson, 1965; Ross et al., 1979; Williams et al., 1991;) to negative (Dorn and Cutler, 1958) as well as no association (Graham et al., 1960; Emster et al., 1978; Emster et al., 1977; La Vecchia et al., 1992). It appears that the relationship between SES and prostatic cancer occurrence must either be variable in different population groups or its true relationship remains unknown because of problems of study design and execution. 75 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4.4.16 Cancer of the Rectum The rectum is the final segment of the large bowel and one might therefore expect that the risk factors for cancer of the rectum would be similar to those of cancer of the colon. In fact, the geographical distribution of rectal cancer is similar to that of colon cancer, but incidence and mortality rates are usually rather lower. The male-female ratio for rectal cancer is substantially higher than that for colon cancer. Like colon cancer, rectal cancer is least common among Latino whites, with blacks and non-Latino whites somewhat higher. Japanese living in Los Angeles County were found to have the highest incidence rate (Bernstein and Ross, 1991). The mortality rates of rectal cancer in Japan have exceeded those of the whites in the U.S., but their incidence rates remain substantially lower. Rectal cancer mortality, but not incidence, has been declining throughout the United States for several decades, presumably reflecting improved results of therapy. Migrant studies give basically the same results as for cancer of the colon. The early studies of Japanese migrants to the U.S. showed an increased risk after migration but little change in second generation migrants (Haenszel and Kurihara, 1968). More recent data suggest that the incidence in US-born Japanese males is considerably higher than that in U.S. whites (Kolonel etal., 1980; Shimizu etal., 1987). Alcohol use appears to be a risk factor for cancer of the rectum; dietary fat may be a risk factor as well, but evidence is not as strong or as consistent as for colon cancer (Ferraroni et al., 1989; Tajima and Tominaga, 1985). Unlike colon cancer, physical exercise does not seem to lower the risk of rectal cancer (Garabrant et al., 1984; Gerhardsson et al., 1986). 76 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Although a few studies reported both positive (Pukkala and Teppo, 1986; Miller, 1982) and negative SES association (Ferraroni etal., 1989; Gorey and Vena, 1995) with rectal cancer, no significant and consistent associations with SES have been established for rectal cancer (Logan, 1982; Cuello etal., 1982; Faivre etal., 1989; Smith etal., 1991; Baqueteta!., 1991; La Vecchia et al., 1992; Van Loon et al., 1995; Faggiano et al., 1995;). 4.4.17 Cancer of the Stomach Stomach cancer was the most common form of cancer in the world in the 1970s and early 1980s, and is probably now only surpassed by lung cancer. Stomach cancer incidence show substantial variation internationally. Rates are highest in Japan and eastern Asia. Other areas of the world have high stomach cancer incidence rates including eastern Europe and parts of Latin America. Incidence rates are generally lower in western Europe and the United States. Stomach cancer incidence and mortality rates in males are approximately double those for females. Stomach cancer incidence rates for racial/ethnic populations in the United States can be broadly into three levels. Those with high age-adjusted incidence rates are Koreans, Vietnamese, Japanese, Alaska Natives, and Hawaiians. Those with intermediate incidence rates are white Hispanic, Chinese, and black populations. Filipinos and non-Hispanic whites have substantially lower incidence rates than the other groups. These patterns hold for both men and women. Mortality rates by race/ethnicity closely parallel incidence rates and tend to be quite high. The survival of stomach cancer patients is poor. Stomach cancer incidence and mortality have been declining consistently and dramatically during the past several decades, not only in the United States, but elsewhere in the world. The reasons for these declining rates are not totally established, but are very likely due to 77 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. better food preservation and storage techniques, primarily less salting and pickling of food, and also to a parallel increase in the per capita consumption of fresh fruits and vegetables which have been found to have a negative association with stomach cancer risk (Higginson, 1966). Although dietary factors have been shown to be the strongest risk indicators in the etiology of stomach cancer, not all studies have been consistent possibly because it is difficult to collect and specifically define the components of diet related to stomach cancer (Wilson, 1989). There is quite strong evidence that salt intake is a major determinant of stomach cancer risk (Hirayama, 1971). Cigarette smoking has been consistently shown to increase risk (Kahn, 1966; Hammond, 1966; Haenszel etal., 1972), but the lack of dose-response relationship in each of the studies suggested that the association was not a causal one. Benign diseases of the stomach, such as gastric ulcers and polyps, also appear to be risk factors, as does infection with a bacterium, Helicobacter pylori, the major cause of chronic active gastritis. Despite different methods, studies have consistently shown a strong association of stomach cancer with low SES (Cohart, 1954; Torgersen and Petersen, 1956; Sigurjonsson, 1967; Hirayama, 1971; Haenszel et al., 1972; Smith et al., 1991; La Vecchia, et al., 1992; Faggiano et al., 1995; Gorey and Vena, 1995). Yet the specific etiology of stomach cancer is far from clear. The associations were thought to be related to dietary factors and differences in alcohol and tobacco consumption among SES groups. 4.4.18 Cancer of the Testis Cancer of the testis is relatively rare and accounts for approximately one percent of the cancer diagnosed in the U.S. among males. Unlike most cancers, testicular cancer is primarily a disease of young men. The incidence rate peaks among men around age 30, with a decline up to 78 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. age 50, followed by a small increase after the age of 65. Germ-cell tumors comprise the great majority (about 95 percent) of all testicular tumors and for essentially 100 percent of the tumors of the testis in young men. Testicular cancer incidence rates vary widely among the racial/ethnic populations. Worldwide, blacks and Asians have lower risk of testicular cancer than whites. In the U.S., the incidence rate for non-Hispanic white is about seven times higher than the rate for blacks. Although the number of cases among Asians is small, their rate is intermediate between whites and blacks. Incidence for white Hispanics are about one-half the rate for white non-Hispanics. With the introduction of multiple chemotherapy treatment regimens in the 1970s, the survival rates for testis cancer have increased substantially. Black men have mortality rates about one half of white men, but considering that their incidence rate is seven times lower, the percentage of black men who die of their disease is much higher than for white men (Miller et al., 1996) The major risk factor for cancer of the testis is a persistently undescended testis (i.e., a testis that does not descend into the scrotum), which usually can be detected in early childhood. About 10% of all testicular cancer patients have this condition. Since testicular descent is under hormonal control and normally occurs prior to birth, maternal hormonal patterns during the index pregnancy are thought to play a role in the risk in this cancer (Schottenfeld and Warshauer, 1982). Single men have a higher incidence than married men at ail ages (Tomatis et al., 1990; Bernstein and Ross, 1991). There are no consistent patterns with religion, marital status, sexual activity, and fertility (Ross et al., 1979; Morrison, 1976). Studies have shown a positive relationship between SES and testicular cancer. Risk of testicular cancer is raised in men of high SES (Swerdlow et al., 1991). The SES of the mothers was found to be more pertinent than the cancer patients themselves (Moller and Skakkebaek, 79 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1996). No consistent association between any one occupation and testicular cancer has been found. The positive SES association in testicular cancer may reflect the influence of some other aspects of SES and not occupational exposure per se (Van den Eeden et al., 1991; Pearce et al., 1987). The strong association of testicular cancer with SES could explain much of the white-black differential in this cancer in the U.S.. However, the low rates in both African and American blacks would seem to suggest that genetic factors are somewhat important in the etiology of this disease (Schottenfeld and Warshauer, 1982). 4.4.19 Cancer of the Thyroid Thyroid cancer is one of the rarer and less virulent neoplasms, yet it has aroused interest and concern far beyond its prevalence. It generally represents 1-2% of all cancers in the U.S. population. Excluding a few geographic areas with particularly high incidence rates, the incidence of thyroid cancer shows little variation by country. Furthermore, unlike many other cancer sites, it lacks systematic geographic or ethnic distribution patterns and has no predilection for developed, underdeveloped, industrial, or agricultural areas (Waterhouse et al., 1976). Cancer of the thyroid consists of a number of distinct diseases microscopically, and the importance of these distinct tumors varies somewhat among different populations and even for different age groups. Thyroid cancer occurs in all age groups. Whereas the incidence of most other cancers increases markedly with age, thyroid cancer reaches its highest incidence in young adults and remains fairly constant throughout the rest of life. Incidence rates are higher in females than in males, but the relative difference depends on age: the ratio is higher in the young. Incidence rates for people of each sex appear to be increasing; these increases have been greatest in younger age groups. This may be due partly to increased diagnosis of clinically occult lesions, and possibly also to exposure to radiation, particularly in childhood (Ron and Modan, 1982). Despite increasing 80 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. incidence, there has been a general decline in mortality rates. Most types of thyroid cancer rank quite high in terms of successful treatment and long term survival. However, some rare subtypes may have a poor prognosis. Overall, thyroid cancer is a disease with a good prognosis and low mortality. Differences in the incidence of this cancer according to racial/ethnic populations in the U.S. were particularly striking. Compared with white men and women, Puerto Rico Hispanics and blacks have significantly lower thyroid cancer rates. New Mexico Hispanic men and Chinese, Japanese, Hawaiian and Filipino men and women have significantly higher rates. Incidence rates are elevated for residents of Hawaii, regardless of race/ethnicity. Variations in thyroid cancer risk according to race/ethnicity and geographical residence may reflect SES or local environmental influences, including the possibility of a carcinogenic agent in volcanic lava (Spitz et al., 1988). Radiation, especially for the diagnosis or treatment of benign conditions, is the most firmly established risk factor for thyroid cancer. The role of hormonal factors and diet on the risk of thyroid cancer are not yet understood, but are currently being evaluated by cancer epidemiologists. Research on the relationship between SES and thyroid cancer is very limited and the findings are mixed. Patients with thyroid cancer tend to be better educated and of higher SES (La Vecchia etal., 1992; Levi etal., 1991; Logan, 1982), but the graded SES association has hardly been established. 81 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 5 STUDY DESIGN AND MATERIALS Based on the information reviewed in the previous chapters, it is clear that as an important health indicator, SES also plays an important role in cancer risk. Examination of the variations in cancer risk by SES may lead to a better understanding of the components of the causal chain between social environment and cancer risk. In general, SES has a negative association with disease morbidity and mortality, i.e., the increasing SES is accompanied by decreasing disease incidence and death rates. However, when it comes to cancer incidence, the chances of developing cancer, the association with SES is not that clear-cut. As reviewed in Chapter 4, cancer is such a complex and poorly understood disease. It not only has numerous forms/sites which are considered as different diseases, within each form/site it has several different histologies which also have different epidemiology and maybe etiology. Up to date, some cancers have been confirmed to have associations with affluence and people of high SES while some other cancers have the association reversed. There are still other cancers whose relationships with SES are unknown or inconsistent Research effort on the relationship between SES and specific cancer has been limited due to the following factors: 82 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1) Absence of SES information in large cancer data. Since cancer is a relatively rare disease, the data source for most of the cancer studies is the regional or national cancer registry. The cancer data in those registries come from hospital charts which do not include information on SES. Therefore, SES estimation procedures must be developed to overcome the absence of SES indicators in the cancer data. 2) Like most other sociological notions, the concept of SES has many elements. The phenomenon it describes is real enough, but it is difficult to operationalize and measure its fundamental nature. Even though some disagreement continues regarding issues in social stratification, there is sufficient agreement upon using income, education, and/or occupation to quantify relative position within society. With such an agreement, it is still an open question in terms of how these three dimensions ought to be measured, which one is more important than others in a specific issue, and whether these three dimensions can be used individually or collectively. Therefore, every investigator uses his/her own method to measure the SES. There have been inconsistent, sometimes contradictory, findings on the relationships between some types of cancer and SES. It is hard to know whether these differences are because of different populations, different time periods, or different methods defining SES. 3) The contribution of SES to cancer research is complicated by its association with race/ethnicity and other risk factors that may be associated with both race/ethnicity and SES (e.g., dietary, lifestyle, and environmental/occupational exposures). The correlation between SES and race/ethnicity makes the issue more complex. Most of the SES studies in cancer research were conducted among white populations, a few of them included blacks. Given today’s U.S. population with it’s diverse racial/ethnic composition, the difference between blacks and whites can no longer adequately explain what is going on in the society as a whole. Data for Hispanics and Asians need to be presented as well. This provision obviously adds more difficulty to obtaining the 83 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. race/ethnicity-specific data which have to be sufficient enough to bear the further classifications, and to the interpretation of the data. 5.1 Study Design This study was set up in a background as described above. It was designed to examines the relationship between SES and cancer incidence rates among different racial/ethnic groups, not only whites and blacks but also Hispanics and Asians. It was intended to use one single SES measurement to study many types of cancer in order to achieve the comparability between cancer sites. The purpose of this study is to answer the following questions: 1) After controlling for the confounding factors, such as race/ethnicity and age, is SES associated with specific cancer risk? 2) Does the pattern of a SES association for a specific cancers remain the same across different racial/ethnic groups? 3) Will the racial/ethnic differences in cancer incidence rates disappear after adjusting for SES and age? 4) Does the interaction between race/ethnicity and SES affect the cancer risk? Los Angeles County was chosen as the study area, because of its vast and diverse populations and complete population-based cancer registry for the past two decades. The cumulative cancer incidence data from 1972 to 1992 in the Los Angeles Cancer Surveillance Program were used in the analysis. Nineteen cancers were included in the analysis, including cancers of the lung, larynx, esophagus, female breast, cervix uteri, corpus uteri, ovary, prostate, testis, colon, rectum, stomach, liver, pancreas, bladder, kidney, melanoma of the skin, central nervous system, and thyroid. The selection of the cancer sites was based on the following considerations: 1) they are 84 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. commonly known human cancers with high or relatively high incidence, or 2) the etiology of these cancers, no matter how much is known, is of particular interest among the studied populations. In the existing literature, reviewed in Chapter 4, the relationships between the SES and the incidence rates of the 19 selected cancers vary: positive associations with SES have been well established for canaries of female breast, melanoma, and testis; negative associations with SES are known for cancers of the cervix uteri, esophagus, larynx, liver, lung, and stomach; no association with SES has been found for bladder cancer; inconsistent findings have been reported for cancers of the kidney, ovary, pancreas, prostate, rectum, and thyroid, while positive associations with SES were suspected for cancers of the central nervous system, colon, and corpus uteri. From what is known, the hypotheses of this study are: 1) The association with SES depends on the risk factors involved in a particular cancer. If the risk factors have association with SES then there obviously should be a relationship between this particular cancer and SES. 2) Since cigarette smoking and greater alcohol use are found to be more common among people of low SES, among cancers which are heavily affected by smoking and drinking, a negative association with SES should be expected. 3) Since some lifestyle characteristics of people of high SES contribute to some cancer risks (e.g., low fertility and late pregnancies are risk factors for female breast cancer and ovarian cancer), a positive association with SES is expected among some cancers. 4) Since genetic and racial elements are suspected playing a role in some cancers, e.g., melanoma of the skin and testicular cancer, therefore, differences in cancer risk among different racial/ethnic groups may exist even after controlling the effect of other major confounding factors such as SES and age. 85 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The above hypotheses focus on the two individually important risk factors in cancer incidence, namely race/ethnicity and SES. Little is known about the effect of the interaction between the two factors on cancer development The contributing elements to the unknown relationship include the following: 1) lack of knowledge on the relationship between SES and cancer risk, 2) the complex blends of race/ethnicity and SES distinction, and 3) the fact that cancer is such a complex and poorly understood disease. By considering race/ethnicity and SES conjointly and treating them as equally important variables in the analysis, this study has taken the steps to avoid overemphasis on the importance of either one of them. This study, as many other studies of the same nature, is used to generate hypothesis and to serve as a starting point for providing clues about many etiologic agents. 5.2 IfagStudy Area The study area, Los Angeles County, is a 4,000-square-mile area located in the southern part of the State of California on the west coast of the United States. It has highly varied geographic and climatic conditions, from the desert to the sea and from the mountains to the valleys. Constituting almost three percent of the country's total population, it is the most populous county in the United States. The diversity of its population has won Los Angeles the reputation as the "melting pot" of different cultures. 5.2.1 The Diverse Population The population in Los Angeles County has grown rapidly, from 4 million in 1950 to more than 8.9 million in 1990. Such growth in population is substantially faster than the corresponding growth in the nation as a whole. Dramatic changes in the racial/ethnic composition of Los Angeles residents have been occurring in the recent decades and are likely to continue into the future. In 86 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1950, non-Hispanic whites dominated the Los Angeles population, comprising more than 85% of the county's total (Fred and Kirk, 1956). Now they constitute less than half, i.e., 41%, of the total population (U. S. Bureau of the Census, 1993b). According to the 1990 population census, with 8.9 million persons, 3.6% of the total U.S. population resides in Los Angeles County; over 15% of the country's Hispanics and 13% of the Asians/Pacific Islanders live in the county. The proportions of the national total of selected specific Asian/Pacific Islander groups living in Los Angeles County are even higher 18% of Koreans, 20% of Cambodians, 20% of Thais, and 19% of Samoans. The 3.3 million Hispanic population is a diverse group. In the 1990 census, as in previous years, a large proportion of Hispanics identified themselves as “Other Race" with write-in descriptions such as Chicano, Colombian, Cuban, Hispanic, Hispano, La Raza, Latin American, Mestizo, Mexican, Mexican-American, Mexicano, South American, Spanish, Spanish American, and Spanish Mexican. Fifty-five percent of Los Angeles Hispanics called themselves “ Other" race compared to 44% of U.S. Hispanics as a whole. The non-Hispanic white population in Los Angeles County also has highly diverse origins. In the past several decades there have been large waves of immigrants from Iran, Lebanon, and the former Soviet Union. There is a very large Armenian community, estimated to be over 200,000. The population of European origin contains large numbers from Britain and from Northern, Southern, Eastern, and Western Europe. Every numerically important religious group in the United States is also represented with sizable populations in Los Angeles County. These include Seventh-day Adventists and Mormons, who are particularly interesting to cancer epidemiologists because of their different exposures to several important cancer risk factors. With over one-half million Jews living in Los Angeles 87 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. County, it is the second largest Jewish community in the world outside of Israel (Bernstein and Ross, 1991). 5.2.2 The Cancer Surveillance Program The Los Angeles County Cancer Surveillance Program (CSP) is the population-based cancer registry for Los Angeles County. It was organized in 1970 and operates within the administrative structure of the University of Southern California (USC) School of Medicine. The CSP was initially a component of a laboratory-based viral oncology program and, as such, was part of the National Viral Cancer Program. The registry became essentially population-based by 1972 and complete incidence data for Los Angeles County are available from that year onward. To date, the CSP master file contains over 900,000 records and some 37,000 incident cancers are added annually. Since 1981, the CSP has been the designated legal agent of Los Angeles County for collecting information on all new cancer cases occurring among county residents for the purpose of monitoring cancer incidence patterns and trends. In 1987, it became the agent of the State of California for collection of demographic and treatment information on all new cancers diagnosed or treated among Los Angeles County residents. In 1992, the CSP became the largest of the 11 National Cancer Institute-funded Surveillance, Epidemiology, and End Results (SEER) registries and added patient follow-up and SEER extent of disease coding to the program. Under the California State model of reporting, a passive cancer surveillance system has been implemented in which hospitals and other facilities where cancer is diagnosed and treated bear the responsibility, including the fiscal responsibility, for identifying, abstracting and reporting cancer cases to the regional registry within six months after the patient’s admission. 88 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In order to provide complete demographic and treatment information on each new cancer occurring among the residents in Los Angeles County and guarantee compliance with reporting requirements, the CSP combines elements of an active and a passive surveillance system. For active surveillance, each of the medical facilities in which microscopic verification of cancer occurs is visited periodically by a CSP field technician who systematically screens all hematology and pathology reports, and collects a copy of each that describes a previously undiagnosed cancer. The State-mandated passive surveillance system requires each hospital or other reporting facility to complete a full abstract, including stage and treatment information, on every cancer case seen in the facility. All of these completed abstracts are linked by the CSP to the pathology reports obtained under active surveillance to assure that one abstract is completed for each histologically verified case. In addition, any previously unrecognized cancer diagnoses among Los Angeles County residents, identified as a result of searching computerized death records, are followed back to patient records in hospitals or other facilities so that data can be abstracted, when possible, in a similar way to data found using pathology reports. Because of its large and diverse population and the complete cancer registry, Los Angeles County serves as an ideal study area for cancer research. The CSP data serve as a descriptive epidemiological resource to generate new hypotheses regarding specific cancer sites or histologic subtypes, to monitor descriptive trends and patterns of cancer incidence, and to identify demographic subgroups at high risk of cancer. 5.3 The Materials This study examines the relationship between SES and cancer risk. Cancer risk is measured by incidence rates. In order to calculate the incidence rates, the number of cancer 89 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. cases occurring and the populations at risk during the study period are needed. Data that contain socioeconomic information of the population and cases are also necessary. 5.3.1. The Case Data The cancer incidence data used in this study are obtained from the Los Angeles County Cancer Surveillance Program (CSP). Since the registry of a year’s cancer cases takes years to complete, the CSP made available all of their annual cancer registry data from 1972 to 1992. The estimated completeness of case registration for these years is above 98%. The data set contains the cancer cases diagnosed between January 1,1972 and December 31,1992 among Los Angeles County residents that were reported to the Cancer Surveillance Program (CSP) as of September 1995. For the purpose of this study, the cases were coded into mutually exclusive categories of age at diagnosis, year of diagnosis, sex, race/ethnicity, cancer anatomical site, cancer histological behavior, and 1990 census tract without personal identifiers in order to protect the confidentiality. The single-year age at diagnosis categories were then further grouped into seven age groups of 15-24, 25-34, 35-44,45-54,55-64,65-74, and 75 and over. Cases under 15 years of age are not used in this study due to the concern over very small number of cases and the decision that this study does not include childhood cancer. The sex categories are male and female. The race/ethnicity contains five major racial/ethnic groups: white, black, Hispanic, Asian, and other. The definitions for race/ethnicity follow the CSP’s convention: white is “non-Spanish- sumamed white"; Hispanic is “Spanish-surnamed white"; black is not further distinguished by Hispanic origin or Spanish surnames. Asian includes major Asian ethnic groups such as Chinese, Japanese, Korean, and Filipino, and other comprises residual small population groups such as American Indians, Pacific Islanders, and other non-specified populations. Cancer anatomical sites 90 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and histological behavior were coded according to the International Classification of Diseases for Oncology, Second Edition (ICD-O-2) (Percy, Van Holten, and Muir, 1990). Sites were then grouped by the conventions of the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute (Appendix B). (In the SEER recode, lung cancer includes lung and bronchus, kidney cancer includes kidney and renal pelvis.) Each case was assigned a 1990 census tract according to its residential address at diagnosis. 5.3.2 The Population Data The CSP also provided the population census data for Los Angeles County from the 1970,1980, and 1990 U. S. Population and Housing Census. These census results came from special data files that the CSP ordered from the Bureau of the Census after each census, which subdivided the County population into the racial/ethnic categories compatible with the CSP’s racial/ethnic definition of cases. The population data were cross-categorized by sex, 5-year age group, race/ethnicity, and census tract. 5.3.3 The 1970-80-90 Census Tract Correspondence File Due to the population growth and change in population distribution, the census tract boundaries in Los Angeles County had been modified from one census to the next The change in census geography made the process of relating 1970 or 1980 data to 1990 census tracts difficult The Population Research Laboratory (Pop Lab) of USC obtained a special data file from the California State Census Data Center, which eliminated much of the difficulty by adjusting the 1970 and 1980 census tract level census data into 1990 census tract boundaries for all the counties in California. This file allows the user to easily compare census tract data between 1970 and 1990 for the demographic and economic changes during this period. Each of the records in this data file 91 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. is defined by the the 1990 census tracts and has its corresponding population count (if the tract did not change over the years) or estimate (if the tract changed overtime) for 1970 and 1980, in addition to its 1990 actual count The Pop Lab provided this data file for this study. There are 1,652 census tracts for Los Angeles County in the 1990 census. The 1970-80-90 correspondence file has 1,640 records after excluding 12 special tracts. Ten of these 12 tracts have a suffix of "99" in the 6-digit tract identification number indicating that the tracts are associated with a water body or docking area with a population of vessel crews. The other two tracts are: tract 3200 which covers the area of Universal Studio with zero residential population, and tract 4082.01 which has a total population of 5 people. This 1970-80-90 Census Tract Correspondence File includes the following variables for the years of 1970,1980, and 1990: Total, white non-Hispanic, black non-Hispanic, other non-Hispanic, and Hispanic population. Age categories: 0-4, 5-17,18-64, 65+, and median age. Marital status categories: single, married, and other. Educational attainment categories: less than high school, high school, and college. Occupation categories: white collar, and blue collar. Residence in 1965,1975, and 1985. Housing unit categories: total, single family, and other. Median household income for 1980 and 1990. Median family income for 1970. Median housing unit value for 1970,1980, and 1990. Median housing unit rent for 1970,1980, and 1990. Land area. Geographical centroid. 92 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 6 METHODOLOGY 6.1 Developing the SES Index To study the cancer incidence rates by SES, it is necessary to classify the cancer cases and the population at risk into appropriate SES groups. For this study, since there is no individual level information available to make SES classification for both the cases and the populations, the aggregate approach was adopted. The SES index was developed at the census tract level, then was attributed to the cases and population living within the census tract. The cancer case data for the study range from 1972 to 1992. The census tract boundaries in Los Angeles County had been changed from one census to the next due to population growth and change in population distribution. Parts of the census tract boundaries were modified in 1980 census from the 1970’s. The changes in some census tract boundaries occurred again in 1990 census. The CSP has updated the case data into 1990 census tract definition. Accordingly, this study also adopted the 1990 census tract as the standard in order to obtain the historical comparability. The availability of 1970-80-90 Census Tract Correspondence File, described in chapter 5, made it possible to develop the SES index for 1970, 1980, and 1990 at the 1990 census tract level. 93 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. As reviewed in Chapter 3, there are three variables that have been used most often either individually or collectively to reflect the concept of SES, i.e. income, education, and occupation. I agree with the argument that these variables are distinct but related components measuring the multiple aspects of SES. One indicator by itself does not constitute a good indicator of a multidimensional construct like SES. To reflect the multidimensionality of SES, I decided to use an index that composes of more than one SES indicator. Due to the lack of necessary data, it is impossible for this study to utilize any of the existing indices reviewed in chapter 3. Therefore, a SES index was developed for the analysis of this study. After evaluating the variables in the 1970-80-90 census tract correspondence file, I chose to combine education and income together to provide a measurement for SES. I believe that occupation prestige is reflected in both education and income. Therefore, the SES model in this study is based upon the combined effect of both education and income. Without an empirical basis for weighting the two variables (i.e., education and income) in the assessment of socioeconomic status, equal weight was assumed. The education variable is the weighted Average Years of Schooling. People with college education were assigned 16 years of schooling, 12 was assigned to people with high school education, and 9 was assigned to people with less than high school education. The average years of schooling in a given census tract, E, was obtained by the calculation of the following formula: 16»C + 12*HS + 9*Q C +H S+O C is the number of people with college education, HS is the number of people with high school education, O is the number of people with less than high school education. 94 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The income variable in the SES model is the Median Household Income of the census tract The SES index was obtained by the following method: 1) rank all the census tracts by the values of the education variable and assign each census tract an education ranking score; 2) rank all the census tracts by the values of the income variable and assign each census tract an income ranking score; 3) add the above two ranking scores together; 4) rank all the census tracts by the combined score; and 5) cut the entire range into quintiles. This method was applied to the data from 1970,1980, and 1990 respectively, in order to get the SES designation for each of the years. There are a few census tracts that have missing SES values. (5 tracts for 1990,10 tracts for 1980, and 7 for 1970). The reason for this is twofold: 1) The two variables use to define the SES of a census tract, i.e. the average years of schooling completed by the residents and the median household income, are available only for people who were 25 years or older at the time of the census and who were living in households. For people who were younger than 25 and were living in group quarters these two statistics are not available. 2) Some census data are being withheld to avoid disclosure of individuals when the population in a census tract is too small. If any one of the two characteristics is missing, the SES was not defined automatically for that census tract by the SES model. There were 12 such tracts that have one or both characteristics missing in one or more than one of the censuses. They cover mainly institutions such as LA Civic Center, university campuses (USC, Cal. State Pomona, Cal State Long Beach), Long Beach Airport, Long Beach Harbor, Veteran's Administration, etc.. Eventually their SES designations were manually assigned based on the SES information of adjacent tracts or the SES score of the same census tracts in other census years. 95 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The 1970 SES was then assigned to the cases and population before 1974, the 1980 SES for cases and population between 1975 and 1984, and the 1990 SES assigned to cases and population after 1985. 6.2 Population Estimates for the Intercensat and Postcensal Years In order to calculate race/ethnicity-specific incidence rates by age, sex, and SES, annual population estimates by age, sex, race/ethnicity, and SES are necessary. Since the SES index was developed at the census tract level by 1990 census tract definition, the population estimates should be done at the same level in order to classify the population by SES as well as race/ethnicity. If the census tract boundaries had not changed between 1970 and 1990, this could have been a straight forward task. However, because the census tract boundaries did change from one census to the next, adjustments have to be made based on the 1990 census tract definition before the race/ethnicity and SES-specific annual population estimates. The 1970-80-90 Census Tract Correspondence File only provides the adjustment of 1970 and 1980 census tract-specific total population into 1990 census tract boundaries. The population structures by age, sex, and race/ethnicity of each census tract contained in the actual population census data are essential in allocating the total population in the 1970-80-90 Census Tract Correspondence File. The demographic structure for each census tract, taken from the CSP's 1970 and 1980 population census, were applied respectively to the adjusted 1970 and 1980 census tract total population defined by the 1990 census tract. Generally speaking, there are three kinds of modifications of the census tracts in Los Angeles County over the years: 96 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1) Splitting of old tracts. Some census tracts, because of their rapid growth of population, were divided into multiple smaller new tracts. The identification numbers of the newly defined tracts have the identical first 4-digit number as the old tract indicating the origin, plus 2 more digits as a suffix to distinguish each tract 2) Collapsing of old tracts. Two or more adjacent tracts were combined to form one single new tract In cases like this the identification number of the new tract is completely new. 3) Expanding of the old tracts. The boundaries of some tracts were extended to include small additional areas; with these relatively small changes the new tract still keeps the old identification number. 4) More complicated than above, including complete breakdown and regrouping of parts of several old tracts. The above mentioned allocation method was sufficient for allocating the total population into specific categories if the census tract boundary did not change over time. When encountering the changed census tracts, given the fact that census tracts are geographically very small units and the population living inside each tract are relatively homogeneous, the following assumptions were made: 1) If the 1990 census tract had been created by splitting 1980 or 1970 census tract, the population characteristics for that tract in 1980 or in 1970 were assumed to be identical to those for the entire unsplit tract in 1980 or 1970. 97 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2) If the 1990 census tract had been created by merging two or more 1980 or 1970 census tracts, then the population characteristics for that tract in 1980 or 1970 were assumed to be equal to the population characteristics of the combined tracts in 1980 or 1970. 3) If only "small" changes happened in 1990 to the 1980 or 1970 census tracts (such as including one or more blocks), it is assumed that the structure of the population remained the same. 4) If "big" changes happened in 1990 to the boundaries of the 1980 or 1970 census tracts and the 1990 tract include one or two other complete 1980 or 1970 tracts plus portions of other 1980 or 1970 tracts (e.g. the LAX area), the population structure of the combined complete 1980 or 1970 tracts was used for the 1990 census tract. With the adjustment of 1970 and 1980 census results by age, sex, and race/ethnicity into 1990 census tract boundaries, it is possible to assign the SES to the population and estimate the population for the intercensal and postcensal years at the 1990 census tract level. Between the linear (assuming that the population changed at a constant number annually over the period of time) and exponential (assuming that the population changed at a constant rate annually over the period of time) methods of interpolation (Shryock et al., 1976), it has been decide to use the former. The decision was made based on the following information: 1) When the numbers are small, both methods produce similar results. When the total population of the County are distributed into the sex(2)-age(18)-race(5)-tract(1640)-specific categories, the number in each cell is relatively small. 98 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2) The State Department of Finance estimated the annual population for each of the counties in California for the intercensal years. They used information from many source (such as Driver’s License Address Change, change in school enrollment, Medicare statistics, estimates of international migration, population residing in group quarters, federal income tax returns, vital statistics, etc.) to estimate the individual components of the population change. The plots of their annual sex-age-race-specific population for Los Angeles County over the years look very linear. Since this study analyzed the data from 1972 to 1992, there are two years past the last 1990 census for which the annual population by age, sex, race/ethnicity, and SES needed to be estimated. The population estimates for the postcensal years are more difficult than intercensal estimates. As a mathematical method, interpolation is invariably more reliable than extrapolation. In interpolation the two census figures usually establish narrow limits on the possible size of the intercensal estimate. It is understood that the longer the estimating period and the smaller the geographic area, the less reliable are the resulting population estimates. To demonstrate the difficulty in estimating the postcensal populations, here are the population estimates for Los Angeles County on July 1,1992: According to the Bureau of the Census, it was 9,071,441 (U. S. Bureau of the Census, 1996); the same estimate done by the California State Department of Finance Demographic Research Unit in 1994 was 9,132,400 (Report 94 E-2), subsequently in 1995 they revised the estimate to 9,200,100 (Report 95 E-2). For this study, the extrapolation for the populations of 1991 and 1992 assumed the same amount of annual change in population as for the years between 1980 and 1990. For the purpose of comparison with the estimates done by the Census Bureau and the State of California, the estimate for 1992 by this method is 9,181,357. In any event, since the estimates are only for two 99 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. years, it is most likely that the issue of accuracy will not affect the analysis of the whole period of 1972-1992. 6.3 Tbe Age-SPecific and Aoe-adiusted Incidence Rates The age-specific and age-adjusted incidence rates of a particular cancer by SES were calculated for each sex and racial/ethnic group, in order to examine the SES impact among different groups of population at different ages as well as to see the SES effect after adjusting for the age influences in each special population. 6.3.1 Age-specific Incidence Rate Age-specific incidence rates are calculated by dividing the total number of cases in a specific age group by the total population in that age group (Fleiss, 1981). This rate is then multiplied by 100,000 to yield an age-specific incidence rate per 100,000 population. where r, is the age-specific incidence rate for age group /, cf is the count of cases for that age group, and n, is the count of persons at risk (i.e., the population) for that age group; rates are presented per 100,000 population. Age groups used in the age-specific rates are: 15-24, 25-34, 35-44, 45-54, 55-64, 65-74, and 75 and over. The age-specific cancer incidence rates by SES can show the SES impact on specific cancer at different ages. 100 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 6.3.2 Age-adjusted Incidence Rate Age-adjusted incidence rate is a weighted average of the age-specific rates, where the weights represent the age distribution of a standard population. Age-adjusted incidence rates in this study are age-adjusted by the direct method (Fieiss, 1981) to the 1970 US population (Appendix C). Age-adjustment allows meaningful comparisons of cancer risk to be made by controlling for differences in the age distribution among populations, which can profoundly affect cancer rates. 75+ A.A.I.R.= ZtWiO) M S -24 where A.A.I.R. represents the age-adjusted incidence rate, wf is the proportion of age group / in the standard population, and r, is the Los Angeles County age-specific incidence rate for age group /. 6.4 Poisson Regression The ability of Poisson regression to adjust for covariates is an important strength (Nystrom et al., 1990; McMahon et al., 1991). The main difficulty with estimation of effects separately for each level of exposure is that information is lost in not considering the continuity of the underlying variable (Rothman, 1986). The Poisson regression analysis offers a means to evaluate risks with a multivariate model. The Poisson distribution has been promoted as the distribution of choice for relatively rare diseases rates. The Poisson distribution is an approximation to the binomial distribution where the probability for the event is small and the number of all possible events is large. The Poisson probability distribution with parameter p is given by the formula (Kleinbaum et al., 1988) 101 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Pr(Y = y;p) = ~ ~ ~ y=0 ,1 .......« (1) A Poisson random variable can take any nonnegative, integer value. The Poisson distribution has only one parameter p equal to the mean and variance. The Poisson distribution is often used to model the occurrence of rare events. It is usually used for the analysis of cancer data. The Poisson regression model is generally applied to situations in which the dependent variable is a count (e.g., number of cancer cases in a population). To specify a Poisson regression model, it is assumed that the dependent variable follows the Poisson distribution and that a rate function \(X, P) that describes the relationship between disease rates, the predictor variables (X), and the unknown vector of parameters (P) is given. The goal of Poisson regression is to fit to observed data a regression equation that accurately models the expected value of the dependent variable Y, E(Y), as a function X of a set X of independent variables X,, ..., Xi and p regression parameters. If Y is the number of events in a subgroup, and N is the population size in that subgroup, then E(Y) = NX(X, pj. (2) If this function (equation 2) is substituted into equation 1 above, the general form of the likelihood function for Poisson regression analysis is obtained: L(Y;P) = U [N k (X ,V )]Ye-Nk(X* > / / / . (3) Estimates of the p parameters are obtained by maximizing this likelihood function. The outcomes (Y) in each subgroup defined by the independent variables (X) are required to be independent for this likelihood to be correct To use the likelihood function, it is necessary to specify the function X that is generally assumed to be log-linear. It is the natural log (In) of the expected rate of events Y that is modeled as a linear function of the X predictor variables and thus X(X, p) = exp(Xp ) = exp( p 1X, + p 2X 2+...+p, X,). 102 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In sum, Poisson regression models can be understood as a subclass of generalized linear models in which the systematic effects are multiplicative, the distribution of the errors is Poisson, and the link function is the natural log. The general method of fitting a Poisson regression model is to use the Poisson model formulation to derive a likelihood function that can then be maximized so that parameters, estimated standard errors, maximized likelihood statistics, and other information can be produced. A feature of Poisson regression is that the regression coefficients can be interpreted as an estimate of the log of the relative risk, adjusted for the other predictors in the model. Confidence intervals and hypothesis tests for the regression coefficients can be calculated by assuming asymptotic normality of the maximum likelihood estimates of the regression parameters (Kuhn et al., 1994). In this study, the Poisson regression analysis was used to evaluate the effect of SES with adjustment for age and race/ethnicity and the effect of race/ethnicity with adjustment for age and SES. Males and females were considered separately within each cancer site. The analysis was earned out by using the SAS GENMOD procedure (SAS Institute Inc.). Three separate regression models were fitted by sex. In the first model, It assumes that the number of cases occurring in each age-race/ethnicity-SES category follows the Poisson distribution, with the logarithm of the Poisson parameter being a linear function of race, age, and SES factors. Binary dummy variables were used to model each race/ethnicity, age, and SES category separately. The statistical significance of SES and race/ethnicity in the model and general goodness of fit of the regression model were assessed. Rate ratio estimates among SES groups and racial/ethnic groups were obtained by transforming the coefficients of the SES or 103 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. racial/ethnic categories. The corresponding 95% confidence intervals were calculated with additional information from standard errors. Second, SES was entered as a continuous variable to represent the underlying SES trend. The resulting trend evaluation, which indicate the existence of a SES gradient, will be unconfounded by all the factors taken into account in the Poisson regression model. The above two models can be summarized as following: lnE(Y) = a + $ 1(age) + $ 2(race) + $3(SES). Finally, if the first model did not fit well, interactions among the three independent variables (i.e., age, race/ethnicity, and SES) were included in the regression model and evaluated: lnE(Y) = a + $ i(ag e)+ $ 2( race)+ $ 3(SES)+ $ 4(age • race)+ $s(age'SES)+ $s(race'SES). The need for this model will be assessed based on the results from other analysis. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 7 RESULTS AND FINDINGS 7.1 The SES and Population Structure The SES index was developed using the method described in Chapter 6 for 1970,1980 and 1990 by 1990 census tract boundaries (listed in Appendix A). The top 20% of population on the SES ranking spectrum was classified as SES1 representing the highest socioeconomic status. SES5 designates the lowest quintile identifying the populations of the lowest socioeconomic position. The average level for each of the two SES components, i.e., education and income, increased over the years. As shown in Figure 1, the education level, represented by average years of schooling, shows more significant increase among the higher SES groups, i.e., SES1 and SES2, compared to the lower SES groups. Average years of schooling for people of SES1 increased from 12.7 in 1970 to 13.6 in 1990, while the increase for people of SES5 is merely 0.1 years for the same period. The increase of income over the years is more dramatic than that of education (see Figure 2). The averaged median household income for SES1 jumped from $18,031 in 1970 to $65,941 in 1990. The averaged median household income for SES5 in 1970 is $7,010 and $19,649 in 1990. Although a great proportion of the income increase may be due to inflation, the widening gap between the rich and poor emerges from these numbers. Comparing SES1, the highest SES group, to SES5, the lowest SES group, the ratio of averaged median household income increased from 2.6 in 1970 to 3.4 in 1990. 105 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The population profile in Los Angeles County has changed greatly from 1970s to the 1990s. According to the Population Census, from 1970 to 1990, the non-Hispanic white population in Los Angeles County dropped from 72.6% in 1970 to 43.42% in 1990, while the percentage of Hispanic and Asian populations rose from 12.88% and 2.65% in 1970 to 31.33 and 10.77 in 1990, respectively (Table 1.). The SES index was developed by the characteristics of the general population irrespective of race/ethnicity. The numbers in Table 1 and their graphical presentation in Figures 3-5 exhibit the patterns of SES distribution among racial/ethnic groups for each census year. In general whites are socioeconomically advantaged and blacks and Hispanics are disadvantaged: the majority of whites are in the higher SES groups (57.8% in 1990) and the majority of blacks and Hispanics are in the low and very low SES range (67.0%). Although the proportions of extremely poor blacks and Hispanics are decreasing, the differences in the SES distribution between whites verses blacks and Hispanics still exist The population distribution of Asians by SES is more evenly distributed. The proportion of Asians in higher SES groups is increasing over the years, from 28.7% in 1970 to 40.2% in 1990. It is interesting to note, even though the SES was defined by ranking quintiles of all the census tracts in Los Angeles, the population distribution by SES shows more people in the lower SES groups than in the higher SES. This is a reflection of higher population density and crowded housing conditions in the socioeconomically poorer tracts. Maps 1-3 give the geographical presentation of the SES distribution by 1990 census tract boundary in Los Angeles County in 1970,1980, and 1990. The poor are concentrated in the south-central part of the County, and the socioeconomically more wealthy people usually live on the west side and coastal areas in the County. The geographical patterns of population distribution by SES did not change greatly from 1970 to 1990. 106 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 1. Average Education by SES, Los Angeles County, 1970,1980, and 1990. □ 1970 11980 B1990 11.8 12 1 1.211. 2 1 0 2 1 0 -4 1 0 .3 SES 2 SES 5 SES 1 SES 3 SES 4 Figure 2. Average Income by SES, Los Angeles County, 1970,1980, and 1990 70.000 - Sf 60,000 f IU O 50.000 o z 9 40.000 05 30,000 T Z 20,000 f 2 10,000 □ 1970 11980 B1990 SES 1 SES 2 SES 3 SES 4 SES 5 107 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Table 1. Population Structure by Race/Ethnicity and SES, Los Angeles County, 1970,1980, and 1990. N u m b e r P e rc e n t W h ite B la c k H is p a n ic A s ia n O th e r A ll W h ite B la c k H is p a n ic A s ia n O th e r All 1990 S E S 1 1 ,1 5 2 ,0 6 8 6 4 ,3 4 4 1 0 2 ,6 7 3 1 9 4 ,5 7 5 1 6 ,0 8 9 1 ,5 2 9 ,7 4 9 2 9 .9 6 6 .4 9 3 .7 0 2 0 .3 9 5 .5 4 1 7 .2 7 S E S 2 1 ,0 7 2 ,0 8 6 1 0 1 ,8 9 6 2 2 4 ,9 2 8 1 8 8 ,8 7 5 2 9 ,5 5 9 1 ,6 1 7 ,3 4 4 2 7 .8 8 1 0 .2 8 8 .1 1 1 9 .8 0 1 0 .1 7 1 8 .2 6 S E S 3 8 8 7 ,8 4 7 1 6 0 ,6 4 9 4 3 5 ,2 9 4 2 1 0 ,9 5 6 4 8 ,7 8 6 1 ,7 4 3 ,5 3 2 2 3 .0 9 1 6 .2 0 1 5 .6 9 2 2 .1 1 1 6 .7 9 1 9 .6 9 S E S 4 5 2 1 ,6 0 5 3 1 6 ,0 7 7 8 4 9 ,2 4 7 2 2 9 ,6 7 3 8 3 ,4 2 4 2 ,0 0 0 ,0 2 6 1 3 .5 6 3 1 .8 8 3 0 .6 1 2 4 .0 7 2 8 .7 1 2 2 .5 8 S E S 5 2 1 1 ,9 1 7 3 4 8 ,6 1 5 1 ,1 6 2 ,1 9 5 1 2 9 ,9 8 6 1 1 2 ,7 0 5 1 ,9 6 5 ,4 1 8 5.5 1 3 5 .1 6 4 1 .8 9 1 3 .6 2 3 8 .7 9 2 2 .1 9 T O T A L (race%) 3 ,8 4 5 ,5 2 3 43.42 9 9 1 ,5 8 1 11.20 2 ,7 7 4 ,3 3 7 31.33 9 5 4 ,0 6 5 10.77 2 9 0 ,5 6 3 3.28 8 ,8 5 6 ,0 6 9 100.00 1980 1 0 0 .0 0 1 0 0 .0 0 1 0 0 .0 0 1 0 0 .0 0 1 0 0 .0 0 1 0 0 .0 0 S E S 1 1 ,1 4 7 ,0 0 8 6 4 ,2 5 8 7 0 ,1 5 9 8 1 ,3 8 0 3 7 ,9 2 7 1 ,4 0 0 ,7 3 2 2 5 .9 3 6 .0 3 5 .5 5 1 9 .9 7 1 2 .2 9 1 8 .7 5 S E S 2 1 ,1 1 3 ,0 2 8 7 3 ,8 2 7 1 0 3 ,9 8 4 6 8 ,8 8 7 4 5 ,4 2 3 1 ,4 0 5 ,1 4 9 2 5 .1 6 6 .9 3 8 .2 3 1 6 .9 0 1 4 .7 2 1 8 .6 1 S E S 3 1 ,0 0 8 ,8 0 4 1 3 8 ,4 5 1 1 8 7 ,4 6 2 9 2 ,2 1 1 6 6 ,9 6 6 1 ,4 9 3 ,8 9 4 2 2 .8 1 1 2 .9 9 1 4 .8 3 2 2 .6 3 2 1 .7 0 2 0 .0 0 S E S 4 7 7 9 ,1 5 0 3 0 2 ,2 4 1 3 4 1 ,2 4 6 9 3 ,2 2 4 8 3 ,2 9 7 1 ,5 9 9 ,1 5 8 1 7 .6 2 2 8 .3 5 2 6 .9 9 2 2 .8 8 2 7 .0 0 2 1 .4 1 S E S S 3 7 4 ,9 4 0 4 8 7 ,2 4 0 5 6 1 ,3 2 7 7 1 ,7 9 8 7 4 ,9 4 7 1 ,5 7 0 ,2 5 2 8 .4 8 4 5 .7 1 4 4 .4 0 1 7 .6 2 2 4 .2 9 2 1 .0 2 T O T A L (race%) 4 ,4 2 2 ,9 3 0 59.22 1 ,0 6 6 ,0 1 7 14.27 1 ,2 6 4 ,1 7 8 16.93 4 0 7 ,5 0 0 5.46 3 0 8 ,5 6 0 4.13 7 ,4 6 9 ,1 8 5 100.00 1970 1 0 0 .0 0 1 0 0 .0 0 1 0 0 .0 0 1 0 0 .0 0 1 0 0 .0 0 1 0 0 .0 0 S E S 1 1 ,1 7 4 ,1 1 1 2 3 ,9 0 0 4 5 ,1 5 4 2 2 ,7 6 9 5 ,4 3 0 1 ,2 7 1 ,3 6 4 2 3 .0 4 3 .1 7 5 .0 0 1 2 .2 3 7 .1 9 1 8 .1 2 S E S 2 1 ,2 5 8 ,1 9 8 3 3 ,9 9 8 7 8 ,2 6 2 3 0 ,6 0 5 8 ,7 3 6 1 ,4 0 9 ,7 9 9 2 4 .6 9 4 .5 1 8 .6 6 1 6 .4 3 1 1 .5 7 2 0 .1 0 S E S 3 1 ,1 5 0 ,5 0 0 6 9 ,8 1 4 1 3 5 ,1 6 8 4 5 ,9 5 2 1 4 ,9 1 7 1 ,4 1 6 ,3 5 1 2 2 .5 8 9 .2 6 1 4 .9 6 2 4 .6 7 1 9 .7 5 2 0 .1 9 S E S 4 1 ,0 1 5 ,9 9 2 1 9 5 ,5 4 9 2 3 1 ,9 9 1 4 6 ,4 9 4 2 1 ,7 9 8 1 ,5 1 1 ,8 2 4 1 9 .9 4 2 5 .9 4 2 5 .6 7 2 4 .9 7 2 8 .8 6 2 1 .5 5 S E S 5 4 9 7 ,4 3 4 4 3 0 ,5 8 2 4 1 3 ,0 5 7 4 0 ,4 0 9 2 4 ,6 4 7 1 ,4 0 6 ,1 2 9 9 .7 6 5 7 .1 2 4 5 .7 1 2 1 .7 0 3 2 .6 3 2 0 .0 4 T O T A L (race%) 5 ,0 9 6 ,2 3 5 72.64 7 5 3 ,8 4 3 10.76 9 0 3 ,6 3 2 12.68 1 8 6 ,2 2 9 2.65 7 5 ,5 2 8 1.08 7 ,0 1 5 ,4 6 7 100.00 1 0 0 .0 0 1 0 0 .0 0 1 0 0 .0 0 1 0 0 .0 0 1 0 0 .0 0 1 0 0 .0 0 o c o Figure 3. Population Distribution by SES among Racial/Ethnic Groups, Los Angeles County, 1990. Figure 4. Figure 5 O S E S 1 P S E S 2 B S E S 3 B S E S 4 B S E S 5 ill W h ite B la c k H is p a n ic A s ia n O th e r R A C E /E T H N IC IT Y A ll Population Distribution by SES among Racial/Ethnic Groups, Los Angeles County, 1980. i C L ! O a . O S E S 1 D S E S 2 B S E S 3 B S E S 4 B S E S 5 ! W h ite B la c k H is p a n ic A s ia n O th e r A ll R A C E /E T H N IC IT Y Population Distribution by SES among Racial/Ethnic Groups, Los Angeles County, 1970. Q S E S 1 D S E S 2 B S E S 3 B S E S 4 B S E S S I i s P I z I 2 I Q . : O : c l W h ite B la c k H is p a n ic A s ia n R A C E /E T H N IC IT Y O th e r 109 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Map 1. Population Distribution by SES at 1990 Census Tract Level, Los Angeles County, 1990. North of LA Co South of LA Co Socioeconom ic S tatus (S E S ) SESl (High) H | SES4 SBS2 ■ SES5 (Low) SES3 (Hadiunj I N/A O Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Map 2. Population Distribution by SES at 1990 Census Tract Level, Los Angeles County, 1980. North o f LA Co South of LA Co S o cioeconom ic S tatus (S E S ) SESl (High) ■ SB34 SES2 SESS (Low) SE33 (Madiunt I N/A Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Map 3. Population Distribution by SES at 1990 Census Tract Level, Los Angeles County, 1970. IV) North o f L A Co South o f LA Co S o cioeconom ic S tatus (S E S ) SBSl (High) SES4 SE32 ■ SE35 (Low) SES3 (Madiunj I N/A 7.2 The Aae-adiusted Cancer Incidence Rates Initially, the case data were screened to eliminate cases with unknown information on age, sex, and race/ethnicity. It was made sure that no case is missing codes on cancer site and histology, or residential address at diagnosis. The total number of cases used in this study are listed in Table 2 by sex for each cancer. Among the 19 selected cancer sites, the top five most common cancers among male population in Los Angeles County during the period of 1972-1992 are: cancers of prostate (55,915 cases), lung (51,137), colon (24,131), bladder (14,552), and stomach (9,118); among females: cancers of breast (82,453), lung (29,944), colon (27,324), corpus uteri (21,667), and ovary (13,002). The age-adjusted incidence rates by race/ethnicity and SES offer abundant information (Table 3, Figures 6-37). The most prominent features in the plotted charts are: 1) obvious SES gradients exist in most of the cancers; 2) that the SES association with cancer varies by cancer site as well as race/ethnicity; 3) that some cancers have different relationships with SES for men and women; 4) that differences in incidence rates still exist after considering the influence of SES; and 5) no consistent and significant interactions between race/ethnicity and SES were found. As is known, bladder cancer incidence rates are higher in males than in females with white males having the highest and Hispanic males having the second highest rates. Monotonic SES trend was not observed in either men or women or any race/ethnicity-specific populations (Figures 6-7). Female breast cancer shows a distinct positive association with SES, i.e., the higher the SES the higher the breast cancer risk (Figure 8). Such SES trend is reflected in not only white and Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. black women, but also in Hispanic and Asian women as well. White women have the highest risk for breast cancer, followed by black and Hispanic women. Asian women have the lowest incidence rates for breast cancer. After adjusting for SES, the differences in incidence rates among racial/ethnic groups still exist The positive relationship between SES and breast cancer is in accordance with the literature. The age-adjusted incidence rates for cancer of the central nervous system (CNS) among men are, in general, a little higher than those among women across race/ethnicity. Both white men and white women have higher incidence rates than other population groups (Figures 9-10). Increasing CNS incidence rates are associated with increasing SES among whites in both men and women. Blacks, Hispanics, and Asians do not show relationships with SES in CNS cancer incidence rates. As previously known, cancer of the cervix uteri has a negative relationship with SES: the higher the SES, the lower the risk. This pattern was found clearly in white women and, to some extent, in other racial/ethnic groups as well (Figure 11). Hispanics, especially of lower social class, have the highest cervical cancer incidence rates. The disadvantage of being Hispanic and in lower SES in relation to developing cancer, did not appear systematically in other cancers. Asians have the lowest cervical cancer risk among all the population groups. Higher SES was found to be associated with elevated colon cancer risk in both Hispanic men and Hispanic women (Figures 12-13). Such relationship was also observed in white men and total male population, but cannot be established for other populations. 114 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Cancer of the corpus uteri is positively associated with SES among the total female population (Figure 14). This pattern was further noticed among white females and Hispanic females, but not for Asians and blacks. White women experience the highest risk for developing cancer of the corpus uteri. Hispanic women are the second in such risk. Controlling for SES did not eliminate the risk differences among racial/ethnic groups. A negative association for esophageal cancer and SES was shown more clearly in males than in females (Figures 15-16). Increasing incidence rates are associated with decreasing socioeconomic status. Male incidence rates are about two times as high as those of females. Black men of the lowest SES, SES5, have excessively greater risks than other gender/ethnic/SES groups. Compared to their white counterparts, black men of SES5 have about three times higher the risk. Black women of SES5 also have the highest esophageal cancer risk among women populations. However, this astonishing race-SES effect does not appear systematically in other cancers, which makes it inadequate to claim the impact of interaction between race/ethnicity and SES. In this case, the small case number in the category may have contributed to the unstable rates. Kidney cancer was not found to be related with SES in any population groups (Figures 17-18). Males have about two times the incidence rates of women in kidney cancer. Whites, blacks, and Hispanics have approximately the same level of risk, with the rates for Hispanics slightly elevated. Asians have the lowest incidence rates in both men and women compared to other populations. Age-adjusted incidence rates for the cancer of the larynx are much higher in men than in women. Increasing incidence rates are associated with decreasing socioeconomic status in both 115 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. men and women, particularly in white men and black men who have higher incidence rates than others (Figures 19-20). Although women have much lower incidence rates compared to men, the negative SES relationship is also found in white and black women. The SES differentials in Hispanics are less substantial than whites and blacks. Asians have the lowest incidence rates among all the population groups and display no relationship with SES in their laryngeal cancer risks. Liver cancer is one of the a few cancers in which Asians show the highest risk among the racial/ethnic populations. However, Asians do not display a SES trend in their incidence rates for liver cancer (Figures 21-22). With much lower risk than Asians, whites and blacks do exhibit a distinct negative relationship with liver cancer risk in men but not so clearly in women. Hispanics have the second highest incidence rates for liver cancer next to Asians and, as Asians, do not show monotonic associations with SES . Higher incidence rates are related with lower SES in lung cancer among the total male population (Figures 23-24). Such negative SES relationship is also present in white and black men. No SES trend was found in any female populations. Black men have higher lung cancer risk than white men, while black women have slightly lower incidence rates than white women after adjusting for age and SES. Women have a lower lung cancer risk than men across race/ethnicity. Asians have the lowest risk in lung cancer, for both men and women. Melanoma is mainly a cancer occurring in white people. In both white men and white women, the age-adjusted incidence rates are many times higher than other population groups. Melanoma exhibits a distinctive positive association with SES, i.e., higher SES is connected with elevated incidence rates (Figures 25-26). This positive relationship with SES appears in the 116 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. incidence rates for white and total population as well, which is governed by the disproportionately high rates of whites. No SES gradients were observed among other racial/ethnic populations except black women who also display a positive association with SES as whites, although their rates are much lower than white women. Interestingly, black men do not show any monotonic SES trend in their age-adjusted incidence rates for melanoma. When the total female population was examined, ovarian cancer appears to have a clear positive relationship with SES (Figure 27). However, among each individual racial/ethnic group, the SES pattern is subtle and different Whites and blacks apparently show a decline in risk with decreased SES. No SES gradients were found for Hispanic and Asian women, but the highest SES group, SES1, of Hispanics shows the lowest risk for ovarian cancer among Hispanics by SES, while Asians of SES1 show the highest risk among all the Asian SES groups. In pancreatic cancer the incidence rates are a little lower for women than men. In both men and women, blacks and Hispanics have higher risk of pancreatic cancer than other population groups. The age-adjusted incidence rates by SES did not reveal a consistent trend in both men and women regarding the risk of developing cancer of the pancreas by SES classification (Figures 28-29). Black men have the highest age-adjusted incidence rates for prostate cancer followed by Hispanics and whites, whereas Asians have the lowest risk of all population groups. Prostate cancer was found to be positively associated with SES (Figure 30). Such relationship can be seen very obviously in blacks, whites, and Hispanics. Asian men are the only racial/ethnic group whose risk of developing prostate cancer is not related with their SES. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The racial/ethnic differences in the rectal cancer incidence are small. The incidence rates of cancer of the rectum does not seem to be influenced by SES for both men and women in general and in race-specific populations (Figures 31-32). The age-adjusted incidence rates of stomach cancer is higher in men than in women (Figures 33-34). Stomach is another cancer site in which Asians, especially men, hold the highest incidence rates compared to other racial/ethnic populations. In men, the incidence rates are associated with SES negatively for each race/ethnicity, i.e., the lower the SES the higher the risk. Such SES relationship in women exists only among whites and the total population. Black, Hispanic, and Asian women do not demonstrate any SES relationship in their stomach cancer risk. The incidence rates of testicular cancer are much higher among white and Hispanic men compared to blacks and Asians (Figure 35). The increasing testicular cancer incidence rates are associated with increasing socioeconomic status in whites and Hispanics. Black and Asian men show no association with SES in their testicular cancer incidence rates. The incidence rates of the total population, which are basically ruled by the rates of the whites and Hispanics, also show a positive relationship with SES. Higher SES is associated with higher incidence rates in thyroid cancer in both men and women in general, especially among the white population (Figures 36-37). The risk for thyroid cancer is higher for women than for men. While Hispanic men exhibit no monotonic change of risk by SES, Hispanics women show a slight positive trend with SES in the thyroid cancer risk. No relationship with SES were found in the incidence rates for Blacks and Asians. 118 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 2. Number of Cancer Cases for People 15 Years of Age and Older, by Site and Sex, All Races/Ethnicities Combined, Los Angeles County, 1972-1992 Site Males Females Total Bladder 14,552 5,553 20,105 Breast 82,453 82,453 Central Nervous System (CNS) 4,184 3,312 7,496 Cervix Uteri 10,697 10,697 Colon 24,131 27,324 51,455 Corpus Uteri 21,667 21,667 Esophagus 3,553 1,830 5,383 Kidney 6,525 3,872 10,397 Larynx 5,357 1,290 6,647 Liver 2,837 1,275 4,112 Lung 51,137 29,944 81,081 Melanoma of the Skin 7,697 6,708 14,405 Ovary 13,002 13,002 Pancreas 7,244 7,376 14,620 Prostate 55,915 55,915 Rectum 7,532 6,308 13,840 Stomach 9,118 6,216 15,334 Testis 3,307 3,307 Thyroid 1,941 5,321 7,262 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 3 . Age-adjusted Incidence Rates b y Race/Ethnicity a n d SES, L o s Angeles County, 1972-92 . c O C O UJ LiJ « Q . *3 J O G O © § C O 05 o> C O C O C O C O p ^ C O o in m 8 C O C O N . C M C M 05 G O C O C M C O in G O C O C O C O 05 o 3 C O id co' id id ■ M * ’O ' o T“ S & 05 G O co' co co' co' co' C M C O g o ' o ’ o ’ C M o> ’O * C O 5 LO h - C M C M 05 G O C M C O 3 C M C M C O o CO G O C M C M C O S C M C M o C O 05 05 in co o o ' T ” id G O 05 to C O C O T“ C O 0 5 * o ' C M id o ' g o ' C O T~ 3 C O G O r - C O h - T“ G O C M O in T - N . CO C O C M h * C M O CO o C O m in C M M* h * C O 05 C M T— c m ' V cd h-’ M* g o ' id -O ’ co’ in ' C O T“ cd g o ' g o ’ 05 ’ 0 5 * I D C M o h - N - C O o h*. h - to 5 S G O o C O 3 C O C O 05 m m C M in 05 r ^ C O 3 C M C O C O id •o* C O co c m ’ G O C M C O C O h * C O C O o C O C O C O C O C O C O C M T“ c d id 3 T - C O C O 3 C O 05 o o N . 05 0 0 05 C M O C O G O G O r ^ C M p ^ C O in r ^ C M C O G O 05 o in 0 0 ■ o * id •O ’ * id ’M * o’ o id 05 id 0 0 3 C M r* . C M C O * C M c m ' c m ' co’ r * o' cd r ^ ’ C O r — lO ’ O ' V C O r- h - 00 3 O h - C O h - m o C O 05 00 in C O C M C O CO 3 C M 05 05 o C O C O C O C M s C O C O C D C D id S s 05 05 05 id h * "T C O co' id 05 C M cd o C M o C O C M 05 3 05' C M 05' C M g o ' C M c d C M h - o C M O i C M C M 05 G O cd V d T“ 3 C O 05 O C O i n' cd cd T“ V* C M g i c m ' C M C M C O C M O O C O 8 G O C O v M * i n' c o c d C O C M 05 C O C O G O o m m 05 C M o C O o C O G O C M 0 ) £ O C O UJ r e Q . C Q c o IT ) M ; C M 0 5 C O in C M 0 0 m r - o C O i n 3 C D C M p ^ C O G O R C O co c m ' C M • M * C M C O C M o C M cd cd cd i n 0 5 C O C O cd C O id C O C M C O io G O M * 05 m C M C M o p ^ C O 05 to C O C O m * < r 3 p ^ C M 0 5 ' 1^ 05 C M C M C M T“ C M C M c d C M C M C M cd C O C O 0 5 N » C O C M G O c o 3 C O in S O m in T ~ i n in ■ M * O T“ s 0 0 cd 0 5 * C M * T “ c m ' C M * c d C M 05 cd C M s i 0 5 8 C M T “ 05 C O C O M * C M C O p " * C O i n C O 05 to Nj i n c o a > r^ M ’ s C O * G O * cd V C O * c m ’ cd i n' if d 3 o C O g o ’ C M id C M C O o C O C M C M C O C M 05 r— C O o C O o C O C O C O o C M C O C M C M o r^ o c m ' cd c d cd M * id x f cd i d ■ o * o c v i ^r C M C O o o C M s . 00 C O in C M 00 C M C M in C O o G O M 3 05 v m G O C M C M cd C M C M i n C M 3 cd c d id id o •O' 05 C O g o ' C O c o ' C O *— C M C O M * to f - C M C O in T- C M C O in * - C M C O M* m C O C O C O C O C O C O C O C O C O C O co C O C O C O C O C O C O C O C O C O UJ UJ HI UJ UJ UJ UJ U J U J UJ UJ UJ UJ UJ UJ i l l UJ UJ UJ U J C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C C 1 1 1 O O 5 C O C O S £ n c < 0 = £ i § B Ifl J i » ? ( D O > q O 2 W X a UJ o — W P I 'T co co co co UJ UJ 1IJ UJ co co co co z o o o - J .c « 4 » * c : § C D -Q ,o 120 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. S E S 5 34.10 37.71 23.74 24.82 9 .9 0 31.41 28.17 32.91 16.77 14.31 6 .5 6 25.38 Table 3 . Age-adjusted Incidence R ates b y Race/Ethnicity a n d SES, L o s Angeles County, 1972-92 (Continued) C O L U UJ L i . < o c < 0 Q . tn X a m C D £ IE 5 C O UJ c r e < : J O c « a . o r e C O I I T ) o > C M C O C O o > C O C M 8 £ I O I s - 0) C O 0) o i n 0 3 o I s - I s - M * m M * o C M 0 3 C M I s - G O C M C O h - i q T — 0 3 o o C M C M C O $ O C O C O C M M * C M S C O t — c m ' c m ' c d n r M *M * * T - t - T “ T — I O C O G O C M O I s - C O T * “ I s - o o o o C O C O I s - C M o o 0 3 0 3 I s - C M 0 3 C O 0 3 C M o o s s o o o o I s - C O C O m ; C O c d c o ’ a >c dc o ' o ' o ' r - o ’ C M C M c m ' T “ o * r - o ' o ' o ' C M c m ’ T * C M I s - i n s I s - C M C M O ) C O o 0 3 I D I s - I s - M ; o I s - C O I s - 2> i n T — 0 3 G O I s - i o M * C M i n G O C O C O i n C M C M 0 0 C O o C O S o ' 0 0 * 0 3 r C G O * o ' o’ o’ v o ’ T * c m ' V o ’ o ' o ' o ' o ’ c o ' c d n *C M C O 0 0 C O C O C O C O C O CM l O o co' I s- ' id CM *** t- ^ t- 0 5 o r CM C O Q ) I O CO Is- ’ i d C M * C O * TT 8 h - CM O CM f» cm co c o o ' c d c d T “ — C O C O CM CM CM CO in in CM GO CO I s- CO O CM m CM o c o in CO o in I s- 0 3 0 3 CM CO c q Is- p T“* in CM Is- 0 3 Is - o p Is - CO CM o o ' o ' n r id id id id o o o o cm' CM c m' o in CO o CO CO o CO CO CO Is- £ GO 0 3 o 0 3 CO in GO p 0 0 M * CO CM 0 3 o o Is- CO Is- o CO CO c d c d cm' c d id id id M * o c m' T“ CM o C M * V - V - CO o 0 3 I s- o CO in GO GO 0 3 CO CO CM o 0 0 I s- c o p o Is- p p CM CM C O r * . o in GO 0 3 o 0 3 T“ T“* c m' C M c d n r M* T - c m ' CM o o * — O 0 0 CO Is- in 0 3 0 0 CO O CO CO GO in o CO T “ o m ; v - I s : in T * 00 CM m GO in M* GO Is - Is - 0 3 o I s- O C O * d id 03' 0 3 03* 03' 0 3 CO id Is ! 1 ^ c o 0 3 CM c d c d id Is- CM v - CO CO in O CM CO GO CM M t QO T “ in CO iq CO o CO CO CO C O c q Is- T — GO CO in P I s- CM T“* c d c d c d c d n r CM c d c d CM c d c d c d o T — d T“ T * “ in in 0 3 Is- M * GO Is - o 0 3 CO CO O CO v - 1 ^ o in CO in T“ M* M* 0 3 I s- CM 0 3 CO Is - Is - G O i ^ o m in 0 3 I s- o c d c m c d cm' id c d c d c d M" T * cm ' T ~ CM CM o c d n I CM V * Is- CO o CO CO o m o 0 3 < 6 M* in Is- co CO CM T— CM Is- 0 3 0 0 CO CD CO p m CM p in CO M * CM in 0 3 M * T " r - m id c d M* id M* o CM o id c d c d c d CO c d G O v - T — CO CO r — < o 0 3 I s- <Q CM o 0 3 GO in CO 0 0 CO 0 3 CO 0 3 00 t— c q o M* in I s- CO CM 0 3 T“ 0 3 M - C M o CO CO o c d id 1 ^ T — c d o o d o GO M * n I o c d CM M * c d ▼ — v T * ’r " Is- 03 00 C D Is - 0 3 0 3 CO GO O o 03 T — GO in Is- CM o co o Is - p Is - V in in 00 G O Is - o M ; CO c o CO c d •<* M 1 c d 0 3 o 0 3 0 3 0 3 id 1 ^ 00 d T — CM CM CM CO ▼ - T “ T - C M C O m * — C M CO m T— CM C O M* m ▼ — C M C O M* in *— C M C O M* C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O CO C O C O C O C O C O U l UJ UJ U I UJ UJ UJ UJ UJ UJ UJ U J UJ UJ UJ UJ UJ UJ UJ UJ UJ U l UJ UJ C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O Z> Q. c c o o C O o o < X CL o c o U 1 X z £ 5 a : UJ > — J . c Cm c o o a > -Q £ 121 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. S E S 5 3 .7 6 6 .6 3 8 .0 0 12 .9 0 1 1.1 4 6 .4 5 1 .4 6 2 .5 5 2.61 2 .8 0 3 .3 9 2.12 Table 3 . Age-adjusted Incidence Rates b y Race/Ethnicity a n d SES, L o s Angeles County, 1972-92 (Continued) ( 0 . c 5 C O LL I UJ U . * O c (9 a ■ s C O C Q C O UJ O c ( 0 a -s r a m co C O C O oo CO I O to C O C D CM 'M * 01 to CM tT o to 01 01 01 I O O l p CO to CO C O T - CM CO r ^ I O 01 to cm ’ CO 8 i d CO c d C O o > * C M o i K CM i d T " to ' c d C M T ~ h -’ o o' CO G O 8 C M ? I O CO o C O 00 p I O O l O l C O h - I O O l h - £ I O 01 C O I O o N . oo o 3 O l CM o ’ ■ * ” o o o o i go ' cd c m ’ i d CM s C O o ? f f oo 0 ) 00 00 o I O CM to C M T~ I O 3 o CO C M o 01 o r - C M CO O P T~ co ' c o ' i d c d cm ' o o o d G O * c d G O ’ M * cd c d 00 C M C O I O I O C M co CO 00 CM CM 8 N * CM O l 8 01 C M GO I O I O oo h - O l C O 01 o T “ O C M c o ' C M T“ C M o i T “ o ' i d c d c m ' o i cd cd cd o i g o ' 1 ^' N - ' o i CO to r - CO 1 ^ s C M s CO p - 0 01 CO CO O C O I O CM CO CO h - O C O C O to ’ M * 00 o 3 CM C O G O * C M g o ' C O cd CO 3 i d CO c d < r~ d o - o T * o i o i d o o i o o I O C l CM <31 55 8 C M t" . CM to r** CM s i GO CM to ▼* 00 o to I O C O N - C M G O O to CO 00 3 o CM co ' CO g o ' C O o i CO o ’ G O * CO cd d t o ’ cd c d cd to i d T * h - ‘ o o' 5 CM C O h - C M CO O l CO CO S i CO T“ O l h - r * . 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C M * cd c d cm ' cm ' i d T “* o T“ cm ' C M t — cd 00 r C h - C M M ; G O a> o 0 ) r - I O C O C M C M r - O CO o o CO o r* - p 01 C M C M T“ to CO to § co ' CO C O cm ' O ) o o ’ o * C M C M cm ’ d M* M* M * T~ d CO 3 cm ’ o i CO T ™ O l 01 o I O O ) CO C M G O CO O m ; 3 C M G O CO M* CO o CO O l 3 o to CO l O to oo o I O cd I O cd oo 3 o T ~ o i c d d K o o o T“ s 00 GO CM oo to r * . T - C M C O M ' M l T“ CM CO M ' M l T - CM c o M* M l I — CM c o M l T - CM CO M * co C O C O C O C O C O C O C O C O C O co C O C O C O C O C O C O C O C O C O C O C O C O C O UJ UJ LU UJ UJ UJ UJ UJ UJ UJ UJ UJ UJ UJ UJ UJ UJ UJ UJ UJ UJ UJ UJ UJ C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C O C D O z 5 m s > c c I C O s s c c o z 2 U l S C O o c c a c c o o © •Q £ 122 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. S E S 5 73.00 121.94 75.77 32.14 28.92 81.76 Table 3. Age-adjusted Incidence R ates b y Race/Ethnicity a n d SES, L o s Angeles County, 1972-92 (Continued) C O U J U J u. © .c 6 C J O 5 o c CQ a i2 X •8 . 2 C O £ 0 0 0 0 o > h - M * o o o > p o > C M C O W C O 0 ) 5 C O I O c o C M I f ) i n 3 O ) C O c d c d c d c d i d i d i d i d c d o o * c d c d i d i d C O I O o C M C O C O5 C O ? i n C D h * o s c o o r*- C M C O C M If) C M C O C O N . ' c d M * c d C M i d M 2 c d h - * M - ' M - * c d C M * O C MC M c o o C O M * C O - C M 0 0 h- C M I O S ) C MC M 3 0 ) I O h- C O i d c d i d i d r -* r— T * oi C M * i d c d i d i d c d m s v - c o O ) c o O ) 1 * ^ h- O 8 C O C M C O 0 ) h - Is - C M C O h- o T “ 0 ) C D C O O ) c d K c d T ~ o T “ o C M c d c d C M o C O o C O O ) 0 0 T ~ s $ s c o to T — ’ 3 C O o C M C O h- C M8 o o * O ) I s - * c d o T — c d 0 0 C O * C O * c d C M * C O * c d C Or *- 0 0 C O o o 0 0 C M o r*. c n to I O p o If) M * 0 0 o o C O o C O r- s C O o o o C O c d c d c d N - * c d i d i d i d C O * i d M - * c d © . c 5 « U i £ o c (0 a . © C D C M O) C M C M N . C M O) N . If) C O 00 t — C M C O M* C M C O T - C M If) C O IO o C O Is- m ; co C O oo in O) C O C O C M o r - o r ) o o C M * id oo* c d c d C M * r * c d C M * C M * C M * T" T “ * T— T“ T~ o C M o T“ o 0 ) in o o C O C O O ) o in o 0 0 C M CO o 00 o T-* o If) 00 O ) u ) C O p C M * oo* id o i T“ o i c d c d T“ T - o d o c d c d C M r— CO C M O ) o C O o © IO co O) M* 00 C O m CD C M oo C O M* o o IO C O 00 C O C O 0 ) o co M* 0 ) C O M* i ^ p p T— p o oo* O ) Is - o i id o o C M c d o o o o o T“ V - C M T“ T “ C M C M C M C M C O C M h - CO T“ o N . h - M* C O C M T“ C O C M O ) O i M r h - T— C M 3 ) C O C M h * M * C M o 0 ) C O r — T " I f ) o h - O ) p o V " o o i id C O * o T~ s i cd c d C O * C M c d C M C M C M T” T— T~ C M C M C M t o o Cp o N * C M N* m m C O O Is — C O O i Is- r - o Is - t o O) V“ C O M* T— oo co o C O Is - o T— C O T— Is -* c d 0 0 * o o i c d C M * C O * o T“ o o V * o o o C M r * T — ■ * “ ▼ — C M C M o C O C M o G O o C O o 0 ) C M C O C O C O o C O C O C O C M O ) M* C O M * CO C O If) co C O M- p C O o r - oo C O o p o t -T C M * C M * o i o r * C M * c d id C M * c d C M C M * C M * T — T “ T“ T— T — C MC O t o C O C OC OC OC O U J U l U J U J U J C OC O C OC O C O V C MC O M * m C O C OC OC OC O U l U J U J U J U J C O C OC O C OC O V - C MC O I f ) c o C OC OC O C O U J U J U J U l U J C OC OC OC O C O T —C MC O m C O C OC O C OC O U l U J U J U J U J C O C O C OC O C O 123 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Figure 6-8. Age-Adjusted Incidence Rates (AAIR) by Race/Ethnicity and SES, Los Angeles County, 1972-1992 Figure 6. Bladder, Males □SES 1 OSES 2 OSES 3 BSES 4 BSES5 | □SES 1 OSES 2 BSES 3 BSES 4 BSES 5 30 r 30 r § 25 O o ’ o £ £ 20 15 10 5 0 Vttiite Black Hispanic Asian Other All RACE/ETHNICITY Figure 7. Bladder, Females § 25 3 20 ° 15 2 10 £ 5 White Black Hispanic Asian Other All RACE/ETHNICITY Figure 8. Breast, Females 140 □SES 1 OSES 2 BSES3 1SES4 BSES 5 I 100 o 2 £ 80 60 40 20 0 lllfrli White Black Hispanic Asian Other All RACE/ETHNICITY N J a Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Figure 9-11. Age-Adjusted Incidence Rates (AAIR) by Race/Ethnicity and SES, Los Angeles County, 1972-1992 o o O o 0 1 2 8 7 6 5 4 3 2 1 0 Figure 9. Cen. Nerv. Sys., Males Figure 10. Cen. Nerv. Sys., Females □SES 1 OSES 2 OSES 3 BSES 4 BSES 5 □SES 1 QSES 2 BSES 3 BSES 4 BSES 5 White Black Hispanic Asian Other RACE/ETHNICITY All \Miite Black Hispanic Asian Other All RACE/ETHNICITY Figure 11. Cervix Uteri, Females □SES1 OSES 2 BSES 3 BSES 4 BSES 5 White Black Hispanic Asian Other RACE/ETHNICITY All ro u ? Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Figure 12-14. Age-Adjusted Incidence Rates (AAIR) by Race/Ethnicity and SES, Los Angeles County, 1972-1992 Figure 12. Colon, Males □SES 1 OSES2 USES3 B SES4BSES5 I o 30 White Black Hispanic Asian Other All RACE/ETHNICITY 50 o 40 0 S 30 1 20 5 10 Figure 13. Colon, Females [□SES 1 E3SES2 BSES 3 BSES 4 BSES 5] Vttiite Black Hispanic Asian Other All RACE/ETHNICITY Figure 14. Corpus Uteri, Females □SES 1 OSES 2 BSES3 BSES4 BSES5 o 30 o 25 § 20 £ 15 2= 10 Vttiite Black Hispanic Asian Other Ail RACE/ETHNICITY ro o > Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Figure 15-18. Age-Adjusted Incidence Rates (AAIR) by Race/Ethnicity and SES, Los Angeles County, 1972-1992 o 20 o 15 c ? ° 10 § 5 Figure 15. Esophagus, Males (□SES 1 OSES2 BSES3 BSES4 BSES5] V\Me Black Hispani Asian Other All c RACE/ETHNICITY Figure 16. Esophagus, Females 20 O § 15 0 ° 10 1 5 □SES 1 □SES2 BSES 3 BSES 4 BSES 5 o J , VW iite Black Hispanic Asian Other All RACE/ETHNICITY Figure 17. Kidney, Males □SES 1 OSES 2 BSES 3 BSES 4 BSES 5 16 o 14 § 12 o 10 I B I lllin lk ill \Miite Black Hispanic Asian Other All RACE/ETHNICITY o o o o o Figure 18. Kidney, Females □SES1 OSES 2 BSES 3 BSES 4 BSES 5 16 14 12 10 8 § ! 5 2 Vttiite Black Hispanic Asian Other All RACE/ETHNICITY M - ^ 1 Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Figure 19-22. Age-Adjusted Incidence Rates (AAIR) by Race/Ethnicity and SES, Los Angeles County, 1972-1992 O o o o o $ Figure 19. Larynx, Males [□SES 1 □SES2 BSES 3 B SES4B SES5] d u ik l i VWte Black Hispanic Asian Other All RACE/ETHNICITY o o o o’ o § $ Figure 20. Larynx, Female 14 12 10 8 6 4 2 0 □SES 1 BSES 2 BSES 3 BSES 4 BSES 5] U M l+ C E f ll i ■ ■ ■ i - White Black Hispanic Asian Other All RACE/ETHNICITY 14 o 1 2 S 1 0 £ 4 Figure 21. Liver, Males □ SES 1 OSES 2 BSES 3 BSES 4 BSES 5 Write Black Hispanic Asian Other All RACE/ETHNICITY O o o o " o $ 14 12 10 8 6 4 2 0 Figure 22. Liver, Females □SES 1 OSES 2 BSES 3 BSES 4 BSES 5 Vttiite Black Hispanic Asian Other RACE/ETHNICITY All r o o o Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Figure 23-26. Age-Adjusted Incidence Rates (AAIR) by Race/Ethnicity and SES, Los Angeles County, 1972-1992 Figure 23. Lung, Males [□SES 1 USES 2 DSES 3 1 SES 4 1 SES 5 j o 100 VW iite Black Hispanic Asian Other All RACE/ETHNICITY Figure 24. Lung, Females 140 o 120 o 100 § 80 5 60 | 40 < 20 [□SES 1 JOSES2 BSES3 B SB S4B SES 5] White Black Hispanic Asian Other All RACE/ETHNICITY Figure 25. Melanoma, Males □SES 1 OSES 2 BSES 3 BSES 4 BSES 5 ° 10 White Black Hispanic Asian Other All RACE/ETHNICITY O o o o ’ 0 1 $ 20 15 10 5 0 Figure 26. Melanoma, Females □SES1 OSES 2 BSES 3 BSES 4 BSES 5 White Black Hispanic Asian Other All RACE/ETHNICITY M CD Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Figure 27-29. Age-Adjusted Incidence Rates (AAIR) by Race/Ethnicity and SES, Los Angeles County, 1972-1992 Figure 27. Ovary, Females □SES 1 QSES 2 BSES 3 BSES 4 BSES 5 20 T V\Me Black Hispanic Asian Other All RACE/ETHNICITY 16 o 14 o o o 12 10 o T “ 8 i? 6 2 I Figure 28. Pancreas, Males □SES1 OSES 2 BSES 3 BSES 4 BSES 5 White Black Hispanic Asian Other RACE/ETHNICITY All Figure 29. Pancreas, Females □SES 1 OSES 2 BSES 3 BSES 4 BSES 5 Vttiite Black Hispanic Asian Other RACE/ETHNICITY All 0 3 O % Reproduced with permission o f th e copyright owner. Further reproduction prohibited without permission. Figure 30-32. Age-Adjusted Incidence Rates (AAIR) by Race/Ethnicity and SES, Los Angeles County, 1972-1992 Figure 30. Prostate, Males I OSES 1 □SES2 BSES 3 BSES4BSES5 I 200 o o o 160 o’ o 120 2 80 ? 40 0 \Miite Black Hispanic Asian Other All RACE/ETHNICITY Figure 31. Rectum, Males [□SES TB S ES 2 B S E S 3liS E S 4 o 10 V\friite Black Hispanic Asian Other RACE/ETHNICITY All Figure 32. Rectum, Females 14 0 12 8 10 8 8 1 5 < 2 □SES1 BSES 2 BSES 3 BSES 4 BSESS] M l l l h i i k l V W iite Black Hispanic Asian Other All RACE/ETHNICITY CO Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Figure 33-35. Age-Adjusted Incidence Rates (AAIR) by Race/Ethnicity and SES, Los Angeles County, 1972-1992 o o o o' o 25 20 15 | 10 2 5 0 6 § 5 § 4 o 3 E 2 2 2 1 0 Figure 33. Stomach, Males I □ SES 1 OSES 2 BSES 3 BSES 4 1 SES 5 I V\Me Black Hispanic Asian Other RACE/ETHNICITY All Figure 35. Testis, Males □SES 1 QSES2 BSES 3 BSES 4 BSES 5 I . Q i a , . f c i H U i f l M i . h Vttiite Black Hispanic Asian Other All RACE/ETHNICITY o o o 25 20 Figure 34. Stomach, Females [□SES 1 QSES2 BSES 3 BSES 4 BSES 5 8 15 | 10 2 5 VWte Black Hispanic Asian Other All RACE/ETHNICITY c o N J Reproduced with permission o f th e copyright owner. Further reproduction prohibited without permission. Figure 36-37. Age-Adjusted Incidence Rates (AAIR) by Race/Ethnicity and SES, Los Angeles County, 1972-1992 O o o o o Figure 36. Thyroid, Males (□SES 1 OSES 2 BSES 3 BSES 4 BSES 5 i 8 7 6 5 4 g I 3 ? k r t o H t . l * L i t * White Black Hispanic Asian Other RACE/ETHNICITY All o o o o 0 1 % Figure 37. Thyroid, Females OSES 1 OSES 2 BSES 3 BSES 4 BSES 5 Vttiite Black Hispanic Asian Other RACE/ETHNICITY All O i w 7,3 The Aae-specific Cancer Incidence Rates In addition to the age-adjusted incidence rates, the age-specific incidence rates by race/ethnicity, SES, and sex offer opportunities for evaluating the SES trend at each age category for each gender and racial/ethnic group. Because cancer is a relatively rare disease, the cases compared to the population at risk are numerically small. The total number of cases for each cancer studied in this project (listed in Table 2) are cumulatives of the twenty-one years from 1972 to 1992. Subdividing these total numbers into 21 years, 2 sex groups, 5 racial/ethnic groups, 5 SES groups, and 7 age groups, the number ended in each cell can be small. Mathematically, when the denominator is large, a small numerator can result in an unstable estimate of the rate. Some of the fluctuations in the age-specific rates shown on the following pages may be explained by such reasoning. Due to such concern, the ‘ ‘other’ ’ population group which by definition is the smallest one will not be presented graphically in this chapter as the other major racial/ethnic populations. Bladder The age-specific incidence rates reveal that the risk of bladder cancer increases steadily with age (Table 4, Figures 38-47). As shown in the age-adjusted rates, bladder cancer is not found to be associated with SES. The age-specific rates further display that there is no consistent monotonic SES pattern in bladder cancer incidence rates across ages among all racial/ethnic populations. 134 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 4. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Bladder Cancer MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.28 1.04 3.76 18.48 53.82 131.28 222.70 SES2 0.15 0.91 4.36 18.08 63.71 140.57 241.92 SES3 0.15 1.22 3.80 21.16 64.20 146.38 245.47 SES4 0.19 0.78 5.78 18.94 60.10 133.68 233.23 SES5 0.60 0.34 2.92 17.86 57.26 139.30 212.59 BLACK SES1 0.00 0.91 3.83 12.09 15.58 67.58 121.11 SES2 0.00 1.27 1.53 10.90 33.77 84.42 118.03 SES3 0.36 0.34 2.01 7.22 36.46 65.60 136.36 SES4 0.00 0.18 1.49 10.16 31.32 79.03 129.63 SES5 0.13 0.15 2.64 6.47 28.80 71.43 133.81 HISPANIC SES1 0.61 1.44 1.73 9.41 46.07 75.52 154.70 SES2 0.27 0.98 3.44 6.26 27.96 107.26 228.38 SES3 0.27 0.17 3.50 7.06 26.71 88.22 186.65 SES4 0.06 0.80 0.39 5.83 32.12 73.95 136.08 SES5 0.04 0.62 0.73 8.18 25.27 62.80 138.85 ASIAN SES1 0.00 0.00 0.92 2.99 12.83 40.09 113.86 SES2 0.00 0.42 1.72 3.41 14.29 45.39 86.48 SES3 0.00 0.33 1.40 3.02 8.91 36.62 73.91 SES4 0.00 0.00 2.04 3.18 20.11 41.21 76.31 SES5 0.00 0.00 0.94 5.89 8.45 56.40 109.98 OTHER SES1 0.00 0.00 2.99 8.51 24.93 101.53 48.25 SES2 0.00 0.00 2.53 14.91 28.22 24.62 93.07 SES3 0.00 0.00 1.92 2.95 17.40 18.95 111.23 SES4 0.00 0.00 3.96 9.23 25.87 37.65 91.11 SES5 0.00 0.00 0.00 2.45 7.07 7.65 21.98 ALL SES1 0.27 0.95 3.39 16.66 50.48 124.94 214.57 SES2 0.14 0.88 3.85 15.79 57.87 132.08 231.87 SES3 0.17 • 0.83 3.29 16.33 54.53 130.25 228.94 SES4 0.10 0.59 3.12 13.08 47.76 110.17 200.28 SES5 0.16 0.40 1.62 10.06 36.06 94.66 168.37 (To be continued) 135 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 4. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Bladder Cancer (continued) FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.06 0.53 1.52 5.26 16.06 27.91 56.18 SES2 0.16 0.57 1.09 5.24 15.52 32.68 58.89 SES3 0.00 0.56 1.34 5.30 16.40 35.37 56.61 SES4 0.11 0.40 1.08 5.79 18.32 34.50 56.81 SES5 0.00 0.00 0.30 3.77 13.27 33.17 56.12 BLACK SES1 0.00 0.00 0.94 2.59 16.98 17.95 45.37 SES2 0.61 0.00 0.00 3.67 17.59 7.66 78.27 SES3 0.00 0.00 0.52 3.60 4.78 23.26 70.20 SES4 0.00 0.00 0.42 1.68 13.15 20.24 61.97 SES5 0.10 0.27 0.97 3.54 11.16 24.88 49.68 HISPANIC SES1 0.00 1.24 0.00 4.25 8.85 20.73 40.95 SES2 0.00 0.33 1.13 4.40 4.52 31.31 56.01 SES3 0.00 0.18 1.31 2.26 7.24 32.73 43.10 SES4 0.00 0.00 0.54 3.68 8.43 17.59 35.82 SES5 0.18 0.28 0.29 3.33 6.54 15.07 45.25 ASIAN SES1 0.00 0.00 0.00 0.00 1.34 4.87 18.88 SES2 0.00 0.00 0.54 1.58 5.85 14.74 17.72 SES3 0.00 0.00 0.39 0.00 5.79 6.35 13.28 SES4 0.00 0.00 0.00 1.38 4.43 6.80 22.98 SES5 0.00 0.00 0.91 1.10 4.85 18.24 42.19 OTHER SES1 0.00 0.00 0.00 0.00 13.99 0.00 70.23 SES2 0.00 1.25 0.00 0.00 5.27 0.00 0.00 SES3 0.00 0.00 0.00 0.00 0.00 12.91 19.27 SES4 0.00 0.00 0.00 1.71 3.29 0.00 6.74 SES5 0.00 0.00 0.00 1.85 5.92 4.39 6.69 ALL SES1 0.05 0.50 1.23 4.71 15.09 26.24 54.51 SES2 0.15 0.48 0.95 4.77 14.38 30.93 57.61 SES3 0.00 0.36 1.12 4.23 13.91 32.89 54.71 SES4 0.04 0.15 0.65 4.08 14.64 28.20 53.30 SES5 0.11 0.20 0.51 3.29 9.98 24.97 50.96 136 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 38. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Bladder Cancer, White Males S E S 1 S E S 4 -S E S 2 S E S 5 S E S 3 2 5 0 o 2 0 0 - o o' o T “ t r s 1 5 0 - C O t u UJ 10° - o z U l a y 5 0 ■ 1 5 -2 4 5 5 -6 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 A G E G R O U P S 6 5 -7 4 7 5 + Figure 39. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Bladder Cancer, White Females iS E gl — — s e s 2 - - - SE s3 i S E S 4 ----------------S E S 5 I 2 5 0 § 200 . o' o I UJ u z 100 . UJ a o z 5 0 ■ 7 5 + 1 5 -2 4 3 5 -4 4 4 5 -5 4 6 5 -7 4 2 5 -3 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 40. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Bladder Cancer, Black Males 'S E S 2 S E S 5 S E S 1 S E S 4 S E S 3 2 5 0 § 200 • o © o £ 1 5 0 • C O UJ U I 100 • o 2 UJ Q § 5 0 ■ 2 5 -3 4 4 5 -5 4 A G E G R O U P S 6 5 -7 4 1 5 -2 4 7 5 + Figure 41. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Bladder Cancer, Black Females S E S 1 — — S E S 2 - - - S E S 3 S E S 4 S E S 5 2 5 0 o 200 o cT o ( T t . 1 5 0 C O UJ UJ 100 o z U J q o 5 0 0 t= . 1 5 -2 4 5 5 -6 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 6 5 -7 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 42. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Bladder Cancer, Hispanic Males - S E S 1 - S E S 4 - S E S 2 - S E S 5 S E S 3 2 5 0 § 200 o o' o Q C s 1 5 0 ■ C O u i 2 1 0 0-. o z UJ Q U 5 0 - 2 5 -3 4 3 5 -4 4 4 5 -5 4 6 5 -7 4 1 5 -2 4 7 5 + A G E G R O U P S Figure 43. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Bladder Cancer, Hispanic Females O O o o ' 0 T — < r Ui S t c o U i 1 UJ o z U J a o z 2 5 0 200 1 5 0 100 5 0 • •S E S 1 - S E S 4 ■ S E S 2 - S E S 5 S E S 3 0 — - --- 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 A G E G R O U P S 5 5 - 6 4 6 5 -7 4 7 5 + Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 44. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Bladder Cancer, Asian Males S E S 1 S E S 4 S E S 2 S E S 5 S E S 3 2 5 0 200 - 1 5 0 ■ 100 5 0 - 1 5 -2 4 2 5 -3 4 5 5 -6 4 3 5 -4 4 4 5 -5 4 A G E G R O U P S 6 5 -7 4 7 5 + Figure 45. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Bladder Cancer, Asian Females j ■ S E S 1 ------- — S E S 2 - - - S E S 3 i j ! ................... S E S 4 ............ — S E S 5 i | 2 5 0 ; 1 200 1 o’ o ! X : t 1 5 0 C O U J ^ 100 U i o ■ z U J Q O 5 0 z 0 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 - 5 4 5 5 - 6 4 6 5 -7 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 46. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Bladder Cancer, All Males 'S E S 1 S E S 4 'S E S 2 S E S 5 - S E S 3 2 5 0 o 200 o o ’ o tr £ 1 5 0 C O UJ i H I o z ID g o z 100 ■ 5 0 2 5 -3 4 6 5 -7 4 1 5 -2 4 3 5 -4 4 4 5 - 5 4 A G E G R O U P S 7 5 + Figure 47. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Bladder Cancer, All Females S E S 1 - — S E S 2 - - - S E S 3 ! S E S 4 - S E S 5 j 2 5 0 § 200 - o o ’ o ( C t. 1 5 0 05 UJ 100 ■ UJ C J z U J g o z 1 5 -2 4 2 5 -3 4 4 5 - 5 4 5 5 -6 4 6 5 -7 4 7 5 + 3 5 -4 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Breast Breast cancer risk in women increases steadily after age 25-34 for almost all trie population groups except Asians (Table 5, Figures 48-52). The age-specific incidence rates of breast cancer in Asian women seem to have two peaks: one at ages 45-54 and the other at ages 65-74, while in white, black, and Hispanic women the rates consistently climb into old age. The incidence rates for Asians are the lowest among the racial/ethnic groups. In the age-adjusted incidence rates, female breast cancer showed a positive association with SES in almost all the racial/ethnic groups. In the age-specific incidence rates, the positive SES effect is present at every age after 25-34 for white women and all women combined. Higher incidence rates are related with higher SES status. However, in black women the incidence rates of SES2 exceed the ones of SES1 at age 35-44 and age 65-74. The cross-overs at certain ages by lower SES groups exceeding the higher SES groups in risk can also be seen in Hispanics and Asians. An explanation for this phenomenon may be related to random effect of the unstable rates due to small numbers of observed cases. 142 with permission of the copyright owner. Further reproduction prohibited without permission. Table 5. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Breast Cancer FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.58 18.54 111.31 263.12 360.10 426.66 448.20 SES2 0.29 15.95 98.36 220.57 306.25 409.11 407.11 SES3 0.60 17.04 88.10 199.50 297.10 377.92 384.55 SES4 0.45 15.91 82.40 184.72 265.39 337.86 362.68 SES5 0.75 16.90 60.71 140.47 220.93 293.71 335.86 BLACK SES1 0.00 19.24 107.32 218.58 269.45 341.83 410.13 SES2 1.82 17.19 111.44 185.59 259.54 349.66 369.43 SES3 0.93 22.09 102.53 174.48 243.23 271.19 319.81 SES4 1.18 18.11 88.02 174.89 240.23 308.46 299.18 SES5 0.21 20.18 74.35 152.03 191.46 246.22 306.77 HISPANIC SES1 0.00 15.14 76.84 159.84 212.89 298.33 426.27 SES2 0.59 15.45 81.92 160.53 204.01 346.60 349.11 SES3 0.76 14.04 73.39 166.07 212.39 273.26 304.44 SES4 0.63 13.86 71.47 141.86 189.21 237.65 290.20 SES5 0.76 11.27 57.28 124.07 174.42 209.16 243.92 ASIAN SES1 1.10 13.23 63.18 126.68 118.31 155.94 105.01 SES2 0.47 10.83 61.73 119.19 125.88 159.74 145.97 SES3 0.35 10.64 52.35 121.59 123.23 137.59 121.93 SES4 0.72 11.66 53.78 107.31 113.00 142.46 107.75 SES5 0.00 9.13 45.70 78.06 99.69 101.24 122.78 OTHER SES1 1.76 13.46 118.55 192.83 299.76 271.26 118.33 SES2 1.14 5.01 81.84 144.40 205.83 144.24 139.02 SES3 2.45 8.40 73.39 98.92 61.70 89.57 109.09 SES4 0.48 5.35 39.61 85.36 83.25 97.91 70.41 SES5 0.00 5.45 12.95 44.56 73.16 51.67 56.83 ALL SES1 0.57 17.71 104.58 246.75 340.01 408.22 432.85 SES2 0.45 15.23 93.91 206.07 288.52 392.01 396.01 SES3 0.72 16.05 83.06 184.55 270.47 349.88 367.35 SES4 0.65 14.79 75.91 163.71 233.89 304.83 335.86 SES5 0.54 13.90 59.52 130.12 186.59 241.80 294.25 143 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 48. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Breast Cancer, White Females S E S 1 — — S E S 2 - - - S E S 3 i S E S 4 -----------------S E S 5 I 5 00 4 5 0 - o o o o " o 4 0 0 - 350 - 0 1 £ 300 UJ 2 5 0 - f - 2 200 Ui o z 1 1 1 Q O H 150 - 100 - 1 5 -2 4 35-44 4 5 - 5 4 55-64 6 5 -7 4 2 5-34 7 5 + A G E G R O U P S Figure 49. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Breast Cancer, Black Females O o 0 01 U J Q _ C O $ 1 1 1 o z 1 1 1 g o z •S E S 1 - S E S 4 ■ S E S 2 " S E S 5 S E S 3 350 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 50. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Breast Cancer, Hispanic Females ■ S E S 1 - S E S 4 • S E S 2 - S E S 5 S E S 3 ° 350 - £ 30Q UJ 250 O 100 15-24 25-34 35-44 45-54 55-64 65-74 A G E G R O U P S 75+ Figure 51. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Breast Cancer, Asian Females S E S 1 — — S E S 2 - - - S E S 3 S E S 4 ----------------S E S 5 500 450 8 400 o § 350 a : £ 300 uj 250 uj 2 0 0 o S 15° a § 100 25-34 35-44 45-54 55-64 65-74 15-24 75+ A G E G R O U P S 145 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 52. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Breast Cancer, All Females S E S 1 ------- — S E S 2 - - - S E S 3 S E S 4 -------- — S E S 5 5 0 0 4 5 0 8 4 0 0 - o § 3 5 0 c c £ 3 0 0 - UJ 2 5 0 i U J o z 200 iu 1 5 0 g o 100- 5 0 ■ 7 5 + 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 1 5 -2 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Central Nervous System The age-specific incidence rates by sex, race/ethnicity, and SES for cancer of the central nervous system (CNS) are shown in Table 6 and graphed in Figures 53-62. Before ages 35-44, the CNS incidence increases slightly with age and the differences between males and females are small. However, after ages 35-44, incidence rates increase greatly with age, especially among males, until ages 65-74 where they start to decline. Although the positive SES association with CNS cancer is clear for whites in age-adjusted incidence rates, in age-specific rates the higher rates do not always correlate with higher SES. For white men between ages 45-54 and 65-74, the positive SES trend is present For white women, there are many cross-overs at different ages. For the rest of the populations, the age-specific incidence rates by SES fluctuate greatly due to the fact that CNS cancer is relatively rare and the rates are calculated based on small number after the cross-classification by many criteria (i.e., race/ethnicity, age, sex, and SES). The SES pattern in the age-specific incidence rates for total males and total females reflect the pattern of whites, given whites have the highest incidences for CNS cancer and are high in proportion in population distribution. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 6. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Cancer of the Central Nervous System MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 2.96 3.33 5.79 9.69 20.09 28.89 26.32 SES2 2.40 3.53 4.65 10.07 15.80 24.13 28.38 SES3 1.78 3.19 4.52 8.49 17.81 24.04 21.23 SES4 2.17 3.03 5.30 9.09 14.91 20.65 21.92 SES5 0.86 3.37 3.74 8.91 13.74 19.45 18.32 BLACK SES1 3.83 1.82 6.68 7.93 6.20 15.25 0.00 SES2 0.00 3.67 2.53 9.63 15.05 15.45 23.88 SES3 0.39 3.53 3.27 4.81 13.64 19.01 13.22 SES4 0.88 1.83 3.37 5.50 13.96 17.73 8.35 SES5 0.98 2.70 4.35 6.51 9.95 8.58 11.77 HISPANIC SES1 1.28 2.30 2.67 6.07 15.08 7.15 0.00 SES2 2.16 3.93 2.14 3.83 11.37 21.17 13.20 SES3 1.78 3.77 4.02 8.93 12.75 19.81 19.21 SES4 1.59 2.64 4.54 5.05 9.43 16.76 29.51 SES5 1.43 3.24 3.31 4.67 10.18 23.64 22.23 ASIAN SES1 1.05 0.00 0.47 0.75 3.96 19.11 12.87 SES2 0.48 2.78 1.72 0.80 1.45 7.62 5.77 SES3 1.19 2.12 0.56 0.78 6.68 1.93 7.82 SES4 2.17 1.64 2.97 2.37 3.19 10.66 9.71 SES5 0.71 1.77 3.08 2.37 2.88 6.71 13.64 OTHER SES1 0.00 3.94 0.00 4.77 0.00 19.18 48.25 SES2 5.74 1.29 4.33 7.18 0.00 0.00 0.00 SES3 0.00 0.89 1.92 8.38 5.80 9.12 0.00 SES4 0.00 0.57 0.97 4.86 9.38 0.00 0.00 SES5 0.81 1.11 1.39 0.00 4.62 7.65 0.00 ALL SES1 2.66 2.95 5.08 8.76 18.66 27.70 25.05 SES2 2.18 3.46 4.04 8.91 14.61 22.81 26.69 SES3 1.53 3.14 3.87 7.61 16.15 21.95 19.89 SES4 1.62 2.49 4.34 6.91 12.83 18.66 19.98 SES5 1.18 2.96 3.54 6.04 10.74 16.04 16.91 (To be continued) 148 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 6. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Cancer of the Central Nervous System (continued) FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 1.86 3.37 3.51 5.72 11.03 18.42 17.38 SES2 1.58 2.82 3.83 6.45 10.48 14.91 15.09 SES3 1.88 2.78 3.01 7.43 11.03 16.18 13.28 SES4 1.48 2.02 3.49 5.59 9.01 14.33 13.37 SES5 2.76 3.15 3.24 2.65 7.04 11.33 10.45 BLACK SES1 0.00 1.06 0.94 2.76 11.84 8.64 17.29 SES2 1.34 0.00 4.35 4.51 6.14 15.82 13.35 SES3 1.14 0.32 2.87 5.93 8.21 5.70 3.51 SES4 1.63 0.82 1.50 3.32 6.39 7.58 10.45 SES5 0.99 0.80 2.08 3.83 8.21 10.31 11.33 HISPANIC SES1 1.90 2.48 3.49 7.37 9.23 12.15 0.00 SES2 2.33 1.01 2.37 6.52 6.03 18.24 3.39 SES3 0.92 1.83 3.25 7.66 8.71 8.26 18.73 SES4 2.11 2.52 2.55 4.17 10.85 11.43 12.11 SES5 1.31 1.70 2.29 4.72 9.55 12.09 10.62 ASIAN SES1 0.00 0.57 1.15 0.00 7.39 1.98 9.86 SES2 1.11 0.45 2.51 0.84 2.33 4.44 3.91 SES3 1.20 0.66 0.78 0.66 1.94 8.07 3.72 SES4 0.00 1.00 0.39 2.77 3.63 6.37 2.55 SES5 0.00 1.67 0.00 2.14 3.66 6.10 6.34 OTHER SES1 2.10 0.00 2.02 11.69 0.00 25.86 21.23 SES2 0.00 0.00 1.71 0.00 0.00 0.00 13.67 SES3 3.14 1.68 1.20 0.00 0.00 6.65 0.00 SES4 2.76 0.00 2.15 3.41 2.85 9.83 7.96 SES5 0.46 1.09 1.20 1.55 0.00 13.02 0.00 ALL SES1 1.61 2.86 3.13 5.36 10.71 17.37 16.74 SES2 1.57 2.19 3.57 5.89 9.52 14.46 14.40 SES3 1.62 2.11 2.74 6.57 9.87 14.58 12.89 SES4 1.70 1.74 2.48 4.57 8.43 12.47 12.60 SES5 1.35 1.68 2.21 3.57 7.64 10.80 10.32 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 53. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Central Nervous System, White Males S E S 1 ------- — S E S 2 - - - S E S 3 S E S 4 S E S 5 „ 3 0 o o C3 o 2 5 T “ £ E L U 20 C O UJ H I o z 15 ■ in 10 g o z 2 5 -3 4 45-54 5 5 -6 4 6 5 - 7 4 1 5 -2 4 3 5 -4 4 7 5 + A G E G R O U P S I Figure 54. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Central Nervous System, White Females S E S 1 ------- — S E S 2 - - - S E S 3 j S E S 4 ......... - S E S 5 3 0 o o o _ o 25 c c UJ ^ 20 C O UJ 15 U l o z U J Q O z 5 5 -6 4 6 5 - 7 4 2 5 -3 4 3 5 -4 4 45-54 7 5 + 1 5-24 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 55. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Central Nervous System, Black Males S E S 1 — — S E S 2 - - - S E S 3 S E S 4 ----------— S E S 5 o © o_ o 2 5 < T LU ^ 20 ■ C O 1 1 1 15 L U o m 1 0 ■ a o z 7 ^ ^ 3 5 - 4 4 4 5 -5 4 6 5 - 7 4 1 5 -2 4 2 5 -3 4 5 5 -6 4 7 5 + A G E G R O U P S Figure 56. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Central Nervous System, Black Females -----------------S E S 1 — — S E S 2 - - - S E S 3 ; ....................S E S 4 - S E S 5 o o o o o 2 5 z c U J 0 . C O U J I H I o z 1 1 1 a o z me . 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 - 7 4 7 5 + 1 5 -2 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 57. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Central Nervous System, Hispanic Males •S E S 1 ------- — S E S 2 - - - S E S 3 S E S 4 --------— S E S 5 3 5 „ 3 0 - o o q | 2 5 - O ' H i 20 - c o H I 1 5 - H I O m 10 - g C J z 5 5 - 6 4 6 5 -7 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 7 5 + A G E G R O U P S Figure 58. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Central Nervous System, Hispanic Females - - - S E S 1 — — S E S 2 - - - S E S 3 i .................... S E S 4 - -S E S 5 — 3 0 O o o o 2 5 o : u i 2 0 C O UJ A 1 5 - U J o z H I d o z . - 1 5 -2 4 5 5 -6 4 6 5 -7 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 7 5 + A G E G R O U P S 152 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 59. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Central Nervous System, Asian Males ■SES1 ------- — S E S 2 - - - S E S 3 S E S 4 — ------- — S E S 5 „ 3 0 - o 0 © 8 2 5 a . L U 20 - C O lu 1 1 5 - U J a § 10 - a o z 1 5 -2 4 3 5 -4 4 4 5 -5 4 6 5 -7 4 7 5 + 2 5 -3 4 A G E G R O U P S Figure 60. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Central Nervous System, Asian Females S E S 1 ------- — S E S 2 - - - S E S 3 j S E S 4 — — S E S 5 _ 30 o o o . 8 25 ■ a . UJ 20 - C O U J ^ 15 - UJ o S 10 Q o z 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 61. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Central Nervous System, All Males S E S 1 — — S E S 2 - - - S E S 3 S E S 4 S E S 5 3 0 - © o o o 2 5 t c . LU ^ 20 - c o UJ 1 5 ■ UJ o 2 10 - Q O Z 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 - 5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 62. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Central Nervous System, All Females S E S 1 ------- — S E S 2 - - - S E S 3 j S E S 4 --------------- S E S 5 _ 3 0 ■ O 0 1 2 5 (£ UJ ^ 2 0 C O UJ 1 5 - UJ o 2 10 ■ Q o Z 2 5 -3 4 4 5 - 5 4 5 5 -6 4 6 5 -7 4 1 5 -2 4 3 5 -4 4 7 5 + A G E G R O U P S 154 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Cervix Uteri Cervical cancer is inversely related to SES with the highest incidence rates found among women of the lowest SES and the lowest rates found among women of the highest SES (Table 7, Figures 63-67). The patterns of age-specific incidence rates of cervical cancer by SES vary greatly among racial/ethnic populations. The inverse SES association in cervical cancer is typically demonstrated in white women throughout all age groups. The incidence rates of the highest SES group, SES1, in whites remain stable after age 25-34 with a little increase after age 65-74. For whites in SES5, the lowest SES group, the incidence rates peaked at age 45-54 and then start to declined, but not without another resurgence at age 65-74. Black women of SES1 have higher age-specific incidence rates at some age points than SES2. This cross-over is summarized in the age-adjusted incidence rates where black women of SES1 have higher rate than black women of SES2 (Figure 11). In addition, the rate of black women of SES1 at age 65-75 is even higher than that of SES5. The increase in incidence rates along age is more dramatic among Hispanic women who have the highest risk of developing cervical cancer among all populations. The highest cervical cancer incidence rate of 82.19 per 100,000 is found in Hispanic women of SES5, the lowest SES group, at age 55-64. The lowest incidence rate for this age group is 11.08 per 100,000 among white women of SES1. Hispanic women of SES1 have the lowest age-specific incidence rates at all ages except age 75+ where their rate exceeds that of SES2 and SES3. The age-specific incidence rates do not reflect a consistent SES pattern among Asians, except in general terms that Asian women of higher SES shows a lower risk as compared to those of lower SES. The incidence rates seem to drop after age 75+ among all the Asian SES groups. 155 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 7. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Cervical Cancer FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 1.04 8.89 10.67 10.70 11.08 11.47 15.23 SES2 0.82 9.41 13.65 14.96 15.65 17.27 14.70 SES3 1.10 10.88 17.56 19.28 18.80 19.24 18.48 SES4 1.13 13.48 23.56 27.19 24.77 24.92 22.17 SES5 1.14 16.30 31.18 40.28 36.11 37.67 26.80 BLACK SES1 0.00 9.83 18.86 18.97 25.25 51.55 62.38 SES2 0.61 11.30 14.99 18.10 24.95 38.80 28.30 SES3 1.66 7.52 17.82 20.56 26.41 53.61 48.55 SES4 1.28 10.28 24.40 30.54 30.82 36.30 44.29 SES5 2.29 13.01 27.20 40.95 35.65 44.73 53.95 HISPANIC SES1 0.57 12.19 23.73 24.23 28.42 20.73 53.95 SES2 1.86 13.86 31.98 28.93 44.66 33.17 34.41 SES3 1.53 16.06 28.05 28.42 34.47 36.57 39.55 SES4 2.19 14.86 45.12 50.93 63.50 52.93 59.16 SES5 2.02 23.96 50.01 70.04 82.19 69.91 68.17 ASIAN SES1 0.00 2.00 8.25 6.83 25.37 28.51 14.20 SES2 0.00 3.92 10.56 16.24 18.65 31.95 28.07 SES3 0.00 7.42 12.15 13.73 25.01 28.59 22.41 SES4 0.36 4.65 9.69 22.26 30.42 36.58 16.88 SES5 0.00 3.50 14.04 15.17 32.24 24.20 27.92 OTHER SES1 0.00 5.27 27.11 11.69 46.25 25.36 21.23 SES2 0.00 6.37 23.02 30.48 38.86 52.72 41.47 SES3 0.70 6.73 12.34 32.13 40.62 12.91 20.62 SES4 0.48 5.39 18.50 21.40 39.76 19.52 23.08 SES5 0.46 1.64 15.34 7.10 30.93 30.29 28.04 ALL SES1 0.84 8.39 11.81 11.39 13.05 13.38 16.66 SES2 0.84 9.42 15.33 16.48 18.06 19.32 16.11 • SES3 1.13 10.92 18.49 20.52 21.48 22.32 20.65 SES4 1.41 12.04 27.74 32.33 32.67 30.41 27.31 SES5 1.76 17.50 36.18 47.71 48.10 45.55 40.69 156 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 63. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cervical Cancer, White Females ■SES1 — — - S E S 2 - - - S E S 3 S E S 4 ----------------S E S 5 100 9 0 - o o o o' o 8 0 • 7 0 a : LU C L c o LU 6 0 5 0 - 4 0 - UJ o Z 3 0 - L U a o 2 0 10 - 2 5 - 3 4 4 5 -5 4 5 5 -6 4 6 5 - 7 4 7 5 + 1 5 - 2 4 A G E G R O U P S | t Figure 64. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cervical Cancer, Black Females S E S 1 ------- — S E S 2 - - - S E S 3 S E S 4 S E S 5 100 9 0 8 0 7 0 c c fe . 60 ■ LU 5 0 - < “ 4 0 UJ o z UJ Q O z 3 0 20 10 - 5 5 -6 4 6 5 -7 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 7 5 + A G E G R O U P S 157 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 65. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cervical Cancer, Hispanic Females 'SEsa S E S 5 S E S 1 S E S 4 S E S 3 100 9 0 - o o o o ‘ o 8 0 ■ 7 0 ■ 6 0 ■ 5 0 - 4 0 - UJ O z UJ Q O z 3 0 - 20 10 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 1 5 -2 4 7 5 + A G E G R O U P S Figure 66. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cervical Cancer, Asian Females S E S 1 ------- — S E S 2 - - - S E S 3 i S E S 4 ----------------S E S 5 100 o 8 0 - o o ' ° 70 t. 6 0 ' S 5 0 < K 4 0 ■ UJ o 5 3 0 - Q O 2 0 - 10 6 5 -7 4 4 5 -5 4 5 5 -6 4 7 5 + 1 5 -2 4 2 5 -3 4 3 5 -4 4 A G E G R O U P S 158 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 67. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cervical Cancer, All Females ■SES1 ------- — S E S 2 - - - S E S 3 S E S 4 -----------------S E S 5 100 9 0 - O O o 80 © 5 7 0 .. a : s 6 0 ■ S 5 0 -■ ^ 4 0 - LLI O S 3 0 ■ ■ g o 2 0 10 ■ 2 5 -3 4 3 5 -4 4 4 5 - 5 4 5 5 -6 4 6 5 -7 4 7 5 + 1 5 -2 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Colon Colon cancer risk increases with age and is higher in men than in women (Table 8, Figures 68-77). The age-specific incidence rates start to go up more significantly after age 45-54. The SES gradient in age-specific incidence rates do not appear consistently across age. Not until age 65-74, for example, do white men begin to show the higher incidence rates associated with higher SES. There are many cross-overs in the age-specific incidence rates between SES groups in the racial/ethnic groups. The SES differentials observed in age-adjusted incidence rates for colon cancer actually may be due to the SES differentials found among older people. 160 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 8. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Colon Cancer MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.17 1.84 7.63 23.53 86.44 208.91 422.31 SES2 0.19 1.41 6.75 25.21 84.06 209.84 394.71 SES3 0.35 1.71 6.31 24.16 81.52 209.38 376.84 SES4 0.00 1.63 6.08 26.34 75.62 208.65 391.71 SES5 0.39 1.37 5.95 19.14 79.07 185.00 331.80 BLACK SES1 0.00 0.91 15.34 28.39 113.22 208.26 452.54 SES2 0.00 1.14 10.50 41.66 79.81 214.10 365.86 SES3 0.36 1.05 9.61 32.21 114.72 224.86 359.48 SES4 0.34 2.37 10.65 30.49 115.66 199.14 388.90 SES5 0.48 1.21 9.83 34.62 82.64 194.79 344.68 HISPANIC SES1 0.00 0.00 8.79 11.02 63.40 161.34 451.27 SES2 0.00 0.66 2.84 25.38 66.03 180.70 280.14 SES3 0.41 1.55 4.88 22.65 62.46 142.28 283.87 SES4 0.13 1.33 4.86 19.01 56.29 141.34 222.73 SES5 0.15 0.86 4.58 14.33 50.97 123.26 246.65 ASIAN SES1 0.00 0.47 5.55 15.04 59.82 120.78 219.76 SES2 0.00 1.86 3.45 10.73 49.43 102.42 181.68 SES3 0.00 1.70 2.63 21.30 51.67 160.37 229.76 SES4 0.00 0.98 4.09 12.65 48.64 127.77 214.98 SES5 0.71 0.00 4.26 10.40 72.60 139.92 208.51 OTHER SES1 0.00 1.97 8.99 30.29 39.66 60.36 274.59 SES2 0.00 1.29 5.07 11.04 31.07 172.91 294.10 SES3 0.96 5.00 3.20 4.96 55.12 146.92 167.83 SES4 0.70 1.88 6.94 13.13 43.62 103.12 88.73 SES5 0.00 0.64 1.83 11.12 22.00 63.57 64.98 ALL SES1 0.13 1.59 7.85 22.73 84.88 203.22 415.04 SES2 0.14 1.34 6.32 24.82 80.75 203.09 381.78 SES3 0.35 1.75 5.94 24.00 78.95 201.25 360.76 SES4 0.13 1.60 6.35 23.84 75.52 191.00 357.81 SES5 0.28 0.96 5.96 20.86 70.83 168.22 304.12 (To be continued) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 8. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Colon Cancer (continued) FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.35 1.33 4.92 23.13 64.40 150.67 303.61 SES2 0.18 1.42 5.66 25.98 65.09 159.74 295.52 SES3 0.22 1.77 5.58 24.45 65.63 152.15 295.41 SES4 0.17 0.89 6.32 24.88 67.06 142.09 267.28 SES5 0.22 0.63 7.34 21.96 66.73 133.78 277.77 BLACK SES1 0.00 1.52 13.79 32.41 92.66 205.51 313.41 SES2 0.00 1.04 9.67 35.36 87.64 243.59 341.95 SES3 1.45 0.61 7.99 40.54 97.42 158.81 288.13 SES4 0.15 1.81 9.76 34.48 89.16 159.58 286.50 SES5 0.87 1.59 11.84 27.43 83.32 155.09 292.54 HISPANIC SES1 0.00 0.57 3.85 17.43 39.71 111.35 297.70 SES2 0.00 0.67 6.72 19.01 59.16 109.95 185.52 SES3 0.36 1.10 5.63 22.59 48.49 101.02 190.16 SES4 0.26 1.20 4.71 14.68 41.35 83.91 171.51 SES5 0.21 0.90 4.33 11.72 31.92 87.12 174.51 ASIAN SES1 1.10 0.93 3.95 10.49 28.40 74.69 168.57 SES2 0.00 0.72 5.11 16.12 38.48 84.89 147.60 SES3 0.00 0.61 3.86 18.01 33.71 72.78 186.02 SES4 0.00 1.00 0.89 18.79 33.68 78.08 165.42 SES5 0.00 0.56 2.73 9.76 39.47 68.24 134.24 OTHER SES1 0.00 0.00 8.25 13.05 39.26 39.04 124.23 SES2 0.00 1.30 2.37 3.55 34.58 97.46 52.27 SES3 0.00 1.68 4.63 17.42 16.37 78.25 58.87 SES4 0.00 0.60 4.75 3.60 43.94 44.16 83.92 SES5 0.00 0.00 1.20 3.40 17.49 30.29 68.71 ALL SES1 0.36 1.21 5.20 22.31 62.33 146.67 297.91 SES2 0.13 1.26 5.88 24.81 63.68 155.62 287.28 SES3 0.35 1.42 5.62 24.75 62.93 143.79 284.38 SES4 0.18 1.14 5.90 23.17 63.13 131.41 254.31 SES5 0.36 0.96 6.71 18.57 59.09 122.70 250.76 162 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 68. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Colon Cancer, White Males : O i e T ; O ' c c ; U J ; c l ‘ C O I UJ ! t I W <-) z U l I Q : a : Z • S E S 1 - S E S 4 - S E S 2 - S E S 5 - S E S 3 3 5 -4 4 4 5 - 5 4 5 5 - 6 4 A G E G R O U P S 7 5 + Figure 69. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Colon Cancer, White Females S E S 1 ------- — S E S 2 - - - S E S 3 I S E S 4 -------- S E S 5 5 0 0 4 5 0 § 4 0 0 o " ° 3 5 0 3 0 0 UJ 2 5 0 200 U J O Z 1 5 0 UJ Q O 100 z 5 0 2 5 -3 4 1 5 -2 4 3 5 -4 4 5 5 -6 4 6 5 -7 4 4 5 -5 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 70. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Colon Cancer, Black Males S E S 3 ! ’S E S 1 S E S 4 'S E S 2 S E S 5 5 0 0 4 5 0 - § 4 0 0 o_ I 3 5 0 O ' £ 3 0 0 - 2 5 0 - 200 - UJ o 2 UJ o o 2 1 5 0 100 - 5 0 ■ 1 5 -2 4 2 5 - 3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 71. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Colon Cancer, Black Females S E S 1 ------- — S E S 2 - - - S E S 3 | S E S 4 ---------------- S E S 5 5 0 0 4 5 0 ■ o 4 0 0 o | 3 5 0 a : 3 0 0 ffi 2 5 0 200 - u i o Z 15 0 Q o 100 5 0 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S 164 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 72. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Colon Cancer, Hispanic Males •S E S 1 - S E S 4 — S E S 2 S E S 5 - - - S E S 3 - O o . o : o " ( s ! a: I U J , £ L C O ! i ; UJ , O 1 z ■ U J ; Q £ n on 4 5 0 4 0 0 3 5 0 3 0 0 2 5 0 2 0 0 1 5 0 1 0 0 5 0 0 1 5 -2 4 2 5 - 3 4 3 5 - 4 4 4 5 -5 4 5 5 -6 4 A G E G R O U P S 6 5 - 7 4 7 5 + Figure 73. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Colon Cancer, Hispanic Females S E S 1 ------- — S E S 2 - - - S E S 3 ! S E S 4 S E S 5 j 5 0 0 4 5 0 - § 4 0 0 © _ 3 5 0 O ' s 3 0 0 - S 2 5 0 ■ h ~ 200 H I o z u i Q O z 1 5 0 100 2 5 -3 4 3 5 -4 4 1 5 -2 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 74. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Colon Cancer, Asian Males — S E S 2 S E S 5 2 5 - 3 4 3 5 -4 4 4 5 - 5 4 5 5 - 6 4 6 5 -7 4 7 5 + ! A G E G R O U P S Figure 75. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Colon Cancer, Asian Females — — S E S 1 ------- — S E S 2 - - - S E S 3 ! .................... S E S 4 S E S 5 5 0 0 4 5 0 o o o o ' o 4 0 0 _ 3 5 0 O ' SI 3 0 0 - IS 2 5 0 1 UJ o z 200 Qj 150 " Q O 100 5 0 1 5 -2 4 2 5 -3 4 3 5 -4 4 5 5 -6 4 6 5 -7 4 4 5 -5 4 7 5 + A G E G R O U P S 166 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 76. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Colon Cancer, All Males S E S 1 ------- — S E S 2 - - - S E S 3 | S E S 4 -----------------S E S 5 i 5 0 0 4 5 0 - o 4 0 0 o § 3 5 0 £ 3 0 0 UJ 2 5 0 S UJ a z UJ Q O z 200 1 5 0 100 - 2 5 -3 4 4 5 - 5 4 6 5 -7 4 7 5 + 1 5 -2 4 35-44 A G E G R O U P S Figure 77. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Colon Cancer, All Females S E S 1 — — — S E S 2 - - - S E S 3 I S E S 4 S E S 5 I 5 0 0 4 5 0 - 4 0 0 O o c ? o 3 5 0 cr £ 3 0 0 “ 2 5 0 - UJ 1 200 UJ ( _ > z UJ Q O z 1 5 0 1 0 0 5 0 1 5 -2 4 2 5 -3 4 4 5 - 5 4 5 5 -6 4 6 5 -7 4 7 5 + 3 5 -4 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Corpus Uteri The pattern of the age-specific incidence rates by SES for cancer of the corpus uteri of total female population is dominated by that of white women. The rates accelerate after age 44 and peak at ages 65-74 (Table 9, Figures 78-82). The positive SES trend is present at every age category in white women after age 45-54, and in Hispanic women between ages 55-64 and 65-74. More cases of cancer of the corpus uteri are diagnosed among women of the high SES. The SES patterns are not very clear for blacks and Asians. White females have the highest risk for cancer of the corpus compared to other racial/ethnic counterparts, while Asian women have the lowest risk. Whites and Hispanics have a drop in their incidence rates after age 65-74, whereas such decline is not universal among Blacks and Asians. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 9. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Cancer of the Corpus Uteri FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.00 1.31 8.52 49.77 137.34 156.16 110.03 SES2 0.11 1.57 9.67 52.50 124.02 141.55 91.97 SES3 0.13 2.21 10.00 46.58 111.37 130.57 87.60 SES4 0.13 1.96 12.25 43.48 101.99 117.73 86.42 SES5 0.00 3.34 11.39 33.20 80.22 101.04 74.70 BLACK SES1 0.00 1.52 6.35 15.69 47.36 96.76 113.40 SES2 0.00 1.76 7.25 13.37 61.07 71.57 75.50 SES3 0.00 0.00 5.63 13.50 34.33 86.58 61.88 SES4 0.00 1.62 5.40 12.10 48.09 69.13 71.25 SES5 0.52 1.59 4.33 16.90 46.10 72.49 78.57 HISPANIC SES1 0.00 1.14 8.78 28.63 78.51 104.14 76.42 SES2 0.00 1.64 8.50 35.57 75.74 84.90 38.73 SES3 0.31 2.39 8.88 33.44 63.33 79.73 40.91 SES4 0.50 2.84 11.33 32.64 51.36 74.59 68.28 SES5 0.23 2.08 9.04 31.86 51.67 68.93 44.60 ASIAN SES1 0.00 1.64 5.58 16.61 41.50 38.87 40.31 SES2 0.00 0.36 6.97 16.65 33.71 31.56 21.66 SES3 0.00 2.20 4.87 28.47 32.72 31.76 16.78 SES4 0.00 1.50 7.13 13.21 18.67 36.73 21.56 SES5 0.00 1.11 10.14 13.00 22.83 39.47 22.36 OTHER SES1 0.00 1.99 2.75 35.08 77.08 64.39 21.23 SES2 0.00 3.91 4.74 34.03 26.35 80.70 27.34 SES3 0.00 0.83 9.94 18.75 27.86 38.33 20.62 SES4 0.48 1.18 9.49 14.20 18.01 24.39 7.96 SES5 0.00 0.56 5.11 10.51 14.53 8.63 0.00 ALL SES1 0.00 1.36 8.05 45.26 127.64 147.61 106.21 SES2 0.08 1.55 9.07 46.71 113.36 132.19 87.66 SES3 0.13 1.96 8.84 40.10 95.84 118.54 81.60 SES4 0.24 2.08 10.02 32.16 77.70 99.38 79.56 SES5 0.24 2.02 7.99 25.72 56.22 78.98 65.42 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 78. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Corpus Uteri, White Females S E S 1 — — S E S 2 - - - S E S 3 S E S 4 -------— S E S 5 1 6 0 ~ 1 4 0 I 1 2 0 - o m 100 - £ L tu 8 0 6 0 V U J o z U J Q O z 4 0 20 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + 1 5 -2 4 A G E G R O U P S _________________________________ i Figure 79. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Corpus Uteri, Black Females S E S 1 ------- — S E S 2 - - - S E S 3 j S E S 4 ----------- — S E S 5 ! 1 6 0 1 4 0 - I 120 ■ o K 100 - C L l u 8 0 I U J C J z U J o o z 4 0 20 4 5 -5 4 5 5 -6 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 6 5 -7 4 7 5 + A G E G R O U P S 170 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 80. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Corpus Uteri, Hispanic Females 'S E S 2 S E S 5 S E S 3 S E S 1 S E S 4 1 60 1 4 0 - S 1 2 0.. o T — £ 100 ■ lu 8 0 lu 6 0 C J z U J D 4 0 o Z 20 ■ 25-34 4 5 - 5 4 A G E G R O U P S 5 5 -6 4 6 5 -7 4 1 5 -2 4 35-44 7 5 + Figure 81. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Corpus Uteri, Asian Females S E S 1 ------- — S E S 2 - - - S E S 3 S E S 4 ----------------S E S 5 160 140 ■ I ,2 0 - o £ 100 - (L UJ 8 0 - H lu 6 0 - o z U J O 4 0 O z 20 6 5 -7 4 7 5 + 1 5 -2 4 2 5-34 35-44 4 5 -5 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 82. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Cancer of the Corpus Uteri, All Females S E S 1 S E S 4 'S E S 2 S E S 5 S E S 3 1 6 0 1 4 0 - 1 1 2 0 ■ O £ 100 - Q _ iu 8 0 UJ o z UJ Q O z 4 0 20 7 5 + 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Esophagus Table 10 and Figures 83-92 describe the age-specific incidence rates by sex, race/ethnicity, and SES for esophageal cancer. The risk for cancer of the esophagus increases with age. There are great differences between males and females, and among racial/ethnic populations by SES in the incidence rates for this cancer. Men have much higher rates compared to women. Among blacks and Hispanics the gender differences are greater than those among whites and Asians. Black men of SES5 experience the highest risk for esophageal cancer than their counterparts of other race/ethnicity. As shown in the age-adjusted incidence rates, high risk of esophageal cancer was related with low SES in whites and blacks. The negative SES association was distinctive especially in white men. The age-specific incidence rates further show that such SES association exists until age 65-74 in white men. Black men of lower SES have much higher incidence rates than those of higher SES. However, the incidence rates in some SES groups in blacks drop after age 65-74, while the rates for whites continued climbing. The age-specific SES pattern for Hispanics and Asians were not clear. For total male population, the relationship between age-specific risk of esophagus cancer and SES reflects the ones in whites and blacks. 173 with permission of the copyright owner. Further reproduction prohibited without permission. Table 10. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Esophageal Cancer MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.00 0.05 0.55 2.59 9.50 20.67 23.18 SES2 0.00 0.00 0.44 3.70 13.17 24.22 24.81 SES3 0.00 0.05 0.59 3.94 16.46 25.15 32.26 SES4 0.00 0.00 0.82 4.97 17.10 26.16 30.27 SES5 0.00 0.33 1.05 4.97 22.16 32.52 38.05 BLACK SES1 0.00 0.00 0.99 5.54 19.31 27.36 73.21 SES2 0.00 0.00 0.68 5.07 20.03 40.75 22.55 SES3 0.00 0.00 3.14 8.23 24.90 25.43 52.75 SES4 0.00 0.18 2.11 17.30 40.10 67.12 35.89 SES5 0.00 0.15 6.45 30.72 71.68 83.50 57.64 HISPANIC SES1 0.00 0.00 0.00 2.35 15.08 23.68 76.69 SES2 0.00 0.00 0.57 2.30 15.96 39.68 70.48 SES3 0.00 0.17 0.67 4.62 12.50 17.88 38.42 SES4 0.00 0.27 0.39 2.62 15.59 27.77 31.45 SES5 0.04 0.06 0.41 3.63 13.18 42.78 36.24 ASIAN SES1 0.00 0.00 0.47 4.20 10.98 14.78 18.91 SES2 0.00 0.00 0.00 0.90 6.92 6.90 34.40 SES3 0.00 0.00 0.00 4.54 6.80 19.45 30.81 SES4 0.00 0.00 0.00 2.37 7.41 13.70 31.66 SES5 0.00 0.00 0.00 2.37 14.17 34.17 55.50 OTHER SES1 0.00 0.00 0.00 0.00 0.00 19.18 40.03 SES2 0.00 0.00 0.00 0.00 0.00 24.62 0.00 SES3 0.00 0.00 0.00 2.48 5.80 18.23 36.95 SES4 0.00 0.00 0.00 2.43 10.66 7.09 35.30 SES5 0.00 0.00 0.00 0.00 18.75 14.25 21.02 ALL SES1 0.00 0.04 0.53 2.77 9.92 20.60 24.81 SES2 0.00 0.00 0.42 3.41 13.10 24.30 26.27 SES3 0.00 0.06 0.77 4.39 15.78 24.18 33.03 SES4 0.00 0.11 0.80 6.16 19.35 30.18 30.60 SES5 0.02 0.12 1.96 11.10 33.29 48.34 43.62 (To be continued) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 10. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Esophageal Cancer (continued) FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.00 0.00 0.31 0.98 5.39 10.47 12.67 SES2 0.00 0.05 0.25 1.29 5.49 10.40 12.98 SES3 0.00 0.00 0.26 2.77 5.02 9.94 10.33 SES4 0.00 0.08 0.13 2.84 7.38 10.57 11.27 SES5 0.00 0.21 0.30 3.43 9.46 11.52 11.91 BLACK SES1 0.00 0.00 0.82 3.79 16.98 4.32 26.56 SES2 0.00 0.00 0.00 6.26 13.49 14.84 6.37 SES3 0.00 0.00 1.04 3.51 10.40 13.10 12.66 SES4 0.00 0.17 0.48 5.35 14.06 18.08 12.91 SES5 0.00 0.13 1.40 15.35 22.25 17.07 20.98 HISPANIC SES1 0.00 0.00 0.00 0.00 5.46 4.29 0.00 SES2 0.00 0.00 0.41 1.51 3.47 4.10 4.38 SES3 0.00 0.00 0.00 0.00 3.99 3.42 9.95 SES4 0.00 0.00 0.40 1.39 3.46 4.21 11.53 SES5 0.00 0.20 0.00 1.26 2.47 7.79 12.04 ASIAN SES1 0.00 0.00 0.00 0.79 2.52 0.00 9.86 SES2 0.00 0.00 0.00 0.00 1.18 4.44 13.80 SES3 0.00 0.00 0.00 0.00 0.00 1.72 17.21 SES4 0.00 0.00 0.00 0.00 2.61 9.44 17.46 SES5 0.00 0.00 0.00 0.00 0.00 6.14 8.65 OTHER SES1 0.00 0.00 0.00 0.00 0.00 0.00 0.00 SES2 0.00 0.00 0.00 0.00 0.00 0.00 0.00 SES3 0.00 0.00 0.00 2.23 0.00 6.26 19.27 SES4 0.00 0.00 0.00 1.89 0.00 0.00 28.19 SES5 0.00 0.00 0.00 0.00 0.00 0.00 0.00 ALL SES1 0.00 0.00 0.28 1.02 5.50 9.63 12.42 SES2 0.00 0.03 0.22 1.41 5.30 9.87 12.44 SES3 0.00 0.00 0.26 2.26 4.82 9.17 10.61 SES4 0.00 0.06 0.25 2.71 7.21 10.40 11.95 SES5 0.00 0.16 0.45 5.93 10.61 11.64 13.77 175 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 83. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Esophageal Cancer, White Males S E S 1 ------- — S E S 2 - - - S E S 3 I S E S 4 ----------------S E S 5 ! 8 0 O o 7 0 • c T 0 C 6 0 - LLi 1 UJ 4 0 I UJ o z UJ g a z 3 0 - 20 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 - 7 4 7 5 + 1 5 -2 4 A G E G R O U P S ! i Figure 84. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Esophageal Cancer, White Females S E S 1 --- — S E S 2 - - - S E S 3 i S E S 4 • - S E S 5 ; 8 0 o § 7 0 o " o K 6 0 U l ^ 5 0 c o u i 4 0 - S UJ o z UJ Q O z 3 0 20 10 3 5 -4 4 6 5 -7 4 7 5 + 2 5 - 3 4 4 5 -5 4 1 5 -2 4 A G E G R O U P S 176 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 85. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Esophageal Cancer, Black Males S E S 1 — — S E S 2 - - - S E S 3 S E S 4 ---------------- S E S 5 80 ■ o o 70 - © o K 6 0 - U J “ 50 - to UJ 40 i- c £ U J o z 30 - U J § 20 z 10 ■ 3 5 -4 4 4 5 -5 4 6 5 -7 4 1 5 -2 4 2 5 -3 4 5 5 -6 4 7 5 + A G E G R O U P S Figure 86. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Esophageal Cancer, Black Females i S E S 1 ------- — S E S 2 - - - S E S 3 i S E S 4 “ S E S 5 i 8 0 - o' o 70 - o" o K 6 0 ' U J 0 . — 5 0 c o u UJ 4 0 - U J § 3 0 - U J § 2 0 - z ** 1 0 - 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + 1 5 -2 4 2 5 -3 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 87. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Esophageal Cancer, Hispanic Males 'S E S 1 ------- — S E S 2 - - - S E S 3 | S E S 4 - S E S 5 I 9 0 8 0 - © o 7 0 © o K 6 0 UJ ~ 5 0 to UJ 4 0 i- UJ o z UJ Q O z 3 0 20 10 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 88. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Esophageal Cancer, Hispanic Females S E S 1 ------- — S E S 2 - - - S E S 3 | S E S 4 --------------- S E S 5 i 8 0 - O o 7 0 o o e 6 0 ■ UJ ~ 5 0 - to 4 0 - UJ U 3 0 UJ § 20 z 10 3 5 -4 4 4 5 -5 4 5 5 - 6 4 6 5 -7 4 7 5 + 1 5 -2 4 2 5 -3 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 89. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Esophageal Cancer, Asian Males 'S E S 1 — — S E S 2 - - - S E S 3 I •S E S 4 ---------------- S E S 5 I 8 0 - o o 7 0 - o ‘ 0 5 6 0 UJ UJ 1 40 - U J O 3 0 - U J § 2 0 z 1 5 - 2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 90. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Esophageal Cancer, Asian Females •S E S 1 ------- — S E S 2 - - - S E S 3 ! S E S 4 ----------------S E S 5 ! 8 0 - O o 7 0 - o “ 0 £ 6 0 UJ 1 ■ - UJ 4 0 UJ o z UJ Q O z 3 0 - 20 10 2 5 -3 4 6 5 -7 4 7 5 + 1 5 -2 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 91. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Esophageal Cancer, All Males S E S 1 — SES2 - - - SES3 | SES4 ------------SESS i 80 - O 8 70 - o' o 60 a : U i a . CO l l i U i O 30 ■ U i § 20 z 10 15-24 25-34 35-44 45-54 65-74 75+ AGE GROUPS Figure 92. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Esophageal Cancer, All Females •SES1 -SES4 — SES2 — SES5 - SES3 80 o‘ o 70 o' o £ 60 - U i ~ 50 c o 40 U i O 30 u i § 20 z 65-74 1 5 -2 4 25-34 35-44 45-54 55-64 75+ AGE GROUPS Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Kidney There are little variations among racial/ethnic and SES groups in the age-specific incidence rates for kidney cancer (Table 11, Figures 93-102). The incidence rates for kidney cancer increase in relation with age. Besides age, sex is another strong indicator of kidney cancer risk. Women have about half the risk that men have across age groups. Although Hispanic males of SES1 showed a much elevated incidence rate of 146.51 per 100,000 at ages 75 and over, the stability of the value is questionable given there are only 9 cases for that subgroup for the entire period of 1972-1992. No apparent SES trend was observed in kidney cancer. 181 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 11. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Kidney Cancer MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.23 0.79 4.59 13.37 28.17 47.29 56.88 SES2 0.12 0.76 4.16 12.65 28.23 54.22 60.27 SES3 0.08 0.80 3.87 12.08 28.65 46.09 57.46 SES4 0.13 0.85 3.75 14.54 28.15 47.40 55.65 SES5 0.13 1.35 4.51 11.49 31.03 43.55 52.98 BLACK SES1 0.00 0.00 2.97 8.94 27.17 68.78 64.51 SES2 0.00 0.00 3.06 26.20 28.21 53.53 36.44 SES3 0.39 0.68 5.90 10.64 27.87 46.71 87.89 SES4 0.71 1.28 3.68 13.34 32.30 47.76 59.03 SES5 0.12 0.60 4.23 14.62 23.32 38.29 39.48 HISPANIC SES1 0.00 3.02 1.73 4.83 36.67 80.67 146.51 SES2 0.27 0.33 2.41 10.62 41.63 46.47 61.84 SES3 0.13 0.52 2.86 15.42 29.15 81.68 62.93 SES4 0.16 0.44 2.07 11.71 42.12 52.62 78.82 SES5 0.11 0.37 2.81 15.37 28.76 57.54 60.41 ASIAN SES1 0.00 0.00 0.00 5.41 8.24 10.49 33.66 SES2 0.00 0.00 1.22 6.71 11.25 25.79 12.25 SES3 0.00 0.66 0.56 3.71 5.62 21.38 24.35 SES4 0.00 0.36 3.40 2.45 13.74 31.92 23.26 SES5 0.00 0.00 0.00 8.22 15.58 15.37 22.73 OTHER SES1 0.00 0.00 5.32 0.00 20.38 38.36 48.25 SES2 0.00 0.00 8.67 3.87 12.71 36.85 0.00 SES3 0.00 0.00 0.00 11.80 15.96 0.00 0.00 SES4 0.70 0.00 0.00 0.00 11.79 7.09 0.00 SES5 0.00 0.64 1.39 2.45 11.69 28.49 10.03 ALL SES1 0.18 0.81 3.96 12.14 27.40 46.68 57.49 SES2 0.12 0.60 3.80 12.62 27.92 52.32 57.42 SES3 0.11 0.70 3.47 11.69 26.97 46.50 56.29 SES4 0.25 0.70 3.09 12.23 29.78 46.38 55.27 SES5 0.10 0.59 3.25 13.19 26.67 42.34 48.01 (To be continued) 182 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 11. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Kidney Cancer (continued) FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.06 0.40 1.54 4.97 9.10 17.82 26.01 SES2 0.18 0.47 2.31 6.51 12.48 20.27 28.82 SES3 0.13 0.44 2.62 6.45 12.81 22.21 24.20 SES4 0.17 0.32 1.22 6.01 12.53 20.69 24.05 SES5 0.16 0.62 1.18 7.04 13.20 20.82 23.51 BLACK SES1 0.00 0.76 4.34 8.10 16.98 18.62 9.54 SES2 0.73 0.62 4.51 7.33 6.14 30.65 49.11 SES3 0.00 0.98 3.39 5.65 18.61 17.11 40.09 SES4 0.15 0.50 2.79 9.02 12.74 19.15 15.71 SES5 0.31 1.07 1.66 7.15 13.72 18.05 18.91 HISPANIC SES1 0.00 2.38 3.22 5.53 15.63 26.40 9.24 SES2 0.00 0.34 2.66 5.71 15.80 20.48 54.28 SES3 0.00 0.36 2.18 5.78 19.89 29.89 28.51 SES4 0.00 0.51 2.28 4.67 17.60 22.91 33.64 SES5 0.13 0.56 1.89 6.93 14.55 27.10 37.66 ASIAN SES1 0.00 1.64 0.36 3.18 6.39 8.84 0.00 SES2 0.64 0.00 0.00 1.58 3.45 8.48 13.82 SES3 0.00 0.00 0.00 0.71 6.77 7.81 25.78 SES4 0.00 0.00 0.50 0.70 3.56 10.83 20.40 SES5 0.00 0.00 1.63 1.10 3.85 7.60 11.74 OTHER SES1 0.00 0.00 2.02 4.35 15.42 12.68 0.00 SES2 0.00 0.00 0.00 6.61 23.05 17.98 14.14 SES3 0.00 0.84 0.00 2.23 4.25 19.56 8.66 SES4 0.00 0.58 0.00 1.89 16.48 4.88 15.92 SES5 0.00 0.00 0.00 1.85 0.00 8.63 14.74 ALL SES1 0.05 0.66 1.65 4.95 9.47 17.63 24.35 SES2 0.22 0.41 2.21 6.15 12.11 19.97 29.23 SES3 0.07 0.46 2.27 5.72 13.27 21.78 24.73 SES4 0.09 0.39 1.70 5.68 12.74 19.94 24.11 SES5 0.16 0.63 1.56 6.36 12.67 20.23 23.71 183 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 93. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Kidney Cancer, White Males ■■ i i - S E S I ...................S E S 4 — — S E S 2 ---------------- S E S 5 - - - S E S 3 1 6 0 J- 1 5 0 1 4 0 | 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 - 5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S I Figure 94. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Kidney Cancer, White Females S E S 1 — — S E S 2 - - - S E S 3 S E S 4 S E S 5 1 6 0 j - 1 5 0 - 1 4 0 g 1 3 0 § 1 2 0 ? 1 1 0 u 3 1 0 0 ~ 9 0 uj 8 0 7 0 i UJ a z UJ a a z 5 0 4 0 3 0 20 10 1 5 -2 4 2 5 -3 4 3 5 -4 4 5 5 -6 4 4 5 -5 4 6 5 -7 4 A G E G R O U P S 184 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 95. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Kidney Cancer, Black Males 1 S E S 1 ................... S E S 4 — — S E S 2 ---------------- S E S 5 . . . S E S 3 1 6 0 T 1 5 0 1 4 0 f 1 3 0 O O ° 110 2 5 100 ~ 9 0 U J 8 0 £ 7 0 u j 6 0 • ■ Z 5 0 - g 4 0 § 3 0 “ 2 0 10 4 5 - 5 4 6 5 -7 4 7 5 + 1 5 -2 4 2 5 -3 4 3 5 -4 4 5 5 -6 4 A G E G R O U P S Figure 96. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Kidney Cancer, Black Females — ■ — S E S 1 — — S E S 2 - - - S E S 3 ....................S E S 4 _______ S E S 5 _______________________ 1 6 0 ------------------------------------------------------------------------------------------------------------------------------------ 1 5 0 ■ 1 4 0 § 1 3 0 -- § 1 2 0 2 110 5 i 100 - 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + ! A G E G R O U P S i Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 97. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Kidney Cancer, Hispanic Males • S E S 1 - S E S 4 ■ S E S 2 -S E S S - - - S E S 3 B 100 3 5 - 4 4 4 5 -5 4 5 5 -6 4 A G E G R O U P S 7 5 + Figure 98. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Kidney Cancer, Hispanic Females — — — - S E S 1 — — S E S 2 - - - S E S 3 I ....................S E S 4 S E S 5 1 6 0 y 1 5 0 - 1 4 0 - § 1 3 0 - § 1 2 0 ° 110 - a 1 0 0 ■ ~ 9 0 u j 8 0 £ 7 0 6 0 UJ o 2 UJ Q O 2 4 0 - 3 0 20 10 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 99. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Kidney Cancer, Asian Males o o o o o t r U J (L CO U J I- (5 U J o Z U J g o z 1 6 0 1 5 0 1 4 0 1 3 0 120 110 100 | 9 0 8 0 7 0 6 0 5 0 4 0 3 0 20 f- 10 0 1 5 -2 4 • S E S 1 - S E S 4 — S E S 2 S E S 5 S E S 3 2 5 -3 4 3 5 -4 4 4 5 -5 4 A G E G R O U P S 5 5 -6 4 6 5 - 7 4 7 5 + i Figure 100. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Kidney Cancer, Asian Females S E S 1 ------- — S E S 2 - - - S E S 3 j S E S 4 S E S 5 1 6 0 y 1 5 0 1 4 0 - f 1 3 0 o ' 120 ° 110 ■ £ 100 — 9 0 8 0 • 7 0 6 0 5 0 4 0 3 0 UJ O z U J Q O z 10 - 1 5 -2 4 2 5 -3 4 3 5 - 4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 101. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Kidney Cancer, All Males ! O I o 0 I o ° ' (T UJ I £L (0 UJ 1 UJ o '5 : O O ■ S E S 1 - S E S 4 ■ S E S 2 - S E S 5 - S E S 3 3 5 - 4 4 4 5 - 5 4 A G E G R O U P S 6 5 - 7 4 7 5 + Figure 102. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Kidney Cancer, All Females O O c f o 2 5 ioo w U J J - U l o z UJ Q O z • S E S 1 - S E S 4 • S E S 2 - S E S 5 - - S E S 3 1 5 0 120 1 5 - 2 4 2 5 - 3 4 3 5 - 4 4 4 5 - 5 4 A G E G R O U P S 5 5 - 6 4 6 5 - 7 4 7 5 + Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Larynx The gender difference in larynx cancer incidence rates is prevalent at all racial/ethnic groups (Table 12, Figures 103-112). Men have incidence rates more than three times as high as women. The variation in incidence rates by sex is smaller at younger ages and maximizes at ages 65-74. The difference between male and female larynx cancer risk is less in Asians comparing to other racial/ethnic populations. The SES association with incidence rates is apparent in larynx cancer for whites and total populations, especially in males. Blacks of lower SES tend to have higher risks than blacks of higher SES groups. However, there are some crossovers at different age points in the incidence rates between the SES groups in both black men and black women. In general, it seems the larynx cancer incidence rates reach the highest point in men at age group 65-74 and start to decline thereafter. The incidence for SES1 in Hispanic population reached the highest point of 74.70 per 100,000 among all population groups. The explanation may again reside in the small numbers: 5 cases occurred in this subgroup of population during 1972- 1992. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 12. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Larynx Cancer MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.00 0.15 1.09 7.31 19.65 29.65 32.34 SES2 0.05 0.27 2.02 8.89 27.98 42.82 37.89 SES3 0.00 0.20 2.43 12.03 31.31 46.91 34.67 SES4 0.00 0.28 2.32 14.65 37.61 52.18 38.78 SES5 0.00 0.34 5.12 18.54 45.01 51.58 38.91 BLACK SES1 0.00 0.00 0.99 3.96 24.55 27.36 13.33 SES2 0.00 0.00 1.69 8.53 25.00 51.94 12.60 SES3 0.00 0.34 2.13 13.61 31.74 27.70 41.10 SES4 0.00 0.00 4.45 14.09 43.16 51.37 33.04 SES5 0.00 0.00 5.96 23.38 49.04 61.50 44.72 HISPANIC SES1 0.00 0.00 1.88 3.47 15.49 16.53 74.70 SES2 0.00 0.66 2.29 5.28 23.05 33.82 35.43 SES3 0.00 0.00 1.91 5.73 23.12 30.72 37.37 SES4 0.06 0.09 0.65 7.97 20.25 36.43 39.74 SES5 0.11 0.12 0.82 7.76 21.54 39.64 41.25 ASIAN SES1 0.00 0.00 0.00 2.56 8.56 4.94 9.46 SES2 0.00 0.42 0.00 0.90 9.35 18.17 18.01 SES3 0.00 0.00 0.00 1.51 4.46 12.62 11.39 SES4 0.00 0.00 0.00 4.73 6.35 9.10 8.92 SES5 0.00 0.00 0.71 2.37 11.38 7.03 19.99 OTHER SES1 0.00 0.00 0.00 0.00 0.00 39.76 106.25 SES2 0.00 0.00 0.00 0.00 18.35 12.22 0.00 SES3 0.00 0.00 1.92 0.00 4.36 36.82 14.42 SES4 0.00 0.00 0.00 1.95 12.93 8.18 33.87 SES5 0.00 0.00 1.39 2.45 8.15 29.55 21.98 ALL SES1 0.00 0.12 1.00 6.63 18.98 28.38 32.15 SES2 0.04 0.30 1.81 7.93 26.56 41.13 36.14 SES3 0.00 0.15 2.07 10.20 28.44 42.49 33.53 SES4 0.02 0.14 1.91 11.92 32.79 45.74 36.04 SES5 0.06 0.12 2.96 14.38 36.62 47.33 38.69 (To be continued) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 12. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Larynx Cancer (continued) FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.00 0.11 0.31 1.56 6.30 5.21 4.10 SES2 0.00 0.19 0.30 2.12 5.73 6.66 3.96 SES3 0.00 0.16 0.76 3.46 7.25 7.75 4.09 SES4 0.00 0.00 0.64 4.57 8.11 8.88 4.08 SES5 0.00 0.00 0.54 4.29 12.05 11.55 4.90 BLACK SES1 0.00 0.00 0.00 1.38 4.63 0.00 9.27 SES2 0.00 0.00 1.45 2.14 1.91 4.08 6.37 SES3 0.00 0.00 0.00 4.28 8.07 9.70 6.31 SES4 0.00 0.17 0.54 4.33 4.52 10.90 2.16 SES5 0.00 0.27 1.78 5.29 12.41 8.86 4.28 HISPANIC SES1 0.00 0.00 0.80 1.13 0.00 0.00 0.00 SES2 0.00 0.00 0.56 0.00 3.47 5.95 0.00 SES3 0.00 0.37 0.25 0.94 3.39 5.76 2.10 SES4 0.00 0.00 0.00 0.29 3.42 3.56 3.64 SES5 0.00 0.00 0.39 0.41 1.54 6.88 10.97 ASIAN SES1 0.00 0.00 0.00 0.00 1.34 1.98 0.00 SES2 0.00 0.00 0.00 0.00 0.00 5.86 3.91 SES3 0.00 0.00 0.00 1.43 0.97 3.18 6.23 SES4 0.00 0.00 0.00 0.00 0.91 1.24 0.00 SES5 0.00 0.00 0.91 0.00 2.38 3.07 0.00 OTHER SES1 0.00 0.00 0.00 0.00 0.00 0.00 0.00 SES2 0.00 0.00 0.00 0.00 5.27 9.19 0.00 SES3 0.00 0.00 0.00 2.23 4.25 0.00 0.00 SES4 0.00 0.00 0.00 0.00 0.00 0.00 0.00 SES5 0.00 0.00 0.00 0.00 0.00 0.00 0.00 ALL SES1 0.00 0.09 0.29 1.41 5.74 4.79 3.93 SES2 0.00 0.13 0.36 1.81 5.18 6.55 3.87 SES3 0.00 0.16 0.50 3.02 6.45 7.31 4.12 SES4 0.00 0.03 0.36 3.07 6.06 7.80 3.66 SES5 0.00 0.06 0.80 2.79 8.25 8.79 5.24 191 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 103. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Larynx Cancer, White Males — ■ S E S 1 ...................S E S 4 ------- — S E S 2 --------- — S E S 5 • - - S E S 3 7 5 - 7 0 6 5 6 0 2 5 5 85 5 0 ~ 4 5 t o (U 4 0 3 5 - u j 3 0 2 2 5 Q 20 g 1 5 - 10 ■ o o 0 1 5 -2 4 2 5 -3 4 3 5 - 4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 104. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Larynx Cancer, White Females S E S 1 ------- — S E S 2 - - - S E S 3 ! S E S 4 S E S 5 | 7 5 § 6 5 • 6 0 ° 55 £ 5 0 - — 4 5 - UJ 4 0 3 5 UJ 3 0 - Z 2 5 Q 2 0 | 15 • 10 - i 6 5 -7 4 4 5 -5 4 5 5 -6 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 105. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Larynx Cancer, Black Males S E S 1 ------- — - S E S 2 - - - S E S 3 S E S 4 -----------------S E S 5 8 0 y 7 5 ■ 7 0 § 6 5 S' 6 0 5 5 5 £ 5 0 • 4 5 - u j 4 0 - 3 5 u j 3 0 - “ 2 5 - 20 1 5 10 - z U J Q O z 1 5 - 2 4 3 5 -4 4 4 5 - 5 4 6 5 - 7 4 2 5 - 3 4 7 5 + A G E G R O U P S Figure 106. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Larynx Cancer, Black Females S E S 1 ------- — S E S 2 - - - S E S 3 1 S E S 4 — S E S 5 ! 7 5 - 7 0 - § 6 5 S 6 0 ? 5 5 £ 5 0 • t 4 5 - u j 40 - 3 5 u j 3 0 - Z 2 5 Q 20 y 1 5 - 10 5 5 - 6 4 7 5 + 4 5 - 5 4 6 5 - 7 4 1 5 - 2 4 2 5 - 3 4 3 5 - 4 4 A G E G R O U P S 193 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 107. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Larynx Cancer, Hispanic Males S E S 1 ------- — S E S 2 - - - S E S 3 S E S 4 ---------------- S E S 5 75 70 f OS S’ 60 ° 55 £ 5 0 - 3> 4 5 uj 4 0 35 30 2 5 20 15 - 10 l- UJ C J z U J g o z 15-24 25-3 4 3 5-4 4 45 -5 4 55-64 65 -7 4 75+ A G E G R O U P S Figure 108. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Larynx Cancer, Hispanic Females S E S 1 ------- — S E S 2 “ - S E S 3 j S E S 4 ----------------S E S 5 I „ 70 § 65 S 6 0 - ° 55 £ 50 45 lU 4 0 - 35 U J J U • • Z 25 g 20 - O 1 5 - 55-64 6 5 -7 4 15-24 25-34 4 5 -5 4 3 5 -4 4 75+ A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 109. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Larynx Cancer, Asian Males — — S E S 1 — ■ — S E S 2 - - - S E S 3 ....................S E S 4 ----------------S E S 5 7 5 - 7 0 § 6 5 § 6 0 - 2 5 5 2 5 5 0 ~ 4 5 - u j 4 0 I- 2 z UJ g o z 1 5 10 - 1 5 - 2 4 2 5 -3 4 3 5 -4 4 4 5 - 5 4 5 5 - 6 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 110. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Larynx Cancer, Asian Females S E S 1 ------- — S E S 2 - - - S E S 3 ! S E S 4 - - S E S 5 ' 7 5 ■ 7 0 - § 6 5 - 6 0 ° 5 5 u i 5 0 ^ 4 5 U J 4 0 3 5 u j 3 0 Z 2 5 Q 2 0 2 1 5 1 5 - 2 4 2 5 -3 4 5 5 -6 4 3 5 -4 4 4 5 -5 4 6 5 - 7 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 111. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Larynx Cancer, All Males S E S 1 — — S E S 2 - - - S E S 3 S E S 4 - S E S 5 7 5 • 7 0 - § 6 5 5 6 0 - ° 5 5 - £ 5 0 - — 4 5 £ 4 0 • 3 5 • in 3 0 52 2 5 - 20 - 15 10 z UJ Q o z 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 - 5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 112. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Larynx Cancer, All Females S E S 1 - — S E S 2 - - - S E S 3 i S E S 4 ---------------- S E S 5 | 7 5 7 0 - g 6 5 ■ o ' 6 0 ° 5 5 £ 5 0 ^ 4 5 - LU 4 0 - 3 5 u j 3 0 - Z 2 5 Q 20 % 1 5 10 s 4 5 -5 4 5 5 -6 4 6 5 -7 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Liver Generally, men tend to have a higher liver cancer risk than women (Table 13, Figures 113-122). Liver cancer is more common in Asians and Hispanics than in whites and blacks. In feet, whites have the lowest liver cancer risk than other racial/ethnic populations. The occurrence of liver cancer among Asians is earlier in age (after age 34) than Hispanics (starting age 44). However, the SES trends are not obvious in the age-specific incidence rates for these populations. There is a negative SES association in age-specific liver cancer incidence rates in whites, especially in white men, although the differences among the SES groups are not substantial. Overall, men and women do display a negative SES pattern across ages in the total population. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 13. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Liver Cancer MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.34 0.26 0.38 1.67 5.57 12.15 20.53 SES2 0.06 0.28 0.37 1.82 5.71 13.35 19.56 SES3 0.15 0.30 0.47 3.14 6.88 12.65 19.83 SES4 0.06 0.35 0.90 3.33 8.94 14.32 23.20 SES5 0.00 0.17 0.71 4.35 9.02 21.30 27.65 BLACK SES1 0.00 0.00 1.98 5.54 9.93 5.08 0.00 SES2 1.43 0.00 1.69 4.73 4.38 26.64 35.15 SES3 0.00 0.34 2.01 3.15 19.87 21.40 24.87 SES4 0.20 0.74 0.55 7.76 19.85 32.55 30.62 SES5 0.12 0.60 1.43 11.56 25.04 26.18 30.88 HISPANIC SES1 0.00 0.00 0.00 3.71 14.68 61.21 50.71 SES2 0.00 0.33 2.29 1.58 21.18 29.56 50.12 SES3 0.46 0.34 2.15 7.06 25.21 40.36 57.93 SES4 0.00 0.09 1.30 8.23 20.03 46.64 47.63 SES5 0.00 0.43 2.13 6.27 23.41 45.96 54.38 ASIAN SES1 0.00 0.93 4.64 8.59 41.24 33.29 81.71 SES2 0.00 1.86 2.95 12.83 40.07 27.62 41.79 SES3 0.00 0.33 6.01 7.62 25.56 27.63 57.41 SES4 0.00 2.17 7.20 15.34 41.25 45.69 70.41 SES5 0.71 1.68 8.04 17.51 36.94 60.64 68.32 OTHER SES1 2.09 0.00 5.99 8.51 35.12 58.94 40.03 SES2 0.00 2.65 1.80 3.87 25.42 24.45 74.22 SES3 0.00 2.66 10.24 21.26 40.66 56.13 14.42 SES4 0.00 2.45 5.39 19.46 24.73 60.02 44.84 SES5 1.22 0.56 8.25 11.68 46.73 56.98 21.98 ALL SES1 0.31 0.28 0.92 2.47 7.80 14.26 23.03 SES2 0.14 0.44 0.87 2.72 8.52 15.04 22.01 SES3 0.19 0.39 1.69 4.46 11.11 16.44 23.79 SES4 0.06 0.59 1.73 6.65 15.10 23.95 29.85 SES5 0.12 0.49 2.31 8.07 20.32 31.84 36.73 (To be continued) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 13. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Liver Cancer (continued) FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.24 0.05 0.21 0.87 1.61 3.82 8.18 SES2 0.21 0.14 0.24 0.84 2.24 4.43 7.10 SES3 0.13 0.17 0.54 1.03 2.51 4.74 7.01 SES4 0.06 0.41 0.13 1.11 2.68 4.28 7.21 SES5 0.16 0.21 0.27 2.33 3.64 6.36 10.30 BLACK SES1 0.00 0.00 0.00 0.00 0.00 12.96 0.00 SES2 0.00 0.00 1.45 1.07 6.14 18.91 0.00 SES3 0.00 0.30 0.52 0.77 3.56 11.55 15.44 SES4 0.35 0.17 1.17 0.99 3.67 4.10 12.62 SES5 0.25 0.13 1.32 2.88 6.64 13.89 14.89 HISPANIC SES1 0.00 0.00 0.00 1.13 1.70 12.15 14.03 SES2 0.00 0.33 0.00 0.75 4.52 14.92 34.11 SES3 0.15 0.00 0.34 1.87 8.75 9.35 25.39 SES4 0.11 0.29 0.68 1.44 6.01 12.74 16.50 SES5 0.05 0.14 0.15 1.89 4.63 14.27 28.16 ASIAN SES1 0.00 0.36 1.15 5.62 7.89 16.15 18.49 SES2 0.00 0.00 0.87 3.16 8.10 10.30 49.26 SES3 0.00 0.36 1.79 4.28 9.63 22.77 34.42 SES4 0.00 0.00 0.00 2.79 10.65 11.93 13.75 SES5 0.00 0.00 1.63 2.14 3.66 16.74 26.85 OTHER SES1 0.00 0.00 0.00 4.35 6.99 13.18 0.00 SES2 0.00 0.00 0.00 0.00 17.78 0.00 27.80 SES3 0.00 0.00 1.20 2.23 3.62 6.26 8.66 SES4 0.00 0.60 3.00 7.38 6.59 4.91 0.00 SES5 0.00 0.56 1.96 6.80 13.99 12.88 6.69 ALL SES1 0.18 0.07 0.28 1.21 1.94 4.83 8.45 SES2 0.15 0.13 0.34 0.99 2.97 5.36 8.74 SES3 0.10 0.16 0.66 1.39 3.64 6.28 8.81 SES4 0.13 0.30 0.60 1.48 3.99 5.79 8.67 SES5 0.12 0.16 0.67 2.50 5.14 11.10 15.15 199 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 113. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Liver Cancer, White Males S E S 1 - — S E S 2 - - - S E S 3 S E S 4 ----------------- S E S 5 8 5 8 0 o 7 5 o 7 0 § 6 5 K 60 a 55 - — 5 0 0 3 U J 4 5 $ 40 w 35 O 3 0 - u j 2 5 § 20 Z 1 5 - 10 5 5 -6 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 6 5 -7 4 4 5 -5 4 7 5 + A G E G R O U P S Figure 114. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Liver Cancer, White Females S E S 1 --------- — S E S 2 - - - S E S 3 | S E S 4 — — - S E S 5 8 0 S ' 7 5 - § 7 0 § 6 5 £ 60 - u j 5 5 « 5 " u l 4 5 4 0 u j 3 5 ■ O 3 0 w 2 5 § 2 0 Z 1 5 10 1 5 -2 4 2 5 -3 4 4 5 - 5 4 5 5 -6 4 6 5 -7 4 3 5 -4 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 115. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Liver Cancer, Black Males ■S E S 1 -S E S 4 ■ S E S 2 - S E S 5 S E S 3 8 5 8 0 S ' 7 5 o 7 0 - § 6 5 K 8 0 - 8! 55 — 5 0 -- c o ~ Z iu 4 5 4 0 u, 3 5 o 3 0 iu 2 5 § 20 2 15 - 10 ■ 6 5 -7 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 5 5 -6 4 4 5 -5 4 A G E G R O U P S Figure 116. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Liver Cancer, Black Females •S E S 1 ------- — S E S 2 - - - S E S 3 I S E S 4 ---------------- S E S 5 \ 8 5 - 8 0 • o 7 5 o 7 0 8 6 5 ■ K 6 0 u i 5 5 u j 4 5 - 4 0 1 UJ o 2 U I Q O 2 3 0 - 2 5 1 5 1 5 -2 4 2 5 -3 4 5 5 - 6 4 6 5 -7 4 3 5 -4 4 4 5 -5 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 117. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Liver Cancer, Hispanic Males •S E S 1 ------- — S E S 2 - - - S E S 3 S E S 4 — S E S 5 8 5 - 8 0 - & 7 5 - o 7 0 § 6 5 ■ K 6 0 ' a 5 5 - — 5 0 - co ” u i 4 5 4 0 3 5 - 3 0 2 5 20 15 10 4 5 -5 4 5 5 -6 4 6 5 - 7 4 7 5 + 1 5 -2 4 2 5 -3 4 3 5 -4 4 A G E G R O U P S Figure 118. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Liver Cancer, Hispanic Females S E S 1 - — S E S 2 - - - S E S 3 S E S 4 S E S 5 8 5 - 8 0 ■ S ' 7 5 o 7 0 § 6 5 - £ 6 0 - ui 5 5 - — 5 0 c o ~ ~ ui 4 5 - S 3 5 i u O 3 0 u j 2 5 § 20 Z 15 10 0 1 5 -2 4 2 5 -3 4 4 5 -5 4 6 5 -7 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 119. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Liver Cancer, Asian Males SES1 SES4 'SES2 SES5 SES3 85 - 80 o 75 o 70 § 65 C 6 0 £ 5 5 ~ 50 - 0 5 uj 45 40 uj 35 — U 30 - w 25 § 20 Z 15 10 45-54 55-64 65-74 15-24 25-34 35-44 75+ AGE GROUPS Figure 120. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Liver Cancer, Asian Females SES1 — — SES2 - - - SES3 | SES4 — — SES5 ; 85 - 80 - o 75 - § 70 8 65 - S 6 0 - uj 5 5 - =• 50 ui 45 - 40 - ui 35 — g 30 - uj 25 - § 2 0 - ? 15 - 10 I 65-74 25-34 35-44 45-54 55-64 75+ 15-24 AGE GROUPS 203 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 121. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Liver Cancer, All Males S E S 1 ------- — S E S 2 - - - S E S 3 S E S 4 --------------- 'S E S 5 8 5 8 0 - o 7 5 ■ § 7 0 § 6 5 - £ 6 0 - UJ 5 5 » 2 " u i 4 5 - 4 0 Ui 3 5 — O 3 0 u j 2 5 - B 2 0 - z 1 5 - 10 - $ 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 - 5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 122. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Liver Cancer, All Females S E S 1 ------- — S E S 2 - - - S E S 3 | S E S 4 -----------------S E S 5 ! 8 5 8 0 • o 75 o 7 0 - § 6 5 J 6 0 - u j 5 5 — 5 0 • w 4 5 ■ 4 0 u j ' ■ O 3 0 ■ uj 2 5 § 2 0 - 2 15 5 5 -6 4 6 5 -7 4 7 5 + 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 - 5 4 A G E G R O U P S 204 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Lung Table 14 and Figures 123-132 contain the age-specific incidence rates for lung cancer by sex, race/ethnicity, and SES. The lung cancer incidence rates are very low in females compared to males, except in younger ages when the rates are very low. The risk of lung cancer increases with age. The increase of risk becomes more substantial after ages 45-54. However, Hispanics and Asians show a lower risk of lung cancer at younger ages when compared to whites and blacks. The negative SES association exists in white males at almost all ages and in black males in most of the ages. The relationships between SES and age-specific lung cancer incidence rates in Hispanic and Asian men are not consistent at different ages. The total male population reflect the experiences of whites and blacks in relation to the SES association. There is no systematic SES variations in female lung cancer risk. 205 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 14. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Lung Cancer MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.28 -1.02 9.98 51.16 157.25 315.24 430.79 SES2 0.15 1.70 11.98 76.47 233.40 426.00 505.49 SES3 0.10 1.25 16.55 88.91 270.70 494.76 539.74 SES4 0.19 1.34 18.66 107.87 299.00 517.64 552.43 SES5 0.21 2.38 21.32 124.90 332.63 561.19 531.27 BLACK SES1 0.00 1.82 14.73 74.22 196.09 339.53 383.40 SES2 0.00 0.57 19.67 115.18 263.86 477.98 415.03 SES3 0.72 1.02 23.33 111.32 301.53 495.30 519.09 SES4 0.34 1.27 28.77 141.62 364.85 577.06 525.51 SES5 0.23 1.82 42.24 198.01 434.84 586.53 555.50 HISPANIC SES1 1.84 2.30 8.63 32.32 97.42 355.51 483.54 SES2 0.35 1.64 6.15 20.26 102.13 317.63 672.62 SES3 0.19 0.87 7.47 31.62 112.59 257.82 525.57 SES4 0.36 0.90 6.74 33.52 109.19 282.09 487.21 SES5 0.13 1.10 4.90 33.70 110.97 289.07 459.81 ASIAN SES1 0.00 0.47 5.60 14.57 80.24 167.03 218.59 SES2 0.00 0.42 7.67 35.38 106.38 221.93 282.47 SES3 0.00 0.38 5.69 33.51 87.86 186.41 331.01 SES4 0.00 0.71 8.15 39.51 107.05 241.61 323.83 SES5 0.00 0.00 3.78 41.10 105.01 265.19 381.58 OTHER SES1 0.00 0.00 5.32 37.11 75.87 194.59 296.66 SES2 0.00 0.00 13.74 18.21 64.98 171.65 105.22 SES3 0.96 3.55 10.87 35.54 108.87 185.91 267.52 SES4 0.00 0.00 10.90 34.52 89.52 241.17 240.44 SES5 0.00 0.00 5.50 39.04 85.84 203.89 339.29 ALL SES1 0.35 1.07 9.66 48.55 152.48 309.30 422.03 SES2 0.15 1.49 11.57 70.52 218.70 410.42 496.40 SES3 0.20 1.16 14.52 77.44 242.52 454.22 523.00 SES4 0.25 1.07 15.74 88.94 258.35 467.86 520.81 SES5 0.15 1.37 17.16 104.07 280.70 478.03 503.78 (To be continued) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 14. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Lung Cancer (continued) FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.12 1.31 9.22 42.27 108.67 187.51 172.72 SES2 0.23 0.83 11.95 55.01 135.25 197.40 178.20 SES3 0.10 1.27 13.27 60.81 138.72 203.28 163.92 SES4 0.17 1.21 16.28 61.17 139.77 201.37 158.17 SES5 0.16 1.25 11.03 65.86 131.55 187.22 167.16 BLACK SES1 0.90 0.76 6.10 48.10 87.08 134.97 157.24 SES2 0.00 1.66 14.01 48.88 145.98 179.97 171.32 SES3 0.41 2.20 14.30 50.29 109.45 169.03 151.85 SES4 0.30 0.96 16.58 52.77 127.35 152.14 145.58 SES5 0.21 1.73 14.31 66.20 123.31 155.69 133.20 HISPANIC SES1 0.00 0.00 4.84 20.27 44.80 124.22 152.40 SES2 0.00 0.67 7.13 24.91 59.79 118.06 189.72 SES3 0.20 0.18 4.70 24.81 57.28 112.63 151.80 SES4 0.11 0.90 4.78 18.25 52.89 99.35 146.73 SES5 0.05 0.21 3.99 16.76 43.72 105.00 186.21 ASIAN SES1 0.00 0.36 1.94 12.21 26.71 72.53 141.37 SES2 0.00 0.72 2.18 14.97 29.20 67.55 111.44 SES3 0.00 0.61 5.61 15.26 28.92 84.03 138.68 SES4 0.00 0.60 3.91 12.39 31.93 79.62 106.95 SES5 0.00 0.00 3.25 7.56 31.57 75.84 112.56 OTHER SES1 0.00 0.00 10.27 11.69 36.40 65.40 133.92 SES2 0.00 0.00 4.74 12.72 15.81 98.68 55.61 SES3 0.70 1.68 1.72 6.69 15.74 109.93 126.71 SES4 0.00 0.00 4.30 12.87 28.34 73.37 37.36 SES5 0.00 0.00 6.63 3.40 22.32 81.81 84.12 ALL SES1 0.14 1.08 8.11 39.13 101.25 178.66 170.36 SES2 0.17 0.84 10.59 49.04 124.30 187.16 175.18 SES3 0.17 1.13 10.86 50.31 120.07 187.89 161.33 SES4 0.15 0.96 11.50 44.83 113.42 172.16 151.12 SES5 0.10 0.73 8.22 42.57 95.22 149.00 155.56 207 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 123. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Lung Cancer, White Males o o o o o a : u i Q. in a o z 1 5 -2 4 ■ S E S 1 - S E S 4 ■ S E S 2 - S E S 5 - S E S 3 7 0 0 6 5 0 6 0 0 5 5 0 5 0 0 4 5 0 4 0 0 / • / y 3 5 0 ; V / 3 0 0 . • > / / 2 5 0 V ' / X 2 0 0 X X 1 5 0 X / 1 0 0 5 0 0 . . . • — 2 5 -3 4 3 5 - 4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 A G E G R O U P S 7 5 + Figure 124. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Lung Cancer, White Females • S E S 1 - S E S 4 • S E S 2 “ S E S 5 S E S 3 _ 6 0 0 C C 4 5 0 4 0 0 uj 3 5 0 S 200 Q 3 5 - 4 4 4 5 -5 4 A G E G R O U P S 7 5 + 208 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 125. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Lung Cancer, Black Males - - S E S 3 6 5 0 - C O Ui 3 5 0 ! W 2 5 0 - u j 2 0 0 a O 1 5 0 z 100 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 126. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Lung Cancer, Black Females 7 0 0 .0 0 6 5 0 .0 0 : _ 6 0 0 .0 0 : I 5 5 0 .0 0 i o 5 0 0 .0 0 : Qj 4 5 0 .0 0 t 4 0 0 .0 0 i UJ 3 5 0 .0 0 , § 3 0 0 .0 0 g 2 5 0 .0 0 m 200.00 Q i o 1 5 0 .0 0 ~ 100.00 5 0 .0 0 0.00 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S S E S 1 S E S 4 'S E S 2 S E S 5 S E S 3 j I 209 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 127. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Lung Cancer, Hispanic Males i — ■ - S E S 1 ------- — S E S 2 - - - S E S 3 ! : S E S 4 ----------— S E S 5 ! | 7 0 0 ! 6 5 0 ' _ 6 0 0 i 2 § 5 5 0 i § 5 0 0 4 5 0 i UJ ! t 4 0 0 | UJ 3 5 0 £ 3 0 0 i S 2 5 0 ! u j 2 0 0 i O : O 1 5 0 - 100 5 0 0 1 5 - 2 4 2 5 - 3 4 3 5 - 4 4 4 5 - 5 4 5 5 - 6 4 6 5 - 7 4 7 5 + A G E G R O U P S Figure 128. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Lung Cancer, Hispanic Females • S E S 1 - S E S 4 — S E S 2 S E S 5 - S E S 3 UJ 3 5 0 W 2 5 0 1 5 -2 4 2 5 - 3 4 3 5 - 4 4 4 5 -5 4 A G E G R O U P S 5 5 -6 4 6 5 - 7 4 7 5 + 210 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 129. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Lung Cancer, Asian Males O o o o 0 C C UJ C O u i 1 UJ o z UJ o o z / 0 0 6 5 0 6 0 0 5 5 0 5 0 0 4 5 0 4 0 0 3 5 0 3 0 0 2 5 0 2 0 0 1 5 0 1 0 0 5 0 0 1 5 -2 4 • S E S 1 - S E S 4 ■ S E S 2 S E S 3 2 5 -3 4 3 5 - 4 4 4 5 -5 4 5 5 -6 4 A G E G R O U P S 6 5 -7 4 7 5 + Figure 130. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Lung Cancer, Asian Females •S E S 1 - S E S 4 - S E S 2 - S E S 5 S E S 3 5 5 0 5 0 0 t r 4 5 0 UJ 3 5 0 u j 2 0 0 Q 2 5 -3 4 3 5 - 4 4 4 5 -5 4 A G E G R O U P S 5 5 -6 4 6 5 -7 4 7 5 + Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 131. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Lung Cancer, All Males j S E S 1 — — S E S 2 - - - S E S 3 | i S E S 4 - S E S 5 | 7 0 0 | 6 5 0 i 6 0 0 ! § 5 5 0 o 5 0 0 | UJ 3 5 0 : £ 3 0 0 I o 2 5 0 ' m 200 ! Q | O 1 5 0 - 100 5 0 I 0 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + I A G E G R O U P S | Figure 132. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Lung Cancer, All Females - ■ ' S E S 1 — — S E S 2 - - - S E S 3 I ....................S E S 4 - S E S 5 __________________________ ; 7 0 0 ----------------------------------------------------------------------------------------------------------------------------------------- 6 5 0 ~ 6 0 0 ■ § 5 5 0 o 5 0 0 g 450 S i 4 0 0 uj 3 5 0 ^ 3 0 0 £ 2 5 0 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S 212 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Melanoma White people experience the highest incidence rates of melanoma than any other racial/ethnic group (Table 15, Figures 133-142). Compared to white men, white women have much lower melanoma risk at older ages. For both white men and women, the incidence rates start before age 15 and steadily increase with age until ages 25-34. After ages 25-34, the incidence rates for white males continue to climb, whereas the rates for white females start to level off for the remaining years of life. For other populations the incidence rates for melanoma are relatively low across all ages. The positive SES association in melanoma incidence rates was found in both white men and women at all ages. With white men, the differences between the highest and lowest SES groups becomes larger as the age increases, whereas for white females the differences in risk between SES groups remain almost constant after age 34. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 15. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Melanoma MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 3.82 13.79 22.76 34.32 47.55 61.70 71.73 SES2 2.92 9.22 18.50 25.49 34.41 44.78 49.51 SES3 3.28 9.71 15.22 24.03 31.19 38.41 50.54 SES4 1.96 8.03 12.68 16.13 23.95 30.03 39.99 SES5 1.56 4.23 10.17 13.56 17.66 25.13 31.20 BLACK SES1 0.00 0.00 2.84 0.00 7.31 14.06 13.33 SES2 1.38 0.69 1.53 0.00 9.36 14.11 0.00 SES3 0.00 0.74 0.00 3.15 6.82 0.00 0.00 SES4 0.00 0.00 0.00 0.79 1.05 5.06 9.62 SES5 0.23 0.00 0.93 1.12 2.40 3.52 8.44 HISPANIC SES1 2.46 1.44 3.46 4.71 6.18 14.07 0.00 SES2 0.63 0.99 2.26 6.92 8.66 15.19 6.41 SES3 0.27 2.23 2.86 4.31 8.87 17.45 15.08 SES4 0.30 0.44 1.81 3.97 5.21 7.53 20.34 SES5 0.26 0.73 1.09 2.87 4.08 9.59 14.53 ASIAN SES1 0.00 0.47 0.00 0.61 0.00 7.41 5.67 SES2 0.48 0.00 0.61 1.71 0.00 7.62 4.95 SES3 0.00 0.00 0.98 0.00 1.06 5.12 3.57 SES4 0.00 0.00 0.00 0.00 1.05 0.00 4.08 SES5 0.55 0.00 0.00 0.00 0.00 3.44 5.62 OTHER SES1 0.00 0.00 0.00 0.00 10.19 20.59 40.03 SES2 0.00 0.00 0.00 3.87 0.00 0.00 21.59 SES3 0.00 0.00 0.00 2.95 0.00 9.12 0.00 SES4 0.00 0.00 0.97 0.00 3.55 0.00 22.90 SES5 0.00 0.00 0.00 0.00 4.62 7.65 10.99 ALL SES1 3.16 11.12 18.46 29.02 42.65 57.24 66.93 SES2 2.27 6.98 14.13 20.84 29.96 40.60 45.33 SES3 1.93 6.37 10.00 17.28 25.19 32.76 44.12 SES4 0.82 3.34 5.81 9.02 15.44 21.18 32.43 SES5 0.48 1.14 2.79 5.08 8.21 13.66 20.20 (To be continued) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 15. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Melanoma (continued) FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 5.63 17.97 22.35 25.39 24.56 27.28 26.22 SES2 4.72 15.77 18.79 18.51 21.76 22.75 23.44 SES3 3.73 14.18 15.97 17.77 19.61 22.00 22.65 SES4 2.05 9.30 11.13 12.30 13.79 16.96 21.66 SES5 1.21 5.45 5.19 11.13 11.88 17.11 15.22 BLACK SES1 0.90 0.00 1.89 2.59 7.20 14.30 26.56 SES2 1.34 0.62 3.23 2.37 2.32 7.66 0.00 SES3 0.31 0.30 1.20 1.55 1.09 7.70 3.53 SES4 0.20 0.33 1.38 2.02 0.89 2.87 4.91 SES5 0.33 0.27 0.17 0.23 1.65 2.50 5.00 HISPANIC SES1 1.23 9.15 8.15 2.97 12.99 12.15 6.62 SES2 1.18 5.05 6.96 11.48 8.87 15.23 14.50 SES3 1.32 1.65 4.43 4.04 5.32 11.02 13.33 SES4 0.50 1.61 3.45 3.68 5.91 5.62 13.16 SES5 0.55 1.10 2.18 2.91 4.04 9.68 16.96 ASIAN SES1 0.00 1.64 0.79 1.22 4.87 0.00 0.00 SES2 0.00 0.36 0.43 0.00 0.00 0.00 9.22 SES3 0.70 0.31 0.00 2.76 3.86 0.00 6.44 SES4 0.00 0.00 0.00 1.38 0.00 0.00 2.55 SES5 0.00 0.00 0.00 2.17 0.00 0.00 0.00 OTHER SES1 0.00 1.64 2.02 4.35 8.42 0.00 0.00 SES2 0.00 0.00 0.00 3.55 11.53 0.00 0.00 SES3 0.00 0.84 2.92 2.23 0.00 0.00 10.31 SES4 0.00 1.18 0.00 0.00 3.29 4.91 0.00 SES5 0.00 0.00 0.00 1.85 2.96 4.24 6.61 ALL SES1 4.47 14.64 18.12 21.57 22.56 25.16 24.81 SES2 3.62 12.02 14.59 15.68 19.17 20.94 22.21 SES3 2.52 8.68 10.50 13.00 15.85 19.19 20.94 SES4 0.98 4.06 5.51 7.22 9.33 12.46 18.26 SES5 0.55 1.45 1.91 4.07 5.53 9.63 11.84 215 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 133. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Melanoma, White Males 13E51 — — SES2 - - - SES3 SES4 SES5 1 6 5 o 6 0 .. o 5 5 . O ' „ u j 5 0 .. ^ 4 5 UJ 4 0 .. 3 5 .. u j 3 0 . g 2 5 .. g 20.. O 1 5 .. ^ 10.. 5 5 -6 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 45-54 65-74 7 5 + AGE GROUPS i Figure 134. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Melanoma, White Females — ~ ~ 1 35E51 — — SES2 - - - SES3 SES4 SES5 7 5 . 7 0 .. 1 6 5 . 8 6 0 5 5 .. O ' „ u j 5 0 .. ~ 4 5 . S 4 0 -. 3 5 .. l- UJ o z 2 5 .. g 2 0 a 15 .. ^ 10.. 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 - 5 4 5 5 -6 4 65-74 7 5 + AGE GROUPS 216 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 135. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Melanoma, Black Males I5E 5T — — SE52 - - - SES3 ] SES4 -SES5 I _______________________________ i 7 5 ■ 7 0 I 6 5 o 6 0 . o S 5 5 uj 5 0 -- — 4 5 .. c o U J 4 0 - u j 3 0 - - § 2 5 . . g 20 . O 1 5 - - 1 0 - 2 5 -3 4 1 5 -2 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + AGE GROUPS Figure 136. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Melanoma, Black Females :5 E S 1 ------- — ' — SES2------- - " S E S 3 SES4 SES5 7 5 . 7 0 . 1 6 5 - . 9 6 0 . o 5 5 .. £ E „ u j 5 0 .. — 4 5 m 4 0 - 3 5 .. UJ o z_ 25 g 20.. O 15 - 1 0 -- 6 5 -7 4 7 5 + 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 AGE GROUPS Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 137. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Melanoma, Hispanic Males I5 E 5 1 — — S E 52 - - - S E S 3 I S E S 4 - - - - - - - - - - - - -S E S 5 I 75 . 70 .. 65 .. 60 .. ” 55 .. u 50 - . ~ 45 .. U J 40 -. 35 .. m 30 - - g 25- a 20 . O 15 . - 1 0 . o o o o o 15-24 25-34 35-44 45-54 5 5 -6 4 65-74 7 5 + A G E G R O U P S Figure 138. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Melanoma, Hispanic Females S E S 2 - - S E S 3 S E S 4 S E S 5 7 0 .. 6 5 .. 6 0 - 55- B 5 0 - 45- l u 4 0 3 5 - u i 3 0 • ■ ^ 2 5 - g 20 O 1 5 - 1 0 • o o o o' o 1 5 - 2 4 2 5 -3 4 65-74 3 5 -4 4 4 5 -5 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 139. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Melanoma, Asian Males I5E51 — — SESZ - - - SES3 SES4 - -SES5 7 5 .. 7 0 .. g 6 5 . o 6 0 - - ° 5 5 . S 5 0 — 4 5 U J 4 0 - 3 5 .. iu 3 0 - g 2 5 . g 20-. O 1 5 • • - 1 0 - ■ 1 5 - 2 4 2 5 -3 4 3 5 - 4 4 6 5 -7 4 4 5 -5 4 7 5 + A G E G R O U P S Figure 140. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Melanoma, Asian Females ^E S I -— SES2 SES3" ? S E S 4 S E S 5 7 5 ■ 7 0 - 6 5 - 6 0 . 5 5 . cr „ uj 5 0 - ^ 4 5 ‘ UJ 4 0 - 3 5 - u j 3 0 - y 2 5 ■ S 20 O 1 5 - o o o o" o 1 5 - 2 4 2 5 -3 4 3 5 - 4 4 4 5 -5 4 6 5 -7 4 7 5 + A G E G R O U P S 219 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 141. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Melanoma, All Males o o o o (T U J 0 . UJ o Z UJ Q O -S E S 1 • S E S 4 =SEST S E S 5 ' - “S E S T 8 0 7 5 7 0 6 5 6 0 5 5 5 0 4 5 4 0 3 5 3 0 2 5 2 0 1 5 1 0 5 0 1 5 - 2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 6 5 - 7 4 7 5 + A G E G R O U P S Figure 142. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Melanoma, All Females S E 5 1 -------------= ~ = 5 E S 2 ------------ _ - ~ - S E S 3 ' ' S E S 4 S E S 5 8 0 7 5 7 0 6 5 6 0 5 5 5 0 4 5 4 0 3 5 3 0 2 5 2 0 1 5 1 0 5 0 1 5 - 2 4 2 5 -3 4 6 5 - 7 4 3 5 -4 4 4 5 -5 4 7 5 + A G E G R O U P S 220 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Ovary The risk of ovarian cancer increases with age. Ovarian cancer incidence rates start with a low level of approximately 1 to 3 per 100,000 at ages 15-24, then gradually increase with age (Table 16, Figures 143-147). The pattern of age-specific incidence rates for ovarian cancer is similar among racial/ethnic populations. The SES is found positively related with ovarian cancer risk among the total female population. This may be due to small numbers of cases. The age-specific incidence rates fluctuate over age groups and across SES groups in black, Hispanic, and Asian women. The positive SES relationship is relatively clear in white women, although it is not monotonically consistent over age. For all women combined, this SES pattern starts to show after age 35-44. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 16. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Ovarian Cancer FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 1.86 5.07 12.01 31.81 52.31 62.75 59.84 SES2 1.79 4.49 14.04 30.96 49.38 61.91 58.68 SES3 2.54 4.26 13.76 30.92 50.11 55.77 60.98 SES4 1.84 5.67 14.52 27.92 44.29 52.68 57.07 SES5 2.91 4.39 13.04 28.25 41.50 54.24 58.81 BLACK SES1 2.78 9.83 8.80 11.38 17.48 68.82 53.39 SES2 2.79 0.62 7.74 15.27 35.31 27.56 83.78 SES3 1.35 4.31 8.67 11.39 25.98 56.22 34.51 SES4 1.62 2.94 8.01 16.25 26.28 43.17 34.09 SES5 1.87 2.52 5.51 15.94 28.12 0 38.02 48.30 HISPANIC SES1 3.03 5.53 10.39 18.28 19.77 49.24 49.16 SES2 4.16 4.65 10.06 23.53 38.97 51.72 54.95 SES3 2.04 5.34 9.86 30.46 33.27 35.82 59.09 SES4 2.43 4.29 11.60 27.34 35.95 53.59 59.39 SES5 2.73 4.28 11.04 23.93 36.19 44.92 63.25 ASIAN SES1 1.10 3.57 7.23 26.81 23.01 19.66 18.43 SES2 1.40 4.46 9.47 16.75 19.83 13.95 7.82 SES3 1.05 4.20 9.47 17.25 22.11 12.44 20.54 SES4 2.69 2.59 9.57 19.26 22.24 17.56 22.39 SES5 1.93 2.22 2.34 16.22 15.93 33.34 22.98 OTHER SES1 3.51 4.92 11.54 31.41 16.85 50.71 0.00 SES2 1.14 3.81 12.24 29.49 11.53 36.36 27.80 SES3 0.00 5.87 6.50 12.05 24.25 26.61 29.58 SES4 0.48 3.55 9.90 17.62 23.27 29.35 30.22 SES5 0.91 2.20 5.11 12.06 11.03 0.00 14.74 ALL SES1 1.97 5.16 11.29 30.05 48.49 60.53 57.59 SES2 2.10 4.24 12.81 28.70 46.37 58.43 57.33 SES3 2.09 4.52 11.94 27.72 44.85 51.63 58.31 SES4 1.98 4.36 11.78 24.79 38.20 48.89 53.23 SES5 2.40 3.63 9.04 21.57 33.34 44.39 53.47 222 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 143. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Ovarian Cancer, White Females 3 3 E 5 1 — — S E S 2 - - - S E S 3 S E S 4 S E S 5 8 5 .. 8 0 - 7 5 .. 7 0 - • 6 5 .. £ 6 0 £ 5 5 5 0 - t o ~Z u i 4 5 ■ 4 0 .. u j 35.. O 3 0 .. 2 5 .. 2 0 .. 1 5 - 1 0 - o o o o o 1 5 - 2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 144. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Ovarian Cancer, Black Females ^S E S I — — S E S 2 - - ' S E S 3" S E S 4 S E S 5 8 5 . 8 0 . § 7 5 o 7 0 .. o 6 5 S 6 0 .. £ 55.. 5 0 . to " U J 4 5 .. 1 UJ o z 3 0 .. t u 2 5 .. 9 2 0 ■ 2 1 5 1 0 .. 1 5 - 2 4 2 5 - 3 4 5 5 -6 4 6 5 -7 4 7 5 + 4 5 -5 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 145. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Ovarian Cancer, Hispanic Females BEST---------- = ^ -= = 5 E 3 2 ------ i V - . 5E55T S E S 4 ---------- — S E S 5 8 5 .. 8 0 - g 7 5 - S 70 - o 6 5 - £ 6 0 g 5 5 . . « 5 0 UJ 4 5 . 4 0 . i u j a 3 0 . . g 2 5 . Q 20 - g 1 5 - " 1 0 . o r~ "- 1 5 - 2 4 2 5 - 3 4 4 5 -5 4 6 5 - 7 4 3 5 - 4 4 7 5 + A G E G R O U P S Figure 146. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Ovarian Cancer, Asian Females BEST SE52 - SES3 S E S 4 . .. . -S E S 5 ! 8 5 . . 8 0 ■ § 7 5 - <=> 7 0 - . o 6 5 . . £ 6 0 . . £ 5 5 — 5 0 . . u i 4 5 - t 4 0 . “ 3 5 . . U J o n O 3 0 . g 2 5 - - 9 20 - g 1 5 - " 1 0 . 1 5 - 2 4 2 5 - 3 4 4 5 - 5 4 6 5 - 7 4 7 5 + 3 5 - 4 4 A G E G R O U P S 224 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 147. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Ovarian Cancer, All Females IS E 5 1 — S E S 2 - - - S E S 3 | S E S 4 ------------------ S E S 5 | 8 5 .. 8 0 .. o 75- < = > 7 0 .. 8 6 5 .. 5 6 0 S 5 5 “ 5 0 .. 0 5 V r U J 4 5 4 0 .. 3 5 . 3 0 . 2 5 .. 2 0 .. 1 5 . 1 0 .. i- £ UJ o z UJ □ o z 2 5 -3 4 6 5 -7 4 1 5 -2 4 3 5 -4 4 4 5 -5 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Pancreas The pancreatic cancer incidence rates are also related with age (Table 17, Figures 148- 157). There is very little difference in pancreatic cancer risk among racial/ethnic groups. Women in general have a slightly lower risk than men, but the differences are very small compared to other cancers where sex is a predictor. There is essentially no consistent SES variation across age in the incidence rates of pancreatic cancer. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 17. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Pancreatic Cancer MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.11 0.21 1.74 8.24 23.81 56.65 96.67 SES2 0.05 0.27 2.32 9.32 27.83 60.47 91.07 SES3 0.10 0.45 2.00 9.97 27.13 58.74 91.04 SES4 0.00 0.50 1.73 8.83 28.64 56.82 92.70 SES5 0.21 0.17 2.48 9.95 30.25 62.76 80.50 BLACK SES1 0.00 0.00 2.91 7.93 30.75 72.66 92.52 SES2 0.00 0.00 4.06 10.90 35.67 74.82 126.52 SES3 0.00 0.34 2.57 17.40 32.61 78.44 107.01 SES4 0.20 0.18 3.06 14.45 37.21 82.48 96.15 SES5 0.00 0.15 3.74 16.31 43.21 67.33 116.40 HISPANIC SES1 0.61 0.00 0.94 3.47 37.16 49.60 212.28 SES2 0.00 0.33 2.29 9.96 27.02 87.91 136.86 SES3 0.00 0.51 2.49 9.28 23.62 64.23 99.32 SES4 0.00 0.09 1.23 11.97 24.41 61.34 80.97 SES5 0.06 0.30 1.41 6.65 26.95 62.89 99.64 ASIAN SES1 0.00 0.00 2.29 4.20 10.41 18.51 51.46 SES2 0.00 0.00 0.61 3.41 8.36 33.06 99.35 SES3 0.00 0.00 1.53 6.94 14.21 42.42 73.27 SES4 0.00 0.31 2.18 3.18 20.15 27.27 46.96 SES5 0.00 0.00 1.89 1.19 8.54 37.76 84.16 OTHER SES1 0.00 0.00 0.00 9.53 0.00 58.94 0.00 SES2 0.00 0.00 0.00 7.18 18.35 24.62 0.00 SES3 0.00 0.89 1.92 5.43 14.53 64.89 44.35 SES4 0.00 0.00 1.49 0.00 4.69 24.55 57.72 SES5 0.41 0.00 0.00 2.45 12.77 22.96 80.88 ALL SES1 0.13 0.17 1.77 7.75 23.59 55.20 96.40 SES2 0.04 0.24 2.23 9.02 26.92 60.32 92.62 SES3 0.06 0.43 2.09 10.14 26.09 58.93 90.62 SES4 0.04 0.28 1.84 9.74 28.16 57.59 88.31 SES5 0.09 0.22 2.18 9.67 31.06 61.17 91.92 (To be continued) 227 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 17. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Pancreatic Cancer (continued) FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.11 0.05 1.31 5.66 15.47 38.71 67.88 SES2 0.11 0.18 1.37 5.78 18.44 41.00 70.75 SES3 0.00 0.17 2.04 6.22 19.66 42.62 66.29 SES4 0.00 0.25 1.48 6.68 19.34 36.57 63.21 SES5 0.00 0.21 2.09 7.94 22.80 41.53 63.94 BLACK SES1 0.00 0.00 0.94 10.52 14.41 57.21 117.29 SES2 0.00 0.62 3.06 7.56 26.45 57.72 77.41 SES3 0.00 0.00 0.52 9.26 19.83 45.76 89.35 SES4 0.15 0.00 1.92 7.72 25.01 57.68 106.66 SES5 0.00 0.13 2.72 8.30 23.65 55.84 100.29 HISPANIC SES1 0.00 0.57 1.61 4.25 17.50 62.84 90.45 SES2 0.00 0.33 2.66 2.89 16.70 45.08 103.81 SES3 0.36 0.00 2.86 6.76 16.04 35.98 83.74 SES4 0.00 0.00 0.62 5.93 15.52 40.50 87.58 SES5 0.00 0.41 2.38 3.93 19.83 47.28 96.60 ASIAN SES1 0.00 0.36 0.36 5.25 12.27 24.99 38.15 SES2 0.00 0.00 0.00 3.16 2.33 26.08 52.48 SES3 0.00 0.31 1.01 4.84 9.65 33.21 79.92 SES4 0.00 0.35 0.50 3.50 5.42 31.32 53.12 SES5 0.00 0.00 0.91 1.10 12.27 30.47 78.86 OTHER SES1 0.00 0.00 0.00 0.00 8.42 13.18 25.29 SES2 0.00 1.25 0.00 6.12 12.51 26.76 55.15 SES3 0.00 0.00 0.00 0.00 11.49 38.73 17.62 SES4 0.00 0.00 0.00 0.00 9.45 9.79 23.48 SES5 0.00 0.00 0.00 1.85 0.00 8.63 14.74 ALL SES1 0.09 0.11 1.20 5.72 15.28 38.89 67.69 SES2 0.08 0.24 1.44 5.48 17.71 40.73 71.18 SES3 0.07 0.13 1.84 6.29 18.54 41.82 67.46 SES4 0.02 0.12 1.19 6.19 18.29 38.81 67.69 SES5 0.00 0.26 2.21 6.00 20.82 45.47 78.29 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 148. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Pancreatic Cancer, White Males — - S E S 2 - S E S 5 - S E S 3 220 .. 200 .. 1 8 0 . . 1 6 0 . . 1 4 0 1 5 - 2 4 2 5 - 3 4 3 5 - 4 4 4 5 - 5 4 A G E G R O U P S 5 5 -6 4 6 5 - 7 4 7 5 + Figure 149. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Pancreatic Cancer, White Females IS E 51 — — S E S 2 - - S E S 3 i S E S 4 - S E S 5 I 2 4 0 220 .. ° 200 .. 1 8 0 . O o o o a : 1 6 0 . . UJ 9 = , 1 4 0 . . CO U J 1 2 0 . £ 1 0 0 .. UJ O 8 0 . | 6 0 . . ^ 4 0 . . 2 0 . 5 5 - 6 4 6 5 - 7 4 1 5 - 2 4 2 5 - 3 4 3 5 -4 4 4 5 - 5 4 7 5 + A G E G R O U P S 229 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 150. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Pancreatic Cancer, Black Males iSEsr - S E S 4 - S E S 2 - S E S 5 - S E S 3 200 .. 180 . 140 .. 3 5 -4 4 4 5 -5 4 5 5 -6 4 A G E G R O U P S 7 5 + Figure 151. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Pancreatic Cancer, Black Females 35E 51 -— “ — S E S 2 - 'S E S 3 I S E S 4 S E S 5 , 2 4 0 r 220 . S 200 - © o 180 - o ^ 160 - c c UJ a . 140 - UJ 1 2 0 - - UJ o z UJ g o z 1 0 0 - 8 0 .. 6 0 ■ 4 0 • 2 0 - 6 5 -7 4 1 5 -2 4 2 5 - 3 4 3 5 -4 4 4 5 -5 4 7 5 + A G E G R O U P S 230 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 152. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Pancreatic Cancer, Hispanic Males -S E sr - S E S 4 • S E S 2 •S E S 5 S E S 3 220 .. 1 8 0 .. u j 120 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 A G E G R O U P S 7 5 + Figure 153. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Pancreatic Cancer, Hispanic Females — ---------SEsr : .................... S E S 4 = S E 5 2 T ■SES5 ~ m m m S E S 3 220 .. u j 1 2 0 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 A G E G R O U P S 6 5 -7 4 7 5 + Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 154. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Pancreatic Cancer, Asian Males i5E5r S E S 4 2 4 0 r 220 .. 200 .. 1 8 0 . . O' 1 6 0 . . u i i . 1 4 0 . . 120 .. 100 .. 8 0 .. 6 0 .. 4 0 ■ 2 0 .. 1 5 -2 4 2 5 -3 4 4 5 -5 4 A G E G R O U P S 6 5 -7 4 Figure 155. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Pancreatic Cancer, Asian Females ^ S E 5 T S E S 4 S E S 3 2 4 0 r 220 .. 200 1 8 0 .. 1 6 0 .. t 1 4 0 .. 120 .. 100 8 0 .. 6 0 . 4 0 . 2 0 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S 232 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 156. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Pancreatic Cancer, All Males O O o o' o T — Q C UJ C L CO H i I H i ; o 2 i UJ ; o o 1 2 O it\ 2 2 0 2 0 0 1 8 0 1 6 0 1 4 0 1 2 0 1 0 0 8 0 . 6 0 4 0 2 0 0 1 5 -2 4 •S ES1 • S E S 4 ■5E 52" S E S 5 S E S 3 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 A G E G R O U P S 6 5 - 7 4 7 5 + Figure 157. Age-specific Incidence Rates by SESt Los Angeles County, 1972-92, Pancreatic Cancer, All Females 2 4 0 o o o o' 0 1 — (Z U J CL CO U J 1 U i o z U J Q o z -SES1 - S E S 4 ^sesr S E S 5 - - - SES3 3 5 -4 4 4 5 - 5 4 5 5 -6 4 A G E G R O U P S 7 5 + 233 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Prostate As seen in Table 18 and Figures 158-162, the risk of developing prostate cancer increases with age. The significant increase in the incidence rates of prostate cancer begin after age 45-54 for white, black, and Hispanic men, and age 55-64 for Asians. The incidence rates continue to grow steadily into old age in all racial/ethnic populations. The positive SES association with prostate cancer risk shows that across ages in white men, the increasing risk of prostate cancer is associated with an increasing SES. The differences between SES groups in whites are relatively small, but consistent In black and Hispanic men, such positive SES association is not consistent across ages. There seems no relationship between SES and prostate cancer in Asian men. 234 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 18. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Prostate Cancer MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.06 0.06 0.39 18.15 178.57 683.45 1121.25 SES2 0.00 0.04 0.52 15.02 144.78 573.30 1024.89 SES3 0.00 0.05 0.62 15.67 141.22 521.26 963.36 SES4 0.11 0.00 0.59 11.63 122.37 473.05 905.07 SES5 0.00 0.00 0.83 15.37 122.57 436.33 886.18 BLACK SES1 0.00 0.00 0.00 42.18 306.43 1116.99 1737.41 SES2 0.00 0.00 0.85 29.56 409.35 1007.38 1390.02 SES3 0.00 0.00 1.70 36.08 304.14 873.88 1518.52 SES4 0.00 0.00 1.80 33.47 272.08 894.20 1488.45 SES5 0.00 0.30 2.36 30.91 232.13 735.93 1381.93 HISPANIC SES1 0.00 0.79 0.00 21.92 145.19 814.45 1515.30 SES2 0.00 0.00 1.15 12.39 159.94 567.68 1247.76 SES3 0.00 0.00 1.01 17.67 151.27 561.39 972.88 SES4 0.06 0.09 0.32 9.02 119.20 465.04 975.83 SES5 0.00 0.06 0.50 8.25 109.95 466.33 964.26 ASIAN SES1 0.00 0.00 0.00 4.34 31.47 208.43 461.12 SES2 0.00 0.00 0.00 2.61 39.23 230.26 612.12 SES3 0.00 0.00 0.00 4.69 44.37 216.89 617.35 SES4 0.00 0.00 0.00 2.37 38.19 191.92 615.35 SES5 0.00 0.00 0.00 3.48 39.66 182.32 452.23 OTHER SES1 0.00 0.00 0.00 9.53 93.42 536.13 679.04 SES2 0.00 0.00 0.00 11.60 67.83 320.47 586.23 SES3 0.00 0.00 0.00 2.48 43.52 147.64 453.75 SES4 0.00 0.00 0.00 0.00 22.31 211.15 332.98 SES5 0.00 0.00 0.00 0.00 26.62 169.87 429.13 ALL SES1 0.04 0.10 0.31 18.11 173.64 673.58 1110.68 SES2 0.00 0.03 0.54 14.63 147.54 564.44 1018.10 SES3 0.00 0.03 0.70 16.30 143.45 514.69 955.47 SES4 0.06 0.03 0.64 13.55 134.56 497.19 936.15 SES5 0.00 0.09 0.97 15.74 142.47 498.22 968.35 235 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 158. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Prostate Cancer, White Males J 5 E 5 1 — — SE52 - - - SE S3 S E S 4 ----------------S E S 5 2 0 0 0 1 8 0 0 . . O o 1 6 0 0 • - o © ° 1 4 0 0 - £ 1 2 0 0 . u j 1 0 0 0 ■ 8 0 0 - U J o 6 0 0 -■ z U J Q O z 4 0 0 ■ 200 - 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 159. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Prostate Cancer, Black Males ^ E S I — — S E S 2 « ~ S E S 3 ~ " S E S 4 S E S 5 2000 1 8 0 0 •. O o o o o 1 6 0 0 - ^ 1 4 0 0 - - S 1200-- u j 1 0 0 0 - - 8 0 0 -. U J o z U l a u z 6 0 0 .. 4 0 0 . 200 1 5 -2 4 3 5 -4 4 4 5 -5 4 6 5 -7 4 7 5 + 2 5 -3 4 A G E G R O U P S 236 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 160. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Prostate Cancer, Hispanic Males »S E S 1 - S E S 4 — S E S 2 - S E S 5 - - - SES3 > ! O • o : o ! © ; O I UJ I I C O : u j ;1 U J is is o Z Figure 161. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Prostate Cancer, Asian Males ~ i=.~ ^5E51-------— —'S E 52------ - - SES3 i : S E S 4 S E S 5 | 2000 1 8 0 0 1 1 6 0 0 O ° 1 4 0 0 S l 1200 2 1000 2 8 0 0 U J Z 6 0 0 UJ § 4 0 0 z 200 0 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S 237 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 162. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Prostate Cancer, All Males j 2000 _ j 1 8 0 0 .. j § 1 6 0 0 . | 2 1 4 0 0 . . : tr ! £ 1200 .. ; 2 1000 . ! ^ i K 8 0 0 .. U J i Z 6 0 0 .. U J Q O 4 0 0 . , z 200 - 0 . _ 1 5 -2 4 238 ^ S E S I — — S E S 2 - - - S E S J S E S 4 ------------ — --------S E S 5 3 5 -4 4 4 5 -5 4 6 5 -7 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Rectum Rectal cancer risk increases with age (Table 19, Figures 163-172). Women tend to have relatively lower rectal cancer incidence rates than men. In blacks, Hispanics, and Asians, there are considerable fluctuations among SES groups in the age-specific incidence rates. This may be due to small numbers of cases in these populations. No consistent and monotonic SES trends were found in the age-specific rectal cancer incidence rates, but it seems high SES is associated with lower rectal cancer risk among white men. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 19. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Rectal Cancer MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.06 0.88 2.14 8.58 26.40 54.11 83.41 SES2 0.05 0.63 2.47 9.61 31.04 64.87 93.00 SES3 0.13 0.81 2.26 9.30 31.11 66.21 95.48 SES4 0.00 0.85 2.83 11.86 34.85 67.85 88.47 SES5 0.13 1.01 2.04 10.22 33.25 68.73 93.39 BLACK SES1 0.88 1.26 3.90 7.74 27.58 39.47 31.29 SES2 0.00 1.14 3.22 13.43 46.34 45.26 105.42 SES3 0.00 0.34 4.84 11.94 22.24 42.06 57.17 SES4 0.17 0.55 4.00 9.75 29.87 54.63 75.24 SES5 0.12 0.15 3.77 9.87 28.81 49.19 71.03 HISPANIC SES1 0.00 0.00 3.31 12.01 27.45 52.06 115.57 SES2 0.00 0.33 2.14 10.68 39.85 43.16 62.21 SES3 0.00 0.68 2.30 13.96 37.09 51.93 73.68 SES4 0.20 0.35 2.52 6.25 31.28 52.79 101.11 SES5 0.15 0.54 2.59 7.18 24.95 49.14 75.03 ASIAN SES1 0.00 0.69 3.24 13.83 22.28 45.64 85.12 SES2 0.00 0.42 2.83 7.72 19.16 34.88 77.19 SES3 0.36 0.71 3.90 4.49 28.12 56.30 63.91 SES4 0.00 0.93 1.35 9.72 25.40 39.56 41.68 SES5 0.00 0.56 2.37 11.58 28.39 42.83 77.96 OTHER SES1 0.00 0.00 2.32 3.74 35.12 78.12 88.28 SES2 2.20 0.00 11.20 7.73 11.28 74.05 0.00 SES3 0.00 1.69 0.00 13.35 20.33 27.35 14.42 SES4 0.45 1.32 3.44 0.00 4.69 30.56 34.35 SES5 0.00 0.64 2.77 0.00 11.69 29.55 30.09 ALL SES1 0.09 0.81 2.40 9.00 26.36 53.53 83.23 SES2 0.11 0.60 2.69 9.72 31.22 62.30 90.88 SES3 0.10 0.77 2.60 9.89 30.90 63.10 90.41 SES4 0.12 0.68 2.81 9.74 32.24 61.36 84.64 SES5 0.12 0.55 2.73 8.74 28.90 56.27 82.25 (To be continued) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 19. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Rectal Cancer (continued) FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.06 0.38 1.91 6.88 18.05 33.39 53.57 SES2 0.00 0.74 1.83 7.27 18.32 33.94 52.83 SES3 0.10 0.56 1.75 7.70 18.54 30.45 56.08 SES4 0.00 0.25 2.43 6.45 20.63 38.80 52.56 SES5 0.16 0.42 4.38 4.21 18.95 32.19 51.64 BLACK SES1 0.00 0.76 4.72 6.38 26.25 28.60 66.82 SES2 0.00 0.00 3.71 12.30 25.35 46.47 54.39 SES3 0.00 0.32 2.36 16.42 22.16 32.81 45.70 SES4 0.20 0.64 3.21 9.43 14.50 35.14 74.86 SES5 0.00 0.14 2.59 4.97 16.11 34.12 44.63 HISPANIC SES1 0.00 0.67 0.63 2.27 19.20 40.73 55.77 SES2 0.89 0.34 1.96 6.52 15.34 28.30 73.59 SES3 0.00 0.92 3.35 5.83 18.05 38.49 38.54 SES4 0.00 0.61 1.53 5.59 10.88 22.46 43.62 SES5 0.13 0.41 1.99 6.24 9.88 21.72 41.10 ASIAN SES1 0.55 0.36 5.22 5.62 9.75 25.61 36.41 SES2 0.00 0.36 3.60 3.90 16.46 33.77 46.48 SES3 0.00 0.36 2.41 5.56 13.51 21.96 39.84 SES4 0.00 0.00 1.90 6.89 14.32 28.03 37.38 SES5 0.00 0.64 4.56 9.76 21.97 25.73 49.65 OTHER SES1 0.00 0.00 0.00 4.35 32.27 39.04 46.52 SES2 0.00 1.25 4.08 3.06 6.26 27.17 0.00 SES3 0.00 0.83 1.72 0.00 15.11 32.47 18.97 SES4 0.00 1.78 0.85 10.97 0.00 19.52 22.66 SES5 0.00 0.00 1.20 3.70 5.92 17.27 0.00 ALL SES1 0.09 0.41 2.27 6.56 17.99 33.15 53.14 SES2 0.10 0.64 2.17 7.14 18.16 33.87 52.85 SES3 0.06 0.59 2.13 7.78 18.30 30.76 54.00 SES4 0.04 0.48 2.24 6.97 17.29 35.36 52.71 SES5 0.08 0.33 2.72 5.50 15.45 29.73 46.94 241 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 163. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Rectal Cancer, White Males 3 5 E S 1 -------— " — S E S 2------- - - S E S 3 S E S 4 - S E S 5 120 r 110 . o o o o " o y — 9 0 . . 8 0 . . { £ . U J < L co U J 70 6 0 . 5 0 .. U J O z U J d o z 4 0 .. 3 0 .. 2 0 .. 1 0 .. 2 5 -3 4 3 5 -4 4 4 5 -5 4 1 5 -2 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 164. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Rectal Cancer, White Females S E S 2 - - SE53 ■ S E S 4 S E S 5 120 T 110 .. o o o o' o 9 0 . 8 0 . < r U J 0 ; _ c o UJ 6 0 .. 5 0 U J o z UJ a o z 3 0 . 6 5 -7 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 7 5 + A G E G R O U P S 242 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 165. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Rectal Cancer, Black Males S E 5 1 — — S E S 2 - - - S E S 3 S E S 4 S E S 5 120 _ 110 .. g 100.. O o 9 0 .. o 5 8 0 U J 7 0 -- U J 6 0 - 5 0 .. i U J o z U J g o z 4 0 .. 3 0 - 20 - 10 .. 2 5 -3 4 6 5 -7 4 1 5 -2 4 3 5 -4 4 4 5 -5 4 7 5 + A G E G R O U P S Figure 166. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Rectal Cancer, Black Females I5E51 ----- — SES2 - - - SES3 j S E S 4 -S E S 5 120 110 Q O o o " o 8 0 . 7 0 . 6 0 . 5 0 .. U J o z 4 0 . U J 3 0 . 20 Q O Z 6 5 -7 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 7 5 + A G E G R O U P S 243 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 167. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Rectal Cancer, Hispanic Males I5E51 — — SE52 - - - SES3 SES4 -SES5 120 110 .. § 100.. o' 9 0 . o e 8 0 - U J ^ 7 0 . 3 6 0 £ 5 0 . UJ O 4 0 .. | 3 0 .. ■£ 20 10 .. ! 3 5 -4 4 6 5 -7 4 1 5 -2 4 2 5 -3 4 4 5 -5 4 7 5 + A G E G R O U P S Figure 168. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Rectal Cancer, Hispanic Females 15E 51----------- — — S E S 2 S E S 3 j S E S 4 S E S 5 ! ______________________________ I 120 110 .. o o o o ’ o 9 0 - - 8 0 - - 7 0 . t r UJ w 6 0 .. 5 0 .. O 4 0 .. | 3 0 .. 20 - 10 - 2 5 -3 4 3 5 - 4 4 4 5 -5 4 6 5 -7 4 7 5 + 1 5 -2 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 169. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Rectal Cancer, Asian Males IS E 51 — — S fc S 2 - - - S E S 3 S E S 4 - S E S 5 120 _ 110 .. o o o o' o ,— 9 0 . . 8 0 . 7 0 . K U i CL co u i 6 0 .. 5 0 .. UJ O z UI Q o z 4 0 - 3 0 . . 20 - 10 - 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S 1 ________________________________________________________________i Figure 170. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Rectal Cancer, Asian Females iS E S T------------ — '' — S E S 2 - - S E S 3 S E S 4 S E S 5 120 110 O o o o " o 8 0 -. IT UJ CO u i 7 0 - I UJ u z UJ a o z 5 0 .. 4 0 . 3 0 . 6 5 -7 4 7 5 + 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 A G E G R O U P S 245 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 171. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Rectal Cancer, All Males IS E 5 1 — — S E S Z - - - S E S 3 S E S 4 S E S S 120 110 .. o o o o' o 9 0 . 8 0 .. a. l U ( L « UJ 6 0 .. 5 0 .. u i o z U I g o z 4 0 .. 3 0 .. 20 ■ 10 .. 1 5 -2 4 2 5 - 3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 172. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Rectal Cancer, All Females TSE51------------- = - = S E 5 2 ---------- - - S E S 3 S E S 4 -S E S 5 120 110 . Q O O o " 9 0 . o E C 8 0 UJ 7 0 . w u j 6 0 . $ 5 0 .. O 4 0 .. | 3 0 .. 2 20 -. 10 . 4 5 -5 4 1 5 - 2 4 2 5 - 3 4 3 5 -4 4 5 5 - 6 4 6 5 -7 4 7 5 + A G E G R O U P S 246 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Stomach Table 20 and Figures 173-182 contain the age-specific incidence rates for stomach cancer by sex, race/ethnicity, and SES. Hispanics and Asians have higher stomach cancer incidence rates than whites and blacks across all ages. Negative SES association with incidence rates were found at almost all ages among Asian and white men but not women and not among other racial/ethnic groups. The differences between the highest and lowest SES groups grow larger as the age increases in Asian men. 247 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 20. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Stomach Cancer MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.06 0.59 1.54 7.95 23.21 44.70 92.22 SES2 0.00 0.22 1.42 10.22 26.90 56.19 94.60 SES3 0.10 0.65 2.84 10.80 25.87 55.14 105.77 SES4 0.00 0.50 2.90 12.77 31.85 58.90 110.55 SES5 0.00 0.34 4.41 14.30 33.58 71.95 110.60 BLACK SES1 0.00 0.91 5.82 21.28 29.65 77.75 66.65 SES2 0.00 1.72 2.37 10.73 36.26 50.61 115.29 SES3 0.36 1.05 4.27 14.16 31.13 96.57 153.77 SES4 0.00 1.10 4.40 18.34 55.56 108.89 159.89 SES5 0.00 0.75 5.99 25.05 49.73 113.44 160.62 HISPANIC SES1 0.00 0.00 6.42 8.17 40.61 123.12 60.88 SES2 0.00 1.64 3.71 13.91 45.28 106.37 157.61 SES3 0.27 1.03 4.92 12.26 32.53 113.07 224.98 SES4 0.20 1.68 4.67 13.39 47.89 104.11 215.69 SES5 0.30 1.17 6.40 16.51 53.00 128.51 232.08 ASIAN SES1 0.00 0.47 4.63 11.29 37.85 81.95 133.55 SES2 0.00 2.28 3.33 20.65 54.75 90.07 188.42 SES3 0.36 1.74 5.56 17.69 47.62 85.65 223.21 SES4 0.00 0.93 5.84 20.40 50.78 109.62 202.22 SES5 0.00 1.68 6.39 17.59 59.90 121.32 214.11 OTHER SES1 0.00 0.00 5.32 0.00 0.00 60.36 128.32 SES2 0.00 0.00 6.13 9.92 45.20 49.07 62.03 SES3 0.00 0.89 0.00 5.43 10.16 83.48 59.85 SES4 0.00 0.66 4.93 17.03 47.04 86.75 124.99 SES5 0.00 0.64 3.68 8.12 24.45 56.98 157.49 ALL SES1 0.04 0.55 2.31 8.66 24.43 48.57 93.03 SES2 0.00 0.60 1.94 11.23 29.81 59.44 99.92 SES3 0.18 0.85 3.50 11.69 28.07 63.38 118.80 SES4 0.07 1.01 4.01 14.60 39.58 75.46 131.97 SES5 0.16 0.93 5.79 18.10 45.01 99.26 153.77 (To be continued) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 20. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Stomach Cancer (continued) FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 0.17 0.22 1.13 3.99 9.23 21.47 47.64 SES2 0.05 0.38 1.37 3.81 11.94 21.22 51.13 SES3 0.00 0.56 1.05 4.40 11.56 22.87 49.72 SES4 0.06 0.90 1.44 5.32 10.31 25.91 54.05 SES5 0.16 0.21 2.86 4.98 15.03 23.66 56.30 BLACK SES1 0.00 0.00 0.00 15.86 15.98 78.14 68.88 SES2 0.61 0.52 0.81 2.60 14.18 42.39 66.35 SES3 0.00 1.24 3.51 3.01 12.99 52.37 92.14 SES4 0.00 0.96 4.17 5.99 18.60 43.96 77.14 SES5 0.12 0.93 2.12 7.07 17.04 43.09 80.74 HISPANIC SES1 0.00 1.14 0.80 9.78 29.74 49.97 185.12 SES2 0.38 0.33 2.93 9.66 21.68 52.11 88.07 SES3 0.31 1.66 3.84 7.57 24.70 43.17 127.12 SES4 0.00 1.21 5.72 9.77 21.83 50.52 104.78 SES5 0.28 2.30 3.64 11.77 27.55 55.13 127.52 ASIAN SES1 0.55 0.57 6.19 13.01 18.98 56.38 95.05 SES2 0.00 1.55 6.97 10.97 26.65 44.86 117.39 SES3 0.00 2.66 3.86 10.20 16.35 48.55 76.56 SES4 0.53 1.99 3.29 7.68 17.84 39.95 146.39 SES5 0.58 1.19 3.45 11.85 29.48 53.07 121.99 OTHER SES1 0.00 1.64 2.02 3.67 15.42 26.36 40.88 SES2 0.00 2.56 2.37 3.55 5.27 35.95 26.14 SES3 0.70 2.53 3.44 6.69 15.74 25.42 39.60 SES4 0.00 0.58 5.60 7.20 9.45 44.06 52.07 SES5 0.00 0.00 1.96 4.95 5.65 30.29 27.28 ALL SES1 0.18 0.33 1.59 5.28 10.66 24.98 51.64 SES2 0.12 0.54 2.02 4.67 13.31 24.13 53.65 SES3 0.09 1.10 2.12 5.30 13.31 26.95 55.08 SES4 0.06 1.08 3.50 6.68 13.95 32.21 63.04 SES5 0.22 1.42 2.97 8.43 19.77 38.49 77.30 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 173. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Stomach Cancer, White Males [ l S E f f l — — S E S 2 - - - S E 5 3 j ! S E S 4 S E S 5 I ! 220 .. i g 200. i I g 1 8 0 .. i £ 1 6 0 . > UJ I S t 1 4 0 . ! c o : u j 120 . i £ 100 . 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 6 5 -7 4 7 5 + ! A G E G R O U P S ! Figure 174. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Stomach Cancer, White Females I5E51 — — S E S 2 'S E S 3' S E S 4 S E S 5 2 4 0 220 . 1 2 0 0 o ‘ 1 8 0 . o X 1 6 0 . . UJ t 1 4 0 . lu 1 2 0 . 100 .. UJ o z UJ a o z 8 0 . 4 0 . 4 5 -5 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 6 5 -7 4 7 5 + A G E G R O U P S 250 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 175. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Stomach Cancer, Black Males •S E S 1 - S E S 4 • S E S 2 - S E S 5 S E S 3 220 .. 1 8 0 .. 120 .. 2 5 -3 4 3 5 -4 4 4 5 -5 4 5 5 -6 4 A G E G R O U P S 7 5 + | Figure 176. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Stomach Cancer, Black Females O o 0 a : UJ < o UJ 1 UJ o z UJ o C J z 2 4 0 220 .. - S E S T - S E S 4 i 5 E S 2 ” S E S 5 “ S E S 3 ~ 2 5 -3 4 3 5 -4 4 4 5 5 4 5 5 -6 4 6 5 7 4 A G E G R O U P S 7 5 + Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 177. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Stomach Cancer, Hispanic Males — . . - S E S 1 — — S E S 2 - - - S E S 3 ....................S E S 4 --------------- S E S 5 240 220 .. 200 .. 180 . o O O o' 0 K 1 6 0 - UJ 140 - UJ 120 - 1 100 - UJ O 80 .. | 60 .. Z 4 0 - 20 - 1 5 -2 4 25-3 4 35-44 45-54 55-64 65-74 75+ A G E G R O U P S Figure 178. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Stomach Cancer, Hispanic Females S E S 1 — - i S E S 2 - - - S E S 3 S E S 4 -S E S 5 240 r 220 . § 200 o o' o £ 1 6 0 .. UJ ^ 140 - u 120 .. 100 .. U 80 .. | 60 ^ 40 ■ i 15-24 25-3 4 35-44 55-64 65-74 75+ 45-54 A G E G R O U P S I 252 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 179. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Stomach Cancer, Asian Males -sesi -SES4 ■ S E S 2 -SES5 - S E S 3 I 8 200 . 180 - u j 1 2 0 . . 100 . 1 5 -2 4 25-34 35-44 45-54 55-64 AGE GROUPS 6 5 -7 4 7 5 + Figure 180. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Stomach Cancer, Asian Females 2 4 0 , O o o o' o O ' LU I ( L CO UJ UJ o z UJ Q O z ^3E5T -SES4 T SES5 "5E53" 220 . AGE GROUPS 253 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 181. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Stomach Cancer, All Males ! 8 O ’ o’ ! ° is I Q. i U i ; o ! z ; U J ! Q o z jsest - S E S 4 ■Sesi - S E S 5 - - - S E S 3 2 4 0 2 2 0 . 2 0 0 1 80 1 6 0 1 4 0 1 20 0 0 * 1 00 * ' * ^ 8 0 6 0 . 4 0 • 2 0 . 0 L. 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 A G E G R O U P S 5 5 -6 4 6 5 -7 4 7 5 + i Figure 182. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Stomach Cancer, All Females ;3E 5r - S E S 4 ■ S E S 2 “ S E S 5 S E S 3 220 .. m 120 3 5 -4 4 4 5 -5 4 A G E G R O U P S 6 5 -7 4 7 5 + 254 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Testis Test's cancer is a disease that attacks mostly young men (Tables 21, Figures 183-187). Test's cancer is more common in white and Hispanics males than in black and Asian males. The test's cancer incidence rates peak around ages 25-34 and then decline with age. A second peak, at a much lower level around ages 55-64, is seen in some populaton groups in Hispanics and Asians. The posih've relat'onship between SES and test's cancer risk is seen in white males and Hispanic males around ages 25-34. 255 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 21. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Testis Cancer MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 7.93 15.78 9.96 5.20 2.15 1.38 1.85 SES2 6.13 14.31 7.33 3.55 1.98 1.65 1.91 SES3 5.75 13.45 8.51 3.74 1.64 1.57 1.89 SES4 5.58 11.61 10.54 3.76 1.75 1.49 1.46 SES5 3.56 8.09 5.76 3.12 2.51 0.70 1.02 BLACK SES1 1.03 3.42 0.93 1.20 0.00 0.00 0.00 SES2 1.33 1.14 1.37 1.10 0.00 0.00 0.00 SES3 1.11 4.17 0.00 0.74 0.00 0.00 7.36 SES4 1.11 1.66 1.43 0.38 0.00 0.90 0.00 SES5 0.83 1.66 1.71 0.28 0.69 0.49 0.95 HISPANIC SES1 6.23 17.25 6.12 1.11 0.00 0.00 0.00 SES2 3.98 11.48 7.78 2.24 5.01 3.37 0.00 SES3 6.63 9.25 6.83 1.38 3.01 1.82 0.00 SES4 5.17 8.14 6.36 1.98 1.39 0.85 2.33 SES5 3.36 5.94 2.99 1.95 1.80 1.37 0.00 ASIAN SES1 0.53 1.86 0.90 0.61 0.00 0.00 0.00 SES2 0.48 4.23 1.00 0.90 1.29 0.00 0.00 SES3 1.43 1.52 1.40 0.73 2.22 0.00 0.00 SES4 0.36 2.31 1.21 0.00 0.00 0.00 0.00 SES5 1.09 1.73 0.94 1.15 0.00 1.80 0.00 OTHER SES1 1.89 1.97 4.65 0.00 0.00 0.00 0.00 SES2 2.20 2.65 2.53 0.00 0.00 0.00 0.00 SES3 0.00 3.39 1.28 0.00 0.00 0.00 0.00 SES4 0.70 0.66 2.47 0.00 3.55 0.00 0.00 SES5 1.22 1.20 0.00 2.45 3.53 0.00 0.00 ALL SES1 6.77 13.95 8.45 4.49 1.91 1.26 1.71 SES2 5.05 12.26 6.40 3.07 2.03 1.56 1.72 SES3 4.91 10.46 6.55 2.86 1.71 1.39 1.83 SES4 4.14 7.70 6.60 2.37 1.34 1.21 1.30 SES5 2.60 5.00 2.99 1.80 1.66 0.85 0.73 256 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 183. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Testis Cancer, White Males 5E5T S E S 4 I5E5? S E S 5 1 7 . . 1 6 . . § 1 5 - 1 4 . . o 1 3 . e 1 2 - a 1 1 • « 1 2 u j 9 1 UJ o z U j o ■ - g 4 .. O o i Z 3 2 5 -3 4 1 5 -2 4 3 5 -4 4 4 5 -5 4 6 5 - 7 4 7 5 + i A G E G R O U P S Figure 184. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Testis Cancer, Black Males iS E S I — - ^ 3 E S 2 ------------------------ S E S 3 S E S 4 S E S 5 17 .. S 1 5 O 14 - 0 13 .. K 1 2 - a 1 1 - a ' I 1 w L O 6 . g 5 9 4 - U - j Z 3 5 5 -6 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 6 5 -7 4 7 5 + A G E G R O U P S 257 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 185. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Testis Cancer, Hispanic Males 3 5 E S 1 ------ ---- — S E S 2------ -~~-S E 53 "j S E S 4 - - S E S 5 1 7 . . 16 - § 1 5 o 1 4 .. o 13 - K « - a i i - CO 1 ? ' u i 9 . u i O z UI Q O z 6 5 -7 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 -5 4 7 5 + A G E G R O U P S Figure 186. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Testis Cancer, Asian Males ;S E 5 1 — '■ — S E S 2 - - - sES3 i S E S 4 - S E S 5 i 17 . 16 .. o 15 o 14 . o 1 3 .. 5 1 2 - a 1 1 « 1 2 u j 9 . UJ o z UJ a o z 2 5 -3 4 5 5 -6 4 1 5 -2 4 4 5 - 5 4 6 5 -7 4 7 5 + A G E G R O U P S 258 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 187. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Testis Cancer, All Males • > * » S E S 1 — — S E S 2 . . . S E S 3 ....................S E S 4 --------------S E S 5 1 7 . . 1 6 . . 8 is o 1 4 . o 1 3 - K 12- . a 1 1 « 1 2 u j 9 . u i O z UI g o z 5 5 -6 4 6 5 -7 4 1 5 -2 4 2 5 -3 4 4 5 -5 4 7 5 + A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Thyroid Thyroid cancer occurs early in life, i.e., before age 15 (Table 22 and Figures 188-197). It is more common in women than in men. In white men, the risk of developing thyroid cancer increases steadily with age. In white women, the risk reaches the highest level around age 35-44 and then levels off. Black women of SES1 show the highest thyroid cancer incidence rate for age 75 and over, but the stability of the rate is questionable. The variation in thyroid cancer incidence rates by SES is observed mainly in white, which is also largely reflected in the total population. The increasing risk of thyroid cancer is associated with increasing SES. In total males, the positive relationship with SES is evident at each age group before age 65-74. However, in total females as well as in white females, the SES gradient in thyroid cancer incidence rates is more prominent around age 35-44. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 22. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Thyroid Cancer MALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 1.77 4.03 5.77 5.83 7.68 8.05 10.42 SES2 1.06 2.98 3.32 5.40 7.53 5.06 6.88 SES3 0.43 2.58 3.45 4.05 5.53 5.51 6.46 SES4 0.19 1.70 3.06 3.76 4.95 5.40 5.97 SES5 0.13 0.85 2.04 4.75 5.48 3.56 8.36 BLACK SES1 0.00 0.91 0.00 4.15 2.07 0.00 0.00 SES2 0.00 0.69 2.90 2.37 1.90 12.78 11.28 SES3 0.00 1.05 1.31 3.89 0.00 2.39 7.30 SES4 0.00 0.73 0.86 3.09 3.54 2.90 9.17 SES5 0.12 0.76 1.57 2.83 2.40 4.24 1.91 HISPANIC SES1 2.53 2.87 1.73 4.58 10.03 9.38 13.81 SES2 1.17 2.30 2.98 0.79 3.86 9.28 6.79 SES3 0.64 1.70 3.68 6.00 11.25 2.79 4.42 SES4 0.93 1.69 1.81 3.73 6.94 11.00 16.84 SES5 0.43 1.44 2.08 2.71 2.92 10.56 6.86 ASIAN SES1 0.53 4.63 2.76 1.96 2.43 2.47 11.34 SES2 0.00 1.76 3.33 2.51 5.33 2.54 0.00 SES3 0.00 0.66 1.53 3.86 6.80 7.05 11.39 SES4 0.00 0.31 3.66 6.78 4.24 3.02 3.50 SES5 0.00 1.77 2.37 1.15 10.03 3.28 2.68 OTHER SES1 0.00 2.29 2.32 3.74 27.75 0.00 0.00 SES2 1.55 1.33 7.60 3.87 7.07 0.00 21.59 SES3 0.00 0.89 1.92 0.00 0.00 37.18 0.00 SES4 0.00 2.36 1.49 6.80 0.00 8.18 0.00 SES5 0.41 0.00 0.00 1.89 4.62 15.30 0.00 ALL SES1 1.60 3.83 4.98 5.41 7.51 7.65 10.33 SES2 0.95 2.65 3.34 4.69 7.03 5.24 6.82 SES3 0.39 2.07 3.06 4.21 5.78 5.70 6.51 SES4 0.41 1.46 2.34 4.02 4.90 5.59 7.10 SES5 0.29 1.14 1.90 3.17 4.19 5.50 5.86 (To be continued) 261 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 13. Age-specific Incidence Rates by Sex, Race/Ethnicity and SES, Los Angeles County, 1972-1992, Thyroid Cancer (continued) FEMALES 15-24 25-34 35-44 45-54 55-64 65-74 75+ WHITE SES1 5.28 10.66 13.73 11.51 10.47 10.13 10.20 SES2 4.42 11.20 11.21 12.70 9.89 9.96 10.14 SES3 3.64 9.31 10.18 9.39 9.25 9.79 7.71 SES4 3.06 7.67 7.08 7.51 8.27 10.45 7.93 SES5 2.17 7.14 3.24 6.74 7.24 8.32 6.44 BLACK SES1 0.90 5.90 5.28 5.17 11.34 13.63 26.56 SES2 1.22 4.45 2.73 11.84 6.95 0.00 0.00 SES3 1.14 2.57 4.88 5.93 2.46 5.70 0.00 SES4 1.23 3.62 4.17 8.27 5.02 7.13 8.02 SES5 1.67 2.92 5.49 4.78 6.60 6.41 6.59 HISPANIC SES1 6.15 6.67 10.30 12.33 13.36 16.44 16.65 SES2 5.37 11.90 10.61 14.43 9.03 13.07 7.77 SES3 3.83 11.77 12.58 9.87 12.09 10.60 18.08 SES4 3.95 9.53 10.09 13.34 14.21 9.53 15.35 SES5 2.85 6.20 9.15 12.74 17.17 15.07 18.92 ASIAN SES1 2.20 7.65 6.74 6.04 13.78 16.77 9.41 SES2 1.11 6.01 11.65 10.97 20.84 3.65 20.96 SES3 2.75 6.60 9.90 4.95 11.54 18.79 6.83 SES4 2.52 4.44 10.31 9.71 15.12 10.39 8.06 SES5 2.51 4.69 16.26 7.61 17.41 9.03 13.25 OTHER SES1 1.76 8.89 17.04 24.75 16.85 0.00 0.00 SES2 2.28 10.23 13.95 0.00 5.27 17.98 0.00 SES3 1.75 3.37 7.70 9.53 7.87 12.91 8.66 SES4 2.00 6.47 3.00 3.41 9.45 4.88 15.52 SES5 2.27 1.12 3.91 7.10 5.38 8.63 0.00 ALL SES1 4.80 9.86 12.51 11.11 10.79 10.60 10.40 SES2 4.03 10.40 10.72 12.45 10.28 9.62 10.11 SES3 3.29 8.55 9.91 8.75 9.22 10.16 7.81 SES4 2.94 7.13 7.51 8.96 9.24 9.82 8.71 SES5 2.39 5.15 7.24 8.36 10.47 9.31 8.91 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 188. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Thyroid Cancer, White Males S E S 1 ------- — S E S 2 - - - S E S 3 S E S 4 ---------------- S E S 5 3 8 • 3 6 — 3 4 o 3 2 o ' 3 0 ° 2 8 a . 2 6 S 2 4 - w 2 2 - W “ u j 2 0 18 ■ 16 S 1 4 - 2 12 " Q 1 0 ■ 0 8 1 a 1 5 -2 4 2 5 -3 4 5 5 - 6 4 6 5 -7 4 3 5 -4 4 4 5 -5 4 A G E G R O U P S Figure 189. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Thyroid Cancer, White Females S E S 1 — — S E S 2 - - - S E S 3 S E S 4 S E S 5 38 36 o 3 4 o 32 30 ? 28 o: 26 S 24 o j 2 2 - 18 1 6 ■ UJ <A o 1 4 - Z 12 - U J Q 1 0 • O 8 ? R 1 5 -2 4 2 5 -3 4 5 5 -6 4 3 5 -4 4 4 5 -5 4 6 5 - 7 4 A G E G R O U P S 263 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 190. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Thyroid Cancer, Black Males 'S E S 1 — — S E S 2 - - - S E S 3 I S E S 4 S E S 5 • 3 8 3 6 — 3 4 - o 3 2 3 0 - ° 2 8 ( £ . 2 6 !S! 2 4 - w ^ i l l 2 0 - 1 8 - 16 1 4 ■ u i 1 2 Q 1 0 O 8 - ^ e 2 U l o z 4 5 - 5 4 5 5 -6 4 6 5 -7 4 1 5 -2 4 2 5 -3 4 3 5 -4 4 7 5 + A G E G R O U P S Figure 191. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Thyroid Cancer, Black Females - — S E S 1 — — S E S 2 “ “ - S E S 3 ! ....................S E S 4 S E S 5 I 3 4 O o o © o C C UJ CL C O UJ UJ o z UJ g o z V . 2 5 -3 4 6 5 -7 4 1 5 -2 4 4 5 - 5 4 5 5 -6 4 3 5 -4 4 7 5 + A G E G R O U P S 264 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 192. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Thyroid Cancer, Hispanic Males •S E S 1 - S E S 4 - S E S 2 - S E S 5 - - - S E S 3 40 r 3 8 - 3 6 ~ 3 4 § 3 2 3 0 - ^ 2 8 a . 2 6 £ 2 4 ^ 22 W “f U i 2 0 * 1 8 1 6 * ^ 1A o 14 - Z 12 •• uj 1 *• q 10 - O 8 - - 6 4 - o o 1 5 -2 4 2 5 -3 4 3 5 -4 4 5 5 -6 4 6 5 -7 4 4 5 - 5 4 7 5 + A G E G R O U P S Figure 193. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Thyroid Cancer, Hispanic Females • S E S 1 - S E S 4 ■ S E S 2 S E S 5 - - S E S 3 a: U i Q. UJ C J z UJ Q O 4 0 3 8 3 6 3 4 3 2 3 0 2 8 2 6 2 4 22 20 18 1 6 1 4 12 10 8 6 4 2 0 2 5 -3 4 4 5 - 5 4 5 5 -6 4 6 5 -7 4 7 5 + 1 5 -2 4 3 5 -4 4 A G E G R O U P S 265 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 194. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Thyroid Cancer, Asian Males S E S 1 — - — S E S 2 - - - S E S 3 I S E S 4 S E S S i 4° r 3 8 • 3 6 ~ 3 4 o 3 2 o ' 3 0 - ° 2 8 - I T 2 6 S 24 - to ?? ' Ui 2 0 1 8 u i O 1 4 - - Z 1 2 - u j Q 1 0 ■ O 8 - t c 1 5 -2 4 2 5 -3 4 3 5 -4 4 4 5 - 5 4 5 5 -6 4 6 5 -7 4 7 5 + A G E G R O U P S Figure 195. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Thyroid Cancer, Asian Females •S E S 1 ------- — S E S 2 - - - S E S 3 S E S 4 - S E S 5 4 0 O o o c T o <r Ui CL C O Ui I UI o * V z Ui Q o z 1 5 -2 4 2 5 -3 4 3 5 -4 4 5 5 -6 4 6 5 -7 4 7 5 + 4 5 -5 4 A G E G R O U P S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 196. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Thyroid Cancer, All Males ■SES1 — — S E S 2 - - - S E S 3 j S E S 4 ---------------- S E S 5 4 0 r 3 8 - 3 6 ~ 3 4 o 3 2 § 3 0 ° 2 8 K 2 6 a 2 4 c o 2 2 u j 2 0 - 1 8 1 6 - 1 4 ■ ui 12 - Q 1 0 - O 8 = C 2 5 - 3 4 3 5 - 4 4 4 5 - 5 4 6 5 - 7 4 7 5 + 1 5 - 2 4 5 5 - 6 4 A G E G R O U P S Figure 197. Age-specific Incidence Rates by SES, Los Angeles County, 1972-92, Thyroid Cancer, All Females S E S 1 ------- — S E S 2 - - - S E S 3 : S E S 4 S E S 5 3 8 o 3 2 § 3 0 ° 2 8 cr 2 6 S! 2 4 ■ CO 2 2 -- u j 2 0 18 i UJ o z UJ g o z 12 10 - 2 f 6 5 - 7 4 1 5 - 2 4 2 5 - 3 4 3 5 - 4 4 4 5 - 5 4 5 5 - 6 4 7 5 + A G E G R O U P S 267 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 7.4 The Poisson Regression Analysis As described in Chapter 6, two Poisson regression models were fit to the data using the number of observed cases as the dependent variable, the population size as the offset, and age, race/ethnicity, and SES as independent variables. Based on the results of age-adjusted and age- specific incidence rates, no systematic interactions between independent variables (particularly between race/ethnicity and SES) was observed in the relationship with cancer risk, therefore, the Poisson regression models did not include interaction terms. The results from these Poisson regression analyses are summarized in Tables 23 and 24. The model fits the data reasonably well for all the cancer sites, except lung cancer. SES was found to be an important and significant variable in explaining the variances where the SES gradients were found (Table 23). With adjustment of age, sex, and race/ethnicity, the analysis found positive SES trends in the risks for cancers of the female breast, central nervous system, colon, corpus uteri, melanoma of the skin, ovary, prostate, testis, and thyroid. Negative SES trend in cancer risk was found among cancers of the cervix uteri, esophagus, liver (males), lung (males), and stomach. No SES association was found in either male or female populations for cancers of the bladder, kidney, pancreas, and rectum. Although SES gradients were found among males for lung and liver cancer, no SES effect was seen for these two cancers among female populations. Race/ethnicity was found to be a significant factor in the model. After adjusting for age, sex, and SES, variations in cancer risk by race/ethnicity still exist for all nineteen cancer sites evaluated. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 23. Relative Risk (R.R.) by SES with 95% Confidence Interval (C.l.) and Test for Trend Adjusting for Race/Ethnicity and Age for Selected Cancers, Los Angeles County, 1972-1992 S E S T re n d G o o d n e s s S ig n ific a n c e C a n c e r S ite 5 (L o w ) 4 3 (M e d iu m ) 2 1 (H ig h ) P - v a lu e o f F it P P - v a lu e B l a d d e r M a le s R .R . 9 5 % C .l. 1 .0 0 1 .0 5 ( 0 .9 9 , 1 .1 2 ) 1 .1 2 ( 1 . 0 5 , 1 . 1 9 ) 1 .1 0 ( 1 .0 3 , 1 .1 6 ) 1 .0 0 ( 0 . 9 4 ,1 . 0 6 ) 0 .6 1 0 .2 3 0 .0 0 0 1 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .0 4 ( 0 .9 5 , 1 .1 4 ) 1 .0 6 ( 0 . 9 6 , 1 . 1 6 ) 1 .0 4 ( 0 . 9 5 , 1 . 1 4 ) 0 .9 7 ( 0 .8 8 ,1 . 0 8 ) 0 .4 7 0 .2 7 0 .3 0 B r e a s t F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .1 7 ( 1 .1 4 , 1 .2 0 ) 1 .2 7 ( 1 . 2 4 ,1 . 3 1 ) 1 .3 6 ( 1 .3 3 , 1 .4 0 ) 1 .5 3 ( 1 .4 9 , 1 . 5 7 ) 0 .0 0 0 1 0 .0 5 0 .0 0 0 1 C e r v ix U t e r i F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .7 9 ( 0 .7 5 , 0 .8 3 ) 0 .6 1 ( 0 .5 8 , 0 .6 5 ) 0 .5 3 ( 0 .5 0 , 0 .5 7 ) 0 .4 2 (0 .4 0 , 0 .4 6 ) 0 .0 0 0 1 0 .0 7 0 .0 0 0 1 C e n t r a l N e r v o u s S y s t e m M a le s R .R . 1 .0 0 9 5 % C .l. 1 .0 7 ( 0 . 9 6 , 1 . 1 9 ) 1 .1 3 ( 1 . 0 1 , 1 . 2 7 ) 1 .1 9 ( 1 .0 7 , 1 . 3 3 ) 1 .3 3 ( 1 .1 9 , 1 . 4 9 ) 0 .0 0 0 1 0 .3 0 0 .0 0 0 1 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .0 9 ( 0 . 9 6 , 1 . 2 3 ) 1 .2 1 ( 1 .0 7 , 1 . 3 7 ) 1 .2 1 ( 1 .0 7 , 1 . 3 8 ) 1 .3 2 ( 1 . 1 6 ,1 . 5 0 ) 0 .0 0 0 1 0 .3 6 0 .0 0 3 C o lo n M a le s R .R . 9 5 % C .l. 1 .0 0 1 .1 2 ( 1 .0 7 , 1 .1 7 ) 1 .1 3 ( 1 .0 8 , 1 . 1 9 ) 1 .1 5 ( 1 .1 0 , 1 .2 0 ) 1 .1 7 ( 1 .1 2 , 1 .2 3 ) 0 .0 0 0 1 0 .2 3 0 .0 0 0 1 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .0 3 ( 0 . 9 9 , 1 . 0 8 ) 1.1 1 ( 1 .0 6 , 1 .1 6 ) 1 .1 3 ( 1 .0 8 , 1 .1 8 ) 1 .0 9 ( 1 .0 5 ,1 . 1 4 ) 0 .0 0 0 1 0 .2 2 0 .0 0 0 1 C o r p u s U te r i F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .1 0 ( 1 . 0 5 , 1 . 1 6 ) 1 .1 8 ( 1 . 1 2 , 1 . 2 4 ) 1 .2 9 ( 1 .2 2 , 1 .3 5 ) 1 .3 9 ( 1 .3 2 ,1 . 4 6 ) 0 .0 0 0 1 0 .0 7 0 .0 0 0 1 E s o p h a g u s M a le s R .R . 9 5 % C .l. 1 .0 0 0 .7 1 ( 0 .6 4 , 0 .7 8 ) 0 .6 6 ( 0 .5 9 , 0 .7 3 ) 0 .5 8 ( 0 .5 2 , 0 .6 5 ) 0 .4 8 ( 0 .4 2 , 0 .5 4 ) 0 .0 0 0 1 0 .1 3 0 .0 0 0 1 F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .7 9 ( 0 .6 8 , 0 .9 1 ) 0 .6 9 ( 0 .5 9 , 0 .8 0 ) 0 .7 2 ( 0 .6 1 , 0 .8 4 ) 0 .6 6 ( 0 .5 8 , 0 .8 0 ) 0 .0 0 0 1 0 .1 5 0 .0 0 0 1 (To be continued) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 23. Relative Risk (R.R.) by SES with 95% Confidence Interval (C.l.) and Test for Trend Adjusting for Race/Ethnicity and Age for Selected Cancers, Los Angeles County, 1972-1992 (continued) S E S T re n d G o o d n e s s S ig n ific a n c e C a n c e r S ite 5 (L o w ) 4 3 (M e d iu m ) 2 1 (H ig h ) P - v a lu e o f F it P P - v a l u e K id n e y M a le s R .R . 9 5 % C .l. 1 .0 0 1 .1 0 ( 1 .0 1 , 1 .2 0 ) 1 .0 7 ( 0 .9 8 ,1 . 1 7 ) 1 .1 3 ( 1 .0 4 , 1 .2 3 ) 1 .0 9 ( 1 . 0 0 , 1 . 1 9 ) 0 .0 9 0 .2 5 0 . 0 7 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .0 1 ( 0 . 9 0 , 1 . 1 2 ) 1 .0 8 ( 0 .9 7 ,1 . 2 1 ) 1.1 ( 0 . 9 8 , 1 . 2 3 ) 0 . 9 2 ( 0 . 8 1 , 1 . 0 3 ) 0 .4 6 0 .3 0 0 . 0 0 3 2 L a r y n x M a le s R .R . 9 5 % C .l. 1 .0 0 0 .8 7 ( 0 .8 0 , 0 .9 5 ) 0 .7 7 ( 0 .7 0 , 0 .8 4 ) 0 .7 0 ( 0 .6 4 , 0 . 7 7 ) 0 . 5 0 ( 0 .4 6 , 0 .5 6 ) 0 .0 0 0 1 0 .2 3 0 .0 0 0 1 F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .7 6 ( 0 .6 4 , 0 .9 0 ) 0 .7 3 ( 0 . 6 1 , 0 . 8 7 ) 0 .5 8 ( 0 .4 8 , 0 . 7 0 ) 0 .5 1 ( 0 .4 2 , 0 .6 3 ) 0 .0 0 0 1 0 .2 4 0 .0 0 0 1 L i v e r M a le s R .R . 9 5 % C .l. 1 .0 0 0 .9 2 ( 0 .8 3 , 1 .0 2 ) 0 .7 8 ( 0 .7 0 , 0 .8 8 ) 0 .6 9 ( 0 . 6 1 , 0 . 7 8 ) 0 .6 9 ( 0 . 6 1 , 0 . 7 9 ) 0 .0 0 0 1 0 .1 9 0 .0 0 0 1 F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .7 8 ( 0 .6 6 , 0 .9 2 ) 0 .8 7 ( 0 .7 3 ,1 . 0 3 ) 0 .8 2 ( 0 . 6 8 , 0 . 9 9 ) 0 .7 5 ( 0 . 6 1 , 0 . 9 1 ) 0 .0 2 0 .3 1 0 . 0 2 L u n g M a le s R .R . 9 5 % C .l. 1 .0 0 0 .9 3 ( 0 .9 0 , 0 .9 6 ) 0 .8 6 ( 0 .8 4 , 0 .8 9 ) 0 . 7 7 (0 .7 4 , 0 . 7 9 ) 0 .5 6 ( 0 .5 4 , 0 .5 8 ) 0 .0 0 0 1 0 .0 0 0 .0 0 0 1 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .0 1 ( 0 .9 8 , 1 .0 6 ) 1 .0 4 ( 0 .9 9 ,1 . 0 8 ) 1 .0 2 ( 0 . 9 8 , 1 . 0 7 ) 0 .8 9 ( 0 .8 6 , 0 .9 3 ) 0 .0 0 0 1 0 .0 3 0 .0 0 0 1 M e la n o m a o f t h e S k in M a le s R .R . 1 .0 0 9 5 % C .l. 1 .2 6 ( 1 .1 3 , 1 .4 2 ) 1 .6 8 ( 1 .5 1 , 1 .8 7 ) 1 .8 1 ( 1 .6 2 , 2 .0 1 ) 2 .4 6 ( 2 .2 2 , 2 .7 3 ) 0 .0 0 0 1 0 .3 0 0 .0 0 0 1 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .2 7 ( 1 .1 3 , 1 .4 3 ) 1 .7 3 ( 1 .5 4 ,1 . 9 4 ) 1 .9 5 ( 1 .7 4 , 2 .1 9 ) 2 .3 1 ( 2 .0 7 , 2 .5 9 ) 0 .0 0 0 1 0 .1 5 0 .0 0 0 1 O v a r y F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .0 2 ( 0 .9 6 , 1 .0 9 ) 1 .0 7 ( 1 .0 0 ,1 . 1 4 ) 1 .0 9 ( 1 .0 2 , 1 .1 6 ) 1 .1 1 ( 1 .0 4 , 1 .1 8 ) 0 .0 0 0 2 0 . 2 2 0 . 0 0 6 4 (To be continued) 270 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 23. Relative Risk (R.R.) by SES with 95% Confidence Interval (C.l.) and Test for Trend Adjusting for Race/Ethnicity and Age for Selected Cancers, Los Angeles County, 1972-1992 (continued) S E S T re n d G o o d n e s s S ig n ific a n c e C a n c e r S ite 5 (L o w ) 4 3 (M e d iu m ) 2 1 (H ig h ) P - v a lu e o f F it P P - v a lu e P a n c r e a s M a le s R .R . 9 5 % C .l. 1 .0 0 0 .9 9 ( 0 . 9 1 .1 . 0 7 ) 1 .0 1 ( 0 . 9 4 , 1 . 1 0 ) 1 .0 2 ( 0 . 9 4 , 1 . 1 1 ) 0 .9 4 ( 0 .8 7 ,1 . 0 2 ) 0 .2 8 0 .3 0 0 .1 8 5 9 F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .9 2 ( 0 .8 5 . 0 .9 9 ) 0 . 9 8 ( 0 . 9 0 , 1 . 0 6 ) 0 .9 7 ( 0 .9 0 , 1 .0 5 ) 0 .9 0 ( 0 .8 3 , 0 .9 8 ) 0 .1 4 0 .2 8 0 .0 3 P r o s t a t e M a le s R .R . 9 5 % C .l. 1 .0 0 1 .0 7 ( 1 . 0 4 ,1 . 1 0 ) 1 .1 6 ( 1 . 1 3 , 1 . 1 9 ) 1 .2 4 ( 1 . 2 0 , 1 . 2 8 ) 1 .4 2 ( 1 .3 8 , 1 . 4 6 ) 0 .0 0 0 1 0 .0 5 0 .0 0 0 1 R e c tu m M a le s R .R . 9 5 % C .l. 1 .0 0 1 .0 5 ( 0 . 9 7 ,1 . 1 3 ) 1 .0 4 ( 0 . 9 6 , 1 . 1 2 ) 1 .0 2 ( 0 . 9 4 , 1 . 1 0 ) 0 .8 9 ( 0 .8 2 , 0 .9 7 ) 0 .0 0 1 3 0 .2 8 0 .0 0 0 1 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .1 3 ( 1 .0 4 ,1 . 2 3 ) 1 .1 0 ( 1 . 0 1 , 1 . 2 0 ) 1 .1 1 ( 1 . 0 2 , 1 . 2 1 ) 1 .0 8 ( 0 . 9 8 ,1 . 1 8 ) 0 .4 2 0 . 2 8 0 .0 7 S t o m a c h M a le s R .R . 9 5 % C .l. 1 .0 0 0 .9 2 ( 0 .8 6 , 0 .9 7 ) 0 .8 2 ( 0 .7 7 , 0 . 8 7 ) 0 .7 8 ( 0 .7 3 , 0 .8 4 ) 0 .6 7 ( 0 .6 3 , 0 .7 3 ) 0 .0 0 0 1 0 . 2 7 0 .0 0 0 1 F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .9 4 ( 0 .8 8 ,1 . 0 2 ) 0 .8 9 ( 0 .8 2 , 0 .9 7 ) 0 .8 8 ( 0 .8 0 , 0 .9 5 ) 0 .8 5 ( 0 .7 7 , 0 .9 2 ) 0 .0 0 0 1 0 . 2 7 0 .0 0 2 0 T e s t is M a le s R .R . 9 5 % C .l. 1 .0 0 1 .4 6 ( 1 .2 8 ,1 . 6 6 ) 1 .5 8 ( 1 .3 8 , 1 .8 0 ) 1 .5 8 ( 1 .3 8 , 1 . 8 1 ) 1 .8 5 ( 1 .6 2 , 2 .1 2 ) 0 .0 0 0 1 0 .3 3 0 .0 0 0 1 T h y r o id M a le s R .R . 9 5 % C .l. 1 .0 0 1 .1 5 ( 0 .9 7 , 1 .3 6 ) 1 .2 9 ( 1 . 0 9 , 1 . 5 4 ) 1 .4 7 ( 1 .2 3 , 1 . 7 4 ) 1 .9 3 ( 1 .6 4 , 2 .2 9 ) 0 .0 0 0 1 0 .2 5 0 .0 0 0 1 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .1 0 ( 1 .0 0 , 1 .2 1 ) 1 .2 0 ( 1 . 0 8 , 1 . 3 2 ) 1 .4 1 ( 1 .2 8 , 1 . 5 6 ) 1 .4 6 ( 1 .3 2 ,1 . 6 1 ) 0 .0 0 0 1 0 .1 9 0 .0 0 0 1 271 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 24. Relative Risk (R.R.) by Race/Ethnicity with 95% Confidence Interval (C.l.) and Test for Trend Adjusting for SES and Age for Selected Cancers, Los Angeles County, 1972-1992 R a c e /E th n ic ity H e te ro g e n e ity G o o d n e s s C a n c e r S ite W h ite B la c k H is p a n ic A s ia n O th e r P - v a lu e o f F it P B la d d e r M a te s R .R . 9 5 % C .l. 1 .0 0 0 .5 3 ( 0 .4 9 , 0 .5 7 ) 0 .5 2 ( 0 .4 9 , 0 .5 6 ) 0 .3 0 ( 0 .2 7 , 0 .3 4 ) 0 .3 0 ( 0 .2 3 , 0 .3 7 ) 0 .0 0 0 1 0 .2 3 F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .7 8 ( 0 .7 0 , 0 .8 7 ) 0 .6 1 ( 0 . 5 5 , 0 . 6 8 ) 0 .3 4 ( 0 .2 7 , 0 .4 1 ) 0 . 3 2 ( 0 .2 0 , 0 .5 0 ) 0 .0 0 0 1 0 . 2 7 B r e a s t F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .9 1 ( 0 .8 9 , 0 .9 4 ) 0 .7 5 ( 0 .7 3 , 0 .7 7 ) 0 .4 7 ( 0 .4 5 , 0 .4 8 ) 0 . 4 3 ( 0 .4 0 , 0 .4 7 ) 0 .0 0 0 1 0 .0 5 C e r v ix U t e r i F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .2 3 ( 1 .1 5 , 1 .3 1 ) 1 .9 6 ( 1 .8 6 , 2 .0 6 ) 0 .8 1 ( 0 .7 4 , 0 .8 9 ) 0 . 8 7 ( 0 . 7 6 , 1 . 0 0 ) 0 .0 0 0 1 0 .0 7 C N S M a le s R .R . 9 5 % C .l. 1 .0 0 0 .7 1 ( 0 .6 3 , 0 .8 0 ) 0 .8 1 ( 0 .7 3 , 0 .8 9 ) 0 .3 4 ( 0 .2 8 , 0 .4 2 ) 0 . 5 0 ( 0 .3 5 , 0 .7 0 ) 0 .0 0 0 1 0 .3 0 F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .6 9 ( 0 .6 0 , 0 .7 9 ) 0 .8 9 ( 0 . 8 0 ,1 . 0 0 ) 0 .3 6 ( 0 .2 8 , 0 .4 5 ) 0 . 7 2 ( 0 . 5 2 , 1 . 0 0 ) 0 .0 0 0 1 0 .3 6 C o lo n M a le s R .R . 9 5 % C .l. 1 .0 0 1 .1 2 ( 1 .0 7 , 1 .1 7 ) 0 .7 0 ( 0 .6 6 , 0 .7 4 ) 0 .6 2 ( 0 .5 8 , 0 .6 6 ) 0 .5 0 ( 0 .4 4 , 0 .5 8 ) 0 .0 0 0 1 0 .2 3 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .1 9 ( 1 . 1 5 , 1 . 2 5 ) 0 .6 4 ( 0 .6 1 ,0 . 6 7 ) 0 .5 4 ( 0 .5 0 , 0 .5 8 ) 0 . 3 5 ( 0 .2 9 , 0 .4 1 ) 0 .0 0 0 1 0 .2 2 C o r p u s U t e r i F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .5 5 ( 0 . 5 1 , 0 . 5 8 ) 0 .6 7 ( 0 . 6 3 ,0 . 7 0 ) 0 .3 3 ( 0 .3 0 , 0 .3 6 ) 0 . 3 4 ( 0 .2 9 , 0 .4 0 ) 0 .0 0 0 1 0 .0 7 E s o p h a g u s M a le s R .R . 9 5 % C .l. 1 .0 0 2 .4 2 ( 2 . 2 1 , 2 . 6 4 ) 0 .8 7 ( 0 .7 7 , 0 .9 8 ) 0 .7 4 ( 0 .6 2 , 0 .8 7 ) 0 .6 1 ( 0 . 4 1 , 0 . 9 2 ) 0 .0 0 0 1 0 .1 3 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .9 4 ( 1 .7 0 , 2 .2 1 ) 0 .5 5 ( 0 .4 5 , 0 .6 8 ) 0 .6 0 ( 0 .4 4 , 0 .8 3 ) 1 .3 5 ( 0 .7 0 , 2 .6 1 ) 0 .0 0 0 1 0 .1 5 (To be continued) 272 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 24. Relative Risk (R.R.) by Race/Ethnicity with 95% Confidence Interval (C.l.) and Test for Trend Adjusting for SES and Age for Selected Cancers, Los Angeles County, 1972-1992 (continued) R a c e /E th n ic ity H e te ro g e n e ity G o o d n e s s C a n c e r S ite W h ite B la c k H is p a n ic A s ia n O th e r P - v a lu e o f F it P K id n e y & R e n a l P e lv is M a le s R .R . 1 .0 0 9 5 % C .l. 1 .0 0 ( 0 .9 1 ,1 . 0 9 ) 1 .1 1 ( 1 . 0 2 ,1 . 2 0 ) 0 .4 2 ( 0 .3 6 , 0 .4 8 ) 0 .5 4 ( 0 .3 9 , 0 .7 3 ) 0 .0 0 0 1 0 .2 5 F e m a le s R .R . 9 5 % C . l . 1 .0 0 1 .0 9 ( 0 .9 8 ,1 . 2 2 ) 1 .2 4 ( 1 . 1 2 , 1 . 3 8 ) 0 .4 5 ( 0 .3 7 , 0 . 5 6 ) 0 .6 8 ( 0 .4 9 , 0 . 9 5 ) 0 .0 0 0 1 0 .3 0 L a r y n x M a le s R .R . 9 5 % C .l. 1 .0 0 1.1 1 ( 1 .0 1 , 1 .2 1 ) 0 .6 2 ( 0 .5 6 , 0 .6 8 ) 0 .2 5 ( 0 .2 0 , 0 .3 0 ) 0 .4 0 ( 0 .2 8 , 0 .5 6 ) 0 .0 0 0 1 0 .2 3 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .0 3 ( 0 . 8 6 ,1 . 2 3 ) 0 .4 4 ( 0 .3 4 , 0 .5 5 ) 0 . 3 2 ( 0 . 2 1 , 0 . 5 0 ) 0 .8 0 ( 0 .3 0 , 2 .1 5 ) 0 .0 0 0 1 0 .2 4 L i v e r M a le s R .R . 9 5 % C .l. 1 .0 0 1 .91 ( 1 .6 9 , 2 .1 6 ) 2 .3 7 ( 2 .1 3 , 2 .6 5 ) 3 .8 5 ( 3 .4 6 , 4 .2 8 ) 4 .1 9 ( 3 .4 9 , 5 .0 2 ) 0 .0 0 0 1 0 .1 9 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .9 8 ( 1 .6 5 , 2 .3 8 ) 2 .1 9 ( 1 .8 6 , 2 . 5 9 ) 3 .3 7 ( 2 .8 3 , 4 .0 1 ) 3 .2 0 ( 2 . 3 1 , 4 . 4 3 ) 0 .0 0 0 1 0 .3 1 L u n g M a le s R .R . 9 5 % C .l. 1 .0 0 1 .21 ( 1 .1 8 , 1 .2 4 ) 0 .4 9 ( 0 .4 7 , 0 .5 1 ) 0 . 4 4 ( 0 .4 2 , 0 .4 7 ) 0 .3 8 ( 0 .3 4 , 0 .4 2 ) 0 .0 0 0 1 0 .0 0 F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .9 1 ( 0 .8 7 , 0 .9 5 ) 0 .5 0 ( 0 .4 8 , 0 .5 3 ) 0 .3 5 ( 0 .3 2 , 0 .3 8 ) 0 .3 1 ( 0 .2 7 , 0 .3 6 ) 0 .0 0 0 1 0 .0 3 M e la n o m a o f t h e S k in M a le s R .R . 1 .0 0 9 5 % C .l. 0 .1 3 ( 0 . 1 1 ,0 . 1 7 ) 0 .2 0 ( 0 .1 8 , 0 .2 3 ) 0 .0 8 ( 0 .0 5 , 0 . 1 1 ) 0 .2 3 ( 0 .1 3 , 0 .3 8 ) 0 .0 0 0 1 0 . 3 0 F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .1 1 ( 0 .0 9 , 0 .1 4 ) 0 .3 2 ( 0 .2 8 , 0 .3 5 ) 0 .0 9 ( 0 .0 7 , 0 .1 3 ) 0 .1 8 ( 0 .1 1 , 0 . 2 7 ) 0 .0 0 0 1 0 . 1 5 O v a r y F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .6 4 ( 0 .6 0 , 0 .6 9 ) 0 .8 6 ( 0 .8 1 , 0 .9 1 ) 0 .5 0 ( 0 .4 6 , 0 .5 5 ) 0 .5 6 ( 0 .4 7 , 0 .6 5 ) 0 .0 0 0 1 0 . 2 2 (To be continued) 273 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 24. Relative Risk (R.R.) by Race/Ethnicity with 95% Confidence Interval (C.l.) and Test for Trend Adjusting for SES and Age for Selected Cancers, Los Angeles County, 1972-1992 (continued) R a c e /E th n ic ity H e te r o g e n e ity G o o d n e s s C a n c e r S ite W h ite B la c k H is p a n ic A s ia n O th e r P - v a lu e o f F it P P a n c r e a s M a le s R .R . 9 5 % C .l. 1 .0 0 1 .3 3 ( 1 .2 3 , 1 . 4 4 ) 1 .0 1 ( 0 .9 3 ,1 . 0 9 ) 0 .5 8 ( 0 . 5 1 , 0 . 6 6 ) 0 .5 2 ( 0 .3 9 , 0 .7 0 ) 0 .0 0 0 1 0 . 3 0 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .3 6 ( 1 .2 6 , 1 . 4 7 ) 1 .0 9 ( 1 .0 1 ,1 . 1 9 ) 0 .7 0 ( 0 .6 2 , 0 .8 0 ) 0 .4 4 ( 0 .3 2 , 0 .6 1 ) 0 .0 0 0 1 0 . 2 8 P r o s ta t e M a le s R .R . 9 5 % C .l. 1 .0 0 1 .7 4 ( 1 .7 0 ,1 . 7 9 ) 1 .0 1 ( 0 .9 8 ,1 . 0 5 ) 0 .4 3 ( 0 . 4 1 ,0 . 4 5 ) 0 .4 0 ( 0 .3 6 , 0 .4 5 ) 0 .0 0 0 1 0 . 0 5 R e c tu m M a le s R .R . 9 5 % C .l. 1 .0 0 0 .8 7 ( 0 .8 0 , 0 .9 5 ) 0 .8 6 ( 0 .7 9 , 0 .9 3 ) 0 .7 8 ( 0 .7 0 , 0 .8 6 ) 0 .6 7 ( 0 .5 3 , 0 .8 5 ) 0 .0 0 0 1 0 . 2 8 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .0 6 ( 0 .9 7 ,1 . 1 6 ) 0 .8 0 ( 0 .7 3 , 0 .8 8 ) 0 .8 6 ( 0 .7 6 , 0 .9 6 ) 0 .7 2 ( 0 .5 5 , 0 .9 3 ) 0 .0 0 0 1 0 .2 8 S t o m a c h M a le s R .R . 9 5 % C .l. 1 .0 0 1 .5 4 ( 1 .4 4 ,1 . 6 5 ) 1 .6 7 ( 1 .5 7 , 1 .7 8 ) 1 .7 5 ( 1 .6 3 , 1 .8 8 ) 1 .0 7 ( 0 . 9 0 ,1 . 2 8 ) 0 .0 0 0 1 0 . 2 7 F e m a le s R .R . 9 5 % C .l. 1 .0 0 1 .5 5 ( 1 . 4 2 ,1 . 6 9 ) 2 .1 6 ( 2 .0 1 , 2 .3 3 ) 2 .1 4 ( 1 . 9 6 , 2 . 3 5 ) 1 .1 2 ( 0 . 9 1 , 1 . 3 8 ) 0 .0 0 0 1 0 . 2 7 T e s tis M a le s R .R . 9 5 % C .l. 1 .0 0 0 .2 0 ( 0 .1 6 , 0 .2 5 ) 0 .7 7 ( 0 .7 0 , 0 .8 5 ) 0 .1 8 ( 0 .1 3 , 0 .2 3 ) 0 .2 2 ( 0 .1 5 , 0 .3 2 ) 0 .0 0 0 1 0 . 3 3 T h y r o id M a le s R .R . 9 5 % C .l. 1 .0 0 0 .5 9 ( 0 .4 7 , 0 .7 3 ) 0 .9 8 ( 0 .8 6 , 1 .1 3 ) 0 .7 7 ( 0 .6 3 , 0 .9 4 ) 1 .0 9 ( 0 .7 8 , 1 .5 4 ) 0 .0 0 0 1 0 . 2 5 F e m a le s R .R . 9 5 % C .l. 1 .0 0 0 .5 8 ( 0 .5 1 , 0 .6 5 ) 1 .2 4 ( 1 .1 4 ,1 . 3 4 ) 0 .9 6 ( 0 .8 6 , 1 .0 6 ) 0 .7 5 ( 0 .6 2 , 0 .9 1 ) 0 .0 0 0 1 0 . 1 9 274 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 8 DISCUSSION The most important findings of this study are that for some cancers the increasing risk is associated with increasing socioeconomic status (SES), for other cancers the relationship is reversed, and for still other forms of cancer no relationship with SES is apparent These results support the hypothesis that the association with SES depends on the risk factors involved in a particular cancer. Findings of this study, described in chapter 7, can be summarized into the following: 1)Positive SES associations (increasing incidence rates with increasing SES) were found for cancers of female breast, central nervous system, colon, corpus uteri, melanoma, ovary, prostate, testis, and thyroid. 2) Negative SES associations (decreasing incidence rates with increasing SES) were found for cancers of cervix uteri, esophagus, larynx, and stomach. 3) Negative SES associations were found among males only, while no SES pattern was observed for females, for cancers of liver and lung. 4) No relationship was established between SES and cancers of bladder, kidney, pancreas, and rectum. 5) The magnitude and direction of SES associations vary by race/ethnicity. 6) After controlling for age, sex, and SES, the differences in cancer incidence rates among racial/ethnic groups still exist 7) For cancers with SES associations, the differences in cancer incidence rates by SES groups become more substantial as age increases. 8) In general, Asians show less SES variation in cancer risk than blacks and whites. 275 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8.1 Positive SES Associations with Some Cancers In this study, 15 out of 19 cancers showed SES associations. Among the 15 cancers, 9 of them displayed a positive relationship with SES, i.e., the higher the SES, the higher the risk. This seems contrary to the conventional generality that low social class is associated with high morbidity. However, looking at these positive SES associations with reference to the known risk factors of the cancer and the relationship between the known risk factors and SES, some explanations for such positive relationship with SES are obvious. Many cancer risk factors are related to lifestyle. These factors can be habits or other behavioral features which may vary according to SES. When factors related to lifestyle are the major etiology agents, it is no longer clear that the mortality and morbidity differences should favor upper social class (Rimpela and Pukkala, 1987). 8.1.1 Explanations and Speculations for the Positive Relationship Major etiological factors, including early menarche, late age at first birth, nulliparity or fewer children, greatly influence the risk of developing breast cancer in women (Kelsey and Bernstein, 1996). These factors have been found associated with high SES. The higher social classes are linked with earlier menarche. In fact because the relationship is so consistent that age at menarche is used as a population-based indicator of general socioeconomic and nutritional well being (Lavelle, 1994). Women with higher education have had their first birth later than average and their fertility has been lower (Rindfuss et al., 1996; Yamaguchi and Ferguson, 1995). These reproductive factors also play roles in explaining the SES differences in ovarian cancer and cancers of the corpus uteri. 276 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The causes for cancers of the central nervous system (CNS) is yet to be determined. Except the exposure to radiation, other possible risk factors are currently being studied. The positive association with SES can help the search for potential risks. However, the increasing incidence rates with increasing SES may at least in part reflect the diagnostic bias that people of high SES are more likely to be diagnosed if they have CNS cancer, because they are more likely to have regular visits to the doctor and to have diagnostic workups when compared to people of low SES. Dietary factors have been proposed to account for approximately 30% of cancers in western societies (Doll and Peto, 1981). The role of diet has been emphasized especially in the etiology of colon cancer (Pukkala and Teppo, 1986). Nevertheless, dietary exposure assessment is fraught with difficulties since people have complex diets that can change at will; energy intake and expenditure have profound implications that only recently have been addressed; confounding among nutrients that are inherently correlated through their presence in the same foods can be all but intractable. In addition, theoretical reasons and power limitations typically prohibit adequate examination of complex interactive patterns (Willett, 1996). Given these and several other problems, it should not be surprising that the role of diet in the causation of cancer is not better understood. The SES gradient found in colon cancer incidence rates indicates that colon cancer may be related to environmental and behavioral factors including diet A recent study has confirmed that in 1960s proportionally more people of high SES had a less healthful diet (Popkin et al., 1996). This may partially explain the increasing cancer risk with increasing SES. One of the most important known risk factors in malignant melanoma is the exposure to sunlight, sunburn being the factor which especially increases the risk (Green et al., 1985). The strong positive SES gradient in melanoma incidence rates may be accounted for by the following facts: People of higher social classes do not get exposed to sunlight in their work and are more 277 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. likely to get severe sunburn if exposed to it Highly educated professionals were found to dominate in wilderness use, i.e., recreation participation in designated wilderness (Walker and Kiecolt 1995). If the interaction between race/ethnicity and social class is considered, it renders more explanation. A higher proportion of whites were classified into higher SES groups, whereas white people have higher risk than colored people since the skin pigmentation is a protective factor for melanoma. Worship of suntanned skin color among rich people resulted in voluntary sun exposure and the use of tanning devices, which in turn seems to coincide with the increasing incidence of the disease. The risk factors in prostate cancer are largely unknown. Since prostate cancer has a relatively low mortality rate and certain cell types of prostate cancer are not life threatening, undetected prostate cancer is common. This fact furnishes the possibility that people of high SES are more likely than their low SES counterparts to have routine visits to the doctor, thus to be diagnosed early. However, it should be pointed out that the data used in this study covers 21 years, and the cancer cases came from both hospital diagnosis and death certificates. Given these facts, the diagnostic bias should be very minimal in accessing the risk in this data set, since the cancer incidence would have been eventually recorded by death certificate if not by diagnosis at an earlier time. Nevertheless, towards the end of the long study period it is still possible that higher proportion of high SES cases were registered in the data. Diagnostic bias remains to be an concern especially for cancers which have a relatively good prognosis. In the case of prostate cancer, the detection bias cannot be completely ruled out. In addition, the differences between some risk factors and SES cannot be excluded. Prenatal lectors have been suggested as etiological agents in testicular cancer. Cryptorchidism (development defect characterized by failure of the testis to descend into the scrotum) is one of the strongest factors in the etiology of testicular cancer. Modified hormonal 278 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. milieu affecting both mother and her offspring have also been emphasized (Swerdlow et al., 1983). The positive SES association in testicular cancer may reflect the influence of some aspect of SES, which need to be identified. It has been suggested that genetic factors are somewhat important in the etiology of this disease (Schottenfeld and Warshauer, 1982). The etiology of thyroid cancer has not been well understood and its risk factors have not been well identified. The positive association with SES may help searching for the etiological agents. However, like prostate cancer, given the low mortality rate of this cancer, the positive SES association may be at least partially contributed to the detection bias among SES groups. Since thyroid cancer consists of a number of distinct diseases microscopically, it would be helpful to examine the association with SES by histology within the general category of thyroid cancer. Although such effort is beyond the scope of the present study, it would be worthwhile for future studies. 8.1.2 Positive SES Association in Predicting Survival The positive SES associations with some forms of cancer cannot predict the survival chances with these cancers by SES. Higher incidence rates occurring in high SES do not necessarily indicate that mortality rates are higher among high SES populations. The positive SES association in malignant melanoma risk was found to be reversed in the mortality of this disease (MacKie and Hole, 1996; Geller et al., 1996). The apparent mortality benefit enjoyed by people of high SES are contributed to earlier detection, earlier and better treatment (Williams et al., 1996). In general, the survival advantage of the high SES groups are notable for cancers that have a good prognosis if caught at treatable stage. 279 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Of all defenses against cancer, early detection is by far the most familiar. Early detection is presumed to benefit the patient by allowing treatment to begin early in the disease process, before dissemination of malignant cells becomes extensive. Early detection of cervical cancer through the Pap test is apparently valuable in improving chances for survival (Stenkvist et al., 1984). Breast cancer is also amenable to early detection (Vernon et al., 1985). Patients with early colon and rectal cancers have much better survival chances than those with later-stage diagnosis (Greenwald, 1992). However, the fact that cancer comprises a large number of diseases with vastly different characteristics limits the effectiveness of early detection in promoting survival. In lung cancer, the impact of early detection on survival is uncertain. Lung cancer may occur in several different forms, some highly resistant to treatment even if caught early (Flehinger and Kimmel, 1987). The benefits of early detection in prostate cancer are likewise uncertain. Uncertainty arises in part from the highly variable nature of the disease. Even at early-stage, some prostate cancers spread rapidly to surrounding tissues and bones, while others remain indolent for years (Whitmore, 1990). The mechanism by which SES affects cancer survival appears to differ from cancer to cancer. But the fact is that people in lower SES generally have poorer prospects for survival. Lower SES women are found to be diagnosed at later stage and experience higher mortality (Wells and Horm, 1992; Wagenerand Schatzkin, 1994). Although the relationship between SES and mortality can help identify survival differences, this study is focused on the SES associations with incidence rates to help generate hypothesis to identify the risk factors leading to the etiological causes of developing cancer. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8.1.3. Implications of the Positive Association History has shown that when changes happen in diseases, treatments, risks, and/or knowledge about risks, people of high SES always eventually come out ahead. As health-related situations change, those with the most resources are best able to avoid diseases and their consequences. No matter what the profile of diseases and known risks happen to be at any given time, those who have greater access to important social and economic resources will be less afflicted by disease (Link and Phelan, 1996). A recent article published in the New England Journal of Medicine provides evidence for such theory. The upper social classes were found to act more quickly than the lower social classes in modifying their diet toward a more healthful one (Popkin et al., 1996). The positive SES associations with so many cancers indicate that the public as well as health service providers do not have adequate information in order to take preventive measures against cancer. It points to the lack of understanding of cancer and the need for research. Without research, we will not be able to advance our knowledge. With research, there is a virtual guarantee that many of the cancers that cannot be prevented today will be controlled in the future. Differences in cancer risk by SES can be used to find clues for etiological factors of the diseases. As a matter of fact, upper social class people do not have as high general susceptibility to diseases as do people of lower social classes (Syme and Berkman, 1976). The positive SES association should make it easier to find specific etiological factors common in these groups for these cancers. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8.2 Comparisons with Other Studies The study has confirmed all of the previously well established SES associations: the positive association with female breast cancer, melanoma, and testicular cancer; no SES association with bladder cancer; the known negative SES association with cancer of the cervix uteri, esophagus, larynx, and stomach (see literature reviews in chapter 4). The conformity proves the usefulness of the SES model that this study adopted and leaves little possibility that the SES trends detected in this study are artifacts. The results also confirmed previously suspected positive association between SES and cancers of the central nervous system, colon, and corpus uteri. As discussed earlier, the relationships between SES and cancer risk factors dictates the relationships between SES and the cancer. The cancers which have negative association with SES, except cervical cancer, are all heavily influenced by smoking and drinking behaviors. And smoking and drinking behaviors are known to have a SES gradient Heavy smoking are correlated with low SES (Conrad etal., 1992). Alcohol abusers are of lower income (Heien, 1996). Naturally, the increasing risk is associated with decreasing SES for these cancers. Inverse relationship between SES and fertility (Rindfuss et al., 1996), early pregnancy (Rindfuss et al., 1996), and premarital coitus (Aitken-Swan and Baird, 1966; Russell, 1994) have been observed and may help to explain the negative association between SES and cervical cancer. Furthermore, this study identified different relationships among men and women for cancers of the lung and liver, in which heavy smoking and drinking are also considered as main etiological factors: negative SES associations among men and no SES associations among women. There are plausible explanations for such gender differences in the SES relationship in lung cancer. Men have higher rates of cigarette consumption than women (Rogers et al., 1995; Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Emster, 1987) Besides differences in smoking behaviors between men and women by SES, the histologic distribution of lung cancers is different for men and women. The majority of male lung cancers are squamous cell carcinomas and small cell anaplastic carcinomas (Fraumeni and Blot, 1982). Both are closely linked to smoking, whereas high percentages of female lung cancer cases are adenocarcinoma which is less closely related to smoking (Travis et al., 1995). A few other studies have reported the SES relationship with lung cancer in female population from being negative (Cohart, 1955; Ashley, 1969; Wynder and Stellman, 1977) to nonexistent (Brown et al., 1975; Wynder et al., 1973; Devesa and Diamond, 1983) to positive (MacLennan et al., 1977; Hinds etal., 1981). Gender differences in SES association with liver cancer have not been reported earlier. Most studies of SES and cancer risk are confined to a subgroup of the population, e.g., white males or white females, due to the availability of cancer data as well as SES information. The differences between men and women in their cancer risk with respect to SES is consequently less studied. The gender differences in SES association found in this study need to be further investigated. For cancers whose relationships with SES have been unclear, this study found positive association with cancers of the ovary, prostate, and thyroid, and no SES association in cancers of the kidney, pancreas, and rectum. As pointed out earlier, in studying the relationship between SES and a particular cancer, a variety of approaches has been adopted. Different investigators had different ways measuring the SES and different study designs. It is hard to compare the differences in findings. Take prostate cancer as an example, its relationship with SES changes over time and among different studies. Table 25 shows a summary of past studies on the relationship between cancer risk and SES. It appears that the relationship between SES and 283 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. prostatic cancer occurrence must be either variable in different population groups or its true relationship remains unknown because of problems of study design and execution. There are some other interesting findings in this study. Laryngeal cancer is thought to have the same risk factors as lung cancer. A negative SES association with laryngeal cancer among females was established in the study, but the results failed to show that SES is in any way related to lung cancer risk of women. Rectal cancer is identified to have similar risk factors as colon cancer. However, the study found higher colon cancer incidence rates among people of higher SES, which is consistent with other findings, but no SES variations for rectal cancer. The findings suggest that there are possible differences in the etiology between laryngeal cancer and lung cancer particularly among women and between rectal cancer and colon cancer in both sexes. 8.3 Cancer Risk bv SES among Racial/Ethnic Populations Socioeconomic status (SES) has been used as an indicator/predictor for a person's life- chances for a good education, occupation, income, and living environment Race/ethnicity has been found to be highly associated with SES. Ever since the publication of the book The Declining Significance of Race (Wilson, 1978), there has been heated and protracted debates in the field of sociology. In the book, Wilson argues that in present times, race is receding in importance and economic class is becoming a far more important determinant of life-chances. He notes that talented and educated blacks are experiencing new opportunities in governmental and corporate sectors that are at least as great as those of whites with comparable educational qualifications. However, Wilson’s view on the declining significance of race is criticized as being premature. 284 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Wilson’s critics pointed out that his fallacy seems to lie in the belief that an increase in the predictive power of one set of variables (class) necessitates a decrease in the predictive power of another set (race). It was noted that the black poor are much worse off than the white poor, and the black middle-class have a considerable distance to go before catching up to the white middle- class standard of wealth and economic security (Pettigrew, 1989). While social class may have an increased importance for the life-chances of blacks, race may remain as crucial as ever. In the health front, the debate over the biological versus social concept of race led to three major conclusions: (1) In the biological sense, there is no such thing as race. Human variation does not occur in discrete packages. The appearance of a highly consistent pattern of differential mortality and morbidity between races can only be ascribed to environmental (i.e., social) rather than genetic factors. (2) The concept of race itself is a social category. The definition of a population subgroup is a result of economic and historical, not evolutionary, developments. (3) The health status of racial groups should be viewed within this context (Cooper and David, 1986). These conclusions may not be universally accepted, however, the compelling importance of social factors should be acknowledged. Previous studies on SES and cancer risk only investigated the relationship in one subgroup of population, usually white; a few included blacks. The present study is a pioneer in providing comparisons among diverse populations regarding the SES distribution in cancer incidence rates. To sum, the magnitude and direction of SES associations vary by race/ethnicity. No apparent interactions between race/ethnicity and SES were found in cancer development In general, SES trends in whites and blacks reflect the overall SES trend in the total population in most of the cancers except cancers of the stomach (females only), testis, thyroid, and central nervous system, in which blacks did not show any SES trend. For cancers of female 285 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. breast, corpus uteri, bladder, testis, melanoma, thyroid, and central nervous system, whites have higher incidence rates than blacks across all the SES groups. Blacks have the highest incidence rates across all the SES groups in cancers of lung (males only), prostate, colon, esophagus, and pancreas (females only). These differences between blacks and whites may show their different exposures to risk factors. It is known from recent investigations that blacks smoke heavier tar cigarettes than do whites (Wagenknecht et al., 1990) and that most of the blacks who do smoke these cigarettes are in the lower-income groups. Lower-income earners of either race are more likely to be cigarette smokers than are upper-income earners (Center for Disease Control, 1990). Asians and Hispanics sometimes display different SES relationship from the total population. Compared to other racial/ethnic populations, Asians tend to have the least SES variations and lowest incidence rates in these cancers except cancers of the stomach and liver. The homogeneity exhibited here by the Asians may be explained by the fact that Asian-Americans are such a group of mixed ethnicities with different immigration history and different risks to various cancers (Bernstein and Ross, 1991; Miller et al., 1996). Also since Asians are usually a minority in their census tract, their SES may not be reflected in the average SES of their census tract Nevertheless, The existence of SES gradients in female breast cancer and male stomach cancer among Asians seems to certify the utility of the SES index in Asian populations. There are interesting discoveries in this study about the Hispanic population. While the high SES groups in other populations show a decreased risk compared to the low SES groups, the high SES groups in Hispanics show an equivalent, if not increased risk as the low SES groups, especially in smoking related cancers, e.g., lung, esophagus, pancreas. These findings are puzzling as well as fascinating, and they point to unique exposures among this specific population. After adjusting for age, sex, and SES, all the cancers in this study still display significant racial/ethnic differences in cancer risk. Stepwise elimination of racial/ethnic differences by more 286 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. responsible variables should be an important consideration in future investigation into potential environmental sources of cancer risk. The identification of specific risk factors that account for observed differences will not only contribute to the basic understanding of disease processes, but also introduce the possibility of primary prevention for race/ethnicity associated conditions. 8.4 Cancer Risk by SES at Different Age To what extent do social disparities in morbidity persist at different ages? Do the social inequalities in health diminish with age? There appear to be two rival hypotheses. One holds that social disparities will be less in old age than at younger ages, because of many reasons. First, for example, it is argued that the survivors into advanced old age of the most disadvantaged groups present an elite composed of the very healthy, since less viable individuals will have perished early in life. By contrast, the veterans of more advantaged groups in contemporary industrial society contain more vulnerable weaklings whose survival into old age has been assisted by better social conditions and medical care (Gruenberg, 1977). Moreover, once retirement age has been reached, the advantages of those who have been relatively prosperous in middle age are successively eroded with long noneaming periods. Their incomes and savings are no longer adequate to meet the increasing cost of maintaining physical health and functional capacity by medical and nonmedical means. Ageist practices and attitude that operate to restrict access to high-quality lifesaving, rehabilitative, or palliative care are ubiquitous. They do not respect individuals on the basis of past status. Old age is a social leveller. The alternative hypothesis about patterns of mortality, morbidity, and disability in old age is that the factors that contribute to social differentials in health at earlier life stages continue to exert influence in the oldest phase. All those people who exposed to factors that undermined their health and functional performance in childhood and adult life do not die at the same age. Those 287 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. who survive carry with them into later life the habits and effects of long-term poor nutritional status, which are likely to restrict their capacity to resist the additional hazards of the intrinsic aging process (Fox and Goldblatt, 1982). Income and wealth disparities are not eliminated by statutory welfare provision. Housing and adverse environmental conditions continue to disadvantage the members of low social class. Lifelong educational deficits make it less likely that they can profit from individual or community-oriented health promotion activities. Lifelong poverty and insecurity render support from kin or neighbors in the increasing frailty of old age more fragile and problematic for the most socially disadvantaged than it is for the more prosperous (Taylor, 1992). The age-specific incidence rates by SES, race/ethnicity, sex, and cancer site showed a variety of pictures. For populations that do not show associations with SES in their cancer incidence rates, the SES-specific rates are very close to each other with crossovers between the SES groups at different age points. The fluctuation of the rates within certain SES groups may be due to the small case numbers upon which the rates were calculated. Where the SES gradients exist, the differences in incidence rates between SES groups, particularly between the highest SES group and the lowest SES group, become more obvious as age increases in some cases (e.g., melanoma in white men), and in most cases the SES differences remain into old age (e.g., cancer of the corpus uteri, female breast cervix uteri, larynx). The age association in the SES relationship depends the specific cancer, sex, and race/ethnicity. The age point where the substantiation of the SES difference begins depends on the specific cancer. For example, in female breast cancer the increasing differences start after age 45-54 and in cancers of the central nervous system the starting point is after age 55-64 in men, and after age 65-74 in women. The less variation by SES at younger ages may possibly be caused by the small number of cases at younger age. 288 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The relative risks between SES groups in incidence rates seem persistent into old age in some forms of cancer (e.g., colon, liver, melanoma, prostate, and stomach), and reduced in others (e.g., cervix uteri, corpus uteri, ovary, esophagus, lung, larynx, testis, and thyroid). The declining SES effect in old age in some cancers may be due to the specific epidemiology of the diseases which may occur mainly in the young age such as testicular cancer and thyroid cancer. For others the explanations for the changes need to be explored in the future. This is the first study which has reported the changing SES effect by age. The changing SES effect by age also varies by race/ethnicity. 8.5 Limitations of This Study There are two major methodological limitations in this study. One is related with using aggregate approach to classify individuals’ SES according to group characteristics. The other limitation resides with the inclusion of education and income in the SES definition and assigning equal weight to these two factors. As the only alternative for conducting a study like this with such scale, aggregate measures at census tract level have been repeatedly used in health investigations. Its validity and usefulness have been demonstrated (Morgenstem, 1985; Liberatos etal., 1988; Krieger, 1992; Krieger and Fee, 1994). The weak or less obvious SES differentials among Asian population compared to whites and blacks legitimately warrant concern over the applicability or effectiveness of such methodology in minority populations. At the same time, it may reveal some valuable information pointing to the homogeneity in lifestyle among Asians regardless of the differences in SES. Asians do show distinctly graded SES associations in incidence rates as whites and blacks in cancers of stomach (male), lung (male), breast (female), and cervix uteri. Nevertheless, the validity of applying the aggregate approach to specific populations should be studied. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The limitation of data led to the inclusion of education and income as the only measures of the SES components. Additional data on occupation may contribute further information to better the SES measurement Due to lack of empirical evidence, the study adopted equal weight of education and income in composing the SES index. Studies have found differences in influencing health status and cancer risk between education and income (Devesa and Diamond, 1980). The use of composite measure may, as some believe, jeopardize the opportunity to evaluate independent effects and important interactions between indicators. It is wise to examine the impact of education and income separately in association with cancer incidence rates, in order to detect the risk factors. 8.6 Recommendations for Future Studies Given the frequently present SES influence on cancer risk found in this study, future studies on differences in cancer risk among populations should adjust for SES along with other confounding factors. Future studies should try to address the following questions: 1) What does the time trend look like in the SES association with cancer? Do the found SES relationships persist over time? Answers to these questions can put the associations in a societal context, in order to isolate the contributing factors. 2) Is there any relationship between SES and more detailed cancer classification by subsite and histology? Since differences by histology and subsite of cancer may have totally different implications in etiology and treatment, the relationship with respect to SES in more finely defined diseases can help target specific causes. 3) What are the individual relationships between each of the SES indicators, i.e., education and income, on cancer risk? The use of multiple indicators of SES instead of composite measures may increase the chance to detect an existing relationship with SES. 4) Do the interactions between SES and race/ethnicity and other independent variables contribute significantly to the differences in cancer 290 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. risk among populations? To include interaction terms in the analytic models can help to understand the meaning and fashion by which the independent variables exert their influences. 5) Does the stage of cancer at diagnosis vary by SES? Do people of high SES consistently have a advantage of early detection? 6) Does the aggregate method of assigning census tract characteristics of SES to individuals living in the census tract apply equally well to each racial/ethnic group? Answers to the above questions will help to better understand the potential environmental and behavioral sources of health differentials and cancer risk, as well as address the methodological issues in measuring the SES phenomenon in cancer research. In conclusion, the socioeconomic differentials displayed by a particular cancer do offer clues to its etiology. The investigation of the causes of a particular cancer can benefit from consideration of the SES relationships that it displays, and any complete etiological explanation should be consistent with the existence of such relationships. There is no general occurrence of higher cancer rates among low SES groups as compared to high SES. For some cancers such generalization is true, for others it is not Also, the SES effect varies at different ages among different racial/ethnic populations. The heterogeneity in the relationships between specific cancers and socioeconomic status suggests that no single factor can account for these associations. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Table 25. Summary of Epidemiological Studies of Prostatic Cancer Risk and Socioeconomic Status (SES) Reference Study design Data Source SES indicator Time period Population* SES association C le m m e s e n & N ie ls e n ( 1 9 5 1 ) In c id e n c e R e g is try H o u s e re n t o f d is tric t 1 9 4 3 - 1 9 4 7 W h ite s ( C o p e n h a g e n ) N o n e D o rn & C u tle r (1 9 5 8 ) In c id e n c e S u rv e y In c o m e le v e l o f c e n s u s tra c t 1 9 4 7 W h ite s , N o n w h ite s N e g a tiv e G ra h a m e t a l . (1 9 6 0 ) In c id e n c e R e g is try E d u c a tio n le v e l o f c e n s u s tra c t 1 9 4 8 -1 9 5 2 W h ite s N o n e R ic h a rd s o n (1 9 6 5 ) In c id e n c e H o s p ita l A d m is s io n s R e g is tra G e n e r a l O c c u p a tio n a l C la s s ific a tio n 1 9 6 1 -1 9 6 2 W h ite s (S c o tla n d ) P o s itiv e W y n d e r e t a l . (1 9 7 1 ) C a s e -c o n tro l E d u c a tio n 1 9 6 5 -1 9 6 7 W h ite s , N o n w h ite s N o n e E rn s te r e t a l. (1 9 7 7 ) In c id e n c e R e g is try In c o m e a n d e d u c a tio n le v e l o f c e n s u s tra c t 1 9 6 0 - 1 9 6 9 W h ite s , B la c k s N o n e K ra in (1 9 7 4 ) C a s e -c o n tro l E d u c a tio n 1 9 7 1 -1 9 7 2 W h ite s , N o n w h ite s N o n e R im p e la & P u k k a la ( 1 9 8 7 ) In c id e n c e R e g is try O c c u p a tio n , e d u c a tio n 1 9 7 1 -1 9 7 5 W h ite s (F in la n d ) P o s itiv e B a q u e t e t a l. (1 9 9 1 ) In c id e n c e R e g is try In c o m e a n d e d u c a tio n le v e l o f c e n s u s tra c t 1 9 7 8 -1 9 8 2 W h ite s , B la c k s N o n e W illia m e t a l . (1 9 9 1 ) In c id e n c e R e g is try R e g io n a l c o m p o s ite m e a s u re 1 9 8 2 -1 9 8 3 T o ta l (M e lb o u rn e ) P o s itiv e m s study (1996) Incidence Registry Composite m easure at census tract level 1972-1992 Whites, Blacks, Hispanics Asians Positive * Unless otherwise Indicated, study samples are US based. REFERENCES Abramson J. 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Cancer Epidemiology and Prevention. W. B. Saunders Company. 313 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Zippin C. and Petrakis N. L. 1971. Identification of high risk groups in breast cancer. Cancer. 28:1381-1387. 314 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX A SES DESIGNATION FOR CENSUS TRACTS IN LOS ANGELES COUNTY, 1970.1980. AND 1990 1990 1970 1980 1990 Census Tract SES SES SES 1011 3 2 2 1012 4 4 4 1013 2 2 2 1014 2 2 2 1021.01 2 2 3 1021.02 2 1 2 1031.01 3 2 2 1031.02 3 3 3 1032 2 2 2 1033 2 1 1 1034 3 3 3 1041.01 2 3 3 1041.02 4 4 4 1042.01 4 4 4 1042.02 4 4 4 1043 5 4 5 1044.01 5 4 4 1044.02 5 4 4 1045 5 4 4 1046 5 4 4 1047.01 5 5 5 1047.02 5 5 4 1048 4 4 4 1060 2 2 2 1061.02 3 4 3 1061.11 2 2 2 1061.12 2 2 3 1064.01 3 3 4 1064.02 3 3 3 1065 3 3 3 1066.01 3 3 4 1066.02 1 1 1 1066.03 1 1 1 1066.41 1 1 1 1066.42 1 1 1 1066.43 1070 1 1 1 1081.01 1 1 1 1081.02 1 1 1 1990 1970 1980 1990 Census Tract SES SES SES 1081.03 1 1 1 1081.04 1 1 1 1082 1 1 1 1091 4 3 3 1092 2 2 2 1093 2 2 2 1094 3 3 3 1095 5 4 4 1096.01 2 2 3 1096.02 2 2 2 1097 2 2 2 1098 2 2 2 1111 2 2 2 1112.01 1 1 1 1112.02 2 2 2 1112.03 1 1 1 1112.04 1 1 1 1113.01 2 2 2 1113.02 1 1 1 1114 1 2 2 1131 1 1 1 1132.02 3 2 1 1132.11 2 1 1 1132.12 2 1 1 1132.13 1 1 2 1132.31 1 2 1 1132.32 1 2 1 1132.33 1 2 3 1132.34 1 2 4 1133.01 1 1 1 1133.03 2 1 2 1133.21 1 1 2 1133.22 1 1 1 1134.01 2 1 2 1134.21 2 2 3 1134.22 2 2 2 1151.01 1 1 1 1151.02 1 1 2 1152.01 1 2 2 315 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 1152.02 2 2 2 1153.01 1 1 1 1153.02 2 4 4 1154.01 1 1 2 1154.02 3 3 3 1171 2 2 2 1172 1 2 2 1173.01 1 1 2 1173.02 1 1 1 1173.03 2 1 2 1174.01 3 4 4 1174.04 1 1 2 1175 3 3 4 1190 3 3 3 1191 4 4 4 1192 3 3 3 1193 2 3 4 1194 2 2 3 1197 2 2 2 1198 2 2 3 1199 3 2 3 1200 4 4 5 1201.01 4 4 4 1201.02 3 4 4 1203 3 3 3 1204 2 2 3 1210 2 3 3 1211 4 4 3 1212 4 3 4 1216 2 2 2 1218 4 3 4 1219 4 3 4 1220 2 2 2 1221 3 4 4 1222 4 4 4 1224 4 4 5 1230 4 4 4 1231.02 3 4 3 1232.01 4 5 5 1232.02 4 5 5 1233.01 3 2 3 1233.02 3 3 3 1234 3 4 4 1235 2 3 4 1236.01 2 3 3 1236.02 2 2 2 1237 2 3 3 1238 2 3 2 1239 2 3 3 1990 1970 1980 1990 Census Tract SES SES SES 1240 1 1 2 1241.01 4 4 4 1241.02 3 4 4 1242.01 3 - 3 4 1242.02 4 4 4 1243 4 4 4 1244 2 2 2 1245 1 2 2 1246 1 2 2 1247 1 1 2 1249.01 3 3 3 1251 2 3 2 1252 3 3 3 1253 4 4 5 1254 4 3 3 1255 3 3 3 1256 1 1 2 1271.01 3 3 4 1271.02 2 2 3 1272 2 3 4 1273 3 2 3 1274 3 4 4 1275 3 4 4 1276.01 3 3 4 1276.02 3 3 4 1277 2 3 3 1278.01 2 3 4 1278.02 3 3 4 1279 3 3 4 1281 3 3 3 1282 4 4 4 1283.01 4 4 5 1284 2 2 2 1285 2 3 3 1286 2 2 3 1287.01 1 2 2 1287.02 1 2 2 1288 2 2 2 1289 2 3 2 1310 3 3 3 1311 2 2 2 1312 2 2 2 1313 2 2 3 1314 2 2 3 1316 2 2 2 1317 3 3 2 1318 3 3 3 1319 3 2 2 1320 2 2 2 316 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 1321 2 2 2 1323 2 3 4 1325 3 3 3 1327 2 2 3 1329 2 2 2 1330 2 2 2 1331.01 2 3 3 1340 3 3 3 1341.01 2 2 2 1341.02 2 2 2 1342.01 2 2 2 1343.01 2 2 3 1343.02 1 1 2 1343.03 2 2 2 1344.01 1 1 1 1344.21 1 1 1 1344.22 1 1 1 1345 5 4 4 1347 2 2 3 1348 2 2 2 1349.01 1 1 1 1349.02 2 2 3 1351.02 1 1 1 1351.11 2 2 2 1351.12 2 2 3 1352.01 1 1 1 1352.02 1 1 1 1352.03 1 1 1 1370 1 1 1 1371.01 1 1 1 1371.02 1 1 1 1372.01 1 2 2 1373.01 1 1 1 1373.02 1 1 1 1374.01 1 1 1 1374.02 1 1 1 1375.01 1 1 1 1375.02 1 1 1 1375.04 1 1 1 1380 1 1 1 1390 1 2 2 1392 3 2 2 1393.01 2 2 1 1393.02 2 2 3 1393.03 2 2 2 1394 1 2 2 1395.01 2 3 3 1395.02 2 3 2 1396 1 1 1 1990 1970 1980 1990 Census Tract SES SES SES 1397.01 1 1 1 1397.02 1 1 1 1397.03 1 1 1 1398.01 1 1 1 1398.02 1 1 1 1411 2 2 2 1412 2 3 2 1413.01 2 2 2 1413.02 2 2 2 1414 1 1 1 1415 1 1 1 1416 1 1 1 1417 1 1 1 1431 1 2 2 1432 2 2 3 1433 2 2 2 1434.01 2 2 2 1434.02 2 1 3 1435 1 2 1 1436.01 2 3 2 1436.02 2 2 1 1437 1 1 1 1438 1 1 1 1439.01 1 1 1 1439.02 1 1 1 1810 2 2 2 1813 2 2 1 1814 3 4 4 1815 3 3 2 1816 3 4 3 1831.01 4 4 3 1831.02 3 4 4 1832 4 4 4 1833 4 4 4 1834 4 4 4 1835 4 4 4 1836 4 5 4 1837 4 4 4 1838 4 5 5 1851 3 2 3 1852.01 4 4 4 1852.02 4 4 3 1853 5 5 5 1861 3 2 2 1862 3 3 3 1863 3 3 3 1864.01 5 5 5 1864.02 5 5 4 1871 4 4 4 317 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 1872 4 4 4 1873 2 2 2 1881 3 4 4 1882 1 2 2 1883 4 3 3 1891 2 2 3 1892 2 3 3 1893 1 1 1 1894 1 1 1 1895 2 3 3 1896 1 2 2 1897.01 1 1 1 1897.02 1 1 2 1898 2 3 2 1899.01 3 3 3 1899.02 3 3 4 1901 3 3 4 1902 3 4 5 1903.01 3 4 4 1904 3 4 4 1905 4 5 5 1907 4 5 5 1908 4 4 5 1909.01 4 5 5 1909.02 4 5 5 1910 3 4 4 1911 4 5 5 1912.01 3 4 5 1912.02 3 4 5 1913 4 4 4 1914 4 5 5 1915 3 4 4 1916 4 4 5 1917 4 5 5 1918 4 4 5 1919 3 3 3 1920 4 4 3 1923 1 2 2 1924 3 3 4 1925 3 4 4 1926 3 4 5 1927 4 4 4 1941 1 1 1 1942 1 1 1 1943 1 1 1 1944 4 3 3 1945 4 3 2 1951 1 1 1 1952 2 2 2 1990 1970 1980 1990 Census Tract SES SES SES 1953 4 4 3 1954 2 2 3 1955 3 3 2 1956 4 4 4 1957 5 5 5 1958.01 4 4 4 1958.02 4 4 4 1959 3 3 4 1971 5 5 5 1972 5 4 4 1973 4 4 4 1974 4 4 4 1975 5 5 5 1976 5 5 5 1977 5 5 5 1990 5 5 5 1991 5 5 5 1992.01 5 5 5 1992.02 5 5 5 1993 4 4 4 1994 5 5 5 1997 5 5 5 1998 5 5 5 1999 5 5 5 2011 5 5 5 2012 5 5 4 2013.01 5 4 4 2013.02 5 5 1 2014.01 5 5 5 2014.02 3 4 4 2015.01 4 5 4 2015.02 5 5 5 2016 4 4 4 2017 3 4 3 2031 5 5 5 2032 5 5 5 2033 3 3 4 2034 5 5 5 2035 5 5 5 2036 5 5 5 2037 5 5 5 2038 5 5 5 2039 5 5 5 2041 5 5 5 2042 5 5 5 2043 5 5 5 2044 5 5 5 2045 5 5 5 2046 5 5 5 318 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 2047 5 5 5 2048 5 5 5 2049 5 5 5 2051 5 5 5 2060 5 5 5 2062 5 5 5 2063 5 5 5 2071 5 5 5 2073 5 5 5 2074 5 5 5 2075 1 1 3 2077 5 5 5 2079 5 5 3 2080 5 5 5 2083 5 5 5 2084 5 5 5 2085 4 4 5 2086 3 3 4 2087 3 4 4 2088 4 5 5 2089.01 5 5 5 2089.02 5 5 5 2091.01 5 5 5 2091.02 5 5 5 2092 5 5 5 2093 5 5 5 2094.01 5 5 5 2094.02 5 5 5 2094.03 5 5 5 2095 5 5 5 2098 5 5 5 2100 5 5 5 2110 1 1 1 2111 3 3 4 2112 3 4 5 2113 4 4 5 2114 3 3 4 2115 1 2 3 2117.01 2 3 2 2117.02 2 3 4 2118.01 2 3 3 2118.02 2 3 4 2119 2 4 4 2121 3 4 4 2122.01 4 5 5 2122.02 4 5 5 2123.01 4 5 5 2123.02 4 5 5 2124 3 3 5 1990 1970 1980 1990 Census Tract SES SES SES 2125 3 4 4 2126 3 4 4 2127 2 2 2 2128 3 4 4 2129 4 4 5 2131 3 3 4 2132.01 4 5 5 2132.02 4 5 5 2133 4 5 5 2134.01 3 5 5 2134.02 3 5 5 2140 1 2 1 2141 1 1 1 2144 5 4 2 2145 2 3 2 2146 4 3 3 2147 3 2 2 2148 3 3 3 2149 2 3 2 2151 5 4 2 2161 1 1 2 2162 2 3 2 2163 2 2 2 2164 3 4 3 2167 3 3 3 2168 2 2 2 2169 4 3 3 2170 3 3 2 2171 4 4 3 2172 3 3 3 2181 4 5 4 2182 4 4 4 2183 4 4 4 2184 4 4 4 2185 4 4 4 2186 4 4 5 2187 4 4 4 2188 4 5 5 2189 4 4 4 2190 5 5 4 2193 4 4 5 2195 2 2 3 2197 4 5 5 2198 5 5 5 2199 4 4 5 2200 4 4 4 2201 2 3 3 2211 5 5 5 2212 5 5 5 319 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 2213.01 4 5 5 2213.02 4 5 5 2214 4 5 5 2215 5 5 5 2216 5 5 5 2217 5 5 5 2218 5 5 4 2219 4 5 5 2220 5 5 5 2221 5 5 5 2222 5 5 5 2225 5 5 5 2226 5 5 5 2227 3 3 3 2240 5 5 5 2242 5 5 5 2243 5 5 5 2244 5 5 5 2246 5 5 5 2247 3 4 5 2260 5 5 5 2264 5 5 5 2267 5 5 5 2270 5 5 5 2281 5 5 5 2282 5 5 5 2283 5 5 5 2284 5 5 5 2285 5 5 5 2286 5 5 5 2287 5 5 5 2288 5 5 5 2289 5 5 5 2291 5 5 5 2292 5 5 5 2293 5 5 5 2294 5 5 5 2311 5 5 5 2312 5 5 5 2313 5 5 5 2314 5 5 5 2315 4 4 4 2316 5 5 5 2317 5 5 5 2318 5 5 5 2319 5 5 5 2321 5 5 5 2322 5 5 5 2323 5 5 5 1990 1970 1980 1990 Census Tract SES SES SES 2324 5 5 5 2325 5 5 5 2326 5 5 5 2327 5 5 5 2328 5 5 5 2340 3 3 3 2342 2 2 2 2343 2 3 4 2345 4 4 4 2346 4 4 4 2347 4 4 4 2348 4 4 4 2349 4 5 5 2351 2 2 3 2352.01 4 4 4 2352.02 3 4 4 2360 1 1 1 2361 3 4 4 2362.01 3 4 5 2362.02 3 4 5 2364 1 1 2 2371 5 5 5 2372 5 5 5 2373 4 4 4 2374 5 5 5 2375 5 5 5 2376 5 5 5 2377 5 5 5 2378 4 4 4 2379 4 4 4 2380 3 3 3 2381 4 4 4 2382 4 4 4 2383 5 5 5 2384 4 3 3 2392 5 5 5 2393 5 5 5 2395 5 5 5 2396 5 5 5 2397 5 5 5 2398 5 5 5 2400 5 5 5 2402 5 5 5 2403 5 5 5 2404 5 5 5 2405 5 5 5 2406 5 5 5 2407 5 5 5 2408 5 5 5 320 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 2409 5 5 5 2410 5 5 5 2411 5 5 5 2412 4 4 4 2413 3 4 4 2414 5 5 5 2420 5 5 5 2421 5 5 5 2422 5 5 5 2423 5 5 5 2426 5 5 5 2427 5 5 5 2430 5 5 5 2431 5 5 5 2611.01 1 1 1 2611.02 1 1 1 2612 1 1 1 2621 1 1 1 2622 1 1 1 2623.01 1 1 1 2623.02 1 1 1 2623.03 1 1 1 2624 1 1 1 2625 1 1 1 2626.01 1 1 1 2626.02 1 1 1 2627.01 1 1 1 2627.02 1 1 1 2628 1 1 1 2640 1 1 1 2641.01 2643.01 1 1 1 1 1 2643.02 1 1 1 2651 1 1 1 2652 2653.01 2653.02 1 1 1 1 1 2654 1 1 1 2655 1 1 1 2656 1 1 1 2657 1 1 1 2671 1 1 1 2672 1 2 1 2673 3 3 3 2674.01 2 2 2 2674.02 1 2 2 2675.01 2 3 2 2675.02 3 3 2 2676 3 3 2 1990 1970 1980 1990 Census Tract SES SES SES 2677 4 4 3 2678 2 1 1 2679 1 1 1 2690 1 1 1 2691 2 2 2 2693 1 1 1 2695 1 1 1 2696 3 3 4 2697 2 3 2 2698 3 2 2 2699.01 2 3 2 2699.02 3 3 2 2701 2 2 2 2702 4 4 4 2703 3 3 3 2711 2 2 2 2712 3 3 2 2713 3 2 2 2714 1 1 1 2715 1 1 1 2716 1 1 1 2717.01 1 2 2 2717.02 2 2 2 2718.01 2 2 2 2718.02 2 2 2 2719 2 2 2 2721 2 2 2 2722 3 3 3 2723.01 3 3 3 2723.02 3 4 3 2731 3 3 2 2732 5 4 4 2733 5 5 4 2734 4 3 3 2735 4 3 2 2736 4 3 2 2737 4 3 2 2738 4 3 3 2739 3 2 1 2741 3 2 1 2742 1 1 1 2751 3 3 3 2752 4 4 3 2753.02 1 1 1 2753.11 3 2 2 2753.12 3 2 2 2754 4 2 2 2755 5 5 5 2756 2 3 3 321 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 1990 1970 1980 1990 Census Tract SES SES SES Census Tract SES SES SES 2760 1 1 1 3005 3 3 3 2761 2 3 2 3006 2 2 2 2764 1 1 1 3007.01 1 1 1 2765 1 1 1 3007.02 1 1 1 2766.01 1 1 1 3008 1 1 1 2766.02 1 1 1 3009 1 1 1 2770 1 1 1 3010 2 2 2 2771 1 1 1 3011 2 2 2 2772 3 3 3 3012.01 2 3 3 2774 3 2 3 3012.02 2 2 2 2780 2 2 2 3013 1 1 1 2781 1 1 1 3014 1 1 1 2911 4 4 4 3015 3 3 3 2912 3 3 3 3016.01 4 4 4 2913 2 3 2 3016.02 4 4 4 2920 4 4 4 3017 3 4 3 2932.01 3 3 3 3018 4 4 3 2932.02 5 4 4 3019 2 3 2 2933.01 3 2 1 3020.01 4 4 3 2933.02 3 2 3 3020.02 4 4 3 2933.03 3 2 4 3021.01 4 4 4 2941 4 4 4 3021.02 3 3 3 2942 4 4 4 3022 4 4 4 2943 4 4 4 3023 4 4 4 2944 5 4 4 3024 4 5 4 2945 5 4 5 3025.01 4 4 4 2946 5 5 5 3025.02 4 4 4 2947 5 5 5 3101 1 1 1 2948 5 5 5 3102 2 3 2 2949 5 5 5 3103 1 1 1 2951 2 1 2 3104 2 2 3 2961 3 2 3 3105 4 4 5 2962 5 5 5 3106 3 3 3 2963 5 3 1 3107 4 4 3 2964 3 2 2 3108 3 3 3 2965 5 5 4 3109 3 3 3 2966 5 5 4 3110 3 3 3 2969 5 4 4 3111 3 3 3 2970 3 3 2 3112 3 3 3 2971 5 5 5 3113 3 3 3 2972 4 4 3 3114 2 3 2 2973 4 2 2 3115 3 3 3 2974 1 1 1 3116 2 2 2 2975 2 2 2 3117 2 3 2 2976 3 3 2 3118 4 4 4 3001 1 1 1 3201 3 3 4 3002 2 2 2 3202 4 4 4 3003 1 1 1 3203 5 5 5 3004 2 2 2 4002.01 1 1 1 322 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 4002.02 1 1 1 4003.01 2 1 2 4003.02 2 1 2 4004.01 1 1 1 4004.02 1 1 2 4005 1 1 1 4006.01 3 3 2 4006.02 3 3 4 4008 3 2 3 4009 2 2 2 4010.01 1 1 1 4010.02 2 3 3 4011.01 3 3 3 4011.02 4 4 3 4012.01 2 2 2 4012.02 3 2 2 4012.03 3 2 2 4013.02 1 1 1 4013.11 3 2 2 4013.12 3 3 3 4015 5 4 3 4016.01 2 2 2 4016.02 2 2 3 4016.03 2 2 3 4017.01 1 1 1 4017.02 1 3 3 4018 1 1 1 4019.01 2 3 3 4019.02 1 2 1 4020 1 2 2 4021.01 4 4 4 4021.02 2 3 3 4022 1 2 2 4023.01 4 4 4 4023.02 4 5 5 4024.01 4 4 4 4024.02 3 4 3 4024.03 3 4 4 4024.04 2 2 3 4025.01 5 5 5 4025.02 5 5 5 4026 3 4 4 4027.01 2 3 3 4027.02 4 4 5 4028 5 5 5 4029.01 4 4 4 4029.02 4 4 4 4030 5 4 4 4032 3 3 3 1990 1970 1980 1990 Census Tract SES SES SES 4033.02 1 1 1 4033.11 4033.12 1 1 1 1 1 4033.13 1 1 1 4033.14 1 1 1 4033.15 1 1 1 4034 1 1 1 4035 1 1 1 4036 1 1 1 4037.01 2 2 2 4037.21 2 2 3 4037.22 2 3 3 4038.01 3 3 3 4038.02 3 3 3 4039.01 3 3 3 4039.02 3 3 2 4040 3 3 3 4041 4 3 3 4042 3 4 4 4043 5 4 4 4044 5 4 4 4045 5 4 4 4046 5 4 4 4047 5 4 4 4048 5 4 4 4049 4 4 3 4050 4 4 4 4051 5 5 4 4052 4 4 4 4053 3 3 3 4054 3 3 3 4055 2 2 3 4056 2 2 3 4057 3 3 3 4058 3 3 3 4059 2 3 3 4060 2 2 3 4061.01 3 4 3 4061.02 3 4 3 4062 2 3 3 4063 1 1 1 4064.02 1 1 1 4064.11 1 2 3 4064.12 1 2 2 4065 2 2 3 4066.01 1 1 2 4066.02 2 2 3 4067 2 2 3 4068 2 2 2 323 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 4069 3 3 3 4070 4 3 4 4071.01 4 4 4 4071.02 4 4 4 4072 4 4 4 4073 4 3 3 4074 3 2 3 4075 4 3 4 4076 4 4 4 4077 4 4 4 4078 3 3 3 4079 3 2 2 4080.01 2 1 2 4080.02 2 2 2 4081.01 2 2 2 4081.02 4 4 4 4081.31 5 1 2 4081.32 5 4 4 4082.02 4 4 4 4082.11 3 2 3 4082.12 3 2 2 4083.01 5 4 4 4083.02 2 2 2 4083.03 2 2 2 4084.01 2 2 3 4084.02 1 1 1 4085.01 4 3 3 4085.02 2 2 2 4085.03 1 1 1 4086.01 3 3 3 4086.21 1 1 1 4086.22 1 1 1 4086.23 1 1 2 4086.24 1 1 1 4086.25 1 1 1 4087.01 2 2 2 4087.21 3 3 3 4087.22 3 3 2 4088 5 5 5 4300.01 1 1 1 4300.02 4 3 3 4301.01 4 4 4 4301.02 4 4 4 4302 1 1 1 4303.01 2 2 1 4303.02 2 2 2 4304 1 1 1 4305.01 1 1 1 4305.02 2 2 1 1990 1970 1980 1990 Census Tract SES SES SES 4306 1 1 1 4307.01 1 1 1 4307.21 2 1 2 4307.22 2 2 3 4308.01 4 4 3 4308.02 1 1 1 4308.03 1 1 1 4309 4 4 3 4310.01 4 4 3 4310.02 4 4 3 4311 5 5 4 4312 4 4 4 4313 2 2 2 4314 3 3 3 4315 2 3 3 4316 1 1 1 4317 1 1 1 4318 2 2 2 4319 3 3 3 4320 2 2 2 4321.01 3 2 2 4321.02 2 2 2 4322 4 3 3 4323 3 3 3 4324 4 4 4 4325 4 3 4 4326 4 4 4 4327 5 4 5 4328 5 5 5 4329 4 3 4 4331 5 4 4 4332 4 5 5 4333 5 5 5 4334 5 5 5 4335 5 5 5 4336.01 5 4 4 4336.02 4 4 5 4337 4 4 4 4338 5 5 4 4339 5 5 5 4340 5 5 5 4600 1 1 1 4601 1 1 1 4602 2 2 1 4603.01 3 2 2 4603.02 3 2 3 4604 2 1 1 4605.01 1 1 1 4605.02 1 1 1 324 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 4606 1 1 1 4607 1 1 1 4608 1 1 1 4609 4 4 4 4610 4 4 3 4611 3 3 3 4612 1 1 1 4613 2 3 2 4614 3 3 3 4615 4 4 4 4616 5 4 4 4617 1 1 1 4619 5 5 5 4620 5 5 5 4621 4 4 4 4622 3 4 4 4623 4 4 3 4624 3 3 2 4625 2 3 2 4626 1 1 1 4627 4 3 2 4628 3 3 3 4629 2 2 2 4630 1 1 1 4631.01 4 2 3 4631.02 2 1 1 4632 2 2 2 4633 1 1 1 4634 2 2 2 4635 2 2 2 4636 3 3 2 4637 1 1 1 4638 1 1 1 4639 1 1 1 4640 1 1 1 4641 1 1 1 4642 1 1 1 4800.02 1 1 1 4800.11 2 2 3 4800.12 2 2 2 4801.01 3 3 2 4801.02 2 2 2 4802 1 1 1 4803 3 3 3 4804 2 2 3 4805 1 1 1 4806 2 2 1 4807.01 2 2 2 4807.02 1 1 1 1990 1970 1980 1990 Census Tract SES SES SES 4808.01 3 4 3 4808.02 4 4 4 4809 4 4 4 4810 4 3 3 4811 3 4 4 4812.01 3 3 3 4812.02 3 3 3 4813 4 4 4 4814 3 4 4 4815 2 2 3 4816.01 3 3 4 4816.02 3 4 4 4817.02 4 4 4 4817.11 4 4 4 4817.12 4 4 4 4818 2 2 2 4819.01 2 3 3 4819.02 3 3 3 4820.01 1 1 1 4820.02 1 1 2 4821.01 3 3 3 4821.02 1 2 2 4822.01 4 4 4 4822.02 4 4 4 4823.01 5 4 4 4823.02 4 5 5 4824.01 5 5 5 4824.02 4 3 3 4825.01 5 5 5 4825.21 4 3 4 4825.22 4 3 2 4826 2 1 2 4827 3 3 4 4828 2 2 3 5001 1 1 1 5002.01 1 1 1 5002.02 1 1 1 5003 2 1 1 5004.01 4 3 3 5004.02 5 5 5 5005 5 5 4 5006 5 5 4 5007 4 4 4 5008 4 3 4 5009 4 4 5 5010 3 3 3 5012 2 3 3 5013 2 2 3 5014 5 4 4 325 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 5015.01 2 1 1 5015.02 2 4 3 5016 1 1 1 5017 1 1 2 5018 3 4 4 5019 3 3 3 5020.01 2 3 3 5020.02 4 4 4 5021 3 3 3 5022 3 3 3 5023 3 4 4 5024 4 4 4 5025 4 3 3 5026.01 4 3 3 5026.02 3 3 4 5027 4 4 4 5028 3 3 3 5029.01 2 3 3 5029.02 4 4 4 5030 5 4 4 5031.01 4 3 3 5031.02 4 4 4 5032.01 2 2 2 5032.02 3 3 3 5033.01 2 3 2 5033.02 2 3 3 5034.01 2 2 2 5034.02 2 2 2 5035.01 3 3 3 5035.02 2 3 3 5036.01 3 2 2 5036.02 1 1 1 5037.01 1 2 2 5037.02 2 2 2 5037.03 1 1 2 5038.01 2 2 2 5038.02 2 2 2 5039.01 2 2 3 5039.02 2 2 2 5040.01 1 2 2 5040.02 2 2 2 5041.01 3 3 3 5041.02 3 3 5 5300.01 2 2 2 5300.02 1 1 2 5301.01 4 5 5 5301.02 3 4 4 5302.01 4 4 4 5302.02 4 4 4 1990 1970 1980 1990 Census Tract SES SES SES 5303 5 5 5 5304 5 5 5 5305 5 5 5 5306 5 4 5 5307 5 5 5 5308 5 5 5 5309 5 5 5 5310 5 5 5 5311 5 5 5 5312.01 5 5 5 5312.02 5 5 5 5313.01 5 5 5 5313.02 5 5 5 5315.01 5 5 5 5315.02 5 5 5 5316.01 5 5 5 5316.02 5 5 5 5317.01 5 5 5 5317.02 5 5 5 5318 5 5 5 5319.01 5 5 5 5319.02 5 5 5 5320 5 5 5 5321 4 4 4 5322 4 4 4 5323.01 5 5 4 5323.02 5 5 5 5324 4 5 5 5325 5 5 4 5326.01 5 5 5 5326.02 5 5 5 5327 5 5 5 5328 5 5 5 5329 5 5 5 5330 5 5 5 5331.01 5 5 5 5331.02 5 5 5 5332 5 5 5 5333 5 5 5 5334 5 5 5 5335 5 5 5 5336 5 5 5 5337 5 5 5 5338.01 5 5 5 5338.02 4 5 5 5339 5 5 5 5340 5 5 5 5341 5 5 5 5342 5 5 5 326 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 5343 5 5 5 5344.01 5 5 5 5344.02 5 5 5 5345 4 4 4 5347 3 4 4 5348.01 4 5 5 5348.02 4 5 4 5349 5 5 5 5350 5 5 5 5351.01 5 5 5 5351.02 5 5 5 5352 5 5 5 5353 5 5 5 5354 5 5 5 5355 4 5 5 5356.01 5 5 5 5356.02 5 5 5 5357 4 4 5 5358.01 4 5 5 5358.02 4 5 4 5359 4 4 4 5360 5 5 5 5361 3 4 4 5362 4 4 4 5400 4 5 5 5401.01 3 3 4 5401.02 3 3 4 5402 4 5 5 5403 4 5 5 5404 5 5 5 5405 5 5 5 5406 5 5 5 5407 5 5 4 5408 4 4 4 5409.01 5 5 4 5409.02 4 4 4 5410.01 3 4 3 5410.02 3 2 3 5411 5 4 4 5412 4 4 4 5413 5 5 4 5414 5 5 5 5415 5 5 5 5416.01 5 5 5 5416.02 4 5 5 5417 3 3 4 5418 4 4 5 5420 3 3 4 5421.01 4 4 5 1990 1970 1980 1990 Census Tract SES SES SES 5421.02 5 5 5 5422 4 4 4 5424.01 3 4 4 5424.02 4 4 4 5425 5 5 4 5426 5 5 5 5427 5 5 5 5428 5 4 4 5429 5 5 5 5430 4 4 4 5431 4 4 4 5432 5 5 4 5433.01 1 1 2 5433.03 3 2 2 5433.21 2 2 2 5433.22 2 1 1 5434 4 3 3 5435.01 4 3 3 5435.02 4 3 3 5435.03 3 3 2 5436.01 4 3 3 5436.02 3 2 2 5436.03 1 1 2 5436.04 3 2 2 5437.01 4 3 3 5437.02 4 3 3 5437.03 3 2 3 5438.01 3 3 3 5438.02 3 3 3 5439.01 4 4 4 5439.02 4 3 2 5440 4 3 3 5500 3 4 3 5501 4 3 3 5502 4 3 3 5503 3 3 3 5504 3 2 3 5505 1 2 2 5506 2 2 2 5507 2 2 2 5508 2 2 2 5509 2 3 3 5510 2 2 2 5511 4 4 4 5512 3 3 3 5513 4 4 4 5514 2 3 3 5515 2 3 3 5516 3 5 4 327 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 5517 4 3 3 5518 3 3 3 5519 3 3 3 5520 4 4 3 5521 4 4 3 5522 4 4 4 5523 3 3 3 5524 5 4 4 5526 5 4 4 5527 4 4 3 5528 4 4 3 5529 4 3 3 5530 3 3 3 5531 3 3 3 5532 3 3 3 5533 3 4 3 5534 4 3 4 5535 5 4 4 5536 5 5 4 5537 5 5 5 5538 4 5 4 5539 4 4 4 5540 4 4 4 5541 4 4 4 5542 4 4 4 5543 4 4 4 5544.01 3 3 3 5544.02 4 4 4 5545.11 1 1 1 5545.12 1 1 1 5545.13 1 1 1 5545.14 1 1 1 5545.15 1 1 1 5545.16 1 1 1 5545.17 1 1 1 5545.18 1 1 1 5545.19 1 1 1 5545.21 2 1 1 5545.22 2 1 1 5546 3 3 3 5547 5 4 4 5548.01 4 4 4 5548.02 4 3 3 5549 4 4 3 5550 3 3 2 5551.02 4 4 3 5551.98 3 2 2 5552.02 1 1 1 5552.11 5 5 5 1990 1970 1980 1990 Census Tract SES SES SES 5552.12 5 5 4 5700.01 2 2 2 5700.02 3 3 2 5700.03 3 3 2 5701 2 2 2 5702.01 4 4 4 5702.02 4 3 3 5703.01 3 4 4 5703.02 5 4 4 5704 4 4 3 5705 4 3 3 5706 4 3 4 5707.01 3 3 3 5707.02 2 2 3 5708 3 2 2 5709.01 2 2 2 5709.02 2 2 2 5710 2 2 2 5711.01 2 2 2 5711.02 3 2 2 5712 2 2 2 5713 2 2 2 5714 3 2 3 5715.01 3 3 3 5715.02 3 3 3 5716 5 5 5 5717 4 4 4 5718 1 1 1 5719 1 2 2 5720.01 3 2 2 5720.02 1 2 2 5721 3 3 1 5722.01 3 3 2 5722.02 3 4 2 5723 5 4 4 5724 3 2 2 5725 5 4 4 5726 4 3 3 5727 4 3 3 5728 5 4 4 5729 5 5 4 5730 4 4 4 5731 3 4 4 5732.01 5 4 5 5732.02 5 5 5 5733 5 5 5 5734 4 3 3 5735 4 4 4 5736 2 2 2 328 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 5737 2 2 2 5738 2 2 1 5739.01 2 3 1 5739.02 1 1 1 5740 1 1 1 5741 2 2 2 5742.01 1 2 2 5742.02 4 3 3 5743 1 2 2 5744 1 1 1 5745 1 1 1 5746.01 3 3 3 5746.02 1 1 1 5747 2 2 2 5748 1 1 1 5749.01 2 2 2 5749.02 2 2 2 5750.01 3 3 2 5750.02 4 3 3 5751 4 5 4 5752 5 5 5 5753 5 5 5 5754 4 5 5 5755 5 5 5 5756 3 3 3 5757 3 3 3 5758 5 5 5 5759 5 5 5 5760 5 5 3 5761 4 5 4 5762 5 5 5 5763 5 5 5 5764 5 5 5 5765 5 4 4 5766 4 3 3 5767 3 2 2 5768 4 3 3 5769 5 4 4 5770 3 3 2 5771 3 2 2 5772 2 2 2 5773 2 2 1 5774 2 2 1 5775.01 1 1 1 5775.02 1 1 1 5776.01 2 1 1 5776.02 1 1 1 5776.03 1 1 1 5990 3 3 4 1990 1970 1980 1990 Census Tract SES SES SES 5991 3 3 3 6001 5 5 5 6002.01 5 5 5 6002.02 5 5 5 6003.01 5 5 5 6003.02 4 3 3 6004 3 3 3 6005.01 2 2 2 6005.02 2 3 2 6006.01 3 3 2 6006.02 3 3 5 6007.01 2 3 2 6007.02 2 2 2 6008.01 2 3 3 6008.02 2 3 3 6009.02 3 4 4 6009.11 4 4 3 6009.12 4 4 4 6010.01 2 4 4 6010.02 2 4 4 6011 3 4 4 6012.02 3 4 4 6012.11 ^ 3 4 4 6012.12 3 4 4 6013.01 2 1 2 6013.02 2 3 3 6013.03 2 3 4 6014.01 3 4 4 6014.02 3 3 4 6015 4 4 5 6016 4 5 4 6017 4 4 5 6018 5 5 5 6019 4 5 5 6020.01 4 4 4 6020.02 4 4 4 6021.01 3 4 4 6021.02 3 4 4 6022 3 3 3 6023.01 3 3 3 6023.02 1 1 1 6024.01 3 3 3 6024.02 3 2 2 6025.01 3 3 4 6025.02 3 3 4 6025.03 3 4 4 6026 3 2 3 6027 2 2 2 6028 4 4 4 329 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 6029 4 4 4 6030.01 3 4 4 6030.02 3 3 3 6031 3 3 3 6032 3 3 3 6033 3 3 3 6034 2 3 3 6035 3 2 3 6036 3 3 2 6037.01 3 4 3 6037.02 2 2 2 6038 4 4 3 6039 4 3 3 6040 4 4 4 6041 4 3 4 6099 4 4 4 6200 2 2 1 6201 2 2 2 6202 1 1 1 6203.01 1 1 1 6203.02 1 1 1 6203.03 1 1 1 6204 1 1 1 6205.01 3 2 1 6205.21 4 2 1 6205.22 4 2 1 6206.01 4 2 6206.02 3 2 1 6207.01 3 2 1 6207.02 3 2 1 6208 2 1 1 6209.01 1 1 1 6209.02 1 1 1 6210.01 2 1 1 6210.02 1 1 1 6211 2 1 1 6212.01 3 2 1 6212.02 3 2 1 6213.01 2 1 1 6213.21 2 1 1 6213.22 2 1 1 6214 2 2 1 6500.01 2 2 2 6500.02 2 2 2 6501.01 2 1 2 6501.02 2 2 2 6502 2 2 2 6503 3 2 2 6504 2 1 1 1990 1970 1980 1990 Census Tract SES SES SES 6505.01 2 1 2 6505.02 2 1 1 6506.01 2 2 2 6506.02 2 2 2 6506.03 1 1 1 6507.01 1 1 1 6507.02 2 1 1 6508 1 2 1 6509.01 4 4 3 6509.02 4 3 2 6510.01 2 2 2 6510.02 2 1 2 6511.01 1 1 1 6511.02 1 2 2 6512.01 1 1 1 6512.21 1 2 3 6512.22 1 1 1 6513.01 1 1 1 6513.02 1 1 1 6514 2 1 1 6700.01 3 3 3 6700.02 4 3 3 6700.03 4 4 3 6701 4 3 2 6702.01 1 1 1 6702.02 1 1 1 6703.01 1 1 1 6703.21 1 1 1 6703.22 1 1 1 6704.02 1 1 1 6704.11 1 1 1 6704.12 1 1 1 6705 1 1 1 6706 1 1 1 6707.01 1 1 1 6707.02 1 1 1 7001 4 4 4 7002 3 3 3 7003 2 3 2 7004 3 3 3 7005 1 2 2 7006 1 1 1 7007 1 1 1 7008 1 2 2 7009.01 1 1 1 7009.02 1 2 2 7010 1 1 1 7011 2 2 2 7012.01 1 1 1 330 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1990 1970 1980 1990 Census Tract SES SES SES 7012.02 2 2 1 7013.01 1 1 1 7013.02 2 2 2 7014 2 2 2 7015.01 2 2 1 7015.02 3 3 3 7016.01 1 1 1 7016.02 2 2 2 7017.01 3 3 2 7017.02 4 3 3 7018.01 4 4 4 7018.02 5 4 4 7019 4 4 4 7020 3 2 2 7021 3 2 2 7022.01 2 2 2 7022.02 2 2 1 7023 3 3 2 7024 4 3 3 7025 2 1 1 7026 2 1 1 7027 2 1 1 7028.01 3 3 3 7028.02 3 2 2 7028.03 4 3 3 7029 1 1 1 7030.01 1 1 1 7030.02 1 1 1 7031 1 1 1 7032 1 1 1 8001 1 1 1 8002 1 1 1 8003.01 1 1 1 8003.21 1 1 1 8003.22 1 1 1 8004.01 1 1 1 8004.02 1 1 1 8005.01 1 1 1 8005.02 1 1 1 9001 5 3 3 9002 2 4 4 9003 5 4 4 9005 3 2 2 9006.01 3 3 3 9006.02 3 4 4 9006.03 3 2 3 9007.01 2 2 3 9007.02 2 2 3 9008.01 3 3 3 1990 1970 1980 1990 Census Tract SES SES SES 9008.02 2 3 4 9009 4 4 3 9010.01 2 1 2 9010.02 2 1 2 9011 4 3 3 9012.01 4 4 3 9012.02 4 3 2 9100 5 5 3 9101 5 5 5 9102 3 2 2 9103 3 2 2 9104 2 3 3 9105 3 4 3 9106 3 3 3 9107.01 4 3 2 9107.02 4 3 2 9108.01 2 1 1 9108.02 2 2 2 9109 4 2 3 9110 4 2 3 9200.03 2 2 2 9200.11 2 2 1 9200.12 2 2 1 9200.13 2 2 2 9200.21 2 2 2 9200.22 2 2 2 9200.23 2 2 2 9200.24 2 3 2 9200.25 2 2 2 9201.01 3 2 1 9201.02 3 2 2 9202 4 4 4 9203.03 3 4 1 9203.11 3 3 2 9203.12 3 2 1 9203.13 3 2 1 9203.21 1 1 1 9203.22 1 1 1 9203.24 1 1 1 9203.25 1 1 1 9300 2 2 1 9301 4 2 3 9302 3 4 2 331 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX B SEER SITE RECODE FOR ICD-O-2 INCIDENCE DATA Site Description_______________ Site Types Oral cavity and pharynx Lip Tongue Salivary glands Floor of mouth Gum and other mouth Nasopharynx Tonsil Oropharynx Hypopharynx Other buccal cavity and pharynx Digestive system Esophagus C150-C159 (EXC TYPES 9590-9970) Stomach C160-C169 (EXC TYPES 9590-9970) Small intestine C170-C179 (EXC TYPES 9590-9970) Colon exc. rectum Cecum C180 (EXC TYPES 9590-9970) Appendix C181 (EXC TYPES 9590-9970) Ascending colon C182 (EXC TYPES 9590-9970) Hepatic flexure C183 (EXC TYPES 9590-9970) Transverse colon C184 (EXC TYPES 9590-9970) Splenic flexure C185 (EXC TYPES 9590-9970) Descending colon C186 (EXC TYPES 9590-9970) Sigmoid colon C187 (EXC TYPES 9590-9970) Large intestine, NOS C188-C189, C260 (EXC TYPES 9590-9970) Rectum and rectosigmoid Rectosigmoid junction C199 (EXC TYPES 9590-9970) Rectum C209 (EXC TYPES 9590-9970) Anus, anal canal and anorecturm C210-C212, C218 (EXC TYPES 9590-9970) Liver C220 (EXC TYPES 9590-9970) Intrahepatic bile ducts C221 (EXC TYPES 9590-9970) Gallbladder C239 (EXC TYPES 9590-9970) Other biliary C240-C249 (EXC TYPES 9590-9970) Pancreas C250-C259 (EXC TYPES 9590-9970) Retroperitoneum C480 (EXC TYPES 9590-9970) Peritoneum, omentum and mesentery C481-C482 (EXC TYPES 9590-9970) Other digestive organs C268-C269.C488 (EXC TYPES 9590-9970) C000-C009 (EXC TYPES 9590-9970) C019-C029 (EXC TYPES 9590-9970) C079-C089 (EXC TYPES 9590-9970) C040-C049 (EXC TYPES 9590-9970) C030-C039.C050-C059, C060-C069 (EXC TYPES 9590-9970) C110-C119 (EXC TYPES 9590-9970) C090-C099 (EXC TYPES 9590-9970) C0100-C109 (EXC TYPES 9590-9970) C129.C130-C139, C141 (EXC TYPES 9590-9970) C140, C142-C148 (EXC TYPES 9590-9970) 332 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Site Description Site Types Respiratory system Nasal cavity, middle ear and accesory sinuses Larynx Lung and bronchus Pleura Trachea, mediastinum and other respiratory organs Bones and joints Soft tissue (including heart) Skin (excluding basal and squamous) Melanomas - skin Other non-epithelial skin Breast Female genital system Cervix Corpus Uterus, NOS Ovary Vagina Vulva Other female genital organs Male genital system Prostate Testis Penis Other male genital organs Urinary system Bladder Kidney and renal pelvis Uterer Other urinary organs C300-C301, C310-C319 C398 C320-C329 C340-C349 C384 C339.C381-C383, C388 C390, C399 C400-C419 C380, C470-C479, C490-C499 C440-C449 C440-C449 C500-C509 C530-C539 C540-C549 C559 C569 C529 C510-C519 C570-C589 C619 C620-C629 C600-C609 C630-C639 C670-C679 C649.C659 C669 C680-C689 (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (TYPES 872-879) (EXC TYPES 8000-8004, 8010-8012, 8070-8076, 8090-8096, 8720-8790, 9700-9701) (EXC TYPES 9590-9970) (EXC TYPES (EXC TYPES (EXC TYPES (EXC TYPES (EXC TYPES (EXC TYPES (EXC TYPES 9590-9970) 9590-9970) 9590-9970) 9590-9970) 9590-9970) 9590-9970) 9590-9970) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) Eye and orbit C690-C699 (EXC TYPES 9590-9970) 333 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Site Description Site Types Brain and other nervous system Brain C710-C719 Other nervous system C710-C719 C700-C709, C720-C729 Endocrine system Thyroid C739 Other endocrine (includes thymus) C379.C740-C749, C750-C759 Lymphomas Hodgkin's Disease All sites Non-Hodgkin's lymphoma All sites Multiple myeloma All sites Leukemias All sites Lymphocytic Acute lymphocytic Chronic lymphocytic Other lymphocytic Granulocytic Acute granulocytic Chronic granulocytic Other granulocytic Monocytic Acute monocytic Chronic monocytic Other monocytic Other Acute other Chronic other Aleukemia, subleukemic, and NOS llldefined and unspecified sites C760-C768.C809 C420-C424 C770-C779 (EXC TYPES 953,9590- 9970) (TYPE 953) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (EXC TYPES 9590-9970) (TYPES 9650-9667) (TYPES 9590-9595,9670- 9714) (TYPES 9731-9732) (TYPE 9821) (TYPE 9823) (TYPES 9820,9822,9824 9825,9826) (TYPES 9861,9867) (TYPES 9863,9868) (TYPES 9860,9862,9864, 9866) (TYPES 9891) (TYPES 9893) (TYPES 9890,9892,9894) (TYPES 9801,9841) (TYPES 9803,9842,9931) (TYPES 9800,9802,9804, 9827,9830,9840,9850,9870, 9880,9900, 9910,9930- 9941) (TYPES 9720-9723,9740, 9741,9760-9764,9950- 9989) (EXC TYPES 9590-9970) (EXC TYPES 9590-9940) (EXC TYPES 9590-9750) 334 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Site Description_____________________Site_____________________Types__________________ Invalid sites Site or histology code not in valid range or site/histology combination not found in this table. 335 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX C STANDARD POPULATION 1970 United States Standard Population* All Ages <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ 1, 000,000 84,416 98,204 102,304 93,845 80,561 66,320 56,249 54,656 58,958 59,622 54,643 49,077 42,403 34,406 26,789 18,871 11,241 7,435 Census of Population and Housing, 1970: General Population Characteristics, Final Report PC(1)-B. Washington: The Bureau of the Census. 336 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
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Liu, Lihua
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Socioeconomic status and cancer risk among diverse populations in Los Angeles County, 1972-1992
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Doctor of Philosophy
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Sociology
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University of Southern California
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health sciences, public health,OAI-PMH Harvest,sociology, demography,sociology, ethnic and racial studies
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