Public Health Bnefs

cally Mentally Ill Veterans Program was funded

by the US Department of Veterans Affairs. This
paper is based on presentations at the annual
meeting ofthe Society for Traumatic Stress Studies, San Francisco, CA, October25, 1989, and the
annual meeting of the American Psychiatric Association, New York, NY, May 15, 1990.

References
1. Farr RK, Koegel P, Bumam A: A Study of
Homelessness and Mental Illness in the
Skid Row Area of Los Angeles. Los Angeles, CA: Los Angeles County Department of Mental Health, 1986.
2. Gelberg L, Linn LS, Leake: Mental health,
alcohol and drug use and criminal history
among homeless adults. Am J Psychiatry
1988; 145:191-196.

3. Streuning EL, Pittman J, Rosenblatt A:

Characteristics of homeless veterans in the
New York City shelter system. In: Rosenblatt A (ed): Homelessness. Albany, NY:
Rockefeller Institute of Government (in
press).
4. Department of Veteran Affairs: Annual Report 1987. Washington DC: Department of
Veterans Affairs, 1989.
5. Laufer R, Frey Wouters E, Yager T: Postwar trauma, social and psychological problems of Vietnam veterans in the aftermath
of the Vietnam War. In: Legacies of Vietnam, Comparative Adjustment of Veterans
and Their Peers. Washington DC: US Govt
Printing Office, 1981.
6. Kulka R, Schlenger W, Fairbank J, Hough
R, Jordan B, Marmar C, Weiss D: National

7.

8.
9.

10.

Vietnam Veterans Readjustment Study.

Research Triangle Park, NC: Research Triangle Institute, 1988.
Rossi P: Down and Out in America, The
Causes of Homelessness. Chicago, IL:
University of Chicago Press, 1989.
Department of Veteran Affairs: 1987 Survey of Veterans. Washington DC: Department of Veterans Affairs, 1989.
Myths and Realities: A Study of Attitudes
toward Vietnam Era Veterans. Report submitted by the Veterans Administration to
the Committee on Veterans Affairs, US
Senate, Washington, DC, 1980.
Lifton RJ: Home from the War: Vietnam
Veterans, Neither Victims nor Executioners. New York: Simon and Schuster, 1973.

Determinants of Late Stage Diagnosis

of Breast and Cervical Cancer: The
Impact of Age, Race, Social Class,
and Hospital Type
...

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"I'l-,"M 1'.1-K-'l,--,-3,l'l'l"

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Jeanne Mandelblatt, MD, Howard Andrews, PhD, Jon Kemer, PhD, Ann
Zauber, PhD, and Wdliam Bumetu, MD

Intrwoducton
Age and race have each individually
been associated with cancer stage.1-5
However, previous studies have not controlled for the effects of social class and
health care setting. This paper presents
findings from logistic regression analyses
to quantify the individual and combined
effects of age, race, socioeconomic class,
and type of health care setting on breast
and cervical cancer stage.

Metods
Cancer Data-Tumor Registry
The study sample consisted of all
cases of breast and cervical cancer among
New York City (NYC) residents that were

reported to the New York State Department of Health Tumor Registry between
1980 and 1985. More than 90 percent of
incident cases are reported to the registry
from NYC.6 In the study period, there
were 22,111 breast cancer, 2,930 invasive
cervical cancer, and 6,408 cervical carcinoma in-situ cases with known stages reported. Stage was unknown for 7.5 percent and 2.6 percent of the breast and
cervical cases, respectively. Missing stage

was associated with age (p < .0001) and

missing marital status (p < .01) for both
cancers. Age was classified into five-year
categories. Race was reported as either
Black or White. There were insufficient
data to include Hispanic origin in the analysis. Marital status was dichotomized as
"ever"1 versus "never" married. Hospital
type was classed as "public" for the 11
NYC municipal hospitals and "non-public" for the remaining facilities.

Demographic Vanables-Census
Data
Because individual information on
socioeconomic class is not available in
registry data, 1980 United States census
Address reprint requests to Jeanne Mandelblatt, MD, Assistant Professor, Division of
Cancer Control, Department of Epidemiology
and Biostatistics, Memorial Sloan-Kettering
Cancer Center, Box 60, 1275 York Avenue,
New York, NY 10021. Drs. Kerner and Zauber
are also with that Department at the Cancer
Center; Dr. Andrews is with New York State
Psychiatric Institute, New York City; Dr. Burnett is Director, Tumor Registry, New York
State Department of Health, Albany. This paper, submitted to the Journal July 12, 1990, was
revised and accepted for publication December
5, 1990.

May 1991, Vol. 81, No. 5

Public Health Briefs

first model predicted the outcome of late

stage (regional and distant) compared to
early stage (localized and in-situ). As a
result of recent advances in the treatment
of regional disease, a second model was
developed comparing distant to regional
disease. For cervical cancer, the outcome
of the first model was late stage (regional
and distant) versus early stage (localized)
invasive cancer. In addition, invasive and
in-situ disease were compared in a second
model as a measure of the success of Pap
screening. For all models the independent
variables were age, race, marital status,
hospital type, income, and education. Logistic regression models were developed
using SAS programs. Table 1 presents
summary statistics for the cases included
in the models.

Results

data on the median family income and the

percent of adults with a high school education in the census tract of residence of
the case were used as social class measures.

May 1991, Vol. 81, No. 5

Logistic Regression Models

Two models were developed for each
cancer based on groupings with similar
treatment patterns. For breast cancer, the

The logistic regression analysis indicated that, controlling for the other variables, the following factors were associated with late stage breast cancer: postmenopausal age, Black race, low
education, and public hospital use (Table
2). Lower income was also weakly associated with late stage (p < .055). In the
second model, age, public hospital use,
marital status, and low education were
each associated with an increased risk of
distant disease.
Regression coefficients and intercepts from each model were used to calculate the odds of late stage disease for
combinations of variables (Table 3). For
example, the odds of having distant, compared to regional, breast cancer were 4.77
times higher for a Black woman who was
age 70 to 74, unmarried, in the lowest income and education groups, andwho used
the public hospital system, compared to a
White married woman age 40 to 44, in the
highest income and education groups, using a non-public hospital.
For invasive cervical cancer, age and
public hospital setting were each associated with an increased risk of late stage
disease (Table 4). In the second model,
age, race, hospital setting, income, and
education were each associated with invasive disease.
The composite odds of a 70 to 74 year
old, unmarried Blackwoman in the lowest
income and educational group who used
the public hospital system having late
stage invasive cervical cancer were 2.54
times greater than for a White, married, 40
to 44 year old woman in the highest income and educational levels and using a
non-public hospital (Table 5). The odds for

American Journal of Public Health 647

Public Health Bnefs

have the potential to decrease avoidable

cancer morbidity and mortality. O

Acknowledgments
The authors would like to thank the New York
City Health and Hospitals Corporation for their
support of earlier versions of this project.
Portions of this paper were presented at
the American Public Health Association 116th
Annual Meeting, October 19, 1989, Chicago,
Illinois.

References

a woman of the same profile having invasive compared to in-situ disease were
39.75 times higher than for her younger,
White, non-disadvantaged counterpart.

Discussion
This study demonstrates that elderly,
Black, lower socioeconomic status (SES)
women who use public hospitals are at
extremely high risk of having their breast
and cervical cancers diagnosed at late
stages. While our findings are consistent
with and extend the findings of prior
researchers,1-5 there are two caveats that
should be considered in evaluating our
conclusions.
First, in our analysis missing stage
was associated with age. However, since
older women with advanced disease are
less likely to be staged than younger women,7,8 the missing stage information is
likely to underestimate the observed effect
of age on stage.

648 American Journal of Public Health

Second, since the NY State Tumor

Registiy does not contain social class indicators, we assigned to each woman the
median income and educational level of
her community of residence. While we
have no way to determine the relationship
of the individual and community SES indicators, several studies of cancer incidence and/or mortality have used grouplevel data to define socioeconomic
status9-15 and have drawn similar conclusions to studies that use individual
information.16-19 Group data can also capture characteristics of the individual's social "context" which may provide information about class gradients that may not
be reflected by individual characteristics.20'21 It is possible that hospital type is
serving as such a "contextual" measure in
our analysis.
Our findings suggest that cancer control interventions targeted to elderly disadvantaged women, particularly those of
color and those who use public hospitals,

1. Horm JW, Astire AJ, Young JL, Poilack

ES: Cancer Incidence and Mortality in the
United States. SEER 1973-81. NIH Pub.
No. 85-1837, Bethesda, MD: NIH, 1985.
2. Holmes FF, Hearne E: Cancer stage-to age
relationship: Implications for cancer
screening in the elderly. J Am Geriatr Soc
1981; 29:55-57.
3. Goodwin JS, Samet JM, Key CR, Humble
C, Kutvirt D, Hunt C: Stage at diagnosis of
cancer varies with the age of the patient.
JAGS 1986; 34:20-26.
4. Freeman HP, Wasfie TJ: Cancer of the
breast in poor black women. Cancer 1989;
63:2562-2569.
5. Polednak AP: Breast cancer in Black and
White women in New York State. Case
distribution and incidence rates by clinical
stage at diagnosis. Cancer 1986; 58:807815.
6. Bumett W: Cancer incidence and mortality
by county: New York State. Albany: New
York State Dept of Health, 1982.
7. Samet J, Hunt WC, Key C, Humble CG,
Goodwin JS: Choice ofcancer therapyvaries with age of patient. JAMA 1986;
255:3385-3390.
8. Chu J, Diehr P, Feigl P, Glaetke G, Begg C,
Clickson A, et al: The effect of age on care
of women with breast cancer in community
hospitals. J Gerontol 1987; 42:185-189.
9. Clementsen J, Nielsen A: The social distribution of cancer in Copenhagen, 1943 to
1947. Br J Cancer 1951; 5:159-171.
10. Cohart EM: Socioeconomic distribution of
cancer of the female sex organs in New
Haven. Cancer 1955; 8:34-41.
11. Dorn HF, Cutler SJ: Morbidity from cancer in the United States: Parts I and II.
Public Health Monogr 1959; 56:1-287.
12. Graham S, Levin M, Lilienfeld AM: The
socioeconomic distribution of cancer of
various sites in Buffalo, NY, 1948-52. Cancer 1960; 13:180-191.
13. Seidman H: Cancer death rates by site and
sex for religious and socioeconomic groups
in New York City. Environ Res 1970;
3:234-250.
14. Hoover R, Manson TJ, McKay FW, Fraumeni JF Jr: Geographic patterns of cancer
mortality in the United States. In: Fraumeni JF Jr (ed): Persons at High Risk of
Cancer-An Approach to Cancer Etiology
and Control. New York: Academic Press,
1975; 343-360.
15. Dayal HH, Power RN, Chiu C: Race and
social economic status in survival from
breast cancer. J Chronic Dis 1970; 23:105116.

May 1991, Vol. 81, No. 5

Public Health Bnefs

16. Logan WP: Social class variations in mortality. Public Health Rep 1954; 69:12171223.
17. The Registrar General's decennial supplement, England and Wales, 1961: Occupational mortality tables. London: His Majesty's Stationery Office, 1971.
18. The Registrar General's decennial supplement, England and Wales, 1970-72: Occupational mortality. Series D, No. 1. London: Her Majesty's Stationery Office,
1978.
19. Lilienfeld AM, Levin ML, Kessler II: Cancer in the United States. Cambridge, MA:
Harvard University Press, 1972.
20. KriegerN: Race, class, and health: Studies
of breast cancer and hypertension; Doctoral dissertation, University of CaliforniaBerkeley, 1989.
21. Bassett T, Krieger N: Social class and
Black-White differences in breast cancer
survival. Am J Public Health 1986;
76:1400-1403.

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American Journal of Public Health 649