Breast and cervical cancer mortality in the Mississippi Delta, 1979-1998.

Background: Historically, the Mississippi Delta region has been medically underserved. This may lead to lower cancer prevention efforts and higher breast or cervical cancer mortality rates.

Methods: Death rates for 1979 through 1998 were calculated for Mississippi Delta women and for women living elsewhere in the US.

Results: Breast cancer mortality in the Delta was similar to that elsewhere in the US in recent years for both black and white women, but rates were lower in the Delta in the early years of the study period. Overall, cervical cancer mortality was similar in the two areas but rates declined more rapidly elsewhere in the US than in the Delta. Breast and cervical cancer mortality was higher among black women than among white women in both areas. Cervical cancer mortality was higher among white rural and black urban women in the Delta than their counterparts elsewhere.

Conclusion: These results can guide prevention activities for reducing mortality from these diseases.

Key Words: breast cancer, cervical cancer, mortality

**********

Historically, residents of the Mississippi Delta have suffered from high rates of unemployment and poverty, substantial deficits in education, poor nutrition, and inadequate access to health care. Conditions for rural, elderly, and black residents of the Delta are of particular concern. (1) These factors may lead to underuse of cancer screening, in turn leading to a higher incidence of late-stage disease and higher death rates. Unfortunately, little has been published about cancer rates among women in the Mississippi Delta. Studies providing information on small areas within the Delta, however, suggest that the incidence of breast cancer may be lower in the region than nationally, but that cervical cancer may be more common. (2-5) In addition, screening rates for these cancers may be lower in the Delta than in the US as a whole. (6)

The US Department of Health and Human Services (7) sets nationwide targets for breast and cervical cancer mortality. In addition, it has set forth a primary goal of eliminating health disparities. Race, ethnicity, lower education or income, lack of access to health care or health insurance, and rural location have all been associated with less use of preventive screening. (7-9) The quality of screening with mammography and Papanicolaou (Pap) tests is variable; (10,11) where they are substandard, screening may be less effective. These factors, in turn, may lead to detection of cancers at a later stage, leading to poorer survival and higher mortality. (9,12,13)

This study examined trends in death rates from breast and cervical cancer in the Mississippi Delta from 1979 through 1998 for black and white women. Death rates for the Delta were compared with those of the remainder of the US. In addition, rates were examined by age and by rural and socioeconomic indicators for the county of residence.

Methods

In 1988, Congress enacted Public Law 100-460, which established the Lower Mississippi Delta Development Commission to assess the needs, problems, and opportunities of people living in the Lower Delta, a region of 219 counties or parishes (Louisiana) within Arkansas, Illinois, Kentucky, Louisiana, Mississippi, Missouri, and Tennessee. The Consolidated Appropriations Act of 2001 (Public Law 106-554) added 16 Alabama counties to the region, bringing the total to 235. The Delta (Fig. 1) is made up of 16 counties in Alabama, 42 in Arkansas, 16 in Illinois, 21 in Kentucky, 45 (parishes) in Louisiana, 45 in Mississippi, 29 in Missouri, and 21 in Tennessee.

Breast and cervical cancer death rates were calculated using information on death certificates sent by the states to the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC), where it was processed and consolidated. (14) The underlying cause of death of the deceased along with age, race, sex, and county of residence were provided to NCHS. Selection of breast or cervical cancer as the underlying cause of death followed procedures specified by the World Health Organization in the 9th Revision of the Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death. (15) All female breast and cervical cancer deaths reported for 1979 through 1998 for the Mississippi Delta were included in the analysis.

Denominators for the rate calculations were obtained from estimates made by the US Bureau of the Census and provided to the National Cancer Institute. (16) Estimates of the populations of US counties were available for 5-year age groups, sex, and race for each year studied. Rates were directly standardized to the age distribution of the 1970 US standard million population (adjustment was by 5-year groups).

[FIGURE 1 OMITTED]

Annual age-adjusted death rates from 1979 to 1998 were calculated for the entire Mississippi Delta and for other US women. Analyses were conducted on all women and on white (68.3% of Delta female population) and black women (30.8%) separately, but not on other racial or ethnic groups, which were few in number (0.8%). During the study period, breast cancer deaths totaled 19,481 among white women and 7,539 among black women. Cervical cancer deaths were 2,244 and 2,074, respectively. Women of other racial groups had fewer than 70 breast or cervical cancer deaths. Rates were also calculated for age groups (<50, 50-69, and [greater than or equal to]70 yr). This study was exempt from institutional review board review.

We used join point regression techniques to characterize the trends in death rates. (17) The analyses determined the calendar years (joinpoints) when a change in trends occurred; we tested for model fit with a maximum of 4 joinpoints in the model. For each line segment identified, we calculated the estimated annual percent change (EAPC) and 95% confidence interval (CI).

We also calculated average annual age-adjusted death rates for the combined 5-year period 1994 through 1998 for the Delta and non-Delta areas within the 8 states in the study; calculating 5-year rates improved the stability of the estimates. To compare death rates between these regions, the percentage difference, standard error, and z-statistic were calculated. (18)

In addition, average annual age-adjusted death rates for 1994 through 1998 were assessed by county economic levels and degree of rurality as compared within the Mississippi Delta and with the remainder of the US. Counties were defined as economically distressed if they had a three-year (1997-1999) average unemployment rate that was at least 1.5 times (150%) the US average of 4.6%; had a per-capita income that was less than two thirds (67%) of the US average of $23,564; and had a poverty rate that was at least 1.5 times (150%) of the US average of 13.1% or had 2 times (200%) the poverty rate. (19) Distressed counties were compared with all other counties. Counties were classified in three levels of rurality. Urban counties included (I) central and (II) fringe counties of metro areas of 1 million population or more, (III) counties in metropolitan areas of 250,000 to 1 million population, and (IV) counties in metro areas of fewer than 250,000 population (Subcategories I-IV correspond to Codes 0-3 of rural-urban continuum). (20) Nonmetropolitan counties with a population of 20,000 or more that were adjacent (Code 4) or not adjacent (Code 5) to metropolitan areas were defined as suburban. All other counties were defined as rural, including counties with 2,500 to 19,999 population adjacent and not adjacent to metropolitan areas and counties considered rural or with less than 2,500 population that were adjacent or not adjacent to metropolitan areas (Codes 6-9).

Results

Breast Cancer

At the beginning of the 20-year study period (1979), breast cancer death rates (per 100,000 women) for both white (21.3) and black (22.6) women were lower in the Mississippi Delta than elsewhere in the United States (26.4 and 26.0, respectively) (Fig. 2). Death rates among white women elsewhere in the United States decreased during the latter half of the study period to a rate (22.3 in 1998) similar to that of their Mississippi Delta counterparts (21.4). Among black women, breast cancer death rates increased in both areas early on but leveled off and were similar in the latter part of the study period (in 1998 they were 29.4 in the Mississippi Delta and 29.6 elsewhere). Breast cancer death rates were higher among black than among white women in both areas during the later years of the study period.

Age-specific breast cancer death rates were, for the most part, lower in the Delta than elsewhere in the United States (Table 1). In the 1990s, however, rates were relatively higher among Delta women aged less than 50 years, but since 1995 rates among these younger Delta women have decreased (EAPC -6.8). For women aged 50 to 69 years, other US women (EAPC -2.8 for 1990-1995 and -4.4 for 1995-1998) had a greater decrease than their Delta counterparts (EAPC -1.5 for 1990-1998).

[FIGURE 2 OMITTED]

For 1994 through 1998, the average annual age-adjusted breast cancer death rates in the Mississippi Delta area of each of the 8 study states ranged from 21.9 to 26.6 per 100,000 women (Table 2). Significantly elevated rates in the Delta area (versus the remainder of the state) were found in Arkansas and Tennessee; in Illinois, the rate of the Delta area was significantly lower.

Breast cancer death rates in economically distressed counties did not differ between the Mississippi Delta and the remainder of the United States (Table 3). In nondistressed counties, black women in the Delta had a higher death rate than other black women in the United States, but white women in the Delta had a lower death rate than white women elsewhere. Urban white women had a lower death rate in the Delta than white women elsewhere in the United States. Urban black women in both the Delta and elsewhere in the United States had higher death rates than rural black women.

Cervical Cancer

Cervical cancer death rates (per 100,000 women) were similar for white women in the Mississippi Delta to those for white women elsewhere in the US throughout the study period (3.3 in 1979 for both regions; 2.7 in the Delta and 2.2 elsewhere in the United States in 1998) (Fig. 3). Black women in both regions had higher cervical cancer death rates than white women throughout the study period. Although death rates were similar for black women in the two regions at the beginning of the study period (8.7 Delta; 8.9 other US), death rates decreased faster for black women elsewhere in the United States (EAPC -2.9), reaching 4.8 in 1998, than for black women in the Delta (EAPC -2.0), who had a rate of 6.2 in 1998. During the study period, larger decreases were observed for women aged 50 to 69 years and 70 years or more in the remainder of the United States than in the Mississippi Delta (Table 4).

The average annual age-adjusted cervical cancer death rates for 1994 through 1998 in the Mississippi Delta area of each state ranged from 2.6 to 4.4 per 100,000 women (Table 2). Rates were significantly higher in the Delta areas of Alabama, Illinois, Mississippi, Missouri and Tennessee than elsewhere in those states.

The cervical cancer death rate among black women who resided in economically nondistressed counties in the Delta was higher than the death rate for their counterparts elsewhere in the United States (Table 3). Among white women, death rates were higher for women from distressed counties than for women from nondistressed counties in both the Delta and the rest of the United States

[FIGURE 3 OMITTED]

Among whites, suburban and rural women in the Delta had higher death rates than their counterparts in the remainder of the United States (Table 3). Similar to the findings for economically nondistressed counties, urban black women in the Delta had a higher death rate than urban black women elsewhere in the United States Among white women in both regions, rural residents had higher death rates than urban women.

Discussion

Breast Cancer

In this study we found that for both black and white women, breast cancer death rates for Mississippi Delta residents were lower than the rates for women elsewhere in the United States in 1979, but that race-specific rates are now similar for the two regions. Black women have been faring relatively poorly, however, as in both regions their rates have been markedly higher than those of white women in recent years. In the Delta, rates for black women increased substantially until 1991, then declined nonsignificantly. Among black women, residents of counties that were not economically distressed had a higher death rate than their counterparts elsewhere in the United States. Within the Delta, urban black women had higher death rates than their rural counterparts.

The lower death rates from breast cancer among women of the Mississippi Delta at the beginning of the study period may have been preceded by a lower incidence of breast cancer. Incidence rates lower than national and state levels have been found for some parts of the Mississippi Delta in Louisiana for both white and black women. (2,3,5) The regional differences in incidence may be due to differences in risk factors, such as age at first live birth, age at menarche, and age at menopause. (21) Relatively low screening rates in the region may also play a role, as incidence rates would rise after screening is introduced into a population. A higher cancer death rate for black women than white women has been documented in Louisiana. (22)

The rapid rise in death rates for breast cancer among black women during the early years of the study period may be related to increasing incidence rates in conjunction with a lack of screening and access to state-of-the-art treatment. A study from Mississippi (23) revealed that urban black women have a higher incidence of breast cancer and a higher death rate (similar to our findings) than rural black women, possibly due to less access to or use of screening services or to inadequate treatment. In addition, women may move from rural to urban areas to obtain treatment or social or financial support. Nevertheless, screening rates in the 1990s, based on national population surveys, have generally been high for both black and white women. (24-26) Future studies are needed to determine whether there are any differences in screening between black and white women in the Mississippi Delta versus the remainder of the United States. In one small study from rural Mississippi, for example, the number of screening-detected breast cancers was lower than expected for white women and even lower for black women. (6) Screening may be particularly low among black women in areas of the Delta that are not economically distressed. This seemingly contradictory situation may be due to the fact that an urban area may not be economically distressed but can nonetheless include a population of urban poor who may lack health insurance and have less access to or use of screening services.

Cervical Cancer

Death rates from cervical cancer for both black and white women decreased more rapidly during the study period in the remainder of the United States than in the Mississippi Delta. The groups less than 50 years of age in both regions, however, did not experience significant declines in deaths over the study period. In recent years black women of the Mississippi Delta have experienced higher death rates than black women elsewhere in the United States. We also found that for white women, both suburban and rural women in the Delta had higher death rates than their counterparts elsewhere in the United States. For black women, we found higher rates among urban Delta residents.

Cervical cancer incidence rates (1983-1986) in areas of Louisiana that are part of the Delta were comparable to Surveillance, Epidemiology, and End Results (SEER) incidence rates for white women but higher than SEER rates for black women. (2) In the industrial corridor in Louisiana, extending south from Baton Rouge but not including New Orleans, Chen et al (4) found a significantly lower incidence of cervical cancer for white women than in SEER or the state of Louisiana as a whole (not significant) for 1989 to 1993. Among black women, incidence rates were higher than SEER rates but lower than the state rate, but these findings were not statistically significant. Higher cervical cancer death rates among Louisiana black women than in their white counterparts have also been reported. (22)

Our finding that white women in suburban and rural Delta counties had higher death rates than their counterparts elsewhere in the United States or urban white Delta women suggest possible problems with access to screening. Some studies of cancer screening have previously documented lower prevalence among rural compared with urban women, (27-29) but the role of rural residence is unclear. In rural areas, overall incidence and death rates are often lower, but the rate of increase in incidence and the rate of later stage disease have been found to be higher than in urban areas. (13) More recently, in a study of cancer incidence in Mississippi, rural residents were more likely to be diagnosed with later-stage disease than urban residents. (23)

Among Mississippi Delta black women, we found that cervical cancer death rates were higher for those living in nondistressed or urban counties than for their counterparts elsewhere in the US. Lower screening rates in these areas may be related to poverty, education, lack of health insurance, or other barriers (7-9,30) rather than availability of screening facilities. In general, poverty or social class, as measured by occupation, income, or education, has been associated with increased risk of death. (31,32) We also found that death rates among older women declined at a slower pace in the Mississippi Delta than in the remainder of the United States, which may indicate that these women receive less screening or have less access to state-of-the-art treatment for invasive cancer. If all women could adhere to guidelines for cervical cancer screening and receive appropriate follow-up and treatment for precancerous and cancerous lesions, almost all deaths from cervical cancer could be prevented.

General Comments

Previous authors have noted that differences in socioeconomic status account for much of the disproportionately higher rate in cancer mortality among black women compared to white women, and that cancer survival is lower among the poor. Low socioeconomic status, regardless of race, is associated with lack of adherence to cancer screening guidelines. Factors such as low income or educational level, substandard living conditions, inadequate social support, unemployment, poor nutrition, and diminished access to health care may contribute, regardless of race, to decreased cancer survival. (33) Socioeconomically disadvantaged persons are more likely to be uninsured or underinsured, and they often experience delays in diagnosis and treatment or suboptimal treatment once a diagnosis of cancer has been made. (34) The percentage of population with income below the federal poverty level ranged from 13% (Missouri) to 22% (Louisiana and Mississippi) in 2000 in states which have a part of their territory in the Delta region. (35) All but two states had a higher proportion of their population living with incomes below the poverty level than the US average of 16%. All Delta states except Illinois had a higher percentage of their population depending on Medicaid than the national average of 11%.

Previous studies have suggested that minority groups and people in rural areas are less likely to receive preventive health care services than nonminority and urban individuals, which may partly account for geographic differences in cancer mortality. Relatively few studies (36) have examined the cancer mortality experiences of minorities who live in specific rural areas, however. The present analysis provides important information about breast and cervical cancer mortality among women in the Mississippi Delta, including mortality patterns among black women in the rural South. In addition, we found that among some groups, mortality was higher among urban women. Interventions need to be implemented that target specific population groups on the community level and are culturally appropriate. Examples of such interventions that may serve as models are the community cancer control initiatives of the Appalachia Leadership Initiative on Cancer (37) and those that address specific barriers to screening. (38-40)

With respect to study limitations, we defined geographic area of residence as urban, suburban, or rural using county-level data from the census and US Department of Agriculture codes (Beale codes). Although Beale codes are widely used to classify geographic area of residence, rurality based upon population counts of geopolitical units may introduce misclassification. (13) Counties vary in size and in some large counties, many residents live in urban areas even though large numbers of persons live in rural areas of those same counties. (13) Such misclassification may have partly obscured the observed differences in cancer mortality in the present study.

Although the reliance on death certificates is a further limitation, studies of the accuracy of death certificates in the United States have shown breast and cervical cancer to be valid underlying causes of death. (41,42) Data on the proportion of women in the Delta who have undergone hysterectomy are currently lacking, and trends in cervical cancer mortality may be affected by trends in hysterectomy with removal of the cervix. Hysterectomy rates differ by state, race, ethnicity, and socioeconomic status. (43) Similarly, differences in cervical cancer death rates by race, rurality, and socioeconomic distress may be partly due to differences in hysterectomy rates. Access to state-of-the-art treatment for invasive cervical cancer may also account for such differences. Finally, results from joinpoint analyses are influenced by the number of years included, and assume that rate changes are constant over a time interval.

Conclusion

We found that women of some areas in the Mississippi Delta have higher breast and cervical cancer death rates than their counterparts elsewhere in the United States. Mortality trends in breast and cervical cancer may provide information to guide prevention and control activities for reducing premature mortality from these diseases.

Table 1. Death rates from cancer of the breast, by region and age (yr),
1979-1998 (a)

                         Mississippi Delta
               <50        50-69       [greater than or equal to]70

1979           5.6        62.4         93.2
1980           5.7        64.2         98.5
1981           5.3        71.4         92.3
1982           5.5        67.8         98.6
1983           6.4        62.5         99.8
1984           6.0        65.3        107.0
1985           6.8        67.8        123.5
1986           6.3        70.5         97.3
1987           6.2        67.8        120.5
1988           7.3        73.1        123.8
1989           8.4        71.6        123.8
1990           8.2        73.2        130.1
1991           8.1        70.5        134.9
1992           8.4        72.0        127.5
1993           7.7        67.0        134.0
1994           8.2        64.7        131.5
1995           8.8        69.5        126.9
1996           7.9        67.0        128.7
1997           8.0        67.4        127.3
1998           7.1        61.8        131.8
EAPC and JP
  EAPC         3.2         1.1          3.1
  95% CI       2.3, 4.1    0.3, 2.0     2.1, 4.2
  JP           1995        1990         1991
  EAPC        -6.8        -1.5         -0.4
  95% CI     -16.4, 3.9   -2.9, -0.1   -2.7, 2.0
  JP
  EAPC
  95% CI
  JP
  EAPC
  95% CI

                         Other US
              <50         50-69           [greater than or equal to]70+

1979          6.2         76.6              122.7
1980          6.1         78.3              125.2
1981          6.1         78.4              128.7
1982          6.2         79.0              131.5
1983          6.1         79.8              132.3
1984          6.6         81.0              136.0
1985          6.6         81.5              135.9
1986          6.8         80.4              137.9
1987          6.9         80.1              137.2
1988          6.9         80.8              141.7
1989          7.1         79.5              144.8
1990          7.2         79.2              145.0
1991          7.2         78.0              144.1
1992          7.0         74.4              142.7
1993          6.8         72.6              146.0
1994          6.9         70.7              144.8
1995          7.0         69.4              143.7
1996          6.9         66.0              141.8
1997          6.7         62.7              135.1
1998          6.4         60.5              135.1
EAPC and JP
  EAPC        1.7          0.9                1.5
  95% CI      1.2, 2.2     0.5, 1.3           1.2, 1.8
  JP          1990         1985               1989
  EAPC       -1.1         -0.5                0
  95% CI     -1.8, -0.3   -1.3, -.3          -0.9, 0.9
  JP                       1990               1995
  EAPC                    -2.8               -2.5
  95% CI                  -3.5, -2.0         -4.4, -0.5
  JP                       1995
  EAPC                    -4.4
  95% CI                  -5.5, -3.2

(a) Rates are per 100,000 women. JP, joint points: EAPC, estimated
annual percent change; CI, 95% confidence interval.

Table 2. Average annual deaths from cancer of the breast and cervix in
the Mississippi Delta counties within Delta states and comparison of
Delta counties with non-Delta counties, 1994-1998 (a)

                             Breast
             Count  Rate (b)  95% CI      D (c)   P

Alabama        261  21.9      19.2, 24.9  -0.3    0.84
Arkansas     1,131  23.4      22.0, 24.9   2.9   <0.01
Illinois       301  21.9      19.2, 24.8  -4.2   <0.01
Kentucky       405  22.0      19.8, 24.5  -2.1    0.11
Louisiana    2,387  25.5      24.4, 26.6  -0.2    0.83
Mississippi  1,089  24.0      22.5, 25.5   1.4    0.22
Missouri       567  23.8      21.8, 26.0  -0.1    0.93
Tennessee    1,241  26.6      25.1, 28.2   3.1   <0.01
Total        7.382  24.5      23.9, 25.1

                             Cervix
             Count  Rate (b)  95% CI      D (c)   P

Alabama         49  4.1       3.0, 5.6     1.30   0.03
Arkansas       149  3.3       2.8, 4.0     0.10   0.81
Illinois        57  4.4       3.2, 5.9     1.60   0.01
Kentucky        41  2.6       1.8, 3.6    -1.00   0.03
Louisiana      339  3.7       3.3, 4.1     0.20   0.58
Mississippi    175  3.9       3.4, 4.6     1.00   0.02
Missouri        80  3.8       3.0, 4.8     1.10   0.01
Tennessee      193  4.3       3.7, 5.0     1.20  <0.01
Total        1,083  3.7       3.5, 4.0

(a) CI, confidence interval.
(b) Rates are per 100,000 and age adjusted to the 1970 US standard
population.
(c) Difference between the rate in the Mississippi Delta region within
the state and the rate for the remainder of the state.

Table 3. Average annual death rates from cancer of the breast and
cervix, by race and region, United States, 1994-1998 (a)

                                      White women
                            MS Delta               Other US
                   Count  Rate (b)  95% CI       Count   Rate

Breast
  County
      economic
      status (c)
    Distressed     1,515  22.3      21.1, 23.5    6,345  22.3
    Nondistressed  3,623  22.4      21.6, 23.2  171,589  23.9
  Rurality (d)
    Urban          2,225  22.8      21.9, 23.8  140,639  24.1
    Suburban         602  23.0      21.1, 25.1   11,456  23.3
    Rural          2,311  21.9      20.9, 22.8   26,194  22.6
Cervix
  County
      economic
      status (c)
    Distressed       198  3.3        2.8, 3.8     1,002   3.7
    Nondistressed    379  2.5        2.3, 2.8   155,293   2.3
  Rurality (d)
    Urban            200  2.1        1.8, 2.5    12,419   2.3
    Suburban          80  3.4        2.7, 4.4     1,084   2.4
    Rural            297  3.2        2.8, 3.6     2,819   2.7

                   White women             Black women
                   Other US                MS Delta
                   95% CI        P    Count   Rate  95% CI

Breast
  County
      economic
      status (c)
    Distressed     21.7, 22.8   0.97    761   28.1  26.1, 30.3
    Nondistressed  23.8, 24.0  <0.01  1,468   32.8  31.1, 34.6
  Rurality (d)
    Urban          24.0, 24.2   0.01  1,307   32.7  30.9, 34.6
    Suburban       22.9, 23.8   0.76    211   32.5  28.1, 37.4
    Rural          22.3,, 22.9  0.16    711   28.0  25.9, 30.3
Cervix
  County
      economic
      status (c)
    Distressed      3.5, 4.0    0.10    177    6.2   5.3, 7.3
    Nondistressed   2.3, 2.3    0.10    321    7.1   6.3, 7.9
  Rurality (d)
    Urban           2.2, 2.3    0.34    297    7.4   6.5, 8.3
    Suburban        2.3, 2.6    0.01     39    5.8   4.1, 8.1
    Rural           2.6, 2.8    0.03    162    6.1   5.1, 7.2

                        Black women
                         Other US
                    Count  Rate  95% CI      P

Breast
  County
      economic
      status (c)
    Distressed      1,287  29.5  27.8, 31.2  0.32
    Nondistressed  22,473  31.0  30.6, 31.4  0.05
  Rurality (d)
    Urban          20,987  31.2  30.8, 31.6  0.11
    Suburban          766  28.6  26.6, 30.8  0.13
    Rural           2,116  29.6  28.3, 30.9  0.24
Cervix
  County
      economic
      status (c)
    Distressed        239   5.5   4.8, 6.2   0.20
    Nondistressed   3,926   5.2   5.0, 5.4  <0.01
  Rurality (d)
    Urban           3,616   5.2   5.0, 5.3  <0.01
    Suburban          145   5.2   4.4, 6.2   0.60
    Rural             420   5.9   5.4, 6.6   0.79

(a) MS. Mississippi: CI, confidence interval.
(b) Rates are per 100,000 population and are age adjusted to the 1970 US
standard population.
(c) Counties were defined as distressed if they had a 3-year (1997-1999)
average unemployment rate at least 1.5 times (150%) the US average of
4.6%, a per capita income that was less than two-thirds (67%) of the US
average of $23.564: and had a poverty rate that was at least 1.5 times
(150%) the US average of 13.1% or had 2 times (200%) the poverty rate.
(d) Beale codes 1993.

Table 4. Death rates from cervical cancer, by region and age (yr),
1979-1998 (a)

                   Delta                                   Other US
            <50    50-69  [greater than or equal to]70  <50       50-69

1979         2.4    9.7   15.7                           1.4       10.0
1980         2.1   10.7   17.4                           1.5        9.4
1981         1.8   10.3   15.6                           1.4        9.4
1982         1.7    9.9   16.2                           1.4        8.8
1983         1.7   11.3   18.8                           1.4        8.7
1984         2.2    9.6   14.5                           1.4        8.2
1985         2.1    8.1   20.8                           1.4        7.9
1986         2.1   10.2   16.1                           1.5        8.2
1987         2.0   10.5   13.6                           1.5        7.5
1988         1.7    8.0   15.1                           1.5        7.6
1989         2.0    8.8   17.2                           1.5        7.5
1990         1.9    8.9   13.8                           1.6        7.5
1991         1.9    8.5   15.6                           1.6        7.3
1992         2.5    9.1   13.6                           1.6        7.1
1993         2.2    8.2   14.1                           1.6        6.9
1994         2.5    9.9   11.7                           1.6        7.1
1995         2.2    8.3   13.0                           1.6        6.4
1996         2.3    8.5   13.2                           1.6        6.9
1997         2.6    9.2   11.6                           1.6        6.6
1998         2.0    8.5   13.6                           1.6        5.9
EAPC and
  JP

  EAPC       0.9   -1.0   -1.7                          -0.5       -2.2
  95% CI    -0.1,  -1.7,  -2.6,                         -2.1,      -2.5,
             1.9   -0.3   -0.9                           1.1       -1.9
  JP                                                    1984

  EAPC                                                   2.0
  95% CI                                                 0.7, 3.2
  JP                                                    1991

  EAPC                                                   0
  95% CI                                                -1.0,
                                                          1.0

             Other US
             [greater than or equal to]70

1979         14.9
1980         14.3
1981         13.8
1982         13.0
1983         12.5
1984         12.1
1985         12.1
1986         11.2
1987         10.9
1988         10.9
1989         10.6
1990         10.6
1991         10.1
1992         10.4
1993         10.3
1994          9.5
1995          9.7
1996          9.0
1997          8.4
1998          8.2
EAPC and
  JP

  EAPC       -3.8
  95% CI     -4.5, -3

  JP         1987

  EAPC       -1.1
  95% CI     -2.6, 0.5
  JP         1993

  EAPC       -4.3
  95% CI     -5.8, -2.8

(a) Rates are per 100,000 women, JP, joint points; EAPC, estimated
annual percent changes; CI, confidence interval.

Accepted September 29, 2003.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9703-0264

References

1. US Department of Transportation. Delta Vision, Delta Voices: The Mississippi Delta Beyond 2000. Washington, DC, US Department of Transportation. Available at: http://ntl.bts.gov/data/DeltaVision-Voices.PDF. Accessed October 28, 2003.

2. Chen VW, Groves FD, Fontham ET, et al. Cancer in south Louisiana: Part III--Cancers of the breast and the reproductive system. J La State Med Soc 1992;144:171-177.

3. Chen VW, Wu XC, Andrews PA, et al. Highlights of cancer incidence in Louisiana, 1988-1992. J La State Med Soc 1997;149:119-124.

4. Chen VW, Andrews PA, Wu XC, et al. Cancer incidence in the industrial corridor: An update. J La State Med Soc 1998;150:158-167.

5. Groves FD, Andrews PA, Chen VW, et al. Is there a "cancer corridor" in Louisiana? J La State Med Soc 1996;148:155-165.

6. Carreno OJ, Field RJ III, Field RJ Jr. A ten year retrospective study of breast cancer in a rural Mississippi setting. J Miss State Med Assoc 1994;35:255-258.

7. US Department of Health and Human Services. Healthy People 2010. Washington, DC, US Department of Health and Human Services, January 2000, 2 vols. Available at: http://www.healthypeople.gov/document/. Accessed October 28, 2003.

8. Potosky AL, Breen N, Graubard BI, et al. The association between health care coverage and the use of cancer screening tests: Results from the 1992 National Health Interview Survey. Med Care 1998;36:257-270.

9. Risser DR, Condon KW. Stage of cancer diagnosis in rural versus urban areas of Texas: implications for changing the disparity through health services. Tex J Rural Health 1995;14:20-27.

10. Brown ML, Fintor L. Accreditation of mammography facilities by the American College of Radiology: Results of a national survey. Am J Prev Med 1994;10:162-167.

11. Henry JA, Wadehra V. Influence of smear quality on the rate of detecting significant cervical cytologic abnormalities. Acta Cytol 1996;40:529-535.

12. Chen VW, Wu XC, Andrews PA, et al. Advanced stage at diagnosis: An explanation for higher than expected cancer death rates in Louisiana? J La State Med Soc 1994;146:137-145.

13. Monroe AC, Ricketts TC, Savitz LA. Cancer in rural versus urban populations: A review. J Rural Health 1992;8:212-220.

14. National Vital Statistics System, National Center for Health Statistics, Centers for Disease Control and Prevention. Mortality data, multiple cause-of-death, 1972-1998 (machine-readable public-use data tapes). Hyattsville, MD, US Department of Health and Human Services, US Public Health Service, Centers for Disease Control and Prevention, 1999.

15. World Health Organization. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, Based on the Recommendations of the Ninth Revision Conference, 1975. Geneva, World Health Organization, 1977.

16. Surveillance, Epidemiology, and End Results (SEER), National Cancer Institute. US Populations, Individual State Populations: County Level. Available at: http://seer.cancer.gov/popdata/download.html. Accessed October 28, 2003.

17. Kim HJ, Fay MP, Feuer EJ, et al. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med 2000;19:335-351.

18. Ries LAG, Kosary CL, Hankey BF, et al (eds). SEER Cancer Statistics Review, 1973-1994 (NIH Publication No. 97-2789). Bethesda, MD, National Cancer Institute, 1997. Available at: http://seer.cancer.gov/csr/1973_1994/. Accessed October 28, 2003.

19. Appalachian Regional Commission. Distressed Counties Program. Washington, DC, Appalachian Regional Commission. Available at: http://www.arc.gov/index.do?nodeId=18. Accessed October 28, 2003.

20. Economic Research Service, US Department of Agriculture. Measuring Rurality: Rural-Urban Continuum Codes. Available at: http://www.ers.usda.gov/briefing/rurality/RuralUrbCon/. Accessed October 28, 2003.

21. Kelsey JL, Gammon MD, John EM. Reproductive factors and breast cancer. Epidemiol Rev 1993;15:36-47.

22. Chen VW, Craig JF, Fontham ET, et al. Excessive cancer rates among blacks in Louisiana: An opportunity for physician intervention. J La State Med Soc 1990;142:18-26.

23. Higginbotham JC, Moulder J, Currier M. Rural v. urban aspects of cancer: First-year data from the Mississippi Central Cancer Registry. Fam Community Health 2001;24:1-9.

24. Anderson LM, May DS. Has the use of cervical, breast, and colorectal cancer screening increased in the United States? Am J Public Health 1995;85:840-842.

25. Blackman DK, Bennett EM, Miller DS. Trends in self-reported use of mammograms (1989-1997) and Papanicolaou tests (1991-1997): Behavioral Risk Factor Surveillance System. MMWR CDC Surveill Summ 1999;48(6):1-22.

26. The National Cancer Institute Cancer Screening Consortium for Underserved Women. Breast and cervical cancer screening among underserved women: Baseline survey results from six states. Arch Fam Med 1995;4:617-624.

27. Coughlin SS, Thompson TD, Hall HI, et al. Breast and cervical carcinoma screening practices among women in rural and nonrural areas of the United States, 1998-1999. Cancer 2002;94:2801-2812.

28. Casey MM, Thiede Call K, Klingner JM. Are rural residents less likely to obtain recommended preventive healthcare services? Am J Prev Med 2001;21:182-188.

29. Ramsbottom-Lucier M, Emmett K, Rich EC, et al. Hills, ridges, mountains, and roads: Geographical factors and access to care in rural Kentucky. J Rural Health 1996;12:386-394.

30. Zhang P, Tao G, Irwin KL. Utilization of preventive medical services in the United States: A comparison between rural and urban populations. J Rural Health 2000;16:349-356.

31. Fein O. The influence of social class on health status: American and British research on health inequalities. J Gen Intern Med 1995;10:577-586.

32. Hahn RA, Eaker E, Barker ND, et al. Poverty and death in the United States: 1973 and 1991. Epidemiology 1995;6:490-497.

33. Freeman H. Race, poverty, and cancer. J Natl Cancer Inst 1991;83:526-527 (editorial).

34. Pamies RJ, Woodard LJ. Cancer in socioeconomically disadvantaged populations. Prim Care 1992;19:443-450.

35. The Henry J. Kaiser Family Foundation. State Health Facts Online. Available at: http://www.statehealthfacts.kff.org/. Accessed October 28, 2003.

36. Strickland J, Strickland DL. Barriers to preventive health services for minority households in the rural south. J Rural Health 1996;12:206-217.

37. Friedell GH, Rubio A, Maretzki A, et al. Community cancer control in a rural, underserved population: The Appalachian Leadership Initiative on Cancer Project. J Health Care Poor Underserved 2001;12:5-19.

38. Earp JA, Altpeter M, Mayne L, et al. The North Carolina Breast Cancer Screening Program: Foundations and design of a model for reaching older, minority, rural women. Breast Cancer Res Treat 1995;35:7-22.

39. Scroggins TG Jr, Bartley TK. Enhancing cancer control: Assessing cancer knowledge, attitudes, and beliefs in disadvantaged communities. J La State Med Soc 1999;151:202-208.

40. Walker R, Lucas W, Crespo R. The West Virginia Rural Cancer Prevention project. Cancer Pract 1994;2:421-426.

41. Gittelsohn A, Senning J. Studies on the reliability of vital and health records: Part I--Comparison of cause of death and hospital record diagnoses. Am J Public Health 1979;69:680-689.

42. Percy C, Stanek E III, Gloeckler L. Accuracy of cancer death certificates and its effect on cancer mortality statistics. Am J Public Health 1981;71:242-250.

43. Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Online Prevalence Data, 1995-2002. Available at: http://apps.nccd.cdc.gov/brfss/. Accessed October 28, 2003.

RELATED ARTICLE: Key Points

* Breast cancer mortality in the Mississippi Delta region was similar to that elsewhere in the United States in recent years for both black and white women, but rates were lower in the Delta in the early years of the study period.

* Overall, cervical cancer mortality was similar in the two areas but rates declined more rapidly elsewhere in the United States than in the Mississippi Delta region.

* Breast and cervical cancer mortality was higher among black women than among white women in both areas.

H. Irene Hall, PHD, Patricia M. Jamison, MPH, and Steven S. Coughlin, PHD

From the Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.

This work was conducted by employees of the US government.

Reprint requests to H. Irene Hall, PhD, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Mailstop E 47, 1600 Clifton Road, Atlanta, GA 30333. Email: [e-mail]