Income, inflammation and cancer mortality: a study of U.S. National Health and Nutrition Examination Survey mortality fo
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RESEARCH ARTICLE
Open Access
Income, inflammation and cancer mortality: a study of U.S. National Health and Nutrition Examination Survey mortality follow-up cohorts Joshua E. Chan1, Amandeep K. Mann2, Daniel S. Kapp3 and David H. Rehkopf1*
Abstract Background: To estimate the relationship between inflammatory biomarkers and cancer mortality in a nationally representative sample of the U.S. population while controlling for education, occupation, and income. Methods: Data were obtained from the U.S. National Health and Nutrition Examination Survey from 1988 to 1994 (N = 7817) and 1999–2002 (N = 2344). We fit Cox proportional hazard models to examine the relationship between C-reactive protein (CRP) and fibrinogen with cancer mortality. Results: In the full Cox multivariate model, clinically raised CRP was associated with cancer mortality in NHANES 1988–1994 (> 0.99 mg/dL: 95%CI: 1.04–2.13). However, across two inflammatory biomarkers (CRP and Fibrinogen), two NHANES time periods (1998–1994 and 1999–2002) and three income levels (12 strata in total), Hazard ratio confidence intervals did not include the null only for one association: CRP and cancer mortality among low income participants from 1988 to 1994 (HR = 1.83, 95% CI: 1.10–3.04). Conclusions: We find evidence that only in one unique stratum is earlier life CRP, and not fibrinogen, associated with prospective cancer mortality. After more complete control for socioeconomic confounding, CRP and fibrinogen do not predict cancer mortality in most subpopulations. Keywords: Inflammation, C-reactive protein, Fibrinogen, Socioeconomic status, Cancer mortality
Background Prior studies have found a relationship between higher levels of inflammation and worse cancer prognosis [1, 2]. C-reactive protein (CRP) and fibrinogen are acute-phase proteins that are used to represent low-grade inflammation and associated with cancer incidence and mortality [3–5]. CRP has been correlated with an accumulation of myeloid derived cells * Correspondence: [email protected] 1 Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, 1701 Page Mill Road, Room 229, Palo Alto, Stanford, CA 94304, USA Full list of author information is available at the end of the article
with suppressor functions, which are linked to several pathologies, and a heightened risk of cancer mortality, particularly in colorectal cancer [6, 7]. Furthermore, systemic inflammation, especially marked by high CRP levels, has been associated with higher morbidity and mortality among older ages [8, 9]. Fibrinogen is another inflammatory marker that is associated with increased risk and poorer prognosis in epithelial ovarian and other cancers [10]. However, the impact of socioeconomic position (SEP) on these relationships is unclear. Socioeconomic position could act as a confounder or effect modifier of these relationships. One study found a 25% increase in
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 Inter
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