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Influence of State and Local Social and Public Health Spending on Cancer Incidence and Mortality
*Laura E. Newton M.D.1, Andrew P. Loehrer 2
1General Surgery, Dartmouth Health, Lebanon, NH; 2Surgical Oncology, Dartmouth Health, Lebanon, NH

Background: Social drivers of health impact over 50% of cancer outcomes in the United States. Specific governmental policies, regulations, and funding shape the social environment in which we live and thus our health, including risk of diseases such as cancer. Significant gaps in knowledge exist regarding how public spending influences the incidence and mortality of common cancers in the United States. We aimed to evaluate the influence of state and local spending on non-medical care social and public health services on the incidence and mortality of cancers associated with social poverty. Study Design: This cross-sectional cohort study evaluated state-level incidence and mortality rates for adults age 20-64 years diagnosed with poverty-associated cancers in the United States between 2004-2020. The exposure was combined state- and local-level social and public health spending (SPHS), with spending values reported as dollars per capita and inflation adjusted to 2021 dollars. We used data from the United States Census Bureau Census on Governments to determine annual SPHS for each state. Deciles of SPHS were then determined at the annual basis. Primary outcomes were yearly incidence of poverty-related cancers and mortality, reported as rate ratios where the first decile (lowest spending) serves as the reference group. Cancer incidence and mortality data along with population estimates were obtained for all 50 states and the District of Columbia through the Center for Disease Control and Prevention (CDC) Wonder database. Poisson regression models were used to determine incident and mortality rate ratio controlling for state fixed-effects and year, with standard errors being clustered at level of state. Results: From 2004-2020, the overall median state SPHS was $7,071 per capita (IQR $6,373-$8,098), the two largest components of which were education and public welfare (Table 1). SPHS was associated with lower incidence rates in states with the upper deciles of spending (Incidence Rate Ratio 0.96 (0.92-0.99) and 0.92 (0.88 – 0.96) for 9th and 10th decile, respectively) (Figure 1a). Similarly, SPHS was associated with lower mortality rates with spending in the upper deciles (Mortality Rate Ratio 0.95 (0.90 – 0.99), 0.94 (0.89 – 0.88), and 0.91 (0.85 – 0.98) for the 8th, 9th, and 10th deciles, respectively) (Figure 1b). Results of sensitivity analysis excluding the year 2020 given its pandemic-related lower incidence rates did not differ significantly. Conclusions: This work demonstrates a statistically significant association between state and local social and public health spending with decreased incidence and mortality from poverty-associated cancers in the United States. The association was nonlinear and only associated with improved outcomes for states with the highest levels of social spending. These results can inform how state-level policies addressing social drivers of health may have downstream impacts on cancer incidence and mortality.
Table 1. Median social spending, overall and by individual components.
ComponentSocial Spending*
median (IQR)
Overall7,071.00 (6,373.00 - 8,098.00)
Total Assistance and Individual Subsidies165.00 (126.00 - 231.00)
Total Elementary and Secondary Education3,340.00 (3,020.00 - 3,658.00)
Total Public Health283.00 (207.00 - 392.00)
Total Highways640.00 (538.00 - 800.00)
Housing and Community Development152.00 (113.00 - 215.00)
Libraries42.00 (31.00 - 54.00)
Parks and Recreation135.00 (101.00 - 191.00)
Public Welfare1,797.00 (1,508.00 - 2,333.00)
Sanitation and Sewage255 (214.00 - 311.00)

*dollars per capita (inflation adjusted to the year 2021)

Figure 1. Association between social and public health spending and the a) incidence and b) mortality of poverty-related cancer.


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