Educational attainment and mortality among World Trade Center Health Registry enrollees diagnosed with cancer after 9/11
Abstract
Individuals exposed to the World Trade Center (WTC) terrorist attacks on 9/11/2001 have elevated risks for certain cancers, highlighting the need to identify determinants of mortality after cancer diagnosis in this population. Our prior work identified racial/ethnic disparities in cancer mortality among WTC-exposed individuals. It is unknown whether educational attainment, a determinant of cancer survival in the general population, also contributes to disparities. We used WTC Health Registry data to examine associations between educational attainment (≤high school (HS) degree, some college, bachelor’s degree, graduate degree) and mortality among 6,603 individuals who were aged ≥25 at enrollment in 2003-2004 and were diagnosed with a first cancer after 9/11/2001. Cox proportional hazards models were used to evaluate all-cause mortality, with cause-specific Cox models assessing cancer-specific and non-cancer mortality. Person-time was calculated from cancer diagnosis to death or censoring on 12/31/2022, with left truncation applied for participants diagnosed before study enrollment. Premature mortality was also assessed among cases diagnosed before age 65 (n=4,467), with censoring at age 65. Models were stratified by age at diagnosis and adjusted for demographic, clinical, and prognostic factors. There were 1,965 deaths (817 premature) over follow-up. Compared to individuals with a graduate degree, those with ≤HS degree had higher risks of all-cause (HR=1.26, 95% CI=1.09-1.44) and cancer-specific (HR=1.23, 95% CI=1.04-1.47) mortality; no association was found for non-cancer mortality. Similar patterns were observed for premature mortality (all-cause: HR=1.37, 95% CI=1.08–1.74; cancer-specific: HR=1.36, 95% CI=1.04–1.79). Findings support that education is associated with cancer-specific mortality, including premature deaths, among 9/11-exposed individuals, highlighting the need for targeted monitoring and support for those with lower education in this population.
