Allostatic Load, Educational Attainment, and Risk of Cancer Mortality Among US Men

Importance Health disparities among racial and ethnic minoritized populations, particularly for cancer mortality rates, remain a major public health concern. Men from underrepresented backgrounds (Black and Hispanic men, specifically) face the pervasive effects of discrimination in their daily lives, which also contribute to the complex associations among allostatic load (a marker of chronic stress), educational opportunities, and elevated risks of cancer mortality. Objective To elucidate the associations among educational attainment, allostatic load, and cancer mortality risk among men. Design, Setting, and Participants This is a retrospective cohort analysis of data from the National Health and Nutrition Examination Survey, a nationally representative sample of approximately 5000 people across the US, from 1988 to 2010 linked with data from the National Death Index, which served as follow-up data for the cohort and was available through December 31, 2019. Participants included men aged 18 years and older. Data were analyzed from June to October 2024. Exposure Allostatic load data were stratified by educational attainment levels, categorized as (1) less than high school education and (2) high school graduate and above. Allostatic load score was calculated as the sum of total abnormal biomarkers and health measures (9 total). Participants were considered to have high allostatic load if their score was 3 or more. Main Outcomes and Measures The primary outcome was cancer death. Weighted Cox proportional hazards models were fitted to estimate adjusted hazard ratios (HRs) of cancer death between educational attainment and allostatic load (adjusted for age, income, and smoking status). Results Among all 20 529 men (mean [SE] age, 41.00 [0.22] years), those with high AL and less than high school educational attainment had a greater than 4-fold increased risk of cancer mortality (unadjusted HR, 4.71; 95% CI, 3.36-6.60) compared with those with low allostatic load and a college degree or higher. Similarly, both Black men (HR, 4.19; 95% CI, 2.09-8.40) and White men (HR, 5.77; 95% CI, 4.06-8.20) with high allostatic load and less than high school educational attainment had higher risks for cancer death compared with race-specific counterparts with college education and low allostatic load. After adjustments for age, poverty-to-income ratio, smoking status, history of cancer, and ever congestive heart failure and heart attack, the associations were attenuated, but all men (HR, 1.69; 95% CI, 1.15-2.47) and White men (HR, 1.82; 95% CI, 1.16-2.85) still had greater than 50% increased risk of cancer death compared with men with college education and low allostatic load. Conclusions and Relevance This study highlights the detrimental association of not attaining a high school degree, combined with high allostatic load as a marker of chronic stress, with cancer mortality. Efforts to promote educational attainment and address the underlying social determinants of health are imperative in reducing cancer disparities in this population.