Geographic trends in prostate cancer mortality: An application of spatial smoothers and the need for adjustment

Prostate cancer mortality among whites and nonwhites in U.S. counties are analyzed for geographic effects. To better visualize geographical effects, the data are smoothed with a bivariate smoother using age-specific rates. Among nonwhites, an important explanatory variable is the proportion of African Americans. A relationship between the mortality rate and this variable is derived, and the data are adjusted for this variable using this relationship. When the rates are adjusted for age only, among whites there is a north-south gradient: rates are higher in the north, lower in the south. Among nonwhites, the gradient runs east to west: higher in the east, lower in the west. The latter gradient disappears when the rates are further adjusted for African Americans. The study reveals the importance of both smoothing the data to visualize patterns in geography and adjusting the data for an important variable to identify underlying patterns. The additional adjustment permits the identification of other areas of the country with elevated or depressed rates.