OBJECTIVES: This study described factors related to colorectal cancer stage at diagnosis. METHODS: Logistic regression analyses were used on data from the New York State Tumor Registry and US Census area-level social class indicators. RESULTS: After the effects of other predictors were controlled for, the odds of late-stage cancer increased as age decreased; women and African Americans were significantly more likely to have late stage than men and Whites; and individuals living in areas of low socioeconomic status (SES) were significantly more likely to be diagnosed at late stage than those living in higher SES areas. Stratified analyses showed that living in a low SES area was the most important determinant of stage for all age, race, gender and source-of-care groups. CONCLUSIONS: While all populations would benefit from the systematic use of screening socioeconomically disadvantaged groups may also benefit from targeted screening.

This study examined the impact of individual demographic characteristics (age, race/ethnicity, and type of reporting hospital), together with measures of social context, including area of residence socioeconomic status (SES), change in SES, and access to screening (area mammography capacity), on breast cancer stage at diagnosis among New York City residents diagnosed between 1980 and 1985. Three logistic regression models evaluated the impact of individual variables, social context variables, and both classes of variables combined on the outcome of having late-stage (regional or distant) compared to early-stage (local) cancer. The logistic regression models indicated that women aged 50 to 64 years were independently more likely to have late-stage cancer than those younger or older. Controlling for individual and social context variables, African American women were 25 percent more likely than White women to have late-stage breast cancer (p < 0.0001); higher odds seen in the individual model for Hispanic women disappeared after controlling for area SES. In the combined model, women diagnosed from public hospitals were 44 percent more likely to have late-stage disease than those diagnosed in nonpublic settings (p < 0.0001). In both the social context and combined models, area mammography capacity was a significant independent predictor of stage (p = 0.016); area-level SES, but not change in SES, was independently related to late-stage disease (p = 0.002). These data suggest that breast cancer control activities should more actively ensure adequate access to screening, particularly for minorities, populations living in socioeconomically disadvantaged areas, and those cared for in the public sector.

In Muscatine, Iowa, a medically underserved rural area, a cohort study of health care utilization was made before and after a significant increase in medical manpower. There was a slight increase, rather than a decrease, in the use of chiropractic services associated with the growth in the physician manpower pool. The level of access to physician services was not a significant predictor of chiropractice utilization. (Am J Public Health 70: 415-417, 1980.) ed opportunities of chiropractors make rural locations relatively attractive to them."5 That is, chiropractors could have a "filling" effect by offering their services in medically underserved rural areas, with rural residents using chiropractors to fill primary care needs.We recently had the opportunity to examine whether chiropractic utilization serves as a substitute for orthodox medical services employing two surveys of medical care utilization in a rural community, before and after a dramatic increase in the number of primary care physicians. Methods IntroductionThe place of chiropractic in the delivery of personal health services is not well defined. To many in the medical community it is synonymous with quackery, but to over seven-and-a-half million Americans, chiropractors are a source of health care.' Rural residents, whose health care supply is often deficient, are among the highest users of chiropractors,1 a fact not totally explained by the higher average age and lower family incomes of rural consumers. In keeping with the reduced medical service supply, rural residents average fewer physician visits per year than their urban counterparts. [1][2][3][4] Hassinger, et al, hypothesized that the "erosion of medical and osteopathic physicians (from rural areas) results in need for personal health services, and the more limit-

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