Within-Group Racial and Ethnic Differences in County-Level Socio-Behavioral Risk Across Cancer Mortality Tertiles in the United States

ImportancePersistent racial and ethnic disparities in breast and prostate cancer mortality are well documented. Most prior studies emphasize between-group differences and rely on population averages or single composite measures of social disadvantage, which can obscure high-need communities within groups. How socio-behavioral determinants of health vary within groups across local gradients of cancer mortality remains incompletely characterized. A framework that combines race- and cancer-specific mortality with local, domain-level socio-behavioral profiles may help identify where burden is greatest and which specific barriers warrant prioritization. ObjectiveTo determine how socio-behavioral risk relates to breast and prostate cancer mortality within racial and ethnic groups and to characterize domain-specific behavioral profiles across low-, moderate- and high-mortality counties to inform targeted, equity-oriented cancer control strategies. DesignCross-sectional study of U.S. counties. Setting United States, county-level analysis. Participants3,141 U.S. counties, stratified within Non-Hispanic White, Non-Hispanic Black, and Hispanic populations. ExposuresCounty-level socio-behavioral determinants of health measured using a composite index comprising seven domains: community solidarity; education, health literacy, and digital connectivity; quality of care; housing and environmental risk; economic livelihoods; lifestyle behaviors; and touchpoints with care. Main outcomes and measuresRace/ethnicity-specific, age-adjusted breast and prostate cancer mortality rates (2018-2022) and county-level socio-behavioral risk scores. Counties were grouped into mortality tertiles within each race/ethnicity-by-cancer-stratum. ResultsAcross groups, higher socio-behavioral risk was associated with higher breast and prostate cancer mortality. For breast cancer, socio-behavioral risk increased monotonically across mortality tertiles for all groups, with the largest within-group increases among Hispanic and Non-Hispanic Black women. For prostate cancer, risk generally increased across mortality tertiles for all groups. Although Hispanic populations had lower population-average mortality, high-mortality Hispanic counties exhibited pronounced risk in lifestyle behaviors, economic livelihoods, and touchpoints with care. Domain patterns associated with high mortality varied by race, ethnicity, and cancer type, with touchpoints with care and economic livelihoods consistently prominent. Conclusions and relevanceWithin-group heterogeneity in socio-behavioral risk is substantial across U.S. counties. Linking population-specific, domain-level socio-behavioral profiles to cancer mortality may support more precise and equity-oriented cancer control strategies than reliance on group averages or composite indices. Key pointsO_ST_ABSQuestionC_ST_ABSWithin racial and ethnic groups, how do socio-behavioral determinants of health vary across US counties with low, moderate, and high breast and prostate cancer mortality? FindingsIn this cross-sectional study, higher county-level socio-behavioral risk was associated with higher breast and prostate cancer mortality across racial and ethnic groups. Race/ethnicity-specific, domain-level profiles revealed within-group heterogeneity, including persistently elevated risk among Non-Hispanic Black populations and pronounced domain-specific gaps in high-mortality Hispanic counties. MeaningLinking population-specific socio-behavioral profiles to local cancer mortality can guide more precise and equity-oriented prioritization of intervention domains and geographies than reliance on group averages or composite indices.