Contextual effects and cancer outcomes in the United States: a systematic review of characteristics in multilevel analyses

Whitney E. Zahnd, Sara L McLafferty

Research output: Contribution to journalReview articlepeer-review


Purpose There is increasing call for the utilization of multilevel modeling to explore the relationship between place-based contextual effects and cancer outcomes in the United States. To gain a better understanding of how contextual factors are being considered, we performed a systematic review. Methods We reviewed studies published between January 1, 2002 and December 31, 2016 and assessed the following attributes: (1) contextual considerations such as geographic scale and contextual factors used; (2) methods used to quantify contextual factors; and (3) cancer type and outcomes. We searched PubMed, Scopus, and Web of Science and initially identified 1060 studies. One hundred twenty-two studies remained after exclusions. Results Most studies utilized a two-level structure; census tracts were the most commonly used geographic scale. Socioeconomic factors, health care access, racial/ethnic factors, and rural-urban status were the most common contextual factors addressed in multilevel models. Breast and colorectal cancers were the most common cancer types, and screening and staging were the most common outcomes assessed in these studies. Conclusions Opportunities for future research include deriving contextual factors using more rigorous approaches, considering cross-classified structures and cross-level interactions, and using multilevel modeling to explore understudied cancers and outcomes.

Original languageEnglish (US)
Pages (from-to)739-748.e3
JournalAnnals of Epidemiology
Issue number11
StatePublished - Nov 2017


  • Cancer
  • Contextual effects
  • Multilevel analysis
  • Social epidemiology
  • Spatial epidemiology
  • USA

ASJC Scopus subject areas

  • Epidemiology


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