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PubMed1995

Cancer patterns among women in the United States.

The American Cancer Society estimated that 576,000 invasive cancers would be diagnosed among American women in 1994 and that 255,000 women will have died of cancer during that year. Six cancers account for almost 70% of the cases in women and more than 60% of the deaths. Risk factors associated with breast, lung, colorectal, cervix uteri, corpus uteri, and ovarian cancers are presented. The patterns of occurrence in the population, time trends, survival rates, and etiologic factors vary considerably, suggesting a constellation of diseases in women. One of the most important factors influencing outcome is early diagnosis.

Adult↗
PubMed2002

The epidemic of esophageal adenocarcinoma.

The incidence and mortality related to esophageal adenocarcinoma (EAC) have been increasing in the United States, several European countries, and Oceania for the past 2 to 3 decades. Survival remains dismal, with little improvement during the same time period. Variations in the coding, classification, and detection of gastroesophageal malignancy may have contributed partially to the observed trends. Remarkable differences related to gender, ethnicity, and geography characterize the epidemiology of EAC. Gastroesophageal reflux disease (GERD) is the main risk factor for Barrett's esophagus, which is the only known precursor lesion for EAC. Several risk factors that promote the development of GERD and/or Barrett's esophagus have been proposed to explain these rising trends; these factors include the declining rates of Helicobacter pylori infection, obesity, dietary factors, and certain drugs.

Adenocarcinoma↗
PubMed2000

Strategies for improving comorbidity measures based on Medicare and Medicaid claims data.

Claims-based measures of comorbid illness severity have generally relied on the diagnoses listed for a single hospitalization. Unfortunately, such diagnostic information is often limited because patients have not been hospitalized during periods of interest, because of incomplete coding of diagnoses on claims forms, or because listed diagnoses represent complications of the hospitalization rather than pre-existing comorbid conditions. To address these limitations, we developed and tested four comorbidity index scores for patients with breast cancer, each based on different sources of health services claims from Medicare and Medicaid: hospitalization for breast cancer surgery; outpatient care prior to the hospitalization; other inpatient care prior to the hospitalization; and all sources combined. Varying the number and type of sources of diagnostic information yielded only very small improvements in the prediction of mortality at 1 and 3 years. Surprisingly, even simpler measures of comorbidity (crude number of diagnoses) and of prior health care utilization (total days spent in the hospital) performed at least as well in predicting mortality as did the more complex index scores which assigned points and weights for specific conditions. The greatest improvement in explanatory power was observed when another source of clinical information (cancer stage derived from a population-based cancer registry) was used to supplement claims information. Expanding the source of claims diagnoses and focusing on time periods prior to an index hospitalization are insufficient for substantially improving the explanatory power of claims-based comorbidity indices. Other improvements suggested by our results should include: increasing the completeness and accuracy of claims diagnoses; supplementing diagnoses with health care utilization information in claims data; and supplementing claims data with other sources of clinical information.

Aged↗
PubMed2001

Bone mineral density and breast cancer risk in postmenopausal women.

Two recent studies have shown a woman's bone mineral density (BMD) (a composite measure of exposure to many different factors throughout one's lifetime) predicts breast cancer. In a prospective cohort study, we examined whether hip BMD was associated with breast cancer risk among 8203 postmenopausal women. During an average follow-up of 3.7 years, 131 incident breast cancer cases (102 invasive) were identified. Cox proportional hazards models were used to obtain estimates of the relative risk of breast cancer. Our results demonstrate an increase in breast cancer risk among women with higher BMD. Independent of age, geographic area, and body mass index, relative to the lowest BMD quartile the risk of breast cancer (95% confidence interval) by increasing quartile was 1.9 (1.1, 3.2), 1.5 (0.8, 2.6), and 1.5 (0.8, 2.7), respectively. An examination of other factors important in determining BMD may help explain the positive association between BMD and breast cancer.

Aged↗
PubMed2001

Changing rates of cancer. The hazards of using a single definition.

Changing cancer rates, abstracted from tumor registries, are used to make inferences about the effect of carcinogens and cancer treatments on a population-wide basis. We compared the annual age-standardized incidence rates of extremity soft tissue sarcomas from two large tumor registries using different case definitions. We identified all limb soft tissue sarcoma cases diagnosed 1973-1993 in the Ontario Cancer Registry (OCR) and the Surveillance, Epidemiology, and End Results (SEER) databases. Two case definitions for limb soft tissue sarcoma were used based on missing data, incomplete diagnostic methods and ICD-9 codes; an upper limit estimate of the rates which included all possible cases of limb soft tissue sarcoma and a lower limit estimate of the rates which included all definite cases of limb soft tissue sarcoma (with the true rates lying in between). The upper limit OCR rates showed a statistically significant decreasing linear trend (slope = -0.021, P < 0.01). Whereas the slope of the OCR lower limit regression line showed a statistically significant increase in rates (slope = 0.01, P = 0.04). Neither the upper or lower limit SEER rates had a statistically significant linear trend (slope = 0.002, P = 0.60 and slope = 0.001, P = 0.18, respectively). Case definition affects incidence rates and changing rates of cancer. Thus the use of a single case definition along with changing coding practices may alone explain changing cancer rates.

Age Factors↗
PubMed2003

Geographic variation within the United States in the incidence of hepatocellular carcinoma.

Geographic variation in hepatocellular carcinoma (HCC) has not been previously studied in the United States. Using data collected by the Surveillance, Epidemiology, and End Results registries (SEER) and the 1990 Behavioral Risk Factor Surveillance System (BRFSS), we analyzed incidence and risk factors for HCC in nine geographic regions in the United States. We identified all individuals with HCC during 1975-1998 in five states (Connecticut, Iowa, Utah, New Mexico, and Hawaii) and four metropolitan areas (Detroit-Metropolitan, San Francisco-Oakland, Seattle-Puget Sound, and Atlanta-Metropolitan). Age-adjusted incidence rates were calculated for each geographic region. The association between HCC incidence and geographic regions were examined in Poisson multivariate regression model controlling for age, gender, race, and year of diagnosis. Hierarchical linear modeling was also used to examine these associations while adjusting for potential clustering of persons with similar characteristics within geographic regions, and to assess the effect of the prevalence of smoking, alcohol use, obesity, and diabetes in the underlying population in these geographical regions. A total of 11,547 persons with HCC were examined. Hawaii had the highest age-adjusted incidence rate (4.6), followed by San Francisco-Oakland (3.2), New Mexico (2.0), Detroit-Metropolitan (1.9), Seattle-Puget Sound (1.8), Atlanta-Metropolitan (1.7), Connecticut (1.6), Iowa (1.1), and Utah (1.0); all rates per 100,000. Whites had an age-adjusted incidence rate of 1.5, Blacks 3.2, and other races "Asian, American Indian, Pacific Islander" 7.0. However, Blacks and "other races" in Seattle-Puget Sound had higher age-adjusted incidence rates (4.4 and 8.2, respectively) than Blacks and other races in any other registry, while Whites in Hawaii had a higher rate (2.5) than Whites in any other registry. In general, men had a two to three times higher age-adjusted incidence rate than women. However, Hawaiian men had significantly higher age-adjusted rates (7.0) than men in other regions, while Utah had the lowest rates of HCC in men (1.5). Adjusting for variations in ethnicity, gender, age, and time of diagnosis, the Poisson regression analysis showed persistent geographic differences in HCC as well as a change in the order with New Mexico having the highest HCC incidence followed San Francisco-Oakland. Hierarchical linear modeling confirmed geographic variations in HCC but failed to show a significant effect for the prevalence of smoking, alcohol use, obesity, and diabetes in the underlying population. Significant geographic variation in HCC incidence exist in the United States. These variations are only partly explained by differences in age, gender, race, and year of diagnosis.

Age Distribution↗
PubMed2003

The development and validation of a comorbidity index for prostate cancer among Black men.

BACKGROUND AND OBJECTIVES: The purpose of this study was to develop a comorbidity index specific to Black Men with prostate cancer, because certain comorbidities and prostate cancer are particularly prevalent among this racial group. METHODS: This research used the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database to develop an index of comorbidity burden based on survival, and the presence/absence of comorbid illness in 2,931 Black males diagnosed with prostate cancer. Comorbidity burden was recognized using inpatient, outpatient, and physician claims for a 2-year period prior to the diagnosis of prostate cancer. We compared five different statistical models, each with two-way, three-way, and/or four-way interactions among the comorbidities, and selected the model with only two-way interactions as the optimal choice. We demonstrated the utility of refining the simplest model, with 27 comorbidity categories only, by adjusting for the number of different diagnoses within statistically significant categories.

Black or African American↗
PubMed1997

Generalizability of the surveillance, epidemiology, and end results registry population: factors relevant to epidemiologic and health care research.

To assess the generalizability of the population included in the Surveillance, Epidemiology, and End Results (SEER) tumor registries to the overall United States population, we compared the population of the 198 SEER counties to the population of the 2882 non-SEER counties regarding sociodemographic factors, physician availability, and availability of pertinent hospital resources. The population residing within the SEER areas is more affluent, has lower unemployment, and is substantially more urban than the remainder of the U.S. population (p < 0.001 for each). The SEER areas have fewer general and family practice physicians, but more total nonfederal physicians, general internists, and specialists relevant to cancer care. SEER areas have fewer Joint Commission on Accreditation of Hospitals accredited hospitals, hospital beds, and hospitals with CT scanners, but more hospitals with bone marrow transplantation. The differences between the SEER population and the remainder of the United States, especially SEER's higher socioeconomic status and more urban population, should be considered when generalizing from SEER to the entire country.

Health Services Research↗
PubMed1999

Information on radiation treatment in patients with breast cancer: the advantages of the linked medicare and SEER data. Surveillance, Epidemiology and End Results.

Several studies have found underutilization of radiotherapy in patients with breast cancer; but there are concerns about the completeness of various databases on radiotherapy. We used the linked Medicare-SEER (Surveillance, Epidemiology and End Results) database to compare information on receipt of radiotherapy after diagnosis of breast cancer. More than 18% of women identified by Medicare data as receiving radiotherapy were not so identified by SEER, and 7% of those identified as receiving radiotherapy by SEER were not identified by Medicare. Risk of discordance on radiotherapy information between the two data sets was especially high in women receiving breast-conserving surgery. The combined SEER-Medicare database gives a more complete picture on the use of radiotherapy. The previously reported geographic variations in the use of radiotherapy for breast cancer may be due in part to underreporting of radiotherapy in some areas.

Adult↗
PubMed2000

An approach to identifying incident breast cancer cases using Medicare claims data.

This study developed and evaluated a method for ascertaining a newly diagnosed breast cancer case using multiple sources of data from the Medicare claims system. Predictors of an incident case were operationally defined as codes for breast cancer-related diagnoses and procedures from hospital inpatient, hospital outpatient, and physician claims. The optimal combination of predictors was then determined from a logistic regression model using 1992 data from the linked SEER registries-Medicare claims data base and a sample of noncancer controls drawn from the SEER areas. While the ROC curve demonstrates that the model can produce levels of sensitivity and specificity above 90%, the positive predictive value is comparatively low (67-70%). This low predictive value is largely the result of the model's limitation in distinguishing recurrent and secondary malignancies from incident cases and possibly from the model identifying true incident cases not identified by SEER. Nevertheless, the logistic regression approach is a useful method for ascertaining incident cases because it allows for greater flexibility in changing the performance characteristics by selecting different cut-points depending on the application (e.g., high sensitivity for registry validation, high specificity for outcomes research). It also allows us to make specific adjustments to population based estimates of breast cancer incidence with claims.

Aged↗
PubMed2002

Lessons learnt about early prostate cancer from large scale databases: population-based pearls of wisdom.

Prostate cancer is one of most common solid tumors in men and poses some of the most difficult problems in clinical research. Although many clinical research hypotheses in this condition have been explored using single center cases series and multi-center clinical trials, the results of these studies have often been equivocal, leaving many questions unanswered. Recently, investigators have utilized large, administrative datasets for prostate cancer research. These databases tend to include large numbers of patients from different geographic regions increasing their generalizability and statistical power. The goal of this report is to review lessons learnt about early prostate cancer using these data sources. In particular, we focus on the application of large, population-based datasets to address issues concerning the natural history of prostate cancer, the impact of race on outcomes in prostate cancer and the effectiveness of various treatments for localized disease. Information gathered from large, administrative databases will be helpful when counseling patients regarding their treatments options for localized prostate cancer and in identifying future directions for prostate cancer research.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2003

Adjuvant therapy for older women with breast cancer.

The major risk factor for breast cancer is increasing age and more than half of all breast cancers in affluent nations occur in women 65 years and older. Co-morbidity is a key consideration in offering systemic adjuvant treatment to older women since significant co-morbidity minimizes the potential value of any adjuvant therapy. Tamoxifen has clearly been shown to significantly decrease the risk of recurrence and improve survival in women of all ages who have estrogen (ER) or progesterone receptor (PR) positive invasive breast cancer, including those 70 years and older. Chemotherapy in older patients can improve survival but adds little to tamoxifen in women with node-negative, ER+ or PR+ tumors: it should be reserved for older women who have reasonable life-expectancy and larger node-negative tumors, or node-positive tumors. Ageism is still a barrier to clinical trials participation and clinical trials focusing on older women are needed.

Aged↗
PubMed2003

Treatment of older breast cancer patients with high recurrence risk.

Adjuvant treatment of elderly women affected by breast cancer who have a high risk of recurrence is one of the most questionable issues in clinical oncology. The use of tamoxifen in women with hormone receptor-positive tumors is a relatively simple therapeutic option considering the favourable toxicity profile, whereas the administration of adjuvant chemotherapy is more complicated and a variety of aspects need to be considered. The estimated life expectancy, the presence and degree of comorbid conditions, the geriatric assessment and estimated benefit from treatment should be taken into account. Due to the lack of data from clinical trials in women over the age of 70, the approach is still experimental. Clinical trials evaluating the role of adjuvant chemotherapy in high risk patients are currently being developed and hopefully in the near future, more convincing data on the best drugs, regimens and benefits for the treatment of elderly breast cancer patients will become available.

Aged↗
PubMed2002

Potential for selection bias with tumor tissue retrieval in molecular epidemiology studies.

Molecular epidemiological studies of cancer generally require tumor tissue to evaluate somatic genetic alterations. Frequently this requires retrieval of fixed tissue blocks from hospital pathology archives. The availability of this material may be associated with disease severity, diagnostic practices, hospitals, or risk factors for disease. Tumor material is not available when the diagnosis is made clinically without histological confirmation. These characteristics create difficulties in defining the study base population. Incomplete access to tumor tissue has implications for description of the natural history of disease, estimates of the prevalence of mutation in the population, and evaluation of environmental exposures and critical target gene mutations. Differential diagnostic practices by age groups or across hospitals may create a biased population with respect to potential risk factors. However, this will not bias case-case comparisons unless the mutation of interest is associated both with the exposure of interest and the presence of a tumor block. When subjects with less severe disease are more likely to have biopsies, information regarding the natural history of the disease will be obscured. Investigation of the interaction of environmental agents and critical target gene mutations may be limited if, for example, an environmental agent is associated with a more aggressive form of the disease. Using an ongoing pancreatic cancer case-control study as an example, we discuss the potential for bias associated with differential availability of tumor blocks including consideration of tumor, patient, and hospital characteristics. Due to incomplete retrieval of tissue, the determinants of selection should be described in all studies using tumor tissue, and the implications for generalizability, power, and interpretation of findings in population-based studies should be considered.

Aged↗
PubMed2001

Measuring the public health burden of cancer in the United States through lifetime and age-conditional risk estimates.

PURPOSE: Effects of an aging population in the United States on lifetime and age-conditional risk estimates of developing site-specific cancers are identified and the potential role these statistics play in monitoring disease burden discussed. METHODS: Risk estimates were derived by applying cross-sectional population-based incidence rates of cancer and mortality rates from other causes to a hypothetical cohort. The cohort was aged through a double decrement life table to determine the expected proportion of the population that would develop the disease. RESULTS: Despite black men having higher invasive cancer incidence rates than white men, and black and white women having similar rates, because of the better life expectancy among whites lifetime risk estimates of developing cancer are higher for whites than blacks: 45.5% in white men, 40.4% in black men, 39.2% in white women, and 32.4% in black women based on 1995-97 data. White men experience higher 10-year cancer risk than black men in only bladder cancer, non-Hodgkin's lymphomas (NHL), and leukemia. White women tended to show a greater risk than black women for cancers of the breast, corpus uteri, ovary, NHL, and leukemia. For both whites and blacks, the 10-year risk of lung cancer ranks first among men aged 40, ranks second to prostate cancer for men aged 50, 60, and 70, and ranks second to breast cancer for women aged 40, 50, 60, and 70. CONCLUSIONS: Lifetime and age-conditional risk measures reflect both changes in the disease incidence rates and age distribution over calendar time such that they are useful for monitoring the disease burden in the population. Even if cancer rates remain stable or fall, it is possible for the cancer burden, as reflected by lifetime and age-conditional risk estimates, to increase due to the aging population.

Adolescent↗
PubMed2002

Comparison of interviewed and non-interviewed non-Hodgkin's lymphoma (NHL) patients in the San Francisco Bay Area.

PURPOSE: To determine whether interviewed non-Hodgkin's lymphoma (NHL) patients differed from non-interviewed NHL patients and to revise the population-based risk estimate for NHL associated with HIV infection in homosexual men in the San Francisco Bay Area. Differences between study participants and non-participants are a concern in epidemiologic studies. Recruitment techniques can be modified when nonparticipation is a result of subject refusal. However, the solutions for nonparticipation due to death are less clear, especially when rapid case ascertainment (RCA) is used to identify newly diagnosed patients. METHODS: A large population-based case-control study was conducted in the San Francisco Bay Area between 1988 and 1995 to investigate risk factors for NHL. Nearly 1600 patients were interviewed and included in this study. A total of 1047 NHL patients were not interviewed because they had died prior to contact (602 patients) or we had received their RCA information after the study had ended (445 patients). We compared available demographic, clinical, and histologic profiles of the interviewed and non-interviewed NHL patients. RESULTS: Compared with the interviewed group, the non-interviewed group was younger, had more single HIV-infected homosexual men and a higher incidence of high-grade and "not-otherwise-specified" lymphoma. When categorized by sex and sexual preference, median age at diagnosis of NHL was the same for the interviewed and non-interviewed homosexual men. Combining interviewed and non-interviewed patients, the estimated risk for NHL associated with HIV infection in homosexual men [odds ratio (OR) = 50] is substantially higher than we had estimated in our earlier publications (OR = 20). CONCLUSIONS: High-grade lymphomas associated with poor survival in homosexual men are likely to be under-represented in case-control studies of NHL.

Adult↗
PubMed2004

Ethnicity, but not cancer family history, is related to response to a population-based mailed questionnaire.

PURPOSE: To determine if family history and ethnic background are factors affecting response to a mailed cancer family history questionnaire from the Ontario Familial Breast Cancer Registry. METHODS: Individuals diagnosed with primary invasive breast carcinomas (probands) were mailed a family history questionnaire, the first contact in a multi-stage process. This questionnaire obtained cancer family history and ethnicity data. After one month, a follow up telephone call was made to those who did not return this questionnaire and attempts were made to ask similar questions by telephone interview. Characteristics of those responding to the mailed questionnaire were compared to those who responded to the telephone interview only. RESULTS: 339 probands were included in this study: 242 returned a mailed version of the questionnaire; 57 completed the questionnaire over the phone. Cancer family history/genetic risk criteria was not significantly related to type of response. Probands identifying themselves as visible minorities were significantly less likely to respond to the mailed questionnaire than the telephone interview (11.6% vs. 22.8%, P=0.03). CONCLUSIONS: Having a family history of cancer did not appear to influence response to a mailed questionnaire, but those reporting an ethnic/racial background other than White were more likely to respond to a telephone interview.

Adult↗
PubMed2002

Epidemiologic trends in esophageal and gastric cancer in the United States.

Use of tobacco, moderate to heavy alcohol ingestion, infrequent consumption of raw fruits and vegetables, and low income accounted for more [figure: see text] than 98% of the SCE rates among both African American and white men and for 99% of the excess incidence among African Americans compared to whites in a case-control study in three areas of the United States [14]. Thus, it is likely that declines in the prevalence of smoking and drinking, especially among men, and increased intake of fresh fruits and vegetables may have contributed to the downward incidence and mortality rate trends reported for SCE. In addition, it seems plausible that obesity, GERD, and possibly reductions in H. pylori prevalence have contributed to the upward trends in ACE rates. Reductions in smoking, improved diet, and reductions in H. pylori prevalence probably have contributed to the consistent reductions observed for NGA. Contributing factors are less clear for the rising incidence rates of GCA during the 1970s and 1980s. These incidence rates have not continued to rise in recent years.

Adenocarcinoma↗