Changes in lung cancer incidence and mortality rates among Americans: 1969--78.

Cancer incidence data from two large cancer surveys and cancer mortality data for the entire United States were used to estimate trends in lung cancer incidence and mortality rates among whites for specific age groups during the 10 years 1969--78. Data for the Third National Cancer Survey were from 1969 to 1971; data for the Surveillance, Epidemiology, and End Results Program were from 1973 to 1978. For both incidence and mortality, the rates for women increased much more rapidly than the rates for men, except in the oldest age group (greater than or equal to 85). For both men and women, there was a striking similarity between the average annual percent changes for age-specific incidence rates and those for age-specific mortality rates. For the first time women and men had a similar incidence rate for the youngest (35--44) age group in 1978. If these trends continue, the data suggest that the total incidence rates for men and women will be equal by the year 2000.

Trends in cancer incidence and mortality in the United States, 1969-76.

Trends in cancer incidence and mortality in the United States were analyzed over the period 1969 through 1976. The greatest increase in incidence among whites occurred for lung cancer among females (almost 9%/yr), whereas the incidence of cancer of the uterine corpus increased 6% per year. Cancer of the cervix showed the greatest decrease in incidence, an average of 6% per year. Stomach cancer incidence and mortality showed a substantial decline for each sex, and rectal cancer incidence increased for each sex whereas mortality declined. The incidence of cancer of the female breast increased 1.8% per year without inclusion of the rates for 1974 and 1975, when an unusually large increase occurred. Cancer mortality data were presented for the total United States on the basis of data from the National Center for Health Statistics. Emphasis was focused on the comparability of cancer incidence data over the time period studied, given the fact that cancer incidence was measured by the Third National Cancer Survey for the period 1969-71 and by the Surveillance, Epidemiology, and End Results Program for the period 1973-76. Each survey covered approximately 10% of the U.S. population but had four geographic areas in common. Investigation of the comparability of these two surveys revealed that the incidence rates for whites were sufficiently comparable to permit an analysis of trends in cancer incidence over the entire period 1969-1976. Such comparability was not found for blacks. Therefore, cancer incidence data are presented only for whites, but cancer mortality data are presented for both whites and blacks.

Association of cancer sites with tobacco and alcohol consumption and socioeconomic status of patients: interview study from the Third National Cancer Survey.

From personal interviews obtained for 7,518 incident cases of invasive cancer from the population-based Third National Cancer Survey, the quantitative lifetime use of cigarettes, cigars, pipes, unsmoked tobacco, wine, beer, hard liquor, and combined alcohol were recorded, as well as education and family income level. In an initial screening analysis of these data, Mantel-Haenszel 2 X 2 contingency tabulations and multiple regression analyses were used to compare each specific cancer site with controls from other sites to test for associations with the "exposure variables." Significant positive associations with cigarette smoking were found for cancers of the lung, larynx, oral cavity, esophagus, stomach, pancreas, bladder, kidney, and uterine cervix. Other forms of tobacco were associated with cancers of the oral cavity, larynx, lung, and cervix. Consumption of wine, beer, hard liquor, and all combined showed positive associations with neoplasms of the oral cavity larynx, esophagus, colon, rectum, breast, and thyroid gland. College educaton and high income both showed positive associations with cancers of the breast, thyroid gland, uterine corpus, and melanomas in males. These same indicators of high socioeconomic status showed inverse associations with invasive neoplasms of the uterine cervix, lung, lip-tongue, and colon in females. College attendance (but not income) showed an inverse association with stomach cancer and positive association with pancreatic cancer in males. Still other tumor sties showed "suggestive" associations with each of these exposure variables. In the analyses producing these results, age, race, sex, smoking, drinking, education, income, parity, foreign birth, marital status, and geographic location were used as stratification variables separately or in combination when appropriate to assess and control for their potentially confounding affects and to examine results in different strata to assess interaction.

Socioeconomic factors and cancer incidence among blacks and whites.

Findings from previous studies suggest that differences in socioeconomic status may be responsible for some, if not all, of the elevated incidence of cancer among blacks as compared with whites. Using incidence data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program, we tested this hypothesis by correlating black and white cancer incidence rates in three US metropolitan areas between 1978 and 1982 with data from the 1980 census on socioeconomic status within individual census tracts. The study analyzed data on the incidence of cancer at all sites combined (greater than 100 cancer sites) and at seven major sites separately. As in other studies, income and educational levels served as surrogates for socioeconomic status. The present study also used census-tract data on population density as a surrogate factor. Each of these measures of socioeconomic status was analyzed independently. Before correlation with census-tract data, age-adjusted data on cancer incidence showed statistically significant elevated risks among blacks for cancer at all sites combined and at four of the seven separate sites; whites showed an elevated risk for cancer at two sites. Cancer at only one site, the colon, showed no significant association with race. When age-adjusted incidence data were correlated with socioeconomic status, the comparative black-white risks changed: Whites showed an elevated risk of cancer at all sites combined and at three of the seven separate sites; blacks maintained their elevated risk at three sites. These findings suggest that the disproportionate distribution of blacks at lower socioeconomic levels accounts for much of the excess cancer burden among blacks. They also suggest that for both blacks and whites unidentified racial factors, which may be either cultural or genetic and which are not closely linked to socioeconomic status, may play a role in the incidence of some cancers.

Incidence of Kaposi's sarcoma and mycosis fungoides in the United States including Puerto Rico, 1973-81.

The incidence of Kaposi's sarcoma (KS) was examined with the use of data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. KS is a manifestation of the recent epidemic of acquired immunodeficiency syndrome (AIDS) that has occurred particularly among homosexual men. The incidence of KS in 1973-79 was found to be higher (0.29 male and 0.07 female cases/100,000/yr) than is usually cited for the pre-AIDS KS incidence rates. Collectively, the 9 SEER registries in the United States showed only a slight increase in the incidence of KS between 1973-79 and 1980-81. However, the SEER registry covering San Francisco, which is a high-risk area for AIDS, showed a marked excess of KS in 1981. The KS case rate among never-married men younger than 50 years old, a surrogate index of homosexuality, was found to be markedly elevated in the post-AIDS period, compared with the case rate of a reference disease, mycosis fungoides. Never-married men younger than 50 years old, therefore, constitute a SEER-identifiable population who can be monitored for risk of KS and other neoplasms that might be related to AIDS. In addition, the incidence rate of KS in the SEER registry of Puerto Rico was generally higher than that in the U.S. SEER registries, despite data that suggested that KS may be underreported. The demographic characteristics of patients diagnosed as having KS in Puerto Rico suggested the classical rather than the AIDS-related form of KS.

Representativeness of the surveillance, epidemiology, and end results program data: recent trends in cancer mortality rates.

BACKGROUND: Mortality, incidence, and survival rates are the primary measures used by the National Cancer Institute (NCI) to monitor cancer in the United States. The Surveillance, Epidemiology, and End Results (SEER) data system collects data on all cancers diagnosed among residents in geographically defined populations, which comprise about 10% of the U.S. population. This data system is the major component of the NCI system for tracking these rates. Thus, it is important to assess the degree to which SEER data are representative of the entire U.S. population. PURPOSE: National data on mortality, but not on incidence or survival, are available from the National Center for Health Statistics. These data provide a census against which mortality data from the subset of the SEER regions may be compared. METHODS: Multivariate regression analyses of age-adjusted mortality rates from 1975 to 1988, computed for the SEER areas and for the entire United States, were performed for race- and sex-specific data from 15 cancer sites. Representativeness was evaluated by testing for differences in trends and levels between the data from the U.S. population and those from the SEER Program. RESULTS: Data from the SEER regions reflected the correct direction of trend for all sites, although some race-, sex-, and site-specific differences existed for the magnitude of the trends and levels of mortality when compared with data from the U.S. population. CONCLUSIONS: The demonstration that data from the SEER population do occasionally yield mortality rates that differ from those for the entire U.S. population suggests that data from the SEER coverage population are, in some cases, not representative of the greater U.S. population. IMPLICATIONS: This issue is of particular relevance to the interpretation of incidence measures, computed from the SEER data, for which there is no national database. Future efforts should be directed at a better understanding of how the SEER population differs from the U.S. population so that SEER rates can be adjusted to be more nationally representative.

Rise in prostatic cancer incidence associated with increased use of transurethral resection.

We examined the association between prostatic cancer incidence rates and the rates of transurethral prostatectomy to explore reasons for the nationally reported dramatic increases in incidence rates of prostatic cancer from 1973 through 1986. There was a strong correlation between both incidence of all stages of prostatic cancer combined and of localized disease and the increasing use of transurethral resection, a common surgical procedure usually performed to relieve urinary obstruction due to benign enlargement of the prostate. Our analyses suggest that increased detection of existing tumors via transurethral resection was the primary reason for the observed increase in incidence rates of prostatic cancer. However, analyses of mortality trends, particularly among nonwhites, and laboratory studies of the histologic nature of clinically asymptomatic tumors suggest that part of the increase may reflect changes in the real risk of prostatic cancer.

Cancer trends in a population at risk of acquired immunodeficiency syndrome.

Recent case reports have suggested that the acquired immunodeficiency syndrome (AIDS) may be associated with cancers other than Kaposi's sarcoma (KS). We have used the population-based registries of the Surveillance, Epidemiology, and End Results (SEER) Program to examine these relationships on a statistical basis by comparing the morbidity odds ratio (OR) and 95% confidence interval (CI) for specific cancer sites in pre- and post-AIDS time periods. Among never-married 20- to 49-year-old men, a surrogate group representing homosexual men, significant increases in the morbidity OR's for KS between 1973-80 and 1981-82 were apparent in the San Francisco standard metropolitan statistical area (OR: 51.8; CI: 18.6-143.6) and in other areas covered by the SEER Program (OR: 18.6; CI: 2.2-154.5). Furthermore, a significant increase was found in the morbidity OR for Burkitt-like lymphoma in the San Francisco metropolitan area (OR: 9.1; CI: 1.8-45.6). In San Francisco County (which includes the City of San Francisco), there was a 2,043-fold increase in the morbidity OR for KS and a fivefold increase for Burkitt-like lymphomas, but there were no significant changes for other cancers between 1973-79 and 1982. Similarly, no significant changes in morbidity OR's were observed for other cancers in the remaining SEER registries. These findings provided statistical support for the excess risk of Burkitt-like lymphoma in a group at risk of AIDS.

Projections of the incidence of non-Hodgkin's lymphoma related to acquired immunodeficiency syndrome.

Advances in antiretroviral therapy and treatment or prophylaxis against opportunistic infection have resulted in prolongation of the survival of patients with acquired immunodeficiency syndrome (AIDS). Previous research has demonstrated an association between AIDS and risk of non-Hodgkin's lymphoma (NHL). In addition to the approximately 3% of individuals found to have NHL at the time of AIDS onset, others continue to develop NHL following AIDS diagnosis. Data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute demonstrated a sharply increasing incidence of NHL among men in the age range 20-49 years since 1983 in the United States. Based on new data on the risk of NHL following AIDS diagnosis, on estimates of improved survival following AIDS diagnosis, and on projections of future AIDS incidence, we considered four sets of assumptions and estimated the number of AIDS-related NHL cases in 1992 to be between 2900 and 9800. Three of these projections were higher than the estimate of 4700 cases obtained by linear extrapolation of SEER incidence trends. These projections of AIDS-related NHL incidence suggest that between 8% and 27% of all NHL cases that occur in the United States in 1992 will arise as a consequence of infection with the human immunodeficiency virus (HIV), imposing a substantial health care burden. More research into the pathogenesis of lymphoma and new approaches to antiretroviral and antilymphoma therapy will be necessary to prevent and treat this formidable complication of infection with HIV.

Cancer incidence and mortality trends among whites in the United States, 1947-84.

Cancer incidence trends from the late 1940s to 1983-84 were assessed among white residents of five geographic areas (Atlanta, Connecticut, Detroit, Iowa, San Francisco-Oakland) by means of data derived from several National Cancer Institute surveys, the Connecticut Tumor Registry, and the Surveillance, Epidemiology, and End Results Program. Incidence trends were compared with mortality trends for the entire United States and for the same five study areas. This study documented rising incidence and mortality rates for four cancers: lung cancer, melanoma of the skin, multiple myeloma, and non-Hodgkin's lymphomas. Increases in lung cancer continued through the early 1980s, but the rate of increase has been moderating during recent years, particularly among males and at younger ages for whom recent declines are evident. Overall, lung cancer incidence rates increased more than 220 and 400% among males and females, respectively. Although much rarer than lung cancer, melanoma of the skin and multiple myeloma increased greatly until the early 1980s among both males and females. The overall rate of increase in melanoma incidence among males was greater than that for lung cancer, and the rate of increase in multiple myeloma mortality among females was exceeded only by that for lung cancer. Increases of 70-120% were observed for non-Hodgkin's lymphomas. Increases in incidence and mortality rates for pancreatic cancer were apparent during the early years but less conspicuous in recent years. Laryngeal and kidney cancer rates generally increased substantially, although the changes were not remarkable for laryngeal cancer mortality among males and kidney cancer mortality among females. The rates for cancers of the mouth and pharynx increased among females but not males. Prostate, colon, and bladder cancer incidence rates increased more than 65% among males, whereas mortality rates changed only moderately. The incidence of thyroid cancer increased more than 75% among both sexes until the late 1970s, but mortality rates have declined during the period of study. Breast cancer incidence increased 30%, whereas mortality rates remained remarkably constant. The incidence of corpus uteri cancer increased dramatically during the mid-1970s and decreased substantially thereafter; these changes were not reflected in the mortality rates, which continually declined during the entire time period. The incidence of testicular cancer increased more than 90% and that of Hodgkin's disease did not change greatly; however, mortality rates for both cancers declined more than 50% since the late 1960s and early 1970s.(ABSTRACT TRUNCATED AT 400 WORDS)

Improving question wording in surveys of culturally diverse populations.

PURPOSE: The purpose of this paper is to briefly describe a theoretical model articulating cognitive theory and sources of potential response bias resulting from racial or ethnic cultural experience to survey questions that deal with health behavior. The theory components are then evaluated using questions obtained from national health surveys conducted by the National Center for Health Statistics and Centers for Disease Control and Prevention. The analysis explores the effects of four cognitive tasks involved in responding to questions as specified by the model: question interpretation, information retrieval from memory, judgment formation, and response editing. Implications for epidemiological research are considered. METHODS: Data were collected from a purposive sample of 423 adults aged 18 through 50 who were recruited to ensure equal numbers of African American, Puerto Rican, Mexican American, and non-Hispanic white respondents, stratified by age, gender, and education. Individual questions were selected for evaluation to ensure variation by topic and question format. Probes related to each of the cognitive tasks were designed to obtain insight into the underlying cognitive processes used by respondents to answer survey questions. All statistical analyses used logistic regression or ordinary least squares multiple regression as appropriate. RESULTS: Variation by race/ethnicity was found in the way respondents defined physical activity in a series of questions used in the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System (BRFSS). Gender and race/ethnicity appeared to influence interpretation in the absence of specific cues in the question format about how to respond. Strategies used to retrieve information from memory did not appear to be influenced by respondent culture; however, frequency of the event was associated with the recall strategy in that more frequent or regular events were more likely to result in estimates about frequency, whereas unusual or seldom occurring events were counted. Effects of race/ethnicity on judgment formation seem to be reflected in the propensity of respondents' willingness to use extreme response categories. Most effects due to race/ethnicity were found in respondent editing of answers. Race/ethnicity was found to be associated with a social desirability trait; with willingness to disclose socially undesirable behavior, particularly to interviews from racial or ethnic groups that differed from the respondent; and with the tendency to overreport socially desirable behavior. CONCLUSIONS: Overall, the results of this research suggest several ways in which the validity of questions about risk behavior can be improved. In designing such questions, the investigator should envision the interview as a structured conversation in which ordinary conversational norms apply. Thus, questions that might request redundant information or that are threatening to the respondent need to be asked in ways that minimize these effects. Using interviewers of the same racial or ethnic group is important. Attending to the order of questions to ensure that redundant information is not requested is important. Writing questions to ensure that where response cues occur they lead the respondent to answer in unbiased ways is also important. Testing questions for potential racial or ethnic bias before using them is also important, even if the questions have been used successfully with population groups other than that or those included in a study.

The incidence of retinoblastoma in the United States: 1974 through 1985.

We have estimated the incidence of retinoblastoma in the United States from data available form the Surveillance, Epidemiology, and End Results program of the National Cancer Institute, Bethesda, Md (1974 through 1985). The larger number of cases available (220) compared with those of previous US population-based studies enabled us to evaluate change in incidence over time and to more precisely estimate incidence according to various demographic characteristics. The incidence of retinoblastoma has been almost uniform form 1974 to 1985. The average annual incidence of retinoblastoma was 5.8 per million for children younger than 10 years and 10.9 per million for children younger than 5 years. There was no difference in the incidence of retinoblastoma by either sex or race. The overall 5-year cumulative survival rate was 91% (95% confidence interval, 87% to 95%). The data indicate a worsening survival with increasing age at diagnosis, through age 2 years, but a less clear relationship of survival with diagnosis beyond age 2 years.

Estimating cancer mortality rates from SEER incidence and survival data.

A method to estimate site-specific cancer mortality rates using Surveillance, Epidemiology, and End Results (SEER) Program incidence and survival data is proposed, calculated, and validated. This measure, the life table-derived mortality rate (LTM), is the sum of the product of the probability of being alive at the beginning of an interval times the probability of dying of the cancer of interest during the interval times the annual age-adjusted incidence rate for each year that data have been collected. When the LTM is compared to death certificate mortality rates (DCM) for organ sites with no known misclassification problems, the LTM was within 10 percent of the death certificate rates for 13 of 14 organ sites. In the sites that have problems with the death certificate rates, there were major disagreements between the LTM and DCM. The LTM was systematically lower than the DCM for sites if there was overreporting on the death certificates, and the LTM was higher than the DCM for sites if there was underreporting. The limitations and applications of the LTM are detailed.

Uterine cancers of unspecified origin--a reassessment.

Uterine cancer ranks third in cancer incidence and fifth in cancer mortality among American women. The epidemiologic characteristics of cancer of the cervix uteri and the corpus uteri are different. When only "cancer of the uterus, not otherwise specified (NOS)" is reported, problems arise in data analysis. In this study, uterine cancer deaths from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program, 1977-79, are compared with those from three previous studies. Uterine cancer deaths certified only as uterus, NOS, on death certificates have decreased 34 percent in the past 30 years. However, even in the late seventies, 25 percent of the uterine cancer deaths were still not being specified as either cervix uteri or corpus uteri on death certificates. Following the deaths certified as cancer of uterus, NOS, back to the pertinent hospital records showed that in recent years 75 percent of these deaths were actually diagnosed as cancer of the corpus uteri, compared with 20 percent 30 years ago. The failure to assign these unspecified uterine cancers to corpus uteri indicates that mortality from cancer of the corpus uteri is still underreported. Although the reporting of the specific subsites of cancer of the uterus on death certificates has improved during the past 30 years, every effort should be made to achieve further improvement in accuracy.

Current status of prostate cancer in North American black males.

The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program is used to examine the most recent data available to draw inferences about black and white males in the United States with prostate cancer. Findings include a continuing rise in the incidence of prostate cancer which, as of 1985 SEER data, is 50% higher in the black male population than in white males. With the exception of minor fluctuations over the last 17 years, the mortality rate for black males demonstrates an upward trend. Combining all stages and ages, the survival rate for black males is 10% poorer than for white males. These data provide a glimpse into the problem of prostatic carcinoma in the United States today. To develop preventive strategies and cancer control interventions, a fuller understanding of the nature of the disease and its biologic course is necessary. Epidemiologic questions concerning socioeconomic status among and within racial groups, lifestyles, and behaviors that affect health seeking and diagnosis and treatment of prostatic cancer must be answered. By examining SEER data for prostatic cancer, we update the current status of this disease in North American blacks and infer possible directions for future epidemiologic surveys and cancer control intervention research.

Who in America is trying to lose weight?

OBJECTIVES: To describe the characteristics and weight-loss methods of persons who are trying to lose weight; to compare the knowledges and practices regarding weight loss between those persons trying to lose weight and those not trying to lose weight; and to evaluate trends in these knowledges and practices between 1985 and 1990. DESIGN: Large (approximately 120,000 persons per year), nationally representative random sample of the U.S. population. SETTING: The 1985 and 1990 Health Promotion Disease Prevention Current Health Topics Supplements to the National Health Interview Survey. PARTICIPANTS: Random sample of the U.S. population. MEASUREMENTS: Proportions of the NHIS sample with characteristics of interest weighted to be representative of the U.S. population. RESULTS: Approximately 44 million persons 25 years or older were trying to lose weight in 1990; 61.8% of men and 59.6% of women were doing so by increasing their physical activity. Both proportions are significantly increased compared to the 1985 proportions of 56.9% and 56.2%, respectively. Twenty-seven percent of those persons who saw themselves as overweight were not trying to lose weight. CONCLUSIONS: More than one third of Americans see themselves as overweight, but fewer than two thirds of these persons are trying to lose weight. About 4% of self-perceived underweight persons and 11.4% of persons who think their weight was about right are also trying to lose weight. Most persons who are trying to lose weight are doing so by eating less, by increasing their physical activity, or by a combination of these methods.

Population-based estimate of survival and determinants of prognosis in patients with mycosis fungoides.

Mycosis fungoides is the most common cutaneous lymphoma in the US, and it is increasing rapidly in both incidence and mortality. Our knowledge of its prognosis derives primarily from case series, which are subject to possible selection bias and other limitations. The current analysis examines trends in survival and prognostic factors in data from nine population-based cancer registries in the US. Among the 650 cases followed with known dates of diagnosis and no history of prior malignancy, the median survival time was 7.8 years. Advanced age, black race, prior malignancy, and Sezary syndrome presence at the time of diagnosis were each independently associated with poor prognosis. Fatality was not influenced by sex or geographic area. There was no consistent evidence of improved survival with time over the 12-year study period.