Annual report to the nation on the status of cancer (1973 through 1998), featuring cancers with recent increasing trends.

BACKGROUND: The American Cancer Society, the National Cancer Institute (NCI), the North American Association of Central Cancer Registries, and the Centers for Disease Control and Prevention, including the National Center for Health Statistics (NCHS), collaborate to provide an annual update on cancer occurrence and trends in the United States. This year's report contains a special feature that focuses on cancers with recent increasing trends. METHODS: From 1992 through 1998, age-adjusted rates and annual percent changes are calculated for cancer incidence and underlying cause of death with the use of NCI incidence and NCHS mortality data. Joinpoint analysis, a model of joined line segments, is used to examine long-term trends for the four most common cancers and for those cancers with recent increasing trends in incidence or mortality. Statistically significant findings are based on a P value of.05 by use of a two-sided test. State-specific incidence and death rates for 1994 through 1998 are reported for major cancers. RESULTS: From 1992 through 1998, total cancer death rates declined in males and females, while cancer incidence rates declined only in males. Incidence rates in females increased slightly, largely because of breast cancer increases that occurred in some older age groups, possibly as a result of increased early detection. Female lung cancer mortality, a major cause of death in women, continued to increase but more slowly than in earlier years. In addition, the incidence or mortality rate increased in 10 other sites, accounting for about 13% of total cancer incidence and mortality in the United States. CONCLUSIONS: Overall cancer incidence and death rates continued to decline in the United States. Future progress will require sustained improvements in cancer prevention, screening, and treatment.

A systematic consideration of the neoplastic spectrum of AIDS: registry linkage in Illinois.

To examine unexplored aspects of the association between AIDS and neoplasia, the Illinois AIDS and Cancer Registries were linked. The method integrated use of a personal computer to find exact matches on names and dates of birth with manual review to assure satisfaction of a match definition. Of the factors examined, white race and homosexuality predicted Kaposi's sarcoma (KS) among people with AIDS (PWAs), and white race predicted non-Hodgkin's lymphoma (NHL). Earlier reports of a declining proportion of PWAs with KS were confirmed. Lymphoma (mixed lymphocytic/histiocytic type), while not currently diagnostic of AIDS, occurred more frequently among PWAs than in the Illinois population. For the first time, rates of cancers other than KS and NHL were demonstrated to be significantly increased among PWAs compared with general populations. In the light of these findings, reconsideration of current neoplastic definitions may be useful.

Case-control studies of cancer in Illinois farmers using data from the Illinois State Cancer Registry and the U.S. Census of Agriculture.

A series of case-control studies have been carried out to compare farmers reported to the Illinois State Cancer Registry (ISCR) with other males reported to the ISCR between 1986 and 1988. Data on the number of farms in each Illinois county producing given agricultural commodities were obtained from the United States Census of Agriculture and used as surrogate exposure indicators. Employment as a farmer was found to be associated with cancer of the eye [odds ratio (OR) = 6.49, 95% confidence interval (CI) = 1.78, 23.71], lip (OR = 4.42, 95% CI = 2.46, 7.94), prostate (OR = 1.15, 95% CI = 0.99, 1.35) and leukaemia (OR = 1.51, 95% CI = 1.01, 2.25). Wheat and soybean production were found to be positively associated with leukaemia. Hay and beef production were found to be positively associated with cancer of the prostate.

Predicting public concern regarding toxic substances in the environment.

The purpose of this research was to identify the variables that increase concern about the health, environmental contamination, and economic consequences of toxic substances in the environment. A mail survey was sent to a New York State sample, and a 66% response was obtained. Seven indices were developed from specific concerns about toxic substances in the environment including, among others, exposure, health effects, pollution, and economic consequences. Stepwise regression analysis was conducted for each concern index. The results suggest that the number of information sources regarding environmental issues was a strong predictor of concern in nearly all models. Other variables that were repeatedly found to be important contributors to the models were years of education, attitudes about government involvement in private industry, knowledge of epidemiology and the scientific method, and the perceived proximity to sources of potential contamination. Unlike other research, women and mothers of sick children did not make large contributions to the model.

Chorionic villus sampling and transverse digital deficiencies: evidence for anatomic and gestational-age specificity of the digital deficiencies in two studies.

Several but not all studies indicate that chorionic villus sampling (CVS) is associated with an increased risk for transverse limb deficiencies, including digital deficiencies. It has been suggested that variations in results regarding the transverse digital deficiencies (TDDs) may be due to the use of different classification criteria. We present the combined analysis of two case-control studies, the U.S. Multistate CVS (US) study and the Italian Multicentric Birth Defects (IP-IMC) study, using two different definitions of TDDs. We compared the frequency of CVS exposure in control infants with that among those infants with any number of affected digits (any TDD), and those with all five digits of at least one limb affected (extensive TDDs). The estimated relative risk (RR) for any TDD following CVS was 10.6 (IPIMC) and 6.6 (US). For the extensive TDDs, the RR was 30.5 (IPIMC) and 10.7 (US). In both studies, extensive TDDs were less than 25% of all TDDs. Compared to all TDDs, extensive TDDs were more likely to occur after CVS performed earlier in the first trimester (before 10-11 weeks' gestation). These findings suggest a relationship between the timing of CVS and the severity of TDDs; indicate that using a restrictive definition of TDDs (all five digits affected) may limit the ability to evaluate the association between CVS and TDDs in populations in whom CVS is usually performed at or after 10 weeks' gestation; and highlight the necessity to consider gestational age in any evaluation of the relative risk for limb deficiencies associated with CVS.

Early abortion and breast cancer risk among women under age 40.

In New York State, incidence of cancer and fetal death are reportable health events mandated by state law. These data enabled a population-based record linkage study of the effect of early pregnancy termination on breast cancer risk to be conducted. In upstate New York 1451 cases under age 40 were reported to the Cancer Registry during 1976-1980. Cases were matched with 1451 population controls by year of birth and by residence using zip codes. All names including those changed by marriage were matched with the reports of fetal deaths occurring between 1971 and 1980. Matched pairs analyses revealed an excess of early pregnancy terminations among cases in all categories. Odds ratios (OR) were significantly elevated among those with an induced abortion (OR = 1.9) and a spontaneous abortion (OR = 1.5). Elevated risks were also noted for consecutive abortion events without intervening livebirths.

Repeat mammography among women over 50 years of age.

Mammography decreases mortality among women 50 years of age and older. Although recent surveys show that mammography use has increased since 1983, it continues to be underused by women at risk for breast cancer. The frequency of repeat screening at recommended intervals remains an important unanswered question. This record audit study included all visits from 1986 to 1988 for active female patients, 51-64 years of age, in a family medicine practice. The practice has a disproportionately black patient population, many of whom are on public assistance, characteristics associated with lower compliance with cancer screening guidelines. I reviewed medical records for a physician's recommendation for mammography and also for a radiology report documenting receipt of the mammogram. I also abstracted from the medical record the reason for mammography, a history of breast cancer risk factors, and sociodemographic information. In addition, I noted documentation of a clinical breast examination (CBE) and CBE results. Records for 150 patients were included in the analysis. The results indicate that repeat screening mammography is not common: 3% had three mammograms during the study period; 19% had two; 33% had one; and 44% had none. Physician recommendation for first-time mammography and clinical examination occurred with low frequency. As others report, mammography use is strongly associated with physician recommendation for a mammogram.

Increased risk of malignancy in patients with systemic lupus erythematosus.

BACKGROUND: Systemic lupus erythematosus is a chronic, multisystem, autoimmune disorder that primarily affects women. Morbidity and mortality have improved for lupus patients during the last 15 years. An increased risk of malignancy in patients with lupus has been shown in some, but not all studies. The purpose of this study was to ascertain cancer risk in lupus patients by linking two disease registries. METHODS: Participants in the Chicago Lupus Cohort included 616 women with lupus who were residents of Cook County, Illinois. They were seen during 1985-1995 at 4 University, inner city, and suburban inpatient and outpatient clinics in Chicago. Malignancies occurring in these subjects during the study interval, 1985-1995, were identified from the Illinois State Cancer Registry by matching name, birthdate, and social security number. Standardized incidence ratios (SIRs) were estimated for all malignancies in this cohort of lupus patients using age, gender, and all race or race-stratified specific cancer incidence data from Cook County, Illinois. RESULTS: The registry linkage study with the Illinois State Cancer Registry documented that 30 women with lupus had a malignancy. The expected number of malignancies for women in the lupus cohort was 15.0. There were 8 cases of breast cancer and 4 each of lung and cervical cancer. In the remaining 14 women, 12 different types of cancers were noted. The SIR and 95% confidence interval (CI) for malignancy for all women with lupus in the study were 2.0 (1.4, 2.9) and lung cancer was the only individual cancer increased in all women--SIR and 95% CI were 3.1 (1.3, 7.9). In the analysis stratified by race, the risk of malignancy (SIR and 95% CI) was increased in Caucasian women, 2.3 (1.4, 3.9). Breast cancer was the only individual cancer increased in Caucasian women with lupus with an SIR and 95% CI of 2.9 (1.4, 6.4). CONCLUSIONS: Lupus patients have an increased risk of malignancy. Breast, lung, and gynecological malignancies were the most common malignancies observed in the cohort and breast cancer was significantly increased in Caucasian women.

Enhancing the effectiveness of media messages promoting regular breast self-examination: messages based on innovation adoption principles.

As public health departments have come to rely more and more on the mass media for the promotion of healthful behavior, it has become increasingly desirable to determine the motivating capability of the messages used in this promotion. A fact that is well understood is that many times any message at all is better than none. However, the effectiveness of various media health messages has not been well researched.A study was therefore undertaken of the comparative effectiveness of two different messages describing how to do a breast self-examination. An "experimental message" for the study was designed by applying the principles that facilitate innovation adoption to the message's format and presentation. This message's impact was then compared with that of the American Cancer Society's pamphlet "How To Examine Your Breasts." This pamphlet had been mailed to a sample of women similar to those receiving the experimental message, but who lived in a different geographic area. The use in each area of control groups who had received no messages afforded an opportunity to study maturation effects (other factors than the mailings that might have influenced study results).The experimental message proved more successful in persuading women to adopt breast self-examination than the comparison message. The women who reported a change in breast self-examination practice following the mailing could be characterized as having a more extensive social support system to promote breast examinations and as having a pre-experiment perception that breast self-examination was a complex practice to perform repeatedly at regular intervals.

Public concern about chemicals in the environment: regional differences based on threat potential.

While the hazards of chronic environmental pollution remain unclear, people are making decisions about their exposure to pollution and its possible effects on their health. To compare people's concerns about environmental problems, a systematic, stratified sample was surveyed. The sample was made up of residents, ages 25 through 74 years, of three areas of New York State. The three areas were western New York, with a high density of toxic dump sites; Long Island, with a major shallow ground water aquifer; and the remainder of the State, excluding New York City, as a comparison area. The sampling list was obtained from records of licensed drivers of the New York State Department of Motor Vehicles. A 66 percent response rate was obtained to the mailed survey. As expected, most concerns were greater for western New York and Long Island, the two areas with highest threat potential for exposure or contamination, than for the comparison area. The single exception was that no regional differences were noted for concerns about environmental pollution and contamination. All concerns were associated with perceived distance between one's residence and a source of potential exposure. Regardless of region, women were more concerned than men about exposures, pollution, and related health effects. No sex differences, however, were noted for economic concerns.

Recency of Pap smear screening: a multivariate model.

Most descriptive reports of women who have not received recent Pap smear screening have been limited to bivariate descriptions. The purpose of this study was to develop a multivariate model to predict the recency of Pap smear screening. A systematic sample of women residents, aged 25 to 74 years, in upstate New York was selected. The women were asked to report use of Pap smear screening during several time periods, their congruence with recommended medical practice, general use of medical services, and a variety of sociodemographic indicators. A log linear weighted least squares regression model was developed, and it explained 30 percent of the variance in recency of Pap smear screening behavior. While the sociodemographic variables were important predictors in the model, the medical care variables were the strongest predictors of recent Pap smear use. A significant relationship between race and recency of Pap smear testing was not supported by these data.

Education of rural physicians about breast cancer through an oncology outreach program.

In 1990, the Rural Illinois Cancer Consortium initiated an intervention in the management of breast cancer for all rural hospitals. Regional data from a 12-county area were used to identify issues and develop an intervention emphasis. The data suggested two management issues: eliminate unilateral diagnostic mammography and increase the number of patients that have their tumor staged. The intervention involved seminars to provide feedback to physicians on management of breast cancer patients in the region. A series of personalized mailings emphasizing the intervention message were also deployed. Although data are not yet available to measure the intervention impact, immediate feedback on the interventions was sought through a physician survey and several process measures. The immediate feedback measures were assessed. These measures were the penetration of the rural hospital seminars, physician behavior self-reported by mail survey, and number of inquiries to the Physician Data Query. Each of the nine hospitals held a seminar, and 39 percent of the rural physicians treating breast cancer patients attended. Survey data showed physician behavior change in the desired direction, compared with data from the baseline medical record audit conducted in 1986-87. Intervention feedback was useful in defining the implementation success of the interventions. The outcome evaluation, based on medical record audits, is in progress.

Cancer incidence following exposure to drinking water with asbestos leachate.

In November 1985, the New York State Department of Health was altered to extraordinary concentrations of asbestos leachate in the drinking water in the Town of Woodstock. Concentrations of 3.2 million fibers per liter (MFL) to 304.5 MFL were found, depending on location. An investigation of cancer incidence in the area was conducted for the period 1973-83 using the State Cancer Registry to compute standardized incidence ratios. No evidence was found of elevated cancer incidence at sites associated with asbestos exposure. A statistically non-significant excess of kidney cancer was seen among men, but not women. Colon cancer among men was significantly low, but incidence among women was similar to that expected. Lung cancer incidence was lower than expected for both sexes. Ovarian cancer rates were not different from expected rates. At sites not previously related to asbestos exposure, cancer of the oral cavity was significantly high, with most affected persons having a history of cigarette smoking. Surveillance of the community is continuing because of an insufficient latent period for some exposed groups.

Effects of physician outreach programs on rural-urban differences in breast cancer management.

In 1986 to 1987, urban-rural differences in several breast cancer management practices were noted in Illinois data. Several intervention programs for physicians were initiated to improve rural patients' access to state-of-the-art breast cancer management to reduce these differences. This report compares an intensive rural oncology outreach intervention program with a lower intensity physician education program. Medical records from 1986 to 1991 were reviewed on 2,277 breast cancer patients in a 12-county study area. The care received by urban patients was compared with three groups of rural patients: those managed in rural hospitals with intensive oncology outreach programs beginning in 1988 (Rural group 1), and in those rural hospitals with less intensive interventions using an audit with feedback strategy beginning in 1989 (Rural group 2). Rural patients who traveled to one of the urban facilities also were included in the analysis because the less intensive interventions also took place in these facilities, and these patients showed unique patterns of care in the baseline analysis (Rural Group 3). The years 1986 to 1987 constituted the baseline, and 1990 to 1991 constituted the final evaluation period. Chi square and multivariate analyses were conducted to compare the effect of the two types of interventions on changing breast cancer management practices and reducing the urban-rural differences. By the final evaluation period, the high intensity intervention was not more successful in reducing or eliminating the urban-rural differences than the low intensity intervention for many practices. However, often the frequency estimates were higher in Rural Group 1, which received the high intensity intervention. The changes noted in Rural Group 3 were not always the same as in Rural Group 2, even though both received the same low intensity interventions, lending evidence to the observation that travel distance and other nonmedical factors affect the choices of management modalities for these patients. Finally, given the nonrandomized study design, other explanations for the changes could not be ruled out.

Age differences in the breast cancer management of rural women.

This article describes the effect of age on the pattern of access to breast cancer care among rural women diagnosed in 1986-1989. Cases were identified by the Illinois State Cancer Registry and information on breast cancer management was obtained through review of hospital records and physician survey. Case follow-back was more than 99% complete. State-of-the-art breast cancer management was defined by the Physician Data Query (PDQ) and included diagnostic evaluation, prognostic evaluation, and stage-specific definitive treatment. The data did not indicate age differences in bilateral diagnostic mammography, performance of hormone receptor assays, radiation therapy, and stage-appropriate treatment. Tumor staging and axillary node dissection did differ by age with significant negative trends in the multivariate model. Also, women younger than 55 years were the most likely to receive separate diagnostic biopsy, limited surgery, and chemotherapy, whereas women 55 to 74 years were most likely to receive hormone therapy. Although rural populations may experience barriers to some aspects of state-of-the-art breast cancer management, age does not always exacerbate them.

Physicians' attitudes toward breast self-examination: a pilot study.

Recent case control studies suggest that breast self-examination (BSE) is efficacious in the early clinical diagnosis of breast cancer. Population studies also indicate that adoption of this behavior depends largely on physicians. This pilot study was designed to determine whether physicians' attitudes on this subject could be obtained through a mail questionnaire. The results show that a self-administered mail questionnaire can be used successfully in physician studies. Although questionnaire length does affect response rates (78% one page, 69% four page, and 57% eight page), it does not affect either respondent characteristics or question response.

A comparison of actual and perceived residential proximity to toxic waste sites.

Studies of Memphis and Three Mile Island have noted a positive association between actual residential distance and public concern about exposure to the potential of contamination, whereas none was found at Love Canal. In this study, concern about environmental contamination and exposure was examined in relation to both perceived and actual proximity to a toxic waste disposal site (TWDS). It was hypothesized that perceived residential proximity would better predict concern levels that would actual residential distance. The data were abstracted from a New York State, excluding New York City, survey using all respondents (N = 317) from one county known to have a large number of TWDSs. Using linear regression, the variance explained in concern scores was 22 times higher with perceived distance than for actual distance. Perceived residential distance was a significant predictor of concern scores, while actual distance was not. However, perceived distance explained less than 5% of the variance in concern scores.

Breast self-examination palpation skill: a methodological note.

A current issue in research of breast self-examination (BSE) efficacy is the competency of BSE performance. A nonverbal method for testing two palpation skills were developed. They were designed for mail surveys, or other cost-effective methods of following up subjects in a longitudinal study design. They were also designed to avoid semantics problems associated with verbal descriptions of BSE performance, as noted in earlier research of the author. These pictorial questions were included in three mail surveys of the general female population. The data were consistent across all three surveys for both the verbal and nonverbal questions of palpation skill. The diagram index of the hand part used in BSE suggested that a higher proportion of BSE practicers are using the recommended hand part than their verbal reports would indicate. However, the data from the diagram assessing the amount of pressure used for BSE were not very different from the results of the verbal questions.

Increasing efficiency in evaluation research: the use of sequential analysis.

This paper describes Wald's sequential analysis and briefly reviews the history of its applied use. Two public health applications are presented as examples of how the method helped overcome two common problems associated with evaluation research. In one case, the sequential technique reduced dramatically the workload in an evaluation project where hospital records were being reviewed. In the second case, prompt feedback of data to a breast screening program was facilitated by the sequential method allowing program administrators to refocus their efforts on problem areas before the end of the funding period. On the average, Wald's sequential method results in a savings of 50 per cent in observations as compared to classical sampling procedures. The sample sizes will always terminate with a finite number and will rarely exceed three times the average sample size for any single sample.

Social factors associated with breast self-examination among high risk women.

A sample of 708 women, who by sociodemographic characteristics are high risk to breast cancer, were interviewed by telephone about their knowledge, attitude, and practice of breast self-examination (BSE). Reported frequency of BSE, knowledge of BSE and breast cancer, and BSE attitude in this sample are comparable to data reported by others. This report analyzes the associations between the frequency of a breast self-examination practice and the variables, age, education, detection confidence, social influence, modesty, preventive health behaviors, and memory. These relationships are discussed and several new hypotheses are proposed. Since the data were collected retrospectively, they are not able to describe causal relationships.