Trends in reported incidence of primary malignant brain tumors in children in the United States.

BACKGROUND: The reported incidence of primary malignant brain tumors among children in the United States increased by 35% during the period from 1973 through 1994. The purpose of our study was twofold: 1) to determine whether the reported incidence rates for this period are better represented by a linear increase over the entire period ("linear model") or, alternatively, by a step function, with a lower rate in the years preceding 1984-1985 and a constant higher rate afterward ("jump model"); and 2) to identify the specific brain regions and histologic subtypes that have increased in incidence. METHODS: Incidence data from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute for the period from 1973 through 1994 for primary malignant brain tumors in children were used to model the number of cases in a year as a random variable from a Poisson distribution by use of either a linear model or a jump model. RESULTS/CONCLUSIONS: The increase in reported incidence of childhood primary malignant brain tumors is best explained by the jump model, with a step increase in incidence occurring in the mid-1980s. The brain stem and the cerebrum are the primary sites for which an increase in tumor incidence has been reported. The increase in reported incidence of low-grade gliomas in the cerebrum and the brain stem (unaccompanied by an increase in mortality for these sites) supports the substantial contribution of low-grade gliomas to the overall increase in reported incidence for childhood brain tumors. IMPLICATIONS: The significantly better fit of the data to a jump model supports the hypothesis that the observed increase in incidence somehow resulted from changes in detection and/or reporting of childhood primary malignant brain tumors during the mid-1980s.

Temporal patterns in colorectal cancer incidence, survival, and mortality from 1950 through 1990.

BACKGROUND: Colorectal cancer mortality rates among U.S. white males remained relatively constant from 1950 through 1984 but declined sharply from 1985 through 1990. Those for U.S. white females decreased consistently from 1950 through 1984, with an acceleration of the decline from 1985 through 1990. PURPOSE: A study was planned to investigate patterns in incidence, survival, and mortality rates over time in order to examine possible reasons for the gender difference in mortality trends and for the decrease in the slope of the mortality trends for both males and females in the late 1980s. METHODS: Incidence and survival data from the Connecticut Cancer Registry were examined to investigate the gender differences in mortality rates from 1950 through 1984. Incidence and survival data from the Surveillance, Epidemiology, and End Results (SEER) Program were investigated to examine reasons for the abrupt downturn in mortality rates for both white males and white females beginning around 1985. RESULTS: During the period 1950 through 1984, the colorectal cancer incidence rates in Connecticut increased for males and declined slightly for females. Survival rates were similar for both sexes, increasing on average over 1% per year for both females and males from 1950 through 1984. Examination of SEER data from 1975 through 1990 revealed that for both males and females there were 1) declines in overall incidence and mortality rates beginning in the mid-1980s, 2) steady declines in distant disease incidence rates since 1975, 3) increases in regional disease incidence rates until the early 1980s followed by declines in the late 1980s, and 4) increases in local disease incidence rates until the mid-1980s followed by declines in the late 1980s. Age-period-cohort analyses of mortality rates indicated a statistically significant moderation of colorectal cancer risk with both advancing birth cohorts and recent calendar periods. CONCLUSIONS: The gender differences in colorectal cancer mortality rate trends observed from 1950 through 1984 are due to differences in incidence rate trends between males and females. Declining colorectal mortality rates in the late 1980s for males and females appear to reflect improved early detection. The peaking and subsequent decline of stage-specific incidence rates at later years for successively lower stage indicate sequential stage shifts as cancers are detected increasingly earlier over time. The increased use of sigmoidoscopy and fecal occult blood tests (triggering colonoscopy) appears to have played an important role in reducing colorectal cancer mortality. Improvements in birth cohort trends in risk for colorectal cancer for each sex suggest that lifestyle changes may have also contributed to the steady reductions in colorectal cancer mortality.

Cancer surveillance series: recent trends in childhood cancer incidence and mortality in the United States.

BACKGROUND: Public concern about possible increases in childhood cancer incidence in the United States led us to examine recent incidence and mortality patterns. METHODS: Cancers diagnosed in 14540 children under age 15 years from 1975 through 1995 and reported to nine population-based registries in the National Cancer Institute's Surveillance, Epidemiology, and End Results Program were investigated. Age-adjusted incidence was analyzed according to anatomic site and histologic categories of the International Classification of Childhood Cancer. Age-adjusted U.S. mortality rates were calculated. Trends in rates were evaluated by use of standard regression methods. RESULTS: A modest rise in the incidence of leukemia, the most common childhood cancer, was largely due to an abrupt increase from 1983 to 1984; rates have decreased slightly since 1989. For brain and other central nervous system (CNS) cancers, incidence rose modestly, although statistically significantly (two-sided P = .020), largely from 1983 through 1986. A few rare childhood cancers demonstrated upward trends (e.g., the 40% of skin cancers designated as dermatofibrosarcomas, adrenal neuroblastomas, and retinoblastomas, the latter two in infants only). In contrast, incidence decreased modestly but statistically significantly for Hodgkin's disease (two-sided P = .037). Mortality rates declined steadily for all major childhood cancer categories, although less rapidly for brain/CNS cancers. CONCLUSIONS: There was no substantial change in incidence for the major pediatric cancers, and rates have remained relatively stable since the mid-1980s. The modest increases that were observed for brain/CNS cancers, leukemia, and infant neuroblastoma were confined to the mid-1980s. The patterns suggest that the increases likely reflected diagnostic improvements or reporting changes. Dramatic declines in childhood cancer mortality represent treatment-related improvements in survival.

Cancer surveillance series: interpreting trends in prostate cancer--part I: Evidence of the effects of screening in recent prostate cancer incidence, mortality, and survival rates.

BACKGROUND: The prostate-specific antigen test was approved by the U.S. Food and Drug Administration in 1986 to monitor the disease status in patients with prostate cancer and, in 1994, to aid in prostate cancer detection. However, after 1986, the test was performed on many men who had not been previously diagnosed with prostate cancer, apparently resulting in the diagnosis of a substantial number of early tumors. Our purpose is to provide insight into the effect of screening on prostate cancer rates. Detailed data are presented for whites because the size of the population allows for calculating statistically reliable rates; however, similar overall trends are seen for African-Americans and other races. METHODS: Prostate cancer incidence data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program and mortality data from the National Center for Health Statistics were analyzed. RESULTS/CONCLUSIONS: The following findings are consistent with a screening effect: 1) the recent decrease since 1991 in the incidence of distant stage disease, after not having been perturbed by screening; 2) the decline in the incidence of earlier stage disease beginning the following year (i.e., 1992); 3) the recent increases and decreases in prostate cancer incidence and mortality by age that appear to indicate a calendar period effect; and 4) trends in the incidence of distant stage disease by tumor grade and trends in the survival of patients with distant stage disease by calendar year that provide suggestive evidence of the tendency of screening to detect slower growing tumors. IMPLICATIONS: The decline in the incidence of distant stage disease holds the promise that testing for prostate-specific antigen may lead to a sustained decline in prostate cancer mortality. However, population data are complex, and it is difficult to confidently attribute relatively small changes in mortality to any one cause.

Cancer surveillance series [corrected]: brain and other central nervous system cancers: recent trends in incidence and mortality.

BACKGROUND: During the 1980s, the incidence of primary malignant brain and other central nervous system tumors (hereafter called brain cancer) was reported to be increasing among all age groups in the United States, while mortality was declining for persons younger than 65 years. We analyzed these data to provide updates on incidence and mortality trends for brain cancer in the United States and to examine these patterns in search of their causes. METHODS: Data on incidence, overall and according to histology and anatomic site, and on relative survival were obtained from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute for 1975 through 1995. Mortality data were obtained from the National Center for Health Statistics. Medicare procedure claims from the National Cancer Institute's SEER-Medicare database were used for imaging trends. Statistically significant changes in incidence trends were identified, and annual percent changes were computed for log linear models. RESULTS/CONCLUSIONS: Rates stabilized for all age groups during the most recent period for which SEER data were available, except for the group containing individuals 85 years of age or older. Mortality trends continued to decline for the younger age groups, and the steep increases in mortality seen in the past for the elderly slowed substantially. Patterns differed by age group according to the site and grade of tumors between younger and older patients. During the last decade, use of computed tomography scans was relatively stable for those 65-74 years old but increased among those 85 years old or older. IMPLICATIONS: Improvements in diagnosis and changes in the diagnosis and treatment of elderly patients provide likely explanations for the observed patterns in brain cancer trends.

Recent trends in U.S. breast cancer incidence, survival, and mortality rates.

BACKGROUND: Clinical trials have demonstrated that use of mammographic screening and advances in therapy can improve prognosis for women with breast cancer. PURPOSE: We determined the trends in breast cancer mortality rates, as well as incidence and survival rates by extent of disease at diagnosis, for white women in the United States and considered whether these trends are consistent with widespread use of such beneficial medical interventions. METHODS: We examined mortality data from the National Center for Health Statistics and incidence and survival data by extent of disease from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute, all stratified by patient age, using statistical-regression techniques to determine changes in the slope of trends over time. RESULTS: The age-adjusted breast cancer mortality rate for U.S. white females dropped 6.8% from 1989 through 1993. A significant decrease in the slope of the mortality trend of approximately 2% per year was observed in every decade of age from 40 to 79 years of age. Trends in incidence rates were also similar among these age groups: localized disease rates increased rapidly from 1982 through 1987 and stabilized or increased more slowly thereafter; regional disease rates decreased after 1987; and distant disease rates have remained level over the past 20 years. Three-year relative survival rates increased steadily and significantly for both localized and regional disease from 1980 through 1989 in all ages, with no evidence of an increase in slope in the late 1980s. IMPLICATIONS: The decrease in the diagnosis of regional disease in the late 1980s in women over the age of 40 years likely reflects the increased use of mammography earlier in the 1980s. The increase in survival rates, particularly for regional disease, likely reflects improvements in systemic adjuvant therapy. Statistical modeling indicates that the recent drop in breast cancer mortality is too rapid to be explained only by the increased use of mammography; likewise, there has been no equivalent dramatic increase in survival rates that would implicate therapy alone. Thus, indications are that both are involved in the recent rapid decline in breast cancer mortality rates in the United States.

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.

Annual report to the nation on the status of cancer, 1973-1996, with a special section on lung cancer and tobacco smoking.

BACKGROUND: The American Cancer Society, the National Cancer Institute (NCI), and the Centers for Disease Control and Prevention (CDC), including the National Center for Health Statistics (NCHS), provide the second annual report to the nation on progress in cancer prevention and control, with a special section on lung cancer and tobacco smoking. METHODS: Age-adjusted rates (using the 1970 U.S. standard population) were based on cancer incidence data from NCI and underlying cause of death data compiled by NCHS. The prevalence of tobacco use was derived from CDC surveys. Reported P values are two-sided. RESULTS: From 1990 through 1996, cancer incidence (-0.9% per year; P = .16) and cancer death (-0.6% per year; P = .001) rates for all sites combined decreased. Among the 10 leading cancer incidence sites, statistically significant decreases in incidence rates were seen in males for leukemia and cancers of the lung, colon/rectum, urinary bladder, and oral cavity and pharynx. Except for lung cancer, incidence rates for these cancers also declined in females. Among the 10 leading cancer mortality sites, statistically significant decreases in cancer death rates were seen for cancers of the male lung, female breast, the prostate, male pancreas, and male brain and, for both sexes, cancers of the colon/rectum and stomach. Age-specific analyses of lung cancer revealed that rates in males first declined at younger ages and then for each older age group successively over time; rates in females appeared to be in the early stages of following the same pattern, with rates decreasing for women aged 40-59 years. CONCLUSIONS: The declines in cancer incidence and death rates, particularly for lung cancer, are encouraging. However, unless recent upward trends in smoking among adolescents can be reversed, the lung cancer rates that are currently declining in the United States may rise again.

Long-term cancer patient survival in the United States.

Although survival rates are useful for monitoring progress in the early detection and treatment of cancer and are of particular interest to patients with new diagnoses, there are limited population-based estimates of long-term survival rates. We used data collected by the Surveillance, Epidemiology, and End Results Program for cases diagnosed during 1974-1991 and followed through 1992 to estimate relative survival at 5, 10, and 15 years after diagnosis of cancer of the breast, prostate, colon and rectum, and lung. Relative survival after diagnosis of breast and prostate cancer continued to decline up through 15 years after diagnosis, whereas survival after diagnosis of lung and colon or rectal cancer remained approximately constant after 5 and 10 years, respectively. Age-specific patterns of survival varied by site, stage, and demographics. Among patients with localized breast and prostate cancer, women who were younger than age 45 at breast cancer diagnosis and men who were 75 years and older at prostate cancer diagnosis had the poorest relative survival. Relative survival among lung cancer patients decreased with age at diagnosis, regardless of stage or demographics, and age-specific patterns of relative survival for patients with cancer of the colon and rectum differed according to race. Among white patients diagnosed with cancers of the colon and rectum, relative survival did not vary by age at diagnosis; among black patients older than 45 at diagnosis, relative survival decreased with age. This study provides population-based estimates of long-term survival and confirms black/white, male/female, and stage- and age-specific differences for the major cancers.

Aging and cancer in America. Demographic and epidemiologic perspectives.

It has been stated in this article and elsewhere that cancer patients aged 65 years and older deserve special attention as a target group for research efforts across the cancer-control spectrum. The available data show that the vulnerability of older persons to cancer is unmistakable. Clinicians will be treating more older patients as the nation ages. The future needs of this segment of the population must be anticipated. In this context, the following generic treatment questions are pertinent. What are the peculiarities of the aged host of which clinicians must be aware in evaluating the older cancer patient? Do various forms of cancer present differently in the elderly? How can be complications caused by the multiple pathologies inherent in the older patient be anticipated? What are the potential hazards and limitations of surgery, radiotherapy, and chemotherapy for older persons with cancer? What is known regarding increased risk of adverse reactions to medications, drugs, and interaction of drugs in older patients? The surveillance data and population estimates and projections presented in this article illustrate the extent of the problems of cancer in the elderly at the macro level. For the individual patient, the special knowledge of aging individuals and their health status based on geriatric medicine and gerontology that has been accumulating for the past several decades needs to be incorporated into the oncology armamentarium that has developed during the same period. The information and expertise from both fields must converge, and new knowledge must be developed at the aging/cancer interface and applied for the optimal treatment of cancer in the elderly.

A comparison of population-based cancer incidence rates in Israel and Jordan.

Reliable information about comparative cancer incidence in the Middle East has been lacking. The Middle East Cancer Consortium (MECC) has formed a network of population-based registries with standardized basic data. Here the age-adjusted cancer incidences are compared for four populations: Israeli Jews, Israeli non-Jews, Jordanians and the US Surveillance Epidemiology and End Results (SEER) population, for the years 1996-1997 (Israel) and 1996-1998 (other populations). The all-sites rate of cancer is approximately twice as high in Israeli Jews and SEER, compared with Israeli non-Jews and Jordanians. Rates of lung cancer are similar among Israeli Jews and non-Jews and about twice as high as in Jordanians. Childhood leukaemia rates in Jordan are higher than in Israeli Jews, but lower than SEER. Hodgkin lymphoma rates in Israeli non-Jews and Jordanians are similar to SEER, but non-Hodgkin lymphoma rates are lower than SEER. The previous suspicion of higher overall leukaemia and lymphoma rates in Jordan is thus not confirmed.

Influence of extent of disease, histology, and demographic factors on lung cancer survival in the SEER population-based data.

Rates calculated from the Surveillance, Epidemiology, and End Results (SEER) Program are used to show variations in lung cancer survival by prognostic factors with an emphasis on the extent of disease and demographic variables. The analysis is based on 52,755 histologically confirmed cases of invasive lung cancer diagnosed from 1983 through 1987 and 51,377 cases diagnosed from 1977 through 1982. Females survived better than males. In general, white patients survived better than blacks. However, if both race and sex are considered together, black females survived better than white males and white females had the highest rates and black males the lowest. Age, however, proved to be the strongest predictor of survival of the demographic variables. Young females (< 45 years) with non-small cell lung cancer had an 81% 5-year relative survival rate compared to 44% for those 75 years and over. Survival for small cell lung cancer was lower than that for any other histologic type even when stratified on stage of disease (stages I and II, all stages). Survival for stages III and IV did not vary by histologic type. The histologic grade showed prognostic value only for patients assigned stage I. More detailed extent of disease information was used to show how often specific sites of distant metastases are seen at diagnosis. It also demonstrated the inter-relationship of the different extent of disease variables and their effect on outcome.

Ovarian cancer. Survival and treatment differences by age.

BACKGROUND: Cancer of the ovary is a disease of older American women with an incidence rate of 9.4 per 100,000 for those under 65 compared to 54.8 per 100,000 for those 65 years of age and over. METHODS: Over 22,000 women were diagnosed with ovarian cancer between 1973 and 1987 within the Surveillance, Epidemiology and End Results (SEER) Program of the National Cancer Institute. SEER is a population-based program that covers nearly 10% of the U.S. population for cancer incidence and survival. RESULTS: Ovarian cancer survival rates vary dramatically by stage. Within stage, however, differences are noted in survival by age, with younger women surviving better than older women even after adjustment for the general life expectancy of each age group (relative survival). For Stages III-IV disease, women under 45 years of age have a 5-year relative survival rate of over 45% compared to only 8% for those 85 years of age and over. Between 1973-1977 and 1983-1987, the treatment for Stages III-IV disease has changed. For all age groups, there were sharp increases in the percentage having surgery and chemotherapy/hormonal therapy and decreases in those having surgery and radiation as part of the first course of therapy. Over 40% of women 85 years of age and over did not receive any definitive treatment according to the hospital medical record. In 1983-1987, younger women received more combination therapy (surgery with chemotherapy/hormonal therapy) versus older women who received more single modalities such as surgery only or chemotherapy/hormonal therapy only. CONCLUSIONS: Older women with ovarian cancer are treated less aggressively than their younger counterparts and have poorer survival rates.

Progress in early breast cancer detection.

Evidence indicates progress in the early detection of breast cancer. After 1982 there was a reported increase in the incidence of breast cancer, presumably as a result of increased screening for the disease. The increase was especially noted in early stage breast cancer. The incidence of in situ cases also increased. Since 1973 the San Francisco-Oakland Bay area has reported a statistically significant decrease in mortality for white women. The evidence supports continued efforts at early breast cancer detection.

On the estimation of survival.

The advantages and disadvantages of the different methods for calculating survival according to the TNM (Topography, Lymph Node, and Metastasis) are described. Methods include the observed, relative, and conditional survival rates. For large cohorts, relative survival calculated by the life table method is most useful. Conditional survival, which requires long-term follow-up, is clinically the most informative. In addition, follow-up methods employed by tumor registries are considered.

Cancer in older persons. Magnitude of the problem--how do we apply what we know?

The elderly experience the major impact of cancer. The incidence rate for those aged 65 and older is 2085.3 per 100,000 as compared with 193.9 per 100,000 for those younger than 65. Overall, 58% of all cancer incidence is in the older segment of the population. Cancer mortality in the elderly now accounts for 67% of all cancer deaths. Data from the National Cancer Institute Surveillance, Epidemiology, and End Results program for 1985-1989 reveal many salient facts. Older persons have a risk of developing cancer 10 times greater than that for individuals younger than 65. This paper outlines the magnitude of the major cancers that affect the elderly. Incidence and mortality data are presented according to individual tumors (colon, rectum, lung/bronchus, pancreas, stomach, urinary bladder, breast, ovary, and prostate). Demographic data from the U.S. Bureau of the Census focus on the expanding elderly population in the United States and projections for the future. Needs for cancer care and treatment for the elderly, already great, are likely to increase. It is imperative that older persons receive special attention for cancer prevention, early diagnosis, and treatment efforts, especially because there is almost always an overlay of other chronic diseases and age-associated declines concurrent with the diagnosis of cancer in the elderly. This paper highlights issues unique to older persons as individuals at high risk for cancer and suggests research strategies that should be made in anticipation of the even greater cancer burden for the elderly as this subset of the population expands.