The Cancer Mortality Risk Project - Cancer Mortality Risks by Anatomic Site: Part 1 - Introductory Overview; Part II - Carcinoma of the Colon: 20-Year Mortality Follow-up Derived from 1973-2013 (NCI) SEER*Stat Survival Database.

This introductory overview describes the recommencement of the Cancer Mortality Risks project, a systematic medical-actuarial comparative analysis of selected cancer mortality risks originally initiated by the authors in the year 2002 utilizing the National Cancer Institute (NCI) SEER*Stat 4.2.3 (Surveillance, Epidemiology, and End Results) database between 1973 and 2002 and released April 3, 2002. This study is based on approximately 40 major invasive cancer anatomic sites used in previous conversions of the National Cancer Institute SEER survival data to comparative mortality in the Medical Risks monographs published in 19761 and 1990.2 Anatomic site-specific cancer mortality abstracts of SEER survival data containing 20-year comparative mortality follow-up by cohort entry-period, histologic type, age, sex, race, stage, grade and other variables was proposed for publication as a monograph, compendium or a series of concise but detailed mortality articles.

A brief historical sketch of the Association of Life Insurance Medical Directors of America (ALIMDA), the predecessor of the American Academy of Insurance Medicine (AAIM).

This is a brief historical sketch of ALIMDA, the name of our professional organization when it was founded at a meeting of a few medical directors in New York City in 1898. The principal source for its contents is based on recollections of my own experience with ALIMDA/AAIM since I first became a member after appointment as an Assistant Medical Director of the company then known as New England Mutual Life Insurance Company, in Boston, in 1952. I was never an officer of ALIMDA or AAIM, but I attended most of its meetings, and I was involved in our mortality research activites.

Mortality in active adults age 70-79 years in relation to performance in a long-distance corridor walk.

The authors conducted the source study to determine if a brisk corridor walk of 400 meters could be used to classify the performance of active older adults and relate this performance to mortality and other outcomes over a 6-year follow-up. The cohort consisted of 3075 adults resident in designated ZIP codes in Pittsburgh, Pa, and Memphis, Tenn, participating in the Health Aging and Body Composition Study. Out of this cohort, 395 subjects were excluded after evaluation revealed abnormal vital signs or ECG findings, recent cardiac symptoms, recent surgery, recent chest pain, shortness of breath or fainting. Another 356 subjects were unable to complete the 400-meter walk. The 2324 subjects who completed the walk were divided into quartiles according to the time in seconds required for completion (the overall time required ranged widely from 201 to 942 seconds). These 3 groups were designated as "excluded," "stopped," and "completed." Outcomes reported for the 3075 subjects in the total cohort included mortality, new cardiovascular disease events, mobility limitation, and mobility disability. Cardiovascular events were reported for the 2234 subjects (73% of the total) who were free of cardiovascular disease at entry. Results in the article were given in tables and figures and included numbers of entrants, exposures, and events, annual event rates and hazard ratios with SDs. Out of the 3075 entrant subjects, 430 died in the 6 years of follow-up (FU). Excess mortality measured as excess death rate (EDR) was much higher in the excluded and stopped groups (about 22 per 1000 per year) compared with an EDR of 6.4 per 1000 in the completed group. The corresponding mortality ratios (MR), designated as a hazard ratio in the article were about 220% and 135%. Results for comparative morbidity are also given in this abstract.

Mortality in older adults in relation to daily activity energy expenditure.

INTRODUCTION: The authors of the article forming the basis of this mortality abstract refer to past observational studies, which have shown that older subjects with limited daily activity have a higher mortality than those with greater physical activity. However, in these studies degree of activity was assessed by answers to a questionnaire. The authors of the source article utilized an isotopic method that measured total energy expediture (TEE), from which daily activity energy expenditure (DAEE) could be derived, after measurement of basal metabolic rate (BMR) and adjustment for the thermic energy of meals. The equation used for this derivation is: DAEE = 0.9TEE - BMR. METHODOLOGY: Expected 7-year survival rates were calculated from the 1989-1991 US Life Tables, and from these mean annual survival and mortality rates were derived as geometric means, for white male, white female, nonwhite male and nonwhite female cohorts, with age 75 the initial age and age 82 the terminal age. There were minor race differences but major sex differences in the race/sex distribution in each DAEE group; the weighting calculations are described in detail. Weighting is utilized not only for the expected but also for the observed mean annual rates. Mean annual mortality rates per 1000 person-years are given in the article, but no exposure data. Exposure has been estimated as E = d/(decimal q). RESULTS: The 302 patients followed were divided into approximately equal groups, but the proportion of females was highest (71/101) in the group with lowest DAEE, 53/102 in the middle DAEE group, and only 26/99 in the group with maximum DAEE. The disparity in sex distribution resulted in a disparity in expected mortality and the need to adjust the observed survival and mortality rates. The group with the highest DAEE (> 770 kcal/ day) had the lowest adjusted annual mortality rate (21.2 deaths per 1000 person-years). This was used as the reference "expected" mortality rate for the intergroup comparisons of excess mortality. The excess death rate (EDR) for the group with intermediate DAEE (521-770 kcal/day) was 7.3 extra deaths per 1000 per year; the EDR for the group with lowest DAEE (< 521 kcal) was 14.8 per 1000 per year. When mortality in the total cohort of 302 subjects was compared with that expected in the matched US population, the mortality ratio was only 49%, and the EDR was -31 per 1000 per year.

Comparative mortality in asymptomatic men issued standard insurance with routine ECG classified as normal or with minor T wave changes.

METHODS: From a prospective electrocardiogram (ECG) study file at the New England Mutual Life Insurance Company, cases were selected on the basis of men issued standard insurance, without symptoms, but with a routine ECG interpreted as normal or with minor low amplitude T wave (+0.5 mm to +1.0 mm). There were 1460 men so classified, with interpretations made between May 1, 1954, and December 31, 1966, and cases followed to July 1, 1970. RESULTS: In a mean follow-up (FU) of 7.6 years, there were 50 deaths in 12,043 person-years of exposure, with a mean annual mortality rate of 4.4 per 1000 per year, lower than the 4.9 expected from company age/sex/duration-matched rates. However, the annual excess death rate (EDR) of the 12% of men with minor low T waves was +3.1 per 1000 per year, significantly higher than the EDR of -0.9 in the 88% of men with T waves of normal amplitude (+1.0 mm or higher). CONCLUSION: When a routine ECG is classified as satisfactory for standard issue (normal or with minor low T wave), the mortality is lower than for all standard issues on male applicants of all ages (mostly without any ECG for review). Nevertheless, in the 12% of men with minor low T wave amplitude as defined for this study, there was significant excess mortality observed, with a mortality ratio (MR) of 188% and an EDR of +4.0 per 1000 per year, when compared with mortality of the men with completely normal T Waves.

Comparative mortality in HIV-infected patients in Denmark, 1995-2005.

Excess mortality in patients infected with HIV has decreased markedly since 1995. The source article utilized for this abstract provides a very detailed follow-up (FU) of a cohort based on all patients treated for HIV infection in Denmark during the period, January 1, 1995 to May, 2005. The FU cohort consisted of 3990 patients treated at 8 specialized clinics for HIV-infected patients incident in Denmark. The Danish Civil Registration System (CRS) provided a database for this FU study. Results are given for exposures, deaths, annual mortality and excess death rates by quinquennial age group for male (M), female (F) and M and F combined, and for groups positive or negative to Hepatitis C virus (HCV+ or HCV-). Excess mortality was estimated by matching each HIV patient to about 92 uninfected persons in the general population and obtaining their "expected" mortality rates. The experience of the total cohort was divided into three groups according to years of entry: 1995-1996, 1997-1999, and 2000-2005. There were 970 deaths observed in the HIV cohort in an exposure of 22,744 patient-years during 1995-2005. Mean annual mortality rate, q, over the observation period increased from 30 per 1000 at age 25-30 years to 93 per 1000 in the oldest age group of 65-70 years. For all ages combined, q was 47 per 1000 in males and 29 in females. In the 18% of cases that were HCV+ q was 54/1000/year, much higher than in the majority of cases who were HCV-, who had a q of 32/1000/year. The overall q for the entire cohort was 38/1000/year.

Mortality in insureds with complete right or left bundle branch block.

BACKGROUND: On May 1, 1954, a prospective mortality study was instituted in the Medical Department of the New England Mutual Life Insurance Company for all persons on whom an electrocardiogram (ECG) was made. Details were coded on an 80-column, mark-sense punched card for the ECG interpretation, for clinical findings, and for demographic/insurance data. RESULTS: Mortality is based on the experience of 231 policy-holders with complete right bundle branch block (RBBB) and 45 policyholders with complete left bundle branch block (LBBB). These were drawn from 28,687 interpretation records 1954-1966, if there was some follow-up (FU) exposure between 1954 and 1975. Mortality data are for all ages and all durations combined. In cases with associated rated cardiovascular (CV) impairment, there were 22 observed vs 7.72 expected deaths in RBBB, and 6 observed vs 2.72 expected deaths in LBBB. Exposures and deaths were smaller when there was no rated CV impairment associated with the ECG abnormality: 11 observed vs 8.11 expected deaths in RBBB, and 3 observed vs 1.78 expected deaths in LBBB. CONCLUSIONS: In complete RBBB, excess mortality was significant at the Poisson 95% confidence level when a rated CV impairment was associated with the RBBB, but the excess was minimal and not significant when the RBBB was essentially an isolated finding with no associated CV impairment. In LBBB the numbers of deaths were too few to permit even a 90% confidence level of significance when there was an associated CV impairment (the 2.72 expected deaths were just above the lower limit of 2.6 deaths at the 90% level).

Mortality in co-morbidity (II)--excess death rates derived from a follow-up study on 10,025 subjects divided into 4 groups with or without depression and diabetes mellitus.

BACKGROUND: Most mortality follow-up (FU) studies focus on excess mortality in a single risk factor or impairment. However, many persons in the general population with 1 important medical risk factor are likely to have co-morbidity in the form of other risk factors, some minor, but others that may be of major significance. Logically, with 2 major significant risk factors present, the combined excess mortality may be smaller or greater than the sum of the individual mortality rates, or may be nearly the same as the sum. When 2 major co-morbid risk factors are present, it is important to know which of these 3 possibilities is present. In the first article of this series, we analyzed the results of 57 individual impairments in the Multiple Medical Impairment Study2 (MMIS). We found that, when elevated blood pressure (EBP) was the comorbid impairment, the excess mortality outcomes were divided almost equally among these 3 possibilities. ARTICLE BY EGEDE ET AL: This informative 2005 article has utilized data from an 11-year FU of subjects in the 1971-1975 National Health and Nutrition Examination Survey, from which mean annual mortality rates per 1000 have been presented in 4 groups of subjects: Group 1 with no depression (D) or diabetes mellitus (DM), Group 2 with D only, Group 3 with DM only and Group 4 with both D and DM present. Total subjects numbered 10,025, of whom 70.2% were in Group 1, 22.7% in Group 2, 4.5% in Group 3, and only 2.6% in Group 4. In addition to mean age, proportions were given in each group for sex and race, 3 additional demographic and 8 additional medical risk factors. Two different models were used to calculate hazard ratios, by the Cox proportional hazards method, for total mortality rates and rate for death rates due to coronary heart disease (CHD). The unadjusted mortality rates (q) were given for each group as the ratio of deaths (d) to 1000 person-years of exposure (E). In obtaining hazard ratios the authors used the mortality rate of Group 1 as the reference or expected rate (q') for adjusting the rates in the other groups to derive the hazard ratios in the 2 adjustment models employed. METHODOLOGY OF CURRENT ARTICLE: For Groups 2-4, with 1 or both of the impairments present, we have estimated an adjusted mortality rate, q(a), by multiplying the reference q' (19.1 per 1000 per year) by the appropriate decimal hazard ratio given in Table 2 of the article. For each of the impaired groups, 2-4, the corresponding adjusted EDR has been derived as EDR = q(a) - q' = q(a) - 19.1. We use EDR values as a difference between mortality rates instead of a ratio of rates because EDR values when age/sex/race-adjusted are directly additive and do not require weighting. RESULTS: In Model 1, with adjustment for age, sex, race and 4 other demographic factors, annual EDR values were 6.5, 16.8 and 48.5 per 1000, respectively, in Groups 2, 3 and 4. In Model 2, with all factors in Model 1 and additional medical risk factors, such as heart disease, hypertension and cancer, EDRs were reduced to 3.8, 16.8 and 28.6, respectively in the D, DM and D+DM groups. CONCLUSION: When group mortality differences were adjusted (for other demographic and medical factors as well the basic factors of age, sex and race), EDR in Group 4 subjects, with both D and DM present exceeded the sum of EDRs in Group 2 (D alone) and Group 3 (DM alone) by 83% in Model 1 and by 39% in Model 2. We conclude that the authors of this study have provided convincing evidence that excess mortality measured as EDR is greater in subjects with both depression and diabetes mellitus present than the sum of the EDRs in the groups when each impairment is present alone. This particular combination of impairments has a strong synergistic effect on excess mortality.

Mortality in co-morbidity (I)--Analysis of the results in the Multiple Medical impairment Study for impairments with elevated blood pressure as the second or co-morbid impairment.

BACKGROUND: In life insurance medicine as in general medicine, it has long been recognized that chronic medical conditions often occur in persons, not as a single impairment or risk factor, but as multiple co-morbid conditions. Nevertheless, it was not until 1999 that the first intercompany Multiple Medical Impairment Study (MMIS) was completed by Harry A. Woodman, FSA. Prior intercompany mortality studies from 1903 to 1983 had been almost 100% devoted to single impairments excluding all comorbid impairments except minor ones with a mortality ratio (MR) of 125% or less. However, abundant co-morbid mortality data have been presented in other clinical and single company studies. Examples are in the studies on diabetes mellitus abstracted in the 1976 Medical Risks monograph and two more recent studies. In this article, we analyze overall mortality and mortality for most of the individual impairments with elevated blood pressure (EBP) as the co-morbid impairment, provided that exposures and deaths were sufficient in number to utilize. METHODS: From the standardized results page for the impairments published in the MMIS, we have extracted 3 tables of aggregate mortality experience on groups with a single impairment, 2 impairments, and 3 impairments. Then we prepared a similar table from the substandard experience of the 1979 Blood Pressure Study. Weighted mean age was calculated, for all groups, and excess death rates (EDRs) in the group with EBP were adjusted to the mean age of the 2-impairment group. Next a subsidiary table was prepared of data from 57 impairments in Section III of the MMIS. The data included the name of the impairment, exposures, observed and expected deaths (d and d'), overall EDR as a multiple and as a single impairment, and as a co-morbid impairment with EBP as the second impairment. The age-adjusted EDR for EBP alone was added to the EDR as a single impairment, and the sum was compared with the co-morbid EDR for the impairment and EBP. The 57 impairments were then divided into 3 groups (Tables 4-6), depending on whether the comorbid EDR exceeded the sum of the separate EDRs, was less than the sum, or approximately equal to the sum. RESULTS: EDR rose with decennial age group in each of the 4 groups shown in Table 1. Mean annual EDR, all ages combined, increased from 2.6 per 1000 for a single impairment to 5.2 for 2 impairments to 9.2 for 3 impairments. In males in the 1979 Blood Pressure Study, the mean EDR, all rated policies combined, was 5.0 per 1000, and the mean rate of increase per decennial age group was 2.77 per 1000, aged 20-29 to 60-69. In 18 of 57 comparisons, the co-morbid EDR exceeded the sum of the separate EDRs by 1.0 or more; in 20 the 2 EDR values were approximately equal, within +/- 0.9; and in 19 the co-morbid EDR was less than the sum of the separate EDRs by 1.0 or more. In Table 4, we listed the 18 impairments whose co-morbid EDR exceeded the sum of the separate EDRs, entering the overall co-morbid mortality data (combined impairment and EBP), and the comparison EDRs. The mean co-morbid EDR was 11.3 per 1000 per year, with a range from 6.8 to 17.7; the mean sum of EDRs was 8.3 per 1000 (range 5.6 to 12.5). The mean excess EDR was +2.8, with a range from +1.2 to +9.2. Results are shown in Tables 5 and 6 for the groups in which the co-morbid EDR was less than or approximately equal to the sum of the separate EDRs. CONCLUSION: In 18 of 57 comparisons made in MMIS, there was a synergistic excess mortality when the co-morbid EDR (impairment with EBP as second impairment) was compared with the summated EDR of the impairment alone and the EDR for EBP alone. In the remaining 68% of the impairments, the co-morbid EDR was approximately equal to or less than the sum of the separate EDRs.

Mortality in a complete 4-year follow up of 85-year-old residents of Leiden, classified by serum level of thyrotropin and thyroxine.

BACKGROUND: The authors of the source article emphasize the clinical tendency to screen for, detect and treat for thyroid dysfunction in very elderly patients, in which it is a fairly common disorder, often with occult or no symptoms. Published evidence is conflicting on the benefit, if any, of such a program. Accordingly, they devised a prospective, population-based study to determine outcomes, including survival outcome, based on serum levels of thyroid-stimulating hormone (TSH) and thyroxine. METHODS: A cohort of 558 subjects who had their 85th birthday between September 1997 and September 1999 was enrolled after consent of the subject and screening examination that included serum TSH and thyroxine levels. This represented a 79% sample of all 85-year-old residents of Leiden, the Netherlands. Follow up was complete for survival 4 years to the subject's 89th birthday or prior death, although 70 subjects refused the annual re-examination. Thyroid function, disability, cognitive function and number of chronic diseases were analyzed, in addition to mortality, through Cox regression and other statistical methods. RESULTS: In 67 subjects with abnormally high TSH (>4.8 mIU/ L), the mean annual mortality rate was derived as 64 deaths per 1000 per year. In the 491 subjects with normal TSH or low TSH (<0.3 mIU/L), the mean annual mortality rate was derived at 114 per 1000 per year. Laboratory evidence of hypothyroidism (initially low serum thyroxine) was found in only 37 of the 67 subjects. CONCLUSION: In the 13% of elderly subjects in Leiden with abnormally high serum TSH levels, the mean annual mortality rate was significantly lower than the mortality rate in the 87% of the elderly patients with normal or low serum TSH. The significance is based on 95% confidence levels of the Poisson distribution. The rate in the group with high TSH levels had 16 deaths in 264 person-years of follow up (FU). The majority with normal or low TSH levels had 193 deaths in 1698 person-years of FU.

Use of a mean entry age underestimates expected mean mortality rate.

OBJECTIVE: To explain the impact of the 10% annual increase in mortality rate in the life tables from about age 45 to 90 years on mean expected mortality rate in any follow-up (FU) group with a wide age range. Use of the mean age to enter a life table invariably underestimates the true mean expected mortality rate in small age groups with an age range of 5 to 10 years. As a result, when mean age and standard deviation (SD) are the only age characteristic given for the cohort reported in a FU study, the mean age must be adjusted upward to enter the life table to obtain a valid mean expected mortality rate of the entire cohort. METHOD: The 1989-91 Decennial US Life Table is used to illustrate the variation of expected annual rate, q', with age, x. The magnitude of the error in mean q' introduced by failure to adjust mean age to obtain mean q' is illustrated in examples of both cardiovascular and cancer FU studies. Other tabular analytical data are also presented. RESULTS: From the 1989-91 US Life Tables for the white population, it is shown that the mean increase in annual mortality rate between ages 45 and 90 years has been found to be 9.36 +/- 0.79% per year for males and 9.94 +/- 1.13 for females. For age groups with a narrow range (10 years or less), a mean age can be used to estimate an accurate mean q'. But if the range exceeds about 15 years, as it does in most groups of patients in a FU study, a tabular q; obtained by entering the life table with the mean age is underestimated and is lower than the actual mean q'. The magnitude of the error increases with the magnitude of the range or SD. Examples are given of the magnitude of the error in one group as patients with coronary heart disease and in another group with cancer. Summary data on the magnitude of the error are also given for multiple groups in each category. CONCLUSION: Recommendations are made on how to adjust the mean age, when possible, to provide a more accurate q', when data by separate age groups are not available.

Progression of mean age and mean expected mortality rate by duration of follow up in cohorts with a wide range of age.

BACKGROUND: [corrected] In a previous article, it was demonstrated that use of mean age to enter a life table to obtain a mean expected mortality rate of a cohort with a wide age range invariably underestimates the true mean expected mortality rate, q'. This is due to the bias introduced by the average 10% annual increase in q' in the approximate age range of 45 to 90 years (rates in the population life table, ages 0-109 years were analyzed to illustrate this). The magnitude of the error was demonstrated in various examples. All of these data were limited to the first year of FU (follow-up) duration. In this article, we analyze progression of mean age, x, and mean expected mortality rate, q', with FU duration in cohorts with all ages combined. When the age range is only 5 or 10 years, the mean age of the survivors does increase very nearly a full year with each year of FU duration. RESULTS: We utilized a 1973-1987 cohort in the SEER database for prostate cancer, all ages and all stages combined, and from this derived a comparative mortality table. We first demonstrated the difference between cumulative expected survival rate, P', as calculated in the SEER database, and the actuarial calculation of P'. The SEER method results in a 5% underestimate of P' vs the actual P' at a duration 14-15 years, and a corresponding overestimate of Q' and q'. Second, we found that the annual mean age of the survivors in the prostate cancer cohort increased from 72.4 years at entry to 80.2 years in a FU of 15 years. Mean expected q' increased from 66.7 per 1000 in the first year to 93.1 per 1000 in the 15th year. The geometric mean annual increase in mean q' was only 2.4% per year, instead of the approximate 10% seen in the life table from about age 45 to 90. Progression patterns by duration for mean age and mean q' are very different in female thyroid cancer, all ages and all stages combined, again for a 1973-1987 cohort. In thyroid cancer, females outnumber males; in both sexes, the proportion of younger patients, under age 45, is much greater than in typical cancer sites, such as prostate cancer. In female thyroid cancer, both mean age and mean q' actually decreased from the mean values at entry for 5 years or more. At entry, mean age was 43.9 years, and mean q' was 8.2 per 1000. These values decreased to 43.5 years and 6.8 per 1000, respectively, at duration 1-2 years, then leveled off and began a gradual increase. At duration 14-15 years, mean age was 53.7 years, and mean q' was 11.4 deaths per 1000 per year. CONCLUSION: Progression of mean q' is erratic and unpredictable, because annual mean age of survivors is highly dependent on the proportion of younger patients in the cohort being followed. If the proportion of patients under age 45 years is high enough, both mean age and mean q' may show an initial decrease from the values found in the year of entry, because, even though each survivor is a year older, the progression of mean age is so heavily biased by the slower progression of q' at the younger than at the older ages. However, with the SEER database, if annual expected survival rates are converted to annual expected mortality rates, the derivation of mean expected mortality rate, q' is accurate, regardless of the width of the age range in the cohort selected and being analyzed. The user of the SEER database is warned that the expected cumulative survival rate, P', is derived in the SEER survival tables on the basis of the first-year age distribution, not on the basis of the changing age distribution that is actuarially observed.

How to prepare a life expectancy report for an attorney in a tort case.

The purpose of this methodology article is to describe a suitable format for a legally acceptable report on the life expectancy of the principal in a tort case that is being advocated or defended by an attorney. Life insurance medical directors and underwriters are clearly skilled and experienced in mortality risk classification for life insurance. However, the judicial system is accustomed to measuring excess mortality only in terms of reduced life expectancy. The analyst preparing the report must convert the excess mortality into a figure for reduced life expectancy and compare this with the life expectancy of persons matched by age, sex and race in the latest Decennial US Life Tables. This process is different from the life insurance underwriting process. A life table projected to age 109 must be constructed as an essential part of the report, and the entire process must be presented clearly and convincingly. There are good reasons why the excess death rate (EDR) should be used as the index of excess mortality in constructing the life table, in preference to the mortality ratio (MR), which is used most of the time in life insurance risk classification. All of these considerations are discussed in this article, which is based on a sample of 40 cases handled by the author, a retired life insurance medical director.

Life expectancy--a commentary on this life table variable.

In 1992, I wrote an article on a method of modifying the Decennial US Life Table to accommodate any pattern of excess mortality expressed in terms of excess death rate (EDR), for the specific purpose of calculating the reduced life expectancy, e. I believe this was the first article published in the Journal of Insurance Medicine (JIM) that dealt specifically with life expectancy as an index of survival and risk appraisal, never used in the classification of extra mortality risk in applicants for life insurance. In this commentary, I discuss the 1989-91 US Decennial Life Table in detail. I link the subject matter of the 1992 article with several more recent articles that also focus on the utility of life expectancy in underwriting structured settlement annuities and preparing reports on life expectancy for an attorney in a tort case. A few references are given for further reading on life table methodology and its use in the most accurate estimate of life expectancy, given the inherent limitations of the life table and the limited duration of follow-up studies.

Mortality derived from 5-year survival in patients with Alzheimer disease.

OBJECTIVE: The objective of the authors of the source article was to investigate survival and course of the disease in a registry of patients with Alzheimer disease diagnosed from 1987-1996. The objective of this article is to derive expected mortality, age/sex-matched as closely as possible to data available in the article, and to derive comparative mortality from the survival results at 5 years. METHODS: The cohort of 521 patients with newly recognized senile dementia (Alzheimer disease) was drawn from a health organization in western Washington with an enrollment of 23,000 members age 60 years and older. After initial selection, a careful evaluation was made to confirm the diagnosis. The cohort was followed to death or 2001, with follow-up (FU) ranging from 0.2 to 14 years (mean 5.2 years). The authors used elaborate statistical methods in their analysis of results. A detailed description is given in the text of this article on the derivation of both observed and expected mean annual mortality rates to obtain excess death rates (EDR) and mortality ratios (MR) as indices of excess mortality averaged over 5 years of FU. RESULTS: All patients were age 60 or older, mean age was 80.2 years, and females outnumbered males, 66% to 34%. The overall EDR, all patients combined, was 37 extra deaths per 1000 per year. For all males EDR was 52; and for all females, EDR was 33 per 1000 per year. The corresponding MR values were 142%, 149% and 141%. EDR and MR increased with test scores measuring severity of cognitive impairment, with physical features of the severity of the dementia, and especially with the presence of comorbid diseases such as stroke, coronary heart disease (CHD) and congestive heart failure (CHF). With a mean age of 80 years, MR values are relatively low in comparison with EDR, owing to the high mean expected mortality. CONCLUSION: An approximate pattern of increased mortality has been found in a cohort of senile dementia patients in the Group Health Cooperative, in the area of Seattle, Washington, despite some uncertainty attributable to absence of sex and race distribution data within each of the 4 individual age groups.

Mortality in a recent study of 625 patients with chronic obstructive pulmonary disease compared with results of 3 older studies.

OBJECTIVE: To assess comparative mortality in COPD patients by severity in a recent study with results in 3 older studies. METHOD: Analysis is made of a recent multicenter study (7 clinics in the United States, Spain, and Venezuela) of COPD patients. An evaluation cohort of 207 patients was utilized to establish a scoring system based on body mass index (B), airflow obstruction (O--measured by FEV1, forced expiratory volume at 1 second), dyspnea (D), and exercise capacity (E). A scoring system for each of these 4 severity factors led to the development of the BODE Index, with a range of 0-10. This index was shown to produce a wider range of mortality than staging (1 to 3) by the FEV1 alone. RESULTS: From the FEV1 Stage and the BODE Index data, a validation cohort of 625 COPD patients was observed for 52 months. This follow-up showed a wider range of mortality by the BODE Index than that obtained by use of FEV1 staging alone. This recent experience (1997-2002) is compared with results of 3 previously published mortality studies of COPD. CONCLUSION: Incorporation of additional severity factors such as dyspnea and exercise capacity improves the prediction of mortality by severity of the COPD, as compared with the use of FEV1 staging alone. Mortality remains at a very high level in all cases, except for those with the mildest form of COPD.

Comparative mortality in medically treated aortic regurgitation.

OBJECTIVE: To present and discuss in this article a table of comparative mortality of medically treated patients with aortic regurgitation, derived from data presented in the source article. BACKGROUND: Although there is abundant information on the follow-up (FU) of patients after surgical replacement of a leaking aortic valve, FU studies of patients with aortic regurgitation prior to valve replacement give discordant and confusing results for a number of reasons. The aim of the source study was to confine the results to patients who had been and continued to be on medical treatment only. METHODS: In this article, the triple decrement approach to life table analysis has been emphasized (death, withdrawal due to surgery, and withdrawal due to end of FU). Data in the source article were used to calculate exposures and to prepare a life table incorporating exposures, observed and expected deaths, to derive observed, expected, and excess death rates and mortality ratios. RESULTS: There was no significant excess mortality above that in the age/sex-matched US population in the NYHA class I group. In NYHA class II group, the excess death rate (EDR) averaged 28 per 1000 per year over 0-10 years. In NYHA class III and IV groups, the EDR was very high, averaging 205 per 1000 per year over 0-5 years, with a mortality ratio (MR) of 1100%. CONCLUSION: Based on data presented in the source article, there was no excess mortality in medically treated aortic regurgitation patients with no functional impairment (NYHA class I), compared to the control population. However, the long-term outlook for the AR patients with good NYHA functional classification includes a high incidence of heart failure and valve surgery. Excess mortality was significant in NYHA class II patients, and was very high in patients with NYHA class III and IV impairments. In the source study, exposure to risk of medically managed aortic regurgitation was greatly curtailed by the performance of aortic valve surgery soon after initial diagnosis, most within the first year of FU.

Conversion of mortality ratios to a numerical rating classification for life insurance underwriting-revisited.

This is a commentary requested by the J Insur Med Editor to accompany a reprinting in this 2004 issue of my 1988 article on "Conversion of Mortality Ratios to a Numerical Rating Classification for Life Underwriting" (J Insur Med 1988;20:54-61). Topics discussed in this commentary include the distinction between short-term and long-term mortality follow-up in certain conditions, the format and the introductory text of the US Decennial Life Tables, the distinction between mortality rate and mortality probability, averaging mortality rates over a period of years, and the great value of the exemplary follow-up study used in the 1988 article.

Abnormal delay in recovery of pulse rate in 9454 patients referred for treadmill exercise test to Cleveland Clinic, 1990-1997--an independent predictor of excess mortality.

OBJECTIVE: The objective of this article is to present results from the latest of 3 recent reports from the Cleveland Clinic on excess mortality associated with abnormal delay in the recovery of an elevated pulse rate produced in a treadmill exercise test. This is done in the context of a long-standing medical interest in this phenomenon and its prognostic significance (see Comment section). BACKGROUND: Delay in return of the pulse rate after exercise has long attracted medical interest as a potentially unfavorable prognostic factor. However, this has not become a factor in the interpretation of the treadmill exercise test. Cardiologist staff members of the Cleveland Clinic have recently studied the mortality predictive effect of delay in pulse recovery in 3 different cohorts of patients given a treadmill exercise test (modified Bruce protocol). The newest, largest and most complete of these studies is the source article for this report. STUDY DESIGN: This was an observational follow-up (FU) study with a median of 5.2 years (range 1.4-8.7 years). The patients were categorized as abnormal pulse recovery at 1 minute after peak exercise with decrease of only 12 beats per minute or less, and normal if >12 beats per minute. These classes were combined with dichotomous classes according to the exercise test result and with other associated risk factors. RESULTS: A good approximation of exposure was achieved for each of the 4 pulse recovery/exercise test groups. From numerical data in the article, it was possible to derive aggregate mean annual mortality rates for these groups and selected combinations of pulse recovery with other risk factors. Mortality was lowest (2.8 per 1000) in the group with pulse recovery and exercise test both normal (66% of the total patients screened), and this was used as the "expected" rate, without adjustment for any differences in age. On this basis the excess death rate (EDR) was about 7 per 1000 per year when either pulse recovery or exercise test was abnormal, and 28 per 1000 when both were abnormal. Similar levels of EDR were found in the combinations of pulse recovery with other risk factors. CONCLUSION: Abnormal pulse recovery after the treadmill exercise test is a powerful and independent predictor of significant excess mortality.

Fecal occult blood testing and the incidence of colorectal cancer.

OBJECTIVE: The objective of this abstract is to demonstrate by life table methodology a significant reduction in the mean annual incidence rate of colorectal cancer in randomized groups with annual or biennial screening for fecal occult blood, as compared with the annual incidence rate in the control group. BACKGROUND: Testing for the presence of fecal occult blood has long been used for the early detection of colorectal polyps and potential cancers. The Minnesota Colon Cancer Study, in an earlier report, has shown that colorectal cancer mortality was significantly reduced, but a 12% reduction in incidence of colorectal cancer was not statistically significant. Follow-up in the Minnesota Study has now been extended to 18 years for augmented incidence results, which have now been reported in the source article and in this morbidity abstract. RESULTS: Subjects in Minnesota were recruited in 1975-1978 and randomized into annual or biennial screening for fecal occult blood, and a control group receiving "usual care." Screening was continued 1976-1982, discontinued, then resumed 1986-1992. During 18 years of follow-up, about 235,000 person-years of exposure were accumulated in each randomized group, with 417 and 435 cases of colorectal cancer in each of the screening groups and 507 cases in the control group. CONCLUSION: Aggregate mean annual incidence rates of colorectal cancer were significantly lower in both screening groups than in the control group, as shown in Table 1. In the source article the same was true for the 18-year cumulative incidence rates, which were also significantly reduced (p < 0.001 for the annual screening group and p = 0.002 for the biennial screening group).