Lip Cancer: 20-Year Comparative Survival and Mortality Analysis by Age, Sex, Race, Stage, Grade, Cohort Entry Time-Period and Disease Duration A Systematic Review of 19,213 Cases for Diagnosis Years 1973-2014: (SEER*Stat 8.3.5).

This report summarizes the incidence, relative frequency distributions and survival & mortality by age, sex, stage and grade, of adult invasive primary cancers of the lip in two entrant time-periods as recorded in the SEER Program of the National Cancer Institute for diagnosis years 1973-2014 (SEER Stat 8.3.5). While the occurrence rates and frequency are low in the United States, they are exceptionally important from a clinical and surgical standpoint because of the morphological and functional changes involved.

Non-Hodgkin Lymphoma - Nodal and Extranodal: 20-Year Comparative Mortality, Survival & Biologic Behavior Analysis by Age, Sex, Race, Stage, Cell Morphology/Histology, Cohort Entry Time-Period and Disease Duration: A Systematic Review of 384,651 Total NHL Cases Including 261,144 Nodal and 123,507 Extranodal Cases for Diagnosis Years 1975-2016: (SEER*Stat 8.3.6).

During the past 5 decades, there have been reports of increases in the incidence and mortality rates of non-Hodgkin lymphoma (NHL) in the United States and globally. The ability to address the epidemiologic diversity, prognosis and treatment of NHL depends on the use of an accurate and consistent classification system. Historically, uniform treatment for NHL has been hampered by the lack of a systematic taxonomy of non-Hodgkin lymphoma. Before 1982, there were 6 competing classification schemes with contending terminologies for NHL: the Rappaport, Lukes-Collins, Kiel, World Health Organization, British, and Dorfman systems without consensus as to which system is most satisfactory regarding clinical relevance, scientific accuracy and reproducibility and presenting a difficult task for abstractors of incidence information. In 1982, the National Cancer Institute sponsored a workshop1 that developed a working formulation designed to: 1) provide clinicians with prognostic information for the various types of NHLs, and 2) provide a common language that might be used to compare clinical trials from various treatment centers around the world. Studies imply that prognosis is dependent on tumor stage and histology rather than the primary localization per se.2 This study utilizes the National Cancer Institute PDQ adaptation of the World Health Organization's (WHO) updated REAL (Revised European American Lymphoma) classification3 of lymphoproliferative diseases, and the SEER*Stat 8.3.6 database (released Aug 8, 2019) for diagnosis years 1975-2016. In this article, we make use of 40 years of data to examine patterns of incidence, survival and mortality, and selected cell bio-behavioral characteristics of NHL in the United States. OBJECTIVE: -To update trends in incidence and prevalence in the United States of non-Hodgkin lymphoma, examine, compare and contrast short and long-term patterns of survival and mortality, and consider the outcome impacts of anatomic location of NHL nodal and extranodal subdivisions, utilizing selected ICD-O-3 histologic oncotypes stratified by age, sex, race/ethnicity, stage, cell behavioral morphology and histologic typology, cohort entry time-period and disease duration, employing the statistical database of the National Cancer Institute SEER*Stat 8.3.6 program for diagnosis years 1975-2016.4 Methods.- A retrospective, population-based cohort study using nationally representative data from the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) program to evaluate 384,651 NHL cases for diagnosis years 1975-2016 comparing multiple variables of age, sex, race, stage, cell behavioral morphology, cohort entry time-period, disease duration and histologic oncotype. Relative survival statistics were analyzed in two cohorts: 1975-1995 and 1996-2016. Survival statistics were derived from SEER*Stat Database: Incidence - SEER 9 Regs Research Data, November 2018 Submission (1975-2016) released April 2019, based on the November 2018 submission. RESULTS: - Incidence rates, relative frequency distributions, survival and mortality by age, sex, stage and cell behavioral morphology, of adult nodal (N) and extranodal (EN) NHL in 2 entrant time-periods as recorded in the SEER Program of the National Cancer Institute for diagnosis years 1975-2016 (SEER Stat 8.3.6) are summarized. Shifts in trends over time are identified, and the findings are correlated with prognosis, including short and long-term observed (actual), expected and relative survival, median observed and relative survival, mortality rates and excess death rates per 1000 people. CONCLUSIONS: - Trends in SEER incidence, prevalence, survival and mortality by age, sex, race, stage, cell behavioral morphology, cohort entry time-period, relative frequency and percent distribution, were examined to provide a current epidemiologic and medical-actuarial risk assessment framework for nodal (N) and extranodal (EN) non-Hodgkin's lymphoma in the 1975-2016 timeframe.

Tongue Carcinoma - 20-Year Comparative Survival and Mortality Analysis by Age, Sex, Race, Stage, Grade, Cohort Entry Time-Period and Disease Duration.

Cancer of the tongue is an uncommon cancer site, with only 31,378 cases in the SEER 1975-2017 database, fewer than 1% of all reported cancers. This article updates trends in incidence, prevalence, short and long-term survival and mortality of tongue carcinoma.

Breast Cancer: 20-Year Comparative Mortality and Survival Analysis by Age, Sex, Race/Ethnicity, Stage, Grade, Disease Duration, Selected ICD-O-3 Oncophenotypes, and Cohort Entry Time-Period.

Breast cancer remains the most common non-cutaneous malignancy in women in both Europe and the United States and the second leading cause of cancer-related deaths. In this breast cancer mortality and survival study, a US retrospective population-based analysis of 656,501 microscopically confirmed breast cancer cases, 1975-2019, data is derived from the NCI Surveillance Epidemiology & End Results Program, SEER*Stat 8.4.0.1.

Cancer of the Liver, Intrahepatic Bile Ducts, Gallbladder, Exocrine and Neuroendocrine Pancreas: 20-Year Comparative Survival and Mortality Analysis by Age, Sex, Race, Stage, Grade, Cohort Entry Time-Period, Disease Duration & Selected ICD-O-3 Oncologic Phenotypes A Systematic Review of 367,420 Cases for Diagnosis Years 1973-2014: (SEER*Stat 8.3.4).

This article summarizes the results of a review of adult invasive primary cancers of the liver, intrahepatic bile ducts, gallbladder, exocrine and endocrine pancreas, as recorded in the SEER Program of the National Cancer Institute for diagnosis years 1973-2014 (SEER Stat 8.3.4).

Cancer of the Rectum and Rectosigmoid Junction: 20-Year Comparative Survival and Mortality Analysis by Age, Sex, Race, Stage, Grade, Cohort Entry Time-Period and Disease Duration: A Systematic Review of 266,898 Cases for Diagnosis Years 1973-2014: (SEER*Stat 8.3.4).

This article reviews a 20-year retrospective population-based study using the statistical database of SEER*Stat 8.3.4 to compare the occurrence, long-term survival and mortality indices of 266,898 patients with cancer of the rectum and rectosigmoid junction (RSJ) juxtaposed by age, sex, race, stage, grade, disease duration, in two cohort entry time-periods, 1973-1994 & 1995-2014.

Cancers of the Oral Cavity and Pharynx: 20-Year Comparative Survival and Mortality Analysis by Age, Sex, Race, Stage, Grade, Cohort Entry Time-Period and Disease Duration: A Systematic Review of 218,066 Cases for Diagnosis Years 1973-2014: (SEER*Stat 8.3.5).

This article summarizes the results of a retrospective population-based cohort study using the statistical database of SEER*Stat 8.3.54 (produced 3/5/2018 for diagnosis years 1973-2014) to assess, determine, compare, and summarize the occurrence, long-term survival, and mortality indices of 218,066 patients with oral cavity and pharynx cancers by age, sex, race, stage, grade, and disease duration.

20-Year Comparative Survival and Mortality of Cancer of the Stomach by Age, Sex, Race, Stage, Grade, Cohort Entry Time-Period, Disease Duration & Selected ICD-O-3 Oncologic Phenotypes: A Systematic Review of 157,258 Cases for Diagnosis Years 1973-2014: (SEER*Stat 8.3.4).

Background and Importance.-Globally, almost one million new cases of stomach cancer were estimated to have occurred in 2012 (952,000 cases, 6.8% of the total), making it the fifth most common malignancy in the world, after lung, breast, colorectal, and prostate. Gastric cancer was the world's third leading cause of cancer mortality in 2012, responsible for 723,000 deaths, 8.8% of total cancer deaths. 1 In 2017, 28,000 new cases and 10,960 deaths are estimated for gastric cancer in the United States. 2 Estimated United States prevalence counts on January 1, 2014, for patients diagnosed within the previous 5-years was 48,271 (SEER Cancer Statistics Review-2014). Prognostic indices of survival & mortality in patients with gastric cancer are related to tumor stage including nodal involvement, direct tumor extension beyond the gastric wall, and wide-spread dissemination. Tumor histologic grade (degree of loss of cellular differentiation), and oncotype-specific ICD-O-3 phenotypes also provides important prognostic information. By more than 90%, the most common histologic type of stomach cancer is adenocarcinoma. The National Cancer Institute (NCI) ICD-O-3 SEER Site/Histology Validation List catalog (September 18, 2015) enumerates almost 200 subtypes for gastric cancer sites C160-C166, C168-C169. Based on the results of molecular evaluation of 295 primary gastric adenocarcinomas reported to The Cancer Genome Atlas (TCGA) project in 2014, a novel classification separating gastric cancers into four subtypes according to Epstein-Barr virus positive status, microsatellite instability, chromosomal instability, or genomic stability was proposed. 3 Of interest, Helicobacter Pylori infection and its role in the development of gastric cancer is not mentioned. All cancer has a genetic basis. However, given the histologic and etiologic heterogeneity of gastric cancer, eventual comprehensive molecular characterization and genomic sequencing with identification of chromosomal aberrations, nucleotide substitutions mortality follow-up study is focused on short- and long-term comparative patient outcomes of stomach adenocarcinoma, ICD-O-3 8140-8147, and other selected gastric cancer oncotypes. Objective.-To update trends in incidence, prevalence, short- and long-term survival, and mortality of gastric cancer using the statistical database of SEER*Stat 8.3.4 for diagnosis years 1973-2014 employing multiple case selection variables. Methods.-A retrospective, population-based study using nationally representative data from the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) program to evaluate 157,258 cases for diagnosis years 1973-2014 comparing multiple variables of age, sex, race, stage, grade, cohort entry time-period, disease duration and histologic oncotype: Relative survival statistics were analyzed in two cohorts: 1973-1994 and 1995-2014. Survival statistics were derived from: SEER*Stat Database: Incidence - SEER 9 Regs Research Data, November 2016 Submission (1973-2014) Released April 2017. Results.-By more than 90%, the most common type of stomach cancer is adenocarcinoma. From 1975 to 2014, gastric cancer incidence has been steadily decreasing in the United States at the rate of -1.5% per year. In a total of 157,258 cases of invasive staged cancer of the stomach, mean age in males was 67.5 years, females 69.6 years, both male & female 67.4 years. Greater than 90% of cases occurred between ages 45-85+ years with the zenith in males at 70-74 years (15.1%) and 85+ years in females (17.9%). The overall annual US death rate per 100,000 per year for stomach cancer from 1975 to 2014 has decreased from 5.1 to 3.1, but excess mortality at 0-5 years remains exceedingly high. Mortality is a function of incidence and survival, and unfortunately, almost all of this decrease is due to the decrease in incidence of stomach cancer. Of the 157,258 invasive cases, 86.6% were clinically staged and 76.8% were histologically graded. Conclusions.-Given the histologic and etiologic heterogeneity of gastric cancer, major improvements in mortality and survival outcomes await the development of diagnostic markers for earlier diagnosis, and genomic sequencing and identification of chromosomal aberrations, nucleotide substitutions and epigenetic modifications that drive malignant transformation, for the development of targeted therapies for almost 200 gastric cancer subtypes.

Medical Malpractice Defense: The Predictive and Protective Power of Mortality, Survival, and Life Expectancy.

Introduction.-The defense of medical malpractice presents a significant challenge to Assistant United States Attorneys (AUSAs). A medical malpractice claim consists of proof of: (1) duty, (2) breach of the duty, (3) causation, and (4) damages. Often the breach of the duty and the causation elements present complex medical issues involving multiple specialties and subspecialties of medicine. A considerable amount of time is required to prepare the defense pertaining to the alleged breach of the duty and causation elements. The damages aspect of the medical malpractice case is often not given equal treatment and may not be fully developed. As a result, damage awards can be surprisingly high once the breach of the standard of care and the causation defenses fail. Purpose.-The purpose of this article is to underscore the importance of developing the damages aspect of the case. This article will demonstrate through a case study the power of using fact-based medical-actuarial risk statistics and life expectancy testimony to limit, by thousands if not millions of dollars, economic damages to impairment-specific "years of life lost" in medical-malpractice torts. The important points to remember are that from the moment a case is assigned to an AUSA, the AUSA must: (1) focus as much, if not more, attention on damages; (2) execute a discovery strategy that ensures all aspects of damages are thoroughly investigated; and (3) retain the appropriate experts, including, in appropriate cases, an expert on medical risk appraisal and life expectancy.

Thyroid Cancer: 20-Year Comparative Mortality and Survival Analysis of Six Thyroid Cancer Histologic Subtypes by Age, Sex, Race, Stage, Cohort Entry Time-Period and Disease Duration (SEER*Stat 8.3.2) A Systematic Review of 145,457 Cases for Diagnosis Years 1993-2013.

BACKGROUND: -Incidence and prognosis of cancers of the endocrine glands vary greatly by stage and histologic type, and, thyroid cancer accounts for most (92%) of the cancers of the endocrine glands. It is the 8th most common of cancers and has been rising in incidence since 1975. It remains a formidable health threat in the United States in 2016 with estimated cases of 64,300 and 1980 deaths. OBJECTIVE: -Provide 20-year comparative mortality analysis of thyroid cancer in a recent group of 145,457 staged cases (97.5%) of a total of 149,202 patients during the 1993-2013 entry time-period in six histologic subtypes by age, sex, race, stage and disease duration. METHODS: -Population-based data from SEER registries, 1 1973-2013, (SEER*Stat 8.3.2.) were analyzed. RESULTS: - Tables 1 - 8 provide basic SEER epidemiologic, demographic, case-statistics, and comparative mortality follow-up data of 4 principal and 2 supplementary thyroid cancer oncotypes by age, sex, race, stage and disease duration of patients in the 1993-2013 time-period. [Table: see text] [Table: see text] [Table: see text] [Table: see text] [Table: see text] [Table: see text] [Table: see text] [Table: see text] Conclusions.-Thyroid cancer when localized has a very good prognosis, with no significant excess mortality after diagnosis in papillary and papillary follicular variant cancers (PFV). Because nearly two thirds of thyroid cancers are localized, and excess death rate (EDR) is small in patients with regional cancer under age 50, overall excess mortality for all ages also virtually disappeared after 10 years in papillary and follicular cancer. Overall, the 5-year survival rate is greater than 90% for papillary and follicular carcinomas. Nevertheless, because of the marked predominance of papillary carcinoma, the continued increase in its relative frequency and annual projected deaths, thyroid carcinoma remains a significant health concern in the current era.

Plasma Cell Myeloma - 20-Year Comparative Survival and Mortality of Three Plasma Cell Myeloma ICD-O-3 Oncologic Phenotypes by Age, Sex, Race, Stage, Cohort Entry Time-Period and Disease Duration: A Systematic Review of 111,041 Cases for Diagnosis Years 1973-2014: (SEER*Stat 8.3.4).

BACKGROUND: -The values of SEER site recode variables are based on the primary site and histology data fields submitted to SEER by the registries. The site recode variables define the major cancer site/histology groups that are commonly used in the reporting of cancer incidence data and are added to the SEER databases as a convenience for researchers. These codes and definitions are periodically updated and changed by the National Cancer Institute as newer and more applicable information becomes available. Because this myeloma analysis includes cases diagnosed 2010+, the ICD-O-3 recode-updates with adjustment for WHO 2008 hematopoietic histologies that account for changes in the obsolete classification of hematopoietic histology codes, and the assignment of new names (ie, multiple myeloma-MM - to - plasma cell myeloma-PCM) is adhered to and used here. Plasma cell myeloma (PCM) is a bone-marrow based multifocal plasma cell malignancy (primary site C421). PCM is characterized by a single clone of plasma cells, believed to be derived from lymphoid B cells, and spans a clinical spectrum from asymptomatic to aggressive forms, plus disorders caused by the deposition of abnormal immunoglobulin chains in tissue. The current myeloma group ICD-O-3 histologic morphology types consists of: ICD-O-3 9731: Plasmacytoma, NOS, occurring in bone (osseous plasmacytoma malignancy data reportable to SEER only beginning since 1986); ICD-O-3 9732: Plasma cell myeloma - composed of three clinical variants: a) asymptomatic, b) Non-secretory myeloma, and c) Plasma cell leukemia (all coded to 9732); ICD-O-3 9734: Extramedullary plasmacytoma; anatomic sites other than bone. OBJECTIVE: -Using the statistical database of SEER*Stat 8.3.4 (produced 4/14/2017 for diagnosis years 1973-2014), to assess, determine, compare, and summarize the occurrence, long-term survival and mortality indices of the three morphologic types of myeloma by age, sex, race and stage in two-cohort entry time-periods (1973-1994 and 1995-2014). All analyses are accomplished within the context of current SEER Site Recode ICD-O-3 (1/27/2003) definitions, terminologies and descriptions, and also in accordance with the rules of the consolidated Hematopoietic and Lymphoid Neoplasm Coding Manual data base (effective 1/1/2010 - release date January 2015). METHODS: -Population data including 111,041 cases collected by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Frequency Database (18 SEER Registries Research Data + Hurricane Katrina Impacted Louisiana Cases, November 2016 Submission, 1973-2014 varying) for diagnosis years 1973-2014: Relative Survival Statistics were analyzed in two cohorts: 1973-1994 and 1995-2014. Survival statistics were derived from: SEER*Stat Database: Incidence - SEER 9 Regs Research Data, November 2016 Submission (1973-2014) Released April 2017. RESULTS: -Tables 1-3 provide basic SEER comparative survival and mortality data of the three myeloma oncotypes by age, sex, stage and disease duration of patients in the 1973-2014 time-period. Epidemiologic, demographic, and case statistics data extracted from the most current NCI Cancer Statistics Review (CSR 2010-2014) are included. CONCLUSIONS: -Recent SEER age-adjusted incidence trends, 2011-2014, for all races has been downward, with an annual percentage change (APC) of -2.5% per year. Mean age in plasma cell myeloma (PCM) patients was about 1-year less in males (67.8 yrs) than in females (69.2 yrs). PCM is accompanied by a very high excess mortality and much reduced 5-year relative survival ratio especially in older age groups. Generally, first year excess death rates (EDRs) decreased with duration but increased with advancing entry age, and there was no sex difference. First year EDRs in blacks, all ages combined, was quite high but lower than EDRs in whites. Median survival, actual survival and 5-year relative survival ratios diminished precipitously to extremely low levels with increasing entry age attesting to the lethal character of this disease especially in older patients.

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.

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.

MMLC - ISCS aviation and hazardous sports study.

OBJECTIVE: This study used the Impairment Study Capture System (ISCS) to examine the relationship between mortality and participation in aviation and/or hazardous sports in an insured population. BACKGROUND: With ever improving mortality in the industry, the significance of mortality from these "risky" activities may be more impactful than ever. This study fills a 20-year gap in intercompany studies of these risks. METHODS: We studied 45,206 policies submitted through the ISCS between 1989 and 2004 with codes signifying recent or anticipated participation in aviation or hazardous sports. Aviation activity included both private and commercial flying and was crudely stratified by hours flown. Hazardous sports included motor vehicle racing, flying in other than conventional aircraft, underwater sports, and other. Excess death rates per thousand, relative to the 2001 VBT were computed. Results were stratified by underwriting factors of interest. RESULTS: Sixty-nine deaths were observed in the aviation study and 60 in hazardous sports over an average followup of 3.2 years. An additional 6 deaths were observed in policies belonging to both studies. Extra mortality was observed for aviation in early durations only whereas mortality from hazardous sports persisted longer. Mortality was higher for policies rated for these activities vs those issued at standard rates. No other variable of underwriting significance was meaningful. CONCLUSIONS: Life insurance underwriting identifies the least risky of these activities and classifies them appropriately. The absence of extra mortality in later durations may be real or could be the artifact of study design.

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 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 study of policies on insured lives with diabetes mellitus known at time of issue.

BACKGROUND: This is an Impairment Study Capture System (ISCS) study of contemporary diabetes mellitus mortality among insured lives. Because the diagnosis and treatment of diabetes has changed during the last 15 years, many applicants may be expected to exhibit more favorable outcomes than in the past. The study covers policy-years durational experience extending to only 10 years. METHODS: We analyzed the total mortality experience of 41,972 insurance policies. The policies were issued at standard or substandard premium rates between 1989 and 2002 policy anniversaries. The number of policies terminated by death (actual deaths) is compared with expected deaths using the 2001 Valuation Basic Table (2001 VBT). Main outcome measures are expressed as mortality ratios (MR %) and excess death rates/1000 (EDR/M). Poisson confidence intervals are used to test the statistical significance of mortality ratios at the 95% confidence limit. RESULTS: The total experience is based on 103,104 policy-years exposure: males 57,888 policy-years (56%) and females 45,216 policy-years (44%). There were 495 policy-deaths 284 male and 211 female. Substandard risks represented the majority of the total exposure, 76,658 policy-years in both sexes combined (male 56%, female 44%). The mean duration of substandard exposure was 2.3 years. Total mortality for all insured age-groups and risk categories combined was 187%. The mortality ratios for policies rated standard had confidence intervals that were consistent with 100% of the 2001 VBT. The mortality ratios for policies rated substandard had confidence intervals that were above 100% of the 2001 VBT. Mortality ratios varied with the type of treatment. They were lowest in those treated with diet alone and highest in individuals treated with diet plus insulin. CONCLUSION: A clinical diagnosis of diabetes continues to demonstrate evidence of increased, but improving, mortality in insured individuals. The underwriting risk appraisal process effectively categorizes the risk, especially for the substandard classes where the ratings assigned to policies were consistent with the mortality results. The lack of significant differences in the mortality ratios between males and females as well as between nonsmokers and smokers indicate that the early duration variations by gender and smoking status in the 2001 VBT account for these differences in early duration diabetes mortality. Subsequent follow-up studies containing longer durations may show these differences emerging. Results must be interpreted with caution because of the small data set, limited number of ISCS participating companies, and durational experience extending to only 10 policy years.