Cancer screening in the United States, 2016: A review of current American Cancer Society guidelines and current issues in cancer screening

Each year the American Cancer Society (ACS) publishes a summary of its guidelines for early cancer detection, data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, we summarize current ACS cancer screening guidelines, including the update of the breast cancer screening guideline, discuss quality issues in colorectal cancer screening and new developments in lung cancer screening, and provide the latest data on utilization of cancer screening from the National Health Interview Survey.

Cancer statistics for African Americans, 2016: Progress and opportunities in reducing racial disparities

In this article, the American Cancer Society provides the estimated number of new cancer cases and deaths for blacks in the United States and the most recent data on cancer incidence, mortality, survival, screening, and risk factors for cancer. Incidence data are from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries, and mortality data are from the National Center for Health Statistics. Approximately 189,910 new cases of cancer and 69,410 cancer deaths will occur among blacks in 2016. Although blacks continue to have higher cancer death rates than whites, the disparity has narrowed for all cancers combined in men and women and for lung and prostate cancers in men. In contrast, the racial gap in death rates has widened for breast cancer in women and remained level for colorectal cancer in men. The reduction in overall cancer death rates since the early 1990s translates to the avoidance of more than 300,000 deaths among blacks. In men, incidence rates from 2003 to 2012 decreased for all cancers combined (by 2.0% per year) as well as for the top 3 cancer sites (prostate, lung, and colorectal). In women, overall rates during the corresponding time period remained unchanged, reflecting increasing trends in breast cancer combined with decreasing trends in lung and colorectal cancer rates. Five-year relative survival is lower for blacks than whites for most cancers at each stage of diagnosis. The extent to which these disparities reflect unequal access to health care versus other factors remains an active area of research. Progress in reducing cancer death rates could be accelerated by ensuring equitable access to prevention, early detection, and high-quality treatment. CA Cancer J Clin 2016;66:290-308. © 2016 American Cancer Society.

Prevalence of major risk factors and use of screening tests for cancer in the United States

Much of the suffering and death from cancer could be prevented by more systematic efforts to reduce tobacco use, improve diet, increase physical activity, reduce obesity, and expand the use of established screening tests. Monitoring the prevalence of cancer risk factors and screening is important to measure progress and strengthen cancer prevention and early detection efforts. In this review article, we provide recent prevalence estimates for several cancer risk factors, including tobacco, obesity, physical activity, nutrition, ultraviolet radiation exposure as well as human papillomavirus and hepatitis B vaccination coverage and cancer screening prevalence in the United States. In 2013, cigarette smoking prevalence was 17.8% among adults nationally, but ranged from 10.3% in Utah to 27.3% in West Virginia. In addition, 15.7% of U.S. high school students were current smokers. In 2011-2012, obesity prevalence was high among both adults (34.9%) and adolescents (20.5%), but has leveled off since 2002. About 20.2% of high school girls were users of indoor tanning devices, compared with 5.3% of boys. In 2013, cancer screening prevalence ranged from 58.6% for colorectal cancer to 80.8% for cervical cancer and remains low among the uninsured, particularly for colorectal cancer screening where only 21.9% of eligible adults received recommended colorectal cancer screening.

Prostate cancer screening in Switzerland: 20-year trends and socioeconomic disparities

BACKGROUND

Despite important controversy in its efficacy, prostate cancer (PCa) screening has become widespread. Important socioeconomic screening disparities have been reported. However, trends in PCa screening and social disparities have not been investigated in Switzerland, a high risk country for PCa. We used data from five waves (from 1992-2012) of the population-based Swiss Health Interview Survey to evaluate trends in PCa screening and its association with socioeconomic indicators.

METHODS

We used multivariable Poisson regression to estimate prevalence ratios (PR) and 95% Confidence Intervals (CI) adjusting for demographics, health status, and use of healthcare.

RESULTS

The study included 12,034 men aged ≥50 years (mean age: 63.9). Between 1992 and 2012, ever use of PCa screening increased from 55.3% to 70.0% and its use within the last two years from 32.6% to 42.4% (p-value <0.05). Income, education, and occupational class were independently associated with PCa screening. PCa screening within the last two years was greater in men with the highest (>$6,000/month) vs. lowest income (≤$2,000) (46.5% vs. 38.7% in 2012, PR for overall period =1.29, 95%CI: 1.13-1.48). These socioeconomic disparities did not significantly change over time.

CONCLUSIONS

This study shows that about half of Swiss men had performed at least one PCa screening. Men belonging to high socioeconomic status are clearly more frequently screened than those less favored. Given the uncertainty of the usefulness of PCa screening, men, including those with high socioeconomic status, should be clearly informed about benefits and harms of PCa screening, in particular, the adverse effect of over-diagnosis and of associated over-treatment.

Breast cancer statistics, 2015: Convergence of incidence rates between black and white women

In this article, the American Cancer Society provides an overview of female breast cancer statistics in the United States, including data on incidence, mortality, survival, and screening. Approximately 231,840 new cases of invasive breast cancer and 40,290 breast cancer deaths are expected to occur among US women in 2015. Breast cancer incidence rates increased among non-Hispanic black (black) and Asian/Pacific Islander women and were stable among non-Hispanic white (white), Hispanic, and American Indian/Alaska Native women from 2008 to 2012. Although white women have historically had higher incidence rates than black women, in 2012, the rates converged. Notably, during 2008 through 2012, incidence rates were significantly higher in black women compared with white women in 7 states, primarily located in the South. From 1989 to 2012, breast cancer death rates decreased by 36%, which translates to 249,000 breast cancer deaths averted in the United States over this period. This decrease in death rates was evident in all racial/ethnic groups except American Indians/Alaska Natives. However, the mortality disparity between black and white women nationwide has continued to widen; and, by 2012, death rates were 42% higher in black women than in white women. During 2003 through 2012, breast cancer death rates declined for white women in all 50 states; but, for black women, declines occurred in 27 of 30 states that had sufficient data to analyze trends. In 3 states (Mississippi, Oklahoma, and Wisconsin), breast cancer death rates in black women were stable during 2003 through 2012. Widening racial disparities in breast cancer mortality are likely to continue, at least in the short term, in view of the increasing trends in breast cancer incidence rates in black women.

Prostate Cancer Incidence and PSA Testing Patterns in Relation to USPSTF Screening Recommendations

IMPORTANCE

Prostate cancer incidence in men 75 years and older substantially decreased following the 2008 US Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen (PSA)-based screening for this age group. It is unknown whether incidence has changed since the USPSTF recommendation against screening for all men in May 2012.

OBJECTIVE

To examine recent changes in stage-specific prostate cancer incidence and PSA screening rates following the 2008 and 2012 USPSTF recommendations.

DESIGN AND SETTINGS

Ecologic study of age-standardized prostate cancer incidence (newly diagnosed cases/100,000 men aged ≥50 years) by stage from 2005 through 2012 using data from 18 population-based Surveillance, Epidemiology, and End Results (SEER) registries and PSA screening rate in the past year among men 50 years and older without a history of prostate cancer who responded to the 2005 (n = 4580), 2008 (n = 3476), 2010 (n = 4157), and 2013 (n = 6172) National Health Interview Survey (NHIS).

EXPOSURES

The USPSTF recommendations to omit PSA-based screening for average-risk men.

MAIN OUTCOMES AND MEASURES

Prostate cancer incidence and incidence ratios (IRs) comparing consecutive years from 2005 through 2012 by age (≥50, 50-74, and ≥75 years) and SEER summary stage categorized as local/regional or distant and PSA screening rate and rate ratios (SRRs) comparing successive survey years by age.

RESULTS

Prostate cancer incidence per 100,000 in men 50 years and older (N = 446,009 in SEER areas) was 534.9 in 2005, 540.8 in 2008, 505.0 in 2010, and 416.2 in 2012; rates began decreasing in 2008 and the largest decrease occurred between 2011 and 2012, from 498.3 (99% CI, 492.8-503.9) to 416.2 (99% CI, 411.2-421.2). The number of men 50 years and older diagnosed with prostate cancer nationwide declined by 33,519, from 213,562 men in 2011 to 180,043 men in 2012. Declines in incidence since 2008 were confined to local/regional-stage disease and were similar across age and race/ethnicity groups. The percentage of men 50 years and older reporting PSA screening in the past 12 months was 36.9% in 2005, 40.6% in 2008, 37.8% in 2010, and 30.8% in 2013. In relative terms, screening rates increased by 10% (SRR, 1.10; 99% CI, 1.01-1.21) between 2005 and 2008 and then decreased by 18% (SRR, 0.82; 99% CI, 0.75-0.89) between 2010 and 2013. Similar screening patterns were found in age subgroups 50 to 74 years and 75 years and older.

CONCLUSIONS AND RELEVANCE

Both the incidence of early-stage prostate cancer and rates of PSA screening have declined and coincide with 2012 USPSTF recommendation to omit PSA screening from routine primary care for men. Longer follow-up is needed to see whether these decreases are associated with trends in mortality.

Cancer statistics for Hispanics/Latinos, 2015

Cancer is the leading cause of death among Hispanics/Latinos, who represent the largest racial/ethnic minority group in the United States, accounting for 17.4% (55.4 million/318 million) of the total US population in 2014. Every 3 years, the American Cancer Society reports on cancer statistics for Hispanics based on incidence data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics. Among Hispanics in 2015, there will be an estimated 125,900 new cancer cases diagnosed and 37,800 cancer deaths. For all cancers combined, Hispanics have 20% lower incidence rates and 30% lower death rates compared with non-Hispanic whites (NHWs); however, death rates are slightly higher among Hispanics during adolescence (aged 15-19 years). Hispanic cancer rates vary by country of origin and are generally lowest in Mexicans, with the exception of infection-associated cancers. Liver cancer incidence rates in Hispanic men, which are twice those in NHW men, doubled from 1992 to 2012; however, rates in men aged younger than 50 years declined by 43% since 2003, perhaps a bellwether of future trends for this highly fatal cancer. Variations in cancer risk between Hispanics and NHWs, as well as between subpopulations, are driven by differences in exposure to cancer-causing infectious agents, rates of screening, and lifestyle patterns. Strategies for reducing cancer risk in Hispanic populations include increasing the uptake of preventive services (e.g., screening and vaccination) and targeted interventions to reduce obesity, tobacco use, and alcohol consumption.

Bone metastasis in prostate cancer: Recurring mitochondrial DNA mutation reveals selective pressure exerted by the bone microenvironment

BACKGROUND

Cancer progression and metastasis occur such that cells with acquired mutations enhancing growth and survival (or inhibiting cell death) increase in number, a concept that has been recognized as analogous to Darwinian evolution of species since Peter C. Nowell's description in 1976. Selective forces include those intrinsic to the host (including metastatic site) as well as those resulting from anti-cancer therapies. By examining the mutational status of multiple tumor sites within an individual patient some insight may be gained into those genetic variants that enhance site-specific metastasis. By comparing these data across multiple individuals, recurrent patterns may identify alterations that are fundamental to successful site-specific metastasis.

METHODS

We sequenced the mitochondrial genome in 10 prostate cancer patients with bone metastases enrolled in a rapid autopsy program. Patients had late stage disease and received androgen ablation and frequently other systemic therapies. For each of 9 patients, 4 separate tissues were sequenced: the primary prostate cancer, a soft tissue metastasis, a bone metastasis and an uninvolved normal tissue that served as the non-cancerous control. An additional (10th) patient had no primary prostate available for sequencing but had both metastatic sites (and control DNA) sequenced. We then examined the number and location of somatically acquired mitochondrial DNA (mtDNA) mutations in the primary tumor and two metastatic sites in each individual patient. Finally, we compared patients with each other to determine any common patterns of somatic mutation.

RESULTS

Somatic mutations were significantly more numerous in the bone compared to either the primary tumor or soft tissue metastases. A missense mutation at nucleotide position (n.p.) 10398 (A10398G; Thr114Ala) in the respiratory complex I gene ND3 was the most common (7 of 10 patients) and was detected only in the bone. Other notable somatic mutations that occurred in more than one patient include a tRNA Arg mutation at n.p. 10436 and a tRNA Thr mutation at n.p. 15928. The tRNA Arg mutation was restricted to bone metastases and occurred in three of 10 patients (30%). Somatic mutation at 15928 was not restricted to the bone and also occurred in three patients.

CONCLUSIONS

Mitochondrial genomic variation was greater in metastatic sites than in the primary tumor and bone metastases had statistically significantly greater numbers of somatic mutations than either the primary or the soft tissue metastases. The genome was not mutated randomly. At least one mutational "hot-spot" was identified at the individual base level (nucleotide position 10398 in bone metastases) indicating a pervasive selective pressure for bone metastatic cells that had acquired the 10398 mtDNA mutation. Two additional recurrent mutations (tRNA Arg and tRNA Thr) support the concept of bone site-specific "survival of the fittest" as revealed by variation in the mitochondrial genome and selective pressure exerted by the metastatic site.

How many individuals will need to be screened to increase colorectal cancer screening prevalence to 80% by 2018?

BACKGROUND

A recent study estimates that 277,000 colorectal cancer (CRC) cases and 203,000 CRC deaths will be averted between 2013 and 2030 if the National Colorectal Cancer Roundtable goal of increasing CRC screening prevalence to 80% by 2018 is reached. However, the number of individuals who need to be screened (NNS) to achieve this goal is unknown. In this communication, the authors estimate the NNS to achieve 80% by 2018 nationwide and by state.

METHODS

The authors estimated the NNS by subtracting adults aged 50 to 75 years who would need to be screened to achieve an 80% CRC screening prevalence from the number who are currently guideline-compliant from population estimates for this age group. The 2013 National Health Interview Survey and the 2012 Behavioral Risk Factor Surveillance System were used to estimate CRC screening prevalence and data from the US Census Bureau were used to estimate population projections. The NNS were age-standardized and sex-standardized.

RESULTS

Nationwide, 24.39 million individuals (95% confidence interval, 24.37-24.41 million) aged 50 to 75 years will need to be screened to achieve 80% by 2018. By state, the NNS ranged from 45,400 in Vermont to 2.72 million in California. The majority of individuals who need to be screened are aged 50 to 64 years and the largest subgroup is privately insured.

CONCLUSIONS

The authors estimated that at least 24.4 million additional individuals in the United States will need to be screened to achieve the National Colorectal Cancer Roundtable goal of increasing CRC screening prevalence to 80% by 2018. To reach this goal, improving facilitators of CRC screening, including physician recommendation and patient awareness, is needed.

Colorectal Cancer Screening in Switzerland: Cross-Sectional Trends (2007-2012) in Socioeconomic Disparities

BACKGROUND

Despite universal health care coverage, disparities in colorectal cancer (CRC) screening by income in Switzerland have been reported. However, it is not known if these disparities have changed over time. This study examines the association between socioeconomic position and CRC screening in Switzerland between 2007 and 2012.

METHODS

Data from the 2007 (n = 5,946) and 2012 (n = 7,224) population-based Swiss Health Interview Survey data (SHIS) were used to evaluate the association between monthly household income, education, and employment with CRC screening, defined as endoscopy in the past 10 years or fecal occult blood test (FOBT) in the past 2 years. Multivariable Poisson regression was used to estimate prevalence ratios (PR) and 95% Confidence Intervals (CI) adjusting for demographics, health status, and health utilization.

RESULTS

CRC screening increased from 18.9% in 2007 to 22.2% in 2012 (padjusted: = 0.036). During the corresponding time period, endoscopy increased (8.2% vs. 15.0%, padjusted:<0.001) and FOBT decreased (13.0% vs. 9.8%, padjusted:0.002). CRC screening prevalence was greater in the highest income (>$6,000) vs. lowest income (≤$2,000) group in 2007 (24.5% vs. 10.5%, PR:1.37, 95%CI: 0.96-1.96) and in 2012 (28.6% vs. 16.0%, PR:1.45, 95%CI: 1.09-1.92); this disparity did not significantly change over time.

CONCLUSIONS

While CRC screening prevalence in Switzerland increased from 2007 to 2012, CRC screening coverage remains low and disparities in CRC screening by income persisted over time. These findings highlight the need for increased access to CRC screening as well as enhanced awareness of the benefits of CRC screening in the Swiss population, particularly among low-income residents.

Differential uptake of recent Papanicolaou testing by HPV vaccination status among young women in the United States, 2008-2013

BACKGROUND

A positive association between recent Papanicolaou (Pap) test uptake and initiation of HPV vaccination among U.S. women has been reported. However, it is unknown whether recent Pap testing by HPV vaccination status varies by race/ethnicity. Discerning racial/ethnic variations is important given the higher prevalence of HPV types other than 16 and 18 in some racial/ethnic groups. We assessed whether uptake of recent Pap testing differed among women aged 21-30 years who had not initiated the HPV vaccination series versus those who had and whether this pattern differed by sociodemographic factors.

METHODS

2008, 2010, and 2013 National Health Interview Survey data were used to generate weighted prevalence estimates and 95% confidence intervals (CIs) (n=7095). Adjusted predicted marginal models were used to generate adjusted prevalence ratios (aPRs) to assess the relationship between recent Pap test uptake and HPV vaccination series initiation by race/ethnicity.

RESULTS

The uptake of recent Pap testing among those who had not initiated the HPV vaccination series was significantly lower (81.0%) compared to those who had initiated vaccination (90.5%) (aPR=0.93, 95% CI: 0.90-0.96). This finding was consistent across most sociodemographic factors, though not statistically significant for Blacks, Hispanics, those with lower levels of education, or those with higher levels of income.

CONCLUSION

Young women who had not initiated HPV vaccination were less likely to have had a recent Pap test compared to women who had initiated vaccination. Concerted efforts are needed to increase uptake of recommended cervical cancer screening and HPV vaccination among young women.

Elimination of cost-sharing and receipt of screening for colorectal and breast cancer

BACKGROUND

The aim of the cost-sharing provision of the Patient Protection and Affordable Care Act (ACA) was to reduce financial barriers for preventive services, including screening for colorectal cancer (CRC) and breast cancer (BC) among privately and Medicare-insured individuals. Whether the provision has affected CRC and BC screening prevalence is unknown. The current study investigated whether CRC and BC screening prevalence among privately and Medicare-insured adults by socioeconomic status (SES) changed before and after the ACA.

METHODS

Data obtained from the National Health Interview Survey pertaining to privately and Medicare-insured adults from 2008 (before the ACA) and 2013 (after the ACA) were used. There were 15,786 adults aged 50 to 75 years in the CRC screening analysis and 14,530 women aged ≥40 years in the BC screening analysis. Changes in guideline-recommended screening between 2008 and 2013 by SES were expressed as the prevalence difference (PD) and 95% confidence interval (95% CI) adjusted for demographics, insurance, income, education, body mass index, and having a usual provider.

RESULTS

Overall, CRC screening prevalence increased from 57.3% to 61.2% between 2008 and 2013 (P<.001). Adjusted CRC screening prevalence during the corresponding period increased in low-income (PD, 5.9; 95% CI, 1.8 to 10.2), least-educated (PD, 7.2; 95% CI, 0.9 to 13.5), and Medicare-insured (PD, 6.2; 95% CI, 1.7 to 10.7) individuals, but not in high-income, most-educated, and privately insured respondents. BC screening remained unchanged overall (70.5% in 2008 vs 70.2% in 2013) and in the low SES groups.

CONCLUSIONS

Increases in CRC screening prevalence between 2008 and 2013 were confined to respondents with low SES. These findings may in part reflect the ACA's removal of financial barriers.

Prognostic indicators in well-differentiated thyroid carcinoma when controlling for stage and treatment

OBJECTIVES/HYPOTHESIS

The incidence of thyroid carcinoma is rising. Few studies have examined patient characteristics that influence survival when adjusting for treatment and tumor stage/extent.

STUDY DESIGN

Retrospective analysis was performed using the Surveillance Epidemiology and End Results registry data among patients diagnosed with well-differentiated thyroid (WDT) carcinoma during 1988-2009.

METHODS

Kaplan-Meir survival curves were used to estimate 5- and 10-year cause-specific and overall survival differences by sociodemographics, clinical characteristics, and treatment. Multivariate Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

A total of 83,985 patients were identified with WDT carcinoma. Blacks had higher hazard of death at 5 years (HR, 1.67; 95% CI, 1.42-1.96) and 10 years (HR, 1.57; 95% CI, 1.37-1.80) when compared to Caucasians, but there were no significant differences in cause-specific deaths. Hispanics had higher overall and cause-specific 5-year and 10-year hazard of death (5-year cause-specific: HR, 1.56; 95% CI, 1.23-1.99). Age was the most significant predictor of cause-specific and overall survival, with risk increasing in a nonlinear fashion. After age 45 years, the HR for 5- and 10-year cause-specific survival rose drastically, reaching an HR of 153 for individuals aged 85 years and older (HR, 153.45; 95% CI, 97.84-240.67).

CONCLUSIONS

Age was the strongest factor associated with WDT cancer in our study. African Americans had worse overall survival, although only Hispanics had a significantly worse cause-specific survival. These factors should be taken into account in counseling patients and treatment planning.

Low income, community poverty and risk of end stage renal disease

BACKGROUND

The risk of end stage renal disease (ESRD) is increased among individuals with low income and in low income communities. However, few studies have examined the relation of both individual and community socioeconomic status (SES) with incident ESRD.

METHODS

Among 23,314 U.S. adults in the population-based Reasons for Geographic and Racial Differences in Stroke study, we assessed participant differences across geospatially-linked categories of county poverty [outlier poverty, extremely high poverty, very high poverty, high poverty, neither (reference), high affluence and outlier affluence]. Multivariable Cox proportional hazards models were used to examine associations of annual household income and geospatially-linked county poverty measures with incident ESRD, while accounting for death as a competing event using the Fine and Gray method.

RESULTS

There were 158 ESRD cases during follow-up. Incident ESRD rates were 178.8 per 100,000 person-years (105 py) in high poverty outlier counties and were 76.3 /105 py in affluent outlier counties, p trend=0.06. In unadjusted competing risk models, persons residing in high poverty outlier counties had higher incidence of ESRD (which was not statistically significant) when compared to those persons residing in counties with neither high poverty nor affluence [hazard ratio (HR) 1.54, 95% Confidence Interval (CI) 0.75-3.20]. This association was markedly attenuated following adjustment for socio-demographic factors (age, sex, race, education, and income); HR 0.96, 95% CI 0.46-2.00. However, in the same adjusted model, income was independently associated with risk of ESRD [HR 3.75, 95% CI 1.62-8.64, comparing the <$20,000 income group to the >$75,000 group]. There were no statistically significant associations of county measures of poverty with incident ESRD, and no evidence of effect modification.

CONCLUSIONS

In contrast to annual family income, geospatially-linked measures of county poverty have little relation with risk of ESRD. Efforts to mitigate socioeconomic disparities in kidney disease may be best appropriated at the individual level.

The association between race and income on risk of mortality in patients with moderate chronic kidney disease

Background

Socioeconomic status (SES) is independently associated with chronic kidney disease (CKD) progression; however, its association with other CKD outcomes is unclear. In particular, the potential differential effect of SES on mortality among blacks and whites is understudied in CKD. We aimed to examine survival among individuals with prevalent CKD by income and race in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.

Methods

We examined 2,761 participants with prevalent CKD stage 3 or 4 between 2003 and 2007 in the REGARDS cohort. Participants were followed through March 2013. Mortality from any cause was assessed by income and race (black or white). Low income was defined as an annual household income < $20,000, and was compared to higher incomes (≥$20,000). Cox proportional hazards models adjusted for age, gender, education, insurance, CKD stage, comorbidity and county-level poverty were used to estimate hazard ratios (HR) and 95% confidence intervals (CI).

Results

A total of 750 deaths (27.5%) occurred during the follow-up period. Average follow-up time was 6.6 years among those alive and 3.7 years among those who died. Low income participants had an elevated adjusted hazard of mortality (HR = 1.58, 95% CI 1.24-2.00) compared to higher income participants. Low income was associated with all-cause mortality regardless of race (HR 1.53; 95% CI 1.18-1.99 among blacks and HR 1.38; 95% CI 1.10-1.74 among whites), with no significant statistical interaction between household income and race (p-value = 0.634). However, black participants had a higher adjusted hazard of mortality (HR = 1.30, 95% CI 1.02-1.65) compared to whites, which was independent of income.

Conclusion

Income was associated with increased mortality for both blacks and whites with CKD. Blacks with CKD had higher mortality than whites even after adjusting for important socio-demographic and clinical factors.

Clinical-pathologic stage discrepancy in bladder cancer patients treated with radical cystectomy: results from the national cancer data base

PURPOSE

To examine the accuracy of clinical staging and its effects on outcome in bladder cancer (BC) patients treated with radical cystectomy (RC), using a large national database.

METHODS AND MATERIALS

A total of 16,953 patients with BC without distant metastases treated with RC from 1998 to 2009 were analyzed. Factors associated with clinical-pathologic stage discrepancy were assessed by multivariate generalized estimating equation models. Survival analysis was conducted for patients treated between 1998 and 2004 (n=7270) using the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

At RC 41.9% of patients were upstaged, whereas 5.9% were downstaged. Upstaging was more common in females, the elderly, and in patients who underwent a more extensive lymphadenectomy. Downstaging was less common in patients treated at community centers, in the elderly, and in Hispanics. Receipt of preoperative chemotherapy was highly associated with downstaging. Five-year overall survival rates for patients with clinical stages 0, I, II, III, and IV were 67.2%, 62.9%, 50.4%, 36.9%, and 27.2%, respectively, whereas those for the same pathologic stages were 70.8%, 75.8%, 63.7%, 41.5%, and 24.7%, respectively. On multivariate analysis, upstaging was associated with increased 5-year mortality (hazard ratio [HR] 1.80, P<.001), but downstaging was not associated with survival (HR 0.88, P=.160). In contrast, more extensive lymphadenectomy was associated with decreased 5-year mortality (HR 0.76 for ≥10 lymph nodes examined, P<.001), as was treatment at an National Cancer Institute-designated cancer center (HR 0.90, P=.042).

CONCLUSIONS

Clinical-pathologic stage discrepancy in BC patients is remarkably common across the United States. These findings should be considered when selecting patients for preoperative or nonoperative management strategies and when comparing the outcomes of bladder sparing approaches to RC.

Receipt of surgical treatment in US women with early stage breast cancer: does place of birth matter?

BACKGROUND

While effects of age, race, place of residence, and marital status on receipt of treatment among female breast cancer patients have been well documented, place of birth is a relatively less studied factor. The purpose of our study was to assess the relationship between birth place and type of surgery performed for early-stage breast cancer among US women of different racial and ethnic backgrounds.

METHODS

Eligible cases (n=119,560) were selected from the SEER registries for the period 2004-2009. US-born and foreign-born patients of different racial/ethnic groups were compared to US-born non-Hispanic Whites (NHW) with respect to receipt of breast conserving surgery (BCS) or mastectomy. Results of multivariable logistic regression analyses were expressed as adjusted odds ratios (OR) and the corresponding 95% confidence intervals (CI).

RESULTS

The proportion of BCS was highest in foreign-born Whites (62.5%) and lowest in foreign-born Asians (50.3%). Relative to US-born NHW, BCS was more common in foreign-born Whites (OR=1.21. 95% CI: 1.15-1.28) and foreign-born Blacks (OR=1.21. 95% CI: 1.15-1.28). In contrast, foreign-born Asians received less BCS compared to both US-born NHW (OR=.76, 95% CI: .72-0.80) and US-born Asians (OR=.74, 95% CI: .64-.86).

CONCLUSIONS

Foreign-born Asian breast cancer patients are less likely to receive BSC compared to US-born Whites or Asian-Americans, whereas foreign-born Whites and foreign-born Blacks are more likely to receive BCS than US-born Whites. Further studies are needed to understand cultural and or health systems factors that may explain these observations.

Clinical-pathologic stage discrepancy in patients with bladder cancer treated with radical cystectomy: Associations with clinical variables and survival

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Background: Radical cystectomy (RC) is the most common treatment for bladder cancer (BC) in the United States. We examined clinical-pathologic stage discrepancy using the National Cancer Data Base. Methods: 16,953 patients with BC treated with RC between 1998 and 2009 were analyzed. Clinical factors associated with stage discrepancy were assessed by multivariable generalized estimating equation models. Survival analysis was conducted for patients treated between 1998 and 2004 (N=7,270) using a Cox proportional hazards model. Results: 41.9% of patients were upstaged at RC while 5.9% were downstaged. Upstaging was more common in females (OR 1.08, p=.04), the elderly (OR 1.26 for age ≥80 vs. 18-59, p=.001), higher tumor grade (OR 2.29 for grade 3-4 vs. grade 1, p<.0001), non-urothelial histology (OR 1.31, p=.002 for squamous and OR 1.26, p=.03 for adenocarcinoma), and with extended lymphadenectomy (OR 1.27 for ≥10 lymph nodes examined vs. 0-9, p<.0001). Downstaging was less common in the elderly (OR 0.50 for age ≥80 vs. 18-59, p<.0001), in Hispanics (OR 0.58, p=.009) and with variant histology (OR 0.55, p=.003 for squamous and OR 0.3, p<.0001 for adenocarcinoma). Receipt of neoadjuvant chemotherapy (CT) was highly associated with downstaging (OR 2.31, p<.0001). 5-year survival by stage is shown in the table. Upstaging was associated with increased 5-year mortality (HR 1.79, p<.0001) as was receipt of CT (HR 1.28, p=.02 for neoadjuvant and HR 1.23, p<.0001 for adjuvant). Extended lymphadenectomy was associated with decreased 5-year mortality (HR 0.82 for ≥10 lymph nodes examined vs. 0-9, p<.0001). Downstaging was not associated with survival (HR 0.88, p=0.17). Conclusions: This study is the largest to date to analyze stage discrepancy and survival in BC patients treated with RC. Upstaging is common and is associated with decreased 5-year survival. These data can be used in pre-operative risk stratification, treatment decision making and comparison with studies of non-operative management. [Table: see text]

Use of potentially curative therapies for muscle-invasive bladder cancer in the United States: results from the National Cancer Data Base

BACKGROUND

Despite its lethal potential, many patients with muscle-invasive bladder cancer (MIBC) do not receive aggressive, potentially curative therapy consistent with established practice standards.

OBJECTIVE

To characterize the treatments received by patients with MIBC and analyze their use according to sociodemographic, clinical, pathologic, and facility measures.

DESIGN, SETTING, AND PARTICIPANTS

Using the National Cancer Data Base, we analyzed 28 691 patients with MIBC (stages II-IV) treated between 2004 and 2008, excluding those with cT4b tumors or distant metastases. Treatments included radical or partial cystectomy with or without chemotherapy (CT), chemoradiotherapy (CRT), radiation therapy (RT), or CT alone and observation following biopsy. Aggressive therapy (AT) was defined as radical or partial cystectomy or definitive RT/CRT (total dose ≥ 50 Gy).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

AT use and correlating variables were assessed by multivariable, generalized estimating equation models adjusted for facility clustering.

RESULTS AND LIMITATIONS

According to the database, 52.5% of patients received AT; 44.9% were treated surgically, 7.6% received definitive CRT or RT, and 25.9% of patients received observation only. AT use decreased with advancing age (odds ratio [OR]: 0.34 for age 81-90 yr vs ≤ 50 yr; p<0.001). AT use was also lower in racial minorities (OR: 0.74 for black race; p<0.001), the uninsured (OR: 0.73; p<0.001), Medicaid-insured patients (OR: 0.81; p=0.01), and at low-volume centers (OR: 0.64 vs high-volume centers; p<0.001). Use of AT was higher with increasing tumor stage (OR: 2.23 for T3/T4a vs T2; p<0.001) and nonurothelial histology (OR: 1.25 and 1.43 for squamous and adenocarcinoma, respectively; p<0.001). Study limitations include retrospective design and lack of information about patient and provider motivations regarding therapy selection.

CONCLUSIONS

AT for MIBC appears underused, especially in the elderly and in groups with poor socioeconomic status. These data point to a significant unmet need to inform policy makers, payers, and physicians regarding appropriate therapies for MIBC.

Disparities in the early adoption of chemoimmunotherapy for diffuse large B-cell lymphoma in the United States

BACKGROUND

Since the 1970s, CHOP chemotherapy has been the standard treatment for patients with diffuse large B-cell lymphoma (DLBCL). In 2002, randomized trials changed this standard by showing that adding rituximab immunotherapy to CHOP improved survival. However, how these results influenced chemoimmunotherapy adoption in clinical practice remains unclear.

METHODS

Using the National Cancer Database to compare chemoimmunotherapy use with chemotherapy alone, we collected data on demographics, stage, health insurance, area-level socioeconomic status (SES), facility characteristics, and type of treatment for DLBCL patients diagnosed in the United States 2001-2004. Multivariable log binomial models examined associations between race, insurance, and treatment allocation, adjusting for covariates.

RESULTS

Among 38,002 patients with DLBCL, 27% received chemoimmunotherapy and 50% chemotherapy alone. Patients who had localized disease, were diagnosed in 2001 or who were black, uninsured/Medicaid insured, or lower SES were less likely to receive any form of chemotherapy (all P < 0.0001). Patients who were diagnosed in 2001 or who were black [relative risk (RR), 0.83; 95% confidence interval (CI), 0.78-0.89], >60 years (RR, 0.94; 95% CI, 0.90-0.98), or had localized disease (RR, 0.89; 95% CI, 0.86-0.92) were less likely to receive chemoimmunotherapy. Receiving treatment at high DLBCL volume teaching/research facilities was associated with the greatest likelihood of chemoimmunotherapy (RR, 1.69; 95% CI, 1.52-1.89).

CONCLUSIONS

Black DLBCL patients were less likely to receive chemotherapy or chemoimmunotherapy during this period.

IMPACT

This large national cohort study shows disparities in the diffusion of chemoimmunotherapy for DLBCL. Improving DLBCL outcomes will require efforts to extend access to proven advances in therapy to all segments of the population.

Association of insurance status and age with cervical cancer stage at diagnosis: National Cancer Database, 2000-2007

OBJECTIVES

We examined the relationship of age at diagnosis and insurance status with stage among cervical cancer patients aged 21 to 85 years.

METHODS

We selected data on women (n = 69 739) diagnosed with invasive cervical cancer between 2000 and 2007 from the National Cancer Database. We evaluated the association between late stage (stage III/IV) and both insurance and age, with adjustment for race/ethnicity and other sociodemographic and clinical factors. We used multivariable log binomial models to estimate risk ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

The proportion of late-stage disease increased with age: from 16.53% (21-34 years) to 42.44% (≥ 70 years). The adjusted relative risk of advanced-stage disease among women aged 50 years and older was 2.2 to 2.5 times that of patients aged 21 to 34 years. Uninsured (RR = 1.44; 95% CI = 1.40, 1.49), Medicaid (RR = 1.37, 95% CI = 1.34, 1.41), younger Medicare (RR = 1.12, 95% CI = 1.06, 1.19), and older Medicare (RR = 1.20, 95% CI = 1.15, 1.26) patients had a higher risk of late-stage disease than did privately insured patients.

CONCLUSIONS

Screening should be encouraged for women at high risk for advanced-stage disease.

Receipt of aggressive therapies for muscle-invasive bladder cancer: Results from the National Cancer Data Base

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Background: Over 17,000 patients are diagnosed with muscle-invasive bladder cancer (MIBC) in the United States each year. Despite its lethal potential, emerging data has suggested that many patients do not receive aggressive therapy consistent with established practice standards. Using data from American College of Surgeons Commission on Cancer accredited facilities, we seek to characterize treatment patterns for patients with MIBC according to demographic, clinical, pathologic and facility variables.

Methods: 28,691 adult patients diagnosed with MIBC (stages II-IV), excluding those with T4b tumors or distant metastases between 2004 and 2008 were selected for analyses from the National Cancer Database. Treatments included radical or partial cystectomy +/− chemotherapy (CT), chemoradiotherapy (CRT), radiotherapy (RT) or CT alone and surveillance. Aggressive therapy (AT) was defined as any open surgery or RT with a total dose ≥50 Gy. Determinants of AT were assessed by multivariate generalized estimating equations accounting for facility clustering.

Results: 52.5% of patients received AT (45% were treated surgically while 7.5% received CRT or RT), 11.7% received palliative CT or RT, and 25.9% received surveillance only. Receipt of AT decreased significantly with advancing age (OR 0.29 for age >80 vs. 18-59, p<.001). AT was also received less frequently by minorities (OR 0.72 for blacks p<.001), the uninsured (OR 0.72, p<.001), Medicaid-insured patients (OR 0.81, p=.006) and by those patients treated at low-volume centers (OR 0.63 vs. high-volume, p<.001). Receipt of AT increased with more advanced stage (OR 2.33 for stage III vs. stage II, p<.001) and in patients with non-urothelial histology (OR 1.32 and 1.50 for squamous and adenocarcinoma histology respectively, p<.001). Hydronephrosis was associated with decreased use of AT (OR 0.70, p<.001).

Conclusions: Aggressive therapies for MIBC are received less frequently by the elderly and those with historically poorer socioeconomic status. These data indicate a significant unmet clinical need for physician education regarding appropriate selection of patients for cystectomy and RT-based bladder sparing therapy.

"Lumping" vs "splitting" in oncologic pathology: association with cancer center type and case volume

CONTEXT

Prior studies reported associations of cancer center facility type and case volume with cancer outcomes (such as survival) and treatment-related processes (such as treatment with chemotherapy, surgery, or radiotherapy).

OBJECTIVE

To determine whether facility characteristics are associated with use of broad (lumped) vs narrow (split) diagnoses in cancer pathology.

DESIGN

We examined associations of facility characteristics and prevalence of broad diagnoses that might adversely affect treatment decisions (based on National Comprehensive Cancer Network treatment guidelines) in National Cancer Data Base records for patients diagnosed from 2004-2008. Logistic regression was used to determine whether associations of facility type and volume with prevalence of broad diagnoses were independent of patient demographic/socioeconomic factors.

RESULTS

Among 10 high incidence cancer sites, 5 had a prevalence of broad diagnoses exceeding 6%. For 4 of these, use of broad diagnoses was independently lower in NCI (National Cancer Institute)- designated comprehensive programs than in community programs, with multivariate prevalence ratios (PR) as low as 0.46 (95% confidence interval [CI] 0.35-0.59) for uterine corpus cancers and 0.49 (95% CI 0.44-0.55) for kidney and renal pelvis cancers. Differences between low- and high-volume facilities were observed for 4 of the 5 sites, with multivariate PR as low as 0.67 (95% CI 0.59-0.77) and 0.72 (95% CI 0.63-0.82) for cancers of the uterine corpus and lung, respectively.

CONCLUSION

Prevalence of broad cancer diagnoses varies independently by cancer site/type, facility type, and facility volume. Broader diagnoses tend to be used most often by community cancer centers and low-volume centers. This association has implications for use of registry data in pathology quality assessment and quality improvement.

Abstract B75: Association of insurance status and age with stage at diagnosis among cervical cancer patients, National Cancer Database 2000–2007

Introduction: Late stage cervical cancer at diagnosis is associated with greater morbidity and mortality and higher treatment costs. Few studies have examined the association between insurance status and cervical cancer stage at diagnosis. Existing studies have been either state-specific or limited to elderly Medicare recipients. This study aims to examine the relationship between patient characteristics, with a particular focus on age at diagnosis and insurance status, and stage in a large number of cervical cancer patients aged 21–85 in the National Cancer Database (NCDB).

Methods: Women diagnosed with their first primary invasive cervical cancer between 2000 and 2007 were selected from the NCDB. We evaluated the association between late stage (stage III/IV) and insurance and age while adjusting for race/ethnicity and other socio-demographic and clinical factors. Multivariate log binomial models were used to estimate risk ratios (RR) and 95% confidence intervals (CIs), respectively.

Results: Among the 69,739 evaluable patients, the rate of late stage disease increased from 16.53% in 21–34 year olds to 42.44% in women ≥70. The adjusted risk of advanced stage of disease among women 50 years and older was 2.2 to 2.5 times that of patients aged 21–34. Uninsured (RR=1.44, 95% CI 1.40–1.49), Medicaid (RR=1.37, 95% CI 1.34–1.41), Younger Medicare (RR=1.12, 95% CI 1.06–1.19), and Older Medicare (RR=1.20, 95% CI 1.15–1.26) patients had a higher risk of late stage disease compared to privately insured patients. African Americans (RR=1.05, 95%CI 1.02–1.08) had slightly higher risks of advanced stage disease while Hispanics (RR=0.86, 95%CI 0.83–0.89) and other race/ethnicities (RR=0.88, 95%CI 0.84–0.92) had a lower risks compared to whites.

Conclusion: In a large national sample of women diagnosed with cervical cancer, the strongest predictor of late stage at diagnosis was age. Patients without private insurance were also more likely to be diagnosed at later stages, particularly uninsured and Medicaid insured patients. Screening should be encouraged for those women for whom it is recommended, especially those at higher risk of advanced stage disease. Consideration of these findings in developing future guidelines for cervical cancer screening among older women is recommended.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B75.

Race and ethnicity are associated with delays in breast cancer treatment (2003-2006)

Access to timely treatment may be one contributing factor to survival differences by race/ethnicity among breast cancer patients. In this study, we examined the relationship between race and treatment delay among breast cancer patients diagnosed between 2003 and 2006 with Stage I-III breast cancer from the National Cancer Database (n=250,007). We evaluated factors associated with receipt of initial treatment more than 30, 60, and 90 days after biopsy using multivariable log binomial models to estimate risk ratios (RR) and 95% confidence intervals (CI). The average time to treatment was 34.30 days (±31.77). Independent of health insurance, stage at diagnosis, and age, Black and Hispanic patients had higher risks of 30, 60, and 90-day treatment delay compared with White patients. Further studies are needed to define the role of structural, health system, physician, clinical and patient factors in treatment delay among Black and Hispanic women and appropriate interventions.

Abstract B87: The impact of insurance and treatment on racial differences in uterine cancer survival: A study of patients in the National Cancer Database

Introduction: Among uterine cancer patients, the age-adjusted mortality for African Americans is substantially higher relative to white patients. Previous studies have attributed this survival disparity to an elevated rate of aggressive tumors and advanced stage of disease among African Americans. However, the role of access to care in this racial disparity has not been fully elucidated. The aim of this study is to examine the impact of insurance status and treatment on racial/ethnic survival disparities among a large cohort of uterine cancer patients from the National Cancer Database (NCDB).

Methods: Women diagnosed with stage I-III uterine cancer between 2000-2007 were selected from the NCDB. The association between race/ethnicity and all cause mortality was analyzed adjusting for patient demographic and clinical factors, health insurance, treatment (which included categories for no surgery, surgery alone, and surgery plus systemic treatment), area-level education, and facility characteristics. Kaplan Meir (KM) and multivariate Cox proportional hazards were used to estimate 4 year survival rates and hazard ratios (HR) and 95% confidence intervals (CI) among patients diagnosed between 2000-2002, respectively. Log binomial models were used to estimate risk ratios (RR) and 95% CI of likelihood of surgical treatment and among patients receiving surgery, the risk of lymphadectomy and systemic (radiation and/or chemotherapy) therapy.

Results: Among the 178,891 evaluable patients, 73.79%, 4.39% 8.66%, 3.07% and 10.08% were white, Hispanic, African American, Other and missing race. The 4 year survival rate was 81.81% for whites, 81.50% for Hispanic, 63.19% for African American and 85.62% for other races. African Americans had a higher risk of death compared to whites (HR=1.43 95%CI1.31 −1.56) after adjusting for all covariates except treatment and insurance. After additional adjustment of treatment the risk death decreased among African Americans (HR=1.32 95%CI1.21 −1.45) and subsequent adjustment for insurance further reduced the hazard of death (HR=1.28 95% CI1.16-1.40). Patients with insurance other than private had an increased risk of death (Uninsured HR= 1.46 95%CI1.22-1.75, Medicaid HR=1.74,95%CI1.49-2.02, Medicare among patients aged 18-64 HR=2.52,95% CI 2.13-2.99, Medicare among patients aged 65-99 HR=1.26,95% 1.16-1.38). African Americans (RR= 0.96 95% CI 0.96-0.97) and Hispanics (RR=0.99 95% CI 0.99-1.00) had similar surgical treatment rates compared to whites and among patients receiving surgical treatment, similar rates of lymphadectomy and systemic treatment by race/ethnicity were observed.

Conclusions: Our results suggest that a portion of the survival disparity between African Americans and whites is attributable to variations in access to care; the hazard ratios of death decreased 11% when treatment was accounted for and an additional 4% when insurance was accounted for. Despite accounting for these and other factors, African American patients had 32% greater risk of death. Future studies examining the role of lifestyle factors and non insurance related barriers to medical care, such as lower income, prior experiences and trust in the health care system, language and geographic barriers, cultural and communication barriers are warranted.

Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B87.

Delays in Adjuvant Chemotherapy Treatment Among Patients With Breast Cancer Are More Likely in African American and Hispanic Populations: A National Cohort Study 2004-2006

Purpose

Previous studies have indicated poorer survival among women receiving adjuvant chemotherapy > 90 days after surgery compared with women receiving adjuvant chemotherapy within 90 days of surgery.

Patients and Methods

Women diagnosed between 2004 and 2006 with invasive breast cancer (stages I to III) and treated with surgery and adjuvant chemotherapy were selected from the National Cancer Database (n = 107,587). We evaluated factors associated with prolonged time to start adjuvant chemotherapy (≥ 60 and ≥ 90 days after surgical resection) using multivariable log binomial models to estimate risk ratios (RRs) and 95% CIs.

Results

The average time to adjuvant chemotherapy was 41.46 days (± 24.46 days). Overall, 85.2% and 95.8% of women received adjuvant chemotherapy within 60 and 90 days of surgery, respectively. African American and Hispanic patients had higher risk of 60-day delay (RR, 1.36; 95% CI, 1.30 to 1.41 and RR, 1.31; 95% CI, 1.23 to 1.39, respectively) and 90-day delay (RR, 1.56; 95% CI, 1.44 to 1.69 and RR, 1.41; 95% CI, 1.26 to 1.59, respectively) compared with white patients. Insurance type, stage, comorbidity, and facility type were also associated with adjuvant chemotherapy delay.

Conclusion

The majority of women in our study received adjuvant chemotherapy within the time frame (90 days) for which there is no evidence of poorer outcome. However, the rate of delay varied by patient and by clinical and facility factors. Future studies on the role of structural, physician, clinical, and patient factors in adjuvant chemotherapy delay in populations of women with higher rates of delay and potential interventions are needed.

Association of insurance and race/ethnicity with disease severity among men diagnosed with prostate cancer, National Cancer Database 2004-2006

BACKGROUND

Previous studies documenting variations in severity of prostate cancer at diagnosis by race/ethnicity and insurance status have been limited to small sample sizes and patients ≥65 years of age. This study examines disease severity among patients ages 18 to 99 from the National Cancer Database (NCDB).

METHODS

Patients diagnosed between 2004 and 2006 with prostate cancer were selected from the NCDB (n = 312,339). We evaluated the association among three disease severity measures: prostate specific antigen (PSA) level, Gleason score 8 to 10, and clinical T-stage 3/4, by race/ethnicity and insurance while adjusting for sociodemographic and clinical factors.

RESULTS

Uninsured and Medicaid-insured patients had elevated PSA levels, higher odds of advanced Gleason score [uninsured odds ratio (OR), 1.97; 95% confidence interval (95% CI), 1.82-2.12; Medicaid OR, 1.67; 95% CI, 1.55-1.79], and advanced clinical T stage (uninsured OR, 1.85; 95% CI, 1.69-2.03; Medicaid OR, 1.49; 95% CI, 1.35-1.63) compared with privately insured patients. Black (OR, 1.19; 95% CI, 1.15-1.23), Hispanic (OR, 1.16; 95% CI, 1.10-1.23), and Asian patients (OR, 1.22; 95% CI, 1.24-1.43) had higher odds of advanced Gleason score and similar odds of advanced stage of disease relative to whites.

CONCLUSION

Insurance status is strongly associated with disease severity among prostate cancer patients.

IMPACT

Strong associations between insurance and disease severity may be related to lack of access to preventive services such as PSA screening and barriers to medical evaluation. Although the risks and benefits of PSA screening have not been fully elucidated, it is important that all men have the opportunity to be informed about this option and preventative medical services.

Incidence analyses of bladder cancer in the Nile delta region of Egypt

Bladder cancer is the most common malignancy among Egyptian males and previously has been attributed to Schistosoma infection, a major risk factor for squamous cell carcinoma (SCC). Recently, transitional cell carcinoma (TCC) incidence has been increasing while SCC has declined. To investigate this shift, we analyzed the geographical patterns of all bladder cancers cases recorded in Egypt's Gharbiah Population-Based Cancer Registry from 1999 through 2002. Data on tumor grade, stage, and morphology, as well as smoking, community of residence, age and sex, were collected on 1209 bladder cancer cases. Age-adjusted incidence rates were calculated for males, females, and the total population for the eight administrative Districts and 316 communities in Gharbiah. Incidence Rate Ratios (IRR) and 95% confidence intervals (CI) were computed using Poisson Regression. The male age-adjusted incidence rate (IR) in Gharbiah Province was 13.65/100,000 person years (PY). The District of Kotour had the highest age-adjusted IR 28.96/100,000 among males. The District of Kotour also had the highest IRR among all Districts, IRR=2.15 95% CI (1.72, 2.70). Kotour's capital city had the highest bladder cancer incidence among the 316 communities (IR=73.11/100,000 PY). Future studies on sources and types of environmental pollution and exposures in relation to the spatial patterns of bladder cancer, particularly in Kotour District, may improve our understating of risk factors for bladder cancer in the region.

Insurance status, comorbidity level, and survival among colorectal cancer patients age 18 to 64 years in the National Cancer Data Base from 2003 to 2005

PURPOSE

Previous analyses have found that insurance status is a strong predictor of survival among patients with colorectal cancer aged 18 to 64 years. We investigated whether differences in comorbidity level may account in part for the association between insurance status and survival.

METHODS

We used 2003 to 2005 data from the National Cancer Data Base, a national hospital-based cancer registry, to examine the relationship between baseline characteristics and overall survival at 1 year among 64,304 white and black patients with colorectal cancer. In race-specific analyses, we used Cox proportional hazards models to assess 1-year survival by insurance status, controlling first for age, stage, facility type, and neighborhood education level and income, and then further controlling for comorbidity level. RESULTS; Comorbidity level was lowest among those with private insurance, higher for those who were uninsured or insured by Medicaid, and highest for those insured by Medicare. Survival at 1 year was significantly poorer for patients without private insurance, even after adjusting for important covariates. In these multivariate models, risk of death at 1 year was approximately 50% to 90% higher for white and black patients without private insurance. Further adjustment for number of comorbidities had only a modest impact on the association between insurance status and survival. In multivariate analyses, patients with > or = three comorbid conditions had approximately 40% to 50% higher risk of death at 1 year. CONCLUSION Among white and black patients aged 18 to 64 years, differences in comorbidity level do not account for the association between insurance status and survival in patients with colorectal cancer.

Individual lifetime exposure to inorganic arsenic using a space-time information system

OBJECTIVES

A space-time information system (STIS) based method is introduced for calculating individual-level estimates of inorganic arsenic exposure over the adult life-course. STIS enables visualization and analysis of space-time data, overcoming some of the constraints inherent to spatial-only Geographic Information System software. The power of this new methodology is demonstrated using data from southeastern Michigan where 8% of the population is exposed to arsenic >10 microg/l (the World Health Organization guideline) in home drinking water.

METHODS

Participants (N=440) are members of a control group in a population-based bladder cancer case-control study in southeastern Michigan and were recruited by phone using random digit dialing. Water samples were collected and analyzed for arsenic at current residence and participants were required to answer questions concerning lifetime mobility history and dietary habits. Inorganic arsenic concentrations were estimated at past residences and workplaces, and in select foods. Fluid and food consumption data were integrated with mobility histories and arsenic concentrations to calculate continuous estimates of inorganic arsenic intake over the adult life-course.

RESULTS

Estimates of continuous arsenic exposure are displayed, making use of both participant age and calendar year as measures of time. Results illustrate considerable temporal variability in individual-level exposure, with 26% of the participants experiencing a change in drinking water arsenic concentration of at least +/-10 microg/l over their adult lives. The average cumulative intake over the adult life-course ranges from 2.53 x 10(4)-1.30 x 10(5) microg, depending on the selected exposure metric.

CONCLUSIONS

The STIS-based exposure assessment method allows for flexible inclusion of different parameters or alternative formulations of those parameters, thus enabling the calculation of different exposure metrics. This flexibility is particularly useful when additional exposure routes are considered, input datasets are updated, or when a scientific consensus does not exist regarding the proper formulation of the exposure metric. These results demonstrate the potential of STIS as a useful tool for calculating continuous estimates of adult lifetime exposure to arsenic or other environmental contaminants for application in exposure and risk assessment.