Trends in malignant melanoma incidence and mortality in Wisconsin, 1979-1997

OBJECTIVE

To explore trends in malignant melanoma incidence and mortality in Wisconsin from 1979 to 1997, by age, gender and time period. Comparisons are also made to US trends over this period.

DATA

Incidence data for Wisconsin were provided by the Wisconsin Cancer Reporting System Bureau of Health Information, within the Wisconsin Department of Health and Family Services, while US data were extracted using SEER*Stat 3.0. Mortality data for both Wisconsin and the US were compiled using CDC WONDER.

RESULTS

Wisconsin malignant melanoma incidence rates rose 25% from 1979 to 1998, compared to a US increase of 132%. For mortality rates, however, both Wisconsin (22%) and the US (15%) exhibited only modest increases. Between the mid-1980s and mid-1990s, the largest increases in both incidence and mortality (over 70%) occurred among males over age 65. In contrast, declines of 30% to 40% were found for males age 0-34. Patterns were less consistent among females.

CONCLUSIONS

Since the mid-1980s, malignant melanoma incidence in Wisconsin appears to have increased sharply among males and females over age 65, with a corresponding rise in mortality among males in this age group. These trends should be a source of concern for clinicians and policy makers alike. Because current evidence on the effectiveness of early treatment is inconclusive, it is especially important to take preventive measures now--such as educational and community-based interventions--to reduce future incidence.

Electric blanket or mattress cover use and breast cancer incidence in women 50-79 years of age

Previous research has demonstrated inconsistent associations between electromagnetic radiation, especially from electric blanket use, and breast cancer. Breast cancer risk according to electric blanket or mattress cover use was examined as part of a multicenter population-based case-control study. Breast cancer patients 50-79 years of age (N = 1949) were identified from statewide tumor registries in Massachusetts, New Hampshire, and Wisconsin from the period June 1994 to July 1995. Women of similar age were randomly selected from population lists as controls. Information regarding electric blanket and mattress cover use and breast cancer risk factors was obtained through telephone interviews. After adjustment for age, body mass index, and other breast cancer risk factors, the risk of breast cancer was similar among ever-users (relative risk = 0.93; 95% confidence interval = 0.82-1.06) and lower among current users than among never-users (relative risk = 0.79; 95% confidence interval = 0.66-0.95). There was no evidence of a dose-response relation with increasing number of months that electric blankets had been used. This study provides evidence against a positive association between electric blanket or mattress cover use and breast cancer.

Women's Health Alliance Intervention Study: increasing community breast and cervical cancer screening

The Women's Health Alliance Intervention Study is a quasi-experimental intervention designed to test if county-based coalitions can increase breast and cervical cancer screening compliance among women aged 40 years and older living in rural communities. A number of interventions were designed and implemented by coalitions in four counties in north-central Wisconsin during a 2-year period. Four control counties in southwestern Wisconsin were identified for comparison. Judging from the results of this study, community-based intervention efforts can increase breast and cervical cancer screening compliance significantly among women living in rural communities.

Women's Health Alliance Intervention Study: description of a breast and cervical cancer screening program

The Women's Health Alliance Intervention Study is a community-based intervention study designed to determine if county-based coalitions can increase breast and cervical cancer screening rates among women aged 40 and older in four rural Wisconsin counties. This article describes the intervention process and demonstrates the feasibility of rural volunteer coalitions to promote breast and cervical cancer screening in communities. An accompanying article in this issue describes the effectiveness of these interventions.

Cigarette smoking in Wisconsin: the influence of race, ethnicity, and socioeconomics

A disparate burden of cigarette use has been demonstrated among demographic subgroups both in the United States and Wisconsin. We examined patterns of adult current smoking prevalence in Wisconsin by race, Hispanic ethnicity, household income, and education to assess whether differences exist among these subgroups. This analysis revealed a strong graded relationship between household income, education, and smoking prevalence, consistent among non-Hispanic whites and blacks, though not Hispanics. Respondents with less than a high school education had significantly higher smoking prevalence rates (41%) than those with a college degree or more (13%). Smoking prevalence rates did not significantly differ between the race and ethnicity subgroups overall, or by gender and education, although they differed in some age and income subgroups. Possible explanations for the socioeconomic gradient include differences in tobacco product marketing practices, indoor workplace smoking policies, and access to health information, resources, and consistent, high-quality health care.

Progress in reducing per capita cigarette sales in Wisconsin, 1985-1999

Over the past several decades, initiatives have been undertaken both on a national and state level to reduce cigarette smoking and its resultant health consequences. We compared trends in per capita cigarette sales in Wisconsin versus other states from 1985-1999. During this time period, per capita cigarette sales declined 21% in Wisconsin, versus 26% in the United States. Although the average per capita sales in Wisconsin were less than sales in the United States in both 1985 (107 versus 122 packs per capita) and 1999 (84 versus 90 packs per capita), Wisconsin's sales have declined at a slower rate, narrowing the gap between Wisconsin and US sales. Other states, such as California and Massachusetts, with large statewide tobacco control programs had rates of decline in cigarette sales over twice the Wisconsin decline from 1985-1999. In 1985, only 10 states had lower per capita sales than Wisconsin. By 1999, 24 states had lower rates, indicating greater relative progress in reducing sales in other states. Possible explanations for the greater decline in per capita cigarette sales in other states include differences in tobacco control programs, tobacco excise tax increases, and other tobacco policy initiatives.

Risk factors for carcinoma in situ of the breast

As more women obtain screening mammograms regularly and at younger ages, the diagnosis of breast carcinoma in situ becomes more frequent. To examine whether risk factors for carcinoma in situ correspond with risk factors for invasive breast cancer, we analyzed data from a population-based case-control study conducted in 1988-1990. We identified newly diagnosed cases of carcinoma in situ (n = 301) and invasive breast cancer (n = 3789) in women 18-74 years of age from Wisconsin's statewide tumor registry. Cases and population controls (n = 3999) completed structured telephone interviews. Overall, associations with risk of carcinoma in situ in relation to many reproductive life-style risk factors were similar to those associated with risk of invasive disease. Women who reported a family history of breast cancer had a 2-fold elevated risk of carcinoma in situ (odds ratio, 2.67; 95% confidence interval, 2.00-3.57). Personal history of benign biopsied breast disease also increased risk of carcinoma in situ (odds ratio, 2.19; 95% confidence interval, 1.62-2.95). Subgroup analysis suggested that high vitamin A intake and high alcohol intake may be associated with risk of ductal but not lobular carcinoma in situ. These data support the presence of common risk factors between in situ and invasive breast cancer.

Early-life physical activity and postmenopausal breast cancer: effect of body size and weight change

It is not yet known whether early-life physical activity reduces the risk of developing breast cancer. Subgroup analyses according to menopausal status and body mass may help clarify this association. Data from a population-based case-control study of female residents of Wisconsin, Massachusetts, Maine, and New Hampshire were used to examine associations between body mass and breast cancer risk. Cases (n = 4614) were identified by each state's tumor registry; controls (n = 5817) were randomly selected from population lists. Frequency of participation in strenuous physical activity when 14-22 years of age, weight at age 18 and 5 years before interview, height, and other factors were ascertained through structured telephone interviews. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were computed using logistic regression. Reductions in postmenopausal breast cancer risk associated with strenuous physical activity were greatest for women in the fourth quartile of body mass index at age 18; the OR for women with the highest activity frequency on average (> or =once/day) was 0.45 (95% CI = 0.26-0.79). Associations with frequency of activity also varied by weight change. Compared to women with no activity and little adult weight gain, frequent physical activity was associated with reduced postmenopausal breast cancer risk in women who had lost weight since age 18 (OR = 0.19, 95% CI = 0.05-0.70) or had gained little or modest amounts of weight (weight gain: first tertile, OR = 0.36, 95% CI = 0.05-0.85; second tertile, OR = 0.31, 95% CI = 0.14-0.66). Weighted MET score analyses yielded similar but less inverse results. These findings suggest that the reduced risk of postmenopausal breast cancer associated with frequent, early-life physical activity may be greatest in women who, over the adult years, either lost weight or gained only modest amounts.

Training internal medicine residents to screen for domestic violence

Internal medicine residency programs will need to train residents about domestic violence to comply with the Residency Review Commission standards. To assess the effectiveness of an educational intervention intended to increase screening of patients for domestic violence by internal medicine resident physicians and identify characteristics associated with increased screening, we used a quasi-experimental, pretest/posttest trial. This was conducted in an internal medicine residency program and its affiliated primary care clinic with categorical internal medicine and combined medicine/pediatrics resident physicians. Exit interview surveys of patients were conducted at baseline and following the educational program. Patients were questioned about demographics and if they were asked about domestic violence during the current visit. Physicians were questioned about demographics and attitudes and beliefs related to domestic violence. Prior to the intervention, only 0.8% (1 of 122) of patients reported being asked about domestic violence. After the intervention, the percentage asked rose to 17% (20 of 116). The odds ratio (OR) for being asked about domestic violence after training was 25.2 (6.1-104). Patients who were younger than 50 years were more likely to be asked (OR 2.5, 1.5-4.6). Caucasian physicians were more likely to ask (OR 2.8, 1.1-7.6). Patients reporting they were taught breast self-examination at that day's visit were also more likely to be screened (OR 2.9, 1.1-7.9). We found evidence that moderately intense training and focusing on results can increase resident physician screening rates for domestic violence. To do so effectively, we recommend a training session similar to this one and continued monitoring of outcome in the clinical setting.

Use of patient reminder letters to promote cancer screening services in women: A population-based study in Wisconsin

BACKGROUND

Patient reminder letters are an effective method of promoting cancer screening services in women; however, information on their actual use in a population setting is lacking.

METHODS

Data were obtained from a population-based, random digit dial telephone survey of 896 adult women living in Wisconsin. Respondents were asked if they had received a reminder letter for Pap or mammography screening within the past year.

RESULTS

Among women aged >/=18 years, 12.9% (95% confidence interval [95% CI] = 10.1-15. 6) received a Pap test reminder within the past year, while 13.0% (95% CI = 9.3-16.7) of women aged >/=40 years received a mammography reminder. Women without health care coverage were unlikely to receive either type of reminder. Current compliance with screening recommendations was greater among those women who received a reminder letter for Pap tests (94.3 versus 78.1%, P < 0.0001) and for mammography (81.7 versus 59.4%, P < 0.001). In contrast to the infrequent use of cancer screening reminders, 54.2% (95% CI = 50. 1-58.3) and 72.7% (95% CI = 67.6-77.8) of women reported receiving a reminder letter from their dentist or veterinarian, respectively.

CONCLUSIONS

Reminder letters for cancer screening services were rarely utilized in this study population. Receipt of a reminder letter was associated with greater compliance with current screening recommendations.

Breast cancer screening and family history among rural women in Wisconsin

This study examines the relationship between family history of breast cancer and current compliance with mammography screening guidelines. A random telephone survey of women age 40 or older living in rural Wisconsin (N = 2398) was conducted to determine mammography screening knowledge, family history of breast cancer, attitudes, intentions, physician recommendation, and compliance with screening guidelines. Compared with women without a family history of breast cancer, women with a family history were significantly more likely to demonstrate correct knowledge (p = 0. 01); express intentions in compliance with recommended screening guidelines (p < 0.001); report having been advised by a physician to obtain a mammogram (p < 0.001); and be in current compliance with mammography screening guidelines (p < 0.001). Results of simultaneous and individual logistic regression suggest that the effects of family history on compliance with screening guidelines are directly mediated through the combination of women's knowledge, women's intentions, and physician recommendation. Thus, programs to increase compliance with mammography screening guidelines should address both women and providers.

Trends in United States ovarian cancer mortality, 1979-1995

OBJECTIVE

To describe the epidemiology of ovarian cancer mortality in the United States from 1979 to 1995.

METHODS

The mortality data of the Centers for Disease Control and Prevention were accessed using the Wide-ranging Online Data for Epidemiologic Research (WONDER). We selected all deaths among women with International Classification of Diseases, Ninth Revision (ICD-9) code 183.0 (ovarian malignant neoplasm). Mortality data for the years 1979-1995 were age-adjusted to the United States 1990 female population, and mortality rates for each year were calculated for females of all ages by age category, by race, and by geographic location. Trends were obtained for the periods 1979-1983 to 1991-1995, and the impact on the number of ovarian cancer deaths was calculated.

RESULTS

Age-adjusted ovarian cancer mortality rates have changed little in the United States from 1979 to 1995, but rates are increasing in older women (65 years and older) and decreasing in younger women. Age-adjusted mortality rates are higher among whites than in blacks. Ovarian cancer mortality rates are higher in northern compared with southern states.

CONCLUSION

The trends in ovarian cancer mortality among younger and older women parallel published changes in incidence and may be due to changes in risk factors, such as the use of oral contraceptives. The reasons for the higher ovarian cancer death rates in northern states are unknown. Better understanding of how modifiable risk factors and treatment methods affect ovarian cancer mortality trends is needed.

Cervical cancer screening among women with and without hysterectomies

OBJECTIVE

To compare the rate of Papanicolaou testing in a population-based sample of women with medical documentation of 1) total hysterectomy for benign conditions, 2) total hysterectomy for malignant conditions, and 3) hysterectomy with cervix intact to rates among women who had not had a hysterectomy.

METHODS

The Marshfield Epidemiologic Study Area was used to identify a retrospective cohort of women with hysterectomies age-matched to women without hysterectomies. This study compares the Papanicolaou test rate per year (outcome) by hysterectomy status (exposure) for women with total hysterectomy for benign reasons (n=197), total hysterectomy for malignancy (n=75), supracervical hysterectomy (n=43), and no hysterectomy (n=315).

RESULTS

Compared with women who did not have a hysterectomy (nonexposed), women with a hysterectomy (exposed) for benign reasons had significantly fewer Papanicolaou tests; on average, one less test every 3 years (mean difference=-0.34 tests/year, P < .001). Contrary to this, women with a malignancy-related hysterectomy had significantly more tests than their nonexposed counterparts (mean difference=0.87 tests/year, P < .001); nearly one additional test per year. Finally, women with supracervical hysterectomies had the same rate of testing as their nonexposed counterparts (mean difference=-0.03 tests/year, P=.62); on average, one test every 2.5 years.

CONCLUSION

This study demonstrates that Papanicolaou testing rates vary by type and reason for hysterectomy. Women with hysterectomies for benign reasons may be receiving from two to three times as many tests as needed. Notably, women with intact cervices following hysterectomy have similar testing rates (one every 2.5 years) as women without hysterectomies. This has direct implications for leaving a woman's cervix intact given normal cytology at the time of hysterectomy.

Relationship between age and mortality due to intracerebral versus subarachnoid hemorrhage

This cross-sectional study compares trends in mortality by age for intracerebral and subarachnoid hemorrhage. United States mortality data from the Centers for Disease Control from the years 1991 to 1992 are examined with the program CDC Wonder, and mortality rates for 10-year age groups for each disease are compared. As expected, the crude mortality rate attributable to intracerebral hemorrhage, at 7.1 per 100,000, is much greater than that of subarachnoid hemorrhage, at 2.7 per 100,000. However, the age distribution of this mortality is found to be very different in the two conditions (chi(2), P<.0001), with a younger population affected by subarachnoid hemorrhage. This difference is even more pronounced in earlier United States mortality data from 1979 to 1980. This has important implications for epidemiological studies of hemorrhagic stroke as a whole.

Chronic disease mortality among Wisconsin Native American Indians, 1984-1993

Premature chronic disease mortality continues to be a problem among American Indian populations. To document the chronic disease burden in the Wisconsin American Indian population, age- and sex-specific incidence-density mortality rates for ten chronic diseases (ischemic heart disease, stroke, diabetes, chronic obstructive pulmonary disease, cirrhosis, and cancer of the breast, cervix, lung, colorectum and prostate) were estimated for a 10-year period (1984-1993) and compared with the Wisconsin non-Hispanic white population. Compared with whites, American Indians had markedly higher mortality rates from diabetes and cirrhosis in all age- and sex-specific groups. Ischemic heart disease mortality was significantly greater in both American Indian men and women 45-64 years of age (Rate Ratio [RR] = 1.7 and 2.1, respectively) compared to whites of the same age, but was lower in American Indians 65 years of age or older (RR = 0.9 for both sexes). Overall, these ten chronic diseases were responsible for a significant excess number of deaths in middle-aged American Indian men and women (i.e., 45-64 years of age), whereas the chronic disease mortality experience of older American Indian men and women (i.e., > or = 65 years of age) was similar to that of the older white population. Diabetes and cirrhosis were the most important causes of increased mortality overall; however, ischemic heart disease was responsible for a large number of excess deaths in middle-aged American Indian men and women.

The direct effects of nicotine use on human health

Tobacco is one of the leading preventable causes of death in the United States. The role of some of the specific components of tobacco and tobacco pyrolysis in causing human disease has been well described. However, the health risks attributable to nicotine alone have not been fully determined, especially for long-term use. Nicotine is a potent chemical that has powerful effects on the human body, especially when administered rapidly or at high doses. Although many of these effects are deleterious, others may be beneficial. In certain special populations, such as the developing fetus, or persons with significant cardiovascular disease, nicotine has greater adverse effects. Because of the recent emphasis on using nicotine to treat tobacco dependence, as well as the interest in using nicotine as a possible agent for reducing overall tobacco use, clarifying the effects of long-term nicotine use on human health is important.

Nonsteroidal anti-inflammatory drug use and protection against colorectal cancer in women

Several epidemiological studies have identified an association between nonsteroidal anti-inflammatory drug (NSAID) use and colorectal cancer risk in women. We examined this association in a population-based case-control study in Wisconsin women. Between 1991 and 1992, 184 women ages 40-74 years with colorectal cancer were identified through the statewide cancer registry and 293 population-based control women were randomly selected via telephone. Regular NSAID use was defined as at least twice weekly for 12 months or longer. After adjusting the data for age, controls were more likely than cases to report regular NSAID use (38 versus 27%). Following adjustment for age, prior sigmoidoscopy use, family history of large bowel cancer, and body mass index, women who regularly used NSAIDs were approximately one-third less likely to be diagnosed with colorectal cancer compared to women who did not use NSAIDs [odds ratio (OR), 0.65; 95% confidence interval (CI), 0.40-1.03]. A statistically significant effect of duration of use was identified, although the ORs did not show a consistent trend. No significant effect of frequency of NSAID use was observed. When the type of NSAID used was examined (aspirin or nonaspirin), subjects who used nonaspirin compounds had a statistically significantly lower risk of colorectal cancer (OR, 0.43; 95% CI, 0.20-0.89), compared to nonusers, whereas aspirin users had only a small, nonsignificant reduction in cancer risk (OR, 0.79; 95% CI, 0.46-1.36). These data add support to the hypothesis that regular NSAID use is associated with lower colorectal cancer risk in women and suggest that the type of NSAID used may be important.

Diabetes mortality trends in Wisconsin and the United States, 1979-1991

The mortality trends analyzed suggest lack of progress toward both national and state objectives and the need for primary and secondary prevention programs targeting black and older adults with diabetes.

Body mass and breast cancer. Relationship between method of detection and stage of disease

BACKGROUND

Obesity is associated with advanced stage breast cancer at diagnosis and a poorer prognosis. Stage of breast cancer at diagnosis is also strongly influenced by the method of cancer detection. The objective of this study was to determine the relationship between body mass index (BMI) and breast cancer disease stage, taking into account the method of cancer detection (i.e., self-detection, screening mammography, and clinical breast examination [CBE]).

METHODS

From 1988 to 1990, 2863 patients with invasive breast cancer were identified through a statewide, population-based, cancer reporting system and were interviewed as part of a larger study of breast cancer etiology. Stage of disease was classified as either localized or nonlocalized (regional and distant disease combined). The relation between BMI and disease stage was examined by using multiple logistic regression adjusting for age, education, race, year of diagnosis, and prior mammography use.

RESULTS

Thirty-eight percent (1092 of 2863) of the women had nonlocalized breast cancer. A strong dose-response relationship was observed between increased BMI and the likelihood of nonlocalized disease (P < 0.001). However, this association was present only among the 55% of women (1585 of 2863) who self-detected their tumors. The odds ratios for nonlocalized cancer increased from 1.0 for the lowest quintile of BMI to 1.3, 1.6, 1.7, and 1.8 for the second through fifth quintiles, respectively, for this group.

CONCLUSIONS

Greater body mass was associated with nonlocalized breast cancer; however, this association was restricted to women who detected their own cancer. No association was found between BMI and stage of disease among cases detected by either mammography or CBE.